Implant Abutments and Crowns on your CEREC. Welcome
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- Aubrie Smith
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1 Welcome
2 Welcome Bob Marcus D.M.D. UConn Dental 1993 Poway (SD) office since 1997 CEREC user since 2004 CEREC Mentor and Trainer Founder of Kick Your Apps, Inc. Control Freak
3 Welcome
4 Welcome Many thanks to our sponsors!
5 OmniCam or BlueCam? Yes.
6 Before We Start Terminology :Abutment (split) ~versus~ Hybrid (Big Mama)
7 Before We Start Why Make Abutments In-House? You already own a CEREC: strive to be ALL digital Control - you re the doctor FUN!! Great marketing tool - every CEREC design is a chance to increase your patient pool Cost Effective CAD/CAM margins Esthetics: no more ugly metal
8 Before We Start Are e.max blocks strong enough?
9 Before We Start Is subgingival e.max biocompatible? glazed! preventing biofilm formation polished à optimal for the gingival adhesion
10 Before We Start Is subgingival e.max biocompatible? glazed e.max favored cell migration polished and untreated e.max showed considerable cell density and higher cell adhesion no cytotoxicity *Brackett MG, Lockwood PE, Messer RL, Lewis JB, Bouillaguet S, Wataha JC. In vitro cytotoxic response to lithium disilicate dental ceramics. Dent Mater 2008;24(4): * Messer RL, Lockwood PE, Wataha JC, Lewis JB, Norris S, Bouillaguet S.In vitro cytotoxicity of traditional versus contemporary dental ceramics. J Prosthet Dent 2003;90(5):452-8.
11 Before We Start Contraindications to e.max abutments (per Ivoclar) Failure to observe the requirements stipulated by the implant manufacturer for using the selected implant type (diameter, length, position) Failure to observe the permissible maximum and minimum ceramic wall thicknesses Parafunctions (e.g. bruxism) Use of a luting composite other than Multilink Hybrid Abutment to lute IPS e.max CAD to the Ti base Intraoral adhesion of the ceramic structures to the Ti base Temporary cementation of the crown on the hybrid abutment
12 Before We Start
13 Before We Start The Plan: Part I: Consult appointment Part II: Parts in stock Part III: Imaging Part IV: Design and Mill Part V: Try in, Crystallize, Finishing & Delivery
14 Before We Start The Plan: Can this be done in one appointment? Part I: Consult appointment 15 minutes (?) Part II: Parts in stock Part III: Imaging 15 minutes Part IV: Design and Mill minutes Part V: Try in, Crystallize, Finishing & Delivery 60 minutes Total: about 2 hours
15 Part I Consult Appointment
16 Part I: Consult Appointment Present the Case clear expectations about healing times, post-op pain, food entrapment, hygiene, options Discuss Fees it s not just an abutment and crown! possible additional fees: OS/perio bone graft surgical guide temporary tissue adjustments
17 Part I: Consult Appointment Make the Referral (if needed) YOU CONTROL THIS! convey to the surgeon: implant brand desired implant size desired depth requested angulation requested guide if needed Meet with your surgeon and set general preferences for all cases.
18 Part I: Consult Appointment Decide Temporary Style none flipper Essex One-Wing Maryland Bridge Immediate load (careful!) Have samples available!
19 Part I: Consult Appointment Select Shade photos if needed
20 Part I: Consult Appointment Schedule Patient for Imaging Appointment leave enough lead time to order/receive parts.
21 Part I: Consult Appointment
22 Implant is placed and healed. Now it s ready to restore.
23 Part II: Parts
24 Part II: Parts Parts to order/stock Scan Post (used many times) TiBase Kit (one per restoration) Screwdriver/Torque Wrench Scanbody Blocks Crystallization Pins Monobond Plus Monobond Etch and Prime Ivoclar Multilink Hybrid Abutment Cement.
25 Part II: Parts
26 Part II: Parts: Scanpost
27 Part II: Parts: TiBase Kit
28 Part II: Parts: Scanbody
29 Part II: Parts: Screwdriver
30 Part II: Parts
31 Part II: Parts: Ordering
32 Company name Surname, first name House number, street Zip code, City Phone Customer number Fax TiBase and ScanPost are delivered without Scanbody. Please order this separately! 1) 2) 3) Manufacturer / Implant TiBase Abutment Screw ScanPost Implant Platform Connection in torque in REF Quantity Tightening REF Quantity REF diameter units units Dentsply Sirona S AT EV 3.0 GH1 S AT EV AT EV 3.0 S Implants AstraTech Osseospeed EV 3,6 3.6 S AT EV 3.6 GH1 S AT EV AT EV 3.6 S ,2 4.2 L AT EV 4.2 GH1 L Ncm AT EV AT EV 4.2 L ,8 4.8 L AT EV 4.8 GH1 L AT EV AT EV 4.8 L ,4 5.4 L AT EV 5.4 GH1 L AT EV AT EV 5.4 L Dentsply Sirona 3.5 S / 4.0 S 3.5 / 4.0 L AT OS 3.5/4.0 L AT OS 3.5/ AT OS 3.5/4.0 L Implants AstraTech 25 Ncm Osseospeed TX 4.5 / 5.0 / 5.0 S 4.5 / 5.0 L AT OS 4.5/5.0 L AT OS 4.5/ AT OS 4.5/5.0 L Dentsply Sirona ANK C/ GH1 S Implants Ankylos ANK C/ GH2 S A, B, C, D C/X S 15 Ncm Not available ANK S ANK /X GH1 S ANK /X GH2 S Dentsply Sirona 3,4 3.4 S FX 3.4 S FX 3.4 S Implants Frialit / Xive 3,8 3.8 S FX 3.8 S FX 3.8 S Ncm FX 3.4, 3.8, 4.5, ,5 4.5 L FX 4.5 L FX 4.5 L ,5 5.5 L FX 5.5 L FX 5.5 L Connection Omnicam 4) Bluecam 4) meso F0.5 meso F2 Scanbodies for Scanbodies for incoris ZI incoris ZI Quantity Quantity Quantity Quantity REF in units REF in units REF in units REF in units S L ) 1x Titanium base, 1x Abutment screw, 2) 2x Abutment screw, 3) 1x ScanPost, 1x Abutment screw, 4) 36x Scanbody Page 1/3 Quantity in units Part II: Parts: Ordering Your Order Form for TiBase, Abutment Screw and ScanPost Fill out and or fax to your specialized dealer. (36 in box) The following components are compatible depending on the connection Technische Änderungen und Irrtümer vorbehalten, Best.-Nr. A91100-M43-B680, Printed in Germany, Dispo-Nr , 0916.V0.3
33 Part II: Parts: Blocks Why e.max?
34 Part II: Parts: Blocks Why e.max? Strength Usually MPa Influenced by many factors (finishing, firing, etc.) Fracture Toughness Inherent to a material Resistance to crack propagation A more appropriate way to compare materials Zirconia As translucency increases, fracture toughness decreases HT Zirconia about same fracture toughness as e.max
35 Part II: Parts: Blocks Why e.max? Fracture toughness of Five CAD/CAM glass-ceramics T. Hill 1* and G. W. Tysowsky 1 1 Ivoclar Vivadent, Inc., Amherst, NY, USA. INTRODUCTION CAD/CAM technology is becoming more common in the production of dental restorations. With the increased number of available restorative materials, it is difficult for clinicians to differentiate between them. Many mechanical properties are required to determine the long term clinical success. One clinically relevant property is fracture toughness. Fracture toughness is an important property of dental ceramics since it is often inherent to the material and can be used to predict other properties, such as strength. Therefore, fracture toughness values allow meaningful comparisons to be made among ceramics used for structural purposes. 1 MATERIALS AND METH Figure 4. diamond paste V-notch Creation The V-notch was finished to mm using a razor blade with µm diamond paste (DMT Di paste). The specimens were c in ethanol bath. Specimen Testing Specimens were loaded to failu three-point testing fixture (s mm) at a crosshead speed of 0. min in an Instron testing mach
36 Part II: Parts: Blocks Why e.max?
37 Part II: Parts: Blocks Why e.max?
38 Part II: Parts: Blocks Why e.max?
39 Part II: Parts: Blocks Which e.max block should we choose? Ask yourself: will we split? Your choice will mostly depend on these factors: Need to place a temporary crown over abutment? Screw access position Path of draw Esthetics Personal preference
40 Part II: Parts: Blocks Hybrid Abutment Crown Blocks All are LT BL2, A1, A2, A3, A3.5 B1, B2 C1, C2 D2 14 or 16 mm These can be custom stained in addition.
41 Part II: Parts: Blocks Hybrid Abutment Crown Blocks
42 Part II: Parts: Blocks Abutment Blocks MO 0 for shades BL1-4 MO 1 for shades A1, A2, B1, B2, C1, C2 MO 2 for shades A3, A3.5, MO 3 for shades A4, D3, D4 MO 4 for shades C3, C4, D2 These can be custom stained in addition.
43 Part II: Parts Crystallization Pins
44 Part II: Parts Cost Scan Post ($98.50, used up to 100 times) TiBase Kit ($87.50, one kit per restoration) Screwdriver Kit (you have this already) Scanbody ($35.50 for a box of 36 - Omnicam only) e.max Blocks (Abutment: $58.40; Hybrid $68.20) Crystallization Pins ($39.95 for 3, used many times) Ivoclar Monobond Plus (you have this already) Ivoclar Monobond Etch and Prime (you have this already) Ivoclar Multilink Hybrid Abutment Cement ($180; many uses per tube; comes with Monobond Plus) FINAL COST PER TOOTH: $
45 Part II: Parts Other Handy Parts Bone Profiling Kit Latch Extender Pictured: Straumann Kit (contact your rep) Flexi-Flange Drill Extender Patterson Item #
46 Part II: Parts
47 Part III: Imaging Appointment
48 Part III: Imaging Appointment 3 key differences from a standard crown Trimming: Careful here the software will let you go forward without! Gingival Mask: we are now dealing with tissue more than ever. Split function
49 Part III: Imaging Appointment Parameters Best practice is to set the defaults (in Configuration) versus each case separately.
50 Part III: Imaging Appointment Parameters: Abutment Anatomic
51 Part III: Imaging Appointment Parameters: Abutment Multilayer Framework
52 Part III: Imaging Appointment Parameters: Abutment Crown Veneering Structure
53 Part III: Imaging Appointment But first. Which burs should be used?
54 Part III: Imaging Appointment While we re in the settings. Burs for Zirconia
55 Part III: Imaging Appointment While we re in the settings. Burs for e.max 12S not 12
56 Part III: Imaging Appointment Administration Key point: Multilayer versus screw retained -or- Multilayer Abutment and Crown Hybrid Abutment Crown Bottom line: choose multilayer no matter what!
57 Part III: Imaging Appointment Administration Key point: TiBase versus Scanpost Bottom line: Don t do this! Choose carefully!
58 Part III: Imaging Appointment Scanning Scanpost notch will affect sprue position. Sprue position cannot be adjusted in the mill preview. This is because the notch is already built into the block and that will determine orientation.
59 Part III: Imaging Appointment Scanning Scanpost notch will affect sprue position. Hybrid abutment/ crown: place the notch away from the direct buccal or lingual to keep the sprue off the contact!
60 Part III: Imaging Appointment Scanning Scanpost notch will affect sprue position. Abutment: place the notch at the direct buccal or lingual to force the sprue to the mesial or distal where there s more room and it won t be on you margin. (By the way this doesn t always work.)
61 Part III: Imaging Appointment Version 4.4 versus Version 4.5
62 Part III: Imaging Appointment Version 4.4 Scanning Gingival Mask What is it? Why do we need it? Managing the tissue as part of a CEREC restoration is new to us. More on this later.
63 Part III: Imaging Appointment Version 4.4 Scanning Gingival Mask Remember. You MUST add this catalog manually. Click Add Catalog and choose the correct gingival mask catalog.
64 Part III: Imaging Appointment Version 4.4 Scanning Always follow a set sequence so you don t forget anything remember: the patient is going to leave! 1. Buccal Bite 2. Opposing Arch -Remove the Cover Screw- 3. Gingival Mask (IP contacts are important here) -Place the ScanPost, copy over, slice of bread 4. Treatment Arch
65 Part III: Imaging Appointment Version 4.4 Scanning Scanning Notes Omnicam users may copy the gingival mask catalog over to the treatment arch catalog. Use caution. If your Scanbody floats over the model the machine will consider it an artifact! Using the cut tool is highly recommended prior to scan. Slice of bread. Understand the tissue architecture and quality and your plan for it (i.e. blanch, laser, cut, etc.) Move forward to process the models until the design phase while the patient is still there!
66 Part III: Imaging Appointment Version 4.5.x Scanning scanning demo
67 Part III: Imaging Appointment Version 4.5.x Scanning Always follow a set sequence so you don t forget anything remember: the patient is going to leave! 1. Buccal Bite 2. Opposing Arch -Remove the Cover Screw- 3. Treatment Arch (IP contacts are important here) -Place the ScanPost and Scanbody- 4. Scanbody Arch
68 Part III: Imaging Appointment Version 4.5.x Scanning Scanning Notes Scanning the treatment arch then copying it to the scan body arch is not recommended. Understand the tissue architecture and quality and your plan for it (i.e. blanch, laser, cut, etc.) Move forward to process the models until the design phase while the patient is still there!
69 Part III: Imaging Appointment Version 4.4 & Version 4.5 (slight differences)
70 Part III: Imaging Appointment Model Axis Easy way: 50 tips
71 Part III: Imaging Appointment Trim (required) Slice of bread method
72 Part III: Imaging Appointment Trim (required) Slice of bread method
73 Part III: Imaging Appointment Trim (required)
74 Part III: Imaging Appointment Trim (required) Ut-oh.
75 Part III: Imaging Appointment Trim (required) That s better.
76 Part III: Imaging Appointment Click Scanbody head Double Click
77 Part III: Imaging Appointment Did you get a blue line (not an error)? You can now dismiss the patient.
78 Part III: Imaging Appointment Schedule Patient for Delivery Appointment Same day if other treatment to be done 1-3 days MAX! Show off the technology!
79 Part III: Imaging Appointment
80 Part IV: Design and Mill
81 Part IV: Design and Mill But first: a quick review of prep guidelines, which we will need to remember later for abutment design.
82 The wall thickness of the crown must be at least 0.5 mm. The hybrid abutment should be designed in a similar way as a prepared natural tooth, i.e. shoulder with rounded inner edges or a chamfer. In order for the crown to be cemented to the hybrid abutment using a conventional/self-adhesive cementation protocol, retentive surfaces and a sufficient "preparation height" must be observed. Create an emergence profile with a right angle at the transition to the crown (see picture green checkmark). The crown width is limited to 6.0 mm from the axial height of contour to the screw channel of the hybrid abutment (which mean can use entire block). The notes of the implant manufacturer must be observed regarding the maximum height of the hybrid abutment and separate crown (i.e. crown to root ratio). The preparation guidelines for the implant crown being seated on top of the abutment should be observed (i.e. e.max CAD 1.5mm thickness on functioning cusp, etc.) Part IV: Design and Mill Layer thicknesses: abutment with crown
83 Part IV: Design and Mill Layer thicknesses: hybrid abutment/crown The wall thickness of hybrid abutment crown must be larger than 1.5 mm for the entire circumference. The opening of the screw channel must not be located in the area of contact points. If this is not possible, a hybrid abutment with a separate crown would be preferred. The width of the hybrid abutment crown is limited to 6.0 mm from the axial height of contour to the screw channel. The notes of the implant manufacturer must be observed regarding the maximum height of the hybrid abutment crown.
84 Part III: Imaging Appointment Gingival Mask Here we must make a choice: use the tissue contour as scanned or not.
85 Part III: Imaging Appointment Gingival Mask Gingival Mask off flying saucer.
86 Part III: Imaging Appointment Gingival Mask Gingival Mask off flying saucer.
87 Part III: Imaging Appointment Gingival Mask Gingival Mask on mimics the tissue contour per your parameters.
88 Part III: Imaging Appointment Insertion Axis Line up the arrow as desired.
89 Part III: Imaging Appointment Initial Proposal Without gingival mask active
90 Part III: Imaging Appointment Initial Proposal With gingival mask active
91 Part III: Imaging Appointment Using Biojaw Very Important for implant proposals which often are not as perfect as standard crowns.
92 Part IV: Design and Mill design demo and hands-on!!
93 Part IV: Design and Mill
94 Part V: Finishing and Delivery
95 Part V: Finishing and Delivery Sequencing Note Some prefer to crystallize/glaze/polish and assemble prior to the delivery appointment, and some prefer to try everything in prior for adjustments. The TiBase fits snugly in the crown for try in. Once cemented together, you cannot place it in the oven again (i.e. no adding contacts)! Make sure your shade is correct. My choice? Try in pre-crystallized state.
96 Part V: Finishing and Delivery 1. Remove the attachment
97 Part V: Finishing and Delivery 2. Test the fit (it always fits)
98 Part V: Finishing and Delivery 3. Remove the sprue (same as usual)
99 Part V: Finishing and Delivery 4. Clinical Try-in Optional
100 Part V: Finishing and Delivery 5. Stain and glaze as you wish. You may stain BUT NOT GLAZE the area of an abutment that will be bonded to a crown. Stain will not reduce your bond. Polish is recommended for areas that will contact tissue.
101 Part V: Finishing and Delivery 6. Prepare for crystallization
102 Part V: Finishing and Delivery 7. Crystallize Hybrid Abutment/Crown: Cycle 1 MO Abutment: Cycle 7 (other ovens: ask your Ivoclar rep)
103 Part V: Finishing and Delivery Final Assembly Materials Needed: Monobond Plus Monobond Etch and Prime Multilink Hybrid Abutment Cement
104 Part V: Finishing and Delivery Assembly Step 1: Sandblast TiBase TIP: You can use the back side of the TiBase kit foam as a quick sandblast tool! Sandblast bonding surface only!
105 Part V: Finishing and Delivery Assembly Step 1: Sandblast TiBase TIP: Or, you can use a composite cap: Sandblast bonding surface only!
106 Part V: Finishing and Delivery Assembly Step 2: Monobond Etch and Prime Etch/prime e.max bonding surface only. Etch to very top on hybrid abutment/crown.
107 Part V: Finishing and Delivery Assembly Step 3: Monobond Plus TiBase only 60 seconds, air dry. No rinse.
108 Part V: Finishing and Delivery Assembly Step 4: Apply cement and join. use sparingly twist to find the notch and press firmly together clean up excess with cotton roll self (not dual) cure: 6 minutes polish the juncture afterward (fine football carbide/diashine)
109 Part V: Finishing and Delivery Seating: Hybrid Abutment/Crown Same protocol as e.max (i.e. no sandblast!) Monobond Etch and Prime internally, wash, dry seat, torque, dry, place plumber s tape to cover screw bond, composite (Tetric IvoFlow then IvoCeram) if, during the process, the surface is contaminated, you may etch and prime in the mouth.
110 Part V: Finishing and Delivery Seating: Abutment Same protocol as e.max (i.e. no sandblast!) Monobond Etch and Prime in and out; wash, dry seat, place plumber s tape to cover screw seat crown by your normal method if, during the process, the surface is contaminated, you may etch and prime in the mouth.
111 Tips Milling errors 12S not 12 Milling times What about a screw-retained bridge What about tissue training? 3.3 S BL: too wide at base? TiBase too tall? Multiple Unit insertion path
112 Last chance for questions! Part I: Consult Part II: Parts Part III: Imaging Part IV: Design and Mill Part V: Try in, Crystallize, Finishing & Delivery
113 The End!
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