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Premolar Crown Replacement with Medit i500 and CORiTEC ONE

In this case presentation, we utilize the medit i500 to image the pre-existing crown and to fabricate a restoration that is a replica of the pre-existing condition. The patient was advised that the recurrent decay was in close proximity to the canal space and that endodontic treatment may be a possibility. The CBCT showed no evidence of any peri-apical radiolucency and the premolar tested vital prior to treatment

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CT used to evaluate apex of premolar for crown replacement

Case set up involved imaging the pre-existing condition in the pre-op catalog box.  Excess information was cropped to reduce file size.  The data was then copied to the maxillary arch catalog box and the area to prepared was edited out in preparation for final optical impressions.

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crown removal, prep refinement, and tissue displacement for imaging

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optical impression of preparation

quick copy case design

Immediate Post Op
The remaining decay and previous build up material was removed just prior to bonding the restoration with NX3 dual cure resin cement so the dentin was exposed for the least amount of time possible.

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Our First Shining 3D Aoralscan Case- A Preview

At CAD-Ray, we are big proponents of open architecture and the doctors control the flow of their patients’ digital data, whether it is a CT scan or an digital impression system.  We have put the Aoralscan through a battery of tests. For single unit, it delivers on quality that equals any other scanner on the market.  We were particularly impressed with this deep margin and how well the graphics could differentiate tissue from tooth structure on the distal of the prep

image upper and lower arch with shining 3d aoralscan
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image upper and lower arch with shining 3d aoralscan

buccal bite capture with shining 3d Aoralscan

fidning and marking margins

click to download the OBJ file of this case (note: we only scanned to pick up data for the margins)

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check out how well the shining 3d aoralscan picks up deep margins
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Second Molar Crown Replacement in Copy Mode

crown replacement using medit i500 to mark margins

In this case presentation, we feature a crown that needs to be replaced due to open margins and recurrent decay.

With the Medit i500, after the patient is anesthetized and the area is isolated, the pre-existing crown is imaged in the pre-op catalog box. The area to be prepared is cropped out in anticipation of the imaging the modified preparation.

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Once the crown is removed, expasyl is packed into the sulcus with a Number 2 cord. With the pre-op bitewings X-ray it was readily apparent that the tissue should be positively displaced in order to capture the margins. It took two layers of cord to achieve hemostasis for imaging with the Medit i500.

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While placing the margin in the native imaging software, it was noted that some tissue was obscuring the margin on the lingual side. The area was isolated both clinically and in the software. It was cropped out and filled in with ‘good data’ after proper protection of the adjacent teeth and margins so that we did not obscure their geometry.

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Once the margins are identified and the case is processed it is automatically imported into exocad for design and then sent to the Imes Icore CORiTEC Once for manufacturing. The emax restoration was tried in and then delivered after crystalization.

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Immediate Post-Op X-Ray taken to verify seat and no excess resin cement

Click Image to Download the OBJ Files And design Along

 

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Placing Margin In Medit’s Native Software and Directly Importing The Coordinates Into exocad

medit 2.1 software marking margins

On September 5, 2019 Medit will officially launch the 2.1 software that will allow dentists to mark their own margins before sending to the lab.  Since most images captured from models are inherently large in file size, you can selectively focus on the area where the raw images are taken.  You highlight the area and you process the data sets as shown in the first video.

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Isolate area for margin and process limited data

Once the area is identified, you can utilize the margin marking tool.  You have many aids to help with margins, including the ability to visualize the transition from one plane to another, along with colors in the models.

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draw margin line

In this preview, you can see which models were rendered: the lower pre-op, the lower prepped arch, and the coordinates of the margin line.

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margin line drawn in Medit i500 native scanning software

Once you have captured this detail you can click on the cad software and continue with design or submit it to your lab so they can proceed with the design and fabrication.

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launch into exocad and proceed with design

Click On Image to Download The Case And  Import Into Exocad

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Premolar Anatomic Copy Case with Medit i500, exocad, and imes icore eMax Milled Restoration

medit i500 manage crown replacement on second upper molar

In this article, we demonstrate how to manage a crown replacement on a second upper premolar with the Medit i500, exocad, and the imes icore CORiTEC ONE milling machine.  The pre-existing crown was over 2 decades old and the recession revealed a supra-gingival margin.  Furthermore, there was no room to improve the anatomy or its outline form as it was in occlusion with the opposing dentition.

A powerful design technique is the copy of the pre-existing crown. Images of the pre-op are taken while the patient is numb and its contours are copied onto the final design of the restoration.  This process usually takes a minute or so, after which we milled a size 12 emax block restoration.

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imaging sequence of a second premolar wit medit i500

design of second premolar crown

make sure the water spray is directed to tip of grinding drill

immediate post op delivery of second pre-molar crown

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How to Cut Off a Bonded Ivoclar eMax Restoration

One of the most dreaded procedures in dentistry is to cut off a bonded lithium disilicate material. With zirconia, since the bond strength is weak, just “rattling” the crown helps it pop off. You could also debond the restoration with a laser pretty quickly. With emax, you must use copious amounts of water so you don’t fry the pulp. You must also refrain from splitting the crown with a crown remover because you can damage the remaining tooth structure catastrophically.

In this sequence of photos, you will see how we recommend the removal of the bonded restoration. You must first create a trough across the occlusal surface of the crown. Ideally, use a 1.6 mm disposable bur to reach the interface between tooth structure and restorative material. As soon as you reach this junction, take a flat ended diamond bur and start working that same location and remove all the ceramic on the occlusal surface. Staying right at the junction of the material and tooth is the critical part of the process.

After you have removed the occlusal surface, you can take any bur and work the junction one the axial wall. By this time enough work has been done where the walls of the restoration start to break and peel off on their own.

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Steps in cutting off an emax crown
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Keep The CORiTEC ONE Spray Channels Clean

ortho plier and orthowires to unclog lines

All milling machines have guidelines for proper cleaning and maintanance. The imes icore CORITEC ONE’s spray channels must be kept clean, otherwise they will spray off the target block materials. Essentially you will dry mill ceramic which will damage the material and break the drills very quickly.

You can see how little particles of ceramic and titanium dust can clog the lines.

Here we just used an ortho plier and orthowires to unclog the lines. It’s easiest to have the water spraying so you can identify the channels and see the immediate results.

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keep irrigation lines clear

When cleaned and clear make sure the water it sprayed on tip of the drill from all channels.

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Instant Designs In Copy Mode and Cement Spacer Settings

In this particular case, we are restoring a lower left molar with a full coverage crown. The pre-existing condition has multiple fracture lines and the patient currently wears a retainer. The pre-op optical impression is taken while the patient is reaching anesthesia. Once enough reduction has been achieved, the preparation is captured and an immediate proposal is rendered that replicates the pre-op condition perfectly.

Note how the settings for the start of the adhesive gap influence the cement line that you see on the post-op bitewing after immediate delivery, even though it was milled with the CEREC MCXL.

copy mode- instant proposal
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copy mode- instant proposal

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Automatic Scanbody Detection and Auto-Import Into Exocad and Immediate Fixture Identification

A new feature coming to Medit i500 is the automatic detection of scanbodies while you are imaging. In this clinical case, two implants are placed in the lower left quadrant in a fully guided fashion. Spacing limitations and proximity to vital anatomy did not allow for proper parallelism. This can create all kinds of headaches with analog dentistry where the trays can inadvertently lock in the mouth of distort upon poor up.

With the digital approach, you can scan the gingiva, the arch with easy access to adjacent contacts, and then the scanbodies themselves. What is great is that you do not disturb the primary stability you just achieved by placing physical forces on freshly placed implants.

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Once the images are captured and the scanbodies are identified, we launch exocad and the data is not only automatically imported into the Computer Aided Design Software, it also plots the fixtures in the correct position and identifies their location and timing so you can proceed with the design of the custom abutment and / or tibase restoration.

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auto-import of scanbodies into exocad and immediate identification of implant analogs
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Three Unit Bridge and A Single Unit Veneer Milled with 40 mm Emax Block

three unit bridge and single unit vaneer milled

This 4 unit case was imaged in Medit i500 and designed in exocad. The final restoration was taken to CEREC inlab cam. When the construction file is imported into cam, it contains data such as the margin line which is important for the milling machine to know for its tool path calculations.

In this particular situation, the construction file dictated the position of the restoration in the block which would have not allowed for proper milling. Instead of loading the construction file, we imported the stl design, redrew the margins really quickly and were able to mill the two separate (4 unit) case out of a single emax block.

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pros and cons of construction line delineating margin lines

The milled restorations were then separated and finished free-hand

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4 units milled out of a 40 mm block

try in and deliver of 3 unit bridge and single unit veneer after extraction of right central incisor

try in and delivery of a 3 unit bridge and a single unit veneer
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try in and delivery of a 3 unit bridge and a single unit veneer

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Full Coverage Crown on a Fractured Second Molar and Two Bites

capturing two bites for fractured second molar

Same visit crowns can be a practice builder. We had a patient referred for in house fabrication of a restoration because she did not want to go through the procedure twice. A family member made the referral for a broken tooth.

After the tooth tested vital and the patient consented to treatment, she was anesthetized. While waiting for the onsite of anesthesia, the upper arch was imaged along with the lower arch and the bite in the occlusal one window box. The case was set up for just imaging the preparation. Most of this can be delegated to team members.

fractured DL susp of lower second molar
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fractured DL susp of lower second molar

two bites taken to verfiy proper vertical dimension

We highly recommend that you capture the final bite after you have finished preparing the most distal tooth. You can use your camera to visualize your clearance. You can keep reducing the occlusal surface until you have enough clearance.

In this particular case, when we took the second occlusion images, the models would not turn green. When this happens, you should immediately ascertain if you have captured the first or second bite correctly. Double check to see if the jaw settled or if the patient moved their jaw during this acquisition step.

You can watch how we troubleshoot the bite and manually choose the second bite to relate the arches together.

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Correcting the occlusal relationship with second bite

Once the bite is captured, the isolite is re-inserted and the tissue is displaced and isolation is achieved. Then the predation is captured.

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imaging the prep after enough clearance has been established

After the crown is seated a final bitewing is taken to verify seat and if any excess resin is left behind.

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post op bitewing to verify seat and resin clean up

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Conelog (CAMLOG) Hybrid / Tibase Abutment Testing

conelog hybrid and tibase abutment testing

At CAD-Ray we are constantly testing milling machines that can render ceramic or metal abutment restorations. In this particular case, we are testing the conelog line of tibases and utilizing the automated identification of the scanbody with the new Medit i500 V2.1 Artificial Intelligence program. Not only does the software identify the scanbody and locate the fixture but it also imports the whole complex into the cad software where the fixture and digital tibase are already identified and aligned.

We scanned the tibase as well on the model and merged it to the digital proposal to see how closely the digital proposals matched the physical model.


It is very important to properly identify the scanbodies and to label them accordingly. A single mis-step can result in ill fitting restorations and cause disappointment. If the nomenclature or the math doesn’t add up, it is always a good idea to contact the manufacturer of the scanbody to verify your findings.

In the first set of videos, we demonstrate how the scanbody is imaged with the Medit i500.  For this particular demonstration, we placed a tibase on a conelog 4.3 mm diameter fixture and then a peek scanbody on top of it. Indexing and making sure it is seated is of paramount importance. Once the software identifies the complex it can automatically import it into exocad software so you can proceed with the design.

articial intellegence identification of tibase and scanbdoy
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articial intellegence identification of tibase and scanbdoy

scan of tibase itself on model for verification of indexing

This test case is milled for record keeping and FDA compliance as we are distributors of multiple scanners and milling machines.  We are only concerned about the fit of the restoration.  After the design was completed it was then imported into milbox CAM software, nested, and the sprue was configured for the mill.

autoimport and design hybrid abutment crown
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autoimport and design hybrid abutment crown

Nesting and Sprue Design in Millbox

Milling Simulation

The first produced restoration did not seat completely and the internal was relieved in an analog manner.  It did finally seat but by then, it lost its anti-rotation mechanism.  The case was then reloaded in millbox and the internal relief was increased by – 0.05 mm.  That simple adjustment allowed for proper seating without any analog adjustments.  You can also appreciate some residual material that may keep you from seating.  Both the software and the carbon marks left on the intaglio of the restoration can be clear indications of what needs to be adjusted.

provide relief
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provide relief

look of intaglio from relief

perfect fit of restoration to tibase
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Digital Copy Milling (Anatomic Wax Up) Vs. Scan Pre-Op Model

In CAD-Ray’s version of exocad, we have dramatically reduced the steps necessary to get a final proposal with copying a pre-op, mock up, or wax-up. We’ve configured the wizzard to walk you through the steps of defining your path of draw after margin placement, trimming away material you don’t want your proposal “to touch” and giving instant proposals.

There is one difference you need to be aware of in design modes; Anatomic Crown vs. Anatomic Wax up. When designing a crown, you can choose to include the pre-existing model in the equation. When you select “YES” to “Scan Pre-Op Model?” you tell the design software to incorporate that into the equation, but you will get a free form proposal and then you adapt it to the pre-op model. Alternatively you can choose Anantomic Wax Up and you will design an restoration in under a minute that is to your liking.

Digital Copy Milling Vs. Scan Pre-Op Model
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Digital Copy Milling Vs. Scan Pre-Op Model

Instant Proposals With Anatomic Wax Up Mode
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Anterior Copy Crown With Medit i500 Direct Import Into CAD for Design and Mill with CEREC MCXL and CORiTEC ONE

medit i500 direc timport into cad for design and mill with cerec mcxl vs coritec one

In this article, we feature an upper left lateral crown that needed to be replaced due to recurrent decay.  While the patient was getting numb, we defined the job description in the Medit i500 software and imaged the pre-existing crown, the opposing and the bite.  We digitally cropped out the tooth to be prepared and proceeded with crown removal. Once the margins were refined and the tissue was displaced, we imaged the preparation in HD mode and processed the case.

Crown Replacement Due To Recurrent Decay with Medit i500
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Crown Replacement Due To Recurrent Decay with Medit i500

Image Pre-op, the opposing, the bite while the patient is getting numb

Image prep and process models

Once the digital models were rendered, we launched the integrated CAD software that automatically imported the pre-op, the opposing, the prep model, and the bite. Their relationship is preserved in the CAD software and no modifications were necessary.  You have two ways to copy the pre-op; one way is to program the CAD software so it replicates the pre-op perfectly while the other gives you a raw proposal that you can then choose to adapt to pre-existing situation.

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Direct Import of Models into CAD Software for Design and Mill

Once the case is designed in the CAD software, you can then take it to any CAM and Milling Machine to produce a restoration. Here we milled an emax restoration with the CEREC MCXL and the imes icore CORiTEC ONE at the same time so we can compare the final results.  The CEREC milling machine produced a restoration faster by about 90 seconds but the final results of the margins by the CORiTEC Machine was far superior.  Also, the CAM software, Millbox in this situation, allows us to choose a third drill that is 0.6 mm in diameter.  This increases milling time but results in less overmilling than the 1.2 mm burrs that milll the intaglio of the CEREC Machine.

 

Nesting to Mill To imes icore CORiTEC One
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Nesting to Mill To imes icore CORiTEC One

Lateral Incisor Milled with CEREC and CORiTEC One for Coparisson of Finished Restoration

Dueling Milling Machines

 

Hacked Margins by CEREC
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Hacked Margins by CEREC

Same Case Milled with CORiTEC ONE with 0.6 mm Internal Cavity Drilling

Ceramic Margins Scanned by Medit for Comparisson

Immediate post op 

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Artificial Intelligence in Medit i500 Automatically Identifies Implant Location into Imports into CAD Software

artificial intelligence medit i500 identifies location of your scanbody and automatically launches that information into CAD software

Please, take a seat, you should not be standing while you watch this.

Artificial intelligence by Medit i500 now identifies the location of your scanbody but it also automatically launches all that proper information into CAD software for instant abutment designs. Make sure to watch both videos.  Enjoy.

Medit's i500 Artifical Intelligence Identifies Implant Fixture
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Medit's i500 Artifical Intelligence Identifies Implant Fixture

ALL of the Pertinent Information is Imported into exocad as One Complex
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Tired of Nuclear or Atomic Mushroom Bomb Cloud Shaped Abutment Crowns?

using exocad to design restorations

A very common source of frustration for most dentists or those who are new to designing implant crowns is the emergence profile of the abutment or crown.  Most of the time, the shape of the tissue dictates the digital design and this article showcases how we used the medit i500 for the intra-oral scan of the patient and then used exocad to design the restorations.  Our advanced users can appreciate how we bring the arch model in twice- once as the maxillary model and once as the gingiva model.  We then digital sculpt the tissue to create the proper profile yet we still have the original model to reflect back to asses the changes.

Download to ImplantCrownShaping.ZIP to design along

Medit i500 Beta Testing of Artificial Intelligence that Identifies Scanbody location
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Medit i500 Beta Testing of Artificial Intelligence that Identifies Scanbody location

Digital Tissue Contouring for Implant Abutments and Crowns

importing models in proper order

Digital Contouring of Gingiva Model to Create Proper Emergence Profile

DESS Library Information for Nobe Active Compatible Components

NobelActiveCompatibleComponents-DESSUSA2019-2

 

NobelActiveCompatibleComponents-DESSUSA2019-2
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Managing Second Molars And Clearance

protocol to reduce surprises and post op adjustmenst second molar restoration

Few things in dentistry that can be as frustrating as seating a second molar restoration, whether you are doing same day dentistry or having a lab made prosthesis delivered.  Here is a protocol we recommend that you follow to dramatically reduce surprises and post op adjustments.  In this particular clinical case a zirconia crown debonded and we elected to fabricate an in-office emax restoration.  The sequence is as follows:

  • While the patient is anesthetized and you are waiting for the onset of anesthesia, capture the opposing impression and the arch models.  Trim away the prep digitally and then proceed to the buccal bite capture
  • Do NOT capture the bite until you verify clearance.  In the sequences of videos that follow, watch how we use the Medit i500 to capture digital pictures of the clearance
  • Once we verify clearance, we image the bite.   You have the option at this point to see how well your occlusal stamps match the digital stamps if you want to.  A large deviation may mean the jaw settled or the patient moved during the bite capture.  Note that unlike conventional dentistry, you capture the bite here BEFORE the prep is finalized
  • Once you achieve isolation you can finalize the prep and retract the tissue and capture the prep.  We elected to capture the preparation in HD mode
  • The case is then immediately imported into the CAD software for design and fabrication
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second molar case set up in medit link

capture opposing and arch and trim away prep

check clearnace and then take bite after rough prep

capture prep in hd

autoimport into cad and design
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Emax at Delivery

Immediate post op x-rays were taken to verify seat and aid in resin cement removal.  The excess cement was removed after the x-rays were taken

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How To Create A Flat Base That Is Parallel To The Occlusal Plane With The Medit i500

flat base that matches the occlusal plane of the arches

A common request when processing models is to create a plan that matches the occlusal plane of the arches. To keep it simple the algorithms of the Medit iScan will create a plane from the lowest data point on one side of the model to the highest point on the model on the contralateral side. You can control this plane by using the edit tool in the arches and crop out data so that you help the software to find this plane more easily.  The more discrepancy there is between these data points will render drastically different planes than the occlusal scheme as seen in the attached photo.  Besides, the less data you have to process, the faster the models will be rendered.

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How To Create A Flat Base In The Model That Is Parallel To The Occlusal Plane
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Problems Milling to a Tibase From a Scanbody Digital Impression ?

milling to a tibase from a scanbody impression

We got a bat signal from a group of doctors who were having trouble with ill fitting restorations to tibases.  This can suck up a lot of time and energy to pinpoint the exact source of the issue, and you basically have to go through a pilot’s checklist before take off.  Here’s a list you can use for yourself to determine what the cause of the issue, after you understand what the issue really is.

  • Take a picture of the scanbody and a picture of the tibase and then pictures of their packaging material and verify you ordered the right parts
  • Do not mix scanbody from company A to image implant fixture from company B and then mill a restoration to a tibase manufactured by company C even though they all say they are compatible with company D.
  • Verify that you have the latest library of scanbodies
  • Verify that you correctly chose the right scanbody from the large list of implant possibilities on the market
  • Verify that you have the correct height as a lot of companies have the multiple height scanbodies for same diameter fixture
  • When starting a case, you select either Custom Abutment for the implant restoration if there is no screw access hole and Screw Retained Abutment if you do have a screw access channel
  • Understand that the decision for custom titanium abutment is made when you identify the scanbody in the design step, not in the job definition step
  • You will not be able to verify seat / index until you fire and shrink material like zirconia
  • The smallest drill in your milling machine will determine if you can carve out that much detail
Retrofit Designs to Tibase
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Milling Internal for Tibases

Retrofit Designs to Tibase

Desinged In Millbox and Milled in CORiTEC ONE

Designed and Millled in VHF Z4

We took the case file from our users and directly imported their design case into a few of the CAM systems we have at CAD-Ray. We used Celtra Duo burner blocks to verify the fit. The screw-mentable restorations were binding on the walls of the tibase so it took a few adjustments to seat it completely. The good part is that the carbon on the titanium abutment leaves metal marks on the internal intaglio, so it is easy to know where to adjust

 

 

 

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The restoration still needed some adjustments so we played around with some of the spacer settings, screw access holes, and other parameters to get it to seat all the way.

Could Screw Access Space Provide Relief?
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Changing Manufacturing Parameters to Aid in Seating

Could Screw Access Space Provide Relief?

Fit to Tibase Still Too Tight

Perhaps Internal Relief with Spacer Could be the Answer

Quick Way to Guage if Spacer / Adhesive Gap Have and Effect on Internal

Even with these adjustments of the parameters a little analog milling helped get the restoration seated. The CAM software can give you plenty of hints on where it will bind. We recommend that you don’t change your spacer settings and understand that you will likely bind on the walls of the tibase and/or restorations as it is difficult for any machine to mill out all the detail you need to have NO adjustments. The good news is that the indexing and anti-rotation mechanism work properly.

Minor Adjustment at Seat
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Minor Adjustment at Seat

Minor Adjustment at Seat

Hints of Areas that Still May Bind

In conclusion, it is physically impossible to mill the intaglio of a ceramic restoration to perfectly retrofit most tibases as they have too much detail that even 5 axis milling machines cannot reach. The choices are to increase the space between the walls of the tibase and the restoration providing enough relief to allow you to seat the restoration, but that comes at the risk of losing your antirotation mechanism. Alternatively you can mill them out knowing full well that they will bind and using the sophisticated CAM to pinpoint the areas that need adjustment.