Clinical Case Report by Dr. Koray Kendir

PEG-SHAPED LATERAL INCISOR RESTORED WITH UNIVERSAL COMPOSITE (6-MONTH FOLLOW-UP)

Peg-shaped lateral incisors present a unique restorative challenge, combining aesthetic demands with the need for precise morphological reconstruction. While direct composite restorations offer a minimally invasive solution, long-term success is often compromised when anatomical principles are overlooked or when repeated additive approaches fail to address underlying structural deficiencies.

This case report describes the management of a peg-shaped maxillary lateral incisor using a simplified, anatomy-driven approach with a universal composite system.

INITIAL PRESENTATION AND CLINICAL HISTORY

A 35-year-old male patient presented with a unilateral peg-shaped maxillary left lateral incisor (tooth #22, FDI notation). The patient's dental history revealed multiple direct composite restorations placed since the age of 16, all performed without tooth preparation. However, these restorations failed approximately every two years due to fractures or severe marginal discolouration.

Fig. 1. Initial clinical situation: Vestibular view of the existing restoration.

CLINICAL ASSESSMENT AND PRE-OPERATIVE EVALUATION

Rubber dam isolation was performed and baseline clinical photographs were taken. The existing restoration was limited to closing the mesial and distal diastemas, resulting in significant marginal discrepancies and morphological disharmony. A palatal view revealed a more critical issue: concave, non-cleansable proximal contact areas, leading to food impaction and periodontal risk.

Fig. 2. Initial clinical situation: Palatal view of the existing restoration.

MINIMALLY INVASIVE PREPARATION

The primary goal was the complete removal of the failing composite without compromising the underlying natural tooth structure. Following removal, the tooth required three-dimensional expansion: mesially and distally, incisally, and labially.

Key anatomical considerations during reconstruction:

• Incisocervical positioning of mesial and distal contact areas.
• Contact area geometry (point vs. surface contact).
• Incisal edge position and line angle symmetry.
• Correct palatal wall orientation.

Fig. 3. Failing composite completely removed without compromising the tooth structure.

ADHESIVE PROTOCOL AND MATERIAL SELECTION

To support a streamlined workflow and maintain focus on anatomical reconstruction, the Universal Excellence product series was selected.

• Bonding: CLEARFIL™ Universal Bond Quick 2 was applied using a simplified one-step protocol, providing rapid and reliable adhesion.
• Restoration: CLEARFIL MAJESTY™ ES-2 Universal in U shade was chosen to provide predictable and harmonious aesthetics with a single-shade approach, allowing the clinician to focus on the primary anatomical determinants of form and function rather than complex multi-shade layering.

STRATIFICATION AND POLYMERIZATION

The composite was applied using a layering technique to minimize polymerization shrinkage stress, while gradually building the predetermined anatomical landmarks. Post-operative results demonstrated a seamless integration with the surrounding dentition.

Fig. 4. Single-shade layering of the vestibular surface.

Fig. 5. Palatal view of the tooth during layering.

Fig. 6. Finished and polished restoration surface.

Fig. 7. The composite restorations seamlessly integrated with the adjacent tooth structure.

Fig. 8. Frontal view of all maxillary anterior teeth.

SIX-MONTH FOLLOW-UP

The patient was recalled after six months for evaluation. Due to the superior polishability and high mechanical strength of CLEARFIL MAJESTY ES-2 Universal, the restoration maintained its surface lustre and marginal integrity with no signs of wear or staining.

Fig. 9. Appearance of the restorations six months after treatment.

Fig. 10. Close-up of the restoration, confirming smooth optical integration.

Fig. 11. The surface of the restoration still appears well-polished and unstained after six months.

CONCLUSION

While complex layering techniques can enhance optical properties, they may inadvertently shift focus away from fundamental anatomical principles. The Excellence system from Kuraray Noritake Dental Inc. offers a practical and dependable solution for complex morphological challenges, supporting both clinician focus and long-term clinical success.

Read more about Universal Excellence: https://www.kuraraynoritake.eu/en/newsroom/universal-excellence-smart-streamlined-solutions-for-modern-restorative-dentistry

Discover Universal Excellence products in practice: https://www.kuraraynoritake.eu/en/newsroom/universal-excellence-in-restorative-dentistry

More Clinical Cases from Dr Kendir:

https://www.kuraraynoritake.eu/en/newsroom/posterior-direct-composite-restoration-within-the-universal-excellence-concept

https://www.kuraraynoritake.eu/en/newsroom/restoring-confidence-after-trauma-a-biomimetic-approach

Case by Dr. Onur Alp Yünük

A STEP-BY-STEP GUIDE TO POLYCHROMATIC LAYERING

Complicated crown fractures in the anterior region present both functional and aesthetic challenges. They require a restorative approach that closely mimics natural tooth structure. Thanks to modern developments in adhesive dentistry and composite materials, it is possible to achieve highly aesthetic outcomes in a minimally invasive way.

This case report outlines a straightforward, yet highly aesthetic approach to restoring a traumatised lateral incisor using a polychromatic layering technique. By combining precise shade selection, anatomical analysis, and controlled composite layering, it is possible to recreate the optical properties of natural dentition and achieve seamless optical integration.

CASE OVERVIEW

A young female patient visited our clinic with a history of dental trauma, which resulted in a complicated crown fracture of her maxillary left lateral incisor (tooth #22, FDI notation). After completing the necessary endodontic and periodontal treatments for the affected tooth, we placed a temporary composite restoration. This case outlines a straightforward yet highly aesthetic approach to restoring the tooth using a polychromatic layering technique.

Fig. 1. Initial presentation of a complicated crown fracture on tooth #22 following dental trauma.

VISUAL ASSESSMENT AND SHADE MATCHING

Before beginning the definitive restorative phase, we took initial baseline photographs. Using a cross-polarized filter allowed us to evaluate the true internal optical properties of the adjacent dentition without distracting light reflections. Shade matching was performed using a bilaminar colour selection technique in conjunction with the cross-polarized filter to provide for absolute precision.

Fig. 2. Tooth #22 temporarily restored with composite resin after the completion of endodontic and periodontal treatments.

Fig. 3. Pre-operative view and cross-polarized photograph taken before initiating the definitive restorative treatment.

Fig. 4. Shade selection performed using a bilaminar technique combined with an image taken with a cross-polarized filter for accurate colour mapping.

CLINICAL EXECUTION

Following rubber dam isolation, the temporary restoration was carefully removed and the adhesive system (CLEARFIL™ SE BOND 2) was applied. Before layering the composite, we analysed the primary and secondary anatomy of the adjacent teeth from the occlusal plane to guide the build-up.

Fig. 5. Rubber dam isolation and complete removal of the provisional restoration.

Fig. 6. Occlusal view allowing for the evaluation of the primary and secondary anatomy of the adjacent teeth.

THE RESTORATION WAS CARRIED OUT IN SYSTEMATIC LAYERS

• Dentin core: We established the artificial dentin layer using CLEARFIL MAJESTY™ ES-2 in shades A3D and A2D (Kuraray Noritake Dental Inc.).
• Marginal ridges and incisal edge: The mesial and distal marginal ridges were built using CLEARFIL MAJESTY ES-2 A2, while CLEARFIL MAJESTY ES-2 Blue was applied to the incisal region to mimic natural translucency.
• Characterization: To replicate natural internal characteristics, we applied white and yellow tints. A quick control photograph taken at this stage with a cross-polarized filter is useful to verify the internal effects.
• Final enamel layer: The restoration was completed with a final layer of CLEARFIL MAJESTY ES-2 WE. Immediate post-operative photographs were taken right after the procedure.

Fig. 7. Artificial dentin layering utilizing CLEARFIL MAJESTY ES-2 A3D and A2D shades.

Fig. 8. Artificial dentin layering utilizing CLEARFIL MAJESTY ES-2 A3D and A2D shades.

Fig. 9. CLEARFIL MAJESTY ES-2 A2 used for the marginal ridges and CLEARFIL MAJESTY ES-2 Blue for the incisal area. Application of white and yellow tints for internal characterization, verified with a cross-polarized filter.

Fig. 10. Immediate post-operative views after finalizing the restoration with CLEARFIL MAJESTY ES-2 WE composite.

Fig. 11. Immediate post-operative view taken with a cross-polarized filter.

MANAGING COMPLICATIONS

During the course of treatment, the adjacent central incisor (tooth #21) failed to respond to vitality tests. Consequently, endodontic treatment and internal bleaching were successfully performed on tooth #21 in the subsequent sessions.

FINAL OUTCOME

At the final follow-up appointment, comprehensive control photographs were taken. An occlusal view confirmed the successful recreation of both primary and secondary anatomy. Most importantly, evaluating the final result with a cross-polarized filter image demonstrated a seamless colour integration with the surrounding natural teeth.

Fig. 12. Occlusal view confirming the successful recreation of the primary and secondary anatomy.

Fig. 13. Cross-polarized control photograph demonstrating seamless composite shade integration.

Fig. 14. Final result.

Case by Jotautas Kaktys, DDS

An endodontically treated, structurally compromised mandibular molar with recurrent failure of direct composite restorations presents both biomechanical and aesthetic challenges. In patients with parafunctional habits such as bruxism, excessive tensile forces further increase the risk of fracture. This case report describes a minimally invasive, cost-conscious approach using a CAD/CAM hybrid material (KATANA™ AVENCIA™ Block 2, Kuraray Noritake Dental Inc.) to restore function, strength, and aesthetics while preserving remaining tooth structure.

CASE EXAMPLE: INITIAL SITUATION

The patient presented with a structurally compromised mandibular first molar and reported repeated failure of composite restorations, as well as dissatisfaction with aesthetics (Figs. 1 to 3). Longevity, strength, and cost-effectiveness of the treatment were key concerns.

Clinical findings, including worn canines and multiple cervical lesions, indicated a bruxing patient with group guidance during lateral movements, leading to excessive tensile stress and increased fracture risk. An indirect restoration with cusp coverage was indicated. Due to financial limitations and uncertain endodontic prognosis, a CAD/CAM hybrid material KATANA AVENCIA Block 2 ML (Kuraray Noritake Dental Inc.) in the shade A3 (Fig. 4) was selected.

Fig. 1. Initial situation: Buccal view of the mandibular first molar in need of treatment due to a cervical lesion and a leaking composite restoration.

Fig. 2. Buccal view of the teeth in occlusion.

Fig. 3. Occlusal view of the tooth revealing a number of defects.

Fig. 4. Shade selection: Image taken with the A3 tab of the VITA classical A1-D4 shade guide for communication with the dental technician.

TOOTH PREPARATION AND IMMEDIATE DENTIN SEALING

Preparation was kept minimally invasive to preserve remaining tooth structure while creating space for adequate material thickness (~1.5 mm; Figs. 5 and 6). Weak cusps were reduced with minimal biological sacrifice.

After sandblasting and pre-treatment of the old composite and fiber post surfaces with silane, exposed dentin was sealed using CLEARFIL™ SE Protect and coated with CLEARFIL MAJESTY™ ES Flow (Low flowability, shade A3D; both Kuraray Noritake Dental Inc.; Figs. 7 and 8). Due to the presence of sclerotic dentin, we decided to reactivate the surface and use a two-step self-etch system instead of a universal adhesive. Resin coating was performed to protect the underlying tooth structure and mask discolouration.

Fig. 5. Tooth preparation preserving the remaining enamel and the cervical tissues.

Fig. 6. Adequate occlusal clearance.

Fig. 7. Immediate dentin sealing and resin coating.

CLEARFIL SE Protect for IDS (Immediate Dentin Sealing).

CLEARFIL MAJESTY ES Flow High for RC (resin coating).

CLEARFIL™ CERAMIC PRIMER PLUS for adhesion to old sandblasted composite.

Fig. 8. Tooth ready for intraoral scanning.

DIGITAL WORKFLOW

The intraoral situation was digitised using an intraoral scanner (Figs. 9 to 11). This enabled efficient computer-aided design and manufacturing (exocad DentalCAD; Figs. 12 to 14). The occlusal design was adjusted to minimise tensile forces during lateral movements. The restoration was milled and required only minimal finishing and polishing (TWIST™ DIA for Composite, Kuraray Noritake Dental Inc.), which was quick and effective (Fig. 15).

Fig. 9. Digital model of maxilla and mandible revealing sufficient space for the planned restoration.

Fig. 10. Preparation margins clearly visible both in the coloured …

Fig. 11. … and the black-and-white modes of the software.

Fig. 12. Computer-aided design in the laboratory using exocad DentalCAD.

Fig. 13. Milled restoration with milling sprue positioned at the buccal wall – an area which is easily adjustable (no interproximal or occlusal contacts affected) and stable.

Fig. 14. Milled restoration with smooth margins (no irregularities) due to non-brittleness of the hybrid ceramic material.

Fig. 15. Polishing is accomplished in two to three minutes and leads to great results.

TRY-IN AND PLACEMENT

Tissues had healed nicely in the three weeks between impression taking and final restoration placement (Fig. 16). Try-in confirmed a perfect fit of the restoration. Optical integration was difficult to assess without try-in paste (Fig. 17), but the patient was happy anyway, so that it was decided to move on immediately.

Isolation was achieved using a retraction cord (size 00) and PTFE tape (Fig. 18). As the bonding substrate consisted mainly of enamel and composite, a universal adhesive CLEARFIL™ Universal Bond Quick was selected. It was applied after phosphoric acid etching and treated with a gentle stream of air until the adhesive layer was uniformly thin (no pooling) and the surface did no longer move. As some remaining exposed dentin was present, the adhesive was polymerised to stabilize the hybrid layer. The restoration was pretreated (sandblasting, cleaning, CLEARFIL CERAMIC PRIMER PLUS) and adhesively cemented using a light-curing resin cement system to provide for dependable bonding.

Fig. 16. Healthy tissues at the delivery visit.

Fig. 17. Try-in of the restoration to assess the fit – no adjustments were necessary.

Fig. 18. Soft tissue management and moisture control with a retraction cord and PTFE tape, surface sandblasted to prepare for adhesive cementation.

TREATMENT OUTCOME

While the soft tissues were still slightly retracted after treatment and the optical integration difficult to assess due to dehydrated tooth structure (Fig. 19), radiographic examination confirmed proper biological integration (Fig. 20) and the patient was satisfied immediately. When she returned for a check-up after six months, we saw healthy soft tissues, a great marginal seal and proper aesthetic integration (Fig. 21). The restoration margins blended in nicely, no signs of wear were detectable and polish retention was great (Fig. 22).

Fig. 19. Immediate treatment outcome.

Fig. 20. Final radiograph.

Fig. 21. Restoration at a recall after six months. The gingiva appears healthy and has grown over the restoration margin, which is a sign of the material's biocompatibility.

Fig. 22. Smooth occlusal surface without any signs of wear.

CONCLUSION

Minimally invasive cusp coverage with KATANA AVENCIA Block 2 offers a predictable and cost-effective solution for structurally compromised posterior teeth. This is because the production procedure involves fewer manual steps, such as characterisation and glazing, while completely eliminating the need for heat treatment. A high level of automation further supports this efficiency. Successful outcomes depend on preserving the remaining tooth structure, careful treatment planning, and adherence to the recommended adhesive protocols.

Special thanks to dental technician Tautvilas Kaktys (my twin brother) and the dental laboratory RiCreo for their outstanding laboratory support and craftsmanship.

kliniskt fall av och med Viktor Henarejos-Domingo - DDS, MSc

Den moderna indirekta restaurativa tandvården utvecklas mot allt mer effektiva, digitala och förenklade protokoll. Genom att integrera CAD/CAM-teknik med universella material kan man optimera de kliniska rutinerna, minska komplexiteten i ingreppen och öka förutsägbarheten vid restaurativa behandlingar. De allra bästa resinbaserade hybridmaterialen, i kombination med självadhesiva resincment och universaladhesiver ger utmärkta
mekaniska och estetiska resultat och möjliggör samtidigt enklare och mindre teknikkänsliga cementeringsprotokoll än förr.

Det aktuella kliniska fallet visar hur CLEARFIL MAJESTY™ ES Flow Universal Low (UD). KATANA™ Cleaner, CLEARFIL™ Universal Bond Quick 2, KATANA™ AVENCIA™ Block 2, PANAVIA™ SA Cement Universal och putssystemet TWIST™ DIA for Composite (alla produkter finns hos Kuraray Noritake Dental Inc.) används för adhesiv behandling av en endodontiskt behandlad molar.

FALLBESKRIVNING

En 48-årig kvinna sökte sig till kliniken med en omfattande koronal skada på en underkäksmolar (tand 47). Skadan var kopplad till symtom och endodotisk behandling som hade påbörjats på en annan klinik. Efter röntgen och klinisk undersökning beslutades att slutföra den endodontiska behandlingen och att tanden därefter skulle återställas med hjälp av en CAD/CAM-framställd partialkrona. (Fig. 1).

Figur 1 (och bild på vänster sida): Utgångsläge, tand 47. Lägg märke till den omfattande koronala skadan.

Efter rotbehandlingen behövde den kvarvarande tandstrukturen justeras för att åstadkomma ett stabilt underlag för den planerade partialkronan (Fig. 2). Emaljen selektivetsades med K-ETCHANT Syringe, en 35%-ig fosforsyragel, som erbjuder precis applicering och kontrollerad konsistens. Därefter applicerades CLEARFIL™ Universal Bond Quick 2. Uppbyggnaden av tanden slutfördes sedan med CLEARFIL MAJESTY ES Flow Universal Low (UD), en flytande universalkomposit med hög fyllnadsgrad och utmärkta mekaniska egenskaper - särskilt lämpad för posteriora ersättningar som utsätts för kännbara tuggkrafter (Fig.3).

Figur 2: Röntgen och klinisk utvärdering av den skadade molaren åtföljs av endodontisk behandling innan övrig behandling påbörjas.

Figur 3: Direktuppbyggnad utförs med CLEARFIL MAJESTY™ ES Flow Universal Low (UD). Observera justeringen som görs i syfte att skapa en adekvat mängd stödvävnad inför kommande preparation.

Därefter preparerades tanden för en adhesivt cementerad partialkrona enligt principerna för defektorienterad och minimalinvasiv tandvård (Fig. 4). De digitala avtrycken togs med en intraoral skanner, TRIOS 5 (3shape) (Fig. 5). Ersättningen designades i dator och partialkronan frästes ur ett KATANA AVENCIA Block 2 av den högtranslucenta varianten (HT). Det translucenta resinbaserade hybridkeramiska CAD/CAM-blocket är särskilt lämpligt att använda vid framställning av partiella ersättningar. Materialet utmärker sig genom hög mekanisk styrka, utmärkt optisk integrering och att det är snabbpolerat (Fig. 6).

Figur 4: Anatomiskt guidad preparation för en partialkrona. Notera att frisk tandvävnad sparats och att preparationsgränserna är väldefinierade inför den kommande avtryckstagningen.

Figur 5: Digitalt avtryck och datorstödd design av ersättningen.

Figur 6: Partialkronan som frästs ut ur KATANA™ AVENCIA™ Block 2 HT. Observera den anatomiska karaktäriseringen som gynnar den estetiska integrationen.

Inför definitivcementeringen en vecka senare (Fig. 7) rengjordes både kronans insida och den preparerade tanden med KATANA Cleaner. Denna universalrengörare innehåller MDP-salt (baserat på MDP-teknologi), som på bara tio sekunder effektivt tar bort föroreningar av blod och saliv, både intra- och extraoralt (Fig. 8). Målet var att skapa optimal adhesion och på så sätt bidra till en förutsägbar och hållbar adhesivcementering.

Figur 7: Behandlingsområdet isoleras med kofferdam innan den adhesiva cementeringen påbörjas.

Figur 8: Kronans inneryta förbereds kemiskt genom sandblästring med aluminiumoxidpartiklar och rengörs med KATANA™ Cleaner.

Emaljen selektivetsades återigen med K-ETCHANT Syringe, följt av applicering av CLEARFIL Universal Bond Quick 2. Denna nya generations universaladhesiv kännetecknas av det förenklade protokolllet, med endast
en snabb applicering utan väntetid och samtidigt ger utmärkt vätbarhet och hållbar vidhäftning till både emalj och dentin (Fig. 9)

Figur 9: Rengöring av tandstrukturen med KATANA™ Cleaner, därefter emaljetsning och applicering av CLEARFIL™ Universal Bond Quick 2. Notera det förenklade protokollet för adhesiven.

Definitivcementeringen gjordes med PANAVIA SA Cement Universal Automix (Universal – A2). Detta självadhesiva universalcement innehåller både MDP-monomer och det innovativa LCSi-silanet som möjliggör kemisk bindning till zirkonia, kompositer och keramer utan ytterligare primers. Produkten är enkel att handha och överskotten enkla att avlägsna: Ett inledande två till fem sekunders ljushärdningsprotokoll gör att cementöverskottet enkelt och kontrollerat kan avlägsnas, underlättar den kliniska hanteringen och optimerar den adhesiva cementeringen. (Figs. 10, 11 och 12). Kombinationen av KATANA™ Cleaner, CLEARFIL™ Universal Bond Quick 2 och PANAVIA™ SA Cement Universal främjar ett förenklat, effektivt och arbetsflöde utan överraskningar. Det möjliggör en arbetsgång med färre komponenter och kliniska moment som inte kompromissar med vare sig bindningskvaliteten eller ersättningens livslängd.

Figur 10: Partialkronan definitivcementeras adhesivt med PANAVIA™ SA Cement Universal Automix (Universal - A2).
Lägg märke till kronans fina passform och den kontrollerade appliceringen av cement under cementeringen.

Figur 11: Avlägsnande av cementöverskott följt av punktvis härdning av PANAVIA™ SA Cement Universal Automix.

Figur 12: De viktigaste produkterna i den restaurativa proceduren, i enlighet med Kuraray Noritake Dental Inc.s koncept “Universal Excellence”.

Slutligen justerades ocklusionen och ersättningen yta polerades med TWIST DIA for Composite. Detta diamantbaserade tvåstegssystem har kapacitet att snabbt leverera en naturlig och bestående glans på både direkta och indirekta ersättningar (Figs. 13, 14 och 15).

Figur 13: Ersättningen slutpoleras med TWIST™ DIA for Composite.

Figur 14: Lateral vy av den hybridkeramiska partialkronan omedelbart efter adhesivcementering.
Observera den utmärkta kantanslutningen, anatomin och optiska integreringen.

Figur 15: Klinisk dokumentation och röntgen en månad efter adhesivcementering.

SAMMANFATTNING OCH KLINISKA SLUTSATSER

Införlivandet av universalmaterial i de digitala, restorativa protokollen ger stöd för förenkling av indirekta, adhesiva behandlingar och optimerar samtidigt den kliniska effektiviteten och minskar dessutom teknikkänsligheten. Kombinationen av CAD/CAM-framställda ersättningar och adhesiver och cement av universaltyp underlättar bevarande, effektiva och höggradigt förutsägbara behandlingar, helt i linje med kraven inom den samtida tandvården.

Litteratur:

1. Tian F, Jett K, Flaugher R, Arora S, Bergeron B, Shen Y, Tay F. Effects of dentine surface cleaning on bonding of a self-etch adhesive to root canal sealer-contaminated dentine. J Dent 2021;112:103766.
2. Breschi L, Van Meerbeek B. Editorial: Universal adhesives – to etch or not to etch? J Adhes Dent 2021;23(4):283.
3. Breschi L, Maravic T, Mazzitelli C, Josic U, Mancuso E, Cadenaro M, Pfeifer CS, Mazzoni A. The evolution of adhesive dentistry: From etch-and-rinse to universal bonding systems. Dent Mater 2025;41(2):141–158.
4. Maravić T, Mazzitelli C, Mancuso E, Del Bianco F, Josić U, Cadenaro M, Breschi L, Mazzoni A. Resin composite cements: Current status and a novel classification proposal. J Esthet Restor Dent 2023;35(7):1085–1097.
5. Sulaiman TA, Abdulmajeed AA, Altitinchi A, Ahmed SN, Donovan TE. Mechanical properties of resin-based cements with different dispensing and mixing methods. J Prosthet Dent 2018;119(6):1007–1013.

By Dr. Gintautas Rumbaitis, DDS

A CLINICAL CASE EXAMPLE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Fig. 11. Modelling finished.

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

Fig. 13. Result of the polishing procedure.

Fig. 14. Buccal view of the polished restoration.

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

CONCLUSION

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

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

Clinical case by Dr. Zygintas Jonaitis

MINIMALLY INVASIVE INDIRECT RESTORATION PROCEDURE IN THE POSTERIOR REGION

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

RESTORATION REPLACEMENT REQUIRED

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

Fig. 1. Initial clinical situation.

SELECTIVE CARIES REMOVAL

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

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

Fig. 3. Removal of the old composite restoration.

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

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

ADHESIVE PROCEDURE AND BIO-BASE CREATION

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

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

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

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

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

TOOTH PREPARATION AND ADHESIVE CEMENTATION

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

Fig. 10. Prepared tooth prior to adhesive cementation.

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

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

Fig. 13. Restoration in place.

Fig. 14. Occlusal view of the final restoration.

Fig. 15. Occlusal view of the final restoration

CONCLUSION

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

Ett fall av Dr Onur Alp Yünük  

Vackra tänder och ett felfritt leende: Att leva upp till patienternas estetiska krav på fasadbehandlingar kan vara en utmaning. Vissa patienter har konkreta idéer om hur deras nya tänder ska se ut, medan andra har svårare att uttrycka sina förväntningar. I de fallen är det viktigt att välja en behandling som ger utrymme för modifiering - antingen i form av en mer omfattande planering med digital smile design, eller genom att göra kompositersättningar som enkelt kan modifieras intraoralt. 

Den senare metoden valdes i det här fallet: En ung kvinna som sökte sig till vår klinik eftersom hon var missnöjd med de fasader hon hade i överkäksfronten (Fig. 1 till 4). Vid undersökningen konstaterades att de befintliga ersättningarna hade en ojämn och rå yta, missfärgade kantanslutningar och att kompositen hade dålig hållfasthet. För att skapa optimal funktion och estetik beslutades att de befintliga ersättningarna skulle avlägsnas och ersättas av nya kompositersättningar i hela överkäksfronten (tand #13 till #23 enligt FDI). Patienten uttryckte önskemål om mer individualisering och karaktär för att får ett finare leende.

Fig. 1: Kompositfasaderna i överkäksfronten uppvisade otillfredställande estetik och funktion.

Fig. 2: Ocklusal bild med synliga defekter på kompositfasaderna.

Fig. 3: Lateral vy (höger sida) avslöjar ojämnheter i ytan.

Fig. 4: Lateral vy (vänster sida) avslöjar ett stort område där kompositen släppt.

NYA KOMPOSITFASADER

För att imitera translucensen hos patientens egna tänder och för att uppfylla hennes estetiska önskemål användes ett polykromatiskt system och dualskiktsteknik för ett fint, optiskt samspel av translucenser i det anteriora området.

Under färgtagningen användes den bilaminära färgbedömningstekniken (BSAT), som bygger på färgkombinationen av dentin- och emaljkompositer. I denna teknik lades den önskade emaljfärgen i skikt över den önskade dentinfärgen för att utvärdera den resulterande färgen som skapades av de två kompositfärgskikten. Materialen polymeriserades på tandytan utan bonding för att verifiera den kumulativa färguppfattningen som uppstod genom skiktningen, snarare än materialens individuella nyanser, för att säkerställa harmoni med den naturliga tandstrukturen vid behandlingens början. Fotografier togs med en kamera utrustad med ett korspolariserat filter (Fig. 5). Därefter avlägsnades retainern, liksom de befintliga kompositfasaderna. För att bevara så mycket som möjligt av den underliggande friska tandstrukturen utfördes ingreppet under förstoring och med blått ljus, röda och gula diamanter samt hårdmetallfräsar.

Fig. 5: Färgtagning - bilden är tagen med korspolariserande filter som eliminerar ljusreflexer.

Fig. 6: Tänderna när de defekta fasaderna avlägsnats.

Tänderna isolerades med kofferdam som säkrades med tandtråd i de cervikala områdena. Därefter påbörjades behandlingen. Emaljen etsades och behandlades med självetsande bonding (CLEARFIL™ SE Bond 2, Kuraray Noritake Dental Inc.) och CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.)  appliceras: dentinkärnan med sin uttalade mamelonstruktur modellerades med A1D. De incisala skären accentuerades med hjälp av vita pigment. För att skapa en opalescerande effekt skiktades ett tunt lager av den translucenta färgen Blue vid incisalskären. Emaljskiktet byggdes upp med emaljfärgen WE. Eftersom retainern tagits bort framställdes en transparent aligner som patienten ombads att använda fram till nästa behandlingstillfälle.

Fig. 7: Isolering med kofferdam inför behandling av lateraler och hörntänder.

Fig. 8: Det vestibulära emaljskiktet skiktas på tänderna.

Fig. 9: Form och färg enligt patientens önskemål.

Efter finishering och polering med Twist DIA for Composite skickades patienten hem och en ny tid bokades för utvärdering och slutjustering.

Vid kontrollen bad patienten oss att minska den incisala translucensen och valören en aning samt att ändra tändernas form: Hon ville ha längre centraler med mjukare och rundare hörn och med en jämnare incisal form. Kofferdam placerades igen och de vestibulära ytorna slipades ner en aning  med hjälp av röda och gula diamanter. För att förbättra förutsättningarna för optimal mikromekanisk anslutning ruggades och sandblästrades ytan med 50µm aluminiumdioxid. Fosforsyra, silan och CLEARFIL™ SE Bond 2 applicerades steg-för-steg som en del av det adhesiva protokollet. Ersättningarna modifierades sedan genom förlängning, färgen korrigerades med CLEARFIL MAJESTY™ ES-2 Premium, A1D och A1E och den anatomiska formen f injusterades (Fig. 10 och 11).

Fig. 10: Modifiering av ersättningarna på de centrala incisiverna.

Fig. 11: Modifierat leende: Tänderna har fått en jämnare form och kontur och en naturligare färg.

Vid det sista behandlingstillfället uttryckte patienten att hon var mycket nöjd med sitt nya leende. Ersättningarnas ytor polerades igen, en ny retainer bondades fast och slutresultatet fotograferades (Fig. 12 till 16).

Fig. 12: Slutresultat - frontal vy.

Fig. 13: Slutresultat - ocklusal vy.

Fig. 14: Slutresultat - lateral vy.

Fig. 15: Slutresultat - patientens leende.

Fig. 16: Detaljerad bild av innerstrukturen - som blir synlig med ett polariserande filter.

SAMMANFATTNING

Att prata med patienterna om varje liten detalj i behandlingen och att lyssna uppmärksamt på deras idéer, förväntningar och krav räcker inte alltid för att förhindra att det ändå blir en del justeringsarbete - helt enkelt därför att patienterna behöver se resultatet innan de kan avgöra om de tycker om det eller inte. Turligt nog ger rätt val av material och teknik tandläkaren utrymme att skapa ett nytt leende som kan modifieras utan att man skadar frisk tandvävnad. Det är alltså inte längre så svårt att göra även den mest krävande patienten nöjd.

Ett fall av dr Onur Alp Yünük

KOMBINERA HÖGKVALITATIVA REDSKAP OCH MATERIAL FÖR HÅLLBARA RESULTAT

Direkta kompositersättningar är ett högkvalitativt behandlingsalternativ, även i de fall då mycket tandvävnad måste ersättas. Detta beror på de senaste framstegen inom kompositmaterial och limteknik. Genom att välja lämpliga material och skiktningstekniker i kombination med moderna digitala verktyg för utvärdering av färgskillnader är det möjligt att på ett förutsägbart sätt uppnå mycket estetiska resultat, vilket framgår av följande fallbeskrivning.

Utmaningen

En ung man sökte sig till vår klinik med önskemål om att byta ut befintliga kompositersättningar i överkäken (tand #12 och #11 enligt FDI). Den kliniska undersökningen avslöjade omfattande retentionsförlust på den laterala incisiven. Dessutom observerades anatomiska avvikelser, missfärgning och förlust av ytglans på tand #11. Den andra centralen uppvisade liknande problem gällande färg och ytputs.

Vid konsultationen beslutades att byta ut de befintliga ersättningarna med hjälp av ett modernt kompositmaterial, särskilt framtaget för dualskiktning – CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.).  För en exakt färganalys togs fotografier både utan och med korspolariserande filter (Fig. 1 till 4).

Fig. 1: Frontal vy: Omfattande retentionsförlust på den höger lateralen.

Fig. 2: Korspolariserat fotografi tillåter detaljerad analys av färgavvikelserna.

Fig. 3: Lateral vy.

Fig. 4: Laterl vy - korspolariserat fotografi.

Lösningen

De ursprungliga ersättningarna avlägsnades varefter området isolerades med hjälp av kofferdam. Selektiv etsning av emaljen utfördes och därefter applicerades självetsande adhesiv (CLEARFIL™ SE Bond 2, Kuraray Noritake Dental Inc.) varefter de palatinala ytorna byggdes upp med CLEARFIL MAJESTY™ ES-2 Premium,  nyans A1E (Fig- 5 och 6). Mamelonstrukturen återskapades med hjälp av CLEARFIL MAJESTY™ ES-2 Premium, nyans A1D, och den translucenta nyansen Blue applicerades i det opalescerande området. Slutligen användes gula och vita pigment för karaktärisering. Figur 7 visar utseendet före polering och figur 8 efter.

Fig. 5: Palatinalytorna skapas med hjälp av emaljmassan A1E.

Fig. 6: Lateral vy visar tänderna under behandlingen.

Fig. 7: Ersättningarna före finishering och puts.

Fig. 8: Ersättningarna efter finishering och puts.

Resultatet

För att kunna utvärdera det färdiga resultatet fotograferades ersättningen med korspolariserande filter och ett gråkort som referens och för kalibrering (Fig. 9 och 10). Den laterala vyn av de färdiga ersättningarna (Fig. 11) visar både att rätt färgkombination använts och den naturliga yttextur som krävs för ett högestetiskt resultat.

Fig. 9: Frontal vy med korspolariserande filter.

Fig. 10: Kalibrering med det grå referenskortet och L*a*b*koordinaterna för ersättningen.

Fig. 11: Lateral vy som understryker vikten av yttextur.

DISKUSSION OCH SAMMANFATTNING

Observation med stöd av moderna verktyg för fotografi och bildanalys (som polariserande filter och L*a*b*-koordinater) är viktiga färdigheter för att skapa naturliga och levande ersättningar av kompositmaterial. Genom att kombinera de här färdigheterna med högkvalitativ komposit med bestämda färgkombinationer och innovativ light diffusion technology - som ger fantastiskt färgadaption till omgivande tandstruktur - är det inte svårt att skapa vackra ersättningar.

I fallet som presenterats här blev patienten nöjd med resultatet både vad gäller estetik och funktion. Vid de regelbundna återbesöken kontrolleras ersättningarna - och de uppvisar fortsatt fin funktion och utmärkt estetik.

By Dr Wiktor Pietraszewski BSC(HONS) DMD

INTRODUCTION

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

THE CASE

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

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

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

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

THE PLAN

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

Main features of the Digital Smile Design (DSD) plan

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

PREPARATION, SCAN & TEMPORISATION

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

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

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

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

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

CEMENTS

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

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

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

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

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

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

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

PANAVIA™ VENEER LC

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

Fig. 8. PANAVIA™ Veneer LC Paste shades.

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

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

TRY-IN

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

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

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

CEMENTATION STEPS

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

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

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

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

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

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

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

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

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

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

Fig. 15a. Priming of the tooth structure.

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

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

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

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

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

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

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

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

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

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

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

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

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

Fig. 18. Immediate post-operative appearance.

Fig. 19. Check-up after three weeks.

FINAL SITUATION

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

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

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

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

FOLLOW-UP VISIT

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

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Clinical case by Dr Manuel Tinto

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

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

Fig. 1. Pre-operative photograph.

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

Fig. 2. Application of Caries Detector.

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

Fig. 4. Finished and cleaned cavities.

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

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

Fig. 6. Quad Matrix ring in position.

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

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

The Class I cavity was completed by layering two materials:

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

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

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

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

FINAL CONSIDERATIONS

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

Clinical case by Dr Luca Alibrandi

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

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

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

Fig. 3. Detail of the maxillary anterior region.

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

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

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

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

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

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

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

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

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

Fig. 7. Post-injection situation.

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

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

FINAL CONSIDERATIONS

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

Case by Dr. Onur Alp Yünük

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

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

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

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

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

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

REPLACEMENT OF THE COMPOSITE VENEERS

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

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

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

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

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

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

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

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

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

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

Fig. 10. Modification of the central incisor restorations.

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

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

Fig. 12. Final treatment outcome – frontal view.

Fig. 13. Final treatment outcome – occlusal view.

Fig. 14. Final treatment outcome – lateral view.

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

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

CONCLUSION

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