By Drs. Mart Ramaekers

A 20-year-old patient was dissatisfied with her discolored composite restorations on her maxillary central incisors and the right lateral incisor. The original restorations had been placed after an accident with traumatic dental injuries approximately five years ago. We went through all available options that would enable us to improve the aesthetics of her anterior teeth and finally opted for replacement of the existing restorations by new direct restorations made of composite resin.

Prior to the restorative procedure, a home bleaching procedure was carried out with Opalescence 10% (Ultradent). In addition, a palatal silicon index was produced to record the shape and morphology of the existing restorations and dentition.

Initial situation

Frontal view of the initial situation.

Lateral view: The discolorations are particularly visible on the maxillary right central and lateral incisor.

Close-up view of the upper anterior teeth.

The existing restorations were removed after the administration of local anesthesia. Then, labial and palatal bevels were created, followed by sandblasting of the prepared tooth structure with alumina (50 μm). Hereafter, the enamel was etched for 30 seconds (K-Etchant Syringe, Kuraray Noritake Dental), before the primer and bond of CLEARFIL™ SE BOND (Kuraray Noritake Dental) were used according to the instructions.

Build-up of the palatal walls with a first increment of ‘enamel’ composite (CLEARFIL MAJESTY™ ES-2 Premium A2E, Kuraray Noritake Dental) using the silicon index.

Creation of the mesial and distal marginal ridges in A2E enamel composite. The procedure was facilitated by the vertical placement of sectional matrices (Contact Matrices Stiff Flex Large, Danville) in the interproximal space.

Creation of the dentin core and the dentinal mamelons by placement of an opaque composite increment (CLEARFIL MAJESTY™ ES-2 Premium, A2D). It increases the opacity in the middle third of the restoration.

Filling of the space between the mamelons with translucent composite (CLEARFIL MAJESTY™ ES-2 Premium, Translucent Clear).

Labial finishing of the restorations with a layer of semi-translucent composite (CLEARFIL MAJESTY™ ES-2 Premium, A2E).

Application of glycerin gel on top of the last layer of composite to prevent formation of an oxygen inhibited layer during the final light-curing procedure. Final contouring and polishing were performed by using red (fine) and yellow (x-fine) finishing diamonds followed by high gloss polishing with CLEARFIL™ TWIST DIA (Kuraray Noritake Dental).

Final situation

Frontal view of the final situation.

Lateral view: No shade differences or restoration margins are visible.

Close-up view of the new restorations on the upper anterior teeth.

Ceramist:

Drs. Mart Ramaekers

Academic education
2002 - 2007   Tandheelkunde, Radboud Universiteit Nijmegen

Non-academic education
2013 - 2014   Academy of Reconstructive Dentistry, Beuningen
2019              Biomimetic Dentistry, Los Angeles

Career
2008 - 2013    Mondzorg Jekerdal Maastricht
2013 - 2015    De Drietand Maastricht
2009 - 2020    Amalia Kliniek Kerkrade
2020 - now      Espenbos Kliniek Cadier en Keer

Materials used: Kuraray Noritake Dental: CLEARFIL™ SE BOND 2, K-Etchant Syringe, CLEARFIL MAJESTY™ ES-2 Premium Enamel A2E, CLEARFIL MAJESTY™ ES-2 Premium Dentin A2D , CLEARFIL MAJESTY™ ES-2 Premium Translucent Clear and CLEARFIL™ TWIST DIA. Heavy Putty (Provil Novo, Heraeus Kulzer), Glycerine gel (K-Yelly Johnson&Johnson), Rubberdam non-latex Heavy (Sigma), Contact Matrices Stiff Flex Large (Danville), Optragate Regular (Ivoclar)

CERABIEN™ ZR
High translucent and opal porcelain for True-to-life, highly aesthetic restoration.

Blue-tinged light translucency at incisor edge of enamel was reproduced with LTx and LT Royal Blue.

Initial situation.

LTx and LT Royal Blue were used at the incisor edges to reproduce the bluish opalescence and translucency effect.

Step 1: Build-up of internal structures.

In order to reproduce the mamelon structure with stain and dentin color, Internal Stains were applied, then baked.

Step 2: Applied the first Internal Stain, then baked it.

In order to reproduce the stain in the internal enamel structure, Luster porcelains were applied and baked as a base.

Step 3: Applied the first enamel structure, then baked.

In order to reproduce the white spot and the incisor halo, Internal Stains were applied before baking.

Step 4: Applied the second Internal Stain before baking it.

To reproduce the subtle color and translucency of enamel, Luster porcelains were applied before baking.

Step 5: Applied the second enamel structure before baking it.

Step 6: Final situation.

Photos: Courtesy of Otani Dental Clinic, MDT Ryuzo Shiba and MDT Naoto Yuasa.

CERABIEN™ ZR
High translucent and opal porcelain for True-to-life, highly aesthetic restoration.

Blue-tinged light translucency at incisor edge of enamel was reproduced with LTx and LT Royal Blue.

Initial situation.

LTx and LT Royal Blue were used at the incisor edges to reproduce the bluish opalescence and translucency effect.

Step 1: Build-up of internal structures.

In order to reproduce the mamelon structure with stain and dentin color, Internal Stains were applied, then baked.

Step 2: Applied the first Internal Stain, then baked it.

In order to reproduce the stain in the internal enamel structure, Luster porcelains were applied and baked as a base.

Step 3: Applied the first enamel structure, then baked.

In order to reproduce the white spot and the incisor halo, Internal Stains were applied before baking.

Step 4: Applied the second Internal Stain before baking it.

To reproduce the subtle color and translucency of enamel, Luster porcelains were applied before baking.

Step 5: Applied the second enamel structure before baking it.

Step 6: Final situation.

Photos: Courtesy of Otani Dental Clinic, MDT Ryuzo Shiba and MDT Naoto Yuasa.

By Dr. PhD. Jusuf Lukarcanin

Is it possible to fulfil high aesthetic demands by restoring anterior teeth with composite resin? It is – provided that several important factors are respected. One of these factors is the faithful reproduction of the natural tooth morphology, which has a decisive impact on aesthetics and function. Moreover, success is determined by the selection of the right shades of high-quality composite resin and their purposeful combination using proper layering techniques.

Introduction

The aesthetic appearance of direct anterior restorations is affected by proper shade selection on the one hand and the creation of a natural shape and texture on the other¹. Hence, the dental practitioner’s own artistic skills play a decisive role. According to Fahl, information about the tooth morphology and function, and the optical properties of the tooth should be taken into consideration when the most suitable restorative material and shade are selected².

These minimally invasive composite restorations are no longer a temporary solution for the anterior region. Instead, they are regarded as an adequate alternative to indirect restorations, as they are both durable and able to closely imitate the natural tooth structure³⁴.

Clinical case example 1

This 45-year-old female patient presented with a diastema and a disproportion in the size and shape of her maxillary central incisors (Fig. 1). In the first step, a detailed case history was taken and an intra-oral examination was carried out. Subsequently, the initial situation was recorded by taking intra-oral photographs, which would allow for a computer-aided morphological evaluation and treatment planning (Fig. 2).

Fig. 1: Pre-operative image.

Fig. 2: Digital mock-up.

The patient’s second visit started with a professional tooth cleaning procedure followed by isolation of the maxillary anterior teeth. Afterwards, the tooth shade was determined and appropriate composite shades were selected. In this case, the shades A2E, Amber Translucent and A3D of CLEARFIL™ Majesty ES-2 Premium (Kuraray Noritake Dental, Japan) appeared to be most suitable. In addition, a mock-up was created using mock-up resin in order to produce a silicone key.

Opting for a minimally invasive procedure, no mechanical tooth preparation using drills was performed after removal of the mock-up. Instead, the enamel was merely etched with 35% phosphoric acid gel (K-Etchant, Kuraray Noritake Dental) to increase the surface roughness. After rinsing and drying, the adhesive agent (CLEARFIL™ Universal Bond, Kuraray Noritake Dental) was applied to the etched surfaces. Composite layering started with the build-up of palatal shells with the aid of the silicone key. Following light-curing of the shells, a small amount of composite in the dentin shade A3D was applied to the proximal surfaces using a thin spatula and a brush. The aim was to reduce light transmission in the area of the dentin core. The restoration was completed with a combination of the composite shades A2E (enamel) and Amber Translucent, which were applied using a modeling brush.

Finishing and polishing was accomplished using flexible rubber polishing discs containing diamond particles (CLEARFIL™ Twist DIA, Kuraray Noritake Dental) with a low-speed handpiece. No additional finishing and contouring was necessary due to the use of a brush during layering, which ensured the creation of a natural shape and surface texture. Figure 3 shows the outcome of the restoration procedure.

Fig. 3: Treatment outcome immediately after polishing.

Oral hygiene training was provided and follow-up examinations were performed after three, six and twelve months (Fig. 4). Healthy hard and soft tissue conditions were observed during these visits.

Fig. 4: Clinical situation at the one-year recall.

Clinical case example 2

This 30-year-old female patient had a diastema, irregularly shaped anterior teeth and showed signs of abrasive tooth wear (Fig. 5). Following a detailed anamnesis and intra-oral examination, the tooth shade was determined and the composite CLEARFIL™ Majesty ES-2 Premium selected in the monochromatic shade Universal A1.

Fig. 5: Pre-operative clinical situation.

Following the isolation of the working field, 35% phosphoric acid etchant (K-Etchant) was applied to the enamel of all teeth between the maxillary right canine and the maxillary left first molar. The surfaces were then treated with a universal bonding agent (CLEARFIL™ Universal Bond) as recommended by the manufacturer. Modeling was carried out with a thin spatula and a modeling brush for composite. Neither a silicone key nor any wetting or modeling resin were used in the procedure. For polishing, the flexible polishing discs CLEARFIL™ Twist DIA were used at low rotational speed. Thanks to the use of the modeling brush, no additional finishing with diamond-coated instruments was necessary. Figures 6 and 7 show the final restoration at baseline and one week after completion of the treatment.

Fig. 6: Treatment outcome at the day of the restorative procedure.

Fig. 7: Clinical situation after one week.

This patient also received oral hygiene training and presented for recalls three, six and twelve months after the treatment. The patient maintained an exemplary oral hygiene behaviour, so that it came as no surprise that the soft tissues were healthy and the restorations were in a perfect condition after one year (Fig. 8).

Fig. 8: Clinical situation one year after the restorative treatment.

Discussion

Nowadays, direct composite restorations are becoming increasingly popular. Especially for young patients and all those who do not want to sacrifice large amounts of healthy tooth structure, the technique is an ideal treatment option⁵. In many cases, aesthetic outcomes are possible without mechanical tooth preparation, but a selective etching procedure only⁶.

The clinical lifetime of these restorations depends on many factors. Important prerequisites for high-quality outcomes include the selection of a suitable composite material with the required surface hardness, appropriate finishing and polishing, a good oral hygiene behaviour, and proper maintenance measures during periodical follow-up visits. As a matter of course, the manual skills of the dental practitioner and the use of selected materials according to the manufacturer’s instructions for use also have a direct impact on the long-term success of the restorations⁷⁸⁹. A user’s inability to meet one of these requirements and failure to carry out all working steps correctly may have a direct impact on the quality of the restoration.

Conclusion

Composite resin is a popular material class for the production of aesthetic anterior restorations die to their straightforward use and rapid application, good repair options and high aesthetic potential when used properly . The two case examples illustrate that a treatment with composite resin is often the best treatment option when a non-invasive procedure completed within a single visit is desired.

References

^{1. Heymann HO (1987) The artistry of conservative esthetic dentistry Journal of the American Dental Association 115(Supplement)14-23.}

^{2. Fahl N Jr (2012) Single-shaded direct anterior composite restorations: A simplified technique for enhanced results Compendium of Continuing Education in Dentistry 33(2) 150-154.}

^{3. Barrantes, J. C. R., Araujo Jr, E., & Baratieri, L. N. (2014). Clinical Evaluation of Direct Composite Resin Restorations in Fractured Anterior Teeth. Odovtos-International Journal of Dental Sciences, (16), 47-61.}

^{4. Vargas M (2011) Clinical techniques: Monocromatic vs. polycromatic layering: How to select the appropriate technique ADA Professional Product Review 6(4) 16-17.}

^{5. Ferracane, J. L. (2011). Resin composite—state of the art. Dental materials, 27(1), 29-38.}

^{6. Norling, N. A. (2010). Combining “prep-less” and conservatively prepared veneers to correct enamel defects and asymmetry. Journal of Cosmetic Dentistry, 2010.}

^{7. Ölmez, A., & Kisbet, S. (2012). Kompozit rezin restorasyonlarda bitirme ve polisaj işlemlerindeki yeni gelişmeler. Acta Odontologica Turcica, 30(2), 115-22.}

^{8. Senawongse, P., & Pongprueksa, P. (2007). Surface roughness of nanofill and nanohybrid resin composites after polishing and brushing. Journal of Esthetic and Restorative Dentistry, 19(5), 265-273.}

^{9. Giacomelli, L., Derchi, G., Frustaci, A., Bruno, O., Covani, U., Barone, A., Chiappelli, F. (2010). Surface roughness of commercial composites after different polishing protocols: an analysis with atomic force microscopy. The open dentistry journal, 4, 191.}

^{10. Hickel, R., Heidemann, D., Staehle, H. J., Minnig, P., & Wilson, N. H. F. (2004). Direct composite restorations. Clin Oral Invest, 8, 43-44.}

^{11. Korkut, B., Yanıkoğlu, F., & Günday, M. (2013). Direct composite laminate veneers: three case reports. Journal of dental research, dental clinics, dental prospects, 7(2), 105.}

By Dr. PhD. Jusuf Lukarcanin

Is it possible to fulfil high aesthetic demands by restoring anterior teeth with composite resin? It is – provided that several important factors are respected. One of these factors is the faithful reproduction of the natural tooth morphology, which has a decisive impact on aesthetics and function. Moreover, success is determined by the selection of the right shades of high-quality composite resin and their purposeful combination using proper layering techniques.

Introduction

The aesthetic appearance of direct anterior restorations is affected by proper shade selection on the one hand and the creation of a natural shape and texture on the other¹. Hence, the dental practitioner’s own artistic skills play a decisive role. According to Fahl, information about the tooth morphology and function, and the optical properties of the tooth should be taken into consideration when the most suitable restorative material and shade are selected².

These minimally invasive composite restorations are no longer a temporary solution for the anterior region. Instead, they are regarded as an adequate alternative to indirect restorations, as they are both durable and able to closely imitate the natural tooth structure³⁴.

Clinical case example 1

This 45-year-old female patient presented with a diastema and a disproportion in the size and shape of her maxillary central incisors (Fig. 1). In the first step, a detailed case history was taken and an intra-oral examination was carried out. Subsequently, the initial situation was recorded by taking intra-oral photographs, which would allow for a computer-aided morphological evaluation and treatment planning (Fig. 2).

Fig. 1: Pre-operative image.

Fig. 2: Digital mock-up.

The patient’s second visit started with a professional tooth cleaning procedure followed by isolation of the maxillary anterior teeth. Afterwards, the tooth shade was determined and appropriate composite shades were selected. In this case, the shades A2E, Amber Translucent and A3D of CLEARFIL™ Majesty ES-2 Premium (Kuraray Noritake Dental, Japan) appeared to be most suitable. In addition, a mock-up was created using mock-up resin in order to produce a silicone key.

Opting for a minimally invasive procedure, no mechanical tooth preparation using drills was performed after removal of the mock-up. Instead, the enamel was merely etched with 35% phosphoric acid gel (K-Etchant, Kuraray Noritake Dental) to increase the surface roughness. After rinsing and drying, the adhesive agent (CLEARFIL™ Universal Bond, Kuraray Noritake Dental) was applied to the etched surfaces. Composite layering started with the build-up of palatal shells with the aid of the silicone key. Following light-curing of the shells, a small amount of composite in the dentin shade A3D was applied to the proximal surfaces using a thin spatula and a brush. The aim was to reduce light transmission in the area of the dentin core. The restoration was completed with a combination of the composite shades A2E (enamel) and Amber Translucent, which were applied using a modeling brush.

Finishing and polishing was accomplished using flexible rubber polishing discs containing diamond particles (CLEARFIL™ Twist DIA, Kuraray Noritake Dental) with a low-speed handpiece. No additional finishing and contouring was necessary due to the use of a brush during layering, which ensured the creation of a natural shape and surface texture. Figure 3 shows the outcome of the restoration procedure.

Fig. 3: Treatment outcome immediately after polishing.

Oral hygiene training was provided and follow-up examinations were performed after three, six and twelve months (Fig. 4). Healthy hard and soft tissue conditions were observed during these visits.

Fig. 4: Clinical situation at the one-year recall.

Clinical case example 2

This 30-year-old female patient had a diastema, irregularly shaped anterior teeth and showed signs of abrasive tooth wear (Fig. 5). Following a detailed anamnesis and intra-oral examination, the tooth shade was determined and the composite CLEARFIL™ Majesty ES-2 Premium selected in the monochromatic shade Universal A1.

Fig. 5: Pre-operative clinical situation.

Following the isolation of the working field, 35% phosphoric acid etchant (K-Etchant) was applied to the enamel of all teeth between the maxillary right canine and the maxillary left first molar. The surfaces were then treated with a universal bonding agent (CLEARFIL™ Universal Bond) as recommended by the manufacturer. Modeling was carried out with a thin spatula and a modeling brush for composite. Neither a silicone key nor any wetting or modeling resin were used in the procedure. For polishing, the flexible polishing discs CLEARFIL™ Twist DIA were used at low rotational speed. Thanks to the use of the modeling brush, no additional finishing with diamond-coated instruments was necessary. Figures 6 and 7 show the final restoration at baseline and one week after completion of the treatment.

Fig. 6: Treatment outcome at the day of the restorative procedure.

Fig. 7: Clinical situation after one week.

This patient also received oral hygiene training and presented for recalls three, six and twelve months after the treatment. The patient maintained an exemplary oral hygiene behaviour, so that it came as no surprise that the soft tissues were healthy and the restorations were in a perfect condition after one year (Fig. 8).

Fig. 8: Clinical situation one year after the restorative treatment.

Discussion

Nowadays, direct composite restorations are becoming increasingly popular. Especially for young patients and all those who do not want to sacrifice large amounts of healthy tooth structure, the technique is an ideal treatment option⁵. In many cases, aesthetic outcomes are possible without mechanical tooth preparation, but a selective etching procedure only⁶.

The clinical lifetime of these restorations depends on many factors. Important prerequisites for high-quality outcomes include the selection of a suitable composite material with the required surface hardness, appropriate finishing and polishing, a good oral hygiene behaviour, and proper maintenance measures during periodical follow-up visits. As a matter of course, the manual skills of the dental practitioner and the use of selected materials according to the manufacturer’s instructions for use also have a direct impact on the long-term success of the restorations⁷⁸⁹. A user’s inability to meet one of these requirements and failure to carry out all working steps correctly may have a direct impact on the quality of the restoration.

Conclusion

Composite resin is a popular material class for the production of aesthetic anterior restorations die to their straightforward use and rapid application, good repair options and high aesthetic potential when used properly . The two case examples illustrate that a treatment with composite resin is often the best treatment option when a non-invasive procedure completed within a single visit is desired.

About the author

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 2018, he received a PhD degree from the Department of Restorative Dentistry of the same university, where he also worked as a researcher for six years. Between 2012 and 2019, Dr. Lukarcanin was the head doctor and general manager at Ozel Gen Dental Clinic (OZEL GEN Ağız ve Diş Sağlığı Polikliniği) in Izmir. Currently, he works at Tinaztepe GALEN Hospital in the Tinaztepe Health Group of Tinaztepe University and in the Department of Research & Development of GULSA Company in Izmir.

References

^{1. Heymann HO (1987) The artistry of conservative esthetic dentistry Journal of the American Dental Association 115(Supplement)14-23.}

^{2. Fahl N Jr (2012) Single-shaded direct anterior composite restorations: A simplified technique for enhanced results Compendium of Continuing Education in Dentistry 33(2) 150-154.}

^{3. Barrantes, J. C. R., Araujo Jr, E., & Baratieri, L. N. (2014). Clinical Evaluation of Direct Composite Resin Restorations in Fractured Anterior Teeth. Odovtos-International Journal of Dental Sciences, (16), 47-61.}

^{4. Vargas M (2011) Clinical techniques: Monocromatic vs. polycromatic layering: How to select the appropriate technique ADA Professional Product Review 6(4) 16-17.}

^{5. Ferracane, J. L. (2011). Resin composite—state of the art. Dental materials, 27(1), 29-38.}

^{6. Norling, N. A. (2010). Combining “prep-less” and conservatively prepared veneers to correct enamel defects and asymmetry. Journal of Cosmetic Dentistry, 2010.}

^{7. Ölmez, A., & Kisbet, S. (2012). Kompozit rezin restorasyonlarda bitirme ve polisaj işlemlerindeki yeni gelişmeler. Acta Odontologica Turcica, 30(2), 115-22.}

^{8. Senawongse, P., & Pongprueksa, P. (2007). Surface roughness of nanofill and nanohybrid resin composites after polishing and brushing. Journal of Esthetic and Restorative Dentistry, 19(5), 265-273.}

^{9. Giacomelli, L., Derchi, G., Frustaci, A., Bruno, O., Covani, U., Barone, A., Chiappelli, F. (2010). Surface roughness of commercial composites after different polishing protocols: an analysis with atomic force microscopy. The open dentistry journal, 4, 191.}

^{10. Hickel, R., Heidemann, D., Staehle, H. J., Minnig, P., & Wilson, N. H. F. (2004). Direct composite restorations. Clin Oral Invest, 8, 43-44.}

^{11. Korkut, B., Yanıkoğlu, F., & Günday, M. (2013). Direct composite laminate veneers: three case reports. Journal of dental research, dental clinics, dental prospects, 7(2), 105.}

By Daniele Rondoni, RDT

A middle-aged patient sought dental advice because she felt uncomfortable with the aesthetic appearance of her upper front jaw, specifically regions 11, 12, 21 and 22. Additionally, she was not happy about the diastema between her upper central incisors.

Fig. 1: Initial situation.

The oral examination showed four crown regions (12-22) and revealed that all of them have deteriorated. Tooth 21 had undergone an endodontic treatment, while teeth 11 to 22 have been newly built up. Due to the deteriorated conditions, all affected teeth were taken into consideration in the planning and designing of new restorations, including the intention to close the diastema between the width-to-length-ratio for the incisors.

The best suitable material for a natural look in combination with a close gingival attachment to the restoration is, in this case, zirconia, because of its biocompatibility and gentleness to the gingival region. The KATANA^TM Zirconia series from Kuraray Noritake Dental, offers a line-up of high-quality materials combined with true-to-life aesthetics, due to its natural color gradient within the material.

Fig. 2: Preparations, showing discoloration in the cervical area of tooth 21.

Fig. 3: Occlusal view of the preparations.

Fig. 4: The four zirconia crowns after designing followed by milling.

Fig. 5: Result directly after sintering.

To achieve an even more natural-looking and aesthetic restoration, CZR FC Paste Stains were used externally on the zirconia surface.

Fig. 6: Characterization of the restoration.

As often done, Cervical 2 was used to give an orange tint to the cervical area, to accentuate even better the natural tooth gradation. For the incisal areas, Grayish Blue in combination with Value was used to enhance transparency and opalescence. Same procedure applied to the approximal areas. Mamelon Orange 2 was used to reproduce dark orange stain on the mamelons.

Fig. 7: Result after cementation of the four new zirconia crowns. Their shape and chroma blend harmoniously with the arch.

Fig. 8: The vestibular view showing natural-looking characterization.

During a period of five years, annual check-ups showed intact crowns and a healthy gingiva. Additionally, the durability of the restorations, including their mechanical and optical properties revealed no signs of deterioration.

By Daniele Rondoni, RDT

A middle-aged patient sought dental advice because she felt uncomfortable with the aesthetic appearance of her upper front jaw, specifically regions 11, 12, 21 and 22. Additionally, she was not happy about the diastema between her upper central incisors.

Fig. 1: Initial situation.

The oral examination showed four crown regions (12-22) and revealed that all of them have deteriorated. Tooth 21 had undergone an endodontic treatment, while teeth 11 to 22 have been newly built up. Due to the deteriorated conditions, all affected teeth were taken into consideration in the planning and designing of new restorations, including the intention to close the diastema between the width-to-length-ratio for the incisors.

The best suitable material for a natural look in combination with a close gingival attachment to the restoration is, in this case, zirconia, because of its biocompatibility and gentleness to the gingival region. The KATANA^TM Zirconia series from Kuraray Noritake Dental, offers a line-up of high-quality materials combined with true-to-life aesthetics, due to its natural color gradient within the material.

Fig. 2: Preparations, showing discoloration in the cervical area of tooth 21.

Fig. 3: Occlusal view of the preparations.

Fig. 4: The four zirconia crowns after designing followed by milling.

Fig. 5: Result directly after sintering.

To achieve an even more natural-looking and aesthetic restoration, CZR FC Paste Stains were used externally on the zirconia surface.

Fig. 6: Characterization of the restoration.

As often done, Cervical 2 was used to give an orange tint to the cervical area, to accentuate even better the natural tooth gradation. For the incisal areas, Grayish Blue in combination with Value was used to enhance transparency and opalescence. Same procedure applied to the approximal areas. Mamelon Orange 2 was used to reproduce dark orange stain on the mamelons.

Fig. 7: Result after cementation of the four new zirconia crowns. Their shape and chroma blend harmoniously with the arch.

Fig. 8: The vestibular view showing natural-looking characterization.

During a period of five years, annual check-ups showed intact crowns and a healthy gingiva. Additionally, the durability of the restorations, including their mechanical and optical properties revealed no signs of deterioration.

To achieve excellence it is crucial to know the properties of modern materials and their correct clinical procedure. With this premise, surprising clinical results can also be achieved by combining different materials in the same clinical case.

This clinical case follows the aesthetic request of the patient who wanted to solve the pathology concerning the incisors with a direct composite restoration on 2.1 and a KATANA^TM STML crown on 1.1.

Following the mock-up the patient wanted larger incisor shapes with a strong character. The 2.1 was restored only with the MAJESTY^TM ES-2 Classic A2 mass exploiting the extraordinary ability of mimicry that comes from the Kuraray Noritake Dental light diffusion technology - LDT. The restoration on the 2.5 was performed with a CAD/CAM hybrid ceramic block - KATANA^TM AVENCIA^TM.

KATANA^TM AVENCIA^TM Block was characterized with a staining resin before cementation with the new PANAVIA^TM SA Cement Universal. PANAVIA^TM SA Cement Universal includes in its formulation a new type of silane coupling agent – LCSi monomer and this ensures strong and durable chemical bond to glass ceramics and composite resins without pretreatment with silane.

To achieve excellence it is crucial to know the properties of modern materials and their correct clinical procedure. With this premise, surprising clinical results can also be achieved by combining different materials in the same clinical case.

This clinical case follows the aesthetic request of the patient who wanted to solve the pathology concerning the incisors with a direct composite restoration on 2.1 and a KATANA^TM STML crown on 1.1.

Following the mock-up the patient wanted larger incisor shapes with a strong character. The 2.1 was restored only with the MAJESTY^TM ES-2 Classic A2 mass exploiting the extraordinary ability of mimicry that comes from the Kuraray Noritake Dental light diffusion technology - LDT. The restoration on the 2.5 was performed with a CAD/CAM hybrid ceramic block - KATANA^TM AVENCIA^TM.

KATANA^TM AVENCIA^TM Block was characterized with a staining resin before cementation with the new PANAVIA^TM SA Cement Universal. PANAVIA^TM SA Cement Universal includes in its formulation a new type of silane coupling agent – LCSi monomer and this ensures strong and durable chemical bond to glass ceramics and composite resins without pretreatment with silane.

By Japanese Dr. Shigeru Adachi, Cusp Dental Supply Co. Ltd

Initial situation

Checking of the shade (Posterior Crowns: FC Paste Stain, Anterior Crowns: Micro layered CERABIEN™ ZR)

Checking the restoration on the model

Final situation

Ceramist:

MDT Shigeru Adachi, Cusp Dental Supply Co. Ltd

MDT Adachi is a promising ceramist of the new generation, who has been working for Cusp Dental Supply Co. Ltd. since 2013. He received the Award of Excellence 2018 at QDT TECHNICAL CONTEST.

April, 2013 - Present
Working for Cusp Dental Supply Co., Ltd.
March, 2013
Graduated from the Osaka Ceramic Training Center
April, 2009 - March, 2011
Worked for Tsuruga Denatal Laboratory
March, 2009
Graduated from the Aishi Dental Technician College

MDT SHIGERU ADACHI USED KATANA™ ZIRCONIA HTML AND CZR FC PASTE STAIN FOR HIS CASE STUDY

By Japanese Dr. Shigeru Adachi, Cusp Dental Supply Co. Ltd

Initial situation

Checking of the shade (Posterior Crowns: FC Paste Stain, Anterior Crowns: Micro layered CERABIEN™ ZR)

Checking the restoration on the model

Final situation

Ceramist:

MDT Shigeru Adachi, Cusp Dental Supply Co. Ltd

MDT Adachi is a promising ceramist of the new generation, who has been working for Cusp Dental Supply Co. Ltd. since 2013. He received the Award of Excellence 2018 at QDT TECHNICAL CONTEST.

April, 2013 - Present
Working for Cusp Dental Supply Co., Ltd.
March, 2013
Graduated from the Osaka Ceramic Training Center
April, 2009 - March, 2011
Worked for Tsuruga Denatal Laboratory
March, 2009
Graduated from the Aishi Dental Technician College

MDT SHIGERU ADACHI USED KATANA™ ZIRCONIA HTML AND CZR FC PASTE STAIN FOR HIS CASE STUDY

Clinical case by Irfan Abas

A healthy 42 year-old male patient requested reconstruction of his central incisors, which were badly worn.

Pre-Treatment

After producing the mock-up, grooves were prepared through the mock-up.

To fit two lithium disilicate veneers, a preparation of 1 mm was required. After removing the mock-up, the preparation was perfected.

Checking the space using a silicone mold.

Definitive preparation (frontal)

Temporary veneers made from temporary resin based material (Protemp)

Spot-etching before bonding the temporary veneers in place.

A small amount of flowable composite applied to the etched surfaces.

Light curing the entire surface of the temporary veneers.

Finished temporary veneers.

The veneers constructed by the dental technician.

Checking the fit of the veneers

Rubber dam fitted to enable controlled adhesive cementation.

Etching with 35% phosphoric acid K-Etchant Syringe for 10 seconds.

Treatment with selfetching primer PANAVIA™ V5 Tooth Primer (left on for 20 sec.)

Etching of the lithium disilicate veneers with hydrogen fluoride.

Clearfil Ceramic Primer Plus MDP-silane primer applied to the veneers.

Veneers secured to a placement instrument before definitive cementation

PANAVIA V5 Paste applied to the inner surface of the veneer.

PANAVIA V5 Paste spread over the veneer.

Veneer fitted and excess removed.

Light curing (minimum 10 sec.).

Immediately after the adhesive cementation with PANAVIA V5.

Immediately post-op.

Immediately post-op.

Two months post-op.

One year post-op.

One year post-op.