By Dr. Gintautas Rumbaitis, DDS

A CLINICAL CASE EXAMPLE

Low polymerization shrinkage, high strength and excellent wear resistance are among the most important criteria when selecting a restorative material for the posterior region. Low shrinkage supports marginal integrity after curing, while high mechanical strength provides for long-term stability even under high occlusal load. High wear resistance, in turn, contributes to long-term morphological stability. Together, these characteristics form the basis for the long-term success of posterior restorations.

The CLEARFIL MAJESTY™ family from Kuraray Noritake Dental Inc. offers materials designed to meet these requirements. They enable the creation of restorations that not only provide an appealing aesthetic outcome, but - more importantly - effectively restore the function and anatomy of the teeth. The portfolio includes a range of paste-type composites supporting different shade concepts, from single-shade to multi-shade approaches, as well as high-strength flowable composite materials.

CLEARFIL MAJESTY™ ES Flow is available in three levels of flowability and multiple shades. The universal alternative introduced in 2025, CLEARFIL MAJESTY™ ES Flow Universal, is offered in Low and Super Low flowabilities and two shades. These flowable materials provide the mechanical properties required for the successful restoration of all cavity classes. They can be used alone or in combination with paste-type composites, allowing clinicians to select the restorative concept best suited to each clinical situation.

A restoration procedure combining the new flowable material with a paste-type composite from the MAJESTY family (CLEARFIL MAJESTY ES-2) is demonstrated below using a clinical case example.

The patient presented for replacement of existing composite restorations in the posterior region. Clinical examination revealed that the restoration on the maxillary left first molar (FDI notation: tooth #26) showed marginal leakage as well as insufficient anatomical structure and occlusal height (Fig. 1). Replacement of the restoration was therefore planned. The clinical procedure is illustrated and described in Figures 2-12, while Figures 13-15 show the treatment outcome.

Fig. 1. Restoration on the first molar that needs to be replaced.

Fig. 2. Situation after removal of  the existing restoration. Removal  of the remains near the cavity floor performed using a carbide burr, without water, at slow speed.

Fig. 3. Cavity checked using Caries Detector (Kuraray Noritake Dental Inc.) for remaining decay.

Fig. 4. A distal crack is observable on the proximal wall of the first molar.

Fig. 5. Appearance after dissection of the cracked area and careful removal of the remnants of the composite restoration.

Fig. 6. Tooth after placement of a sectional matrix and sandblasting of the surface with 27 µm aluminium oxide powder.

Fig. 7. Selective etching with phosphoric acid etchant for 15 seconds.

Fig. 8. Strengthening of the cavity floor with fibres embedded in CLEARFIL™ AP-X composite (Kuraray Noritake Dental Inc.)

Fig. 9. Application of CLEARFIL MAJESTY ES Flow Universal in the shade UD (Universal Dark) in 2 mm increments, primarily to replace the dentin.

Fig. 10. Modelling of the occlusal area with CLEARFIL MAJESTY ES Flow Universal in the shade U (Universal).

Fig. 11. Modelling finished.

Fig. 12. Brown stains and CLEARFIL MAJESTY ES-2 in the shade WD applied for optical effects.

Fig. 13. Result of the polishing procedure.

Fig. 14. Buccal view of the polished restoration.

Fig. 15. Immediate treatment outcome with the tooth structure still being dehydrated.

CONCLUSION

The presented clinical case demonstrates how posterior teeth can be restored predictably and efficiently using materials from the CLEARFIL MAJESTY ES-2 portfolio. The combination of CLEARFIL MAJESTY ES Flow Universal as a flowable base layer and CLEARFIL MAJESTY ES-2 as a paste-type composite enables controlled placement, excellent adaptation to the cavity walls and the precise reconstruction of anatomical structures.

Thanks to their low polymerization shrinkage, high mechanical strength and excellent wear resistance, the materials support marginal integrity and functional stability over time. At the same time, the wide range of flowabilities and shade concepts provides dental practitioners with the flexibility desired to adapt the restorative concept to individual preferences and clinical situations.

Clinical case by Dr. Zygintas Jonaitis

MINIMALLY INVASIVE INDIRECT RESTORATION PROCEDURE IN THE POSTERIOR REGION

The aim of preserving as much natural tooth structure as possible is ever-present in modern restorative concepts. No matter whether a direct or indirect restorative procedure is preferred, a whole array of tools, techniques and materials are available that help make the clinician's life easier and treatment outcomes more predictable and durable. Those solutions are designed to facilitate identification of tooth structure that needs to be removed, aid cavity cleansing or maximise the bonding performance without adding complexity to the treatment. Using the following clinical example, a possible restorative workflow is described.

RESTORATION REPLACEMENT REQUIRED

This patient presented with a composite restoration on a first molar that attracted our attention. The very extensive composite restoration was worn, lacked good anatomical form and proper occlusal contacts, showed leakage and signs of secondary caries (Fig. 1). The tooth reacted to sweets and cold. It was clear that repair was not the best option: the restoration needed to be replaced. Due to the size of the existing composite filling, it was decided to place an indirect partial restoration that would allow us to save as much natural tooth structure as possible while providing for long clinical service life.

Fig. 1. Initial clinical situation.

SELECTIVE CARIES REMOVAL

After rubber dam placement, the existing restoration was removed carefully, revealing secondary caries underneath the composite (Figs. 2 and 3). To facilitate selective caries removal down to remineralisable (non-infected) dentin, Caries Detector was applied (Fig. 4). This liquid stains only the infected tissue, so that it is easily identified and selectively removed using diamond instruments (Fig. 5). This helps users preserve remineralisable (affected) dentin that may be left untouched and – whenever well-sealed – does not pose a risk for the future restoration.

Fig. 2. Isolation of the working field with rubber dam.

Fig. 3. Removal of the old composite restoration.

Fig. 4. Application of Caries Detector to visualise infected dentin.

Fig. 5. Cavity after the removal of infected dentin.

ADHESIVE PROCEDURE AND BIO-BASE CREATION

To create a stable basis for the indirect restoration, the tooth surface was first cleaned thoroughly using KATANA™ Cleaner (Fig. 6). This cleaning agent developed for intra- and extra-oral use effectively removes contaminants that might compromise adhesion from the surface – a decisive step as a strong and durable bond is the creation of a stable foundation. Subsequently, CLEARFIL™ SE Protect, a self-etching adhesive with MDPB, an antibacterial monomer was applied according to the manufacturer's instructions for use (Fig. 7). Next, a layer of poly ethylene fiber, wettened with CLEARFIL SE Protect Bond was placed and covered with flowable composite (CLEARFIL MAJESTY™ ES Flow Universal). Hereafter a layer of fiber reinforced flowable composite was placed and cured. An impression was taken with an intra-oral scanner and a glass-ceramic restoration produced in the laboratory.

Fig. 6. Cleaning of the tooth structure with KATANA Cleaner.

Fig. 7. Self-etch adhesive with anti bacterial effect applied to the tooth structure.

Fig. 8. Foundation created with fibres, bond and flowable composite.

Fig. 9. Completed with a layer consisting of short-fibre reinforced composite.

TOOTH PREPARATION AND ADHESIVE CEMENTATION

Tooth preparation was performed (Fig. 10). followed by pre-treatment of all surfaces to provide for a strong and durable connection between the foundation and the indirect restoration. The bonding surface of the glass ceramic restoration was etched with hydrofluoric acid before applying a ceramic primer (CLEARFIL™ Ceramic Primer Plus) . Followed by applying PANAVIA™ V5 Paste onto the restoration (Fig. 12). The tooth structure and foundation were treated according to the manufacturers instructions with the system-specific PANAVIA V5 Tooth Primer before placing the restoration. The cement was light-cured thoroughly, restoration margins were cleaned and polished (Fig. 13) and the rubber dam was removed. Figures 14 and 15 show the treatment outcome.

Fig. 10. Prepared tooth prior to adhesive cementation.

Fig. 11. Pre-treatment of the bonding surface of the restoration with a ceramic primer.

Fig. 12. Application of the selected adhesive resin cement onto the restoration.

Fig. 13. Restoration in place.

Fig. 14. Occlusal view of the final restoration.

Fig. 15. Occlusal view of the final restoration

CONCLUSION

The described procedure shows the restoration of a posterior tooth's anatomy and occlusal contacts in cases with severe loss of sound tooth structure. The remaining tissue is preserved wherever possible, while the protective foundation provides for a tight seal of the underlying tooth structure. Utilizing the indirect restoration method supports the restoration's marginal integrity. A long clinical service life may be expected.

Kasus av Dr. Onur Alp Yünük 

Vakre tenner og et lyst, feilfritt smil: Å imøtekomme de estetiske kravene fra pasienter som ønsker fasettbehandling kan være utfordrende. Mens noen pasienter har klare forestillinger om hvordan de nye tennene skal se ut, kan det være vanskeligere for andre å uttrykke sine forventninger. I slike tilfeller er det viktig å velge en behandlingsmetode som gir rom for justeringer – enten i form av en utvidet planleggingsfase som inkluderer digital smildesign, eller ved å legge komposittrestaureringer som enkelt kan modifiseres intraoralt.

Den sistnevnte tilnærmingen ble valgt for en ung kvinnelig pasient som oppsøkte klinikken vår fordi hun var misfornøyd med komposittfasettene som tidligere var blitt lagt på overkjevens incisiver (fig. 1–4). Under den intraorale undersøkelsen var det tydelig at de eksisterende restaureringene på overkjeveincisivene og hjørnetennene var uregelmessige og hadde ru overflater, misfargede randsoner samt redusert strukturell integritet i komposittmaterialet.

På bakgrunn av disse funnene ble det planlagt å fjerne de eksisterende restaureringene på fronttennene i overkjeven og gjenopprette optimal estetisk og funksjonell integritet med nye direkte komposittrestaureringer (fra tann #13–#23 i henhold til FDI-notasjonen). Pasienten uttrykte også et ønske om mer individualitet og karakter i tennene, samt et lysere smil enn det hun hadde med de eksisterende restaureringene.

Fig. 1: Komposittfasetter på overkjevens incisiver med redusert estetisk og funksjonell kvalitet.

Fig. 2: Okklusalvisning av overkjevens fronttenner med synlige defekter i komposittfasettene.

Fig. 3: Sidevisning fra høyre som viser ujevnheter i overflaten.

Fig. 4: Sidevisning fra venstre som viser et større område med tap av binding og fraktur i komposittmaterialet. 

UTSKIFTING AV KOMPOSITTFASSETTER

For å gjenskape translucensegenskapene til pasientens naturlige tenner og samtidig oppfylle hennes estetiske ønsker, ble det planlagt å bruke et polykromatisk lagdelingssystem og en tolags-teknikk. Dette gjør det mulig å skape et naturlig samspill av translucens i frontregionen.

Under fargeuttaket ble Bilaminar Shade Assessment Technique (BSAT) benyttet. Denne teknikken er basert på fargekombinasjonen av dentin- og emaljekompositter. I metoden ble den planlagte emaljenyansen stratifisert over måldentinet for å evaluere den resulterende nyansen som dannes av de to komposittlagene. Materialene ble polymerisert på tannoverflaten uten bruk av bondingmiddel. Dermed kunne den samlede fargeopplevelsen som oppstår ved lagdeling – og ikke de enkelte materialnyansene isolert sett – vurderes med hensyn til harmoni med den naturlige tannstrukturen allerede ved behandlingsstart. Fotografier ble tatt med et kamera utstyrt med krysspolarisert filter (fig. 5). Deretter ble den faste retaineren fjernet, sammen med de eksisterende komposittfasettene. For å bevare mest mulig av den underliggende friske tannsubstansen ble prosedyren utført under forstørrelse og med blålys-belysning. De valgte instrumentene var diamantbor med rød og gul ring samt tungstenkarbidbor. Figur 6 viser resultatet etter denne prosedyren.

Fig. 5: Fargebestemmelse – bilde tatt med et krysspolarisert filter som eliminerer refleksjoner.

Fig. 6: Tennene etter fjerning av utilstrekkelige komposittfasetter.

Tennene ble isolert med kofferdam, som ble sikret cervikalt med tanntråd. Deretter ble restaureringsprosedyren på tennene påbegynt. Etter etsing av emaljen og applisering av et selvetsende bondingmiddel (CLEARFIL™ SE Bond 2, Kuraray Noritake Dental Inc.) ble CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.)  brukt. Dentinkjernen med tydelige mameloner ble modellert ved hjelp av nyansen A1D. De incisale kantene og mamelonene ble fremhevet med små mengder hvit tint. For å skape en opalescent effekt ble et tynt lag av den translucente nyansen Blue lagt over. Emaljedelene ble deretter bygget opp med emaljenyansen WE. Siden retaineren var fjernet, ble det fremstilt en klar aligner, som pasienten fikk utlevert ved slutten av behandlingsøkten for bruk frem til neste time. 

Fig. 7: Isolasjon med kofferdam for restaurering av laterale incisiver og hjørnetenner.

Fig. 8: Vestibulært emaljelag applisert på tennene.

Fig. 9: Form og farge på restaureringene utformet i samsvar med pasientens forventninger. 

Etter finishing og polering med Twist DIA for composite ble pasienten sendt hjem, og det ble avtalt en ny time for reevaluering og endelige justeringer.

Ved kontrolltimen ønsket pasienten at de incisale translucenseffektene og lysheten i overkjevens incisiver skulle reduseres noe, og at formen på alle de restaurerte tennene skulle justeres. Hun ønsket lengre sentrale incisiver i overkjeven, med mykere og mer avrundede linjevinkler samt en jevnere incisalkontur. Kofferdam ble lagt på nytt. Deretter ble de vestibulære overflatene på komposittrestaureringene på overkjevens incisiver redusert noe ved hjelp av diamantbor med rød og gul ring. For å rue opp overflaten og forbedre topografien for optimal mikromekanisk retensjon, ble komposittoverflaten sandblåst  med 50 µm aluminiumoksidpartikler. Fosforsyreets, silan og CLEARFIL™ SE Bond 2  ble deretter applisert sekvensielt som  en del av adhesivprotokollen. Restaureringene ble deretter modifisert ved å forlenge dem, korrigere fargen ved bruk av CLEARFIL MAJESTY™ ES-2 Premium i nyansene A1D og A1E, samt ved å raffinere de anatomiske konturene (fig. 10 og 11). 

Fig. 10: Modifisering av restaureringene på  de sentrale incisivene.

Fig. 11: Modifisert smil med mer harmoniske tannformer og konturer samt en mer naturlig tannfarge.

Under denne siste behandlingsøkten uttrykte pasienten at hun var svært fornøyd med sitt nye smil. Overflatene på restaureringene ble polert på nytt, en ny retainer ble festet, og det ble tatt avsluttende fotografier (fig. 12–16).

Fig. 12: Endelig behandlingsresultat – frontalvisning.

Fig. 13: Endelig behandlingsresultat – okklusalvisning.

Fig. 14: Endelig behandlingsresultat – sidevisning.

Fig. 15: Endelig behandlingsresultat – pasientens smil.

Fig. 16: Detaljert visning av den indre fargestrukturen, synliggjort ved hjelp av et polarisert filter. 

KONKLUSJON

Å diskutere alle detaljer i behandlingen med pasienten og lytte nøye til deres ideer, forventninger og ønsker beskytter oss ikke alltid mot behovet for justeringer – ganske enkelt fordi pasientene må se resultatet før de kan vurdere om de er fornøyde. Heldigvis gjør valg av riktige materialer og teknikker det mulig for tannleger å skape nye smil som kan modifiseres uten å skade frisk tannsubstans. Dermed er det ikke lenger en utfordring å tilfredsstille selv de mest krevende pasientene.

Kasus av Dr. Onur Alp Yünük 

KOMBINERT MED HØYYTENDE VERKTØY OG MATERIALER FOR ET FORUTSIGBART BEHANDLINGSRESULTAT 

Direkte komposittrestaureringer er et behandlingsalternativ av høy kvalitet, selv når store mengder tannsubstans må erstattes. Dette skyldes nyere fremskritt innen resinbaserte komposittmaterialer og adhesiv teknologi. Ved å velge egnede materialer og lagdelingsteknikker, kombinert med moderne digitale verktøy for evaluering av fargeforskjeller, er det mulig å oppnå forutsigbare og svært estetiske resultater, slik det demonstreres i følgende kasus.

Utfordringen

En ung mannlig pasient oppsøkte klinikken vår med ønske om å få erstattet sine eksisterende komposittrestaureringer på overkjevens incisiver (tennene #12 og #11 i henhold til FDI-notasjonen). Den kliniske undersøkelsen avdekket betydelig tap av restaureringsmateriale på lateralen. I tillegg ble det observert anatomiske uregelmessigheter, misfarging og tap av overflateglans på tann #11. Den tilstøtende sentrale incisiven viste tilsvarende problemer når det gjaldt farge og overflatepolering.

I samråd med pasienten ble det besluttet å erstatte de eksisterende restaureringene ved hjelp av et moderne komposittmateriale som er spesielt utviklet for lagdeling med to nyanser – CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.). For en nøyaktig fargeanalyse ble det tatt fotografier både med og uten krysspolarisert filter (fig. 1–4).

Fig. 1: Frontalvisning av tennene med omfattende tap av restaureringsmateriale på  overkjevens høyre laterale incisiv.

Fig. 2: Krysspolarisert fotografi av  tennene som muliggjør en detaljert analyse  av fargeuregelmessigheter.

Fig. 3: Sidevisning av tennene.

Fig. 4: Sidevisning – krysspolarisert fotografi. 

Løsningen

Etter fjerning av de eksisterende restaureringene ble det plassert en kofferdam for isolering av arbeidsfeltet. Et selvetsende adhesiv (CLEARFIL™ SE Bond 2, Kuraray Noritake Dental Inc.)  ble applisert ved selektiv emaljeetsing før det palatinale skallet ble etablert med CLEARFIL MAJESTY™ ES-2 Premium i nyansen A1E (fig. 5 og 6). Mamelonstrukturene ble deretter rekonstruert med CLEARFIL MAJESTY™ ES-2 Premium i nyansen A1D, mens den translucente nyansen Blue ble påført i den opalescente sonen. Til slutt ble gule og hvite tinter brukt for karakterisering. Figur 7 viser situasjonen før, og figur 8 etter finishing og polering.

Fig. 5: Palatinalt skall etablert med emaljenyanssen A1E av det valgte komposittmaterialet.

Fig. 6: Sidevisning av tennene under restaureringsprosedyren.

Fig. 7: Restaureringen før finishing og polering.

Fig. 8: Restaureringene etter finishing og polering. 

Resultatet

For å evaluere den endelige fargeintegrasjonen ble det tatt et nytt fotografi med krysspolarisert filter, der et grått referansekort ble holdt på plass for kalibrering (fig. 9 og 10). Sidevisningen av de restaurerte tennene (fig. 11) viser at ikke bare riktig fargekombinasjon, men også en naturlig overflatestruktur er nødvendig for å oppnå et svært estetisk resultat.

Fig. 9: Frontalvisning av de restaurerte tennene tatt med krysspolarisert filter.

Fig. 10: Kalibrering med  grått referansekort og de resulterende L*a*b*-koordinatene  for restaureringen.

Fig. 11: Sidevisning av de restaurerte tennene som understreker betydningen av overflatestruktur. 

DISKUSJON OG KONKLUSJON

Observasjon, støttet av moderne verktøy for fotografering og bildeanalyse (som polariserte filtre og L*a*b*-koordinater), er en viktig ferdighet for å oppnå naturtro rekonstruksjon av tenner med direkte komposittmaterialer. Ved å kombinere denne ferdigheten med et høytytende komposittsystem som tilbyr faste nyansekombinasjoner og innovativ teknologi for lysspredning, som gir en god integrasjon med den omkringliggende tannstrukturen, blir det mulig å skape estetiske restaureringer med forutsigbare resultater.

I det presenterte kasuset var pasienten svært fornøyd med resultatet både når det gjelder estetikk og funksjon. Ved regelmessige kontroller vurderes kvaliteten på restaureringene – og de viser fortsatt svært god funksjonell og estetisk integrasjon.

By Dr Wiktor Pietraszewski BSC(HONS) DMD

INTRODUCTION

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

THE CASE

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

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

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

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

THE PLAN

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

Main features of the Digital Smile Design (DSD) plan

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

PREPARATION, SCAN & TEMPORISATION

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

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

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

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

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

CEMENTS

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

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

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

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

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

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

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

PANAVIA™ VENEER LC

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

Fig. 8. PANAVIA™ Veneer LC Paste shades.

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

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

TRY-IN

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

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

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

CEMENTATION STEPS

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

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

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

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

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

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

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

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

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

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

Fig. 15a. Priming of the tooth structure.

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

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

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

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

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

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

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

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

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

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

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

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

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

Fig. 18. Immediate post-operative appearance.

Fig. 19. Check-up after three weeks.

FINAL SITUATION

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

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

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

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

FOLLOW-UP VISIT

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

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Clinical case by Dr Manuel Tinto

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

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

Fig. 1. Pre-operative photograph.

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

Fig. 2. Application of Caries Detector.

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

Fig. 4. Finished and cleaned cavities.

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

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

Fig. 6. Quad Matrix ring in position.

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

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

The Class I cavity was completed by layering two materials:

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

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

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

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

FINAL CONSIDERATIONS

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

Clinical case by Dr Luca Alibrandi

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

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

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

Fig. 3. Detail of the maxillary anterior region.

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

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

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

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

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

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

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

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

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

Fig. 7. Post-injection situation.

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

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

FINAL CONSIDERATIONS

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

Case by Dr. Onur Alp Yünük

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

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

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

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

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

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

REPLACEMENT OF THE COMPOSITE VENEERS

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

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

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

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

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

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

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

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

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

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

Fig. 10. Modification of the central incisor restorations.

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

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

Fig. 12. Final treatment outcome – frontal view.

Fig. 13. Final treatment outcome – occlusal view.

Fig. 14. Final treatment outcome – lateral view.

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

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

CONCLUSION

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

Clinical case by Dr. Giuseppe Iacona

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

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

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

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

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

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

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

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

Fig. 4. Baseline.

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

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

Fig. 7. Etching with phosphoric acid etchant.

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

Fig. 9. Injection indices.

Fig. 10. Placement of the injection index.

Fig. 11. Final treatment outcome.

FINAL CONSIDERATIONS

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

Case by Jotautas Kaktys, DDS

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

A CASE AS AN EXAMPLE

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

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

STRUCTURALLY COMPROMISED MOLAR RESTORATION

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

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

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

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

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

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