Case by Dr. Clarence P. Tam, HBSC, DDS, AAACD, FIADFE

Case background

A stable ASA 2 65 year old female presented to the practice for restorative dentistry with a medical history significant for a non-descript immunoglobulin deficiency, for which she receives regular infusions. She reports no known drug allergies. Clinically, she was diagnosed with an occlusal peripheral rim fracture leaving a food trap on tooth 14 (FDI notation). Tooth 15 featured an extensive amalgam with extreme proximity to the distal marginal ridge, which exhibited distal vertical axial fractures as a result of cyclic expansion-contraction over time. The restorative goal of minimally invasive direct dentistry would be complicated by the undoubtedly dark dentin substrate under the amalgam. A material was sought that featured both an excellent chameleon mechanism as well as physical properties to maximize the prognosis of direct restorations in this area.

Restorative procedure

The patient was subjected to topical anesthetic prior to buccal infiltration using 1 carpule of 2% Lignocaine with 1:100,000 epinephrine. A rubber dam was affixed prior to preparation of tooth 15MO with dissection of the distal vertical marginal ridge fracture. The margins of tooth 14O and 15MOD were refined before bevelling as the ends of enamel rods facilitate better bonding relative to the sides of enamel rods. A 27 micron aluminum oxide micro air abrasion treatment was completed prior to affixing, wedge and matrix to reconstruct the mesial marginal ridge of tooth 15. A matrix-in-matrix solution was used to recreate the proximoaxial contour of 15D. This provided hermetic closure at the proximogingival cavosurface margin as well as an ideal contour for the missing axial wall.

Following a total etch technique, a 2% Chlorhexidine scrub was completed for 30 seconds and the dentin blot dried to a moist state. A 5th generation bond was applied, air thinned and cured as per manufacturer instructions. Microlayers are important during the delicate first 5 minutes of hybrid layer formation, and were completed using 0.25 mm increments of CLEARFIL MAJESTY™ Flow (Kuraray Noritake Dental Inc.). This technique can be expected to increase significantly the shear bond strength to dentin^1,2.

This was completed both in the proximal box floor area as well as mid-occlusally. The marginal ridge was completed using CLEARFIL MAJESTY™ ES-2 Universal (Kuraray Noritake Dental Inc.). Since the dentin base was heavily stained, CLEARFIL MAJESTY™ Flow was used before utilizing CLEARFIL MAJESTY™ ES-2 Universal in a lobe-by-lobe creation of occlusal anatomy. Post-operative occlusal checks verify that the restoration is conformative to occlusion and esthetically excellent with no visible marginal show.

Rationale for material choice

The marginal ridges were micro-layered horizontally as was the floor of the resulting Class I preparation as per a reduced layer thickness-technique modification of Nikolaenko et al³, whereas the highest shear bond strengths were found when a 1mm horizontal layering technique was used.

CLEARFIL MAJESTY™ ES-2 Universal is at the forefront of a simplified restorative armamentarium for the modern practice. It takes cloud-shading one step further by offering a “Universal” shaded composite featuring Light Diffusion Technology (LDT) with simultaneous ideal sculptability, optical metamerism and physical properties for use in any restorative situation in the mouth. Featuring barium glass nano fillers and proprietary pre-polymerized nanoparticle fillers, the latter boasts a high refractive matrix that is able to disperse light and fool the eye with even the thinnest of layers, obviating the need for opaquer composites in cases like the one featured. When paired with CLEARFIL MAJESTY™ Flow in a conservative layered technique, the 81% filled flowable produces a radiographically well-demarcated layer, and the superficial CLEARFIL MAJESTY™ ES-2 Universal boasts an easy-to-polish robust single shade restorative solution that will virtually fulfil all of your restorative needs for non-bleaching patients. Physically, with compressive strength is rated at 348 MPa and flexural strength at 116 MPa, CLEARFIL MAJESTY™ ES-2 Universal is in the range of natural enamel and dentin. The built-in fluorescence is very enamelomimetic, which is excellent for nightclub social situations.

FINAL SITUATION

Dentist:

DR CLARENCE P. TAM, HBSC, DDS, AAACD, FIADFE

Clarence is originally from Toronto, Canada, where she completed her Doctor of Dental Surgery and General Practice Residency at the University of Western Ontario and the University of Toronto, respectively. Clarence’s practice is limited to cosmetic and restorative dentistry and she is well-published to both the local and international dental press, writing articles, reviewing and developing prototype products and techniques in clinical dentistry. She frequently and continually lectures internationally. Clarence is the Immediate Past Chairperson of the New Zealand Academy of Cosmetic Dentistry.

She is currently one of two individuals in Australasia to hold Board-Certified Accredited Member Status with the American Academy of Cosmetic Dentistry. Clarence is an Opinion Leader for multinational dental companies Kuraray Noritake, J Morita Corp, Henry Schein NZ, Ivoclar Vivadent, Dentsply Sirona, 3M, Kerr, GC Australasia, SDI and Coltene and is the only Voco Fellow in Australia and New Zealand. She holds Fellowship status with the International Academy for DentoFacial Esthetics and is a passionate and approachable individual, committed to having an interactive approach with patients in all of her cases to maximize predictability.

References

1. Bertschinger C, Paul SJ, Luthy H, Scharer P. Dual application of dentin bonding agents: effect on bond strength. Am J Dent. 1996;9(3):115-119.
2. Magne P, Kim TH, Cassione D, Donovan TE. Immediate dentin sealing improves bond strengths of indirect restorations. J Prosthet Dent. 2005;94(6):511-519.
3. Nikolaenko SA, Lohbauer U, Roggendorf M, Petschelt A, Dasch W, Franenberberger R. Influence of C-Factor and layering technique on microtensile bond strength to dentin. Dental Mater. 2004;20(6):579-585.

Case by Dr. Aleksandra Łyżwińska, Warsaw, Poland

ABSTRACT

Indirect overlays are the contemporary restoration standard for posterior teeth with extensive hard tissue loss. They provide for cuspal coverage, which decreases the likeliness of coronal and/or root fracture. At the same time and in contrast to crowns, overlay preparations minimize the removal of sound tooth structure especially in the cervical region, which is a critical factor.¹ Modern dental resin composites allow for direct cuspal coverage in a single-visit appointment. The results of in-vitro studies suggest that these direct overlays are a suitable alternative to their indirect counterparts in specific situations.^2-6 The following case report is used to describe the direct restoration procedure by means of a maxillary right molar with an extensive, deep MOD lesion.

INTRODUCTION

In the context of treating a tooth with an extensive carious lesion, a biomechanical risk assessment should be performed. The primary method of reducing the likeliness of tooth fracture is treatment with a restoration that provides cuspal coverage. The contemporary gold standard for biomechanically compromised teeth are adhesively cemented overlays as an alternative to crowns.¹ Another option that does not involve labwork is a direct overlay restoration.^2-6 The direct approach is especially suitable for long-term temporization, which may be required during orthodontic treatment, for example.

CLINICAL CASE

The 40-year-old male patient was referred to my office before an orthodontic and prosthetic treatment. Intraoral examination (Figs. 1 and 2) revealed:

• Tetracycline discolouration,
• Multiple extensive composite restorations with marginal leakage,
• Primary and secondary carious lesions, and
• Significant mechanical weakness^7,8 (mesio-occluso-distal (MOD) cavities, cusp loss, cracks).

Fig. 1. Initial situation – extensive MOD composite resin restoration.

Fig. 2. Initial situation – unacceptable contact points, palatal wall crack line.

Based on a clinical and radiological examination (Fig. 3), it was decided to restore the maxillary right first molar with a direct overlay, which should serve as a long-term temporary for the duration of orthodontic treatment. Once the local anaesthetic had been administered, rubber dam was placed in the first quadrant and the cusps of the affected first molar were reduced. For subgingival tooth preparation, a rubber dam sheet was temporarily moved behind the second upper molar (Fig. 4). In order to obtain a good emergence profile of the restoration and a tight fit of the sectional matrix, the gingivectomy was performed with an electric surgical knife (Surtron 50D, LED SPA) (Fig. 5). The main advantages of a diathermal cut are instant tissue coagulation and hemostasis⁹.

Fig. 3. Bite-wing radiograph: Maxillary fist molar with an overhang and negative profile of the distal wall.

Fig. 4. Initial preparation with reduction of the cusps and exposure of gingiva.

Fig. 5. Gingivectomy performed using a surgical electric knife.

In accordance with the European Society of Endodontology’s guidelines on the management of deep caries¹⁰, the deepest part of the cavity was cleaned in full rubber dam isolation (Nic Tone Dental Dam, MDC Dental) (Fig. 6). Carious-tissue excavation was carried out using round burs, then the enamel and dentin were air-abraded with 50-μm aluminum oxide (Microetcher IIa, Danville). Multiple cracks, penetrating through the enamel and partially the dentin, occurred within the mesial and palatal walls. The presence of cracks crossing the dentin-enamel junction is an absolute indication to cuspal coverage^8,11.

An appropriate rubber dam isolation is essential in adhesive dentistry. Beyond the obvious advantage of a clean operation field uncontaminated by saliva and moisture, the rubber dam contributes to keeping periodontal tissues at a distance form a tooth. In order to ensure both, maximum retraction and sufficient space to work, the rubber dam was inverted (introduced to the gingival sulcus) and stabilized using PTFE tape (Fig. 7). The mesial wall was restored using a blue 3D Composite-Tight 3D Fusion matrix ring (Garrison) and a medium standard Sectional Contoured Metal Matrix (TOR VM, Fig. 8). Due to its extensiveness and shape, restoration of the distal wall was more difficult to perform.

Fig. 6. Rubber dam newly placed in the interproximal area. Full isolation is essential for the excavation of the infected dentin in the deepest part of the cavity.

Fig. 7. PTFE tape placement for improving isolation in the gingival area. Al₂O₃ sandblasting.

Fig. 8. Mesial matrix fit.

The first attempt to adapt an elongated Sectional Contoured Metal Matrix and the green 3D Composite-Tight 3D Fusion (Garrison) ended with failure (Fig. 9). The matrix was changed for a longer and more curved one (Fig. 10). The ring was replaced by a smaller Palodent V3 Ring (Dentsply Sirona, Fig. 11). Due to the depth of the carious lesion, an antibacterial adhesive system was used (CLEARFIL™ SE Protect, Kuraray Noritake Dental Inc.). It contains the MDPB monomer, which offers an antibacterial effect that lasts even after hybrid layer formation^12-14. Furthermore, the fluoride included in the bond liquid intensifies the cariostatic mechanism of CLEARFIL™ SE Protect and supports the so-called “Super Dentin” formation¹⁵.

Fig. 9. Insufficient fit of the distal matrix.

Fig. 10. New, longer and more curved matrix in place.

Fig. 11. Different matrix ring placed in the distal area.

After polymerization of the bonding agent, the nanohybrid flowable composite resin (CLEARFIL MAJESTY™ ES Flow High, Kuraray Noritake Dental Inc.) was applied in a thin layer. The proximal wall was restored using both packable (CLEARFIL MAJESTY™ ES-2 Universal, Kuraray Noritake Dental Inc.) and flowable composite resin (CLEARFIL MAJESTY™ ES Flow Super Low, Kuraray Noritake Dental Inc.) (Figs. 12 and 13). Core build-up was performed with bulk-fill type composite. The cusps were reconstructed free-hand with the previously used CLEARFIL MAJESTY™ ES-2 Universal (Figs. 14 and 15). The universality of this product provides for a good optical integration and blending with the adjusted tissue, regardless of the colour of the underlying tooth structure. The fissures were gently highlighted using brown tints.

Fig. 12. Thin layer of flowable composite resin CLEARFIL MAJESTY™ ES Flow High (A2) applied on the cavity floor. The proximal walls are built up with build-up by CLEARFIL MAJESTY™ ES-2 Universal and CLEARFIL MAJESTY™ ES Flow Super Low (A2).

Fig. 13. Proximal walls build-up – palatal view.

Fig. 14. Core build-up. Free-hand cusp coverage with CLEARFIL MAJESTY™ ES-2 Universal, palatal view.

Fig. 15. Cusp coverage – occlusal view.

The initial polishing was performed with the rubber dam still in place. The excesses of composite resin were removed with the aid of abrasive discs, diamond burs and a “Brownie” polisher (BAL, Nevadent). Pre-polishing and high-shine polishing were executed with TWIST™ DIA for Composite (Kuraray Europe GmbH.) supported by a goat hair brush (Micerium) (Figs. 16 to 17).

Fig. 16. Occlusal surface after surface modeling with CLEARFIL MAJESTY™ ES-2 Universal and initial polishing.

Fig. 17. Occlusal surface after modeling with CLEARFIL MAJESTY™ ES-2 Universal and initial polishing – palatal view.

After removal of the rubber dam, the occlusal contact points of the direct overlay were adjusted (Figs. 18 and 19). Every spot touched by the burr was subsequently repolished according to the previously described protocol (Figs. 20 and 21).

Fig. 18. Occlusal adjustment. Contact points recorded with articulation paper (100 μm).

Fig. 19. Occlusal adjustment. Contact points recorded with articulation paper (100 μm= and articulation foil (16 μm).

Fig. 20. Final effect after polishing with TWIST™ DIA for Composite.

FINAL SITUATION

Fig. 21. Final effect – palatal view.

CONCLUSION

As a result of decades of improvements mainly with regard to the filler density and polishability, modern dental composites offer a great gloss retention and favourable wear properties. In addition, polymerization shrinkage has been decreased due to the integration of nanohybrid filler technology. Those features allow us to restore biomechanically compromised teeth using a direct restoration technique.

Direct overlays are a suitable alternative for a conventional indirect restoration in many situations.^18,19 According to researchers, the advantages of direct restorations with cuspal coverage include minimal tooth preparation, vital pulp-oriented treatment, the possibility to treat patients in a single appointment and a potentially lower cost of the treatment.^18-20 However, it should be emphasized that the presented technique requires advanced restorative skills that need to be acquired first before starting to implement it.

Dentist:

DR. ALEKSANDRA ŁYŻWIŃSKA
Warsaw, Poland

Dr. Aleksandra Łyżwińska is a restorative dentist. She graduated from the Warsaw Medical University in 2017, where she was an assistant professor at the Department of Conservative Dentisyty and Endodontics. Her focus lies in modern adhesive techniques, resin composites and biomaterials.

REFERENCES

1. Dietschi D, Duc O, Krejci I, Sadan A. Biomechanical considerations for the restoration of endodontically treated teeth: a systematic review of the literature--Part 1. Composition and micro- and macrostructure alterations. Quintessence Int. 2007 Oct;38(9):733-43.
2. van Dijken JW. Direct resin composite inlays/onlays: an 11 year follow-up. J Dent. 2000 Jul;28(5):299-306. doi: 10.1016/s0300-5712(00)00010-5. PMID: 10785294.
3. Mondelli RF, Ishikiriama SK, de Oliveira Filho O, Mondelli J. Fracture resistance of weakened teeth restored with condensable resin with and without cusp coverage. J Appl Oral Sci. 2009 May-Jun;17(3):161-5.
4. Deliperi S, Bardwell DN. Multiple cuspal-coverage direct composite restorations: functional and esthetic guidelines. J Esthet Restor Dent. 2008;20(5):300-8; discussion 309-12.
5. Deliperi S, Bardwell DN. Clinical evaluation of direct cuspal coverage with posterior composite resin restorations. J Esthet Restor Dent. 2006;18(5):256-65; discussion 266-7.
6. Mincik J, Urban D, Timkova S, Urban R. Fracture Resistance of Endodontically Treated Maxillary Premolars Restored by Various Direct Filling Materials: An In Vitro Study. Int J Biomater. 2016;2016:9138945.
7. Reeh ES, Messer HH, Douglas WH. Reduction in tooth stiffness as a result of endodontic and restorative procedures. J Endod. 1989 Nov;15(11):512-6.
8. Banerji S, Mehta SB, Millar BJ. The management of cracked tooth syndrome in dental practice. Br Dent J. 2017 May 12;222(9):659-666.
9. Bashetty K, Nadig G, Kapoor S. Electrosurgery in aesthetic and restorative dentistry: A literature review and case reports. J Conserv Dent. 2009 Oct;12(4):139-44.
10. European Society of Endodontology (ESE) developed by:, Duncan HF, Galler KM, Tomson PL, Simon S, El-Karim I, Kundzina R, Krastl G, Dammaschke T, Fransson H, Markvart M, Zehnder M, Bjørndal L. European Society of Endodontology position statement: Management of deep caries and the exposed pulp. Int Endod J. 2019 Jul;52(7):923-934.
11. Lynch CD, McConnell RJ. The cracked tooth syndrome. J Can Dent Assoc. 2002 Sep;68(8):470-5.
12. Hashimoto M, Hirose N, Kitagawa H, Yamaguchi S, Imazato S. Improving the durability of resindentin bonds with an antibacterial monomer MDPB. Dent Mater J. 2018 Jul 29;37(4):620-627.
13. Imazato S, Kinomoto Y, Tarumi H, Torii M, Russell RR, McCabe JF. Incorporation of antibacterial monomer MDPB into dentin primer. J Dent Res. 1997 Mar;76(3):768-72.
14. Imazato S, Kinomoto Y, Tarumi H, Ebisu S, Tay FR. Antibacterial activity and bonding characteristics of an adhesive resin containing antibacterial monomer MDPB. Dent Mater. 2003 Jun;19(4):313-9.
15. Nakajima M, Okuda M, Ogata M, Pereira PN, Tagami J, Pashley DH. The durability of a fluoride-releasing resin adhesive system to dentin. Oper Dent. 2003 Mar-Apr;28(2):186-92.
16. Bore Gowda V, Sreenivasa Murthy BV, Hegde S, Venkataramanaswamy SD, Pai VS, Krishna R. Evaluation of Gingival Microleakage in Class II Composite Restorations with Different Lining Techniques: An In Vitro Study. Scientifica (Cairo). 2015;2015:896507.
17. Oficjalne informacje producenta Kuraray Noritake Dental https://www.kuraraynoritake.eu/pl/clearfil-majesty-es-flow (dostęp 08.02.2022).
18. Angeletaki F, Gkogkos A, Papazoglou E, Kloukos D. Direct versus indirect inlay/onlay composite restorations in posterior teeth. A systematic review and meta-analysis. J Dent. 2016 Oct;53:12-21.
19. Dhadwal AS, Hurst D. No difference in the long-term clinical performance of direct and indirect inlay/onlay composite restorations in posterior teeth. Evid Based Dent. 2017 Dec 22;18(4):121-122.
20. Banerji S, Mehta SB, Millar BJ. Cracked tooth syndrome. Part 2: restorative options for the management of cracked tooth syndrome. Br Dent J. 2010 Jun;208(11):503-14.
21. Opdam NJ, Roeters JJ, Loomans BA, Bronkhorst EM. Seven-year clinical evaluation of painful cracked teeth restored with a direct composite restoration. J Endod. 2008 Jul;34(7):808-11.
22. van Dijken JW. Direct resin composite inlays/onlays: an 11 year follow-up. J Dent. 2000 Jul;28(5):299-306.

The vacation period is over and we all are slowly returning back to our everyday routines and work. With all the travel and holidays in the last months you might have missed this great article in the LabLine Summer edition: Graftless solutions and implant-supported monolithic zirconia fixed prostheses.

It is an extensive, beautiful and detailed case report created and documented by team of well known and respected KOLs: Fortunato Alfonsi, Antonio Barone, Marco Stoppaccioli, Romeggio Stefano and Vincenzo Marchio.

Check it out by clicking here.

LAMINATE VENEER RESTORATION
USING LITHIUM DISILICATE

WITH PANAVIA™ Veneer LC (Clear)
Case by Yohei Sato (DMD, PhD) and Keisuke Ihara (CDT)

Fig. 1 The patient visited would like to have the a aesthetics
of the maxillary right and left lateral incisors improved.

Fig. 2 A silicon guide fabricated from a diagnostic wax model
was applied and the necessary clearances were determined.

Fig. 3 Since the lateral teeth are microdonts, the
preparation of each abutment was completed by simply
exposing a fresh enamel surface to be covered with
laminate veneers.

Fig. 4 A layer of porcelain was applied on the lithium
disilicate substrate, to complete the laminate veneers.

Fig. 5 The veneer was conditioned according to the
prosthesis‘ IFU. After trial fitting, the intaglio surface of the
laminate veneer was cleaned with KATANA™ Cleaner.

Fig. 6 CLEARFIL™ CERAMIC PRIMER PLUS was applied and
dried to prime the restoration.

Fig. 7 The preparation was cleaned with KATANA™ Cleaner.
Applied and rubbed for more than 10 seconds. Then, it
was washed off sufficiently (until the cleaner color had
completely disappeared), and dried with compressed air.

Fig. 8 K-ETCHANT Syringe was applied and left for 10
seconds before water-rinsing and compressed air-drying.

Fig. 9 PANAVIA™ V5 Tooth Primer was applied and left for 20
seconds before mild compressed-air drying.

Fig. 10 PANAVIA™ Veneer LC Paste was applied to the
intaglio surface of the laminate veneer.

Fig. 11 The laminate veneer was seated and the fit
checked. Then, the excess cement was tack-cured (not
more than 1 second at each point) and removed. Finally,
the restoration was light-cured and finished.

FINAL SITUATION

Fig. 12 The laminate veneer restorations one month after
placement. The morphology and color of the right and
left lateral incisors have been improved, providing a good
balance to the entire anterior dentition.

LAMINATE VENEER RESTORATION
USING KATANA™ Zirconia STML

WITH PANAVIA™ Veneer LC (Clear)
Case by Yohei Sato (DMD, PhD) and Keisuke Ihara (CDT)

Fig. 1 The patient was referred by an orthodontist. The main
complaints were improper aesthetics of the teeth due to dark
triangles betwen the teeth and incisal wear.

Fig. 2 On the basis of the pre-treatment diagnosis using
a mockup, the teeth were prepared, with keeping in mind
that the enamel should be preserved to the maximal extent
possible.

Fig. 3 A fixation retainer was present at the palatal side,
making it difficult to take coventional silicon impressions.
Therefore, an intraoral scanner was used.

Fig. 4 A layer of porcelain was applied to each KATANA™
Zirconia STML laminate veneer to complete the restorations.
The inner surface of each restoration was sandblasted, being
careful to prevent chipping.

Fig. 5 After trial fitting, bonding inhibiting substances as
blood and saliva were removed using KATANA™ Cleaner.

Fig. 6 CLEARFIL™ CERAMIC PRIMER PLUS was applied and
dried using compressed air.

Fig. 7 The surface of each tooth was cleaned and treated
with K-ETCHANT Syringe for 10 seconds before washing it
away with water and drying with compressed air.

Fig. 8 PANAVIA™ V5 Tooth Primer was applied and left f

Fig. 9 PANAVIA™ Veneer LC Paste was applied and the
laminate veneers were seated. For this case, we placed six
veneers during one session.

Fig. 10 The unpolymerized excess paste was removed with
a brush according to the wet clean-up technique.

Fig. 11 The result after final light curing. Since the excess
cement was easily removed, there were almost no cement
residues.

FINAL SITUATION

Fig. 12 Result one month after placement of the laminate
veneer restorations. The marginal gingiva has been improved
thanks to the good fit of the laminate veneer restorations.

Case by CDT Daniele Rondoni

When planning to replace Class II restorations, many things need to be considered. In order to select the most appropriate restorative technique and preparation design, it is essential to evaluate the amount and state of the remaining tooth structure, first. After repeated restoration replacement or in teeth originally restored with amalgam, for example, the remaining walls and cusps are often weakened and prone to fractures and cracks. When the cavity walls appear to be too thin or the structure is weak at the time of restoration replacement, it may be better to remove walls and cusps and opt for indirect adhesive restorations (overlays) instead of direct composite restorations. Due to favourable material properties – in particular a high flexural and compressive strength while being gentle to the opposing dentition and not too rigid for the surrounding tooth structures – we often opt adhesive restorations made of KATANA™ AVENCIA™ Block in those situations.

The following clinical case is used to describe the replacement of two composite restorations with overlays made of the innovative hybrid ceramic material.

Fig. 1. Initial clinical situation with composite restorations on the second premolar and first molar in need of replacement. The tooth structure particularly of the first molar was weak, with the distobuccal cusp already fractured.

Fig. 2. Prepared tooth structure ...

Fig. 3. Restorations milled from a KATANA™ AVENCIA™ Block after high-gloss polishing and characterization.

Fig. 4. Finalized restorations on a resin model.

Fig. 5. Adhesively cemented restorations in the patient’s mouth.

FINAL SITUATION

Fig. 6. Treatment outcome with a nice transition from the tooth structure to the restoration.

Dentist:

DANIELE RONDONI, MDT

Born in Savona in 1961 where he lives and has worked in his own laboratory since 1982 with his collaborators. Graduated from the dental technician school IPSIA “P. Gaslini” in Genoa in 1979. He continued his education by attending relevant workshops for the “Italian dental school“ and broadened his professional experience in Switzerland, Germany and Japan. Since 2011 Kuraray Noritake Dental International Instructor.

Case by Dr. Jusuf Lukarcanin

Restoring posterior cavities is a standard task we perform virtually every day. Yet, it is a challenging procedure as access to the affected teeth is often limited. This fact complicates many steps from working field isolation to material application and sculpting. By streamlining procedures and establishing protocols that are followed every time, it is possible to achieve predictable outcomes even in difficult situations, as shown below.

Fig. 1. Class II cavity in a second molar after caries removal and cavity preparation.

Fig. 2. Working field isolation.

Fig. 3. Application of adhesive (e.g. CLEARFIL S³ BOND PLUS) into the cavity.

Fig. 4. Build-up of the proximal wall with CLEARFIL MAJESTY™ ES-2 Classic (Kuraray Noritake Dental Inc.) in the shade A2.

Fig. 5. Build-up of the dentin core using the incremental technique with CLEARFIL MAJESTY™ ES-2 Premium in the shade A2D.

Fig. 6. Contouring of the occlusal enamel layer made of CLEARFIL MAJESTY™ ES-2 Premium in the shade A2E.

Fig. 7. Polishing of the restoration with Twist DIA for Composite.

FINAL SITUATION

Fig. 8. Treatment outcome.

Dentist:

DR. JUSUF LUKARCANIN

Dr. Jusuf Lukarcanin is a Certified Dental Technician (DCT) and a Doctor of Dental Science (DDS). He studied dentistry at the Ege University Dental Faculty in Izmir, Turkey, where he obtained a Master‘s degree in 2011. In 2017, he received a Ph.D. degree from the Department of Restorative Dentistry of the same university. Between 2012 and 2019, Dr. Lukarcanin was the head doctor and general manager at a private clinic in Izmir. Between 2019 and 2020, he worked at Tinaztepe GALEN Hospital as a Restorative Dentistry specialist, between 2020-2022 he worked at MEDICANA International Hospital Izmir as a Restorative Dentistry specialist. Currently he is an owner of a private clinic for aesthetics and cosmetics in Izmir.

Compact, time-saving and aesthetic

How many different shades of composite do you need to create appealing restorations in virtually every clinical situation? If you opt for “CLEARFIL MAJESTY™ ES-2” Universal shade concept, a few shades will do the trick.

With wonderful support of our internationally recognized key opinion leaders, we have prepared a Clinical Case brochure of “CLEARFIL MAJESTY™ ES-2” Universal for you. The brochure highlights a variety of clinical cases in the anterior and posterior region to show the all about excellent properties of our latest composite. Let the pictures speak for themselves!

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Start Reading: Special MAJESTY ES-2 Universal - Clinical Cases Brochure

DR. NIKOLA SKOTI
KLĪNISKAIS GADĪJUMS

Atjaunojot sānu zobus ar kompozīta materiālu, tādi funkcionālie aspekti kā cieši un anatomiski pareizi proksimālie kontakti un dabiskas formas okluzālā virsma, kas ir nodilumizturīga un antagonistiem
draudzīga, ir pat svarīgāki par perfektu optisko integrāciju. Tāpēc zobārstiem šādos gadījumos nevajadzētu tērēt daudz laika toņu izvēlei, bet gan pievērsties faktoriem, kas ietekmē restaurācijas uzticamību un ilgmūžību. CLEARFIL MAJESTY™ ES-2 Universal kompozīta materiāls ar vienu universālu toni (U) sānu zobu rajonam ir izcili piemērots šādiem gadījumiem, jo vairs nav nepieciešams noteikt toni pēc krāsu skalas un izvēlēties no dažādiem materiāliem. Tajā pašā laikā, tas labi pielāgojas kavitātes robežām, tam ir zems saraušanās spriegums un augsta nodilumizturība, kas ir svarīgi nosacījumi lieliskiem ilgtermiņa rezultātiem.

1 att. Sākotnējā situācija ar plašu primāru kariozu bojājumu otrā premolāra distālajā virsmā.

2 att. Premolārs pēc darba lauka izolācijas ar koferdamu, kariesa izurbšanas un kavitātes sagatavošanas.

3 att. Sekcionālās matricas un ķīļa ievietošana. Tie tiek noturēti vietā ar atdalošo gredzenu, kas palielina interproksimālo attālumu, tādējādi nodrošinot ciešus, anatomiski pareizus proksimālos kontaktus.

4 att. Proksimālās sienas izveidošana ar CLEARFIL MAJESTY™ ES-2 Universal (U tonis) pēc selektīvas emaljas kodināšanas ar fosforskābi (K-ETCHANT šļirce) un adhezīva CLEARFIL™ SE Bond uzklāšanas un
gaismošanas.

5 att. Plāns plūstošā kompozīta materiāla slānītis (CLEARFIL MAJESTY™ ES FLOW High), uzklāts uz kavitātes pamatnes, lai darbotos kā sveķu pārklājums.

6 att. Restaurācija pabeigta ar CLEARFIL MAJESTY™ ES-2 Universal (U tonis). Lai gan universālais kompozīts ļoti labi saplūst ar apkārtējo zobu struktūru, dabiskais izskats tiek papildināts, pievienojot nedaudz brūnās nokrāsas fisūrā.

7 att. Ārstēšanas rezultāts uzreiz pēc koferdama noņemšanas. Proksimālais kontakts ir ciešs un okluzālā anatomija ir piemērota pacienta sakodienam. Restaurācijas robeža ir praktiski neredzama, savukārt bukālais paugurs šķiet gaišāks dabiskās zoba struktūras dehidratācijas dēļ.

GALA REZULTĀTS

8 att. Ārstēšanas rezultāts pēc diviem mēnešiem.

Secinājumi

Šis klīniskais gadījums parāda, ka izvēlētais kompozīts ir labi piemērots vienkāršām restaurācijām sānu zobu rajonā. Ar materiālu ir viegli strādāt, tam ir tādas pašas mehāniskās īpašības kā citiem CLEARFIL MAJESTY™ ES-2 sērijas materiāliem un tas harmoniski saplūst ar apkārtējām struktūrām, nebūdams pārāk caurspīdīgs. Šādā veidā ir iespējams atbrīvoties no krāsas noteikšanas soļa, nepasliktinot gala rezultātu. Šajā kontekstā ietaupīto laiku var tērēt funkcionālajiem restaurācijas aspektiem vai pat citam pacientam.

DR. NICOLA SCOTTI

Darba autors: Daniele Rondoni (sertificēts zobu tehniķis)

Parasti, uzlabojot keramikas materiālu estētiku, īpaši, lai iegūtu optimālu caurspīdīgumu, neizbēgami tiek kompromitēta tā lieces izturība. Šī iemesla dēļ, līdz šim īpaši caurspīdīgu materiālu izvēle skaistu vairāku vienību monolīta restaurācijām ir bijusi ļoti limitēta. Dažādu caurspīdīguma pakāpju cirkonija oksīda materiālu ienākšanu tirgū situāciju ir mainījusi. 

Viens no šādiem materiāliem ir KATANA^TM Zirconia YML no Kuraray Noritake Dental Inc. Tam ir daudzslāņu struktūra ar augstu lieces izturību (1100 MPa), izteiktu hromacitāti un samazinātu caurspīdīgumu blanka apakšējā daļā. Augšējā un incizālajā daļā ir samazināta lieces izturība un hromacitāte, bet palielināts caurspīdīgums, tāpat kā dabīgiem zobiem. Ievērojot dažus dizaina un pozicionēšanas noteikumus, šim materiālam ir neierobežots indikāciju diapazons. Lai pārbaudītu, vai šie noteikumi neierobežo zobu tehniķa dizaina elastību un

vai estētiskais potenciāls monolīta priekšējo zobu restaurācijām ir pietiekami augsts, mēs rūpīgi pārbaudījām tā apstrādes un optiskās īpašības. Šis klīniskā gadījuma piemērs sniedz lasītājiem priekšstatu par to, ko ir iespējams ar paveikt ar šo inovatīvo daudzslāņu materiālu.

Attēls #1. KATANA™ Zirconia YML četru un sešu vienību tilti pēc frēzēšanas un karsēšanas. Dabiska vestibulārās virsmas tekstūra spēlē zīmīgu lomu estētisku monolīta restaurāciju izgatavošanā.

Attēls #2 .Tie paši divi tilti no okluzālā skata. Lingvālās virsmas dizains palīdz labas mutes dobuma higiēnas uzturēšanai.

Attēls #3. Aiz restaurācijām novietots gaismas avots palīdz vizualizēt incizālo caurspīdīgumu.

GALA REZULTĀTS

Attēls #4. Pacienta mutē uzcementēts 6 vienību tilts no bukālās puses.

Attēls #5. Pacienta mutē uzcementēts 4 vienību tilts no bukālās puses.

Ar šo jauno daudzslāņu cirkonija materiālu ir iespējams izgatavot tik estētiskas monolīta restaurācijas, ka tās būs piemērotas pat priekšzobu rajonam. Neskatoties uz materiāla izturības gradāciju, pieejamajos dizainos pastāv liela dažādība, un, pateicoties caurspīdīgajai incizālajai šķautnei, restaurācija pēc karsēšanas izskatās dabiski. Ultra-mikro kārtu uzklāšana uz monolīta materiāla virsmas un glazēšana nodrošinās tādu rezultātus, kas pilnībā apmierinās pacientus.

Daniele Rondoni (sertificēts zobu tehniķis)

Dzimis Savonā 1961. gadā, kur dzīvo un kopš 1982. gada strādā savā laboratorijā kopā ar kolēģiem. Absolvējis zobu tehniķu skolu IPSIA “P. Gaslini” Dženovā 1979. gadā. Viņš turpināja izglītoties, apmeklējot dažādus seminārus "Itālijas zobārstniecības skolā" un paplašināja savu profesionālo darba pieredzi Šveicē, Vācijā un Japānā. Kopš 2011. gada D. Rondoni ir Kuraray Noritake Dental International instruktors.

Case by Francesco Ferretti and Marco Nicastro

Aesthetic restoration of anterior teeth using KATANA™ UTML Full anatomical crowns, with vestibular stratification and BOPT*¹.

^{*1 Biologically Oriented Preparation Technique}

Initial situation

Final result

Shows excellent aesthetic properties of KATANA™ UTML and the perfect integration in harmony with pink tissues.

Figure 1. The patient requested a solution for an aesthetic problem due to unnatural look of old restorations and black triangles coming from past history of periodontitis. The resulting retraction of the tissues had left the margins of the prosthesis clearly visible, and the loss of the papilla peaks, together with the numerous black spaces between the crowns, required a complex therapeutic approach.

Figure 2. The treatment plan for the periodontal problems con-sisted of a non-surgical approach, with scaling and root planing, and the replacement of the previously fixed prostheses to recondition the marginal tissues and facilitate the restoration of a new, aesthetically pleasing gingival architecture.

Figure 3. From a functional point of view, we decided to reduce the deep frontal bite to restore a correct overjet-overbite ratio. This reduction was also important from an aesthetic point of view, as it allowed us to shape the various elements correctly.

Figure 4. We usually remove old prostheses before beginning a periodontal treatment, and make a first, provisional restoration to create an environment in which the soft tissues can heal. If we have to work beyond the cement enamel joint (CEJ), we prefer a vertical preparation for posts, and the purpose of the provisional restoration is to condition the marginal tissues using Dr. Loi’s BOPT.

Figure 5. For the BOPT, the vertical preparation of the post has a finish line that extends inside the gingival sulcus. The temporary conditioning of the tissues induced by the provisional prosthesis allows us to modify the level of the gingival parables to a certain extent.

Figure 6. The image on the left shows the clinical healing of the tissues one month after the initial periodontal treatment. The role of the provisional restoration, appropriately realigned, is clear. The conditioning of the tissue has been achieved by means of the provisional restoration, which has modified the level and shape of the marginal tissue. Once filled with correctly fitted crowns, the interproximal spaces will be further reduced after the definitive restoration.

Figure 7. The correct management of the provisional restoration is crucial for the healing of the tissues. The placement of a provisional restoration before the periodontal therapy has allowed us to create the right environment for complete healing. At the same time, the vertical preparation has allowed us to gradually condition the marginal gingival tissue by shortening or lengthening the provisional restoration as necessary.

Figure 8. One of the advantages of a vertical preparation is that taking the final impression is easy, because the absence of a horizontal finish line greatly simplifies the procedure. On the other hand, the BOPT also requires the taking of an impression of the sub-gingival portion of the preparation. The dental technician will have to decide marginal shape of restorations according to the position of the gingival line in consultation of the clinician, and based on the tests conducted with the provisional restoration.

Figure 9. After the casting of the model, we prepared the gingival area to accommodate an ideal configuration of gingival parables.

Figure 10. After making a wax model, we assessed whether the height of the gingival zenith level could be further corrected. This photo shows that gingival level of 21 was not yet ideal, so we stretched it distally.

Figure 11. Once the wax model was complete, we extracted the element from the model and evaluated its protrusion. It was only after joining the gingival protrusion to the arbitrary margin of the preparation that we proceeded to a scan and milled the crowns.

Figure 12. The restoration was carried out with Katana™ UTML zirconia based on the new formulation of cubic zirconium oxide. This ultra tralucent material was chosen because we were working with light and non-discolored posts.

Figure 13. We finished the crowns on a positional impression to help to improve the gingival adaptation; we had some dispersion of the tissues in the first precision impression due to the use of retractors. We finished the crowns with CZR FC Paste Stain colours and glaze.

Figure 14. The surface colours and the slight contrast created are highlighted in this black-and-white image taken with a blue filter.

Figure 15. In this translucent image, we can see the natural translucent effect of KATANA™ UTML and invisible fusion between abutments and crowns.

Figure 16. Clinical image one year after cementation made with PANAVIA V5; this shows the good clinical condition of the marginal tissue, with no signs of inflammation or bleeding. The BOPT allowed us to optimise the level of the gingiva without resorting to periodontal surgery, while the shape of the new crowns has made it possible to close all interproximal spaces for an optimally aesthetic result.

Figure 17. The brightness of the restorations (thanks to the use of a particularly translucent zirconia) combined with the shape of the incisors, has greatly im-proved the aesthetic of the restoration, even though the condition initially appeared to be particularly unfavourable.

Figure 18. Compared to the previous prostheses, the incisal reduction allowed not only for the optimisation of the functional phase by reducing the overbite, but also made it possible to achieve a more natural aesthetic, with the contour of the incisal margins following that of the lower lip.

Dentists:

FRANCESCO FERRETTI

Born in Rome on 15th March 1957, Francesco Ferretti gets his degree as dental technician at the Institute “Edmondo de Amicis”, in Rome. In 1980, he starts working and, from 1987 to 1994, he cooperates with IVOCLAR VIVADENT giving consulting as ceramist. In 1992 he starts working exclusively with Prof. Mario MARTIGNONI.

• After one year cooperation with Prof. Martignoni, he starts working with the ORAL DESIGN CENTER founded in Rome by Mr. Willi Geller, and becomes a partner, improving prosthesis esthetics.
• Is registered outside the course of dentistry at the University of Rome Tor Vergata.
• In 2001, he founds ESTECH DENTAL STUDIOS, in cooperation with Pentron for technical training and consulting.
• He has published articles and studies in Italian and American magazines. He is interested in Metal Free techniques.
• Winner of the 2004 Polcan Aiop.
• He is a member of: ANTLO LAZIO ( National Association of Lab Owners) with the president of the Lazio region 2013-2014.
• National cultural manager ANTLO 2017-2020.
• Teacher of prosthetics perfectioning at the University of Chieti for the year 2002, he has been re-confirmed for the year 2003, 2004, 2005 to deal with Metal Free.
• Teacher of prosthetics perfectioning at the University of Naples 2006.
• He has participated as a speaker at numerous conferences in Italy. ESCD member has participated as a speaker at ten in Florence 2009 and Turin 2013.

MARCO NICASTRO

Marco Nicastro takes a degree in “Odontoiatria e Protesi Dentaria (Dentistry and Dental Prosthesis) at the University of Rome “ La Sapienza in 1989. Since the beginning he is interested in prosthesis restoration dentistry and aesthetic problems.

• From 1990 to 1996 he attends Prof. Martignoni’s studio, where he develops his prosthesis knowledge.
• From 1993 to 1998 he cooperates as lecturer with the Oral Design Centre in Rome, directed by Mr. Ferretti and Mr. Felli, giving lectures and courses about aesthetic restoration either in Italy or in foreign countries. In the same period he enlarges his experience in aesthetics, attending training courses at the University of Geneva, in Switzerland.
• Since 1993 he has been cooperating with Mr. Francesco Ferretti in the organization of Courses and Conferences, paying particular attention to metal free methodology.
• Vice President of the European Society of Cosmetic Dentistry (ESCD).
• Founding member and active member of Gimnasium interdisciplinary CAD-CAM (GICC).
• Active member of the Italian Society of Conservative Dentistry (SIDOC).
• Partner of the Italian Academy of Prosthetic Dentistry (AIOP).
• President of Like Mine Dental Education in Rome since 2001.
• He won, with Francesco Ferretti, the Polcan award of the Italian Accademy of Prosthetic Dentistry in 2004.