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Article by Dr. Florian Zwiener
Modern multi-layered zirconia such as KATANA™ Zirconia STML (Kuraray Noritake Dental Inc.) already meets high aesthetic demands due to its natural colour gradient and high translucency. To achieve further characterisation and optical adjustment to the adjacent teeth, there are essentially two options: veneering with feldspathic ceramic or glazing and individualisation with ceramic stains.
While there are still many indications for veneering, especially in the anterior area, more and more cases can now be solved with monolithic restorations. This allows for a time-efficient chairside workflow with same-day treatment, eliminating the need for temporary restorations. Additionally, the absence of a porcelain layer reduces the wall thickness of the restoration and thus the space required, allowing for less invasive preparation. This also reduces the risk of endodontic complications induced by tooth preparation (grinding trauma). Another advantage is a significant reduction in the chipping risk.
Below are the essential steps for individualisation using ceramic stains, demonstrated through the example of a molar crown.
The restoration is designed in full contour as usual, ideally dry-milled, and then sintered. After sintering, the restoration is first sandblasted (aluminium oxide 50 μm, 1 to 1.5 bar pressure). This microscopic roughening of the ceramic surface enables an optimal bond with the glaze. Subsequently, the restoration should be cleaned using a steam cleaner or an ultrasonic cleaner to remove all blasting residue.
The functional restoration surfaces must then be polished to avoid the risk of excessive abrasion on the enamel of the opposing dentition, as zirconia is harder than enamel. Following this, optional glazing and characterization with ceramic stains can be performed. However, for areas not in the aesthetic zone, such as the palatal surfaces of maxillary anterior teeth, this is not necessarily required.
Fig. 1. Sintered and sandblasted zirconia crown.
Fig. 2. Occlusal high-gloss polish.
Fig. 3. TWIST™ DIA for Zirconia (Kuraray Noritake Dental Inc.) enables efficient polishing of zirconia in three steps.
The shades A+, B+, C+, and D+ of the paste-like ceramic stain CERABIEN™ ZR FC Paste Stain (Kuraray Noritake Dental Inc.) enhance the chroma in the cervical area when applied in the respective tooth shade. They are used to strengthen the multicolour effect of the zirconia or to darken the restoration overall. By mixing the stains with glaze or clear glaze in different ratios, the intensity can be adjusted.
Cervical 1 and 2 are suitable for replicating exposed cervical areas or discolouration. Cervical 1 is also useful for marking fissures, as it gives the crown depth and structure without appearing overly dark. Patients typically reject excessively pronounced fissure effects. Since fissure areas in multi-layered materials generally lie in the lightest part of the block (in the enamel layer), it may make sense to darken them slightly with A+, while white hypermineralisations can be replicated on the cusp tips. A narrow band of Grayish Blue below the cusp tips creates an optical translucency effect. In cases where this translucency appears too dark blue or greyish, mixing Grayish Blue with Dark Grey can modify the appearance.
By mixing various colours, numerous different tones can be created. For instance, by adding Yellow to A+, its slightly brownish colour can be adjusted to a warmer, more yellowish tooth shade. It is generally advisable to capture the patient‘s tooth shade with a photo and a custom-made colour ring of the corresponding material before preparation. This can serve as a reference during production, especially in the laboratory, where lighting conditions may differ.
For pronounced characterisations or fine details, it may be necessary to carry out multiple firings to avoid unwanted running effects between the colours and the glaze. This is particularly recommended when replicating anatomical details with high sharpness, such as enamel cracks or local discolourations. For this, a glaze and base shade are first applied and fired, and finer structures are added in a second firing. Alternatively, a fixative firing of the stains without glaze can be performed first, with only a glaze layer fired in the second step. A benefit of CERABIEN™ ZR FC Paste Stain is that its appearance during application closely matches the final firing result. In thick consistency, glaze can also be used to easily rebuild missing proximal contacts.
Alternatives:
Fig. 4. CERABIEN™ ZR FC Paste Stain assortment for the practice laboratory.
Fig. 5. Discoloured fissures can be accurately replicated with an ISO10 endodontic file.
Fig. 6 and 7. Glazing and staining in one firing.
Fig. 8. Shade determination using a custom-made KATANA™ Zirconia STML colour ring (A3.5).
Fig. 9. Bridge made from KATANA™ Zirconia STML, sandblasted and occlusally polished.
Fig. 10. Finished glazed and characterised restoration.
Fig. 11. Bridge 14-16 in place.
Fig. 11. Bridge 14-16 in place.
Dentist:
FLORIAN ZWIENER
Before being allowed to market a dental composite filling material, it must, among other things, meet the set standards within ISO 4049:2019 Dentistry - Polymer-based restorative materials. Prompted by the tremendous positive response Kuraray Noritake Dental Inc. received from users of the CLEARFIL MAJESTY™ ES Flow series, we asked the Nordic Institute of Dental Materials (NIOM), an independent research institute, to test this product line on key aspects within the said ISO standard.
While it was not mandatory for us to have the CLEARFIL MAJESTY™ ES Flow series tested, our confidence in the quality of our product prompted us to do so. NIOM thoroughly evaluated CLEARFIL MAJESTY™ ES Flow in all three different levels of flowability: High, Low, and Super Low (Fig. 1). Among the properties assessed were depth of cure, flexural strength, water sorption and solubility, and colour stability after irradiation and water sorption. NIOM found that regarding all properties, the three flowabilities and different shades proved to comply with the requirements.
We are pleased to have gone the extra mile and proud that an independent party verified that our product meets the stringent ISO standards.
Fig. 1. CLEARFIL MAJESTY™ ES Flow in its three different levels of flowability.
These test results are an external proof for users of the popular flowable composite series that they safely can be used as specified by Kuraray Noritake Dental Inc. in the product’s instructions for use. The NIOM test results obtained regarding the depth of cure imply that, when applied to the recommended layer thickness, the composite will polymerise adequately – which is essential for a great long-term performance. In addition, all three flowabilities offer sufficient strength and water sorption/solubility behaviour even to be suitable for restorations, including the occlusal surface of molars and pre-molars. This means that the materials are very well suited for a wide range of indications, including restoring all cavity classes and repairing existing restorations and cementing (Fig. 2).
Fig. 2. Three variants of CLEARFIL MAJESTY™ ES Flow and the suggested use areas.
On top of these well-balanced mechanical properties, CLEARFIL MAJESTY™ ES Flow in its innovative syringe handles well due to an easy dispensing, bubble-free application, easy sculpting facilitated by its non-sticky formulation, and easy polishing behaviour. Coming in a variety of shades (Fig. 3) and equipped with proprietary Light Diffusion Technology, the material in its three different levels of flowability blends nicely and effortlessly with the surrounding tooth structure, creating a natural overall look. Both handling and aesthetics have been rated very good to excellent by dental advisor consultants in the context of a clinical evaluation.
Fig. 3. Overview of shades available per flowability.
NIOM also provides proof of the positive aesthetic properties: the institute's tests to evaluate colour stability after irradiation and water sorption reveal that CLEARFIL MAJESTY™ ES Flow is expected to remain stable over time. This feature is important for the long-term aesthetics of the restorations created with the materials.
Choose a reliable, high-quality, flowable, direct restorative material that withstands rigorous testing.
Šīs jaunās tehnikas apraksts un zinātniskie pētījumi par sasniegtajiem rezultātiem ir aprakstīti šajā rakstā, kura autors ir prof. Breschi un viņa kolēģi no Boloņas universitātes. Raksta virsraksts: “Selektīvā cementēšana: Jauna metode adhēzijas uzlabošanai, kuru nodrošina universālie sveķu cementi”.
PANAVIA™ SA Cement Universal ir universāls sveķu cements, kura uzklāšana vairumā klīnisko situāciju ir iespējama pašcementējošā metodē – bez jebkādām papildus sastāvdaļām. Turklāt tas pat nodrošina lielisku cementēšanos ar litija disilikātu bez nepieciešamības pēc papildus silāna. In vitro pētījumu rezultātā ir parādīts, ka sveķu cements ir mitrumizturīgs un universāls, veidojot spēcīgu un izturīgu saķeri ar praktiski visu veidu restaurāciju materiāliem, kā arī ar emalju un dentīnu.
Neskatoties uz minēto, vislabāko sasaisti ar zoba virsmu tomēr var iegūt uzklājot tam CLEARFIL™ Universal Bond Quick kā atsevišķu saiti. Tāpēc īpaši sarežģītās situācijās Jūs, iespējams, dosiet priekšroku šai divkomponentu cementēšanas metodei. Tā tāpat nav tik sarežģīta kā tradicionālā cementēšana. Turklāt tā nodrošina izcilus rezultātus.
Tomēr, lai universālie cementi darbotos pareizi, ir nepieciešama pilnīgi sausa darba virsma, savukārt pašcementējošie sveķu cementi ir mazāk jutīgi pret mitrumu. Iespējams Jūs nevarat saprast, kura cementēšanas tehnika ir Jums vispiemērotākā gadījumos, kad ir nepieciešama spēcīgākā iespējamā saķere ar emalju un dentīnu, taču izolācija ar koferdamu ir apgrūtināta vai neiespējama (piemēram, dēļ īsa slīpētā zoba vai zemsmaganas preparācijas). Risinājumu šajā gadījumā ir selektīvā cementēšana. .
Universāla cementa selektīva uzklāšana uz tām kodinātajām emaljas vietām, kuras nav pakļautas mitruma riskam.
Ompozītmateriālu restaurācijas izturība ir atkarīga no daudziem faktoriem. Daži ir ārpus praktizējošā ārsta ietekmes sfēras un ir cieši saistīti ar pacientu. Piemēram, zobu birstes un pastas veids, tīrīšanas tehnika, diēta, stimulanti un higiēnas ieradumi ietekmē restaurāciju. Tomēr vislabākā apdares un pulēšanas protokola ievērošana pilnībā ir zobārsta ziņā.
Pareizas pulēšanas mērķis ir noņemt skābekli kavējošo slāni un radīt gludu restaurācijas virsmu. Pareizi pulēta restaurācija neuzsūks krāsojošās vielas no pārtikas, dzērieniem vai stimulatoriem, kas noved pie kompozītmateriāla krāsas maiņas, nodrošinot ilgstošu restaurācijas estētisko rezultātu.
Kompozītmateriāla pulēšana ir process, kuram jāpievērš īpaša uzmanība. Tas sastāv no vairākiem soļiem un principiem:
Visās tehnikās, tātad arī plūstošās injekcijas metodē, pulēšanas līmenis ietekmē restaurācijas izturību un optiskās un estētiskās īpašības. Tāpēc šim zoba restaurācijas galvenajam solim vajadzētu veltīt pietiekami daudz laika. Kompozītmateriāliem ir raksturīgs dažāds sastāvs un pildvielu daudzums, kas ne tikai ietekmē to īpašības, bet arī to pulēšanas vieglumu. Dažos gadījumos procedūra ir jāatkārto vairākas reizes, lai panāktu "spoguļa efektu". CLEARFIL MAJESTY™ ES Flow ir kompozītmateriāls, ko ir ļoti viegli pulēt līdz augstam spīduma līmenim neskatoties uz tā lielo pildvielu saturu. Īpaši pielāgotas gumijas, sukas un pastas ļauj viegli izveidot gludu virsmu, tādējādi veicinot noturīgu rezultātu.
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Dentist:
MICHAL JACZEWSKI
Mihals Jačevskis 2006. gadā absolvēja Vroclavas Medicīnas universitāti un šodien vada savu privātpraksi Legnicas pilsētā Polijā. Viņš specializējas minimāli invazīvā zobārstniecībā un digitālajā zobārstniecībā un ir Biofunkcionālās oklūzijas skolas dibinātājs. Šeit viņš lasa lekcijas un vada seminārus, koncentrējoties uz visaptverošu pacientu ārstēšanu.
Kompozītmateriālu restaurācija ir visizplatītākā procedūra, ko veic zobārsts. Zobārstniecībā tiek izmantotas daudzas restaurācijas metodes un dažādi restaurācijas materiāli. Neatkarīgi no materiāla veida, restaurācijas metodes un pielietošanas vietas, izplatīta problēma ir gaisa burbuļi kompozītmateriālu slāņos vai uz to virsmas. Kompozītmateriāla restaurācijai jābūt viendabīgai, lai nodrošinātu pildījuma hermētiskumu un tā izturību. Burbuļu defektu labošana ir apnicīga, un dažkārt ir nepieciešams nomainīt pildījumu vai tā daļu. Atkarībā no kompozītmateriāla veida (plūstošs vai pastas kompozītmateriāls) un/vai uzklāšanas tehnikas defektu daudzums var atšķirties, taču ir vairāki izraisošie faktori.
Plūstošās injekcijas metodē mēs izmantojam plūstošus kompozītmateriālus, kas acīmredzami viegli plūst, bet ir arī jutīgi pret nepareizu uzklāšanu. Pirmais gaisa burbuļu veidošanās cēlonis ir paša materiāla viendabīgums. Ražošanas posmā vai lietošanas laikā šļircē var veidoties burbuļi. Izmantojot augstākās kvalitātes produktus, mēs varam būt pārliecināti, ka tiek piegādāts augstākās kvalitātes materiāls un ka šļirces struktūra un dizains nodrošina pareizu darbību, lai samazinātu gaisa burbuļu veidošanos materiālā.
CLEARFIL MAJESTY™ ES Flow kompozītmateriāls ir izstrādāts, lai novērstu gaisa burbuļu veidošanos izspiešanas laikā. Šļirces un virzuļa īpašais dizains ierobežo materiāla pilēšanu kā arī atpakaļplūsmu izspiešanas laikā vai pēc tās.
Unikāla drošības funkcija šļirces iekšpusē ir īpašā O veida gredzena konstrukcija, kas neļauj materiālam plūst pēc spiediena atlaišanas un vienlaikus rūpējas par minimālu ievilkšanu, kā arī novērš virzuļa pārmērīgu ievilkšanos.
Vēl viens gaisa burbuļu veidošanās iemesls ir gaisa iekļūšana šļircē apzināti ievelkot virzuli. Ja praktizējošajam ārstam vai palīgpersonālam ir ieradums pēc kompozītmateriāla ievadīšanas ievilkt virzuli, tas var izraisīt gaisa iekļūšanu šļircē. Turpmākās lietošanas laikā gaiss, visticamāk, parādīsies restaurācijā kā gaisa pora.
Plūstošās injekcijas metodē mēs izmantojam silikona matricu kurā mēs ievadam materiālu, lai izveidotu zobu. Matricai ir cieši jāpieguļ zobiem un tā nedrīkst kustēties vai tikt pārvietota injekcijas laikā. Ja tā notiek, var parādīties gaisa burbuļi. Nospiežot un pēc tam atlaižot matricu radīsies piesūkšanās efekts un kompozītmateriāls tiks noņemts no zoba, kā arī no matricas. Lai izvairītos no defektiem, no materiāla injicēšanas brīža līdz polimerizācijai jāsaglabā matricas stabilitāte.
Var izmantot dažādas silikona matricu modifikācijas, lai ierobežotu tās stabilitāti un samazinātu nekontrolēta spiediena risku uz zobu. Redzamais piemērs parāda matricas pareizu un nepareizu izvietojumu uz augšžokļa zobu modeļa, lai nodrošinātu augstu stabilitāti un darba efektivitāti.
Vēl viens iemesls gaisa iekļūšanai restaurācijā ir injekcijas atveres platums. Ja atvere ir pārāk cieša, ievietošanas vai uzklāšanas laikā matricu var pārvietot ar uzklāšanas uzgali. Lai izvairītos no šīs problēmas, atveri var paplašināt, lai varētu brīvi ievietot, kā arī manipulēt ar uzgali injekcijas laikā. Plašāka atvere arī ļauj izplūst gaisam izspiešanas laikā. Tomēr vissvarīgākais ir uzklāt materiālu ar nepārtrauktu spiedienu un izvairoties no uzgaļa izvilkšanas un atkārtotas ievietošanas matricā. Tā rezultātā var izveidoties nevienmērīgs kompozītmateriāla slānis.
Dentist:
MICHAL JACZEWSKI
Mihals Jačevskis 2006. gadā absolvēja Vroclavas Medicīnas universitāti un šobrīd vada savu privātpraksi Legnicas pilsētā Polijā. Viņš specializējas minimāli invazīvā zobārstniecībā un digitālajā zobārstniecībā, kā arī ir Biofunkcionālās oklūzijas skolas dibinātājs. Šeit viņš lasa lekcijas un vada seminārus, koncentrējoties uz visaptverošu pacientu ārstēšanu
Intervija ar Dr. Michał Jaczewski
Plūstošās injekcijas metode kļūst par populāru tehniku, ko izmanto, lai estētiski restaurētu vairākus zobus ar plūstošu kompozītmateriālu. Mihals Jačevskis ir slavens pasniedzējs, kurš māca zobārstiem prasmes, kas nepieciešamas, lai veiksmīgi izmantotu šo tehniku. Viņš 2006. gadā absolvēja Vroclavas Medicīnas universitāti Polijā un kopš 2011. gada vada savu privātpraksi Legnicas pilsētā. Viņš ir Biofunkcionālās oklūzijas skolas dibinātājs, vada apmācības visaptverošās zobu ārstēšanas jomā, un aizraujas ar estētisko digitālo zobārstniecību. Starptautiskajā 2023. gada zobārstniecības izstādē Ķelnē viņš mums nodemonstrēja, kad, kāpēc un kā savā zobārstniecības kabinetā izmanto plūstošu injekciju.
Plūstošās injekcijas metode ir vienkāršs, paredzams, atkārtojams veids, kā atjaunot zobus, izmantojot plūstošu kompozītmateriālu. Tā ir balstīta uz izvaskojumu, kram tiek izgatavota silikona matrica. Šī matrica pēc tam kalpo kā atslēga plūstoša kompozītmateriāla injekcijai, kas tiek sacietināta gaismā caur caurspīdīgo silikonu. Vissvarīgākais ieguvums ir tas, ka šī metode darbojas gandrīz visos gadījumos ar ļoti minimālu zobu sagatavošanu. Tā ir minimāli invazīva metode, ko var izmantot gan iesācēji, gan pieredzējuši zobārsti. Izmantojot kompozītmateriālu ar labi sabalansētu necaurredzamību 0,3 mm biezumā un īpašu pulēšanas protokolu, ir iespējams sasniegt izcilus morfoloģiskos un optiskos rezultātus.
Es sāku izmantot šo metodi 2018. gadā. Sākotnēji tā tika izgudrota priekšzobu atjaunošanai, taču mūsdienās to veiksmīgi izmanto arī aizmugurējiem zobiem. Manuprāt, tas ir īpaši noderīgi ikreiz, kad ir jākoriģē vairāku zobu forma, lai uzlabotu pacienta smaidu neatkarīgi no tā, vai pacients ir jauns vai vecs. Piemēram, pēc ortodontiskās ārstēšanas. Zobus vienkārši iztaisno un pēc tam atjauno ideālā formā, izmantojot šo neinvazīvo tehniku. Plūstošo injekciju izmantoju arī smaida uzlabošanai, nodilušu zobu atjaunošanai un oklūzijas vertikālās dimensijas maiņai pilnīgas mutes rekonstrukcijas kontekstā. Pēdējā gadījumā restaurācija var būt īslaicīga un izmantota vidējam vai ilgtermiņa "testam". Tomēr tā var kalpot arī kā galīgā restaurācija.
Vissvarīgākais posms, kas būtiski ietekmē šīs metodes panākumus, ir plānošanas posms. Tas sastāv no dokumentācijas, nospiedumu noņemšanas, vaskojuma izgatavošanas, kā arī silikona matricas izveides. Jūs, protams, varat strādāt tradicionālā veidā ar silikona nospiedumu un parasto vasku, taču digitālo tehnoloģiju izmantošana šajā posmā ievērojami uzlabos jūsu darba plūsmu. Es parasti sāku ar foto un video dokumentāciju un digitālo nospiedumu. Ir nepieciešami arī centrisko attiecību un oklūzijas rādītāji. Pēc tam, izmantojot digitālo smaida dizaina programmatūru, tiek izveidots digitāls vaskojums. Šajā solī ir svarīgi ņemt vērā pacienta sejas īpatnības. Tas ir uzdevums, ko vislabāk var paveikt, izmantojot sejas plūsmas koncepciju. Pamatojoties uz iegūto dizainu, virtuālo ārstēšanas rezultātu var parādīt un apspriest ar pacientu. Pēc apstiprināšanas izveidotais zobu vaskojums tiek izprintēts dažādās versijās: pilnais vaskojuma modelis un modelis ar mainīgu dizinu - viens zobs ar vaskojumu, kuram seko zobs bez tā. Šos modeļus izmanto, lai izgatavotu matricas no caurspīdīga silikona.
Digitālais smaida dizains: pacients ar izteiktu zoba nodilumu.
Pacienta mutē tiek parādīts digitālais vaskojums.
Modeļi tiek printeti uz digitālā uzvaskojuma pamata.
Silikona matrica tiek izgatavota uz mainīga modeļa.
Īpaši noderīgi ir strādāt ar pilno un mainīgo (daļējo) silikona matricu, plānojot atjaunot visus zobus augšžoklī. Ar mainīgo matricu man tiek nodrošināta papildus stabilitāte un tiek likts pamats precīzam rezultātam, īpaši attiecībā uz plānoto oklūzijas augstumu. Apakšžoklī, kur ir grūtāk rīkoties ar matricu un kompozītmateriālu siekalu klātbūtnes un kustīgu mīksto audu dēļ, vienmēr iesaku sadalīt darba lauku trīs daļās – vienā priekšējā un divās aizmugurējās daļās – un strādāt ar tiem atsevišķi.
Vairumā gadījumu viss, kas mums nepieciešams, ir emaljas virsmu apstrāde cementēšanai, kas parasti ir iespējama ar gaisa strūklas apstrādi ar alumīnija oksīdu (50 µm zemā spiedienā). Pēc tam emalja tiek kodināta ar fosforskābes kodinātāju un universālu saiti. Tiek uzlikta matrica. Tā ir aprīkota ar injekcijas atveri incisālā malā. Tas ir viegli paveicams ar plūstošā kompozītmateriāla šļirces galu, kuru ir jāizspiež cauri matricai no iekšpuses uz ārpusi. Aizmugurējā rajonā ieteicams izmantot cietāku priekšmetu un katram zobam izveidot divus caurumus uz atsevišķām virsmām – vienu injekcijai un otru ārējai plūsmai. Cietajai matricai šai procedūrai ir nepieciešams dimanta urbulis. Es uzlieku matricu, injicēju plūstošo kompozītmateriālu no apakšas uz augšu, nedaudz gaismā sacietinu materiālu un noņemu matricu. Galīgo polimerizāciju veic pēc matricas noņemšanas un glicerīna gēla slāņa uzklāšanas. Kad liekais materiāls ir noņemts un restaurācijas proksimālā daļa ir perfekti pabeigta, procedūru atkārto pārējiem zobiem pirms restaurāciju pulēšanas.
Silikona matricai izmantoju EXACLEAR (GC), jo tas ir caurspīdīgākais tirgū pieejamais silikons. Mans iecienītākais kompozītmateriāls plūstošai injekcijas metodei ir CLEARFIL MAJESTY™ ES Flow ar zemu viskozitāti (Kuraray Noritake Dental Inc.). Manā zobārstniecības kabinetā un kursu laikā man bija iespēja izmēģināt daudz dažādu produktu. Šajā kontekstā es atklāju, ka Kuraray Noritake Dental materiāls sniedz vairākas priekšrocības. Tas ir moderns nano kompozītmateriāla veids ar plašu indikāciju klāstu un lielu toņu piedāvājumu. Pateicoties tā trim viskozitātēm, to var izmantot daudzās dažādās klīniskās situācijās. Es sāku to lietot pirms pieciem gadiem, un plūstošās injekcijas metodei Low variants ir mana primarā izvēle, jo tas ir universālākais, kas piemērots priekšējiem un aizmugurējiem zobiem. Būtiskākās priekšrocības, kas ietekmēja manu lēmumu to izmantot, ir tā dabiskā estētika un izcilā pulējamība. Jūs varat iegūt iespaidīgu efektu bez īpašām prasmēm. Kā saistvielu es izvēlos izmantot CLEARFIL™ Universal Bond Quick, kas padara manu darba plūsmu vēl vienkāršāku, ātrāku un paredzamāku. Pulēšanai esmu izstrādājis savu protokolu.
Es sāku proksimālajā zonā ar pulēšanas plāksnītēm un dažreiz proksimālo zāģveida loksnīti. Formas korekcijai trīs dažādi dimanta un karbīda urbuļi ir pierādījuši savu nozīmi. Pēc tam es izmantoju smalkus vai īpaši smalkus Sof-Lex™ Finishing and Polishing Discs (3M), ko izmanto konturēšanai un apstrādei, un gumijas pulēšanas līdzekļus TWIST DIA™ for Composite (Kuraray Noritake Dental Inc.), kas bez piepūles rada patīkamu, dabisku virsmas spīdumu. Pēc tam tiek izmantota kazas saru suka ar dimanta pulēšanas pastu (Diamond excel, FGM) un visbeidzot, es izmantoju kokvilnas pulieri kopā ar alumīnija oksīda pulēšanas pastu (Pasta Grigia II, anaxDENT). Tādā veidā iespējams izveidot spoguļveida virsmu.
Emaljas kodināšana ar fosforskābes kodinātāju.
Silikona matricas uzstādīšana.
CLEARFIL™ Universal Bond Quick uzklāšana.
Situācija uzreiz pēc CLEARFIL MAJESTY™ ES Flow (Low) injekcijas, cietināšanas gaismā un silikona matricas noņemšanas.
Proksimālās korekcijas ar rotējošiem instrumentiem.
Pacientiem un zobārstiem lielākās priekšrocības ir laika un naudas ietaupījums. Daudzi pacienti nevar atļauties keramikas venīrus, un viņi ir ārkārtīgi priecīgi, ka viņiem tiek piedāvāta kvalitatīva alternatīva, ko var uzlikt vienā apmeklējuma reizē. Procedūrai nav vajadzīga sagatavošana, un, ja nepieciešams, restaurācijas var viegli koriģēt vai mainīt krāsu, tādējādi ārstēšanai praktiski nav nekāda riska. Zobārsti parasti var sākt ārstēt pacientus pēc tam, kad viņi ir apmeklējuši tikai vienu kursu. Lai gan praktiski treniņi attīsta prasmes, arī pirmie rezultāti nereti jau ir diezgan iespaidīgi, tāpēc iesācējiem nav jāiegulda milzīgi ieguldījumi – ne laika ziņā, ne jaunos materiālos. Protams, jūs varat ieguldīt daudz laika apstrādes un pulēšanas procedūrā, taču esmu pārliecināts, ka jūs atradīsit pareizo līdzsvaru starp piepūli un rezultātu.
Instrumentu komplekts plūstošās injekcijas metodei.
Pirmkārt, vēlos mudināt ikvienu izkāpt no savas komforta zonas un regulāri izmēģināt ko jaunu. Man sākt strādāt ar plūstošo injekcijas metodi bija revolucionārs pagrieziena punkts, un es nekad vairs negribētu strādāt bez tās. Pirms sākt lietot šo metodi, es noteikti apmeklētu kursus, kuros tiek apgūtas visas teorētiskās zināšanas, kas nepieciešamas veiksmīgam pirmajam gadījumam, un varbūt pat praktisko meistarklasi.
Mihals Jačevskis savas prezentācijas laikā Kuraray Noritake Dental stendā Ķelnē.
Article by Dr. Michał Jaczewski
Resin composites are wonderful restorative materials: They allow for minimally invasive, defect oriented tooth preparation, may be modelled as desired, and can be modified and repaired whenever necessary. To achieve all of this, however, a strong and long-lasting bond is an absolute requirement. The bond needs to be established either between enamel and dentin on one side and the resin composite on the other, or between the existing and the newly applied composite material.
Committed to keeping clinical procedures as simple as possible, I use an 8th-generation bonding agent – CLEARFIL™ Universal Bond Quick (Kuraray Noritake Dental Inc.) in my dental office. Containing Rapid Bond Technology, it allows for a particularly easy and straightforward use without the need for extensive rubbing or long waiting times. At the same time, it bonds well to various substrates including enamel, dentin and resin composite as it contains the original MDP monomer.
Its composition and resulting versatility make CLEARFIL™ Universal Bond Quick the first choice for many indications including non- to minimally-invasive repair procedures. As it works extraordinarily well in situations where we want to bond to dentin, enamel or old composite (Fig.1), it is usually not necessary to remove the whole existing restoration that needs to be repaired or modified. Instead, preparation may be limited to the composite part, so that no additional tooth structure needs to be removed.
Fig. 1. CLEARFIL™ Universal Bond Quick establishes a strong bond to dentin, enamel or old composite.
Depending on the condition of the existing restoration surface, the repair protocol may be slightly different. The basic steps are as follows:
- No surface treatment required, rinse with water in case of contamination with blood or saliva, followed by air-drying and (optionally) adhesive application
- Apply new layer of composite immediately
- Remove the composite around the defect and create a bevel at the cavity margin with rotating instruments
- Sandblast the surface with aluminium oxide particles
- Fresh composite surface: Clean the surface with KATANA™ Cleaner (Kuraray Noritake Dental Inc.) or etch with phosphoric acid etchant
- Composite surface older than two weeks: Etch with phosphoric acid etchant
- Apply the universal adhesive (which contains silane)
- Apply a new layer of composite
When an old composite restoration needs to be replaced – e.g. because the existing restoration shows discolouration or the patient asks for a brighter shade – it is possible to remove only a part of the composite and leave the rest in place to save the underlying healthy tooth structure. Accurate control over the amount of material removed and the amount of material left in place is offered by the use of UV light. Under UV light, the composite is perfectly visible (Fig. 2). Hence, a highly conservative structure removal is supported (Fig. 3).
Fig. 2. Controlling structure removal with UV light, which nicely reveals the old composite.
Fig. 3. Tooth preparation with rotating instruments.
Creating a clean, micro-retentive composite surface ideal for bonding: This is the aim of sandblasting the affected composite area with aluminium oxide particles (Fig. 4). The particle size I prefer is 27 μm. Residual particles, may be removed with 37% orthophosphoric acid, which needs to be rinsed off thoroughly before air-drying the surface (Figs. 5a and 5b).
Fig. 4. Air-abrasion with 27 μm aluminium oxide particles.
Fig. 5a. Phosphoric acid etching. Adjacent teeth are protected with PTFE tape.
Fig. 5b. Thorough rinsing to remove the etchant from the surface.
When bonding to old composite, silanisation of the surface is recommended to increase the bond strength. On dentin, a separate silane shows no positive effect. Hence, it is recommended to apply a separate silane to the composite surface only, a challenging task in situations with a surface consisting of tooth structure and composite. As CLEARFIL™ Universal Bond Quick contains silane, the separate silane application step may be skipped, which clearly simplifies the procedure (Figs. 6a and 6b).
Fig. 6a. Application of CLEARFIL™ Universal Bond Quick to the prepared surface.
Fig. 6b. Solvent evaporation with a gentle stream of air.
Whenever detected during restoration, defects in the composite layer or air bubbles can be repaired or eliminated right away. As long as the oxygen inhibition layer is still present, another layer of composite may be applied immediately without any prior steps. However, if the surface has been contaminated by saliva or blood (Figs. 7a and 7b) or it is unclear whether we are bonding to dentin, enamel or composite, CLEARFIL™ Universal Bond Quick may be applied (Fig. 8). On top, a new layer of composite is placed to restore the defect (Fig. 9).
Fig. 7a. Composite surface with a defect near the margin with blood contaminating the affected area.
Fig. 7b. Composite surface with a defect near the margin after thorough rinsing and drying.
Fig. 8. Application of the universal adhesive.
Fig. 9. Application of composite material to restore the defect.
If the defect is small, it is possible to apply the flowable composite directly and remove the excesses (Fig. 10). The obtaining of a natural shape and smooth transition between old and new composite, however, is simplified by the use of a silicone index or matrix (Fig. 11), which might still be present from the original restoration procedure. A possible outcome of this type of repair is shown in Figure 12; both images were taken prior to finishing and polishing.
Fig. 10. Flowable composite spreading and excess removal.
Fig. 11. Silicone index placed over the teeth including the tooth with the defect.
Fig. 12. Outcome of the flowable injection procedure.
Elimination of bubbles or defects in a freshly created restoration, changes in the colour of an existing filling or a shape correction due to wear processes: Modifying composite restorations can be easy – provided that appropriate materials and techniques are used. One of the key elements on the path to success is the selection of a suitable adhesive system, preferably a universal single-bottle adhesive like CLEARFIL™ Universal Bond Quick, which allows for streamlined procedures and supports excellent outcomes. By respecting the provided tips, it is possible to create the desired outcomes in a minimally invasive, straightforward way, laying the foundation for long-lasting aesthetics and function.
Dentist:
MICHAŁ JACZEWSKI
Michał Jaczewski graduated from Wroclaw Medical University in 2006 and today runs his private practice in the city of Legnica, Poland. He specializes in minimally invasive dentistry and digital dentistry and is the founder of the Biofunctional School of Occlusion. Here he lectures and runs workshops with focus on full comprehensive patient treatments.
Leaving work at work, unplugging your mind from the dental office is not rocket science - provided that high-quality dental materials are used. Ideally, they are well-adapted to operator, case, and patient-specific needs. When it comes to restoring cavities with composite, Kuraray Noritake Dental Inc. has got the right products for any dental professional.
The CLEARFIL MAJESTY ES family of dental composites is composed of different product lines designed to meet specific needs. Altogether, the line-up offers a solution for every technique and handling preference, clinical situation and patient requirement.
When utmost simplicity is desired, a highly innovative universal solution such as CLEARFIL MAJESTY ES-2 Universal is an excellent choice. This paste-type composite system includes only four shades: Universal, Universal Light, Universal Dark, and Universal White.
The Universal shade has the highest translucency and is, therefore, most suitable in cases where several cavity walls are still present, such as in Class I or II cavities and the cervical area. In cavities where light easily passes through, the lower-translucency variants Universal Light (for teeth with shades up to A3) and Universal Dark (for teeth darker than A3) are the best options. Universal White is the go-to solution for young patients and whitened teeth. Consequently, there is usually no need for a shade guide, and the optical properties allow application without an opaquer or blocker in most of cases. Both features greatly simplify the clinical procedure.
Clinicians who prefer classical single-shade layering according to a shade guide and a greater number of shades available may prefer CLEARFIL MAJESTY ES-2 Classic. With a line-up of 18 shades, it supports straightforward procedures and leads to aesthetic results.
Whenever the aesthetic needs are very high, such as in the context of restoring a large cavity in the aesthetic anterior region, CLEARFIL MAJESTY ES-2 Premium may be the best option. Designed for simplified multi-shade layering, it comes with fixed shade combinations of dentin and enamel opacity, that greatly support predictable outcomes.
All the CLEARFIL MAJESTY ES paste-type composite systems offer a well-balanced viscosity and excellent mechanical properties, including
A flowable composite completes the portfolio. As the ideal level of viscosity depends on individual preferences and on the specific indication, CLEARFIL MAJESTY ES Flow comes in three different flowabilities: high, low and super low.
They have:
In addition, they are well-received for their easy application, fast polishing and high polish retention. All these features make the product a true versatility powerhouse. Moreover, it is offered in an innovative syringe designed for bubble-free application of the desired amount of composite and easy modelling.
The CLEARFIL MAJESTY ES portfolio offers highly suitable products for many clinical situations, demands and treatment techniques. As they support predictable outcomes and long-lasting success, using them gives dental practitioners the peace of mind needed to leave work at work and truly enjoy their free time—in the evening at home, on weekends or on holiday.
For more information about Kuraray Noritake Dental Inc.’s composite solutions visit the website.
Article by Dr. Michał Jaczewski
When working with composite, one of the most important aspects is to understand the mechanisms of adhesion. Choosing the right composite is one thing, but choosing a suitable bonding system and using it correctly is an equally important aspect affecting the long-term performance of a direct restoration.
There are many bonding products on the market - two-bottle (primer and bond) but also single-bottle systems. For anyone trying to select an ideal adhesive for a specific clinical case, the sheer number of available products can be challenging. The temptation to use them all, in slightly different ways, has the potential to create errors. In my dental practice, I am committed to simplifying procedures.
This is why I started looking for a bonding system that would offer a sense of security in terms of adhesion, but also ease of use in different clinical situations. I have opted for the 8th-generation bonding agent with the desired features - CLEARFIL™ Universal Bond Quick (Kuraray Noritake Dental Inc.). The single-bottle universal adhesive is ideal for a broad variety of bonding procedures carried out in the dental office.
CLEARFIL™ Universal Bond Quick can be used in the total-etch as well as the selective enamel etching technique in combination with an etching gel such as K-ETCHANT Syringe (Kuraray Noritake Dental Inc.). It is also a self-etching adhesive. Used in combination with the dual-cure build-up material CLEARFIL™ DC CORE PLUS or the dual-cure universal resin cement PANAVIA™ SA Cement Universal (both Kuraray Noritake Dental Inc.), it is also an ideal choice for cementation in the root canal and for cementing inlays or crowns made of a variety of different restorative materials – from metal to zirconia or lithium disilicate. Efficient clinical procedures are supported by the incorporated Rapid Bond Technology, which eliminates the need for extensive rubbing or waiting for the adhesive to penetrate the substrate and the solvent to evaporate. Among the key components of this technology are hydrophilic amide monomers, which allow the adhesive solution to penetrate moist dentin extraordinarily quickly, while also having a high curing ability. In addition, the original MDP monomer is included in the formulation. Together with the amide monomers, it provides for a high bond strength to enamel and dentin – achievable in a simple procedure of application, air-drying and light-curing.
The described properties turn CLEARFIL™ Universal Bond Quick into one of the most versatile and easy-to-use adhesive bonding solutions in the dental office. Operator sensitivity is low, as is its technique sensitivity, since the three-step procedure is always the same. The following case examples illustrate its use in the context of different repair procedures.
One of the major benefits of using composite as a restorative material lies in the fact that it may be modified and repaired at any time. Regardless of whether an air bubble is detected on the surface, the shade needs to be adjusted, a fracture occurs or materials need to be added as a result of wear, modification or repair is easily accomplished without needing to sacrifice additional amounts of healthy tooth structure. Whenever a silicone index has been produced for the initial treatment and is still available, and the user knows which composite has been utilized for the original restoration, the Flowable Injection Technique may be selected as a particularly easy and efficient way of repairing a restoration. However the recommended protocol is slightly different depending on the state of the restoration surface.
When a restoration has been damaged or an air bubble has appeared during injection of a flowable composite, the procedure is slightly different. In this case, the oxygen inhibition layer is usually still present on the surface of the restoration. Therefore, it is possible to simply apply an additional portion of composite (Figs. 1a to 1d). Even after contamination of the composite surface with water, saliva or blood, this measure is possible. The surface merely needs to be rinsed thoroughly and dried before applying the new portion of composite. For maximum safety, a universal adhesive may be used as well.
Fig. 1a. Repair procedure applicable for defect within a composite restoration whenever the oxygen inhibition layer has not yet been removed: Air bubble detected in the interproximal region.
Fig. 1b. Application of a new portion of composite after rinsing and drying. The adjacent surface is protected with PTFE tape.
Fig. 1c. Repositioned silicone index used to give the restoration the originally planned shape.
Fig. 1d. Final restoration.
If a similar defect is detected during finishing and polishing, i.e. when the oxygen inhibition layer has already been removed (Fig. 2), a roughening of the surface is strictly necessary. With a bevelled preparation of the area with the air bubble, optimal conditions are created for another layer of composite that blends in well with the surrounding material (Fig. 3). After bevelling, the surface needs to be sandblasted and cleaned either with KATANA™ Cleaner (Kuraray Noritake Dental Inc.) (Fig. 4a) or with 37 % orthophosphoric acid (Fig. 4b). After thorough rinsing and drying, an additional portion of composite may be applied to the surface (Figs. 5a to 5c). As the defect is small, the composite may be applied instead of injected and the silicone index repositioned afterwards.
Fig. 2. Void on the surface, detected during finishing.
Fig. 3. Removed void and bevelled area around the defect.
Fig. 4a. Option 1: Cleaning of the surface with KATANA™ Cleaner.
Fig. 4b. Option 2: Etching with K-ETCHANT Syringe.
Fig. 5a. Application of composite (CLEARFIL MAJESTY™ ES Flow Low).
Fig. 5b. Repositioning of the original silicone index to obtain the desired shape.
Fig. 5c. Final restoration with a nice blend-in of the different layers of composite.
For damaged restorations which have been in place for more than two weeks, an ideal composite-composite interface needs to be created by bevelling and roughening of the surface. A perfect example is presented in Figure 6. The most important step influencing the success of the procedure is proper preparation of the composite surface. To lay the foundation for a strong bond between the new and the old composite as well as for aesthetic outcomes, a bevel needs to be created (Figs 7a and 7b) to facilitate a smooth transition between the two layers. Once the bevel is completed, the surface should be sandblasted with alumina particles sized 27 μm (Fig. 8). The following recommended steps are etching of the composite with 37 % orthophosphoric acid (Fig. 9) and finally application of CLEARFIL™ Universal Bond Quick (Fig. 10). As the universal adhesive contains a silane coupling agent, separate silane application is not necessary. Instead, the new layer of composite may be applied immediately e.g. using the flowable injection technique with an existing matrix (Fig. 11).
Fig. 6. Fractured anterior composite restoration benefitting hugely from repair – the remaining composite is in a great state regarding colour and shape.
Fig. 7a. Bevelling with dedicated instruments.
Fig. 7b. Ideal bevel created to provide for a strong bond and great optical blend-in.
Fig. 8. Sandblasting of the surface with alumina particles.
Fig. 9. Phosphoric acid etching.
Fig. 10. Application of the universal adhesive.
Fig. 11. Composite applied using the flowable injection technique.
Fig. 12. Treatment outcome.
The three described repair protocols are straightforward and work well – provided that a strong bond is established at the composite-composite interface. The way it is established may be slightly different depending on whether the oxygen inhibition layer is still present or has already been removed. Using a universal adhesive like CLEARFIL™ Universal Bond Quick, the procedure is simplified owing to elimination of steps such as the separate application of silane.
Dentist:
MICHAŁ JACZEWSKI
Michał Jaczewski graduated from Wroclaw Medical University in 2006 and today runs his private practice in the city of Legnica, Poland. He specializes in minimally invasive dentistry and digital dentistry and is the founder of the Biofunctional School of Occlusion. Here he lectures and runs workshops with focus on full comprehensive patient treatments.
