Smile Makeover - 1 appointment! CEREC Primescan complete hands on design of 8 crowns

Okay, so we just finished some scanning. I am gonna trim off all this extraneous data. I'd like to make sure the computer has as much free thinking space as is possible. I'm gonna cut off all that junk. I found in the past that that extraneous stuff really slows the computer down. Now we'll go down here. Let's do the same here. Trim all this stuff off. So incidentally, this is a patient who we're working on ten not ten, eight crowns slash veneers. She came in the office wanting to do a smile makeover and it talked about doing a bunch of lower anterior teeth. Her lower front teeth are barely visible when she smiles and so I discussed with her. Let's do some whitening. Let's try the upper front ones and see if generally she's happy with the outcome. We can always do more later. I didn't want to push her into doing upper and lower. I tend to hate doing lower anterior crowns and veneers. There's some docs that really do it well and I have good outcomes and stuff. I just don't it's not something I like to do if I can avoid it. So all right, let's get save if I can find it. I'm gonna go to next. The computer to calculate for us. So I always like to try to save in between steps. The reason for that is self-preservation. One of the things we run across is the machine sometimes we will lose data. It'll crash and if you haven't saved anything that's unsaved there's the potential to lose it. Now previously this case actually crashed but I had saved it so it was not a big deal. The software froze. We had to force close it and so it took us back to where we are now. I'd actually marginated everything. So we're taking a little more caution here moving forward as the computer creates these models for us. So, let me walk you through my prep process. Generally after anesthesia, I'll go ahead and start with an 8-5-6-0-1-6 burr not the L but a regular 8-5-6-0-1-6 and I'll prep and I'll do the bulk reduction. I use that burr for everything except the lingual of anteriors. Usually I'll use an egg-shaped coarse burr diamond to do that. Then I'll finish with an 8-5-6-0-2-5-L. It's a big giant barrel shaped burr with a rounded tip to kind of soften all the line angles and smooth and round everything just to make sure that I've got everything cleared and even and smooth. Hopefully, you know as this proposes for us, you'll be able to see some of my preps pretty clearly. Okay, so we've got a decent number. We've got several teeth here that are prepared. Looks okay. Computer's still processing a little bit. All right. So what I'm going to do is going to go through and I'm just going to go ahead and do some margin updates. So even though the computer's proposed it, that doesn't mean it's where it should be. So I will almost always go back even when we get a decent proposal almost always and update these margins. And what I was trained way back when is that if you're ever in doubt of your margin, of course, you want a clear margin. But if you're ever in doubt of your margin, you always want to be a little wide and a little outside rather than a little inside. So bear that in mind, you know, use it for what it's worth. I'm not talking about a millimeter outside. If you're ever in doubt, it's better to have to burnish your margin back just like we did with gold than it is to cut the tooth back. Unless that's a better situation. So, you know, really just depends on what what you're doing and when and where. So you can see those, you know, fairly smooth and rounded margins. We've got a little bit of undercut here that the computer will calculate away for us. It does a good job of not filling in undercuts, meaning not binding your crowns in. So one thing I am going to do is I'm going to save at a couple of different steps. I don't want to have the computer thinking too hard. So, let's see. I try to save every couple of teeth just so we don't freeze the computer again. Good. So number seven. Now you notice there are only five listed here. The other three are hidden. I don't necessarily have a rhyme or reason to where I start my marginating. I just start somewhere. Some people are real specific about starting on the distal lingual or something. You know, I don't. I just find a place and start. And you'll see a double-clicking to start and double-clicking to stop. You can rotate by pressing and holding instead of clicking. And then the nice thing about this touch screen, touch pad, is you use two fingers and you can pan. One finger, if you press and hold here, you can rotate and then you can pinch to zoom. So that's pretty cool. All right, let's go to number eight. Zoom in. Start. Again, I don't have a particular location. I'm going to switch to manual. I don't like to use magnetic unless all my margins are supra-gingible, in which case it makes it lightning quick. But if anything's sub-gingible, I almost always use this manual mode to outline. And again, when in doubt, take it a little outside. You're not going to harm anything by having to burnish your margin back ever so slightly. You'll notice my preparations are pretty much equi-gingible or slightly sub-gingible. This one I don't like. I don't want to have a knife-edge margin. So I'm going to bring that one back just a little bit. Try to avoid, if you can, sharp junctions, you know, sharp angles in your margins as much as you can. All right, let's go ahead and save here again. I'm just going to save every couple of teeth to make sure it downloads all that data because the more edits we do, all that builds up in the memory of the computer and there's some potential for it to overload. Okay, so I don't see nine here. So we're going to go right here, and there's nine. We'll start here. Go back to manual mode. Now, the computer has been giving me really great proposals. For most posterior teeth, I have to do almost no editing. Now, this is software 5.1.3, just updated a couple of days ago. Aside from the challenges I've had today with a couple of freezings and crashes on this large, large case, I have had no issues. Now, 5.1.2, we had some challenges with communication between our prime mill and this prime scan. The MCXL, we didn't have any issues with, I don't think. And the prime scan, just this guy. Okay, let's go to 10. So 10, the computer attempted a margin there. If you're comfortable with the way they look, you can always leave them. I tend to like my margins a little bit wider than what the computer likes. So, I almost always edit these guys. Almost always. Not always, but almost always. And I think I mentioned earlier, my favorite thing, one of my favorite things about the prime scan, aside from the camera, which is mind-blowing, is the touchpad here. Trackpad. It's great because you can do all these multi finger gestures. The computer will cooperate. I'm going to save again here. But that's also the thing that I like the least about the prime scan, is the trackpad, because I'm so used to having that trackball. All right, so number 11, where did you go? There you are. I'm going to put that on manual mode up there. Pinch to zoom is a lot of fun, kind of like on your iPad. Your iPhone or whatever other device you use. Let's amend 12. I'll save one more time, and we'll see if it'll operate with us moving forward to the next step. Don't forget, you can always go back. You can either go over your margin again, or you can right-click and undo the margin you just applied, the little snippet of margin you just applied. And also, realizing one other thing, you know, this tooth is actually eight millimeters, or whatever it is. And here it's, you know, eight inches, bigger. So some of these little minute adjustments that we make are not going to be visible, or even functional in the mouth. So, saving one last time, and we'll go back to a full view here. I think these margins are pretty decent, nice and smooth. You know, we always, as Dennis knows, beat ourselves up sometimes for over-reducing. But, we have to do some sort of reducing if we're going to have a good outcome. This is what I am comfortable with, our dress tradition. So, let's go ahead and get some proposals here. Let's see what it'll do for us. Oh, we got a lot of red. Looks like we're going to need to do some editing. Let's turn on the lower jaw. That's not going to work. Okay, so she has kind of an interesting bite. Let's turn on her biocopy, so you can see where she was before. Boop. So, we're obviously going to be moving these teeth a little bit, right? All right, let's pull these guys back. She doesn't want worse teeth, probably. One of the things that I usually do when I'm using this particular tool, is I turn this off. I don't like to keep those contacts. You can see that's my prep showing through. All right, let's do this. Let me turn off the lowers. Copy just to get an incisal edge location and distance. Move this around. Bring that down. I want to replicate her incisal edge. Contacts, I really don't like that. I almost never do that, unless it's in posterior. Let's go down. Okay. Jokingly, I suggested that they give us, you know, a joystick. That's what we're designing these restorations. That would, for some of us, be so much easier. Okay, now I have the anterior set up. I know the height. I can turn off that biocopy. We can go in and we can push all these up. And I could group them all together, but I'm going to move them up. And you'll notice, I think, when I select that, keep contacts, it'll remember that for the next time I activate that tool on that tooth. And I'm being real careful once I click on a tooth and activate it to go around the other teeth, because, you know, it'll switch teeth back and forth. But yeah, so right now, as I try to teach when I'm training, always start big to small. I want to get the tooth in the right position. Once it's positioned right, then we can do the nuance editing. We really don't want to start with our our nuance editing, as I like to call it, first. Some people will go in and start editing everything. You know, changing the incisal edges and the embrasures and the rounding everything and this and that. But the problem with that is we'll end up with a significant challenge to our positioning, if you start last, with a positioning last. So always start with the positioning first. All right, we're going to rotate this guy so it's a little more ideal. I might have to sacrifice the lower tooth ever so slightly to give her a good cosmetic outcome. Yep, that lower canine is going to have to come down a little bit. So what I'm trying to do is kind of get them all in an initial interim position. Interim. Now we're going to go back once we get the front six aligned in a way that we like cosmetically and do some finishing touches. But we've got to get them aligned first. If they're not lined up, let's turn on our biocopy to see how we're doing height-wise. All right, that's where we're going. So we're going to have some collisions here that I'm going to need to correct a little bit by adjusting those lower teeth if we're going to end up with a good cosmetic result. So let's turn that lower off. Hold those up just a smidge. Rotate it in the right orientation. Okay, we've got a fairly round curve here. I'm going to pull this guy out. He's sitting in a little bit too far. Let's change our contacts off. Slide that guy out. I want to make sure that as you look down that buccal corridor, we've got a little lumpiness we've got to fix there. As you look down that buccal corridor, that tooth fits. I could adjust the occlusion a smidge there too. She's got a unique little cross-bite situation that we're going to let there. All right, so let's go ahead. We've got some general positioning that we like. I'm going to hit save and I apologize. I'm covering here with my hand because I want to avoid having to edit too much in post-production. Editing out the patient's name and date of birth that sits there on the upper left. That's what my post-it note is for to cover that. I do find value though in being able to see the screen and what's happening down here. That's one of the reasons I like to periodically throw up one of these videos with the hands visible. Okay, so let's start with my circular shape tool. This is the one I do like 90% of my editing with. Anatomic shape tool is great. I find I have a little more control with the circular shape tool. So what I'm doing now is I'm correcting some of the over curvature that we're seeing. Like this line angle here, the distal line angle there is really excessively curved. I'm going to make that tool as big as it gets. Let's rotate that around here and correct some of that curvature. Then we go down in here and we can pull some of that cervical curvature back out to zip that contact up. One thing I'd suggest to you is as you're closing these contacts, we've got a little work to do on the lingual as well, as you're closing these contacts do so from the lingual thickness on. You'll get a feel for how thin everything is. Yep, that's obviously too thin. So depending on what your parameters are set at, you may want to more or less additions. You can see that's my actual preparation. Now she had fairly bulky laterals. It's interesting the anatomy on the lingual for laterals is real bulky. So I don't think she'll mind having that bulk restored. Because she's accustomed to it. I'm going to do our very best to avoid those black triangles down along the gingiva. Which I'll do some more correcting here. Let's see what this canine looks like. So I told her, she's back in the room right now, I told her I'd do an initial setup proposal. And then I'd weld the machine in and we'd give some, she'd give some feedback, some input, approval, denial, whatever. And then we can get things milling. I will, once I get the initial proposal, which I'll feel comfortable with, I just want to make sure I get her buy-in. Because these are her teeth that she's paying for. And I want her to be happy with the outcome. Because she is the reason we're here today, on a Saturday. You know, I have people sometimes ask me, well, how much would it take for you to get out of bed on a Saturday to come in and do a bigger case like this? And my answer is, well, it's not about the dollar sign. It's about the patient. You know, we as dentists get so focused, unfortunately, sometimes, most of the time, we get so focused on dollar signs. You know, we're talking about what our reimbursement fee for a crown is. We're talking about our, you know, overhead, cash flow, all this stuff. I'm going to save again here. But really, if we have, you know, the basics in place from the standpoint of managing cost structures and team member salaries and, you know, savings and, you know, keeping money in the business, and we've got a relatively average patient flow, then our primary focus should be on keeping patients happy. You know, I would suggest being very cautious with projecting financial goals. Because, remember, the income that we have as an office is an indication of how well we are serving our patients. Now, there are some offices. I don't know where they are, and I don't know any specifics, but I know of them. There's some offices that are, you know, purely based on volume of patient flow. And sometimes those offices do really, really well. Sometimes those offices don't do well in the long term. Now, short term, you know, you sign up for a new HMO and everybody's directed to you. And let me talk about this a little bit. We're going to change the restoration parameters a little bit. There's our spacer. I like to max that out. Minimal thickness occlusal. I'm going to change this. I'm going to drop that down to 500. Minimal thickness occlusal. I'm going to put that down to 800. Because of the way her bite is, I don't think we'll run into any. I'm going to apply this to all the crowns. So that'll apply to all crowns if I hit this. I'm going to hit okay, and it's going to recalculate. Anyway, so a lot of us sometimes get too focused on the dollar signs. We forget about the patients that are on the other end of the teeth. If we can focus on the patients and their care and explaining to them the problems, the consequences, and the solutions that we can offer them and the benefits of those solutions, then everything else will come. You know, the financial question marks, it will all come. But we have to make sure that we're focused on our patients first. If we're focused too much on income, on making goals, on number of crowns per day, then all these things will end up backfiring. Patients are people. They're smart. And they can sense when we are using them. And I hate to use that word, but there are some doctors out there who use patients. They use them as a means to an income. They use them for, you know, production. They use them. And I hate using that word in that, you know, it's awful to think. But it's true. You know, we will run into people whose sole purpose here is to be, you know, to bring in money. And I wish them the best, but generally that will not end up in happiness. You might end up making some money. But if you want to come to work and enjoy what you do, you've got to make sure that we're focused on the right things. And that's our patients and their happiness. Okay. All right. So a couple of things here. You can see we got a little waviness up there. So my favorite thing to fix waviness is my smooth tool. So I'm going to go in here with a smooth tool and I'm just going to tap on the most convex areas. And it'll draw that waviness to a more of a straight line. Now we still have to make sure we have a good contact point and we got to make sure we like the abrasions and all that jazz. So again, I'm going to take this in the room here in a few minutes and I'm going to approve it with her. I want to make sure that she gets to give us the input as far as what she likes. Generally, I think this is a pretty good proposal. Let me blend here this lumpy bumpiness. I hate lumpy bumpiness down along margins. I don't like the big cervical lumps. So I am acknowledging that there's a bunch of red spots here. These red spots are definitely needing some attention. But I'm going to adjust these red spots on the patient's lower arch on where they're contacting. So what I'm going to do now, I'm going to go in and I'm going to start adjusting the contacts. Interproximal contacts. Let's make sure we get this occlusal updated here. My favorite tool. Make sure when you're looking at contacts that you have your model contacts on as well. If you don't, you'll have no reference point. All right. So let's change our... Turn these off. Now for me as I'm designing multiple restorations, I want just green. These are going to be emacs. So I want just green as a contact. So I'll take this one because there's red. I'll take this one down to yellow and I'll go to the next one. Take that to green. That way I'm splitting the difference if you will. And then after we we get the contacts, I want to make sure that I still like the aesthetics because sometimes in this smoothing process we'll change the cosmetics of the restorations. So we want to be cautious with that. We don't want to overdo that and then we want to add some nuance to make sure that the crowns are attractive and they look natural. Okay, we're moving right along. A little bit of blue is not a big deal. I would suggest though if you have a large patch that you correct that depending on what your parameters are setting and setting parameters are set at. All right, let's turn that up just a smidge. Make sure we have a nice contact there approximately there. I'll go to seven. And then once we get a decent proposal here, I'm going to take this in the room and have her take a look at it. And then we'll take some post-op pictures and give you some pointers and an outcome discussion about how things went. So I'm just finishing these contacts. Again, I'm shooting for green. Too much. Just green because we've got multiple teeth. If I were to line it up as some yellow, then they'd be too tight. Let's see. That's again, this is something we're going to adjust in the mouth rather than compromising the cosmetics. All right, let's hit five. Looks good. One of the interesting errors we sometimes see is a glitch. Software will allow us to run through that anterior limit. Almost there. Apparently I've been overworking the computer. Let's go back to 12. Make sure I look good. And then I'll show you one of my favorite tools which is the incisal variation. The low and broad. All right, let's turn on the upper jaw. Do a little low. So we still have a couple of dark spots there. This one right here. We've got to fix that. So we're going to go to the lingual. I'm going to use my circular shape tool because I like the control I get from the circular shape tool. I can increase or decrease down here. And I did cut through some of the gingiva there. So she may, she will have a rebound of the gingiva space. It would be embarrassing to design a set of crowns or veneers and have a space in between these anterior teeth. Like I mentioned at the beginning, we, uh, we're looking at an object that's, you know, six or eight millimeters in whatever this is, 30 inches or something. So you have to take with a grain of salt sometimes these edits that we're doing because some of them will not be visible at all. Not in the slightest. Okay, now that I've changed the contact tightness, I gotta go back and verify it. So I'm going to split the difference. Again, I'm using my smooth tool. Just blending back nice and evenly. Then we're going to go back over here and I gotta roll that. That contact is approximating this one. Trying to split that difference. I don't want so much low contact that it won't seat. But I need a nice contact. There we go. Good. All right. So a couple of things to watch are these lateral embrasures. Sometimes they get really, really round. So you want to be cautious with that. I like to use my smooth tool. I'm just going to straighten that little curvature that's cervically. You can see how it's straightening ever so slightly. I'm going to go over here and I'm going to do the same thing. Except we have those big roundy spots. And they tend to look really weird. All right, I'm going to go up here and save again. Then we're going to do our incisal variation tool by grouping all the teeth together. Once that's done, we'll start the start the manufacture process. Okay, I've been worried there for a second. I wasn't going to save. I'm going to end up crashing. I'm going to re-align all these things. Okay, so the group tool, first thing I'm going to do is turn off the cursor. No, not that one. This one and this one. So I want to see just the teeth. Now you can see this is a little too straight. So I might edit this just a little bit with my favorite tool, the circular shape tool. I'm going to roll this guy around just a little bit right there. I'm really just, I don't know if you can see, my right index finger is just rolling a little. All right, now we're going to group. So I'm going to use the group tool. I've grouped them all. I'm going to click all of the teeth. You can hear the computer, just all the fans kicking on because this is a lot of memory. It's grabbing all these restorations. Okay, got a little bulk there and I have to smooth. So now that they're grouped, any tool that I use will affect all of them at the same location in the same intensity. So we're going to go down here to this one right here, this incisal variation. So it doesn't work for the bicuspids. I'm going to turn those guys off. Okay, we're going to, not the cuspids, I'm sorry, the cuspids. Let's reset here. We just want to group the anteriors. Okay, group just the anteriors here. All right, now we can use our incisal variation tool. And what I'm going to do is I'm going to go to about 25% strength. That seems to work well. And what I want you to do is take a look at the incisal edges, the facial surfaces. Do you just want me to take the PA of the front teeth or do you want to see the CT? Does she have any pain? Yeah, just a PA and a photo. Okay. Pop through the variations. You can see the anatomy changes right along the cervical third for the most part. So I tend to like number one or number three and then you can turn it up and down, up and down. And you can see when you turn it too far, it starts to violate that minimal thickness because it's I'm pressing in there. So about 25% is where I like to go. All right, so I think I'm liking this number three. Two, one, two, three. Okay, let's leave it at number one. All right. So I can see a couple of things. I want to adjust looking at it from a distance. I'm going to apply variation one at 25% strength. And after that, realize all your teeth are still grouped. So you're going to have to reset right here. Reset that group. It'll unselect all of them. Then I can go in and make those little final edits that I wanted to do. And then I'll bring it in and show our patient. And give her a chance to give me some feedback. Okay, all right. Use the anatomic variation to slide this lateral down. Just a skosh. Okay, now we got to turn back on our contacts. And turn off the upper jaw. And see how much I edited that? How the contact is now really, really tight. We're going to blend that back in to just green. Good there. Dark triangles. Cool. And of course when these come out of the machine, I'm going to add some hand variation with a with an instrument, with a burr. To make sure that we like them. Okay. So let's save. One final time. Then I'm going to wheel this in on the left patient. Take a look. Let me do one more thing here while I got you. We'll turn on the the before and after. Just for fun. So the colors confuse patients. So we're going to turn those off. And then what I'm going to do here, I'm going to group them all. Some biocopy. The restoration. So that's where we started. And we'll see if she likes them a little bit longer, a little bit shorter. We can always pull them back. Anyway, this is where we're at. So, thanks for watching. Hopefully this has been productive. It's been an adventure. We'll see what the patient says and I'll give you some post-op pictures here in a little bit. Okay. Bye.