Article by Prof. Lorenzo Breschi

Fewer bottles, more choices – this is possibly the shortest way to describe the category of universal resin cements. Being self-adhesive, these dual-cure resin-based cements allow for a single-component workflow without the need for separate tooth or restoration primers in many clinical situations. The bond strength obtained in this way is usually high enough to provide for a stable bond between the tooth and the restoration in a wide range of indications. However, it is slightly lower than that achieved with conventional resin cement systems consisting of several components (typically tooth primer, resin cement and restoration primer).

Apart from the self-adhesive application mode, universal resin cements may be combined with additional system components to increase the bond strength to tooth structure or the restorative material, respectively. This opens up new possibilities with regard to the product’s use: depending on the required or desired bonding performance, the universal resin cement may be applied alone or in combination with a tooth primer, a restoration primer or both components. In addition, hybrid concepts become feasible, as explained in this article that focuses on PANAVIA™ SA Cement Universal (Kuraray Noritake Dental Inc.) as an example.

Self-adhesive luting: for many indications

PANAVIA™ SA Cement Universal is a dual-cure universal resin cement that is indicated for a wide range of applications when used in the self-adhesive mode. The bond established to restorative substrates (including silicate ceramics) is high without the use of a separate primer or silane^1-4. This is due to two different adhesive monomers contained in the formulation – the Original MDP Monomer and the LCSi Monomer (a long carbon-chain silane coupling agent responsible for a strong chemical bond to silicate ceramics). Hence, it is possible to use the resin cement without any additional component applied on the side of the restoration – even in cases with a lack of retention and consequently high bond-strength requirements.

A strong bond to enamel and dentin is also obtained in the self-adhesive mode. In certain situations, however, it may be useful to further increase the bond strength to tooth structure with the aid of a tooth primer.

Adhesive luting: for challenging situations

The tooth primer recommended for PANAVIA™ SA Cement Universal is CLEARFIL™ Universal Bond Quick (Kuraray Noritake Dental Inc.). Its application is recommended whenever a user feels that the treatment would benefit from an extraordinarily strong and durable chemical bond, i.e. in particularly challenging situations with insufficient mechanical retention. The effectiveness of this measure has been confirmed in an in-vitro study conducted in Japan, in which the 24-hour micro-tensile bond strength to dentin was increased significantly by the application of the universal adhesive⁵. When a separate adhesive is used, however, the importance of a completely dry working field increases. The reason is that the moisture tolerance of resin cements is usually higher than that of adhesives. Consequently, the application of a rubber dam is highly recommended.

Selective adhesive luting: for short abutments and subgingival margins

For situations in which proper isolation of the working field with a rubber dam is difficult, a third application option is available and proposed by a group of Italian researchers: Selective Adhesive Luting. In this case, CLEARFIL™ Universal Bond Quick is applied solely to those parts of the prepared tooth that allow for proper moisture control, while relying on the self-adhesive functionality of PANAVIA™ SA Cement Universal in areas where it is challenging to obtain the desired dry working field. Situations which are predestined for this technique are abutment teeth with a subgingival preparation margin and particularly short abutment teeth (that hinder the placement of a rubber dam).

The effectiveness of the selective adhesive luting technique has been verified in an in-vitro study that compared the three adhesive strategies – self-adhesive luting, full adhesive luting and selective adhesive luting – with the aid of shear bond strength testing⁶. The results of the tests show that users are able to enhance the bond strength of PANAVIA™ SA Cement Universal to dentin and enamel by applying the adhesive to a part of the tooth surface only. For the cementation system consisting of PANAVIA™ SA Cement Universal and CLEARFIL™ Universal Bond Quick, the full adhesive and the selective adhesive approach led to similar outcomes.

For situations in which proper isolation of the working field with a rubber dam is difficult, a third application option is available and proposed by a group of Italian researchers: Selective Adhesive Luting.

RECOMMENDED STEPS FOR SELECTIVE ADHESIVE LUTING

Fig. 1. Tooth preparation.

Fig. 2. Selective etching of the enamel with phosphoric acid etchant.

Fig. 3. Application of the universal adhesive + air-drying.

Fig. 4. Crown placement after application of the resin cement into the crown.

Fig. 5. Tack-curing.

Fig. 6. Excess removal and final light curing.

Fig. 7. Treatment outcome at a recall after one year.

Benefits of selective adhesive luting

Apart from the desired (long-term) increase in bond strength achieved by applying a separate adhesive to a part of the or the whole prepared tooth surface, the technique offers additional benefits. Compared to multi-step cementation systems, the protocol is simplified as no separate restoration primer is needed. Light-curing of the adhesive is not required as long as the user stays within the recommended system. And in contrast to the full adhesive approach requiring rubber dam placement, the need for this step is eliminated in the selective adhesive approach. In this way, the chair-time is reduced and patient comfort increased.

Conclusion

Depending on the indication, clinical variables and individual preferences, users of universal resin cements like PANAVIA™ SA Cement Universal may select the technique that is likely to deliver the best clinical outcomes. It is this flexibility and the generally wide range of applications that makes the innovative product category truly universal. With fewer components to be used, universal materials facilitate the streamlining and standardization of clinical procedures, while with fewer bottles to be stored, they help staff gain control over order and storage management as well.

Dentist:

LORENZO BRESCHI

Prof. Lorenzo Breschi is Professor of Restorative Dentistry and Dental Materials at the University of Bologna. He is actively involved in research on the ultrastructural aspects of enamel and dentin. He is Past-President of the Academy of Dental Materials (ADM), President-Elect of the European Federation of Conservative Dentistry (EFCD), President-Elect of the Dental Materials Group IADR, President-Elect of the Italian Academy of Conservative Dentistry (AIC), President-Elect of the International Academy of Adhesive Dentistry (IAAD).

References

1. Cowen M, Cunha S, Powers JM. Novel Cement Bond Strength to Multiple Substrates. DENTAL ADVISOR Biomaterials Research Center, Biomaterials Research Report, Number 132 – June 16, 2020.
2. Patel N, Anadioti E, Conejo J, Ozer F, Mante F, Blatz M. Bond Strength of Different Self-Adhesive Resin Cements to Zirconia” (2021). Dental Theses. 62. https://repository.upenn.edu/dental_theses/62.
3. Yoshihara K, Nagaoka N, Maruo Y, Nishigawa G, Yoshida Y, Van Meerbeek B. Silane-coupling effect of a silane-containing self-adhesive composite cement. Dent Mater. 2020 Jul;36(7):914-926.
4. Irie M, Tokunaga E, Maruo Y, Nishigawa G, Yoshihara K, Nagaoka N, Minagi S, Matsumoto T. Shear bond strength of a resin cement to CAD/CAM Blocks for molars. P-2, 37th Annual Meeting of the Japanese Society of Adhesive Dentistry 2018.
5. Ohara N. Bonding strength of resin cement containing silane coupling agent to dentin or core resin. Results presented at the 150th meeting of the Japanese Society of Conservative Dentistry.
6. Breschi L, Josic U, Maravic T, et al. Selective adhesive luting: A novel technique for improving adhesion achieved by universal resin cements. J Esthet Restor Dent. 2023;1-9. doi:10.1111/jerd.13037.

May 15th, 2024 at 21:00 CET

From margin elevation to restoration

Did you ever wonder how to optimize teamwork, efficiency, and patient satisfaction in the context of a combined endodontic and restorative treatment? As a general or restorative dentist, you can easily contribute to streamlined procedures and better outcomes for your patients. The measures to be taken are in the center of this webinar by experienced and knowledgeable Dr. Wiktor Pietraszewski.

Endodontic treamtment and pre-refferal strategies

In the first part of his lecture, Dr. Pietraszewski reveals how to proceed before referring the patient to the endodontic specialist to improve the overall prognosis of the treatment on the one hand, and the patient experience on the other. Materials and techniques, such as deep margin elevation, caries removal, and tooth build-up, will be described and examined. But most importantly, many practical tips will be shared with the audience.

Post-endodontic restoration options for long term success

In the second part, the speaker will focus on post-endodontic treatment. He will describe the available materials and types of post-endodontic restorations. Dr. Pietraszewski will shed light on the most important factors guiding the most crucial treatment decisions and will elaborate on the factors influencing long-term success.

Go to the Facebook Event of the webinar and click „Livevideo”!

We look forward to seeing you!

About the speaker

Dr. Pietraszewski is a general and restorative dentist working in private practice in London. He utilizes biomimetic adhesive protocols in his restorative cases and uses gold standard materials to emulate the natural appearance, bio-mechanical function, and internal structure of teeth when restoring them.

He has a special interest in direct and indirect restorations in the posterior dentition, and his dentistry is fueled by his passion for dental photography.

From The Medical University in Lodz (Poland) to private clinics in Malta and London, his dental journey reflects dedication to excellence.

Importance of high-quality prosthodontic treatment

High-quality treatment is probably the most important element on the road to patient satisfaction. During every single appointment, the patient wants to feel well cared for by a skilled professional, while chair time and the number of appointments should be reduced to the necessary minimum. This implies that, in the context of prosthodontic treatment, a restoration needs to fit perfectly straight away and be stable over time to avoid remakes and extra appointments.

But how is it possible to deliver perfectly fitting, high-quality restorations every time? Among the potential sources of problems with the quality of indirect restorations are common mistakes made in the dental office or laboratory, communication issues and – often overlooked – the use of low-quality dental zirconia.

Zirconia restorations – contemporary and aesthetic dental solution

More than 20 years ago, zirconia entered the dental market as a substitute to metal used for the production of crowns and bridges. Both materials – zirconia and metal – were usually combined with a layer of porcelain, forming porcelain-fused-to-metal or porcelain-fused-to-zirconia restorations. In the years to come, several leading manufacturers of dental zirconia (like Kuraray Noritake Dental Inc.) focused on material improvements. These improvements gradually transformed the original white-opaque framework material into a ceramic material with tooth-like optical and excellent mechanical properties. The latest zirconia variants, available with different levels of translucency and strength, are regarded as the best-possible treatment option in a wide variety of patients and indications by many dental professionals around the world. One reason is that they require just a small or no layer of porcelain. Another is that, with low minimum wall thicknesses, they allow for conservative tooth preparations, while they offer a favourable long-term behaviour – that is, if a high-quality material is used.

Quality differences of dental zirconia

Zirconia product quality may vary depending on various factors such as the purity of the raw materials (not only zirconia, but also alumina and yttria as well as colour additives etc.), the exact chemical composition, the grain size and particle distribution. Every step in the blank production process – from powder compilation to blank pressing and pre-sintering – has an impact on the final quality, i.e., the mechanical and optical properties of the zirconia, too.

Common issues resulting from low-quality zirconia

Whenever there is something wrong with the optical properties of a restoration – with its translucency, its overall colour or the transition from one layer to the next in blanks with a multi-layered colour structure – the problem will become apparent after the final sintering procedure in the laboratory. A remake might be necessary and eventually, the blemish might be identified during try-in, which will most likely have a negative impact on patient satisfaction. The same is true for cases with an improper fit resulting from inhomogeneities in the material structure, for example. What is even worse is an inferior biocompatibility, surface quality, edge stability, flexural strength or fracture toughness. These issues are identifiable only with testing equipment that is very expensive and usually not available in dental laboratories. This means that flaws of this kind usually remain undetected until a real clinical problem – like gingival recession, increased plaque accumulation, higher wear or an early failure that might cause pain and discomfort – occurs.

Overview of potential problems and clinical consequences for patients

Certification and standardization of dental zirconia

That is why specialists have developed an ISO standard (ISO 6872:2015), which describes in-vitro tests every manufacturer of dental zirconia used in Europe or the United States needs to conduct in order to pass FDA approval and receive the CE mark. The described tests are used to measure the flexural strength and fracture toughness, the two probably most important properties determining the long-term behaviour of restorations produced from the material. Every material used in Europe or the United States needs to have passed these tests.

How to avoid placing low-quality dental zirconia restorations in your patients’ mouths

Hence, everyone using this certified dental zirconia should be safe and able to minimize material-related risks. However, the increasing popularity of dental zirconia has attracted the attention of companies trying to have their share of the cake without undergoing the necessary efforts needed to safeguard a high product quality and pass certification. Non-certified products that lack CE marking have one thing in common: they definitely put your business and patient at risk.

So how is it possible to safeguard zirconia product quality from the dental office? The good news is that there are some simple rules available. By following them, you are able to avoid placing counterfeit or low-quality dental zirconia restorations in your patients’ mouths.

Avoid placing counterfeit or low-quality dental zirconia restorations in your patients’ mouths.

Three golden rules to provide your patients with high-quality zirconia restorations:

• Only order restorations that are produced domestically or in a region with the same standards as your own: restorations produced in dental laboratories in China, for example, need to fulfil lower standards (thus lacking CE mark) and might not live up to your expectations.
• Talk to your (domestic) laboratory partner about the source of their zirconia: make sure they are purchasing zirconia from leading manufacturers (e.g. Kuraray Noritake Dental Inc.) via authorized distributors or sellers they really know.
• Avoid deals that are too good to be true: low prices may be tempting, but the final cost of a treatment may be even higher than usual when complications occur.

Long-term impact for patients when using certified zirconia restorations

Making certain that the zirconia placed in your dental office fulfils the highest possible quality standards is an important contribution to long-term patient satisfaction. Even if the initial cost of high-quality zirconia restorations is somewhat higher than that of inferior-quality work, the overall investment may be lower when the restorations last longer and remakes are eliminated. Your happy patients are likely to be more engaged and compliant with oral hygiene regimens as well as loyal, with a positive impact on your reputation and patient base.

Research zirconia options and choose for products from certified manufacturers

If you would like to go one step further, you can even compare certified zirconia variants from several manufacturers and detect differences. Kuraray Noritake Dental Inc., for example, is one of very few manufacturers of dental zirconia carrying out the whole manufacturing process including raw material production in-house. In this way, the company is able to control every step in the procedure and provide for an outstanding product quality – no matter which material variant is selected. With the available portfolio consisting of KATANA™ Zirconia UTML (ultra translucent multi-layered), KATANA™ Zirconia STML (superior translucent multi-layered) and the high-translucent multi-layered HTML PLUS as well as YML (with additional strength and translucency gradation), it is possible to cover virtually every indication.

Case by Dr. Ioannis Memis

Single-shade or two-shade approach? Using modern resin composites, it is possible to treat virtually every patient in need of a direct restoration in an aesthetic way using one of those two techniques. If the defect is rather small, a single shade of composite restorative in a body opacity may be sufficient – especially when the tooth to be restored is in the posterior region. Larger defects and those located in the aesthetic zone may require a combination of two different shades – one as a dentin replacement and one as translucent as enamel – to closely imitate the optical characteristics of the natural tooth.

With CLEARFIL MAJESTY™ ES-2, Kuraray Noritake Dental Inc. offers a complete composite system designed to simplify procedures in bot, the single-shade and the two-shade approach. CLEARFIL MAJESTY™ ES-2 Classic is a typical composite for the single-shade technique consisting of 18 shades offered in a single universal opacity. Shade determination is brightness-based, meaning that the brightness is selected first and the hue and colour saturation in a second step (using the VITA Classical A1 – D4 shade guide). For those who want to skip shade determination completely, CLEARFIL MAJESTY™ ES-2 Universal has been introduced. It consists of only two shades for the anterior and one shade for the posterior region, selectable without using shade tabs. For the two-shade technique, CLEARFIL MAJESTY™ ES-2 Premium is the solution: It allows users to copy natural enamel and dentin layers with a total of seven enamel, seven dentin and four translucent shades. Its exceptional feature: pre-defined colour combinations with one Premium shade combination covering three VITA Classical shades. A natural blending into the environment is achieved with the Light Diffusion Technology in the formulation.

All three versions of CLEARFIL MAJESTY™ ES-2 are compatible with each other and offer the same favourable handling properties. The use of different techniques, shades and opacities is demonstrated using the following patient case.

YOUNG PATIENT WITH MULTIPLE CARIOUS LESIONS

A 24-year-old female patient was referred from undergraduate clinic of Operative Dentistry of the Aristotle’s University of Thessaloniki - School of Dentistry (Greece). Patient presented multiple interproximal carious lesions in need of restorative treatment. In the clinical and radiographic examination, the following defects were identified:

Quadrant 1 (maxillary right):

- Distal lesion on the lateral incisor (Class III)

- Mesial and distal lesions on the first premolar (Class II)

- Mesial and distal lesions on the second premolar (Class II)

- Mesial lesion on the first molar (Class II)

Quadrant 2 (maxillary left):

- Distal lesion on the lateral incisor (Class III)

- Mesial lesion on the first premolar (Class II)

- Mesial and distal lesions on the second premolar (both Class II)

- Mesial lesion on the first molar (Class II)

Quadrant 3 (mandibular left):

- Distal lesion on the first molar (Class II)

- Mesial lesion on the second molar (Class II)

In a stepwise procedure, the teeth were restored with CLEARFIL MAJESTY™ ES-2 either in a single-shade or in a two-shade approach depending on the size of the lesions.

INITIAL SITUATION

Fig. 1. Initial situation: Frontal view.

Fig. 2. Occlusal view of the maxilla.

Fig. 3. Occlusal view of the mandible.

RESTORING THE TEETH IN QUADRANT 1

The six carious lesions in this quadrant were restored in three steps. At first, the focus was on the first molar and second premolar. Opening the larger cavity mesially of the first molar provided access to the smaller lesion on the premolar’s distal surface. After caries excavation and cavity preparation, rubber dam was placed and fixed with a clamp on the second molar. The enamel in the cavities was treated with phosphoric acid etchant for 15 seconds before CLEARFIL™ Universal Bond Quick (Kuraray Noritake Dental Inc.) was applied according to the manufacturer’s instructions. For a morphologically correct designing of the proximal contact point and area, the use of a sectional matrix system with rings was utilized. Both cavities were restored with CLEARFIL MAJESTY™ ES-2 Premium in the shades A3D and A2E. Finishing and polishing of the occlusal surface accomplished with silicon cups and Twist Dia disks on a slow speed handpiece.

In the second step, the distal lesion on the first and mesial lesion on the second premolar were restored in an identical procedure with CLEARFIL MAJESTY™ ES-2 Premium in the shade A3D and CLEARFIL MAJESTY™ ES-2 Classic in the shade A3. A different approach was selected in step 3 for the lesions on the distal part of the lateral incisor and the mesial part of the first premolar. Due to the small size and the all-but-prominent position of the lesions, a single-shade technique using CLEARFIL MAJESTY™ ES-2 Classic in the shade A3 was selected. Between the lateral incisor and canine, a posterior sectional matrix was placed in an upright position and fixed with a wedge to support a proper restoration of the contact point, while both elements were used in the usual way between the canine and first premolar.

Fig. 4. Simultaneous restoration of the mesial lesion on the first molar and the distal lesion on the second premolar with CLEARFIL MAJESTY™ ES-2 Premium.

Fig. 5. Restoration of the distal lesion on the lateral incisor and the mesial lesion on the first premolar with CLEARFIL MAJESTY™ ES-2 Classic.

RESTORING THE TEETH IN QUADRANT 2

For the small disto-palatal lesion on the maxillary left lateral incisor, a single-shade technique with CLEARFIL MAJESTY™ ES-2 Classic in the shade A3 also produced aesthetic outcomes. The four lesions at the posterior region of the quadrant were restored in two steps – one for each pair of proximal lesions – with a combination of CLEARFIL MAJESTY™ ES-2 Premium in the shade A3D and CLEARFIL MAJESTY™ ES-2 Classic in the shade A1.

Fig. 6. A single-shade technique is sufficient to aesthetically restore this small lesion on the left lateral incisor.

Fig. 7. Simultaneous restoration of the mesial lesion on the second premolar and the distal lesion on the first premolar.

Fig. 8. Simultaneous restoration of the mesial lesion on the first molar and distal lesion on the second premolar.

RESTORING THE TEETH IN QUADRANT 3

In this quadrant, only a single pair of proximal lesions needed treatment. A simultaneous restoration procedure was selected once again due to the favourable space conditions. Although the size of the lesion was like those in the posterior region of the maxilla, a single-shade restoration was selected with the use of CLEARFIL MAJESTY™ ES-2 Classic (shade A3).

Fig. 9. Treatment of the lesions in quadrant 3.

CONCLUSION

In the present patient case, several different shades, opacities, and combinations of CLEARFIL MAJESTY™ ES-2 were utilized either in a single- or in a two-shade approach. All combinations and techniques produced good outcomes. As shown in Figure 4, the enamel opacity of CLEARFIL MAJESTY™ ES-2 Premium is visibly more translucent than the universal opacity of CLEARFIL MAJESTY™ ES-2 Classic. Experience shows that enamel shades translucency is highly valuable for aesthetic anterior restorations, while in posterior restorations, the universal shade approach is aesthetically adequate, particularly for medium-sized restorations, as shown in Figure 9. This is clearly an evidence of Light Diffusion Technology which is blending hue and colour saturation to the surrounding tooth structure.

Handling of all selected composite pastes is comfortable: non-sticky, adaptable to cavity walls and allowing precise occlusal sculpting. Polishing with Silicone Cups and TWIST DIA for Composite is easy, quick and leaves a natural gloss on the surface.Dentist:

DR. IOANNIS MEMIS

Postgraduate Student, Operative Dentistry Dept., School of Dentistry
Aristotle University of Thessaloniki, Greece

AWARD WINNING PRODUCT

For the 10th time, the self-etch adhesive CLEARFIL™ SE Protect has been named a Top Product by DENTAL ADVISOR, which announced its choices for dental materials and equipment found by its evaluators to deliver the best practice-based performance in its JAN/FEB 2024 issue.

The publication included CLEARFIL™ SE Protect among honorees in the Bonding Agent Self-Etch category, noting attributes that go far beyond providing a reliable bond.

ABOUT THE PRODUCT

This outstanding toolbox staple is built on the same system of the gold-standard adhesive CLEARFIL™ SE BOND, so it offers excellent bond strength for enamel and dentin. Its MMP inhibiting effect protects the bond from degradation over time and hence supports bond durability. Beyond that reliable bond, it provides an antibacterial cavity-cleansing effect that eliminates the need for the use of a separate cavity cleanser, thanks to the proprietary MDPB monomer it contains.

In short, CLEARFIL™ SE Protect offers you following benefits:

• Fast and simple procedure with low technique sensitivity
• Excellent bond strength for enamel and dentin
• Long-lasting bond strength
• Antibacterial cavity-cleansing effect
• Virtually no post-operative sensitivity

It is also a highly versatile adhesive system that can be used in the context of:

• Placing direct restorations
• As a cavity sealant
• For the treatment of hypersensitive or exposed root surfaces

Among the extended indications are cementation with composite resin cement or core build-up with self- or dual-cured resin materials in combination with CLEARFIL™ DC Activator.

EVALUATION

Its attributes are reflected in the study findings and comments of DENTAL ADVISOR’s editors and consultants, who assessed it over a six-week period during which over 150 restorations were placed. It received a 98% clinical rating by consultants using a 1-5 rating scale.

The practitioners evaluating the product found no post-operative sensitivity. Among their observations mentioned in the online DA report were the fact that the primer and bond wet the tooth evenly. They also considered the antibacterial and fluoride releasing qualities “an added benefit”. On the topic of sensitivity, they mentioned that “CLEARFIL SE Protect is effective in the reduction of sensitivity when placed on areas of recession or similar areas of sensitive tooth structure.”.

ABOUT DENTAL ADVISOR

The Top Product or Preferred Product Awards conferred by US-based DENTAL ADVISOR were initially introduced to help busy practitioners make sense of the numerous new solutions indicated for less invasive techniques, standardised or simplified procedures, ultimately to achieve better outcomes regularly.

DENTAL ADVISOR conducts its practice-based clinical evaluations and product performance tests shortly after product launch, and publishes results annually online to help potential users identify high-quality new dental materials and determine which among them are best suited to fulfill their individual requirements.

For more information visit the website of DENTAL ADVISOR: www.dentaladvisor.com

Interview met Dr. Michał Jaczewski

Kan je de techniek kort beschrijven?

De Flowable Injection Technique biedt een eenvoudige, voorspelbare en reproduceerbare manier om restauraties uit te voeren met vloeibaar composiet. Het is gebaseerd op een wax-up, waarvan een siliconenindex wordt geproduceerd. Deze index dient vervolgens als mal voor het injecteren van de vloeibare composiet. Hierna wordt door de transparante siliconenmal, het composiet met licht uitgehard. Het belangrijkste voordeel is dat deze techniek werkt zonder, of in sommige gevallen met zeer minimale, weefselopoffering. Het is een populaire techniek voor zowel beginnende als ervaren tandartsen. Met behulp van een composiet met een uitgebalanceerde dekking, gebruikt in een dikte van ca. 0,3 mm en een speciaal polijstprotocol, creëer je een uitstekende morfologie en bereik je prachtige optische resultaten.

Wanneer ben je begonnen met het gebruik van de Flowable Injection Technique en wat zijn de belangrijkste indicaties?

Ik begon de techniek in 2018 te gebruiken. Oorspronkelijk was die ontwikkeld voor anterieure restauraties, maar tegenwoordig is hij ook succesvol toe te passen in het posterieure gebied. Ik vind het voornamelijk handig wanneer de vorm van meerdere tanden moet worden gecorrigeerd om de glimlach van een patiënt te verbeteren, ongeacht jong of oud. Dit is vaak het geval na een orthodontische behandeling. Na de regulering restaureer je op eenvoudige wijze en creëer je de perfecte vorm en esthetiek met behulp van deze niet-invasieve methode. Ik gebruik de Flowable Injection Technique ook voor een smile-make-over, om slijtage defecten te herstellen en de occlusiehoogte aan te passen in het geval van een volledige reconstructie. In het laatste geval is de restauratie mogelijk tijdelijk en wordt gebruikt voor een “proefrit” op middellange tot lange termijn. Maar ook vaak als definitieve restauratie.

Hoe begin je met de Flowable Injection Technique?

De belangrijkste fase die het succes van deze techniek sterk beinvloedt is de planningsfase. Die bestaat uit het maken van het behandelplan waaronder het vervaardigen van afdrukken, een wax-up en een mock-up, evenals de productie van de siliconenindex. Je kunt uiteraard op de traditionele manier werken met een siliconenafdruk en conventionele wax-up, maar het gebruik van digitale technieken verbetert de workflow aanzienlijk. Ik begin meestal met foto- en videodocumentatie en een digitale impressie. Registratie van de centrale relatie en occlusie zijn ook nodig. Vervolgens wordt een virtuele wax-up gemaakt met behulp van Digital Smile Design software (DSD). Bij deze stap is het belangrijk om rekening te houden met de gezichtskenmerken van de patiënt, bijvoorbeeld via het face-flow-concept. Gebaseerd op het resulterende ontwerp presenteer je een virtueel behandelresultaat en bespreek je deze met de patiënt. Eenmaal goedgekeurd wordt het model via de wax-up in verschillende versies vervaardigd: een volledige fuctionele wax-up en een alternerend, zogenaamd “interlip model”. Deze modellen gebruik je om de siliconen indexen te (laten) vervaardigen.

Digital Smile Design: Patiënt met ernstige slijtage.

Virtuele wax-up weergegeven in de mond van de patiënt.

Modellen afgedrukt op basis van de virtuele mock-up.

Siliconenindex geproduceerd op de alternerende (interlip) wax-up

Wanneer maak je meer dan één siliconenindex, en waarom?

Het is vooral nuttig om te werken met zowel de volledige als de alternerende siliconenindex wanneer alle tanden in de bovenkaak worden gerestaureerd. Met de alternerende index verkrijg je extra stabiliteit en leg je, vooral ten aanzien van de beoogde occlusale hoogte, de basis voor een trefzeker resultaat. In de onderkaak is het werken met de index en composiet lastiger vanwege de aanwezigheid van speeksel en beweeglijk zacht weefsel. Ik raad altijd aan om daar het werkgebied te verdelen in drie secties - één anterieure en twee posterieure - en die apart te bewerken.

Hoe bereid je de elementen voor en injecteer je het vloeibare composiet?

In de meeste gevallen is het enige wat je moet doen, het opruwen van het glazuuroppervlak voor de hechtingsprocedure. Ik zandstraal meestal met aluminiumoxide (50 μm op lage druk). Vervolgens ets ik het glazuur met fosforzuur en breng een universele bonding aan. De siliconenindex is voorzien van een injectieopening ter plaatse van de incisale rand. Hierin wordt gemakkelijk de naaldpunt van de vloeibarecomposietspuit naar binnen gebracht. Het is raadzaam om posterieur een harder materiaal voor de index te gebruiken en ter hoogte van de knobbels twee afzonderlijke gaten te maken voor elk element – één voor de injectie en één voor de ‘ontluchting’. Bij gebruik van een harde index is een diamantboor nodig om de gaatjes mee te maken. Ik plaats de index, injecteer de vloeibaar composiet van onderaf, hard het materiaal kort uit en verwijder de index. De finale polymerisatie voer ik uit na het verwijderen van de index onder een laagje glycerinegel. Zodra de overmaat aan composiet is verwijderd en het proximale deel van de restauratie geperfectioneerd is, wordt de procedure bij de andere elementen herhaald waarna de restauraties gepolijst worden.

Heb je favoriete producten voor de techniek?

Voor de siliconenindex gebruik ik Exaclear (GC), omdat dit de meest transparante silicone is die op de markt verkrijgbaar is. Maar er zijn meer fabrikanten die doorzichtig materiaal van goede kwaliteit leveren die uitstekend geschikt zijn voor het beoogde doel. Mijn favoriete composiet voor de Flowable Injection Technique is  CLEARFIL MAJESTY™ ES Flow  Low (Kuraray Noritake Dental Inc.). In mijn praktijk en tijdens mijn cursussen heb ik de kans om veel verschillende producten te testen. In deze context ontdekte ik dat het materiaal van Kuraray Noritake Dental een aantal voordelen biedt boven andere fabrikaten. Het is een modern nanocomposiet met een breed scala aan indicaties en een groot kleuraanbod. Met zijn drie vloeibaarheden biedt het flexibiliteit en is het in te zetten tijdens veel verschillende klinische situaties. Ik begon het vijf jaar geleden te gebruiken voor de Flowable Injection Technique. De variant met de middelste viscositeit (Low) is mijn eerste keuze, omdat deze de meest universele is, geschikt voor zowel anterieur als posterieur. De meest doorslaggevende voordelen die van invloed waren op mijn beslissing zijn de natuurlijke esthetiek en superieure polijstbaarheid. Je bereikt een spectaculair effect zonder extreme vaardigheden aan te moeten leren. Mijn voorkeursbonding is CLEARFIL™ Universal Bond Quick, dit onder andere om mijn workflow nog eenvoudiger, sneller en voorspelbaarder te maken. Voor het polijsten heb ik mijn eigen protocol ontwikkeld.

Hoe werk je restauraties af en polijst je ze?

Ik begin in het proximale gebied met polijststrips en soms een proximale zaag. Voor vormaanpassingen gebruik ik drieverschillende diamant- en hardmetalen boren die hun waarde hebben bewezen. Vervolgens ga ik over tot fijn of extrafijn afwerken met schuurschijfjes en hierna polijst ik met de flexibele polijstrubbers, TWIST DIA™(Kuraray Noritake Dental), die al een mooi, natuurlijk, glanzend oppervlak creëren. Hierna gebruik ik een wielvormige borstel van geitenhaar met diamantpolijstpasta en ten slotte een katoenen borstel met een aluminiumoxide-polijstpasta. Op deze manier creëer je een prachtige natuurlijke hoogglans.

Etsen van het glazuur met fosforzuur.

Volledige siliconenindex op zijn plaats.

Aanbrengen van CLEARFIL™ Universal Bond Quick.

Situatie onmiddellijk na de injectie van CLEARFIL MAJESTY™ES Flow (Low), lichtuitharding en verwijdering van de siliconenindex.

Proximale aanpassingen met roterende instrumenten.

Wat zijn de grootste voordelen van de Flowable Injection Technique?

Voor patiënten en tandartsen zijn de grootste voordelen besparing in tijd en geld. Veel patiënten zijn heel blij met dit kwalitatief hoogwaardig alternatief voor keramische veneers. De procedure vereist geen voorbereiding. Indien gewenst zijn aanpassingen in vorm en kleur eenvoudig te realiseren. Het is een behandelingsoptie met slechts een beperkt risico. Als tandarts kan je vaak al beginnen met het behandelen van patiënten na het volgen van één goede cursus. Wetende dat oefening leidt naar perfectie, zijn de eerste resultaten toch vaak al behoorlijk indrukwekkend, zodat er geen sprake is van enorm investeringen voor beginners – noch in tijd, noch in nieuwe materialen. Natuurlijk kun je veel tijd investeren in de afwerkings- en polijstprocedure, maar ik weet zeker dat u de juiste balans tussen inspanning en resultaat zult vinden.

Michal's instrumentenset voor gebruik bij de Flowable Injection Technique

Heb je een aanbeveling hoe de techniek te gebruiken?

Allereerst wil ik iedereen aanmoedigen om de comfortzone te verlaten, probeer regelmatig iets nieuws. Voor mij is het werken met de Flowable Injection Technique echt een gamechanger gebleken en ik zou nooit meer zonder willen. Voordat je de techniek toepast in de praktijk, adviseer ik zeker een cursus te volgen die je alles leert. In ieder geval de theoretische kennis die nodig is voor een succesvolle eerste behandeling en misschien zelfs een praktische workshop. Ik bied beide soorten regelmatig aan met mijn lezingen en hands-on cursussen.

Michał Jaczewski tijdens zijn presentatie op de Kuraray Noritake Dental-stand in Keulen (IDS 2023).

By Dr. Michał Jaczewski

The durability of a composite restoration depends on many factors. Some are outside the practitioner's sphere of influence and are strongly patient-related. For example toothbrush and toothpaste type, brushing technique, diet, stimulants and hygiene habits all have an impact on the restoration. Following the best finishing and polishing protocol, however, is fully up to the dentist.

Correct polishing aims to remove the oxygen inhibition layer and produce a smooth restoration surface. A properly polished restoration will not absorb staining agents from food, drink or stimulants that lead to discoloration of the composite, ensuring a long-lasting aesthetic result of the restoration.

Polishing the composite is a process to which special attention should be paid. It consists of several steps and principles:

• The use of finishing discs allows for a smooth restoration surface , excess composite to be removed and the final shape to be given to the restoration. It is important to remember to work on a moistened surface with a maximum speed of 5,000-10,000 rpm on a 1:1 dental handpiece.

• Polishing rubbers, there are many types and shapes on the market. One of the most universal designed specifically for composite is TWIST™ DIA for Composite. This is a set consisting of two rubbers with different levels of abrasion. The first (dark blue) is used for preliminary rough polishing, the second (light-blue) for final gloss and smoothness. It should be remembered that working with these tools should be carried out on a dry surface without water cooling. Dry working carries the risk of irritating the dental pulp, so the working speed should be limited to between 5000 and 10000 rpm and excessive pressure must be avoided.

• The next step is to use a diamond polishing paste with a gradient of 1 to 5 microns. The use of a polishing goat wheel brush is recommended to use with this paste. The type of brush is not important, however, don’t use rigid bristles that could scratch the composite. Using the polishing brush and polishing paste make it possible to reach places which are difficult to access, such as the cervical area and proximal surfaces. In addition to this step, a celluloid diamond containing abrasive strip is used to polish the proximal surfaces more precisely. In order not to alter the contact points, low abrasive (Super Fine) strips should be used.

• A further step to increase the gloss of the restoration and to protect it against discoloration is an aluminum oxide paste with a cotton polishing brush. The use of such paste, originally dedicated to ceramics, results in an exceptionally smooth surface and a high gloss of the restoration surface. This step is carried out in a dry environment at a maximum speed of 5,000-10,000 rpm.

In all techniques, thus also the Flowable Injection Technique, the level of polishing influences the durability and the optical and aesthetic properties of the restoration. This key step in tooth restoration should therefore devoted sufficient time. Composites are characterized by different compositions and amounts of fillers which not only influence their properties, but also the ease with which they can be polished. In some cases, the procedure has to be repeated several times to achieve a "mirror effect". CLEARFIL MAJESTY™ ES Flow is a composite which is very easy to polish to a high shine level, despite its high filler content. Specially adapted rubbers, brushers and pastes enable easy creation of a smooth surface thereby contributing to a lasting result.

BEFORE

AFTER

3-YEARS RECALL

MAKE THEM SHINE, MAKE THEM SMILE!

Would you like to know more about Flowable Injection Technique? Read the insightful and inspirational interview with Dr. Michał Jaczewski.

Dentist:

MICHAL JACZEWSKI

Michał Jaczewski graduated from Wroclaw Medical University in 2006 and today runs his private practice in the city of Legnica, Poland. He specializes in minimally invasive dentistry and digital dentistry and is the founder of the Biofunctional School of Occlusion. Here he lectures and runs workshops with focus on full comprehensive patient treatments.

AWARD WINNING PRODUCT

DENTAL ADVISOR has once again recognized PANAVIA™ SA Cement Universal as a Top Product in the category of Indirect Restoratives. This dual-cure, fluoride-releasing, radiopaque self-adhesive resin cement adheres to virtually all substrates — including lithium disilicate — in a single-step procedure without the need for a separate primer or silane. It also offers easy, gingival-friendly removal of excess cement and requires no refrigeration.

SCIENCE BEHIND THE PRODUCT

It is because PANAVIA™ SA Cement Universal combines two innovative technologies in a single product that a strong and durable bond can be achieved in a single step. The silane-coupling agent, LCSi monomer, establishes a durable, chemical bond with porcelain, lithium disilicate, and composite resin; and the original MDP monomer provides for chemical reactiveness with zirconia, dentin and enamel.

WIDE INDICATION RANGE

Due to its unique chemistry PANAVIA™ SA Cement Universal represents a convenient, versatile, and efficacious single solution to practitioners’ everyday cementation needs for a wide variety of indications, including cementation of crowns/bridges, inlays/onlays, posts, splints, and even adhesion bridges.

EVALUATION

In its commendation, DENTAL ADVISOR stated, “As tested in DENTAL ADVISOR Laboratories, PANAVIA™ SA Cement Universal with an incorporated silane primer had exceptional initial bond strength to dentin, lithium disilicate, and zirconia.”

The benefits and quality of PANAVIA™ SA Cement Universal were further reflected in the findings and feedback of the 31 clinical evaluators who tested the cement during 516 applications. They praised its ease of use, handling characteristics, and aesthetics, and gave it an overall clinical rating of 96 percent. Among their comments: "Has an ideal film thickness and flows well.”,  "You can use this in a moist environment with no issues.” , and “Excess cement peels right away from the margin.”

ABOUT DENTAL ADVISOR

The Top Product and Preferred Product Awards conferred by US-based DENTAL ADVISOR were initially introduced to help busy practitioners make sense of the numerous new solutions indicated for less invasive techniques and standardised or simplified procedures, ultimately, to achieve better outcomes regularly.

DENTAL ADVISOR conducts its practice-based clinical evaluations and product performance tests shortly after product launch. It publishes results annually online in its January/February issue to help potential users identify high-quality new dental materials and determine which among them are best suited to fulfil their individual requirements.

AWARD WINNING PRODUCT

CLEARFIL™ Universal Bond Quick has again been named a 2024 Preferred Product in the bonding agent category by DENTAL ADVISOR, which also recognized this universal bonding agent as an Editor’s Choice bonding agent. DENTAL ADVISOR’S roster of award-winning dental materials and equipment found by its evaluators to deliver the best practice-based performance was announced in its JAN/FEB 2024 issue.

ABOUT THE PRODUCT

CLEARFIL™ Universal Bond Quick is a single-bottle, fluoride-releasing universal adhesive suitable for all direct and indirect restorations using a quick and simple technique. The material utilizes Rapid Bond Technology, merger of MDP monomer with new hydrophilic amide monomers, which creates a strong chemical bond to hydroxyapatite. Thanks to the amide monomer, which is highly hydrophilic, the adhesive quickly penetrates dental tissue to create a fast chemical bond to dentin and enamel, eliminating the need for prolonged scrubbing application of the adhesive into the dentin and long waiting times. After curing, the innovative amide monomer forms a moisture-resistant cross-linked polymer network.

APPLY AND PROCEED

Despite its ease of use and reduced application and wait times, there is no tradeoff in terms of bond strength: CLEARFIL™ Universal Bond Quick delivers a bond that is moisture-resistant, stable, and durable.

VERSATILITY OF APPLICATION

This fast and versatile agent bonds directly to dentin, enamel, metals, zirconia and lithium disilicate restorative materials, and is appropriate for bonding direct and indirect restorations; it can also be used for total-etch, selective-etch, or self-etch methods.

CLEARFIL™ Universal Bond Quick is also an excellent choice when doing post cementation and core build-up procedures with CLEARFIL™ DC CORE PLUS . It can be used for treatment of the post surface, be it fiber or metal, but also for the tooth surface preparation before cementing with PANAVIA™ SA Cement Universal, for example. Universal excellence at its best!

REMARKS FROM EVALUATORS

practitioners evaluating the CLEARFIL™ Universal Bond Quick commented on its ease in dispensing and placement, viscosity, suitability for all bonding procedures, and convenience. Among their remarks were: "Quick application and cure time is ideal for situations where isolation is difficult, especially in a high moisture area.", "Loved that it is compatible with dual/self-cured resins and that it can be used in self-cure mode with CLEARFIL™ DC Activator”. and “It is compatible with virtually any bonding procedure."

ABOUT DENTAL ADVISOR

Honors such as Editor’s Choice and Preferred Product that are conferred by US-based DENTAL ADVISOR were introduced to help busy practitioners make sense of the numerous new solutions indicated for less invasive techniques and standardised or simplified procedures, ultimately to achieve better outcomes regularly.

DENTAL ADVISOR conducts its practice-based clinical evaluations and product performance tests shortly after product launch, and publishes results annually online to help potential users identify high-quality new dental materials and determine which among them are best suited to fulfill their individual requirements.

Klinische casus - Samengestelde restauratie in minder dan 10 minuten door Dr. Adham Elsayed.

Deze video legt het concept uit van het uitvoeren van klasse I-restauraties in minder dan 10 minuten. Dr. Elsayed gebruikt Clearfil Majesty ES Flow, Clearfil Universal Bond Quick en Clearfil Twist Dia en toont één van de voordelen van flows ten opzichte van conventionele composieten.

Met behulp van de stempeltechniek (optioneel) kunnen snelle en eenvoudige restauraties worden uitgevoerd met Clearfil Universal Bond Quick (geen wachttijd) en verschillende viscositeiten van flows. Dit is zeer praktisch voor composietrestauraties in het molaargebied.

Bekijk hier de video.

Dr Adham Elsayed

Certified specialist in dental prosthodontics and
implants and clinical and scientific manager at Kuraray Noritake Dental