Interview with Dr. Michał Jaczewski

The flowable injection technique is becoming a popular technique used to aesthetically restore multiple teeth with flowable composite. A renowned instructor who teaches dental practitioners the skills needed to use the technique successfully is Michał Jaczewski. He graduated from Wroclaw Medical University (Poland) in 2006 and runs his own private practice in the city of Legnica since 2011. He is the founder of the Biofunctional School of Occlusion, which conducts trainings in the field of comprehensive dental treatments, and is passionate about aesthetic digital dentistry. At the International Dental Show 2023 in Cologne, he showed us when, why and how he uses flowable injection in his dental office.

Could you please describe the technique in a few words?

The flowable injection technique is a simple, predictable, repeatable way to restore teeth using flowable composite. It is based on a wax-up, over which a silicone index is produced. This index then serves as the key for the injection of the flowable composite, which is light-cured through the transparent silicone. The most important benefit is that this technique works without or in some cases with a very minimal tooth preparation. It is a minimally invasive technique that can be used by beginners and by experienced dentists. Using a composite with a well-balanced opacity in a thickness of 0.3 mm and a special polishing protocol, it is possible to achieve excellent morphological and optical outcomes.

When did you start using the flowable injection technique and what are its major indications?

I started using the technique in 2018. It was originally invented to restore anterior teeth, but nowadays, it is successfully used in the posterior region as well. To my mind, it is particularly useful whenever the shape of multiple teeth needs to be corrected to improve a patient’s smile, no matter whether young or old. This may be the case after orthodontic treatment. The teeth are simply aligned and then restored to the perfect shape using this non-invasive technique. I also use flowable injection for a smile makeover, to restore worn teeth and to change the vertical dimension of occlusion in the context of full-mouth reconstructions. In the latter case, the restoration may be temporary and used for a mid- to long-term “test drive”. However, it can also serve as the final restoration.

How do you start when planning to restore a patient’s teeth with the flowable injection technique?

The most important phase heavily influencing the success of this technique is the planning phase. It consists of documentation, impression taking and the creation of a wax-up and mock-up as well as the production of the silicone index. You can of course work in the traditional way with a silicone impression and conventional wax-up, but the use of digital technologies in this phase will improve your workflow significantly. I usually start with photo and video documentation and a digital impression. Records of the centric relation and occlusion are needed as well. Then, a virtual wax-up is created using digital smile design software. In this step, it is important to take into account the facial characteristics of the patient, a task that is best accomplished using the facial flow concept. Based on the resulting design, a virtual treatment outcome can be displayed and discussed with the patient. Once approved, the model with wax-up is printed in different versions: the full wax-up model and an “interlip model” with an alternating design – one tooth with wax-up followed by one tooth without. These models are used to produce the required indexes made of transparent silicone.

Digital Smile Design: Patient with severe tooth wear.

Virtual wax-up displayed in the patient’s mouth.

Models printed on the basis of the virtual mock-up.

Silicone index produced on the alternating (interlip) model.

When and why do you produce more than one silicone index?

It is particularly useful to work with the complete and the alternating (partial) silicone index when planning to restore all teeth in the maxilla. Starting with the alternating index gives me additional stability and lays the foundation for a precise outcome especially with regard to the planned occlusal height. In the lower jaw, where the handling of the index and the composite is more difficult due to the presence of saliva and moving soft tissues, I always recommend to divide the working field into three sections – one anterior and two posterior regions – and work on them separately.

How do you prepare the teeth and inject the flowable composite?

In most cases, all we need is a roughening of the enamel surfaces for the bonding procedure, which is usually possible by air abrasion with aluminum oxide (50 μm at low pressure). Then, the enamel is etched with phosphoric acid etchant and a universal bonding agent is applied. The silicone index is equipped with an injection hole on the incisal edge. This is easily accomplished with the cannula of the flowable composite syringe pressed through the material from the inside to the outside. In the posterior region, it may be useful to utilize a harder material and integrate two holes for each tooth on separate cusps – one for the injection and one for the outward flow. On a hard index, a diamond bur is needed for this procedure. I place the index, inject the flowable composite from the bottom to the top, light-cure the material shortly and remove the index. Final polymerization is carried out after index removal and the application of a layer of glycerin gel. Once the excess material is removed and the proximal part of the restoration is finished perfectly, the procedure is repeated for the other teeth before the restorations are polished.

Do you have any favourite products for the technique?

For the silicone index, I use EXACLEAR (GC), as it is the most transparent silicone available on the market. My favourite composite for the flowable injection technique is CLEARFIL MAJESTY™ ES Flow of low viscosity (Kuraray Noritake Dental Inc.). In my dental office and during my courses, I had the chance to test a lot of different products. In this context, I found that the material from Kuraray Noritake Dental offers a few advantages. It is a modern type of nano composite with a wide range of indications and a large shade offering. With its three viscosities, it can be used in many different clinical situations. I started using it five years ago and for the flowable injection technique, the Low variant is my first choice, as it is the most universal one suitable for anterior and posterior teeth. The most decisive advantages that influenced my decision to use it are its natural aesthetics and superior polishability. You can achieve a spectacular effect without any special skills. As a bonding agent, I prefer to use CLEARFIL™ Universal Bond Quick, which makes my workflow even easier, faster and more predictable. For polishing, I have developed my own protocol.

How do you finish and polish your restorations?

I start in the proximal area with polishing strips and sometimes a proximal saw. For shape adjustments, three different diamond and carbide burs have proven their worth. Subsequently, I proceed with fine or extra fine Sof-Lex™ Finishing and Polishing Discs (3M) used for contouring and finishing and rubber polishers TWIST DIA™ for Composite (Kuraray Noritake Dental Inc.), which already create a nice, natural surface gloss with low effort. Then, a wheel brush made of goat hair is used with diamond polishing paste (Diamond excel, FGM) and finally, I use a cotton wheel along with an aluminum oxide polishing paste (Pasta Grigia II, anaxDENT). In this way, it is possible to create a mirror finish.

Etching of the enamel with phosphoric acid etchant.

Complete silicone index in place.

Application of CLEARFIL™ Universal Bond Quick.

Situation immediately after the injection of CLEARFIL MAJESTY™ ES Flow (Low), light curing and removal of the silicone index.

Proximal adjustments with rotating instruments.

What are the biggest benefits of the flowable injection technique?

For patients and dental practitioners, the biggest advantages are savings in time and money. Many patients cannot afford ceramic veneers, and they are extremely happy to be offered a high-quality alternative that can be delivered in a single appointment. The procedure is prepless and the restorations can easily be repaired or the colour changed if they wish, so that there is virtually no risk involved in the treatment. Dental practitioners are usually able to start treating patients after they have attended a single course. While practicing makes them perfect, the first results are often already quite impressive, so that there is no huge investment involved for beginners – neither in time nor in new materials. Of course, you can invest lots of time in the finishing and polishing procedure, but I am sure you will find the right balance between effort and outcome.

Set of instruments for the flowable injection technique.

Do you have any recommendation of how to start using the technique?

First of all, I would like to encourage everyone to leave their comfort zone and try something new on a regular basis. For me, starting to work with the flowable injection technique was a real gamechanger, and I would never want to work without it again. Before starting to use the technique, I would definitely attend a course that teaches you all the theoretical knowledge needed for a successful first case, and maybe even a practical workshop.

Michał Jaczewski during his presentation at the Kuraray Noritake Dental booth in Cologne.

For further insights and resources on the Flowable Injection Technique, we invite you to explore additional materials available. Dive deeper into this innovative approach, check out another clinical case using Flowable Injection Technique, as demonstrated by Dr. Michał Jaczewski. Additionally, read the expert advise on how to avoid air bubbles in the composite restorations! These valuable tips will enhance your understanding and application of the technique.

Article by Dr. Bassem Jaidane

Among the most common problems in modern dentistry is that of restoring a patient‘s lost aesthetic dental appearance. To do this, new technologies are available to practitioners. For anterior teeth where aesthetics are paramount, dentists prefer the least invasive treatments possible, such as layered dental veneers (cut-back). In cosmetic dentistry, practitioners are often faced with cases requiring a multidisciplinary treatment plan or different types of restorative materials to be used at the same time. For cases of prosthetic restoration combining dental veneers, dental crowns and dental bridges, dentists are often faced with situations where the difference in shade is noticeable in the final result, this is explained by the difference in restorative material, product, adhesion technique, the thickness of the prosthetic element and the colour of the abutment, whether it is a living natural tooth, devitalized, or even an implant abutment^1-2.

In the presence of a treatment plan requiring dental veneers, crowns and dental bridges, choosing zirconia as the only restorative material is no longer an option but an obligation. The is due to the limited mechanical properties of lithium disilicate and feldspar porcelain restorations, which contraindicate their use as dental bridges. There are different factors explaining the reluctance of practitioners to use the zirconia dental veneer technique³: One is the absence of the vitreous phase. It makes impossible to create an optimal adhesion surface with hydrofluoric acid at the level of the intaglio of the zirconia veneers. Another is the lack of translucency of the first zirconia generations.

Modern zirconia materials, however, are particularly well-suited for cases requiring a combination of veneers, crowns and dental bridges of the same optical appearance. This is due to their increased translucency and excellent mechanical properties. The following article describes and discusses the realization of a clinical case treated with dental veneers and a crown using KATANA™ Zirconia UTML (Kuraray Noritake Dental Inc.). the veneers were placed with PANAVIA™ Veneer LC (Kuraray Noritake Dental Inc.). The patient presented an aesthetic problem at the level of an anterior implant-supported crown.

CASE OBSERVATION

Patient S, from the Tunisian Sahel, engineer in France, with no significant pathological history and aged 29, presented in January 2023 due to an aesthetic problem negatively affecting her smile. The extraoral examination was without abnormalities, while the intraoral examination showed good oral hygiene, healthy gums, a thin free gingiva and a protruded zirconia crown on an implant in the region of the maxillary right central incisor (figs 1 and 2).

Fig. 1. Initial clinical situation.

Fig. 2. Occlusal view revealing the volume and position of the crown on the central incisor.

During the preliminary interview, it turned out that the implant in the region of the right central incisor had been placed in 2020. The patient’s former dentist had left Tunisian territory. The patient does not have any document or reference on the dental implant, and she wishes to “straighten” the crown and improve the aesthetics of her smile before her planned wedding ten days after her first consultation.

TREATMENT PLAN

After having had the informed consent of the patient and after having asked the indication of dental veneers for aesthetic reasons, the treatment was initiated. According to the treatment plan, seven maxillary anterior teeth (from first premolar to first premolar) should receive an incisal overlap preparation (depth: 0.1 to 0.3 mm) for the placement of veneers made of KATANA™ Zirconia UTML. For the implant in the region of the right central incisor, it was planned to replace the existing crown by a crown made of KATANA™ Zirconia UTML without replacing the abutment. This was due to the lack of information about the implant type and the lack of time.

TREATMENT

After taking the preoperative photos (fig 3), choosing the color of the veneers and anesthetizing the maxillary anterior region, the incisal overlap preparation was carried out on the seven maxillary teeth and the zirconia crown was removed from the implant. A cylindrical diamond bur was used to separate the zirconia part from the abutment. Subsequently, a bite record and impressions were taken using the wash technique. In addition, a temporary crown was produced and placed on the abutment.

Fig. 3. Preoperative picture.

In the dental laboratory, virtual models were created based on the conventional impressions (fig. 4). Then, the zirconia restorations were designed in full contour, cut back for the veneering porcelain and finished by layering with CERABIEN™ ZR porcelain (Kuraray Noritake Dental Inc.). At try-in during the second session, we checked the insertion, the gingival margins, and the contact points between the veneers and the crown on the implant. Given the superior mechanical properties of the zirconia veneer, the shape and thickness of the veneers were modified chairside to have a harmonious anterior curve and a better aesthetic rendering. After determining the colour of the resin cement, the temporary crown was put back in place.

Fig. 4. Virtual model.

After glazing and preparation of the bonding surfaces in the dental laboratory, the upper veneers were cemented according to the PANAVIA™ Veneer LC protocol. We ended the session by removing excess cement. An occlusion check and postoperative photos were taken after three days.

DISCUSSION

In this case, the dental veneers and the crown on the implant were produced using a KATANA™ Zirconia UTML disc. This type of zirconia has an yttrium oxide proportion of 5 mol%, leading to about 70 % cubic zirconia phase, and therefore a higher translucency than earlier generations of zirconia. With a translucency of 51 % (light transmission, illuminant: D65, specimen thickness: 1.0 mm. Source: Kuraray Noritake Dental Inc); this zirconia allows us to have remarkable optical properties (fig 5).

Fig. 5. Remarkable optical properties of the final restorations.

The patient chose color BL1 and requested a transparent incisal edge. For this reason, a cutback design of the zirconia (fig. 6) and porcelain layering was the technique of choice. Figure 7 shows the slight transparency in the incisal edge region of the new restorations. The zirconia veneers technique was chosen to avoid the color difference between the crown on the implant and the veneers. The pleasant aesthetic appearance and a harmonious smile are confirmed by the post-operative picture (fig 8). According to the manufacturer, the flexural strength of KATANA™ Zirconia UTML is 557 MPa, which is higher than that of lithium disilicate and feldspathic porcelains. As zirconia veneers will be more resistant to shear forces, it is possible to eliminate contact points that interfere during try-in or even safely modify the shape of the restorations in vivo. This is done with specific burs adapted to zirconia during different stages of the fittings according to the wishes of the patient⁴.

Fig. 6. Cutback design of the restorations.

Fig. 7. Slight transparency at the incisal edges of the restorations.

Fig. 8. Immediate post-operative picture.

In the present case, we were able to adjust the crown until we had a perfect anterior line. It was thus possible to optimize the inclination of the crown without replacing the dental implant, in just one week.

Given the significant shear resistance, the dental laboratory technician made zirconia dental veneers with an average thickness of 0.3 mm. Such a thin veneer requires less preparation of the dental tissue, which will be limited to enamel instead of extending into the dentin, where the adhesion value is lower due to its low chemical composition in minerals⁵.

The expected difficulty in bonding zirconia veneers is explained by the absence of a vitreous phase given the poor adhesion of the crystalline phase to the bonding cement. However, the desired surface modification can be achieved with a different procedure: tribochemical silica coating. It was used in the present case to improve the adhesion of the zirconia veneers to the resin cement system. Indeed, it was found in an in-vitro evaluation that the tribochemical preparation technique and the application of MDP provide an optimized adhesive interface⁶. In this study, dual-beam focused ion-beam technology followed by scanning electron microscopy were used to compare the resin/zirconia bonding interface with tribochemical preparation/MDP and the bonding interface between resin/zirconia without this preparation.

The tribochemical process consists of an aero-abrasion of the zirconia surface with particles coated with silica combined with a silane primer containing MDP. The phosphate ester groups of this silane bind to the surface oxides of the zirconia, and the methacrylate group makes covalent bonds with the resin matrix of the PANAVIA™ Veneer LC cement⁷.

In the present clinical cases, the KATANA™ Zirconia UTML veneers were abraded with silicon dioxide with the formula SiO2. As a primer, we chose CLEARFIL™ CERAMIC PRIMER PLUS (Kuraray Noritake Dental Inc.), because it contains the original MDP monomer, developed Kuraray Co., Ltd.⁸.

To clean the veneers before applying CLEARFIL™ CERAMIC PRIMER PLUS, KATANA™ Cleaner (Kuraray Noritake Dental Inc.) was used. The presence of saliva and residues from fittings can alter the interface with the resin cement, which presents a risk of bonding failure of Zirconia veneers⁹.

One of the most important challenges in this case was to be able to hide the greyish color of the implant abutment which was visible through the zirconia crown. To hide the gray of the abutment, a resin opaker was applied. These techniques combined with the PANAVIA™ Veneer LC white gave us an optimal result (figs. 9 and 10)¹⁰.

Fig. 9. Treatment outcome.

Fig. 10. New smile designed according to the individual desires of the patient.

CONCLUSION

KATANA™ Zirconia UTML veneers have better mechanical properties than conventional veneers, so that the zirconia veneers technique allows users to combine bridges, crowns and dental veneers without a noticeable difference in shade. It offers acceptable translucency and aesthetics according to our observation. The technique of bonding the zirconia veneers with PANAVIA™ Veneer LC combined with a tribochemical treatment and the application of MDP on the adhesion surfaces allowed for a secure bonding, while the dyschromia caused by the implant abutment was effectively concealed.

Dentist:

DR. BASSEM JAIDANE

Born in Sousse, Tunisia, on June 12, 1983, Dr. Bassem Jaidane obtained his Doctorate in Dental Medicine in 2010 at the Faculty of Monastir. He opened his own clinic in 2010, specializing in aesthetics and dental implants, as well as dental veneers. Omni-patrician and passionate about all areas of dentistry, he has also developed advanced knowledge in dental prosthetics: 3D design, ceramic layering, finishing and glazing of crowns, bridges and veneers…

Dr. Bassem Jaidane has therefore acquired a certain expertise on the different types of dental veneers, whether pressed ceramic veneers, machined veneers, layereded veneers with the cut-back technique and lumineers veneers, after having carried out numerous cases. in feldspathic and lithium disilicate veneers, Dr. Bassem Jaidane has become one of the pioneers of the technique of dental veneers on zirconia.

References

1. Restaurations esthétiques grâce à la technique du cut-back Par Fleur Nadal, Geoffrey Di Bacco, Julien Chesnot Publié le 01.06.2019. Paru dans L‘Information Dentaire n°23 – 12 juin 2019 (page 28-29).
2. Effects of ceramic layer thickness, cement color, and abutment tooth color on color reproduction of feldspathic veneers Christopher Igiel, Michael Weyhrauch, Barbara Mayer, Herbert Scheller, Karl Martin Lehmann PMID: 29379907 Int J Esthet Dent 2018;13(1):110-119.
3. Influence of Air-Particle Deposition Protocols on the Surface Topography and Adhesion of Resin Cement to Zirconia. Acta Odontol: Sarmento, H.R.; Campos, F.; Sousa, R.S.; Machado, J.P.B.; Souza, R.O.A.; Bottino, M.A.; Ozcan, M: Acta Odontol Scand . 2014 Jul;72(5):346-53.doi: 10.3109/00016357.2013.837958. Epub 2013 Oct 31.
4. Comparison of the Mechanical Properties of Translucent Zirconia and Lithium Disilicate:Kwon, S.J.; Lawson, N.C.; McLaren, E.E.; Nejat, A.H.; Burgess, J.O. J.Prosthet:: J Prosthet Dent . 2018 Jul;120(1):132-137. doi: 10.1016/j.prosdent.2017.08.004. Epub 2018 Jan 6.
5. The Success of Dental Veneers According To Preparation Design and Material Type:Yousef Alothman, Maryam Saleh Bamasoud: Open Access Maced J Med Sci. 2018 Dec 14;6(12):2402-408.doi:10.3889/oamjms.2018.353. eCollection 2018 Dec 20.
6. The Effect of Resin Bonding on Long-Term Success of High-Strength Ceramics: Blatz, M.B.; Vonderheide, M.; Conejo, J: J Dent Res 2018 Feb;97(2):132-139. doi: 10.1177/0022034517729134. Epub 2017 Sep 6.
7. Ultra-thin monolithic zirconia veneers: reality or future? Report of a clinical case and one-year follow-up: Rodrigo Othávio Assunção Souza, Fernanda Pinheiro Barbosa, Gabriela Monteiro de Araújo, Eduardo Miyashita, Marco Antonio Bottino, Renata Marques de Melo, and Yu Zhang :Oper Dent :2018 ;43(1) :3_11.doi :10.234/16-350-T.
8. Functional monomer impurity affects adhesive performance :Kumiko Yoshihara 1 , Noriyuki Nagaoka, Takumi Okihara , Manabu Kuroboshi, Satoshi Hayakawa, Yukinori Maruo, Goro Nishigawa, Jan De Munck, Yasuhiro Yoshida, Bart Van Meerbeek : Dent Mater : 2015 Dec;31(12):1493-501.doi: 10.1016/j.dental.2015.09.019. Epub 2015 Oct 28.
9. Effect of decontamination materials on bond strength of saliva-contaminated CAD/CAM resin block and dentin Kei Takahashi, Tomohiro Yoshiyama, Akihito Yokoyama, Yasushi Shimada, Masahiro Yoshiyama : Dent Mater J 2022 Jul 30;41(4):601-607. doi: 10.4012/dmj.2021-268. Epub 2022 Apr 13.
10. Masking ability of implant abutment substrates by using different ceramic restorative systems Pablo Machado Soares , Ana Carolina Cadore-Rodrigues , Maria Gabriela Packaeser , Atais Bacchi , Luiz Felipe Valandro , Gabriel Kalil Rocha Pereira , Marília Pivetta Rippe J Prosthet Dent 2022 Sep;128(3):496.e1-496.e8. doi: 10.1016/j.prosdent.2022.05.010. Epub 2022 Aug 16. Affiliations PMID: 35985853 DOI: 10.1016/j.prosdent.2022.05.010.

DENTAL ADVISOR Editor’s Choice and 2023 Preferred Product award recipient, quickly provides durable bond in a single procedure

CLEARFIL™ Universal Bond Quick has been named a 2023 Editor’s Choice by DENTAL ADVISOR, which evaluates dental products and equipment and publishes its findings annually. It has also received recognition as DENTAL ADVISOR’s Preferred Product this year in the category of Universal Bonding Agents. The 31 consultants who evaluated its application during 1,065 usages gave it the excellent overall rating of 98%.

CLEARFIL™ Universal Bond Quick is a single-bottle fluoride-releasing, universal adhesive with MDP monomer and amide monomer chemistry called rapid bond technology. This combination of the MDP monomer, which creates a strong chemical bond to hydroxyapatite, and newly developed hydrophilic amide monomer, which is highly hydrophilic, is responsible for fast chemical bonding and quick penetration into dental tissue. Because the amide monomer rapidly permeates dentin and enamel, it eliminates the need for long rubbing application of the adhesive into the dentin and reduces the wait time after application. After curing, the innovative amide monomer forms a moisture-resistant cross-linked polymer network.

As a result, the bonding is moisture-resistant and stable, with durable results. This method, which reduces application time without compromising bond strengths, sealing, or desensitizing, also reduces technique sensitivity.

A fast and versatile agent that bonds directly to dentin, enamel, metals, zirconia and lithium disilicate restorative materials, CLEARFIL™ Universal Bond Quick is suitable for bonding direct and indirect restoration and can be used for total-etch, selective-etch, or self-etch methods. When mixed with CLEARFIL™ DC Activator, CLEARFIL™ Universal Bond Quick becomes dual-cure and has universal use with both self- and dual-cured resin cements and core build-up resins. 

The practitioners evaluating the product commented on its ease in dispensing and placement, viscosity, suitability for all bonding procedures, and convenience. Among their remarks were: “Perfect viscosity. Ease of use and speed were great.” and “Great for replacement of silane to prime crowns for cementation with resin cement - will self-cure with the dual-cured resin.”

Honors such as Editor’s Choice that are conferred by US-based DENTAL ADVISOR were introduced to help busy practitioners make sense of the numerous new solutions indicated for less invasive techniques, standardized or simplified procedures, and better outcomes on a regular basis. DENTAL ADVISOR conducts its practice-based clinical evaluations and product performance tests shortly after product launch, and publishes results annually online to help potential users identify high-quality new dental materials and determine which among them are best suited to fulfill their individual requirements.

A pioneer in digital dental photography, the editor-in-chief of the “International Journal of Esthetic Dentistry” and a supporter of universal products: We are talking about Dr Alessandro Devigus, the owner of a private practice in Bülach, Switzerland. At the International Dental Show 2023 in Cologne, we had a conversation with him about his favourite products from Kuraray Noritake Dental Inc. and the concept of universal excellence.

Dr Adham Elsayed, Clinical and Scientific Manager at Kuraray Noritake Dental Inc., interviewing Dr Alessandro Devigus.

Dr Devigus, why did universal products attract your attention?

We all would like to reduce the number of products and components used in our dental offices to make our lives easier and more predictable. Several years ago, when the first universal products started entering the dental market, I realized that these products and the concept behind them are able to help me achieve this goal.

For what kinds of treatments do you currently use universal products?

The main field of application is restorative dentistry, in indirect and direct restorative workflows, which often go hand in hand. Whenever possible and in accordance with the needs and desires of the patient, I opt for minimally invasive direct composite restorations, often realized using universal products. Cosmetic corrections or tooth wear treatments in the lower jaw, for example, are often carried out in a prepless procedure with resin composite applied with a single-shade technique. For anterior restorations in the upper jaw of the same patient, however, I might opt for ceramic restorations, luted with a universal resin cement.

What are your favourite indirect restorative materials, for which indications do you use them and when do universal products come into play?

I produce most of my single-tooth restorations chairside with CEREC. In the anterior region, the choice is usually between different types of glass ceramic materials. In some indications, when two central incisors or all four maxillary incisors need to be restored, zirconia is also a suitable option. In these cases and for indirect restorations in the posterior region, KATANA™ Zirconia Block is my preferred material. Having tested many different types of chairside zirconia, I can say that this product simply offers the most natural colour gradation and the desired vitality. Hence, finishing is quick and easy. At the same time, the high flexural strength of the material supports me in my striving for minimally invasive preparations. For definitive placement of the produced overlays and crowns, PANAVIA™ SA Cement Universal from Kuraray Noritake Dental Inc. is my dual-cure resin cement of choice. It bonds to virtually every surface including lithium disilicate without a separate primer and offers a good flowability that facilitates restoration placement. An additional feature contributing to a quick and stress-free clinical procedure is its easy and gingiva-friendly excess removal after tack curing.

What about direct restorations?

One of my favourite resin composites is CLEARFIL MAJESTY™ ES-2 Universal (Kuraray Noritake Dental Inc.). Its single shade for the posterior and two shades for the anterior region offer just the right combination of translucency and intrinsic colour to imitate a large number of tooth shades. The effect is that it blends in nicely with the surrounding tooth structure without appearing grayish. In the posterior region, I was able to observe a certain masking potential, so that discoloured abutment teeth do not cause any problems. With this material, the shade determination step is eliminated. Clinical workflows are also simplified by the use of CLEARFIL™ Universal Bond Quick. The universal adhesive is not only versatile as it is suitable for many indications and all etching techniques, but also extraordinarily quick in its application, as the need for an extensive rubbing into the tooth structure is eliminated. In this way, it is possible to streamline direct restorative procedures.

Why do you use so many products from Kuraray Noritake Dental Inc.?

I simply like products from Japanese companies. They stand for quality, integrity and clinical relevance. Japanese people seem to be deeply committed to the company they work for and to their work, pay attention to every detail and try to deliver the best outcomes possible. This attitude is reflected in Kuraray’s mission “For people and the planet—to achieve what no one else can.”, and it is reflected in the products of the company as well. They offer the properties I need to deliver high-quality dental treatments.

You said that making your life easier and more predictable is the main reason for you to opt for universal materials. Please explain.

In the first place, using fewer products and components that are easy and quick in their application allows me to get a grip on costs. With fewer steps and fewer bottles, shortened application times and standardized workflows, the time a patient needs to sit in the chair is reduced, which allows me to save the most valuable factor in the office: my time. At the same time, material storage and order management are streamlined, so that it is much easier to keep track of dates of expiry, hence saving material costs as well. And the best thing about it is that all these savings are possible without compromising treatment quality. Provided that the user is able to handle the materials properly – which is facilitated by the minimal number of steps and ease of use – the quality of the outcomes is extremely high!

Dr Devigus, we thank you for sharing your insights with us.

Article by Michael Braian DDS, CDT, PHD

Digital advancements revolutionized dentistry, providing efficient, precise dental care¹. Intraoral scanners replace traditional impressions, enabling virtual models for procedures like implant placement, orthodontics, and prosthodontics². Scan bodies aid in digitizing implants, while CAD/CAM improves prosthesis design and fabrication³. Milling and 3D printing offer speed, accuracy, and complexity in creating dental prostheses⁴. These innovations promise a bright future for dental professionals and patients.

The integration of digital technologies in dentistry has brought about significant advancements in dental care1. This case study presents a comprehensive dental rehabilitation of a patient utilizing a digital workflow, including extraction, dentures, implant surgery, intraoral scanning, 3D printed try-ins, and the fabrication of the final monolithic prosthetic construction.

EXTRACTION OF SEVERELY DECAYED TEETH

The first step in the patient‘s dental rehabilitation involved the extraction of severely decayed teeth. This procedure was necessary to eliminate the source of infection and discomfort and to prepare the oral cavity for the subsequent steps in the rehabilitation process. The dentures are later used to simplify the guided surgery planning⁵. Following the extraction, the patient was provided with appropriate postoperative care instructions and a healing period was allowed before proceeding with the next steps (Fig.1).

Fig. 1. Severely decayed teeth prior to extraction.

DENTURES DURING THE HEALING PERIOD

During the healing period of approximately seven months, the patient was fitted with dentures to replace the extracted teeth. This temporary solution allowed the patient to maintain oral function, appearance, and confidence while the extraction sites healed, and the oral tissues prepared for the implant surgery⁶.

IMPLANT SURGERY

In the upper jaw, six implants were placed, while only four were placed in the lower jaw (Fig.2). This decision was based on the patient‘s individual needs and oral anatomy. Studies have shown that the number of implants required for optimal support and stability depends on various factors, including bone quality and quantity, implant position, and prosthesis design⁷. Research suggests that six implants in the upper jaw and four in the lower jaw are sufficient to provide adequate support for a full-arch fixed prosthesis, with high success rates and patient satisfaction reported⁷. Additionally, placing fewer implants can help reduce surgical time and cost, as well as minimize the risk of complications associated with multiple implant placements. Therefore, this approach was deemed appropriate for this particular patient‘s case.

2023 DENTAL ADVISOR Top Product is an everyday cement that eliminates the need for a separate primer

PANAVIA™ SA Cement Universal adheres to virtually all substrates, including lithium disilicate, in a single procedure without the need for a separate primer or silane, and it also offers easy, gingival-friendly removal of excess cement and requires no refrigeration. Therefore it is no wonder that this year DENTAL ADVISOR gave PANAVIA™ SA Cement Universal Top Product award in the category of Indirect Restoratives.

What makes its strong and durable bond possible without the added step of applying a separate substrate is that PANAVIA™ SA Cement Universal combines two innovative technologies in a single product. The silane coupling agent, LCSi monomer, establishes a durable, chemical bond with porcelain, lithium disilicate, and composite resin; and the original MDP monomer provides for chemical reactiveness with zirconia, dentin and enamel.

The result is a convenient, versatile, and efficacious single solution to practitioners’ everyday cementation needs for a wide variety of indications, including cementation of crowns/bridges, inlays/onlays, posts, splints, and even adhesion bridges.

The significant benefits and quality of PANAVIA™ SA Cement Universal are reflected in the study findings and feedback of the 31 DENTAL ADVISOR clinical evaluators who used the cement in 516 applications and gave it an overall clinical rating of 96 percent. Their comments on its ease of use, handling characteristics, and aesthetics included: “Good flow and film thickness;” “Amazing viscosity, tack cure-ability, and very easy cleanup;” and “Great color match, and I liked the universal ability to work with so many substrates.”

The Top Product or Preferred Product Awards conferred by US-based DENTAL ADVISOR were introduced to help busy practitioners make sense of the numerous new solutions indicated for less invasive techniques, standardized or simplified procedures, and better outcomes on a regular basis. DENTAL ADVISOR conducts its practice-based clinical evaluations and product performance tests shortly after product launch, and publishes results annually online to help potential users identify high-quality new dental materials and determine which among them are best suited to fulfill their individual requirements.

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

Five-time DENTAL ADVISOR Top Product delivers more than a reliable bond

For the fifth time CLEARFIL™ SE Protect has made DENTAL ADVISOR’S list of Top Products for 2023, placing it among dental materials and equipment deemed to deliver the best practice-based performance based on the publication’s annual review of such products.

Featured in the Bonding Agent Self-etch category, CLEARFIL™ SE Protect is a self-etch adhesive that offers more than just a reliable bond. It is:

• Antibacterial (self-etch) primer thanks to containing MDPB monomer
• Built on the same system of the gold standard adhesive CLEARFIL™ SE BOND
• Possible to use it for extended indications of core build-up and indirect restoration with CLEARIFL™ DC Activator.

All in all - surely a great addon to your dental toolbox.

Application of CLEARFIL SE Protect is also truly versatile – you can use it for any direct restorations, but in particular when treating hypersensitive teeth. It is also widely used for core build-up with self- or dual-cured resin materials and for cementation with composite resin cement in combination with CLEARFIL™ DC Activator.

CLEARFIL™ SE Protect offers you following features:

• Virtually no post-operative sensitivity
• Excellent bond strength for enamel and dentin
• Fast and simple procedure with low technique sensitivity

These attributes are reflected in the study findings and comments of the 13 DENTAL ADVISOR editors and consultants—seven of whom had previously used CLEARFIL™ SE BOND in their practices. After CLEARFIL™ SE Protect was assessed over a six-week period during which over 150 restorations were placed, it received a 98% clinical rating by consultants using a 1-5 rating scale,

The practitioners evaluating the product found no post-operative sensitivity. Among their observations mentioned in the online DENTAL ADVISOR report were the fact that the primer and bond wet the tooth evenly. They also mentioned that CLEARFIL™ SE BOND is effective in the reduction of sensitivity when placed on areas of recession or similar areas of sensitive tooth structure.

The Top Product or Preferred Product Awards conferred by US-based DENTAL ADVISOR were introduced to help busy practitioners make sense of the numerous new solutions indicated for less invasive techniques, standardized or simplified procedures, and better outcomes on a regular basis. DENTAL ADVISOR conducts its practice-based clinical evaluations and product performance tests shortly after product launch, and publishes results annually online to help potential users identify high-quality new dental materials and determine which among them are best suited to fulfill their individual requirements.

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

DENTAL ADVISOR Top Product to address everyday dental challenges

For the 8^th straight year, CLEARFIL MAJESTY™ ES Flow has been included among DENTAL ADVISOR’S Top Products, which is made up of dental materials and equipment deemed to deliver the best practice-based performance based on the publication’s annual review of such products.

Featured in the Direct Restorative category, CLEARFIL MAJESTY™ ES Flow comes in three different levels of flowability designed to cover a range of flowable composite indications that cannot be addressed with a single viscosity. Whether the practitioner needs the product to be firm enough to stay put where applied, malleable enough to create a specific shape, or runny enough to flow into every corner or undercut, one of the three versions is appropriate for the job. For example, the high flowability variant is the perfect choice for cavity linings and as a resin coat in immediate dentin sealing (IDS) procedures, while the super low flowability option is suitable for direct veneer procedures and for build-up of posterior cusps etc.

Equipped with Kuraray Noritake Dental Inc.’s Light Diffusion Technology, the universal flowable composite integrates seamlessly with the surrounding tooth structure. If no recontouring required, then a glossy surface can be obtained simply by wiping with a cotton roll soaked in alcohol.

The version tested by the 29 DENTAL ADVISOR consultants in more than 900 applications in their dental practices was the medium flowability variant (Low) of CLEARFIL MAJESTY™ ES Flow. They evaluated properties including placement/handling, aesthetics, viscosity, and polishability and rated all to be “excellent,” with no running during placement and a good adaptation to the cavity walls and when flowed into narrow areas. This led to a recommendation rate of 100 percent and a 98 percent overall clinical rating.

Among their comments were: “The material blended so well with the tooth structure that you had to look hard to find the interface;” “Syringe design prevents oozing from the tip;” and “Readily apparent on radiographs.”

The Top Product or Preferred Product Awards conferred by US-based DENTAL ADVISOR were introduced to help busy practitioners make sense of the numerous new solutions indicated for less invasive techniques, standardized or simplified procedures, and better outcomes on a regular basis. DENTAL ADVISOR conducts its practice-based clinical evaluations and product performance tests shortly after product launch. It publishes results annually online in its January/February issue to help potential users identify high-quality new dental materials and determine which among them are best suited to fulfill their individual requirements.

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

The 46^th congress of European Prosthodontic Debates, also known as EPA2023, will take place in Vilnius, Lithuania 14-16^th of September, 2023.

It stands as a pinnacle gathering for dental professionals and researchers in the field of prosthodontics. This highly anticipated event serves as a platform to exchange knowledge, share insights, and engage in lively discussions on the latest advancements, achievements and challenges in prosthodontics.

EPA2023 promises to be an extraordinary occasion, attracting more than 50 experts from across Europe and beyond. Renowned speakers will present the newest advances in clinical prosthodontics and restorative dentistry. Daniele Rondoni, Matthias Kern, Nicola Scotti and Kazuyoshi Baba are only some of experts at the event; check out complete speaker line-up on the website www.epa2023.lt.

The event will feature thought-provoking debates, where experts will engage in intellectual discourse on current topics of prosthodontics, stimulating a lively exchange of ideas and perspectives. Special attention will be given to the successful application of digital solutions.

Beyond the scientific program, EPA2023 will provide ample opportunities for networking and collaboration. Attendees will have the chance to interact with colleagues, forge new partnerships, and establish connections with industry leaders, further enriching their professional networks.

As the European Prosthodontic Debates event continues to push the boundaries of prosthodontics, EPA2023 is expected to be a landmark occasion, empowering dental professionals to advance their knowledge, skills, and expertise in the ever-evolving field of prosthodontics.

Register now for EPA2023: www.epa2023.lt

Shortly before KATANA™ Zirconia ML was launched at the IDS in Cologne ten years ago, I had the pleasure to be invited to Japan. We visited the KATANA™ Zirconia production facilities and learned from Kazunobu Yamada and Takuro Nagura how the new material worked. So far, all dental zirconia I had used was white and quite opaque.

I was immediately impressed by the complexity of the production procedure including all the measures taken by Kuraray Noritake Dental to provide for an extremely high material and blank quality. The blanks appeared to have an extremely homogeneous multi-layered structure and a high density responsible for stable edges and smooth surfaces. What we were told in the manufacturing plant was confirmed by Kazunobu Yamada, who shared his experience and showed us several full-contour cases. I was pleasantly surprised by the fact that he was able to produce impressive outcomes without adding any colour. Moreover, Kazunobu Yamada was obviously able to polish the surface of his restorations within seconds. The perfectly smooth surface would allow us avoid the use of glaze, which usually wears off very quickly, leaving a potentially rough surface that may harm the antagonist.

Based on what I had learned in Japan, I went back to Italy and started experimenting with the amazing new material. While Kazunobu Yamada had identified KATANA™ Zirconia ML as the solution for monolithic restorations in the posterior area, I started using it in every region of the mouth – with different design concepts from full-contour to micro-cutback with micro-layering in the vestibular area. The occlusal contact area was always held in plain, polished zirconia.

Fig. 1. Early example of anterior restorations made of KATANA™ Zirconia ML individualized with CERABIEN™ ZR using the new micro-layering technique.

Fig. 2. Possible cutback design.

During the testing period, I learned a lot about the new zirconia, which was so different from earlier generations. The most important insight was that that the processing conditions have a huge impact on the final outcome. Kuraray Noritake Dental provided valuable support e.g. in the form of sintering protocols and processing and finishing recommendations. This helped me develop my own workflow and concept based on a full-contour design in the posterior and different micro-cutback options with micro-layering in the anterior region. For me, this is a perfect combination of the new type of zirconia (KATANA) and the traditional porcelain material (CERABIEN™ ZR Luster Porcelain and Internal Stain).

In May 2013, at a meeting of the Noritake Study Club in Florence, Italy, I presented the new approach for the first time. Many colleagues were enthusiastic about it and started adopting it. While further developments like more translucent (cubic) material variants and a new generation multi-layered zirconia with a flexural strength and translucency gradient increased the application options and aesthetic potential, micro-layering became a truly popular approach used by dental technicians all over the world. In 2016, it was recognized as a relevat workflow during a closed meeting of the European Academy of Aesthetic Dentistry.

Fig. 3. Perfectly polished palatal zirconia surfaces of anterior restorations.

Fig. 4. More recent case showing a patient who received restorations made of KATANA™ Zirconia STML …

Fig. 5. … finished with CERABIEN™ ZR Internal Stains and a micro-layer of CERABIEN™ Luster Porcelain LT1.

But what is the major reason for the success of the concept and of multi-layered zirconia with KATANA™ Zirconia ML as the pioneer? In my opinion, it should not be implemented for greater simplicity or economic reasons, as one might assume at first thought. The time saved in the layering procedure should be spent on other tasks such as surface texturing and a fine-tuning of the processing procedure. The real benefit is that KATANA™ Zirconia ML and its successors allow for better solutions adapted to the patient’s needs. First of all, they enable us to save natural tooth structure, as the required wall thickness is reduced. They also offer mechanical advantages, as chipping is avoided, and the occlusal contact area remains smooth over time. In my dental laboratory, we changed our workflows completely and – preferring a more conservative approach whenever indicated for the case on hand – we often abandon full layering.

KATANA™ Zirconia can be considered as a great contribution to the digital workflow in the dental laboratory and office, which increases the efficiency of prosthodontic procedures. With the KATANA™ Zirconia Multi-Layered series, it is easy to hold our promise of delivering the best possible quality and aesthetics. The reason is that the materials support us in an ideal way, delivering the perfect combination of tradition and innovation.