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Cerec for the Dentist

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 technology. In fact, if you had asked us how firm we felt about its worth, as much as 6 months into the learning curve (in the year 2003), the best we could have given you was a tentative thumbs up. Now though,... so many years later, we can tell you without reservation that CEREC has been the most valuable technology we have every come across. It has helped countless patients avoid root canals. It has allowed us to save teeth that would otherwise have been extracted. It has saved patient a lot of money because they don't have the expense of build-ups and root canals. It has made thousands of patients comfortable with 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. WE ONLY USE OUR CEREC MACHINES FOR ONLAYS AND COSMETIC DENTISTRY. As you may know, the vast majority of CEREC Dentists use it to spin down every tooth for a crown. We happen to think that goes against the quintessential reason this technology is superior to conventional crowns: It saves as much natural enamel as possible! But lets 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 statistics and one of them is the percent of dental work that 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 well-done crowns. Secondly, we would like to submit that all of us only see each others failures, whether its CEREC or lost fillings or bad dentures : Patients only switch dentists if the last office failed to meet their expectations. So if you have seen some disappointing CEREC's, there is likely to be"a story" that affected the outcome: Limited opening, cementation fiasco, difficult anesthesia,  etc.. We have had our share of those problems with CEREC as sell as every other dental procedure. No one can hit a home run 100% of the time. If you think you do,.. God bless you! Chuck and I NEVER pass judgement on the dental work we see from other offices. There is usually a story if things don't turn out ideal. In addition, CEREC has its limitations like any other tool and there will always be users who push the envelop, in any field. We can't speak to that issue. We keep doing what works for us.  Bottom-line: If we had seen routine problems with CEREC, we would have abandoned the technology long ago.  With every passing year, we get more and more thankful that we started SAVING our patients' enamel with CEREC onlays in 2003! Every time I sit down with a 50+ year old patient in the hygiene visit, who looks like they have no restorations in their mouth,... yet on the X-ray, I can see 6 to 8 onlays,... I absolutely marvel at our luck for having discovered this technology so early! For our part, we have been using CEREC technology since its 3D inception in March of 2003, but you may know that the technology itself has been around for nearly 25 years. Again, Chuck and I are very conservative. Of the more than 6000 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. We have had 9 intraoral cameras in our office since 1997, so we have photographed all the stages of nearly every CEREC that we've ever done. Here are some perfect examples:
	As you can see, here 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 have done a good old-fashioned gold crown. But we have had so much success with conserving enamel on teeth that look like this one,that we recommended CEREC onlays for both these teeth.
	Here is what we found 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 receive our onlays with perfect paths of insertion.
	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.
	Here are the final results: This project took about 1 hour and a half, with plenty of quality time spent chatting 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.
	Here is an example of what we call a "Hail Mary Pass from the 50 yard line". 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. Occasionally, 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. Bottom-line: We have done enough of these that we are confident about the outcomes! *** This restoration was done in May of 2004. It's still cooking,... no endo!
	Another "Hail Mary" attempt to save a tooth without endo. October 2005. Still cooking,.. no endo,... no fractures.

 

 

The previous photos of our successful "Hail Mary" efforts are always rewarding, but this picture demonstrates a very typical kind of restoration that we might do two or three times a day with CEREC. It's a beautiful thing to restore a tooth like this so thoroughly, painlessly, invisibly and simply in one visit for a patient.


After so many years of this, we would say that we simply could never go back to shaving every fragile tooth down for a crown. Its just not necessary.

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:

We are disgusted by the number of the CE courses that market themselves teaching us how to do crowns faster, better, cheaper. 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 crowns. They don't want their tooth shaved down to a stump. And we have found that its just not necessary.

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 have a "ta da" moment with every patient when we are finished and walk them through all the photos we took of every step.

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. We finish our CERECs as if good ol' Dr. Skeeters from dental school was going to come around for a check. They MUST be invisible. In short, that's one of our goals. Patients are amazed.

   

ENDO?

It still amazes us how few very deep restorations need endo when we use CEREC. In addition, 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.

We can't explain it (although maybe some researchers can) but the deepest CERECs that we do just don't give us a moments 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.

The following photos are typical of the "Hail Mary" CEREC's that we've don that help the patient AVOID ENDO for the sake of post placement, and it's still a mystery why these folks don't have post-op pain. But very few do, and most never need endo! Check out the steps through this terrific CEREC. (It still looks fine at hygiene checks!)...

   

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 so many years, we think we would have seen bonding failure routinely by now if that were going to be an issue. In fact, most of these deep margins look so good that I would be happy to show good'ol Dr. Skeeters these margins too. (THE MAN at our dental school who was most difficult to get our work to pass by in the clinic!) 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 all these 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 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 constantly. If one of us had called tech support for an issue, then the other instantly had a leg up. We could 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.

Here's something to consider very carefully: 

 

• We did not find the company itself very engaged after the sale. You might as well be set adrift. Be certain you have access to regular and immediate tech support. We had a horrifying beginning with Serona. They sold us, and 109 other doctors, old hardware that hadn't been tested with their new software. (That was worst and longest six months of our lives.) And would never have owned up to it, had we not discovered this oversight.
• We haven't needed tech support in years, but the last time we did, we were very unimpressed. The agent asked us if we had turned the machine on and off,... and did be pull down the shades in the office. Huh???
• CEREC users need an office-wide support from every staff member. We found that was not a problem after the team got comfortable with what they were seeing on X-rays and all the invisible restoration they were NOT seeing!  
• There just doesn't seem to be enough support to get over the initial hump in learning to use CEREC effectively. And we know of many CEREC machines collecting dust in offices that just couldn't endure 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 commitment to the process. 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.

  
A 51 year old realestate broker.                                  Our CEREC Make-Over, in one visit!

 

***But here is the most important thing to consider when thinking about CEREC: No one teaches CEREC onlays anymore!!!.. At least we can't seem to find any continuing education out there!..

We think we may be among a very tiny, TINY minority of dentists using the machine for its best purpose: conservative enamel preservation!

We walked out of our last CEREC continuing education course after only a couple hours, after giving the whole room a lecture about how shameful they were all being. WOW!... We could not believe our ears. The whole course was designed around getting the doctor in and out of the room in minutes: leaving the often high school educated dental assistant to make most of the highly-technical decisions about onlay design. We were just appalled! In addition, everything being taught revolved around making crowns. We saw slide after slide of teeth unnecessarily being shaved down for crowns. 

After about 3 hours of that, I raised my hand and told the room a story that had really happened that very week. And here it is...

One morning I came into a treatment room and said "Hello! How are you John?", to my first patient. John was a hard working man who I watched repairing the city sidewalks outside our office. John looked up at me with a toothy grin and said, "Well hello Dr. Lynda! How are you?" I said - in a matter of habit - "Fine John. Just great!"  And then he said, "No REALLY. How ARE you?!"  He fixed me with a warm but serious gaze. I said, "I'm really good!". Then he stopped me in my tracks... He said, "Well, I want to make sure you are fine, Dr. Lynda. I'm paying you almost a thousand dollars an hour to fix my tooth. I have a very bad back, and live on Advil, for the work I did to make that thousand dollars. I want to be certain you are at your best this morning." 

Whowa!... I remember, to this day, exactly where I was standing when he said that to me!.. I was transfixed. He was absolutely right to bring my focus exactly where it should be: On him... On doing my VERY best... On giving him all MY time... Not my assistant's time!..  Not a 1 minute crown prep! I was going to give him the best all porcelain onlay that a patient ever had!

And fron that day forward, I have looked at every Onlay, like it was John's onlay.

So,.. that's my little sermon folks on being mindful about our responsibility to do the right thing, 100% of the time for our patients. CEREC onlays,... not crowns,... Done with my many years of expertise,.. are the right thing for 95% of the teeth that any other dentist would put a crown on.

 

 

WHAT TO LOOK FOR ON X-RAYS?

Now that we have 10 years worth of X-rays on our patients, we feel we can really demonstrate many of the points I've just mentioned. 

In addition, you should know that we see our CERECs done under extreme stress from our initial few months with the technology. If you are an "early adopter" of technologies, this story might sound familiar: When we bought our CEREC machine for $80,000 in 2003, Serona gave us their new 3D software, without having tested it on the hardware they sold us. Of course, the incompatibilities were numerous because they had done NO Beta Testing. We struggled to learn and use the technology for 8 months. Finally, ONLY AFTER we demanded our money back, they owned up to the problems and replaced all our equipment. It's was the darkest professional nightmare of our careers.

That said, we have X-rays of CERECs that have a lot of cement under them, because of the computer inaccuracies. We are still surprised when we see them on X-rays because the teeth are healthy, and the restorations still flawlessly sealed! 

 date of BW X-ray:  April 2011

#19 and #18 were done in those dark days of 2003. Thick cement, but still look great!

 

 

 

 

 Xray taken December 2011

#18 was probably one that I needed Ibuprofen after cementing,... But it still looks great!

Even the cement under #13 is a bit thicker that we now see it. It's cerca 2006 or so. In 2012, our cement layer is never that thick.

 

 

 X-ray taken September 2011 

These two (#13 and #14) are a couple that were some nightmare-ish project in 2003 when CEREC sold us the computer software that was not compatible with hardware. (What a nightmare!) The onlays are still serving just fine and look great in the mouth. This technology may be more forgiving than anybody ever dreamed as long as you have superb bonding technique,.. which we have always taken pride in!

 X-rays taken January 1012

This is more typical of well-cemented CERECs on #31, #30, #29. Done in late 2011. The cement layers are very thin these days on X-ray inspection.

*** Incidentally,.. In this x-ray you can see that the porcelain was chiped on the distal box of #29,.. BUT.. the bond at the cervical margin of the onlay stayed in tact.  Only a small piece of the occlusal porcelain was lost. This woman was a unapologetic hard candy chewer and she admitted putting her teeth through the mill.  Our policy on replacement of failed CEREC's is that if they fail within 5 years, we replace them for free. This one was 9 years old, so we just ended up taking out the old CEREC - it's not that easy - and making her a slightly larger onlay with a bit thicker marginal ridge to stand up to the beating. 

 

So what about the sub-par CERECs?

Of course we've seen some crummy CEREC restorations, (if they are ours, we replace them FOR 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 that we are faced with several times a year: 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 always see during that process, we get a terrific sampling of our results,..  and were proud of what we see in our "body of work".

In addition, we travel quite a lot,..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  that  we have done, the ones 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. And as I mentioned, we are always good about replacing things for free when we think we could have done better.

Look...  Chuck and I would definitely know if there was something inherently flawed about this technology by now. We would be pulling our hair out with re-dos. 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 cant possibly understand this technology without using it. We don't say that to be confrontational... It's just such a new way of thinking in restorative dentistry. You truly can't appreciate it without having experienced success with it, over, and over, and over.

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.

Its 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. And it will change your patients' dental future if you only use CEREC to do onlays. Chuck and I would be glad to speak to you if you want more information about this transformational technology. Just call! We are very happy to help!