Case by Dr. Cyril Gaillard

In the past few years, the number of patients diagnosed with sleep apnea has increased. Fortunately, we can propose different options of treatments today, which can provide positive clinical results and improve the quality of life of our patients.

This clinical case presents the use of a new CAD-CAM material, KATANA™ AVENCIA™ block, produced using the unique manufacturing method of Kuraray Noritake Dental, which offers remarkable mechanical properties.

The goals of the treatment are:

• Biological and minimally invasive, when it comes to teeth (non-invasive), periodontics, and occlusion (muscular and articular).
• To maintain health on the long-term (ease of hygiene).
• To re-establish an effective function (mastication) without compromising aesthetics.

This article presents the rehabilitation of a patient suffering from sleep apnea, integrating the concept of minimally invasive and adhesive dentistry with most importantly, functional dentistry by identifying precisely the occlusal concept and mandibular position given to the patient.

The forty-year-old patient came to the office for his annual check-up. During initial examination, we discussed his problem of sleep apnea and the fact that he feels uncomfortable with his occlusion.

The extra-oral exam revealed a largely reduced lower face area. We noted the presence of a crown in the place of tooth #46 and amalgams on the molars. The crown had to be removed and the root extracted, one implant would be placed.

The patient told us he did not suffer from muscle spasms nor from articular pain, but conveyed an increasing discomfort during mastication and a constant search for the right position to his mandible.

Based on my diagnosis, it was judged that the treatment with KATANA™ AVENCIA™ is within the scope of indications since the occlusion problem is a minor issue.

TREATMENT PLAN

To create the treatment plan, we always follow the same steps:

• Discussion with the patient to identify his or her wishes and limitations in terms of treatment.
• Occlusal planning, search for the appropriate mandibular position in order to determine the quantity of destroyed dental tissue; this is done by TENS machine.
• Periodontic diagnosis and support teeth.

We proceed in the following manner for the treatment:

• Cleaning of all teeth.
• Complete in-mouth mock-up for the lower arch.
• The mock-up will be left in the mouth in order to validate the new occlusion.
• Use of CAD-CAM technology to create the definitive prostheses, integrating the concept of minimally invasive dentistry. We will use KATANA™ AVENCIA™ block as material for the overlays.

Initial situation with occlusion troubles causing discomfort during mastication.

Once the mock-up had been placed in the mouth, it was necessary to test the new occlusion and adjust if needed. The mock-up was milled in PMMA by Roland DG Corporation milling machine.

The teeth are prepared through the mock-up to be as minimally invasive as possible. The thickness is 1,5 mm for occlusal and 1 mm for buccal surface.

Overlays and crown(s) on implant were designed by 3Shape software (3Shape A/S) and milled by Roland milling machine. The final restorations were created using two digital impressions. On the impression of the preparations, the cervical limits were marked. Next, the software matched the two impressions by subtraction and proposed the shape of the restorations to be milled.

These restorations are the exact copy (morphology) of what the patient wore in his mouth for two months. If the work is done by section, it is easier for the computer to match the impressions.

KATANA™ AVENCIA™ block was milled.

Polishing of the restoration with CLEARFIL™ TWIST DIA.

After milling, the restorations were stained using a 3D staining technique. 3D staining requires a specific sequence to create 3D optical illusions.

Final esthetic results after staining.

A classic bonding procedure was followed with PANAVIA™ V5. To begin, all KATANA™ AVENCIA™ elements were tried one by one for validation and adjustment, then all together to check the contact points.

Rubber dam was placed on the mandible. The intrados of the elements were blasted with alumina power, then we applied K-Etchant gel, rinsed well and dried. A layer of silane was applied (CLEARFIL™ CERAMIC PRIMER PLUS) for 60 seconds* then dried.

Application of K-Etchant gel for 30 seconds on enamel. Surfaces were rinsed, dried, and the adhesive PANAVIA™ V5 Tooth Primer was applied, left for 20 seconds, then dried.

Restorations were bonded one by one with PANAVIA™ V5 Paste. The excess was removed and the final photo-polymerization using glycerin was performed.

A final polishing was performed with CLEARFIL™ TWIST DIA.

To conclude, the occlusion was verified in static position with cuspfossa contact, then laterality, propulsion, and finally mastication.

Final situation. We can observe a good and esthetic integration of the restorations. A long term follow-up should be necessary to confirm the success of the treatment.

FINAL SITUATION

“KATANA™ AVENCIA™ MAKES MY DAILY WORK EASIER… AND MY PATIENTS ARE HAPPY”

Dentist:

DR. CYRIL GAILLARD
DENTAL SURGEON AND CEO OF GAD-CENTER
PRIVATE PRACTICE, BORDEAUX

1998 Graduated from the University of Bordeaux
2000 CES Fixed Prostheses
2002 DU of Implantology, University of Bordeaux
2002 SAPO Implant
2003 Certificate Bone grafting
2006 of Maxillo Faciale Surgical Rehabilitation, Paris VII
CES of Anatomy Physiology
CES of Removable Prostheses

Case by Dr. Vincenzo Picciariello

Innovative single-shade composites are an attractive option at least for posterior restorations, as they allow clinicians to skip laborious steps and save time. Nevertheless, the aesthetic and functional demands are high. The following case example demonstrates how CLEARFIL MAJESTY™ ES-2 Universal performs in the clinical environment and reveals how well the material blends in with surrounding tooth structure.

A 33-year-old female patient came to the clinic with a request to replace amalgam restorations in the upper right quadrant (Fig. 1). The second molar had an occlusal carious lesion, while the amalgam restoration on the first molar showed marginal leakage most likely leading to secondary caries. After the placement of rubber dam (Fig. 2), the existing restorations were removed, revealing secondary caries in the first molar and the second premolar (Fig. 3). The cavities were finished using fine-grained diamond burrs and sonic instruments and subsequently sandblasted with 50-micron aluminium oxide in order to facilitate the adhesive procedures (Fig. 4). In this way, the surface energy, bonding surface area, and surface roughness are increased and the wetting ability of the adhesive is improved for a high-quality bond with the enamel and dentin.

Fig. 1. Pre-operative image.

Fig. 2. Isolation of the working field with rubber dam.

Fig. 3. Secondary caries visible after removal of the amalgam restorations.

Fig. 4. Completed cavity preparation with air-abraded bonding surfaces.

Wooden wedges, sectional matrices and relative separator rings were placed to transform the Class II MOD cavity of the first molar into a Class I cavity by means of the centripetal build-up technique (Fig. 5). On each tooth, selective etching of the enamel was performed with 35% phosphoric acid etching gel (K-ETCHANT Syringe, Kuraray Noritake Dental Inc.), which was removed by thorough rinsing and drying, before applying the two components of CLEARFIL™ SE BOND – the self-etching primer and the light-curing bonding agent. The bond was treated with a gentle stream of air to make a uniform surface and finally, the adhesive layer was light cured for 40 seconds. The procedure was completed with immediate dentin sealing using a flowable composite (CLEARFIL MAJESTY™ ES-FLOW Low in the shade A3) in controlled thicknesses.

The restoration of the cavities was completed using CLEARFIL MAJESTY™ ES-2 Universal (Kuraray Noritake Dental Inc.) in the only available posterior shade Universal. In order to characterize the fissures and enhance the appearance of the occlusal morphology, staining agent in the shade dark-brown was applied. CLEARFIL™ Twist DIA (Kuraray Noritake Dental Inc.) was the polishing system of choice. After polishing, the difference in colour between the restorations and the visibly dehydrated enamel surfaces could be observed (Fig. 6). Upon inspection after 30 days, the restorations showed adequate and satisfactory chromatic integration (Fig. 7).

Fig. 5. Wedges, sectional matrices and rings placed for build-up of the first molar’s proximal walls.

Fig. 6. Image taken immediately after polishing with dehydrated enamel and the rubber dam still in place.

FINAL SITUATION

Fig. 7. Picture of the treatment outcome taken after 30 days.

The treatment of this quadrant demonstrates how CLEARFIL MAJESTY™ ES-2 Universal composite is an integrative innovation to the Kuraray Noritake Dental Inc. line of composites that allows the clinician to simplify the modeling procedures for direct restorations in the posterior regions, obtaining excellent aesthetic and functional results.

Dentist:

DR. VINCENZO PICCIARIELLO

Graduated from the faculty of dentistry and dental prostheses of Bari in 2009; specialized in direct and indirect conservative dentistry. Completed his training in aesthetic adhesive restorative dentistry in Geneva by attending the Anterior Bio-Esthetic Restorations Master Program of Dr. Didier Dietschi. He perfected himself under the guidance of Dr. Salvatore Scolavino and Dr. Gaetano Paolone at WeRestore in Rome. Member of the Italian Academy of Conservative Dentistry. Author of national and international publications.

Speaker at national and international conferences on adhesive dentistry topics. Since 2009, he has been working as a freelancer in Bitonto, dedicating himself mainly to implant and periodontal surgery and to adhesive aesthetic restorative-prosthetic dentistry.

Fig. 1. Initial situation: caries lesions and insufficient restorations are detected on the occlusal surface of the second molar.

Fig. 2. Situation after placement of rubber dam for moisture control.

Fig. 3. Appearance of the teeth following caries removal and placement of sectional matrix.

Fig. 4. Etch-and-Rinse technique (Enamel for 30 sec. and Dentin for 15 sec.).

Fig. 5. Situation after rinsing. Etch patterns are visible in the enamel.

Fig. 6. Appearance of the teeth following application of CLEARFIL™ Universal Bond Quick.

Fig. 7. Cavity lining with a layer of flowable composite (CLEARFIL MAJESTY™ ES-Flow Low, A2).

Fig. 8. Occlusal view of the final restorations produced with CLEARFIL MAJESTY™ ES-2 Universal (U shade).

Fig. 9. Situation after rubber dam removal and occlusal adjustments.

FINAL SITUATION

Fig. 10. Follow-up after 7 days.

Case by Aleksandra Łyżwińska, DMD

This clinical case concerns a patient with a lesion on the occluso-distal aspect of the mandibular left first premolar. We opted for a direct treatment approach with a combination of flowable and high-viscosity composite resin (CLEARFIL MAJESTY™ ES Flow - Super Low A2, CLEARFIL MAJESTY™ ES-2 Classic A2). In order to establish a strong bond between the tooth structure and the restorative material, we decided to selectively etch the enamel and then apply a clinically proven self-etch adhesive (CLEARFIL™ SE BOND 2).

Fig. 1. Initial clinical situation.

Fig. 2. Appearance of the premolar after caries removal.

Fig. 3. Placement of a sectional matrix for anatomical shaping, the establishing of tight interproximal contacts and protection of the adjacent tooth.

Fig. 4. Appearance of the tooth structure after selective enamel etching.

Fig. 5. Interproximal wall built up with CLEARFIL MAJESTY™ ES-2 Classic (A2 shade) and cavity filled with CLEARFIL MAJESTY™ ES Flow - Super Low A2.

Fig. 6. After initial polishing.

FINAL SITUATION

Fig. 7. Occlusal view of the treatment outcome after finishing and polishing.

Fig. 8. Follow up after 1 week.

Dentist:

ALEKSANDRA ŁYŻWIŃSKA
Warsaw, Poland

Aleksandra Łyżwińska, DMD, is a passionate aesthetic and adhesive dentist. Driven by Evidence Based Dentistry, her goal includes using modern composite materials and bonding agents in her clinical practise. In addition to her primary job, she worked as a lecturer and an assistant professor at the Department of Conservative Dentistry and Endodontics of Medical University of Warsaw, her alma mater.

Case by Dr. Michał Pokojski

Universal resin composites with a simplified shade concept are popular as they streamline direct restoration procedures. Unfortunately, many of the available products that claim to blend in well with the surrounding tooth structure independent of its shade need a blocker or opaquer to mask dark areas. According to Kuraray Noritake Dental, CLEARFIL MAJESTY™ ES-2 Universal is different. This is why I decided to test its Universal shade (U) designed for all kinds of restorations in the posterior region in the context of replacing an amalgam restoration.

The restoration that needed to be replaced due to secondary caries was located in the maxillary molar region of a male patient. As usual under amalgam restorations, the remaining healthy tooth structure showed some discolouration. The cavity was prepared, the enamel etched and the whole bonding surface treated with CLEARFIL™ SE Bond. Subsequently, the restoration was built up using CLEARFIL MAJESTY™ ES-2 Universal in several layers. For a natural appearance, some brown tint was added to the fissures before finishing and polishing. The restoration shows a natural integration into the surrounding structure and is able to mask the discolouration on the cavity floor.

Fig. 1. Pre-operative image showing the amalgam restorations to be replaced.

Fig. 2. Appearance of the tooth after removal of the amalgam, caries excavation and cavity preparation.

Fig. 3. Tooth built up with CLEARFIL MAJESTY™ ES-2 Universal (U shade).

FINAL SITUATION

Fig. 4. Immediate treatment outcome.

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.

Clinical case by Dr Salvatore Scolavino

This video illustrates the recontouring treatment with dental light-cured restorative composite CLEARFIL MAJESTY ES-2.

Dentist:

DR SALVATORE SCOLAVINO

• Specialist in Asthetic Dentistry from Naples, Italy
• Member of the Styleitaliano group which focuses on minimally invasive dentistry techniques
• Private practice in Nola (NA)
• Active member SIDOC (Italian Society of Conservative Dentistry), IAED (Italian Academy of Esthetic Dentistry)
• Author and co-author of scientific publications on national and international journals
• Lecturer in national and international congresses and events

Case by Dr Adrien Lavenant

Introduction

The patient consulted for a follow-up examination and presented with recurrent caries at the maxillary right first molar. A direct treatment with composite needed to be performed. We decided to use Kuraray Noritake Dental Inc.´s CLEARFIL MAJESTY™ ES-2 Universal composite for several reasons: the efficiency of the treatment, favourable handling properties and ease of use.

The clinical case illustrations below show the step-by-step approach carried out during a 30-minute treatment session.

Fig. 1. Initial situation showing an occlusal caries lesion on the maxillary right first molar.

Fig. 2. Pre-operative X-ray.

Fig. 3. Isolation of the working field with rubber dam.

Fig. 4. Situation after caries excavation and tissue preparation.

Fig. 5. Cavity ready for the application of the universal composite: CLEARFIL™ Universal Bond Quick is visible on dentin and enamel and the cavity floor is covered by a thin layer of CLEARFIL MAJESTY™ ES Flow Low.

Fig. 6. Appearance of the tooth after buildup of the restoration with several layers of CLEARFIL MAJESTY™ ES-2 Universal composite (in the shade U developed for the posterior area).

Fig. 7. Stains applied in the occlusal fissures ensure an even more natural appearance.

Fig. 8. Final result after polishing with CLEARFIL™ Twist DIA and checking of the occlusion.

Fig. 9. Final result immediately after rubber dam removal.

Fig. 10. Post-operative X-ray.

FINAL SITUATION

Fig. 11. Check-up after 15 days with rehydrated dental tissues.

Dentist:

DR ADRIEN LAVENANT

Dr Adrien Lavenant obtained his DDS degree at the University of Aix-Marseille in 2010. He pursued his post-graduate education in the field of periodontology, restorative and aesthetic dentistry (University Aix-Marseille and Paris).

Dr Lavenant is a former member of the teaching staff of the University of Aix-Marseille since 2011 and he continues to teach in the postgraduate program in restorative and aesthetic dentistry.

Since 2010, he owns a private practice in Aix-en-Provence specialised in restorative, prosthetic and aesthetic implant dentistry. He has been part of the international Bio-emulation group since 2019 and shares his philosophy of patient care in accordance with the principles of biomimetic dentistry.

Case by Dr. Max Andrup

This patient presented with a fractured amalgam restoration in the occlusal aspect of the mandibular right first molar. The cavity was shallow resulting in a very favourable C-factor. The C-factor describes the relationship between bonded and unbonded restorative material surfaces and is used as an indicator for polymerization shrinkage stress development in a cavity. Hence, it is essential to manage this factor when working with resin composites.

Fig. 1. Initial situation with the fractured amalgam restoration. In the distal aspect of the restoration, some recurrent decay is also visible.

Fig. 2. First molar ready for a new restoration after removal of the amalgam and bevelling of the enamel.

Fig. 3. Selective etching of the enamel prior to the application of CLEARFIL™ SE Protect into the cavity. Selective etching is performed in order to maximize the bond strength to enamel (by etching) and to dentin (without etching).

FINAL SITUATION

Fig. 4. Final situation after restoration of the cavity with CLEARFIL MAJESTY™ ES-2 Universal in the shade U developed for posterior restorations. The favourable C-factor and the fact that the polymerization shrinkage stress produced by the selected material is very low provide the conditions for a good long-term behaviour of the new restoration.

Dentist:

Dr. 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. 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.

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.