LabLine magazine is an English language publication catering to the field of lab-side dentistry. It provides comprehensive coverage of the latest techniques and trends in dental laboratory technology and materials, showcasing them via sophisticated, challenging and aesthetic clinical cases done by some of the most known experts in Europe. With its expertly curated content, LabLine serves as an invaluable resource for dental professionals seeking to enhance their knowledge and stay at the forefront of the industry.

In the SPRING edition of LabLine you can find a wonderful AESTHETIC CASE by Mikel Villar Gonzales and DT Pilar Ballesteros Galan. The patient, a 21-year-old female had a hypoplasia defect on her permanent teeth, 1.1 and 1.2., presumably due to trauma on her deciduous anterior teeth. Click the image below and check out how the case was done!

Case by Michal Jaczewski

This patient came to the clinic to improve the aesthetics of her smile. After an aesthetic and functional analysis, it was decided to align and restore the teeth using a minimally invasive protocol with flowable composite.

INITIAL SITUATION

Fig. 1. The patient had worn teeth, visible abrasion, erosion and crowding in the lower arch.

Fig. 2. Situation after orthodontic treatment, full arch ready to restore.

Fig. 3. A silicon mould is used for the Flowable Injection Technique to restore the teeth with flowable composite. The silicone injection mould had injection channels prepared and was placed to check for proper fit.

Fig. 4. For this case it was decided to use CLEARFIL MAJESTY™ ES Flow Low in shade XW.

Fig. 5. Teflon tape was used, in order to separate the teeth.

Fig. 6. The restoration is completely additive; the teeth are not prepared at all. Total etching of the enamel is the best pre-treatment in this situation. K-Etchant Syringe (35% phosphoric acid) was applied for 10 seconds.

Fig. 7. A surgical suction tip was used in order to carefully remove the phosphoric acid gel and protect the isolations on the teeth. Followed by rinsing off completely with water in the usual manner.

Fig. 8. Each tooth was gently air dried for 10 seconds. CLEARFIL™ Universal Bond Quick was applied with a rubbing motion without additional waiting time. Followed by drying of the entire bonding treated surfaces by blowing mild air for more than 5 seconds until the bonding no longer moves.

Fig. 9. Light curing of each bonded tooth for 10 sec.

Fig. 10. The silicon mould is used to inject CLEARFIL MAJESTY™ ES Flow Low (optimal flowability, and properties for a case like this).

Fig. 11. Using the protocol „Treat one, skip one” several teeth are restored simultaneously.

Fig. 12. Situation directly after first round of injections.

Fig. 13. Situation after restoring all teeth, before polishing.

Fig. 14. To create a natural gloss the following polishing protocol was used: 1.) Sof-Lex™* discs, 2.) CLEARFIL™ Twist DIA for Composite polishing wheels, 3.) diamond paste and finally zinc oxide paste.

*Not a brand name of Kuraray Noritake Dental.

Fig. 15. High-shine results after polishing.

FINAL SITUATION

Fig. 16. Final restoration, immediately after treatment.

Fig. 17. Final restoration after 2 days.

Dentist:

MICHAL JACZEWSKI

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

Case by Kokla Thalia, Postgraduate student in Restorative Dentistry program, Faculty of Dentistry, National and Kapodistrian University of Athens, Greece

Restoring Class II cavities can be challenging due to limited access to the posterior area, where the interproximal contact needs to re-established in a proper way. Inadequate contacts tend to result in increased plaque accumulation, food impaction and, as a consequence, the development of caries and irritation of the interproximal gingiva. Therefore, it is essential that the interproximal contact is restored based on the model of nature. A suitable matrix system and a proper clinical protocol can help us succeed in this context. The following clinical case is used to illustrate a possible strategy.

Fig. 1. Initial clinical situation. 23-year-old female patient with caries on the mandibular left second premolar.

Fig. 2. Situation after cavity preparation, isolation of the working field with rubber dam and the placement of a sectional matrix fixed with a ring. It is essential that the matrix imitates the natural shape of the contact area, which is usually rather flat or concave cervically and convex in the middle and occlusal parts.

Fig. 3. Etching of the tooth structure with phosphoric acid etchant. Afterwards, the adhesive needs to be applied (in this case, Universal Bond Quick was used according to the manufacturer’s instructions).

Fig. 4. CLEARFIL MAJESTY™ ES-2 Premium in the shade A3E is applied in the distal box to build up the wall first. In this way, the available space is used to model the most critical part of the restoration before simply filling the cavity in increments with the dentin shade A3D.

FINAL SITUATION

Fig. 5. Final restoration after finishing and polishing. In accordance with the concept behind CLEARFIL MAJESTY™ ES-2 Premium with its pre-defined shade combinations, the final enamel layer was build-up using the shade A3E. However, the use of a single opacity is also possible in the posterior region depending on the aesthetic demands.

CONCLUSION

By elevating deep interproximal margins, it is possible to focus on the critical designing of the contact point when there is still sufficient space available to do so. This simplifies the procedure, while all that is left to do can be managed in a straightforward way like a Class I restoration.

HOW MANY SHADES DO WE NEED?

Case by Gasparatos Spyros, Postgraduate student in Restorative Dentistry program, Faculty of Dentistry, National and Kapodistrian University of Athens, Greece

Restoring anterior teeth with large defects using composite seems to be quite challenging. With high-performance materials at hand and a systematic layering concept in mind, however, it is possible to produce highly aesthetic results in a reproducible way. The clinical case below is used to illustrate a dual-shade layering technique with CLEARFIL MAJESTY™ ES-2 Premium, a composite system with pre-defined colour combinations.

CASE EXAMPLE

The patient, a young male, was unhappy with the appearance of his maxillary anterior teeth. Several years ago, his central incisors had been restored with composite. These existing restorations had defective and heavily discoloured margins, while their shade did not match the adjacent natural tooth structure. The maxillary lateral incisors were peg-shaped (microdontia). Economic considerations and the desire to save as much natural tooth structure as possible made the team decide to restore all four maxillary incisors with composite. CLEARFIL MAJESTY™ ES-2 Premium became the material of choice as it eliminates the need for complicated shade combination formulas and supports predictable outcomes.

Fig. 1. The patient’s initial smile.

Fig. 2. Intraoral image of the initial situation with defective composite restorations and microdonts. Two composite buttons on the right lateral incisor are used to verify the determined shade combination.

RESTORING THE CENTRAL INCISORS

We decided to restore the central incisors first and then focus on the lateral incisors. The tooth shade was determined using the VITA™ classical A1-D4 shade guide, while composite buttons were applied to the teeth to verify the determined shade combination. In order to simplify the restoration procedure, a palatal silicon index was produced before removing the existing restorations. During minimally invasive tooth preparation, bevels were created at the margins to provide for a smooth optical transition from the natural tooth structure to the composite.

An adhesive (CLEARFIL™ Universal Bond Quick) was applied after selective etching of the enamel to achieve a strong bond. With the aid of the silicon index, it was easy to create the palatal shells of the restorations with CLEARFIL MAJESTY™ ES-2 Premium in the shade A3E (enamel), which matches the determined tooth shade A3. The dentin core was built up with the same composite in the recommended shade A3D (dentin), mamelons were modelled and some CLEARFIL MAJESTY™ ES-2 Premium in the shade WD added for the incisal halo, while some individual effects (like enamel cracks) were imitated with brown stain. The build-up was finalized in the interproximal and labial areas with composite in the shade A3E. Between the central incisors, a wedge was used to retract the papilla and facilitate the designing of the interproximal contact area. The finished and pre-polished restorations already had a natural appearance.

Fig. 3. Central incisors after removal of the old restorations and the beveling of the enamel.

Fig. 4. Light-cured palatal shells made of CLEARFIL MAJESTY™ ES-2 Premium in the shade A3E.

Fig. 5. Build-up of the dentin core with mamelons individualized with the shade WD and brown stain.

Fig. 6. Situation after finalization of the central incisor restorations with composite in the enamel opacity.

Fig. 7. Central incisor restorations after finishing and initial polishing.

RESTORING THE LATERAL INCISORS

Tooth preparation was not required on the lateral incisors. Instead, they were merely cleaned after a slight roughening of the enamel surfaces. The build-up procedure was similar to the one used for the central incisors. The adjacent tooth was protected with PTFE tape, and the palatal shell was created with the aid of a finger instead of a silicone index. Afterwards, we focused on the build-up of the interproximal walls before a small amount of dentin was placed and the shape was finalized by applying the labial enamel layer.

Fig. 8. Build-up of the left lateral incisor.

Fig. 9. Situation after finishing and polishing.

FINAL SITUATION

Fig. 10. Final smile of the patient's demands.

CONCLUSION

Two different opacities, a single shade combination and some bleached shade plus stain for special effects – in the present patient case, a simple formula allowed us to create lifelike anterior restorations. With one enamel and one dentin paste used, it is possible to simply rebuild the natural anatomy without the risk of ending up with a bulky core that – once reduced – will lose its special optical structure. It is also easy to control the thickness of the final enamel layer with its huge impact on the light-optical properties of the whole restoration. For most patients and teeth with a simple or medium-to-complex internal colour structure, the selected concept is very well suited and will lead to pleasing outcomes.

Denne pasienten kom til klinikken for å få et penere smil. Etter en estetisk og funksjonell analyse, ble det besluttet å
rette opp og restaurere tennene ved hjelp av en minimal invasiv protokoll med flow-kompositt.

Case by 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.

Case by Dr. Yohei Sato, DMD, PhD, Department of Removable Prosthodontics, Tsurumi University School of Dental Medicine, JAPAN and Dr. Keisuke Ihara, CDT, i- Dental Lab, JAPAN.

Fig. 1. The patient visited us with a chief complaint of a desire for improved esthetics of the maxillary right and left lateral incisors.

Fig. 2. A core fabricated from a diagnostic wax model was applied and the necessary clearances were determined.

Fig. 3. Since the teeth are microdonts, the preparation of each abutment was completed by simply exposing a fresh surface to be covered by the laminate veneers.

Fig. 4. A layer of porcelain was applied on the lithium disilicate glass substrate, to make a complete laminate veneer.

Fig. 5. After a trial fitting, the inner surface of the laminate veneer was cleaned with KATANA™ Cleaner. The inner surface was conditioned according to the prosthesis‘ IFU.

Fig. 6. Milling. CLEARFIL™ CERAMIC PRIMER PLUS was applied and dried to silane couple the restoration.

Fig. 7. After a trial fitting, KATANA™ Cleaner was applied to the abutment, and rubbed for more than 10 seconds. Then, it was washed off sufficiently (until the cleaner color had completely disappeared), and dried with compressed air.

Fig. 8. K-ETCHANT Syringe was applied and left for 10 seconds before water-washing and compressed air-drying.

Fig. 9. PANAVIA™ V5 Tooth Primer was applied and left for 20 seconds before compressed-air drying.

Fig. 10. PANAVIA™ Veneer LC Paste was applied to the inner surface of the laminate veneer.

Fig. 11. The laminate veneer was seated and the fit checked. Then, the excess cement was tack-cured (not more than 1 second at any one point) and removed. Finally, the restoration was light-cured and finished.

FINAL SITUATION

Fig. 12. This photo shows the laminate veneer restorations one month after placement. The morphology and color of the right and left lateral incisors have been improved, providing a good balance to the entire anterior dentition.

Case by Richard Young DDS, San Bernardino, CA

Easy procedure, reliable outcome: that is what most dental practitioners may wish for when placing indirect restorations. The following clinical case example is used to demonstrate an easy, but highly successful clinical protocol for the luting of a lithium disilicate crown.

Fig. 1. Lithium disilicate crown after etching of the intaglio surface with hydrofluoric acid and try-in.

Fig. 2a. Application of KATANA™ Cleaner into the crown for a complete removal of contaminants such as proteins from blood and saliva, which may compromise the performance of any resin cement system.

OR Fig. 2b. Alternatively, KATANA™ Cleaner is applied into a mixing well.

Fig. 3. Application of KATANA™ Cleaner to the restoration.

Fig. 4. KATANA™ Cleaner is applied to the prepared tooth structure in the same way (rubbing for ten seconds followed by rinsing and drying).

Fig. 5. Application of PANAVIA™ SA Cement Universal into the cleaned crown.

Fig. 6. The cement contains a unique silane coupling agent – the LCSi monomer - for a strong and reliable bond to lithium disilicate and other restorative materials like glass ceramics and hybrid ceramics.

   The Silane is activated in the mixing tip by Original MDP.

Fig. 7. Easy clean-up after two to five seconds of tack-curing.

Fig. 8. The excess resin cement is in its gel-state and removed in one piece with an explorer.

FINAL SITUATION

Fig. 9. Treatment outcome immediately after crown placement.

Dentist:

RICHARD YOUNG DDS

Case and images courtesy of Richard Young DDS, San Bernardino, CA

USING THE NEXT-GENERATION SELF-ADHESIVE CEMENTS

by Dr. Tomohiro Takagaki.

INTRODUCTION

In recent years, the use of CAD/CAM systems for the production of indirect restorations has become increasingly popular. The shortage of young, qualified staff in the field of dental technology in Japan¹) is likely to contribute to a further increase of automated production techniques such as CAD/CAM, which require fewer manual production steps compared to traditional manufacturing techniques. Also globally, the number of restorations fabricated using CAD/CAM systems is rapidly increasing. This leads to an even more widespread use of innovative, tooth-coloured restorative materials such as zirconia, silicate ceramics and resins.

Demand for placing restorations using the principle of adhesion by resin cements is more and more increasing in daily clinical settings. However, it is difficult and complicated to condition the tooth and restoration surfaces using many primers correctly. In addition, the combination of many different components is time-consuming, complex and cost-intensive. Self-adhesive resin cements, which do not require conditioning the surface of teeth or some restorations with primers, have been released recently, and have become popular among dental practitioners. However, there are many reports²) on the dislodgement of resin-based CAD/CAM restorations and full-zirconia crowns that have been placed using self-adhesive cements. Hence, demand is high for a resin cement system that is both simple to use and reliable in performance.

In this document, I explain the fundamental technology of resin cement systems and their range of applications. In addition, I will introduce the method of using a next-generation self-adhesive cement, PANAVIA™ SA Cement Universal (Kuraray Noritake Dental Inc., Fig. 1), as an example.

Case by Dr. David Garcia Baeza and DT. Pilar Ballesteros Galan

Shade determination in the planning phase, shade evaluation at try-in: How is it possible to accomplish these highly important tasks in the production of lifelike anterior restorations without meeting the patient in person? A computer-based shade documentation and try-in system is a great solution. Download this clinical case example describing the aesthetic restoration of two maxillary anterior teeth to learn more about one such system and its use!