for this case the patient presents with existing pfm restorations on tooth numbers eight and nine
you can see the classic pfm appearance especially in the anterior where the restorations and soft
tissue have quite a bit of a gray appearance having been endodontically treated the exposed
dark tooth structure also lends to the poor aesthetics of these teeth the contours could
also be improved so we do want to enhance this patient's aesthetic situation with some
new restorations and there's also another reason why we do want to replace these as you can see in
the radiograph a periapical radiolucency on number eight we will refer this patient to an endodontist
for the retreatment before that happens we are going to make things easier for the endodontist
to perform their retreatment by removing the old restorations and provisionalize the teeth
dr manolilly is going to begin the treatment by removing the pfm restorations here in this
first appointment she's making a vertical cut through the facial aspect of both eight and nine
starting off with a fine grit diamond burr she likes using a diamond bur to cut through the
feldspathic porcelain to the metal substructure and then changes to a carbide 557 burr
to finish off through the metal aspect of these restorations which typically a carbide burr cuts
through metal substructure relatively quickly typically i just go straight to a 557 myself
but that's what's kind of cool about dentistry everyone has their own way to get from a to b
cutting through the pfms has actually become one of my favorite things because you can kind of
zip through those old crowns because it's a lot more obvious once you make it through the metal
and see the tooth structure you still need to be careful though because the transitions can
come very quickly once the crowns are removed she switches back to a round in tapered diamond in 856
018 bur to smooth and refine the prep to establish a nice chamfered margin here she's packing a
size zero cord down into the sulcus and that helps drop the gingival margins apically a bit
so she can further reduce those gingival margins on the preps for a better aesthetic outcome
for the future restorations at this point she's preparing for the digital impression
here she removes the cords and as the cord should provide a good amount of tissue deflection
to expose those margins she's taken the case through the glidewell dot io in office solution
to fabricate biotim's now provisional restorations temps are a long lasting pmma acrylic material
that mills out very quickly with each of these restorations milling out in less than 10 minutes
this is the quickest way to get a perfect fitting restoration in a very short amount of time
once the restorations are milled out you can achieve a very nice finish on
these restorations using a chair side composite polishing system in this case dr manulili uses
the venus super polishing kit to achieve a nice smooth surface and a great luster
on these provisional restorations these bio temps are now temporarily cemented using temp bond clear
as you can see the excess clear cement is extruded beyond the margins this cement does have a light
activation component to it so with a few seconds of light curing the cement accelerates into
the gel phase making cleanup a breeze this is one of my favorite cements to clean up
as you can see how easily it is to separate off the margins in a very nice solid piece and with
the floss knot you can see how effectively the inner proximal areas can be cleared out
now on to our second appointment the patient has now received their endodontic retreatment and we
will remove these bio temps now restorations and see what we will need to do to finalize the preps
i'm using an round in tapered diamond to remove the irm from the access cavity on number eight
carefully making my way down to the protective barrier left by the endodontist after i pop the
cotton pellet out i use a slow speed round carbide to gently remove any remaining irm
and sealer from the access channel to prep for the fiber post i'll etch the area with 37 phosphoric
acid for 10 seconds rinse and dry and then scrub 3ms scotch bond universal into the tooth structure
as i will bond the posts with 3m's adhesive resin cement relyx ultimate after suctioning the excess
and air thinning the adhesive we light cure for 10 seconds a thin layer of adhesive is also applied
to the post and cured cement is applied to both the canal and the post and seat it slowly to
help minimize the risk of bubbles the post i'm using is coleteen's parapost taper lux
the tapered nature fits really well into the canal space with good retentive features
once it's seated i'm applying apical pressure while we fully cure the top for 20 seconds
whatever cement you use make sure it's a self or dual cure so that the deeper areas set properly
for the rest of the buildup i'm using the rest of my discontinued camouflage flowable composite
flowable works well and has good mechanical properties
but dedicated build up materials are going to be cheaper for these purposes
once the composite is dropped into place i use an explorer to pop air bubbles that form and
to tease the material into place so there's a nice transition to the tooth now it's back to
the round in taper diamond to eliminate the top of the post and refine the preps you can see here
i'm dropping the mesial margin apically so we can establish a better emergence profile of the
final restorations if you recall there was quite a large black triangle between the previous crowns
anytime you want to close a space or minimize black triangles a more apical margin position
can assist you and the lab to create a better emergence for those restorations if the margins
are set too high any attempt to accomplish the closure will be more of a ridge lap
which can have an undesirable appearance in these aesthetic areas so initially i wasn't
planning on redoing the build up on number nine but i noticed some voids during the
prep refinement so now i'm removing as much of the buildup without disturbing the post
i switched to a flame shaped diamond to carefully remove material between the post
and tooth structure and as you'd expect the post loses retention and is now removed
now i'll repeat the same fiber post process as i did on number eight first establishing enough
width and depth of at least about two thirds down the osseous root length to accommodate the post
now we etch bond and using relyx ultimate once again after the preps are refined
i like using a composite polisher to help smooth and round over any sharp line angles
this will help create a much better adaptation for today's digitally fabricated all ceramic materials
to ensure we can visualize our prep margins i'm seating a humidity soaked size 1 ultra pack
knitted cord down into the sulcus this is really important for equi-gingival and sub-gingival
margins to help provide good tissue retraction while that cord is seated we begin our digital
impressions sequence by first scanning the lower arch with the itaro element 2 slowly sweeping the
wand along the occlusal incisal lingual and facial surfaces to build the digital model
next i remove the cord from the preps dry the area really well and begin scanning the upper
arch following a similar scanning pattern with digital impressions it's important to follow the
pattern that maximizes the scanner's acquisition ability and also to evaluate the digital model as
its building to ensure the critical areas for restorative accuracy and precision are filled
in so basically for the prep side i'm double checking to make sure all of the preps margins
contact surfaces of the adjacent teeth and most of the neighboring dentition are captured properly
and when i say margins really ensure there was proper tissue retraction provided and that you
can see where you basically stop prepping on the teeth if you can't see it the lab can't see it
the beauty with digital is you have this opportunity to go back
and improve any aspect of your prep on the patient and make edits to your impression straight away
once the upper lower and byte are captured the digital file is open on my chair side
fast design workstation the first step of any design is identifying the margin position the ease
of this step is entirely dependent on how well you prep and expose the margins on the patient this
dark model that i just activated is actually the pre-treatment scan of the bio-temp provisionals
before we remove them since those represented a good midline and incisal edge position
i wanted to re-establish these aspects for the new design the software is able to copy and paste the
contours of the pre-treatment model for the new designs once the copy is made we can evaluate the
overall contours and relationship of the design with the adjacent teeth and opposing dentition
with the popularity of the fully centered bruxer now material in the posterior glidewell has now
expanded chairside solid zirconia to the anterior with bruxer aesthetic now which
has improved translucency for restorations in the aesthetic zone and it's still incredibly durable
at over 900 megapascal of flexural strength here you can see the cylindrical shape of the bruxer
aesthetic now block to maximize efficiency for milling this fully centered material
after the designs are sent to the fast mill it's easy to seat and tighten the blocks
into place each block also comes with a single use diamond burn once the job starts the fully
electric fast mill takes over there is lots of water spray during the milling to ensure the bur
and the materials are kept cool after 45 minutes our completed crown is now removed from the mill
the mill as you can see thins out the sprue connection and it makes it real easy to separate
from the mandrel once i snap the crown at the sprue i'm using the long tapered diamond from
the bruxer adjustment and polishing kit to finish the residual sprue area down any fine
grit diamond burr can also work well after a quick try in to check the fit and the contacts
i continue polishing with the polishing wheels from the bruxer adjustment and polishing kit here
i'm using the brown disk polisher to pre-polish and remove any fine surface scratches and then
we move on to the blue disk for a nice high shine since i'm planning to bond these restorations in
we air braid the antaglio with 50 micron aluminum oxide using this danville chair side micro etcher
this will help create a rough and internal surface to improve the bond and it also removes any
salivary contaminants that may be on the crowns from the try-in if you're using restorations from
the lab an alternative to air abrasion to remove contaminants are these special zirconia cleaners
such as avaclar's ivaclean here our rda will is demonstrating how to use this
we place a drop of the material inside and scrub for 20 seconds and then you rinse and dry
you now have a clean surface to bond to since we're bonding we now place avaklar's monobond plus
which has the right phosphate monomers to prime zirconia this is applied on the entire internal
surface and the margins and allowed to react for a minute it will typically air dry on its own now
to cement these in i'm using the same adhesive resin we used to lock those fiber posts in place
3ms relyx ultimate since it's an adhesive cement their adhesive scotchbond universal
is applied on the preps and air thinned you have the option to light cure or not light cure
if you plan to cure really make sure you thin the material down to avoid pulling which could
interfere with the complete seating of your restorations with the cement load in the crowns
i seat each down slowly onto the preps since this is a dual cure resin it will eventually fully set
on its own but i like to tack here for about two to three seconds to reach a gel phase where we can
begin picking off the excess now looking at the removal it's a a hair past the ideal gel phase for
easier removal a little more force on my scaler is needed to remove the excess but it isn't too bad
every cement curing light distance position even its power will be slightly different if
you haven't found that perfect gel state start low and gradually work your way up in time i've
got a prosthodontist friend that actually prefers fully curing before cleaning the excess and that
works for him i guess there's something good knowing the restorations aren't going anywhere
but for myself i just find it way less traumatic for the patient if i can take most of the cement
off while it's soft after the bulk is removed from the facial the lingual and interproximal areas
we do a full light cure just to make sure things are set right the research has shown mechanical
properties of dual cure resins are better when cured with a light all right we're almost home
free we're now checking along the margins and in our proximal areas to remove any last bits of
remaining cement and then check the occlusion and make any necessary adjustments let's take a look
at this final transformation from pfms to these in in-office fabricated bruxer aesthetic crowns
take note of the soft tissue appearance with light transmission increase from virtually zero with the
pfms the tissue looks much nicer and healthier despite this being monolithic zirconia the
translucency has now reached levels on par with natural dentition i was honestly a bit skeptical
about using a material straight from the mill to the patient in these anterior situations but i was
pleasantly surprised at how nicely these restorations blended in with the rest of
her natural dentition i continue to be amazed at what we're able to accomplish with this robust
versatile chairside cad cam system the future is here folks this is the easiest way to take control
of single unit fabrication in your practice and also for putting smiles on our patients faces
because really at the end of the day that's why we do what we do on behalf of everyone at
glidewall thank you for your time are you enjoying this instructional video i hope so if you'd like
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