hello and welcome to chairside live I'm your host Megan strong we have a
wonderful show for you today dr. Qi is practicing single appointment dentistry
he's using the TS 150 mil to fabricate an obsidian onlay for tooth number three and
getting in some extra work while at mills then viewer mail returns for an important
question about bio Tim Provisionals but Before we jump into that let's talk about this case
dr. Chi's presenting a case where he milled an obsidian onlay chairside and while the on Leigh
was milling he used camouflage Nano hybrid composite to restore tooth number 18 talk
about capitalizing on that chairside time cha-ching take it away dr. chief
hello there welcome back for another case of the week our patient today is a 32 year old
female whose chief complaint is severe thermal sensitivity in the upper right quadrant she
presents with a large cavitating carious lesion on the distal side of number three
radiographic examination also reveals a high possibility of pulpo involvement
our goal here is to preserve as much healthy to structure as possible by circumscribing the
decayed area of the tooth we begin the caries cleanup process by expanding the cavity along
the buccal lingual gingival and axial prep walls here I'm using a round aided tapered
diamond bur to extend the prep walls until I reach healthy sound tooth structure along the dej caries
indicator is a useful aid in determining whether or not to extend the preparation as it stains
demineralized areas of the tooth I will apply the caries indicator dye and remove to structure
until the dej no longer stains once the infected dentin is exposed I use a slow speed round bird
to carefully remove the soft tooth structure beginning at the outermost areas near the dej
deep caries removal reveals a pinpoint exposure with fortunately no hemorrhaging a direct pulp
cap with a GI liner is applied to help maintain the vitality of the tooth at this point once all
the infected tissue is removed we as Dennis must face the decision of whether to restore this tooth
using a direct or indirect method ultimately we must provide the patient with the best service
possible using the technology and materials we are comfortable with I elect to restore this case with
an indirect ceramic Onley that can be fabricated chairside since it will be an indirect restoration
I modify the preparation so the internal walls are divergent eliminating any undercuts since we
will take a digital impression ideally we want at least half a millimeter separation between
the margins of our prep and the adjacent tooth number two we want to remove any unsupported
enamel along the margins that could compromise the seal of our restoration gingival retraction
is also very important when taking impressions either conventionally or digitally so I place
a size triple zero cord first to help displace the tissues apical e in areas that are really
difficult to access to use a probe to help with the placement to ensure the cord is fully seated
within the sulcus away from the margins of the tooth I then place a size-two core to
help displace the tissue laterally away from the margins after about five minutes we removed the
top cord and spray the contrast agent for the 3m true definition scanner on the teeth in the upper
right quadrant the scanner acquires the data very quickly as I move along the occlusal to lay the
initial foundation of our digital model and then begin to rotate the camera towards the buccal
and lingual to ensure we have all the surfaces digitally impressed after the maxillary scans of
our preparation site are complete I apply contrast agent to the lower right quadrant for the opposing
set of scans I follow a similar scan pattern as the preparation scans to ensure I've included
all the surfaces the third set of scans are quite easy they're taken with the patient biting down
fully in centric to properly align the maxillary and mandibular scans once all of the three scans
are completed our super RDA will Schmidt assists with the completion of the digital prescription he
selects the prep site what type of restoration and where we want this digital impression to
be sent to for this case we are directing it to our in-house lab computer that contains our
fast design software where we're going to design it right here in the operatory and send the file
to our TS 150 chairside mill once it transfers I open the file and begin the design process I
first indicate to the software the occlusal path of insertion direction and next is the placement
of the margin as long as proper tissue management is performed this part is completed very quickly
as the software has an automatic detection where it will seek out the edge of the margin after the
initial placement we have the option to modify the margin by dragging the line to a more desired
position it's important to check the margin from different views to ensure it is position properly
on the next page we indicate to the software the buckle direction so the built-in library
can create the proper alignment for the initial proposal the software does a great job of filling
in the missing areas by restoring the preparation to proper contours we have the freedom to make
modifications to the design using a multitude of tools at our disposal here I'm making a slight
modification to the distal lingual groove area and also the marginal Ridge position using the
freeform tool once the occlusion and proximal contacts and the overall design are completed I
advance to the final page I have the ability to direct the sprue position at this point towards
the in this case the distal lingual area away from the contact area it just helps with the removal of
the sprue once the restoration is milled out for this case we are using an obsidian CAD a1 block in
our t is 150 mil an excellent way to utilize our time while the restoration is milling is
to complete any other direct restorations the patient may need in this instance our patient
has a class 1 lesion on the occlusal of number-18 so we will go ahead and take care of that while
the restoration is in the milling unit after the complete removal of the decay on number 18 that's
verified with caries indicator dye we go on with our standard bonding sequence as with any other
direct restoration after about 10 minutes the ts1 50 has completed the milling cycle for our only
and I am now using a slow-speed lab handpiece to remove the screw on the distal lingual portion of
the restoration it's extremely important to do this while your hands are stabilized to avoid
inadvertently hitting the margins the burr I'm using is actually the same bird that was used in
the Tia's 150 unit to mill out these restorations it seats perfectly into a straight lab handpiece
for obsidian CAD which is a lithium silicate material it must undergo a crystallization
cycle to transform the material to its final high-strength state of 385 mega Pascal's of
flexural strength for the restoration I stabilize it with super peg material which is a high heat
resistant refractory paste it helps to eliminate firing distortion and also any contamination once
the paste is placed on the entire surface of the Onley I seated on a firing tray that's
then placed into our whit mix porcelain oven to expedite the process it's really not necessary
to stain and glaze the restoration after the 20 minute crystallization cycle I choose to polish
the onlay with - ein diamond polishing paste and a soft bristle Robinson brush it doesn't
take much time until a high luster is achieved on these ceramic surface now that the only is
completed we tried in with the aid of the IVA klar opto stick which I highly recommend when
seating these small partial coverage restorations to cement this only I use three M's relax unison
which is a self-adhesive resin cement even though it's not required I selectively etched the enamel
margins with 37% phosphoric acid and also apply an additional bonding agent to the entire preparation
obsidian CAD ceramic must also be pretreated with hydrofluoric acid in a five percent concentration
for ten seconds and then primed with silane once that's done the resin cement can either
be applied to the restoration or directly into the preparation cavity the cement can
be removed immediately with a micro brush after the restoration is placed while it's still in a
low viscous state or after a two second tack cure to accelerate it into a gel state don't
wait too long however otherwise you may end up having to mill the cement off of the tooth using
slow speed rubber polishing wheels I smooth any surface roughness along the margins to ensure a
smooth transition between the Onley and the tooth here I use a aqua brush to provide some additional
polish to the restoration once all the excess cement is removed with only a polished finish
the Obsidian CAD chairside material blends in really well with the patient's natural dentition
it's an amazing time in dentistry where we can provide high quality ceramic restorations for
our patients within a single appointment while offering a tremendous convenience for them and
also creating the opportunity for us as dentists to be more efficient thank you so much for tuning
in for this week's case of the week and we look forward to seeing you back for the next one back
to you Meghan thank you for that dr. Qi now let's explain who this guy is and why you're not in the
operatory and you're sitting here ladies and gentlemen gladwell laboratories very own will
Schmidt our registered dental assistant how you doing I'm doing great Meghan thank you good I'm
glad you're here today to talk with me and because normally when you and I meet I'm in the chair and
I just unfortunately for you yes no I'm glad to not be in that chair and be in this chair but
you're here today because I hear that a doctor wrote in with a question for you correct they
did absolutely that's awesome I love it okay so here we go because it's another segment of viewer
mail so I'm excited I've viewer mail back and in this viewer mail dr. Mao wrote in to will and he
said I just finished watching the video on large cosmetic preparation the doctors are referring to
episode 188 you were talking about your protocol for setting up for large cosmetic cases he goes
on I have questions on the bio temps veneers what is your cement of choice for these biotech veneers
also what is the lab cost for this whole procedure before the final veneer okay I can answer that in
two part first of all whenever I'm cementing a large latent veneer case and that all cases
are going to be all bio ten veneers they could be combinations bridges crowns if I'm going to
do a combination type case where I have crowns veneers bridges I like to use a cement that's
clear usually Templin clear is my cement of choice simply because it's not new gional we all know
that usual cements can sometimes take away the adhering effects or resin cement resin composite
cements we all know that we already knows that especially yeah but I like to use teflon clear for
those combination cases as well as any case that's strictly biotin veneer for regular crown or bridge
cases I'll go ahead and just use a regular tint bond or tint bond non eugenol usually your your
preference however tip line clear works for me the triclosan is also an ingredient in there there's
an antibacterial and antifungal agent which is using things like toothpastes and a lot of other
dental materials as well nice okay so that's great we answered that now what about the the cost for
the lab before the final the final veneer so Global laboratories makes it really easy for
doctors to send in cases and make it affordable for their patients if a doctor is just starting
off with study models our laboratory fees are roughly six dollars for simply an articulated
poured up brown stone study model after that if we start going to custom trays like I mentioned
$22 per arch custom trays for diagnostic wax models $25 per unit on diagnostic wax models
however if you send your case to be fabricated at Glidewell laboratories we provide a 50% discount
on those so $25 units turn into 12 dollar and fifty cent units for your diagnostic wax up for
bio temp whether a bio temp bridge unit than your unit or crown unit $29 per unit so just to give
you a little overview if you're going to do a six unit case from start to finish the way I I put it
out in episode 188 you're looking with bio temps single arch custom tray your D wax and a steady
model about three hundred and fifty dollars you're taking in consideration that $75 discount if you
send the case back to be fabricated you're looking at about two hundred and seventy seven dollars so
what I like to do is when I would present these to the treatment I'm sorry present these treatments
to the patient I don't necessarily like to put everything out in detail so one by one so I
don't like to put diagnostic wax up per tooth one two three four five six and itemize and let the
patient start to look through and and realize that there's so many different things were charging for
and not get overwhelmed I said I like to bundle all these up and make that a certain fee to the
patient can see what they're paying for but make it more of a fee like a diagnostic bundle sure the
bundles always work the bottles work except for in cable yeah that's true but the bundle package
really does happen give a sense to the consumer of a deal and it's the last less questions about
okay well how much did this cost and how much it you know every single little itemized detail in
my experience if you start itemizing things to patients that gives them a chance to say what's
this what's this what's this and even worse can we do without it so instead they know what a tooth is
they know what a crown is and the fee for that you start throwing in little bitty things like
that wax models upper/lower custom trays it's just going to raise a bunch of questions so in
my experience if you're going to present treatment on things like this best to bundle it up find a
way for you to describe to the patient and not let them get overwhelmed well thank you so much
we'll for being here today I really appreciate you coming on to answer this question well thank you
so much for having me Megan yeah any time and if you have a question for Will or any of the doctors
here at chairside live heck even for me yeah sure you can write to us at chairside live at gladwell
dental comm well that about wraps it up for this episode of chairside live on behalf of everyone
here at glial laboratories thank you for watching and I'll meet you right back here next time
you