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APPLICATION AND DISPENSING
Easy dispensing and high application control are achieved thanks to the specially designed syringe and application tip.
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:
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 coverage8,11.
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 formation12-14. 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.
The vacation period is over and we all are slowly returning back to our everyday routines and work. With all the travel and holidays in the last months you might have missed this great article in the LabLine Summer edition: Graftless solutions and implant-supported monolithic zirconia fixed prostheses.
It is an extensive, beautiful and detailed case report created and documented by team of well known and respected KOLs: Fortunato Alfonsi, Antonio Barone, Marco Stoppaccioli, Romeggio Stefano and Vincenzo Marchio.
Check it out by clicking here.
LAMINATE VENEER RESTORATION
USING LITHIUM DISILICATE
WITH PANAVIA™ Veneer LC (Clear)
Case by Yohei Sato (DMD, PhD) and Keisuke Ihara (CDT)
Fig. 1 The patient visited would like to have the a aesthetics
of the maxillary right and left lateral incisors improved.
Fig. 2 A silicon guide fabricated from a diagnostic wax model
was applied and the necessary clearances were determined.
Fig. 3 Since the lateral teeth are microdonts, the
preparation of each abutment was completed by simply
exposing a fresh enamel surface to be covered with
laminate veneers.
Fig. 4 A layer of porcelain was applied on the lithium
disilicate substrate, to complete the laminate veneers.
Fig. 5 The veneer was conditioned according to the
prosthesis‘ IFU. After trial fitting, the intaglio surface of the
laminate veneer was cleaned with KATANA™ Cleaner.
Fig. 6 CLEARFIL™ CERAMIC PRIMER PLUS was applied and
dried to prime the restoration.
Fig. 7 The preparation was cleaned with KATANA™ Cleaner.
Applied 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-rinsing and compressed air-drying.
Fig. 9 PANAVIA™ V5 Tooth Primer was applied and left for 20
seconds before mild compressed-air drying.
Fig. 10 PANAVIA™ Veneer LC Paste was applied to the
intaglio 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 each point) and removed. Finally,
the restoration was light-cured and finished.
FINAL SITUATION
Fig. 12 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.
LAMINATE VENEER RESTORATION
USING KATANA™ Zirconia STML
WITH PANAVIA™ Veneer LC (Clear)
Case by Yohei Sato (DMD, PhD) and Keisuke Ihara (CDT)
Fig. 1 The patient was referred by an orthodontist. The main
complaints were improper aesthetics of the teeth due to dark
triangles betwen the teeth and incisal wear.
Fig. 2 On the basis of the pre-treatment diagnosis using
a mockup, the teeth were prepared, with keeping in mind
that the enamel should be preserved to the maximal extent
possible.
Fig. 3 A fixation retainer was present at the palatal side,
making it difficult to take coventional silicon impressions.
Therefore, an intraoral scanner was used.
Fig. 4 A layer of porcelain was applied to each KATANA™
Zirconia STML laminate veneer to complete the restorations.
The inner surface of each restoration was sandblasted, being
careful to prevent chipping.
Fig. 5 After trial fitting, bonding inhibiting substances as
blood and saliva were removed using KATANA™ Cleaner.
Fig. 6 CLEARFIL™ CERAMIC PRIMER PLUS was applied and
dried using compressed air.
Fig. 7 The surface of each tooth was cleaned and treated
with K-ETCHANT Syringe for 10 seconds before washing it
away with water and drying with compressed air.
Fig. 8 PANAVIA™ V5 Tooth Primer was applied and left f
Fig. 9 PANAVIA™ Veneer LC Paste was applied and the
laminate veneers were seated. For this case, we placed six
veneers during one session.
Fig. 10 The unpolymerized excess paste was removed with
a brush according to the wet clean-up technique.
Fig. 11 The result after final light curing. Since the excess
cement was easily removed, there were almost no cement
residues.
FINAL SITUATION
Fig. 12 Result one month after placement of the laminate
veneer restorations. The marginal gingiva has been improved
thanks to the good fit of the laminate veneer restorations.
Prosthodontic treatment concepts have evolved over the past decades. While some time ago, porcelain-fused-to-metal crowns and bridges were placed wherever a defect was too large for a direct restoration, the current trend is toward less invasive therapies with highly aesthetic, tooth-coloured materials.
These modern treatment concepts can lead to reliable outcomes when a high-performance resin cement system is used that establishes a durably strong bond to tooth structure on one side and the restoration on the other. The reason is that less invasive often means that restorations have minimal or no retentive elements and extremely thin walls, and a strong chemical bond is a mechanism that holds them in place over time. Depending on the type of restoration and area in the mouth, aesthetic properties of the cementation system are also extremely important, as the typically highly translucent, thin restorations tend to reveal the appearance of the structures underneath to a certain extent.
Universal cements
In the context of striving toward the streamlining of clinical procedures in restorative dentistry, several manufacturers have developed resins cements that work with fewer components and are suitable for a large number of indications. PANAVIA™ SA Cement Universal is a popular example. The self-adhesive, dual-cure resin cement is the only product of its category that works as a standalone solution even on glass ceramics (without the need for a separate primer).
The need for specialists
There are specific clinical situations, however, that require more working time than a dual-cure resin cement can offer. This is the case whenever multiple non-retentive restorations are to be placed simultaneously, a technique that is recommended for veneers. The greatest benefits of placing the thin and highly aesthetic restorations at once lie in the proper positioning of the restorations and in the minimized risk of contamination: When the veneers are placed one after the other, a slightly malpositioned and already fixed veneer might hinder proper positioning of the adjacent restorations and haemorrhage occurring in the context of excess cement removal or finishing of the margin might contaminate the working field. When all veneers are placed simultaneously, repositioning is possible, while excess removal and polishing are accomplished in a moment when blood and debris will no longer endanger the integrity of the restorations, which increases the security during the whole procedure. This task is best fulfilled by a light-curing veneer specialist.
Handling of a thin ceramic veneer.
Required properties of veneers cements
Undoubtedly, the key feature of a specialist resin cement system is a long working time sufficient for simultaneous cementation of multiple restorations. In addition, its consistency and handling properties are also important as they can help users overcome the challenge of accurate positioning and reduce the time and effort involved in veneer placement. And finally, the system needs to provide excellent bond strength over time and support long-lasting aesthetics, properties valuable for every kind of resin cement, but the latter being particularly important for thin restorations in the aesthetic zone. Luckily, PANAVIA™ Veneer LC offers all those features.
The system consists of PANAVIA™ V5 Tooth Primer that establishes a strong bond to enamel and dentin, PANAVIA™ Veneer LC Paste as the cement and the CLEARFIL™ CERAMIC PRIMER PLUS that has been part of PANAVIA™ V5 cementation system. The latter is responsible for a high bond strength to all types of restorative materials.
Mastering the working time challenge
The light-curing cement paste offers a long working time of 200 seconds* due to its excellent stability under ambient light. As a consequence, dental practitioners may place multiple veneers simultaneously without having to race against setting. Polymerization may be started whenever the user is ready for it. The one-component self-etching tooth primer (PANAVIA™ V5 Tooth Primer) does not contain any photo initiators and does not cure alone. When applied, it etches and penetrates into the tooth surface for 20 seconds and is ready to bond strongly to PANAVIA™ Veneer LC Paste. The integrated touch-cure technology is the key feature safeguarding a high bond strength to tooth structure without shortening the working time.
*Working time under ambient light on PANAVIA™ V5 Tooth Primer (8000 Lux): 200 seconds
Providing for precise placement
In order to streamline the clinical seating procedure from cement application to polishing, PANAVIA™ Veneer LC has been equipped with a set of well-balanced handling properties. Newly developed spherical silica fillers in the cement provide that it stays put where applied, but flows well when the veneer is seated on the tooth – for easy placement without drifting or sagging. During application across the intaglio surface, the resin cement does not stick to the application tip, a property achieved by the addition of nanocluster filler technology. The special design of the syringe’s application tip optimizes control over the amount of cement applied. Ans last but not least, excess cement may be easily removed in one piece using an explorer after a one-second tack-cure, while polishing of the margins is quickly accomplished.
Hiding the margins
Being extremely thin, highly translucent and mainly used to restore teeth in the exposed anterior region of the maxilla, veneers have to be placed with a cement that is and remains undetectable underneath the restoration and at its margins. PANAVIA™ Veneer LC is available in four highly aesthetic shades with matching try-in pastes, so that a precise shade match with the restoration can be achieved and verified in the patient’s mouth. Additional features contributing to undetectable margins are the resin cement’s flowability and low film thickness: They enable users to easily produce an evenly distributed, thin cement layer for aesthetic outcomes. For those afraid that coffee, tea, acidic drinks or constant tooth brushing might reveal the margins over time, there is good news as well: PANAVIA™ Veneer LC offers a high polish retention and colour stability over time. The well-balanced formulation and the touch-cure technology are responsible for this resistance to discolouration.
Trusted expertise
All these beneficial features make PANAVIA™ Veneer LC worth testing. Additional arguments are the fact that its primers are tried and tested components of the highly popular PANAVIA™ V5 system and that Kuraray Noritake Dental Inc. is a proven expert on adhesive products. It developed the original MDP Monomer in 1981 and introduced the first adhesive resin cement containing this monomer in 1983. Since then, the company has improved existing formulations and developed existing technologies that ultimately resulted in the current line-up of cementation solutions for every need and indication.
Excellent gloss retention is one of the properties providing for undetectable margins over time.
Kuraray Noritake Dental’s reputation as a pioneer in the field of dental adhesives is grounded in its development of the MDP monomer. Patented in 1981, the monomer was used two years later in the composite cement PANAVIA™ EX and has since formed the backbone of many other successful products. Now, the company has combined the original MDP monomer with hydrophilic amide monomers to create rapid bond technology that powers CLEARFIL™ Universal Bond Quick - a universal solution emblematic of Kuraray Noritake Dental’s history of success and commitment to innovation.
Advances in modern dental bonding technology have resulted in a reduction in the number of components needed for total-etching and self-etching processes. However, the basic handling of these adhesives has, by and large, changed surprisingly little. Many adhesives require a shaking of the bottle before usage, extensive rubbing of the liquid and/or waiting for a period of time. Often the application of multiple layers is needed. A reliance on slow penetrating monomers means that, for traditional one-bottle adhesives, bonding to the challenging dentine substrate is a slow and technique-sensitive process.
Through the integration of newly developed amide monomers, rapid bond technology provides CLEARFIL™ Universal Bond Quick with excellent hydrophilic properties and the ability to penetrate the wet dentine fast and effectively. There is no need to wait after the application for air-drying before proceeding - this delay has been eliminated - and a tight and long-lasting seal of the cavity is established after light-curing. Bonding with CLEARFIL™ Universal Bond Quick is easy and efficient and comes with predictable clinical outcomes, thanks to rapid bond technology.
Impressively low water sorption
One of the most important indicators of long-term success in dentine bonding is the level of water sorption in the bond’s organic matrix. A high rate of water sorption has been clinically linked to the ongoing physical deterioration of bonds, which may lead to the development of secondary caries. For this reason, we have chosen to keep the HEMA content as low as possible.
CLEARFIL™ Universal Bond Quick creates a highly cross-linked polymer network owing to the amide monomers used in rapid bond technology. As a result, it demonstrates a relatively low rate of water sorption, meaning that these cross-linked polymers are more stable in the long term.
Aesthetic, effective bonds
Rapid bond technology does not just provide a basis for long-lasting bonding excellence. The thin film layer (5–10 μm) of CLEARFIL™ Universal Bond Quick delivers restorations a clear aesthetic appeal, and its densely cross-linked polymer network reinforces the stability of this outer layer and provides resistance to marginal discoloration.
By combining Kuraray Noritake Dental’s original MDP monomer with hydrophilic amide monomers, rapid bond technology is truly the engine that powers CLEARFIL™ Universal Bond Quick.
By Franklin Tay, BDSc (Hons), PhD
STATE-OF-THE-ART CURRENT ADHESIVES
Manufacturers have adopted an etch-and-rinse approach or a self-etch approach in the design of adhesives for bonding restorative materials to tooth structures, which differ in how these adhesives interact with dental hard tissues. Etch-and-rinse adhesives are offered as two- or three-step systems, depending on whether primer and bonding are separate or combined in a single bottle. Likewise, self-etch adhesives are available as one- or two-step systems. Etch-and-rinse adhesives are often preferred when large areas of enamel are still present, while self-etch adhesives provide more predictable bonds to dentin.
Despite current trends toward fewer and simpler application steps, one-step adhesive systems appear to be less predictable than multi-step etch-and-rinse and self-etch systems. Some manufacturers have recently introduced more versatile single-bottle “universal” or “multi-mode” adhesives that encompass self-etch chemistry but also enable the same adhesive to be used with phosphoric acid-etching in the etch-and-rinse mode. Some universal adhesives also incorporate silane primer for chemical bonding to silica-based ceramics, and methacryloyloxydecyl dihydrogen phosphate (MDP) for chemical bonding to zirconia-based ceramics. Because clinical studies on universal adhesives are short-term, they cannot be considered state-of-the-art in the context of evidence-based dentistry. Conversely, two-step mild, self- etch adhesives have been well-tested in clinical trials and represent the current state-of-the-art for bonding to dentin, with reduced incidence of postoperative sensitivity when compared to etch-and rinse adhesives.
DEVELOPMENT OF CONTEMPORARY ADHESIVES FROM A RESEARCHER’S PERSPECTIVE
The current thinking by researchers is that dentin bonding is not as durable as it was originally perceived. This lack of durability is attributed partially to secondary caries around restorative margins that are devoid of enamel and partially to the degradation of the adhesive joint. The latter may be caused by the hydrolysis of ester bonds in the adhesive component by salivary esterases, or by degradation of water-rich, resin-sparse regions of the hybrid layers by endogenous collagen-bound proteases such as matrix metalloproteinases (MMP) and cathepsin K, that are activated from their dormant preforms to active forms by the acidity of contemporary adhesives. These activated enzymes slowly degrade the denuded collagen matrix within hybrid layers, resulting in gradual loss of adhesion.
Much work has been done in developing therapeutic dental adhesives that are able to resist secondary caries and degradation of the adhesive joint. One of the most thoroughly studied antimicrobial resin monomers is the quaternary ammonium methacrylate developed by Kuraray known as methacryloyloxydodec ylpyridinium bromide (MDPB). This polymerizable resin monomer is incorporated in the two-step self-etch adhesive CLEARFIL™ SE Protect. Recent research has demonstrated that MDPB resin is also an effective inhibitor of both MMP and cysteine cathepsins, thereby providing a mechanism to increase the longevity of resin–dentin bonds by preventing collagen degradation. Indeed, an in-vitro and in-vivo study (Donmez, et al. J Dent Res. 2005;84:355-359) showed that resin-dentin bonds created with CLEARFIL™ SE Protect (aka, CLEARFIL™ Protect Bond) did not degrade after 1 year when compared with a similar self-etch adhesive that did not incorporate the MDPB resin monomer.
MOST COMMON CLINICAL APPLICATIONS OF CLEARFIL™ SE PROTECT
As a board-certified endodontist, the author uses CLEARFIL™ SE Protect as an antimicrobial adhesive to establish coronal seal after finishing root canal treatment to prevent reinfection of the peri-radicular tissues via coronal leakage through the filled root canals (Figure 1 and Figure 2). Another common use of CLEARFIL™ SE Protect is the restoration of the access cavity prepared through a zirconia-based full-coverage restoration. By taking advantage of the MDP component, the author feels more confident that he can bond to the zirconia with a resin composite without causing leakage along the composite-zirconia interface.
Disclaimer: This article was provided by Dr. Tay.
Fig 1. Preoperative radiograph of tooth No. 18. Diagnosis: pulpal necrosis with symptomatic api-cal periodontitis.
Fig 2. Postoperative radiograph of tooth No. 18. Coronal seal was created with radiolucent antimicrobial self-etching adhesive (CLEARFIL™ SE Protect, arrow) and a radiopaque flowable composite, followed by placement of a cotton pellet and a temporary restoration.
ADVANCED NEW FEATURES FOR MORE CONFIDENCE
Studies show that the risk of bacteria remaining in cavities tends to increase with smaller minimal intervention cavities (S. Imazato; Dent. Mater. J. 2009).
CLEARFIL™ SE Protect contains a new functional monomer MDPB, which exhibits an “Antibacterial Cavity Cleansing Effect” (Fig 3).
Fig 3. The bactericidal mechanism of MDPB is presumed to be similar to the well-known antibacterial agent CPC**, which is in many toothpastes and mouth rinses. **Cetyl pyridinium chloride
EXCEPTIONAL RESEARCH RESULTS
Increased durability of resin-dentin bonds
Recent research has demonstrated that MDPB is also an effective inhibitor of matrix metaloprotinases (MMP) that may deplete collagen.
The advantage of MDPB over chlorhexidine (CHX) is that it polymerizes with adhesive resins and cannot leach from the hybrid layer.
(Pashley et al. Compend Contin Educ Dent. 2011)
Fluoride-release
CLEARFIL™ SE Protect contains a patented, specially treated sodium fluoride (NaF); the NaF in CLEARFIL™ SE Protect is coated with a unique polymer capsule that allows release of NaF while the bonding layer physical properties, including strength, are maintained.
Simple proven procedure - avoid technique sensitivity
CLEARFIL™ SE Protect is a two bottle primer and adhesive bonding system.
DIRECT RESTORATION
Follow the standard procedures for isolation, moisture control, cavity preparation and pulp protection.
Dentist:
FRANKLIN TAY, BDSC (HONS), PHD
Franklin Tay is Professor and Chair in the Department of Endodontics, College of Dental Medicine, Georgia Regents University, Augusta, Georgia, and a Fellow of the Academy of Dental Materials, as well as a Diplomate of the American Board of Endodontics. With more than 400 papers published in peer reviewed journals, his research interests include biomineralization of collagen scaffolds with apatite and/or silica, remineralization of resin-dentin bonds, antimicrobial sol-gel chemistry, mesoporous silica, and endodontic materials.
First published in COMPENDIUM, April 2014, Volume 35, Number 4.
For the placement of veneers, a resin cement must be selected that supports long-lasting aesthetics, is easily applied, offers a working time sufficient for simultaneous cementation of multiple restorations and provides excellent bond strength. The new “PANAVIA™ Veneer LC” is precisely what you need.
For the pretreatment of the tooth you can use PANAVIA V5 Tooth Primer as shown in our previous workflow video.
BUT did you know that CLEARFIL Universal Bond Quick is also an option? Today’s video demonstrates exactly how. Check it out!
Hypersensitivities make patients suffer, no matter what their cause is. Kuraray Noritake Dental Inc.’s TEETHMATE™ DESENSITIZER is the solution for all of them. Designed to crystallize hydroxyapatite (HAp) from the ground up, the material effectively and durably occludes exposed dentinal tubules and enamel cracks. The tubules may be exposed due to gingival recession, dental erosion or excessive toothbrushing, professional tooth cleaning, scaling and root planning, tooth whitening or restorative procedures. TEETHMATE™ DESENSITIZER provides lasting hypersensitivity relief in all those cases – a fact that is surely one of the reasons for its winning of a Dental Advisor award for the eighth consecutive year.
Consisting of natural calcium and phosphate, the product may even be applied to freshly prepared tooth structure without negatively affecting the bond strength of subsequently utilized dental adhesives or cements.
The consultants of the Dental Advisor conducted a six-month clinical study to be able to evaluate the performance of TEETHMATE™ DESENSITIZER. They selected 27 patients with hypersensitivity issues in their dental practices. Thermal testing with cold air was used to identify the affected teeth, 54 of which were included in the evaluation. For the initial assessment, patients were asked to evaluate their level and frequency of hypersensitivity per tooth on a five-point scale (1 = severe, persistent sensitivity to 5 = no sensitivity). Subsequently, TEETHMATE™ DESENSITIZER was applied according to the instructions for use. Sensitivity was evaluated again immediately after the treatment and six months later. At baseline, 91 percent of the patients stated that they had no or only mild, sporadic sensitivity, which was still the case for 85 percent after six months. This indicates that the product is very effective in providing immediate and even long-term hypersensitivity relief.
Hence, it is not surprising that TEETHMATE™ DESENSITIZER has been among the winners of the Dental Advisor’s Top Product Award every year between 2015 and 2022.
Study results that confirm the material’s effectiveness in reducing pre- and post-operative sensitivity in the context of tooth whitening1 and indirect restoration procedures2 are also available, so that users can count on a reliable performance in a wide range of indications.
1 Mehta D, Jyothi S, Moogi P, Finger WJ, Sasaki K. Novel treatment of in-office tooth bleaching sensitivity: A randomized, placebo-controlled clinical study. J Esthet Restor Dent. 2018 May;30(3):254-258.
2 Shetty R, Bhat AN, Mehta D, Finger WJ. Effect of a Calcium Phosphate Desensitizer on Pre- and Postcementation Sensitivity of Teeth Prepared for Full-Coverage Restorations: A Randomized, Placebo-Controlled Clinical Study. Int J Prosthodont. 2017 Jan/Feb;30(1):38-42.
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.
It is difficult to cover every flowable composite indication with a single viscosity: Sometimes, you need it to stay put where applied or malleable to create a specific shape. In other situations, you need it runny so that it flows into every corner or undercut. In order to meet all those needs, Kuraray Noritake Dental Inc. offers CLEARFIL MAJESTY™ ES Flow with three different levels of flowability: High, Low, and Super Low. The level of flowability is selected depending on the indication, the geometry and size of the cavity. For example, the high-flowability option is best suited as a cavity liner, while the super low flowability variant is preferable in the context of composite veneering.
However, the material has much more to offer, as confirmed by the consultants of the Dental Advisor who have honored the product with an Editors’ Choice and a Top Product Award for the seventh time in a row (Volume 39, Number 01, January-February 2022).
The 29 Dental Advisor consultants tested the medium flowability variant (Low) of CLEARFIL MAJESTY™ ES Flow in their dental practices. They assessed the product’s performance regarding placement/handling, aesthetics, viscosity and polishability. All four properties received an “excellent” rating. CLEARFIL MAJESTY™ ES Flow Low shows no running during placement, while it offers a good adaptation to the cavity walls and even flows into narrow areas. Equipped with Kuraray Noritake Dental Inc.’s Light Diffusion Technology, the material integrates seamlessly with the surrounding tooth structure and a glossy surface is obtained simply by wiping with a cotton roll soaked in alcohol.
Due to these properties and a convincing overall performance, the product received a 98 percent rating, and all 29 consultants stated that they would recommend CLEARFIL MAJESTY™ ES Flow to a colleague. Since 2015, the product has won the Top Product Award time and again, and with its three viscosities, it is likely to become your favourite product for an even broader range of indications.
