SELECTION OF CLINICAL CASES

Dr. Louis Mackenzie Prof. Antonio Cerutti Dr. Maciej Mikołajczyk Dr. Thierry Caire Prof. Luigi Cianconi Dr. Gabriele Conte Dr. Manuele Mancini Dr. Rainer Tilse Dr. Raphaël Boudas Dr. Philippe Chpindel

Contents

Harmonize™

The next generation universal composite bringing lifelike results and simplicity to the practise of dentistry

Class IV direct restoration using Harmonize™ nanohybrid universal compositeDr. Louis Mackenzie

Aesthetic restoration following traumatic dental injuryProf. Antonio Cerutti

Multiple diastemata closures with Harmonize™

Prof. Antonio Cerutti

Diastema closure using Harmonize™ nanohybrid universal compositeDr. Maciej Mikołajczyk

Three clinical cases showing the implementation of a next generation universal composite: Harmonize™ Dr. Thierry Caire

Class IV aesthetic restoration of an upper central incisorProf. Luigi Cianconi, Dr. Gabriele Conte, Dr. Manuele Mancini

Dentine-enamel fractures to maxillary incisorsDr. Rainer Tilse

Aesthetic restoration and integration using a simplified stratification technique with a next generation compositeDr. Raphaël Boudas

Impact of the incisal composite and polishingDr. Philippe Chpindel, Yanis Chpindel

Disclaimer: The Doctors are paid consultants for Kerr Dental.The opinions expressed in these articles/clinical cases are those of the Doctors. Kerr Dental is a medical device manufacturer and does not dispense medical advice. Clinicians should use their own professional judgment in treating their patients.

All trademarks are property of their respective owners.

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Harmonize™ The next generation universal composite bringing lifelike results and simplicity to the practise of dentistry.In restorative dentistry, aesthetic takes the meaning of undetectable. Successful dental work lives in perfect harmony with all surrounding teeth, making it impossible to discern with a naked eye what is natural and what has been crafted by the hand of a dentist.

Finding a composite that can mimic every aspect of the natural tooth is a must, yet the selection of materials available often forces dentists to choose between handling, aesthetics and strength.

Designed to work with youBuilding on a rich history of Kerr material knowledge, Harmonize nanohybrid universal composite is infused with the exclusive Adaptive Response Technology (ART).

Its innovative formula confers the material lifelike aesthetic qualities, noticeable the moment you extrude it. The same technology also leads to remarkable handling and strength that are comparable to those of a natural tooth.• Adaptive and realistic light reflection properties, for better blending and an enhanced chameleon

effect;• Excellent gloss retention and polishability;• Dynamic viscosity at each step, to give you complete control during positioning, shaping and carving;• Minimised stickiness and no slumping;• Better curing efficacy for a long-lasting performance.

A collection of experiencesProfessionals worldwide have already tested Harmonize and come to treasure its results.

This booklet of clinical cases collects many of these experiences to demonstrate the product’s versatility and its success in giving both anterior and posterior restorations the aesthetic results they deserve.

An in-vitro study completes this collection by providing the scientific evidence backing this innovative universal composite.

If you would like to find out more about the technology behind this breakthrough product, book a demo or view this document online, please visit www.kerrdental.com/try-harmonize.

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A R TAdaptive Response Technology

This clinical case report describes the minimally invasive direct restoration of a fractured maxillary right lateral incisor (Fig. 1) using an innovative nanohybrid composite material called Harmonize™ (Kerr™).

Pre-operative patient examination included assessment of the fractured incisor and of the adjacent failed distopalatal Class III composite, as well as shade selection for a replacement with a direct composite restoration (Fig. 2). In clinical situations where both enamel and dentine require replacement with direct composite, the use of different material layers with distinct optical characteristics has been recommended, as use of a single material may deliver a

compromised aesthetic result.1,2 The Harmonize composite material described in this case is suitable for both anterior and posterior restorations and is available in a range of 8 dentine shades, 17 enamel shades and 5 incisal shades. The dentine shades are designed to accurately match the natural opacities of dentine and are used for the majority of the restoration. Enamel shades mimic the translucency of the overlying enamel and may be further overlaid with thin increments of incisal shades to modify translucency or confer opalescent properties as enamel does in nature. Shade selection was carried out immediately prior to isolation to prevent teeth from becoming dehydrated, lightened and more opaque, as can happen in less than three minutes.1 Maximum dehydration is reported to

Dr. Louis MackenzieLouis Mackenzie is a general dentist working in Birmingham, England and is a clinical lecturer at the University of Birmingham School of Dentistry and in the postgraduate department at King’s College London. He delivers postgraduate lectures nationally and internationally on direct and indirect restorative techniques and minimally invasive dentistry, and runs a series of popular hands-on courses. He is co-founder of dentaljuce.com the online dental CE library, is a member of the editorial board of Dental Update Journal and is the head of clinical training at Denplan Ltd.

Class IV direct restoration using Harmonize™ nanohybrid universal composite

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occur 30–45 minutes after isolation and complete rehydration may not occur for 24–48 hours postoperatively.1 Dehydration may also mask internal colourations which are commonly present in the enamel tips of maxillary incisors. Figure 2 further demonstrates how a sample of the Harmonize composite material was applied to the middle third of the labial surface of the fractured incisor to accurately determine the basic shade.

Occlusal assessment revealed attritional wear facets on the palatal surfaces of the maxillary anterior teeth, as demonstrated on the sectional model in Figure 3. The model was used for fabrication of a diagnostic wax-up and construction of a silicone template (Fig. 4). Use of a template is designed to simplify anatomical shaping of the palatal surfaces of direct anterior composite restorations, which can be challenging when trying to optimise functional integration.1

As blood, saliva and gingival crevicular fluid will all adversely affect adhesion, moisture control was achieved using rubber dam isolation (Fig. 5). Three holes were prepared in the dam, which was secured with the specialised universal SoftClamp™ (Kerr) made from radiopaque plastic. The multi-use SoftClamp provided a firm grip on the distal clamped tooth and reduced the risk of periodontal or dental iatrogenic damage. Isolation was further optimised using dam stabilising cord and a dental floss ligature tied around the lateral incisor.

Minimally invasive cavity preparation aimed to preserve the maximum amount of healthy residual tooth tissue and carefully remove the failed Class III composite restoration and the underlying calcium hydroxide lining material (Fig. 6).

Use of traditional lining materials under resin-based composite restorations is contraindicated3 as they are unnecessary, do not provide a seal and reduce the surface area available for dentine bonding. CaOH2 materials should be reserved for pulp capping of obvious exposures only.3

A sound cavity margin of enamel was preserved to optimise bonding, improve the marginal seal and reduce the long-term risk of micro-leakage and marginal staining. Preparation was completed by placement of a 1.0 mm labial bevel to optimise adhesive retention and to disguise the transition between tooth structure and the restorative material (Fig. 7). Medical grade polytetrafluoroethylene (PTFE) tape (a.k.a Plumber’s tape) was then wrapped around the adjacent teeth to protect the teeth from etch, adhesive, and excess composite (Fig. 8). As PTFE tape is of negligible thickness, its use

promotes tight contact formation and, as demonstrated in Figure 9, it does not interfere with adaptation of silicone templates. At the try-in stage, the template fit was assessed to ensure that it was adapted perfectly to the palatal surfaces and allowed access for placement of the initial palatal increment of the Harmonize composite.

Following preparation, the cavity was thoroughly washed, dried and inspected for any debris. Starting with the enamel, 37.5 percent phosphoric acid etchant gel was applied to the entire cavity and just beyond the margins. Etchant excess should be minimised to prevent adhesion of composite excess, which may be difficult to remove without causing iatrogenic damage to underlying enamel. The unique purple coloured gel is designed to optimise controlled placement and promote easy rinsing (Fig. 10). The etchant was left for a maximum of 15 seconds on the dentine before being thoroughly rinsed off with copious water spray (Fig. 11). The cavity was then carefully dried with gentle air flow to avoid desiccation of the dentine. Leaving the dentine ‘visibly moist, but with no obvious pooling’ will promote dentine bonding and reduce the risk of post-operative sensitivity.1

As Class IV cavities generally exhibit limited retention and resistance form, a ‘gold standard’ three–step, etch, primer and adhesive system (OptiBond™ FL, Kerr) was selected and applied using the following protocol: two ‘sloppy wet’ coats of primer were applied to the etched surface and the solvent was evaporated with gentle air flow, then a uniform layer of adhesive was applied before further solvent evaporation and light-cured for 10 seconds (Fig. 12). The entire cavity should appear glossy/shiny prior to restoration.

As successful adhesion is a fundamental requirement for long-lasting restorations, fastidious attention must be given to the manufacturers’ protocols. Following adhesive application, the silicone template was placed palatally and a thin (~1.0 mm) initial increment of composite was applied using a composite placement and shaping instrument with interchangeable silicone tips CompoRoller™ (Kerr) (Fig. 13). Harmonize is a nanohybrid composite with a filler (81 percent by weight) made of small (Average particle size ~50 nanometers), spherical, fused particles of silica and zirconia. As well as conferring the strength and aesthetics necessary for loadbearing Class IV restorations, the chemical composition optimises handling properties, making the material very easy to place and shape (even in thin increments) without stickiness or slumping. Once the palatal composite shell had been light-cured for 40 seconds, the silicone template was removed and more opaque dentine shades of Harmonize were placed to replicate the polychromatic layers of the

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natural tooth. The final enamel increment of Harmonize was easily adapted using the conical rotating tip of the CompoRoller instrument (Fig. 14). It is recommended to slightly overbuild anterior restorations before reducing them to the correct contour using rotary instruments. This avoids the need for time-consuming additions, which may also lead to visible layers/voids between increments. The restoration was then light-cured for 60 seconds using the ergonomically designed Demi Ultra™ (Kerr) light curing unit4, which delivers a high light irradiance (1100-1330 mW/cm²). The generally recommended protocols for light curing were followed by keeping the light tip as close and as perpendicular to the surface of the material as possible (Fig. 15).

Following polymerisation, shaping was initiated using fine (yellow band. 34-40µm) then ultrafine (violet band. 17-23µm) composite finishing diamonds with copious water coolant. Composite finishing discs (OptiDisc™, Kerr) were then employed to further shape and smoothen the restoration (Fig. 16). OptiDiscs are available in four grit sizes (10, 20, 40 and 80µm), have two mandrel length options and have smaller diameter discs for improved access when shaping transition lines and blending restorative margins (Fig. 17). The single-sided OptiDiscs also reduce the risk of iatrogenic damage to adjacent teeth. Care was taken to replicate that lateral incisor’s natural morphology and surface texture, as these are critical determinants of aesthetic success.

A significant advantage of the palatal silicone template technique is that it reduces or eliminates the need for palatal adjustments, which can otherwise be challenging and time consuming. In this case, the palatal restorative surface was simply polished using Occlubrush™ (Kerr) (Fig. 18). These unique, extremely hard-wearing, silicone carbide impregnated brushes are very useful for finishing

and polishing palatal concavities. They are also particularly useful for polishing the occlusal fossae of posterior composite restorations and are autoclavable for multiple patient use. Finishing and polishing are well-researched procedures and play an essential role in the way the light interacts with the restoration.1,2 The small, uniform particle size of the Harmonize nanohybrid resin composite is designed to increase the speed and quality of polishability. In this example, a high gloss surface luster was very quickly achieved using an Opti1Step™ (Kerr) polishing disc (Fig. 19). The multiuse Opti1Step tips are available in three patterns (disc, flame and cup), which may be used dry or with lubrication, and with variable pressure to allow the introduction of secondary surface texture anatomical features such as developmental grooves.

By controlling the size and shape of the Harmonize nanoparticle filler network, the material has enhanced light scattering properties making it very easy to blend the restoration seamlessly with the naturally-attractive surface lustre of the adjacent enamel (Fig. 20). Three months post-operatively, the restoration was reviewed to assess functional and aesthetic integration (Fig. 21). The light diffusion and reflection properties of the Harmonize nanohybrid material were identical to the natural tooth structure and revealed a pleasing aesthetic outcome for both the patient and operator. The undetectable restorative margins and high surface lustre were maintained and may be expected to reduce the risk of plaque retention and staining in the long term.

As with all direct and indirect restorative procedures, the patient was informed of the need for regular examination appointments to allow routine restoration monitoring.

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Bibliography 1. Mackenzie L, Parmar D, Shortall ACC, Burke FJT. Direct anterior composites: a practical guide. Dental Update. 2013 May; 40(4):297-3082. Manauat J, Salat A. Layers: An Atlas of Composite Resin Stratification. London: Quintessence Publishing Co Ltd, 20133. Bonsor SJ. Contemporary Strategies and Materials to Protect the Dental Pulp. Dental Update 2017; 44: 731–741 4. Burke FJTP, Crisp RJ. A PREP Panel, Practice-Based, Evaluation of the Handling of the Kerr Demi-Ultra Light Curing Unit. Dental Update 2015; 42: 674-679

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Traumatic dental injury is a common finding in everyday clinical practice. It can affect any age group, with higher rates among children and adolescents.

A 22-year-old female patient came to our dental office after a bicycle fall, complaining of dental trauma. Clinical examination revealed Ellis and Davey Class I fracture of the maxillary left central incisor (# 21), with small loss of dentine and enamel (Fig. 1). A resin composite direct restoration, without diagnostic waxing, is proposed to complete the aesthetic and functional rehabilitation in a single visit.

A rubber dam is placed on both fractured and surrounding teeth to ensure proper isolation of the field from saliva and other biological fluids. The fractured element is prepared on the buccal face with a bevel bur on a high-speed hand-piece (Figs. 2-4). The tooth is then prepared with orthophosphoric acid etching (Gel Etchant, Kerr™), the bonding agent is applied (OptiBond™ XTR, Kerr) and light cured with DemiT™ Ultra (Kerr) for 20 seconds. A first layer of Harmonize™ (Kerr) translucent enamel composite is placed to create the palatal surface of the restoration (Fig. 5). The

internal anatomy of the tooth (mamelons) is defined with the use of Harmonize opaque dentine A2 layers placed into the palatal shell - without reaching the incisal edge of the tooth - and completed with the application of Harmonize enamel A2 composite , in order to reproduce the original colour of the fractured tooth (Figs. 6-7). Following the removal of the rubber dam, the restoration is finished and polished with a pre-defined sequence: a soft silicone rubber is used for initial polishing; tooth micro geography and enamel growth lines are defined using large-grain diamond burs; final polishing is obtained with fine abrasives (Fig. 8).

Prof. Antonio CeruttiAntonio Cerutti is Professor of Restorative Dentistry at Dental School and Dental Hygiene School at University of Brescia. He is also Chair and Director of the Restorative Department at the University of Brescia Dental School. Active Member and Committee Evaluation Member of the Endodontics Italian Society (SIE), Active Member of the Restorative Dentistry Italian Society (SIDOC) and the International Association for Dental Research (IADR). He is President in charge of Italian Academy of Esthetic Dentistry (IAED), Founder Member of Italian Academy of Esthetic Dentistry (IAED).

Aesthetic restoration following traumatic dental injury

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Diastemata are a common aesthetic problem in mixed and early permanent dentitions at the time of eruption of the maxillary incisors. Different materials such as composite resin and ceramics are commonly used as part of the indirect technique, yet recent major improvements in composite resin properties suggest a more conservative approach.

In this case, we are going to show multiple diastema closures (Figs. 1-3) using the direct technique, following the removal of previous pigmented restorations.

After removing the previous restorations (Figs. 4-6) and isolating the field with a rubber dam, each tooth surface undergoes orthophosphoric acid etching (Gel Etchant, Kerr™) (Figs. 7), is coated with the bonding agent (OptiBond™ XTR, Kerr) and light cured with Demi™ Ultra (Kerr) for 20 seconds.

A transparent matrix combined with a wooden wedge is a useful aid when creating interproximal anatomy. It allows the composite layer to be highly adaptable to the palatal dental morphology when interposing small increments of Harmonize clear (Fig. 8).

Once the interproximal layer is well defined, it is possible to focus on building up the internal body with the combined application of chromatic materials, such as low-saturation Harmonize opaque dentine (A2) and Harmonize enamel A1, followed by a 20 seconds light cure with Demi Ultra (Fig. 9). The Harmonize composite is used to recreate the natural-looking shape and colour of all the interested elements (Figs. 10 and 11).

Finishing and polishing are performed after removing the rubber dam: a soft silicone rubber is used for initial polishing; tooth micro geography and enamel growth lines are defined using large grain diamond burs; final polishing is obtained with fine abrasives (Figs. 12 and 13).

Prof. Antonio CeruttiAntonio Cerutti is Professor of Restorative Dentistry at Dental School and Dental Hygiene School at University of Brescia. He is also Chair and Director of the Restorative Department at the University of Brescia Dental School. Active Member and Committee Evaluation Member of the Endodontics Italian Society (SIE), Active Member of the Restorative Dentistry Italian Society (SIDOC) and the International Association for Dental Research (IADR). He is President in charge of the Italian Academy of Aesthetic Dentistry (IAED), Founding Member of the Italian Academy of Esthetic Dentistry (IAED).

Multiple diastemata closures with Harmonize™

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Diastema is rarely a functional problem for patients, but usually they want to eliminate or minimise the size because of aesthetic reasons. In the oral cavity, it produces a dark background for teeth thus enhancing the diastema and destroying the symmetrical “white teeth” effect.

Diastema closure however can be a tricky treatment procedure, as it requires enlargement of the anterior teeth. This could lead to disruption of the proportions between the maxillary central and lateral incisors and an unexpected aesthetic effect.

Options for diastema closure include orthodontic or prosthetic treatment, but it is best to start with the least invasive treatment and make composite restoration as a temporary or final procedure.

Such a treatment requires a very aesthetic composite material to mimic sound enamel and dentine. In the present case Harmonize™ (Kerr™) was chosen because of its great chameleon features,

as well as great ability to create a natural-looking surface and blending ability to the tooth enamel. The conservative approach is also of great importance, as we do not plan to prepare or remove enamel structure with a bur.

On some occasions, the diastema is so wide, that it is not indicated to close it completely as it might not produce the reasonable aesthetic effect that is expected by the patient (Fig. 1).The treatment plan is prepared with one layer of contrast composite material. It is a good moment to discuss with a patient how to achieve a compromise between size of diastema and enlargement of the maxillary anterior teeth (Fig. 2). A silicon key mould for the new shape of the incisors is prepared.

Teeth should be isolated from saliva contamination with a dental dam (OptiDam™, Kerr), then the silicone mould is cut in half and fitted from the lingual side of the anterior teeth (Fig. 3).

Dr. Maciej MikołajczykDr. Mikołajczyk graduated from the Medical University in Lodz, Poland, where he also achieved his PhD. Between 2004 and 2008 he was an assistant in the Cathedra of Children Dentistry at the Medical University in Lodz. From 2010 to 2012 Dr. Mikołajczyk was the scientific director and lecturer of the postgraduate college “Dental Practice Forum”. Since 2013 he is editor-in-chief of the “Endodontics in dental practice” series of books. He is the author and co-author of multiple scientific papers and lectures concerning minimally invasive dentistry, as well as the use of lasers and microscopy in dentistry.

Diastema closure using Harmonize™ nanohybrid universal composite

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In order to achieve the best possible adhesion, enamel is prepared with an air abrasion device (Rondoflex, KaVo) to remove the aprismatic enamel surface layer (Fig. 4).

Next, the enamel is acid etched with 37 percent phosphoric acid in a gel form (Gel Etchant, Kerr) to ensure precise acid application and to eliminate flow of the gel into unwanted areas (Fig. 5).

OptiBond™ FL (Kerr) bonding system is chosen because of its scientifically proven high adhesion parameters to enamel. The primer is applied first, followed by the adhesive and polymerisation (Fig. 6).

Harmonize A1 enamel shade is used as a palatal layer with the silicone key. Compothixo™ (Kerr) device was used, as its vibrating tip facilitates layering of the composite material (Fig. 7).

The palatal layer of the enamel shade makes a base for subsequent application of dentine shades to build up a natural-looking restoration (Fig. 8).

This also allows to measure different shades of composite to match tooth tissue, as the Harmonize composite material does not change its colour after polymerisation (Fig. 9).

The external layer of the palatal build-up is rounded with an oscillating EVA contra-angle (KaVo) with a fine diamond coated file (Fig. 10).

To ensure excellent emergence profile a metal matrix (Polydentia) is used with some flow material to fix it in place (Fig. 11).

Harmonize A3 dentine shade was placed in the cervical region of the build-up to form a deeper and “warmer” colour layer. The Harmonize dentine shades look very natural thanks to a very realistic light diffusion and reflection. CompoRoller™ (Kerr) device is used to shape dentine layer according to the patient’s tooth colour scheme (Fig. 12).

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The middle third of the tooth needs a different colour than the cervical region, so Harmonize A2 dentine shade is used (Fig. 13).

Easy handling of Harmonize material allows to recreate irregularities in the dentine layer to make light reflection and diffusion more scattered, as it is observed in the patient’s tooth (Fig. 14).

A thin layer of A1 enamel shade forms the superficial layer of this build-up, as well as its incisal margin (Fig. 15).

Each layer of material is polymerised for 10 seconds, but the final polymerisation is done for 20 seconds (Fig. 16).

The same procedure is performed for the adjacent maxillary incisor tooth, then both restorations are finished with the use of the fine polishing OptiDisc™ (Kerr) (Fig. 17).

Polishing of the enamel layer is done with the Hiluster polishing kit (Kerr). Harmonize gives a very shiny superficial layer of material right after polymerisation, making polishing a very easy and fast procedure (Fig. 18).

Occlubrush™ (Kerr) is used to give a “final touch” and ensure the longevity of the smoothness of the restoration (Fig. 19).

This case shows that complete diastema closure is impossible to achieve, because the teeth would become too wide and large, and aesthetically unacceptable. The Harmonize composite material proved to be fully capable of reproducing the natural tooth aesthetics with great ease of work (Fig. 20).

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Dr. Thierry CaireDoctor of Dental Surgery. | Graduate of the Paris Descartes University. | Postgraduate certificate in Biomaterials. Postgraduate certificate in Periodontology. | University certificate in Implantology. | Member of the Mimesis Group as an expert in esthetic dentistry. | Private practice in Lambesc, Provence.

Author of publications and papers on precision in fixed bridge prostheses, the dental dam in adhesive dentistry, and dental photography.

Three clinical cases showing the implementation of a next generation universal composite: Harmonize™

Bibliography: 1. Angeletaki F, Gkogkos A, Papazoglou E, Kloukos D. Direct versus indirect inlay/onlay composite restorations in posterior teeth. A systematic review and meta-analysis. J Dent. 2016 Oct;53:12-21. “I would like to pay tribute to Professor Michel DEGRANGE, an exceptional clinician and visionary researcher in the field of adhesive dentistry who gave me the opportunity to work by his side. He has influenced my work greatly.”

Class IV central incisorA 43 year old patient wanted her teeth to be whitened and her incisor tooth, which had been broken since childhood, to be repaired (Fig. 1). Figure 2 shows the results after three weeks of wearing a night guard with 10 percent carbamide peroxide. The colour obtained is very luminous and the whitened spot of hypermineralisation is accentuated. The opaque spot is removed as little as possible with a bur. The edges are straightened with a fine-grain diamond bur (Fig. 3).

A single-component total-etch adhesive system was chosen (OptiBond™ Solo Plus, Kerr). The incisal edge and the lingual surface is built from A1 enamel composite using a silicone matrix made from a wax-up (Fig. 4). A1 dentine composite is applied while recreating the mamelons and conserving a thickness of 0.5 mm

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IntroductionNot too long ago, composite was considered to be a short-term restoration solution or a temporary measure before the application of a more durable material, usually a ceramic. Direct restorations were in particular considered a second-choice option, often dictated by economic considerations. Composite’s reputation began to improve through its use in indirect restorations, although studies have not shown any significant difference in longevity between the two types of implementation.1 For several years—following the example of the Italian and Swiss schools—we have seen the emergence of fantastic advances in direct restorations using composite combined with rigorous implementation protocols. In particular, this is due to the systematic use of waterproof dental rubber dams. The most recent development is the ability to routinely achieve perfect aesthetic integration without resorting to complex and time-consuming stratification techniques. This integration is primarily due to the blending of light in the composite with the tooth structure, the accuracy of the shades and the ability to create the “mirror like” polish of ceramics. In this article, we present our first cases using the latest generation of composites, following the standard protocol in place in our general dental practice. This product is manufactured by Kerr. It is a universal nanohybrid composed of silicon and zirconia that allows an unprecedented loading at 81 percent.

for the final layer of enamel (Figs. 5 and 6). The A1 enamel shade is then applied (Fig. 7). Figure 8 shows the results after shaping with a coarse-grain disc followed by a medium-grain, diamond, red-ring bur, and pre-polishing with a Brownie bur. The palatal view shows the good optical integration of the composite (Fig. 9). The final shaping of the free edge is performed copying the wear of

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#11. The addition of a very thin layer of composite presented a risk of chipping. In this case, the length difference between the lateral and central teeth was harmonious and the simulation of the wear on #21 made the restoration look more natural. The final polish is achieved with a brush soaked in silicon carbide under a strong water spray (Fig. 10).

In natural lighting, the restoration mimics its surroundings surprisingly well given that the stratification is limited to one enamel and one dentine, and given the speed of the polishing stage. Neither diamond paste or gloss were required (Figs. 11 and 12).

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Class II on second molar cusp47’s disto-lingual cusp is fractured with occlusal loss of the restoration. The tooth’s pulp vitality test to cold is normal. Intraosseous anesthesia is given (Fig. 1).

A dental rubber dam is put in place. Due to the supragingival nature of the fracture, we chose to restore the tooth with a direct composite resin, reducing the occlusal height of the cusp and cusp angle, in order to avoid interference from the antagonist cusp in non-functional movements (Fig. 2).

The edges of the preparation are straightened and a sectional matrix is slid under the clamp’s grip, holding it in place against the tooth (Fig. 3).

OptiBond™ XTR primer and adhesive (Kerr) are applied, and the edge and bottom of the cavity are covered with a fine layer of a flowable composite, which is then polymerised (Fig. 4).

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Class II second bicuspidAn emergency patient came to the office with pulpal sensitivity on tooth # 35. A diagnosis of reversible pulpitis is given. Only the restoration of 35 will be carried out in this appointment (Fig. 1). Intraosseous anesthesia is given and a dental dam is placed (Fig. 2). The very large cavity shows unsupported enamel on the vestibular and lingual surfaces (Fig. 3).

A sectional matrix is placed and held in position with the aid of a matrix clamp (Fig. 4). OptiBond XTR primer/adhesive system’s then placed, polymerised and a flowable composite resin is placed at the margin and bottom of the cavity (Fig. 5).

Closure of the box to diminish the effects of the polymerisation contraction (Fig. 6).

V and L surfaces are covered with thin layers of A2 enamel (Fig. 7). A3 dentine camposite is placed in two layers. You can already notice the colour accuracy in these standard shades (Fig. 8). A thin layer of A2 enamel is sculpted (Fig. 9).

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A layer of A2 enamel closes off the disto-lingual wall, after which a layer of A3 dentine is placed and then polymerised. Finally, a fine layer of A2 enamel is shaped using a P.K. Thomas No. 3 instrument (Figs. 5 and 6).

The matrix is removed and the contours are shaped and pre-polished with a Brownie rubber point and cup under water spray (Fig. 7).

The occlusion is adjusted and the tooth is polished with silicon-carbide impregnated brushes under water spray. The integration is excellent with just one shade of enamel and one shade of dentine (Figs. 8 and 9).

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The restoration is smoothened with a Brownie rubber cup under water spray. The overly curved distal wall will be corrected during the restoration of # 36 (Fig. 10). No fissures, however fine, appear on the enamel surfaces. The integration is very good with one dentine shade and one enamel shade. The final polish is quickly achieved with a brush soaked in silicon carbide under water spray (Figs. 11 and 12).

One month later, # 36 is restored. The patient did not report any symptoms in tooth # 35. # 36 is treated using the same protocol as # 35 (Fig. 13-15). The integration is remarkable, particularly the very realistic opalescence of the enamel (Figs. 16 and 17).

Conclusion The use of direct composite resins, even for large restorations, has become a mechanically reliable alternative thanks to the rigorous implementation protocols (rubber dental dam), high-performance equipment (matrix systems), and improved resin materials (low polymerisation shrinkage).

From a clinical perspective, Harmonize next generation composite presents clear improvements in aesthetic/optical and mechanical performance. The composite performs highly in all types of restorations (anterior and posterior), is easy to shape, and shows a genuine chameleon effect with the surrounding dental tissue.

The polishing stage is fast and requires the use of fewer instruments. The suitability of the shades offered to respond to special circumstances, such as very strong colours, still needs to be evaluated in future clinical cases.

Finally, we will monitor the surface finish in the mouth, which is a weak point of composite compared to ceramic.

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Class IV aesthetic restoration of an upper central incisor

Dr. Gabriele ConteDoctor of Dental Materials Research, Università degli Studi di Roma “Tor Vergata”.Professional in Rome.

A 37-year-old male patient came to our practice office requesting the replacement of the resin restoration of his left central incisor due to minor chipping and lack of colour and shape integration (Figs 1-3).

When minor changes to the tooth shape are requested, a direct mockup is indicated. Besides saving time and money for the patient, it also allows static and dynamic occlusal adjustment and effective shade selection before the restoration is performed. Therefore, in this case, a direct mockup of the tooth was preferred instead of a traditional laboratory wax-up (Fig 4).

After rubber dam isolation, the old restoration was removed with diamond burs on a 5:1 handpiece. Margins were carefully finished to a mini-chamfer design and polished with rubber points (Fig. 5).

A total-etch three-step adhesive (OptiBond™ FL, Kerr) was used strictly following the manufacturer’s instructions. The restoration of the palatal and incisal walls was easily performed with the aid of a custom PVS matrix (previously formed on the direct mockup) respectively using enamel A2 and incisal clear shades of the HarmonizeTM (Kerr) nanohybrid universal composite (Figs. 6 and 7).

Anatomical simplified layering was then performed with dentine A2 to reproduce the dentinal part of the tooth, while incisal amber was placed between the mamelons (Fig. 8).

A controlled 0,5 mm thick enamel A2 shade was used to reproduce the buccal surface of the tooth. Before the rubber dam was removed, the surface of the restoration was roughly finished and polished (Fig. 9).

Prof. Luigi CianconiAdjunct Professor in Conservative Dentistry, Università degli Studi di Roma “Tor Vergata”.Professional in Rome.

Dr. Manuele ManciniDoctor of Dental Materials Research, Università degli Studi di Roma “Tor Vergata”.Professional in Rome.

BEFORE AFTER

15In vivo

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Figures 10 and 11 respectively show teeth before and after the procedure using polarised light.

Rehydration shows the excellent chromatic integration of the restoration despite the extremely basic layering protocol. Two days later, once the shade matching of the restoration was confirmed, the surface was carefully finished and polished with fine grit diamond burs, rubber points and decreasing diamond grit pastes (Figs. 12 and 13).

The Harmonize nanohybrid universal composite shows a very good aesthetic integration when it comes to both shade matching and polishability. In addition, we experienced very easy handling of the material, which helps achieve good anatomic layering as well as effective marginal adaptation.

16 In vivo

The 21 year old patient came to the practice on a Monday morning as an emergency visit. The examination showed moderate swelling of the maxillary lip and a small superficial skin laceration (Fig. 1). Intraorally, the four maxillary incisors showed dentine-enamel fractures with no exposure of the pulp (Fig. 2). All teeth were vital, and in the x-ray there was no sign of a root fracture.

After brief preparation, etching and bonding (OptiBond™ FL, Kerr), the teeth were built-up using Harmonize™ shades A2 dentine, A2 enamel and CLR incisal. After finishing with OptDiscs™ (Kerr), polishing was performed with the Opti1Step (Kerr) polisher. Given this case was an emergency, there was no time for preparations with wax-up or step by step documentation, However, the case demonstrates that even under time pressure conditions, very aesthetic results are possible.

Harmonize has specific features that are very helpful to treat a case like this. First of all, the handling of the material: once you start working with it, Harmonize feels like a typical highly filled and highly viscous material. As the procedure continues, the material softens becoming very easy to handle and to adapt. This feature is triggered

by rheological modifiers that are able to change the viscosity of the composite during the application process.

SonicFill™ 2 (Kerr) users may be familiar with these effects. The handling of Harmonize facilitates easy adaptation, shaping and build-up, since it is not sticky and stays precisely in the molded position. The specific filler particles give the material enhanced polishability, and by using the Opti1Step polisher the procedure is far less time consuming.

The result shows nice blending and the chameleon effect of the specific filler particles. Finally, the light reflection of Harmonize restorations is very similar to enamel. After only 90 minutes, the patient was able to return to work (Fig. 3).

Dr. Rainer TilseDr. Tilse graduated in dentistry from the Berlin Free University (North) in 1990. His postgraduate research was carried out at UCLA Dental School, Oral Medicine Department. 1990: Dr. med. dent. (Department of oral surgery, Prof. Dr. P. Reichart). Returning to Berlin, he worked in a private practice, then relocated to the University Hospital of Freiburg im Breisgau, Department of Prosthetic Dentistry (Prof. Dr. J. Strub) as an assistant professor. Since 1993 he has run his own private practice in Pforzheim in partnership with four colleagues. His research covers: aesthetic filling therapy, prophylaxis, oral surgery, periodontics, implantology, and high quality restorations.

Dentine-enamel fracturesto maxillary incisors

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BEFORE AFTER

17In vivo

Aesthetic restoration and integration using a simplified stratification technique with a next generation composite

BEFORE AFTER

18 In vivo

IntroductionThe contribution of composite adhesive techniques allows minimal conservative restoration of dental tissue.1 Next generation composites improve mechanical strength criteria, notably through the emergence of nanofilled composite resins with increased tensile strength, compression strength, and wear resistance. However, aesthetic appearance is still a significant challenge due to the visual difficulty of mimicking the adjacent teeth and achieving an integrated restoration in terms of shade (colour, luminosity, translucency).2,3 The dentine and enamel stratification technique allows to obtain a good aesthetic result, but presents significant technical difficulties for the operator, who must master the complexities associated with the stratification of the different materials and thicknesses needed to perform a perfectly aesthetically integrated restoration.4 Another disadvantage of complex stratification techniques is that they are time consuming. The solution provided by bi-component simplified stratification makes it easier for the operator to perform the different stages of a highly aesthetic restoration and saves a significant amount of time, therefore allowing this type of technique to be developed in dental practices.

Initial clinical examination and treatment planThe case presented is that of a young woman of 20 years of age with an elevated caries risk requiring numerous conservative treatments, particularly for the aesthetics of the anterior sector. This area shows signs of a recurrence of carious lesions on previous composite

restorations due to their significantly reduced impermeability. Given the aesthetic damage and the caries observed, a technique of simplified aesthetic stratification is indicated, in order to restore the damaged tissue and create an aesthetic integration of the treatments performed. Treatment with bonded ceramic adhesive restorations could be performed as a second step, after the patient’s risk of caries has been reduced, to further improve the aesthetic result and the durability of the restorations.5

Equipment and methodTo begin, we performed an aesthetic analysis of the patient’s smile, in order to integrate the future restorations as well as possible, in keeping with the patient’s smile, and to determine the shade of the teeth and characterisation features.6,7 To perform this simplified aesthetic composite stratification technique, we used a next generation nanohybrid composite (Harmonize™, Kerr). The visual – and therefore aesthetic – properties of this composite are further improved by the nanoparticle composition and the great mechanical strength afforded by the highly filled structure, composed of zirconia and colloidal silica. The placement of a dam is essential to perform the bonding procedure in the right conditions, protected from the humidity of the oral environment. A rubber dam is used for the removal of the previous restorations, giving visual comfort to the operator, and for improved intrasulcular insertion of the dam guided by the surfaces of the still healthy teeth.

Dr. Raphaël BoudasDr. Raphaël Boudas is a dental surgeon specializing in full-mouth rehabilitation and smile esthetics. He was awarded the 2nd ethics prize from the national council of the order of dental surgeons in 2008 and graduated from the Strasbourg Department of Dental Surgery in 2009 with the congratulations of the board of examiners. Out of passion for the subject, he continued his studies with a Masters in Clinical Research and Epidemiology and completed training in smile esthetics for which he was top of his clinical cases class in 2014. In 2015, he gained his accreditation with the Mimesis group. Dr. Bourdas has also participated in numerous international conferences including the Nobel Biocare Symposium in New York, ORCA in Montpellier—where he presented his thesis—, and the 23rd Global Dentists and Pediatric Dentistry Annual Meeting in Munich in 2017—during which he exhibited his publications regarding complex rehabilitation cases using the latest biomimetic data.

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13 14 15Figs.1 and 2. Front view photograph of mandibular advancement before treatmentFig. 3. Front view photograph with contraster before treatmentFig. 4. Front view photograph of incisal sector of the upper jaw bone with dam in place Fig. 5. Intra-oral photograph of removal of the previous composite restorationsFig. 6. Intra-oral photograph of removal of the carious lesions Fig. 7. Photograph of Gel Etchant (Kerr)Fig. 8. Photograph of initial etching with 35% orthophosphoric acid

Fig. 9. Photograph after etching Fig. 10. Photograph of self-etch adhesive, Optibond XTR (Kerr), and transparent strips, Striproll (Kerr)Fig. 11. Photograph of application of primer with microbrush Fig. 12. Application of primer to dentine Fig. 13. Photograph of application of Optibond XTR adhesive with microbrushFig. 14. Application of adhesive to toothFig. 15. Photograph of photopolymerisation of the adhesiveFig. 16. Photograph of stratification with Harmonize A3 dentine

19In vivo

After the cleaning and ablation of the recurring carious lesions with a round tungsten bur, we created ligatures with dental floss to correctly evert the dam towards the intrasulcular face. It is recommended that the teeth be air particle abraded to clean the surface perfectly. This is recommended before the differentiated etching of enamel and dentine, where a total-etch adhesive (etching, rinsing, primer, and adhesive in two bottles) such as OptiBond™ FL (Kerr) is used, or prior to bonding without initial etching, where a self-etch or universal adhesive that includes the etching in the primer bottle (OptiBond™ XTR, Kerr) is used. The use of transparent strips allows the different teeth to be isolated during the placement and photopolymerisation of the adhesive. We then performed the bi-compound stratification8,9 tooth by tooth, starting with dentine of a darker tone than the shade

determined before the placement of the rubber dam. In this instance, shade A3 was chosen for the dentine, in order to mask the oral cavity in a base layer and avoid a grayish appearance to the restoration. We then finished by affixing the enamel composite with multiple layers, to avoid as much as possible C factor polymerisation shrinkage. We therefore chose a shade for the enamel mass identical to the shade it was before restoration. We polished the restoration with Opti1Step (Kerr) polishing discs, followed by 3-μ then 1-μ diamond pastes (Enamel plus shiny / Micerium) combined with a soft disc (Enhance polishing cups / Dentsply). We then removed the rubber dam that had isolated the area during stratification. The shapes and edges of the teeth were finished before giving the restoration a final polish and use of diamond abrasive strips of different grit sizes.8,9

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Bibliography1. Tirlet G, Attal JP. Le gradient thérapeutique : un concept médical pour les traitements esthétiques. [The treatment gradient: a medical concept for esthetic

treatments.] Inf Dent. 2009; 91(41-42): 2561-25682. Dietschi D. Free-hand composite resin restorations : a key to anterior aesthetics. Pract Periodontics Aesthet Dent 1995;7(7):15-25;quiz27.3. Dietschi D. Free-hand bonding in the esthetic treatment of anterior teeth: creating the illusion. J Esthet Dent 1997;9(4):156-644. Weisrock G, Merz R, Ortet S, Koubi S, Tassery H, Faucher A. Clonage artificial de l’émail. Apropos d’un nouveau composite. [Artificial cloning of enamel. On

a new composite.] Inf Dent 2009 ;35 :2020-6.5. Magne P. Bonded porcelain restorations in the anterior dentition. Chicago: Berlin; Paris (etc.): Quintessence Publ 2002.6. Paris JC, Faucher AJ. Le guide esthétique. Comment réussir le sourire de vos patients. [The esthetic guide. How to achieve your patient’s smile.] Paris:

Quintessence International, 20047. Paris JC, Ortet S, Larmy A, Brouillet JL, Faucher AJ. Smile esthetics: a methodology for success in a complex case. Eur J Esthet Dent. 2011 Spring;6

(1):50-74.8. Vanini L, Mangani F, Klimovskaia O. Conservative restoration of anterior teeth. ACME 20059. Vanini L. Light and color in anterior composite restorations. Pract Periodontics Aesthet Dent 1996;8(7):673/82;quiz684.

17. Photograph of finished placement of the Harmonize dentine composite18. Photograph after application of Harmonize A2 enamel19. Photograph of completed composite stratification20. Photograph after removal of the dam and initial finishing

21. Photograph after shape finishing with a red ring diamond bur22. Front view photograph after polishing the composite with 3-micron and 1-micron diamond pastes23. Front view photograph with contraster after treatment

20 In vivo

DiscussionThe next generation nanohybrid composite by Kerr, Harmonize, allows a fully satisfactory restoration and aesthetic clinical results to be achieved, combining the strength of its nanofillers and the aesthetics of its improved visual properties associated with a very high level of luminance. The dull appearance then leads to low aesthetic satisfaction. In addition, stratification with Harmonize is easy thanks to the improved handling and consistency, which does not stick to the spatula, allowing simple and precise implementation and manipulation, avoiding the need to heat the composite before it can be modelled. This property of easy handling is extremely important as it will allow this bi-compound composite stratification technique to be more widely used in dental practices due to its time saving properties and the ease of placement for the operator. The fact that Harmonize does not require heating also guarantees that the physical and chemical properties of the nanohybrid composite will not change. In fact, even if studies carried out to date do not show changes in the composite under certain heating conditions, some doubts remain due to the small sample size used in the studies, the lack of follow-up, and the multiple variations in the technical temperatures of the heating lamps or heaters, heating time, and temperature. For this reason, it

seems important to find alternatives to heating the composite and to obtain a suitable texture for the optimal use and implementation of the composite, without heating it. ConclusionThe next generations of nanohybrid composites to which Harmonize belongs are of real clinical and practical interest. This should encourage their use in aesthetic bi-compound stratification techniques under rubber dam to become widespread in dental practices. Their visual properties of luminance and mimicry lead to rapid, optimal aesthetic results. Harmonize also offers increased mechanical strength, afforded by the zirconia nanofillers combined with the colloidal silica. Their improved handling compared to existing aesthetic composites means there is no need to heat the composite. This removes any doubts concerning the physical and chemical effects that heating has on the composite, due to the variability in temperatures, which are not easy to regulate, at least until any significant prospective clinical studies are carried out to evaluate this practice.

For years now, new composites have been regularly becoming available on the dental market. The colours are usually suggested based on the well-known Vita shade guide for dentine and enamel. But what about incisal composites? We investigated their impact on the final shade of the tooth. Each brand uses a different classification (C1, C2, Trans 20 and 30, opal, grey, transparent, amber, etc.). The kit rarely contains an incisal shade guide. The representatives of the different brands are unable themselves to explain the nuances, the ease of application, the polishing obtained or the impact of the application of this product on the final outcome of our restoration. We will try to show you the differences obtained only with this final layer. This test was conducted with the new composite offered by Kerr, Harmonize™. Five incisal shades are available (Fig. 1 and 1A): amber (AMB), blue (BLU), clear (CLR), grey (GRY), and super clear (SCLR).

The SCLR shade looks like transparent glass. This composite is very difficult to apply because its extreme transparency shows all the defects, folds, inlays, bubbles, etc. It is to be used sparingly by applying very small increments while verifying the absence of defects during its application. In order to observe its impact, we created hand-made samples on a small transparent plastic rod. A layer of Harmonize dentine is applied, and the mamelons are defined (Fig. 2).

Then, a layer of enamel is applied to the same mamelons (Fig. 3). Note that the enamel shade appears to be more yellow before polymerisation compared to after. Application of an incisal composite on dentine and enamel A1, and a few colourings on the SCLR sample (Fig. 4).

Dr Philippe ChpindelDoctor of Dental Surgery and owner of a professional practice in Paris 75017. Graduated from the Faculty of Paris VII Garancière in 1986.

Yanis ChpindelStudent in the 4th year of dentistry at the Faculty of Paris VII. Garancière.

Impact of the incisal composite and polishing

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Fig. 1 - Amber (AMB), blue (BLU), clear (CLR), grey (GRY), and super clear (SCLR).Fig. 2 - Dentine A1.Fig. 3 - Enamel A1 before polymerization.Fig. 4 - Application of an incisal composite on dentine and enamel A1, and a few colourings on the SCLR sample.

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21In vitro

On each of the five identical samples, an incisal layer is applied with a spatula, then polished with diamond burs of different grain sizes (Fig. 5).

Considerable differences in shades are observed just with the nuances of incisal composite (Fig. 6).

We mounted another tooth in “ceramist-style”, with nothing more than different layers of dentine A1 and by defining the dentine lobes. We then applied an incisal composite, followed

by colourants (Figs. 7-13). Figure 14 clearly shows the difference between the CLR shade (left) and the glass-like SCLR shade (right), which allows all the effects to be seen.

Composites XL and XL2The composite XL1 is the very clear dentine, whereas the composite XL2 is the corresponding enamel. Figure 15 shows the difference in shade between dentine A1 and dentine XL1. In Figure 16, a layer of enamel was applied onto the dentine.

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13 14 15Fig. 5 - Polishing with diamond burs.Fig. 6 - Polishing with Kerr Opti1Step Polisher kit.Fig. 7 - Dentine A1.Fig. 8 - BLU on both angles and AMB at the centre of the incisal edge.Fig. 9 - One third of the edge is covered with CLR.Fig. 10 - An ochre colouring is applied with a brush.Fig. 11 - Layer of CLR sealing the ochre colouring between the two walls of CLR, and application of a white tint with a brush.

Fig. 12 - Layer of CLR sealing the white tint between the two walls of CLR, and application of very small layers of ochre colouring on the dentine with a brush.Fig. 13 - Last application of SCLR on the entire surface of the tooth edge on the right.Fig. 14 - Polishing.Fig. 15 - Dentine A1 (left) and dentine XL1 (right).Fig. 16 - Enamel A1 (left) and enamel XL2 (right).

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22 In vitro

The shade of XL composite, unpolished is already lighter than the shade of composite A1.

PolishingWe compared two polishing kits: Identoflex Diamond Composite Polisher (Kerr) (Fig. 17) and Opti1Step™ Polisher (Kerr) (Fig. 19). Several shapes of polishers are available for each kit. Disc, point and cup.

The polishers of the first kit are blue and those of the second kit are grey. We detected a considerable difference in terms of abrasion performance. The blue polisher does not allow smoothing without leaving traces of extra composite on the existing restoration. The seam will not be smooth. Blue residues have the annoying tendency to accumulate in all crevices, bubbles and seams that are not smooth. This drawback is however actually an advantage, because it allows you to see all the areas that are not perfectly smooth before the final polishing step.

In Figure 18, the tooth on the left side (A1) was polished with the Opti1Step Grey Polisher (Fig.17), whereas the tooth on the right side (XL) was polished with the Identoflex Diamond Composite Blue Polisher (Fig. 19). We observe a difference in the polish. The

grey polisher produces immediately a glossier polish than the blue polisher.

Figure 20 shows use of the Opti1Step Polisher to finish the tooth in A1 and XL and to emphasise the shape of the vestibular surfaces. The ability to modify the abrasiveness through simple changes in the pressure applied is very interesting. Its longevity saves money. The disc shape makes deeper marks, whereas the point shape is softer. This kit provides results comparable to those of multi-step systems.

ConclusionsIn conclusion, this test shows that an incisal composite has a very high impact which is often unrecognised, as it allows us:• to give a more natural appearance to our restorations, and • to modify this appearance at the last minute or during a

subsequent appointment.

The Opti1Step Polisher kit is very efficient because it is considerably less time-consuming. Furthermore, it offers the possibility of removing the desired amount of material to yield a very accurate surface morphology with a very appealing glossy finish.

18 19Fig. 17 - Opti1Step Polisher.Fig. 18 – A1 (left) polished with One Step grey, XL2 (right) polished with Identoflex blueFig. 19 - Identoflex Diamond Composite Polisher.Fig. 20 - Use of the Opti1Step Polisher to finish the tooth in A1 and XL2 and to emphasise the shape of the vestibular surfaces.

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23In vitro

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KerrHawe SA | Via Strecce 4 | 6934 Bioggio | Switzerland www.kerrdental.com

Harmonize™ is the next generation composite infused with

Adaptive Response Technology (ART) to give all your

restorations better blanding capabilities and an enhanced

structural integrity. Create lasting lifelike restorations with

more ease and simplicity.

Harmonize™ - Nanohybrid Universal Composite

Book a free demo now: www.kerrdental.com/try-Harmonize

Harmonize with nature.

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