Single Central...What's the plan and how do you execute it?
I'm sure many feel like anteriors can be a labor of love, especially handling single centrals. I never feel like I charge enough for some of these cases. Here's a case I completed today. This was a college student who was heading back to school on Sunday and his family wanted me to complete his case before he headed back. He had some trauma to #9 about 7 years ago and had it repaired by his pediatric dentist. He also plays the clarinet competitively as well and the asymmetry between #8 and 9 was causing him some frustrations with his mouthpiece. Because of his scholarship for music, he had zero interest in orthodontics.
So when I see cases like this, I'm trying to plan the case before I touch the tooth with a bur. Mike, Sam and Flem really do a great job of getting you to develop a gameplan before you tackle these cases in Level 4. Prep design, Facial reduction, core color, occlusion, block selection, characterization, etc...
As you can see, the VITA Classic Shade of A1 is close in color to the adjacent tooth #8. I choose IPS Empress CAD Multi for this case and even though Empress to me tends to be a little brighter, I chose a B1 Multi block for this case. I know that with less facial reduction and the goal of trying to preserve enamel, I will get a value drop on these cases. Your facial thickness of porcelain is critical to take into account on all of these cases. If you ignore it, you can get burned quickly, ask me how I know.
The preps look aggressive but the facial reduction is minimal 0.5-0.7mm. I almost always break contacts and I try to have smooth, rounded margins to help allow the restorations to drop into place and have a great fit with CEREC. This case was stained and glazed with Empress Stain and Glazes and fired on P4. I missed the texture a little on this case and width could have been better as well. Overall, I would call the case a success with a happy young man and family before he heads off to college.
This looks great. Quick question, do you use teflon tape on adjacent teeth when you cement?
john
Great result Daniel. Now that I see the prep, my prior question is answered. I see the distal line angle is a hair off but his smile is not at all symmetrical so I think it blends in really well. The texture is really close. I find it tough at times to get the kind of texture that’s on 8. Any tips that work well for you?
Lastly, do you move the crown in the block on these for more or less translucency. I find if I move it to allow more translucency, it greys out quickly.
Hey Dan! Great work as always. 2 questions: did you stain and glaze intraorally? And what did you use to get that prep so smooth?
Decent result Dan. Very few people will see your crown at 1:1 photographic magnification. About texture, with the kind of texture on this patients #8, sometimes the best way to duplicate it is to apply a slightly lumpy coat of glaze. That works pretty well as long as the glaze doesn't wear off.
@John: yes, I like to use Teflon tape for a number of uses but I do like to protect the adjacent teeth with the Teflon. I will Etch, Prime and bond the tooth and bond the restoration in with the Teflon tape in place. It is thin enough to not affect the seating of the restoration in the proximal contacts. I also don’t worry about accidentally getting Etch and bonding the adjacent teeth making my clean up even more difficult.
I stopped obsessing about protecting the adjacent teeth long ago. I found it to be a waste of time and mostly ineffective. Maybe once in 20 times I will get some set up bonding resin blocking an interproximal area. The easiest way to remedy that problem is to run a white Contact Eeze between the teeth. The white Contact Eeze has no abrasive on either surface and frees up the interproximal contact in 2 seconds. Easy peasy.
@Jeff: texture is something I don’t think I’m great with. Trying to get better and better and really look lab technicians and clinicians on this site can set their restorations apart with the secondary and tertiary anatomy. For me personally, I have the CEREC doctors polishing kit by Meisinger and love it. I will polish my restoration after I’m happy with the contour with the green wheel and feather lite polisher. At this point, I will put texture in with the small diamond disc that is in the kit. This case had both horizontal and vertical striations. I won’t go back and polish with the green wheel or feather lite because it will polish out the anatomy. So I will polish again after I do my stain and glazing with the blue and red wheels. If others have tips or different lab burs to add texture I’d love to hear them.
I didn’t move the restoration much in this case. These cases are always tough because if you have minimal facial reduction, I am tending to choose a block that it a few shades bright to accommodation for the value drop with less porcelain thickness. And then you really have to pay attention with what cement you use. On this case I used Variolink Esthetic DC Light. If I used Neutral I would have probably drop in value about 1/2 shade.
@Dennis: 1) yes, I do stain and glaze intraorally. I isolate with an optragate and have everything in the op to transfer the restoration to the pin to minimize how much I handle the restoration. I will typically hold the restoration after I tease it out in the interproximal areas. So after I have it on the firing pin, I clean up any smudges or imperfections then.
2) I polish my preps with 3M polishing discs. I helps to smooth the preps and round off the sharp corners in my prep as well.
@Armin: the intention was to do BioReference but I got a crazy proposal and didn’t want to waste too much time messing with everything trying to figure out where the issue was. So I ended up with Biogeneric Individual and spent a little more time contouring chairside.
Beautifully done Dan! Love the result, and explanations of your considerations from prep, to block choice, thickness and value issues and ramifications, and cement choices.....This could be a half day lecture! 
I'd be in the front row...
Mark
On 1/5/2019 at 10:49 am, Charles LoGiudice said...I stopped obsessing about protecting the adjacent teeth long ago. I found it to be a waste of time and mostly ineffective. Maybe once in 20 times I will get some set up bonding resin blocking an interproximal area. The easiest way to remedy that problem is to run a white Contact Eeze between the teeth. The white Contact Eeze has no abrasive on either surface and frees up the interproximal contact in 2 seconds. Easy peasy.
Agree wholeheartedly
Fantastic job. However, to critique something about shape isn't quite right. I think the incisal edge isn't quite there?
And i agree that these restorations often look better unglazec and poilished
Dan, your staining skills are over the top! I think you did an awesome job!
Thanks for sharing this case with us!
@Barry...completely agree. His occlusion is less than ideal and the lingualized lateral threw the mesial distal spacing off. I tried hard with the contouring and I still don’t love it but that’s why I take pictures and post it on here.
Daniel. Very quickly I’ll say Bravo. I think for this case you did a great job. The dreaded single central is always a nightmare.
JZ
Very nice result on a case dropped into your lap with a deadline. Awesome that YOU could get it done and make it look so awesome without some of the tools we all love to use in the anterior on a single central: a wax up?!?
I might be missing it, but I looked at the various angles, I think the only issue with your texture is actually some deeper lobes on the facial with the BFD (Big, Fat Diamond--credit to Dr. Fleming) or the Brasseler rounded bullet lab diamond. A few deeper lobes may have been all you needed....however, as thin as this was, that may not have been possible. Either way, that competitive clarinet playin' college student should be THRILLED. I can only imagine the black lined PFM from somewhere down the road would have looked like! Yikes!
A+ work! We're all heading to the Pacific Northwest should a CEREC doc mess up a front tooth so either you or Kris can tackle the dreaded single central ON A DENTIST!
Thank you Ernie!! I appreciate the compliment and the tip on the bur. We hope nothing happens to you on your adventures to in the NW but we are always here for you!
There is some serious skill at the Wilson/Aadland Household! I know we beat ourselves up about texture and line angles, but you should be proud of that case. Great job.
