Another Thread on Anterior Translucency
There are many threads always going on asking "what block should I use". I will tell you first off, this is almost impossible to answer just by looking at a picture. Ross Enfinger has a really nice thread on this as well.
Just one quick case that will basically give you my theory on anterior teeth cosmetics.
In short:
- Always use the most translucent block that will get the job done
- All the natural value, translucency, and opalescence is in the enamel... so if you remove all the enamel, your job is going to be more difficult making the teeth look natural.
- Always as conservative as possible. That is, Veneers always before Crowns if that is appropriate. Veneers are hard, but crowns are much more destructive to the tooth. The more you prep the tooth, the biomechanics change quite a bit and it weakens it dramatically.
- Don't forget composite. After sitting through part of the Spear Composite course last week, I was reminded that we should use composite more in the anterior than most of us do.
Here is a case:
Woman in her 50's came to my office for a consultation on her anterior teeth. She had a pretty nice fracture in #9 and #8 was chipped on the incisal edge. Both teeth had a fair amount of erosion on the facial as well.
We talked about 2 options really: Composite and Veneers. She really had done some research on this already and visited a couple dentist with varying opinions (some to crown the front 6 even) and knew she wanted veneers. I was personally relieved because I didn't want her to choose composite because then I was going to have to execute it :)
After we decided on veneers on 8 and 9 I had to get an idea of what material to use. She has a lot of translucency, so my choice was either e.max HT OR Vita/Vita Trilux... I wasn't sure quite yet. I was concerned about the wear on the teeth, but I also knew that Vita was going to be easier. Either way, I knew if I was going to control translucency and value, I needed to control prep. With her facial erosion, it would be easy to over reduce and increase the material thickness (thus decreasing the value).
So the next thing we do is a quick composite mockup:
From here we can do our proper depth reductions using the Winter Reduction Burs from the Restorative Design Kit and get conservative Veneer preparations:
In the end, I chose Vita Feldspathic veneers on her and protected them with a night guard. You also could have used e.max HT I feel and got a great result as well.
Hopefully this helps and spurs some additional thinking. Also read Ross's thread. I will try and link to it.
Great result, the patient must be ecstatic. What are her thoughts about dealing with the other visible cervical erosions?
For now Gary we are going to leave them and have her not brush her teeth like she is actively trying to remove enamel ;)
I have the same problem on my own teeth actually. I blame my childhood dentist who told me that I have gingivitis and my teeth were going to fall out. From then on I brushed my teeth very aggressively
Here's Trilux with no staining. We have a subtle translucency change which this patient was very happy with. Just finished this case a few minutes ago.
Forgot to use the black background darn it
Mike, where can I find this restorative design kit? Curious to compare it to what I use. Thanks.
Mike I was going to ask... Why crowns on the two centrals? were they cracked? Also, male or female patient?
Great explanation of what you do Mike! I know we have spoke at length about it but always good to hear again. Do you have an Incisal photo of your preps. I think that would be of value.
Before level 4 and talking to you and Sam, the traditional veneer preps are hard to do with CEREC. As you know, you can prep and overlay the lingual aspect but if you call it a veneer, there is a chance that the lingual margin won't seat down completely because of how the CEREC mills in veneer mode. On the flip side you can call them crowns but you then again have the issue of overmill. So frankly, I would say many CEREC users do crowns because it is easier. Just my two cents because I know I have run into these issues when I first started doing anteriors with CEREC
Mike,
love seeing your restorations. I have learned so much from your presentations on here and at Scottsdale, thanks. Do you have a picture to see what your preps look like from the lingual?
Skramy why prep the Interproximal? Was there restorations?
Great result I'm just curious as to the reasoning.
Also why Emax HT? I agree when. Replacing enamel with minimal prep HT's are the best if you need the strength. Why not vita or empress?
Darin I did use Vita, you must have read it wrong;)
IMO you really have to break contact with veneers using CEREC to get the best result. By not doing so, it's really tough with the contours.
On 9/1/2016 at 5:38 pm, Darin O'Bryan (Faculty) said... Skramy why prep the Interproximal? Was there restorations? Great result I'm just curious as to the reasoning.
Darin,
Can you show us some cases without prepping into the interproximal with CEREC? I've tried and it just didn't work out so instead of seating the veneers, I went back and broke contacts, and re-designed from there
Skramy I read the part about you could have used Emax HT and that must have stuck in my head.
Dan
I'll post a case when I get home.
Or you can look in the CDocs magazine. It was in the previous issue. Not the one that just came out the one before.
Looks like some subtle staining or is that just polished?
Really nice work Mike.
You are able to access your Cerec at home? Is that through splashtop?
Darin, thanks! Reading the article now. Sorry I didn't read your article, there was another doc that got featured in that issue that I got distracted by :)
Jeff-
I have my CEREC AC database linked via both Hightail and Dropbox... So I can access all the cases even from my phone. That being said, I cannot find this case. Go figure ;) I will keep looking. If I cannot find it. I have other images I can post from the lingual that are similar. Will do tomorrow
And sorry... Yes the case is stained and glazed... Then polished to match adjacent teeth luster
Here are the photos of a case that I did not break contact.
To help with imaging and getting a definitive margin I use a finishing strip to smooth the jagged edge of the enamel. A profin handpiece also works, I am just cheap.
I agree with Skramy that most of the time we need to break contact. Usually there are restorations, spacing issues and/or emergence issues that need to be addressed and breaking the contact is the only way to get good control of them. But there are some cases that it is not necessary to break contact and you can still get a very good result.
Great post. Thank you for all the great photos. Mike's veneers look awesome, I would like to see how he stained them.
Carrie
