Cerec for the Dentist
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Chuck and I get a lot of questions from dentists about the efficacy of CEREC technology. We too had our doubts about the value of this leap in dental restoration. In fact, if you had asked us as much as 6 months into the learning curve, in the year 2003, how firm we felt about its worth, the best we could have given you was a tentative thumbs up. Now though,... more than 7 years later, we can tell you without reservation that CEREC has been the most valuable technology we have every come across. It has saved countless patients from root canals. It has allowed us to save teeth that would otherwise have been extracted. And it has made thousands of patients comfortable about having advanced dental work. Bottom-line: Any patient who has had a conventional crown, and then a CEREC onlay, would never let a dentist do another crown again. Crowns feel like a "project", and CEREC restoration are just "non-events" for the vast number of people. But let’s get down to brass tacks… We know that some dentists have formed a negative opinion of this new treatment modality after seeing a few CEREC “failures”. Firstly, let us say that in our office, since 1993, we have been meticulous about tracking all kinds of numbers in our practice and one of them is the percent of dental work we replace, at no charge to the patient, because of a premature problem. After tracking CEREC in the same meticulous manner all these years, we have found no difference what-so-ever in it's longevity compared to really conservative, well-done crowns. Secondly, we would like to submit that all of us only see each other’s failures, whether its CEREC or lost fillings or loose bridges : Patients only switch dentists if the last office failed to meet their expectations. So if you have seen some dissappointing CEREC's, there is likely to be a story that does not represent the kind of CEREC's that we see all day in our practice, on teeth that have been restored long, long ago. In addition, CEREC has its limitations like any other tool and there will always be users who push the envelop, in any field. For our part, we have been using CEREC technology since its 3D inception in March of 2003. (You may know that the technology itself has been around for nearly 25 years.) Chuck and I are very conservative. Of the more than 4000 CERECs we have done, perhaps only 200 have been full crowns. We essentially use the technology for onlays, large and small, in order to conserve as much natural enamel as possible. Here are some perfect examples: |
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We photograph nearly every CEREC in the following 4 stages. Here is our "before" picture. As you can see, we have 2 upper molars with failing old fillings: one a typical resin and the other a 25+ year old amalgam. You could make a case for doing a crown on the second molar and if the patient had any history of bruxism or signs of wear or a "short" crown height, we would surely error on the side of caution and do a good old-fashioned gold crown. But we have had such success with conserving enamel on teeth that look like this one, that we recommended CEREC onlays for both these teeth.
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Here is what we found just under the old fillings. We make a point to show every patient these photos so they will understand that even if their tooth didn't hurt, there was active dental disease going on under the old fillings. After we take this photo, we remove all the decay and shape the teeth to recieve our onlays with perfect paths of insertion. |
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Here are the two teeth on the computer screen after all the decay was removed and preps were finalized. The second molar's onlay has been designed, and you can see the prep on the first molar. |
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Here are the final results. This project took about 1 hour and a half, with plenty of quality time spent chating with the patient about life, liberty and happiness. Patient is thrilled: no temp crowns, no retraction cord, no impression material. It's basically a "non-event" compared to conventional crown and bridge.
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CEREC has helped us save teeth that others would have extracted,... or the patient would have had to go through endo, post and core build-ups and then crown. Occassionally, when the patient can barely afford a crown, and can't afford the endo and P&C, we are faced with a choice of extraction or doing the best we can. Enormous CEREC onlays appear to have filled that niche for us. We have done enough of these, (sometimes against our better judgment) that we are pleasantly surprised with the outcomes! Here is an example of a "Hail Mary pass from the 60 yard line". This transformation was done in May of 2004. It's still cooking,... no endo.
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Another "Hail Mary" attempt to save a tooth without endo. October 2005. Still cooking,.. no endo,... no fractures. |
Now, it is nearly 7 years and more than 4000 CEREC restorations,… We would say we could never go back to shaving every fragile tooth down for a crown. It’s just not necessary.
In fact, only 200 of our thousands of CEREC restorations have been CEREC crowns. The rest are a broad spectrum of different sized and shaped onlays.
And here is where our experience with this technology is probably unique: We just never got into the habit of ever using it for crowns. We have found the inlay/onlay potential with CEREC to be nearly limitless. And that may be why we can speak to an aspect of the promise of CAD/CAM dentistry that you hear little about. We’ve just never considered CEREC a replacement for lab made crowns. Both have their place in our practice. CEREC is just one tool in our tool box.
NO ONE WANTS A CROWN : Firstly, we can tell you unequivocally - Folks don’t want crowns, no matter how fast you tell them that you can do it, or how few visits you can promise. They intuitively just don’t want their tooth shaved down to a nub,… and again,… We’ve found that it’s just not necessary. In fact, later on this webpage, I will show you some more “Hail Mary passes from the 60 yard line” that we have done with enormous onlays.
And we simply can’t tell you how rewarding it is to show every patient a before/after photo of their newly restored tooth, often after less than an hour of treatment time.
We should tell you that we have had 9 intraoral cameras in our office - one in every operatory – since 1997. Since the start, we have photographed the steps of nearly every CEREC we’ve ever done. We divide the 20 inch monitor screens into 4 quads and then take the photos in the stages you will see here on our website. I think we’ve had to pay special attention to the details of finishing a restoration since we are going to put the final result on a TV screen, magnified 50 times.
Here's another tip: When you show people your work on a big TV screen and you live for that “Tah-Dah” moment with every patient, it inspires a certain necessity of thoroughness. They MUST be invisible. In short, that's one of our goals. Patients are amazed.
ENDO? : Most importantly, doing these very large onlays allowed us to avoid the root canal and post build-up that would have been mandatory if we only had conventional crown and bridge to offer our patients. It still amazes us how few of these very deep CERECs never need endo. To our knowledge 99% of these “Hail Mary’s” that we’ve done look good and are still unremarkable endodontically, years after treatment.
More and more though, we don’t think of it as “luck”. We can’t explain it (although maybe some researchers can) but the deepest CERECs we do just don’t give us a moment’s worry. We make it a practice to call many of our patients after challenging treatment and it never ceases to amaze us how few patients report post-treatment pain.
BONDING? : From time to time, our largest onlays have very deep sub-gingival margins. We’ve heard the concern about not placing CEREC bonded restorations where we might be bonding below the CEJ, but we just have not had a problem with that. And after 7 years, we think we would have by now. In fact, most of these deep margins look so good that I would be happy to show good ol’ Dr. Skeeters (our toughest restorative instructor from dental school). Most are better than we could get with conventional crown and bridge because we use a laser for retraction and can visualize the margin with microscopic accuracy on the CEREC screen when designing.
To tell you the truth, sometimes when we see X-rays of these amazingly deep margins holding up so beautifully after 5-6 years, we still marvel at the luck we’ve had in discovering CEREC. We can certainly appreciate the need for crown lengthening, but our patients are always truly grateful to avoid gum surgery and the possible food catch that sometimes develops in the “black triangle” beside teeth with crown lengthening.
THE LEARNING CURVE : We can tell you that CEREC technology has a HUGE learning curve. That first year was the most difficult professional undertaking that my husband and I have ever been through and that's saying something considering the number and variety of emerging technologies that we have tackled in the past 20 years. I have to be honest and say that we probably only got through it with our sanity because there were two of us working hand in hand every day. We could run in and out of each other's rooms and compare notes and insights constantly. If one had called tech support for an issue, then the other instantly had a leg up. We could read or do other CE and then one of us could distill 4 hours of information into sound bites for the other.
Most importantly, we could constantly cover hygiene for each other when one of us ran behind. (And you will run behind in the beginning…. A lot.) If you have very high standards for your work like Chuck and I do, you will run behind for at least a full year, in order to meet those high standards and do enough CERECs to justify to effort.
We can’t speak to the current set-up, but personally, we did not find the company itself very engaged after the sale. (We purchased CEREC just before it went 3D in January of 2003.) And we know of many CEREC machines collecting dust in offices that just couldn’t get over the hump on the learning curve. Again,.. We think that we did, only because there were two of us, the time was right for us as a team, and we were incredibly perseverant.
Frankly, the logistics of the learning curve is something to be considered VERY seriously before getting into CEREC. You should not take this on if your other office systems and staffing are not in very good order. And if you have a partner, you must be on exactly the same wave-length as far as perseverance goes. If one of you bails out emotionally on the technology early, the other cannot survive unsupported. We know of an office where one doc stayed with it, but the other eventually bad-mouthed the technology so much that the learning curve was insurmountable. All things to consider before you dive into something that could prove to be an expensive nightmare.
QUALITY? : So how do we respond to complaints from other dentists about the poor “quality” of some of the CEREC restorations they see?
Well, here’s the bottom line: We dentists only see each other’s failures - If the tooth feels fine and the patient is happy, then they wouldn’t be switching dentists. We rarely see each other’s many terrific outcomes. If you’ve seen some rough looking CEREC restorations, there is probably “a story” that goes along with it that you are unaware of: A patient with unexpected limited opening.... A software mal-adjustment.... A cement that didn't keep its promise...
When Chuck and I see dental work that we don’t like from another dental office, we make it a practice NEVER to pre-judge. As we all have learned (often the hard way) - you never know what the previous dentist went through to get a certain result,… until you try to re-do the work yourself!
Of course we’ve seen some crummy CEREC restorations, (if they are ours, we replace them free right away.) But we all see crummy conventional crowns, ugly dentures and poor cosmetic dentistry from time to time. CEREC is no different. Every circumstance and dental office has its challenges. No one can hit a home run 100% of the time. If you think you can – God Bless You.
Here’s a simple test: We can assess our success with CEREC best after we get back from a week of vacation: Sounds funny, but this is when we have to sit down and consecutively check hundreds of bite-wing X-rays waiting for us from all the hygiene visits that took place during our absence. With the hundreds and hundreds of CERECs that we’d see during that process, we see a terrific sampling of our results. We’re proud of what we see in our body of work.
In addition, we travel quite a lot and if we had CERECs breaking frequently this would be a nightmare for our staff and the dentists who cover for us. But we just don’t see it folks. With all the onlays we have done, the one’s that fail are exceedingly rare and we can always put our finger on exactly why… Either it was that bad batch of Maxem cement that we used for 4 months in 2005 (quite a hair raising story on its own), but more often, it is our misjudging some occlusal stress point. Thankfully, they are rare.
Look,.. Chuck and I have been putting in CEREC onlays for nearly 7 years. We would definitely know if there was something inherently flawed about this technology by now. We would be pulling our hair out with re-do’s. We’ve done so many, that we would be in a world of hurt. But time has passed, and so many good results and happy patients later, we continue to be amazed at how remarkably stable and predictable CEREC technology can be.
If you are one of the doctors who speak against CEREC without ever having used it or seen it used well, then you have to be honest with yourself about your motivations. You can’t possibly understand this technology without using it. CEREC can’t be too shabby if the leading dental researcher in the world – Dr. Gordon Christensen – built a multi-million dollar clinic as a CEREC teaching center.
We know the drawbacks: CEREC is an enormous investment: too much for some docs to get their head around. The learning curve is titanic if you have very high standards: too vast for some docs to get their head around. It’s definitely not for everyone. But if you’re young (ish) and you want to invest where the future is, CEREC will change your professional life entirely. Chuck and I would be glad to speak to you if you want more information about this transformational technology.