IPS e.max HT in the esthetic zone
I know there is a lot of discussion about what materials to use in the anterior zone. I don't think there is necessarily a universal answer but what I've learned over the years is to understand the properties of these materials and their strengths and weaknesses.
In general, I'm trying to use Feldspathic porcelain (VITABLOCS typically for me Mark II or TriLuxe) or Leucite Re-inforced Glass Ceramics (IPS Empress) in the anterior region. I feel like they have more vitality, given the right case, you can just mill polish and cement and get a really nice result. This is a case with VITA TriLuxe 1M2 polish only
I know the go-to block when using e.max in the anterior region is e.max MT. I really like the block and use it quite often as well. My point for this discussion is that a lot of doctors will shy away from e.max HT. There is the big fear of the dreaded "grey" crown or a crown that has "low" value. It is a real concern. I've had it happen to me and if you aren't careful, it can happen quite easily. This was my first case I posted on CEREC doctors and at the time I thought it was quite good. Now I would have approached it differently because of the "low" value of #8,9.
This case I did about a year ago. It's not perfect but it is a vast improvement over what she started with. She is quite happy, but I always evaluate my photos and have other CEREC doctors look at them and give me their feedback. Dr. Tom Monahan and I share cases back and forth, and aren't afraid to pick apart our cases. It makes us better and I would encourage you to do the same.
So I chose HT for this case because I felt like I did see some C-tones in this case. I felt like MT would be too bright or high in value for this and I didn't feel great about using Feldspathic on this case because of limited space on the lingual. So I used A1 HT. I compensated about 2 shades in order to offset the drop in value. I wish I would have taken a pre-op pic with a shade tab but she was closer to A3.
There are a lot of ways to approach these anterior cases, but I felt like e.max HT was the best solution and what I saw for the case in my eyes.
Thanks for sharing that Dan! Really nice examples showing what each of these materials might do, and your thought process on approaching each.
Nice cases Daniel.
I also like the vita and empress multi blocks for anteriors.
What is your criteria for choosing one over other(vita,empress) if any ?
thank you
Gautam
Hi Daniel, nice cases and thanks for sharing!
I would love to see lower jaw +bite of that last case where you changed old pfms to emax. There seems to be crowding on lower jaw or tongue thrust which is making a diastema between centrals after 1 year. There is a good change that original pfms were made so that there were no diastema
Great post Dan - Thanks for posting this! As you noted, the MT shades, although preferred in the anterior region, are often too bright when trying to get them to match the remaining dentition. Additionally the range of shade availability for the MT's is rather limited as opposed to the LT's and HT's. I too like using the feldspathics in the anterior region when possible, but often the occlusal forces and parafunctional habits preclude me from using the feldspathics (in many cases restoring multiple anteriors are a result of existing parafunctional issues, and often times patients don't want to deal with ortho).
Winnie
Great comment Marko. I didn’t emphasize the tongue thrust enough to the patient and she didn’t return to the office for over a year. I see it starting to open. We briefly spoke about it last appointment but there was other issues periodontally that popped up as well.
I’m on my phone and don’t have access to a computer but I’ll post some photos and further comment on the other questions too.
This was my first case I posted on CEREC doctors and at the time I thought it was quite good. Now I would have approached it differently because of the "low" value of #8,9.Hi What would be your block selection today if you were going to replace those crowns??
@Harry: probably VITA TriLuxe. When I see patients that have more characterization in their teeth I will tend to choose TriLuxe
@Gautam: general criteria for VITA Mark II:
I like to use this on cases with some darker stumps. I will subopaque with Cosmedent opaquers. Also, I will use on patients that don’t have much translucency or brighter cases since it comes in an 0M1. TriLuxe and TriLuxe Forte do not.
TriLuxe for cases where there is some translucency or character.
Empress Multi for brighter cases. Personally I tend to use Empress the least but that isn’t because it isn’t a nice block I just tend to use VITA a lot more and I’m more comfortable with what I see and what I can accomplish with VITA.
On 8/24/2018 at 11:45 pm, Marko Ahonen said... Hi Daniel, nice cases and thanks for sharing! I would love to see lower jaw +bite of that last case where you changed old pfms to emax. There seems to be crowding on lower jaw or tongue thrust which is making a diastema between centrals after 1 year. There is a good change that original pfms were made so that there were no diastema
@Marko: Here are the pics. I think you are right on the money with the tongue thrust. I will be referring her to an oral myofunctional therapist and ruling out an airway issue.
Great insight Dan!
We absolutely use HT in the anterior.
We shy away from ultimatums like...... " I never use HT in the anterior.....I always use LT in the posterior only"
We use whichever shade and translucency best fits the patient which can be any translucency. Using our custom milled out emax shade and translucency guide, I am quite surprised at how often HT actually looks best when trying to match a single unit to their existing dentition.
I must say I am a little hurt though; I thought Tom only traded pics with me 
What thickness did you mill put your “custom” shade guide to for each shade tab?
And Tom looks like he has some explaining to do to me. You can have Michael Snider to talk about contouring and staining and glaze after the restoration comes out of the miller
On 8/27/2018 at 8:26 am, Daniel Wilson said... What thickness did you mill put your “custom” shade guide to for each shade tab? And Tom looks like he has some explaining to do to me. You can have Michael Snider to talk about contouring and staining and glaze after the restoration comes out of the miller
Hence, Snider's constant fascination with Miller Time!
Jake,
I share with everyone, sorry to burst your bubble 
.
Dan,
As far as the eMax HT discussion goes, I think it has its place. I'm just a huge fan of it on posteriors with high margins and not a lot of restorations in the same quadrant. It works beautifully. On anterior teeth, I think we just have so many better options as far as mimicking nature. eMax HT is so depending on the thickness of the material as well as the underlying tooth structure. The variables you get with it are hard to control with a chairside approach. That is why I'm always amazed when Kris, Dan, and others on here can make it look great in the anterior. This case is about 3 years old, but this is what I will normally see.
Prep was non eventful. Just replacing an old 3/4 crown on my assistant that was a peg lateral. 
This was eMax HT B1 at try in.
This was the Vita Mark 2 1M1 at try in. 
Again, just my preference. I think depending on the clinician you can make it work, it's just too tough especially when you start involving multiple teeth to control the value. So nowadays, if I am using eMax in the anterior I'll stick with MT or LT (if matching PFMs)
Cheerio,
Tom
Really incredible work Dan!
Tom, I've had the same thing happen with e.max HT in the anterior. Once I started picking blocks a few shaded lighter in value like Dan mentioned, this issue went away. The last case I did was a match for C1 so I picked an A1 Ht block and it turned out great.
On 8/27/2018 at 10:18 am, Daniel Butterman said...Really incredible work Dan!
Tom, I've had the same thing happen with e.max HT in the anterior. Once I started picking blocks a few shaded lighter in value like Dan mentioned, this issue went away. The last case I did was a match for C1 so I picked an A1 Ht block and it turned out great.
Dan,
I agree with your statement. I'll do the same thing on posterior teeth, but I have just had a hard time with that on anteriors. Thanks for the tip.
Tom
If we are talking about blocks I wish Ivoclar rolled out, it is something Mike Skramstad has been asking for a while now. B32 bridge block in MT.
Dan, I'm not sure, I will have to look that up but it was a #6 that I milled out of left over blocks for each shade and translucency. It was a standard emax prep with my emax preset paramaters....
We glued them on tabs, and it's been working out great.
Tom, everyone huh? So you're just like the neighborhood bike I guess. Everyone gets a ride. :)
