Monaldo SaracinelliI’ve been a student of prof. Fabio Toffenetti and Riccardo Garberoglio.
Jordi ManautaWas born in Mexico City, where he graduated cum laude. in dentistry from UNITEC.
Daniele RondoniBorn in Savona in 1961 where he lives and has worked in his own laboratory since...
Vincenzo MusellaVincenzo Musella graduated in dental technician. Proud friend and student of...
Giuseppe MarchettiGiuseppe Marchetti was born in Parma (Italy) in October of 1972 and graduated from...
Simone GrandiniChair of Endodontics and Restorative Dentistry, University of Siena, Italy.
Giovanna OrsiniGiovanna Orsini is a well known researcher in Italy and internationally.
Paulo MonteiroMy passion for esthetic dentistry began when I attended the last year...
Louis HardanHead of Restorative and Esthetic department in Saint-Joseph University in...
Patrizia LucchiPatrizia Lucchi Graduated in Dentistry cum Laude in 1995 at the University of Verona
Anna SalatDr Anna Salat graduated with a degree in dentistry from the International University of Catalonia…
Giulio PavolucciAfter graduation magna cum laude in Dentistry, I started focusing my daily work on...
Marcos VargasDr. Marcos Vargas attended Cayetano Heredia University School of Dentistry in Lima...
Stefan KoubiDr. Koubi graduated from University of Marseille where he...
Engin TavilogluDr. Taviloglu graduated from ?stanbul University School of Dentistry in...
Dimitar FiltchevCo-founder of the Laser Dental Center and the Implant...
Angie SegattoMy commitment to arts has determined my specialisation.
Gregory CamaleonteI was born in 1980 in Marseille-France and i have graduated in 2006 from...
Caroline WerkhovenCaroline Werkhoven graduated in 2002 at ACTA, the dental faculty in Amsterdam..
Ajay JunejaAjay Juneja finished his BDS in the year 1995...
Carlos Fernández VillaresMember of SEPES Spanish Soc...
Sulivan LeiteSulivan Leite graduated from the Ribeirao...
Giuseppe ChioderaMy name is Giuseppe Chiodera , i was born born in 1979 in Brescia .
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Janos GroszGraduated summa cum laude in 2006 from the University of Szeged, Faculty of Dentistry, Hungary...
EVENTS BY THIS MEMBER
ARTICLES PUBLISHED BY THIS AUTHOR
The use of composites in the rehabilitation of worn dentition was discussed in my article published on the Style Italiano web page in Feb 2016 (http://www.styleitaliano.org/full-mouth-composite-rehabilitation).
In this article I will explain four very important steps of composite occlusal rehabilitation that will make this procedure more repeatable for every dentist.
Clinical Case Overview
A 45-year-old female patient with fair oral hygiene presented at the surgery asking for new full porcelain crowns on two upper central incisors (Fig 1). Her existing porcelain crowns, made 12 years ago, were not aesthetic due to chipping. Moreover, the anterior teeth were overloaded and indicated fremitus (a vibration palpable when the teeth come into contact with each other) on the two upper central incisors.
Identifying fremitus only requires placing the fingernail/tip of our index finger lightly on the facial surfaces of the teeth and asking patient to “tap-tap” gently and firmly, then grind around. If you feel any movement or vibration… fremitus is present.
The upper central incisors were root canal treated teeth (Fig 2), and the right one in particular was structurally compromised by a fibre post cemented in the past.
The patient mentioned that her lower anteriors had worn considerably in the last five years. Wear pattern on the facial mandibular anterior teeth was observed.
Her medical history was unremarkable; the patient was healthy with no contraindications to dental treatment.
The maximum opening was 45 mm, the range of motion was normal, and there was no deviation on opening. No clicking, popping, or crepitus could be detected in either joint. Dawson Loading test findings were negative.
Step A. Plan the Aesthetics of the Upper Anterior Teeth.
It is crucial to understand the aesthetics that we would like to achieve at the end of the treatment. Therefore we need to plan the length of the upper anteriors and evaluate their relation to the upper and lower lip in the rest position and during smiling and talking (phonetic evaluation).
In this particular case the patient was satisfied with the length of the previous crowns, being concerned only with the slight “black triangle” between her upper central incisors and gum recession around the gingival margin of the porcelain crowns.
The aesthetic plan was confirmed with DSD and a mock-up procedure.
Step B. Find the “0” Position for your Restorative Treatment: Centric Relation (CR) Position Using the Kois Deprogrammer.
The Kois Deprogrammer (KD) was used for four weeks, in order to deprogramme the patient and record the centric relation (CR) position.
A constricted chewing pattern was confirmed by means of the deprogrammer (anterior initial contact - following deprogramming).
A facebow transfer was performed and the upper and lower jaw study models were mounted in the articulator in order to obtain a diagnostic wax-up
Step C. Plan the Volume of Restorations in the Posterior Teeth: Functional Wax-up
How much should the occlusal vertical dimension be altered?
The minimum necessary to satisfy restorative objectives (Kois, J: “Course Manual - Functional Occlusion II”).
A functional wax-up was fabricated in order to increase the vertical dimension and ensure a sufficient envelope of function for the previously accepted length of the anterior teeth (Fig 8 ).
Step D. Restorative Phase
Direct Composite Reconstructions - Posterior teeth (increasing OVD): Occlusal Direct Composite Restorations on teeth: 38, 37, 35, 34, 44, 46, 47 and 48.
A transparent silicon index (Memosil 2, Hereus Kulzer) was created by means of the wax-up prepared earlier. Then the silicon was trimmed using surgical blade No 15 (Swann-Morton), in order to use a single index for each separate tooth. The posterior teeth were isolated with a rubber dam, and each of tooth was restored separately using the following protocol:
- Air abrasion with 50 m aluminium oxide / rotary instrument for delicate abrasion of the enamel surface.
- Enamel etching
- Applying bond (G-PremioBOND, GC) (followed by leaving for 10 s undisturbed, 5 s intensive drying, and 20s curing).
- To avoid risk of an excess of restorative material, two metal matrices (mesial and distal) were placed.
- Try-in of the previously trimmed transparent index for proper fitting (this should be checked both on the cast and intra-orally, after placement of metal matrices).
- Placement of the first part of the composite layers (inner dentin layers, MD, Essentia, GC) on the cusps of the tooth with LM Arte Applica.
- Placement of the index, and polymerisation of the first layers, initially for 60 s.
- Placement of the second part of the composite layers (outer enamel layers, LE, Essentia, GC) inside the transparent index. Then, with the index inside the mouth, delicate finger pressure was maintained and excess composite was removed with LM Arte Fissura.
- Polymerisation of the enamel layers, initially for 60 s.
- Final 60 s mesial and 60 s distal polymerisation after index removal.
- Careful removal of excess composite by means of LM Eccesso, surgical blade no 12 and Soflex discs.
Anterior teeth: Direct Composite Reconstructions
In accordance with the wax-up, the silicon index (this time hard laboratory silicon) was taken and cut in such a way as to facilitate the composite reconstruction. .
The incisal parts of the teeth were abraded with 50 micron aluminium oxide particles.
On the incisal vestibular edge, a 1mm chamfer was obtained using a diamond ball tip and the lower part of the chamfer was delicately elongated with a bevel (around 0.5 mm).
The enamel was etched with 38% phosphoric acid for 20 s, then the G- PremioBOND adhesive was meticulously placed on the dentin and enamel, rinsed with air and light-cured for 20 s.
The first layer of the composite resin (LE, Essentia, GC) was placed on the silicon index in order to create the lingual wall of the teeth. Next, the approximal walls were built utilising Blue View Varistrip (Garisson) matrices and, again, enamel composite resin. In this way a kind of frame was created to make the final composite layering much easier.
When the enamel frame had been created, all that remained was to achieve the right proportion between the dentin and enamel resin material, which was achieved using a Misura instrument. After final polymerisation and removal of excess composite, the appropriate characterisation was obtained.
Screw-retained implant-supported crowns: teeth 35, 45 and 46.
Full porcelain crowns on upper central incisors (Lithium disilicate)
The old full porcelain crowns were removed and temporary acrylic crowns were obtained for 14 days. Then, following the final impression, lithium disilicate porcelain crowns were fabricated in the laboratory with special attention being paid to closing “the black triangles”. After aesthetic and functional try-in, the inner parts of the crowns were etched with hydrofluoric acid for 20 s, then meticulously rinsed, dried and treated with G- Multi Primer (GC). Teeth 11 and 21 were delicately abraded with 27 micron aluminium oxide particles, rinsed, dried, and treated with G- Premio Bond (GC). Lithium disilicate crowns were simultaneously luted with G-CEM LinkForce.
When composite reconstructions had been completed, an occlusal check was carried out in order to achieve:
- Equal, simultaneous bilateral posterior contacts
- Anterior guidance
- Canine guidance
In the last century, cast metal post represented the method of choice in the philosophy of root canal tooth reconstruction. The procedure usually involved the use of a porcelain fused to metal crown, but in the 1990s full porcelain crowns started to replace the metal base crowns and the problem of how to hide severe tooth discolourations or metal posts arose.
The era of microscopes and ultrasonic devices in endodontics brought the possibility of metal post removal, which may be rational in the event that retreatment is necessary, but can be very risky in terms of dental tissue loss.
There are several indications and contraindications of metal post removal, which are summarised in Img. 1, but the most important rule today should be the preservation of the coronal and radicular tooth structure, which is essential for the long-term success of endodontically treated teeth.
A female patient reported in the dental office in order to improve her smile because she did not like her left upper central incisor that had been restored with a porcelain crown (Img. 2, 3). The colour and shape of the crown did not match the neighbouring teeth. DSD analysis revealed a discrepancy between the midline of the two central upper incisors and the vertical reference line - the face midline (Img. 4, 5).
Functional analysis was performed, and after four weeks of Kois Deprogrammer application, the premature occlusal contacts were removed and stabile bilateral occlusion was confirmed.
Based on DSD analysis, the mock-up procedure was carried out and it was decided that the best solution would be to change the shape of both upper central incisors and to correct the midline between teeth 11 and 22. The patient refused the orthodontic option, and we decided to carry out two restorations: a crown in tooth 21 and veneer in tooth 11, both from the same ceramic material - lithium disilicate.
The colour of tooth 21, previously restored with a metal post, posed a potential problem.
The periapical and endodontic status of tooth 21 were acceptable (Img. 6), and there was no need for retreatment. The removal of the metal post and replacement with a fiber post could be aesthetically beneficial, but could compromise the remaining dentin and create a structural risk for future restoration. Therefore, the complicated procedure of metal post removal for purely aesthetic reasons was not indicated.
Instead, an opaque layer of composite material was planned to be placed over the buccally reduced cast core in order to decrease the light absorption and increase the reflectance of the metal. The desired effect was to raise the value of the core in order to approach the visual qualities of dentin. This allows more depth and translucence of the crown, as light penetrates further into it.
The PFM crown was removed from tooth 21 (Img. 7-9), and after rubber dam isolation the buccal 0.5 mm of the metal post was removed (Img. 10). This procedure can be easily done with an Amalgam Remover H32 (Komet) drill or diamond drill suitable for crown preparation.
Then, the metal post was sand-blasted (AquaCare Dental Air Abrasion) with 53 micron aluminium oxide particles (proCut, Coarse Cutting Powder) (Img 11)and the three functional monomers (4-MET, MDP and MDTP) adhesive system (G-Premio Bond, GC) was applied on the metal core and supra-gingival tooth structure in order to provide adhesion to both the dentin and the metal.
Next, the metal surface was covered by two thin layers of opaque composite resin (Essentia Masking Liner, GC), followed by a soft viscosity composite dentin layer (Essentia MD, GC) with the use of a brush in order to create a masking thickness of 0.5 mm in total. The last layer was placed with a little overextension on the remaining tooth structure (Img. 12).
The pre-prepared shell crown (polymethyl methacrylate, Unifast Trad; GC) was then adjusted and relined directly on the tooth abutment (Img. 13-15).
The final preparation and impression taking was postponed for one month later and in meantime the teeth bleaching was obtained in the lower and upper arch (6% Hydrogen Peroxide, WHITE DENTAL BEAUTY, Optident)
The silicon index was prepared based on the wax-up. At the next appointment, the minimal veneer preparation and final crown preparation were carried out, followed by impressions and face-bow registration (Img. 16-20).
The dental technician prepared two lithium disilicate ceramic restorations (E-Max, Ivoclar), which were cemented with dual-cure adhesive luting cement (G-CEM LinkForce, GC) (Img. 21-24). First, the porcelain veneer was cemented in rubber dam isolation (Img. 25) Then, after adequate light-curing and the removal of excess cement, the porcelain crown was double checked for proper fitting before being cemented into its final position (Img. 26, 27).