429 Too Many Requests

Case by Dr. Aleksandra Łyżwińska, Warsaw, Poland

ABSTRACT

Indirect overlays are the contemporary restoration standard for posterior teeth with extensive hard tissue loss. They provide for cuspal coverage, which decreases the likeliness of coronal and/or root fracture. At the same time and in contrast to crowns, overlay preparations minimize the removal of sound tooth structure especially in the cervical region, which is a critical factor.¹ Modern dental resin composites allow for direct cuspal coverage in a single-visit appointment. The results of in-vitro studies suggest that these direct overlays are a suitable alternative to their indirect counterparts in specific situations.^2-6 The following case report is used to describe the direct restoration procedure by means of a maxillary right molar with an extensive, deep MOD lesion.

INTRODUCTION

In the context of treating a tooth with an extensive carious lesion, a biomechanical risk assessment should be performed. The primary method of reducing the likeliness of tooth fracture is treatment with a restoration that provides cuspal coverage. The contemporary gold standard for biomechanically compromised teeth are adhesively cemented overlays as an alternative to crowns.¹ Another option that does not involve labwork is a direct overlay restoration.^2-6 The direct approach is especially suitable for long-term temporization, which may be required during orthodontic treatment, for example.

CLINICAL CASE

The 40-year-old male patient was referred to my office before an orthodontic and prosthetic treatment. Intraoral examination (Figs. 1 and 2) revealed:

• Tetracycline discolouration,
• Multiple extensive composite restorations with marginal leakage,
• Primary and secondary carious lesions, and
• Significant mechanical weakness^7,8 (mesio-occluso-distal (MOD) cavities, cusp loss, cracks).

Fig. 1. Initial situation – extensive MOD composite resin restoration.

Fig. 2. Initial situation – unacceptable contact points, palatal wall crack line.

Based on a clinical and radiological examination (Fig. 3), it was decided to restore the maxillary right first molar with a direct overlay, which should serve as a long-term temporary for the duration of orthodontic treatment. Once the local anaesthetic had been administered, rubber dam was placed in the first quadrant and the cusps of the affected first molar were reduced. For subgingival tooth preparation, a rubber dam sheet was temporarily moved behind the second upper molar (Fig. 4). In order to obtain a good emergence profile of the restoration and a tight fit of the sectional matrix, the gingivectomy was performed with an electric surgical knife (Surtron 50D, LED SPA) (Fig. 5). The main advantages of a diathermal cut are instant tissue coagulation and hemostasis⁹.

Fig. 3. Bite-wing radiograph: Maxillary fist molar with an overhang and negative profile of the distal wall.

Fig. 4. Initial preparation with reduction of the cusps and exposure of gingiva.

Fig. 5. Gingivectomy performed using a surgical electric knife.

In accordance with the European Society of Endodontology’s guidelines on the management of deep caries¹⁰, the deepest part of the cavity was cleaned in full rubber dam isolation (Nic Tone Dental Dam, MDC Dental) (Fig. 6). Carious-tissue excavation was carried out using round burs, then the enamel and dentin were air-abraded with 50-μm aluminum oxide (Microetcher IIa, Danville). Multiple cracks, penetrating through the enamel and partially the dentin, occurred within the mesial and palatal walls. The presence of cracks crossing the dentin-enamel junction is an absolute indication to cuspal coverage^8,11.

An appropriate rubber dam isolation is essential in adhesive dentistry. Beyond the obvious advantage of a clean operation field uncontaminated by saliva and moisture, the rubber dam contributes to keeping periodontal tissues at a distance form a tooth. In order to ensure both, maximum retraction and sufficient space to work, the rubber dam was inverted (introduced to the gingival sulcus) and stabilized using PTFE tape (Fig. 7). The mesial wall was restored using a blue 3D Composite-Tight 3D Fusion matrix ring (Garrison) and a medium standard Sectional Contoured Metal Matrix (TOR VM, Fig. 8). Due to its extensiveness and shape, restoration of the distal wall was more difficult to perform.

Fig. 6. Rubber dam newly placed in the interproximal area. Full isolation is essential for the excavation of the infected dentin in the deepest part of the cavity.

Fig. 7. PTFE tape placement for improving isolation in the gingival area. Al₂O₃ sandblasting.

Fig. 8. Mesial matrix fit.

The first attempt to adapt an elongated Sectional Contoured Metal Matrix and the green 3D Composite-Tight 3D Fusion (Garrison) ended with failure (Fig. 9). The matrix was changed for a longer and more curved one (Fig. 10). The ring was replaced by a smaller Palodent V3 Ring (Dentsply Sirona, Fig. 11). Due to the depth of the carious lesion, an antibacterial adhesive system was used (CLEARFIL™ SE Protect, Kuraray Noritake Dental Inc.). It contains the MDPB monomer, which offers an antibacterial effect that lasts even after hybrid layer formation^12-14. Furthermore, the fluoride included in the bond liquid intensifies the cariostatic mechanism of CLEARFIL™ SE Protect and supports the so-called “Super Dentin” formation¹⁵.

Fig. 9. Insufficient fit of the distal matrix.

Fig. 10. New, longer and more curved matrix in place.

Fig. 11. Different matrix ring placed in the distal area.

After polymerization of the bonding agent, the nanohybrid flowable composite resin (CLEARFIL MAJESTY™ ES Flow High, Kuraray Noritake Dental Inc.) was applied in a thin layer. The proximal wall was restored using both packable (CLEARFIL MAJESTY™ ES-2 Universal, Kuraray Noritake Dental Inc.) and flowable composite resin (CLEARFIL MAJESTY™ ES Flow Super Low, Kuraray Noritake Dental Inc.) (Figs. 12 and 13). Core build-up was performed with bulk-fill type composite. The cusps were reconstructed free-hand with the previously used CLEARFIL MAJESTY™ ES-2 Universal (Figs. 14 and 15). The universality of this product provides for a good optical integration and blending with the adjusted tissue, regardless of the colour of the underlying tooth structure. The fissures were gently highlighted using brown tints.

Fig. 12. Thin layer of flowable composite resin CLEARFIL MAJESTY™ ES Flow High (A2) applied on the cavity floor. The proximal walls are built up with build-up by CLEARFIL MAJESTY™ ES-2 Universal and CLEARFIL MAJESTY™ ES Flow Super Low (A2).

Fig. 13. Proximal walls build-up – palatal view.

Fig. 14. Core build-up. Free-hand cusp coverage with CLEARFIL MAJESTY™ ES-2 Universal, palatal view.

Fig. 15. Cusp coverage – occlusal view.

The initial polishing was performed with the rubber dam still in place. The excesses of composite resin were removed with the aid of abrasive discs, diamond burs and a “Brownie” polisher (BAL, Nevadent). Pre-polishing and high-shine polishing were executed with TWIST™ DIA for Composite (Kuraray Europe GmbH.) supported by a goat hair brush (Micerium) (Figs. 16 to 17).

Fig. 16. Occlusal surface after surface modeling with CLEARFIL MAJESTY™ ES-2 Universal and initial polishing.

Fig. 17. Occlusal surface after modeling with CLEARFIL MAJESTY™ ES-2 Universal and initial polishing – palatal view.

After removal of the rubber dam, the occlusal contact points of the direct overlay were adjusted (Figs. 18 and 19). Every spot touched by the burr was subsequently repolished according to the previously described protocol (Figs. 20 and 21).

Fig. 18. Occlusal adjustment. Contact points recorded with articulation paper (100 μm).

Fig. 19. Occlusal adjustment. Contact points recorded with articulation paper (100 μm= and articulation foil (16 μm).

Fig. 20. Final effect after polishing with TWIST™ DIA for Composite.

FINAL SITUATION

Fig. 21. Final effect – palatal view.

CONCLUSION

As a result of decades of improvements mainly with regard to the filler density and polishability, modern dental composites offer a great gloss retention and favourable wear properties. In addition, polymerization shrinkage has been decreased due to the integration of nanohybrid filler technology. Those features allow us to restore biomechanically compromised teeth using a direct restoration technique.

Direct overlays are a suitable alternative for a conventional indirect restoration in many situations.^18,19 According to researchers, the advantages of direct restorations with cuspal coverage include minimal tooth preparation, vital pulp-oriented treatment, the possibility to treat patients in a single appointment and a potentially lower cost of the treatment.^18-20 However, it should be emphasized that the presented technique requires advanced restorative skills that need to be acquired first before starting to implement it.

Dentist:

DR. ALEKSANDRA ŁYŻWIŃSKA
Warsaw, Poland

Dr. Aleksandra Łyżwińska is a restorative dentist. She graduated from the Warsaw Medical University in 2017, where she was an assistant professor at the Department of Conservative Dentisyty and Endodontics. Her focus lies in modern adhesive techniques, resin composites and biomaterials.

REFERENCES

1. Dietschi D, Duc O, Krejci I, Sadan A. Biomechanical considerations for the restoration of endodontically treated teeth: a systematic review of the literature--Part 1. Composition and micro- and macrostructure alterations. Quintessence Int. 2007 Oct;38(9):733-43.
2. van Dijken JW. Direct resin composite inlays/onlays: an 11 year follow-up. J Dent. 2000 Jul;28(5):299-306. doi: 10.1016/s0300-5712(00)00010-5. PMID: 10785294.
3. Mondelli RF, Ishikiriama SK, de Oliveira Filho O, Mondelli J. Fracture resistance of weakened teeth restored with condensable resin with and without cusp coverage. J Appl Oral Sci. 2009 May-Jun;17(3):161-5.
4. Deliperi S, Bardwell DN. Multiple cuspal-coverage direct composite restorations: functional and esthetic guidelines. J Esthet Restor Dent. 2008;20(5):300-8; discussion 309-12.
5. Deliperi S, Bardwell DN. Clinical evaluation of direct cuspal coverage with posterior composite resin restorations. J Esthet Restor Dent. 2006;18(5):256-65; discussion 266-7.
6. Mincik J, Urban D, Timkova S, Urban R. Fracture Resistance of Endodontically Treated Maxillary Premolars Restored by Various Direct Filling Materials: An In Vitro Study. Int J Biomater. 2016;2016:9138945.
7. Reeh ES, Messer HH, Douglas WH. Reduction in tooth stiffness as a result of endodontic and restorative procedures. J Endod. 1989 Nov;15(11):512-6.
8. Banerji S, Mehta SB, Millar BJ. The management of cracked tooth syndrome in dental practice. Br Dent J. 2017 May 12;222(9):659-666.
9. Bashetty K, Nadig G, Kapoor S. Electrosurgery in aesthetic and restorative dentistry: A literature review and case reports. J Conserv Dent. 2009 Oct;12(4):139-44.
10. European Society of Endodontology (ESE) developed by:, Duncan HF, Galler KM, Tomson PL, Simon S, El-Karim I, Kundzina R, Krastl G, Dammaschke T, Fransson H, Markvart M, Zehnder M, Bjørndal L. European Society of Endodontology position statement: Management of deep caries and the exposed pulp. Int Endod J. 2019 Jul;52(7):923-934.
11. Lynch CD, McConnell RJ. The cracked tooth syndrome. J Can Dent Assoc. 2002 Sep;68(8):470-5.
12. Hashimoto M, Hirose N, Kitagawa H, Yamaguchi S, Imazato S. Improving the durability of resindentin bonds with an antibacterial monomer MDPB. Dent Mater J. 2018 Jul 29;37(4):620-627.
13. Imazato S, Kinomoto Y, Tarumi H, Torii M, Russell RR, McCabe JF. Incorporation of antibacterial monomer MDPB into dentin primer. J Dent Res. 1997 Mar;76(3):768-72.
14. Imazato S, Kinomoto Y, Tarumi H, Ebisu S, Tay FR. Antibacterial activity and bonding characteristics of an adhesive resin containing antibacterial monomer MDPB. Dent Mater. 2003 Jun;19(4):313-9.
15. Nakajima M, Okuda M, Ogata M, Pereira PN, Tagami J, Pashley DH. The durability of a fluoride-releasing resin adhesive system to dentin. Oper Dent. 2003 Mar-Apr;28(2):186-92.
16. Bore Gowda V, Sreenivasa Murthy BV, Hegde S, Venkataramanaswamy SD, Pai VS, Krishna R. Evaluation of Gingival Microleakage in Class II Composite Restorations with Different Lining Techniques: An In Vitro Study. Scientifica (Cairo). 2015;2015:896507.
17. Oficjalne informacje producenta Kuraray Noritake Dental https://www.kuraraynoritake.eu/pl/clearfil-majesty-es-flow (dostęp 08.02.2022).
18. Angeletaki F, Gkogkos A, Papazoglou E, Kloukos D. Direct versus indirect inlay/onlay composite restorations in posterior teeth. A systematic review and meta-analysis. J Dent. 2016 Oct;53:12-21.
19. Dhadwal AS, Hurst D. No difference in the long-term clinical performance of direct and indirect inlay/onlay composite restorations in posterior teeth. Evid Based Dent. 2017 Dec 22;18(4):121-122.
20. Banerji S, Mehta SB, Millar BJ. Cracked tooth syndrome. Part 2: restorative options for the management of cracked tooth syndrome. Br Dent J. 2010 Jun;208(11):503-14.
21. Opdam NJ, Roeters JJ, Loomans BA, Bronkhorst EM. Seven-year clinical evaluation of painful cracked teeth restored with a direct composite restoration. J Endod. 2008 Jul;34(7):808-11.
22. van Dijken JW. Direct resin composite inlays/onlays: an 11 year follow-up. J Dent. 2000 Jul;28(5):299-306.

Case by CDT Daniele Rondoni

When planning to replace Class II restorations, many things need to be considered. In order to select the most appropriate restorative technique and preparation design, it is essential to evaluate the amount and state of the remaining tooth structure, first. After repeated restoration replacement or in teeth originally restored with amalgam, for example, the remaining walls and cusps are often weakened and prone to fractures and cracks. When the cavity walls appear to be too thin or the structure is weak at the time of restoration replacement, it may be better to remove walls and cusps and opt for indirect adhesive restorations (overlays) instead of direct composite restorations. Due to favourable material properties – in particular a high flexural and compressive strength while being gentle to the opposing dentition and not too rigid for the surrounding tooth structures – we often opt adhesive restorations made of KATANA™ AVENCIA™ Block in those situations.

The following clinical case is used to describe the replacement of two composite restorations with overlays made of the innovative hybrid ceramic material.

Fig. 1. Initial clinical situation with composite restorations on the second premolar and first molar in need of replacement. The tooth structure particularly of the first molar was weak, with the distobuccal cusp already fractured.

Fig. 2. Prepared tooth structure ...

Fig. 3. Restorations milled from a KATANA™ AVENCIA™ Block after high-gloss polishing and characterization.

Fig. 4. Finalized restorations on a resin model.

Fig. 5. Adhesively cemented restorations in the patient’s mouth.

FINAL SITUATION

Fig. 6. Treatment outcome with a nice transition from the tooth structure to the restoration.

Dentist:

DANIELE RONDONI, MDT

Born in Savona in 1961 where he lives and has worked in his own laboratory since 1982 with his collaborators. Graduated from the dental technician school IPSIA “P. Gaslini” in Genoa in 1979. He continued his education by attending relevant workshops for the “Italian dental school“ and broadened his professional experience in Switzerland, Germany and Japan. Since 2011 Kuraray Noritake Dental International Instructor.

Case by Dr. Jusuf Lukarcanin

Restoring posterior cavities is a standard task we perform virtually every day. Yet, it is a challenging procedure as access to the affected teeth is often limited. This fact complicates many steps from working field isolation to material application and sculpting. By streamlining procedures and establishing protocols that are followed every time, it is possible to achieve predictable outcomes even in difficult situations, as shown below.

Fig. 1. Class II cavity in a second molar after caries removal and cavity preparation.

Fig. 2. Working field isolation.

Fig. 3. Application of adhesive (e.g. CLEARFIL S³ BOND PLUS) into the cavity.

Fig. 4. Build-up of the proximal wall with CLEARFIL MAJESTY™ ES-2 Classic (Kuraray Noritake Dental Inc.) in the shade A2.

Fig. 5. Build-up of the dentin core using the incremental technique with CLEARFIL MAJESTY™ ES-2 Premium in the shade A2D.

Fig. 6. Contouring of the occlusal enamel layer made of CLEARFIL MAJESTY™ ES-2 Premium in the shade A2E.

Fig. 7. Polishing of the restoration with Twist DIA for Composite.

FINAL SITUATION

Fig. 8. Treatment outcome.

Dentist:

DR. JUSUF LUKARCANIN

Dr. Jusuf Lukarcanin is a Certified Dental Technician (DCT) and a Doctor of Dental Science (DDS). He studied dentistry at the Ege University Dental Faculty in Izmir, Turkey, where he obtained a Master‘s degree in 2011. In 2017, he received a Ph.D. degree from the Department of Restorative Dentistry of the same university. Between 2012 and 2019, Dr. Lukarcanin was the head doctor and general manager at a private clinic in Izmir. Between 2019 and 2020, he worked at Tinaztepe GALEN Hospital as a Restorative Dentistry specialist, between 2020-2022 he worked at MEDICANA International Hospital Izmir as a Restorative Dentistry specialist. Currently he is an owner of a private clinic for aesthetics and cosmetics in Izmir.

Compact, time-saving and aesthetic

How many different shades of composite do you need to create appealing restorations in virtually every clinical situation? If you opt for “CLEARFIL MAJESTY™ ES-2” Universal shade concept, a few shades will do the trick.

With wonderful support of our internationally recognized key opinion leaders, we have prepared a Clinical Case brochure of “CLEARFIL MAJESTY™ ES-2” Universal for you. The brochure highlights a variety of clinical cases in the anterior and posterior region to show the all about excellent properties of our latest composite. Let the pictures speak for themselves!

Click here to view. Enjoy!

Start Reading: Special MAJESTY ES-2 Universal - Clinical Cases Brochure

Case by Dr. Nicola Scotti

When restoring posterior teeth with resin composite, functional aspects such as tight and anatomically correct proximal contacts and a naturally shaped occlusal surface that is wear-resistant and antagonist-friendly are even more important than a perfect optical integration. This is why every dental practitioner should avoid spending a lot of time on shade selection in these cases and focus on the factors that have an impact on the reliability and longevity of the restoration. Great support in accomplishing this task is offered by CLEARFIL MAJESTY™ ES-2 Universal, a resin composite with a single universal shade (U) for the posterior region that eliminates the need for shade taking and selection. At the same time, it offers good marginal adaptation, low shrinkage stress and high wear resistance needed for great long-term results.

Fig. 1. Initial situation with a wide primary carious lesion in the distal aspect of the second premolar.

Fig. 2. Premolar after isolation of the working field with rubber dam, caries excavation and cavity preparation.

Fig. 3. Placement of a sectional matrix and a wedge to optimize the fit. Both are held in place with a separation ring, which increases the interproximal space and hence ensures tight, anatomically correct proximal contacts.

Fig. 4. Build-up of the proximal wall with CLEARFIL MAJESTY™ ES-2 Universal (U shade) following selective enamel etching with phosphoric acid (K-ETCHANT Syringe) and bonding with CLEARFIL™ SE Bond.

Fig. 5. A thin layer of flowable composite (CLEARFIL MAJESTY™ ES FLOW High) applied to the cavity floor to act as a resin coat.

Fig. 6. Restoration completed with CLEARFIL MAJESTY™ ES-2 Universal (U shade). While the universal shade composite blends in very well with the surrounding tooth structure, the natural look is completed by adding a tiny bit of brown tint to the fissure.

Fig. 7. Treatment outcome immediately after rubber dam removal. The proximal contact is tight and the occlusal anatomy well-shaped for the patient’s individual masticatory dynamics. The margin of the restoration is virtually invisible, while the buccal cusp appears lighter due to dehydration of the natural tooth structure.

FINAL SITUATION

Fig. 8. Treatment outcome after two months.

Conclusion

The present case demonstrates that the selected composite is well-suited for simplified restoration procedures in the posterior region. The material handles well, offers the same mechanical properties as other materials from the CLEARFIL MAJESTY™ ES-2 series and blends in harmoniously with the surrounding structures without being too translucent. This way, it is possible to waive the shade-taking process without compromising the treatment outcome. The time saved in this context may be spent on functional aspects – or even on another patient.

Dentist:

DR. NICOLA SCOTTI

Case by Dr. Kristine Aadland.

Fig. 1. Preparation.

The patient’s old PFM bridge (shown here) was removed, and the existing preps for teeth #6 and #8 were modified with a medium chamfer with smooth and rounded edges to accommodate a 3-unit KATANA™ Zirconia bridge. There was no abutment for tooth #7, as that space serves as the pontic. Tooth #9 was similarly prepared to receive a single-unit KATANA™ crown.

Fig. 2. Define Restorations.

To begin, each restoration type is defined in the CEREC software, as the design mode (Biogeneric Individual), material type (KATANA™ Zirconia Block), and milling device (CEREC MC XL).

Fig. 3. Digital Impression.

A digital impression of the upper arch was performed using CEREC Primescan.

Fig. 4. Restoration Design.

The patient did not like the size of her centrals and wanted them smaller. She also didn’t like that her smile was slanted/canted. While designing, it really helps to use the patient’s old smile as a reference. This is why I used Bioindividual when designing the restorations, and added a BioCopy folder in the acquisition screen. I can ghost over the previous smile and readily see where I am.

Fig. 5. Restoration Design: Occlusal.

The BioCopy design function is also utilized to ensure a correct occlusal profile.

Fig. 6. Milling.

A KATANA™ Zirconia Block for bridge (14Z L) was used for the 3-unit bridge, and a KATANA™ Zirconia 12Z single-unit block was used for the single crown. The bridge block mills out in about 18 minutes, which is the fastest-milled chairside bridge block currently available.

Fig. 7. Characterization & Sintering.

Kuraray Noritake CERABIEN™ ZR FC Paste Stain and Glaze Kit was used for characterizing. The colors are very natural and it is not simply a metal oxide like other stains, but actually adding porcelain, giving the restorations more vitality. The oven cycle is quick at approximately 10 minutes, which means multiple fires are easy to do without excess time.

Fig. 8. Seating & Final Smile.

PANAVIA™ SA Cement Universal and CLEARFIL™ Universal Bond Quick were used for cementation and bonding. I love the ease of use and clean-up with PANAVIA™ SA Cement Universal, and its MDP monomer creates a strong chemical bond to the tooth structure and zirconia. CLEARFIL™ Universal Bond Quick has a quick technique without reducing bond strengths, releases fluoride and has a low film thickness. I simply rub CLEARFIL™ Universal Bond Quick into the tooth for a few seconds and air dry. There is no need to light-cure, since it cures very well with PANAVIA™ SA Cement Universal. The patient was very happy with the results. She loved that she no longer saw metal margins, and her smile was much more uniform and lifelike.

DR. KRISTINE AADLAND