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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Clinical case by Dr. Claudia Mazzitelli and Dr. Edoardo Mancuso

INTRODUCTION

Dental aesthetics are gaining increasing importance and require predictable, rapid, and affordable treatments. Minimally invasive dentistry favours direct restorations, which are now simplified by the evolution of flowable composites. Recent variants of flowable composites offer optical and mechanical characteristics equal or superior to those of paste-type composites. The evolution of flowable resins has led to widespread application using the flowable injection technique (FIT). In addition, the possibility of 3D printing an index for injection reduces operator-dependent variability, providing for high-level aesthetics.

CLINICAL CASE

A 24-year-old patient complained of an unattractive smile. After clinical and radiographic examinations, an aesthetic restoration using FIT was planned. A digital wax-up, created on the basis of intraoral scans (Trios 5, 3Shape), allowed for the design of a customised index or template, which was printed using transparent resin (IBT Flex Resin, Formlabs). After preparation and isolation, the teeth were sandblasted, etched, and a universal adhesive (CLEARFIL™ Universal Bond Quick 2) was applied and light-cured. Flowable composite (CLEARFIL MAJESTY™ ES Flow Low) was injected through the injection holes in the index, followed by thorough curing, finishing and polishing (TWIST™ DIA for Composite, all Kuraray Noritake Dental Inc.).

RESULTS

The treatment, completed in two hours, led to immediate and stable aesthetic improvement, confirmed during check-ups after one week and six months, with excellent gum health and restoration maintenance.

DISCUSSION

FIT offers predictable aesthetic results, a digital workflow option, and reduced clinical time compared to indirect restorations, while maintaining the possibility of future prosthetic treatments. The evolution of flowable composites and 3D-printed indexes has improved the accuracy of clinical transfer and reproducibility, allowing for rapid, conservative aesthetic solutions.

CLINICAL CASE

A 24-year-old male patient presented at our practice dissatisfied with the aesthetics of his smile, with an impact on his spontaneity and social life. After taking his medical and dental history, an interview was conducted to understand his aesthetic and functional expectations as well as financial possibilities.

The clinical visual examination, accompanied by photographs, static and dynamic videos, periodontal analysis, and radiographs, revealed incongruous Class IV restorations on teeth 11 and 21 (FDI notation), with asymmetry of the anterior maxillary region  (Fig. 1). Aesthetic rehabilitation using the Flowable Injection Technique (FIT) extended to the six maxillary anterior teeth was therefore proposed.

Fig. 1. Initial clinical situation.

TREATMENT PLANNING

An intraoral scanner (Trios 5, 3Shape) was used for impression taking. The resulting digital model was used to create a digital wax-up, which then served as the basis for digitally designing an index for the injection of the flowable composite (Fig. 2). The index was printed in transparent resin (IBT Flex Resin, Formlabs) (Fig. 3). Once post-processing was complete, calibrated injection holes were integrated. They allow for insertion of the syringe tip and precise injection of the flowable composite (Fig. 4).

Fig. 2. Computer-aided index design.

Fig. 3. 3D-printed transparent index for composite injection.

Fig. 4. Injection holes integrated in the incisal areas of the index.

OPERATIVE PROCEDURE

After obtaining informed consent from the patient, the old restorations on the maxillary central incisors were removed with diamond burs under irrigation. The margins were finished and bevelled (Fig. 5). The index was positioned on the upper arch and evaluated for stability and retention. To produce the restorations alternately, PTFE tape (0.076 mm) was applied to isolate the adjacent teeth. The surfaces of the teeth to be restored were sandblasted with aluminium oxide (50 µm), etched with 37 % orthophosphoric acid etchant for 15 seconds, rinsed, and dried (Fig. 6).

Fig. 5. Maxillary central incisors after restoration removal and bevelling of the margins.

Fig. 6. Etching of the tooth surfaces with orthophosphoric acid etchant.

A universal adhesive (CLEARFIL™ Universal Bond Quick 2, Kuraray Noritake Dental Inc.) was then applied (Fig. 7) and polymerized with an LED curing light (SmartLite® Pro, Dentsply Sirona) for 10 seconds per tooth (Fig. 8).

A flowable composite (CLEARFIL MAJESTY™ ES Flow Low, colour W, Kuraray Noritake Dental Inc.) was injected through the holes until the index of the first prepared tooth was filled (Fig. 9). After light-curing for 40 seconds per tooth through the transparent index, the template was removed and the restoration was light-cured for a second time. Excess composite was then removed with a scaler.

Fig. 7. Application of a universal adhesive.

Fig. 8. Light-curing of the adhesive layer.

Fig. 9. Flowable composite injection.

The same procedure was subsequently repeated for the other teeth to be treated, isolating those already restored using PTFE tape (Figs. 10 to 15).

Fig. 10. Restored teeth isolated with PTFE tape.

Fig. 11. Etching of the tooth structure with 37 % orthophosphoric acid etchant.

Fig. 12. Application of the universal adhesive.

Fig. 13. Light-curing of the adhesive layer.

Fig. 14. Injection of the flowable composite into the index.

Fig. 15. Light-curing of the flowable composite through the transparent index.

Once the index was removed and excess material was eliminated. Then, the teeth were isolated with rubber dam using the split dam technique to improve patient comfort and visibility, and the restorations were finished with fine-grained diamond burs. Finally, progressive polishing was performed with polishing discs  (TWIST™ DIA for Composite, Kuraray Noritake Dental Inc.) (Figs. 16 and 17).

Fig. 16. Polishing of the restorations with the pre-polisher.

Fig. 17. Final polishing with the high-gloss polisher.

CLINICAL RESULTS

Once the restorations were completed (Figs. 18 and 19) and the occlusal and dynamic contacts were checked, the patient expressed immediate satisfaction. This was confirmed at the one-week follow-up (Fig. 20). The rehabilitation took a total of two hours, including photographic documentation. This represents a rapid, minimally invasive and cost-effective treatment compared to indirect restorations.

Fig. 18. Treatment outcome.

Fig. 19. Detailed view of the freshly restored teeth.

Fig. 20. Post-operative photograph taken after one week.

The six-month check-up (Figs. 21 and 22) not only confirmed the survival of the restorations but also showed excellent gingival health, demonstrating the correctness of the emergence profile and the high polishability of the cervical margins obtained with this restorative technique.

Fig. 21. Restorations at the six-month recall.

Fig. 22. Optical integration of the new restorations into the overall picture.

DISCUSSION

The Flowable Injection Technique is now a valid alternative in the field of direct restoration, as it combines operational simplicity with predictable aesthetic results. The main advantage lies in the reduction of variability linked to the operator's manual skills, thanks to the guiding role of the index, which allows the digital design or initial wax-up to be transferred with high accuracy. The aesthetic outcome is therefore highly controllable, while the clinical approach complies with the principles of minimally invasive dentistry. Added to this is the efficiency of the method, which allows for shorter operating times and lower costs compared to rehabilitation with indirect restorations. At the same time, it maintains the possibility of a subsequent transition to more complex prosthetic solutions.

A key enabler of this approach is the evolution of flowable composites. The latest generation has overcome the historical limitations of fragility and wear, offering mechanical and optical characteristics comparable to, if not superior to, paste-type composite materials. This progress has made it possible to use flowable materials not only as a complementary support, but as the real protagonist of a restorative technique that aims to simplify clinical work and improve the predictability of results.

Furthermore, the development of 3D printing applied to the production of transparent indexes has introduced a further leap in quality. The digital workflow makes it possible to reduce manufacturing times, standardize procedures, achieve high reproducibility, and design customized templates based on intraoral scans. The accuracy of clinical transfer is thus significantly increased, with a positive impact on the quality and stability of the final restoration.

The synergy between high-performance flowable resins and 3D-printed digital index therefore offers clinicians the option of offering patients aesthetic solutions that are rapid, accessible, and at the same time adhere to the principles of modern conservative dentistry.

CONCLUSION

The Flowable Injection Technique, supported by the latest generation of flowable composites and the potential of 3D printing, represents a modern and effective restorative strategy. The clinical case presented highlights how it is possible to offer patients a satisfactory, rapid, and conservative aesthetic treatment, while keeping open the option of a future transition to indirect restorations.

By combining innovative materials and digital technologies, this technique marks a step forward towards increasingly predictable, accessible, and patient-centred cosmetic dentistry.

Dental technicians:

CLAUDIA MAZZITELLI

Scientific director of the Dental Biomaterials Laboratory.

Clinical tutor for the International Master's Degree in Conservative Dentistry and Aesthetic Prosthetics, head of teaching activities for the Degree Course in Dental Hygiene at the University of Bologna.

Speaker at numerous national and international conferences and author of scientific publications in high-impact indexed journals.

EDOARDO MANCUSO

Expert in conservative and prosthetic dentistry with a minimally invasive approach.

Collaborates with international research groups on adhesive techniques and minimally invasive preparations.

Practices as a freelancer in Bologna.

Speaker and author of scientific papers presented at national and international conferences, publishes articles in leading scientific journals.

References

Terry DA, Powers JM. A predictable resin composite injection technique, Part I. Dent Today. 2014 Apr;33(4):96, 98-101.

Checchi V, Generali L, Corciolani L, Breschi L, Mazzitelli C, Maravic T. Wear and roughness analysis of two highly filled flowable composites. Odontology. 2025 Apr;113(2):724-733. doi: 10.1007/s10266-024-01013-0.

Liaropoulou YM, Jiménez AK, Chierico F, Blatz MB. The Multilayer Flowable Injection Technique for Highly Esthetic Restorations. J Esthet Restor Dent. 2025 Jun 27. doi: 10.1111/jerd.13500.

Watanabe K, Tanaka E, Kamoi K, Tichy A, Shiba T, Yonerakura K, Nakajima M, Han R, Hosaka K. A dual composite resin injection molding technique with 3D-printed flexible indices for biomimetic replacement of a missing mandibular lateral incisor. J Prosthodont Res. 2024 Oct 16;68(4):667-671. doi: 10.2186/jpr.JPR_D_23_00239.

Shui Y, Wu J, Luo T, Sun M, Yu H. Three dimensionally printed template with an interproximal isolation design guide consecutive closure of multiple diastema with injectable resin composite. J Esthet Restor Dent. 2024 Oct;36(10):1381-1387. doi: 10.1111/jerd.13268.

Hulac S, Kois JC. Managing the transition to a complex full mouth rehabilitation utilizing injectable composite. J Esthet Restor Dent. 2023 Jul;35(5):796-802. doi: 10.1111/jerd.13065.

Lawson NC, Greene Z, Machado N, Tadros D, Robles A, Rocha M. Resin Composite Depth of Cure Through Transparent Matrix Materials Used for Injection Molding. Oper Dent. 2025 Mar 1;50(2):185-193. doi: 10.2341/24-100-L.

Case by Dt. Koray Kendir, DDS, Turkey (İzmir)

SAMMENDRAG

Denne kliniske kasuistikken beskriver en direkte posterior komposittrestaurering utført ved bruk av Kuraray Noritake Dental Inc. sitt «Universal Excellence»-konsept. Et universelt adhesiv (CLEARFIL™ Universal Bond Quick 2) og et høyfyllt, flytende kompositt med universalfarge (CLEARFIL MAJESTY™ ES Flow Universal) ble benyttet for å oppnå både enkel arbeidsflyt og forutsigbarhet. Trinnvis dokumentasjon viser isolasjon, kavitetspreparering, deep margin elevation (DME), adhesivprotokoll og sluttrestaurering.

KLINISK BESKRIVELSE

En 38 år gammel kvinnelig pasient oppsøkte klinikken med blødning mellom tennene og ising mellom overkjevens venstre hjørnetann og første premolar (tennene #23 og #24 etter FDI-systemet). Klinisk undersøkelse viste åpen margin og sekundær karies ved det gingivale området av den eksisterende restaureringen på tann #23. Etter isolering med kofferdam ble trinnvis behandling igangsatt.

KLINISK PROSEDYRE

Trinn 1. Tann #23 viste en åpen gingival margin og karies (Fig. 1).

Trinn 2. Trinn 2. Etter fjerning av emalje ble karies ekskavert ned til gingivalnivå. Lesjonen på tann #24 ble observert å strekke seg subgingivalt (Fig. 2).

Trinn 3. Etter fullstendig kariesekskavering og raffinering av kaviteten ble behovet for deep margin elevation (DME) på tann #24 tydelig (Fig. 3).

Trinn 4. DME ble utført på tann #24 ved hjelp av en tilpasset seksjonskile. Først ble selektiv ets og CLEARFIL™ Universal Bond Quick 2 applisert, etterfulgt av CLEARFIL MAJESTY™ ES Flow Universal (Super Low)  (Fig. 4–6).

Trinn 5. Etter fullført DME ble egnet matrisebånd plassert, og direkte restaurering av tennene #23 og #24 ble utført med CLEARFIL MAJESTY™ ES Flow Universal (Super Low) (Fig. 7–9). Takket være materialets brukervennlighet, fargetilpasning og utmerkede poleringsegenskaper ble denne krevende DME-behandlingen gjennomført effektivt og forutsigbart.

Behandlingsresultatet vises i figur 10 og 11.

Fig. 1: Preoperativt bilde under kofferdamisolering

Fig. 2: Klinisk situasjon etter kariesekskavering

Fig. 3: Ferdigpreparerte kaviteter med dyp margin på premolaren

Fig. 4: Tilpasset kile plassert for å heve marginen

Fig. 5: Bukkal visning etter DME med universelle produkter

Fig. 6: Okklusal visning etter DME med universelle produkter

Fig. 7: Plassering av seksjonsmatrise

Fig. 8: Bukkal visning av restaurering med universalfarget flytende kompositt (Super Low)

Fig. 9: Okklusal visning av restaurering med universalfarget flytende kompositt

Fig. 10: Okklusal visning av endelige restaureringer (#23 og #24), som viser fargeharmoni, anatomisk form og høy glans

Fig. 11: Bukkal visning av endelige restaureringer (#23 og #24), som viser fargeharmoni, anatomisk form og høy glans

DISKUSJON

Universelle adhesiver og moderne flytende kompositter forenkler posteriore direkte restaureringer ved å redusere teknisk sensitivitet, samtidig som de gir holdbare resultater. I dette tilfellet ga CLEARFIL™ Universal Bond Quick 2 sterk adhesjon med minimal påføringstid. Det universelle flytende komposittmaterialet viste utmerket tilpasning, polerbarhet og slitestyrke. Selv med en subgingival margin som krevde DME, ble behandlingen gjennomført med en effektiv og strømlinjeformet tilnærming, uten at kvaliteten ble kompromittert.

CONCLUSION

Kombinasjonen av CLEARFIL™ Universal Bond Quick 2 og CLEARFIL MAJESTY™ ES Flow Universal  gjør det mulig for klinikere å utføre forutsigbare og effektive posteriore restaureringer. Deres universelle allsidighet og gode håndteringsegenskaper samsvarer med konseptet «Universal Excellence», og støtter en enkel, men pålitelig klinisk praksis i hverdagen.

Etikk og faglig tilknytning

Alle prosedyrer ble utført i samsvar med standard odontologisk praksis. Pasienten ga samtykke til behandling og publisering av anonymiserte kliniske bilder. Forfatteren samarbeider med Kuraray Noritake Dental Inc. som rådgiver; innholdet reflekterer klinisk erfaring.

Dentist:

KORAY KENDIR

Dr. Koray Kendir er utdannet ved det odontologiske fakultetet ved Hacettepe University og medgründer av en privat tannklinikk i İzmir. Han spesialiserer seg innen digital odontologi, smile design og datastøttede restaureringer. Dr. Kendir er kjent for sin innovative tilnærming, og er en hyppig foredragsholder på nasjonale tannlegekongresser samt rådgiver for flere dentale selskaper.

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.

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Case report by Dr Mediha Isikver

Tooth fractures and secondary caries are frequently observed in posterior teeth, often resulting from occlusal stress, restoration failure, or secondary bacterial infiltration. These conditions compromise tooth integrity, function, and aesthetics. With advancements in adhesive dentistry, minimally invasive and durable restorative solutions have become achievable. Material selection plays a critical role in the success of composite restorations, influencing marginal adaptation, wear resistance, and patient satisfaction. This case report describes the step-by-step clinical management of a fractured and secondary carious permanent molar restored using materials from Kuraray Noritake Dental Inc.

CASE PRESENTATION

A 32-year-old female patient presented to the clinic with sensitivity and discomfort in the upper left posterior region. Clinical examination revealed a distal wall fracture on tooth #26 (maxillary left first molar) with a secondary carious lesion extending subgingivally. Radiographic evaluation confirmed the absence of periapical pathology. Adjacent teeth (#25 and #27) showed early carious activity, but the patient opted for the restoration of tooth #26 only. The tooth was asymptomatic to percussion and showed normal vitality on pulp testing.

Fig. 1. Initial clinical view of tooth #26 under rubber dam isolation.

TREATMENT PROTOCOL

1. Isolation and caries removal: The tooth was isolated with rubber dam. The existing defective restoration and carious tissue were carefully removed using tungsten carbide burs and a slow-speed handpiece.
2. Surface cleaning: After preparation, KATANA™ Cleaner was applied to remove contaminants and optimize bonding surface quality.
3. Bonding procedure: A single-step, self-etch adhesive, CLEARFIL™ Universal Bond Quick 2, was applied to both enamel and dentin following the protocol recommended by the manufacturer.
4. Restorative phase: The deep and undercut areas were resin coated with CLEARFIL MAJESTY™ ES Flow Universal Low (U shade), ensuring adaptation and stress relief in undercut regions. The remaining cavity was restored incrementally using CLEARFIL MAJESTY™ ES-2 Universal (U shade) paste-type composite, with each 2 mm layer light-cured for 20 seconds.

Fig. 2. Clinical view of tooth #26 after removal of the defective restoration and carious tissue.

Fig. 3. Application of KATANA™ Cleaner to remove contaminants and optimize bonding surface quality after preparation.

Fig. 4. Selective enamel etching performed on tooth #26.

Fig. 5. CLEARFIL™ Universal Bond Quick 2 applied to both enamel and dentin following the manufacturer’s recommended protocol.

Fig. 6. Resin coating with CLEARFIL MAJESTY™ ES Flow Universal Low (U shade).

Fig. 7. Reconstruction of the mesial and distal walls with CLEARFIL MAJESTY™ ES-2 Universal (U shade) composite.

Fig. 8. Incremental build-up of cusps and occlusal anatomy using CLEARFIL MAJESTY™ ES-2 Universal composite, refined with a brush for contour adjustment.

Fig. 9. Initial finishing of the composite restoration performed with darkcoloured TWIST™ DIA for Composite (medium) rubber points to refine surface texture and anatomy.

Fig. 10. Final polishing performed with light-coloured TWIST™ DIA for Composite (fine) rubber points to achieve a highgloss, smooth surface.

FINAL SITUATION

Fig. 11. Final view of the restoration after occlusal adjustment and polishing.

CONCLUSION

This case demonstrates that adhesive and restorative systems from Kuraray Noritake Dental Inc. offer a reliable, efficient and effective approach for treating fractured and secondary carious posterior teeth. The integration of self-etch adhesives and high performance composites contributes to durable and aesthetically pleasing restorations. Continuous follow-up is essential to evaluate the long-term clinical behaviour of these materials.

Dentist:

MEDIHA ISIKVER

Dr Mediha Isikver is a graduate of the Ege University Faculty of Dentistry and the co-founder of Klinik M in Istanbul, Turkey. She focuses her professional practice on aesthetic and restorative dentistry, with particular expertise in composite laminate layering, porcelain laminates, and smile design. Believing that every smile tells its own story, she aims to create personalized aesthetic transformations that blend natural harmony with artistic detail.

Case by Dr. Onur Alp Yünük

COMBINING HIGH-PERFORMANCE TOOLS AND MATERIALS FOR A PREDICTABLE OUTCOME

Direct composite restorations are a high-quality treatment option even when large amounts of tooth structure need to be replaced. This is due to recent advancements in resin composite materials and adhesive technology. By selecting appropriate materials and layering techniques combined with modern digital tools for colour difference evaluation, it is possible to predictably produce highly aesthetic outcomes, as demonstrated in the following case example.

THE CHALLENGE

A young male patient presented to our clinic requesting the replacement of his existing composite restorations on his maxillary incisors (teeth #12 and #11 according to the FDI notation). Clinical examination revealed extensive restoration loss on the lateral incisor. Furthermore, anatomical irregularities, discolouration, and loss of surface gloss were observed on tooth #11. The adjacent central incisor exhibited similar issues regarding colour and surface polish.

In consultation with the patient, it was decided to replace the existing restorations using a modern composite material specifically developed for dual-shade layering – CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.). For an exact shade analysis, photographs were taken with and without a cross-polarized filter (Figs. 1 to 4).

Fig. 1. Frontal view of the teeth with extensive restoration loss on the maxillary left lateral incisor.

Fig. 2. Cross-polarized photograph of the teeth allowing for a detailed analysis of the shade irregularities.

Fig. 3. Lateral view of the teeth.

Fig. 4. Lateral view – cross-polarized photograph.

THE SOLUTION

Following removal of the existing restorations, rubber dam was placed for working field isolation. A self-etching adhesive (CLEARFIL™ SE Bond 2, Kuraray Noritake Dental Inc.) was applied in the selective enamel etching mode before establishing the palatal shell using CLEARFIL MAJESTY™ ES-2 Premium in the shade A1E (Figs. 5 and 6). The mamelon structures were reconstructed with CLEARFIL MAJESTY™ ES-2 Premium in the shade A1D, while the translucent shade Blue was applied to the opalescent zone. Finally, yellow and white tints were used for characterization. Fig. 7 illustrates the appearance before, Fig. 8 after finishing and polishing.

Fig. 5. Palatal shell established with the enamel shade A1E of the selected composite.

Fig. 6. Lateral view of the teeth during the restoration procedure.

Fig. 7. Restoration before finishing and polishing.

Fig. 8. Appearance of the restorations after finishing and polishing.

THE OUTCOME

To evaluate the final colour integration, another photograph was taken with a cross-polarized filter, holding a grey reference card in place for calibration (Figs. 9 and 10). The lateral view of the restored teeth (Fig. 11) reveals that not only the right colour combination, but also a natural surface texture is required for a highly aesthetic outcome.

Fig. 9. Frontal view of the restored teeth taken with a cross-polarized filter.

Fig. 10. Gray reference card calibration and the resulting L*a*b* coordinates of the restoration.

Fig. 11. Lateral view of the restored teeth stressing the importance of surface texture.

DISCUSSION AND CONCLUSION

Observation, supported by modern tools for photography and image analysis (like polarized filters and L*a*b* coordinates), is an important skill needed for the lifelike reconstruction of teeth with direct composite materials. By combining this skill with a high-performance composite system that offers fixed shade combinations and innovative light diffusion technology for a nice blend-in with the surrounding tooth structure, creating beautiful restorations becomes a predictable business.

In the case presented, the patient was very satisfied with the outcome in terms of aesthetics and function. At regular recalls, the quality of the restorations is checked – they still offer a very nice functional and aesthetic integration.

Dentist:

ONUR ALP YÜNÜK

Dr. Onur Alp Yünük completed both his undergraduate and doctoral education at Istanbul University. He currently serves as an Assistant Professor in the Department of Restorative Dentistry at the Istinye University Faculty of Dentistry. His work primarily focuses on direct composite restorations of anterior teeth and on polychromatic layering systems.

Case by DT Vasilis Vasiliou

MICRO-LAYERING WITH CERABIEN MiLai

No matter whether young or old, male or female: Our patients deserve a beautiful smile that matches their adjacent teeth, their face, their character and their individual needs. To be able to produce beautiful restorations that change their life for the better, we (as dental technicians) have to observe closely – and to listen attentively to the stories they tell.

‘We have to observe closely – and to listen attentively to the stories our patients tell us.’
– Vasilis Vasiliou –

Mr Andreas is a perfect example. He presented in the dental office in need of a full-mouth rehabilitation and the wish to improve the aesthetics of his smile. He asked for an age-appropriate, natural restoration design.

After careful observation and listening, I decided that the best way to restore his maxillary incisors would be with zirconia restorations. The plan was to mill the frameworks using low-value KATANA™ Zirconia YML, shade D3 (Kuraray Noritake Dental Inc.). To facilitate the integration of some natural characteristic effects, a framework design with a primarily vestibular cutback was selected. The finishing technique of choice was micro-layering with CERABIEN™ MiLai (Kuraray Noritake Dental Inc.), a porcelain designed specifically for this approach.

Important steps in the finishing procedure were:

• Characterization of the milled zirconia with colouring liquids
• Pre-treatment of the sandblasted zirconia surfaces with SS Fluoro and Margin porcelain
• Internal staining with CERABIEN™ MiLai internal stains
• Application of CERABIEN™ MiLai luster porcelains

LABORATORY WORKFLOW

Zirconia splinted crowns were designed in full contour with the aid of the Leahu Library featuring tailored tooth designs (part of the Truedental Library available for exocad DentalCAD design software; Fig. 1), cut back merely in the vestibular area using the ‘calma’ reduction option (Fig. 2), and then milled and characterized with colouring liquids to optimize the chroma.

Figure 3 shows the sintered frameworks on the model, Figure 4 the try-in in the patient’s mouth. As the fit and shape of the restorations turned out to be excellent, it was time to plan the internal staining and micro-layering procedure (Figs. 5 and 6), always trying to imitate nature as closely as possible.

The tricky part is to use the available space wisely – the reason why a detailed layering sketch is useful even when in the context of micro-layering. Once the planned layering procedure had been put to practice (Figs. 7 to 10), the surface texture was finalized and the restorations were tried in again for an aesthetic evaluation. Finally, they were cemented with the adhesive resin cement PANAVIA™ V5 (Kuraray Noritake Dental Inc.).

The beautiful treatment outcome is shown in Figure 11.

Fig. 1. Computer-aided design of the zirconia frameworks: Splinted crows displayed in a transparent mode to show the abutment teeth.

Fig. 2. Computer-aided design of the zirconia frameworks: Outer contour of the splinted crowns with a strongly elaborated surface texture and sufficient room for micro-layering.

Fig. 3. Restorations after characterization with colouring liquids and sintering on the model.

Fig. 4. Try-in of the restorations.

Fig. 7. Internal staining – specific characteristics elaborated for a natural depth effect.

Fig. 8. Layering in the cervical and body areas.

Fig. 9. Final layering with luster porcelains to complete the morphology.

Fig. 10. Final restorations after surface finishing and polishing as well as glazing on the model.

Fig. 11. Treatment outcome.

CONCLUSION

The patient was thoroughly satisfied with the treatment outcome and confident that his investment was well worth it. By tailoring my approach to his unique needs, carefully observing his teeth, smile, and facial expressions, and utilizing my extensive knowledge of materials, I was able to achieve this goal successfully.

Nonetheless, I remain committed to continuous improvement by critically evaluating each restoration and seeking areas for enhancement. My dedication to growth, supported by exceptional mentors who share innovative techniques and insights, supports me in staying at the forefront of my field, striving at consistently delivering the best possible care.

I am deeply grateful to Dr. Zinonas Evagorou for invaluable partnership and clinical expertise, which were instrumental in achieving this result.

Dental Technician:

VASILIS VASILIOU

Vasilis Vasiliou was born in Nicosia, Cyprus, and graduated from the Technical School for Dental Technicians in Athens in 2004. He has furthered his education by attending several advanced seminars led by mentors and experts in the field, such as Ilias Psarris and Nondas Vlachopoulos.

Throughout his career, Vasilis has made significant contributions to the dental community, including presenting at various conferences in Greece and publishing articles in Greek dental magazines. Since 2020, he has been a key opinion leader for MPF Brush Company and, since 2022, a HASS Ambassador.

Vasilis has been an active member of the International Team for Implantology (ITI) since 2019.

Together with his father, Vasilis runs a successful dental laboratory in Nicosia, specializing in all-ceramic and implant restorations. His extensive experience and commitment to excellence have established him as a respected professional in his field.

Case by Dr. Michał Jaczewski

FLOWABLE INJECTION TECHNIQUE

What are the most important properties of a flowable composite used for the flowable injection technique? Personal experience shows that balanced optical properties are essential, with an appropriate translucency, blend-in ability and surface gloss leading the way. However, the mechanical properties are also important, not least because the restorative material will be in direct contact with the antagonist teeth. And finally, handling properties are essential: The right level of flowability is needed for proper injection, while a void-free application is required for an intact, stain-resistant surface.

For the last seven years, CLEARFIL MAJESTY™ ES Flow Low (Kuraray Noritake Dental Inc.) has been my go-to flowable composite for the flowable injection technique. Its level of flowability is ideal for the technique in the anterior and posterior region. Whenever a lower flowability is needed, it is possible to switch to the Super Low variant. Moreover, I like the shade offering, which – together with the superior polishability of the material – leads to natural aesthetics. Finally, its mechanical properties are so good that the product is approved for a wide indication range without load limitations.

When the company announced the introduction of CLEARFIL MAJESTY™ ES Flow Universal, which comes in just two universal shades and two different levels of flowability (Low and Super Low), I immediately decided to give it a try: The prospect of balanced properties I am already familiar with, combined with a simplified shade selection sounded very promising. So far, the new product comes up to my expectations: The following case example reveals the simplicity of the procedure and the beauty of the results. The patient presented during orthodontic (aligner) treatment for a shape correction in the anterior region due to wear of the incisal edge.

Fig. 1. Initial clinical situation: Patient in need of a shape correction in the maxillary incisor region.

Fig. 2. Application of CLEARFIL™ Universal Bond Quick 2 (Kuraray Noritake Dental Inc.) to the enamel of a central incisor, which has been merely roughened by air abrasion with aluminium oxide (50 μm at low pressure) followed by etching with a phosphoric acid etchant.

Fig. 3. Transparent silicon index placed in the mouth and CLEARFIL MAJESTY ES Flow Universal Low (U shade) already injected in the position of the maxillary right central incisor.

Fig. 4. Shape correction on the maxillary right central incisor completed.

Fig. 5. Situation after finishing and polishing of the incisor restorations.

Fig. 6. Nice shade match leading to a smooth blend-in with the surrounding natural tooth structure.

Fig. 7. Immediate treatment outcome supporting an improvement of the smile aesthetics and hence, the patient‘s quality of life during aligner therapy.

RESULTS THAT SPEAK FOR THEMSELVES

Like its related product CLEARFIL MAJESTY ES Flow, the universal-shade version CLEARFIL MAJESTY ES Flow Universal offers properties which are – from a personal perspective – ideal for the flowable injection technique. The shade-matching properties are astonishing; the translucency is quite high when placed in thin layers (so that enamel is very well imitated), and the polishability is as good as that of CLEARFIL MAJESTY ES Flow. For virtually effortless, bubble-free injection, the product comes in a nicely designed syringe. And last but not least, the product’s mechanical properties provide peace of mind even in the posterior region.

Dentist:

MICHAŁ JACZEWSKI

Michał Jaczewski graduated from Wroclaw Medical University in 2006 and today runs his private practice in the city of Legnica, Poland. He specializes in minimally invasive dentistry and digital dentistry and is the founder of the Biofunctional School of Occlusion. Here he lectures and runs workshops with focus on full comprehensive patient treatments.

Case by Dt. Koray Kendir, DDS, Turkey (İzmir)

LAYERED COMPOSITE TECHNIQUE WITH A1D AND A1E SHADES

Single-shade composite layering techniques are becoming increasingly popular among dental practitioners due to their simplicity. Used in combination with modern composite materials that offer improved optical properties, these techniques lead to aesthetic outcomes in many clinical situations. However, when it comes to restoring anterior teeth with pronounced enamel translucencies and a vivid internal colour structure, playing with two shades and opacities of composite may be the better option.

Luckily, a dual-shade technique does not have to be complicated, either: With CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.), dental practitioners have a material at their disposal that supports simplified procedures and predictable outcomes as well. It comes with fixed shade combinations of Dentin and Enamel, each of which covers three VITA shades. Consequently, the need for complicated shade schemes and colour combination formulas is eliminated.

The following case reveals how to use it in the context of an anterior restoration procedure.

STEP 1 – ISOLATION AND INITIAL EVALUATION

Rubber dam isolation was performed to provide for optimal moisture control and field visibility. Initial photographs were taken to document the preoperative condition. The defects on teeth #22 (mesial), #21 (distal), #11 (distal), and #12 (mesial, FDI notation) were evaluated under dry conditions.

STEP 2 – SHADE SELECTION

Shade selection was performed under rubber dam isolation using CLEARFIL MAJESTY™ ES-2 Premium Shade Guide (Kuraray Noritake Dental Inc.). The selected shades were A1D (dentin) and A1E (enamel) from CLEARFIL MAJESTY™ ES-2 Premium, providing optimal blending with the surrounding natural teeth.

STEP 3 – CAVITY PREPARATION

After completing the shade selection, carious tissue was thoroughly removed from teeth #22, #21, #11, and #12. Conservative Class III cavity were prepared with a focus on maintaining maximum enamel support and preserving tooth structure. Palatal and buccal views were documented to demonstrate the cavity extension and cleanliness of the preparation.

STEP 4 – ETCHING

Selective etching was performed using K-ETCHANT Syringe (Kuraray Noritake Dental Inc.) on the enamel margins of the prepared cavities. Adjacent teeth were protected using PTFE tape to prevent unintended etching. This step provides for optimal micromechanical retention and enhances the bond strength of the adhesive system.

STEP 5 – ADHESIVE APPLICATION

CLEARFIL™ SE BOND 2 (Kuraray Noritake Dental Inc.) was used as the adhesive system. Following the manufacturer’s protocol, the primer was first applied to all cavity surfaces, left undisturbed for 20 seconds to allow adequate penetration, and then gently dried with air. The bond was then applied, air-thinned, and light cured. This two-step self-etch adhesive provides reliable adhesion and long-term stability in direct restorations.

STEP 6 – LIGHT POLYMERIZATION

Following the adhesive application, each surface was light-cured using a high power LED curing unit. The tip of the curing device was positioned as close as possible to the bonding surfaces to enable optimal polymerization of the adhesive layer.

STEP 7 – COMPOSITE RESTORATION AND FINISHING

The restorations were completed using a multilayering approach. Palatal shells were initially built with A1E (enamel shade) to establish the outline form. The dentin body was reconstructed with A1D, followed by a final enamel layer (A1E) to achieve natural translucency and surface texture. After finishing the contouring, polishing was performed to achieve a lifelike gloss and seamless integration with the surrounding dentition.

Dentist:

KORAY KENDIR

Dt. Koray Kendir is a graduate of Hacettepe University Faculty of Dentistry and the co-founder of a private dental clinic in İzmir. He specializes in digital dentistry, smile design, and computer-aided restorative treatments. Known for his innovative approach, Dr. Kendir is a frequent speaker at national dental congresses and serves as an advisor to several dental companies.

Case by Dr. Julien Molia

JA, DET FUNGERER!

Blant mange tannleger er det en utbredt oppfatning at flytende kompositter hovedsakelig egner seg som basemateriale under sterkere pakkbare kompositter og indirekte restaureringer, eller som en midlertidig løsning. Mange antar at bruksområdet er begrenset grunnet svakere mekaniske egenskaper.

EN NY GENERASJON AV FLYTENDE KOMPOSITT 

Heldigvis stemmer ikke dette lenger: Flere nye generasjoner av flytende kompositter – som CLEARFIL MAJESTY™ ES Flow og CLEARFIL MAJESTY™ ES Flow Universal (begge fra Kuraray Noritake Dental Inc.) – har mekaniske egenskaper som er  på nivå med mange pakkbare alternativer. Dette utvider bruksområdene betydelig. For eksempel har CLEARFIL MAJESTY™  ES Flow Universal en høy fyllstoffmengde på 75–78 vektprosent, bøyningsstyrke på over 150 MPa og trykkstyrke på over 370 MPa, ifølge produsenten. Takket være disse egenskapene er den egnet som en varig restaurering, selv i belastede områder som okklusjonsflater i molarområdet.

I tillegg finnes kompositten i to ulike viskositeter – LOW og SUPER LOW – for å tilpasses individuelle preferanser og indikasjoner. Den tilbys i kun to nyanser (universal og universal mørk), noe som gir et enkelt og intuitivt fargevalg, selv i fronten. Dette er muliggjort gjennom en kombinasjon av fargetilpasningsteknologier, inkludert optimalisert lysdiffusjon og emaljelignende translucens.

Det følgende kliniske eksempelelet viser hvordan CLEARFIL MAJESTY™ ES Flow Universal gjør livet mitt enklere i posterior restaureringsprosedyrer.  

KLINISK EXAMPLE

Pasienten kom for utskifting av to gamle amalgamrestaureringer i underkjevens høyre molarer (tenner 46 og 47 i henhold til FDI-notasjon) (Fig. 1). For å oppnå god tilpasning og enkel utfylling ble det valgt å bruke CLEARFIL MAJESTY™ ES Flow Universal LOW som eneste restaureringsmateriale. Tennenes plassering gjorde fargevalget enkelt – nyansen U (universal) fungerer optimalt i alle posteriore restaureringer.

Amalgamfyllingene ble fjernet, og kariøst vev ble ekskavert med fokus på maksimal bevaring av sunt tannvev (Fig. 2 og 3).  En selektiv emaljeetsing ble utført, etterfulgt av adhesivbehandling med CLEARFIL™ Universal Bond Quick 2. Deretter ble CLEARFIL MAJESTY™ ES Flow Universal LOW i nyanse U applisert (Fig. 4). Takket være den innovative sprøyteutformingen ble materialet påført nesten uten luftbobler. I tråd med produsentens retningslinjer ble lagtykkelsen holdt under 2 mm for å sikre full herding (Fig. 5 og 6), noe som er avgjørende for restaureringens langtidsprognose. Hvert lag herdes i 10–20 sekunder, avhengig av herdelampen, før neste lag appliseres. Som vist i Fig. 7, gir den lave viskositeten mulighet for enkel modellering av okklusal morfologi. For mer detaljert utforming kan varianten SUPER LOW være et alternativ. Det tok kun noen sekunder å polere restaureringene til høyglans (Fig. 8).

Fig. 1: To amalgamfyllinger som skal erstattes 

Fig. 2: Etter fjerning av eksisterende amalgam .

Fig. 3: Typisk amalgammisfarging synlig i bunn av kavitet 

Fig. 4: Fyllingsprosedyre: Applisering av det første laget av flytende kompositt

Fig. 5:  Andre molar ferdig fylt, første molar trenger et nytt lag 

Fig. 6: Fylling fullført. 

Fig. 7: Fin morfologi og god fargetilpasning 

Fig. 8: Endelig resultat etter fjerning av kofferdam. Restaureringene smelter naturlig inn i omgivende tannsubstans - med farge og overflateglans.

BRUKERVENNLIG ALTERNATIV FOR PAKKBARE KOMPOSITTER

Spesielt i krevende områder i munnen kan flytende kompositt med balanserte mekaniske egenskaper være et godt alternativ til pakkbare materialer. Egenskaper som avansert fargetilpasning, tilnærmet porefri påføring, enkel adaptering og modellering, samt rask polering, gjør hverdagen enklere for tannlegen. Mange antar at bruken er begrenset på grunn av svakere mekaniske egenskaper.

Dentist:

JULIEN MOLIA

Dr. Julien Molia ble uteksaminert i 2008 med en avhandling om dataassistert implantologi. Han etablerte en allmenn tannlegepraksis i Saint-Jean-de-Luz, hvor han har spesialisert seg på implantatkirurgi og rekonstruksjon av kjeven. I 2017 fullførte han en ny universitetsgrad innen implantologi for å oppdatere og utdype sin kompetanse. Han har også videreutdannet seg innen digital odontologi, ortodontiske miniscrews og mukogingival kirurgi. Med et sterkt engasjement for vevspreservasjon har han fått privat opplæring av Dr. Gil Tirlet og Dr. Jean-Pierre Attal i Paris. Dr. Molia er en av grunnleggerne av det franske forskningsnettverket Southwest BioTeam, en gruppe som fokuserer på klinisk forskning og innovasjon.