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Building the Bridge from Dentist to Ceramist: Why Communication Matters Part II

Part 4 - Matt Roberts begins the posterior build up.

Instructors:
Tom Trinkner, DDS
Matt Roberts, CDT
Matt Roberts begins the posterior build up of the restoration

Use just a little bit of their florescent stain material. Just very slightly give the coping some color gradient. One of the challenges that we have in dentistry is blending different types of restorations. We're using the same layering porcelain on all teeth and in this case we're using Lava but we have five restorations in the anterior that are refractory based that will be etched and bonded directly to tooth enamel so they have good illumination of the under lying tooth. Then we're switching to a Zirconium based Lava substructure on tooth#6 and doing a three unit bridge. It's always inherently difficult to blend different styles of restorations even though we're using the same layering material. In this case we've chosen to do a porcelain margin on tooth #6 since it's in a highly aesthetic area and highly visible. We've cut the Zirconium back away from the margins so we don't get that reflectivity right at the margin and we'll seal the margin with a more transparent porcelain. What I'm going to do now is pull out some shoulder porcelain and go ahead and do a powder build up of that margin and lift it off and fire it in the porcelain oven. So we'll start by laying out a little bit of powder back here and grab a brush and we'll go ahead and take this area that has been cut back and reseal with the porcelain that will be more translucent than the core material. So we have the advantage of the core material for high strength in the bridge but we'll have the aesthetics of some good illumination into the gingival third of the tooth. This will take a couple of firings and so it shrinks a little bit every time you fire it. OK. One of things that I see is in an area where there was some grinding on the coping,we have a little bit of puddling of stain so I'm just going to grab a little electric hand piece here and just clean that off, I don't want a stripe like that on there,I'd rather not have the color at all than have irregular splotchiness. Tiny bit here too. And that black spot is unnecessary. All right other than that things look good. Let's start off and start building from our bicuspid back. I'll use a little more opacious dentin on this tooth than I
do on the rest of them to try and again hide that really dark core material. What we want to do is just build up a tooth the way a natural tooth would be formed which is a nice core of dentin with an overlay of enamel. We're in the bleach shade range here. We're not going to put a lot of color inside. It would be fun to but the patient wouldn't appreciate it if we did. Very simple, straightforward build up. Put our buccal cusp into place, comeback in and do our lingual cusp and I'll check our occlusion here in just a moment and see where we are relative to where we want to be. And we'll just very quickly work our way back. Here in this quadrant doing the same type of thing. OK let's take a look at our occlusion and just see where we are at. I'm expecting to have to modify this quite a bit but that's just roughed in alittle. I'm sure my lingual cusp tips are low but rather than build them up and then squash them on the articulator what I would like to do is to see how far low they are and then build them right into occlusion. So, let's see what we have here. If we can turn this around to the other side. OK so I need to expand my arch form back there in the molars a little bit and if we can get this inside here, hopefully. Yeah there's room to build up lingual cusps certainly on the second bicuspid and on the second molar. I've got a little bit of cross bite going on therein the very back. We'll try to bring that buccal cusp out a little bit and we'll solve that as well. It looked like this one did too. I needed to come up and it needed to moved to the buccal a little bit. The teeth are in alittle bit of a cross bite situation so we'll just try to scoot everything out to the facial on it. I'll move my central fossa a little bit. And then one of the ways that you can scoot a lingual cusp in is to create a cusp with cerebelli on the lingual here that uses some of the horizontal space and allows you to move your main cusp over a little more to the middle of the tooth. So we'll set it up for that as well. Then we'll wrap over that with our enamel and put our anatomy in with enamel porcelain. OK, so I'm going to create a little bit of vitality internally here with some translucent structure, put some little translucent rods between the lobes. Any opal transparent will suffice here. In this case I'm using N1 just because I have it laying on the palate, easily accessible. It's usually just a clear layer right over the dentin in a tooth. Especially in posterior teeth it just adds a little bit of translucency and vitality to the overall look of the tooth. It's not something that you'll specifically see an effect from but if you do one tooth with it and one tooth without it you'll notice the one has much nicer vitality than the other one. So let's take a peek here. It looks like our porcelain margin is pulled back a little bit as I would expect to see it so we'll realign that and be firing that while we're building the other side of the case. Here's the result of our first build up. We see that we've had some shrinkage as we predicted we would. And the color is looking pretty nice;I like the color of the porcelain. Nice vital depth to ableach shade. I'll probably dilute the dentin with alittle bit more translucent at this stage of the game and use a little bit more diluted dentin for the next layer and then we'll switch to just the N1. So we want to have that coming out of the tissue a little further out and that looks a little nicer. Emergent profile there is alittle abrupt. Here the neck is a little exaggerated,we'll clean that up. So we're doing a second bake on this side and getting our anatomy and full contour and then I'm turning back to our veneers and just doing a little bit of touch up here, we're about 90% done with them but as you can see just right at the margins there's a little bit of shrinkage and tearing still right around the margins so I'll use a clear porcelain fill that in. I'll work alittle bit on my deflective zones here get the shape of those correct. And just any place like the little black triangle there that I feel like we're a little bit deficient, I'll try to fix. Once we have that done then we'll go ahead and throw this in the oven one more time and when it comes out it should be ready to do a little bit of surface morphology and some glazing. We're at the point now where we need to do a little bit of final contouring on the veneers in front as well as do surface finishing on the posteriors. I still have this segment of the case in the porcelain oven at the moment and as you can see most of the anatomy has been built in. We will do slight occlusion adjustments to get the occlusion balanced out. At this stage in the game I'll come in and just start tuning the incisal edge. I'll keep checking back to the stick bite and making sure that the stick bite is still perpendicular to our axis. OK, I'm going to continue to work on contour here until I have the shape pretty close to that of the provisionals again. And just lots of grinding. I don't want to bore you with hours of that so from there I'll go ahead and paint a little bit of glaze on, we'll fire these in the porcelain oven again to get the surface glaze on. I'll fit them to a solid model and diamond polish the restorations. Obviously before I fit them to a solid model I'll take them in and divest them off the refractory dies and then do our final fit and finish on the case and then we'll send it off to Tom and you'll see it next in his hands and hopefully everything will look good. I'm excited.