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Dr. Onur Alp Yünük klinikinis atvejis 

PAŽANGIŲ TECHNOLOGIJŲ IR MEDŽIAGŲ DERINIMAS, KAD BŪTŲ PASIEKTI NUMATYTI REZULTATAI

Tiesioginės kompozito restauracijos yra aukštos kokybės gydymo pasirinkimas net ir tais atvejais, kai reikia atkurti daug danties audinio. Tai įmanoma dėl naujausių kompozitinių dervų ir adhezinių technologijų pasiekimų. Pasirinkus tinkamas medžiagas, sluoksniavimo technikas ir pasitelkus šiuolaikines skaitmenines spalvų analizės priemones, galima pasiekti itin estetiškus ir nuspėjamus rezultatus, kaip pavaizduota toliau pateiktame klinikinio atvejo pavyzdyje.

Iššūkis

Į mūsų kliniką kreipėsi jaunas vyras. Jis paprašė pakeisti esamas viršutinių kandžių (12 ir 11 dantys pagal FDI dantų žymėjimo sistemą) kompozito restauracijas. Klinikinė apžiūra parodė didelį šoninio kandžio restauracijos defektą. Be to, buvo pastebėta 11 danties anatominių nelygumų, spalvos pakitimų ir paviršinio blizgesio praradimas. Panašių spalvos ir paviršiaus poliravimo problemų aptikta ir gretimame centriniame kandyje.

Pasitarus su pacientu, buvo nuspręsta pakeisti esamas restauracijas naudojant šiuolaikinę kompozitinę medžiagą, specialiai sukurtą dviejų atspalvių sluoksniavimo technikai – „CLEARFIL MAJESTY™ ES-2 Premium"  („Kuraray Noritake Dental Inc.“). Siekiant tiksliai parinkti spalvą, buvo atlikta fotofiksacija su kryžminio poliarizavimo filtru ir be jo (1–4 pav.).

1 pav. Dantų vaizdas iš priekio, kuriame matyti didelis viršutinio žandikaulio dešinėn šoninio kandžio restauracijos praradimas

2 pav. Dantų nuotrauka su kryžminio poliarizavimo filtru, leidžianti detaliai analizuoti spalvinius nelygumus

3 pav. Dantų vaizdas iš šono

4 pav. Šoninis vaizdas – kryžminio poliarizavimo nuotrauka

Sprendimas

Pašalinus esamas restauracijas, darbinio lauko izoliacijai buvo uždėta koferdamo. Prieš formuojant gomurinį emalio sluoksnį (sienelę) su „CLEARFIL MAJESTY™ ES-2 Premium“ (A1E atspalvis), pritaikyta savaiminio ėsdinimo adhezinė sistema („CLEARFIL™ SE Bond 2“, „Kuraray Noritake Dental Inc.“), naudojant selektyvaus emalio ėsdinimo metodą (5 ir 6 pav.). Mamelonų struktūros atkurtos naudojant „CLEARFIL MAJESTY™ ES-2 Premium“ (A1D atspalvis), opalescencijos zonai suformuoti naudotas melsvas skaidrus atspalvis. Galiausiai rezultatas individualizuotas naudojant geltoną ir baltą pigmentus. 7 pav. pateikiamas vaizdas prieš, o 8 pav. – po galutinės apdailos ir poliravimo.

5 pav. Gomurinė sienelė suformuota naudojant pasirinkto kompozito A1E emalio atspalvį

6 pav. Dantų vaizdas iš šono restauravimo procedūros metu

7 pav. Restauracija prieš galutinį apdirbimą ir poliravimą

8 pav. Restauracijų vaizdas po galutinio apdirbimo ir poliravimo

Rezultatas

Galutiniam spalvos integravimui įvertinti buvo padaryta dar viena nuotrauka su kryžminio poliarizavimo filtru, naudojant pilką kalibravimo etaloninę kortelę (9 ir 10 pav.). Restauruotų dantų vaizdas iš šono (11 pav.) atskleidžia, kad aukštos estetinės kokybės rezultatui pasiekti reikalingas ne tik tinkamas spalvų derinys, bet ir natūrali paviršiaus tekstūra.

9 pav. Restauruotų dantų vaizdas iš priekio, užfiksuotas naudojant kryžminio poliarizavimo filtrą

10 pav. Kalibravimas naudojant pilką etaloninę kortelę ir gautos restauracijos L*a*b* koordinatės

11 pav. Restauruotų dantų vaizdas iš šono, pabrėžiantis paviršiaus tekstūros svarbą

DISKUSIJA IR IŠVADA

Stebėjimas, pasitelkiant modernius fotografijos ir vaizdo analizės įrankius (tokius kaip poliarizuoti filtrai ir L*a*b koordinatės), yra svarbus įgūdis, būtinas tikroviškai dantų rekonstrukcijai tiesioginėmis kompozitinėmis medžiagomis. Šį įgūdį derinant su puikių charakteristikų kompozito sistema, pasižyminčia nustatytais atspalvių deriniais ir inovatyvia šviesos sklaidos technologija, užtikrinančia puikų susiliejimą su aplinkiniais danties audiniais, estetiškų restauracijų kūrimas tampa nuspėjamu procesu.

Aprašytu klinikiniu atveju pacientas liko labai patenkintas rezultatu – tiek estetine išvaizda, tiek atkurtų dantų funkcija. Restauracijų kokybė vertinama per reguliarias patikras – jos vis dar pasižymi puikia funkcine ir estetine integracija.

Dentist:

Apie autorių 

Dr. Onur Alp Yünük baigė bakalauro ir doktorantūros studijas Stambulo universitete. Šiuo metu jis dirba Istinye universiteto Odontologijos fakulteto restauracinės odontologijos katedros docentu. Savo darbe dr. Yünük daugiausia dėmesio skiria priekinių dantų tiesioginėms kompozitinėms restauracijoms ir polichrominėms sluoksniavimo sistemoms.

By Dr Wiktor Pietraszewski BSC(HONS) DMD

INTRODUCTION

According to personal experience, the cementation of glass ceramic veneers is one of the most stressful and technique-sensitive procedures in restorative dentistry. This is not only due to the minimal margin for error, but also the high aesthetic standards that must be met to deliver a result satisfying both clinician and patient. Modern protocols emphasize conservative preparation, ideally remaining entirely within enamel, or at the very least, minimising extension into dentin. It is essential to understand that both preparation design and extent should not be planned in isolation. Instead, they must be carefully co-planned through thorough communication and collaboration between clinician and technician, ensuring the final result is both biologically respectful and aesthetically predictable.

THE CASE

The case to be discussed today is rather unique in that it arose unexpectedly, without the luxury of typical pretreatment planning steps such as a diagnostic wax-up or mock-up. These were omitted due to time and budget constraints on the patient’s part — a reality many clinicians can relate to. The rationale behind this approach will become clearer as we progress through the case. The patient is a 70-year-old retiree, whom I have been managing for several years. Treatment thus far has focused on stabilising and gradually improving her posterior restorations, with the longer-term aim of addressing the anterior dentition to enhance both function and aesthetics.

Nowadays, financial considerations often pose a significant barrier to patients accepting comprehensive treatment plans from the outset. As such, effective communication and phased treatment planning become essential tools in fostering patient trust and long-term commitment. This particular visit was an emergency appointment, with the patient presenting with a fractured porcelain veneer on her maxillary left central incisor — tooth 21 according to the FDI notation (Fig. 1). Fortunately, because of the existing phased approach to her care, we were well-positioned to transition into an aesthetic restorative phase with minimal resistance or hesitation from the patient.

Fig. 1. Pre-operative view - emergency: Chipped existing ceramic veneer.

Fig. 2. The plan - Digital Smile Design - 4 x porcelain veneers - 4 x direct composite restorations.

THE PLAN

After careful discussion, it was decided to remove and replace the four existing porcelain veneers and to replace four existing Class V stained composite restorations with fresh new direct composite (Fig. 2). Everyone involved was happy with the plan, sure it would adequately fulfil the patient’s aesthetic expectations and even surpass them. At the emergency appointment, time was so limited that only the temporary restoration of the chip with direct composite was feasible. Time was an important factor going forward: the patient wanted to proceed and have the case completed as soon as possible.

Main features of the Digital Smile Design (DSD) plan

1. Lengthening - central incisors – incisal edges to reflect the length of the canine tips
2. Equal gingival zeniths
3. Masking of the cervical defects

PREPARATION, SCAN & TEMPORISATION

The first step involved building up the teeth using a flowable composite to create a rough direct mock-up (Fig. 3), guided by the DSD plan (Fig. 2). This mock-up provided a visual and functional prototype, of which an impression was taken to aid in the fabrication of interim temporary restorations for the provisional phase of treatment.

Preparations were carried out using OptraGate isolation. The existing veneers were first removed using high-grit diamond burs at high speed. Once the bulk of the old material was cleared, gingival retraction was achieved using retraction cord, allowing for improved visibility and access. The preparations were then refined with lower-grit diamond burs at a reduced speed to ensure precision and tissue safety. The primary objectives of the preparation phase were to establish harmonious gingival zeniths and to adequately cover the cervical defects that were evident in the previous restorations (Figs. 4 and 5).

Fig. 3. Mock-up made of flowable composite.

Fig. 4. Class V composite restorations replaced on teeth 13, 23, 24 and 25.

Fig. 5. Situation after preparation of the maxillary incisors.

CEMENTS

Traditionally, glass ceramic veneers have been cemented successfully using a vast array of different luting resins available on the market.

Recently, a trend towards the use of flowable resin or heated composite to cement glass ceramic restorations has emerged. Like the abovementioned approach, this option is viable and literature-supported. The benefits of using flowable resin or a heated paste-type composite resin have been widely documented. The probably biggest advantage of this approach arises from the fact that the user is already familiar with the shades of the material used for cementation. Composite shades are often specified using the VITA classical A1 - D4 system, which dental professionals tend to be more accustomed to than to shade descriptions used for resin cements, like Warm, Light, Neutral and the like.

Some resin cement systems offer try-in pastes corresponding to the shades of the cement to overcome this obstacle and allow for precise shade evaluation at try-in to accurately aid in selecting the best cement shade available. PANAVIA™ Veneer LC is a popular example, as it matches the shades of PANAVIA™ V5 Try-In Pastes (Fig. 6).

Fig. 6. PANAVIA ™ V5 Try-in Paste Universal (A2).

Using a cement shade that matches the intended final appearance is crucial when bonding glass-ceramic veneers, as it decisively affects both immediate and longterm aesthetics. This is especially important due to the light-diffusion properties of glass-ceramic materials such as IPS e.max CAD or IPS e.max Press (Ivoclar Vivadent). Restorations can be as thin as 0.3 mm in minimally invasive cases. The thinner the restoration, the more translucent the material, and the greater the cement’s appearance will influence the final outcome.

Of course, the shade of the prepared tooth substantially influences cement shade selection, as well as decisions about the final restoration thickness (and thus preparation depth) and the ceramic translucency selected (IPS e.max, for example, is available in three translucency levels – LT [Light], MT [Medium], and HT [High]; Fig. 7). When the abutments are dark and a bright, white appearance is desired for the final restorations, it is wise to use a ceramic block with lower translucency. This is why taking a photograph of the prepared teeth and sending it to the ceramist is so important. In the present case, the pepared tooth structure appeared quite dark in the incisial third, so that the medium translucency variant of IPS e.max CAD in the determined shade A1 was selected, which would allow for a minimal thickness and a natural outcome.

Fig. 7. Whitewash photograph used to demonstrate the translucent properties of glass ceramic veneers.

PANAVIA™ VENEER LC

PANAVIA™ Veneer LC is a light curing resin cement. Therefore, it is indicated for ceramic and composite restorations with less than 2mm thickness. It comes in four shades – Clear, White, Universal (A2) and Brown (Fig. 8) – with matching PANAVIA™ V5 Try-In Pastes. These pastes facilitate the simulation of the restorations’ final appearance (Fig. 9). The cement system consists of four components (Fig. 10).

Fig. 8. PANAVIA™ Veneer LC Paste shades.

Fig. 9. Matching PANAVIA™ V5 Try-In Paste shades.

Fig. 10. The kit consists of phosphoric acid etchant, resin cement paste, universal ceramic primer and tooth primer.

TRY-IN

Upon delivery of the four lithium disilicate veneers in the selected translucency and shade (MT A1; Fig. 11), it was time to select the resin cement shade for try-in. As a bright result that would still match the colour of the adjacent teeth was desired, the shade of choice was Universal (A2). Patient and practice team were happy with the simulated treatment outcome (Fig. 12), so that the veneers were cleaned and pre-treated for definitive placement.

Fig. 11. Lab work delivered: Lithium disilicate porcelain veneers - medium translucency, shade A1.

Fig. 12. Try-in with PANAVIA™ V5 Try-In Paste Universal (A2).

CEMENTATION STEPS

For adhesive cementation of the veneers, the teeth were isolated with latex-free rubber dam (Isodam HD in thickness Heavy Gauge; Fig. 13a). Clamps were placed and the veneers tried in to check the fit once more (Figs. 13b and c).

Subsequently, the tooth surfaces were pretreated, starting with the central incisors: Protecting the adjacent teeth with a metal strip, the surfaces were first treated using air abrasion with 35-micron aluminium oxide powder (Fig. 14a). Once the surface was rough (Fig. 14b), phosphoric acid etching gel was applied to the sandblasted surface for 15-30 seconds (Fig. 14c). After thorough rinsing and drying of the etched surfaces, the adjacent lateral incisors were isolated with PTFE tape to facilitate excess cement clean-up during the adhesive luting procedure (Fig. 14d).

Fig. 13a. Isolation with latex-free rubber dam.

Fig. 13b. Further retraction with B4 clamps for dry try-in.

Fig. 13c. Fit check with clamps in place to ensure full seating of the veneers.

Fig. 14a. Air-abrasion with 35-micron aluminium oxide powder.

Fig. 14b. Result of the air abrasion procedure.

Fig. 14c. Total etching with 37% phosphoric acid.

Fig. 14d. PTFE tape placement on lateral incisors to simplify clean-up.

The actual cementation steps included priming of the tooth structure with PANAVIA™ V5 Tooth Primer, which is strong on enamel and dentin (Fig. 15a), leaving it for 20 seconds and then drying with mild air. The veneers’ intaglio surfaces were treated with hydrofluoric acid for 20 seconds and - after complete removal of the etchant - primed with CLEARFIL™ CERAMIC PRIMER PLUS (Fig. 15b) and dried. Now, it was time to apply the cement paste (PANAVIA™ Veneer LC) onto the pre-treated ceramic surfaces and seat the veneers carefully (Figs. 15c and d). During placement, gentle but firm pressure is ideally applied using a soft, padded instrument to ensure accurate seating. When using light-cure (LC) resin cements, tack-curing can often be avoided: Excess cement can be carefully brushed away prior to curing, avoiding flash and reducing clean-up. The resin promotes an excellent marginal blend between tooth and restoration, enhancing both the aesthetic and functional integration of the veneers. For light-curing, the restoration margins were covered with glycerine gel to prevent formation of an oxygen inhibition layer (Fig. 15e).

Fig. 15a. Priming of the tooth structure.

Fig. 15b. Etching and priming of the intaglio surfaces of the veneers.

Fig. 15c. Seating of a veneer with a cushioned instrument.

Fig. 15d. Two veneers simultaneously placed on the central incisors.

Fig. 15e. Restoration margins covered with glycerin gel for thorough light-curing from all sides.

The veneers for the lateral incisors were cemented likewise; however, floss was used instead of clamps for gingival retraction (Figs. 16a and b).

Fig. 16a. Gingival retraction for veneer placement on the lateral incisors.

Fig. 16b. Floss is used for a clampless procedure.

The above-mentioned sequenced placement procedure – starting with the central incisors and then moving on to the laterals - is highly recommended: This protocol gives the practitioner full control over the positioning of the central incisor veneers, which is particularly important as their position has a massive impact on the overall appearance of the smile. When the lateral incisor veneers are cemented first, the risk of positioning errors in the central incisor region and resulting catastrophic aesthetic issues is increased. However, any error with the positioning of the central incisor veneers can also lead to problems like the misfit of the lateral incisor veneers. Therefore, the whole procedure needs to be carried out with utmost care and precision.

A robust curing protocol with palatal, incisal and facial light exposition is crucial to ensure that the resin cement is fully set. Figures 17a to c show the veneers in place. Controlled removal of any residual excess was accomplished with ultrahigh molecular weight polyethylene (UHMWPE) floss (Gorilla Floss) used to avoid damaging the margins. For final polishing of the ceramic-tooth interface, polishing rubbers were employed. Rubber dam remained stable throughout the procedure.

The immediate treatment outcome is shown in Figure 18. It is completely normal for the gums to appear red and feel slightly sore following cementation. This is a temporary response, which should improve quickly as the tissue begins to heal. With a consistent and proper oral hygiene routine, the soft tissues will recover fully over the coming days. This has to be communicated to the patient well following rubber dam removal.

Fig. 17a. Lateral incisor veneers after placement and excess removal.

Fig. 17b. All four ceramic veneers in place.

Fig. 17c. Appearance of the veneers after floss removal.

Fig. 18. Immediate post-operative appearance.

Fig. 19. Check-up after three weeks.

FINAL SITUATION

Fig. 20a. Final photographic records: Frontal view.

Fig. 20b. Final photographic records: Lateral view from the left.

Fig. 20c. Final photographic records: Lateral view from the right.

Fig. 20d. Final photographic records: Occlusal view.

FOLLOW-UP VISIT

A check-up appointment is crucial in that it allows clinicians to assess the state of the soft tissue, which was fully recovered in the present case after three weeks (Fig. 19). Even more importantly, however, it enables us to check how our patients are adapting to their new smiles. This is also the best time to take a final photographic record (Figs. 20a to d). At this appointment, it is also essential to check for any excess material left interproximally: It can result in chronic inflammation, leading to persistent redness and an unaesthetic appearance of the final restorations. By careful inspection of the restorations from the occlusal view, it is possible to make sure all excess is removed and optimal gingival health is maintained.

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Clinical case by Dr Manuel Tinto

Nowadays, minimally invasive techniques aimed at preserving healthy tooth structure are favoured for the direct restoration of teeth in the posterior region. Universal materials used in this context make it possible to reduce the chair time while supporting high-quality aesthetic and functional results.

The following case example illustrates the combined use of Caries Detector, CLEARFIL™ Universal Bond Quick 2, CLEARFIL MAJESTY™ ES Flow Universal Low and Super Low, and CLEARFIL MAJESTY™ ES-2 Universal (all Kuraray Noritake Dental Inc.) for the treatment of two interproximal lesions on the maxillary right second premolar and first molar (FDI notation: teeth # 15 and 16; Fig. 1).

Fig. 1. Pre-operative photograph.

To guide the selective removal of carious dentin, Caries Detector was used, allowing visual distinction between infected and affected dentin (Figs. 2 and 3). Excavation was performed dry, at low speed, using a Cera-Bur bur until complete removal of the dye. This resulted in clean, non-geometric cavities (Fig. 4).

Fig. 2. Application of Caries Detector.

Fig. 3. The more intense the colour, the more carious the tissue.

Fig. 4. Finished and cleaned cavities.

After matrix placement (Figs. 5 and 6), a universal adhesive (CLEARFIL™ Universal Bond Quick 2) was applied (Fig. 7). This product produces a thin film and offers excellent wettability, making it particularly suitable in the presence of undercuts. We prefer an adhesive approach with selective enamel etching for 15 seconds. CLEARFIL MAJESTY™ ES Flow Universal Low (Fig. 8) was placed on the cavity floor to level out irregularities, followed by reconstruction of the interproximal walls using CLEARFIL MAJESTY™ ES-2 Universal paste. The Quad Matrix system allows both walls to be shaped simultaneously.

Fig. 5. Matrices in place and double-ended wedge (Quad Matrix) to improve the cervical seal on both matrices.

Fig. 6. Quad Matrix ring in position.

Fig. 7. Application of CLEARFIL™ Universal Bond Quick 2 after selective enamel etching (15 s).

Fig. 8. Placement of CLEARFIL MAJESTY™ ES Flow Universal (U) Low as a cavity liner.

The Class I cavity was completed by layering two materials:

• CLEARFIL MAJESTY™ ES Flow Universal (UD) Super Low for deep and difficult-to-reach areas, simulating dentin.
• CLEARFIL MAJESTY™ ES-2 Universal for the final layer, thanks to its handling, strength and aesthetics. The universal shade blends in perfectly with the surrounding structure (Figs. 9 to 11).

Fig. 9. Restorations carried out using a combination of flowable composite and paste composite.

Fig. 10. Finished restorations refined and polished under rubber dam.

Fig. 11. Finished restorations after checking of the occlusal contacts.

FINAL CONSIDERATIONS

Caries Detector allows selective removal of infected dentin while preserving healthy tooth structure. CLEARFIL™ Universal Bond Quick 2 provides for optimal penetration even in complex cavities. The combination of CLEARFIL MAJESTY™ ES-2 and ES Flow materials provides precise filling, natural aesthetics and long-term durability. Finally, the utilization of universal materials simplifies the clinical protocol, resulting in predictable, minimally invasive and long-lasting restorations.

Clinical case by Dr Luca Alibrandi

In the field of aesthetic dentistry, achieving natural, durable and predictable results requires the use of advanced materials, precise instruments and clinical expertise. Thanks to its versatility and the included innovative technology, CLEARFIL MAJESTY™ ES Flow Universal (Kuraray Noritake Dental Inc.) supports clinicians in standardising aesthetic rehabilitation even in complex cases (Figs 1–3).

Fig. 1. Initial situation with multiple diastemas in the maxillary anterior region. The patient does not wish to undergo indirect veneer therapy.

Fig. 2. Patient with a deep bite and atypical swallowing, which has caused flaring, particularly in the maxillary left anterior region. The patient refuses orthodontic treatment.

Fig. 3. Detail of the maxillary anterior region.

CLEARFIL MAJESTY™ ES Flow Universal is a monochromatic flowable composite that simplifies colour management thanks to its guided shade system, supporting aesthetic harmony without the complexity of multiple shades. Available in two levels of viscosity (Low and Super Low), it offers excellent handling for different restorative areas.

The Low version (75 wt%, 59 vol%) has a flexural strength of 151 MPa and a compressive strength of 373 MPa. It is ideally suited for anterior areas and for injection into IVENEER matrices, thanks to its easy handling and long-lasting gloss. Radiopacity (140% Al) provides for visibility on follow-up radiographs.

The Super Low version, with a filler content of 78 wt% (60 vol%) and radiopacity of 150% Al, has a flexural strength of 152 MPa and compressive strength of 374 MPa. Ideal for posterior sectors, it offers durability and resistance even under high functional loads.

The optimised syringe design supports precise dispensing, reducing waste and facilitating application. Both formulations allow easy polishing and long-lasting shine.

Combined use with IVENEER matrices (Fig. 4) makes it possible to precisely shape incisal morphology, creating an ideal contour and a protected environment that improves surface polymerisation (Fig. 5). The result is a stronger, glossier and more durable restoration. Flowable composites facilitate adaptation of shape and correction of natural proportions, contributing to a harmonious outcome.

The composite veneers can subsequently be refined using subtractive or additive techniques (Figs. 6 to 8), adapting to situations such as wide and irregular diastemata, simplifying the workflow and improving the final result.

Fig. 4. IVENEER in position under rubber dam: these innovative matrices, used with conventional isolation, provide a highly effective seal to prevent contamination during the injection phase.

Fig. 5. Polymerisation is always started on the palatal side to allow resin contraction towards the enamel and to increase adhesion of direct restorations.

Fig. 6. The polishing phase is facilitated by the creation of an environment that helps limit the oxygen-inhibited layer via the matrices. In this case, however, subtractive modelling of the elements is required to recreate overall harmony.

Fig. 7. Post-injection situation.

Fig. 8. Surface texturing with longitudinal morphological characterisations to improve coronal proportions.

Fig. 9. Detailed view of the central incisors after polishing.

FINAL CONSIDERATIONS

The combined use of CLEARFIL MAJESTY™ ES Flow Universal and IVENEER matrices represents a significant advancement in aesthetic incisor restoration. The composite’s properties (strength, handling and gloss), together with the preformed matrices, allow natural, high-quality results to be achieved in reduced treatment times. Thanks to the new technique, even patients with financial limitations can access effective treatments and regain their smile (Fig. 9).

Case by Dr. Onur Alp Yünük

Beautiful teeth, a bright, flawless smile: Meeting the aesthetic demands of patients asking for veneer treatment can be challenging. While some patients share concrete ideas on how their new teeth should look, it is more difficult for others to express their expectations. In this case, it is important to select a treatment approach that allows for modifications – be it in the form of an extended planning phase including digital smile design or by placing composite restorations that can be easily modified intraorally.

The latter approach was selected for a young female patient who presented to our clinic as she was dissatisfied with her composite veneers that had been placed on the upper incisors (Figs. 1 to 4). During intraoral examination, it became evident that the existing restorations on her maxillary incisors and canines had irregular, rough surfaces, discoloured margins and compromised structural integrity of the composite material. In accordance with these findings, removing the existing restorations at the maxillary anterior teeth and re-establishing optimal aesthetic and functional integrity with new direct composite restorations were planned (teeth between #13 - #23 according to the FDI notation). The patient stated that she would like us to add more individuality and character to her teeth and have a brighter smile than with her existing restorations.

Fig. 1. Composite veneers on the maxillary incisors showing aesthetic and functional integrity issues.

Fig. 2. Occlusal view of the maxillary anterior teeth with visible defects in the composite veneers.

Fig. 3. Lateral view from the right revealing surface irregularities.

Fig. 4. Lateral view from the left revealing a large debonded and chipped area.

REPLACEMENT OF THE COMPOSITE VENEERS

To reproduce the translucency characteristics of the patient’s natural teeth and fulfil her aesthetic demands, the use of a polychromatic layering system and a dual-layer technique was planned. This would allow for a nice play of translucencies in the anterior area.

During the shade selection phase, the Bilaminar Shade Assessment Technique (BSAT) was employed, which is based on the color combination of dentin and enamel composites. In this technique, the intended enamel shade was stratified over the target dentin chroma to evaluate the resultant shade created by the two composite color layers. The materials were polymerized on the tooth surface without bonding agents; thus, the cumulative color perception resulting from stratification, rather than the individual shades of the materials, was verified for harmony with the natural tooth structure at the onset of treatment. Photos were taken with a camera equipped with a cross-polarized filter (Fig. 5). Subsequently, the fixed retainer was removed, as were the existing composite veneers. To save as much of the underlying healthy tooth structure as possible, the procedure was performed under magnification and blue-light illumination. The selected instruments were red- and yellow-band diamond burs as well as tungsten carbide burs. Figure 6 shows the result of the procedure.

Fig. 5. Shade determination – image taken with the aid of a cross-polarizing filter that eliminates reflections.

Fig. 6. Teeth after the removal of the deficient composite veneers.

The teeth were isolated using rubber dam, which was secured with floss in the cervical area. Then, restoration procedures were initiated on the teeth. After etching of the enamel and application of a self-etching bonding agent (CLEARFIL™ SE Bond 2, Kuraray Noritake Dental Inc.), CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.) was applied: The dentin core with its pronounced mamelons was modelled using the shade A1D. The incisal edges and mamelons were highlighted with spots of white tint. To create an opalescent effect, a thin layer of the translucent shade Blue was placed on top, while the enamel parts were built up with the enamel shade WE. Since the retainer had been removed, a clear aligner was fabricated and delivered to the patient at the end of the session for use until the subsequent appointment.

Fig. 7. Isolation with rubber dam for restoration of the lateral incisors and canines.

Fig. 8. Vestibular enamel layer applied to the teeth.

Fig. 9. Shape and shade of the restorations created according to the patient’s expectations.

After finishing and polishing with Twist DIA for composite, the patient was sent home and a new appointment was made for re-evaluation and final adjustments.

In the control appointment, the patient asked us to slightly reduce the incisal translucencies and brightness in her maxillary incisors and alter the shape of all restored teeth: She requested longer maxillary central incisors with softer, more rounded line angles and a smoother incisal contour. Rubber dam was placed again. Then, the vestibular surfaces of the composite restorations on the maxillary incisors were reduced slightly using red- and yellow-band diamond burs. To roughen the surface and enhance the topography for optimal micromechanical interlocking, the composite surface was sandblasted with 50-μm aluminium oxide particles. Phosphoric acid etchant, silane and CLEARFIL™ SE Bond 2 were applied sequentially as part of the adhesive protocol. The restorations were then modified by lengthening, shade correction using CLEARFIL MAJESTY™ ES-2 Premium in the shades A1D and A1E and refining of the anatomical contours (Figs. 10 and 11).

Fig. 10. Modification of the central incisor restorations.

Fig. 11. Modified smile with more regular tooth forms and contours as well as a more natural tooth shade.

During this final appointment, the patient expressed that she was very happy with her new smile. The restoration surfaces were re-polished, a new retainer was bonded and final photographs were taken (Figs. 12 to 16).

Fig. 12. Final treatment outcome – frontal view.

Fig. 13. Final treatment outcome – occlusal view.

Fig. 14. Final treatment outcome – lateral view.

Fig. 15. Final treatment outcome – the patient’s smile.

Fig. 16. Detailed view of the inner colour structure – made visible with the aid of a polarized filter.

CONCLUSION

Talking to patients about every detail of the treatment and listening attentively to their ideas, expectations and demands does not always protect us from adjustments – simply because they need to see what they get to be able to judge if they like it. Luckily, selecting appropriate materials and techniques enables dental practitioners to create new smiles that can be modified without harming healthy tooth structure, so that making even the most demanding patients happy is no longer a challenge.

Clinical case by Dr. Giuseppe Iacona

The Flowable Injection Technique represents an innovative and predictable approach for the direct aesthetic restoration of one or more teeth in a single appointment (Fig. 1). This methodology, resulting from close collaboration between clinician and technician, allows reproducible results from the very first intervention, offering patient comfort and long-term durability.

In the case presented, the patient wished to close a diastema between the mandibular central incisors (teeth #31 and 41 according to the FDI notation; Fig. 1). Following clinical, radiographic and periodontal assessment, the injection technique was selected, ruling out orthodontic treatment and veneer solutions.

Fig. 1. Extraoral photographs of the patient: initial situation.

The technique involves the injection of flowable composite through a transparent index (made of silicone or 3D-printed resin), produced from a digital or conventional mock-up (Figs. 1 to 2). It represents a viable treatment option thanks to the combination of advanced composite materials and digital technology.

Intraoral and facial scans were taken to create digital models of the patient’s maxilla and mandible (Fig. 2). Matching the scans made it possible to virtually simulate the initial situation. Based on this dataset, a wax-up was generated and converted into a 3D-printed model and a putty index for wax-up transfer into an intra-oral mock-up.

Transferred into the patient’s mouth through injection of the material into the index, the mock-up (Fig. 3) allowed aesthetic and functional evaluation by providing a preview of the final outcome.

Fig. 3. Mock-up in the patient’s mouth.

Subsequently, the two direct veneers were fabricated using the Flowable Injection Technique in a single appointment (Fig. 4). After placing gingival retraction cords with astringent gel (Fig. 5), isolation with PTFE tape was performed and the surfaces were etched (Figs. 6 and 7), followed by application of the adhesive CLEARFIL™ Universal Bond Quick 2 (Kuraray Noritake Dental Inc., Fig. 8).

Fig. 4. Baseline.

Fig. 5. Application of retraction cords soaked in astringent gel.

Fig. 6. Isolation of adjacent teeth with dental PTFE tape.

Fig. 7. Etching with phosphoric acid etchant.

Fig. 8. Application of CLEARFIL™ Universal Bond Quick 2.

Fig. 9. Injection indices.

Fig. 10. Placement of the injection index.

Fig. 11. Final treatment outcome.

FINAL CONSIDERATIONS

CLEARFIL MAJESTY™ ES Flow Universal (Kuraray Noritake Dental Inc.) stands out for its excellent aesthetic properties, high compressive and flexural strength, and outstanding blend-in ability. Its translucency characteristics, which vary according to thickness, allow for a polychromatic effect using a single material, particularly in the universal variant. The material’s chameleon effect supports seamless colour integration with adjacent teeth, making the restoration indistinguishable from natural tooth structure. This provides for long-term durability, a low incidence of fractures and highly satisfactory results, making it ideal for addressing a wide range of aesthetic and functional requirements.

Case by Jotautas Kaktys, DDS

Post-endodontic restorative treatments can be quite challenging, mainly because so many decisions need to be made. It is up to the clinician to evaluate the structural condition of the tooth to decide whether a direct or indirect restoration should be selected, which cusps to overlay and which ones to keep, and whether a post or fiber placement is required. Depending on the amount and condition of remaining tooth structure, a direct or indirect restorative approach may be more adequate; while selecting the indirect approach means they have the choice between lots of different restorative materials and restoration designs.

A CASE AS AN EXAMPLE

At our &SMILE clinic in Kaunas, Lithuania, the main goal is always to preserve as much natural tooth structure as possible without compromising the longevity of the restoration. Consequently, we opt for the least invasive approach reasonable, thereby using materials that mimic the mechanical and optical properties of the natural dentition. In this context, hybrid ceramics such as KATANA™ AVENCIA™ Block 2 are often a valuable choice.

The following case is used as an example to demonstrate the biomimetic approach in a situation that required an endodontic revision followed by an indirect restoration of the tooth that had previously been restored with composite.

STRUCTURALLY COMPROMISED MOLAR RESTORATION

The patient came in for a regular routine checkup. A massive composite restoration on her maxillary right first molar (FDI notation: tooth #16) attracted our attention as it appeared to be structurally compromised: Clinical examination revealed some occlusal porosities along the restoration margin, as well as cracked and chipped areas (Fig. 1). The buccal margin was stained and leaky (Fig. 2), while on the palatal surface, some micro-cracks were visible in the surrounding tooth structure (Fig. 3).

Fig. 1. Initial clinical situation with a large composite restoration that shows porosities at the margin.

Fig. 2. Buccal surface of the first molar with a stained, leaky margin.

Fig. 3. Palatal surface with micro-cracked tooth structure.

As the tooth had been endodontically treated elsewhere several years ago, a radiograph was taken (Fig. 4). This radiograph revealed that the canals were not filled to the apices of the roots. However, as the patient showed no symptoms, the decision was made to go for an indirect restoration without any endodontic retreatment: Reasons to opt for an indirect restoration included the large size of the existing composite restoration and the compromised condition of the surrounding tooth structure. Cementing indirect restorations offers additional benefits of virtually no polymerization shrinkage as well as minimal stress to the remaining and already compromised tooth structure and results in better mechanical properties. The tooth shade was determined immediately: The adjacent premolar had a tooth shade resembling A3 in the middle third, while the occlusal third showed some whitish spots and appeared brighter, similar to A2 (Fig. 5). This information was recorded for the dental laboratory.

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

INTRODUCTION

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

CLINICAL CASE

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

RESULTS

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

DISCUSSION

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

CLINICAL CASE

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

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

Fig. 1. Initial clinical situation.

TREATMENT PLANNING

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

Fig. 2. Computer-aided index design.

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

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

OPERATIVE PROCEDURE

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

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

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

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

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

Fig. 7. Application of a universal adhesive.

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

Fig. 9. Flowable composite injection.

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

Fig. 10. Restored teeth isolated with PTFE tape.

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

Fig. 12. Application of the universal adhesive.

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

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

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

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

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

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

CLINICAL RESULTS

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

Fig. 18. Treatment outcome.

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

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

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

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

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

DISCUSSION

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

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

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

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

CONCLUSION

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

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

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Watanabe K, Tanaka E, Kamoi K, Tichy A, Shiba T, Yonerakura K, Nakajima M, Han R, Hosaka K. A dual composite resin injection molding technique with 3D-printed flexible indices for biomimetic replacement of a missing mandibular lateral incisor. J Prosthodont Res. 2024 Oct 16;68(4):667-671. doi: 10.2186/jpr.JPR_D_23_00239.

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Hulac S, Kois JC. Managing the transition to a complex full mouth rehabilitation utilizing injectable composite. J Esthet Restor Dent. 2023 Jul;35(5):796-802. doi: 10.1111/jerd.13065.

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

SANTRAUKA

Šis klinikinis atvejis pristato tiesioginę restauraciją kompozitu šoninių dantų srityje, atliktą naudojant Kuraray Noritake Dental Inc. “Universal Excellence”  produkto koncepciją. Siekiant paprastumo ir nuspėjamumo, buvo naudojamas universalus klijai (CLEARFIL™ Universal Bond Quick 2) ir labai užpildytas, universalios spalvos tekantis kompozitas (CLEARFIL MAJESTY™ ES Flow Universal) Žingsnis po žingsnio dokumentacija parodo izoliaciją, ertmės paruošimą, gilų krašto pakėlimą, klijų protokolą ir galutinę restauraciją.

ATVEJO APRAŠYMAS

38 metų moteris kreipėsi dėl kraujavimo tarp dantų ir jautrumo šaltam tarp viršutinio kairiojo ilčio ir pirmojo premoliaro (dantys Nr. 23 ir Nr. 24, FDI žymėjimas). Klinikinis tyrimas parodė atvirą kraštą ir antrinį kariesą danties Nr. 23 esamo restauracijos dantenų dugne. Po izoliavimo guminiu užtvaru, buvo pradėta laipsniška gydymo procedūra.

KLINIKINĖ PROCEDŪRA

1 etapas. 23 dantis turėjo atvirą dantenų kraštą ir kariesą (1 pav.).

2 etapas. Pašalinus emalį, kariesas buvo išvalytas iki dantenų lygio. Buvo pastebėta, kad 24 danties pažeidimas išsiplėtė po dantenomis (2 pav.).

3 etapas. Po visiško karieso išvalymo ir ertmės išlyginimo tapo akivaizdu, kad 24 danties kraštas turi būti pakeltas (DME) (3 pav.).

4 etapas. 24 danties kraštas buvo pakeltas (DME) naudojant specialiai pagamintą sekcinį pleištą. Pirmiausia buvo atliktas selektyvus ėsdinimas ir užteptas CLEARFIL™ Universal Bond Quick 2, po to uždėtas CLEARFIL MAJESTY™ ES Flow Universal (Super Low) (4–6 pav.).

5 etapas. Baigus DME (giluminį krašto pakėlimą), buvo uždėtos atitinkamos matricos juostos, po to tiesiogiai atstatyti 23 ir 24 dantys naudojant CLEARFIL MAJESTY™ ES Flow Universal (Super Low) (7–9 pav.). Dėka medžiagos lengvo naudojimo, spalvos pritaikymo ir puikaus poliravimo, šis sudėtingas DME atvejis buvo sėkmingai ir efektyviai išspręstas.

Gydymo rezultatas parodytas 10 ir 11 pav.

1 pav.: Vaizdas prieš operaciją, izoliavus dantų ertmę koferdamu

2 pav.: Klinikinė situacija po karieso išvalymo

3 pav.: Išvalytos ertmės su giliu kraštu ant premoliaro

4 pav.: Individualus pleištas, skirtas pakelti kraštą

5 pav.: Dantų vaizdas iš burnos pusės po gilaus krašto pakėlimo universaliais produktais

6 pav.: Dantų okliuzinis vaizdas po gilaus krašto pakėlimo universaliais produktais

7 pav.: Sekcinės matricos padėties nustatymas

8 pav.: Dantų, restauruotų universalios spalvos labai mažo klampumo kompozitu, vaizdas iš burnos pusės

9 pav.: Dantų, restauruotų universalios spalvos tekančiu kompozitu, okliuzinis vaizdas

10 pav.: Galutinio dantų #23 ir #24 restauracijos vaizdas iš viršaus, kuriame matoma spalvų dermė, anatominė forma ir paviršiaus blizgesys.

11 pav.: Galutinis dantų Nr. 23 ir Nr. 24 restauravimas, matomas iš burnos pusės, parodantis spalvų derėjimą, anatominę formą ir paviršiaus blizgesį.

DISKUSIJA

Universalūs klijai ir modernūs tekantys kompozitai supaprastina tiesioginį šoninių dalies restauravimą, sumažindami technikos jautrumą ir užtikrindami ilgalaikius rezultatus. Šiuo atveju CLEARFIL™ Universal Bond Quick 2 užtikrino stiprų sukibimą per trumpą laiką. Universalus tekantis kompozitas pasižymėjo puikiu prisitaikymu, poliravimu ir ilgaamžiškumu. Net ir esant subgingivaliam kraštui, reikalaujančiam DME, buvo pasiektas supaprastintas metodas, nepakenkiant kokybei.

IŠVADA

CLEARFIL™ Universal Bond Quick 2 ir CLEARFIL MAJESTY™ ES Flow Universal  derinys leidžia gydytojams atlikti nuspėjamus ir efektyvius užpakalinių dantų restauravimus. Jų universalus pritaikomumas ir naudojimo savybės atitinka „Universal Excellence“ koncepciją, palengvinančią kasdienę praktiką ir užtikrinančią jos patikimumą.

Etika ir informacijos atskleidimas

Visos procedūros buvo atliktos pagal standartinę stomatologinę praktiką. Pacientas davė sutikimą dėl gydymo ir anonimizuotų klinikinių vaizdų publikavimo. Autorius bendradarbiauja su „Kuraray Noritake Dental Inc.“ kaip patarėjas; turinys atspindi klinikinę patirtį.

Dentist:

KORAY KENDIR

Dt. Koray Kendir yra Hacettepe universiteto Stomatologijos fakulteto absolventas ir privačios stomatologijos klinikos Izmire įkūrėjas. Jis specializuojasi skaitmeninėje stomatologijoje, šypsenos dizaino ir kompiuterizuotuose restauraciniuose gydymuose. Žinomas dėl savo novatoriško požiūrio, dr. Kendir dažnai skaito pranešimus nacionaliniuose stomatologijos kongresuose ir yra patarėjas keletui stomatologijos įmonių.

By Dr Wiktor Pietraszewski BSC(HONS) DMD

INTRODUCTION

According to personal experience, the cementation of glass ceramic veneers is one of the most stressful and technique-sensitive procedures in restorative dentistry. This is not only due to the minimal margin for error, but also the high aesthetic standards that must be met to deliver a result satisfying both clinician and patient. Modern protocols emphasize conservative preparation, ideally remaining entirely within enamel, or at the very least, minimising extension into dentin. It is essential to understand that both preparation design and extent should not be planned in isolation. Instead, they must be carefully co-planned through thorough communication and collaboration between clinician and technician, ensuring the final result is both biologically respectful and aesthetically predictable.

THE CASE

The case to be discussed today is rather unique in that it arose unexpectedly, without the luxury of typical pretreatment planning steps such as a diagnostic wax-up or mock-up. These were omitted due to time and budget constraints on the patient’s part — a reality many clinicians can relate to. The rationale behind this approach will become clearer as we progress through the case. The patient is a 70-year-old retiree, whom I have been managing for several years. Treatment thus far has focused on stabilising and gradually improving her posterior restorations, with the longer-term aim of addressing the anterior dentition to enhance both function and aesthetics.

Nowadays, financial considerations often pose a significant barrier to patients accepting comprehensive treatment plans from the outset. As such, effective communication and phased treatment planning become essential tools in fostering patient trust and long-term commitment. This particular visit was an emergency appointment, with the patient presenting with a fractured porcelain veneer on her maxillary left central incisor — tooth 21 according to the FDI notation (Fig. 1). Fortunately, because of the existing phased approach to her care, we were well-positioned to transition into an aesthetic restorative phase with minimal resistance or hesitation from the patient.

Fig. 1. Pre-operative view - emergency: Chipped existing ceramic veneer.

Fig. 2. The plan - Digital Smile Design - 4 x porcelain veneers - 4 x direct composite restorations.

THE PLAN

After careful discussion, it was decided to remove and replace the four existing porcelain veneers and to replace four existing Class V stained composite restorations with fresh new direct composite (Fig. 2). Everyone involved was happy with the plan, sure it would adequately fulfil the patient’s aesthetic expectations and even surpass them. At the emergency appointment, time was so limited that only the temporary restoration of the chip with direct composite was feasible. Time was an important factor going forward: the patient wanted to proceed and have the case completed as soon as possible.

Main features of the Digital Smile Design (DSD) plan

1. Lengthening - central incisors – incisal edges to reflect the length of the canine tips
2. Equal gingival zeniths
3. Masking of the cervical defects

PREPARATION, SCAN & TEMPORISATION

The first step involved building up the teeth using a flowable composite to create a rough direct mock-up (Fig. 3), guided by the DSD plan (Fig. 2). This mock-up provided a visual and functional prototype, of which an impression was taken to aid in the fabrication of interim temporary restorations for the provisional phase of treatment.

Preparations were carried out using OptraGate isolation. The existing veneers were first removed using high-grit diamond burs at high speed. Once the bulk of the old material was cleared, gingival retraction was achieved using retraction cord, allowing for improved visibility and access. The preparations were then refined with lower-grit diamond burs at a reduced speed to ensure precision and tissue safety. The primary objectives of the preparation phase were to establish harmonious gingival zeniths and to adequately cover the cervical defects that were evident in the previous restorations (Figs. 4 and 5).

Fig. 3. Mock-up made of flowable composite.

Fig. 4. Class V composite restorations replaced on teeth 13, 23, 24 and 25.

Fig. 5. Situation after preparation of the maxillary incisors.

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