hello and welcome back to another episode of chair sight live I'm dr. Justin Chi clinical
research associate and a member of the team of practicing dentists here at Glidewell laboratories
Megan strong is on maternity leave so I will be taking over the hosting duties for a while until
she returns for this week's episode dr. ana-maria Mira sean has a great case for us she replaces
failing Pia Femmes with bio temps Kat Provisionals before restoring with Brooks er anterior crowns
and veneers follow along as dr. Muir Shawn explains the benefits of these digitally
fabricated temporaries and how their aesthetics can be transferred to the final restorations
hi everyone thanks for tuning in for my new episode today I'm going to show you my most
favourite step of anaesthetic treatment the temporization step after the clinical part I
will take you behind the scenes here at Gladwell laboratories to show you how the cad/cam bio temps
are fabricated you will see the digital flow from the diagnostic wax up all the way to the final
restorations here is a 48 year old male patient he presented to me with an interest in discussing
cosmetic treatment options in an effort to achieve better aesthetics and a healthier smile micro
leakage is clearly visible at the margins of this all pfm this grows marginal deficiencies resulted
in an extremely unpleasant restorations we can observe the gingival recession that took place
and disrupted the surface smoothness especially around tooth number 10 thus leaving it vulnerable
for plaque accumulation treatment plan was discussed with the patient and the decision was
made to remove all the defective restorations and restore the smile with Broxson anterior veneers
on tooth number 4 6 and 11 and full crowns on maxillary first molar Central's laterals and
left promoters at the same appointment maxillary and mandibular preliminary impressions were taken
along with the shade for the fabrication of the diagnostic cast and biotin CAD Provisionals the
initial shade for the provisional restoration was determined using Vita shade tab and verified with
the Vita ez shade device due to the advances in digital dentistry prior to the preparation
appointment you have the ability to virtually evaluate and approve the future smile that lab
has created digitally at the prep appointment you and the patient can physically look at the
tooth shape size and contour of these teeth before the treatment begins a disappointment a
digital diagnostic wax up can be presented to the patient at no additional charge you can request
the digital diagnostic wax up you approved to come on a printed model or on a white stone model the
white model is the stone replica of the virtually prepped printed model you will also receive an
exact replica of the digitally designed wax app made out of poly methyl methacrylate PMMA to use
as biotech ad provisional if you or the patient would like to see more adjustments to be made
the technician will be able to make all these modifications using the same design file and
transfer these changes to the final restorations our patient loved the wax up and so now we are
ready to start I begin cutting off the crowns by placing a vertical slot onto the labial surface of
the crowns and expand the vertical opening with the Christiansen crown remover upon removal of
the restorations we can see how marginal defect led to micro leakage and secondary decay after
I clean the preparation of debris and leftover cement I like to pack the double zero cord to
ensure that I can drop the margin slightly sub gingival to create a chancre finish line I use a
round and a tapered diamond bur I tried keeping the tip of the bur half way onto the tooth to
avoid the lip formation the unsupported lip of enamel formation here we can see how defective
buildup and secondary caries are removed using a series of ceramic and carbide burs the remaining
tooth structures was desensitized and cleaned with g5 a liner and a base will be applied
then each of them would be cured I used iCal as a cavity liner and I use the Trabant resin-modified
glass ionomer as a base before using the build-up material the preparations were etched with 35%
phosphoric acid rinsed and then bonding material was applied and cured for 20 seconds to rebuild
the remaining tooth structure I use dyke or auto mix it is a dual cure composite and comes in
shades a 2 it is a titanium reinforced composite so the risk of me ditching into the build up
while finishing the prep is reduced because it preps just like the dentin the leaking crown on
the upper right molar was removed the same way making a vertical cut using a steel cut taper
diamond bur due to the amount of marginal leakage I got lucky here the crown came easily using the
Hema step the leftover cement was removed and the tooth was reprimanded premolar was also
removed the remaining tooth structures rebuilt and repaired here I'm finishing the preparations
of the upper left side getting ready for final impressions here are the retraction cords and
camper caps already in place before the final impression to increase the accuracy and feet
of the final restorations on this case I asked the lab to provide me with digital
custom impression trays they were made from the scan model that originated from the preliminary
impressions we took at the initial appointment the 3 millimeter uniform thickness provided very good
rigidity with no flexing and great adaptation full-arch upper impression along with the bite
and an opposing were sent to the lab for the fabrication of Broxson interior restorations
always have a pictures with a shade tab in place so the technician can compare the differences
in chroma and value and make the necessary adjustments like my RDA will Schmitt showed
you in a previous episode use a camera with micro lenses and ring flush to get a closer and a more
detailed photo without having the flash altering the shade note how the temps fit passively with
no interferences most of the times with bottom CAD you will not need the prep guide because
they are designed on a virtual preps they are uniformly hallowed and thin to allow them to
fit over the preps with no resistance prior to realigning a separator medium is applied
over the preps and reliant relaxed attempts by my assistant I want my patients gingival tissue held
around the margins and the popula to be maintained while in temporaries so here you can see we are
getting rid of the realign excess material and opening the interproximal gingival embrasures
to ensure no gingival recession or inflammation will occur during the provisional ization phase
after reevaluating the smile i determined that the height of contour and the incisal edge position
of the right lateral needed some modification a picture was taking after the cementation to
communicate to the tach the changes I would like to see in the final prosthetic outcome
when patient came in for final delivery appointment this is how the bio temp cat looked
like after being in the patient mouth for almost two weeks the potential of this Provisionals
is versatile in that you have the opportunity to evaluate the prosthetic design in the mouth prior
to fabrication of the final prosthesis if there are no alterations needed then these bio temps can
act as a blueprint for the final restorations or they can serve as a prototype to communicate final
changes while maintaining the aesthetic throughout the provisional phase for more tips on how bio
temps CAD are done stay tuned you will get to see it at the end of this clinical presentation here
is at the final delivery appointment removing the temporaries cleaning the preps and getting
ready to try in the final restorations each of the restorations were checked for feet margins
in the proximal and occlusal contacts I always clean and desensitize the preps with g5 prior
to cementation for this case I chose dual cure video link aesthetics as my adhesive cement it
has a total edge option and because it's a hundred percent amine free it has a good shade stability
I found this very reliable when cementing the restorations in the aesthetic zone this will
ensure no shade changes over time especially for anterior crowns because centrioles and laterals
will be cemented at the same time I used teflon tape for isolations to help with cleaning off the
excess cement here we are using co jet to treat the integral surface of a veneer this gorgeous
spray is made of 30 micron silica coated alumina particles when these particles collide with the
hard Secunia surface the high energy of the impact will partially melt the silica onto the zirconia
surface is this transfer of silica from the particles to the target surface in our case
zirconia that researched calls tribal chemistry for more details on this effective technique you
can watch Ursa live episode 185 after cleaning the restoration with IVA clean saline is applied
to the silica coated intaglio surface so mono blonde plus will chemically bond to the silica
coated surface on one side and to the Vario link on the other side creating an adhesive bond here
I'm sitting both crowns 8 & 9 with finger pressure clean off most of the excess then I cure both
restorations from buccal and lingual I always place veneers with light finger pressure then
use wooden sticks as I'm curing after ensuring all excess cement is removed and floss passes
easily through the interproximal spaces I am moving back and get ready to cement the last
set of restorations the first right molar and the left first and second premolars will receive
full contour brush the interior cramps even though Brock's our interior solid zirconia was formulated
to satisfy highly demanded aesthetic areas its flexural strength of a six hundred and fifty
mega Pascal's allows it to be used also on the posteriors as long as adequate occlusal reduction
is provided it needs at least one point five millimeters the patient was instructed to bike
down gently on an art articulating paper occlusion marks were evaluated and very selectively minimal
adjusting was needed because varial Inc is a composite loading cement it is subject
to oxygen inhibition here I'm applying the liquid strip to all margins and cure truly then flush it
out with water to provide better protection at the marginal interface a layer of fluoride varnish was
applied around all margins as a long-term caries prophylaxis with this innovative CAD CAM processed
Provisionals i was able to take aesthetic informed decisions and successfully transform the patient
smile it is now time to take you behind the scenes here at glider laboratories and show you the path
we took to get to this successful smile makeover it began with impressions and ended with digitally
fabricated zirconia crowns the digital workflow can also begin with an intraoral scan of the
maxillary and mandibular arch but for this case I send the lab the preliminary impressions to
fabricate the models we can see the technician here is using a three shaped scanner to first
scan the upper arch then the lower arch then both models articulated because the initial
scan is rough he is using a selection tool to select the scan area that needs more details
this selected area will appear highlighted in red once he finishes the scan he ensures that
the occlusal plane direction is correct and utilized the color scale to make sure occlusal
stays in the Green Zone then the virtual margin line is created following the gingival gum line
and shortened interproximal this will give more room and allows the bio temps to sit easily with
no interferences now he can chooses a number for the amount of reduction of the selected teeth once
the number is chosen the computer will prep same amount of reduction in all directions this virtual
prepped model will have far less reduction than the clinical preparations ensuring a passive feed
of the by attempts over the clinical preps after he's done building the virtual model he can start
the design on these virtual preps he can move rotate resize and realign these outer proposals
and get the teeth into a nice alignment once the design is finished at this point it can be used
as a valuable tool to pre-visualize the cosmetic changes this digitally generated diagnostic whacks
up eliminates guesswork and allows for the doctor acceptance ensuring a predictable result to the
scan and save services at Lyda laboratories the same design digital file can be recalled and used
when milling the final restoration if the doctor does not require any further adjustment once you
approve the design this digital information is and then transferred to the mill at this point it
can be mailed from a wax block to get the digital wax up or it can be milled from a multi-layer PMMA
pack to obtain the bottom cad here the technician is nesting the unit and finding a proper area to
apply the sprues the wax POC is then positioned into the mill then the milling process starts
after the process is finished we will have a wax unit of the pre-approved design this is then sent
to the technician to disprove and seal it on the model here the initial digital design file is sent
to the machine to mill the exact wax replica in PMMA to serve as biotin CAD the full provisional
unit made of this multi-layer PMMA offers more strength than my temporaries fabricated chairside
after technician we cut and smooth out the sprues the biotin CAD is then stained and glazed to add
more characterizations needed to provide the patients with a confident smile while waiting
for the permanent restorations this is prior to milling the blocks of zirconia final restorations
for a case like mine where adjustments were made you will see the CAD file being updated by the
technicians with all necessary modifications prior to milling of the final restorations
it is here where the technicians recalls the initial CAD file overlaps the initial designs
onto the scanned model obtained from the final impressions and makes the requested modifications
this information is then scan and saved and sent to the browser mill the Broxson interior
crowns are milled as single units from a Broxson interior zirconia puck then the technician will
clean and pre color each unit before sintering the crowns are then placed into a sintering tray
over zirconia beads this tray is then placed into the oven the tiny beads will protect the margin
integrity of the crowns while they are shrinking during the sintering process the aesthetic of this
Broxson interior rounds are enhanced by staining and glazing which are then baked in the oven the
result of all these restorations was excellent as you can see here being evaluated by our very
talented dental technician to summarize here you can see the final products of this digital flow
the wax unit the PMMA unit and the glazed bio temp unit you can request to receive the bio
temp as one unit or splinted in two separate pieces you can see here the final crowns that
can compete aesthetically with any old ceramic material in the mouth they blend completely with
the surrounding natural dentition thanks for watching thank you dr. Mira Sean on behalf of
everyone here at the lab thanks for watching chair aside live and we'll see you back here next time
you