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Two Cosmetic Case Reports in Digital Dentistry: The “Whitest Smile” and the Single Central Restoration
Digital impressioning and CAD/CAM have changed what is possible in dentistry. “The effects of digital dentistry in our practice have been to connect the team and to enhance the patient experience,” said Dr. Alan Jurim of Integrated Dental in Woodbury, New York. “Part of our cosmetic case planning involves tying the patient's emotion into their care and, ultimately, working together to achieve a successful outcome. This has been the most exciting part for us in our digital workflows.”
Using CAD/CAM systems, dental practitioners are able to:
Create same-day restorations
Involve patients in their dental restoration
Incorporate more data and insight into the treatment planning process
An active lecturer and digital dentistry “power user,” Dr. Jurim recently sat down with us to discuss CAD/CAM technologies for cosmetic case planning. His journey in digital dentistry started in 2012 when he used it in the lab, and he soon began scanning all patients in his practice. Having a digital patient library enables practitioners like Dr. Jurim to refer back to the historic data on patients and provide better treatment. “It’s a lot easier these days to capture information while we're recording and digitizing our patients,” said Dr. Jurim. “For example, we can now use the 3Shape TRIOSⓇ 4 dental scanner as a diagnostic tool to help us visualize the amount of fluorescent bacteria that's on the tooth or even use transillumination to help diagnose dental caries.”
Digital Dentistry Becomes More Intuitive
Recent advances in digital dentistry have made it much simpler for practitioners to master new technology. For example:
Scanning protocols from CADPro Academy walk you through every step of the way, from creating a case to administering the anesthetic to scanning the patient
Artificial intelligence built into systems like the 3Shape Dental platform allow you to filter out areas such as a patient’s tongue or cheek that you didn’t intend to scan
Compact new WiFi-enabled milling machines simplify the process of milling a restoration or a provisional for a patient while they wait.
Digital Treatment Planning
In his practice, Dr. Jurim uses:
The 3Shape TRIOS dental scanner for diagnostics and restorative workflows
Both arches
Upper and lower jaws and the relationship between the two
Dual bite registrations
Patient-specific motion
Edentulous scanning
High-resolution SRL camera for communication and planning
Peri-oral photos
Full-face photos
Cone beam scanner to see tissue underneath
Radiographs
XDR library
CBCT library
Dentrix
Clinical records
Periodontal records
“The ability to take all this information and to analyze it is where the power of digital dentistry comes into alignment,” said Dr. Jurim. “If we can reduce the number of steps (to perform a procedure) and reduce the susceptibility for errors, that’s where digital workflows can really improve how we get to our end point. When we can make those steps more patient-specific and more accurate, we end up with better results.”
He shared three cosmetic dentistry cases illustrating how CAD/CAM technology impacted patient care; two are outlined below.
Case #2: The Quest for the "Whitest Smile"
The patient said she wanted to have the “whitest smile”. However, it was unclear at first how to achieve this. The patient presented with wear facets; uneven, asymmetrical gingiva; and non-ideal proportions of the anterior teeth. There was also some recession of the tissue for tooth number 10. After combining the data from the 3D X-ray and aligning the data from TRIOS scans and the high-resolution photography, Dr. Jurim set out to determine the best position for the maxillary anterior teeth. He loaded the scanned data into the Smile Design software to create a smile mock-up.
“This is a powerful tool to analyze mid-lines,” he said. “We can also overlay the best proportions of where we want the teeth to be, and present that to the patient so we can better understand their perception of what a white smile or a natural smile really is. This gives us a way to excite the patient, understand what they really want their smile to look like, and guide us to where we want to end up.”
From there, the dental team:
Previewed what the design looks like on the patient's face
Aligned the pre-recorded data to identify where they wanted the margin of the new tooth to end up
Confirmed that crown lengthening was not needed
Digitally produced an appliance to overlay the patient’s unprepared teeth and rest on the palette
Printed the appliance on a 3D printer and cured it
Used the appliance to guide where to trim the tissue for gingival margins
Delivered the provisionals
Performed an aesthetic evaluation
The patient was very happy and there was a lot more confidence in her smile.
Case #3: Restoring A Single Central to March Surrounding Natural Dentition
The patient wanted to have his anterior teeth fixed in the most natural way possible. Tooth number 8 was the primary concern. In addition to having pre-op TRIOS scans and taking high-resolution photos, the dental team recorded the patient’s teeth as well as his pre-operative tooth shade. By aligning the 3D TRIOS scan and 2D full-face photo, the dental team created what’s called a virtual facebow and combined that with a recording of the patient’s jaw motion.
As he was designing the centrals, Dr. Jurim was able to share feedback with the patient about what they would actually look like. He chose a specific Smile Library where the centrals had a natural curvature to them. From there, he created the actual model of the digital tooth setup, and transferred that to the patient’s mouth. The dental assistant recorded this with the rest of the full arch and then began to trim away between 7 and 10.
Once that preparation was done, he followed the digital tooth setup to prepare depth cuts. “This is important for making sure that we don’t over prepare or under prepare the tooth,” said Dr. Jurim. From there, he kept the margins super gingival to help match the shade accurately to the adjacent teeth. Once the preparations were done, he began performing the design, making sure to have the right shade and the right block of materials. The margin lines were set, and he used aligned reference points to establish the ideal smile. He then previewed the result and sent it to the milling machine, which took roughly 25 minutes. Once the milling process was finished, he removed the restorations.
“This process allowed us to deliver very predictable results,” said Dr. Jurim. “The patient was very happy with the results, and got exactly what they were looking for. It’s very exciting to connect the different parts to our digital workflows in this way and apply these for CAD/CAM success.”