Case by Dr. Hendrik Zellerhoff

Not all zirconia is created equal. This finding presented by Prof. Martin Rosentritt⁷ back in 2014 has lost none of its actuality and even appears to be increasingly relevant these days. This is because dental practitioners are spoilt for choice between various zirconia blanks, which differ widely in terms of quality, flexural strength, shade appearance, translucency and production complexity. Hence, each material has its own specific processing requirements and range of indications⁶. Profound knowledge of the available zirconia options is therefore an absolute prerequisite for long-term success of every full contour restoration produced in a time-efficient and economic procedure.

While in the early years of zirconia manufacturing in dentistry, the dental practitioner’s choice was limited to industrially milled zirconia frameworks hand-veneered by the dental technician, a wide range of material variants for chairside CAD/CAM production is nowadays available. Material-specific improvements are one of the reasons for the fact that every single zirconia has its specific indications and its own material parameters⁶. Zirconia milling blocks for monolithic restorations are in principle very well suited for the chairside production of single crowns for the anterior and specifically the load bearing posterior area. This is due to their stability and the reduced processing effort compared to hand- veneered crowns. However, the material in use needs to fulfil high demands with regard to strength, translucency, and shading – parameters that also need to be balanced against each other² (Fig. 1 to 4).

Fig. 1. Initial situation with multiple insufficient fillings.

Fig. 2. Crown milled from a KATANA™ Zirconia Block (Kuraray Noritake Dental Inc., Tokyo, Japan).

Fig. 3. Crown glazed after sintering, with fissures characterized using stains.

Fig. 4. Adhesively cemented crown with the appearance of a natural molar.

NOT ALL ZIRCONIA IS CREATED EQUAL

Due to their high flexural strength of more than 1,000 MPa, tetragonal zirconia variants (3Y-TZP) of the first and second generation are perfectly suited as framework materials. However, they lack the translucency required for monolithic use. It is theoretically possible to improve the translucency of 3Y-TZP materials by increasing the sintering temperature, however, this would result in restorations with insufficient strength. This is different for the third and fourth generations of cubic-tetragonal zirconia (5- TZP and 4-TZP). Due to the increased yttria content in the formulation, cubic crystals grow in the crystal microstructure. These cubic crystals have a larger volume, which leads to reduced scattering at the grain boundaries and improved light transmission. In addition, cubic crystal structures are more isotropic than tetragonal structures, so that incoming light is spread more evenly into all directions⁸. The combination of a high flexural strength and a high translucency in the fourth generation zirconia sets the stage for monolithic use of the material. This, in turn, eliminates the risk of chipping of the veneering porcelain.

PREMISES OF MONOLITHIC CHAIRSIDE RESTORATIONS

In order to ensure the desired long-term stability, intraoral functionality and aesthetics of a monolithic restoration on one hand and a time- and cost-efficient chairside workflow on the other, two factors are crucial. One is a proper functional occlusal adjustment of the restorations, the other is knowledge about the material parameters of the zirconia blocks in use.

Hardness and abrasion

Clinically, monolithic zirconia shows virtually no abrasion and an antagonist-friendly behaviour - provided that the occlusal surface is polished properly, is free of sharp edges and is covered with glaze. In order to leverage this effect and to avoid improper occlusal contacts as factors triggering parafunctions, the dental practitioner should carefully carry out an occlusal and functional analysis. This analysis should include an examination of the vertical dimension and of different jaw movement like protrusion, retrusion, laterotrusion and mediotrusion. Based on the results, a precise dynamic occlusal adjustment is possible. Any retrospective adjustment – even in case of minimal irregularities – is impossible or, more specifically, restricted to the glazing layer. If the surfaces, especially the cusps, are not polished to a high gloss, any wear of the glaze would lead to the exposure of a rough abrasive zirconia surface. Material-specific high-gloss polishing and glazing, however, effectively avoids abrasive wear of the antagonist^3,4,5.

Strength, translucency and shade

Under these premises, 5Y-TZP materials like KATANA™ Zirconia UTML (Ultra Translucent Multi Layered) with a flexural strength of 557 MP and a translucency of 43 percent are particularly well suited for the production of highly aesthetic anterior crown or veneer restorations. In the load-bearing posterior area, however, higher flexural strength values are necessary. Using 4Y-TZP materials like KATANA™ Zirconia Block (Super Translucent Multi Layered) with a flexural strength of 763 MPa provides more stability of the restoration, which is required for the posterior region. The product offers a translucency of 38 percent and is suitable for the chairside production of aesthetically and functionally demanding restorations with high stability even in case of a reduced wall thickness. Thanks to the colour gradient, light shines through in the incisal area in an enamel-like way, while in the cervical area, the level of translucency is similar to dentin. The imitation of a colour gradient found in natural teeth, which ensures that the restoration will blend in perfectly with the adjacent teeth, is obtained with a multi-layered, polychromatic structure with a smooth shade transition from the incisal to the cervical part. This feature eliminates the need for a time-consuming manual application of shades prior to sintering. A patient- specific post-sintering characterisation with stains is optional. As shade, form and effects are already visible during application, the dental practitioner gains full control over aesthetics at all times (Fig. 5 to 8).

Fig. 5. Comparison of flexural strength and translucency.

Fig. 6. Smooth shade transition from the enamel to the dentin and cervical area.

Fig. 7. Comparison of the translucency exhibited by different ceramics.

Fig. 8. Range of shades of KATANA™ Zirconia Single Unit Blocks.

KATANA™ ZIRCONIA BLOCK IN THE CEREC WORKFLOW

Reliable material properties are imperative for a smooth production workflow leading to a consistent high quality of the restorations. They are only obtained with industrially produced zirconia blanks, which offer a defect-free, homogeneous grain structure^1,10. At Kuraray Noritake Dental, the whole manufacturing process of zirconia products is carried out in-house, including the production of the raw materials. Therefore, it is possible to optimize the material parameters of KATANA™ Zirconia Blocks for chairside production and with high-speed sintering process. Using these components, the dental practitioner can reduce the time needed for the production of a monolithic zirconia restoration including scanning, milling and sintering to less than an hour.

Design

For this purpose, the teeth to be restored are prepared and captured together with the adjacent and antagonist teeth using an intraoral scanner (Omnicam or Primescan, Dentsply Sirona). The digital data set is then imported into the CEREC software. The software extracts the required information from the data and generates a design proposal for the restoration. Usually, this proposal may be accepted without major modifications. Due to the high mechanical properties of KATANA™ Zirconia, a wall thickness of 1.0 mm is sufficient for a posterior crown. This design has two positive effects: it optimizes the translucency of the restoration and supports a minimal preparation, which also facilitates clinical procedures in situations with limited space conditions. The shade and translucency of the restoration is also customizable via virtual positioning of the designed crown in the multi-layer block. This enables the dental practitioner to harmonize the brightness and translucency with the parameters of the adjacent teeth (Fig. 9 to 13).

Fig. 9. Initial situation with insufficient porcelain layer.

Fig. 10. Abutment teeth after preparation prior to digital impression taking.

Fig. 11. Restorations after polishing, occlusal and cervical characterization and glaze firing.

Fig. 12 - 13. Final restorations in place - occlusal and frontal view.

Sintering

The designed crown is milled from the KATANA™ Zirconia Block with the CEREC milling machine. Subsequently, finishing steps are carried out and the sintering process is started using the induction furnace CEREC SpeedFire. This furnace reaches a maximum heating rate of 300° C per minute. Neither pre-heating is required nor holding temperatures needed. As the material properties of KATANA™ Zirconia Block are optimally aligned with the CEREC SpeedFire programme, the user can be sure that the device adheres to all sintering parameters. This, in turn, is important for the growth of the crystals as well as phase transformation and stabilization9, which affect the natural shade results after sintering (Fig. 14 to 18).

Fig. 14 - 15. Labial and palatal view of the initial situation with restorations on the lateral incisor and canine.

Fig. 16. Varying shade and translucency gradient depending on the position of the restoration in the multi-layer block.

Fig. 17. Crowns with a natural colour gradient from the incisal to the cervical area merely glazed after sintering (without any additional adjustment).

Fig. 18. Natural aesthetic appearance of the KATANA™ Zirconia crowns even in the esthetic zone.

Individualisation and characterization

After sintering, dental practitioners may individualize or characterize KATANA™ Zirconia Block restorations if desired. This requires only a few simple work steps. The marginal ridges, mamelons, fissures or enamel cracks are imitated controllably using paste stains (CERABIEN™ ZR FC Paste Stain, Kuraray Noritake Dental), as the shade, shape and effects created are already visible during application. For the final glaze firing process with Glaze or Clear Glaze (Kuraray Noritake Dental), the SpeedFire induction furnace is used again (Fig. 19 to 25).

Fig. 19. Initial situation with secondary caries below the amalgam restoration on the maxillary left second premolar (tooth #25).

Fig. 20. Tooth prepared for a core build-up after caries excavation and proximal modification of the adjacent premolar (tooth #24).

Fig. 21. Crown milled from the block before …

Fig. 22. … and after sintering (at try-in).

Fig. 23. Fissures with age-specific characterization.

Fig. 24. Functional contact point created in consideration of the adjacent teeth.

Fig. 25. Final crown after glazing and adhesive cementation with PANAVIA™ V5 (Kuraray Noritake Dental).

Conditioning and placement of the restoration

Prior to restoration placement, the inner surface of the crown is sandblasted with Al2O3 (grain size: 50 μm, pressure: 1 bar) and treated with CLEARFIL™ Ceramic Primer Plus (Kuraray Noritake Dental), whereas PANAVIA™ V5 Tooth Primer (Kuraray Noritake Dental) is applied to the prepared tooth structure. Finally, PANAVIA™ V5 (Kuraray Noritake Dental) is applied for adhesive luting of the crown. The MDP monomer contained in the primer establishes a stable chemical bond and eliminates the need for additional conditioning. The fact that PANAVIA™ V5 is free of amines ensures long-term colour stability of the restoration.

CONCLUSION

With its combination of a high translucency and a high flexural strength, chairside dentists may use KATANA™ Zirconia Block for monolithic restorations with confidence. Restorations made of KATANA™ Zirconia offer the required long-term stability and fulfil the high aesthetic standards demanded from it to be able to serve as an alternative not only to cast metal and PFM crowns, but also to glass ceramic restorations. Due to the lack of a porcelain layer, the risk of chipping does not exist. Optimally aligned components enable dental practitioners to make use of a simplified and constantly monitored digital workflow that offers a high process reliability. Aesthetic functional restorations for the load-bearing posterior and the anterior area can be produced and placed within a single appointment. This is an important factor, which greatly affects patient satisfaction.

Dentist:

DR. HENDRIK ZELLERHOFF

References

1. Edelhoff D, Beuer F, Schweiger J, Brix O, Stimmelmayr M, Güth JF. CAD/CAM-generated high-density polymer restorations for the pretreatment of complex cases: a case report. Quintessence Int 2012;43:457–467.
2. Güth JF, Magne P. Optische Integration von CAD/CAM-Materialien. Int J Esthet Dent 2016;11:380–395.
3. Preis V, Behr M, Handel G, Schneider-Feyrer S, Hahnel S, Rosentritt M. Wear performance of dental ceramics after grinding and polishing treatments. J Mech Behav Biomed Mater 10 (2012); 13-22.
4. Preis V, Weiser F, Handel G, Rosentritt M. Wear performance of monolithic dental ceramics with different surface treatments. Quintessence Int 44 (2013);393-405.
5. Rosentritt M, Behr M, Strasser T, Preis V. Zirkonoxide als Implantatwerkstoff? Quintessenz 2018; 69 (12): 1420–1430.
6. Rosentritt M, Kieschnick A, Hahnel S, Stawarczyk B. Werkstoffkunde-Kompendium. Zirkonoxid. Berlin: Apple ibook; 2018.
7. Rosentritt M. Studie zum Verschleißverhalten von Zirkonoxid – Zirkonoxid ist nicht gleich Zirkonoxid. ZWR 2014;123(11):570-571.
8. Stawarczyk B, Keul C, Eichberger M, Figge D, Edelhoff D, Lümkemann N. Werkstoffkunde-Update: Zirkonoxid und seine Generationen – von verblendet bis monolithisch. Quintessenz Zahntech 2016;42(6):740–765.
9. Stawarczyk B, Özcan M, Hallmann L et al. The effect of zirconia sintering temperature on flexural strength, grain size, and contrast ratio. Clin Oral Investig 2013; 269–274.
10. Stober T, Bermejo JL, Rammelsberg P, Schmitter M. Enamel wear caused by monolithic zirconia crowns after 6 months of clinical use. J Oral Rehabil 2014;41:314–322.

Case by Daniel Vasquez, DDS

The dental practitioner’s time is the most valuable factor in the dental practice. Hence, it should be well spent, and saved wherever possible. In the context of placing direct posterior restorations, the universal composite CLEARFIL MAJESTY™ ES-2 Universal provides valuable support to anyone who would like to achieve this goal - being universally applicable, it allows users to spend less time on material selection. With its universal shade concept consisting of a single posterior shade and two anterior shade options, it eliminates the need for shade determination. This gives users more time to focus on fulfilling their patient’s needs. The following clinical case illustrates the use of the innovative material in the posterior region.

Fig. 1. Pre-operative situation with multiple carious lesions in the second premolar and both molars.

Fig. 2. Isolated working field.

Fig. 3. View of the quadrant after cavity preparation.

Fig. 4. Selective etching of the enamel with phosphoric acid gel.

Fig. 5. Dispensing of the universal adhesive CLEARFIL™ Universal Bond Quick into a mixing dish.

Fig. 6. Application of the universal adhesive to the enamel and dentin after etching, rinsing and air-drying.

Fig. 7. Lining up of the cavity floors with of a thin layer of flowable composite (CLEARFIL MAJESTY™ Flow).

Fig. 8. Immediate treatment outcome after the placement of several layers of CLEARFIL MAJESTY™ ES-2 Universal in the shade Universal.

FINAL SITUATION

Fig. 9. Post-operative image taken after rubber dam removal.

Dentist:

DANIEL VASQUEZ, DDS

Case by Dr. Matthieu Gilli

Fig. 1. A 25 years old female patient was dissatisfied with the aesthetics of the existing composite filling in tooth 21.

Fig. 2. Shade determination of the cervical and middle third of the tooth. By using small amounts of different shades of CLEARFIL MAJESTY™ ES-2 Premium Dentin.

Fig. 3. Contrast increase allows for:

- a better picture of dentinal structure
- dentin shade selection with more accuracy

Fig. 4. Two spheres of two different Premium Enamel shades are put at the incisal edge and the photo turned to black and white to optimise the evaluation of the translucency.

Fig. 5. To allow for the creation of a suitable palatal index, a large isolation field is necessary.

Fig. 6. Since the shape of the existing restoration is still correct the putty index can be made directly in the mouth.

Fig. 7. To improve both adhesion and optical integration, a bevel of 2 mm, 45° has been made as recommended by XU et al. (Eur J Oral Sci 2012).

Fig. 8. Selective enamel etching with 30% phosphoric acid for 30 sec. followed by rinsing and drying.

Fig. 9.

Left: Self-etch primer on dentin followed by bonding with CLEARFIL™ SE Bond.
Middle: 20 sec., 1000 mW/cm2 polymerisation of the bonding.
Right: Completed adhesive procedure with CLEARFIL™ SE Bond.

Fig. 10. Palatal shell made of A1E shade with the aid of the palatal putty index.

Fig. 11. Proximal matrix in place.

Fig. 12. Dentin replaced with CLEARFIL MAJESTY™ ES-2 PREMIUM A2D.

Fig. 13. To create the incisal halo, a small amount of A1D has been applied at the incisal edge.

Fig. 14. A tiny amount of CLEARFIL MAJESTY™ ES-2 Premium Translucent Blue is placed between the mamelons to create translucency.

Fig. 15. A white spot is created with a white opaque staining material to complete internal characterisation.

Fig. 16. A small amount of CLEARFIL MAJESTY™ ES-2 PREMIUM A1E is applied as a final covering layer.

Fig. 17. Secondary anatomy is marked with a pencil as a polishing area guide.

Fig. 18. 2 week follow-up.

FINAL SITUATION

Dentist:

DR. MATTHIEU GILLI

Dr. Matthieu Gilli graduated in 2014 as a dentist from the Université Catholique de Louvain, Brussels. Currently he is completing his PhD study in Service of conservative dentistry, at the same university.

Case by Dr. Aleksandra Łyżwińska, DMD

The maxillary left first molar had a Class I cavity on the occlusal surface restored with resin composite many years ago. The restoration needed to be replaced due to severe signs of wear and discolouration, as well as, the occurrence of secondary caries. After removal of the existing restoration and caries excavation, CLEARFIL™ SE BOND 2 was applied to the cavity to establish a stong and long-lasting chemical adhesion to the available enamel and dentin. Containing the original MDP monomer, the bonding agent is able to fulfill this task reliably. Subequently, the bottom of the cavity was filled with CLEARFIL MAJESTY™ ES Flow - Super Low A2, which shows an excellent marginal adaptation and provides for an even surface. The occlusal surface was built up with CLEARFIL MAJESTY™ ES-2 Classic A2 that blends in very well with the adjacent tooth structure, and characterized with some tints for an even more natural appearance.

Fig. 1. Initial intraoral photograph showing the defective restoration on the maxillary first molar after isolation with rubber dam.

Fig. 2. Occluso-lingual view of the initial situation revealing the wear effect.

Fig. 3. Tooth cavity with a matte surface after cavity preparation.

Fig. 4. Glossy cavity surface after application of CLEARFIL™ SE BOND 2.

Fig. 5. Appearance of the molar immediately after placement of a bottom layer of CLEARFIL MAJESTY™ ES Flow - Super Low A2 and modelling of the occlusal surface anatomy with CLEARFIL MAJESTY™ ES-2 Classic A2.

Fig. 6. Linguo-occlusal view of the situation.

Fig. 7. Appearance of the molar …

Fig. 8. … after the application of some tints.

Fig. 9. Result of the finishing …

Fig. 10. … and polishing procedure.

FINAL SITUATION

Fig. 11. Aesthetic treatment outcome after rubber dam removal …

Fig. 12. … and checking of the occlusal contact points.

Dentist:

DR. ALEKSANDRA ŁYŻWIŃSKA
Warsaw, Poland

Dr. Aleksandra Łyżwińska, DMD, is a passionate aesthetic and adhesive dentist. Driven by Evidence Based Dentistry, her goal includes using modern composite materials and bonding agents in her clinical practise. In addition to her primary job, she worked as a lecturer and an assistant professor at the Department of Conservative Dentistry and Endodontics of Medical University of Warsaw, her alma mater.

Case by Dr. Michael Morgan, DDS

Small to moderate-sized posterior restorations are the bread-and-butter of every dental practice. In a procedure that is carried out so frequently, it is particularly useful to work with a restorative material that handles well and has excellent optical properties that blend in a variety of clinical situations – like CLEARFIL MAJESTY™ ES-2 Universal. The product is available in a single universal shade for the posterior region, which enables users to increase their efficiency and eliminates the need for shade determination or laborious multi-shade layering.

When used with CLEARFIL™ SE Protect adhesive and CLEARFIL MAJESTY™ ES Flow, the innovative universal restorative allows me to confidently restore 70 to 80 percent of my simple posterior composite restorations. It handles extremely well, being slightly soft but not sticky, which allows quick shaping and anatomy formation. The procedure is fast and simple, and it leads to natural outcomes, as shown using the following case example. Anyone who has tested CLEARFIL MAJESTY™ ES-2 Universal in the clinical environment will most likely agree that the material is an easy-to-use workhorse every dentist should have in their composite toolbox.

Fig. 1 Initial clinical situation. Second premolar with a composite restoration and first molar with an amalgam restoration in need of replacement.

Fig. 2 Immediate post-operative image.

Fig. 3 Image taken one week after the treatment showing rehydrated tissues and a smooth optical integration of the direct restorations.

Dentist:

DR. MICHAEL MORGAN, DDS

Case by Dr. Aleksandra Łyżwińska, DMD

One tooth. Two appointments. Two lesions appeared in the upper right second premolar of this 17-year-old patient. We decided to restore the mesial lesions first. Caries was excavated and, due to pulp exposure, direct pulp capping performed with mineral trioxide aggregate (MTA). Chemical adhesion to dentin and the biomaterial was established with the 10-MDP-containing universal adhesive CLEARFIL™ Universal Bond Quick, used in the self-etch mode. One benefit of this material is related to the fact that no extensive rubbing onto the surface is required. Blue composite was placed to mark the region of the exposed pulp, and CLEARFIL MAJESTY™ ES Flow - Super Low A2 was applied to the bottom of the cavity. Due to its high flexural strength, this material is a perfect dentin replacement. The rest of the tooth was restored with temporization material. To fill up the core, bulk-fill flowable composite OliBulk MD was used.

For the second appointment, the temporary was removed and caries was excavated in the distal area of the tooth as well. Following cavity preparation, CLEARFIL™ SE BOND 2 was applied to obtain a strong bond to the remaining composite material and the tooth structure. Both cavities were restored with a combination of CLEARFIL MAJESTY™ ES Flow - Super Low A2 and CLEARFIL MAJESTY™ ES-2 Classic A2.

Fig. 1. Intraoral photograph of the initial situation after isolation with rubber dam.

Fig. 2. Situation after cavity preparation and pulp exposure.

Fig. 3. Mineral trioxide aggregate (MTA) applied to cover and protect the exposed pulp tissue.

Fig. 4. Marking of the exposed pulp area with blue composite.

Fig. 5. Appearance of the cavity after application of the universal adhesive in the self-etch mode.

Fig. 6. Cavity filled up to the level of the interproximal enamel wall with CLEARFIL MAJESTY™ ES Flow - Super Low A2.

Fig. 7. Second visit: Prepared cavities.

Fig. 8. Situation after bonding, build-up of the interproximal walls with paste-like composite, filling with flowable material and coverage with a final layer of paste-like CLEARFIL MAJESTY™ ES-2 Classic A2.

Fig. 9. Appearance of the restored tooth before contouring.

Fig. 10. Result of the polishing procedure …

Fig. 11. … carried out with a rubber polisher and the CLEARFIL™ Twist DIA System.

FINAL SITUATION

Fig. 12. Treatment outcome …

Fig. 13. … immediately after rubber dam removal.

Dentist:

DR. ALEKSANDRA ŁYŻWIŃSKA
Warsaw, Poland

Dr. Aleksandra Łyżwińska, DMD, is a passionate aesthetic and adhesive dentist. Driven by Evidence Based Dentistry, her goal includes using modern composite materials and bonding agents in her clinical practise. In addition to her primary job, she worked as a lecturer and an assistant professor at the Department of Conservative Dentistry and Endodontics of Medical University of Warsaw, her alma mater.

Case by Dr. Jorge F. Zapata, DDS

When replacing amalgam restorations, we often see that the remaining tooth structure is severely stained. Nevertheless, a defect-oriented preparation is preferable over a procedure that involves the removal of healthy, but stained dentin as well. Long-lasting direct restorations with a natural look are obtained by using the universal adhesive CLEARFIL™ Universal Bond Quick, CLEARFIL MAJESTY™ Flow as a cavity liner, CLEARFIL MAJESTY™ ES-2 Premium Dentin to mask the stained areas and a final layer of CLEARFIL MAJESTY™ ES-2 Universal. The following case example confirms that this product combination leads to a nice optical integration.

Fig. 1 Pre-operative image: Maxillary second premolar and first molar with amalgam restorations in need of replacement.

Fig. 2 Situation after removal of the existing amalgam restorations.

Fig. 3 Immediate treatment outcome.

Dentist:

DR. JORGE F. ZAPATA, DDS

Case by Dr. Aleksandra Łyżwińska, DMD

The case presented is regarding a patient with two discoloured composite restorations located in the distal aspect of the maxillary right central incisor and the mesial aspect of the adjacent lateral incisor. A replacement of these restorations was planned due to marginal leakage and for aesthetic reasons. During cavity preparation, a vestibular bevel was created in the enamel of the lateral incisor to provide for a smooth blend-in of the restoration and to improve adhesion. After selective etching of the enamel with phosphoric acid gel, CLEARFIL™ SE BOND 2 was applied. The adhesive contains the original 10-MDP monomer, which establishes a strong bond by adhering to dentin chemically. The restorations were created with CLEARFIL MAJESTY™ ES Flow - Low A2 and CLEARFIL MAJESTY™ ES-2 Classic in the shade A2. Final polishing was accomplished in a four-step procedure with abrasive discs, an aluminum oxide rubber polisher, and the two-disc CLEARFIL™ Twist DIA polishing system.

Fig. 1. Initial clinical situation after rubber dam placement.

Fig. 2. Detailed view of the teeth with a discoloured resin composite restoration visible in the mesial aspect of the lateral incisor.

Fig. 3. Palatal view of the teeth revealing marginal staining of the restoration in the distal aspect of the central incisor.

Fig. 4. Palatal view of the teeth after removal of the restorations and cavity preparation.

Fig. 5. Frontal view of the teeth after removal of the restorations and tooth preparation including beveling of the enamel.

Fig. 6. Upright placement of two sectional contoured matrices designed for the posterior region – palatal view.

Fig. 7. Frontal view of the sectional matrices fixed with a wedge.

Fig. 8. Palatal view of the teeth after selective enamel etching, bonding, and the application and light-curing of CLEARFIL MAJESTY™ ES Flow - Low A2 and CLEARFIL MAJESTY™ ES-2 Classic – A2.

Fig. 9. Frontal view of the situation - a concave “emergence profile” caused by matrix bending.

Fig. 10. Final layer of CLEARFIL MAJESTY™ ES Flow - Low A2 applied to the mesio-labial aspect of the lateral incisor.

Fig. 11. Occlusal view of the final composite layer prior to finishing.

Fig. 12. Polishing with the pre-polisher of the CLEARFIL™ Twist DIA system.

Fig. 13. Polishing with the high-shine polisher of the CLEARFIL™ Twist DIA system.

FINAL SITUATION

Fig. 14. Outcome of the polishing procedure.

Dentist:

DR. ALEKSANDRA ŁYŻWIŃSKA
Warsaw, Poland

Dr. Aleksandra Łyżwińska, DMD, is a passionate aesthetic and adhesive dentist. Driven by Evidence Based Dentistry, her goal includes using modern composite materials and bonding agents in her clinical practise. In addition to her primary job, she worked as a lecturer and an assistant professor at the Department of Conservative Dentistry and Endodontics of Medical University of Warsaw, her alma mater.

By Dr. Jusuf Lukarcanin

Direct resin composite restorations are a great option for diastema closure, shape correction and even an optical alignment of anterior teeth. The treatment approach is conservative with no or only minimal tooth preparation required, and with the right materials, it is possible to obtain beautiful outcomes, which is decisive in the aesthetically demanding anterior region. In this context, one might assume that a wide range of available shades and a meticulous shade selection process are important preconditions for a successful shade match. The following case examples show, however, that great outcomes can also be achieved in a simplified way using CLEARFIL MAJESTY™ ES-2 Universal, a game-changing resin composite with only two shade options for the anterior region.

CLINICAL CASE 1

Fig. 1 Initial situation of a young patient with maxillary and mandibular diastemata to be closed.

Fig. 2 Treatment outcome after direct diastema closure with CLEARFIL MAJESTY™ ES-2 Universal in the shade UL (Universal Light). A precise colour match and a natural gloss are obtained. Apart from the fact that the procedure is simplified be eliminating the need for shade determination and selection, the workflow is the same as with traditional composites.

Fig. 3 Close-up view of the initial and the final situation. A smooth transition from the teeth to the restorations is obtained.

CLINICAL CASE 2

Fig. 1 Female patient with multiple diastemata asking for a minimally-invasive, aesthetic treatment option.

Fig. 2 Treatment outcome after composite veneering with CLEARFIL MAJESTY™ ES-2 Universal in the shade UL (Universal Light).

Fig. 3 The patient’s smile - her teeth have a natural, lighter appearance.

CLINICAL CASE 3

Fig. 1 Young patient with malpositioned maxillary central and lateral incisors.

Fig. 2 Irregularities visible when the patient is smiling. She opted for composite veneering instead of an orthodontic approach.

Fig. 3 Treatment outcome after optical alignment and correction of teeth’s shapes using CLEARFIL MAJESTY™ ES-2 Universal in the shade UL (Universal Light).

„My first reaction to this material was: this is a Game-Changer.“

The results are magical. Smoother and easy handling properties, high-gloss, natural light distribution and the process is simple. Aside from being able to skip the shade selection step, your workflow remains the same as with traditional composites. At first, I might have been a little skeptical about replacing all the different shades of composites we use in office every day. But after a couple of tries I discovered that it indeed works every time, in most cases even without the use of a blocker. Simply ingenious!

Dr. Jusuf Lukarcanin

Dentist:

DR. JUSUF LUKARCANIN

Dr. Jusuf Lukarcanin is a Certified Dental Technician (DCT) and a Doctor of Dental Science (DDS). He studied dentistry at the Ege University Dental Faculty in Izmir, Turkey, where he obtained a Master‘s degree in 2011. In 2017, he received a Ph.D. degree from the Department of Restorative Dentistry of the same university. Between 2012 and 2019, Dr. Lukarcanin was the head doctor and general manager at a private clinic in Izmir. Between 2019 and 2020, he worked at Tinaztepe GALEN Hospital as a Restorative Dentistry specialist, between 2020-2022 he worked at MEDICANA International Hospital Izmir as a Restorative Dentistry specialist. Currently he is an owner of a private clinic for aesthetics and cosmetics in Izmir.

Case by Dr. Cyril Gaillard

In the past few years, the number of patients diagnosed with sleep apnea has increased. Fortunately, we can propose different options of treatments today, which can provide positive clinical results and improve the quality of life of our patients.

This clinical case presents the use of a new CAD-CAM material, KATANA™ AVENCIA™ block, produced using the unique manufacturing method of Kuraray Noritake Dental, which offers remarkable mechanical properties.

The goals of the treatment are:

• Biological and minimally invasive, when it comes to teeth (non-invasive), periodontics, and occlusion (muscular and articular).
• To maintain health on the long-term (ease of hygiene).
• To re-establish an effective function (mastication) without compromising aesthetics.

This article presents the rehabilitation of a patient suffering from sleep apnea, integrating the concept of minimally invasive and adhesive dentistry with most importantly, functional dentistry by identifying precisely the occlusal concept and mandibular position given to the patient.

The forty-year-old patient came to the office for his annual check-up. During initial examination, we discussed his problem of sleep apnea and the fact that he feels uncomfortable with his occlusion.

The extra-oral exam revealed a largely reduced lower face area. We noted the presence of a crown in the place of tooth #46 and amalgams on the molars. The crown had to be removed and the root extracted, one implant would be placed.

The patient told us he did not suffer from muscle spasms nor from articular pain, but conveyed an increasing discomfort during mastication and a constant search for the right position to his mandible.

Based on my diagnosis, it was judged that the treatment with KATANA™ AVENCIA™ is within the scope of indications since the occlusion problem is a minor issue.

TREATMENT PLAN

To create the treatment plan, we always follow the same steps:

• Discussion with the patient to identify his or her wishes and limitations in terms of treatment.
• Occlusal planning, search for the appropriate mandibular position in order to determine the quantity of destroyed dental tissue; this is done by TENS machine.
• Periodontic diagnosis and support teeth.

We proceed in the following manner for the treatment:

• Cleaning of all teeth.
• Complete in-mouth mock-up for the lower arch.
• The mock-up will be left in the mouth in order to validate the new occlusion.
• Use of CAD-CAM technology to create the definitive prostheses, integrating the concept of minimally invasive dentistry. We will use KATANA™ AVENCIA™ block as material for the overlays.

Initial situation with occlusion troubles causing discomfort during mastication.

Once the mock-up had been placed in the mouth, it was necessary to test the new occlusion and adjust if needed. The mock-up was milled in PMMA by Roland DG Corporation milling machine.

The teeth are prepared through the mock-up to be as minimally invasive as possible. The thickness is 1,5 mm for occlusal and 1 mm for buccal surface.

Overlays and crown(s) on implant were designed by 3Shape software (3Shape A/S) and milled by Roland milling machine. The final restorations were created using two digital impressions. On the impression of the preparations, the cervical limits were marked. Next, the software matched the two impressions by subtraction and proposed the shape of the restorations to be milled.

These restorations are the exact copy (morphology) of what the patient wore in his mouth for two months. If the work is done by section, it is easier for the computer to match the impressions.

KATANA™ AVENCIA™ block was milled.

Polishing of the restoration with CLEARFIL™ TWIST DIA.

After milling, the restorations were stained using a 3D staining technique. 3D staining requires a specific sequence to create 3D optical illusions.

Final esthetic results after staining.

A classic bonding procedure was followed with PANAVIA™ V5. To begin, all KATANA™ AVENCIA™ elements were tried one by one for validation and adjustment, then all together to check the contact points.

Rubber dam was placed on the mandible. The intrados of the elements were blasted with alumina power, then we applied K-Etchant gel, rinsed well and dried. A layer of silane was applied (CLEARFIL™ CERAMIC PRIMER PLUS) for 60 seconds* then dried.

Application of K-Etchant gel for 30 seconds on enamel. Surfaces were rinsed, dried, and the adhesive PANAVIA™ V5 Tooth Primer was applied, left for 20 seconds, then dried.

Restorations were bonded one by one with PANAVIA™ V5 Paste. The excess was removed and the final photo-polymerization using glycerin was performed.

A final polishing was performed with CLEARFIL™ TWIST DIA.

To conclude, the occlusion was verified in static position with cuspfossa contact, then laterality, propulsion, and finally mastication.

Final situation. We can observe a good and esthetic integration of the restorations. A long term follow-up should be necessary to confirm the success of the treatment.

FINAL SITUATION

“KATANA™ AVENCIA™ MAKES MY DAILY WORK EASIER… AND MY PATIENTS ARE HAPPY”

Dentist:

DR. CYRIL GAILLARD
DENTAL SURGEON AND CEO OF GAD-CENTER
PRIVATE PRACTICE, BORDEAUX

1998 Graduated from the University of Bordeaux
2000 CES Fixed Prostheses
2002 DU of Implantology, University of Bordeaux
2002 SAPO Implant
2003 Certificate Bone grafting
2006 of Maxillo Faciale Surgical Rehabilitation, Paris VII
CES of Anatomy Physiology
CES of Removable Prostheses