Re: Versatile CAD/CAM Digital Impression Technology

[Anonymous]

CASE REPORT 1
Diagnosis and Treatment Plan
David, a mid-30s male, presented to our office as an emergency patient for a limited exam. His chief complaint was cold sensitivity with lingering throbbing, and a “broken piece of tooth” in the upper right area. He was interested in saving the teeth and wanted to get back on a regular dental schedule. However, due to his hectic work schedule, time was a major consideration.

Limited radiographic (Figure 1) and clinical examination revealed decay into/near the pulp on tooth No. 3 extending subgingivally, and failing amalgam restorations in teeth Nos. 2 and 4 with poor broken down margins (Figure 2).

The limited treatment plan focused on addressing the chief complaint: pain in the upper right area. The patient opted for complete endodontic therapy, a full-coverage restoration on tooth No. 3, and direct composite resin restorations for teeth Nos. 2 and 4. This would be accomplished in a single visit due to his hectic work schedule. The patient was given a prescription for PenVK antibiotic and provided a small deposit to reserve his 2.5-hour appointment a few days later.

When completing multiple teeth in a single visit, whether direct or indirect, it is important to create a “plan of attack” to maximize efficiency. In order to give complete access to finish and polish the interproximal contacts, it was determined to complete the direct restorations first. The crown would then be prepared and fabricated chairside utilizing the CEREC Bluecam, and during the milling process, endodontic treatment would be completed. The final glazed (in-office) restoration would then be delivered.

CLINICAL TREATMENT PROCEDURES
The patient was given anesthetic infiltration (Septocaine [Septodont]) to achieve profound anesthesia, and the upper right quadrant was isolated using the Isolite system (Isolite Systems) (Figure 3). The failing amalgam restorations and recurrent caries were removed and the preparations were finalized for Class II direct composite resin restorations. To assist in forming interproximal contacts and proper contours, V-Rings (Triodent) and wedges were placed on both teeth simultaneously (Figure 4). The direct composite resin restorations (Gradia Direct [GC America]) were finalized using an incremental placement technique (Figure 5). Full attention could now be given to tooth No. 3.

To ensure a uniform and proper occlusal reduction, a 2.0 mm depth reduction bur (Occlusal Router [Meisenger]) was utilized for all-ceramic crown preps (Figure 6). After interproximal reduction was completed (856-016 Coarse [Microcopy Disposable]), a diamond-polishing disc (Super-Snap Disc [Shofu]) was used to smooth any imperfections in the adjacent restorations (Figure 7). At this point, the rough crown preparation was completed with a 856-016 Coarse, and the tooth was inspected for residual decay with caries detecting dye (Seek [Ultradent Products]) (Figure 8). Removal of dye-stained dentin led to pulpal exposure as was predicted based upon evidence found in the radiographic examination. The preparation was finalized with a fine grit diamond bur (856-021 Fine [Microcopy Disposable]) and tissue retraction was accomplished using dental cord (Ultrapak [Ultradent Products]) to allow full visualization of margins.

Once the preparation was completed (Figure 9), the digital impression images were captured quickly and efficiently intraorally with CEREC Bluecam. The restoration was designed chairside and the IPS Empress CAD block (Ivoclar Vivadent) was sent to the in-office CEREC MCXL milling unit for fabrication.

During the milling process, the upper right was isolated with a rubber dam and straight line access was created. Using magnification provided by a dental microscope (Global G6 [Global Surgical]), 4 canals were located and shaped with rotary nickel titanium instrumentation (GT Series X [DENTSPLY Tulsa Dental]) (Figure 10). At this time the milled restoration was retrieved and tried in the mouth to verify marginal integrity. To maximize efficiency, the milled restoration (Empress) was stained and glazed; while all 4 canals were soaked, cleansed, and obturation completed (Figure 11). The buildup and final restoration delivery were completed in a single step utilizing resin buildup/cement (Anchor [Apex Dental]) (Figures 12 and 13).

The technique, as described above, resulted in a single, efficient appointment that provided the patient with an excellent and highly aesthetic outcome (Figure 14). This addressed his chief complaint and built confidence in our practice.