Clinical Case Report by Dr. Koray Kendir

PEG-SHAPED LATERAL INCISOR RESTORED WITH UNIVERSAL COMPOSITE (6-MONTH FOLLOW-UP)

Peg-shaped lateral incisors present a unique restorative challenge, combining aesthetic demands with the need for precise morphological reconstruction. While direct composite restorations offer a minimally invasive solution, long-term success is often compromised when anatomical principles are overlooked or when repeated additive approaches fail to address underlying structural deficiencies.

This case report describes the management of a peg-shaped maxillary lateral incisor using a simplified, anatomy-driven approach with a universal composite system.

INITIAL PRESENTATION AND CLINICAL HISTORY

A 35-year-old male patient presented with a unilateral peg-shaped maxillary left lateral incisor (tooth #22, FDI notation). The patient's dental history revealed multiple direct composite restorations placed since the age of 16, all performed without tooth preparation. However, these restorations failed approximately every two years due to fractures or severe marginal discolouration.

Fig. 1. Initial clinical situation: Vestibular view of the existing restoration.

CLINICAL ASSESSMENT AND PRE-OPERATIVE EVALUATION

Rubber dam isolation was performed and baseline clinical photographs were taken. The existing restoration was limited to closing the mesial and distal diastemas, resulting in significant marginal discrepancies and morphological disharmony. A palatal view revealed a more critical issue: concave, non-cleansable proximal contact areas, leading to food impaction and periodontal risk.

Fig. 2. Initial clinical situation: Palatal view of the existing restoration.

MINIMALLY INVASIVE PREPARATION

The primary goal was the complete removal of the failing composite without compromising the underlying natural tooth structure. Following removal, the tooth required three-dimensional expansion: mesially and distally, incisally, and labially.

Key anatomical considerations during reconstruction:

• Incisocervical positioning of mesial and distal contact areas.
• Contact area geometry (point vs. surface contact).
• Incisal edge position and line angle symmetry.
• Correct palatal wall orientation.

Fig. 3. Failing composite completely removed without compromising the tooth structure.

ADHESIVE PROTOCOL AND MATERIAL SELECTION

To support a streamlined workflow and maintain focus on anatomical reconstruction, the Universal Excellence product series was selected.

• Bonding: CLEARFIL™ Universal Bond Quick 2 was applied using a simplified one-step protocol, providing rapid and reliable adhesion.
• Restoration: CLEARFIL MAJESTY™ ES-2 Universal in U shade was chosen to provide predictable and harmonious aesthetics with a single-shade approach, allowing the clinician to focus on the primary anatomical determinants of form and function rather than complex multi-shade layering.

STRATIFICATION AND POLYMERIZATION

The composite was applied using a layering technique to minimize polymerization shrinkage stress, while gradually building the predetermined anatomical landmarks. Post-operative results demonstrated a seamless integration with the surrounding dentition.

Fig. 4. Single-shade layering of the vestibular surface.

Fig. 5. Palatal view of the tooth during layering.

Fig. 6. Finished and polished restoration surface.

Fig. 7. The composite restorations seamlessly integrated with the adjacent tooth structure.

Fig. 8. Frontal view of all maxillary anterior teeth.

SIX-MONTH FOLLOW-UP

The patient was recalled after six months for evaluation. Due to the superior polishability and high mechanical strength of CLEARFIL MAJESTY ES-2 Universal, the restoration maintained its surface lustre and marginal integrity with no signs of wear or staining.

Fig. 9. Appearance of the restorations six months after treatment.

Fig. 10. Close-up of the restoration, confirming smooth optical integration.

Fig. 11. The surface of the restoration still appears well-polished and unstained after six months.

CONCLUSION

While complex layering techniques can enhance optical properties, they may inadvertently shift focus away from fundamental anatomical principles. The Excellence system from Kuraray Noritake Dental Inc. offers a practical and dependable solution for complex morphological challenges, supporting both clinician focus and long-term clinical success.

Read more about Universal Excellence: https://www.kuraraynoritake.eu/en/newsroom/universal-excellence-smart-streamlined-solutions-for-modern-restorative-dentistry

Discover Universal Excellence products in practice: https://www.kuraraynoritake.eu/en/newsroom/universal-excellence-in-restorative-dentistry

More Clinical Cases from Dr Kendir:

https://www.kuraraynoritake.eu/en/newsroom/posterior-direct-composite-restoration-within-the-universal-excellence-concept

https://www.kuraraynoritake.eu/en/newsroom/restoring-confidence-after-trauma-a-biomimetic-approach

Case by DT Roberto Rossi

BIO-INSPIRED

White and pink aesthetic rehabilitations require a workflow that combines accurate framework design with controlled ceramic layering. When each step is carefully planned, the optical properties of the framework material can be fully exploited, reducing the need for extensive ceramic layering. The following case illustrates this workflow using a bio-inspired approach.

In this case, a micro-layering technique was used to reproduce the vestibular aesthetics while preserving the morphology of the zirconia framework. KATANA™ Zirconia YML was combined with the low-firing ceramic CERABIEN™ MiLai (both Kuraray Noritake Dental Inc.), making this combination well suited to this type of restoration.

FRAMEWORK DESIGN

To enhance the bio-design effect, in which the framework morphology reproduces the natural distribution of dentin and enamel, an accurate milling strategy is essential. The planned framework morphology should be reproduced faithfully, without losing detail in the proximal areas or at the transition between the white and pink aesthetics (Fig. 1). The optical properties of the milled framework (Fig. 2) and the accuracy of the milled surface (Fig. 3) provide the basis for a predictable aesthetic result.

Fig. 1. Milled restoration within the disc.

Fig. 2. Milled zirconia framework reproducing the cut-back design.

Fig. 3. Detailed view of the accurately milled framework surface.

Once the framework has been correctly sintered, the optical properties of the multilayer zirconia and the effect of the cubic zirconia phase can be fully appreciated. Before sintering, however, particular attention should be paid to the framework surface. Any adjustments should preserve, or even improve, the original morphology created during the CAD design stage. The framework should exhibit a smooth, dense surface, free from roughness and porosity, providing the ideal basis for the subsequent characterisation procedures (Fig. 4).

Fig. 4. Framework surface after sintering, surface texturing and finishing.

The shade of the KATANA Zirconia YML disc should generally be selected one shade lighter than the desired final shade. This helps to avoid excessive chroma and a low-value appearance in areas where the zirconia is thicker, while maintaining flexibility during the subsequent characterisation and layering procedures (Fig. 5).

Fig. 5. Sintered framework on the model.

Thanks to the varying light transmission through the different thicknesses of the bio-designed incisal area, the dentinal effect becomes clearly visible after sintering (Fig. 6). Rather than masking these optical properties, the following steps are designed to enhance them through internal characterisation and selective micro-layering.

Fig. 6. Varying light transmission of the framework.

INTERNAL STAINING

The first stage of framework individualisation is carried out using the Internal Live Stain (ILS) technique (Chroma map 1). At this stage, the zirconia framework is considered the dentinal core of the restoration. The technique is simple to apply, provides an immediate visual effect and is particularly suitable for mirror-image tooth groups as well as white and pink aesthetic rehabilitations (Figs. 7 and 8).

Chroma map 1. Initial internal staining planned.

Fig. 7. Dots of internal stains applied to visualize the planned ILS procedure.

Fig. 8. Planned distribution of the internal stains.

The initial application aims to increase the chroma of the zirconia, while maintaining a high value in the incisal third. The high value of KATANA Zirconia YML helps preserve the overall brightness of the restoration after subsequent micro-layering with CERABIEN MiLai.

The Globule Painting technique used consists of three stages: application, shading and inspection. It also offers a modular approach, allowing additional applications whenever a higher level of individualisation is required.

At this stage, only the deeper optical effects should be reproduced with internal stains. Incisal Blue 2 is used to create opalescence, A+ to increase chroma, and Salmon Pink together with Tissue Red to characterise the gingival tissues (Figs. 9a to c). The internal effects are then assessed before firing. After firing, the colours retain their appearance (Fig. 10), allowing the technician to proceed directly to the micro-layering stage.

Fig. 9a. Incisal Blue 2 applied to the incisal area.
Fig. 9b. A+ applied to increase chroma.
Fig. 9c. Salmon Pink and Tissue Red applied to characterise the gingival tissues.

Fig. 10. Framework after firing following the initial internal staining.

Chroma map 2. Comparison of the planned and completed internal staining.

MICRO-LAYERING

After internal staining, the restoration is ready for micro-layering with CERABIEN MiLai. Depending on the effects to be reproduced and the space provided by the CAD design, translucent, opalescent and lustre porcelains can be used to reproduce the enamel layer. Opaque dentin porcelains, used individually or in combination, can be applied in the cervical and middle thirds or to create a more opaque mamelon effect.

The build-up follows a defined sequence (Layering map 1). CCV2 is applied to maintain translucency while increasing chroma (Fig. 11). LT₁ is serves as the main lustre porcelain in the middle third (Fig. 12), while E₂ is used as a transition dentin in the incisal area and provides the basis for the subsequent effects (Fig. 13).

Layering map 1. Overview of the planned micro-layering procedure.

Fig. 11. CCV2 applied to maintain translucency while increasing chroma in the cervical area.

Fig. 12. LT₁ applied as the principal lustre porcelain in the middle third.

Fig. 13. E₂ applied as transition dentin in the incisal area.

To enhance opalescence while maintaining translucency, Aqua Blue 2 is applied to the incisal area (Fig. 14). Value Liner 1 is then applied within the E₂ layer, while Aqua Blue 2 is placed over the incisal edge to increase the contrast of the mamelons (Fig. 15).

Fig. 14. Aqua Blue 2 applied to enhance opalescence.

Fig. 15. Value Liner 1 and Aqua Blue 2 applied to increase mamelon contrast.

The basic morphology is completed with a further application of LT₁, filling the transition between the cervical and incisal areas (Fig. 16). For the gingival portion of the restoration, Tissue 5 is used to reproduce the deeper reddish areas, while Tissue 6 is applied to the superficial alveolar tissues (Fig. 17). After firing, the optical effects created by the internal staining and micro-layering become clearly visible (Fig. 18).

Fig. 16. LT₁ applied to complete the transition between the cervical and incisal areas.

Fig. 17. Tissue 5 and Tissue 6 applied to reproduce the gingival tissues.

Fig. 18. Restoration after firing following the micro-layering procedure.

ILS ADJUSTMENT

One of the strengths of the ILS technique is its modularity. Multiple effects can be applied during the initial characterisation, or the firing cycles can be separated to allow additional effects to be added later. Since the internal stains are designed to remain stable during firing and the internal stains contain no internal flux, further characterisation can be carried out without compromising the previous application.

Another advantage is the immediate appearance of the applied effects. This allows the technician to assess the colour distribution directly during application and compare the result with the desired outcome. The colour stability of the internal stains after firing also provides excellent control throughout the procedure. The appearance observed before firing closely corresponds to the fired result, making it possible to verify the characterisation before the restoration is returned to the furnace. This can be particularly useful when digital shade-matching systems, such as photography or spectrophotometry, are used.

Before applying a second layer of internal stains, the fired surface should be refined with fine diamond burs to obtain a smooth surface for the stains (Fig. 19). At this stage, the superficial enamel effects are refined by reinforcing selected characterisation effects, enhancing opalescence and adding localised spots (Chroma map 3).

In the present case, a mixture of White and Mamelon Orange 2 (4:1) was applied to enhance the mamelons. Incisal Blue 2 was then placed adjacent to the mamelons to enhance the contrast.

Chroma map 3. Map visualizing the planned ILS adjustment.

Fig. 19. Refinement of the framework surface before the second application of internal stains.

FINAL LAYERING

The final layering stage is used to refine both the morphology and the enamel effects using lustre and enamel porcelains. At this stage, all areas characterised with ILS should be covered with ceramic.

LT₁ can be used to complete the cervical and middle thirds where no further increase in chroma is required while maintaining the value of the restoration. At the same step, LTx is applied from the middle third towards the incisal area to increase translucency and create a lower-value effect in the incisal region (Fig. 20). ELT₁ is then used to refine the morphology and reproduce the natural contrast of enamel by creating the impression of greater enamel thickness in the proximal areas. For the gingival tissues, Tissue 5 is applied to compensate for shrinkage between the teeth and in the deeper areas, while Tissue 1 is used to reproduce the translucent appearance of the superficial gingival tissues (Fig. 21).

Fig. 20. Application of LT₁ and LTx during the final layering stage.

Fig. 21. Completed enamel and gingival layering.

SURFACE TEXTURE AND FINISHING

After firing the enamel layer, the surface texture is refined using diamond burs of different shapes to reproduce a natural surface morphology (Fig. 22). Before self-glazing, gold powder can be applied to highlight the surface texture and facilitate its evaluation (Fig. 23).

Fig. 22. Surface texture reproduced with rotary instruments.

Fig. 23. Gold powder applied to highlight the surface texture before self-glazing.

Self-glazing enhances the quality and compactness of the porcelain while preserving the natural concavities and convexities of the surface texture. Following glazing, the surface can be refined mechanically using ceramic polishing rubbers to achieve the final polish.

The restoration can be evaluated under different lighting conditions to assess the optical properties of KATANA Zirconia YML (Fig. 24), the micro-layering effects (Fig. 25) and the surface texture. The final result demonstrates the harmony between the white and pink aesthetics (Fig. 26).

Fig. 24. Transmitted-light view revealing the optical properties of the restoration.

Fig. 25. Micro-layering effects visible in the finished restoration.

Fig. 26. Final white and pink aesthetic result.

FINAL REMARKS

This case demonstrates how controlled internal characterisation and selective micro-layering can be used to preserve and enhance the optical properties of a zirconia framework. By combining accurate framework design with minimal ceramic application, highly natural white and pink aesthetics can be achieved in a predictable and efficient workflow.

UNCOMPROMISED.
UNMATCHED.
YOURS.

Case by Dr. Onur Alp Yünük

A STEP-BY-STEP GUIDE TO POLYCHROMATIC LAYERING

Complicated crown fractures in the anterior region present both functional and aesthetic challenges. They require a restorative approach that closely mimics natural tooth structure. Thanks to modern developments in adhesive dentistry and composite materials, it is possible to achieve highly aesthetic outcomes in a minimally invasive way.

This case report outlines a straightforward, yet highly aesthetic approach to restoring a traumatised lateral incisor using a polychromatic layering technique. By combining precise shade selection, anatomical analysis, and controlled composite layering, it is possible to recreate the optical properties of natural dentition and achieve seamless optical integration.

CASE OVERVIEW

A young female patient visited our clinic with a history of dental trauma, which resulted in a complicated crown fracture of her maxillary left lateral incisor (tooth #22, FDI notation). After completing the necessary endodontic and periodontal treatments for the affected tooth, we placed a temporary composite restoration. This case outlines a straightforward yet highly aesthetic approach to restoring the tooth using a polychromatic layering technique.

Fig. 1. Initial presentation of a complicated crown fracture on tooth #22 following dental trauma.

VISUAL ASSESSMENT AND SHADE MATCHING

Before beginning the definitive restorative phase, we took initial baseline photographs. Using a cross-polarized filter allowed us to evaluate the true internal optical properties of the adjacent dentition without distracting light reflections. Shade matching was performed using a bilaminar colour selection technique in conjunction with the cross-polarized filter to provide for absolute precision.

Fig. 2. Tooth #22 temporarily restored with composite resin after the completion of endodontic and periodontal treatments.

Fig. 3. Pre-operative view and cross-polarized photograph taken before initiating the definitive restorative treatment.

Fig. 4. Shade selection performed using a bilaminar technique combined with an image taken with a cross-polarized filter for accurate colour mapping.

CLINICAL EXECUTION

Following rubber dam isolation, the temporary restoration was carefully removed and the adhesive system (CLEARFIL™ SE BOND 2) was applied. Before layering the composite, we analysed the primary and secondary anatomy of the adjacent teeth from the occlusal plane to guide the build-up.

Fig. 5. Rubber dam isolation and complete removal of the provisional restoration.

Fig. 6. Occlusal view allowing for the evaluation of the primary and secondary anatomy of the adjacent teeth.

THE RESTORATION WAS CARRIED OUT IN SYSTEMATIC LAYERS

• Dentin core: We established the artificial dentin layer using CLEARFIL MAJESTY™ ES-2 in shades A3D and A2D (Kuraray Noritake Dental Inc.).
• Marginal ridges and incisal edge: The mesial and distal marginal ridges were built using CLEARFIL MAJESTY ES-2 A2, while CLEARFIL MAJESTY ES-2 Blue was applied to the incisal region to mimic natural translucency.
• Characterization: To replicate natural internal characteristics, we applied white and yellow tints. A quick control photograph taken at this stage with a cross-polarized filter is useful to verify the internal effects.
• Final enamel layer: The restoration was completed with a final layer of CLEARFIL MAJESTY ES-2 WE. Immediate post-operative photographs were taken right after the procedure.

Fig. 7. Artificial dentin layering utilizing CLEARFIL MAJESTY ES-2 A3D and A2D shades.

Fig. 8. Artificial dentin layering utilizing CLEARFIL MAJESTY ES-2 A3D and A2D shades.

Fig. 9. CLEARFIL MAJESTY ES-2 A2 used for the marginal ridges and CLEARFIL MAJESTY ES-2 Blue for the incisal area. Application of white and yellow tints for internal characterization, verified with a cross-polarized filter.

Fig. 10. Immediate post-operative views after finalizing the restoration with CLEARFIL MAJESTY ES-2 WE composite.

Fig. 11. Immediate post-operative view taken with a cross-polarized filter.

MANAGING COMPLICATIONS

During the course of treatment, the adjacent central incisor (tooth #21) failed to respond to vitality tests. Consequently, endodontic treatment and internal bleaching were successfully performed on tooth #21 in the subsequent sessions.

FINAL OUTCOME

At the final follow-up appointment, comprehensive control photographs were taken. An occlusal view confirmed the successful recreation of both primary and secondary anatomy. Most importantly, evaluating the final result with a cross-polarized filter image demonstrated a seamless colour integration with the surrounding natural teeth.

Fig. 12. Occlusal view confirming the successful recreation of the primary and secondary anatomy.

Fig. 13. Cross-polarized control photograph demonstrating seamless composite shade integration.

Fig. 14. Final result.

Case by DT Ghaith Alousi

MATERIALS USED

KATANA Zirconia YML

ZIRCONIA BLANK

High-esthetic multilayer zirconia blank with a natural colour gradient from cervical to incisal. Combines high flexural strength with excellent translucency. Ideal for partial veneering.

CERABIEN MiLai

VENEERING CERAMIC

New-generation veneering ceramic specifically developed for zirconia and lithium disilicate restorations. Excellent adhesion to zirconia, natural light optics, wide range of masses for detailed layering techniques.

CERABIEN MiLai Internal Stains

STAIN COLORS

Incisal Blue 1, Mamelon Orange 2, A+, Tissue Pink, Salmon Pink, White – all mixed with Bright for optimal consistency and application precision.

CERABIEN MiLai Masses

CERAMIC MASSES

Tx, Creamy Enamel, LTx, CCV-2, ELT₁ for teeth. Tissue 1, 4, 6 for the gingiva.

INTRODUCTION

The technique represents a modern, efficient approach to dental laboratory aesthetics: rather than voluminous ceramic build-ups, minimal yet precisely applied layers are used, which in combination with the intrinsic aesthetic of the zirconia framework achieve an extraordinary result.

In this case report, dental technician Ghaith Alousi documents step-by-step the fabrication of a facially layered maxillary anterior zirconia restoration based on KATANA™ Zirconia YML and the novel veneering ceramic CERABIEN™ MiLai. The key feature: the palatal surface remains monolithic zirconia, while only the vestibular surface is veneered with CERABIEN MiLai. This combines the stability of zirconia with the incomparable aesthetics of a hand-layered porcelain.

STEP 1: ZIRCONIA FRAMEWORK BEFORE SINTERING

CAD/CAM Milling · KATANA Zirconia YML · Green State

The framework was deliberately designed for partial labial veneering: the vestibular surface provides sufficient space for the CERABIEN MiLai ceramic. While the palatal surfaces are entirely monolithic, the occlusal contact points remain on the mechanically superior zirconia.

Fig. 1. Framework before sintering. Framework after milling.

MATERIAL:

KATANA Zirconia YML

STEP 2: AFTER SINTERING

Sintering · Multi-Layer Aesthetics · Sandblasting

Following the sintering cycle at 1550 °C, the KATANA Zirconia YML framework reveals its full multi-layered character. The impressive colour gradient – from a warm, yellowish-cream tone cervically to the cool, translucent incisal edge – is the direct result of the pigment layering integrated into the blank.

The framework was cleaned directly after sintering using sandblasting only (110 μm, 1.5 bar), with no further processing.

Fig. 2. Sintered framework vestibular view – multi-layered colour gradient after sintering.

Fig. 3. Sintered framework - palatal view – monolithic zirconia structure.

PROCESSING:

• Sintering (1550 °C)
• Sandblasting

STEP 3: FIRST STAIN LAYER

CERABIEN MiLai Internal Stains · Colour Foundation · Internal Characterisation

Prior to ceramic layering, a differentiated stain layer is applied directly to the sintered zirconia framework. This layer serves as the colour foundation and internal characterisation – defining depth effect and individuality.

Colour distribution by zone:

Incisal: Incisal Blue 1 + Bright 20 % – to simulate the natural opalescence effect.
Mid incisor area: Mamelon Orange 2 + Bright 20 % – to replicate the characteristic mamelon structure.
Cervical area & interproximal: A+ + Bright 20 % – for increased chroma and saturation in the cervical third.
Gingival area: Tissue Pink + Salmon Pink – for natural tissue toning.

Fig. 4. CERABIEN MiLai Internal Stains applied – unfired state.

CERABIEN MiLai INTERNAL STAINS:

• Incisal Blue 1 + Bright 20 % (incisal area)
• Mamelon Orange 2 + Bright 20 % (mamelons)
• A+ + Bright 20 % (cervical & interproximal areas)
• Tissue Pink (gingiva)
• Salmon Pink (gingiva)

STEP 4: FIRST CERAMIC LAYER & WASH BAKE

Tx + Tissue 1 · Bonding Fire · Bond Optimisation

After firing the stains, the first ceramic layer is applied using CERABIEN MiLai Tx for the tooth areas and Tissue 1 for the gingiva. The goal is to establish an optimal bond between ceramic and zirconia.

A deliberate wash bake is performed: the firing temperature is raised above the normal reference value so that the ceramic mass flows more readily and bonds optimally to the zirconia surface. A liner or wash fire is intentionally omitted.

Fig. 5. First ceramic layer – unfired, frontal view.

Fig. 6. Frontal view – raw first layer.

CERABIEN MiLai MASSES:

• Tx (Translucent) – tooth portions
• Tissue 1 – gingival area
• Firing mode: wash bake (elevated temperature)

STEP 5: AFTER WASH BAKE

Bond Verification · Preparation for Second Stain Layer

The result after the wash bake shows a first ceramic layer fused to the zirconia. The surface appears smooth and uniformly glossy. The Tx layer enhances the intrinsic translucency of KATANA Zirconia YML and allows the multi-layer colour gradient to shine through harmoniously.

Fig. 7. After wash bake – Tx and Tissue 1 perfectly fused to zirconia.

STEP 6: SECOND STAIN LAYER – DETAIL CHARACTERISATION

Natural Cracks · White · Surface Individualization

In the second stain layer, the focus is on maximum precision and detail. CERABIEN MiLai internal stain White is used to apply fine, naturally appearing crack lines (Natural Cracks) to the tooth surface.

These subtle whitish crack lines develop in natural teeth through enamel stresses and impart to them their unmistakable, vital character. They run anatomically correctly in a vertical direction, varying in intensity and length – exactly as found in nature.

Fig. 8. Close-up – fine crack lines with white stain.

Fig. 9. Second stain overview – harmonious detail distribution.

CERABIEN MiLai INTERNAL STAIN:

• White – Natural Cracks / craquelé lines

STEP 7: SECOND CERAMIC LAYER – MAIN BUILD-UP

Morphology · Enamel Masses · Gingival Design

The second ceramic layer requires the highest concentration on colour, morphology, and surface texture simultaneously. This is the main build-up, during which the final form of the restoration is established.

Tooth masses – zonal strategy:

Creamy Enamel establishes the warm body tone. LTx (Luster Translucent) imparts opalescent vitality. CCV-2 (Clear Cervical 2) provides transparent chroma cervically. ELT₁ (Enamel Luster 1) completes the incisal zone with a delicate enamel gloss.

Gingival masses:

Tissue 1, 4, and 6 create a differentiated tissue appearance with light, mid, and deep tones.

Fig. 10. Main build-up – Unfired state.

CERABIEN MiLai MASSES – TEETH:

• Creamy Enamel – body zone
• LTx (Luster Translucent) – opalescent vitality
• CCV-2 (Clear Cervical 2) – cervical chroma
• ELT₁ (Enamel Luster 1) – incisal enamel gloss

Fig. 11. Main build-up – Close-up – surface texture.

Fig. 12. Main build-up – Close-up – surface texture.

CERABIEN MiLai MASSES – GINGIVA:

• Tissue 1 – light, delicate tissue areas
• Tissue 4 – mid gingival tone
• Tissue 6 – depth, shadow, interdental papillae

STEP 8: SECOND CERAMIC FIRING

Not Yet Finished · As-Fired State

The result after the second ceramic firing is already convincing in its raw form. The fired mamelon structures, the fine crack lines, and the differentiated gingival design are clearly visible. The final surface texture and form will be refined in the next step through mechanical finishing.

Fig. 13. After second firing – not yet finished.

STEP 9: MECHANICAL FINISHING

Morphology Refinement · Before Self-Glaze Firing

Mechanical finishing requires artisanal expertise and a trained aesthetic eye. Diamond burs are used to bring form, proportions, and surface texture to their final level.

Special attention is given to surface texture: perikymata, vertical lobule structures, and the cervicogingival transition are individually incorporated. The palatal side remains completely untouched.

Fig. 14. After finishing.

Fig. 15. Finishing, perikymata and surface texture.

STEP 10: FINAL RESULT

Self-Glaze Firing & Mechanical Polishing

The self-glaze firing differs fundamentally from a conventional glaze firing: no glaze material is applied. The restoration is heated to just below the softening temperature of the ceramic – the surface begins to flow on its own, creating an extremely natural, vital gloss that fully preserves the incorporated texture.

Fig. 16 & 17. Final result.

An applied glaze mass would partially level the fine perikymata and crack lines. The self-glaze firing instead preserves exactly that individuality so precisely incorporated during finishing. The final mechanical polishing completes the high gloss and accentuates the translucency of the tissue.

Fig. 18. Cervicogingival transition.

Fig. 19. Final result – close-up.

FINISHING STEPS:

• Self-glaze firing (no applied glaze mass)
• Mechanical polishing of ceramic surfaces

CONCLUSION

KATANA Zirconia YML and CERABIEN MiLai from Kuraray Noritake Dental Inc. open new dimensions in aesthetic dental technology. The combination of an intrinsically highly aesthetic multi-layer zirconia blank with CERABIEN MiLai, a veneering ceramic system designed for micro-layering on zirconia as well as lithium disilicate restorations, enables highly natural aesthetic outcomes with minimal material usage. The conscious omission of a liner firing, the targeted use of wash bake for optimal bonding, and the decision to make use of self-glaze firing instead of conventional glazing all express a thoughtful, material-oriented philosophy. The documented steps make clear that esthetic excellence is not the result of complexity. It is the result of precision, material understanding, and an unerring eye for detail.

The backlight photograph makes it strikingly visible: light flows through the restoration as through a natural tooth – proof of the harmonious interplay of KATANA Zirconia YML and CERABIEN MiLai.

UNCOMPROMISED.
UNMATCHED.
YOURS.

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Case by Jotautas Kaktys, DDS

An endodontically treated, structurally compromised mandibular molar with recurrent failure of direct composite restorations presents both biomechanical and aesthetic challenges. In patients with parafunctional habits such as bruxism, excessive tensile forces further increase the risk of fracture. This case report describes a minimally invasive, cost-conscious approach using a CAD/CAM hybrid material (KATANA™ AVENCIA™ Block 2, Kuraray Noritake Dental Inc.) to restore function, strength, and aesthetics while preserving remaining tooth structure.

CASE EXAMPLE: INITIAL SITUATION

The patient presented with a structurally compromised mandibular first molar and reported repeated failure of composite restorations, as well as dissatisfaction with aesthetics (Figs. 1 to 3). Longevity, strength, and cost-effectiveness of the treatment were key concerns.

Clinical findings, including worn canines and multiple cervical lesions, indicated a bruxing patient with group guidance during lateral movements, leading to excessive tensile stress and increased fracture risk. An indirect restoration with cusp coverage was indicated. Due to financial limitations and uncertain endodontic prognosis, a CAD/CAM hybrid material KATANA AVENCIA Block 2 ML (Kuraray Noritake Dental Inc.) in the shade A3 (Fig. 4) was selected.

Fig. 1. Initial situation: Buccal view of the mandibular first molar in need of treatment due to a cervical lesion and a leaking composite restoration.

Fig. 2. Buccal view of the teeth in occlusion.

Fig. 3. Occlusal view of the tooth revealing a number of defects.

Fig. 4. Shade selection: Image taken with the A3 tab of the VITA classical A1-D4 shade guide for communication with the dental technician.

TOOTH PREPARATION AND IMMEDIATE DENTIN SEALING

Preparation was kept minimally invasive to preserve remaining tooth structure while creating space for adequate material thickness (~1.5 mm; Figs. 5 and 6). Weak cusps were reduced with minimal biological sacrifice.

After sandblasting and pre-treatment of the old composite and fiber post surfaces with silane, exposed dentin was sealed using CLEARFIL™ SE Protect and coated with CLEARFIL MAJESTY™ ES Flow (Low flowability, shade A3D; both Kuraray Noritake Dental Inc.; Figs. 7 and 8). Due to the presence of sclerotic dentin, we decided to reactivate the surface and use a two-step self-etch system instead of a universal adhesive. Resin coating was performed to protect the underlying tooth structure and mask discolouration.

Fig. 5. Tooth preparation preserving the remaining enamel and the cervical tissues.

Fig. 6. Adequate occlusal clearance.

Fig. 7. Immediate dentin sealing and resin coating.

CLEARFIL SE Protect for IDS (Immediate Dentin Sealing).

CLEARFIL MAJESTY ES Flow High for RC (resin coating).

CLEARFIL™ CERAMIC PRIMER PLUS for adhesion to old sandblasted composite.

Fig. 8. Tooth ready for intraoral scanning.

DIGITAL WORKFLOW

The intraoral situation was digitised using an intraoral scanner (Figs. 9 to 11). This enabled efficient computer-aided design and manufacturing (exocad DentalCAD; Figs. 12 to 14). The occlusal design was adjusted to minimise tensile forces during lateral movements. The restoration was milled and required only minimal finishing and polishing (TWIST™ DIA for Composite, Kuraray Noritake Dental Inc.), which was quick and effective (Fig. 15).

Fig. 9. Digital model of maxilla and mandible revealing sufficient space for the planned restoration.

Fig. 10. Preparation margins clearly visible both in the coloured …

Fig. 11. … and the black-and-white modes of the software.

Fig. 12. Computer-aided design in the laboratory using exocad DentalCAD.

Fig. 13. Milled restoration with milling sprue positioned at the buccal wall – an area which is easily adjustable (no interproximal or occlusal contacts affected) and stable.

Fig. 14. Milled restoration with smooth margins (no irregularities) due to non-brittleness of the hybrid ceramic material.

Fig. 15. Polishing is accomplished in two to three minutes and leads to great results.

TRY-IN AND PLACEMENT

Tissues had healed nicely in the three weeks between impression taking and final restoration placement (Fig. 16). Try-in confirmed a perfect fit of the restoration. Optical integration was difficult to assess without try-in paste (Fig. 17), but the patient was happy anyway, so that it was decided to move on immediately.

Isolation was achieved using a retraction cord (size 00) and PTFE tape (Fig. 18). As the bonding substrate consisted mainly of enamel and composite, a universal adhesive CLEARFIL™ Universal Bond Quick was selected. It was applied after phosphoric acid etching and treated with a gentle stream of air until the adhesive layer was uniformly thin (no pooling) and the surface did no longer move. As some remaining exposed dentin was present, the adhesive was polymerised to stabilize the hybrid layer. The restoration was pretreated (sandblasting, cleaning, CLEARFIL CERAMIC PRIMER PLUS) and adhesively cemented using a light-curing resin cement system to provide for dependable bonding.

Fig. 16. Healthy tissues at the delivery visit.

Fig. 17. Try-in of the restoration to assess the fit – no adjustments were necessary.

Fig. 18. Soft tissue management and moisture control with a retraction cord and PTFE tape, surface sandblasted to prepare for adhesive cementation.

TREATMENT OUTCOME

While the soft tissues were still slightly retracted after treatment and the optical integration difficult to assess due to dehydrated tooth structure (Fig. 19), radiographic examination confirmed proper biological integration (Fig. 20) and the patient was satisfied immediately. When she returned for a check-up after six months, we saw healthy soft tissues, a great marginal seal and proper aesthetic integration (Fig. 21). The restoration margins blended in nicely, no signs of wear were detectable and polish retention was great (Fig. 22).

Fig. 19. Immediate treatment outcome.

Fig. 20. Final radiograph.

Fig. 21. Restoration at a recall after six months. The gingiva appears healthy and has grown over the restoration margin, which is a sign of the material's biocompatibility.

Fig. 22. Smooth occlusal surface without any signs of wear.

CONCLUSION

Minimally invasive cusp coverage with KATANA AVENCIA Block 2 offers a predictable and cost-effective solution for structurally compromised posterior teeth. This is because the production procedure involves fewer manual steps, such as characterisation and glazing, while completely eliminating the need for heat treatment. A high level of automation further supports this efficiency. Successful outcomes depend on preserving the remaining tooth structure, careful treatment planning, and adherence to the recommended adhesive protocols.

Special thanks to dental technician Tautvilas Kaktys (my twin brother) and the dental laboratory RiCreo for their outstanding laboratory support and craftsmanship.

By Dr. Gintautas Rumbaitis, DDS

A CLINICAL CASE EXAMPLE

Low polymerization shrinkage, high strength and excellent wear resistance are among the most important criteria when selecting a restorative material for the posterior region. Low shrinkage supports marginal integrity after curing, while high mechanical strength provides for long-term stability even under high occlusal load. High wear resistance, in turn, contributes to long-term morphological stability. Together, these characteristics form the basis for the long-term success of posterior restorations.

The CLEARFIL MAJESTY™ family from Kuraray Noritake Dental Inc. offers materials designed to meet these requirements. They enable the creation of restorations that not only provide an appealing aesthetic outcome, but - more importantly - effectively restore the function and anatomy of the teeth. The portfolio includes a range of paste-type composites supporting different shade concepts, from single-shade to multi-shade approaches, as well as high-strength flowable composite materials.

CLEARFIL MAJESTY™ ES Flow is available in three levels of flowability and multiple shades. The universal alternative introduced in 2025, CLEARFIL MAJESTY™ ES Flow Universal, is offered in Low and Super Low flowabilities and two shades. These flowable materials provide the mechanical properties required for the successful restoration of all cavity classes. They can be used alone or in combination with paste-type composites, allowing clinicians to select the restorative concept best suited to each clinical situation.

A restoration procedure combining the new flowable material with a paste-type composite from the MAJESTY family (CLEARFIL MAJESTY ES-2) is demonstrated below using a clinical case example.

The patient presented for replacement of existing composite restorations in the posterior region. Clinical examination revealed that the restoration on the maxillary left first molar (FDI notation: tooth #26) showed marginal leakage as well as insufficient anatomical structure and occlusal height (Fig. 1). Replacement of the restoration was therefore planned. The clinical procedure is illustrated and described in Figures 2-12, while Figures 13-15 show the treatment outcome.

Fig. 1. Restoration on the first molar that needs to be replaced.

Fig. 2. Situation after removal of  the existing restoration. Removal  of the remains near the cavity floor performed using a carbide burr, without water, at slow speed.

Fig. 3. Cavity checked using Caries Detector (Kuraray Noritake Dental Inc.) for remaining decay.

Fig. 4. A distal crack is observable on the proximal wall of the first molar.

Fig. 5. Appearance after dissection of the cracked area and careful removal of the remnants of the composite restoration.

Fig. 6. Tooth after placement of a sectional matrix and sandblasting of the surface with 27 µm aluminium oxide powder.

Fig. 7. Selective etching with phosphoric acid etchant for 15 seconds.

Fig. 8. Strengthening of the cavity floor with fibres embedded in CLEARFIL™ AP-X composite (Kuraray Noritake Dental Inc.)

Fig. 9. Application of CLEARFIL MAJESTY ES Flow Universal in the shade UD (Universal Dark) in 2 mm increments, primarily to replace the dentin.

Fig. 10. Modelling of the occlusal area with CLEARFIL MAJESTY ES Flow Universal in the shade U (Universal).

Fig. 11. Modelling finished.

Fig. 12. Brown stains and CLEARFIL MAJESTY ES-2 in the shade WD applied for optical effects.

Fig. 13. Result of the polishing procedure.

Fig. 14. Buccal view of the polished restoration.

Fig. 15. Immediate treatment outcome with the tooth structure still being dehydrated.

CONCLUSION

The presented clinical case demonstrates how posterior teeth can be restored predictably and efficiently using materials from the CLEARFIL MAJESTY ES-2 portfolio. The combination of CLEARFIL MAJESTY ES Flow Universal as a flowable base layer and CLEARFIL MAJESTY ES-2 as a paste-type composite enables controlled placement, excellent adaptation to the cavity walls and the precise reconstruction of anatomical structures.

Thanks to their low polymerization shrinkage, high mechanical strength and excellent wear resistance, the materials support marginal integrity and functional stability over time. At the same time, the wide range of flowabilities and shade concepts provides dental practitioners with the flexibility desired to adapt the restorative concept to individual preferences and clinical situations.

Clinical case by Dr. Zygintas Jonaitis

MINIMALLY INVASIVE INDIRECT RESTORATION PROCEDURE IN THE POSTERIOR REGION

The aim of preserving as much natural tooth structure as possible is ever-present in modern restorative concepts. No matter whether a direct or indirect restorative procedure is preferred, a whole array of tools, techniques and materials are available that help make the clinician's life easier and treatment outcomes more predictable and durable. Those solutions are designed to facilitate identification of tooth structure that needs to be removed, aid cavity cleansing or maximise the bonding performance without adding complexity to the treatment. Using the following clinical example, a possible restorative workflow is described.

RESTORATION REPLACEMENT REQUIRED

This patient presented with a composite restoration on a first molar that attracted our attention. The very extensive composite restoration was worn, lacked good anatomical form and proper occlusal contacts, showed leakage and signs of secondary caries (Fig. 1). The tooth reacted to sweets and cold. It was clear that repair was not the best option: the restoration needed to be replaced. Due to the size of the existing composite filling, it was decided to place an indirect partial restoration that would allow us to save as much natural tooth structure as possible while providing for long clinical service life.

Fig. 1. Initial clinical situation.

SELECTIVE CARIES REMOVAL

After rubber dam placement, the existing restoration was removed carefully, revealing secondary caries underneath the composite (Figs. 2 and 3). To facilitate selective caries removal down to remineralisable (non-infected) dentin, Caries Detector was applied (Fig. 4). This liquid stains only the infected tissue, so that it is easily identified and selectively removed using diamond instruments (Fig. 5). This helps users preserve remineralisable (affected) dentin that may be left untouched and – whenever well-sealed – does not pose a risk for the future restoration.

Fig. 2. Isolation of the working field with rubber dam.

Fig. 3. Removal of the old composite restoration.

Fig. 4. Application of Caries Detector to visualise infected dentin.

Fig. 5. Cavity after the removal of infected dentin.

ADHESIVE PROCEDURE AND BIO-BASE CREATION

To create a stable basis for the indirect restoration, the tooth surface was first cleaned thoroughly using KATANA™ Cleaner (Fig. 6). This cleaning agent developed for intra- and extra-oral use effectively removes contaminants that might compromise adhesion from the surface – a decisive step as a strong and durable bond is the creation of a stable foundation. Subsequently, CLEARFIL™ SE Protect, a self-etching adhesive with MDPB, an antibacterial monomer was applied according to the manufacturer's instructions for use (Fig. 7). Next, a layer of poly ethylene fiber, wettened with CLEARFIL SE Protect Bond was placed and covered with flowable composite (CLEARFIL MAJESTY™ ES Flow Universal). Hereafter a layer of fiber reinforced flowable composite was placed and cured. An impression was taken with an intra-oral scanner and a glass-ceramic restoration produced in the laboratory.

Fig. 6. Cleaning of the tooth structure with KATANA Cleaner.

Fig. 7. Self-etch adhesive with anti bacterial effect applied to the tooth structure.

Fig. 8. Foundation created with fibres, bond and flowable composite.

Fig. 9. Completed with a layer consisting of short-fibre reinforced composite.

TOOTH PREPARATION AND ADHESIVE CEMENTATION

Tooth preparation was performed (Fig. 10). followed by pre-treatment of all surfaces to provide for a strong and durable connection between the foundation and the indirect restoration. The bonding surface of the glass ceramic restoration was etched with hydrofluoric acid before applying a ceramic primer (CLEARFIL™ Ceramic Primer Plus) . Followed by applying PANAVIA™ V5 Paste onto the restoration (Fig. 12). The tooth structure and foundation were treated according to the manufacturers instructions with the system-specific PANAVIA V5 Tooth Primer before placing the restoration. The cement was light-cured thoroughly, restoration margins were cleaned and polished (Fig. 13) and the rubber dam was removed. Figures 14 and 15 show the treatment outcome.

Fig. 10. Prepared tooth prior to adhesive cementation.

Fig. 11. Pre-treatment of the bonding surface of the restoration with a ceramic primer.

Fig. 12. Application of the selected adhesive resin cement onto the restoration.

Fig. 13. Restoration in place.

Fig. 14. Occlusal view of the final restoration.

Fig. 15. Occlusal view of the final restoration

CONCLUSION

The described procedure shows the restoration of a posterior tooth's anatomy and occlusal contacts in cases with severe loss of sound tooth structure. The remaining tissue is preserved wherever possible, while the protective foundation provides for a tight seal of the underlying tooth structure. Utilizing the indirect restoration method supports the restoration's marginal integrity. A long clinical service life may be expected.

Case af Dr. Onur Alp Yünük

Flotte tænder; et strålende, perfekt smil: Det kan være udfordrende at imødekomme de æstetiske krav fra patienter, der ønsker plastfacader. Mens nogle patienter deler konkrete ideer til, hvordan deres nye tænder skal se ud, er det sværere for andre at udtrykke deres forventninger. I sådanne tilfælde er det vigtigt at vælge en behandling med mulighed for justeringer – om det er i form af en udvidet planlægningsfase med et digitalt smile design eller ved at lave plastfyldninger, som nemt kan justeres intraoralt.

Den sidstnævnte tilgang blev valgt til en ung kvindelig patient som henvendte sig til vores klinik, da hun var utilfreds med sine plastfacader på overkæbeincisiverne (Fig. 1 til 4). Ved den intraorale undersøgelse viste det sig, at de eksisterende fyldninger på hendes overkæbeincisiver og -hjørnetænder havde ujævne, ru overflader, kantmisfarvninger og kompromitteret strukturel integritet af plastmaterialet. I overensstemmelse med disse fund blev det planlagt at fjerne de eksisterende fyldninger i overkæbefronten og genskabe optimal æstetik og funktionel integritet med nye plastfyldninger (3+ til +3 ad modus Haderup). Patienten udtrykte, at hun godt kunne tænke sig, at vi tilføjede mere individualitet og karakter til hendes tænder samt at hun ønskede at få et mere strålende smil, end hun havde med de eksisterende fyldninger.

Fig. 1: Plastfacader på overkæbeincisiver med mangelfuld æstetik og funktionel integritet.

Fig. 2: Overkæbefronten okklusalt med synlige defekter i plastfacaderne.

Fig. 3: Lateral visning fra højre side, der afslører overfladeujævnheder.

Fig. 4: Lateral visning fra venstre side, der afslører et stort debonded og afskallet område.

UDSKIFTNING AF PLASTFACADERNE

For at genskabe de naturlige tænders karakteristiske translucens og opfylde patientens æstetiske krav, blev det planlagt at anvende et polykromatisk lagdelingssystem og en tolagsteknik. Dette muliggør et flot sammenspil af de forskellige translucenser i fronten.

Under farvevalgsfasen blev Bilaminar Shade Assessment Technique (BSAT), som er baseret på farvekombinationen af dentin- og emaljeplast, anvendt. Med denne teknik blev den tilsigtede emaljefarve lagt i lag over den ønskede dentinfarve for at vurdere den resulterende farve skabt af de to plastfarver. Plasten blev polymeriseret på tandoverfladen uden adhæsiv. Således blev det bekræftet, at den kumulative farveopfattelse, som stammer fra lagdelingen fremfor de individuelle plastfarver, var i harmoni med den naturlige tandsubstans ved behandlingsstart. Fotos blev taget med et kamera udstyret med et krydspolariseringsfilter (Fig. 5). Herefter blev den faste retainer samt de eksisterende plastfacader fjernet. For at bevare så meget af den underliggende, sunde tandsubstans som muligt, blev proceduren lavet under forstørrelse samt brug af orange lys. De valgte instrumenter var røde og gule diamantbor samt hårdmetalbor. Figur 6. viser resultatet efter proceduren.

Fig. 5: Farvevalg – billede taget ved hjælp af et krydspolariseringsfilter, som eliminerer refleksioner.

Fig. 6: Tænderne efter fjernelse af de insufficiente plastfacader.

Tænderne blev isoleret med kofferdam fastgjort med tandtråd cervikalt. Herefter blev fyldningsproceduren påbegyndt.  Efter emaljeætsning og påføring af en selvætsende adhæsiv (CLEARFIL™ SE Bond 2, Kuraray Noritake Dental Inc.), blev CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.) påført. Dentinkernen, med dens fremtrædende mameloner, blev formet i farven A1D. Incisalkanterne og mamelonerne blev fremhævet pletvist med hvid karakteriseringsfarve. For at skabe opalescens blev et tyndt lag af den translucente farve Blue påført ovenpå, mens emaljedelen blev opbygget med emaljefarven WE. Eftersom den faste retainer var blevet fjernet, blev en aftagelig gennemsigtig retainer fremstillet og udleveret til patienten i slutningen af seancen til brug indtil den efterfølgende aftale.

Fig. 7: Isolation med kofferdam til fyldning af de laterale incisiver samt hjørnetænderne.

Fig. 8: Tænderne påført det labiale emaljelag.

Fig. 9: Fyldningernes form og farve lavet i overensstemmelse med patientens forventninger.

Efter pudsning og polering med Twist DIA for composite blev patienten sendt hjem og en ny aftale oprettet til reevaluering samt endelige justeringer.

Til kontrollen bad patienten os mindske den incisale translucens og lyshed i sine overkæbeincisiver samt at ændre formen  af alle de fyldte tænder. Hun ønskede længere centrale overkæbeincisiver med blødere, mere afrundede overgange  (line angles) og en mere jævn incisal kontur. Kofferdam blev igen anlagt. Herefter blev den labiale overflade af plastfacaderne i overkæbeincisiverne reduceret en smule ved brug af røde og gule diamantbor. For at rugøre overfladen og øge topografien for optimal mikromekanisk låsning, blev plastoverfladen sandblæst med 50μm aluminiumoxidpartikler. Fosforsyre, silan og CLEARFIL™ SE Bond 2  blev derefter anvendt som en del af adhæsivprotokollen. Fyldningerne blev efterfølgende justeret med forlængelse, farvekorrektion med brug af CLEARFIL MAJESTY™ ES-2 Premium  i farverne A1D og A1E samt korrektion af de anatomiske konturer (Fig. 10 og 11). 

Fig. 10: Justering af fyldningerne på de centrale incisiver.

Fig. 11: Tilpasset smil med mere normale tandformer og -konturer og en mere naturlig tandfarve.

Under denne sidste aftale udtrykte patienten, at hun var meget glad for sit nye smil. Fyldningsoverfladerne blev genpolerede, en ny fast retainer fikseret og endelige fotos taget (Fig. 12 til 16).

Fig. 12: Endeligt behandlingsresultat –  frontal visning.

Fig. 13: Endeligt behandlingsresultat – okklusal visning.

Fig. 14: Endeligt behandlingsresultat –  lateral visning.

Fig. 15: Endeligt behandlingsresultat – patientens smil.

Fig. 16: Detaljeret visning af den indre farvestruktur – gjort synlig ved hjælp af et polariseringsfilter.

KONKLUSION

At tale med patienter om hver en detalje af behandlingen og at lytte opmærksomt til deres ideer, forventninger og krav, beskytter os ikke altid imod behovet for justeringer – simpelthen fordi patienterne har brug for at se, hvad de får for at kunne bedømme, om de kan lide det. Heldigvis kan valg af velegnede materialer og teknikker gøre det muligt for tandlæger at skabe nye smil, der kan justeres uden at skade sund tandsubstans. Således bliver dét, at gøre de mest krævende patienter glade, ikke længere er en udfordring.

Case af Dr. Onur Alp Yünük.

KOMBINATION AF VÆRKTØJER OG MATERIALER MED HØJ YDEEVNE FOR ET FORUDSIGELIGT RESULTAT

Plastfyldninger er en behandlingsmulighed af høj kvalitet, selv når store mængder tandsubstans skal erstattes. Dette skyldes de seneste fremskridt i plastmaterialer og adhæsivteknologi. Ved at udvælge velegnede materialer og lagdelingsteknikker, kombineret med moderne digitale værktøjer til vurdering af farveforskel, er det muligt at skabe forudsigelige højæstetiske resulter som demonstreret i følgende case.

Udfordringen

En ung mandlig patient henvendte sig til vores klinik med ønske om udskiftning af hans eksisterende plastfyldninger på overkæbeincisiverne (2+, 1+ ad modus Haderup). Den kliniske undersøgelse viste en tabt fyldning på den laterale incisiv. Derudover sås anatomiske afvigelser, misfarvning og tab af overfladeglans.

I samråd med patienten blev det besluttet at erstatte de eksisterende fyldninger ved brug af moderne plastmaterialer specifikt udviklet til tofarvet lagdeling – CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.). For at få en præcis farveanalyse blev der taget fotos med og uden krydspolariseringsfilter (Fig. 1 til 4).

Fig. 1: Frontal visning af tænderne med omfattende fyldningstab på den laterale incisiv i overkæben.

Fig. 2: Krydspolariseret fotografi af tænderne som muliggør en detaljeret analyse af farveafvigelserne.

Fig. 3: Lateral visning af tænderne.

Fig. 4: Lateral visning – krydspolariseret fotografi.

Løsningen

Efter fjernelse af de eksisterende fyldninger blev kofferdam anlagt til isolation af arbejdsfeltet. En selvætsende adhæsiv (CLEARFIL™ SE Bond 2, Kuraray Noritake Dental Inc.) blev påført til selektiv emaljeætsning før etablering af den palatinale væg med CLEARFIL MAJESTY™ ES-2 Premium i farven A1E (Fig. 5 og 6). Mamelonerne blev rekonstrueret med CLEARFIL MAJESTY™ ES-2 Premium i farven A1D, mens den translucente farve Blue blev påført til den opalescente zone. Til sidst blev gule og hvide karakteriseringsfarver anvendt til individualisering. Fig. 7 illustrerer udseendet af fyldningerne før og Fig 8. efter finishering og polering.

Fig. 5: Palatinal væg etableret med emaljefarven  A1E af den valgte plast.

Fig. 6: Lateral visning af tænderne under fyldningsproceduren.

Fig. 7: Fyldning før finishering og polering.

Fig. 8: Fyldningernes udseende efter finishering  og polering.

Resultatet

For at evaluere den endelige farveintegration blev der taget endnu et foto med krydspolariseringsfilter, mens der blev holdt et gråt referencekort på plads til kalibrering (Fig. 9 og 10). Den laterale visning af de fyldte tænder (Fig. 11) viser ikke blot den rigtige farvekombination, men også en naturlig overfladetekstur som kræves for et højæstetisk resultat.

Fig. 9: Frontal visning af de fyldte tænder taget med et polarisationsfilter.

Fig. 10: Kalibrering med gråt referencekort og de resulterende CIELAB koordinater af fyldningen.

Fig. 11: Lateral visning af de fyldte tænder der understreger vigtigheden af overfladetekstur.

DISKUSSION OG KONKLUSION

Observering, understøttet af moderne værktøjer for fotografi og billedanalyse (som polarisationsfiltere og CIELAB koordinater), er en vigtig evne, som er nødvendig for naturtro rekonstruktion af tænder med plastmaterialer. Ved at kombinere denne evne med et højtydende plastsystem, der byder på faste farvekombinationer med innovativ lysdiffusionsteknologi, som giver en god evne til at blende ind med den omgivende tandsubstans, bliver dét at skabe smukke fyldninger en forudsigelig proces.

I den præsenterede case var patienten meget tilfreds med resultatet både i forhold til æstetik og funktion. Ved de regelmæssige eftersyn blev kvaliteten af de fyldte tænder kontrolleret – de udviser stadig en meget fin funktionel og æstetisk integration.

Dentist:

Om forfatteren

Dr. Onur Alp Yünük gennemførte både sin kandidatuddannelse og ph.d. på Istanbul University. Han er på nuværende tidspunkt ansat som Assistant Professor i the Department of Restorative Dentistry på Istinye University Faculty of Dentistry. Hans arbejde fokuserer primært på fortandsplast og polykromatiske lagdelingssystemer.

By Dr Wiktor Pietraszewski BSC(HONS) DMD

INTRODUCTION

According to personal experience, the cementation of glass ceramic veneers is one of the most stressful and technique-sensitive procedures in restorative dentistry. This is not only due to the minimal margin for error, but also the high aesthetic standards that must be met to deliver a result satisfying both clinician and patient. Modern protocols emphasize conservative preparation, ideally remaining entirely within enamel, or at the very least, minimising extension into dentin. It is essential to understand that both preparation design and extent should not be planned in isolation. Instead, they must be carefully co-planned through thorough communication and collaboration between clinician and technician, ensuring the final result is both biologically respectful and aesthetically predictable.

THE CASE

The case to be discussed today is rather unique in that it arose unexpectedly, without the luxury of typical pretreatment planning steps such as a diagnostic wax-up or mock-up. These were omitted due to time and budget constraints on the patient’s part — a reality many clinicians can relate to. The rationale behind this approach will become clearer as we progress through the case. The patient is a 70-year-old retiree, whom I have been managing for several years. Treatment thus far has focused on stabilising and gradually improving her posterior restorations, with the longer-term aim of addressing the anterior dentition to enhance both function and aesthetics.

Nowadays, financial considerations often pose a significant barrier to patients accepting comprehensive treatment plans from the outset. As such, effective communication and phased treatment planning become essential tools in fostering patient trust and long-term commitment. This particular visit was an emergency appointment, with the patient presenting with a fractured porcelain veneer on her maxillary left central incisor — tooth 21 according to the FDI notation (Fig. 1). Fortunately, because of the existing phased approach to her care, we were well-positioned to transition into an aesthetic restorative phase with minimal resistance or hesitation from the patient.

Fig. 1. Pre-operative view - emergency: Chipped existing ceramic veneer.

Fig. 2. The plan - Digital Smile Design - 4 x porcelain veneers - 4 x direct composite restorations.

THE PLAN

After careful discussion, it was decided to remove and replace the four existing porcelain veneers and to replace four existing Class V stained composite restorations with fresh new direct composite (Fig. 2). Everyone involved was happy with the plan, sure it would adequately fulfil the patient’s aesthetic expectations and even surpass them. At the emergency appointment, time was so limited that only the temporary restoration of the chip with direct composite was feasible. Time was an important factor going forward: the patient wanted to proceed and have the case completed as soon as possible.

Main features of the Digital Smile Design (DSD) plan

1. Lengthening - central incisors – incisal edges to reflect the length of the canine tips
2. Equal gingival zeniths
3. Masking of the cervical defects

PREPARATION, SCAN & TEMPORISATION

The first step involved building up the teeth using a flowable composite to create a rough direct mock-up (Fig. 3), guided by the DSD plan (Fig. 2). This mock-up provided a visual and functional prototype, of which an impression was taken to aid in the fabrication of interim temporary restorations for the provisional phase of treatment.

Preparations were carried out using OptraGate isolation. The existing veneers were first removed using high-grit diamond burs at high speed. Once the bulk of the old material was cleared, gingival retraction was achieved using retraction cord, allowing for improved visibility and access. The preparations were then refined with lower-grit diamond burs at a reduced speed to ensure precision and tissue safety. The primary objectives of the preparation phase were to establish harmonious gingival zeniths and to adequately cover the cervical defects that were evident in the previous restorations (Figs. 4 and 5).

Fig. 3. Mock-up made of flowable composite.

Fig. 4. Class V composite restorations replaced on teeth 13, 23, 24 and 25.

Fig. 5. Situation after preparation of the maxillary incisors.

CEMENTS

Traditionally, glass ceramic veneers have been cemented successfully using a vast array of different luting resins available on the market.

Recently, a trend towards the use of flowable resin or heated composite to cement glass ceramic restorations has emerged. Like the abovementioned approach, this option is viable and literature-supported. The benefits of using flowable resin or a heated paste-type composite resin have been widely documented. The probably biggest advantage of this approach arises from the fact that the user is already familiar with the shades of the material used for cementation. Composite shades are often specified using the VITA classical A1 - D4 system, which dental professionals tend to be more accustomed to than to shade descriptions used for resin cements, like Warm, Light, Neutral and the like.

Some resin cement systems offer try-in pastes corresponding to the shades of the cement to overcome this obstacle and allow for precise shade evaluation at try-in to accurately aid in selecting the best cement shade available. PANAVIA™ Veneer LC is a popular example, as it matches the shades of PANAVIA™ V5 Try-In Pastes (Fig. 6).

Fig. 6. PANAVIA ™ V5 Try-in Paste Universal (A2).

Using a cement shade that matches the intended final appearance is crucial when bonding glass-ceramic veneers, as it decisively affects both immediate and longterm aesthetics. This is especially important due to the light-diffusion properties of glass-ceramic materials such as IPS e.max CAD or IPS e.max Press (Ivoclar Vivadent). Restorations can be as thin as 0.3 mm in minimally invasive cases. The thinner the restoration, the more translucent the material, and the greater the cement’s appearance will influence the final outcome.

Of course, the shade of the prepared tooth substantially influences cement shade selection, as well as decisions about the final restoration thickness (and thus preparation depth) and the ceramic translucency selected (IPS e.max, for example, is available in three translucency levels – LT [Light], MT [Medium], and HT [High]; Fig. 7). When the abutments are dark and a bright, white appearance is desired for the final restorations, it is wise to use a ceramic block with lower translucency. This is why taking a photograph of the prepared teeth and sending it to the ceramist is so important. In the present case, the pepared tooth structure appeared quite dark in the incisial third, so that the medium translucency variant of IPS e.max CAD in the determined shade A1 was selected, which would allow for a minimal thickness and a natural outcome.

Fig. 7. Whitewash photograph used to demonstrate the translucent properties of glass ceramic veneers.

PANAVIA™ VENEER LC

PANAVIA™ Veneer LC is a light curing resin cement. Therefore, it is indicated for ceramic and composite restorations with less than 2mm thickness. It comes in four shades – Clear, White, Universal (A2) and Brown (Fig. 8) – with matching PANAVIA™ V5 Try-In Pastes. These pastes facilitate the simulation of the restorations’ final appearance (Fig. 9). The cement system consists of four components (Fig. 10).

Fig. 8. PANAVIA™ Veneer LC Paste shades.

Fig. 9. Matching PANAVIA™ V5 Try-In Paste shades.

Fig. 10. The kit consists of phosphoric acid etchant, resin cement paste, universal ceramic primer and tooth primer.

TRY-IN

Upon delivery of the four lithium disilicate veneers in the selected translucency and shade (MT A1; Fig. 11), it was time to select the resin cement shade for try-in. As a bright result that would still match the colour of the adjacent teeth was desired, the shade of choice was Universal (A2). Patient and practice team were happy with the simulated treatment outcome (Fig. 12), so that the veneers were cleaned and pre-treated for definitive placement.

Fig. 11. Lab work delivered: Lithium disilicate porcelain veneers - medium translucency, shade A1.

Fig. 12. Try-in with PANAVIA™ V5 Try-In Paste Universal (A2).

CEMENTATION STEPS

For adhesive cementation of the veneers, the teeth were isolated with latex-free rubber dam (Isodam HD in thickness Heavy Gauge; Fig. 13a). Clamps were placed and the veneers tried in to check the fit once more (Figs. 13b and c).

Subsequently, the tooth surfaces were pretreated, starting with the central incisors: Protecting the adjacent teeth with a metal strip, the surfaces were first treated using air abrasion with 35-micron aluminium oxide powder (Fig. 14a). Once the surface was rough (Fig. 14b), phosphoric acid etching gel was applied to the sandblasted surface for 15-30 seconds (Fig. 14c). After thorough rinsing and drying of the etched surfaces, the adjacent lateral incisors were isolated with PTFE tape to facilitate excess cement clean-up during the adhesive luting procedure (Fig. 14d).

Fig. 13a. Isolation with latex-free rubber dam.

Fig. 13b. Further retraction with B4 clamps for dry try-in.

Fig. 13c. Fit check with clamps in place to ensure full seating of the veneers.

Fig. 14a. Air-abrasion with 35-micron aluminium oxide powder.

Fig. 14b. Result of the air abrasion procedure.

Fig. 14c. Total etching with 37% phosphoric acid.

Fig. 14d. PTFE tape placement on lateral incisors to simplify clean-up.

The actual cementation steps included priming of the tooth structure with PANAVIA™ V5 Tooth Primer, which is strong on enamel and dentin (Fig. 15a), leaving it for 20 seconds and then drying with mild air. The veneers’ intaglio surfaces were treated with hydrofluoric acid for 20 seconds and - after complete removal of the etchant - primed with CLEARFIL™ CERAMIC PRIMER PLUS (Fig. 15b) and dried. Now, it was time to apply the cement paste (PANAVIA™ Veneer LC) onto the pre-treated ceramic surfaces and seat the veneers carefully (Figs. 15c and d). During placement, gentle but firm pressure is ideally applied using a soft, padded instrument to ensure accurate seating. When using light-cure (LC) resin cements, tack-curing can often be avoided: Excess cement can be carefully brushed away prior to curing, avoiding flash and reducing clean-up. The resin promotes an excellent marginal blend between tooth and restoration, enhancing both the aesthetic and functional integration of the veneers. For light-curing, the restoration margins were covered with glycerine gel to prevent formation of an oxygen inhibition layer (Fig. 15e).

Fig. 15a. Priming of the tooth structure.

Fig. 15b. Etching and priming of the intaglio surfaces of the veneers.

Fig. 15c. Seating of a veneer with a cushioned instrument.

Fig. 15d. Two veneers simultaneously placed on the central incisors.

Fig. 15e. Restoration margins covered with glycerin gel for thorough light-curing from all sides.

The veneers for the lateral incisors were cemented likewise; however, floss was used instead of clamps for gingival retraction (Figs. 16a and b).

Fig. 16a. Gingival retraction for veneer placement on the lateral incisors.

Fig. 16b. Floss is used for a clampless procedure.

The above-mentioned sequenced placement procedure – starting with the central incisors and then moving on to the laterals - is highly recommended: This protocol gives the practitioner full control over the positioning of the central incisor veneers, which is particularly important as their position has a massive impact on the overall appearance of the smile. When the lateral incisor veneers are cemented first, the risk of positioning errors in the central incisor region and resulting catastrophic aesthetic issues is increased. However, any error with the positioning of the central incisor veneers can also lead to problems like the misfit of the lateral incisor veneers. Therefore, the whole procedure needs to be carried out with utmost care and precision.

A robust curing protocol with palatal, incisal and facial light exposition is crucial to ensure that the resin cement is fully set. Figures 17a to c show the veneers in place. Controlled removal of any residual excess was accomplished with ultrahigh molecular weight polyethylene (UHMWPE) floss (Gorilla Floss) used to avoid damaging the margins. For final polishing of the ceramic-tooth interface, polishing rubbers were employed. Rubber dam remained stable throughout the procedure.

The immediate treatment outcome is shown in Figure 18. It is completely normal for the gums to appear red and feel slightly sore following cementation. This is a temporary response, which should improve quickly as the tissue begins to heal. With a consistent and proper oral hygiene routine, the soft tissues will recover fully over the coming days. This has to be communicated to the patient well following rubber dam removal.

Fig. 17a. Lateral incisor veneers after placement and excess removal.

Fig. 17b. All four ceramic veneers in place.

Fig. 17c. Appearance of the veneers after floss removal.

Fig. 18. Immediate post-operative appearance.

Fig. 19. Check-up after three weeks.

FINAL SITUATION

Fig. 20a. Final photographic records: Frontal view.

Fig. 20b. Final photographic records: Lateral view from the left.

Fig. 20c. Final photographic records: Lateral view from the right.

Fig. 20d. Final photographic records: Occlusal view.

FOLLOW-UP VISIT

A check-up appointment is crucial in that it allows clinicians to assess the state of the soft tissue, which was fully recovered in the present case after three weeks (Fig. 19). Even more importantly, however, it enables us to check how our patients are adapting to their new smiles. This is also the best time to take a final photographic record (Figs. 20a to d). At this appointment, it is also essential to check for any excess material left interproximally: It can result in chronic inflammation, leading to persistent redness and an unaesthetic appearance of the final restorations. By careful inspection of the restorations from the occlusal view, it is possible to make sure all excess is removed and optimal gingival health is maintained.

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Clinical case by Dr Manuel Tinto

Nowadays, minimally invasive techniques aimed at preserving healthy tooth structure are favoured for the direct restoration of teeth in the posterior region. Universal materials used in this context make it possible to reduce the chair time while supporting high-quality aesthetic and functional results.

The following case example illustrates the combined use of Caries Detector, CLEARFIL™ Universal Bond Quick 2, CLEARFIL MAJESTY™ ES Flow Universal Low and Super Low, and CLEARFIL MAJESTY™ ES-2 Universal (all Kuraray Noritake Dental Inc.) for the treatment of two interproximal lesions on the maxillary right second premolar and first molar (FDI notation: teeth # 15 and 16; Fig. 1).

Fig. 1. Pre-operative photograph.

To guide the selective removal of carious dentin, Caries Detector was used, allowing visual distinction between infected and affected dentin (Figs. 2 and 3). Excavation was performed dry, at low speed, using a Cera-Bur bur until complete removal of the dye. This resulted in clean, non-geometric cavities (Fig. 4).

Fig. 2. Application of Caries Detector.

Fig. 3. The more intense the colour, the more carious the tissue.

Fig. 4. Finished and cleaned cavities.

After matrix placement (Figs. 5 and 6), a universal adhesive (CLEARFIL™ Universal Bond Quick 2) was applied (Fig. 7). This product produces a thin film and offers excellent wettability, making it particularly suitable in the presence of undercuts. We prefer an adhesive approach with selective enamel etching for 15 seconds. CLEARFIL MAJESTY™ ES Flow Universal Low (Fig. 8) was placed on the cavity floor to level out irregularities, followed by reconstruction of the interproximal walls using CLEARFIL MAJESTY™ ES-2 Universal paste. The Quad Matrix system allows both walls to be shaped simultaneously.

Fig. 5. Matrices in place and double-ended wedge (Quad Matrix) to improve the cervical seal on both matrices.

Fig. 6. Quad Matrix ring in position.

Fig. 7. Application of CLEARFIL™ Universal Bond Quick 2 after selective enamel etching (15 s).

Fig. 8. Placement of CLEARFIL MAJESTY™ ES Flow Universal (U) Low as a cavity liner.

The Class I cavity was completed by layering two materials:

• CLEARFIL MAJESTY™ ES Flow Universal (UD) Super Low for deep and difficult-to-reach areas, simulating dentin.
• CLEARFIL MAJESTY™ ES-2 Universal for the final layer, thanks to its handling, strength and aesthetics. The universal shade blends in perfectly with the surrounding structure (Figs. 9 to 11).

Fig. 9. Restorations carried out using a combination of flowable composite and paste composite.

Fig. 10. Finished restorations refined and polished under rubber dam.

Fig. 11. Finished restorations after checking of the occlusal contacts.

FINAL CONSIDERATIONS

Caries Detector allows selective removal of infected dentin while preserving healthy tooth structure. CLEARFIL™ Universal Bond Quick 2 provides for optimal penetration even in complex cavities. The combination of CLEARFIL MAJESTY™ ES-2 and ES Flow materials provides precise filling, natural aesthetics and long-term durability. Finally, the utilization of universal materials simplifies the clinical protocol, resulting in predictable, minimally invasive and long-lasting restorations.

Clinical case by Dr Luca Alibrandi

In the field of aesthetic dentistry, achieving natural, durable and predictable results requires the use of advanced materials, precise instruments and clinical expertise. Thanks to its versatility and the included innovative technology, CLEARFIL MAJESTY™ ES Flow Universal (Kuraray Noritake Dental Inc.) supports clinicians in standardising aesthetic rehabilitation even in complex cases (Figs 1–3).

Fig. 1. Initial situation with multiple diastemas in the maxillary anterior region. The patient does not wish to undergo indirect veneer therapy.

Fig. 2. Patient with a deep bite and atypical swallowing, which has caused flaring, particularly in the maxillary left anterior region. The patient refuses orthodontic treatment.

Fig. 3. Detail of the maxillary anterior region.

CLEARFIL MAJESTY™ ES Flow Universal is a monochromatic flowable composite that simplifies colour management thanks to its guided shade system, supporting aesthetic harmony without the complexity of multiple shades. Available in two levels of viscosity (Low and Super Low), it offers excellent handling for different restorative areas.

The Low version (75 wt%, 59 vol%) has a flexural strength of 151 MPa and a compressive strength of 373 MPa. It is ideally suited for anterior areas and for injection into IVENEER matrices, thanks to its easy handling and long-lasting gloss. Radiopacity (140% Al) provides for visibility on follow-up radiographs.

The Super Low version, with a filler content of 78 wt% (60 vol%) and radiopacity of 150% Al, has a flexural strength of 152 MPa and compressive strength of 374 MPa. Ideal for posterior sectors, it offers durability and resistance even under high functional loads.

The optimised syringe design supports precise dispensing, reducing waste and facilitating application. Both formulations allow easy polishing and long-lasting shine.

Combined use with IVENEER matrices (Fig. 4) makes it possible to precisely shape incisal morphology, creating an ideal contour and a protected environment that improves surface polymerisation (Fig. 5). The result is a stronger, glossier and more durable restoration. Flowable composites facilitate adaptation of shape and correction of natural proportions, contributing to a harmonious outcome.

The composite veneers can subsequently be refined using subtractive or additive techniques (Figs. 6 to 8), adapting to situations such as wide and irregular diastemata, simplifying the workflow and improving the final result.

Fig. 4. IVENEER in position under rubber dam: these innovative matrices, used with conventional isolation, provide a highly effective seal to prevent contamination during the injection phase.

Fig. 5. Polymerisation is always started on the palatal side to allow resin contraction towards the enamel and to increase adhesion of direct restorations.

Fig. 6. The polishing phase is facilitated by the creation of an environment that helps limit the oxygen-inhibited layer via the matrices. In this case, however, subtractive modelling of the elements is required to recreate overall harmony.

Fig. 7. Post-injection situation.

Fig. 8. Surface texturing with longitudinal morphological characterisations to improve coronal proportions.

Fig. 9. Detailed view of the central incisors after polishing.

FINAL CONSIDERATIONS

The combined use of CLEARFIL MAJESTY™ ES Flow Universal and IVENEER matrices represents a significant advancement in aesthetic incisor restoration. The composite’s properties (strength, handling and gloss), together with the preformed matrices, allow natural, high-quality results to be achieved in reduced treatment times. Thanks to the new technique, even patients with financial limitations can access effective treatments and regain their smile (Fig. 9).