BEHIND-THE-SCENES OF NIIGATA FACTORY

Take a tour of Kuraray Noritake Dental Inc.'s state-of-the-art Niigata Plant, where high-quality dental materials come to life.

This fascinating video highlights our meticulous production process, from initial R&D to final inspections, showcasing the care and precision that go into creating bonding agents, composite resins, and cements. Learn how strict hygiene control, advanced machinery, and skilled craftsmanship ensure a consistent supply of premium dental materials to over 90 countries worldwide.

Watch the video to discover how innovation and dedication drive better oral health for people around the globe!

This year, the Kuraray Noritake Dental stand will be packed with news from the world of dentistry, so we offer not just one reason to visit, but a whole range: new chairside products, new labside products, inspiring lectures, enlightening hands-on demonstrations… And the best thing? You don´t have to choose just one thing, come and see them all at the Kuraray Noritake Dental booth in Hall 11.3 | Stand E010!

Chairside – smart streamlined solutions

When it comes to a dental practice, our vision is clear: a world where your materials and tools work seamlessly in your hands, where complexity is minimized, and where you are given enough time to focus on what matters most: the individual desires and needs of every single patient. This is the future of dentistry - and we are leading the way. Come discover our new additions to the UNIVERSAL EXCELLENCE family: a flowable universal composite and a new generation of a universal bond!

Labside – speed and aesthetics hand in hand

No matter whether a minimally invasive procedure or the best aesthetic outcomes are desired: Kuraray Noritake Dental has the products for you. New in the portfolio: CERABIEN™ MiLai - low-fusing porcelains and internal stains. Come and see for yourself its ultra-thin layering, exceptional mechanical properties and consistent handling for both zirconia and lithium disilicate. And while you're there, have a coffee while speed-sintering with our KATANA™ Zirconia discs takes place in real time.

Get inspired by 12 expert speakers on 2 stages

Are you a user of or interested in one of Kuraray Noritake Dental’s products or solutions, but eager to learn more about their practical use from proven experts in your field? From Wednesday until Saturday, we offer a programme of exciting lectures and live demonstrations - this time simultaneously on two stages: one dedicated to chairside and the other one to labside topics!

Warm welcome

Everyone, from sales person to scientific marketeer, looks forward to giving you a warm welcome, answering your questions and introducing you to the world of innovative Kuraray Noritake Dental products, solutions and workflows. And while you are already in Cologne anyway, why not enjoy the breathtaking beauty of the old town? Have you ever seen its famous Gothic Cathedral? Or its Old Town inviting you to stroll through its narrow alleys, finding traces of history around every corner? This year's IDS offers so many reasons to attend that it's hard not to accept the invitation.

Additional information and the full programme of lectures and hands-on courses at the IDS is available online.

Discover a detailed walkthrough of an advanced shade reproduction technique with this comprehensive guide by DT Tomáš Forejtek. Tailored for professionals working with CERABIEN™ ZR ceramics (Kuraray Noritake Dental Inc.) and the eLAB protocol, this case study provides step-by-step insights into achieving exceptional results, from documentation to shade selection and framework design to final polish. Whether you are refining your craft or exploring new methods, this resource is a valuable addition to your toolkit.

Article by Peter Schouten

Ceramic primers vary widely in composition and effectiveness, despite what their name might suggest. Most common primers include silane, but silane alone is insufficient for pre-treating all materials commonly used in indirect restorations before bonding.

Silane—typically in the form of γ-MPS—has a strong affinity for silica- or glass-based materials. While certain metals and their oxides can chemically react with silane, other components provide a stronger and more reliable bond to metals and metal oxides and should be seriously considered.

For metal(oxide) pretreatment in bonding, the MDP monomer is far more reactive than silane. The original MDP monomer, developed by Kuraray Co., Ltd. in 1981, remains the highest-quality MDP available, as confirmed by research.¹

CLEARFIL™ CERAMIC PRIMER PLUS is a single-component adhesive primer that forms strong bonds with a wide range of restorative materials. This two-in-one primer incorporates the original MDP monomer, which establishes a robust bond with metals and zirconia. Simultaneously, the silane coupling agent (γ-MPS) ensures excellent adhesion to resin composites, hybrid ceramics, and glass-based ceramics such as lithium disilicate and porcelain.

ENHANCED BOTTLE DESIGN

The primer bottle is designed for effortless one-handed operation. Its unique nozzle ensures precise dispensing, minimizing the risk of contamination and spills.

PROVEN EFFECTIVENESS OF MDP-CONTAINING PRIMERS

To enhance the bonding of prosthetic materials, use a primer containing both MDP and silane. Numerous studies have demonstrated the effectiveness of this combination.

OPTIMAL PRIMING FOR ADHESIVE CEMENTING

These studies underscore the critical role of MDP-containing primers in achieving reliable and durable adhesion for prosthetic materials. Products containing only silane, such as RelyX™ Ceramic Primer (3M ESPE), are less effective at creating a durable bond between resin cements or composites and ceramic- or metal-based prosthetic materials.

Image from clinical case by MDT Rondoni and Dr. Attanasio

STRAIGHTFORWARD AND EFFICIENT

The use of CLEARFIL™ CERAMIC PRIMER PLUS is straightforward: just apply it to the bonding surface, dry it, and proceed with the following treatment step. Incorporated into your process to streamline adhesion preparation and achieve reliable results!

JUST APPLY AND DRY

CLEARFIL™ CERAMIC PRIMER PLUS may be applied to any restoration surface after the required pretreatment. Pretreat the adherent surface of the restoration as indicated:

* If your laboratory already treated with a hydrofluoric acid, cleaning and activating with K-ETCHANT Syringe just before applying CLEARFIL™ CERAMIC PRIMER PLUS is recommended.

**When using with PANAVIA™ V5 or CLEARFIL™ DC CORE PLUS

Universal prosthetic primer designed for a strong bond and procedural simplicity

Author:

PETER SCHOUTEN

References

1. Yoshihara K., et al.(2015) Functional monomer impurity affects adhesive performance, Dental Materials, Volume 31, Issue 12, https://doi.org/10.1016/j.dental.2015.09.019. Pilo, R., et al. (2018). “Effect of tribochemical treatments and silane reactivity on resin bonding to zirconia.” Dent Mater 34(2): 306-316.
2. Cao, Y., et al. (2021). The effects of four primers and two cement types on the bonding strength of zirconia. Annals of Translational Medicine. 10. 10.21037/atm-21-4909.
3. Reymus, M., et al. (2019). “Bonding to new CAD/CAM resin composites: influence of air abrasion and conditioning agents as pretreatment strategy.” Clin Oral Investig 23(2): 529-538.
4. Uğur, M., et al. (2023). Effect of ceramic primers with different chemical contents on the shear bond strength of CAD/CAM ceramics with resin cement after thermal ageing. BMC Oral Health. 23. 10.1186/s12903-023-02909-z.
5. Pilo, R., et al. (2018). “Effect of tribochemical treatments and silane reactivity on resin bonding to zirconia.” Dent Mater 34(2): 306-316.
6. Inokoshi, M., et al. (2014). “Bonding effectiveness to different chemically pre-treated dental zirconia.” Clin Oral Investig 18(7): 1803-1812.

THE ART OF RESTORING SMILES: MASTERING THE CHALLENGE OF A SINGLE CENTRAL INCISOR

Restoring a single maxillary central incisor is possibly the biggest challenge a dental technician can face in everyday work. Especially when a patient is young, it is extremely important to restore her or his smile to its original beauty. Any restoration that is perceivable as such might have a negative impact on their self-confidence and quality of life even in the long term.

A STORY OF JOY AND DESPERATION

Take Ioanna, a 14-year-old girl who presented in her dental office in a state of desperation. In the hours before, she had been floating on cloud nine: Her favourite band performed in Cyprus for the first time and she had managed to buy tickets for herself and her best friend. Thrilled, they had arrived at the concert, the band started playing and the crowd danced to the music. It felt like this was going to be the best day of her life. At the time the band played its most popular song, people were delirious, jumping up and down in ecstasy. Between all the exuberant dancing and laughing, however, Ioanna suddenly was hit by a strong push. She fell, her face hitting something hard – a seat in front of her. Pain froze time and it took a few seconds before she understood what had happened: Tasting blood in her mouth, she explored her teeth with her tongue and realized that one of her central incisors had fractured.

AFFECTING THE QUALITY OF LIFE

This is one of the many touching stories we listen to every day. A fall during a concert, a push at somebody’s birthday party, a car accident: There are many incidences that can ruin a young, beautiful smile. By paying attention to the involved patients and their stories, one will come to realize how strongly some of them are affected by all this. They cover their mouths when they laugh or hold back their smiles.

Any dental technician who is committed to restoring their lost smile in the best possible way is probably aware of the impact his or her work can have and the responsibility coming with it: A Beautiful result will restore not only their smile, but also their self-confidence, will let them start laughing happily, expressing themselves comfortably and simply enjoying social interaction again (Figs. 1 to 5). Compromised outcomes, on the other hand, might have the opposite effect. Being aware of this role should be every technician’s motivation to become better day by day. Evolve for these moments, when our work brings tears of joy to our patients.

Fig. 1. Layering sketch for the restoration of a fractured central incisor in three layers: Layer one.

Fig. 2. Layering sketch for the restoration of a fractured central incisor in three layers: Layer two.

Fig. 3. Layering sketch for the restoration of a fractured central incisor in three layers: Layer three. After the first bake, small details were integrated, followed by a second bake. Finally, the restoration was finished with CERABIEN™ ZR FC Paste Stain and Glaze.

Fig. 4. Treatment outcome able to restore not only the smile, but also the self-confidence of the young girl.

Fig. 5. Immediately after cementation of the restoration, the restoration is barely identifiable, only the soft tissue needs some time for recovery.

ASPECTS TO BE CONSIDERED

But how to proceed in restoring single central incisors in the best possible way? The success of this type of restoration is hidden in the shape, which is the most difficult part. Managing to create a natural morphology is more than half the battle. The other important part is colour. The key to reproducing colour is in understanding how the utilized porcelains work. It is all about light reflection, absorption, translucency and opalescence, value and characteristic details. The more you gain experience and understand the optical properties of teeth and ceramics, the better your outcomes will be. Support is offered by a camera, a macro lens and a twin flash, which are used to capture and analyse the intraoral situation. For an initial analysis and understanding of shape and colour, I like to see the patients in my dental laboratory. Feeling the colour helps to develop the most realistic picture of what needs to be created. The key to successful realisation of the plan just developed is the use of reliable, easy-to-handle materials – in my case KATANA™ Zirconia and CERABIEN™ ZR Porcelains (both Kuraray Noritake Dental Inc.).

POSSIBLE STEPS

The first thing to focus on when starting to produce an anterior restoration – like in the case presented in figures 6 to 14 – is the correct value of the tooth. As soon as the framework or base is produced in the right value, you need to place what you see. Does the adjacent tooth show mamelons, traces of blue and orange? Those characteristics simply need to be observed and copied. There is no need to create something fancy. The tricky part is to use the available space reasonably. When there is plenty of space for the porcelain, it may be challenging to keep the value of the framework and avoid a greyish appearance. Depending on the die colour, age of the patient, natural surface texture and space available, an appropriate layering approach and finishing technique may be selected.

Fig. 6. Replacement of an anterior crown: Prepared tooth with severe discolouration. The adjacent central incisor has a special shape and vivid inner colour structure.

Fig. 7. Framework made of KATANA™ Zirconia ML in the shade A3. The target shade being A3.5, a quite opaque material was selected in a slightly brighter shade to achieve the required masking effect.

Fig. 8. Single-bake layering procedure: Application of CERABIEN™ ZR Opacious Body, …

Fig. 9. … Cervical Body, …

Fig. 10. … Body and Transitional Body.

Fig. 11. Incisal cut-back …

Fig. 12. … and creation of the mamelon structure.

Fig. 13. Application of Aqua Blue 1 …

Fig. 14. … followed by T Blue …

Fig. 15. … and Luster Porcelains.

Fig. 16. Halo effect created with Body.

Fig. 17. Treatment outcome. (After a first bake followed by minor adjustments, a second bake, surface texturing and glazing with CERABIEN™ ZR FC Paste Stain Clear Glaze.)

CONCLUSION

Creating a single central takes us out of our comfort zone. By paying attention, observing the adjacent teeth carefully and using materials we really understand, it is possible to meet or exceed our patients’ expectations. While specific tools like cameras and experience with the utilized materials offer support in producing predictable outcomes, my main credo is “If you want things around you to change, you must first change yourself”. For continued improvement, it is thus necessary to focus on professional growth and advancement. With the right mentors who will teach us the secrets of stratification and inspire and motivate us to continue advancing, it becomes easier to restore the smiles and self-confidence of our patients every time they need us to.

Acknowledgements

Special thanks go to the dental practitioners who treated the patients presented above – Andreas Skyllouriotis DDS, MSD, Surgically-Trained Prosthodontist, and Theo Odysseos, DDS, Diplomate, American Board of Oral Implantology / Implant Dentistry.

Dental Technician:

VASILIS VASILIOU

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

Throughout his career, Vasilis has made significant contributions to the dental community, including presenting at various conferences in Greece and publishing articles in Greek dental magazines. Since 2020, he has been a key opinion leader for MPF Brush Company and, since 2022, a HASS Ambassador. Vasilis has been an active member of the International Team for Implantology (ITI) since 2019.

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

Interview with Dr. Efe Celebi

In March 2024, Dr Ahmad Al-Hassiny, Director of the Institute of Digital Dentistry, shared his observations from LMT Lab Day 2024 in Chicago, noting that over 90 percent of U.S. dental laboratories and nearly 50 percent of dental practices have already adopted digital technologies and workflows. These advancements streamline the production of dental models, restorations across various materials, and much more.

Our company Kuraray Noritake Dental Inc. is dedicated not only to developing high-quality products and constantly adapting them to the needs of dentistry, but also to streamlining procedures in the dental laboratory and practice. Aiming to understand the current needs of dental technicians and dental practitioners around the world to provide what would really make a difference, we are in close dialogue with experts in the field. We love to listen to their stories, learn how digital technologies and artificial intelligence are already transforming dental procedures and see how we can contribute to a smooth transition – e.g. with products that support efficient workflows and great outcomes.

Lately, we had the chance to sit down with a leading figure in Turkey’s digital dentistry transformation, Dr Efe Celebi, to discuss the current landscape and future of digital innovation in dentistry. Being convinced that his experience is worth being shared with a broader audience, we have summarized the conversation.

Dr. Celebi, you’re known as a pioneer in digital dentistry. What drove you to establish companies with a strong digital focus?

As the founder of Dentgroup, Turkey’s largest Dental Service Organization (DSO), I have always believed in the power of digital dentistry. My goal was to establish digital workflows for producing indirect restorations, beginning with intraoral scanning at our practices. Initially, we sought laboratory partners in Turkey willing to make this transition with us. But at that time, none of our partner labs were prepared to take the leap, so we decided to build our own. Digitalization, after all, is simplifying work in almost every field, and dentistry is no exception. So, in 2015, we founded DentLab to provide cutting-edge digital laboratory services.

How did you go about implementing digital workflows?

From the very beginning, we aimed to digitize every aspect of our work—from production to data management and communication. Our practices already used our own practice management software, DentSoft, successfully. To connect our clinics with the lab, we developed a specialized lab module. This allowed our dental practitioners to submit every order electronically. It was a huge improvement over the old process, where forms with sketches were mailed physically, just as it had been in in the old days. Now, practitioners can select the teeth in need of treatment, specify restoration colour and design, and upload radiographs, photos, and intraoral scans with just a few clicks. Over time, we have continuously enhanced communication features between clinics and labs, adding things like delivery date notifications for orders, so patients can book their next appointment before they even leave the clinic. These tools have greatly improved coordination between our dentists and lab technicians.

How is communication organized in the software?

We created a chat-style communication area where different team members can talk, with all records saved and accessible to anyone involved in a treatment. This setup is a major improvement over phone calls, as every detail—from treatment notes to radiographs and photos—is stored and easy to reference. We even enabled practitioners to rate the products they receive, and every necessary remake is documented along with the responsible technician. This feedback system has allowed us to maintain high-quality standards, identify issues, and provide targeted training where needed.

Modern digital technologies used at DentLab to provide cutting-edge digital laboratory services.

Have you made other improvements in workflow and communication between clinics and laboratories?

DentLab initially served Dentgroup practices exclusively, but we eventually opened its services to other clinics. In this context, we set standards for incoming orders—from the required data to impression quality. If an order does not meet these standards, we reserve the right to reject it, explaining why, so the submitter can improve. We also implemented a loyalty programme and developed a special, trackable package with a QR code to prevent loss of items in transit. This innovation lets both the team in the lab and the clinic track each package’s location in real time, solving a common logistical challenge. We have even patented this unique packaging system.

Unique patented delivery box used at DentLab to prevent loss of items.

Do you provide guidance on materials and tools for clinics?

Yes, as part of our commitment to quality, we recommend specific intraoral scanners and even distribute them to customers outside our network. We also advise clinics on material choices, pre-treatment needs, and compatible resin cements for permanent placement of the produced restorations. Our protocols cover the entire restorative procedure. For aesthetic cases, we recommend starting with a smile design and using mock-ups. The mock-up evaluation lets practitioners and patients provide feedback, so the responsible lab technician can produce the final restoration with precision.

With digital workflows so well-established, do you think technicians still benefit from meeting patients face-to-face?

Not necessarily. Occasionally, a dentist may request a patient visit the lab, and we accommodate this. However, digitalization has made physical distance irrelevant, as clinics and labs can now work seamlessly from anywhere. In fact, we serve offices in Europe without any face-to-face interactions between patients and lab technicians. For patients, especially in a city like Istanbul, avoiding long travel times is a big plus, while we can still ensure high-quality outcomes.

Would you say digitalization has improved treatment quality overall?

Absolutely. There is a learning curve to digital processes, but once practitioners adjust, the quality is noticeably higher. In traditional workflows, practitioners might bend the rules, asking technicians to work with suboptimal impressions, for example. Digital systems do not allow for such shortcuts; preparation quality is clear from the scan, and impression errors can be corrected instantly before submitting to the lab. Additionally, digital scans will never shrink, distort, or tear during production, unlike physical impressions.

What are the main challenges associated with digital dentistry today?

The biggest challenge is simply taking the first step. Dentistry has been hesitant to change after decades of doing things the same way. Going digital requires an investment in both time and money. But those who make the switch find the rewards—better outcomes and more efficient procedures—well worth it.

What is next for digital dentistry?

With AI advancing quickly, the field is evolving in exciting ways. Today, we can combine digital impressions, facial scans, photographs, and 3D imaging to create a “virtual patient”. Some clinics are already using software to analyze digital data, like dental X-rays, and I predict that robot-assisted or even autonomous clinical procedures are on the horizon. Imagine robot arms taking impressions or patients scanning their own teeth with smartphones. Impression-taking procedures carried out at home already support aligner treatments in some cases. As these technologies advance, the need for dental assistants will likely decrease. The digital future for dentistry is incredibly promising, filled with tools that can transform patient care and practice efficiency on a global scale.

Example of beautiful, precisely fitting all-ceramic restorations produced at DentLab.

INTRODUCING BRAND NEW PRODUCTS FOR SUCCESS WITH STREAMLINED, SMART SOLUTIONS

Kuraray Noritake Dental is pleased to announce that at IDS 2025 it will present a number of innovations that fundamentally improve dental procedures without compromising the quality of the result. Additionally, a number of internationally recognized experts will present their lectures and hands-on demonstrations on two separate stages: one dedicated to chair-side and the other one to lab-side topics. All of this represents not one, but a whole host of reasons to visit the stand (repeatedly).

CHAIR-SIDE NOVELTIES: UNIVERSAL EXCELLENCE

Development of the new products is rooted in a deep understanding of the demands of modern dental practice. Balancing complex procedures, tight schedules and patient needs is no easy task. That is why Kuraray Noritake´s team has been on a relentless journey to streamline, enhance and refine every step of work for decades. The vision is clear: a world where materials and tools work seamlessly in the dentist´s hands, where complexity is minimized, and where professionals are given enough time to focus on what matters most: the individual desires and needs of every single patient. Discover new additions to the UNIVERSAL EXCELLENCE family: a flowable universal composite and a new iteration of a universal bond.

CLEARFIL MAJESTY™ ES Flow Universal represents a fundamental shift in the idea of what universal composites can achieve. By integrating high filler loading and achieving high flexural strength, CLEARFIL MAJESTY™ ES Flow Universal challenges the traditional view of flowable composites as merely temporary fixes. Instead, it positions itself as a permanent solution capable of delivering both aesthetic excellence and structural reliability. Its unique light diffusion technology allows working with just two shades, and, in addition to that, offers a choice of two flowability options for easy handling.

CLEARFIL™ Universal Bond Quick 2 is the latest evolution in dental bonding technology, offering a streamlined, efficient solution for dental practitioners. Following the success of its predecessor CLEARFIL™ Universal Bond Quick, the new version “2” offers a redefined monomer technology that delivers exceptional bonding performance with minimal effort. Kuraray Noritake´s proprietary Advanced Rapid Bond Technology combines three key monomers – the original MDP, Amide and Urethane Tetra Methacrylate. Designed to enhance workflows, this adhesive provides robust performance across a wide variety of clinical situations.

LAB-SIDE NOVELTIES

Patient-centered prosthodontic approaches are enabled by innovative restorative materials and their correct processing in the dental laboratory. No matter whether a minimally invasive procedure or the best aesthetic outcomes are desired: Kuraray Noritake Dental has the solutions. In 2025, a new “smart” finishing material is being launched, delivering both on efficiency and aesthetics.

CERABIEN™ MiLai is a set of porcelains and internal stains specifically designed for the micro-layering technique. The name “MiLai” is derived from the term “micro-layering” and the Japanese word “mirai” (which means future). The innovative product based on synthetic feldspar enables dental technicians to add the final touch to their restorations in a simple and time-saving procedure – for outstanding aesthetics right from the start. The low firing temperature of CERABIEN™ MiLai (740°C) makes it the go-to solution for the finishing of both oxide ceramic (e.g. zirconia) and silicate ceramic (e.g. lithium disilicate) restorations. With fewer lines of porcelain needed, the porcelain inventory is reduced further and fewer decisions need to be taken.

Additional information and the full programme of lectures and hands-on courses at the IDS is available online.

Case by A/Prof Alan Yap, BDS (Syd), MDSc Hons (Pros)(Syd), FAANZP

Since 1983 PANAVIA™ by Kuraray Noritake Dental Inc. has been the gold standard for dental cements throughout the world. Their latest cement, PANAVIA™ Veneer LC, sets a new standard for porcelain veneer cements through incredible performance and ease of use. The following clinical case demonstrates the use of PANAVIA™ Veneer LC.

A 31-year-old female (Fig. 1) was referred for porcelain veneers to replace lost tooth structure and to improve aesthetics. The patient exhibited moderate attrition of her anterior and bicuspid teeth (Fig. 2), the result of nocturnal bruxism and a tendency to an edge-to-edge occlusion. She had a Class I malocclusion on a Skeletal Class I tending III base with the right maxillary canine in cross-bite. The treatment plan included orthodontic treatment, porcelain veneers, and an occlusal splint.

Fig. 1

Fig. 2

Orthodontic treatment (by Dr Nour Tarraf) included full-fixed appliances with TADs and IPR of mandibular anteriors, and arch retractions to reduce protrusion (Fig. 3, post-orthodontic treatment). A preliminary digital design (Fig. 4) was performed to guide the diagnostic wax-up and a digital mock-up (Fig. 5) was utilised to verify the diagnostic wax-up prior to carrying out the intra-oral mock-up. The patient was unable to afford the restoration of the maxillary bicuspids until a later stage so the reconstruction was limited to the maxillary anterior teeth.

Fig. 3

Fig. 4

Fig. 5

Using the diagnostic wax-up, silicone keys were fabricated to guide tooth preparations. Orthodontic treatment allowed prosthetic treatment to be additive in design which meant that tooth preparations could be conservative. Labial reductions were limited to 0.3 mm and incisal reductions were performed only where needed to create an incisal butt joint for the veneer (Fig. 6). Minimal preparations allowed the veneers to be bonded almost entirely to enamel, which is important for the long-term survival of porcelain veneers (Ref 1). There was no need to significantly mask the colour of the cervical region of the tooth and non-carious cervical lesions were absent, so fine chamfer margins were prepared at equi-gingival level.

Fig. 6

Splinted provisional veneers (Fig. 7) were fabricated using bisacryl ensuring sufficient interdental space to allow hygiene access for small interdental brushes. The labial surface of the provisional veneers were glazed with a unfilled resin and cemented using the spot-etch technique, ensuring all excess flowable composite was removed prior to curing (Fig. 8). Twice daily interdental cleaning of the provisional veneers and thorough brushing of labial margins during the provisional phase maintained soft tissue health, important for the try-in and cementation of the definitive veneers.

Fig. 7

Fig. 8

A dry try-in of the definitive veneers was performed to check the fit of the veneers and a wet try-in was performed using try-in paste to assess aesthetics. The PANAVIA™ Try-in pastes accurately mimic the cement shades. Four useful shades are available (Fig. 9). The White and Brown shades are useful to correct small discrepancies in shade requiring subtle increases or decreases in shade value respectively. Conveniently the try-in pastes are the same as the PANAVIA™ V5 range of try-in pastes (excluding opaque). Following the try-in procedure the teeth were isolated using rubber dam and the floss ligature technique. KATANA™ Cleaner (Fig. 10) was used to clean the veneers prior to silanating with CLEARFIL™ CERAMIC PRIMER PLUS (Fig. 11).

Fig. 9

Fig. 10

Fig. 11

Veneers that have not been pre-etched should be etched with hydrofluoric acid prior to silanization. The use of the ProsMate™ Baton allows the cleaning, etching and silanization of all veneers simultaneously (Fig. 12). The veneers are arranged systematically on the ProsMate™ Tray ready for the cementation procedure (Fig. 13). Tooth surfaces were pre-treated with phosphoric acid (K-ETCHANT Syringe) and PANAVIA™ V5 Tooth Primer (Fig. 14).

Fig. 12

Fig. 13

Fig. 14

The newly designed cement applicator tip reduces air bubbles and the wide 16-gauge tip (Fig. 15) allows light and easy control of cement extrusion while also providing efficient wide coverage during application. PANAVIA™ Veneer LC has excellent handling because of its ideal paste consistency. It is non-sticky and its viscosity prevents the cement from flowing beyond the veneer margins until the veneer is seated. It is not runny or stringy. Furthermore its thixotropic properties results in lower film thickness during seating of the veneer. These excellent handling properties are due to the development of new filler technology which consists of spherical silica and nano cluster fillers (Fig. 16). The “touch-cure” mechanism of PANAVIA™ V5 Tooth Primer importantly seals the bonding interface while the extended working time and stability of the cement under ambient light allows the simultaneous cementation of multiple veneers. In this case all six lithium disilicate veneers (technical work by Yugo Hatai) were cemented simultaneously with PANAVIA™ Veneer LC Paste (Clear).

Fig. 15

Fig. 16

Tack-curing each veneer for one second allowed smooth and easy bulk removal of excess cement with an explorer (Fig. 17). Remaining excess of uncured paste was removed with brushes. Final curing was performed by light curing lingual and labial surfaces.

Fig. 17

The optical characteristics of PANAVIA™ Veneer LC, use of fine chamfer margins, and well-fitting translucent restorations produces a gradual and smooth transition of colour from tooth to veneer where margins disappear and soft tissues respond in a healthy way (Fig. 18). The color stability, excellent abrasion resistance and high gloss durability of PANAVIA™ Veneer LC preserves integrity and aesthetics at the margins over the long term. The extraordinary bond strength of PANAVIA™ products, so familiar to our profession over the last 20 years, is still second to none (Fig. 19).

Fig. 18

Fig. 19

“KATANA” is a registered trademark or trademark of NORITAKE CO., LIMITED - “PANAVIA” and “CLEARFIL” are registered trademarks or trademarks of KURARAY CO., LTD.

References

1. Layton DM, Walton TR. The up to 21-year clinical outcome and survival of feldspathic porcelain veneers: accounting for clustering. Int J Prosthodont. 2012 Nov-Dec; 25(6):604-12. PMID: 23101040.

Article by Dr. Clarence Tam HBSc, DDS, FIADFE, AAACD

A NOVEL MDP-BASED SURFACTANT SOLUTION

The everyday practice of adhesive restorative dentistry, whether utilizing direct or indirect restorations, is fraught with the need for ideal environmental conditions to generate an optimal prognosis. The bonding of composite resin is the foundation of direct and indirect restoratives, as it provides the link between restoration and tooth. As dentistry strives to be minimally invasive, the treatment of the bonding interface is reflected in this philosophy by the use of self-etching multi-substrate acidic monomers such as 10-methacryloyloxyldecyl dihydrogen phosphate (10-MDP). There are myriad opportunities for both intaglio and fitting surfaces to be contaminated with varying agents to the detriment of restoration prognosis.

Some of the contaminants to be considered are of course, moisture from exhalation, ambient humidity in the oral cavity, blood, saliva and artificial sources such as provisional cement during a two-stage indirect delivery technique. Moisture is an agent which is only welcomed via a controlled approach during the dentin penetration phase of priming the substrate for adhesion, however if excessive in quantity will compromise the hybridization of the interface. Blood and saliva are ubiquitous in restorative dentistry, and best controlled via the application of rubber dam as part of an absolute isolation philosophy. Contamination of the prepared surface can also occur through artificial cements or lubrication agents. Hemostatic agents such as ferric sulfate and aluminum chloride have the ability to deposit insoluble precipitates on the surface of the tooth in a manner that 33% orthophosphoric acid can only partially remove. Also considered is the particulate deposition of dentin and enamel as part of standard tooth preparation. This smear layer is residual on the dentin surface, often occludes dentinal tubules, and is an obstacle that must be overcome in order to bond to the hydroxyapatite and collagen fibrils of the surface.

Overall, the risks to adhesive compromise and at worst, adhesive failure are high. This report details the use of a novel solution for debriding both indirect restorative and tooth intaglio with a 10-MDP salt-based solution that has the flexibility to be used both extraorally and intraorally.

ENDEMIC CONTAMINANTS: MOISTURE, BLOOD AND SALIVA

Moisture is a critical component to maximize the adhesive bond strength of certain modern universal adhesives. The presence of moisture allows for increased penetration of bonding solutions into dentinal tubules and between collagen fibrils, ultimately bolstering the resilience of the hybrid layer¹. During the cementation of an indirect restoration, both salivary and blood contamination of the mating surfaces have been shown to have a deleterious effect on bond strengths, with blood contamination faring the worst in all conditions². Van Meerbeck et al reported on technique sensitivity with one-step contemporary universal adhesives³. The basis of his findings note that these adhesives require water as an ionization medium for the self-etching reaction, with the need to evaporate water from the interfacial surfaces in order to maximize bond strengths. Despite this, these interfaces are considered semi-permeable which predisposes the hybrid layer to an increased risk of hydrolytic degradation in adhesive solutions that are not 2-hydroxyethyl methacrylate-free (HEMA-free), which has a greater affinity for water.

Periera et al tested varying degrees of wetness of dentin substrate controlled with variables such as short vs. long air blasts, wet vs. dry cotton pellets, microbrush use and an intentionally over-wet surface. In all groups, the “wettest” dentin intaglio surface resulted in the lowest shear bond strength⁴.

The influence of saliva and blood contamination is clearly negative in situations where the bonding interface was contaminated before or after adhesive application. For saliva, this reduction is due to the deposition of salivary glycoprotein on the surface, and relative to blood, macromolecules such as fibrinogen and platelets block access to the tubules for effective bonding. Blood contamination was found consistently to be more profoundly deleterious on bond strength relative to saliva².

In general, on smear layer-affected dentin, chlorhexidine was consistently superior to other agents such as ethanol, EDTA, aloe vera in establishing the highest shear bond strength to dentin. On dentin that had previously been etched and contaminated with blood and saliva, the agent subsequently applied that showed the highest recovery of shear bond strength was 37.5% phosphoric acid⁵. A study on the nanomechanical and nanoroughness of etched dentin and self-etching adhesive treated dentin both contaminated with saliva revealed that KATANA™ Cleaner was capable of restoring control values of complex modulus and nanoroughness relative to control⁶.

SYNTHETIC WORKFLOW CONTAMINANTS: DENTAL STONE, HEMOSTATIC AGENTS, ROOT CANAL SEALERS AND PROVISIONAL CEMENTS

A 2020 study by Marfenko et al demonstrated that salivary contamination showed significantly lower bond strengths relative to intaglio contamination by dental stone from laboratory processes. The application of a silane coupling agent to the intaglio surface has a protective effect on the bond strength⁷. The caveat is that lithium disilicate-based restorations are often requested pre-etched with hydrofluoric acid from the laboratory. Often, the case is returned to the clinician on the secondary or primary model. If already treated with hydrofluoric acid, the surface can now be considered recontaminated with the stone or resin model or simply skin oils from handling. The unprotected surface needs to be decontaminated in any case following the try-in procedure, which now may feature elements of dental stone, blood and saliva, not to mention hemostatic agents such as aluminum chloride and ferric sulphate. If silane coupling agents are applied prior to try-in, the question of whether the intaglio surface was truly contaminant-free after removal from the model.

Aluminum chloride is a hemostatic agent that leaves an insoluble precipitate on the surface of the dentin, that is only partially removed when treated with phosphoric acid, resulting only in a partial recovery of shear bond strength relative to control. The application of ethylene diacetyl tetrasodium acetate (EDTA) returned the bond strengths to the level of normal dentin⁸. The bonding of polycrystalline ceramic restorations and metal alloys is contaminated with saliva upon try-in. This can be removed via steam cleaning and air particle abrasion set at 2.5 bar for 15 seconds⁹. Phosphoric acid is often mistakenly applied as a cleaning agent to the intaglio surface. In polycrystalline ceramics such as tetragonal zirconia polycrystal, this is disastrous, as phosphates will bond firmly to the free sites that the 10-MDP monomer normally bonds to as part of the APC protocol of zirconia bonding, significantly compromising bond strength (Blatz, 2016)¹⁰. A study of modern surface cleaners demonstrated successful debridement of the surface using KATANA™ Cleaner for both blood and saliva-contaminated substrates^{11, 12}.

Provisional cements are thought to have a deleterious effect on the shear bond strength of adhesively-bonded indirect ceramic restorations. Ding et al (2022) uncovered that resin-based and non-eugenol cement use in the provisional phase decreased the bond strength relative to control, whilst the use of calcium hydroxide and polycarboxylate cements exhibited acceptable metrics. Debridement of the prepared surface with air particle abrasion (APA) resulted in recovery of decreased bond values to that of control¹³. Equally useful was the application of Immediate Dentin Sealing (IDS)¹⁴, a technique characterized ideally by APA before adhesive bonding and the application of a resin coat, occluding both the dentin tubules as well as the oxygen inhibition layer, allowing the resin-dentin bond to mature and strengthen in the absence of stresses. This approach is effective in minimizing post-operative hypersensitivity and bacterial ingress, as well as optimizing the shear bond strength particularly when indirect ceramics are concerned¹⁵. Hardan et al found that the shear bond strength was highest when IDS was completed using a three-step etch and rinse adhesive protocol¹⁴.

Hemostatic agents used in clinical dentistry exhibit a pH of 1.1 to 3.0 and are as acidic as self-etching primers¹⁶. Chaibutyr and Kois found that dentin when contaminated with 25% aluminum chloride or 13% ferric sulphate demonstrated a significantly lower shear bond strength to dentin, which was significantly recovered using the etch-and-rinse approach¹⁷. This approach albeit successful was only able to achieve partial reversal of shear bond strength deficits relative to control, with a pre-etching application of EDTA required in order for full recovery⁸. KATANA™ Cleaner was found to have a positive effect on the cleaning of dentin contaminated with both aluminum chloride and ferric sulphate.

The bonding of dentin substrate contaminated with root canal sealers is a concern for the integrity of core buildups post-endodontic treatment. The use of  KATANA™ Cleaner was found to be generally superior to the ethanol test subgroup in the removal of zinc-oxide eugenol-based sealer with equal performance to 70% ethanol for the epoxy resin-based sealer¹⁸.

CLINICAL CASE DEMONSTRATION

A 35 year old ASA 1 female patient presented to the practice with multiple failing composite restorations in the second quadrant that were planned for replacement. Prior to the delivery of topical and local anaesthesia, it is common procedure in the practice to ascertain shade specifics of planned restoratives before potential dehydration can affect the optical properties of the natural tooth. Smart monochromatic composites (Fig. 1) are a class of direct restoratives that leverages the ability of its nanofiller composition and refractive index to mimic the structural color of the surrounding enamel and dentin¹⁹. This typically enables a clinician to have a simplified selection of shades on hand.

Two carpules of 2% Lignocaine with 1:100,000 epinephrine were delivered via buccal infiltration before absolute isolation was achieved using a non-latex rubber dam (Isodam HD Heavy, 4D Rubber, UK) (Fig. 2). The old restorations were excavated along with caries (Fig. 3), and the dentin structure assessed for residual decay with a detector dye (Caries Detector, Kuraray Noritake Dental Inc.). The preparation cavosurface margins were gently bevelled before surface treatment with air particle abrasion (30psi, 29 micron aluminum oxide in a 17.5% ethanol carrier, Aquacare UK) (Fig. 4). The enamel margins were etched with 33% orthophosphoric acid and rinsed (Fig. 5). The preparation surfaces were decontaminated further of any residual smear or powder residue using a MDP-based surfactant (KATANA™ Cleaner, Kuraray Noritake Dental Inc.) (Fig. 6). A single step self-etching universal adhesive was applied to the preparation as per manufacturer instructions and air thinned before light curing (Fig. 7).

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Fig. 7

A matrix-in-matrix approach was utilized for the second bicuspid as the first step to allow for simultaneous anatomic construction of the mesial and distal marginal ridges. This technique does not require the use of a wedge as the outer circumferential Tofflemire matrix (Omnimatrix, Ultradent Products) tightens cervically around the inner anatomically-curved sectional matrix (Garrison Firm Band, Garrison Dental Solutions) allowing for a hermetic gingival seal (Fig. 8). If required, the setup may be further modified by the use of Teflon inserted between the two matrices to provide better proximofaciolingual adaptation. As a result, finishing and contour creation post-band removal is kept to a minimum. Following this, a traditional sectional matrix system may be employed to close contacts and build marginal ridges in the conventional manner (Fig. 9).

Following marginal ridge construction, the matrix assembly was removed and with the Class II lesions converted into a Class I situation, microlayering proceeded with a high flexural strength flowable liner (CLEARFIL MAJESTY™ Flow, Kuraray Noritake Dental Inc.) prior to the application of a monochromatic composite resin (CLEARFIL MAJESTY™ ES-2 Universal U shade, Kuraray Noritake Dental Inc.). The buccal cusps were constructed first as the author considers this essential to establishing restoration lobe proportions (Fig. 10). Subsequent layers were completed in a lobe-by-lobe approach to finish the occlusal anatomy (Fig. 11 and 12). The restoration was checked for occlusal functional conformativity, finished and polished to high shine (Fig. 13).

Fig. 8

Fig. 9

Fig. 10

Fig. 11

Fig. 12

Fig. 13

DISCUSSION

Dental substrates are often contaminated in both direct and indirect restorative processes. Historically, etch-and-rinse approaches have been successful for at least the partial recovery of bond strength however it is not practical in situations where selective or self-etching is the adhesive strategy. The restorative dentist in these cases can use the 10-MDP monomer in self-etching systems to target non-demineralized dentin such as CLEARFIL™ Universal Bond Quick to establish an acid base resistance zone (ABRZ) otherwise known as Super Dentin²⁰. The presence of the operative smear layer impedes full access of the self-etching primer to the dentin substrate in some cases. In such cases, without KATANA™ Cleaner, APA is required to transform the substrate back to control bonding potential. APA as a modality is only utilized by a subset of dental practitioners often due to financial constraints or lack of technique experience. KATANA™ Cleaner thus represents a versatile tool for the decontamination and  optimization of substrate surfaces for adhesive bonding both in intraoral and extraoral applications. Its ability to re-establish ideal bonding values in areas that are not effectively reached by APA such as endodontic canal anatomy in a non-invasive manner literally cements it as a truly indispensable tool for the modern restorative dentist.

Disclaimer: Some indications are not described in the product’s Instructions for Use and are based on published research and/or the author’s experience. Before using each product, read carefully the Instructions for Use supplied with the product for full details and workflows.

Dentist:

CLARENCE TAM

References

1. Sugimura R, Tsujimoto A, Hosoya Y, Fischer NG, Barkmeier WW, Takamizawa T, Latta MA, Miyazaki M. Surface moisture influence on etch-and-rinse universal adhesive bonding. Am J Dent. 2019 Feb;32(1):33-38. PMID: 30834729.
2. Taneja S, Kumari M, Bansal S. Effect of saliva and blood contamination on the shear bond strength of fifth-, seventh-, and eighth-generation bonding agents: An in vitro study. J Conserv Dent. 2017 May-Jun;20(3):157-160. doi: 10.4103/0972-0707.218310. PMID: 29279617; PMCID: PMC5706314.
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5. Haralur SB, Alharthi SM, Abohasel SA, Alqahtani KM. Effect of Decontamination Treatments on Micro-Shear Bond Strength between Blood-Saliva-Contaminated Post-Etched Dentin Substrate and Composite Resin. Healthcare (Basel). 2019 Nov 1;7(4):128. doi: 10.3390/healthcare7040128. PMID: 31683858; PMCID: PMC6956069.
6. Toledano M, Osorio E, Espigares J, González-Fernández JF, Osorio R. Effects of an MDP-based surface cleaner on dentin structure, morphology and nanomechanical properties. J Dent. 2023 Nov;138:104734. doi: 10.1016/ j.jdent.2023.104734. Epub 2023 Oct 2. PMID: 37793561.
7. Marfenko S, Özcan M, Attin T, Tauböck TT. Treatment of surface contamination of lithium disilicate ceramic before adhesive luting. Am J Dent. 2020 Feb;33(1):33-38. PMID: 32056413.
8. Ajami AA, Kahnamoii MA, Kimyai S, Oskoee SS, Pournaghi-Azar F, Bahari M, Firouzmandi M. Effect of three different contamination removal methods on bond strength of a self-etching adhesive to dentin contaminated with an aluminum chloride hemostatic agent. J Contemp Dent Pract. 2013 Jan 1;14(1):26-33. doi: 10.5005/jp-journals-10024-1264. PMID: 23579888.
9. Yang B, Lange-Jansen HC, Scharnberg M, Wolfart S, Ludwig K, Adelung R, Kern M. Influence of saliva contamination on zirconia ceramic bonding. Dent Mater. 2008 Apr;24(4):508-13. doi: 10.1016/j.dental.2007.04.013. Epub 2007 Aug 6. PMID: 17675146.
10. Blatz MB, Alvarez M, Sawyer K, Brindis M. How to Bond Zirconia: The APC Concept. Compend Contin Educ Dent. 2016 Oct;37(9):611-617; quiz 618. PMID: 27700128. (7)
11. Awad MM, Alhalabi F, Alzahrani KM, Almutiri M, Alqanawi F, Albdiri L, Alshehri A, Alrahlah A, Ahmed MH. 10-Methacryloyloxydecyl Dihydrogen Phosphate (10-MDP)-Containing Cleaner Improves Bond Strength to Contaminated Monolithic Zirconia: An In-Vitro Study. Materials (Basel). 2022 Jan 28;15(3):1023. doi: 10.3390/ma15031023. PMID: 35160968; PMCID: PMC8838745.
12. Tian F, Londono J, Villalobos V, Pan Y, Ho HX, Eshera R, Sidow SJ, Bergeron BE, Wang X, Tay FR. Effectiveness of different cleaning measures on the bonding of resin cement to saliva-contaminated or blood-contaminated zirconia. J Dent. 2022 May;120:104084. doi: 10.1016/j.jdent.2022.104084. Epub 2022 Mar 3. PMID: 35248674.
13. Ding J, Jin Y, Feng S, Chen H, Hou Y, Zhu S. Effect of temporary cements and their removal methods on the bond strength of indirect restoration: a systematic review and meta-analysis. Clin Oral Investig. 2023 Jan;27(1):1530. doi: 10.1007/s00784-022-04790-6. Epub 2022 Nov 24. PMID: 36422719; PMCID: PMC9877054.
14. Hardan L, Devoto W, Bourgi R, Cuevas-Suárez CE, Lukomska-Szymanska M, Fernández-Barrera MÁ, Cornejo Ríos E, Monteiro P, Zarow M, Jakubowicz N, Mancino D, Haikel Y, Kharouf N. Immediate Dentin Sealing for Adhesive Cementation of Indirect Restorations: A Systematic Review and Meta-Analysis. Gels. 2022 Mar 11;8(3):175. doi: 10.3390/gels8030175. PMID: 35323288; PMCID: PMC8955250.
15. Samartzi TK, Papalexopoulos D, Sarafianou A, Kourtis S. Immediate Dentin Sealing: A Literature Review. Clin Cosmet Investig Dent. 2021 Jun 21;13:233-256. doi: 10.2147/CCIDE.S307939. PMID: 34188553; PMCID: PMC8232880.
16. Woody RD, Miller A, Staffanou RS. Review of the pH of hemostatic agents used in tissue displacement. J Prosthet Dent. 1993 Aug;70(2):191-2. doi: 10.1016/0022-3913(93)90018-j. PMID: 8371184.
17. Chaiyabutr Y, Kois JC. The effect of tooth-preparation cleansing protocol on the bond strength of self-adhesive resin cement to dentin contaminated with a hemostatic agent. Oper Dent. 2011 Jan-Feb;36(1):18-26. doi: 10.2341/09-308-LR1. Epub 2011 Feb 21. PMID: 21488725.
18. 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 Sep;112:103766. doi: 10.1016/j.jdent.2021.103766. Epub 2021 Aug 5. PMID: 34363888.
19. Ahmed MA, Jouhar R, Khurshid Z. Smart Monochromatic Composite: A Literature Review. Int J Dent. 2022 Nov 8;2022:2445394. doi: 10.1155/2022/2445394. PMID: 36398065; PMCID: PMC9666026.
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Article by Dr. Clarence Tam HBSc, DDS, FIADFE, AAACD

A CHAMELEON SUPERCOMPOSITE

INTRODUCTION

The name of the game in modern-day esthetic and restorative dentistry is that of Responsible Esthetics. The goal of treatment typically strives to correct any structural and cosmetic shortfalls in both biologically-driven and trauma-affected teeth with the precise, artistic placement of various replacement layers, all whilst respecting and retaining a maximal volume of residual tooth structure. Anterior teeth can be affected by enamel and dentin dysplasia, caries and sclerotic conditions and are characterized by a laundry list of genetically-derived and environmentally-acquired conditions with an esthetic deficit that often threaten an individual’s functional and psychosocial integrity if not restored to the seamless picture of health.

Missing and defective tooth structure must be categorized into its attendant enamel and dentin components. Both substrates are distinctly different in composition, with enamel being highly inorganic in nature and dentin proportionately more collagenous in nature. The latter stratum is responsible for the refraction of light, the expression of the true color of the tooth, namely the hue and the endowment of fracture toughness or resilience in functional performance. The value and chroma are the other elements of color and are modified by the thickness of enamel. The replacement of enamel has been found to be best substituted from a biomechanical perspective by adhesively-bonded indirect porcelain restorations, and dentin using both composite resin and short fiber reinforced composite (SFRC), the latter imparting increased fracture toughness in large volume replacement restorations, especially those with pericervical structural deficits.

In adolescent patients, the gold standard of treatment involves direct composite resin, as often zero to minimal tooth structure preparation is required as a foundation to the bonded restorative. It would be impractical to use bonded indirect restorations when the development of the dentition in puberty is continuous, especially with the retraction of gingiva as one progresses to young adulthood. Resin composite allows prescience in the opportunity to predictably modify and/or add to the existing restoration if dental bleaching for the other teeth is desired or if a further traumatic incident is encountered. The ability to modify bonded porcelain is not predictable and frequent marginal failures occur due to a lower shear bond strength to bonded composite, especially after thermocycling. This is despite our ability to establish a chemical linkage via silane coupling agents from silicate ceramics to resin composite especially at a blended interface.

STATEMENT OF PROBLEM

Dental shades in clinical dentistry have long been classified using the VITA^* Classical A1 – D4 shade guide. Despite being ubiquitous in dental practices, composite resin systems with corresponding shade systems do not satisfactorily match to their purported shade¹. Floriani et al found that various mixtures of different shades in one system was required to achieve an acceptable color match with the VITA^* Classical shades using the CIEDE2000 formula. Testing another composite resin, they found that none of the A1, A2 or A3 shades matched acceptably to the standard shade guide². Indeed, even with indirect ceramic layering systems, a wide range of unacceptable discrepancy was noted between VITA^* labeled porcelain shades and the actual shade guide³. The VITA^* Classical shade guide became the standard in dental shade classification with the release of its A1-D4 shade guide in 1985. The majority of human-tested dental shades has been found to be in the A-family (78.5%), followed by C (13.2%), D (5.2%) and B (3.1%)¹. As such, the shade accuracy of a given composite system must be important if they are to be visually naturomimetic.

CHAMELEON EFFECT DEVELOPMENT

There are myriad composite resin systems featuring a simplified shade Universal system that have acceptable chameleon effects due to their balance of translucency, light transmission, diffusion and refractive index properties. There is a concern over how these optical properties may change after both thermocycling and wet storage, potentially compromising the excellent initial esthetic blend⁴. Refractive index (RI) is best optimized when the RI of the inorganic fillers match closely with the RI of the cured organic matrix, typically in a range between 1.47 and 1.52⁵. If the match is dissimilar, this drives up the opacity of the restoration due to heightened refraction and reflection at the filler/matrix interface⁶.

Layering of composite to mask an intraoral defect is complicated by the need to mask any linear defects such as fracture lines superimposed over the shadowing of the dark intraoral cavity in addition to regional color variations. It is confounded by the requirement to recreate natural maverick and translucent effects particularly in the incisal window region of upper and lower incisors and canines, giving the illusion of a virgin, healthy tooth. This has been historically difficult to accomplish in anterior teeth given the need to block out restorative interfaces with natural tooth structure and recreate a seamless internal structure and details. This detailed layer belies a well contoured enamel layer with realistic translucency, polishability and accurate primary and secondary anatomy.

Adding to the complexities described above, the histoanatomical approach to composite layering dictates that missing enamel is replaced by enamel shades, and dentin by the corresponding dentin shade in the appropriate shade. This shade must be selected at the very start of the appointment, as often even a minute of dehydration has a negative effect on both the perceptibility threshold and acceptability threshold of teeth⁷, resulting in the incorrect shade.

DEVELOPMENT

CLEARFIL MAJESTY™ ES-2 is a value-based super-nanofilled composite system that covers 15 VITA^* shades in just 4 shade options with its Universal series. This Universal series provides a chameleon effect and has 4 variants: Universal (U), Universal Light (UL), Universal Dark (UD) and Universal White (UW). It is the VITA^*-approved shading concept relative to color accuracy. Incorporating nano-fillers that consist of silanated barium glass fillers and slanted silica nanoclusters, its wear resistance is high and features minimal abrasiveness against the functional antagonist. The RI of both inorganic filler and organic matrix are well-matched, and the high refractive index of the composite mimics and is extremely similar to natural enamel (1.613) and dentin (1.540), thanks to an innovation labeled Light Diffusion Technology (LDT), which distorts light in a similar way dental tissue does⁸. There is comfort that the stability of refractive index and other optical transmission properties remains statistically stable even after artificial thermocycling and water-storage aging studies⁴. The color stability of CLEARFIL MAJESTY™ ES-2 has been proven over time, where a direct comparison to Filtek Ultimate showed CLEARFIL MAJESTY™ ES-2 to feature significantly less color variation from baseline and marginal functional wear over a three to four year period in teeth featuring amelogenesis imperfecta⁹. This color substantivity is important as dietary and environmental stressors applied over time should have as minimal effect on the restoration to ensure continued esthetic integration.

CLINICAL PROTOCOL

CLEARFIL MAJESTY™ ES-2 Universal is a monochromatic solution that covers the five key shades featured in the CLEARFIL MAJESTY™ ES-2 Premium. As such, it exhibits the most significant LDT relative to all five shades, as its ability is equal when blending to higher value translucent shades as it does to cervical chromatic shades. In a Class IV restoration with a defined fracture line, the challenge is to restore the tooth in a minimal volume of available space. The alchemy requires a complete visual occlusion of the fracture line position, and recreation of internal and external opaque and translucent anatomy along with maverick staining, craze lines and effects. In anterior teeth, the idiom of “the less you see, the less you notice” is not true, especially due to the presence of incisal edge window effects as above, however, materials with the best light diffusion and structure transference properties should be utilized to ensure the highest probability of success.

A 15 year old ASA I female presented to the practice exhibiting aged, chromatic composite restorations with poor marginal integration and gross axial overhangs; essentially a gross failure of primary anatomy and esthetics. She had been involved in a bike accident where she high-sided off braking sharply in a face-meets-concrete scenario, resulting in an uncomplicated moderate enamel-dentin fracture with blushing, affecting both the facial and palatal aspects of tooth 1.1 and a mild uncomplicated enamel dentin fracture affecting the distoincisobuccolingual aspect of tooth 2.1. The restoration overhangs were significant, extending into the proximal contour zone, thus obviating effective interdental cleaning. Vitality tests were confirmed along with radiographs to exclude the presence of apical pathology. The patient accepted the option of pre-prosthetic whitening, to improve the value characteristics of the adjacent teeth, allowing the selection of a brighter value shade combination. Intraoral digital scans were acquired and custom bleaching trays with a no reservoir, cervical seal-priority design were fabricated. The patient was instructed to bleach overnight for a 2 week period using a 10% carbamide peroxide solution (Opalesence, Ultradent Products, UT) until her maximal value was reached. Her baseline shade of the incisors was a 1M1/2M1 combination in the upper incisors and a 2M1 in the lower incisors. On final post-bleach assessment she exhibited a lightened shade of VITA^* 0M3 in all incisors. The patient was instructed to use a fluoride-containing, amorphous calcium phosphate complex (ToothMousse Plus, GC America) during the following 2 weeks after cessation of whitening whilst the residual oxygen radical species dissipated from the teeth.

Fig. 1. Pre-operative unrestricted smile 1:2 ratio view, teeth 1.1 and 2.1 with old, defective composite restorations with excessive chroma.

On the day of the procedure, the pre-dehydrated shade was assessed using the supplied “real composite” shade guide tabs featured in the CLEARFIL MAJESTY™ ES-2 Premium system, with the enamel shade being WE (White Enamel) and the dentin shade WD (White Dentin). It was assessed that both white maverick effects as well as a moderate halo effect was desired along with moderate to strong translucency in the incisal window.

The patient was anesthetized using 1.5 carpules of 2% Lignocaine with 1:100,000 epinephrine (Septodont) before a rubber affixed with individual ties for the central incisors (NicTone Medium). Excavation of the old restorative material was undertaken, and the residual natural incisal edge was found to be undermined by a through-and-through fracture. Thus, the preparation was converted into a true Class IV design, with the facioincisal cavosurface margin subjected to an infinity bevel. The maxillary central incisors were isolated from the lateral incisors by way of a serrated metal strip (Komet) and the prepared surfaces subjected to micro particle abrasion using a 29 micron aluminum oxide powder in 17.5% ethanol carrier (Aquacare). The surfaces were subsequently treated with a calcium sodium phosphosilicate powder (Sylc, Aquacare) to increase the inorganic content of the prepared surface especially extending into the exposed tubules. The teeth were etched using a 33% orthophosphoric acid before a 1 minute 2% chlorhexidine scrub (Vista Products). The surface was reduced to a moist dentin surface before the bond applied, air thinned and cured.

A Mylar strip was pre-crimped in the palatoproximal line angles and positioned on the linguoaxial surface of both teeth 1.1 and 2.1. There is no shade guide for the CLEARFIL MAJESTY™ ES-2 Universal U shade, as it bears a significant chameleon effect however it does come in a light (L) and dark (D) variant. The UL shade was deemed the most suitable for the palatal or lingual shelf, with an average thickness of 0.3mm. This layer was applied in a freehand fashion with a focus on establishing the desired outline form of the tooth relative to the contralateral 2.1. The Mylar matrix setup was removed and a precurved metal matrix (Garrison Slickband, Garrison Dental) was oriented in a position perpendicular to its normal placement interproximally, and the end of the curved band tucked into the sulcus before being secured by a wedge. In this way, there is light separation of the central incisors and an intimate contact between the matrix band and the mesial edge of the freshly applied lingual shelf. A 0.5mm frame extending more than halfway through the contact point was created and cured. The process was repeated on tooth 2.1 with the goal of recreating both lingual and proximal walls of the restoration, leaving only the facial volume to be replaced.

Fig. 2. Pre-crimped Mylar matrix repeated on the DIBP aspect of tooth 2.1 to close the available space. CLEARFIL MAJESTY™ ES-2 Universal UL is used here.

Block-out of the composite extensions against the natural tooth structure was achieved by opacification using an opaque composite resin (WD, CLEARFIL MAJESTY™ ES-2 Premium, Kuraray Noritake Dental Inc.) layered in both horizontal and vertical increments. It is noted that the restorative join line must be completely obscured at the end of layering the dentin volume, otherwise the case will have almost certain esthetic failure. The internal dentin anatomy and its inherent variation was created to mirror that of the 2.1, which had minimal compromise of its incisal window with details intact. A super translucent composite resin (Clear, CLEARFIL MAJESTY™ ES-2 Premium, Kuraray Noritake Dental Inc.) was placed between the lobes of the dentin layers and cured. A 9:1 ratio of white: orange tint was mixed and placed on the incisal edge and proximoincisal corners to recreate the halo effect. A pure white tint was placed in gentle dentin mamelon-connecting spider legs up to the incisal edge to impart the realism. This was layered in a manner consistent with the appearance of the 2.1.

Fig. 3. Both horizontal and vertical dentin composite increments are demonstrated mimicking the contralateral tooth.

Fig. 4 & 5. Final immediate post-operative result after finishing and polishing.

DISCUSSION

The esthetic merit of this case is foundationally supported by composite resin technology on multiple levels. The color and physical stability over time needs to be proven in order for the clinician to have faith in its prognostication. Specifically, the material needs to have an excellent and well-matched refractive index, and one that is unaffected by both water and thermocycling stressors.

The palatal shelf was fabricated using a new-generation super nano-filled universal composite system that boasts a strong chameleon effect. If it is our intention to fool the eye, to obscure, then this first layer works well to start the blockout process of the darkness of the mouth behind the fracture line of the restored tooth. Following this, the chroma and value of the tooth are corrected using the dentin, simultaneous to its continued opacification of the fracture line and intraoral darkness. Both dentin and enamel layers are applied histoanatomically, that is, in a manner respecting the various thickness zones observed in nature.

Ultimately, esthetic success in direct composite resin is not dictated on the first day post-operatively. Factors are in play, from dehydration to occlusal wrinkles that need to be ironed out and corrected. The win depends on what material is used, along with how that material was developed to what standards, and why shade accuracy is so important in a world of variety. In a dental world with myriad composite options, we are looking for precision. Precision in technology leads to efficiency and physicoesthetic maintenance in clinical results. This ultimately results in a boost to clinician-patient confidence and an optimal prognosis.

Dentist:

CLARENCE TAM

*VITA is a trademark of VITA Zahnfabrik, Bad Sackingen, Germany

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