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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.

PREPARATION

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.

PREPARATION: STEPS AT A GLANCE

1. Sandblasting of the sintered restoration (Al2O3 50 μm, 1-1.5 bar)
2. Cleaning (steam cleaner or ultrasonic cleaner)
3. Polishing the occlusal/palatal contact areas

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.

STAINING AND GLAZING

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.

STAINING AND GLAZING: STEPS AT A GLANCE

1. Glaze with Glaze/Clear Glaze
2. Increase chroma (in the cervical area or over large areas) with A+, B+, C+, or D+
   - Adjust intensity by mixing with Glaze/Clear Glaze
   - Create a warmer tone by mixing with Yellow
3. Replicate discolouration/exposed cervical areas: Cervical 1 and 2
4. Customise fissure areas
   - Darken with A+, B+, C+, or D+
   - Accentuate fissures with Cervical 1
5. Customise cusp tips
   - Replicate hypermineralisations with White
   - Create a band below with Grayish Blue (translucency effect)
   - Adjust translucency effect below cusp tips by mixing with Dark Grey
6. Firing

Alternatives:

1. First firing: Glaze plus base shade, second firing: Finer structures
2. First firing: Fixative stain firing without glaze, second firing: Glaze firing

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.

FINAL SITUATION

Fig. 11. Bridge 14-16 in place.

Dentist:

FLORIAN ZWIENER

CLEARFIL MAJESTY™ ES FLOW RECEIVES “NIOM TESTED” QUALITY SEAL

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.

IMPLICATIONS FOR CLINICAL USE

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.

GREAT AESTHETICS AND HANDLING

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.

Een gemakkelijke procedure en een betrouwbaar resultaat; dát zien de meeste tandheelkundige praktijkbeoefenaren het liefst als ze een indirecte restauratie plaatsen. Aan de hand van onderstaande klinische casus wordt een gemakkelijk, maar uiterst succesvol klinisch protocol gepresenteerd voor de bevestiging van een lithiumdisilicaat-kroon.

Afb. 1.  Lithiumdisilicaat-kroon na het etsen van het intagliooppervlak met hydrofluoridezuur en try-in.

Afb. 2a.  Applicatie van KATANA™ Cleaner in de kroon voor volledige verwijdering van contaminanten zoals eiwitten van bloed en speeksel, die afbreuk kunnen doen aan de werking van een composietcementsysteem.

OF Afb. 2b.  Als alternatief wordt KATANA™ Cleaner in een mengbakje geappliceerd.

Afb. 3. Aanbrengen van KATANA™ Cleaner op de restauratie.

Afb. 4. KATANA™ Cleaner wordt op dezelfde manier aangebracht op de geprepareerde tandstructuur (tien seconden wrijven, gevolgd door spoelen en drogen).

Afb. 5. Aanbrengen van PANAVIA™ SA Cement Universal in de gereinigde kroon.

Afb. 6. Het cement bevat een uniek silaankoppelmiddel - het LCSi-monomeer - voor een sterke en betrouwbare bevestiging aan lithiumdisilicaat en andere restauratieve materialen zoals glas- en hybridekeramiek.

  Het silaan wordt in de mengpunt geactiveerd door Original MDP

Afb. 7. Gemakkelijke reiniging na twee tot vijf seconden tack-curing.

Afb. 8. De cementovermaat heeft een gelachtige consistentie en wordt in z‘n geheel verwijderd met een sikkelsonde.

FINAL SITUATION

Afb. 9. Resultaat van de behandeling meteen na plaatsing van de kroon.

Dentist:

RICHARD YOUNG DDS

MET DANK AAN RICHARD YOUNG,  DDS IN SAN BERNARDINO, CA,  VOOR DE CASUS EN BEELDEN

International Marketing Coordinator (32 – 40 uur)

Ben jij een ervaren marketingprofessional met een passie voor communicatie en commerciële projecten? Houd je van het coördineren en uitvoeren van marketingcampagnes en heb je een hands-on mentaliteit? Sluit je dan aan bij ons groeiende team als International Marketing Coordinator!

Over Kuraray Noritake Dental

Kuraray Noritake Dental is wereldwijd actief in de tandheelkundige sector, gespecialiseerd in hoogwaardige materialen voor tandartsen en tandtechnici. Met onze innovatieve producten ondersteunen wij tandheelkundige professionals in het bieden van de beste zorg aan hun patiënten. Ons hoofdkantoor is gevestigd in Tokio, Japan, en ons Noord-Europese kantoor in IJmuiden bedient de Benelux, Nordics, Baltische Staten, het Verenigd Koninkrijk en Ierland.

Als dochteronderneming van Kuraray Inc., een multinational met een jaarlijkse omzet van
4 miljard euro, combineren we de voordelen van een grote organisatie met de persoonlijke cultuur van een kleiner bedrijf (ca. 30 FTE).

Jouw rol als International Marketing Coordinator

In deze rol ben jij de spil tussen diverse afdelingen en marktpartijen, en zorg je ervoor dat onze merken en producten prominent gepositioneerd worden in de diverse regio’s. Je werkt nauw samen met collega’s van Marketing en Sales en houdt contact met lokale markten door middel van reizen en het bijwonen van beurzen en evenementen.

Taken en verantwoordelijkheden:

• Creatief bijdragen aan marketingactiviteiten en initiëren van projecten ter ondersteuning van sales- en marketingdoelstellingen.
• Ontwikkelen van lokale communicatie-uitingen en promotiematerialen, en het coördineren van media-inzet.
• Organiseren en coördineren van evenementen zoals cursussen, beurzen en educatieve events.
• Samenwerken met de afdeling sales voor marketingactiviteiten gericht op tussenhandelaren.
• Je helpt mee met het ontwikkelen van relevante content voor geïntegreerde marketingcampagnes, website en social media.
• Beheren van projectbudgetten en rapporteren aan de Marketing Manager

Jouw profiel:

• HBO werk- en denkniveau.
• Minimaal enkele jaren ervaring in bijvoorbeeld productmanagement, eventorganisatie, marketingcommunicatie of soortgelijke functies.
• Creatief en vaardig in het schrijven van overtuigende teksten.
• Uitstekende beheersing van zowel de Nederlandse als Engelse taal.
• Zelfstandig, flexibel, en goed in het beheren van meerdere projecten tegelijkertijd.
• Zowel analytisch als pragmatisch en altijd gericht op het behalen van resultaten.

Wat wij bieden:

• Grote verantwoordelijkheid en ruimte voor eigen initiatieven.
• Een stabiele en internationale werkomgeving met veel aandacht voor persoonlijke ontwikkeling.
• Enthousiaste collega's en een comfortabele kantooromgeving.
• Een uitstekend salaris, aantrekkelijke arbeidsvoorwaarden, een jaarlijkse bonus, en een zakelijke smartphone en laptop.

Solliciteren:

Heb je vragen over deze vacature? Neem contact op met Saskia van Daalen - ten Brink, Marketing Manager Benelux, Nordics, Baltics & UK en Ireland.
E-mail [email protected] 

Solliciteren door je CV te sturen naar [email protected] 

Kuraray Europe Benelux B.V.
Margadantstraat 20
1976 DN IJmuiden
+(0) 31 255 523 701

De duurzaamheid van een composietrestauratie is afhankelijk van diverse factoren. Sommige factoren vallen buiten de invloedssfeer van de praktijkbeoefenaar en weer andere zijn sterk patiëntgerelateerd. Zo hebben de tandenborstel, het type tandpasta, de poetstechniek, een dieet, genotmiddelen en hygiënische gewoonten allemaal invloed op de restauratie. Het optimale protocol voor het afwerken en polijsten is echter volledig in handen van de tandheelkundige.

Polijsten is bedoeld om de zuurstofinhibitielaag te verwijderen en een glad restauratieoppervlak te realiseren. Een goed gepolijste restauratie absorbeert geen kleurmiddelen uit voedsel, drank of genootsmiddelen die leiden tot verkleuring van de composiet, zodat een langdurig esthetisch effect van de restauratie is gewaarborgd.

Het polijsten van de composiet is een proces dat speciale aandacht vraagt en het proces is opgebouwd uit meerdere stappen en principes.

• Met behulp van afwerkschijfjes komt een glad restauratieoppervlak tot stand, wordt de overmaat van composiet verwijderd en de uiteindelijke vorm aan de restauratie gegeven. Bedenk vooral dat er moet worden gewerkt op een bevochtigd oppervlak met een 1:1 tandheelkundig handstuk bij een snelheid van maximaal 5.000 tot 10.000 tpm.

• Polijstrubbers zijn verkrijgbaar in diverse soorten en formaten. Een van de meest universele polijstrubbers, speciaal ontwikkeld voor composiet, is TWIST™ DIA for Composite. Dit is een set van twee polijstrubbers met verschillende niveaus van ruwheid. De eerste (donkerblauw) wordt gebruikt voor inleidend of voorpolijsten; de tweede (lichtblauw) voor de uiteindelijke hoogglans en gladheid. Er wordt op gewezen dat er met deze instrumenten moet worden gewerkt op een droog oppervlak zonder waterkoeling. Het risico van droog werken is dat er warmte wordt gegenereerd en de pulpa dus kan worden geïrriteerd. Daarom moet de werksnelheid worden beperkt tot 5.000 à 10.000 tpm en dient excessieve druk te worden vermeden.

• De volgende stap is het gebruik van een diamantpolijstpasta met een verloop van 1 tot 5 micron. Bij deze pasta wordt het gebruik van een polijstwieltje van geitenhaar aanbevolen. Het borsteltype is niet belangrijk, maar gebruik vooral geen borstel met stugge haren om krassen op de composiet te voorkomen. Dankzij het gebruik van een polijstborsteltje met pasta kunnen er plekken worden bereikt die anders moeilijk bereikbaar zijn, zoals het cervicale gebied en de proximale vlakken. Naast deze stap wordt er nog een schuurstrip met celluloiddiamant gebruikt om de proximale vlakken preciezer te polijsten. Om de contactpunten intact te laten, moeten er zacht schurende (superfijne) strips worden gebruikt.

• Nog een stap om de glans van de restauratie te verhogen en deze tegen verkleuring te beschermen, is het gebruik van een aluminiumoxidepasta met een katoenen polijstborsteltje. Het gebruik van zo'n pasta - oorspronkelijk bedoeld voor keramiek - resulteert in een uitzonderlijk glad oppervlak en een hoge gans van het restauratieoppervlak. Deze stap wordt uitgevoerd in een droge omgeving bij een snelheid van maximaal 5.000 tot 10.000 tpm.

Bij alle technieken, dus ook de Flowable Injection Technique, heeft het niveau van polijsten invloed op de duurzaamheid en de optische en esthetische eigenschappen van de restauratie. Er moet dan ook voldoende tijd worden besteed aan deze cruciale stap van de tandrestauratie. Composieten worden gekenmerkt door de verschillende samenstellingen en gehalten van vuldeeltjes, die niet alleen hun eigenschappen beïnvloeden, maar tevens het gemak waarmee ze kunnen worden gepolijst. In sommige gevallen moet de procedure meerdere keren worden herhaald om een 'spiegeleffect' te realiseren. CLEARFIL MAJESTY™ ES Flow is een hoog gevuld composiet die zich heel gemakkelijk laat polijsten tot een niveau van hoogglans. Met behulp van polijst rubbers, borsteltjes en pasta's kan er een uitzonderlijk esthetisch resultaat worden behaald.

BEFORE

AFTER

3-YEARS RECALL

ZORG VOOR EEN STRALENDE LACH!

Dentist:

MICHAL JACZEWSKI

Michał Jaczewski studeerde in 2006 af aan de Wroclaw Medical University en momenteel runt hij zijn eigen praktijk in de Poolse stad Legnica. Hij is gespecialiseerd in minimaal invasieve en digitale tandheelkunde, en is de oprichter van de Biofunctional School of Occlusion. Op deze school is hij docent en organiseert hij workshops die zijn gericht op een allesomvattende behandeling van patiënten.

Technical Specialist for Chairside, Volkan Kacmaz, Introduces Himself

Volkan Kacmaz not only worked as a dentist in Turkey, but he also managed two clinics and earned a Master of Business Administration in Berlin. His diverse experiences seem to have led him to his current role as a Technical Specialist at Kuraray Noritake Dental Inc., headquartered near Frankfurt. Who is this friendly, smiley, and curious team member, and why did he specifically choose Kuraray?

While most dentists continue practicing dentistry throughout their careers, Volkan Kacmaz chose a different path. After graduating in 2011, he established his own dental clinic in Istanbul. A few years later, he served in the military for a year as a military dentist. Afterward, he founded two more franchise clinics, taking on the dual roles of manager and dentist. It was during this time that he realized dentistry wasn’t limited to clinical practice. “I’m eager to learn and have always been curious about how products work, the processes behind them, research and development, and the launch of new innovations,” he explains.

INNOVATION

In 2022, Kacmaz became the first dentist to enrol at the Berlin School of Economics and Law, where he learned about marketing, sales, negotiation, and regulations. Upon completing his Master of Business Administration, he made a deliberate decision to join Kuraray Noritake. “Kuraray Noritake's products are of very high quality, both labside and chairside. I already knew this from my experience as a dentist. The company has an excellent and trustworthy reputation among dental professionals,” he says.

Kacmaz also admires the innovative nature of the company. “Kuraray Noritake is responsible for some of the most significant innovations in dentistry. Just look at products like PANAVIA™ cement, the original MDP monomer, and multi-layered zirconia discs and blocks. It’s easy to see that Kuraray Noritake is a major force in the dental market. With their commitment to continuous improvement and innovation, you could call them the Apple of the dental world,” he adds.

Another aspect Kacmaz appreciates is Kuraray Noritake's product lineup. “The catalog isn't extensive, but it’s highly specialized. The company doesn’t produce just any product, but focuses on the ones it excels at, ensuring top-notch quality.” Lastly, Kacmaz loves the company culture. “It's a very respectful environment. I’ve had some bad experiences with respect in the past,” he says with a laugh, referring to his time in the military. “But at Kuraray Noritake, you can feel the respect for employees, which is very important to me. I’m very happy to be part of the Kuraray Noritake family.”

COURAGE

When comparing dentistry in Turkey to Western Europe, Kacmaz doesn’t see significant differences. “The brands, quality, and approaches are all the same.” However, he has noticed one small distinction: German dentists aren’t as enthusiastic about digital dentistry as their Turkish counterparts.

Kacmaz draws on all his previous experiences and knowledge in his role as part of the scientific marketing team. His responsibilities include finding scientific support for marketing initiatives. He collaborates with lecturers and dentists to manage research studies using Kuraray Noritake products, works to update measurements in response to market dynamics, and evaluates new products.

His goal? “To become an authority in the dental world,” he says with a smile. It may sound like an ambitious goal, but Kacmaz has learned to dream big. “The biggest decision of my life was leaving my comfort zone and moving to a country where I didn’t speak the language. But I believe it’s a courage you have to show. If you don’t, your dreams and plans will fade, and you’ll miss out on everything.”

LEARNING NEW THINGS

Moving to Germany, which Kacmaz describes as "the epicentre of the dental market," hasn’t always been easy. Coming from a Mediterranean culture, he was used to a more communal and lively environment. In Germany, he noticed that shops close early, and people value their privacy. Another challenge has been the language. While he prefers English, he says, “ein bisschen Deutsch, nicht so gut.”  Fortunately, Kuraray Noritake provides him with German lessons, and he has the best teacher at home—his three-year-old daughter, who learns the language faster than he does and sometimes corrects him.

Despite the challenges, all the adapting and hard work have been worth it. “I’ve realized that there are no limits to learning. Whether you’re in your 40s, 50s, or even 60s, there’s always something new to discover. You just have to be open to it.”

CONTACT

Volkan Kacmaz can be reached at +49 69 305 35134 or via [email protected].

ABOUT KURARAY NORITAKE DENTAL INC.

Kuraray was founded in 1926 in Kurashiki, Japan. Today, it is a leading global manufacturer of medical products, materials, textiles, chemicals, resins, and more. In 2012, Kuraray Medical and Noritake Dental Supply merged to form Kuraray Noritake Dental Inc. The company continues to deliver reliable dental bonding agents, ceramics, and other products to over 90 countries worldwide. Well-known products include the KATANA™ Zirconia range, CLEARFIL™ Universal Bond Quick, and PANAVIA™ resin cements.

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.

UNIVERSAL ADHESIVE

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.

CLINICAL PROTOCOL

Depending on the condition of the existing restoration surface, the repair protocol may be slightly different. The basic steps are as follows:

PROTOCOL 1: OXYGEN INHIBITION LAYER STILL ON THE SURFACE

- 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

PROTOCOL 2: OXYGEN INHIBITION LAYER ALREADY REMOVED FROM THE COMPOSITE SURFACE

- 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

CLINICAL RECOMMENDATIONS

1. STAY IN THE COMPOSITE DURING PREPARATION

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.

2. INCREASE ADHESION BY SANDBLASTING

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.

3. USE A UNIVERSAL ADHESIVE THAT CONTAINS SILANE

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.

4. IF IN DOUBT, USE A UNIVERSAL ADHESIVE DURING REPAIR PROCEDURES

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.

5. IF AVAILABLE, PLACE A SILICONE INDEX TO SIMPLIFY ANATOMICAL SHAPING

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.

CONCLUSION

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.

UNIVERSAL SOLUTION FOR UTMOST SIMPLICITY

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.

CLASSIC AND PREMIUM OPTIONS FOR SINGLE- AND DUAL-SHADE LAYERING

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.

MECHANICAL PROPERTIES

All the CLEARFIL MAJESTY ES paste-type composite systems offer a well-balanced viscosity and excellent mechanical properties, including

• a high flexural strength of 118 MPa
• a filler load of 78 wt%
• a compressive strength of 347 MPa
• a low volumetric shrinkage of 1.9 %
• a curing depth of 2.0 mm and
• a long working time under ambient light of 4.5 minutes
  
  

VERSATILITY POWERHOUSE IN THREE VISCOSITIES>

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:

• a high flexural strength of 145, 151 and 152 MPa, respectively
• a filler load of 71, 75 and 78 wt%, respectively
• a compressive strength of 358, 373 and 374 MPa, respectively and
• a working time under ambient light of 100 seconds.

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 IDEAL PORTFOLIO FOR PEACE OF MIND

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 8^th-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.

IMPRESSIVE FEATURES

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.

REPAIR OF COMPOSITE RESTORATIONS

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.

CASE EXAMPLE 1: IMMEDIATE REPAIR PROCEDURE

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.

CASE EXAMPLE 2: REPAIR PROCEDURE AFTER POLISHING

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.

CASE EXAMPLE 3: REPAIR PROCEDURE AFTER TWO OR MORE WEEKS

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.

CONCLUSION

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.

DELICATE BALANCE BETWEEN COSTS AND AESTHETICS IN DENTAL LAB

When you are a lab owner striving to achieve high-end results using modern digital techniques, the initial investment in CAD/CAM technology is significant, followed by ongoing costs for expendable items such as milling tools and blanks. That cost can be reduced by selecting universal, high-quality materials.

Undoubtedly, zirconia stands out as one of the most popular materials on the market. From an inventory perspective, however, lab owners often find themselves purchasing multiple discs of the same shade and thickness. The reason is that they need to meet all requirements for strength and aesthetics in different settings – enabling them to cover all kinds of restorations and deliver excellent patient outcomes.

UNIVERSAL SOLUTION FOR DENTAL LABS

At Kuraray Noritake Dental Inc., we take pride in not only developing the first-ever multilayer zirconia, KATANA™ Zirconia ML, but also in our commitment to delivering the highest quality materials that we can.

KATANA™ Zirconia YML, our latest addition to the KATANA™ Zirconia line-up, exemplifies this dedication and offers universal applicability. The universal feature is based on the fact that KATANA™ Zirconia YML disc not only offers colour gradation, but also impressive flexural strength and translucency gradation, with maximum values of up to 1,100 MPa and 49 % translucency, respectively.

INHOUSE PRODUCTION - THE PATH TO HIGH QUALITY ZIRCONIA DISC

Like all our zirconia offerings, KATANA™ Zirconia YML begins its journey to the dental lab in our Japanese facility where raw zirconia powder undergoes special treatment process before the addition of essential components.

Once the material has undergone this thorough initial stage, it progresses to the pressing and pre-sintering phase to form the disc. Every detail is carefully calculated, managed and controlled. This phase of the process takes several days, underscoring our goal to achieve the most aesthetic product.

HIGH-SPEED SINTERING PROGRAM: 54 MINUTES

The unique powder formulation and refinement process, as well as the pressing and pre-sintering technique, is the key to allow our customers to realize restorations of up to three-unit bridges without any compromise in terms of aesthetics or mechanical properties using the 54-minute high-speed sintering* process.

This high quality, lengthy production process results in an exceptionally dense material, which once sintered, goes on to deliver a high strength, high aesthetic final restoration.

HIGH PRECISION SHRINKAGE AND STABLE CTE VALUES FOR EXCEPTIONAL FIT

Outstanding deformation stability during the sintering procedure, contributes to the stability during the final sintering process in the dental laboratory, providing for an exceptional fit of large-span bridges and other restorations.

MULTI-LAYERED STRUCTURE AND EASE OF POSITIONING OF RESTORATIONS IN THE BLANK

To enhance aesthetic qualities, all KATANA™ Zirconia YML discs are designed using ratios rather than fixed measurements of different layers in the multi-layered structure. This means that regardless of the disc's thickness, there is always a consistent ratio of 35 % of raw material that constitutes the translucent enamel zone. Hence, discs with an increased height, which are typically used for the production of larger restorations, will always offer sufficient space in the enamel zone, while smaller discs are optimized for smaller restorations.

ONE DISC. ALL INDICATIONS.

These qualities empower dental lab owners to deliver a wide range of restorations. The material is suitable for single crowns to full-arch structures, for full-contour designs to conventional frameworks, using a single material without compromising on aesthetics: KATANA™ Zirconia YML. For finishing, we offer a well-aligned portfolio of solutions designed for internal and external staining, micro-layering and full layering.

EXPLORE KATANA™ Zirconia YML: WEALTH OF RESOURCES, CLINICAL CASES AND FAQS

Visit our website to discover more about KATANA™ Zirconia YML. You will find useful materials such as brochure, technical guide, in-depth technical information.

Would you like to see the material in action – browse the blog section of our website that offers a variety of clinical cases and articles by world-renowned experts showcasing and proving the versatility and aesthetics of KATANA™ Zirconia YML.

*The material is removed from the furnace at 800°C. A furnace with a configurable KATANA™ Zirconia YML firing program is required.

FLOWABLE INJECTION AND STAMP TECHNIQUE: RESTORING TEETH IN THE POSTERIOR REGION

Restoring the occlusal surface of posterior teeth while preserving the natural morphology and re-establishing correct occlusal contacts has always been challenging for dental practitioners. Free-hand layering requires knowledge of tooth anatomy, composite handling skills and experience. When the occlusal surface of a tooth is damaged at the start of treatment (as is usually the case in teeth with large MOD cavities) or an increase of the vertical dimension of occlusion is planned (e.g. in severely worn teeth), the use of the flowable injection technique may be a suitable alternative. It truly speeds up and facilitates the process of building up the restoration to a natural shape, but requires thorough planning and preparation. In cases with an intact occlusal surface, the stamp technique might be the first choice.

FLOWABLE INJECTION TECHNIQUE: GENERAL CONSIDERATIONS

It is up to the user how exactly the restorations, to be built up by flowable injection, are planned and how the plan is implemented: One can either opt for a conventional wax-up or make use of digital tools in the planning phase. Dedicated design software offers the benefit of facilitating the creation of a natural shape and morphology of the desired restoration and allows for the establishing of an ideal occlusal relationship. Once the wax-up is ready, it needs to be transferred into the patient’s mouth. This is accomplished via a printed or classical model with wax-up, which forms the basis for the production of a matrix or silicon index. This index is then used intraorally for the injection of the flowable composite. To enable proper light curing through the index, the index material should be as transparent as possible.

AREA-SPECIFIC CONSIDERATIONS

In the posterior area, an index made of two different materials – a soft inner silicon structure and a hard outer shell – may be advisable. Due to its higher dimensional stability compared to a soft silicon index, it is possible to put pressure on it for proper adaptation to the isolated teeth and soft tissue without the risk of altering the shape of the tooth. Figure 1 shows such an index on and next to a printed model. It consists of a hard shell made of acrylic and a soft inner structure made of a transparent silicone material (e.g. EXACLEAR™, GC). For production, a high-capacity hydraulic pressure curing unit designed for use with self-curing resins (Aquapres™, Lang Dental) has proven its worth: It ensures a highly accurate reproduction of the (digital) wax-up.

Fig. 1. Printed model and silicone index.

Reconstruction of posterior teeth with the flowable injection technique requires prior removal of all carious lesions and reconstruction of the proximal surfaces to restore the contact points. Hence, the injected composite serves the exclusive purpose of restoring the occlusal surface. When several teeth are treated, a two-step procedure with an alternating technique is recommended to provide for proper separation of the teeth. Blocking the proximal surfaces below the contact point with PTFE tape will reduce the amount of excess material in these areas and make it easier to clean and prepare the proximal surfaces after flowable injection. Proximal and deeper occlusal lesions should be restored with the aid of a matrix, wedge and ring.

CLINICAL PROTOCOL

A possible clinical protocol is illustrated in Figures 2 to 5: After caries excavation and tooth preparation, sectional matrices, wedges and rings were placed to allow for simultaneous treatment of the mesial and occlusal cavities. Following etching and application of the universal adhesive CLEARFIL™ Universal Bond Quick (Kuraray Noritake Dental Inc.), the cavities were restored with CLEARFIL MAJESTY™ ES Flow Super Low in the shade A1 and CLEARFIL MAJESTY™ ES-2 Universal in the shade U. The distal cavity of the first molar was filled in the last step of the free-hand modeling procedure. In order to restore the occlusal surfaces in their original vertical dimension, every second tooth was isolated with rubber dam and the exposed molar etched (total-etch technique with K-ETCHANT Syringe, Kuraray Noritake Dental Inc.). the alternating index was positioned with some pressure and the flowable composite (CLEARFIL MAJESTY™ ES Flow Super Low) injected. Once light curing was completed, it was possible to remove the index, chip off the excess and finish and polish the restoration before repeating the procedure for the adjacent molar.

Fig. 2. Restoration of two molars: Teeth preparation and caries excavation.

Fig. 3. Restoration of two molars: Filling of the proximal and occlusal cavities.

Fig. 4.  Restoration of two molars: Re-establishing the occlusion with the aid of the flowable injection technique.

Fig. 5. Alternating approach: Restoration of the second molar by injecting flowable composite.

DISCUSSION

The use of the flowable injection technique allows for rapid restoration of teeth and the establishment of precise occlusal contacts. This reduces the time spend on occlusal surface modelling and minimizes the risk for prolonged treatment due to a repeated need for occlusal adjustments. In addition to saving time, it is possible with this technique to restore a greater number of teeth in a single appointment. The aesthetics of this type of restoration may be somewhat limited: A skilled practitioner is able to achieve better aesthetic results on the occlusal surface. However, with a detailed wax-up and high-quality model great outcomes can be obtained. The surface quality of printed models can be increased by adjusting the printing parameters including the layer height (Fig. 6). The use of a hydraulic pressure curing unit for silicone index production further increases the quality of the occlusal surface.

When planned and implemented correctly, the established occlusal surface and contacts reflect the natural anatomy without the need for adjustments (Fig. 7). Especially when restoring an entire quadrant, it is possible to increase the efficiency by opting for the flowable injection technique. Doing so reduces the number of appointments and the chair time decisively (Fig. 8).

STAMP TECHNIQUE: CONSIDERATIONS

If the occlusal surface of the tooth is intact, a wax-up may not be necessary. In this case, the better strategy is to duplicate what is still available before initiating treatment. A flowable composite or liquid rubber dam can be used for this purpose. It is important to coat the tooth surface with glycerin gel before applying the material. This will facilitate separation of the stamp from the tooth. It is always advisable to create a stamp that covers not only the details that need to be recorded and duplicated, but is extended over the cusps. This offers better stability in the restoration phase.

CLINICAL PROTOCOL

Figures 9 to 11 illustrate a possible clinical procedure. In this case, a molar with an occlusal carious lesion needed to be restored. The tooth surface was cleaned and a thin layer of glycerin gel applied, followed by a thick layer of liquid rubber dam, which covered the entire occlusal surface. Then, a micro applicator was immersed into the material and the stamp cured. After preparation, etching and application of the bonding system, the cavity was restored with flowable composite (CLEARFIL MAJESTY™ ES Flow Super Low in the shade A2). When the cavity is larger and depending on personal preferences, a paste-type composite (CLEARFIL MAJESTY™ ES-2 Universal) may also be used. Prior to light curing of the composite, the occlusal surface was covered with PTFE tape and the stamp pressed onto it. After firm pressing, the tape and excess material were removed and the restoration polymerized. This restoration faithfully reproduces the occlusal surface and did not require any occlusal adjustments.

Fig. 6. Stamp production with liquid rubber dam.

Fig. 7. The stamp.

Fig. 8. Restoration procedure: From preparation to bonding.

Fig. 9. Restoration procedure: Filling with flowable composite.

Fig. 10. Restoration procedure: Duplication the original occlusal surface with the stamp.

Fig. 11. Tooth before and after treatment using the stamp technique.

CONCLUSION

Techniques that add simplicity and efficiency to clinical procedures are always welcome in the busy practice environment. Depending on the information available at the start of treatment and the number of teeth to be restored, the flowable injection or the stamp technique may be an ideal choice. They are easily implemented and speed up the clinical procedure, but most importantly support predictable outcomes. This saves time in the finishing phase and minimized the risk of repeated adjustments, hence protecting everyone involved from additional appointments and frustration. Especially for practitioners with limited routine in free-hand modelling and for those with maximum patient comfort in mind, both techniques are worth being integrated in their clinical procedures.

Dentist:

MICHAL 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.

Door dr. Clarence Tam, HBSC, DDS, AAACD, FIADFE

Het gebruik van porseleinveneers voor het verbeteren van de vorm, kleur en visuele stand van anterieure tanden is een gebruikelijke techniek binnen de esthetische tandheelkunde. Het biomimetische doel van de restauratie van tanden raakt niet alleen het cosmetische domein; functionele afwegingen spelen ook een rol. Het is essentieel om in acht te nemen dat de intacte omhulsels van de palatale en faciale wanden met betrekking tot anterieure tanden verantwoordelijk zijn voor de intrinsieke buigsterkte. Als de tandheelkundige structuur is aangetast door endodontische invloeden, cariës en/of trauma, moet al het mogelijke worden gedaan om de residuele structuur te behouden en moet er naar worden gestreefd om basisprestaties van een onaangetaste tand te herstellen of overstijgen.

ACHTERGROND

Een vrouwelijke 55-jarige ASA II-patiënt meldde zich bij de praktijk voor een whitening-behandeling. Naar verwachting zou de whitening geen effect hebben op de kleur van een reeds bestaande porseleinen facing op tand 1.2. Deze zou binnen de procedure moeten worden verwijderd, vooral als de kleurveranderingen significant zouden zijn. De patiënt begon met de basiskleur VITA* 1M1:2M1; verhouding 50:50 in het bovenste anterieure gedeelte en 1M1 in het onderste anterieure gedeelte. Na een nightguard-bleekprotocol met 10% carbamideperoxide, 3 tot 4 weken lang gedurende de nacht, werd bij de patiënt een VITA* 0M3-kleur bereikt in de bovenste en onderste tandbogen. Als gevolg daarvan was er een aanzienlijk verschil in value tussen tand 1.2 met facing en de omringende tanden; tevens werd een toegenomen chroma vastgesteld bij de contralaterale tand 2.2 vanwege een faciaal-gerelateerde Klasse III-composietrestauratie. Laatstgenoemde tand stemde qua formaat niet overeen met de contralaterale tand en daarom werd besloten om beide laterale snijtanden te behandelen met geprepareerde laminaatveneers van lithiumdisilicaat. De aangrenzende hoektand (2.3) vertoonde lokale milde tot matige slijtage van de cusps, maar de patiënt wilde hieraan niets laten doen totdat de nieuwe facings zouden zijn geplaatst. Het doel van smile design in deze fase is om uiteindelijk te zorgen voor tweezijdige harmonie met het oog op de plaatsing van een aanvullende indirecte restauratie waarmee het faciale volume en het gebrek van de cusp op tand 2.3 op korte termijn worden hersteld.

PROCEDURE

Een protocol voor een digitaal smile design was niet nodig voor de aanvankelijke opzet, namelijk de individuele behandeling van de laterale snijtanden. Een lichte variatie is toegestaan bij dit tanden van dit type, aangezien deze de lach van de patiënt karakteriseren qua sekse en persoonlijkheid. Voorafgaand aan de verdoving was de doelkleur geselecteerd aan de hand van close-upfoto's die zowel gepolariseerde als ongepolariseerde selecties toonden. De foto's waren geprepareerd voor digitale kleurkalibratie door middel van referentieopnamen met een neutrale 18% grijswit-balanskaart (Afb. 1).

Afb. 1. Referentieopname met neutrale 18% grijskaart.

De basisbodykleur was VITA* 0M2 met een perspiltint BL2. De patiënt werd verdoofd met 1,5 ampul met een 2% lidocaïne-oplossing met epinefrine (verhouding 1:100.000); daarna werd een cofferdam volgens de split-damtechniek geplaatst. De facing op tand 1.2 werd gesectioneerd en verwijderd van tand 1.2; vervolgens werd op tand 2.2. een minimaal invasieve veneerpreparatie uitgevoerd (Afb. 2). De gedeeltelijke vervanging van de oude composietharsrestauratie werd uitgevoerd op het mesioincisobuccopalatale aspect van tand 12, waarbij het intacte segment werd behouden. De adhesie aan de oude composiet werd bereikt door middel van abrasie met microdeeltjes en een silaankoppelproduct (CLEARFIL™ CERAMIC PRIMER PLUS). De randen werden bijgewerkt en de retractiedraden gedrenkt in een aluminiumchloride-oplossing en vastgezet. De kleuren van preparatiestompen werden vastgelegd. Er werden definitieve afdrukken gemaakt met behulp van licht en zwaar polyvinylsiloxaan in een metalen tray. De patiënt verliet de praktijk met een noodvoorziening en instructies om de kleur in het laboratorium in het bisquebake-stadium te controleren. De door het tandtechnische laboratorium vervaardigde modellen bevestigen het minimaal invasieve karakter van deze casus.

Afb. 2. Veneerpreparatie bij tanden 1.2 en 2.2.

Na ontvangst van de modellen werd de patiënt verdoofd en werden de noodvoorzieningen verwijderd. De preparaties werden gereinigd en geprepareerd voor bevestiging door abrasie van de oppervlakken met behulp van aluminiumoxidepoeder (27 micron) bij een druk van 30 tot 40 psi. De facings werden getoetst door middel van een heldere glycerinepasta (PANAVIA™ V5 Try-in Paste Clear, Kuraray Noritake Dental Inc.). De retractiedraden werden vastgezet en de intaglio-oppervlakken van de restauraties werden 20 seconden lang behandeld met een 5% hydrofluoridezuur, waarna een silaankoppelproduct met 10-MDP (CLEARFIL™ CERAMIC PRIMER PLUS) werd aangebracht (Afb. 3). Het tandoppervlak werd gedurende 20 seconden geëtst met een 33% orthofosforzuur en vervolgens gespoeld. Daarna werd een primer met 10-MDP (PANAVIA™ V5 Tooth Primer) op de tand aangebracht (Afb. 4) en conform de instructies van de fabrikant drooggeblazen.

Afb. 3. Aanbrengen van CLEARFIL™ CERAMIC PRIMER PLUS op de intaglio-oppervlakken van de facings.

Afb. 4. Applicatie van PANAVIA™ V5 Tooth Primer op de geëtste tandoppervlakken.

Na het aanbrengen van veneercement (PANAVIA™ Veneer LC Paste Clear) (Afb. 5) werd de facing vastgezet. De cementovermaat had een relatief vaste consistentie en hield de facing goed in positie tijdens alle handelingen om de rand in orde te brengen vóór een tack-cure van 1 seconde (Afb. 6).

Afb. 5. Aanbrengen van PANAVIA™ Veneer LC Paste Clear op de geprepareerde intaglio-oppervlakken van de facings.

Afb. 6. PANAVIA™ Veneer LC Paste meteen na bevestiging. Let op de stroperige, relatief vaste consistentie van het cement, waardoor het gemakkelijk kan worden verwijderd onder vochtige omstandigheden én in de gelfase.

Het cement ging over in een geltoestand, waardoor de cementovermaat kon worden verwijderd bij een minimale reiniging (Afb. 7). Voor de definitieve uitharding werden de randen gecoat met een heldere glycerinegel om de zuurstofinhibitielaag te verwijderen (Afb. 8).

Afb 7. Verwijdering van cementovermaat na tack-cure van 1 seconde.

Afb. 8. Definitieve uitharding van de facings, gelijktijdig vanuit het palatale en faciale aspect.

De randen werden afgewerkt en op hoogglans gepolijst, en de occlusie van de restauraties werd positief bevonden. De postoperatieve opnamen laten een voortreffelijke randintegratie zien (Afb. 9).

Afb. 9. Postoperatieve esthetische verwerking van facings op de tanden 1.2 en 2.2.

Na de behandeling laten gepolariseerde opnames zien dat de restauraties esthetisch en functioneel goed zijn opgenomen in de nieuwe lach (Afb. 10), in afwachting van de esthetische verbetering van tand 2.3 om te harmoniëren met de contralaterale hoektand.

EINDRESULTAAT

Afb. 10. Eindresultaat via een gepolariseerde opname na de behandeling.

Tandarts:

CLARENCE TAM

References

1. Magne P, Douglas WH. Rationalization of esthetic restorative dentistry based on biomimetics. J Esthet Dent. 1999;11(1):5-15. doi: 10.1111/j.1708-8240.1999.tb00371.x. PMID: 10337285.
2. Magne P, Douglas WH. Porcelain veneers: dentin bonding optimization and biomimetic recovery of the crown. Int J Prosthodont. 1999 Mar-Apr;12(2):111-21. PMID: 10371912.
3. Pongprueksa P, Kuphasuk W, Senawongse P. The elastic moduli across various types of resin/dentin interfaces. Dent Mater. 2008 Aug;24(8):1102-6. doi: 10.1016/j.dental.2007.12.008. Epub 2008 Mar 4. PMID: 18304626.
4. Source: Kuraray Noritake Dental Inc. Samples (beam shape; 25 x 2 x 2 mm): The solvents of each material were removed by blowing mild air prior to the test.