emax MT Full Mouth Reconstruction
I think we often forget the power of what we do everyday, esthetically and functionally. This patient presented to our office about 13 months ago. She was considering orthodontic treatment with orthognathic surgery to correct her Class II malocclusion and obvious resulting issues. #2 was hopeless and was extracted with a preservation graft in our office in August of 2016. She completed not only the surgery but also the orthodontic treatment in June of this year.
She presented for records in July 2017 where we did a post ortho/surgery full reconstructive records appointment that included a charting, 3D exam, digital and traditional impressions with bite registration, facebow, and photos. We sent the records to Eddie Corrales at Downtown Dental Designs in San Diego. A wax up and transfer was completed after discussions with the patient as to her final expectations and goals. Emax was the obvious choice based on her function and the natural esthetic properties of the material. I chose MT based on her original color,staining, and age.
Her basic desire was to have a smile she didn't have to think or be worried about, She wanted longer, "less worn down" teeth. Her only real demand was color, which she could only describe as wanting them "bare a** white". We went with BL2.
The ortho and surgery left her almost Class III, but in a great position for the reconstruction. We transferred the wax up one month prior to her prep date and saw her every week and as needed for occlusal adjustments to lock the occlusion into a stable position. She was opened vertically 2mm. As you can see she is challenged vertically, has severe wear, and is slightly opened in the posterior right. She is 36 years old.
I would change a few minor things. The laterals could defn be more mesial inclined. The midline is still off but was post ortho. The patient was thrilled because we gave her what she wanted and she felt stable for the first time in almost 20 years.
After transferring the diagnostic wax up she felt immediately more comfortable and stable.
After one month and five occlusal adjustments she presented for her appointment. Day 1 we completed the Maxillary Arch and Mandibular Posterior. She was in the chair 9 hours. She came back the following morning and we completed the Mandibular Anterior #22-27. Eddie was on site and designed, milled, and finalized all restorations as we continued to prep. Vertical dimension was always maintained by completing the posterior a quadrant at a time.
All restorations were bonded using Variolink Esthetic (Light Shade). Again, slightly white, but she pulled it off easily. She is numb in the photos in the lower anterior and final photos were taken at the end of day 2 appointment.
Fantastic result. And yes, I too think we often forget the power of what we can accomplish because we see/do it on a daily basis. Again, great work. You've now got a lifelong raving fan with barea$$ white teeth. ;)
Amazing work! I can't help but think to myself how much more difficult this would have been to accomplish 10-20 years ago. Thank the Good Lord for this technology and thanks for posting.
Great work Dave. Despite being very white, they work on her fair complexion. See you next week brother.
That is a great case. Day in and day out those folks walk through the door. I have to remind myself that the treatment needs to be discussed even if we think they will say no. Because sometimes, like this one, they say yes! Thank you for posting - I feel inspired!
Dave, Great work and nice work flow!
I agree that that the shade actually looks really great on her, even if it's one we wouldn't go to every day. And just as importantly, exactly what she wanted.
Bob, It is always so nice to bring in a great ceramist on these cases, for efficiency and esthetics.
On 9/5/2017 at 6:07 am, Craig Vacek said...Dave, Great work and nice work flow!
I agree that that the shade actually looks really great on her, even if it's one we wouldn't go to every day. And just as importantly, exactly what she wanted.
Every time I try to talk someone out of a shade they want it usually comes back on me.
Nice job Dave! (and Eddie)... I can't think of a single patient who was disappointed in going too white, even when I thought it was less than "natural".... I CAN think of a whole bunch of cases who wish they went brighter...
Mark
Amazing work Jules! I can't believe how much younger she looks! Looking forward to DS World and catching up!
On 9/5/2017 at 2:26 pm, Daniel Wilson said... Amazing work Jules! I can't believe how much younger she looks! Looking forward to DS World and catching up!
Thanks Dan! See you next week!
Dave, nice work. That was a big project and what a nice result!! Great work, very cool you had a team approach too. JJ
I gotta say, she pulls off that shade wonderfully! She really does look so much younger. Really nice case.
Amazing case! Great planning and execution! Could you elaborate the process “ after transferring the diagnostic wax up, she felt.......” ? Did you prep them all and put in temporaries? Thanks for sharing?
On 9/5/2017 at 4:09 pm, Eric Chen said... Amazing case! Great planning and execution! Could you elaborate the process “ after transferring the diagnostic wax up, she felt.......” ? Did you prep them all and put in temporaries? Thanks for sharing?
Eric,
So after the temps we brought her back every week or as needed for occlusal adjustments. There were five total in 4 weeks. We then prepped the maxillary right posterior, imaged, and while Eddie was designing and milling, I prepped the maxillary left posterior. The right posterior was finished milling so we placed those to maintain the vertical dimension for the buccal bite on the left. We prepped the maxillary anterior while the left maxillary posterior was milling and the right posterior was in the oven. We then delivered the maxillary right posterior and imaged all of the maxillary anterior teeth. As those were milling we delivered the maxillary left posterior and began the mandibular lower posterior preps. We were able to maintain the vertical dimension by never losing a complete side in preps and using one side to help register the vertical while imaging the other side. We then finished both mandibular posteriior quads and sent the patient home for the night. The mandibular anteriors were finished to completion the next morning in three hours. Hope this helps.
Dave,
I really love your result. She didn't look that bad before you started her makeover. But the result is a definite improvement. How do you guys find these patients? I have to twist arms to do single crowns. Well done.
Dave. Great case. Although I have performed many full mouth rehabs, I've not done any as a full mouth Cerec case.
You described it well and look forward to dining it!
On 9/5/2017 at 6:19 pm, Charles LoGiudice said...Dave,
I really love your result. She didn't look that bad before you started her makeover. But the result is a definite improvement. How do you guys find these patients? I have to twist arms to do single crowns. Well done.
Thanks Dr. Chuck. We are lucky to be able to do this every three to four months. Each case is a learning experience and makes the next one a little easier. Hopefully I will see you next week in LV. Happy Birthday my friend!
Dave, thank you so much for choosing me to do these cases, it really is fun when things work out smoothly, planning the case properly is a must, having done many FMR with cerec , I get to build a protocol that works for each case.
Here we started with posteriors and finish with lower anteriors, one full day and three hours the next , done by noon.
i like doing the wax ups by handk due to the control I have with the bites given and articulator setting. I've done plenty digital wax ups but I'm old school. Besides, my printer is in my Florida lab :)
i look forward to the next one coming up.
Hi,
congrats for your beautiful work.
although i'm almost one year in cerec practice, i still cannot imagine how you did this patient in only 9+3 hours and the outcome is so much nice.
would you plz describe your worflow in more detail?? how many milling units do you have??
plz tell us step by step the work you did and the time each step took.
Amazing case. Very beautiful result. Is there a cant between 8 and 9? I'm not talking about the midline being off.
Once the patient is ready for the procedure , after wearing relined occlusals and incisals from my wax up, we start our process. And it goes something like this.
1: We prescan whole upper arch under upper bio copy catalogue, and lower under lower .
2: We prep posterior left, scan preps and buccal bite.
3: At this point, I export the file to the desktop for later use. Doctor starts preping Upper right.
4: While David preps right side, I design left side and start milling.. this part should take me 7 minutes to design 4 teeth and 20 minutes to mill all four.
5: During the twenty minutes of milling , Dave is preping the last teeth of the right side and I am importing the file I exported onto a new cerec file. This may get tricky here. I now have the same images as before ( the same file ) but on this one I will go to admin and change the teeth numbers to the right side, I then go to the images and get rid of the biocopy image ( send to trash ) , I then grab my upper catalogue and drag it to the biocopy window. At this point I will here the same images on two windows ( upper prep and Upper biocopy ). Now I cut the teeth Dave is preping , out of the upper prep catalogue, this will allow me to scan the right side preps ( fill in the scan), now I delete the buccal bite scan and scan the right side buccal bite.. We make sure to have either the molars on the left or a blue moose bite get for left side stability when the patient bites down. Remember the patient has composite on the opposing arch, So if the molars ( Emax in blue state) are a little high, adjust the lower.
6: Now i export the case again to te desk top for anterior segment later.
7: Dave now can take a blue bite of the right side preped. And starts preping anterior six.
8: I start designing posterior right, another 27 minutes, When Dave is done preping anterior six, I open a new cerec and import the second file I exported earlier wit all posterior preped .
9: I get rid of the bio copy, Drag/copy the upper prep catalogue to biocopy window. I now cut the unpreped anterior teeth off the upper prep catalogue/window. This will allow me to introduce the anterior preps Dave is working on.
10: When his is done preping anteriors , we can either place all four molars or bite ref taken earlier to get a good new buccal bite image.
11: At this point is very important to take a final impression of the upper preps for further contouring and midline control, having the milled first premolars in the impressions will help us with the contacts between them and canines that we did by eye using the biocopy catalogue.
From here on, we do the same to the lower arch.
I know many questions will come up from this technique , this is one I used with dave, there a few way to do it, the important thing is to have a plan in the big inning of the day. Also helps to have a second milling unit.
Some may think exporting and importing is overkill, but I've been using this way for nine years doing same day smiles around the world with cerec doctors, so it's my comfort zone, like saving everything you can in case the software reacts !!
Please feel free to ask questions, I would love to share and also learn new ways to approach these cases
On 9/6/2017 at 10:57 am, Damen Patel said...Amazing case. Very beautiful result. Is there a cant between 8 and 9? I'm not talking about the midline being off.
Damen,
I was wondering if anyone would ask that...no cant at all...except the photographer...I took the pic slightly slanted.....lol..... In fact the occlusal plane is almost perfect.
did you temporize canines and anteriors to new vertical dimension? leaving all posterior alone? or did you add vertical stops to one or two of the posterior teeth w composite?
Trying to think through your flow as you said you use one side to preserve vertical... but if you only temporized canines forward (as it looks like you did) then all posterior teeth woudl be open a couple mm....
just curious. i've done a case or two similar but i added vertical stops w composite to centric stops on posterior 1st and 2nd molars.
Bill
Great case! Thanks for sharing. I have a similar case starting next week where the patient wants bright white full makeover smile. He has very heavy tetracycline staining and I'm afraid the emax MT crowns would show through the darkness of his teeth. I am thinking about doing lab zirconia fused to porcelain for his anteriora for this reason. Do you guys have any ideas about material choice for a case like that? Thanks in advance.
You would be shocked what MT will hide. The more porcelain the less life like so I don't always prefer to make the porcelain really thick. Also consider an LT block if need be.
I am redoing some crowns on my hygienist and made a trualbunit with MT bl4 and it looked great while hiding any gray underneath.
On 9/6/2017 at 4:51 pm, Chad Johnson said...I'd love to get some guts and do a full-arch case like this in house.
Great stuff, Dave!
Chad, the key with these is the planning and execution. We can all prep teeth and bond restorations. It is way less complicated than it looks. By systematically prepping and never losing the established new vertical dimension the case flows very well. The efficiency comes by NOT having to design and finish the case. If you can separate yourself from the natural OCD person inside of you (which we ALL are when it comes to our work), it takes so much of the stress out of the procedure. Case selection is so important with your first (and every) case. I will be in Vegas next week, grab me any time and we can talk more.
On 9/5/2017 at 11:57 pm, Harry Abachi said... Hi, congrats for your beautiful work. although i'm almost one year in cerec practice, i still cannot imagine how you did this patient in only 9+3 hours and the outcome is so much nice. would you plz describe your worflow in more detail?? how many milling units do you have?? plz tell us step by step the work you did and the time each step took.
Harry, yeah, it is amazing to be able to accomplish so much in so little time. The key with this is truly the efficiency of having a great lab guy (or gal) doing the design and finish. If you follow the steps Eddie laid out, and the patient is stable occlusally by the prep appointment, they go very smoothly...and quick. An amazing stress free two days also...for me and my staff. They learn a ton from Eddie every time he comes in about stain and glaze, I actually have some down time throughout the two days, and production on those days is obviously amazing. We typically do $60-65k in those two days of dentistry. We work 7 hour days usually, but say we have 16 hours in the office those two days, even though I may only work 12 of them the rest of the office, including my associate is working, That is a $4000/hr day. We try to stack these cases and bring Eddie in every 4 months if not every quarter.
On 9/6/2017 at 5:22 pm, Dipali Thakker said... Great case! Thanks for sharing. I have a similar case starting next week where the patient wants bright white full makeover smile. He has very heavy tetracycline staining and I'm afraid the emax MT crowns would show through the darkness of his teeth. I am thinking about doing lab zirconia fused to porcelain for his anteriora for this reason. Do you guys have any ideas about material choice for a case like that? Thanks in advance.
Dipali,
emax MT will hide and mask more than people realize while still looking so much more natural. Or you could look at emax LT as Jeff said. I love the esthetics of emax over zirconia ANY day. Especially if the anteriors are involved.
Also consider your cement options carefully because the correct choice will enhance your case and hide more than you may think. Variolink Esthetic will work amazing for you because it is color stable and comes in many shade options to help mask internal or stumph variations and staining. Let me know if you need any more help or suggestions with your your case.
Beautifully done! Great job. I love the way Eddie gets the emotional side of it - such a stud
Great Case! I have a similar one I am working on right now. I did her case in a similar work flow but used teliocad as she is phasing out the treatment and we did the case one arch at a time over two days. I like the idea of getting patients in temps the way you did, but I was wondering more about your first visit with her when you transferred the wax up to to mouth.
What was your material of choice and bonding agent to transfer the wax up?
Did you prep the interproximals when you did this appointment in order to get your wax up to seat properly?
Did you trim margins first then cement? Could the patient floss or were the temps connected?
If you could detail this first appointment as the transfer of the wax up is critical to the outcome of the case. I would love to here these details and really appreciate it.
Thanks,
Jarrod
