With PANAVIA™ SA Cement Universal and KATANA™ Zirconia

By using PANAVIA™ SA Cement Universal and its proprietary dual-monomer technology, you can now simplify the bonding of restoration to implant abutments without the use of separate primers or silane. Independent research has confirmed this new dual-monomer technology does not sacrifice adhesion or durability on glass-based ceramics or zirconia. The technique, in this case study, is for custom fabricated abutment & KATANA™ Zirconia YML crown, however, the basic technique on the treatment of the abutment and restoration may be used with any implant restoration combination as long as the proper surface treatments for type of material is followed.

INITIAL FIT OF ABUTMENT & RESTORATION

Basic technique on the treatment of the abutment and restoration.

Fig. 1. Check Initial Fit of Abutment & Restoration: abutment & crown margins should be checked to ensure proper fit.

Fig. 2. Protect base of implant with putty or light-cure block-out resin. The base of the implant should be covered so that it is not air abraded accidentally.

Fig. 3. Abrade titanium abutment with 50 μm alumina oxide powder.

Fig. 4. Clean abutment with KATANA™ Cleaner: Apply KATANA™ Cleaner by rubbing each area for 10 seconds.

KATANA™ Cleaner is a universal cleaner that is indicated to clean metal, zirconia & glass-based restorations. It is also an intra oral cleaner that may be used on dentin and enamel.

TREATMENT OF KATANA™ Zirconia RESTORATION WORKFLOW

Bonding to zirconia has been proven to be durable in research going back to the 1990’s with the original MDP adhesive monomer in the PANAVIA™ resin cements. The three requirements to bonding zirconia are:

1. Air abrade zirconia with 50 μm alumina oxide powder.
2. Clean zirconia
3. Apply an MDP-Based Primer or resin cement. PANAVIA™ SA Cement Universal contains the original MDP that was developed & patented in 1981 by Kuraray Dental.

Fig. 1. Air abrade KATANA™ Zirconia at 14-58 psi.

Fig. 2. Dispense & mix PANAVIA™ SA Cement Universal (it is available in automix or handmix formulations).

Fig. 3. Apply PANAVIA™ SA Cement Universal to the abutment or inside the crown.

Fig. 4. Seat restoration on abutment.

Fig. 5. Remove excess resin with a dry micro-applicator or brush.

Fig. 6. You may light-cure the margins after cleaning up all excess resin. If you fully cure excess resin, It can be difficult to remove. If difficult to remove, change curing time or distance with your light.

Fig. 7. Leave restoration on abutment to self-cure fully for approximately 10 minutes at room temperature.

Fig. 8. Final check of custom abutment KATANA™ Zirconia YML crown on model.

Dentist:

JEAN CHIHA

Technician Jean Chiha CDT, Santa Ana, CA USA

Mr. Chiha is the owner of North Star Dental Laboratory and Milling Center, Santa Ana, CA, and has served as President of the Dental Lab Owners Association of California since 2013. He is a 1985 graduate of Institut Dento Technic, a private dental technology school in France. Mr. Chiha lectures internationally on dental communication and case planning. Jean lectures around the world on a variety of topics and has carved out a niche with his extensive knowledge of zirconia. Affectionately referred to as “Mr. Katana” due to his involvement in the creation of the material.

Case by Dr. Jusuf Lukarcanin

This young patient aged 35 with microdontia presented in the dental office with the desire to have more beautifully shaped teeth. His teeth were almost free of dental caries, but with deficiencies in oral hygiene and signs of gingival inflammation. A deep bite was also evident. After professional tooth cleaning and oral hygiene advice, the teeth were restored with CLEARFIL MAJESTY™ ES-2 Universal in the shade UL.

Fig. 1. Initial situation.

Fig. 2. Initial situation: Deep bite.

Fig. 3. Teeth restored with composite in the single-shade technique.

Fig. 4. Immediate treatment outcome.

Reasons for selecting universal light:

- For younger patients (tooth shades A2 and lighter)

- Situations in which light easily passes through the composite (e.g., Class III, Class IV)

Universal light properties:

- High light scattering effect

- Well-balanced translucency

Dentist:

JUSUF LUKARCANIN

Dr. Jusuf Lukarcanin is a Certified Dental Technician (DCT) and a Doctor of Dental Science (DDS). He studied dentistry at the Ege University Dental Faculty in Izmir, Turkey, where he obtained a Master‘s degree in 2011. In 2017, he received a Ph.D. degree from the Department of Restorative Dentistry of the same university. Between 2012 and 2019, Dr. Lukarcanin was the head doctor and general manager at a private clinic in Izmir.

Between 2019 and 2020, he worked at Tinaztepe GALEN Hospital as a Restorative Dentistry specialist, between 2020-2022 he worked at MEDICANA International Hospital Izmir as a Restorative Dentistry specialist. Currently he is an owner of a private clinic for aesthetics and cosmetics in Izmir.

With PANAVIA™ SA Cement Universal

By using PANAVIA™ SA Cement Universal and its proprietary dual-monomer technology, you can now simplify the bonding of any restoration to implant abutments without the use of separate primers or silane. Independent research has confirmed this new dual-monomer technology does not sacrifice adhesion or durability on glass-based ceramics or zirconia. The technique, in this case study, is for Ti-Base Implants, however, the basic technique on the treatment of the abutment and restoration may be used with any implant restoration combination.

TREATMENT OF TITANIUM ABUTMENT

Fig. 1. After attaching the abutment to the implant analog.

Fig. 2. Protect the base of the abutment with block out resin & light-cure.

Fig. 3. Air abrade the Titanium Abutment with 30-50 μm Alumina Powder @ 32 PSI.

Fig. 4. Clean abutment with KATANA™ Cleaner (10’s Rubbing, Rinse & Dry).

KATANA™ Cleaner is a universal cleaner that is indicated to clean metal, zirconia & glass-based restorations. It is also an intra oral cleaner that may be used on dentin and enamel.

REFERENCE INDEX POINTS TO ENSURE ACCURATE SEATING

Fig. 1. Mark Index position on implant analog.

Fig. 2. Mark index position (notch) on crown.

TREATMENT OF RESTORATION & BONDING TO THE ABUTMENT

Fig. 1. If Lithium Disilicate, HF acid etch Internal Surfaces, with 5% HF etch for 20’seconds then rinse & dry. If Zirconia, air abrade, at 14-58 PSI.

Fig. 2. Inject PANAVIA™ SA Cement Universal (White Shade) onto treated & cleaned abutment.

Fig. 3. Align index points & seat crown onto abutment.

Fig. 4. Place crown & implant into clamps & lightly tighten.

Fig. 5. Tack-Cure Clean-Up: Light-Cure excess cement for 2-5 seconds (time depends on light output & distance held).

Fig. 6. Remove excess cement & block-out resin with an explorer. PANAVIA™ SA Cement Universal has extremely easy clean-up.

Fig. 7. Wipe off remaining resin with gauze.

Fig. 8. Remove index mark with alcohol & gauze.

Fig. 9. Clean & polish restoration prior to seating. Surfaces coming in contact with soft-tissue should be polished.

Dentist:

GREG CAMPBELL

Dentist Greg Campbell DDS, Long Beach, CA USA

Greg Campbell, DDS is recognized internationally as an expert on integrating CAD/CAM dentistry into offices and is frequently sought out by industry leaders to lecture about Digital Dentistry. Dr. Campbell has a great understanding of Digital Technology and trains other dentists how to use this technology and is a certified Advanced CEREC Trainer. He is a former Beta tester for Sirona Dental and has authored two books on CAD/CAM dentistry. Dr. Campbell has created multiple polishing kits used for ceramics and has been trained on advanced adhesion materials, research & techniques and utilizing them clinically for over 8 years. Dr Campbell was an Alpha and Beta Tester for KATANA™ STML.

Dr. Campbell graduated from the University of Southern California School of Dentistry and completed advanced training in Cosmetic Dentistry at UCLA and maintains a private practice in Long Beach California.

4 Clinical cases by Dr. Jusuf Lukarcanin

Composites with a universal shade concept, a reduced number of shades that may be selected without any shade guide are a clear trend in restorative dentistry. With specific blend-in properties, these materials can help streamline restorative procedures and reduce chair time, take some pressure off the dental practitioner and contribute to potentially good outcomes. Some users, however, are skeptical about a wide-scale use of the materials, particularly when it comes to restoring teeth in the anterior region. The reasons may be a comparatively high translucency requiring the separate application of a blocker (or opacious shade) in certain situations, or a too limited shade offering.

Personal experience shows that CLEARFIL MAJESTY™ ES-2 Universal is perfectly suitable for a wide range of single-shade restorations in anterior teeth. It offers great polishability and long-term gloss retention and is available in just four shades: One universal shade (U) originally designed for posterior restorations, universal light (UL) and universal dark (UD) as the two major options for anterior teeth and, finally, universal white (UW) for the imitation of any bleached shade. In general, all four options may be used in the anterior and posterior region. As the blend-in ability is due to proprietary light-diffusion technology and not managed via an increased translucency, the application of a blocker is usually not necessary and even larger areas can be restored quite inconspicuously.

For those asking themselves when to select which shade in the anterior region, the following clinical case examples and comments may provide some useful guidance. The recommendations and practical tips are based on personal experience. All patients were in treatment for diastema closure or shape correction, but the selection criteria are the same for other types of anterior restorations, too.

UNIVERSAL LIGHT: FOR NATURAL RESULTS IN BRIGHTER TEETH

This young patient aged 35 with microdontia presented in the dental office with the desire to have more beautifully shaped teeth. His teeth were almost free of dental caries, but with deficiencies in oral hygiene and signs of gingival inflammation. A deep bite was also evident. After professional tooth cleaning and oral hygiene advice, the teeth were restored with CLEARFIL MAJESTY™ ES-2 Universal in the shade UL.

Fig. 1. Initial situation.

Fig. 2. Initial situation: Deep bite.

Fig. 3. Teeth restored with composite in the single-shade technique.

Fig. 4. Immediate treatment outcome.

Reasons for selecting universal light:

- For younger patients (tooth shades A2 and lighter)

- Situations in which light easily passes through the composite (e.g., Class III, Class IV)

Universal light properties:

- High light scattering effect

- Well-balanced translucency

UNIVERSAL DARK: FOR NATURAL RESULTS IN DARKER TEETH

Abrasion and shape correction was also the major reason for this 58-year-old female patient to ask for cosmetic dental treatment. She was unhappy with the appearance of the anterior teeth in the maxilla, which showed signs of tooth wear and discolouration. The selected treatment approach was composite veneering with CLEARFIL MAJESTY™ ES-2 Universal in the shade UD. The shade was selected based on the indication and the somewhat darker shade of the patient’s natural teeth.

Fig. 1. Initial clinical situation.

Fig. 2. Treatment outcome.

Reasons for selecting universal dark:

- For older patients (tooth shades A3 and darker)

- Situations in which light easily passes through the composite (e.g., Class III, Class IV)

Universal dark properties:

- High light scattering effect

- Well-balanced translucency

UNIVERSAL: WHENEVER A HIGH TRANSLUCENCY IS DESIRED

In teeth in which the areas to be restored are surrounded by a lot of non-discoloured tooth structure - as may be the case in Class I, II and Class V cavities - the use of CLEARFIL MAJESTY™ ES-2 Universal in the shade U may be an option. The 28-year-old patient, who presented for diastema closure, had teeth with a comparatively low translucency and different shades due to smoking and excessive coffee consumption. As the composite was applied in enamel areas only, the relatively high translucency of the universal shade seemed beneficial in this case.

Fig. 1. Initial clinical situation.

Fig. 2. New smile of the patient.

Reasons for selecting universal:

- Large amounts of underlying or surrounding tooth structure present

- Medium light-scattering desired

Universal properties:

- High translucency

- Medium light-scattering effect

UNIVERSAL WHITE: FOR ALL PATIENTS ASKING FOR A BLEACHED EFFECT

For all cases that require a particularly bright tooth shade – e.g. children or patients with bleached teeth / asking for a bleached effect in their restorations – CLEARFIL MAJESTY™ ES-2 Universal in the shade UW is likely to be the first choice. The young patient aged 28 shown below asked for diastema closure including shape and shade correction: She wanted to have a brighter, more beautiful smile.

Fig. 1. Initial clinical situation.

Fig. 2. Shape and shade correction were desired in this case.

Fig. 3. Treatment outcome …

Fig. 4. … leading to the beautiful smile the patient desired.

Reasons for selecting universal white:

- Cases requiring a particularly high brightness or value

- Restorations in deciduous teeth

- Restorations in bleached teeth

Universal white properties:

- Well-balanced translucency

- High light-scattering effect

CONCLUSION

One universal composite, four shades: In the case of CLEARFIL MAJESTY™ ES-2 Universal, this portfolio is absolutely sufficient for single-shade restorations even in the aesthetically demanding anterior region. Properties such as a nice blend-in effect, a great polishability and gloss retention over time support dental practitioners in creating beautiful restorations. As shade determination may be based on very few criteria instead of a complex shade guide, the whole restoration procedure becomes less stressful and more efficient. Furthermore, with only four shades to stock and usually no blocker needed, the number of materials on stock is reduced, leading to facilitations in stock management as well.

Dentist:

JUSUF LUKARCANIN

Dr. Jusuf Lukarcanin is a Certified Dental Technician (DCT) and a Doctor of Dental Science (DDS). He studied dentistry at the Ege University Dental Faculty in Izmir, Turkey, where he obtained a Master‘s degree in 2011. In 2017, he received a Ph.D. degree from the Department of Restorative Dentistry of the same university. Between 2012 and 2019, Dr. Lukarcanin was the head doctor and general manager at a private clinic in Izmir.

Between 2019 and 2020, he worked at Tinaztepe GALEN Hospital as a Restorative Dentistry specialist, between 2020-2022 he worked at MEDICANA International Hospital Izmir as a Restorative Dentistry specialist. Currently he is an owner of a private clinic for aesthetics and cosmetics in Izmir.

Welcome to the latest edition of BOND Magazine, your essential guide to cutting-edge advancements and techniques in the world of dentistry. Volume 11 is packed with insightful articles, expert interviews, and practical advice designed to enhance your dental practice or laboratory and keep you at the forefront of the profession.

In this issue, we dive into the simplicity and predictability of the flowable injection technique with Michał Jaczewski. Learn how this minimally invasive method can transform patient outcomes with minimal preparation, making it accessible for both beginners and experienced practitioners alike.

We also explore the transformative potential of universal resin cement in Prof. Lorenzo Breschi's article, which introduces a third application mode that could revolutionize how you approach luting for challenging restorations.

Meanwhile, Dr. Michael Braian shares his comprehensive guide to dental rehabilitation using digital workflows, ensuring you can leverage the latest technology for superior patient care.

This volume also includes a case reports by Dr. Jose Ignacio Zorzin - discussion on rationalizing clinical procedures with universal adhesives. These insights will help streamline your workflows, reduce chair time, and enhance patient satisfaction.

From detailed explorations of high-performance materials to interviews with leading dental laboratory professionals like Alexander Aronin and Andreas Chatzimpatzakis, BOND Magazine offers a wealth of knowledge for all dental professionals.

Click here to read. Enjoy reading, and let us inspire your journey towards excellence in dentistry.

Start Reading: BOND | VOLUME 11 | 07/2024

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BOND | VOLUME 7 | 10/2020

By Dr. Adrien Lavenant

In many clinical situations, composite restorations offer advantages over all-ceramic restorations. The treatment is less costly, usually less invasive, and the restorations can be modified and repaired at any time. When it comes to restoring multiple teeth, however, a free-hand layering approach used to build up every tooth separately can be very time-consuming and labour-intensive. In these situations, the flowable injection technique –also referred as injection moulding – is a great alternative. It is minimally invasive, suitable as a temporary or permanent solution to issues around tooth wear and irregular shape, and time-efficient in the clinical setting.

Essential materials

While the planning phase including the creation of the wax-up can be accomplished in the traditional way or in the digital workflow and components may differ depending on the preferred way of working, two materials are essential for the implementation of the flowable injection technique: A transparent silicone and a flowable composite. The silicone is used to produce an index and transfer the planned shape of the restorations from the wax-up into the patient’s mouth. Transparency is needed to make sure that the flowable composite will be cured properly through it – an important precondition for high-quality results. The flowable composite is injected into the silicone index. While offering a great flow behaviour during injection, the selected material should also exhibit a high mechanical stability for durability. CLEARFIL MAJESTY™ ES Flow Low (Kuraray Noritake Dental Inc.) offers the desired properties. One possible way to combine the materials and implement the technique is illustrated using the following patient case.

Important step in a complex treatment

This patient came to the dental office after orthodontic treatment with a request to improve the aesthetics of her smile. In the maxillary and mandibular anterior region (incisors and canines), severe tooth wear was diagnosed, with the maxillary central incisors most severely affected (figs. 1 to 4). To restore her maxillary teeth as quickly as possible, the least invasive immediate treatment option was selected: A smile makeover with composite using the flowable injection technique. In the long term, it is planned to perform a full-mouth rehabilitation with all-ceramic restorations.

Fig. 1. Initial situation: Lateral view from the right.

Fig. 2. Initial situation: Lateral view from the left.

Fig. 3. Initial situation: Frontal view.

Fig. 4. Close-up of the severely worn central incisors.

Shade determination and index production

After an analysis of the tooth colour using two different methods (figs. 5 and 6), a digital impression was taken and a wax-up designed with dedicated CAD software. The wax-up model was then printed (fig. 7); it served as the basis for the production of the transparent silicone index (figs. 8 and 9). After complete curing of the material, injection channels were integrated at the incisal edges of each tooth to be restored.

Fig. 5. Determination of the tooth colour using a shade guide.

Fig. 6. Picture taken with a white_balance grey reference card for objective shade quantification.

Fig. 7. 3D-printed model of the upper jaw with the virtually designed wax-up.

Fig. 8. Silicone index produced over the wax-up model with injection channels at the incisal edges of each tooth.

Fig. 9. Close-up view of the index with injection channels.

Shade validation and preparations for injection

To validate the selected shade, small amounts of composite (buttons) in three different shades were applied to the untreated surface of the left central incisor and cured (fig. 10). In this way, it is possible to visualize the colour of the composites in the mouth. The selected shade was A1. The aprismatic enamel layer on the surfaces of the six maxillary anterior teeth was carefully removed with burs to create ideal bonding conditions (fig. 11). The teeth were then isolated with clear matrix strips for the implementation of the bonding protocol on the right canine and central incisor and left lateral incisor: To provide for proper interproximal separation and contacts, it is advisable to treat every other tooth and then repeat the procedure for the rest. The teeth were etched with phosphoric acid, rinsed and carefully dried before applying the selected adhesive (CLEARFIL™ SE PROTECT, Kuraray Noritake Dental Inc.) (fig. 12). For separation and protection of the adjacent teeth during composite injection, PTFE tape is a great choice (fig. 13).

Fig. 10. Composite buttons applied to the left central incisor for shade validation.

Fig. 11. Roughened tooth surfaces.

Fig. 12. Etched and bonded surfaces of the right canine, right central incisor and left lateral incisor after isolation with clear matrix strips.

Fig. 13. Protection of the adjacent teeth with PTFE tape.

Composite injection and treatment of the other teeth

After its application, the silicone index was placed in the mouth and CLEARFIL MAJESTY™ ES Flow Low in the shade A1 injected tooth by tooth through the injection channels (fig. 14). What followed was proper light curing of the composite through the index. The situation after index removal is shown in figure 15. At this stage, the excess still needed to be removed, before protecting and separating the already restored teeth with PTFE tape and repeating the procedure for the other lateral incisor, central incisor and canine.

Fig. 14. Index with injected composite.

Fig. 15. Result after index removal.

Treatment outcome

Once all the excess material was completely removed, the occlusion was checked and adjusted. Finishing and polishing was accomplished with TWIST™ DIA for Composite (Kuraray Noritake Dental Inc.). The immediate treatment outcome is shown in figures 16 to 18, while figures 19 and 20 were taken at a recall after six months.

Fig. 16. Treatment outcome: Frontal view.

Fig. 17. The new smile.

Fig. 18. Treatment outcome: Occlusal view.

Fig. 19. Appearance of the teeth…

Fig. 20. … at the six-month recall.

Conclusion

Thanks to advances in restorative materials and technological tools, it is nowadays possible to restore our patients' smiles quickly and reproducibly. The flowable injection technique is one of the most successful examples of modern aesthetic treatments using composite resin. CLEARFIL MAJESTY™ ES Flow has all the qualities needed to carry out these treatments under the right conditions.

About the Author

Dr. Adrien Lavenant obtained his degree in Dentistry from Aix-Marseille University in 2010. He pursued post-university training in periodontology, implantology, and restorative and aesthetic dentistry (Aix-Marseille University and Paris). Dr. Lavenant has been a former teaching staff member at Aix-Marseille University since 2011 and continues to teach in the postgraduate programme in restorative and aesthetic dentistry. He practices in his private clinic in Aix-en-Provence, specializing in restorative, prosthetic, and aesthetic implant dentistry. He has been a member of the international Bio-Emulation group since 2019 and shares his patient care philosophy in accordance with the principles of biomimetic dentistry.

Case report by Dr. Wissam Dirawi, DDS

During the last decade, zirconia has increasingly established itself as the material of choice in oral prosthodontic rehabilitation. Its great mechanical and inert properties are the main reason for this trend. Since the introduction of multi-layered zirconia blanks more than ten years ago, the optical properties have been improved dramatically. The multi-layered zirconia used nowadays (e.g. KATANA™ Zirconia YML from Kuraray Noritake Dental Inc.) offers well-balanced mechanical properties, translucency and colour. It allows dental technicians from all over the world to produce aesthetic full-contour restorations that are merely stained.

Even in the anterior region, stained monolithic restorations may be an option. Factors such as the age of the patient, the internal colour structure of the adjacent dentition, the number of teeth to be restored (one versus all four or six maxillary anterior teeth), the aesthetic demands of the patient and financial aspects should be taken into account in the material selection process. In the case described below, full-contour zirconia was selected for several reasons.

BACKGROUND

The 71-year-old female presented in the clinical due to aesthetic problems in the maxillary anterior region. Oral hygiene was good and the patient was a non-smoker. Infraposition of the existing implant-based crown (Nobel Biocare Brånemark RP fixture) in the position of the right central incisor (tooth #11 according to the FDI notation) was evident. Moreover, gingival retraction was observed on the maxillary right lateral incisor (tooth #12), while the left lateral incisor (tooth #22) has a major composite filling with discolouration. The patient expressed the desire to adjust the gingival level differences and to restore the four maxillary incisors with all-ceramic crowns for optimal aesthetics.

Fig. 1. Initial situation: Frontal view.

Fig. 2. Initial situation: Facial view.

Fig. 3. Initial situation: Occlusal view of the maxilla.

Fig. 4. Initial situation: Occlusal view of the mandible.

MATERIAL SELECTION

Due to the decision to restore all four anterior incisors, monolithic zirconia was a suitable material option. It would allow the team to obtain the desired results within the financial framework. In order to meet the aesthetic demands of the patient, provide for the required mechanical properties and allow for proper masking of the underlying structures, KATANA™ Zirconia YML was selected. It offers colour, translucency and flexural strength gradation throughout the multi-layered blank.

TREATMENT PROCEDURE: FROM PREP TO TEMPORIZATION

In order to design the indirect restorations, a digital impression was taken with an intraoral scanner and the data was transferred to the dental laboratory Teknodont in Malmoe, Sweden. There, a digital wax-up was created. After patient approval, a matrix was produced and sent to the clinic. Here, the old restorations were removed and the three maxillary incisors (all but the one replaced by an implant) prepared for full coverage restorations. A healing abutment was placed on the implant and a temporary bridge produced chairside using the matrix and Protemp 4 Temporization Material (3M) in the shade A3. Subsequently, a gingivectomy was carried out with a ceramic burr (Ceratip, Kt.314.016 – KOMET) in the buccal aspect of the left central and lateral incisor.

Fig. 5. Chairside-produced temporary in the patient’s mouth.

After the patient’s approval of the aesthetics, phonetics and function of the temporary restoration, the situation was captured with an intraoral scanner again. This allowed the team to duplicate the shape of the construction. Based on the acquired data, a new set of splinted temporary crowns made of PMMA (HUGE Multilayer PMMA) in the shade A3 was milled in laboratory. They were placed to allow the patient to further evaluate the aesthetic appearance and function for a couple of weeks. The patient was happy with the phonetics, function and appearance of the crowns, which were merely slightly too bright in comparison to the adjacent teeth, and approved the shape for the production of the permanent restorations.

Fig. 6. Printed model …

Fig. 7. … with splinted PMMA crowns.

Fig. 8. Lab-made temporary restorations.

Fig. 9. Long-term temporary in place: Lateral view from the right.

Fig. 10. Long-term temporary in place: Frontal view.

Fig. 11. Long-term temporary in place: Lateral view from the left.

FINAL RESTORATIONS: PRODUCTION AND CEMENTATION

Based on the dataset of the temporary restorations, four separate crowns – one implant and three tooth-based – were designed in full contour. Without any anatomical reduction, the restorations were milled from KATANA™ Zirconia YML. Based on the evaluation of the temporary restoration, the shade selected this time was A3.5. CERABIEN™ ZR FC Paste Stain was used for external staining and glazing of the surface. Still in the laboratory, the implant-based crown was cemented to the gold-shaded titanium abutment (Elos Medtech) with PANAVIA™ V5 (Kuraray Noritake Dental Inc.) in the shade opaque for an improved masking effect.

While the abutment crown was screwed onto the implant and the screw hole closed with composite, the three tooth-based crowns were placed using PANAVIA™ SA Cement Universal (Kuraray Noritake Dental Inc.).

Fig. 12. Final restorations on the model.

Fig. 13. Intraoral situation prior to restoration placement.

CONCLUSION

Multilayered zirconia is a suitable material for many clinical situations. Due to the availability of modern types of highly translucent, multi-layered blanks, it is possible to produce aesthetic outcomes even when using the material monolithically – not only in the posterior region, but also in the aesthetic zone in some indications. The present case shows that very good results and patient satisfaction can be obtained. And due to outstanding mechanical properties, these outcomes may be expected to last for a long time.

Fig. 14. Immediate treatment outcome: Facial view.

Fig. 15. Immediate treatment outcome: Frontal view.

Fig. 16. Immediate treatment outcome: Occlusal view.

Dentist:

WISSAM DIRAWI

Dr. Wissam Dirawi, Malmoe, Sweden. DDS.
Specialist in Oral Prosthodontics and Senior Adviser at Aqua Dental.

2000 Master´s degree in dentistry.
2000 - 2018 General Dentist in public dental care and private practice.
2011 - 2018 Part-time teacher and researcher at Malmö University, Faculty of Dentistry.
2018 Specialist in Oral Prosthodontics. Senior clinical adviser. Lecturer.

References

- Alfadhli R, Alshammari Y, Baig MR, Omar R. Clinical outcomes of single crown and 3-unit bi-layered zirconia-based fixed dental prostheses: An up to 6- year retrospective clinical study: Clinical outcomes of zirconia FDPs. J Dent. 2022 Dec;127:104321.
- Le M, Papia E, Larsson C. The clinical success of tooth- and implant-supported zirconia-based fixed dental prostheses. A systematic review. J Oral Rehabil. 2015 Jun;42(6):467-80.
- Alammar A, Blatz MB. The resin bond to high-translucent zirconia-A systematic review. J Esthet Restor Dent. 2022 Jan;34(1):117-135.
- Sadowsky SJ. Has zirconia made a material difference in implant prosthodontics? A review. Dent Mat 2020; 36: 1–8.
- Mazza LC, Lemos CAA, Pesqueira AA, Pellizzer EP. Survival and complications of monolithic ceramic for tooth-supported fixed dental prostheses: A systematic review and meta-analysis. J Prosthet Dent 2022; 128: 566–74.
- Passia N, Mitsias M, Lehmann F, Kern M. Bond strength of a new generation of universal bonding systems to zirconia ceramic. J Mech Behav Biomed Mater. 2016; 62:268–274.
- Sailer I, Makarov NA, Thoma DS, Zwahlen M, Pjetursson BE. All-ceramic or metal-ceramic tooth- supported fixed dental prostheses (FDPs)? A systematic review of the survival and complication rates. Part I: Single crowns (SCs). Dent Mater 2015; 31:603-623.
- Pjetursson BE, Sailer I, Makarov NA, Zwahlen M, Thoma DS. All-ceramic or metal-ceramic tooth- supported fixed dental prostheses (FDPs)? A systematic review of the survival and complication rates. Part II: Multiple-unit FDPs. Dent Mater 2015; 31:624–639.

By Manabu Suzuki, Director of Dental Division, Kuraray America, Inc.

Kiyoko Ban, a prominent figure in the dental technology field, has made a lasting impact as a researcher, developer, and founder of Noritake Dental business (Fig. 1). Renowned for her contributions to dental porcelains like Noritake's CZR and EX-3, and KATANA™ Zirconia, Ms. Ban stands as a pivotal force in the global advancement of dental technology, earning her the esteemed reputation of developer and marketer within the dental technology community.

After completing her university education in Nagoya, Ms. Ban initially assisted in her family's gas station business. However, driven by a desire for a career change, she enrolled in a newly established dental technician college in Nagoya at the age of 30. Her aspiration was to enter a field where gender distinctions held no sway, offering the potential for worldwide recognition based on technical mastery.

In 1977, a college-sponsored tour to American dental laboratories ignited Ms. Ban's dream to work in the United States. However, she delved into research across various fields such as chromatology (the science of color), ceramics and metals, finding a newfound passion for research over clinical work after graduation because she was offered a "Curriculum Chief" position from the college when she graduated (Fig. 2).

Fig. 2. Ms. Ban, a curriculum chief at the Dental Technicians College, devoted her evenings to material research.

Fig. 3. In the 1990s, Ms. Ban actively engaged in promoting EX-3 through sales efforts in Italy.

Her teaching career spanned from the age of 34 to around 40, during which she pioneered porcelain training sessions for technical improvement and arranged lectures over weekends by famous speakers such as Masahiro Kuwata.

At the age of 40, she resigned teaching career and pursued her research career. The opportunity to conduct full-scale experiments led her to the discovery of a company with advanced ceramic technology "Noritake Co., Limited", renowned for its tableware. In 1986, Cusp Dental Supply, a research institute, was established by Ms. Ban in Nagoya, focusing on the development of materials for PFM crowns. The commercialization of Super Porcelain AAA (EX-3) in 1987 marked a significant milestone, addressing issues prevalent in porcelain materials of that time, such as cracks, greening, and fluorescence.

She began traveling all over Japan and around the world to sell the products she had developed and went on to develop new products that were needed by dental technicians worldwide (Fig. 3). She continued to develop new products such as CZR, CZR Press, and KATANA™, the world's first multilayer zirconia.

Ms. Ban has been actively involved in mentoring students and graduates seeking opportunities to work overseas. During summer vacations, she took students and professionals interested in working abroad to countries like Australia, Germany, and the United States. The aim was to visit dental clinics, dental technician schools, and laboratories, fostering exposure and learning in an international context.

Simultaneously, Ms. Ban delved into researching non-precious dental technology. Inspired by her exposure to the term "non-precious" during her time in the United States, she anticipated its potential in Japan. Her research presented at lectures and events highlighted the shift in the landscape as the price of gold surged, rendering precious alloys containing significant amounts of gold impractical for PFM crowns.

As the demand for their developed products grew, the need for global acceptance became apparent. In 1990, Cusp Dental Research was established in Manhattan, New York, marking Ms. Ban's foray into establishing a company overseas. Despite the unfamiliarity with legal procedures and the challenges of setting up a foreign company, Ms. Ban, driven by determination, overcame these hurdles. The establishment of the company in the United States expanded their presence internationally Fig. 4).

Fig. 4. Capturing the essence of ISC 1996 - the International Symposium on Ceramics in Orlando, FL..

Noritake Dental Supply Co., Limited was established in 1998 by the Noritake Co., Limited, which aimed to further expand its dental business. Despite the absence of a capital relationship with Noritake at the time of establishing the research laboratory, Ms. Ban played a key role in joint research efforts with Noritake. Then she was invited to this company as the position of president, owning 60% of the stock, while Noritake held 40% (Fig. 5).

Besides Noritake Dental business, she continued expansion with the establishment of a dental laboratory in Boston in 1995. Despite the challenges posed by the September 11, 2001 World Trade Center incident, they acquired their building in Boston, integrating their New York laboratory into the Boston operations.

Ms. Ban's tenure as president of Noritake Dental Supply persisted until 2009, but organizational changes following the merger with Kuraray in 2011 led to her transition into an advisory role (Fig. 6). Despite the shift in responsibilities, her commitment to the dental technician profession remained steadfast.

Fig. 5. Noritake Dental Supply Inc Inauguration Party, 1998.

Kiyoko Ban's path encapsulates not just a career but a legacy in the field of dental technology. From her early struggles in a tooth carving class to establishing and expanding international laboratories, Ms. Ban's story is one of determination, innovation, and a deep-rooted commitment to advancing the dental technician profession.

Fig. 6. A scene from Ms. Ban’s retirement celebration as Noritake Dental Supply president, surrounded by esteemed dental technicians from around the world.

UNFORGETTABLE WEEK

In April, a team from Kuraray Noritake Dental’s European arm accompanied 18 Key Opinion Leaders (KOLs) from Germany, Italy, Spain, France, Turkey, Poland, England, Romania, Switzerland, the Czech Republic, and Denmark to Kuraray Noritake Dental’s roots in Japan. The week was an incredible blend of professional exchange, cultural immersion, and shared experiences.

The European group included an interdisciplinary team of dentists, dental technicians, professors, and researchers. They toured Kuraray Noritake Dental’s two production sites in Niigata (chair-side manufacturing) and Nagoya (lab-side products) and visited the Head Office in Tokyo.

Visit to the production facility for chair-side products in Niigata.

INTERDISCIPLINARY AND INTERNATIONAL EXCHANGE

As you can imagine, this was a fantastic opportunity for both Kuraray Noritake Dental’s European employees and KOLs to have lively exchanges with Japanese developers and production personnel. Our KOLs highly appreciated the opportunity to present their own work and ongoing results while sharing tips and techniques with the Japanese members.

The importance of this trip for both the KND employees and the European travel group was underlined by the participation of the Head of Kuraray Noritake Dental (Yamaguchi-san) and the inventor of Noritake dental porcelain (Kiyoko Ban). In her welcome speech, she emphasized what an extraordinary opportunity this interdisciplinary and international exchange represents and how pleased she was about the numerous visitors.

Kiyoko Ban during her welcome speech for the delegation from Europe.

Head of Kuraray Noritake Dental (Yamaguchi-san) together with Dr. David Gerdolle, Jakab Daniel, and Honoré Morel during lunch in the Tokyo office.

The tour proved that there really is no substitute for face-to-face, hands-on interaction when it comes to discussions between product developers and specialists as well as seeing behind the scenes for a direct insight into production and quality assurance.

As Dr David Gerdolle said: “Kindness, perfect organization, dedication to precision and professionalism are a rare and precious combination in the actual world. My deepest gratitude to the Kuraray Noritake company for this unforgettable week in Japan.”

EXPLORING JAPAN

However, the visit wasn’t all about work. There was a fabulous opportunity to see Mount Fuji in all its glory on the train ride from Nagoya to Tokyo and as well as a unique chance to explore Japanese culture. Not to forget the visit to Noritake Garden in Nagoya, where the history and traditional art of fine tableware through to modern high-tech materials are on display.

Exhibitions at the Noritake Museum in Nagoya.

As Daniel Dunka (MDT) said: “The whole trip was absolutely wonderful, and I’m grateful to Noritake for the invitation. It has been a wonderful experience mingling with colleagues from all over the world in such a beautiful environment. It has been an inspiration for me and I look forward to continuing to work with your wonderful materials and of course your amazing team.

Jakab Daniel (MDT) added: “The organizational culture [in Japan] is fascinating, it is amazing to be a part of the whole manufacturing process of Noritake ceramics, Zirconium KATANA and all Kuraray products. Very good discussions, opinions, suggestions” while MDT Mathias Berger from France summed up the whole visit with: “Thank you so much for your invitation, I realized a dream.” 

Het belang van hoogwaardige prothetische behandelingen

Een hoogwaardige behandeling is waarschijnlijk het belangrijkste element om patiënten tevreden te stellen. Tijdens elke behandeling wil de patiënt zich goed verzorgd weten door een ervaren professional; tegelijkertijd dienen behandeltijden en het aantal afspraken te worden beperkt tot het noodzakelijke minimum. In de context van prothetische behandelingen betekent dit dat een restauratie meteen perfect dient te passen en door de tijd heen stabiel moet blijven, zodat reparaties en extra afspraken niet nodig zijn.

Echter, hoe zorg je keer op keer voor perfect passende, hoogwaardige restauraties? Mogelijke oorzaken voor problemen rondom de kwaliteit van indirecte restauraties zijn o.a. geregeld voorkomende fouten in de tandartspraktijk of het tandtechnisch laboratorium, communicatiestoornissen en - vaak over het hoofd gezien - het gebruik van inferieur tandheelkundig zirkonium.

Zirkoniumrestauraties - de moderne en esthetische tandheelkundige oplossing

Meer dan twintig jaar geleden kwam zirkonium op de tandheelkundige markt als vervanger van het metaal dat werd gebruikt voor de vervaardiging van kronen en bruggen. Beide materialen - zirkonium en metaal - werden meestal gecombineerd met een laag porselein, de zogenaamde PFM-restauraties(porcelain-fused-to-metal) of PFZ-restauraties (porcelain-fused-to-zirconia). In de jaren daarna concentreerden verschillende toonaangevende fabrikanten van tandheelkundig zirkonium (bijvoorbeeld Kuraray Noritake Dental Inc.) zich op de verbetering van materialen. Dankzij deze verbeteringen werd het originele wit-opake framemateriaal geleidelijk veranderd in een keramisch materiaal met een natuurgetrouwe uitstraling en voortreffelijke mechanische eigenschappen. De nieuwste varianten van zirkonium, die verkrijgbaar zijn in verschillende niveaus van translucentie en sterkte, worden wereldwijd door veel tandheelkundige professionals beschouwd als de optimale behandelingsoptie voor een breed scala van patiënten en indicaties. Eén reden is dat er slechts een kleine laag porselein nodig is, of zelfs géén. Een andere reden is dat deze - bij een lage minimale wanddikte - conserverende tandpreparaties mogelijk maken bij een gunstige functionele duurzaamheid, althans bij gebruik van een hoogwaardig materiaal.

Kwaliteitsverschillen bij tandheelkundig zirkonium

Er kunnen verschillen zijn in de productkwaliteit van zirkonium vanwege meerdere factoren, bijvoorbeeld de zuiverheid van de grondstoffen (niet alleen zirkonium, maar ook aluminiumoxide en yttria evenals kleuradditieven etc.), de precieze chemische samenstelling, korrelgrootte en partikelverdeling. Elke stap van het productieproces van de blanks - van de poedersamenstelling tot het persen van de blanks en het voorsinteren - is van invloed op de uiteindelijke kwaliteit, dus ook op de mechanische en esthetische eigenschappen van het zirkonium.

Vaak voorkomende problemen vanwege inferieur zirkonium

Als er iets niet klopt aan de optische eigenschappen van een restauratie - translucentie, de algehele kleur van de overgang van de ene laag naar de andere bij blanks met een meerlaagse kleurstructuur - wordt het probleem duidelijk na de definitieve sinterprocedure in het lab. Er is wellicht een aanpassing nodig en uiteindelijk komt de tekortkoming misschien aan het licht tijdens het passen, wat de tevredenheid van de patiënt vrijwel zeker negatief zal beïnvloeden. Datzelfde geldt voor gevallen met een verkeerde passing, bijvoorbeeld als gevolg van onvoldoende homogeniteit van de materiaalstructuur. Nóg erger is een gebrek aan biocompatibiliteit, oppervlaktekwaliteit, randstabiliteit, buigsterkte of breukweerstand. Dergelijke problemen kunnen alleen worden onderkend met heel dure testapparatuur, die meestal niet beschikbaar is in tandtechnische laboratoria. Dit betekent dat dergelijke tekortkomingen doorgaans niet worden opgemerkt, totdat zich een concreet klinisch probleem aandient, bijvoorbeeld terugtrekkend tandvlees, verhoogde plaqe-accumulatie, versnelde slijtage of vroegtijdig falen, dat pijn en ongemak kan veroorzaken.

Overzicht van mogelijke problemen en klinische gevolgen voor patiënten

Certificering en standaardisatie van tandheelkundig zirkonium

Om die reden hebben specialisten een ISO-norm (ISO 6872:2015) ontwikkeld, waarin de in-vitrotests staan die elke fabrikant van zirkonium dat wordt gebruikt in Europa of de VS, moet doorlopen voor de FDA-goedkeuring en CE-markering. Deze tests worden gebruikt om de buigsterkte en breukweerstand te meten; de twee producteigenschappen die waarschijnlijk het meest bepalend zijn voor het gedrag op lange termijn van restauraties die van dit materiaal zijn gemaakt. Deze tests zijn verplicht voor elk materiaal dat wordt gebruikt in Europa of de VS.

Hoe u kunt voorkomen dat tandheelkundige zirkoniumrestauraties van lage kwaliteit in de mond van uw patiënten worden geplaatst

Derhalve is iedereen die dit gecertificeerde tandheelkundig zirkonium gebruikt, in principe ingedekt en kunnen materiaalgerelateerde risico's worden geminimaliseerd. De toenemende populariteit van tandheelkundig zirkonium heeft echter de aandacht getrokken van bedrijven die graag een graantje meepikken zonder de inspanningen te plegen die nodig zijn om een hoge productkwaliteit te waarborgen en te worden gecertificeerd. Niet gecertificeerde producten zonder CE-markering hebben één ding gemeen; ze vormen absoluut een risico voor uw praktijk en patiënten.

Hoe kunt u de productkwaliteit van zirkonium dus binnen úw praktijk waarborgen? Het goede nieuws is dat er enkele eenvoudige regels bestaan. Als u die volgt, voorkomt u dat u restauraties van imitatie- of inferieur tandheelkundig zirkonium in de mond van een patiënt plaatst.

Voorkom dat u restauraties van inferieur tandheelkundig zirkonium in de mond van uw patiënten plaatst.

Drie gouden regels om uw patiënten te voorzien van hoogwaardige zirkoniumrestauraties:

• Bestel alleen restauraties die in eigen land zijn vervaardigd, of in een gebied met dezelfde normen als die van u; zo mogen restauraties die bijvoorbeeld in tandtechnische laboratoria in China zijn gemaakt, voldoen aan lagere normen (dus zonder CE-markering) en deze voldoen wellicht niet aan uw verwachtingen.

• Praat met uw (eigen) labpartner over de bron van het gebruikte zirkonium en overtuig u ervan dat er zirkonium wordt betrokken bij toonaangevende fabrikanten (bijvoorbeeld Kuraray Noritake Dental Inc.) via erkende distributeurs of vertrouwde verkopers.

• Vermijd deals die te mooi zijn om waar te zijn; lage prijzen kunnen verleidelijk zijn, maar de uiteindelijke kosten van een behandeling kunnen in geval van complicaties zelfs hoger uitvallen dan normaal.

Effect op lange termijn voor patiënten bij gebruik van gecertificeerde zirkoniumrestauraties

Door te waarborgen dat het in uw praktijk geplaatste zirkonium voldoet aan de hoogst mogelijke kwaliteitsnormen, levert u een belangrijke bijdrage aan patiënttevredenheid op lange termijn. De kosten van hoogwaardige zirkoniumrestauraties zijn in eerste instantie wellicht wat hoger dan die van werk van een mindere kwaliteit. De totale investering kan echter lager uitvallen als de restauraties langer meegaan en reparaties overbodig zijn. Uw tevreden patiënten zijn dan meer betrokken en loyaal, en schikken zich gemakkelijker naar hygiëneregels; dat heeft een positief effect op uw reputatie en patiëntenbasis.

Onderzoek de opties voor zirkonium en kies producten van gecertificeerde fabrikanten

Als u nog een stap verder wilt gaan, kunt u zelfs gecertificeerde zirkoniumvarianten van meerdere fabrikanten met elkaar vergelijken en de verschillen vaststellen. Zo is Kuraray Noritake Dental Inc. een van de weinige fabrikanten van tandheelkundig zirkonium die het volledige productieproces - inclusief de aanmaak van grondstoffen - in eigen huis uitvoert. Op deze manier heeft het bedrijf elke stap van de procedure in eigen hand en is een uitstekende productkwaliteit gegarandeerd, welke materiaalvariant er ook wordt gekozen. Met de uitgebreide portfolio - KATANA™ Zirconia UTML (Ultra-Translucent Multi-Layered), KATANA™ Zirconia STML (Superior Translucent Multi-Layered) en het hoogtranslucente meerlaagse HTML PLUS  en YML (met extra sterkte en verloop van translucentie) - kan worden ingespeeld op vrijwel alle indicaties.