Case by Dr. Michał Pokojski

When restoring primary carious lesions in the posterior area with composite, I wish to use a material that allows me to produce high-quality outcomes in an efficient procedure. The most important qualities of the restoration are its perfect marginal integrity and reliable long-term behaviour, which set the stage for a long and healthy life of the otherwise healthy tooth.

Reliability paired with ease of use is what I expected from the selected material combination: CLEARFIL™ SE Bond 2, a popular self-etch adhesive containing the original MDP monomer, and CLEARFIL MAJESTY™ ES-2 Universal. According to Kuraray Noritake Dental, the innovative resin composite comes with a universal shade concept and mechanical properties such as shrinkage, wear resistance and colour stability similar to those of proven CLEARFIL MAJESTY™ products. As a single shade is available for the posterior region, the need for shade determination is eliminated, which allows the dental practitioner to focus on the clinical work steps. In this case, a small primary defect in a third molar was restored. The outcome speaks for itself.

Fig. 1. Situation during cavity preparation revealing the carious lesion.

Fig. 2. Prepared cavity after the application of the bonding agent.

FINAL SITUATION

Fig. 3. Treatment outcome with the composite harmoniously integrated into the surrounding structure.

Dentist:

DR. MICHAŁ POKOJSKI

Dr. Michał Pokojski is a graduate of the Medical University of Łódź, Poland. He maintains his private practice in Starachowice, Świętokrzyskie Voivodeship. His passion is endodontics and esthetic conservative dentistry. In his everyday duties microscope and camera are his main tools to provide his patients with professional and precise procedures and to ensure proper level of communication and understanding. His practice was guided by EBD from the very beginning, because in his opinion knowledge, scientific facts and dedication for what you do are the fundamentals of medicine and dentistry as well. His goal is to treat patients at the highest level of quality using the best available materials, instruments and procedures. His cases are well-known in the world thanks to modern ways of communication like Facebook and Instagram.

CLEARFIL MAJESTY™ ES-2 Universal Composite

A smart and easy-to-use system that works for the vast majority of your daily cases

Webinar to learn how intelligent simplification benefits your daily work. Discover MAJESTY ES-2 Universal, a smart and easy-to-use system that will work for the vast majority of your daily cases. Its light-cure, radiopaque restorative material provides accurate color matching, high polishability and excellent physical properties. This makes the product ideal for both anterior and posterior restorations.

ABOUT DR JORGE ESPIGARES, DDS, PHD

Dr. Jorge Espigares received his DDS degree at the Faculty of Dentistry, University of Granada in Spain and obtained his PhD degree under the supervision of Prof. Tagami at Tokyo Medical and Dental University in Japan. Specialized in Cariology and Operative Dentistry, Dr. Jorge Espigares has clinical experience in Spain and UK, and has authored and coauthored full-length research publications with his colleagues at TMDU.

In this interview, Dr Adham Elsayed, certified specialist in dental prosthodontics and implants and clinical and scientific manager at Kuraray Noritake Dental, details the benefits of the company’s new CLEARFIL MAJESTY™ ES-2 Universal composite and explains its application in the daily dental workflow.

Though dentists are becoming increasingly specialised, there’s a growing demand for products that can be used for all indications. How does CLEARFIL MAJESTY™ ES-2 Universal fit this model?

First, we need to explain the meaning of the term ‘universal’ in this context. Previously, there have been two types of composites that differ according to the area of application: anterior composites, used in Class III, IV and V restorations where the aesthetic outcome is the priority, and posterior composites, in which the mechanical properties like strength and wear rate are more important. Universal composites, then, are those that can be used for all types of restorations in the anterior as well as the posterior region.

Another way in which ‘universal’ can be considered is in relation to shade. In this case, the term is used to describe a restorative composite system that exists in fewer shades, one that can adapt to the tooth structure independent of the colour of the tooth. A major benefit of this type of composites is that it offers a simplified workflow.

CLEARFIL MAJESTY™ ES-2 Universal is essentially universal in both meanings: it is one system that can be used for posterior and anterior restorations, and it is also provided in only three shades—one for posterior, and two for anterior.

Universal products, whether they are luting cements, bonding agents or composites, are attractive to dentists as long as they offer simplification of the treatment procedure without compromising quality and durability.

How does CLEARFIL MAJESTY™ ES-2 Universal build upon the success of the CLEARFIL MAJESTY™ range?

The CLEARFIL MAJESTY™ family is very well established at this stage. It includes such products as CLEARFIL MAJESTY™ Posterior, one of the most popular posterior composites owing to its superior mechanical properties and minimal polymerisation shrinkage. CLEARFIL MAJESTY™ ES-2 is an extensive system that is highly beneficial thanks to its outstanding optical properties and ability to produce high-end aesthetics in the anterior region using Kuraray Noritake Dental’s multilayering technique. The three flowable alternatives of CLEARFIL MAJESTY™ ES Flow, with different consistencies, are also other successful members of the family.

Kuraray Noritake Dental now continues the success story of CLEARFIL MAJESTY™ with the latest innovative product that can change the definition of the universal composite. CLEARFIL MAJESTY™ ES-2 Universal incorporates several attributes from the well-established ES-2 and ES Flow, including Kuraray Noritake Dental’s light diffusion technology (LDT).

Speaking of LDT—how does this technology benefit the composite?

LDT allows the material to scatter and reflect light rays at many different angles, which, in turn, allows the composite restoration to diffuse light in a similar way to the surrounding tooth structure. Hence, it eliminates aesthetic problems like the visibility of restoration and preparation borders. Thanks to innovative LDT, optimal particle fillers and opacity, CLEARFIL MAJESTY™ ES-2 Universal blends seamlessly with the surrounding tooth structure and emulates natural teeth, eliminating the need for shade selection.

As you mentioned, CLEARFIL MAJESTY™ ES-2 Universal comes with one shade for posterior restorations and two for anterior restorations. Can such a reduced shade range still truly deliver aesthetic restorations?

CLEARFIL MAJESTY™ ES-2 Universal is not the first composite on the market with a reduced shade system. However, we can safely say that it is the first to focus on aesthetics and not just on reducing the number of shades.

We know from experience that using one-shade composite systems in the anterior region mostly leads to unsatisfying aesthetic results, even with the use of an opaquer composite to reduce shade-matching interference. This is due to the fact that trying to provide one shade for all posterior and anterior restorations, and for all tooth shades, compromises the aesthetic to a high extent. In other words, using a highly translucent material to try to match all restorations and shades will result in the interference of other objects in the mouth, such as the tongue, gingivae and so on.

Kuraray Noritake understood this fact well and solved the problem by introducing three shades with translucencies designed to match specific indications. It is important to note the simplicity of the workflow, since only one syringe per restoration is required. This makes CLEARFIL Majesty™ ES-2 Universal a true game-changer, as it provides the perfect match between simplicity and aesthetics.

What other advantages does this new composite deliver?

Other advantages include the superior mechanical properties for which the CLEARFIL MAJESTY™ family is already known, such as favourable wear properties, low shrinkage stress and high strength. It can be polished easily and retains its gloss. Moreover, the handling of the material is a huge advantage: this includes a long working time of about 270 seconds under ambient light. It is non-sticky and can be sculpted easily.

Which dental professionals would benefit most from this product?

The perfect match between simplicity and aesthetics offers the clinician several benefits. It delivers a very straightforward time-saving procedure without compromising aesthetic results. There is no need for exact shade selection, thereby excluding visible errors of non-matching shades, and there is also a reduced amount of material stock needed. Therefore, in my opinion, this should be the product of choice for most cases in everyday practice.

Advances and developments in dental materials are rapidly accelerating, and clinicians should integrate these innovations and make their daily practice more efficient with simplified workflows, time-saving procedures, fewer material selections and, accordingly, less technique sensitivity and less need for dental practice personnel to become acquainted with an abundance of materials.

No shade taking needed. Just one shade to cover all posterior cases. Even the larger Class I's and II's!

A guideline with regard to contemporary materials

The retention of the fixed prosthodontic restorations is a critical factor for the long-term success, as the loss of crown retention is one of the main reasons for failure of crowns and fixed dental prosthesis (FDP) ^{(1, 2)}. There are three main elements that need to be considered to achieve proper retention of the restorations; the tooth preparation, the restorative material and the luting agent.

TOOTH PREPARATION

During tooth preparation there are some important features to be considered, such as the height, angle and surface texture of the abutment tooth, in order to achieve an adequate retention and resistance form which provide stability of the restorations to resist dislodgment and subsequent loss ⁽³⁾. Retention form is responsible for counteracting tensile stresses, whereas resistance form counteracts shear stresses ⁽⁴⁾.

In order to achieve a sufficient retention and resistance form for full coverage crowns it is recommended that the height of the abutment tooth should be at least 4 mm and that the optimal convergence angle should range from 6 to 12 degrees with a maximum of 15 degrees ^{(1, 5-8)}.

RESTORATIVE MATERIAL

With the continuous introduction of new restorative materials to the dental market it is important to take into consideration the different mechanical properties of the various materials. The composition and the surface properties of the material have a decisive role in the ability to accomplish mechanical and/or chemical attachment to the restoration and therefore achieving required retention.

LUTING AGENT

The luting agent is the connection between the tooth and the restoration. Proper luting of indirect restoration is critical in achieving long-term success as it highly influences the retention of the restoration as well as tightly sealing the gap between the restoration and the tooth. Although there are several classifications for the definitive luting agents, they can be , however, classified into two main categories based on the ability to achieve chemical connection to different substrates; conventional (e.g. zinc phosphate, glass-ionomer and resin-modified glass-ionomer cements) and adhesives. Most commonly used and best documented adhesive luting agents are the adhesive composite resin cements.

Composite resin cements can be further classified according to the chemical composition into traditional full-adhesive resin cement and self-adhesive resin cements, both also differ in the bonding procedure. The full-adhesive resin cements require pre-treatment of the tooth structure and restorative material using separate adhesive systems. In this combination of the resin cement and the adhesive system, very durable chemical bonding can be reached.

To simplify the luting procedure and eliminate the need of using several components, the self-adhesive resin cements are a good choice for the daily busy practice, in which reliable bonding can be achieved in only one simple step of cement application, mostly without additional primers or bonding agents.

With the availability of different types of cements, the decision of choosing the suitable luting agent and method can be confusing for the practitioner. Especially with the wide use of contemporary restorative materials such as new generations of highly translucent zirconia as well as reinforced-composites, it is important to take into consideration that the properties of such materials differ highly from metal or earlier generations of zirconia. Subsequently the choice of the luting agent must be appropriate to achieve satisfying results and long-term success. Therefore, in this article, the authors aim to provide insights for the clinicians on choosing the correct luting agent that can help achieve satisfactory results for the dentist as well as the patients.

CONVENTIONAL CEMENTATION OR ADHESIVE LUTING?

The choice of whether to use a conventional cement or an adhesive resin cement depends on several factors, the key factors are:

1. Retention and resistance form of the abutment tooth.
2. Mechanical and optical properties of the restorative material (flexural strength and translucency).
3. Simplicity of the workflow and special requirements of the working environment.

1) RETENTION AND RESISTANCE FORM OF THE ABUTMENT TOOTH

Minimal-invasive restorations, such as resin-bonded FDP, labial and occlusal veneers and inlay-retained FDP are based on a non-retentive preparation form. In this case the only possible method to achieve retention is the adhesive luting ^(9-11).

Even though such preparations completely lack a retentive form, long-term success of the restorations is well-documented when using a durable resin cement (e.g. PANAVIA™ 21, Kuraray Noritake Dental Inc., Japan) and proper bonding procedure ^{(10, 11)}.

For full-coverage restorations (e.g. crowns and FDPs), the guidelines for tooth preparation discussed before (minimum height of 4 mm and maximum convergence of 15 degrees) need to be applied in order to achieve the retention and resistance form required to make cementation with a conventional luting agent acceptable.

However, in reality this retention form is hard to realize due to several factors.

In cases of severe loss of tooth substance, achieving a minimum height of the abutment tooth is only possible with building up the tooth using a core build-up material which in some cases can be considered time consuming especially when the required build-up is minor (for example 1-2 mm). Moreover, increasing the height through core build-up is sometimes not possible, as in cases with short clinical crowns and insufficient occlusal clearance that is essential to provide the minimum thickness required for the restorative material. In such cases surgical crown lengthening is necessary to increase the height of the tooth without compromising the occlusal space required, which can be time consuming for the clinician and undesirable for the patient as it involves a surgical procedure and extends the treatment process.

Concerning the convergence angle, several studies showed that in reality and in daily practice of the dentist, the preparation angle is much higher than 15 degrees ^{(5, 6, 12, 13)}. For instance, preparations from general practitioners were evaluated digitally and compared to clinical recommendations and it was found that the mean convergence angle was 26.7 degree with the distopalatal angle being 31.7 degree ⁽¹²⁾.

Based on the previous concerns, it can be concluded that achieving a proper retention form during daily practice is hard to realize and thus conventional cementation in such cases can present clinical problems especially on the long term. Therefore, adhesive luting can be recommended in these cases as an alternative to conventional cementation ^{(6, 14)}. For full-coverage restorations with preparation designs featuring at least some mechanical retention, the use of self-adhesive resin cements can be considerate a good alternative as it provides high clinical success rates ^{(9, 15)}.

Conclusion / Clinical Significance:

• For non-retentive minimal-invasive restorations, traditional full-adhesive luting is a must.
• For full-coverage restorations, full-adhesive or self-adhesive luting is recommended.
• In case a retentive preparation with minimum height of 4mm and convergence angle of 6-12 degrees, adhesive luting as well as conventional cementation can be used.

2) MECHANICAL AND OPTICAL PROPERTIES OF THE RESTORATIVE MATERIAL

Flexural strength and translucency of the restorative material are critical factors that influence the decision which luting agent to use.

a) Flexural strength

As a general guideline for all-ceramic restorations, ceramics with low and medium flexural strength under 350 MPa should be adhesively luted with composite resin cements, as these restorations rely on resin bonding for reinforcement and support ^{(9, 14, 16)}. This includes feldspathic-, glass-, hybrid-ceramics and composite.

Although discussions on conventional cementation versus adhesive luting for high-strength ceramics with flexure strength of more than 350 MPa have been going on for a long time ⁽⁹⁾, there are several studies showing an increased stability and strength of all types of ceramics, even lithium disilicate and zirconia, when they are adhesively luted ^{(9, 17-20)}.

It is also important to consider that the documented success of most conventional cements is mainly combined with restorations made of metal or early generations of zirconia. Nonetheless, the clinical success of new generations of high-translucent zirconia can be significantly influenced by the luting agent as these new generations have notably lower flexural strength ⁽⁹⁾. And therefore, attention has to be paid to minimal material thickness together with adhesive luting to ensure long-term clinical success and prevent fractures ⁽⁹⁾.

Conclusion / Clinical Significance:

• For glass-ceramic, hybrid-ceramics and composites, adhesive luting is a must.
• For lithium disilicate and zirconia restorations, adhesive luting is highly recommended.
• For metal restorations, adhesive luting as well as conventional cementation can be used.

b) Translucency

To meet the increasing esthetic demands of the patients, new materials and techniques are continuously introduced, aiming to provide the perfect esthetic restorations. This includes not only new restorative materials but also new modifications to the luting agents as well. Highly translucent ceramics can deliver superior esthetics and therefore their popularity and clinical applications expanded widely among clinicians. It is nevertheless very important for the clinician to apprehend that the final esthetic result is influenced by the complete restorative complex and not just by the restorative material, as the luting agent is a key factor in achieving the desired high esthetics ^(21-24).

For that reason, the choice of an opaque conventional cement for cementation of high-translucent restoration should not be recommended as it can negatively influence the final esthetic results. Therefore, composite resin cements are the material of choice, as they are available in different shades and translucencies for the clinician to be able to choose the suitable resin cement to achieve the desired esthetics based on the restorative material and thickness as well as the color of the underlying abutment. Some composite resin cements offer try-in paste so that the clinician and the patient can visualize the final results before luting and therefore better choose the appropriate shade of the resin cement.

Conclusion / Clinical Significance:

• For all translucent ceramic restorations, adhesive luting is highly recommended.
• For metal and opaque high-strength zirconia restorations, adhesive luting as well as conventional cementation can be used.

3) SIMPLICITY OF THE WORKFLOW AND SPECIAL REQUIREMENTS OF THE WORKING ENVIRONMENT

The process of adhesive luting with full-adhesive composite resin cements (e.g. PANAVIA™ V5, Kuraray Noritake Dental Inc.) requires separate etching and priming procedures usually using a self-etch adhesive system (e.g. PANAVIA™ V5 Tooth Primer, Kuraray Noritake Dental Inc.) as well as a primer for the restorative material such as a universal primer that can be used for different substrates including metal, ceramics and composites (e.g. CLEARFIL™ CERAMIC PRIMER PLUS, Kuraray Noritake Dental Inc.). These procedures are technique sensitive and intolerant to contaminations, therefore the luting process needs a dry oral environment avoiding any contamination, such as saliva or blood, preferably using rubber dam, as any contamination can compromise the bond strength. Therefore, inability to maintain dry field as in case of subgingival preparation margins is considered a contraindication for traditional full-adhesive luting. However, this method provides very durable bond strength, therefore it is the luting method of choice for minimal invasive non-retentive preparations, such as resin-bonded FDPs, labial and occlusal veneers and inlay-retained FDPs, in which the retention is mainly dependent on the adhesion ^(9-11).

Still, in everyday practice, clinicians seek efficiency and effectivity by using a simple but durable luting agent for the insertion of full-coverage restorations such as tooth-or implant-supported crowns and FDPs. Although the conventional cements are simple and fast in their use, they provide little or no adhesion at all and therefore they are not recommended in several cases ^{(6, 9, 14, 15, 19, 20)}. A simple but reliable method can be well accomplished by the use of self-adhesive resin cements (e.g. PANAVIA™ SA Cement Universal, Kuraray Noritake Dental Inc.) as they can be considered the best alternative for full-adhesive adhesive luting in less critical situations that do not rely entirely on adhesion ^{(9, 15)}. Furthermore, self-adhesive resin cements are not as technique sensitive and intolerant to contaminations as traditional full-adhesive resin cements.

Typically, a MDP phosphate monomer is integrated in the self-adhesive resin cement, which is required to chemically bond to different substrates, making it possible for the resin cement to chemically bond to non-precious metals and zirconia as well as tooth substance. However, regardless of the self-adhesive resin cement, the use of a separate silane coupling agent is still required when bonding to silica-based ceramics (e.g. leucite, lithium silicate and lithium disilicate), hybrid ceramics and composite restorations.

Recently, a unique self-adhesive resin cement (PANAVIA™ SA Cement Universal, Kuraray Noritake Dental Inc.) was introduced: through an innovative and distinctive production technology, a silane-coupling agent (long carbon chain silane (LCSi)) is integrated in the cement, and thus being the real universal adhesive system that completely eliminate the need for any other adhesive or primer when being used for all substrates including glass ceramics. So the luting process can be in this case truly shortened to one step.

Therefore, this unique cement combines several advantages of adhesive luting as well as the straightforward procedure of the conventional cementation without compromising the clinical success, regardless of the type of the restorative material.

As a conclusion, adhesive luting has more benefits over conventional cementation, regarding retention, esthetics, stabilization of the tooth and the restoration as well as preventing micro leakage ^{(6, 9, 14-17, 19, 20, 25, 26)} (Table 1). Moreover, there are no absolute contraindications for adhesive luting other than hypersensitivity to methacrylate monomers, as self-adhesive resin cements can be used in cases where full-adhesive resin cements are contraindicated, such as inability to avoid contamination (Table 2). As a result, adhesive luting can be generally used in every clinical situation, whereas conventional cementation is limited (Table 3).

Dentist(s):

Prof. Dr. Florian Beuer
Professor and Chair, Department of Prosthodontics, Geriatric Dentistry and Craniomandibular Disorders, Charité – Universitätsmedizin Berlin, Germany.

Dr. Adham Elsayed
Clinical and Scientific manager, Kuraray Europe GmbH, Hattersheim, Germany.

References

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5. Edelhoff D, Özcan M. To what extent does the longevity of fixed dental prostheses depend on the function of the cement? Working Group 4 materials: cementation. Clin Oral Implants Res. 2007;18 Suppl 3:193-204.
6. Güth JF, Stawarczyk B, Edelhoff D, Liebermann A. Zirconia and its novel compositions: What do clinicians need to know? Quintessence Int. 2019;50(7):512-20.
7. Smith CT, Gary JJ, Conkin JE, Franks HL. Effective taper criterion for the full veneer crown preparation in preclinical prosthodontics. J Prosthodont. 1999;8(3):196-200.
8. Uy JN, Neo JC, Chan SH. The effect of tooth and foundation restoration heights on the load fatigue performance of cast crowns. J Prosthet Dent. 2010;104(5):318-24.
9. Blatz MB, Vonderheide M, Conejo J. The Effect of Resin Bonding on Long-Term Success of High-Strength Ceramics. J Dent Res. 2018;97(2):132-9.
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15. Blatz MB, Phark JH, Ozer F, Mante FK, Saleh N, Bergler M, et al. In vitro comparative bond strength of contemporary self-adhesive resin cements to zirconium oxide ceramic with and without air-particle abrasion. Clin Oral Investig. 2010;14(2):187-92.
16. Kern M, Thompson VP, Beuer F, Edelhoff D, Frankenberger R, Kohal RJ, et al. All ceramics at a glance. 3rd English Edition ed: AG Keramik; 2017.
17. Attia A, Abdelaziz KM, Freitag S, Kern M. Fracture load of composite resin and feldspathic all-ceramic CAD/CAM crowns. J Prosthet Dent. 2006;95(2):117-23.
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Case by Max Andrup

The maxillary right first premolar of this patient had a huge defect on the lingual aspect extending subgingivally. In order to facilitate proper working field isolation for the placement of an onlay, it was decided to elevate the margin using the deep margin elevation (DME) technique. Moisture control is more easily handled with a matrix and composite compared to trying to keep a deep box dry at the placement of an indirect restoration. The preferred method used to maximize the bond strength to dentin was immediate dentin sealing combined with resin coating, while the luting material of choice was warmed light-curing resin composite (CLEARFIL™ AP-X). It shows a superior performance compared to dual-cure luting materials e.g. in terms of conversion of monomers to polymers, time available for excess removal, bio-mechanical properties and polymerization shrinkage stress.

Fig. 1. Pre-operative situaton with clearly visible deep distal margin. In reality, it was even deeper than the picture reveals. The Brinker Rubber Dam Clamp B4 placed here is a life saver in cases with subgingival margins. The buccal wall was still intact. We planned to reduce it to allow the onlay to cover it completely, allowing it to work under compression and thus increasing the fracture resistance.

Fig. 2. Situation after placement of a sectional matrix on thedistal aspect of the tooth. In order to retract the rubber dam mesially, PTFE tape was placed in this area. This allowed me to seal the dentin in a perfectly dry environment. For immediate dentin sealing, the smear layer developed on the dentin immediately after tooth preparation was compacted with the aid of air abrasion (50 μm alumina particles) to provide for the best possible bonding conditions, followed by the application of the bonding agent (CLEARFIL™ SE Protect). Afterwards, the bonded dentin was covered with a thin layer of flowable resin composite (CLEARFIL MAJESTY™ ES Flow). This resin coating ensures that the hybrid layer is thick enough and that the dentin is perfectly sealed.

Fig. 3. After immediate dentin sealing and resin coating. The hybrid layer was left to mature for approximately five minutes. This measure leads to an increased bond strength to dentin, which prevents issues that might occur due to the polymerization shrinkage stress occurring after composite placement. Subsequently, CLEARFIL™ AP-X was applied in small increments, starting in the distal box. In this way, the biobase was built up to the desired height. The main arguments for using CLEARFIL™ AP-X as a replacement for deep dentin are that the modulus of elasticity is within the same range as that of dentin and it exhibits an extraordinarily low polymerization shrinkage.

Fig. 4. Lateral view of the tooth at the day of delivery. View of the tooth at the day of delivery after rubber dam placement and prior to air-abrasion treatment of the biobase, which was performed to remove any remaining temporary cement. Following try-in, the lithium disilicate onlay was cleaned with KATANA™ Cleaner and pretreated with CLEARFIL™ Ceramic Primer. The biobase was sandblasted again for cleaning.

Fig. 5. Onlay in place after selective etching of the enamel with 35 % phosphoric acid etchant, and application of CLEARFIL™ SE Bond to the biobase and the intaglio of the onlay as well as luting with heated CLEARFIL™ AP-X. Excess composite was removed and the composite light cured.

FINAL SITUATION

Fig. 6. Occlusial view of the luted restoration.

Dentist:

Max Andrup graduated from the University of Umeå in 2010 and today runs his private practice in the city of Hudiksvall, Sweden. He has a passion for restorative dentistry with a biomimetic approach.

Case by Dr Paul Guicherit

A girl presented to the dental office after a bicycle accident. She had a traumatized maxillary left central incisor and an abrasion injury was visible on and above her upper lip.

The tooth was restored immediately using CLEARFIL™ MAJESTY ES-2 Universal in the shade UL (Universal Light).

The outcome was excellent due to a great optical integration and an invisible transition between the tooth and the resin composite.

Clinical photo credits: Dr Paul Guicherit

Case by Max Andrup

This is the story of cusp fracture due to cuspal tension. This is a common weakness of amalgam-restored teeth associated with expansion of the restorative material. The affected maxillary right first premolar was restored with a crownlay.

For seating of the crownlay, the use of warmed light-curing resin composite (CLEARFIL™ AP-X) has proven its worth. Compared to a dual-cure luting resin, the selected material offers many benefits including the fact that the heat assists in the conversion of monomers to polymers, the time available to remove excess is almost unlimited, and the composite offers better bio-mechanical properties as well as a lower polymerization shrinkage stress.

Fig. 1. Pre-operative situation. The patient requested for an emergency appointment, where we temporarily fixed the lost buccal cusp and made a new appointment for a crownlay preparation. After removing the amalgam and temporary filling, the remaining amount of tooth structure was quite beneficial with a large lingual cusp and a ring of enamel around the whole tooth.

Fig. 2. The decision was made to reduce the lingual cusp and to place a crownlay working in compression. As the thickness of the cusp was adequate for an onlay, this treatment option would have been equally suitable. After tooth preparation, immediate dentin sealing was performed: For this purpose, I air-abraded the dentin to remove the smear layer and give the adhesive the best condition for a strong bond to dentin. Then, CLEARFIL™ SE Protect was applied to the tooth surface and covered with a thin layer of flowable resin composite (CLEARFIL MAJESTY™ Flow) to ensure a total seal.

Fig. 3. The resin composite surface was air-abraded with 50 μm zirconia particles, followed by selective etching of the enamel with a 35-percent phosphoric acid etchant. After try-in of the crownlay made of lithium disilicate, the tooth surface and the restoration were cleaned with KATANA™ Cleaner.

FINAL SITUATION

Fig. 4. The cleaned crownlay was pre-treated with CLEARFIL™ Ceramic Primer, before warmed CLEARFIL™ AP-X was applied to both tooth structure and restoration for luting. The colour of the crownlay matched the colour of the adjacent premolar, while the visible part of the restored tooth’s remaining structure was stained from amalgam corrosion.

Dentist:

Max Andrup graduated from the University of Umeå in 2010 and today runs his private practice in the city of Hudiksvall, Sweden. He has a passion for restorative dentistry with a biomimetic approach.

By Dr Alessandro Devigus

This video illustrates the Cementation of Katana STML Crowns with Panavia V5.

Dentist:

DR. ALESSANDRO DEVIGUS

Dr. Alessandro Devigus received his degree from Zurich University, Switzerland, in 1987. Since 1990 his working in his own private practice with a focus on CAD CAM and Digital Dentistry. He is also CEREC Instructor at the Zurich Dental School.

Dr. Alessandro Devigus is an active member of the European Academy of Esthetic Dentistry (EAED), founder of the Swiss Society of Computerized Dentistry, Neue Gruppe member, ITI fellow and speaker.

Dr. Devigus is editor-in-chief of the International Journal of Esthetic Dentistry, author of various publications and an international lecturer.

Case by Max Andrup

This patient had requested for an emergency appointment and presented with severe erosive tooth wear in several teeth, a crack in the mesial wall of the maxillary first molar and a failing direct restoration with recurrent decay on the adjacent second premolar. I decided to replace the direct resin composite restoration immediately as this was the main cause of discomfort. It was decided to restore the other defects during the next appointment.

The resin composite of choice was CLEARFIL MAJESTY™ ES-2 (Universal shade concept), an innovative material with a single universal shade designed for posterior restorations. The manufacturer claims that, due to the integration of Kuraray Noritake Dental Inc.’s light diffusion technology, this universal shade nicely blends in with the surrounding tooth structure virtually independent of its colour. Curious about the real potential of this concept, I wanted to put the material to a test.

Fig. 1. Pre-operative situation revealing signs of severe erosive tooth wear, a cracked mesial wall of the first molar and a failed filling on the second premolar with recurrent decay.

Fig. 2. Appearance of the tooth after removal of the direct composite restoration. The recurrent caries is obvious.

Fig. 3. Caries Detector applied to the decayed tooth structure.

Fig. 4. Establishing of a peripheral zone totally free of caries with the aid of Caries Detector. It may be useful to apply the dye several times.

Fig. 5. The final situation after several applications of Caries Detector. The peripheral zone is completely free of caries, which is a strict requirement for the establishment of a perfect seal during bonding. Affected caries stained light pink is not removed not to risk going near the pulp.

Fig. 6. Build-up of the proximal wall with CLEARFIL MAJESTY™ ES-2 (U shade) after the application of CLEARFIL™ SE Protect and a small layer of CLEARFIL MAJESTY™ ES Flow in a thickness of about 0,5 mm. By focusing on the proximal wall connecting to enamel first, the hybrid layer is given the time needed to mature. Not putting a new increment on top of the hybrid layer for the first five minutes will lead to an increased bond strength to dentin.

FINAL SITUATION

Fig. 7. Appearance of the tooth immediately after finishing and polishing. Although the rubber dam is still in place and the tooth structure is not yet rehydrated, it is evident that the composite blends in very well with the remaining tooth structure to form a seamless margin.

Dentist:

Max Andrup graduated from the University of Umeå in 2010 and today runs his private practice in the city of Hudiksvall, Sweden. He has a passion for restorative dentistry with a biomimetic approach.