Loving this new Digital Workflow
So I have been working on this case for just over a month and delivered it today. Patient had CC of misaligned teeth and failing composites. Declined ortho, don't blame her she is 71. However, she was made aware of how much I was planning to "pull back" her teeth based on our waxup and how everything overalyed with CEREC. So again, here is how I used our technology and software to our advantage.Â
I scanned the patient with the 4.5.2 software and exported the STL files. They were sent along with photos via dropbox to my lab with instructions on the case.Â
We received the mockup back as an STL file and printed using Form Lab 2 printer.
I opened her case back up and then scanned the digital waxup and overalyed to show the patient at her consult. After she agreed with proceeded with the case.
We rough prepped the teeth and delivered the mockup to the mouth, using it as a reduction guide for the case.Â
When I tried to deliver the bisacryl temps, I nor the patient liked the midline, it was slightly off. So I used the digital model and editted the design and milled out Lava Ultimate temps. This is how tissue presented after 2 weeks.
After approval of the provisionals, we printed her prepped arch and milled 4 vita mark 2 crowns. Here is the following lab process:
These were delivered today. So we will get the patient back in a week or two for finals. But really thrilled with the outcome. I didn't see the "junk" until after the photos 
.
These types of cases have become very predictable in my office. From sending it digitally to the lab and visually seeing how much we are removing, to having a model ready for fine tuning the restorations, I think 3D printing is taking a big part of our digital dentistry arsenal.
Tom
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On 6/7/2018 at 10:26 am, Steven Hernandez said... And THAT is how it's done. Knocked it out of the park.
EXACTLY what I was going to say.... and that IS how it's done...... nice job, and presentation.
Mark
. Great work and documentation Tom! Thank you for sharing.
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Looking at the pre-op wear, her bite and the mandibular crowding/super eruption, was curious if #8 gave you any issues with the occlusion?
Nice work Tom! Thanks for sharing....I have a case coming up similar to this in a few weeks. Well done!
Damn impressive game plan, execution, and final result. Kick your feet up and crack a beer after that one, buddy. You deserve it.
really well done Tom. We'll celebrate that case over this weekend in Chicago. (a louis trey on snider of course!)
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Nice work!! Really great presentation on workflow and a wonderful result. Cheers. I hear you're going to get dragged into this neck of the woods this summer...see you then!!
JJ
Tom, not only was it done incredibly well, but I love the idea of showing the patient the pre-op and wax up results in a biocopy folder as a treatment planning technique. Great Job!
On 6/7/2018 at 10:54 am, Petar Tofovic said...
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Looking at the pre-op wear, her bite and the mandibular crowding/super eruption, was curious if #8 gave you any issues with the occlusion?
Petar,
​After the mockup, I did adjust the incisal edge slightly of the lower just to level it a bit. We also had her wear the temps and did not notice anything unusual with the wear pattern after a few weeks. When I swapped out the lavas today for the vita mark 2s no adjustments needed.
Tom
Seriously though, glad to see you crushing the 3d printer. Believe it or not, many users really struggle to learn and use them. Glad I convinced you to just buy it and you've learned so quickly. Props.
Tom,
 Very nice work, great looking final crowns. You make it look easy when I know its not....
Lovely result Tom. As mentioned here. This is now becoming the workflow. Also, beautifully presented.
First of all, beautiful end result and great documentation of the process from start to finish. Now to some questions - I am a relatively new user (1 year) and want to get started with these types of cases using CEREC and not conventionally the way I have up until now.
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* when do you make the decision to do this in one visit vs. provisionalizing and delivering at a later date?
* when you do the case as you did, how much time between placing provisionals and placing final restorations?
* was the material choice (Mark II) a go to block for you, or was there something in particular with this case where that worked out best?
* on the slide that showed "virtual planning", what was going on with that process?
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As you have time to answer, Tom, it is much appreciated. Thank you in advance.
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Paul
​Paul and everyone thanks for the kind words on this case.
On 6/9/2018 at 7:18 am, Paul Kruth said...First of all, beautiful end result and great documentation of the process from start to finish. Now to some questions - I am a relatively new user (1 year) and want to get started with these types of cases using CEREC and not conventionally the way I have up until now.
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* when do you make the decision to do this in one visit vs. provisionalizing and delivering at a later date?
I have reached a point that anything more than 2 indirect restorations in the anterior I will schedule for 2 visits. This allows the patient to evaluate a "new look" in her mouth and to be able to function with a trial set of teeth. If she approves, I know I have dialed in the final outcome and it will be predictable. Also, it gives me more time with the ceramic to make sure the contours, characteristics, and texture is correct. Doing this in one visit makes me too stressed and I try to limit that feeling as much as possible. Finally, having the patient come back allows me more chairtime for other procedures/patients and I am not having the patient sitting there eating up valuable chair time.
* when you do the case as you did, how much time between placing provisionals and placing final restorations?
It really depends. I have had some patients that take a week to approve them and others that we have to make modifications and it takes a month or two. After they have approved the mockup, if no changes are made, I can copy the digital mockup from the lab. The detail is higher with this workflow than transferring it to mouth and copying it, in my experience. If changes are made, then I will copy the temps in the mouth, but I only cut out areas that I have adjusted. This way, I'm still copying a majority of the digital printed model and areas that were adjusted were cut out and filled in.
* was the material choice (Mark II) a go to block for you, or was there something in particular with this case where that worked out best?
I am a big fan of Vita Materials on anterior teeth. If the teeth are "warmer" in appearance then I'm leaning towards Vita. If the teeth are brighter, I'll lean towards Empress. Within the Vita family, I'll use Mark II and Triluxe and Triluxe Forte. My decision process with these starts with how the shade gradient looks with the tooth. If there is a gradient, i'm leaning towards triluxe (3 shade gradients) or forte (4 shade gradients). If the tooth is pretty much a single shade with characteristics in it, then i'm going to go with Vita Mark II. I try and pick the block that allows me to do the least amount of work to get the end result.
* on the slide that showed "virtual planning", what was going on with that process?
This has been new in my work flow and I have really enjoyed it. The slide is showing the preop condition scanned along with the scan of the printed model. The reason we have to scan the printed model is because we cannot import an stl file back into the software (please sirona incorporate thisÂ
). So now we can overlay the 2 sets of data and explain to the patient some valuable information, including why ortho would be important in this case. It shows where we are starting and what end result we are trying to achieve and the pros and cons of each treatment outcome.
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As you have time to answer, Tom, it is much appreciated. Thank you in advance.
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Paul
Hope this helps Paul. Cheerio
Tom
Finals of the case.
Turned out well, there are some imperfections in my contouring and photography really brings these out. Overall, patient was thrilled and by far one of the most predictable workflows we can do so far.Â
Tom
Thanks for the follow-up. Hand polish only, right? It's how I prefer to finish these types of cases myself. Again, very nicely done.
On 7/12/2018 at 7:08 am, Steven Hernandez said... Thanks for the follow-up. Hand polish only, right? It's how I prefer to finish these types of cases myself. Again, very nicely done.
Steve,
​My assistant did some light characterization and glazing. Then we will always hand polish back to try and match the surface texture to the surrounding teeth.
Thanks,
Tom
Haha. Jake you know me too well. These were stained and glazed by my assistant that has only been with me for 6 months
great results and presentation!!s she must be thrilled...getting close to REALLY considering 3D printing.
