Preoperative Optical Scanning. Just a few thoughts....

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Posted on By richard martin In Digital Scanning & CAD/CAM

After following Dr Pohls case I was inspired to post- Yes it's been a while ! Here are a few pictures somewhat of a hodgepodge of cases but I think one of the things that scanning allows us to do is think about the different ways we want to provisionalize certain teeth- In utilizing bonded provisionals the occlusion is very important and so not for every case. I don't know if a three tooth bonded provisional would work but there's a possibility it can hold with some type of fiber reinforcement. I have a case this week where I am attempting 4 tooth milled reinforced that I will post at least the design if can't get it to work- and so I'll keep you posted!

Extraction site - case scanned prior to removal
Scan showing design of provisional prior to removal

Note size of connectors- important for stability & occlusion
Complete design in 3shape if you decide on guided


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23 Comments

These wings are large must pay close attention to occlusion
Couple weeks post-adjustments can be made to open up contacts to allow papilla fill


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Around 6 weeks- contacts adjusted
Similar case - immed bond


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All Pontic's are ovate and the beauty of this technique is that you are able to adjust the provisional -you can even rescan it as it is in the mouth redesign and replace > I have not I have done this and have not really seen any Ill effects on the tissue

Cheers,

Richard

2 weeks


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Richard....nice. Are you designing and PRINTING these in your office? How long is the process...turn around time. What are you bonding with? What happens if he occlusion does not allow for space for lingual wings and bonding? regards Mo


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Maurice
all great questions I do a bit of the design myself but I found that it is much faster and much more efficient if you allow your lab to do it I and again it depends on whether or not the tooth is missing if the tooth is missing you can intraoral scan and send straight to the lab if the tooth is not missing you have to scan and then go into implant studio through 3 shape extract the tooth virtuallyand then send. You can also take a stone model knock off the tooth scan W trios and send it to them that way. (my lab is in the building next to me- no I don't own it) depending on what scanner I use- the trios scan sending through three shape communicate goes straight to the lab ( to my understanding no matter what system is used once it gets to the lab they pretty much use three shape Design programs )so they are able to start the design right away whereas with Itero it goes to align first and then back to your lab ( you may be able to export straight to your lab through an STL portal) the E4 D system works well too if some folks have that scanner that goes straight to the lab also I believe. As far as printing, we are still milling these because I like to make out of Emax which I believe gives me a better choice in matching the natural teeth and the strength is good in that I have very few Breaking of the wings. You can also mill in acrylic but in my experience when I did this and I had to remove one of the wings would break. We typically cement these with relyx and although it may seem strong to you it does pop right off. with printing I'm wondering how strong it would be and if possible that is my next foray. As far as occlusion, you can make these very narrow and change the width of the wings or possibly move the connectors down as apical as possible. Yes it is occlusion sensitive - as I am sitting here typing my lab just called about a patient with a deep bite - not enough room for thickness of wings- so with have to use transitional partial. However it is is a great option when immediate load or at essix is not desirable

Cheers,

Richard


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Richard
With deep bite you can put wings on facial like no-prep veneers.
Pk


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Richard,
I really appreciate your generous sharing. It is like private lessons...just great.
Here one of my last cases done in traditional way. Yes, acrylic breaks often and I am looking forward to apply everything you are teaching us.
Just one thing - Maryland bridges are shown to be more resistent to fracture if there is just one wing.
Best regards to only one who is not going to be in Madrid :(
Snjezana


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I agree with one wing. Gregory


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Snjezana

Yes I have read that - I think acrylic is more fragile and that's why I like EMax - if it pops off the wings"usually" will not break- so you can re bond

Maurice- I was thinking about some other tricks I have used if occlusion is tight- you can mill or print in acrylic- cut a slot or actually design a slot in it for a wire and bond with composite- also you can flow composite Interprox

As promised here is a printed model that initially had all the teeth - fibercore matrix was placed around pre molars - old school putty matrix was done and the teeth extracted on model and composite used to make teeth ( existing bridge from 6- 10 large defect- 6 non restorable) - will perform large graft for vertical and horizontal gain and do not want transitional prosthesis if can be avoided- wings are long so that I can adjust if needed

As Maurice and Eddie well know I have a tooth practice that keeps me busy especially this time of year but maybe plan Madrid for next year in combo with a vacation -

Cheers,

Richard

Printed model after manual removal of teeth
Model with provisional in place


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Note length of wings- this is "Airbus" size

Cerivical margins will adjusted at time of surgery


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Good technique, Richard...are you altering the mandibular teeth to give you more occlusal room? And finally, what type ceramic did you use?


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Dr Goldstein!

Typically as an OMS I "try" not to adjust if can avoid but at times I do ask my restorative colleagues to do that for me if you get my gist

I like EMax- lithium disilicate - due to bondability to nat teeth and crowns unlike zirconia to my knowledge without prepping tooth

This technique works beautifully in the mandible usually no interference and keep the facial beveled-

I will post a new project that I am working on for posterior teeth - where you can easily keep out of occlusion


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Hi Richard;
Nice to see you posting (as per your promise. lol)
My preference in these situations is one tooth abutment and direct bonding of a custom designed pontic in the mouth. Quick, easy, predictable and if you need to cut it to take the impression, it is easy to rebond it back into place.
Regards,
gerald


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Hi Gerald,

Took a few months! These Pontics are custom designed for the cases I showed earlier and are bonded in the mouth at time of surgery. And yes to take impression just pop out

Cheers,

Richard


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Nice Richard ! Like the adding of technology !!! Miguel


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Thx Miguel !

Was great to meet you !

THX

Richard


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Richard, have you used some of the new translucent Zirconia? It is looking really nice.


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Dr Goldstein,

I do know about the translucents but in these cases as temps would not be applicable.

Cheers,

Richard


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Richard, I am impressed with the few cases we have done with translucent Zirconia...At least it provides an alternative to patients who really need extra posterior support but do not want metal in their treatment plan.


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Dear forum,

To answer the question of "tight" occlusion - one wing works


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EMax X wing
Note articulation- if wing was on central would not fit


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Hi Richard
Those provionals we always tought will be so easy to manage, but having a secure , fixed , are a important part of the treatment , to maintain the papilas, without inflamation, and not change the natural proximal teeth contact point its always a task.


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