Full mouth rehab in the time of CAD-CAM

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jcbdmd

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As a dentist who mainly sees patients who have been with the practice for 30 plus years, their kids, and grandkids, I must say that I do very little full quadrant, let alone full mouth work. We try very hard to help our patients keep all their teeth.

Periodically, though, I get the patient who has had a lifetime of dentistry and is interested in the total transformation.

How is that working in the digital workflow? Traditional C&B, not All-on-X which has major advantages in (mostly) full digital. Impressions, facebow, waxup, scan, print presentation model? Make a wearable waxup / snap on smile type appliance? For that many crowns is design and mill manageable? Easier than pressing a bunch of emax? Are digital articulators viable? How about the new techniques of scanning the patient's face with something to position the models in it? Does that help the lab see the patient, or is a real photo better?

I find myself wondering if it would be better to continue to do it all analog the old way with a lab who has a track record for full mouth, or work with a lab who may be learning some of all of this along with me. Sometimes learners have better attention to detail... At least I feel like I do.

Are any of you guys full digital workflow for most, but old school for FMR? Anyone totally digital (maybe printed models) past the scan? Anyone doing FMR from IOS??? That would blow my mind.
 
JMN

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As a dentist who mainly sees patients who have been with the practice for 30 plus years, their kids, and grandkids, I must say that I do very little full quadrant, let alone full mouth work. We try very hard to help our patients keep all their teeth.

Periodically, though, I get the patient who has had a lifetime of dentistry and is interested in the total transformation.

How is that working in the digital workflow? Traditional C&B, not All-on-X which has major advantages in (mostly) full digital. Impressions, facebow, waxup, scan, print presentation model? Make a wearable waxup / snap on smile type appliance? For that many crowns is design and mill manageable? Easier than pressing a bunch of emax? Are digital articulators viable? How about the new techniques of scanning the patient's face with something to position the models in it? Does that help the lab see the patient, or is a real photo better?

I find myself wondering if it would be better to continue to do it all analog the old way with a lab who has a track record for full mouth, or work with a lab who may be learning some of all of this along with me. Sometimes learners have better attention to detail... At least I feel like I do.

Are any of you guys full digital workflow for most, but old school for FMR? Anyone totally digital (maybe printed models) past the scan? Anyone doing FMR from IOS??? That would blow my mind.
Soooo many ways to do full mouth. Wow. Where to start.

At full mouth anything aside from a denture on attachemnts or screws the line between removable and fixed get really blurry.

You need to work with a lab that you can communicate clearly with and share vision match with. Starting a new relationship with a FMR is a touchy thing. See if the labs you already use have workflows they are using and prefer, or if they have recommendations for a fellow tech that serves that need well for the area.

We can't all do it all all the time.
 
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thanks for asking JCB if you are not doing a lot of big cases then stick with what you know the learning curve is fairly steep for digital . I wouldn't try this as a 1st case. I do have quite a few clients doing digital full arches with great success they wouldn't go back to analog but that is after a lot of singles and small cases to start with.
 
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What if you are in the trial phase (i.e., no preps yet) and you have lost confidence that a lab is going to be what you need. Are there labs that are confident enough to step in?

From a dentist's perspective, we are very hesitant to step-in if "work" has already begun, especially with a new patient. Less so when things are just in the mock-up phase, but still hesitant. So I understand where a lab would look at a "learning" FMR as a no-go.

But all of us learned stuff the first time some time, right?

It sounds like trying to learn a new lab and how they do FMR and the digital FMR work flow at the same time is, indeed crazy. However, a baseball batting coach loves to get a hitter who has never been coached (likely into bad habits).

Are there labs out there who see themselves as teachers, and understand how to take on a new student?

Is geographic location important in 2021?
 
rkm rdt

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I would talk to John Wilson if I were you.
He lectures/demos on the 3Shape page on FB..
 
CoolHandLuke

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for FMR, CADCAM is not the only tool in the box. it is another tool in the box.

you will still go through waxup, articulation, plaster mount on a pinned articulator with a facebow if you use facebow, and bite planning, vdo changes with 2-stage orthotics, etc etc

no FMR case is ever as simple as "just start prepping" and worry about bite later. the entire point is to establish a new one.

the key is in the work ahead of time, the waxup and bite management. if that is done in CADCAM, then you have a fallback parachute. you have landmark data to hit.

its not "easier" with cadcam by any means, it is simply an alternative manufacturing method that generally gives more consistent results than impressions and doesnt gag the patient.
 
Affinity

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Its not analog or digital, its both. You cant make a FMR case without getting your hands on it.. You cant successfully design a case like this in CAD without an analog articulator and facebow. (I know many elite gurus will disagree, but I only sip the koolaid) I would never go back to casting a full mouth metal bridge.. The fit of milled zirconia is light years ahead..

"Begin with the end in mind" I always come back to.. once you prep teeth, youre in the wilderness. When you have a plan, CAD helps you execute it in a way that was impossible not too long ago. The key is an interim temp that can be dialed in before the final, at that point its almost copy/paste. Along the lines of what everyone else posted..
 
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Good, so if I am a mostly analog guy, and still use my trusty whip-mix they made us buy in school (over much better choices, ugh),I am not completely a bad new account if I wanted try a more digitally focused lab for a case. They should be used to this.

With respect to the actual workflow, where is the appropriate analog to digital cross-over point if we were going to start analog and finish digital?

Would the diagnostic wax-up end the analog phase until final impression? Digital orthotics and first temps while refining. Back to PVS impression and then full mouth wax-up of crowns? Scan of waxed crowns and then mill final temps? Or would you skip analog waxing of crowns and go straight to CAD-CAM?

If I wanted to break from the lab I was working and get a fresh pair of eyes on it, where along that timeline would be too late for someone to take a new account over without hesitation?
 
CoolHandLuke

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to "start" digital take a pair of initial scans, and a new test bite (perhaps with pt in tens device, perhaps with one of those bite-on-popsicle-stick devices)

have the lab create digital mockup, printed model with test splint to use as a temp orthotic.

if instead you want to do impressions and do this waxup and first orthotic by hand, fine. to end the case once bite is established, lab would scan the models made, and have you scan the pt with orthotic on and off. lab would make permanent orthotic postive, print the model, make putty. you'd bond the permanent orthotic and wait till final prep time.

then its time for temp matrixes, prep, scan, chairside temp half arch, bite scan, temp other side, take two aspirin and let the lab do its job.

if the waxup was good, the lab is laughing because its only got to copy that, mill it, stain and glaze, done.

everyone wins.
 
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Good, so if I am a mostly analog guy, and still use my trusty whip-mix they made us buy in school (over much better choices, ugh),I am not completely a bad new account if I wanted try a more digitally focused lab for a case. They should be used to this.

With respect to the actual workflow, where is the appropriate analog to digital cross-over point if we were going to start analog and finish digital?

Would the diagnostic wax-up end the analog phase until final impression? Digital orthotics and first temps while refining. Back to PVS impression and then full mouth wax-up of crowns? Scan of waxed crowns and then mill final temps? Or would you skip analog waxing of crowns and go straight to CAD-CAM?

If I wanted to break from the lab I was working and get a fresh pair of eyes on it, where along that timeline would be too late for someone to take a new account over without hesitat
This would all depend on how comfortable the clinician is and what is to be accomplished with a case. On wear cases that require opening, I prefer to wax by hand and switch to digital for overlays, provisionals and finals. If it is restoring form and esthetics, these cases lend themselves well to doing complete digital lab, with mostly digital clinical. The analog portion of the process would be the facebow and bite. Some technology is getting close for jaw registration and movement , Zebris and another that escapes me at the moment, but a pros resident that I worked with did and is continuing the evaluation of this technology as a staff member.
As far as when someone is comfortable taking on a lab case with someone switching from another lab, that depends a lot on what is going wrong with a case. A competent lab tech should be able to keep a clinician out of trouble by recognizing shortcomings they may have in adapting to the technlogy. If the clinician insist on getting in trouble, I can't speak for all, but I would want now part of those cases.

I looked up my friend who is doing the evaluation and he has posted an article in JPD that is relevant to the conversation

 
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Good, so if I am a mostly analog guy, and still use my trusty whip-mix they made us buy in school (over much better choices, ugh),I am not completely a bad new account if I wanted try a more digitally focused lab for a case. They should be used to this.

With respect to the actual workflow, where is the appropriate analog to digital cross-over point if we were going to start analog and finish digital?

Would the diagnostic wax-up end the analog phase until final impression? Digital orthotics and first temps while refining. Back to PVS impression and then full mouth wax-up of crowns? Scan of waxed crowns and then mill final temps? Or would you skip analog waxing of crowns and go straight to CAD-CAM?

If I wanted to break from the lab I was working and get a fresh pair of eyes on it, where along that timeline would be too late for someone to take a new account over without hesitation?
With one Dr I work with we blend the analog to the digital and it's been working well. It's comfortable for both parties to bridge "old and new."

1) We always start with a facebow and current diagnostic models- from there I hand wax a provisional sent for case presentation/ approval ( Dr. likes flat bite plane esk occlusion and I can wax that style way faster then trying to manipulate digital libraries, otherwise digital/ 3d print would be much easier).

2) Hand wax up-> scan to digital provisional and milled PMMA

3) Receive impression of final temps, and final impression (a) or final implant transfer impression (b)

4) (a) Create technique copings -> to be joined together in the mouth with addition of resin bite to make new verified master die model or (b) make verification jig for implants/ bite block

5) Scan everything into comp and get to work

6) Send back PMMA test run (for all on cases only)

7) Final for tryin

8) Final for insert

I would say step 3 is your make it or break it step. If I were handed final pours from another lab, I'd say no...

Just my two cents!
 
TheLabGuy

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I average two digital FMRs a week for over a year now.
Doc takes initial scans, jots down what he likes/dislikes, the patient likes/dislikes...then we do digital mockup. Once digital mockup is done, we usually have Doc TeamViewer in with us to make any changes and see the progress of case. This is usually done with a virtual articulator. If we are opening vdo, a separate leaf guage occlusal bit is captured/sent to us and incorporated into the virtual articulation. Then once Doc signs off, we can mill the temps, or print the mockup and do a putty matrix for chairside temp fabrication. Then prep away (and if your doing one arch at a time, always do lower arch first-helps in determine length of max. anteriors and envelope of function). Place temps and then biggest thing is you can let patient test drive temps for a week, come back and make any changes to temps needed...THEN scan the temps and send to lab. Scanning the temps makes it a slam dunk for lab. The last twenty FMRs had no adjustments needed whatsoever. That's our protocol for these big boys. Only other thing I would mention is that if you are opening the VDO signicantly (more than 6mm),I'd suggest transitional temps, spaced 6-8 weeks apart to you get desired vdo with patient on a Motrin/Tylenol regimen...to allow those muscles adapt to opening the vertical. Hope this helps.
 
Affinity

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"If I wanted to break from the lab I was working and get a fresh pair of eyes on it, where along that timeline would be too late for someone to take a new account over without hesitation?"

The protocols for this type of case are pretty standard, the thing that is not, is the artistic detail/ smile design/ materials/techniques that every lab differs on. Obviously the price differs also. Glidewell can slap these out and its definitely not the same case as if I would do it. The baby step method is the only way to make sure everyone is on the same page, especially the patient who is paying big bucks, and having to use it the rest of their life.
Smile line, symmetry, phonetics, golden proportion, function, lip support... these are crucial and generally better handled by labs with denture experience, many C&B techs lack those skills IMO.

If you really want to judge between two labs, send both the study models and see how each diagnostic waxup compares, I promise you, no two will be alike. For example, some labs will hand wax over the old teeth with a minimal cutback and send a putty matrix, Ive found that with CAD, I scan the pre-op, then prep the teeth as the Dr would ideally, then mill a PMMA bridge that fits like the final will, so you have a prep guide, and a pontential temporary to get them out of the prep appointment with a rough draft, this can easily be modified with the same initial scans for a 2nd mockup if necessary. The patient has to be almost 100% satisfied with the look of the temps for a few weeks before finalizing a case like this... and having them sign an affadavit that they are ok with the mockup, before finalizing the bridge. These are the cases you do not want to come back because they expected something different than they got, which does happen if you dont do the diagnostic phase properly.
 
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Makes me feel good that things don't stray that far from the comfort zone I was trained in, even with the nearly all digital method.

Will definitely keep this in mind the next time this comes around.
 
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ring up a few labs that your colleges who do large cases with and work up a relationship with the one you comfortable with.
 
Affinity

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Like smiles by jonathan?
 
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