Full-mouth composite rehabilitation in one day.
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.
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.
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
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.
Fig 1.- The photo of the patients smile
Fig 2.- Lips in the rest position
Fig 3.- The clinical situation and diagnostic casts before the treatment
Fig 4.- Lower and upper arch in slightly open position
Fig 5.- The upper anterior teeth on black background
Fig 6.- Lower arch before treatment
Fig 7.- Upper arch before treatment
Fig 8.- Slide from DSD presentation demonstrating the planned length of the teeth
Fig 9.- The first wax-up of upper anteriors, created in order to obtain a mock-up and explain the planned aesthetics to the patient; the wax-up of the lower arch, performed in order to increase OVD and the transparent silicon index?
Fig 10.- ?The index was trimmed for each separate tooth
Fig 11.- The surface of the enamel was air abraded with 50 µm aluminium oxide and any sharp edges smoothed using a rotary instrument.
Fig 12.- The enamel was etched and meticulously rinsed
Fig 13.- Placement of the first part of the composite layers (inner dentin layer)?
Fig 14.- Placement of the first part of the composite layers (inner dentin layer)?
Fig 15.- Placement of the second part of the composite layers (outer enamel layers) inside the transparent index, then with the index inside the mouth
Fig 16.- The lower anterior teeth isolated with rubber dam.
Fig 17.- On the incisal vestibular edge, a 1mm chamfer was obtained using a diamond ball tip
Fig 18.- The lower part of the chamfer was delicately elongated with bevel (around 0.5 mm)
Fig 19.- The margin was polished
Fig 20.- A kind of frame was created from enamel composite to make the final layering much easier
Fig 21.- The layers of dentin material were placed and checked for appropriate thickness before polymerisation
Fig 22.- ?The final view of direct composite restorations of lower anterior teeth
Fig 23.- The occlusal view of lower arch after direct composite restorations obtained during one appointment
Fig 24.- The smile of the patient at the end of one-day direct composite rehabilitation (note that upper teeth were restored temporarily with composite resin)?
Fig 25.- ?The smile of the patient at the end of the treatment with six porcelain veneers ?
Fig 26.- The adhesive cementation of porcelain veneers
Fig 27.- The clinical situation following the treatment with direct composite restorations in the lower arch (obtained in one day) and six porcelain veneers in the upper arch