Maciej Zarow

Dr. Maciej Zarow graduates from Semmelweis University in Budapest in 1995. After a three years training program he achieved specialization in Operative Dentistry in 1999. From 1998 till 2005 he was teaching at Jagiellonian Uniwersity in Krakow, where in 2002 he defended PhD and in 2005 he achieved specialization in endodontics. Co- author of more than 60 papers published in Polish and international journals. Author of book edited by Quintessence Publishing: “Endo-Prosthodontics: guidelines for clinical practice” (2013, in Polish, 2014 in Russian, 2015/16 in English). Since 2012 – Editor-in-chief of Medycyna Praktyczna – Stomatologia, dental magazine in Polish language. He has lectured extensively in Poland and other European countries. He runs a private dental clinic (since 1999) and postgraduate course centre (since 2003) in Krakow, Poland (2013, in Polish, 2014 in Russian, 2015/16 in English). Since 2012 – Editor-in-chief of Medycyna Praktyczna – Stomatologia, dental magazine in Polish language. He has lectured extensively in Poland and other European countries.
Dr. Maciej Zarow graduates from Semmelweis University in Budapest in 1995. After a three years training program he achieved specialization in Operative Dentistry in 1999. From 1998 till 2005 he was teaching at Jagiellonian Uniwersity in Krakow, where in 2002 he defended PhD and in 2005 he achieved specialization in endodontics. Co- author of more than 60 papers published in Polish and international journals. Author of book edited by Quintessence Publishing: “Endo-Prosthodontics: guidelines for clinical practice” (2013, in Polish, 2014 in Russian, 2015/16 in English). Since 2012 – Editor-in-chief of Medycyna Praktyczna – Stomatologia, dental magazine in Polish language. He has lectured extensively in Poland and other European countries. He runs a private dental clinic (since 1999) and postgraduate course centre (since 2003) in Krakow, Poland (2013, in Polish, 2014 in Russian, 2015/16 in English). Since 2012 – Editor-in-chief of Medycyna Praktyczna – Stomatologia, dental magazine in Polish language. He has lectured extensively in Poland and other European countries.

EVENTS BY THIS MEMBER

ARTICLES PUBLISHED BY THIS AUTHOR

The use of composites in rehabilitation of worn dentition has been widely discussed in recent years (Ammannato R, D Arcangelo C, Dietschi D, Spreafico R, Vailati, F, Vanini L). The thicknesses of the composite layers along with simplification of the protocols, were significant in allowing more predictable restoration in terms of aesthetics and final colour (Devoto W, Putignano A, Manauta J, Salat A, Paolone G, Hardan LS). On the other hand, concerning the occlusal problems, Dr John Kois managed to simplify the treatment. He teaches his system describing just three steps, which he terms P1, P2 and P3, which should be followed in strict order. First is to place the condyles in a stable position (P1). Next, the posterior tooth contacts should be balanced in maximum intercuspation (P2). Finally, the anterior tooth guidance should be built (P3) so it falls within the envelope of function. Each step should be completed before moving to the next. Connecting the knowledge arising from the above mentioned sources the question can be expressed: are we able in certain cases to obtain full-mouth rehabilitation of worn dentition in a simpler, predictable and repeatable way. This clinical article describes full arch direct composite reconstruction, performed during a one-chair appointment. It has to be noted that patients undergoing such a procedure need adequate preclinical evaluation, treatment planning and eventually pre-restorative treatment of TMJ. This article focuses on lower arch reconstruction with final direct composite restorations. The front upper teeth were reconstructed with direct composite restorations as well. However, six porcelain veneers were planned and fabricated later, during following appointments, as the final treatment of the upper jaw. Clinical case overview A 55 –year-old man with fair oral hygiene presented seeking aesthetic improvement. His anterior teeth had worn significantly in previous 20years making his smile efforts difficult. The medical history was unremarkable. He was healthy with no contraindications to dental treatment. Temporomandibular Joints: The maximum opening was 43 mm, normal 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. The most probable reason of anterior teeth wearing was constricted path of the mandible closure. Treatment Planning A complete facial evaluation, intra-oral and extra-oral photographs, upper and lower study models, and a facebow transfer were performed for a diagnostic wax-up. As it was planned to increase the OVD following the aesthetic analysis, the Kois Deprogrammer (KD) was obtained for four weeks to deprogram the patient and find the centric relation (CR) position. Many studies concerning full-mouth rehabilitation associated with increasing the OVD have shown that it is preferable to plan such cases in a CR position this being acceptable and reproducible. CR has been well described in the literature and, although easy to understand, clinical success is often elusive. Anyone who has attempted to mount cases in CR knows that some patients can be extremely difficult to manage regarding accurate bite relationships. The deprogrammer has been found to be an effective device for achieving these bite registrations. It has several other uses as well, and is an invaluable tool in diagnosing the three most common types of abnormal occlusal attrition: occlusal dysfunction, parafunction (e.g., bruxism), and constricted path of closure. After four weeks of deprogramming, the CR was recorded and a treatment plan was simulated with the wax-up. When is the patient deprogrammed? The patient is deprogrammed when he or she reproduces the same single spot on the KD platform without guidance or support. The spot needs to be repeatable. The aesthetic analysis was carried out (analysis of the face, phonetic analysis, and display of the central incisors) in order to understand the planned length of the upper anteriors (with approx. 2 mm of central incisors displayed when lips are reposed). The Digital Smile Design protocol was obtained (comprising a set of photographs and key note presentation) in order to transfer more visible information to the laboratory and produce a predictable aesthetic wax-up. The aesthetics of the mock-up made of temporary resin were evaluated by means of an appropriate set of photos of the face, smile and teeth, and accepted by the patient and the dental team. Then the functional wax-up was prepared in order to increase the vertical dimension and ensure sufficient space for anterior aesthetic reconstruction. The final goal of such rehabilitation is to provide efficient anterior guidance and stability in the posterior areas, with stable occlusion. Restorative Treatment Posterior Teeth The transparent silicon index (Memosil 2, Hereus Kulzer) was created by means of a wax-up cast. Then the silicon was trimmed using surgical blade No 15 (Swann-Morton), in order to use a single index for each separate tooth (according to Ammannato R). The posterior teeth were isolated with a rubber dam, and each of the teeth were restored separately using the following protocol: - air abrasion with 50 µm aluminium oxide / rotary instrument delicate abrasion of the enamel surface - enamel etching - applying bond (G- PremioBOND, GC) (followed by leaving 10 s undisturbed, 5 s intensive drying and 20s curing) - placement of two metal matrices, mesially and distally to the tooth being restored - try-in of 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 polymerization 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 composite access was removed with LM Arte Fissura - polymerization of the enamel layers, initially for 60 s - final 60 s mesial and 60 s distal polymerization after index removal - careful removal of the composite excess by means of LM Eccesso, surgical blade no 12 and Soflex discs Anterior teeth: When all posteriors of the lower arch had been restored, the lower anteriors were isolated and prepared for composite reconstruction. According to 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 utilizing 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, the only remaining difficulty was to achieve the right proportion between the dentin and enamel resin material, which was achieved using a Misura instrument. After final polymerization and removal of the composite excess, the appropriate characterization was obtained. In the following stage the upper anteriors were reconstructed with composite material following a protocol similar to that applied for the lower anteriors. However, in case of upper anteriors, six porcelain veneers were planned as the final point of the treatment plan. 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 (however, last two points would be finalised with porcelain veneers). Some minor occlusal adjustments were made in order to eliminate points of contact and transfer overloaded surfaces into posterior point contacts (Bausch thick articulating paper; Accufilm II Red /Red, Parkel - 21 microns for micro-occlusal corrections; Shimstock 8 µm) Then the patient was seated upright at 45 degrees, and he was asked to reproduce normal chewing motions while a piece of 200 micron articulating paper was held in place. Where streaks were noted on the vestibular surfaces of the lower anteriors, the surfaces were modified in order to reduce the friction between the lower and upper anteriors, and to reduce the risk of failure of the composite restoration. After the functional occlusal corrections were made, the final polishing was obtained using GC polishing paste and a goat-hair brush. The patient was recalled five days later for additional occlusal check and final adjustments. As a final aesthetic treatment to the upper anterior teeth (13 to 23), six porcelain veneers were fabricated on the following appointments.
Before reconstruction of a root canal treated anterior tooth, the walking bleach technique should always be considered. If the treatment plan includes a prosthetic crown, the aim of internal bleaching is to improve in the colour around the cervical area and coronal portion of the root. These details will determine the final aesthetics within the gingival area. The walking bleach technique is therefore the procedure of choice in such cases. The protocol of internal bleaching was carefully described in the article “Non-Vital Tooth bleaching” published on StyleItaliano (http://www.styleitaliano.org/maciej-zarow-non-vital-tooth-bleaching). The most popular and the safest material for this purpose is still that which has been used routinely in clinical practice for several decades. This is, a paste prepared ad hoc, composed of sodium perborate and 3% H2O2 or distilled water. This article presents a case report of the aesthetic treatment in a case of a severely discoloured root canal treated tooth, where there was a contraindication for internal bleaching. What are the contraindications for internal bleaching? The most important factor in bleaching effectiveness seems to be precise removal of all restorative materials from the access cavity without additional dentin elimination. ?Dentin has to be cleaned in order to facilitate diffusion of the bleaching agent through the dentinal tubules. If a fiber post was cemented in the root canal and the pulp chamber was filled with composite resin, removing the restorative material and post can compromise the amount of sound dentin. Therefore, such a case calls for careful evaluation of aesthetic benefits vs. structural sacrifice.? Other contraindications for internal bleaching include: discolourations caused by amalgam or other metallic materials (not bleachable) Significant dentin loss in the cervical portion (risk of fracture and leakage of bleaching agent) Extensive restorations Visible cracks, especially with subgingival extension (risk of bleaching agent penetrating towards periodontal ligaments) Young patients (<19 years old) A 31-year-old male patient presented in our dental clinic in order to improve the aesthetics of a severely discoloured root canal treated right central incisor (Img. 1-4). Discoloration had been present for more than 10 years, and previous treatment had included fiber post placement. The discoloured tooth had two old composite resin III-class restorations: mesial one, and distal one, and additionally slightly worn incisal edge (Img. 3). The patient was deprogrammed using the Kois Deprogrammer, for four weeks. Minor premature occlusal interferences in posteriors were removed (the patient was occlusally equilibrated). The root canal obturation performed in the past was acceptable. The treatment plan did not consider internal bleaching, as the fiber post had been cemented in the past. The walking bleach technique would, in this case, require the removal of sound structure, thus creating structural risk. Therefore the aesthetic treatment without intervention into the pulp chamber was planned. External bleaching with 6% hydrogen peroxide (Novon technology, Optident) was carried out on the upper and lower arch (Img. 5-7). Three weeks after external bleaching, the composite restorations were replaced and two porcelain veneers were considered to be the best possible treatment option in this case. It can be concluded that three main benefits arose from the above-mentioned treatment plan: 1. It is easier to mask severe discoloration using laboratory techniques; 2. It is much more predictable to perform two symmetrical veneers on two central incisors, than a single, asymmetrical one with unpredictable aesthetic outcome 3. We could improve the symmetry of anterior guidance with the veneers (benefiting function) ?A digital smile design (DSD) plan was created and sent to the laboratory so that a wax-up could be created (Img. 8). Then the temporary resin mock up was made, and presented to the patient in order to discuss the final outcome (Img. 9). After the patient’s acceptance, two upper central incisors were prepared for porcelain veneers with the use of a silicon index in the horizontal and vertical planes (Img. 10-12). An impression was taken using polyvinyl-siloxane material (Flexitime, Hereus), and the dental laboratory created two feldspathic porcelain veneers. At the next appointment the porcelain veneers were tried in by means of glycerin gel (Img. 13). Then the porcelain was etched with 10% HF for 90 s and cleaned in an ultrasonic bath (5 min). Finally, silane was applied to the dried porcelain surface in several layers, and one coat of adhesive resin was applied followed by gentle thinning with air. After rubber dam isolation the porcelain veneers were cemented simultaneously with the composite resin cement (Img. 14-18).

Introduction

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.

Temporomandibular Joints
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

Step D1.
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.

Step D2
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.


Step D3 
Screw-retained implant-supported crowns: teeth 35, 45 and 46.

Step D4 

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.

Case Study

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).

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