Case by Dt. Koray Kendir, DDS, Turkey (İzmir)

LAYERED COMPOSITE TECHNIQUE WITH A1D AND A1E SHADES

Single-shade composite layering techniques are becoming increasingly popular among dental practitioners due to their simplicity. Used in combination with modern composite materials that offer improved optical properties, these techniques lead to aesthetic outcomes in many clinical situations. However, when it comes to restoring anterior teeth with pronounced enamel translucencies and a vivid internal colour structure, playing with two shades and opacities of composite may be the better option.

Luckily, a dual-shade technique does not have to be complicated, either: With CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.), dental practitioners have a material at their disposal that supports simplified procedures and predictable outcomes as well. It comes with fixed shade combinations of Dentin and Enamel, each of which covers three VITA shades. Consequently, the need for complicated shade schemes and colour combination formulas is eliminated.

The following case reveals how to use it in the context of an anterior restoration procedure.

STEP 1 – ISOLATION AND INITIAL EVALUATION

Rubber dam isolation was performed to provide for optimal moisture control and field visibility. Initial photographs were taken to document the preoperative condition. The defects on teeth #22 (mesial), #21 (distal), #11 (distal), and #12 (mesial, FDI notation) were evaluated under dry conditions.

STEP 2 – SHADE SELECTION

Shade selection was performed under rubber dam isolation using CLEARFIL MAJESTY™ ES-2 Premium Shade Guide (Kuraray Noritake Dental Inc.). The selected shades were A1D (dentin) and A1E (enamel) from CLEARFIL MAJESTY™ ES-2 Premium, providing optimal blending with the surrounding natural teeth.

STEP 3 – CAVITY PREPARATION

After completing the shade selection, carious tissue was thoroughly removed from teeth #22, #21, #11, and #12. Conservative Class III cavity were prepared with a focus on maintaining maximum enamel support and preserving tooth structure. Palatal and buccal views were documented to demonstrate the cavity extension and cleanliness of the preparation.

STEP 4 – ETCHING

Selective etching was performed using K-ETCHANT Syringe (Kuraray Noritake Dental Inc.) on the enamel margins of the prepared cavities. Adjacent teeth were protected using PTFE tape to prevent unintended etching. This step provides for optimal micromechanical retention and enhances the bond strength of the adhesive system.

STEP 5 – ADHESIVE APPLICATION

CLEARFIL™ SE BOND 2 (Kuraray Noritake Dental Inc.) was used as the adhesive system. Following the manufacturer’s protocol, the primer was first applied to all cavity surfaces, left undisturbed for 20 seconds to allow adequate penetration, and then gently dried with air. The bond was then applied, air-thinned, and light cured. This two-step self-etch adhesive provides reliable adhesion and long-term stability in direct restorations.

STEP 6 – LIGHT POLYMERIZATION

Following the adhesive application, each surface was light-cured using a high power LED curing unit. The tip of the curing device was positioned as close as possible to the bonding surfaces to enable optimal polymerization of the adhesive layer.

STEP 7 – COMPOSITE RESTORATION AND FINISHING

The restorations were completed using a multilayering approach. Palatal shells were initially built with A1E (enamel shade) to establish the outline form. The dentin body was reconstructed with A1D, followed by a final enamel layer (A1E) to achieve natural translucency and surface texture. After finishing the contouring, polishing was performed to achieve a lifelike gloss and seamless integration with the surrounding dentition.

Dentist:

KORAY KENDIR

Dt. Koray Kendir is a graduate of Hacettepe University Faculty of Dentistry and the co-founder of a private dental clinic in İzmir. He specializes in digital dentistry, smile design, and computer-aided restorative treatments. Known for his innovative approach, Dr. Kendir is a frequent speaker at national dental congresses and serves as an advisor to several dental companies.

Case by Andreas Chatzimpatzakis

Many modern, tooth-coloured dental materials enable us to achieve more with less. By using high-strength ceramics with a multi-layered colour structure and natural translucency, for example, the path to the desired outcomes involves fewer components, smaller layers and a reduced number of bakes. A possible streamlined procedure is illustrated below. The main materials used were KATANA™ Zirconia HTML PLUS for the screw-retained implant-supported superstructure and CERABIEN™ MiLai (both Kuraray Noritake Dental Inc.) for vestibular micro-layering.

Fig. 1. Zirconia-based screw-retained implant-supported prosthesis after milling and carving to obtain a natural surface texture.

Fig. 2. Restoration after sintering. To intensify the colour characteristic of the multi-layered blanks, the surface was treated with Esthetic Colorant (mainly in the incisal area and the gum parts).

Fig. 3. Appearance after the application of CERABIEN™ MiLai SS Fluoro.

Fig. 4. Restoration after the application of CERABIEN™ MiLai internal stains. They add some natural shading effects to the tooth and gum areas.

Fig. 5. Restoration on the model after micro-layering. In the cervical area, CERABIEN™ MiLai LT1 was mainly used, while the middle and incisal areas were individualized with E2 and Tx, the latter adding a seamless gradient in translucency. For the gingiva, the choice fell on the tissue porcelains 1, 5 and 6.

Fig. 6. Finished restoration on the model.

Fig. 7. The micro-layer of porcelain has a brilliant effect.

Fig. 8. The lifelike appearance is due to a smart combination of surface texturing …

Fig. 9. … and micro-layering with a comprehensive set of internal stains plus porcelains.

CONFIDENCE AND CONTROL

Full ceramic layering can produce beautiful results, but can be quite complex and time-consuming. In times with limited availability of skilled personnel and high-performance materials being offered, it may be a valuable strategy to opt for micro-layering with CERABIEN™ MiLai whenever appropriate. The system provides precise control over the layering and shading procedure, so that highly aesthetic and functional outcomes are easily and confidently obtained.

Dental technician:

ANDREAS CHATZIMPATZAKIS

Andreas graduated from the Dental Technology Institute (TEI) of Athens in 1999. During his studies he followed a program at the Helsinki Polytechnic Department of Dental Technique, where he trained on implant superstructures and all ceramic prosthetic restorations. As of 2000, he is running the ACH Dental Laboratory in Athens, Greece, specialized on refractory veneers, zirconia and long span implant prosthesis. In 2017 Andreas visited Japan where he trained under the guidance of Hitoshi Aoshima, Naoto Yuasa and Kazunabu Yamanda and become International Trainer for Kuraray Noritake Dental Inc..

Case by Andreas Chatzimpatzakis

A CONCEPT EVEN FOR AESTHETICALLY DEMANDING CASES

The micro-layering technique is regarded as a more efficient, streamlined approach used as an alternative for full porcelain layering. It requires aesthetic, high-strength ceramics like lithium disilicate or zirconia as a base and – ideally – a set of porcelains specifically designed for reduced layer thicknesses that allows users to focus on imitating the characteristics of enamel. A high-quality example is CERABIEN™ MiLai (Kuraray Noritake Dental Inc.). Consisting of a set of internal stains and porcelains with a firing temperature of just 740 °C and a coefficient of thermal expansion in the range of 9.5~11.0×10-6/K (50 °C – 500 °C), this product works well on lithium disilicate and zirconia.

Its aesthetic potential is surprisingly high: Depending on case-specific requirements, users are given the choice between maximum efficiency using a single-bake technique and maximum aesthetics achieved with more complex layering. The latter option is demonstrated below using the example of six maxillary anterior veneers.

Fig. 1. Lithium disilicate frameworks (Amber Press) on the model.

Fig. 2. CERABIEN™ MiLai Value Liner 1 applied to the framework. This porcelain is typically used on lithium disilicate for wash baking.

Fig. 3. First build-up with CERABIEN™ MiLai CCV2 in the cervical section, …

Fig. 4. … Value Liner 2, …

Fig. 5. … Creamy Enamel in the middle area …

Fig. 6. … and Tx used to add ultimate translucency.

Fig. 7. Appearance of the restorations after the first bake.

Fig. 8. Outcome of the internal staining procedure.

Fig. 9. Application of CERABIEN™ MiLai LT1 for a standard translucency and opalescence effect, …

Fig. 10. … E2, …

Fig. 11. … a mixture of E2 and ELT1 (mixing ratio: 50:50) for translucency and brightness and along the marginal ridges, …

Fig. 12. … Tx mixed with Royal Blue (mixing ratio 70:30) for a blueish translucency in the incisal area…

Fig. 13. … as well as a final layer of LTx to add ultimate translucency and opalescence to the whole enamel surface.

Fig. 14. Outcome of the third bake.

Fig. 15. Cutback for the final layer of porcelain.

Fig. 16. Final layer of CERABIEN™ MiLai added to the central and lateral incisors for translucency.

Fig. 17. Situation after the fourth bake, grinding and use of a rubber polisher.

Fig. 18. Outcome of the fifth bake (self-glaze).

Fig. 19. Beauty shots …

Fig. 20. … of the restorations …

Fig. 21. … on the model.

TRULY BEAUTIFUL OUTCOMES POSSIBLE

This case example reveals that CERABIEN™ MiLai is much more than just a maximum-efficiency solution: With the current line-up of porcelains and internal stains, truly beautiful restorations can be produced. Hence, users are given high flexibility regarding not only the high-strength framework material they prefer, but also the effort and time they would like to invest. This makes CERABIEN™ MiLai a versatile porcelain system that meets many needs and covers a wide range of applications in the dental laboratory.

Dental technician:

ANDREAS CHATZIMPATZAKIS

Andreas graduated from the Dental Technology Institute (TEI) of Athens in 1999. During his studies he followed a program at the Helsinki Polytechnic Department of Dental Technique, where he trained on implant superstructures and all ceramic prosthetic restorations. As of 2000, he is running the ACH Dental Laboratory in Athens, Greece, specialized on refractory veneers, zirconia and long span implant prosthesis. In 2017 Andreas visited Japan where he trained under the guidance of Hitoshi Aoshima, Naoto Yuasa and Kazunabu Yamanda and become International Trainer for Kuraray Noritake Dental Inc..

Case af dr. Julien Molia

JA, DET VIRKER!

Mange tandlæger anser flowplast for at være velegnet som liner el. base under stærkere pastakompositter og indirekte restaureringer og som provisorisk materiale. Mange af dem antager dog, at deres brug er begrænset grundet flowplasts ringe mekaniske egenskaber.

EN NY GENERATION AF FLOWPLAST

Heldigvis er dette ikke længere sandt: flere flowplastmaterialer fra den seneste generation – heriblandt CLEARFIL MAJESTY™ ES Flow og CLEARFIL MAJESTY™ ES Flow Universal (begge Kuraray Noritake Dental Inc.) – er udstyret med mekaniske egenskaber, på linje med mange pastakompositter. Indikationsområdet er udvidet som følge heraf. Eksempelvis har CLEARFIL MAJESTY™ ES Flow Universal ifølge producenten et højt fillerindhold på 75 til 78 vægt%, en bøjestyrke på mere end 150 MPa og en trykstyrke som overgår 370 MPa. Takket være produktets høje styrke tjener det som en pålidelig og permanent løsning egnet til selv spændingsbærende områder, så som kindtænders okklusalflader.

Denne flowplast har dog endnu mere at byde på: den er tilgængelig i to flydeevner – LOW og SUPER LOW – så den dækker et bredere spektrum af personlige præferencer og individuelle indikationsspecifikke behov – og dét med blot to farver (Universal og Universal Dark). Sidstnævnte gør farvevalget intuitivt, selv i det anteriore område, og er muliggjort af en blanding af teknologier til farvematch, herunder optimeret lysdiffusionsteknologi og en emaljeagtig translucens.

Følgende case viser hvordan CLEARFIL MAJESTY™ ES Flow Universal gør mit liv nemmere ved fyldningsprocedurer i kindtandsområdet.

CASE 

Amalgamfyldningerne blev fjernet og caries ekskaveret, og den sunde tandsubstans bevaret mest mulig (fig. 2 og 3). En selektiv emaljeætsningsteknik blev valgt, og en universaladhæsiv påført (CLEARFIL™ Universal Bond Quick 2, Kuraray Noritake Dental Inc.). Derefter blev kaviteterne fyldt med CLEARFIL MAJESTY™ ES Flow Universal i LOW varianten med farven U (fig. 4). Den anvendte flowplast er, takket være det innovative sprøjtedesign, praktisk talt fri for luftbobler. For at sikre komplet polymerisering overskred de enkelte lag ikke 2 millimeters tykkelse, i overensstemmelse med produktets brugsvejledning (fig. 5 og 6), hvilket har en afgørende betydning for de færdige fyldningers langtidsholdbarhed. Hvert lag bør lyshærdes grundigt i 10 til 20 sekunder (afhængigt af polymeriseringslampe), før det næste lag påføres. Som vist i figur 7, giver det anvendte materiales lave flydeevne mulighed for nogen udformning af okklusalrelieffet. Når flere anatomiske detaljer skal genskabes, kan den mere faste SUPER LOW-variant være en mulighed. Det tog blot få sekunder at pudse fyldningerne op til højglans (fig. 8).

Fig. 1. To amalgamfyldninger til udskiftning.

BRUGERVENLIGT ALTERNATIV TIL PASTAPLAST

Brugen af flowplast med velbalancerede mekaniske egenskaber kan være et godt alternativ til pastaplast, særligt i svært tilgængelige områder. Avanceret farvetilpasningsevne, en påføring praktisk talt fri for luftbobler, nem adaptering og opmodellering samt hurtig polering, gør i sandhed klinikerens liv simplere.

Dentist:

JULIEN MOLIA

Case by Kostia Vyshamirski, DT

KATANA™ Zirconia YML AND CERABIEN™ MiLai

Virtually every patient in need of restorative treatment desires functional restorations with an aesthetic appearance. However, the individual expectations and needs may be very different depending on the clinical situation (state of the natural tooth structure, parafunctional behaviour, periodontal health etc.), the patient’s financial resources and personal preferences. A versatile material combination fulfilling many different needs and desires is KATANA™ Zirconia YML finished using micro-layering with the new CERABIEN™ MiLai (both Kuraray Noritake Dental Inc.).

This system supports low invasive preparations due to a favourable minimum wall thickness of the merely monolithic multi-layered zirconium oxide prosthesis and a minimal thickness of the porcelain layer in the aesthetic zone. Moreover, the high strength zirconium oxide prosthesis combined with only a very thin layer of porcelains makes this technique extremely useful in patients with parafunctional habits like bruxism. Last but not least, consisting of a carefully compiled selection of internal stains and porcelain shades, CERABIEN™ MiLai supports the creation of individual 3D shade effects that mimic those of natural teeth even when space is limited. The following case example reveals how this is possible.

INITIAL SITUATION

The patient presented with concerns related to both function and appearance. During the diagnostic phase, it was determined that increasing the vertical dimension of occlusion (VDO) and creating a wax-up in the new jaw position would be necessary to improve both the occlusion and the aesthetic appearance of the smile.

Fig. 1. Intraoral scan of the maxillary teeth revealing severe tooth wear.

Fig. 2. Intraoral scan of both jaws confirming the need for an increase of the VDO.

Fig. 3. Intraoral scan: Occlusal view of the maxillary teeth.

TREATMENT PLANNING AND COMPUTER-AIDED DESIGN

Following the approval of the wax-up, the treatment plan was created. It consisted of restoring the four anterior incisors with zirconia crowns and performing direct composite restorations on the posterior and lower teeth. To conserve as much of the healthy tooth structure as possible, the space created was aligned to the required wall thickness of the planned restoration (framework + micro-layer of porcelain in the vestibular areas only). Following an aesthetic analysis, the crowns were designed with a minimal vestibular cutback. This was due to the patient’s functional problems, which would increase the chipping risk in case of using a more heavy cutback design with a thicker, more conventional porcelain layer. KATANA™ Zirconia YML offers exceptional aesthetics, requiring only a 0.3 mm reduction for the porcelain to achieve natural results. Therefore, it was the logical material choice for this specific case.

Fig. 4. Minimally invasive preparations for the crowns.

Fig. 5. Occlusal view of the preparations.

Fig. 6. Aesthetic analysis – a crucial step for achieving the desired new smile.

Fig. 7. Frontal view of the crowns in their final cutback design.

Fig. 8. Lateral view of the crowns in the CAD software.

CROWN PRODUCTION

Immediately after milling, the zirconia surface was treated with effect liquids. This kind of pre-sintered characterization helps enhance the characteristics of zirconia restorations. In the presented case, orange stain was applied to the cervical area, while a blue stain was used at the incisal edge. In addition, a white opaque liquid was applied to the inner surface of the central zirconia crowns to block out any discolouration from the underlying tooth structure. Following final sintering, the vestibular layer of porcelain was built up with CERABIEN™ MiLai using a combination of internal stains and porcelain micro-layering. After morphological adjustments and surface polishing, the restorations were completed by applying CERABIEN™ ZR FC Paste Stain and Glaze. Final polishing was then performed to enhance the natural appearance of the surfaces.

Fig. 9. Effect liquids applied to the cervical and incisal areas of the crowns.

Fig. 10. Treatment of the central incisor crowns’ inner surfaces.

Fig. 11. KATANA™ Zirconia YML framework after sintering.

Fig. 12. CERABIEN™ MiLai Internal Stains and Porcelains.

Fig. 13. Prepared vestibular surfaces ready for application of the internal stains.

Fig. 14. Application of 0.2-0.3 mm layers of CERABIEN™ MiLai porcelain: CCV2 for the cervical area, LT1 – Creamy Enamel for the main body and luster, LTX at the incisal edge.

Fig. 15. Frontal view of the final restorations on the model.

Fig. 16. Lateral view of the final restorations on the model.

Fig. 17. Polished and glazed palatal surfaces of the crowns.

FINAL OUTCOME

The finalized restorations showcase great details, crafted with CERABIEN™ MiLai internal stains and porcelains. The result are natural-looking restorations. An additional benefit of using zirconia as a restorative material is its excellent compatibility, which is evident in the healthy gingival conditions.

Fig. 18. Restorations in place.

Fig. 19. Natural-looking restorations in the patient’s mouth.

Dental Technician:

KOSTIA VYSHAMIRSKI

DT Kostia Vyshamirski, Riga, Latvia

After earning his Dental Technician Certificate from the Medical College in Minsk, Belarus, in 2014, Kostia began his career as a dental technician, focusing on aesthetic clinical cases that integrate the latest digital and manual technologies. Moving to Riga, Latvia, in 2015 greatly expanded his professional opportunities.

With over a decade of experience, Kanstantsin Vyshamirski now conducts courses, lectures, and seminars worldwide. He is a member of the DTG (Dental Technician Guild), a professional group of dental technicians based in the USA, and an invited guest of the AAED (American Academy of Esthetic Dentistry), an exclusive, invitation-only organization.

Operating his own lab in Riga, Latvia, Kanstantsin specializes in aesthetic prosthetic porcelain work and is an experienced, passionate user of KATANA™ Zirconia and Noritake porcelains.

Case by DT Tomas Forejtek, Forejtek Dental Lab and Dr Ladislav Gregor, Sorriso Dental Clinic

In prosthodontics, assessing the individual needs and expectations of every patient is a crucial factor on the road to success. When it comes to producing fixed dental prostheses, the art is in tailoring the material combination, framework design and finishing concept precisely to the case-specific functional and aesthetic demands. In this context, the availability of high-performance evaluation tools and the freedom to choose between different variants of high-strength ceramics is worth gold.

CASE EXAMPLE

Take the case of a middle-aged female patient: She presented with very unsatisfactory metal-ceramic crowns (Fig. 1) and asked for an aesthetic improvement of the situation. The crowns on her maxillary central incisors and the right lateral incisor clearly needed to be replaced not only for aesthetic, but also for functional reasons. As anterior interferences were present and orthodontic treatment was not an option, the decision was made to select a ceramic material with a particularly high strength – KATANA™ Zirconia HT (Kuraray Noritake Dental Inc.) – and to opt for a design that would support the incisal edge with zirconia. Consequently, porcelain layering (with CERABIEN™ ZR, Kuraray Noritake Dental Inc.) would be limited to the vestibular region. The laboratory procedure – including shade determination and reproduction with the aid of the eLAB® shade matching system* – is illustrated in Figures 2 to 9.

^{*The eLAB® system is a registered trademark of Sascha Hein. It is an independent tool for dental shade determination and communication and is not developed or distributed by Kuraray Noritake Dental Inc.}

Fig. 1. Initial clinical situation.

Fig. 2. Situation after removal of the existing crowns and preparation of the tooth structure for the planned all-ceramic restorations.

Fig. 3. Shade determination with the eLAB® system.

Fig. 4. Layering map for the use of CERABIEN™ ZR on all three crowns.

Fig. 5. Layering procedure: Shade verification.

Fig. 6. Try-in of the crowns to assess the fit and the shade match.

Fig. 7. Palatal view of the crowns on the model.

Fig. 8. Frontal view of the crowns on the model: A natural surface texture is obtained.

Fig. 9. Natural look of the restorations.

THE RESULTS

Fig. 10. Crowns after adhesive cementation with PANAVIA™ V5 (Kuraray Noritake Dental Inc.).

Fig. 11. Aesthetic treatment outcome.

A precise reproduction of the patient’s tooth shade, despite the challenging individual aesthetics.

THE KEY TO SUCCESS: INDIVIDUAL APPROACH, HIGH-QUALITY MATERIALS

The present case is a perfect example of an aesthetically and functionally challenging situation that needed an individual treatment approach. By taking into account the patient- and case-specific requirements and using our material-related knowledge wisely, it was possible to develop an adequate treatment plan. High-quality materials and a smartly selected design concept lay the foundation for long-term success. Valuable tools used during porcelain layering (specifically the eLAB® system) – on the other hand – paved the way for a precise reproduction of the patient’s tooth shade, despite the challenging individual aesthetics: The crowns were delivered on the first attempt.

Dental technicians:

LADISLAV GREGOR

Ladislav Gregor is a prosthodontist at Sorriso Dental Clinic in Brno, Czech Republic. A Masaryk University graduate (2005), he later served at the University of Geneva and earned both a Dr. Med. Dent. (Geneva) and a Ph.D. (ACTA Amsterdam). He has published extensively in adhesive and reconstructive dentistry, lectures internationally, is a certified CADE member, and serves on the Scientific Council of the Czech Dental Chamber.

TOMAS FOREJTEK

Tomas Forejtek is a dental technician in Brno specializing in aesthetic ceramic restorations. After graduating top of his class in 2001, he advanced to head of a leading dental laboratory and trained internationally with renowned mentors. In 2010, he opened his own lab, and since 2016 he has focused on single maxillary central incisor work with the eLAB protocol, becoming an official eLAB instructor in 2018.

Case by Dr. Julien Molia

YES, IT WORKS!

In the minds of many dental practitioners, it has become firmly established that flowable composites are nice liner or base materials below stronger packable composites and indirect restorations or as a temporization material. Many of them assume, however, that their use is limited due to their poor mechanical properties.

A NEW GENERATION OF FLOWABLES

Luckily, this is no longer true: Several flowable composites of the latest generation – like CLEARFIL MAJESTY™ ES Flow and CLEARFIL MAJESTY™ ES Flow Universal (both Kuraray Noritake Dental Inc.) – are equipped with mechanical properties, which are on par with those of many packable alternatives. Consequently, the range of indications is extended. For example, CLEARFIL MAJESTY™ ES Flow Universal, has a high filler loading of 75 to 78 wt/%, a flexural strength of more than 150 MPa and a compressive strength exceeding 370 MPa according to the manufacturer. Thanks to its high strength, it serves as a reliable and permanent solution, even suitable for stress-bearing areas such as the occlusal surfaces of posterior teeth.

However, this flowable composite has even more to offer: It is available in two levels of flowability – LOW and SUPER LOW – to serve a wider range of personal preferences and individual indication-specific needs and in just two shades (universal and universal dark). The latter offers the benefit of intuitive shade selection even in the anterior area and is enabled by a mixture of shade matching technologies, including optimized light diffusion technology and an enamel-like translucency.

The following case example reveals how CLEARFIL MAJESTY™ ES Flow Universal makes my life easier in posterior restoration procedures.

CASE EXAMPLE

This patient presented for the replacement of two amalgam restorations in the mandibular right molars (teeth # 46 and 47 according to the FDI notation) (Fig. 1). As it would facilitate filling and provide for great adaptation to the cavity walls, it was decided to use CLEARFIL MAJESTY™ ES Flow Universal LOW as the only restorative material. The position of the teeth to be restored made shade selection easy: Shade U (universal) is designed to work perfectly for all posterior restorations.

The amalgam restorations were removed and caries was excavated, while saving as much of the healthy tooth structure as possible (Figs. 2 and 3). A selective enamel etching technique was chosen, followed by the application of a universal adhesive (CLEARFIL™ Universal Bond Quick 2, Kuraray Noritake Dental Inc.). Subsequently, CLEARFIL MAJESTY™ ES Flow Universal in the LOW version and the selected shade U was applied into the cavities (Fig. 4). Thanks to the innovative syringe design, the applied flowable composite is virtually free of voids. In line with the instructions for use of the product, the thickness of each layer did not exceed 2 millimetres to provide for a complete cure (Figs. 5 and 6), which has a decisive impact on the long-term performance of the final restorations. Each layer should be thoroughly cured for 10 to 20 seconds (depending on the curing light) before the next layer is applied. As shown in Figure 7, the low flowability of the selected material allows for some modelling of the occlusal surface morphology. When more anatomical details need to be restored, the steadier SUPER LOW variant may be an option. It took just a few seconds to polish the restorations to high gloss (Fig. 8).

Fig. 1. Two amalgam restorations to be replaced.

Fig. 2. Situation after removal of the existing amalgam restorations.

Fig. 3. Typical amalgam staining is visible at the bottom of the larger cavity.

Fig. 4. Filling procedure: Application of the first layer of flowable composite.

Fig. 5. Second molar already filled, first molar in need of another layer of flowable composite.

Fig. 6. Filling completed.

Fig. 7. Nice surface morphology and shade blend-in.

Fig. 8. Treatment outcome after rubber dam removal. The restorations blend in nicely with the surrounding dentition – qua shade and surface gloss.

EASY-TO-USE ALTERNATIVE TO PACKABLE COMPOSITES

Especially in difficult-to-reach areas in the mouth, the use of a flowable composite with well-balanced mechanical properties can be a nice alternative to packable ones. Advanced shade-matching abilities, virtually void-free application, easy adaptation and modelling, and quick polishing truly simplify the life of the dental practitioner. However, many assume their use is limited due to poor mechanical properties.

Dentist:

JULIEN MOLIA

Dr. Julien Molia graduated in 2008 with a thesis on computer-assisted implantology. He established a general dental practice in Saint-Jean-de-Luz, where he has since focused on implant surgery and jawbone reconstruction. In 2017, he completed a second university degree in implantology to update and deepen his expertise. He has also pursued advanced training in digital dentistry, orthodontic miniscrews, and mucogingival surgery. Committed to tissue preservation, he trained privately with Drs. Gil Tirlet and Jean-Pierre Attal in Paris. Dr. Molia is a founding member of the French Southwest BioTeam, a collaborative group dedicated to clinical research and innovation.

Case by Andreas Chatzimpatzakis

When dental technicians from all over the world started using the micro-layering technique, they simply combined a reduced number of porcelains and stains from their original porcelain system. After some time, porcelains specifically designed for micro-layering were introduced to the dental market. Consequently, early adopters had to decide whether or not to switch to one of those new systems.

For me as a frequent user of CERABIEN™ ZR (Kuraray Noritake Dental Inc.), a porcelain system based on synthetic feldspathic porcelain developed for porcelain layering on zirconia frameworks, switching to any micro layering porcelain system was not an option. However, when I had the chance to test the brand-new CERABIEN™ MiLai porcelains and internal stains (Kuraray Noritake Dental Inc.), I grabbed it for two reasons. Firstly, the simplicity! I was surprised how easily I could achieve a high aesthetic result without using too many different ceramic powders. Secondly with this system, I have a micro-layering porcelain system at my disposal that works for both, zirconia and lithium disilicate. Farther more, the product is well-aligned to CERABIEN™ ZR – and offers a very similar handling.

CASE EXAMPLE

The following case is a nice example of how it may be used in the anterior region. The male patient had already been treated with monolithic zirconia crowns from another dental laboratory in the posterior region. Now, he desired a maxillary anterior smile makeover due to discoloured composite restorations and signs of tooth wear. The decision was made to produce six veneers with frameworks made of lithium disilicate (Amber Press), individualized with CERABIEN™ MiLai using the micro-layering technique. I would like to thank the prosthodontist Dr Konstantina Aggelara for the excellent collaboration and the intra oral photos.

For layering, I simply applied CERABIEN™ MiLai Value Liner 1. Then, I used CCV2 in the cervical and Tx in the incisal area, as well as Liner 2 for the mamelons. Internal stains were applied after the first bake. Subsequently, the canines were completed with LT1. The lateral and central incisors were built up with LT1 in the cervical area, Creamy Enamel on the marginal ridges and the middle and E2 mixed with Tx in the ratio 70/30 in the incisal area.

Fig. 1. Initial situation: The patient was unhappy with his lip line and facial appearance, …

Fig. 2. … particularly due to discoloured composite restorations and severe wear in the maxillary anterior region.

Fig. 3. Shade determination after tooth preparation.

Fig. 4. Restorations produced with Amper Press (Shade LT A2), individualized with CERABIEN™ MiLai.

Fig. 5. Lateral view: The internal play of colours (internal stains) creates a nice effect. Natural shading and surface texture.

FINAL SITUATION

Fig. 6a and 6b. Restorations placed in the patient’s mouth.

THE PERFECT COMPLEMENT TO MY STANDARD PORCELAIN SYSTEM

As hoped, CERABIEN™ MiLai offers similarly great handling properties as CERABIEN™ ZR – probably mainly due to the fact that it is also based on synthetic feldspathic ceramic. It is not only responsible for consistent handling, but also for predictable optical properties, eliminating unwanted shadow effects. As the system is designed for micro-layering, it offers a natural appearance when applied in thin layers. This fact – in addition to the broader compatibility (to high-strength oxide and silicate ceramics) – makes it worthwhile to consider using a specific porcelain system for micro-layering. Experience shows that it works just as well on zirconia as it does on lithium disilicate, so that combining both framework materials in a single patient becomes a lot easier, while the line-up is neat.

Dental technician:

ANDREAS CHATZIMPATZAKIS

Andreas graduated from the Dental Technology Institute (TEI) of Athens in 1999. During his studies he followed a program at the Helsinki Polytechnic Department of Dental Technique, where he trained on implant superstructures and all ceramic prosthetic restorations. As of 2000, he is running the ACH Dental Laboratory in Athens, Greece, specialized on refractory veneers, zirconia and long span implant prosthesis. In 2017 Andreas visited Japan where he trained under the guidance of Hitoshi Aoshima, Naoto Yuasa and Kazunabu Yamanda and become International Trainer for Kuraray Noritake Dental Inc..

Case by Dt. Koray Kendir, DDS, Turkey (İzmir)

INTRODUCTION

Trauma-related fractures of anterior teeth require a precise balance between aesthetics and function, often under emotional pressure from the patient. This clinical case demonstrates the restorative rehabilitation of a previously mismanaged central incisor using CLEARFIL MAJESTY™ ES-2 Premium and PANAVIA™ V5 (both Kuraray Noritake Dental Inc.). The team followed a biomimetic approach to re-establish biological, functional, and aesthetic harmony.

CASE SUMMARY

A 23-year-old female patient presented one month after a traumatic injury involving tooth #11 (FDI notation). Immediate root canal treatment and a direct composite build-up had been performed elsewhere in a single visit. The existing restoration showed poor aesthetics and marginal adaptation (Fig. 1).

Fig. 1. Initial clinical situation.

CLINICAL PROCEDURE

STEP 1: ISOLATION AND REMOVAL OF OLD RESTORATION

For the planned rehabilitation, the tooth was isolated with rubber dam (Figs. 2 and 3) and the existing composite restoration was removed. Gutta-percha from the previous endodontic treatment was found to be severely coronally trimmed (Fig. 4). This poses a risk of future discolouration. Consequently, the gutta-percha was condensed apically to a more biologically appropriate level using a downpack device (Figs. 5 to 9).

Fig. 2. Isolation of the working field with rubber dam: Labial view.

Fig. 3. Isolation of the working field with rubber dam: Occlusal view.

Fig. 4. Gutta-percha from the previous treatment.

Fig. 5. Gutta-percha removed, …

Fig. 6. … placed back into the root canal …

Fig. 7. … and condensed …

Fig. 8. … with a downpack device.

Fig. 9. Result of the procedure: Occlusal view.

STEP 2: CORE BUILD-UP

Subsequently, a fiber-reinforced composite was used to provide root-anchored support for the core structure. Then, the bonding surface was treated with phosphoric acid etchant, CLEARFIL™ Universal Bond Quick (Kuraray Noritake Dental Inc.) was applied as a universal adhesive and the core build-up was performed with CLEARFIL MAJESTY™ ES-2 Premium A1D (Figs. 10 to 13).

Fig. 10. Etching with phosphoric acid etchant.

Fig. 11. Application of the universal adhesive.

Fig. 12. Core build-up after thorough light curing.

Fig. 13. Intra-oral periapical radiograph or the treated tooth.

STEP 3: PREPARATION AND DIGITAL IMPRESSION

For definitive restoration, a 3/4 crown preparation was performed and an intraoral scan was taken. Moreover, a temporary crown was fabricated (Fig. 14) and shade photos were taken to finalize the session.

Fig. 14. Temporary restoration in place.

STEP 4: FINAL CEMENTATION

Once the lithium disilicate restoration was received from the laboratory, the temporary crown was removed and the abutment tooth was evaluated (Figs. 15 and 16). Try-in was performed using PANAVIA™ V5 Try-in Paste White to check shade and fit (Fig. 17). No modifications were required; the selected try-in paste contributed to a lifelike appearance of the restoration. For definitive placement, the intaglio surface of the crown was etched with hydrofluoric acid (Fig. 18). Figure 19 shows the appearance of the intaglio after this measure. To provide for optimal bonding conditions, the tooth surface was then cleaned with KATANA™ Cleaner (Kuraray Noritake Dental Inc.), which should be applied with a rubbing motion to the contaminated prepared tooth for more than ten seconds (Figs. 20 to 22). It may also be used to clean the intaglio of a restoration, which is contaminated with blood and saliva e.g. after try-in.

Fig. 15. Situation after removal of the temporary crown: Labial view.

Fig. 16. Situation after removal of the temporary crown: Occlusal view.

Fig. 17. Try-in of the lithium disilicate crown.

Fig. 18. Etching of the crown’s intaglio surface with hydrofluoric acid.

Fig. 19. Appearance of the etched surface.

Fig. 20. Cleaning of the abutment tooth …

Fig. 21. … surface covered with the cleaning agent.

Fig. 22. Thorough rinsing, which should be followed by drying with air.

Adhesive cementation itself was accomplished with the three-component PANAVIA™ V5 (Figs. 23 to 28): The prepared tooth structure and build-up was treated with PANAVIA™ V5 Tooth Primer, the intaglio surface of the crown with CLEARFIL™ CERAMIC PRIMER PLUS. Finally, PANAVIA™ V5 Universal (White) was extruded into the crown and the crown placed. Excess cement is best removed in the gel phase – i.e. after brief polymerization for 3 to 5 seconds before final light curing is performed. Alternatively, it may be removed immediately after seating the restoration with a brush or similar instrument. In this case the first option was chosen. The treatment outcome after rubber dam removal and final clinical and aesthetic evaluation is displayed in Figure 29.

Fig. 23. Priming of the tooth structure.

Fig. 24. Selected resin cement.

Fig. 25. Tooth structure ready for crown placement.

Fig. 26. Restoration in place.

Fig. 27. Lateral view of the restoration.

Fig. 28. Final light curing of the crown.

Fig. 29. Treatment outcome immediately after rubber dam removal.

CONCLUSION

This case highlights a comprehensive restorative approach to preserving a traumatized anterior tooth at risk of loss, while restoring both function and aesthetics. The strong core foundation provided by CLEARFIL MAJESTY™ ES-2 Premium and the reliable adhesive performance of PANAVIA™ V5 played a pivotal role in the successful procedure and outcome.

Dentist:

KORAY KENDIR

Dt. Koray Kendir is a graduate of Hacettepe University Faculty of Dentistry and the co-founder of a private dental clinic in İzmir. He specializes in digital dentistry, smile design, and computer-aided restorative treatments. Known for his innovative approach, Dr. Kendir is a frequent speaker at national dental congresses and serves as an advisor to several dental companies.

Case by Francesco Ferretti, MDT

Is it possible to produce lifelike porcelain veneers using lithium disilicate and a porcelain system with a reduced number of internal stains and porcelains designed for micro-layering? This is what we wanted to find out when we decided to test the new CERABIEN™ MiLai line-up. As loyal users of the CERABIEN ZR family for porcelain layering on zirconia, we hoped that the new product would offer similar handling and optical properties.

The CERABIEN™ MiLai line-up consists of 15 internal stains and 16 porcelains, which are - like CERABIEN ZR - based on synthetic feldspathic porcelain technology from Kuraray Noritake Dental Inc. With a comparatively low firing temperature of 740 °C (or 1,364 °F), the system may be used on zirconia as well as silicate ceramic restorations, provided that the CTE value of the materials is between 10.2 and 10.5 × 10^-6/K (50 °C – 500 °C). This is true for lithium disilicate, our preferred base material for the production of ceramic veneers. The thickness of the porcelain layer is usually smaller than 0.5 mm, which allows us to exploit the aesthetic potential of the underlaying ceramic, while creating some individual effects for the underlying structure and the enamel. A clinical case predestined for the use of the new system is shown below.

Fig. 1. Young male patient with discoloured composite restorations on his maxillary central incisors.

Fig. 2. The patient was unhappy with his smile aesthetics, so that it was decided to place more durable ceramic veneers.

Fig. 3. Appearance of the central incisors after minimally invasive tooth preparation.

Fig. 4. Veneers made of lithium disilicate individualized with CERABIEN™ MiLai placed on the model.

Fig. 5. Intraoral view of the teeth after adhesive cementation of the veneers.

Fig. 6. Close-up view of the anterior teeth.

Fig. 7. Smooth optical integration of the veneers: They show some individual effects and are virtually indistinguishable from natural tooth structure of the adjacent lateral incisors.

Fig. 8. Black-and-white photograph of the maxillary anterior teeth.

Fig. 9. Smile aesthetics.

Fig. 10. Beautiful treatment outcome.

COMPACT SYSTEM

The compact line-up of CERABIEN™ MiLai with its nicely developed internal stains and porcelains enables us to imitate the patient’s natural teeth very well in the great majority of cases. Shades are easily selected and the favourable consistency of the porcelains facilitates application in thin layers. Due to the reduced thickness of the porcelain layer, it is possible to play with the optical properties of the underlying lithium disilicate, creating a final restoration with a natural appearance despite the simplified procedure.

Dentist:

FRANCESCO FERRETTI, MDT

Born in Rome on March 15, 1957, Francesco Ferretti received his dental technician diploma from the Edmondo de Amicis Institute in Rome and began working independently in 1980. His dental career has been versatile and impressive - working under Prof. Mario Martignoni, being partner at ORAL DESIGN Center in Rome (founded by Mr. Willi Geller and Mr. Francesco Felli) and having his own Estech Dental Studios, are just some of the highlights.

He taught the advanced course in prosthesis at the University of Chieti from 2002 to 2010 and the postgraduate course in prosthesis at the University of Naples Federico II in 2007.

He has been using metal free methods for more than 30 years, specialized in prosthesis and implants, has published articles and research in Italian, American, Russian and Asian magazines and has been a speaker at various international conferences and courses.