429 Too Many Requests

Case by Jotautas Kaktys, DDS

Post-endodontic restorative treatments can be quite challenging, mainly because so many decisions need to be made. It is up to the clinician to evaluate the structural condition of the tooth to decide whether a direct or indirect restoration should be selected, which cusps to overlay and which ones to keep, and whether a post or fiber placement is required. Depending on the amount and condition of remaining tooth structure, a direct or indirect restorative approach may be more adequate; while selecting the indirect approach means they have the choice between lots of different restorative materials and restoration designs.

A CASE AS AN EXAMPLE

At our &SMILE clinic in Kaunas, Lithuania, the main goal is always to preserve as much natural tooth structure as possible without compromising the longevity of the restoration. Consequently, we opt for the least invasive approach reasonable, thereby using materials that mimic the mechanical and optical properties of the natural dentition. In this context, hybrid ceramics such as KATANA™ AVENCIA™ Block 2 are often a valuable choice.

The following case is used as an example to demonstrate the biomimetic approach in a situation that required an endodontic revision followed by an indirect restoration of the tooth that had previously been restored with composite.

STRUCTURALLY COMPROMISED MOLAR RESTORATION

The patient came in for a regular routine checkup. A massive composite restoration on her maxillary right first molar (FDI notation: tooth #16) attracted our attention as it appeared to be structurally compromised: Clinical examination revealed some occlusal porosities along the restoration margin, as well as cracked and chipped areas (Fig. 1). The buccal margin was stained and leaky (Fig. 2), while on the palatal surface, some micro-cracks were visible in the surrounding tooth structure (Fig. 3).

Fig. 1. Initial clinical situation with a large composite restoration that shows porosities at the margin.

Fig. 2. Buccal surface of the first molar with a stained, leaky margin.

Fig. 3. Palatal surface with micro-cracked tooth structure.

As the tooth had been endodontically treated elsewhere several years ago, a radiograph was taken (Fig. 4). This radiograph revealed that the canals were not filled to the apices of the roots. However, as the patient showed no symptoms, the decision was made to go for an indirect restoration without any endodontic retreatment: Reasons to opt for an indirect restoration included the large size of the existing composite restoration and the compromised condition of the surrounding tooth structure. Cementing indirect restorations offers additional benefits of virtually no polymerization shrinkage as well as minimal stress to the remaining and already compromised tooth structure and results in better mechanical properties. The tooth shade was determined immediately: The adjacent premolar had a tooth shade resembling A3 in the middle third, while the occlusal third showed some whitish spots and appeared brighter, similar to A2 (Fig. 5). This information was recorded for the dental laboratory.

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Clinical case by Dr. Claudia Mazzitelli and Dr. Edoardo Mancuso

INTRODUCTION

Dental aesthetics are gaining increasing importance and require predictable, rapid, and affordable treatments. Minimally invasive dentistry favours direct restorations, which are now simplified by the evolution of flowable composites. Recent variants of flowable composites offer optical and mechanical characteristics equal or superior to those of paste-type composites. The evolution of flowable resins has led to widespread application using the flowable injection technique (FIT). In addition, the possibility of 3D printing an index for injection reduces operator-dependent variability, providing for high-level aesthetics.

CLINICAL CASE

A 24-year-old patient complained of an unattractive smile. After clinical and radiographic examinations, an aesthetic restoration using FIT was planned. A digital wax-up, created on the basis of intraoral scans (Trios 5, 3Shape), allowed for the design of a customised index or template, which was printed using transparent resin (IBT Flex Resin, Formlabs). After preparation and isolation, the teeth were sandblasted, etched, and a universal adhesive (CLEARFIL™ Universal Bond Quick 2) was applied and light-cured. Flowable composite (CLEARFIL MAJESTY™ ES Flow Low) was injected through the injection holes in the index, followed by thorough curing, finishing and polishing (TWIST™ DIA for Composite, all Kuraray Noritake Dental Inc.).

RESULTS

The treatment, completed in two hours, led to immediate and stable aesthetic improvement, confirmed during check-ups after one week and six months, with excellent gum health and restoration maintenance.

DISCUSSION

FIT offers predictable aesthetic results, a digital workflow option, and reduced clinical time compared to indirect restorations, while maintaining the possibility of future prosthetic treatments. The evolution of flowable composites and 3D-printed indexes has improved the accuracy of clinical transfer and reproducibility, allowing for rapid, conservative aesthetic solutions.

CLINICAL CASE

A 24-year-old male patient presented at our practice dissatisfied with the aesthetics of his smile, with an impact on his spontaneity and social life. After taking his medical and dental history, an interview was conducted to understand his aesthetic and functional expectations as well as financial possibilities.

The clinical visual examination, accompanied by photographs, static and dynamic videos, periodontal analysis, and radiographs, revealed incongruous Class IV restorations on teeth 11 and 21 (FDI notation), with asymmetry of the anterior maxillary region  (Fig. 1). Aesthetic rehabilitation using the Flowable Injection Technique (FIT) extended to the six maxillary anterior teeth was therefore proposed.

Fig. 1. Initial clinical situation.

TREATMENT PLANNING

An intraoral scanner (Trios 5, 3Shape) was used for impression taking. The resulting digital model was used to create a digital wax-up, which then served as the basis for digitally designing an index for the injection of the flowable composite (Fig. 2). The index was printed in transparent resin (IBT Flex Resin, Formlabs) (Fig. 3). Once post-processing was complete, calibrated injection holes were integrated. They allow for insertion of the syringe tip and precise injection of the flowable composite (Fig. 4).

Fig. 2. Computer-aided index design.

Fig. 3. 3D-printed transparent index for composite injection.

Fig. 4. Injection holes integrated in the incisal areas of the index.

OPERATIVE PROCEDURE

After obtaining informed consent from the patient, the old restorations on the maxillary central incisors were removed with diamond burs under irrigation. The margins were finished and bevelled (Fig. 5). The index was positioned on the upper arch and evaluated for stability and retention. To produce the restorations alternately, PTFE tape (0.076 mm) was applied to isolate the adjacent teeth. The surfaces of the teeth to be restored were sandblasted with aluminium oxide (50 µm), etched with 37 % orthophosphoric acid etchant for 15 seconds, rinsed, and dried (Fig. 6).

Fig. 5. Maxillary central incisors after restoration removal and bevelling of the margins.

Fig. 6. Etching of the tooth surfaces with orthophosphoric acid etchant.

A universal adhesive (CLEARFIL™ Universal Bond Quick 2, Kuraray Noritake Dental Inc.) was then applied (Fig. 7) and polymerized with an LED curing light (SmartLite® Pro, Dentsply Sirona) for 10 seconds per tooth (Fig. 8).

A flowable composite (CLEARFIL MAJESTY™ ES Flow Low, colour W, Kuraray Noritake Dental Inc.) was injected through the holes until the index of the first prepared tooth was filled (Fig. 9). After light-curing for 40 seconds per tooth through the transparent index, the template was removed and the restoration was light-cured for a second time. Excess composite was then removed with a scaler.

Fig. 7. Application of a universal adhesive.

Fig. 8. Light-curing of the adhesive layer.

Fig. 9. Flowable composite injection.

The same procedure was subsequently repeated for the other teeth to be treated, isolating those already restored using PTFE tape (Figs. 10 to 15).

Fig. 10. Restored teeth isolated with PTFE tape.

Fig. 11. Etching of the tooth structure with 37 % orthophosphoric acid etchant.

Fig. 12. Application of the universal adhesive.

Fig. 13. Light-curing of the adhesive layer.

Fig. 14. Injection of the flowable composite into the index.

Fig. 15. Light-curing of the flowable composite through the transparent index.

Once the index was removed and excess material was eliminated. Then, the teeth were isolated with rubber dam using the split dam technique to improve patient comfort and visibility, and the restorations were finished with fine-grained diamond burs. Finally, progressive polishing was performed with polishing discs  (TWIST™ DIA for Composite, Kuraray Noritake Dental Inc.) (Figs. 16 and 17).

Fig. 16. Polishing of the restorations with the pre-polisher.

Fig. 17. Final polishing with the high-gloss polisher.

CLINICAL RESULTS

Once the restorations were completed (Figs. 18 and 19) and the occlusal and dynamic contacts were checked, the patient expressed immediate satisfaction. This was confirmed at the one-week follow-up (Fig. 20). The rehabilitation took a total of two hours, including photographic documentation. This represents a rapid, minimally invasive and cost-effective treatment compared to indirect restorations.

Fig. 18. Treatment outcome.

Fig. 19. Detailed view of the freshly restored teeth.

Fig. 20. Post-operative photograph taken after one week.

The six-month check-up (Figs. 21 and 22) not only confirmed the survival of the restorations but also showed excellent gingival health, demonstrating the correctness of the emergence profile and the high polishability of the cervical margins obtained with this restorative technique.

Fig. 21. Restorations at the six-month recall.

Fig. 22. Optical integration of the new restorations into the overall picture.

DISCUSSION

The Flowable Injection Technique is now a valid alternative in the field of direct restoration, as it combines operational simplicity with predictable aesthetic results. The main advantage lies in the reduction of variability linked to the operator's manual skills, thanks to the guiding role of the index, which allows the digital design or initial wax-up to be transferred with high accuracy. The aesthetic outcome is therefore highly controllable, while the clinical approach complies with the principles of minimally invasive dentistry. Added to this is the efficiency of the method, which allows for shorter operating times and lower costs compared to rehabilitation with indirect restorations. At the same time, it maintains the possibility of a subsequent transition to more complex prosthetic solutions.

A key enabler of this approach is the evolution of flowable composites. The latest generation has overcome the historical limitations of fragility and wear, offering mechanical and optical characteristics comparable to, if not superior to, paste-type composite materials. This progress has made it possible to use flowable materials not only as a complementary support, but as the real protagonist of a restorative technique that aims to simplify clinical work and improve the predictability of results.

Furthermore, the development of 3D printing applied to the production of transparent indexes has introduced a further leap in quality. The digital workflow makes it possible to reduce manufacturing times, standardize procedures, achieve high reproducibility, and design customized templates based on intraoral scans. The accuracy of clinical transfer is thus significantly increased, with a positive impact on the quality and stability of the final restoration.

The synergy between high-performance flowable resins and 3D-printed digital index therefore offers clinicians the option of offering patients aesthetic solutions that are rapid, accessible, and at the same time adhere to the principles of modern conservative dentistry.

CONCLUSION

The Flowable Injection Technique, supported by the latest generation of flowable composites and the potential of 3D printing, represents a modern and effective restorative strategy. The clinical case presented highlights how it is possible to offer patients a satisfactory, rapid, and conservative aesthetic treatment, while keeping open the option of a future transition to indirect restorations.

By combining innovative materials and digital technologies, this technique marks a step forward towards increasingly predictable, accessible, and patient-centred cosmetic dentistry.

Dental technicians:

CLAUDIA MAZZITELLI

Scientific director of the Dental Biomaterials Laboratory.

Clinical tutor for the International Master's Degree in Conservative Dentistry and Aesthetic Prosthetics, head of teaching activities for the Degree Course in Dental Hygiene at the University of Bologna.

Speaker at numerous national and international conferences and author of scientific publications in high-impact indexed journals.

EDOARDO MANCUSO

Expert in conservative and prosthetic dentistry with a minimally invasive approach.

Collaborates with international research groups on adhesive techniques and minimally invasive preparations.

Practices as a freelancer in Bologna.

Speaker and author of scientific papers presented at national and international conferences, publishes articles in leading scientific journals.

References

Terry DA, Powers JM. A predictable resin composite injection technique, Part I. Dent Today. 2014 Apr;33(4):96, 98-101.

Checchi V, Generali L, Corciolani L, Breschi L, Mazzitelli C, Maravic T. Wear and roughness analysis of two highly filled flowable composites. Odontology. 2025 Apr;113(2):724-733. doi: 10.1007/s10266-024-01013-0.

Liaropoulou YM, Jiménez AK, Chierico F, Blatz MB. The Multilayer Flowable Injection Technique for Highly Esthetic Restorations. J Esthet Restor Dent. 2025 Jun 27. doi: 10.1111/jerd.13500.

Watanabe K, Tanaka E, Kamoi K, Tichy A, Shiba T, Yonerakura K, Nakajima M, Han R, Hosaka K. A dual composite resin injection molding technique with 3D-printed flexible indices for biomimetic replacement of a missing mandibular lateral incisor. J Prosthodont Res. 2024 Oct 16;68(4):667-671. doi: 10.2186/jpr.JPR_D_23_00239.

Shui Y, Wu J, Luo T, Sun M, Yu H. Three dimensionally printed template with an interproximal isolation design guide consecutive closure of multiple diastema with injectable resin composite. J Esthet Restor Dent. 2024 Oct;36(10):1381-1387. doi: 10.1111/jerd.13268.

Hulac S, Kois JC. Managing the transition to a complex full mouth rehabilitation utilizing injectable composite. J Esthet Restor Dent. 2023 Jul;35(5):796-802. doi: 10.1111/jerd.13065.

Lawson NC, Greene Z, Machado N, Tadros D, Robles A, Rocha M. Resin Composite Depth of Cure Through Transparent Matrix Materials Used for Injection Molding. Oper Dent. 2025 Mar 1;50(2):185-193. doi: 10.2341/24-100-L.

Cases by MDT Leonidas Dimitriou

INTRODUCTION

Patient demands and expectations have never been as concrete as in this day and age: Influenced by role models on social media and new aesthetic standards, our patients ask for brighter smiles or for restorations with specific tooth forms rather than demanding a perfect copy of nature. For us dental technicians, the challenge lies in finding a perfect balance between fulfilling these demands and respecting established biomimetics-inspired principles of aesthetics and function.

To accomplish this task, we need to know which principles need to be respected and where there is room for creativity. At the same time, it is essential to be well-informed about the latest technological advancements and developments in dental materials to be able to select the most appropriate restorative approaches. Only by understanding the selected materials and technological tools very well, will we be able to exploit their potential and deliver the best possible restorative solution. To sum up, we need to keep one foot in the boat of science and the other in the boat of art. Only by balancing both can we navigate the rapid advancements in the field effectively - ensuring they serve patients’ best interests while avoiding practices that lack purpose or meaning.

The challenge lies in finding a perfect balance between fulfilling the patient‘s demands and respecting established biomimetics-inspired principles of aesthetics and function.

MATERIAL CHOICES

Our favored framework materials for the production of aesthetic anterior restorations include KATANA™ Zirconia UTML, KATANA™ Zirconia STML discs (both Kuraray Noritake Dental Inc.) and lithium disilicate-based press ingots Amber® Press (HASS). These high-strength ceramics are ideal for fulfilling the aesthetic and functional demands of anterior restorations. Their balanced optical properties allow for the creation of lifelike restorations. Their physical and mechanical properties, on the other hand, are responsible for stability during all clinical steps from try-in to permanent placement, proven bonding ability and a certain error tolerance: Minor adjustments or modifications are possible without the risk of inducing cracks or dimensional changes when firing repeatedly. Finally, both materials are digital workflow compatible, which means that procedures are quick, mock-up, temporary restoration and definitive restoration easily aligned, and remakes facilitated.

The restorations are usually designed in full contour; a labial cutback of 0.3 to 0.5 mm creates sufficient space for the veneering porcelain. The preferred layering approach is micro-layering combined with the internal live stain technique, which offers the benefits of a controlled procedure and predictable, highly aesthetic outcomes with brilliant depth effects in short time. A layering material that precisely meets our needs regarding the preferred approach and is perfectly compatible with both, lithium disilicate and zirconia, is CERABIEN™ MiLai (Kuraray Noritake Dental Inc.).

The following two case reports are used to illustrate how this material combines with the different framework materials, revealing further benefits of the selected ceramics and techniques.

CASE #01

LITHIUM DISILICATE VENEERS

This 36-year-old female patient wanted to replace her bonded composite veneers. She expressed the demand for a brighter smile with a bleached color (NW 0.5) selected for her six maxillary anterior teeth and first premolars. However, she wanted the tooth preparation for this treatment to be as minimally invasive as possible.

In addition, she specifically requested that the teeth be square in form, with the lateral incisors the same length as the central incisors and the incisal edges straight, without rounded corners – clearly influenced by modern aesthetic standards. We explained our concerns regarding potential aesthetic and functional issues that might necessitate further intervention or adjustments, but she remained firm in her choices.

FROM DESIGN TO PRESSED FRAMEWORK

In line with the patient’s demands, it was planned to restore her maxillary teeth from first premolar to first premolar with lithium disilicate veneers (Amber® Press HT in the shade W2), which would allow for the desired minimally invasive preparations and bright appearance. Following tooth preparation, an analog impression was taken and sent to our laboratory. After the production of the model, the case was digitalized for the virtual designing of the veneers. In order to create space for the porcelain, the labial surfaces of the full-contour restorations were reduced by 0.3 mm with the software (exocad® DentalCAD, Figs. 1 and 2).

The frameworks were then milled in wax and pressed in Amber® Press HT W2 (Figs. 3 and 4). Sprues were cut and the surfaces of the veneer frameworks processed with a Diagen-Turbo-Grinder Ø 3,5 x 11 mm Cone and Wheel.

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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.

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Case by DT Andreas Chatzimpatzakis and Dr Evi Lianou

Selecting the right materials for a successful rehabilitation of edentulous jaws with fixed implant-based prostheses can be quite challenging. High strength and stability are needed to securely connect the implants, biocompatibility is a must and the functional, aesthetic and financial expectations of the patient need to be respected. Experience shows that – in many situations – the combination of a titanium bar with a zirconia framework finished using the micro-layering technique is a great option. This material combination and approach meets the demands mentioned, while supporting efficient procedures and aesthetic outcomes.

In the present case, a 53-year-old male patient with a history of periodontal disease presented in the dental office of Dr Evi Lianou (Dental Clinic, Lamia, Greece). Due to a poor prognosis of the remaining teeth, it was planned to extract them. As a removable full denture was not an option for the patient, the treatment plan included the insertion of four implants in the mandible and six in the maxilla, followed by a healing phase and subsequent definitive rehabilitation with screw-retained, titanium bar-based zirconia superstructures finished by micro-layering. The following figures and captions describe the technical procedure.

Fig. 1. Initial clinical situation showing several remaining teeth with a poor prognosis.

Fig. 2. Screw-retained titanium bar for the mandible.

Fig. 3. Screw-retained titanium bar for the maxilla.

Fig. 4. Mandibular restoration: Milled framework made of KATANA™ Zirconia HTML PLUS (Kuraray Noritake Dental Inc.) with a minimal (0.3 mm) vestibular cutback placed only on the six anterior teeth.

Fig. 5. Maxillary restoration: Milled framework made of KATANA™ Zirconia HTML PLUS with a minimal vestibular cutback (0.3 mm) placed only on the six anterior teeth.

Fig. 6. Mandibular restoration, 33-43 internal staining with CERABIEN™ MiLai Internal Stains (Kuraray Noritake Dental Inc.). 34-37 & 44-47 External characterization with CERABIEN™ ZR FC Paste Stain.

Fig. 7. Maxillary restoration 13-23 internal staining with CERABIEN™ MiLai Internal Stains. 14-17, 24-27 External characterization with CERABIEN™ ZR FC Paste Stain.

Fig. 8. Mandibular and maxillary restorations on the model: Additional internal staining to the anterior. Posterior teeth were completed with CERABIEN™ ZR FC Paste Stain.

Fig. 9. Mandibular restoration after the application of CERABIEN™ MiLai Porcelains LT1 mixed with CCV2 (ratio 50:50) for the cervical and Tx for the incisal.

Fig. 10. Maxillary restoration after the application of CERABIEN™ MiLai Porcelains LT1 mixed with CCV2 (ratio 50:50) for the cervical and Tx for the incisal third.

Fig. 11. Mandibular restoration after the bake, showing some typical characteristics of aged teeth.

Fig. 12. Maxillary restoration after the bake, showing some typical characteristics of aged teeth.

Fig. 13. Mandibular restoration with applied tissue porcelains and corrections in the tooth area.

Fig. 14. Maxillary restoration with applied tissue porcelains and corrections in the tooth area.

Fig. 15. Mandibular restoration after finishing glazing and polishing.

Fig. 16. Maxillary restoration after finishing glazing and polishing.

Fig. 17. Final restorations on the model.

Fig. 18. Final restorations in the patient’s mouth.

Fig. 19. New smile of the patient.

Fig. 20. Patient with new fixed dental prostheses.

CONCLUSION

The described material combination and technique allows for efficient workflows, while supporting aesthetic, durable treatment outcomes. With functional surfaces designed in plain, polished zirconia and just a tiny layer of porcelain in the vestibular region, the restorations are made to last. Moreover, the selected framework material and porcelain system are a perfect match.

The chosen porcelain system works well with other zirconia brands and even with lithium disilicate. It can be used with or without internal stains, making it a versatile tool suitable for a wide range of applications, patient needs, and aesthetic demands.

Case report by Dr Mediha Isikver

Tooth fractures and secondary caries are frequently observed in posterior teeth, often resulting from occlusal stress, restoration failure, or secondary bacterial infiltration. These conditions compromise tooth integrity, function, and aesthetics. With advancements in adhesive dentistry, minimally invasive and durable restorative solutions have become achievable. Material selection plays a critical role in the success of composite restorations, influencing marginal adaptation, wear resistance, and patient satisfaction. This case report describes the step-by-step clinical management of a fractured and secondary carious permanent molar restored using materials from Kuraray Noritake Dental Inc.

CASE PRESENTATION

A 32-year-old female patient presented to the clinic with sensitivity and discomfort in the upper left posterior region. Clinical examination revealed a distal wall fracture on tooth #26 (maxillary left first molar) with a secondary carious lesion extending subgingivally. Radiographic evaluation confirmed the absence of periapical pathology. Adjacent teeth (#25 and #27) showed early carious activity, but the patient opted for the restoration of tooth #26 only. The tooth was asymptomatic to percussion and showed normal vitality on pulp testing.

Fig. 1. Initial clinical view of tooth #26 under rubber dam isolation.

TREATMENT PROTOCOL

1. Isolation and caries removal: The tooth was isolated with rubber dam. The existing defective restoration and carious tissue were carefully removed using tungsten carbide burs and a slow-speed handpiece.
2. Surface cleaning: After preparation, KATANA™ Cleaner was applied to remove contaminants and optimize bonding surface quality.
3. Bonding procedure: A single-step, self-etch adhesive, CLEARFIL™ Universal Bond Quick 2, was applied to both enamel and dentin following the protocol recommended by the manufacturer.
4. Restorative phase: The deep and undercut areas were resin coated with CLEARFIL MAJESTY™ ES Flow Universal Low (U shade), ensuring adaptation and stress relief in undercut regions. The remaining cavity was restored incrementally using CLEARFIL MAJESTY™ ES-2 Universal (U shade) paste-type composite, with each 2 mm layer light-cured for 20 seconds.

Fig. 2. Clinical view of tooth #26 after removal of the defective restoration and carious tissue.

Fig. 3. Application of KATANA™ Cleaner to remove contaminants and optimize bonding surface quality after preparation.

Fig. 4. Selective enamel etching performed on tooth #26.

Fig. 5. CLEARFIL™ Universal Bond Quick 2 applied to both enamel and dentin following the manufacturer’s recommended protocol.

Fig. 6. Resin coating with CLEARFIL MAJESTY™ ES Flow Universal Low (U shade).

Fig. 7. Reconstruction of the mesial and distal walls with CLEARFIL MAJESTY™ ES-2 Universal (U shade) composite.

Fig. 8. Incremental build-up of cusps and occlusal anatomy using CLEARFIL MAJESTY™ ES-2 Universal composite, refined with a brush for contour adjustment.

Fig. 9. Initial finishing of the composite restoration performed with darkcoloured TWIST™ DIA for Composite (medium) rubber points to refine surface texture and anatomy.

Fig. 10. Final polishing performed with light-coloured TWIST™ DIA for Composite (fine) rubber points to achieve a highgloss, smooth surface.

FINAL SITUATION

Fig. 11. Final view of the restoration after occlusal adjustment and polishing.

CONCLUSION

This case demonstrates that adhesive and restorative systems from Kuraray Noritake Dental Inc. offer a reliable, efficient and effective approach for treating fractured and secondary carious posterior teeth. The integration of self-etch adhesives and high performance composites contributes to durable and aesthetically pleasing restorations. Continuous follow-up is essential to evaluate the long-term clinical behaviour of these materials.

Dentist:

MEDIHA ISIKVER

Dr Mediha Isikver is a graduate of the Ege University Faculty of Dentistry and the co-founder of Klinik M in Istanbul, Turkey. She focuses her professional practice on aesthetic and restorative dentistry, with particular expertise in composite laminate layering, porcelain laminates, and smile design. Believing that every smile tells its own story, she aims to create personalized aesthetic transformations that blend natural harmony with artistic detail.

Case by Dr. Onur Alp Yünük

COMBINING HIGH-PERFORMANCE TOOLS AND MATERIALS FOR A PREDICTABLE OUTCOME

Direct composite restorations are a high-quality treatment option even when large amounts of tooth structure need to be replaced. This is due to recent advancements in resin composite materials and adhesive technology. By selecting appropriate materials and layering techniques combined with modern digital tools for colour difference evaluation, it is possible to predictably produce highly aesthetic outcomes, as demonstrated in the following case example.

THE CHALLENGE

A young male patient presented to our clinic requesting the replacement of his existing composite restorations on his maxillary incisors (teeth #12 and #11 according to the FDI notation). Clinical examination revealed extensive restoration loss on the lateral incisor. Furthermore, anatomical irregularities, discolouration, and loss of surface gloss were observed on tooth #11. The adjacent central incisor exhibited similar issues regarding colour and surface polish.

In consultation with the patient, it was decided to replace the existing restorations using a modern composite material specifically developed for dual-shade layering – CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.). For an exact shade analysis, photographs were taken with and without a cross-polarized filter (Figs. 1 to 4).

Fig. 1. Frontal view of the teeth with extensive restoration loss on the maxillary left lateral incisor.

Fig. 2. Cross-polarized photograph of the teeth allowing for a detailed analysis of the shade irregularities.

Fig. 3. Lateral view of the teeth.

Fig. 4. Lateral view – cross-polarized photograph.

THE SOLUTION

Following removal of the existing restorations, rubber dam was placed for working field isolation. A self-etching adhesive (CLEARFIL™ SE Bond 2, Kuraray Noritake Dental Inc.) was applied in the selective enamel etching mode before establishing the palatal shell using CLEARFIL MAJESTY™ ES-2 Premium in the shade A1E (Figs. 5 and 6). The mamelon structures were reconstructed with CLEARFIL MAJESTY™ ES-2 Premium in the shade A1D, while the translucent shade Blue was applied to the opalescent zone. Finally, yellow and white tints were used for characterization. Fig. 7 illustrates the appearance before, Fig. 8 after finishing and polishing.

Fig. 5. Palatal shell established with the enamel shade A1E of the selected composite.

Fig. 6. Lateral view of the teeth during the restoration procedure.

Fig. 7. Restoration before finishing and polishing.

Fig. 8. Appearance of the restorations after finishing and polishing.

THE OUTCOME

To evaluate the final colour integration, another photograph was taken with a cross-polarized filter, holding a grey reference card in place for calibration (Figs. 9 and 10). The lateral view of the restored teeth (Fig. 11) reveals that not only the right colour combination, but also a natural surface texture is required for a highly aesthetic outcome.

Fig. 9. Frontal view of the restored teeth taken with a cross-polarized filter.

Fig. 10. Gray reference card calibration and the resulting L*a*b* coordinates of the restoration.

Fig. 11. Lateral view of the restored teeth stressing the importance of surface texture.

DISCUSSION AND CONCLUSION

Observation, supported by modern tools for photography and image analysis (like polarized filters and L*a*b* coordinates), is an important skill needed for the lifelike reconstruction of teeth with direct composite materials. By combining this skill with a high-performance composite system that offers fixed shade combinations and innovative light diffusion technology for a nice blend-in with the surrounding tooth structure, creating beautiful restorations becomes a predictable business.

In the case presented, the patient was very satisfied with the outcome in terms of aesthetics and function. At regular recalls, the quality of the restorations is checked – they still offer a very nice functional and aesthetic integration.

Dentist:

ONUR ALP YÜNÜK

Dr. Onur Alp Yünük completed both his undergraduate and doctoral education at Istanbul University. He currently serves as an Assistant Professor in the Department of Restorative Dentistry at the Istinye University Faculty of Dentistry. His work primarily focuses on direct composite restorations of anterior teeth and on polychromatic layering systems.

Case report by Vasilis Vasiliou

AESTHETIC RESTORATION OF MAXILLARY INCISORS

Falling in love, applying for a first job, attending a best friend’s wedding: There are so many occasions for young people when looking gorgeous is important. That is why restoring a young patient’s smile to its natural beauty is a special task that demands a lot from us. We need to listen to their touching stories, understand their specific needs and desires – and finally find a way to exceed their expectations. Whenever our plan works and is performed correctly, the outcome will be rewarded with extreme gratitude by those affected. After all, it is not only the smile we restore, but also the patients’ self-confidence and quality of life.

SINGLE BAKE, NATURAL RESULT

The good news: Even highly aesthetic all-ceramic restorations can be produced with a minimal number of bakes. Modern framework materials and porcelain systems allow us to imitate a natural play of colours and translucencies, a virtually unlimited number of individual effects and a vivid surface texture in a predictable way. A possible procedure is illustrated below. The materials utilized in this case were KATANA™ Zirconia STML and CERABIEN™ ZR (Kuraray Noritake Dental Inc.) and the restoration was completed using the One-Bake technique developed by MDT Nondas Vlachopoulos.

Fig. 1. Frameworks made of KATANA Zirconia STML in the shade A1.

Fig. 2. Single-bake layering procedure: Application of CERABIEN ZR Opacious Body in the cervical …

Fig. 3. … and mamelon areas.

Fig. 4. CERABIEN ZR Body porcelain applied in the body area.

Fig. 5. CERABIEN ZR Transitional Dentine used to increase the translucency in the incisal part.

Fig. 6. CERABIEN ZR Opacious Body added in specific areas to create more reflaction.

Fig. 7. Incisal cut-back and creation of the mamelon structure as well as adding of T Blue to give depth.

Fig. 8. … in the body and distal incisal areas.

Fig. 9. Application of Aqua Blue 1 and T Blue on the incisal edges to produce a youthful translucency.

Fig. 10. Creation … effect

Fig. 11. … of mamelons.

Fig. 12. Application of Luster porcelains: LTx, …

Fig. 13. … ELT1 …

Fig. 14. … and LT1.

Fig. 15. Cutback of the dentin for the creation of a halo effect.

Fig. 16. Final shape: Halo effect created with Body.

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

Fig. 18. Restorations adhesively cemented in the patient’s mouth.

CONCLUSION

Restoring a young patient’s smile is a particularly challenging task, as the quality of the outcome has a huge effect on the self-confidence and quality of life of the affected person. By listening closely to our patients’ stories, understanding their needs and knowing our materials well, we are able to deliver exactly what they need. It is their positive feedback and happiness that drives me to never stop learning and practicing with my ceramics and porcelains for continued improvement and even better outcomes.

I would like to express my gratitude to Dr. Loukia Pedoulou for the professional partnership and clinical support in achieving this result.

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.

Case by Dt. Koray Kendir, DDS, Turkey (İzmir)

INTRODUCTION

Trauma-related fractures of anterior teeth require a precise balance between aesthetics and function, often under emotional pressure from the patient. This clinical case demonstrates the restorative rehabilitation of a previously mismanaged central incisor using CLEARFIL MAJESTY™ ES-2 Premium and PANAVIA™ V5 (both Kuraray Noritake Dental Inc.). The team worked to re-establish biological, functional, and aesthetic harmony.

CASE SUMMARY

A 23-year-old female patient presented one month after a traumatic injury involving tooth #11 (FDI notation). Immediate root canal treatment and a direct composite build-up had been performed elsewhere in a single visit. The existing restoration showed poor aesthetics and marginal adaptation (Fig. 1).

Fig. 1. Initial clinical situation.

CLINICAL PROCEDURE

STEP 1: ISOLATION AND REMOVAL OF OLD RESTORATION

For the planned rehabilitation, the tooth was isolated with rubber dam (Figs. 2 and 3) and the existing composite restoration was removed. Gutta-percha from the previous endodontic treatment was found to be severely coronally trimmed (Fig. 4). This poses a risk of future discolouration. Consequently, the gutta-percha was condensed apically to a more biologically appropriate level using a downpack device (Figs. 5 to 9).

Fig. 2. Isolation of the working field with rubber dam: Labial view.

Fig. 3. Isolation of the working field with rubber dam: Occlusal view.

Fig. 4. Gutta-percha from the previous treatment.

Fig. 5. Gutta-percha removed, …

Fig. 6. … placed back into the root canal …

Fig. 7. … and condensed …

Fig. 8. … with a downpack device.

Fig. 9. Result of the procedure: Occlusal view.

STEP 2: CORE BUILD-UP

Subsequently, a fiber-reinforced composite was used to provide root-anchored support for the core structure. Then, the bonding surface was treated with phosphoric acid etchant, CLEARFIL™ Universal Bond Quick (Kuraray Noritake Dental Inc.) was applied as a universal adhesive and the core build-up was performed with CLEARFIL MAJESTY™ ES-2 Premium A1D (Figs. 10 to 13).

Fig. 10. Etching with phosphoric acid etchant.

Fig. 11. Application of the universal adhesive.

Fig. 12. Core build-up after thorough light curing.

Fig. 13. Intra-oral periapical radiograph or the treated tooth.

STEP 3: PREPARATION AND DIGITAL IMPRESSION

For definitive restoration, a 3/4 crown preparation was performed and an intraoral scan was taken. Moreover, a temporary crown was fabricated (Fig. 14) and shade photos were taken to finalize the session.

Fig. 14. Temporary restoration in place.

STEP 4: FINAL CEMENTATION

Once the lithium disilicate restoration was received from the laboratory, the temporary crown was removed and the abutment tooth was evaluated (Figs. 15 and 16). Try-in was performed using PANAVIA™ V5 Try-in Paste White to check shade and fit (Fig. 17). No modifications were required; the selected try-in paste contributed to a lifelike appearance of the restoration. For definitive placement, the intaglio surface of the crown was etched with hydrofluoric acid (Fig. 18). Figure 19 shows the appearance of the intaglio after this measure. To provide for optimal bonding conditions, the tooth surface was then cleaned with KATANA™ Cleaner (Kuraray Noritake Dental Inc.), which should be applied with a rubbing motion to the contaminated prepared tooth for more than ten seconds (Figs. 20 to 22). It may also be used to clean the intaglio of a restoration, which is contaminated with blood and saliva e.g. after try-in.

Fig. 15. Situation after removal of the temporary crown: Labial view.

Fig. 16. Situation after removal of the temporary crown: Occlusal view.

Fig. 17. Try-in of the lithium disilicate crown.

Fig. 18. Etching of the crown’s intaglio surface with hydrofluoric acid.

Fig. 19. Appearance of the etched surface.

Fig. 20. Cleaning of the abutment tooth …

Fig. 21. … surface covered with the cleaning agent.

Fig. 22. Thorough rinsing, which should be followed by drying with air.

Adhesive cementation itself was accomplished with the three-component PANAVIA™ V5 (Figs. 23 to 28): The prepared tooth structure and build-up was treated with PANAVIA™ V5 Tooth Primer, the intaglio surface of the crown with CLEARFIL™ CERAMIC PRIMER PLUS. Finally, PANAVIA™ V5 Universal (White) was extruded into the crown and the crown placed. Excess cement is best removed in the gel phase – i.e. after brief polymerization for 3 to 5 seconds before final light curing is performed. Alternatively, it may be removed immediately after seating the restoration with a brush or similar instrument. In this case the first option was chosen. The treatment outcome after rubber dam removal and final clinical and aesthetic evaluation is displayed in Figure 29.

Fig. 23. Priming of the tooth structure.

Fig. 24. Selected resin cement.

Fig. 25. Tooth structure ready for crown placement.

Fig. 26. Restoration in place.

Fig. 27. Lateral view of the restoration.

Fig. 28. Final light curing of the crown.

Fig. 29. Treatment outcome immediately after rubber dam removal.

CONCLUSION

This case highlights a comprehensive restorative approach to preserving a traumatized anterior tooth at risk of loss, while restoring both function and aesthetics. The strong core foundation provided by CLEARFIL MAJESTY™ ES-2 Premium and the reliable adhesive performance of PANAVIA™ V5 played a pivotal role in the successful procedure and outcome.

Dentist:

KORAY KENDIR

Dt. Koray Kendir is a graduate of Hacettepe University Faculty of Dentistry and the co-founder of a private dental clinic in İzmir. He specializes in digital dentistry, smile design, and computer-aided restorative treatments. Known for his innovative approach, Dr. Kendir is a frequent speaker at national dental congresses and serves as an advisor to several dental companies.

Case by DT Vasilis Vasiliou

MICRO-LAYERING WITH CERABIEN MiLai

No matter whether young or old, male or female: Our patients deserve a beautiful smile that matches their adjacent teeth, their face, their character and their individual needs. To be able to produce beautiful restorations that change their life for the better, we (as dental technicians) have to observe closely – and to listen attentively to the stories they tell.

‘We have to observe closely – and to listen attentively to the stories our patients tell us.’
– Vasilis Vasiliou –

Mr Andreas is a perfect example. He presented in the dental office in need of a full-mouth rehabilitation and the wish to improve the aesthetics of his smile. He asked for an age-appropriate, natural restoration design.

After careful observation and listening, I decided that the best way to restore his maxillary incisors would be with zirconia restorations. The plan was to mill the frameworks using low-value KATANA™ Zirconia YML, shade D3 (Kuraray Noritake Dental Inc.). To facilitate the integration of some natural characteristic effects, a framework design with a primarily vestibular cutback was selected. The finishing technique of choice was micro-layering with CERABIEN™ MiLai (Kuraray Noritake Dental Inc.), a porcelain designed specifically for this approach.

Important steps in the finishing procedure were:

• Characterization of the milled zirconia with colouring liquids
• Pre-treatment of the sandblasted zirconia surfaces with SS Fluoro and Margin porcelain
• Internal staining with CERABIEN™ MiLai internal stains
• Application of CERABIEN™ MiLai luster porcelains

LABORATORY WORKFLOW

Zirconia splinted crowns were designed in full contour with the aid of the Leahu Library featuring tailored tooth designs (part of the Truedental Library available for exocad DentalCAD design software; Fig. 1), cut back merely in the vestibular area using the ‘calma’ reduction option (Fig. 2), and then milled and characterized with colouring liquids to optimize the chroma.

Figure 3 shows the sintered frameworks on the model, Figure 4 the try-in in the patient’s mouth. As the fit and shape of the restorations turned out to be excellent, it was time to plan the internal staining and micro-layering procedure (Figs. 5 and 6), always trying to imitate nature as closely as possible.

The tricky part is to use the available space wisely – the reason why a detailed layering sketch is useful even when in the context of micro-layering. Once the planned layering procedure had been put to practice (Figs. 7 to 10), the surface texture was finalized and the restorations were tried in again for an aesthetic evaluation. Finally, they were cemented with the adhesive resin cement PANAVIA™ V5 (Kuraray Noritake Dental Inc.).

The beautiful treatment outcome is shown in Figure 11.

Fig. 1. Computer-aided design of the zirconia frameworks: Splinted crows displayed in a transparent mode to show the abutment teeth.

Fig. 2. Computer-aided design of the zirconia frameworks: Outer contour of the splinted crowns with a strongly elaborated surface texture and sufficient room for micro-layering.

Fig. 3. Restorations after characterization with colouring liquids and sintering on the model.

Fig. 4. Try-in of the restorations.

Fig. 7. Internal staining – specific characteristics elaborated for a natural depth effect.

Fig. 8. Layering in the cervical and body areas.

Fig. 9. Final layering with luster porcelains to complete the morphology.

Fig. 10. Final restorations after surface finishing and polishing as well as glazing on the model.

Fig. 11. Treatment outcome.

CONCLUSION

The patient was thoroughly satisfied with the treatment outcome and confident that his investment was well worth it. By tailoring my approach to his unique needs, carefully observing his teeth, smile, and facial expressions, and utilizing my extensive knowledge of materials, I was able to achieve this goal successfully.

Nonetheless, I remain committed to continuous improvement by critically evaluating each restoration and seeking areas for enhancement. My dedication to growth, supported by exceptional mentors who share innovative techniques and insights, supports me in staying at the forefront of my field, striving at consistently delivering the best possible care.

I am deeply grateful to Dr. Zinonas Evagorou for invaluable partnership and clinical expertise, which were instrumental in achieving this result.

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.