Case by Dr. Onur Alp Yünük 

COMBINING HIGH-PERFORMANCE TOOLS AND MATERIALS FOR A PREDICTABLE OUTCOME

Direct composite restorations are a high-quality treatment option even when large amounts of tooth structure need to be replaced. This is due to recent advancements in resin composite materials and adhesive technology. By selecting appropriate materials and layering techniques combined with modern digital tools for colour difference evaluation, it is possible to predictably produce highly aesthetic outcomes, as demonstrated in the following case example.

The challenge

A young male patient presented to our clinic requesting the replacement of his existing composite restorations on his maxillary incisors (teeth #12 and #11 according to the FDI notation). Clinical examination revealed extensive restoration loss on the lateral incisor. Furthermore, anatomical irregularities, discolouration, and loss of surface gloss were observed on tooth #11. The adjacent central incisor exhibited similar issues regarding colour and surface polish.

In consultation with the patient, it was decided to replace the existing restorations using a modern composite material specifically developed for dual-shade layering – CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.). For an exact shade analysis, photographs were taken with and without a cross-polarized filter (Figs. 1 to 4).

Fig. 1: Frontal view of the teeth  with extensive restoration loss on the maxillary left lateral incisor.

Fig. 2: Cross-polarized photograph of the teeth allowing for a detailed analysis of the shade irregularities.

Fig. 3: Lateral view of the teeth.

Fig. 4: Lateral view – cross-polarized photograph.

The solution

Following removal of the existing restorations, rubber dam was placed for working field isolation. A self-etching adhesive (CLEARFIL™ SE Bond 2, Kuraray Noritake Dental Inc.) was applied in the selective enamel etching mode before establishing the palatal shell using CLEARFIL MAJESTY™ ES-2 Premium in the shade A1E (Figs. 5 and 6). The mamelon structures were reconstructed with CLEARFIL MAJESTY™ ES-2 Premium in the shade A1D, while the translucent shade Blue was applied  to the opalescent zone. Finally, yellow and white tints were used for characterization. Fig. 7 illustrates the appearance before,  Fig. 8 after finishing and polishing.

Fig. 5: Palatal shell established with the enamel shade A1E of the selected composite.

Fig. 6: Lateral view of the teeth during the restoration procedure.

Fig. 7: Restoration before finishing and polishing.

Fig. 8: Appearance of the restorations after finishing and polishing.

The outcome

To evaluate the final colour integration, another photograph was taken with a cross-polarized filter, holding a grey reference card in place for calibration (Figs. 9 and 10). The lateral view of the restored teeth (Fig. 11) reveals that not only the right colour combination, but also a natural surface texture is required for a highly aesthetic outcome.

Fig. 9: Frontal view of the restored teeth taken with a cross-polarized filter.

Fig. 10: Gray reference card calibration and the resulting L*a*b* coordinates of the restoration.

Fig. 11: Lateral view of the restored teeth stressing the importance of surface texture.

DISCUSSION AND CONCLUSION

Observation, supported by modern tools for photography and image analysis (like polarized filters and L*a*b* coordinates), is  an important skill needed for the lifelike reconstruction of teeth with direct composite materials. By combining this skill with a highperformance composite system that offers fixed shade combinations and innovative light diffusion technology for a nice blend-in  with the surrounding tooth structure, creating beautiful restorations becomes a predictable business.

In the case presented, the patient was very satisfied with the outcome in terms of aesthetics and function. At regular recalls, the quality of the restorations is checked – they still offer a very nice functional and aesthetic integration.

Case report by Vasilis Vasiliou

AESTHETIC RESTORATION OF MAXILLARY INCISORS

Falling in love, applying for a first job, attending a best friend’s wedding: There are so many occasions for young people when looking gorgeous is important. That is why restoring a young patient’s smile to its natural beauty is a special task that demands a lot from us. We need to listen to their touching stories, understand their specific needs and desires – and finally find a way to exceed their expectations. Whenever our plan works and is performed correctly, the outcome will be rewarded with extreme gratitude by those affected. After all, it is not only the smile we restore, but also the patients’ self-confidence and quality of life.

SINGLE BAKE, NATURAL RESULT

The good news: Even highly aesthetic all-ceramic restorations can be produced with a minimal number of bakes. Modern framework materials and porcelain systems allow us to imitate a natural play of colours and translucencies, a virtually unlimited number of individual effects and a vivid surface texture in a predictable way. A possible procedure is illustrated below. The materials utilized in this case were KATANA™ Zirconia STML and CERABIEN™ ZR (Kuraray Noritake Dental Inc.) and the restoration was completed using the One-Bake technique developed by MDT Nondas Vlachopoulos.

Fig. 1. Frameworks made of KATANA Zirconia STML in the shade A1.

Fig. 2. Single-bake layering procedure: Application of CERABIEN ZR Opacious Body in the cervical …

Fig. 3. … and mamelon areas.

Fig. 4. CERABIEN ZR Body porcelain applied in the body area.

Fig. 5. CERABIEN ZR Transitional Dentine used to increase the translucency in the incisal part.

Fig. 6. CERABIEN ZR Opacious Body added in specific areas to create more reflaction.

Fig. 7. Incisal cut-back and creation of the mamelon structure as well as adding of T Blue to give depth.

Fig. 8. … in the body and distal incisal areas.

Fig. 9. Application of Aqua Blue 1 and T Blue on the incisal edges to produce a youthful translucency.

Fig. 10. Creation … effect

Fig. 11. … of mamelons.

Fig. 12. Application of Luster porcelains: LTx, …

Fig. 13. … ELT1 …

Fig. 14. … and LT1.

Fig. 15. Cutback of the dentin for the creation of a halo effect.

Fig. 16. Final shape: Halo effect created with Body.

Fig. 17. Treatment outcome after a first bake followed by minor adjustments, surface texturing and glazing with CERABIEN™ ZR FC Paste Stain Clear Glaze.

Fig. 18. Restorations adhesively cemented in the patient’s mouth.

CONCLUSION

Restoring a young patient’s smile is a particularly challenging task, as the quality of the outcome has a huge effect on the self-confidence and quality of life of the affected person. By listening closely to our patients’ stories, understanding their needs and knowing our materials well, we are able to deliver exactly what they need. It is their positive feedback and happiness that drives me to never stop learning and practicing with my ceramics and porcelains for continued improvement and even better outcomes.

I would like to express my gratitude to Dr. Loukia Pedoulou for the professional partnership and clinical support in achieving this result.

Case by DT Vasilis Vasiliou

MICRO-LAYERING WITH CERABIEN MiLai

No matter whether young or old, male or female: Our patients deserve a beautiful smile that matches their adjacent teeth, their face, their character and their individual needs. To be able to produce beautiful restorations that change their life for the better, we (as dental technicians) have to observe closely – and to listen attentively to the stories they tell.

‘We have to observe closely – and to listen attentively to the stories our patients tell us.’
– Vasilis Vasiliou –

Mr Andreas is a perfect example. He presented in the dental office in need of a full-mouth rehabilitation and the wish to improve the aesthetics of his smile. He asked for an age-appropriate, natural restoration design.

After careful observation and listening, I decided that the best way to restore his maxillary incisors would be with zirconia restorations. The plan was to mill the frameworks using low-value KATANA™ Zirconia YML, shade D3 (Kuraray Noritake Dental Inc.). To facilitate the integration of some natural characteristic effects, a framework design with a primarily vestibular cutback was selected. The finishing technique of choice was micro-layering with CERABIEN™ MiLai (Kuraray Noritake Dental Inc.), a porcelain designed specifically for this approach.

Important steps in the finishing procedure were:

• Characterization of the milled zirconia with colouring liquids
• Pre-treatment of the sandblasted zirconia surfaces with SS Fluoro and Margin porcelain
• Internal staining with CERABIEN™ MiLai internal stains
• Application of CERABIEN™ MiLai luster porcelains

LABORATORY WORKFLOW

Zirconia splinted crowns were designed in full contour with the aid of the Leahu Library featuring tailored tooth designs (part of the Truedental Library available for exocad DentalCAD design software; Fig. 1), cut back merely in the vestibular area using the ‘calma’ reduction option (Fig. 2), and then milled and characterized with colouring liquids to optimize the chroma.

Figure 3 shows the sintered frameworks on the model, Figure 4 the try-in in the patient’s mouth. As the fit and shape of the restorations turned out to be excellent, it was time to plan the internal staining and micro-layering procedure (Figs. 5 and 6), always trying to imitate nature as closely as possible.

The tricky part is to use the available space wisely – the reason why a detailed layering sketch is useful even when in the context of micro-layering. Once the planned layering procedure had been put to practice (Figs. 7 to 10), the surface texture was finalized and the restorations were tried in again for an aesthetic evaluation. Finally, they were cemented with the adhesive resin cement PANAVIA™ V5 (Kuraray Noritake Dental Inc.).

The beautiful treatment outcome is shown in Figure 11.

Fig. 1. Computer-aided design of the zirconia frameworks: Splinted crows displayed in a transparent mode to show the abutment teeth.

Fig. 2. Computer-aided design of the zirconia frameworks: Outer contour of the splinted crowns with a strongly elaborated surface texture and sufficient room for micro-layering.

Fig. 3. Restorations after characterization with colouring liquids and sintering on the model.

Fig. 4. Try-in of the restorations.

Fig. 7. Internal staining – specific characteristics elaborated for a natural depth effect.

Fig. 8. Layering in the cervical and body areas.

Fig. 9. Final layering with luster porcelains to complete the morphology.

Fig. 10. Final restorations after surface finishing and polishing as well as glazing on the model.

Fig. 11. Treatment outcome.

CONCLUSION

The patient was thoroughly satisfied with the treatment outcome and confident that his investment was well worth it. By tailoring my approach to his unique needs, carefully observing his teeth, smile, and facial expressions, and utilizing my extensive knowledge of materials, I was able to achieve this goal successfully.

Nonetheless, I remain committed to continuous improvement by critically evaluating each restoration and seeking areas for enhancement. My dedication to growth, supported by exceptional mentors who share innovative techniques and insights, supports me in staying at the forefront of my field, striving at consistently delivering the best possible care.

I am deeply grateful to Dr. Zinonas Evagorou for invaluable partnership and clinical expertise, which were instrumental in achieving this result.

Case by Dr. Michał Jaczewski

FLOWABLE INJECTION TECHNIQUE

What are the most important properties of a flowable composite used for the flowable injection technique? Personal experience shows that balanced optical properties are essential, with an appropriate translucency, blend-in ability and surface gloss leading the way. However, the mechanical properties are also important, not least because the restorative material will be in direct contact with the antagonist teeth. And finally, handling properties are essential: The right level of flowability is needed for proper injection, while a void-free application is required for an intact, stain-resistant surface.

For the last seven years, CLEARFIL MAJESTY™ ES Flow Low (Kuraray Noritake Dental Inc.) has been my go-to flowable composite for the flowable injection technique. Its level of flowability is ideal for the technique in the anterior and posterior region. Whenever a lower flowability is needed, it is possible to switch to the Super Low variant. Moreover, I like the shade offering, which – together with the superior polishability of the material – leads to natural aesthetics. Finally, its mechanical properties are so good that the product is approved for a wide indication range without load limitations.

When the company announced the introduction of CLEARFIL MAJESTY™ ES Flow Universal, which comes in just two universal shades and two different levels of flowability (Low and Super Low), I immediately decided to give it a try: The prospect of balanced properties I am already familiar with, combined with a simplified shade selection sounded very promising. So far, the new product comes up to my expectations: The following case example reveals the simplicity of the procedure and the beauty of the results. The patient presented during orthodontic (aligner) treatment for a shape correction in the anterior region due to wear of the incisal edge.

Fig. 1. Initial clinical situation: Patient in need of a shape correction in the maxillary incisor region.

Fig. 2. Application of CLEARFIL™ Universal Bond Quick 2 (Kuraray Noritake Dental Inc.) to the enamel of a central incisor, which has been merely roughened by air abrasion with aluminium oxide (50 μm at low pressure) followed by etching with a phosphoric acid etchant.

Fig. 3. Transparent silicon index placed in the mouth and CLEARFIL MAJESTY ES Flow Universal Low (U shade) already injected in the position of the maxillary right central incisor.

Fig. 4. Shape correction on the maxillary right central incisor completed.

Fig. 5. Situation after finishing and polishing of the incisor restorations.

Fig. 6. Nice shade match leading to a smooth blend-in with the surrounding natural tooth structure.

Fig. 7. Immediate treatment outcome supporting an improvement of the smile aesthetics and hence, the patient‘s quality of life during aligner therapy.

RESULTS THAT SPEAK FOR THEMSELVES

Like its related product CLEARFIL MAJESTY ES Flow, the universal-shade version CLEARFIL MAJESTY ES Flow Universal offers properties which are – from a personal perspective – ideal for the flowable injection technique. The shade-matching properties are astonishing; the translucency is quite high when placed in thin layers (so that enamel is very well imitated), and the polishability is as good as that of CLEARFIL MAJESTY ES Flow. For virtually effortless, bubble-free injection, the product comes in a nicely designed syringe. And last but not least, the product’s mechanical properties provide peace of mind even in the posterior region.

Dentist:

MICHAŁ JACZEWSKI

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

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

ABSTRACT

This clinical case report presents a posterior direct composite restoration performed using Kuraray Noritake Dental Inc.’s “Universal Excellence” product concept. A universal adhesive (CLEARFIL™ Universal Bond Quick 2) and a highly filled, universal-shade flowable composite (CLEARFIL MAJESTY™ ES Flow Universal) were utilized to achieve both simplicity and predictability. Step-by-step documentation demonstrates isolation, cavity preparation, deep margin elevation, adhesive protocol, and final restoration.

CASE DESCRIPTION

A 38-year-old female patient presented with complaints of interdental bleeding and cold sensitivity between her maxillary left canine and first premolar (teeth #23 and #24, FDI notation). Clinical examination revealed an open margin and secondary caries at the gingival floor of the existing restoration on tooth #23. After rubber dam isolation, the stepwise treatment procedure was initiated.

CLINICAL PROCEDURE

Step 1. Tooth #23 exhibited an open gingival margin and caries (Fig. 1).

Step 2. After enamel removal, caries was excavated down to the gingival level. The lesion on tooth #24 was observed to extend subgingivally (Fig. 2).

Step 3. After complete caries excavation and cavity refinement, the need for deep margin elevation (DME) on tooth #24 became evident (Fig. 3).

Step 4. Deep margin elevation (DME) was performed on tooth #24 using a custom sectional wedge. First, selective etching and CLEARFIL™ Universal Bond Quick 2 were applied, followed by the placement of CLEARFIL MAJESTY™ ES Flow Universal (Super Low) (Figs. 4 to 6).

Step 5. After completion of the DME (deep margin elevation), appropriate matrix bands were placed, followed by a direct restoration of teeth #23 and #24 with CLEARFIL MAJESTY™ ES Flow Universal (Super Low) (Figs. 7 to 9). Thanks to the material’s easy handling, shade adaptation, and excellent polishability, this challenging DME case was successfully and efficiently managed.

The treatment outcome is shown in Figures 10 and 11.

Fig. 1. Preoperative view under rubber dam isolation.

Fig. 2. Clinical situation after caries excavation.

Fig. 3. Refined cavities with a deep margin on the premolar.

Fig. 4. Custom wedge placed to elevate the margin.

Fig. 5. Buccal view of the teeth after deep margin elevation with universal products.

Fig. 6. Occlusal view of the teeth after deep margin elevation with universal products.

Fig. 7. Placement of a sectional matrix.

Fig. 8. Buccal view of the teeth restored with a universal-shade flowable composite with super low flowability.

Fig. 9. Occlusal view of the teeth restored with a universal-shade flowable composite.

Fig. 10. Occlusal view of the final restorations of teeth #23 and #24, showing colour blending, anatomical form, and surface gloss.

Fig. 11. Buccal view of the final restorations of teeth #23 and #24, showing colour blending, anatomical form, and surface gloss.

DISCUSSION

Universal adhesives and modern flowable composites simplify posterior direct restorations by reducing technique sensitivity while providing for durable outcomes. In this case, CLEARFIL™ Universal Bond Quick 2 provided strong adhesion with minimal application time. The universal flowable composite demonstrated excellent adaptability, polishability, and durability. Even with a subgingival margin requiring DME, a streamlined approach was achieved without compromising quality.

CONCLUSION

The combination of CLEARFIL™ Universal Bond Quick 2 and CLEARFIL MAJESTY™ ES Flow Universal allows clinicians to perform predictable, efficient posterior restorations. Their universal applicability and handling properties align with the “Universal Excellence” concept, supporting simplified, yet reliable daily practice.

Ethics & Disclosure

All procedures were performed in accordance with standard dental practice. The patient provided informed consent for treatment and publication of anonymized clinical images. Author collaborates with Kuraray Noritake Dental Inc. as an advisor; content reflects clinical experience.

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

For zirconia-based screw-retained implant-supported prostheses, diverse finishing concepts are available. Most of them are quite complex and time-consuming. A streamlined approach that brings efficiency into the finishing procedure without compromising aesthetics and function is micro-layering with CERABIEN™ MiLai (Kuraray Noritake Dental Inc.) on a zirconia superstructure with just a slight vestibular cutback. A possible technical procedure is demonstrated using the following case example. The patient was treated by prosthodontist Dr. Georgios Siavikis from Ioannina, Greece.

Fig. 1. Occlusal view of an implant-supported overdenture made of KATANA™ Zirconia HTML PLUS (Kuraray Noritake Dental Inc.) for a male patient with an edentulous maxilla and a removable partial denture in the mandible.

Fig. 2. Frontal view of the milled and sintered screw-retained implant-supported prosthesis.

Fig. 3. Appearance after the application of CERABIEN™ MiLai SS Fluoro and internal stains to enhance the natural shading of the restoration in the tooth and gum areas.

Fig. 4. Result of micro-layering with CERABIEN™ MiLai porcelains LT1 for the cervical as well as E2 and TX for the middle and incisal sections for a seamless gradient in translucency. For an optimal gingival harmony and match with the surrounding tissue, the tissue shades 1, 5 and 6 were applied.

Fig. 5. The restoration after finishing.

Fig. 6. The gingiva and tooth areas have a natural appearance …

Fig. 7. … due to a natural colour, translucency and surface texture.

Fig. 8. Intraoral harmony.

PREDICTABLE OUTCOMES

In this case, the use of an aesthetic, high-strength multi-layered zirconia was a true enabler of a streamlined finishing technique. As a convinced and frequent user of CERABIEN™ ZR, micro-layering with CERABIEN™ MiLai appeared to work flawlessly right from the start. The systems are perfectly aligned to each other, and as they are both based on synthetic feldspathic technology, they offer consistent material properties. These provide precise control over the layering and shading, thus supporting a highly aesthetic and well-integrated implant restoration.

Case by MDT Andreas Chatzimpatzakis and DDS Manousos Pissadakis

ONE SOLUTION, MULTIPLE NEEDS COVERED

The treatment of young patients with a dental condition that affects the appearance of multiple teeth – like enamel hypomineralisation or hyperplasia – is particularly challenging for the restorative team. Dental practitioners and technicians need to be aware of the fact that the condition often involves a life-long disease burden, which typically goes hand in hand with an immense treatment need and increasingly invasive measures required with advancing age. It is their task to make the situation as bearable as possible for patients by delivering treatment that is very well aligned to their specific aesthetic, functional and financial needs, both in the short and long term.

Whenever all-ceramic restorations seem most appropriate, material and technique selection are particularly important: Protection of the affected teeth from extrinsic influences, the saving of sound tooth structure and the safeguarding of the long-term stability of the restorations are key to success. Depending on the aesthetic expectations of the patient, veneers made of zirconia or lithium disilicate, produced with a minimal vestibular cutback and finished using the micro-layering technique, are a great option. A prime example of an innovative porcelain system specifically developed for this technique is CERABIEN™ MiLai (Kuraray Noritake Dental Inc.). It includes a collection of internal stains and porcelains that fire at just 740 °C. With this low firing temperature and a coefficient of thermal expansion between 9.5~11.0×10-6/K (50 °C – 500 °C), this product is ideal for use with lithium disilicate and zirconia. In addition, it offers impressive aesthetic capabilities: Depending on the specific needs of each case, users can adjust the level of complexity and number of bakes.

CASE EXAMPLE

In the present case of a young female patient with hypomineralisation, it was decided to follow a straightforward approach to restore the maxillary teeth for the time being. For this purpose, we produced a wax-up and transferred it into the patient’s mouth in the form of a mock-up. Following guided tooth structure removal trough this mock-up, an impression was taken. The restorations were designed in full contour, pressed using lithium disilicate-based press ingots (Amber® Press LTW3, HASS Corp.) and cut back slightly in the vestibular area (reduction: 0.3 mm). The selected micro-layering system was applied according to the internal stain technique. The following CERABIEN™ MiLai Internal Stains were used: A little Red in the cervical, and Mamelon 2, Incisal Blue 1 and White in the incisal third. What followed was build-up with CERABIEN™ MiLai Porcelains Tx incisally and LTx proximally; some whitish lines were created with Value Liner 1. Then, I applied a mixture of E2 and ELT1 in the middle and LT1 in the cervical area. After the bake, the restorations were treated with green stones, sandpaper and rubber wheels to pre polish the surface. After glazing with CERABIEN™ ZR FC Paste Stain Clear Glaze, final polishing was carried out.

The whole treatment procedure including tooth preparation, shade determination, veneer production and adhesive cementation is illustrated below.

Fig. 1. Portrait of the patient prior to treatment.

Fig. 2. Enamel defects in the maxilla and mandible.

Fig. 3. Initial clinical situation in the maxilla with whitish-brown discolouration and composite restorations in need of replacement.

Fig. 4. Mock-up in the patient’s mouth.

Fig. 5. Labial reduction through the mock-up: The depth of tooth preparation is controlled by using a depth guide and by marking the created depth grooves with a colour marker.

Fig. 6. Silicon index used to check the space created for the veneers.

Fig. 7. Prepared teeth ready for impression taking and temporization.

Fig. 8. Shade determination for the veneers.

Fig. 9. Pressed lithium-disilicate restorations on the model.

Fig. 10. Appearance of the restorations after internal staining.

Fig. 11. Appearance of the teeth after build-up with CERABIEN™ MiLai Porcelain.

Fig. 12. Final restorations on the model.

Fig. 13. Adhesive cementation procedure carried out for two teeth at once: Isolated teeth and a perfectly dry working field.

Fig. 14. Etching of the tooth structure with phosphoric etchant (K-ETCHANT Syringe, Kuraray Noritake Dental Inc.).

Fig. 15. PANAVIA™ V5 Tooth Primer (Kuraray Noritake Dental Inc.) applied to the etched tooth surfaces.

Fig. 16. Veneers – pre-treated with hydrofluoric acid and CLEARFIL™ Ceramic Primer Plus – filled with PANAVIA™ V5 Paste (Both from Kuraray Noritake Dental Inc.) and placed in the patient’s mouth.

Fig. 17. Restorations after excess removal.

Fig. 18. All eight restorations in place.

Fig. 19. Treatment outcome after two weeks.

Fig. 20. Portrait of the patient taken two weeks after treatment.

CONCLUSION

Repeated dental treatment, increasing invasiveness of the measures, often resulting in early tooth loss: To break the vicious cycle in young patients with enamel defects, it is important to carefully evaluate the treatment need and select the appropriate solutions. As dental technicians, we can contribute to long-term treatment success by using high quality materials and production techniques that allow us to create restorations that last.

The presented material combination and the micro-layering technique are very well suited as they offer the required mechanical and optical properties for high aesthetics and durability. Plus, the risk of complications is low due to the high biocompatibility and the layer of porcelain limited to non-load-bearing areas.

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.

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.

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.

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.

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.

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.