Very first Case with AGA Ceramill

[cmsilvoy]

My very first case with the Ceramill system after doing basic training was to treat "Lee."
Lee is a completely disabled American Veteran.
He came to me from the VA hospital in Fayetteville with a cellulitis infection at 7 and 8.
They dismissed him with an antibiotic and no further instructions as to what to do.
His daughter is a hygienist, so she called me and asked if I would be willing to help him.

I was a little taken back from what I saw.
His dentition was severely worn and had exposed pulps at 7 and 8, with no visible crowns on the maxillary arch.
His collapsed VDO was causing significant problems with aggravating sleep apnea.
We took some impressions, did root canals on 7 and 8 and sent him home.
I mounted and waxed up the case at a proposed vertical and made a stent for temporization.
I brought him back and did post and cores and buildups on all of the teeth and temporized both arches in the same day (by myself, which was no fun).
I left him in temps for 2 weeks and then took my impressions, did all of the model work (my least favorite part is plaster work),and scanned the case.
I wish I had documented this whole thing better, but that's why I am here. I'll get better at it.
Anyhow, here we go! Lower design, all units splinted. Occlusion designed to limit excursive interferences.

Units nested and ready for CAM

Milled unfinished Zirconia

Here's where I suffer. I toil at mechanically polishing and finishing the green zirconia. And staining is no fun. At the time, I used the AGA dip technique which produced a fairly solid A2 shade.
On to the upper, model scan


design

proposal

I milled the upper with the AGA Zolid preshade A2. I hoped that I wouldn't have to mess much with staining and I was very pleased with the resulting match to my lowers.
Now, Lee had his upper right quadrant blown out by shrapnel during one of his tours, and he is not healthy enough for me to finish his case with implants.

My challenges in this case were:
Altering his VDO drastically
Designing an occlusal scheme that would allow him to grind his teeth without stressing the prosthetics or his teeth.
Designing pontics and embrasures that could be cleaned with proxi-brushes and rubber tips.

Here is the case on day of seat. A remarkable transformation. If I can find his pre-treatment photos I will edit the post to include them.

I successfully matched the occlusion with only minor intraoral adjustments. He has reprtedly been sleeping better and his CPAP machine works more efficiently now.
His health has not been good, but I check in on him now again and will as long as he's around.
Constructive criticism welcome.

Chris

 

[user name]

First...Thanks for helping a vet. (Im one).

From what I can see, I dont like the design. The midline cants to the left. No golden proportion...the laterals are too narrow. The cuspid is way too short and looks like it wont be involved in any guidance. The bicuspid hangs down like a fang.

Again...thanks for stepping up to help one of our guys, but dont try to do too much yourself. Hire an artist/tech.

 

[cmsilvoy]

The midline cants to the left.

As far as the midline cant, it is slight and likely insignificant to the patient and the untrained eye.
However, how do we avoid this in digital design, where there is no guide to reference?
How should I have transferred a perfect vertical reference to the design software?

No golden proportion...the laterals are too narrow.

And for the "golden proportions," once again, how are "ideal" ratios managed in the digital domain? Are there tools to streamline the process?
Would it have been better to use an ideal waxup and adapt the model to that? (And realize that as a beginner at that time I had not even learned that tool.)

The cuspid is way too short and looks like it wont be involved in any guidance. The bicuspid hangs down like a fang.

With the occlusal design, the canine and the bicuspid act in group function to create a balanced guided occlusion since he has only one functional side.
i spent more time on the articulator and on his temps working this out than any part of the case, although I agree that the bicuspid look quite sharp.

Again...thanks for stepping up to help one of our guys, but dont try to do too much yourself. Hire an artist/tech.

The only reason that I did all of this was because this guy needed my help, and I had no resources for free assistance. I have friends who wold have charged over $15k to do this case.
I did it for free because it was important to me. No way I would spend the time, energy, resources, and money on this case if it didn't mean an awful lot.
Absolutely, from now on I will outsource design until I open the lab in May and hire a lab tech or two.....

Thank you for the insight and I look forward to learning more from posting this case.

Chris

 

[2thm8kr]

As far as the midline cant, it is slight and likely insignificant to the patient and the untrained eye.
However, how do we avoid this in digital design, where there is no guide to reference?
How should I have transferred a perfect vertical reference to the design software?

You said that you did extensive DX work on this case. Did you take a facebow? That will help immensely with the midline, use your preop scan as a guide.

As far as the 'golden proportion' that really only works if the patient's skeletal structure is golden too. My $.02. Function trumps esthetics.

For your first big digital case, my hat's off to you.

 

[charles007]

Thanks for posting your first case Chris which was not easy, can't wait to see more cases..
Shoot me a pm after Christmas when business slows down and I will drive up on the weekend and give a few tips on designing with Cad tools.
In the meantime, take your design as a learning tool and play with it to improve your skills.
Another idea is to mill more difficult cases in wax first and make changes before milling in zirconia. You could also schedule in more training using Teamviewer on real cases to sharpen your designing skills.

Charles

 

[Affinity]

I think its a nice job.

Take a stick bite.. same as you would in the analog world. you can still scan this in and use it to position your models on the screen, use a grid overlay to align midline, etc.

As far as proportion, scanning a diagnostic is almost a must in this situation. You can make a chicklet waxup as long is it has the proper width, length, size proportions. Then overlay this when you are designing the final in CAD. You have your form from the CAD library, and your length, width, midline, from the analog diag. waxup scan. Keep the embrasures open so the mill can get in there and adjust line angles with porcelain if needed. With FCZ .. design is crucial, and less material really helps because you dont really want to contour pre or post sintered zr too much.

If you ever need any help with some designs or a 2nd opinion you have many here or you can dropbox me a file.