429 Too Many Requests

By Dr Salvatore Scolavino and DT Francesco Napolitano 

The dental laboratory is confronted with the greatest aesthetic challenge whenever it comes to the restoration of a single incisor with natural adjacent teeth. In the following case, a young patient had undergone endodontic treatment of her tooth 21 (fig. 1) while all other teeth showed their natural appearance. Tooth 21 was due for replacement now (fig. 2).

Fig. 1:  X-Ray after endodontic treatment (with new crown on tooth 21 in place).

Fig. 2: The former restoration with which the patient showed up in the dentist’s practice.

To keep the natural identity, together with preserving the gingiva outline, the decision was taken in favour of a monolithic zirconia restoration, with a layered block for a full-contour crown. KATANA™ Zirconia STML (Kuraray Noritake Dental) provides for four gradational layers from „Body/Dentine“ (cervical area) to „Enamel“ (incisal aera), varying in chroma and translucency. Using this kind of milling block, it is possible to imitate the natural progression from yellowish to whitish-blue, and this in an easy manner. At the same time this way, the endodontic post wouldn’t shine through and make any aesthetic difference. On the other hand, the zirconia irradiates into the gingiva and results in a natural looking shade allover the anterior area. Furthermore for a lively and most natural-identical appeal, it was intended to individualize the crown by surface stains. With the product CZR™ FC Paste Stain by Kuraray Noritake Dental, 27 shades are available, together with fluorescence. What is essential in the front, too, is this well proven experience: All zirconia material enhances the close gingival attachment and provides for stable results of the pink-and-white aesthetics.

The dentist built up the stump 21, prepared it according to the specifications for zirconia and took the impression (fig. 3). The plaster model followed (fig. 4) and was scanned to start then the digital process. After designing, the crown was milled and tried-in at the next session with the patient (fig. 5).

Fig. 3: Impression taking after preparing tooth 21.

Fig. 4: Plaster model - the prothetic baseline of the case.

Fig. 5: Try-in of the zirconia crown in the patient’s mouth with rubber dam.

SHAPE AND COLOUR

Right when starting the case, the teeth of both jaws had been scrutinized: first for shape. Special attention was payed to the interproximale space between 11 and 21 because this area had worn out in the meantime (see again fig. 2). It was also necessary to move closer to each other the approximale margins 21/22 resp. 11/12 in their cervical-middle parts. When giving the zirconia crown its final shape, this resulted in a widely swinging outer line distally 21. For harmony reasons, tooth 11 was extended distally, too. Here, the clinician used the direct filling composite CLEARFIL MAJESTY™ Classic, shade A2 (fig. 6, 7 and 8). This nano-hybrid composite by Kuraray Noritake Dental is easy-sculpting and integrated fully with the milled crown.

It was most important for crown 21 and tooth 11 too, to create a 3D effect of the tooth structure and an age-appropriate vestibular surface texture. For this, the characteristics of the adjacent teeth and allover both jaws were examined meticulously in general and in detail. Surface burs, discs, stones, and similar instruments sophisticatedly engraved pericymatia and a groove here and there, thus accomplishing the perfect natural look.

Fig. 6: Tooth 11 before recontouring the shape distally.

Fig. 7: Finished crown 21 on the plaster model. Notice: In order to match the shape of crown 21 and close-up the margins 11/12, composite has been added in the interproximal space.

Fig. 8: Finishing the new distal outline of tooth 11.

The final colour touch was given to both teeth by surface staining: with a thin layer of FC Paste Stain measuring only 50-70 micrometers in depth, different shades were applicated. The entire range was used from yellow/orange to blue and white (fig. 9a-d) in order to provoke the effect of mamelons and other structures in all thirds of the restorations.

Fig. 9a: Definitive fitting of the restoration.

Fig. 9b: Directly after the fitting.

FINAL SITUATION

Fig. 9c: View of the lips with the restoration in place.

Fig. 9d: Natural look of the upper and lower jaws.

By Daniele Rondoni, RDT

Hybrid designing meets the functional needs in term of lower abrasiveness and higher toughness.

Step 1
Zirconia Frame (KATANA Zirconia HTML A2) cut-back designed to minic anatomical dentin structure and incisal frame.

Step 2
Application of Internal Stain.

Step 3
Completion of Internal Stain firing.

Step 4
Application of Luster, Clear Cervical and Opacious Body.

Step 5
Completion of firing.

Step 6
Completion of glaze (self-glaze) firing.

Step 7
Polishing of lingual side.

Step 8
Post-operative view.

4-Years Post-operative.

By Drs. Mart Ramaekers

A 20-year-old patient was dissatisfied with her discolored composite restorations on her maxillary central incisors and the right lateral incisor. The original restorations had been placed after an accident with traumatic dental injuries approximately five years ago. We went through all available options that would enable us to improve the aesthetics of her anterior teeth and finally opted for replacement of the existing restorations by new direct restorations made of composite resin.

Prior to the restorative procedure, a home bleaching procedure was carried out with Opalescence 10% (Ultradent). In addition, a palatal silicon index was produced to record the shape and morphology of the existing restorations and dentition.

Initial situation

Frontal view of the initial situation.

Lateral view: The discolorations are particularly visible on the maxillary right central and lateral incisor.

Close-up view of the upper anterior teeth.

The existing restorations were removed after the administration of local anesthesia. Then, labial and palatal bevels were created, followed by sandblasting of the prepared tooth structure with alumina (50 μm). Hereafter, the enamel was etched for 30 seconds (K-Etchant Syringe, Kuraray Noritake Dental), before the primer and bond of CLEARFIL™ SE BOND (Kuraray Noritake Dental) were used according to the instructions.

Build-up of the palatal walls with a first increment of ‘enamel’ composite (CLEARFIL MAJESTY™ ES-2 Premium A2E, Kuraray Noritake Dental) using the silicon index.

Creation of the mesial and distal marginal ridges in A2E enamel composite. The procedure was facilitated by the vertical placement of sectional matrices (Contact Matrices Stiff Flex Large, Danville) in the interproximal space.

Creation of the dentin core and the dentinal mamelons by placement of an opaque composite increment (CLEARFIL MAJESTY™ ES-2 Premium, A2D). It increases the opacity in the middle third of the restoration.

Filling of the space between the mamelons with translucent composite (CLEARFIL MAJESTY™ ES-2 Premium, Translucent Clear).

Labial finishing of the restorations with a layer of semi-translucent composite (CLEARFIL MAJESTY™ ES-2 Premium, A2E).

Application of glycerin gel on top of the last layer of composite to prevent formation of an oxygen inhibited layer during the final light-curing procedure. Final contouring and polishing were performed by using red (fine) and yellow (x-fine) finishing diamonds followed by high gloss polishing with CLEARFIL™ TWIST DIA (Kuraray Noritake Dental).

Final situation

Frontal view of the final situation.

Lateral view: No shade differences or restoration margins are visible.

Close-up view of the new restorations on the upper anterior teeth.

Ceramist:

Drs. Mart Ramaekers

Academic education
2002 - 2007   Tandheelkunde, Radboud Universiteit Nijmegen

Non-academic education
2013 - 2014   Academy of Reconstructive Dentistry, Beuningen
2019              Biomimetic Dentistry, Los Angeles

Career
2008 - 2013    Mondzorg Jekerdal Maastricht
2013 - 2015    De Drietand Maastricht
2009 - 2020    Amalia Kliniek Kerkrade
2020 - now      Espenbos Kliniek Cadier en Keer

Materials used: Kuraray Noritake Dental: CLEARFIL™ SE BOND 2, K-Etchant Syringe, CLEARFIL MAJESTY™ ES-2 Premium Enamel A2E, CLEARFIL MAJESTY™ ES-2 Premium Dentin A2D , CLEARFIL MAJESTY™ ES-2 Premium Translucent Clear and CLEARFIL™ TWIST DIA. Heavy Putty (Provil Novo, Heraeus Kulzer), Glycerine gel (K-Yelly Johnson&Johnson), Rubberdam non-latex Heavy (Sigma), Contact Matrices Stiff Flex Large (Danville), Optragate Regular (Ivoclar)

CERABIEN™ ZR
High translucent and opal porcelain for True-to-life, highly aesthetic restoration.

Blue-tinged light translucency at incisor edge of enamel was reproduced with LTx and LT Royal Blue.

Initial situation.

LTx and LT Royal Blue were used at the incisor edges to reproduce the bluish opalescence and translucency effect.

Step 1: Build-up of internal structures.

In order to reproduce the mamelon structure with stain and dentin color, Internal Stains were applied, then baked.

Step 2: Applied the first Internal Stain, then baked it.

In order to reproduce the stain in the internal enamel structure, Luster porcelains were applied and baked as a base.

Step 3: Applied the first enamel structure, then baked.

In order to reproduce the white spot and the incisor halo, Internal Stains were applied before baking.

Step 4: Applied the second Internal Stain before baking it.

To reproduce the subtle color and translucency of enamel, Luster porcelains were applied before baking.

Step 5: Applied the second enamel structure before baking it.

Step 6: Final situation.

Photos: Courtesy of Otani Dental Clinic, MDT Ryuzo Shiba and MDT Naoto Yuasa.

By Dr. PhD. Jusuf Lukarcanin

Is it possible to fulfil high aesthetic demands by restoring anterior teeth with composite resin? It is – provided that several important factors are respected. One of these factors is the faithful reproduction of the natural tooth morphology, which has a decisive impact on aesthetics and function. Moreover, success is determined by the selection of the right shades of high-quality composite resin and their purposeful combination using proper layering techniques.

Introduction

The aesthetic appearance of direct anterior restorations is affected by proper shade selection on the one hand and the creation of a natural shape and texture on the other¹. Hence, the dental practitioner’s own artistic skills play a decisive role. According to Fahl, information about the tooth morphology and function, and the optical properties of the tooth should be taken into consideration when the most suitable restorative material and shade are selected².

These minimally invasive composite restorations are no longer a temporary solution for the anterior region. Instead, they are regarded as an adequate alternative to indirect restorations, as they are both durable and able to closely imitate the natural tooth structure³⁴.

Clinical case example 1

This 45-year-old female patient presented with a diastema and a disproportion in the size and shape of her maxillary central incisors (Fig. 1). In the first step, a detailed case history was taken and an intra-oral examination was carried out. Subsequently, the initial situation was recorded by taking intra-oral photographs, which would allow for a computer-aided morphological evaluation and treatment planning (Fig. 2).

Fig. 1: Pre-operative image.

Fig. 2: Digital mock-up.

The patient’s second visit started with a professional tooth cleaning procedure followed by isolation of the maxillary anterior teeth. Afterwards, the tooth shade was determined and appropriate composite shades were selected. In this case, the shades A2E, Amber Translucent and A3D of CLEARFIL™ Majesty ES-2 Premium (Kuraray Noritake Dental, Japan) appeared to be most suitable. In addition, a mock-up was created using mock-up resin in order to produce a silicone key.

Opting for a minimally invasive procedure, no mechanical tooth preparation using drills was performed after removal of the mock-up. Instead, the enamel was merely etched with 35% phosphoric acid gel (K-Etchant, Kuraray Noritake Dental) to increase the surface roughness. After rinsing and drying, the adhesive agent (CLEARFIL™ Universal Bond, Kuraray Noritake Dental) was applied to the etched surfaces. Composite layering started with the build-up of palatal shells with the aid of the silicone key. Following light-curing of the shells, a small amount of composite in the dentin shade A3D was applied to the proximal surfaces using a thin spatula and a brush. The aim was to reduce light transmission in the area of the dentin core. The restoration was completed with a combination of the composite shades A2E (enamel) and Amber Translucent, which were applied using a modeling brush.

Finishing and polishing was accomplished using flexible rubber polishing discs containing diamond particles (CLEARFIL™ Twist DIA, Kuraray Noritake Dental) with a low-speed handpiece. No additional finishing and contouring was necessary due to the use of a brush during layering, which ensured the creation of a natural shape and surface texture. Figure 3 shows the outcome of the restoration procedure.

Fig. 3: Treatment outcome immediately after polishing.

Oral hygiene training was provided and follow-up examinations were performed after three, six and twelve months (Fig. 4). Healthy hard and soft tissue conditions were observed during these visits.

Fig. 4: Clinical situation at the one-year recall.

Clinical case example 2

This 30-year-old female patient had a diastema, irregularly shaped anterior teeth and showed signs of abrasive tooth wear (Fig. 5). Following a detailed anamnesis and intra-oral examination, the tooth shade was determined and the composite CLEARFIL™ Majesty ES-2 Premium selected in the monochromatic shade Universal A1.

Fig. 5: Pre-operative clinical situation.

Following the isolation of the working field, 35% phosphoric acid etchant (K-Etchant) was applied to the enamel of all teeth between the maxillary right canine and the maxillary left first molar. The surfaces were then treated with a universal bonding agent (CLEARFIL™ Universal Bond) as recommended by the manufacturer. Modeling was carried out with a thin spatula and a modeling brush for composite. Neither a silicone key nor any wetting or modeling resin were used in the procedure. For polishing, the flexible polishing discs CLEARFIL™ Twist DIA were used at low rotational speed. Thanks to the use of the modeling brush, no additional finishing with diamond-coated instruments was necessary. Figures 6 and 7 show the final restoration at baseline and one week after completion of the treatment.

Fig. 6: Treatment outcome at the day of the restorative procedure.

Fig. 7: Clinical situation after one week.

This patient also received oral hygiene training and presented for recalls three, six and twelve months after the treatment. The patient maintained an exemplary oral hygiene behaviour, so that it came as no surprise that the soft tissues were healthy and the restorations were in a perfect condition after one year (Fig. 8).

Fig. 8: Clinical situation one year after the restorative treatment.

Discussion

Nowadays, direct composite restorations are becoming increasingly popular. Especially for young patients and all those who do not want to sacrifice large amounts of healthy tooth structure, the technique is an ideal treatment option⁵. In many cases, aesthetic outcomes are possible without mechanical tooth preparation, but a selective etching procedure only⁶.

The clinical lifetime of these restorations depends on many factors. Important prerequisites for high-quality outcomes include the selection of a suitable composite material with the required surface hardness, appropriate finishing and polishing, a good oral hygiene behaviour, and proper maintenance measures during periodical follow-up visits. As a matter of course, the manual skills of the dental practitioner and the use of selected materials according to the manufacturer’s instructions for use also have a direct impact on the long-term success of the restorations⁷⁸⁹. A user’s inability to meet one of these requirements and failure to carry out all working steps correctly may have a direct impact on the quality of the restoration.

Conclusion

Composite resin is a popular material class for the production of aesthetic anterior restorations die to their straightforward use and rapid application, good repair options and high aesthetic potential when used properly . The two case examples illustrate that a treatment with composite resin is often the best treatment option when a non-invasive procedure completed within a single visit is desired.

About the author

Dr. Jusuf Lukarcanin is a Certified Dental Technician (DCT) and a Doctor of Dental Science (DDS). He studied dentistry at the Ege University Dental Faculty in Izmir, Turkey, where he obtained a Master‘s degree in 2011. In 2017, he received a Ph.D. degree from the Department of Restorative Dentistry of the same university. Between 2012 and 2019, Dr. Lukarcanin was the head doctor and general manager at a private clinic in Izmir. Between 2019 and 2020, he worked at Tinaztepe GALEN Hospital as a Restorative Dentistry specialist, between 2020-2022 he worked at MEDICANA International Hospital Izmir as a Restorative Dentistry specialist. Currently he is an owner of a private clinic for aesthetics and cosmetics in Izmir.

References

^{1. Heymann HO (1987) The artistry of conservative esthetic dentistry Journal of the American Dental Association 115(Supplement)14-23.}

^{2. Fahl N Jr (2012) Single-shaded direct anterior composite restorations: A simplified technique for enhanced results Compendium of Continuing Education in Dentistry 33(2) 150-154.}

^{3. Barrantes, J. C. R., Araujo Jr, E., & Baratieri, L. N. (2014). Clinical Evaluation of Direct Composite Resin Restorations in Fractured Anterior Teeth. Odovtos-International Journal of Dental Sciences, (16), 47-61.}

^{4. Vargas M (2011) Clinical techniques: Monocromatic vs. polycromatic layering: How to select the appropriate technique ADA Professional Product Review 6(4) 16-17.}

^{5. Ferracane, J. L. (2011). Resin composite—state of the art. Dental materials, 27(1), 29-38.}

^{6. Norling, N. A. (2010). Combining “prep-less” and conservatively prepared veneers to correct enamel defects and asymmetry. Journal of Cosmetic Dentistry, 2010.}

^{7. Ölmez, A., & Kisbet, S. (2012). Kompozit rezin restorasyonlarda bitirme ve polisaj işlemlerindeki yeni gelişmeler. Acta Odontologica Turcica, 30(2), 115-22.}

^{8. Senawongse, P., & Pongprueksa, P. (2007). Surface roughness of nanofill and nanohybrid resin composites after polishing and brushing. Journal of Esthetic and Restorative Dentistry, 19(5), 265-273.}

^{9. Giacomelli, L., Derchi, G., Frustaci, A., Bruno, O., Covani, U., Barone, A., Chiappelli, F. (2010). Surface roughness of commercial composites after different polishing protocols: an analysis with atomic force microscopy. The open dentistry journal, 4, 191.}

^{10. Hickel, R., Heidemann, D., Staehle, H. J., Minnig, P., & Wilson, N. H. F. (2004). Direct composite restorations. Clin Oral Invest, 8, 43-44.}

^{11. Korkut, B., Yanıkoğlu, F., & Günday, M. (2013). Direct composite laminate veneers: three case reports. Journal of dental research, dental clinics, dental prospects, 7(2), 105.}

By Daniele Rondoni, RDT

A middle-aged patient sought dental advice because she felt uncomfortable with the aesthetic appearance of her upper front jaw, specifically regions 11, 12, 21 and 22. Additionally, she was not happy about the diastema between her upper central incisors.

Fig. 1: Initial situation.

The oral examination showed four crown regions (12-22) and revealed that all of them have deteriorated. Tooth 21 had undergone an endodontic treatment, while teeth 11 to 22 have been newly built up. Due to the deteriorated conditions, all affected teeth were taken into consideration in the planning and designing of new restorations, including the intention to close the diastema between the width-to-length-ratio for the incisors.

The best suitable material for a natural look in combination with a close gingival attachment to the restoration is, in this case, zirconia, because of its biocompatibility and gentleness to the gingival region. The KATANA^TM Zirconia series from Kuraray Noritake Dental, offers a line-up of high-quality materials combined with true-to-life aesthetics, due to its natural color gradient within the material.

Fig. 2: Preparations, showing discoloration in the cervical area of tooth 21.

Fig. 3: Occlusal view of the preparations.

Fig. 4: The four zirconia crowns after designing followed by milling.

Fig. 5: Result directly after sintering.

To achieve an even more natural-looking and aesthetic restoration, CZR FC Paste Stains were used externally on the zirconia surface.

Fig. 6: Characterization of the restoration.

As often done, Cervical 2 was used to give an orange tint to the cervical area, to accentuate even better the natural tooth gradation. For the incisal areas, Grayish Blue in combination with Value was used to enhance transparency and opalescence. Same procedure applied to the approximal areas. Mamelon Orange 2 was used to reproduce dark orange stain on the mamelons.

Fig. 7: Result after cementation of the four new zirconia crowns. Their shape and chroma blend harmoniously with the arch.

Fig. 8: The vestibular view showing natural-looking characterization.

During a period of five years, annual check-ups showed intact crowns and a healthy gingiva. Additionally, the durability of the restorations, including their mechanical and optical properties revealed no signs of deterioration.

To achieve excellence it is crucial to know the properties of modern materials and their correct clinical procedure. With this premise, surprising clinical results can also be achieved by combining different materials in the same clinical case.

This clinical case follows the aesthetic request of the patient who wanted to solve the pathology concerning the incisors with a direct composite restoration on 2.1 and a KATANA^TM STML crown on 1.1.

Following the mock-up the patient wanted larger incisor shapes with a strong character. The 2.1 was restored only with the MAJESTY^TM ES-2 Classic A2 mass exploiting the extraordinary ability of mimicry that comes from the Kuraray Noritake Dental light diffusion technology - LDT. The restoration on the 2.5 was performed with a CAD/CAM hybrid ceramic block - KATANA^TM AVENCIA^TM.

KATANA^TM AVENCIA^TM Block was characterized with a staining resin before cementation with the new PANAVIA^TM SA Cement Universal. PANAVIA^TM SA Cement Universal includes in its formulation a new type of silane coupling agent – LCSi monomer and this ensures strong and durable chemical bond to glass ceramics and composite resins without pretreatment with silane.

By Japanese Dr. Shigeru Adachi, Cusp Dental Supply Co. Ltd

Initial situation

Checking of the shade (Posterior Crowns: FC Paste Stain, Anterior Crowns: Micro layered CERABIEN™ ZR)

Checking the restoration on the model

Final situation

Ceramist:

MDT Shigeru Adachi, Cusp Dental Supply Co. Ltd

MDT Adachi is a promising ceramist of the new generation, who has been working for Cusp Dental Supply Co. Ltd. since 2013. He received the Award of Excellence 2018 at QDT TECHNICAL CONTEST.

April, 2013 - Present
Working for Cusp Dental Supply Co., Ltd.
March, 2013
Graduated from the Osaka Ceramic Training Center
April, 2009 - March, 2011
Worked for Tsuruga Denatal Laboratory
March, 2009
Graduated from the Aishi Dental Technician College

MDT SHIGERU ADACHI USED KATANA™ ZIRCONIA HTML AND CZR FC PASTE STAIN FOR HIS CASE STUDY

By Irfan Abas
Dental implantologist & restorative dentist

Irfan Abas is a specialist in the field of oral implantology & restorative dentistry and an international speaker on the subject. He has given more than 20 presentations, workshops and live surgery courses throughout the world. TP - a dutch dental magazine, of which he is also editor, has published multiple articles under his name. Another highlight is a publication in the NTvT, in collaboration with Prof. Gert Meijer (Radboud UMC), under whose supervision Abas successfully completed the four-year postdoctoral training Reconstructive Dentistry in 2014. He is also an instructor and lecturer for the AAIE and chair of MINEC Netherlands. Irfan Abas has his own practice in Bussum, the Netherlands (tandartsabas.nl).

A healthy 42 year-old male patient requested reconstruction of his central incisors, which were badly worn.

Pre-Treatment

After producing the mock-up, grooves were prepared through the mock-up.

To fit two lithium disilicate veneers, a preparation of 1 mm was required. After removing the mock-up, the preparation was perfected.

Checking the space using a silicone mold.

Definitive preparation (frontal)

Temporary veneers made from temporary resin based material (Protemp)

Spot-etching before bonding the temporary veneers in place.

A small amount of flowable composite applied to the etched surfaces.

Light curing the entire surface of the temporary veneers.

Finished temporary veneers.

The veneers constructed by the dental technician.

Checking the fit of the veneers

Rubber dam fitted to enable controlled adhesive cementation.

Etching with 35% phosphoric acid K-Etchant Syringe for 10 seconds.

Treatment with selfetching primer PANAVIA™ V5 Tooth Primer (left on for 20 sec.)

Etching of the lithium disilicate veneers with hydrogen fluoride.

Clearfil Ceramic Primer Plus MDP-silane primer applied to the veneers.

Veneers secured to a placement instrument before definitive cementation

PANAVIA V5 Paste applied to the inner surface of the veneer.

PANAVIA V5 Paste spread over the veneer.

Veneer fitted and excess removed.

Light curing (minimum 10 sec.).

Immediately after the adhesive cementation with PANAVIA V5.

Immediately post-op.

Immediately post-op.

Two months post-op.

One year post-op.

One year post-op.

By Paul de Kok, Amsterdam (KVPA) Periodontic Clinic & ACTA

Picture 1

The Patient
Joris reported to the clinic with two discoloured composite two discoloured class IV composite restorations in tooth 11 and 21 11 and 21 (picture 1). These vital teeth were traumatized in his childhood. He was not satisfied with the aesthetics of the restorations neither with the overall shape and colour of the two teeth. It was therefore decided to make porcelain facings for tooth 11 and 21.

Picture 2

The preparation
In order to limit the sacrifice of healthy tooth tissue while still creating sufficient space for the porcelain, a preparation was chosen with an incisal reduction of 1.5mm and a buccal reduction of 0.5mm. A so-called depth cutter – a diamond drill with 0.5mm deep recesses – was used to achieve this (picture 2).

Picture 3

To be able to adjust the shape of the mid-line to the new facings, cutting was carried out centrally through the contact. From the distal aspect the contactpoint was remained. The thin shoulder was positioned equi-gingivally, so that a dry operative field could be achieved without damage to the gingiva.

The preparations were then finished using fine drills and polishing discs. The existing, well bonded diamonds composite restorations were left in situ (picture 3).

Picture 4

Since the transparent facings are very thin, the colour of the cut teeth is significant. The colour of the cores was therefore matched using the Natural Die colour guide (picture 4). Finally, impressions were made. Temporary restorations were placed by means of 4 spot etching points and bonding.

Picture 5

Cementation
To combine superior aesthetics with adequate strength, pressed lithium disilicate restorations were chosen for Joris. Prior to cementing the facings, they were tried for size and checked for marginal integrity, contact points, occlusion/articulation and aesthetics. Then the correct cement colour was established by testing the facings with various try-in colours PANAVIATM V5 Universal (A2); Universal (A2) appeared to be the most appropriate colour in Joris’s case. The teeth were then polished with pumice and the facings were cleaned with alcohol, after which the teeth from 14 up to and including 24 were isolate by a rubber dam.
An incisor clamp was placed on the first teeth to be cemented. The facing was tried for fitting once more to ensure that it was free of contact with the rubber dam or the clamp and that the operative field of the preparation was totally dry (picture 5).

Picture 6

The facing was etched with 9% fluoricacid (picture 6) for 20 seconds to achieve micro-mechanical retention.

Picture 7

It was then rinsed with water for 20 seconds before being neutralised in a solution containing ceramic neutralising powder. CLEARFILTM CERAMIC PRIMER PLUS was then applied to the facing. This ensures chemical bonding between the facing and the composite cement thanks to the incorporated silane and MDP. The adjacent teeth were separated by means of a transparent strip, after which the preparation was etched with 35% phosphoric acid (picture 7). TOOTH PRIMERTM was applied after thorough rinsing with water and drying after it had taken effect for 20 seconds.

Picture 8

A thin layer of PANAVIA V5 cement was then applied to the facing. The facing was placed on the preparation with the application of light finger pressure. A microbrush was used to remove the major excess along the margins. The cement of the buccal and palatal aspect was light cured for 5 seconds. A sharp scaler and floss were used to remove the final excess. Glycerine gel was then applied to the outline to avoid oxygen inhibition during curing. The cement was finally light cured from both sides for 20 seconds, the glycerine gel was rinsed away and the margins were finished by means of a composite polishing stone. After placement of the first facing, the rubber dam clamp was moved to the neighbouring tooth so the cementation of the second facing could proceed. This facing was once more tried for fit, pre-treated and cemented in an identical manner (picture 8).

Picture 9

The result
The facings were checked a few weeks later (picture 9). Joris was very satisfied with the aesthetics of his two central incisors. The transitions from tooth to restoration were invisible and the gingiva was healthy.

Picture 10

The transparency, surface structure and gloss are better adjusted to the neighbouring elements and to Joris’s smile (picture 10).

Dentist:

Paul de Kok, Amsterdam Periodontics Clinic

Paul de Kok studied dentistry at the ACTA and is an authorised restorative dentist at the Amsterdam Periodontic Clinic (KvPA), where he treats referred patients with restoration and aesthetic issues. In addition, Paul teaches indirect restorative dentistry at the Oral Functional Anatomy faculty of ACTA as well as conducting research in the Materials Science department. He also delivers lectures about this discipline at both a national and international level.

Dental technician: Eric van der Winden, Oral Design Center Holland

PAUL DE KOK USED CLEARFIL CERAMIC PRIMER PLUS AND PANAVIA V5 FOR HIS CASE STUDY

Clinical case by Dr. Claudia Mazzitelli and Dr. Edoardo Mancuso

INTRODUCTION

Dental aesthetics are gaining increasing importance and require predictable, rapid, and affordable treatments. Minimally invasive dentistry favours direct restorations, which are now simplified by the evolution of flowable composites. Recent variants of flowable composites offer optical and mechanical characteristics equal or superior to those of paste-type composites. The evolution of flowable resins has led to widespread application using the flowable injection technique (FIT). In addition, the possibility of 3D printing an index for injection reduces operator-dependent variability, providing for high-level aesthetics.

CLINICAL CASE

A 24-year-old patient complained of an unattractive smile. After clinical and radiographic examinations, an aesthetic restoration using FIT was planned. A digital wax-up, created on the basis of intraoral scans (Trios 5, 3Shape), allowed for the design of a customised index or template, which was printed using transparent resin (IBT Flex Resin, Formlabs). After preparation and isolation, the teeth were sandblasted, etched, and a universal adhesive (CLEARFIL™ Universal Bond Quick 2) was applied and light-cured. Flowable composite (CLEARFIL MAJESTY™ ES Flow Low) was injected through the injection holes in the index, followed by thorough curing, finishing and polishing (TWIST™ DIA for Composite, all Kuraray Noritake Dental Inc.).

RESULTS

The treatment, completed in two hours, led to immediate and stable aesthetic improvement, confirmed during check-ups after one week and six months, with excellent gum health and restoration maintenance.

DISCUSSION

FIT offers predictable aesthetic results, a digital workflow option, and reduced clinical time compared to indirect restorations, while maintaining the possibility of future prosthetic treatments. The evolution of flowable composites and 3D-printed indexes has improved the accuracy of clinical transfer and reproducibility, allowing for rapid, conservative aesthetic solutions.

CLINICAL CASE

A 24-year-old male patient presented at our practice dissatisfied with the aesthetics of his smile, with an impact on his spontaneity and social life. After taking his medical and dental history, an interview was conducted to understand his aesthetic and functional expectations as well as financial possibilities.

The clinical visual examination, accompanied by photographs, static and dynamic videos, periodontal analysis, and radiographs, revealed incongruous Class IV restorations on teeth 11 and 21 (FDI notation), with asymmetry of the anterior maxillary region  (Fig. 1). Aesthetic rehabilitation using the Flowable Injection Technique (FIT) extended to the six maxillary anterior teeth was therefore proposed.

Fig. 1. Initial clinical situation.

TREATMENT PLANNING

An intraoral scanner (Trios 5, 3Shape) was used for impression taking. The resulting digital model was used to create a digital wax-up, which then served as the basis for digitally designing an index for the injection of the flowable composite (Fig. 2). The index was printed in transparent resin (IBT Flex Resin, Formlabs) (Fig. 3). Once post-processing was complete, calibrated injection holes were integrated. They allow for insertion of the syringe tip and precise injection of the flowable composite (Fig. 4).

Fig. 2. Computer-aided index design.

Fig. 3. 3D-printed transparent index for composite injection.

Fig. 4. Injection holes integrated in the incisal areas of the index.

OPERATIVE PROCEDURE

After obtaining informed consent from the patient, the old restorations on the maxillary central incisors were removed with diamond burs under irrigation. The margins were finished and bevelled (Fig. 5). The index was positioned on the upper arch and evaluated for stability and retention. To produce the restorations alternately, PTFE tape (0.076 mm) was applied to isolate the adjacent teeth. The surfaces of the teeth to be restored were sandblasted with aluminium oxide (50 µm), etched with 37 % orthophosphoric acid etchant for 15 seconds, rinsed, and dried (Fig. 6).

Fig. 5. Maxillary central incisors after restoration removal and bevelling of the margins.

Fig. 6. Etching of the tooth surfaces with orthophosphoric acid etchant.

A universal adhesive (CLEARFIL™ Universal Bond Quick 2, Kuraray Noritake Dental Inc.) was then applied (Fig. 7) and polymerized with an LED curing light (SmartLite® Pro, Dentsply Sirona) for 10 seconds per tooth (Fig. 8).

A flowable composite (CLEARFIL MAJESTY™ ES Flow Low, colour W, Kuraray Noritake Dental Inc.) was injected through the holes until the index of the first prepared tooth was filled (Fig. 9). After light-curing for 40 seconds per tooth through the transparent index, the template was removed and the restoration was light-cured for a second time. Excess composite was then removed with a scaler.

Fig. 7. Application of a universal adhesive.

Fig. 8. Light-curing of the adhesive layer.

Fig. 9. Flowable composite injection.

The same procedure was subsequently repeated for the other teeth to be treated, isolating those already restored using PTFE tape (Figs. 10 to 15).

Fig. 10. Restored teeth isolated with PTFE tape.

Fig. 11. Etching of the tooth structure with 37 % orthophosphoric acid etchant.

Fig. 12. Application of the universal adhesive.

Fig. 13. Light-curing of the adhesive layer.

Fig. 14. Injection of the flowable composite into the index.

Fig. 15. Light-curing of the flowable composite through the transparent index.

Once the index was removed and excess material was eliminated. Then, the teeth were isolated with rubber dam using the split dam technique to improve patient comfort and visibility, and the restorations were finished with fine-grained diamond burs. Finally, progressive polishing was performed with polishing discs  (TWIST™ DIA for Composite, Kuraray Noritake Dental Inc.) (Figs. 16 and 17).

Fig. 16. Polishing of the restorations with the pre-polisher.

Fig. 17. Final polishing with the high-gloss polisher.

CLINICAL RESULTS

Once the restorations were completed (Figs. 18 and 19) and the occlusal and dynamic contacts were checked, the patient expressed immediate satisfaction. This was confirmed at the one-week follow-up (Fig. 20). The rehabilitation took a total of two hours, including photographic documentation. This represents a rapid, minimally invasive and cost-effective treatment compared to indirect restorations.

Fig. 18. Treatment outcome.

Fig. 19. Detailed view of the freshly restored teeth.

Fig. 20. Post-operative photograph taken after one week.

The six-month check-up (Figs. 21 and 22) not only confirmed the survival of the restorations but also showed excellent gingival health, demonstrating the correctness of the emergence profile and the high polishability of the cervical margins obtained with this restorative technique.

Fig. 21. Restorations at the six-month recall.

Fig. 22. Optical integration of the new restorations into the overall picture.

DISCUSSION

The Flowable Injection Technique is now a valid alternative in the field of direct restoration, as it combines operational simplicity with predictable aesthetic results. The main advantage lies in the reduction of variability linked to the operator's manual skills, thanks to the guiding role of the index, which allows the digital design or initial wax-up to be transferred with high accuracy. The aesthetic outcome is therefore highly controllable, while the clinical approach complies with the principles of minimally invasive dentistry. Added to this is the efficiency of the method, which allows for shorter operating times and lower costs compared to rehabilitation with indirect restorations. At the same time, it maintains the possibility of a subsequent transition to more complex prosthetic solutions.

A key enabler of this approach is the evolution of flowable composites. The latest generation has overcome the historical limitations of fragility and wear, offering mechanical and optical characteristics comparable to, if not superior to, paste-type composite materials. This progress has made it possible to use flowable materials not only as a complementary support, but as the real protagonist of a restorative technique that aims to simplify clinical work and improve the predictability of results.

Furthermore, the development of 3D printing applied to the production of transparent indexes has introduced a further leap in quality. The digital workflow makes it possible to reduce manufacturing times, standardize procedures, achieve high reproducibility, and design customized templates based on intraoral scans. The accuracy of clinical transfer is thus significantly increased, with a positive impact on the quality and stability of the final restoration.

The synergy between high-performance flowable resins and 3D-printed digital index therefore offers clinicians the option of offering patients aesthetic solutions that are rapid, accessible, and at the same time adhere to the principles of modern conservative dentistry.

CONCLUSION

The Flowable Injection Technique, supported by the latest generation of flowable composites and the potential of 3D printing, represents a modern and effective restorative strategy. The clinical case presented highlights how it is possible to offer patients a satisfactory, rapid, and conservative aesthetic treatment, while keeping open the option of a future transition to indirect restorations.

By combining innovative materials and digital technologies, this technique marks a step forward towards increasingly predictable, accessible, and patient-centred cosmetic dentistry.

Dental technicians:

CLAUDIA MAZZITELLI

Scientific director of the Dental Biomaterials Laboratory.

Clinical tutor for the International Master's Degree in Conservative Dentistry and Aesthetic Prosthetics, head of teaching activities for the Degree Course in Dental Hygiene at the University of Bologna.

Speaker at numerous national and international conferences and author of scientific publications in high-impact indexed journals.

EDOARDO MANCUSO

Expert in conservative and prosthetic dentistry with a minimally invasive approach.

Collaborates with international research groups on adhesive techniques and minimally invasive preparations.

Practices as a freelancer in Bologna.

Speaker and author of scientific papers presented at national and international conferences, publishes articles in leading scientific journals.

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