special edition Vol. 3

Transcription

1 special edition Vol. 3 The nano-optimized composite system Tetric EvoCeram Nano-optimized mouldable ceramic Tetric EvoFlow Nano-optimized flowable composite

2 TA B L E O F C O N T E N T S Tetric EvoCeram The facts speak for themselves 3 Dr. Marion Wanner, Schaan/Liechtenstein Minimal restorations with Tetric EvoFlow 5 Dr. Nicola Barabanti, Coccaglio/Italy; Dr Luca Solimei, Genoa/Italy Tetric EvoFlow and its application options 8 Dr. Jan-W. Harders, Emden/Germany (R)evolution among flowable composites 13 Minimally invasive restorations with the new Tetric EvoFlow Dr. Dr. Christian Hammerer, Vienna/Austria Composite layering technique for anterior teeth 15 using Tetric EvoCeram Dr. Iñaki Gamborena, San Sebastián/Spain Restorations with Tetric EvoFlow and Artemis 18 Dr. Ali H. Özoglu, Düziçi Osmaniye/Turkey Morphological aspects of aesthetic anterior tooth 20 restorations Dentist Ulf Krueger-Janson, Frankfurt am Main/Germany A literature list can be obtained from Ivoclar Vivadent AG

3 Tetric EvoCeram The facts speak for themselves Dr. Marion Wanner, Schaan/Liechtenstein The success Tetric EvoCeram universal composite has experienced so far is based mainly on the material s excellent physical and mechanical properties and its ease of processing. This has also been confirmed by two independent studies which will be presented in this manual. Three-year study by Swedish researchers Excellent clinical performance Four years ago, a clinical study was initiated at the University of Umeå dental clinic under the direction of Professor Dr. Jan van Dijken, a composite specialist and head of the clinical biomaterials research department (1). The study used a splitmouth design and involved the placement of 62 Tetric Evo- Ceram and Tetric Ceram restorations each in a total of 52 patients. Of these restorations, 118 were Class-II restorations, and the remaining were Class-I restorations. Tetric Ceram, a composite resin proven a million times over, served as the standard against which the quality of Tetric EvoCeram restorations was compared. After a three-year wear time, nearly all the Tetric EvoCeram restorations were still in place and an annual failure rate of only 2.8 % was recorded. Moreover, these failures were not due to shortcomings of the material. The surface quality of the Tetric EvoCeram restorations earned particular praise from the authors of the study. Except for one restoration, all of them showed a very smooth surface at recall after three years. Moreover, more than 90 % of the restorations still demonstrated a tooth-like anatomy without any over- or undercontoured areas. Marginal adaptation was found to be good to excellent in more than 98 % of the cases and no visible gaps were present. Professor van Dijken pointed out that in several in-vitro studies conducted with different composite materials and involving restorations extending to or beyond the dentin-enamel interface, marginal adaptation was found to be defective and a distinct marginal gap was discernible. Tetric EvoCeram passed this test with flying colours. Two-year study by Italian researchers Consistent marginal quality Polymerization shrinkage was mentioned by Professor van Dijken as being one of the inevitable causes of marginal gap formation when using composite resin. A clinical two-year study conducted by Professor Antonio Cerutti at the University of Brescia department of restorative dentistry dealt with precisely this issue (2). The objective of the study was to find out whether Tetric EvoCeram restorations showed a different behaviour when exposed to different curing light intensities and whether this eventually led to different prognoses. For this purpose, two Class I or II restorations each were placed in a total of fifty patients. While one restoration in each patient was polymerized for 20 seconds at 650 mw/cm 2, the other one was polymerized for 10 seconds at 1200 mw/cm 2. According to the total energy concept, the application rate Fig. 1: 24-month recall evaluation of tooth # 3.6 (mw/cm 2 ), which is defined as the product of light intensity x time, was thus the same. The two-year results showed no discernible difference in marginal quality between those restorations polymerized at a lower light intensity and those polymerized at a higher light intensity. This confirms that longevity of the restoration is ensured with either curing mode, provided that low-shrinkage composites such as Tetric EvoCeram are used. Results of the clinical study conducted by Prof. Cerutti Criterion* At baseline Result after 24 months Curing mode 650 mw/cm mw/cm mw/cm mw/cm 2 (Astralis10) 20 sec 10 sec 20 sec 10 sec Marginal integrity A 94% A 94% A 88% A 94% B 6% B 6% B 12% B 6% Marginal discoloration A 98% A 100% A 94% A 98% B 2% B 6% B 2% Surface texture A 88% A 94% A 90% A 94% B 12% B 6% B 10% B 4% C 2% Secondary decay A 100% A 100% A 98% A 100% B 2% Postoperative A 98% A 98% A 98% A 98% sensitivity B 2% B 2% B 2% B 2% Survival rate A 100% A 100% A 100% A 100% Anatomical A 90% A 94% A 88% A 94% shape B 10% B 6% B 12% B 6% *acc. to modified Ryge criteria: A (Alpha) optimal; B (Bravo) clinically acceptable; C (Charlie) insufficient Source: Prof. Antonio Cerutti, 2007 Page 3

4 2 3 Fig. 2: 24-month recall evaluation of tooth # 3.5 Fig. 3: 24-month recall evaluation of # tooth 4.6 Benefits to users Both studies presented attest to the outstanding quality and performance of Tetric EvoCeram restorations, even in regard to critical parameters such as marginal integrity and marginal gap formation. As the bond between the composite resin and the tooth structure only has to withstand low-level tensile stress, the restorations are expected to deliver a long service life. Even fast curing procedures can be used without detrimentally affecting the adhesive bond. Among other things, this is due to the low shrinkage stress demonstrated by the material. As a result, light-curing is uncomplicated. The user may choose the light-curing mode which best suits his/her practice routine and does not need to spend time on reflecting this issue. Moreover, the well-known A-D system, facilitates the selection of suitable shades. As the nano-colour pigments are finely distributed in the composite and ensure uniform aesthetics, shade matching is easy to achieve and an excellent chameleon effect is attained. Tetric EvoFlow An ideal partner When deep and narrow cavities have to be restored, the well-coordinated flowable composite Tetric EvoFlow can be used as a first layer prior to placing Tetric EvoCeram to build up the restoration. This helps prevent voids on the cavity floor, particularly in areas which are difficult to access. Tetric EvoFlow features a low viscosity and demonstrates good surface affinity. In addition, the well-balanced filler composition provides an ideal basis for optimum polishability and a longlasting, high-gloss finish. Reporting on his experiences, Dr. Stefan Schwöbel (3) said: I recommend using Tetric EvoFlow as a cavity liner. It creates an even surface, which allows the subsequent condensable composite layers to be more quickly and easily adapted. If old amalgam fillings are removed, the flowable composite can be used for blocking out undercuts. If used properly and in the right indication, the material is the perfect complement to the universal composite Tetric EvoCeram. Apart from serving as a cavity liner, Tetric EvoFlow can also be used as a repair material or to restore small caries lesions in the anterior region, cervical lesions or incipient fissure lesions. Since the material is based on the same technology as Tetric EvoCeram, it exhibits similar shade matching, polishing and wear properties. Moreover, Tetric EvoFlow features a radiopacity of 360% Al and thus clearly outmatches all other commercial flowable composites in this respect. Scientific studies and user reports on Tetric EvoCeram and Tetric EvoFlow are available from Ivoclar Vivadent. (1) van Dijken JWV (2006): The Clinical Performance of Tetric EvoCeram and Tetric Ceram in Class II and Class I Cavities. Three-year report. Editor: Ivoclar Vivadent, Schaan, Liechtenstein. 9 pages. (2) Cerutti A (2007): Tetric EvoCeram: Marginal quality of class I and II restorations as function of the light curing mode. 24-month clinical report. Editor: Ivoclar Vivadent, Schaan, Liechtenstein. 7 pages. (3) Peters G (2007): Dr. Stefan Schwöbel über Erfahrungen aus der Praxis mit einem Flowable. In: Dental Magazin 2007, Issue 3/June Der blaue Bereich: Fließfähige Composites; 2007; 3: Dr. Marion Wanner Bendererstrasse 2, 9494 Schaan Liechtenstein Marion.Wanner@ivoclarvivadent.com Page 4

5 Minimal restorations with Tetric EvoFlow Dr. Nicola Barabanti, Coccaglio/Italy, Dr. Luca Solimei, Genoa/Italy Due to the preventative dental programs established today, dentists are increasingly confronted with the task of placing minimal restorations. In order to be able to restore small tooth cavities with minimally invasive techniques, suitable materials and techniques are required that ensure a satisfactory outcome from both an aesthetic and functional viewpoint. Once carious decay has extended beyond the enamel/dentin interface, a conventional treatment approach similar to that used for larger tooth cavities is usually required. After having placed a rubber dam to ensure proper isolation of the operating field, all the carious tissue needs to be completely removed. This is best done with carbide burs, as these instruments allow controlled preparation of even very small cavities. If the carious lesion has already progressed into the dentin, hand instruments or multiblade burs should be used to excavate the carious tissue. For control purposes, a thin probe is used which produces the typical scratching sound on healthy tooth structure. Along the enamel margins, either a micro-chamfer is prepared or a short bevel is applied to ensure that the enamel prisms are cut in the right direction to effectively counteract shrinkage stress. After cavity preparation has been completed, the cavity is rinsed with water and all debris is removed using rotary brushes. At this stage, conditioning of the tooth structure with a suitable adhesive system is performed. State-of-theart, all-in-one adhesive systems can be applied to both dentin and enamel surfaces. This saves time and prevents excessive or insufficient etching of the dental hard tissues. The adhesive is applied to the cavity and cured after allowing a reaction time of 30 seconds. restoration. Tetric EvoFlow, which is available in Vita shades, facilitates the subsequent layering of more viscous composite. Even if only a very thin layer of dentin material is applied, an aesthetically appealing result can be achieved. To avoid the formation of voids and bubbles, the flowable composite is directly dispensed from the syringe into the cavity and spread with a thin probe. The layer thickness should not exceed 0.5 mm. When the composite is light-polymerized, care should be taken to hold the light probe of the curing Fig. 1: bluephase unit as close to the cavity as possible. For restorations involving minimal layer thicknesses, Turbo light probes are the most suitable ones because they are the most efficient (Fig.1). The initial flowable composite layer usually provides sufficient chroma, so it is even possible to build all further layers with the more translucent Enamel materials. In deeper cavities, dentin materials need to be used, on top of which the Enamel materials are placed. As both Tetric EvoFlow and Tetric EvoCeram are based on the same shade scheme, the desired shading effects are achieved with ease. In regard to cavity type and size, certain issues have to be kept in mind. Tiny cavities are usually difficult to access and contour in line with the natural tooth anatomy. Flowable composites are very helpful, as they are capable of reliably sealing the cavity floor thanks to their flow properties. Even though they exhibit higher polymerization shrinkage than conventional composites, flowable composites demonstrate a prolonged pre-gel phase, which means that they maintain a certain fluidity throughout the polymerization phase and thus minimize the stress that is exerted on the cavity walls. Consequently, they act as a shock absorber below the Fig. 2: bluephase in the LOP mode Page 5

6 3 4 Fig. 3: Rubber dam isolation 5 6 Fig. 4: Cavity margins after finishing and cleaning with rotary brushes Fig. 5: Tetric EvoFlow Shade A2 was applied with a probe Fig. 6: Reconstruction of the cusp with Tetric EvoCeram A2 Enamel Fig. 7: Finished and polished restorations margins Fig. 8: Final result 7 8 Case Presentation 1 In a young patient who presented to our clinic, the placement of a sealant was required in tooth 1.6. Examination with a thin explorer revealed a certain stickiness of the occlusal surface as it offered minor resistance to explorer removal after moderate pressure. Therefore, it was decided to perform extended fissure sealing. Following rubber dam isolation to ensure a dry operating field (Fig. 3), the area of decay was opened with a multiblade tungsten-carbide bur and the carious tissue removed with a multiblade ball-type bur on a slow-speed handpiece. Following this, the cavity margins were finished and cleaned using rotary brushes (Fig. 4). The self-etching AdheSE was chosen as the adhesive system. AdheSE offers ease of use and no etching gel needs to be rinsed off. Separate etching of the enamel and dentin surfaces tends to be rather difficult in small-size cavities. A coat of primer was applied, rubbed into the cavity surface and left to react for 30 seconds. The solvent was evaporated with a strong stream of air. Following this, the AdheSE bonding agent was applied and cured for 10 seconds with the bluephase curing light at 650 mw/cm 2 using the LOP mode (Low-Power mode, Fig. 2). Next, a thin layer of flowable composite was placed on the cavity floor. For this purpose, shade A2 was chosen from the Tetric EvoFlow range, which is based on the Vita shade system. The procedure involved the application of the material with a probe in order to avoid bubble formation (Fig. 5). Then a Tetric EvoCeram A2 Enamel increment was placed to reproduce the superficial areas of the cusps (Fig 6). Finally, the margins of the restorations were finished and polished (Figs. 7 and 8). Page 6

7 9 10 Fig. 9: Tooth # 3.6 with provisional restoration Fig. 10: Secondary caries below the provisional restoration Fig. 11: Cavity margins after finishing with finishing diamonds Fig. 12: Application of the Tetric EvoFlow A3.5 layer Fig. 13: Build up withtetric EvoCeram A3.5 Dentin and A3 Enamel Fig. 14: Final result Case presentation 2 A patient presented to our clinic with a desire to have his tooth 3.6 permanently restored. A temporary restoration had been placed a while ago to protect the tooth (Fig. 9). First, a rubber dam was placed to ensure a dry operating field and then the temporary restoration was removed using ultrasound. Examination revealed that secondary decay had formed under the temporary filling (Fig. 10). The carious tissue was removed using rotary instruments. Then the cavity margins were finished with finishing diamonds (small sphere, 0.12 to 0.20 µm) to ensure that the enamel prisms were cut in the right direction (Fig. 11). After having completed the cavity preparation, the adhesive was applied and cured for 10 seconds with the bluephase curing light at 650 mw/cm 2 using the LOP mode. Then a layer of Tetric EvoFlow A3.5 with a maximum thickness of 0.5 mm was applied to the cavity floor to achieve an even surface and create a mechanical buffer that would ensure a better distribution of the masticatory stress (Fig. 12). Once the first increment was thoroughly cured, the dentin layer was built with Tetric EvoCeram A3.5 Dentin and subsequently covered with a layer of Tetric EvoCeram Enamel (Fig. 13). This was followed by finishing the margins of the restoration and removing the rubber dam. After occlusion had been verified, the patient was satisfied with the result (Fig. 14). Dr. Luca Solimei Piazza Corvetto 1/1, Genoa Italy lucasolimei@hotmail.it Dr. Nicola Barabanti Via Giovaninetti, 22, Coccaglio (BS) Italy nicola.barabanti@tin.it Page 7

8 Tetric EvoFlow and its application options Dr. Jan-W. Harders, Emden/Germany Introduction There was nothing spectacular about the launch of the first flowable composite more than ten years ago. At a time when composite restoratives were still not routinely used by the large majority of dentists, many clinicians asked themselves whether this new product was really necessary. Nevertheless, the first flowable composites were already offered in the most popular shades. In addition, they facilitated extended sealing of pits and fissures and allowed aesthetically appealing results to be achieved. However, special fissure sealants, such as the well known Helioseal, had already been available for some time. Therefore, scepticism prevailed among the dental professionals who were convinced that a flowable composite could only be of inferior quality compared to a conventional composite. Thus initially, only few daring individuals of the composite scene used flowable composite as only few dental professionals were aware of its wide array of applications and the advantages it offered in the fabrication of composite restorations. Roughly ten years ago, this attitude changed abruptly, when Ivoclar Vivadent introduced Tetric Flow. As the little sister of the tried-and-tested Tetric Ceram, the flowable composite soon won the trust of dentists and finally became a standard material routinely used in daily practice. Among other things, it was the numerous lectures, seminars and publications of Professor Roulet and Dr. Spreafica that made Tetric Flow and its versatile applications so popular throughout the dental world. Why a new Tetric Flow? Meanwhile, Tetric Flow has established itself as an industry leader. It was only a logical consequence to implement the same improvements in the flowable version that were achieved in the regular-viscosity composite Tetric EvoCeram by incorporating nano-technology. In Tetric EvoFlow, three types of nano-scale particles with a particle size of less than 100 nanometers or 0.1 micrometers are employed. Therefore, Tetric EvoFlow can justifiably be called a nano-hybrid composite with well-balanced filler technology. The well-balanced filler technology optimally combines fillers of various types and sizes. It forms the basis for the material s excellent aesthetics and clinical success. The lower wear and increased strength compared to Tetric Flow, as well as the material s excellent polishing properties, high surface gloss and unsurpassed radiopacity speak for themselves. As light sensitivity has been further reduced, sufficient time is available to place and contour the material. The nano-colour pigments are responsible for improving the adjustment of the shade of the restoration. The material's outstanding chameleon effect makes small restorations virtually invisible to the naked eye. The nano-modifier ensures optimum surface affinity of the material in all situations whilst providing the stability required for small Class V restorations. Just as in Tetric EvoCeram, ytterbiumfluoride is responsible for the high radiopacity and thus facilitates the detection of secondary caries. Spherical mixed oxide forms the basis for the reduced wear, balanced consistency and life-like translucency of the material. Just as in Tetric EvoCeram, prepolymers are employed in Tetric EvoFlow. However, they are more finely ground than those in Tetric EvoCeram. The use of finely ground prepolymers enables very thin layers of composite to be placed so that Tetric EvoFlow can be used as a light-curing luting material similar to Tetric Flow. What is important in a flowable composite? In 2005, the Clinical Research Associates (CRA), a private clinical research institute in the US, interviewed 1,652 dentists on their habit of using flowable composite. Seventy nine percent of the respondents indicated that they work with flowable composite. To turn the argument on its head, this means that at least one fifth of all the dentists still do not use flowable composite. Meanwhile, flowable composites have become indispensable in restorative dentistry, as they can be used in areas where regular-viscosity composites are not really suitable. This is partly due to the material s optimum surface affinity, which enables Tetric EvoFlow to penetrate areas that are hard to reach and is thus ideal as a first layer (liner) under regular-viscosity composite. Simultaneously, it provides the stability required for Class V restorations. This means that Ivoclar Vivadent has actually succeeded in squaring the circle. The radiopacity of flowable composite is important when it is used as a cavity liner. In Tetric EvoFlow, the radiopacity has been significantly increased compared to Tetric Flow. Therefore, secondary caries caused by microleakage can be diagnosed much more easily on the x-ray. However, as was stated by Attar et al, secondary caries should not occur at all if composites are correctly processed. These researchers investigated the effect of flowable composites on the marginal seal of Page 8

9 restorations in cervical areas in conjunction with two different packable composites and one micro-hybrid. The use of flowable composite resulted in a statistically significant reduction of microleakage (p<0.05) in all the restorative materials tested. Indications According to a CRA survey, 66 % of the respondents use flowable composites as a liner, 43 % as a restorative material for Class I, II and V restorations, 16 % use it as a fissure sealant and 14 % for repairs. For which indications do you use flowable composite most? More than 130 dentists were asked this question during training courses conducted at Ivoclar Vivadent s ICDE (International Center for Dental Education). The use as a liner under composite restorations, extended fissure sealing and the restoration of Class V and small cavities turned out to be the most frequent indications for flowable composite. These are exactly the indications for which Tetric EvoFlow is recommended. EXAMPLES FOR THE MOST IMPORTANT INDICATIONS: 1. Cavity lining with a layer thickness of mm 2. Extended fissure sealing 3. Class V restorations (cervical restorations) 4. Very small cavities 5. Restoration of deciduous teeth 6. Creation of an auxiliary cavity (endodontics) 1. Liner Matrix band Fig. 2: Radiographic image of Tetric EvoFlow as a liner under a composite restoration (extracted teeth placed in silicone material): Tetric EvoFlow demonstrates a higher radiopacity than all comparable competitor products (350 % Al). 2. Extended fissure sealing Tetric EvoFlow is simply ideal for the extended sealing of fissures, as the material flows into the cavity by itself (Fig. 3). It can be easily spread into very fine fissures using a probe (Fig. 4). If only small increments are placed, occlusal adjustments are hardly required. With Astrobrush, the restoration surface can be polished to a high lustre finish in no time. Appropriate isolation of the operating field is required to ensure high-quality restorations and efficient procedures (Fig. 5). One possibility is to use OptraDam, which can be inserted quickly and easily. Normally, no frames and clamps are required. I just use one molar clamp to secure the dam when restoring terminal molars. Tetric EvoFlow is cured with light in the wave length range between nm (blue light). In conjunction with a light intensity of at least 1,100 mw/cm 2, the exposure time is 10 seconds. bluephase 16i achieves light intensities of 1,600 mw/cm 2 and thus offers an even more reliable cure (Fig. 6). Wedge Fig. 1: Due to the material s excellent surface affinity, perfect cavity margins are achieved in the proximal area: A = Tetric EvoFlow B = initial Tetric EvoCeram layer 1-3: further composite layers using the incremental technique Due to the material s excellent surface affinity, perfect cavity margins are achieved in the proximal area: In the process, the acute angles between the cavity wall and matrix band are filled with a thin composite layer of < 0.5 mm thickness. As a result, the marginal seal is significantly improved (Fig. 1). The radiographic representation of a restoration shows that Tetric EvoFlow demonstrates a higher radiopacity than comparable competitor products. When flowable composites are used as cavity liners, the marginal seal of composite restaurations is significantly improved. 3. Class V cavities (cervical restorations) Tetric EvoFlow is suitable for use as a liner, and in particular for ensuring a gap-free transition from the gingival cavity margin to the restoration (Fig. 7). Small Class V cavities can be completely restored with flowable composite. Nevertheless, the layer thickness should not exceed 1.5 mm. As a result, the application of several increments may be required. The placement of retraction cords can be very helpful in the creation of a dry treatment field, and an aesthetic surface gloss is achieved with Astropol polishers (Fig. 8). Tetric EvoFlow is now available in two additional shades, IVA5 and IVA6. They enable dental professionals to create cervical restorations in dark or discoloured teeth that are hardly discernible. Page 9

10 3 4 Fig. 3: Tetric EvoFlow flows into the cavity by itself Fig. 4: The flowable composite is easily spread into the very fine fissures using a probe Fig. 5: Isolation of the operating field to ensure high-quality restorations and efficient procedures Fig. 6: Tetric EvoFlow is cured with light in the wave length range between nm (blue light) Fig. 7: Tetric EvoFlow is suitable for use as a liner, and in particular for ensuring a gapfree transition from the gingival cavity margin to the restoration Fig. 8: A beautiful surface gloss is achieved with Astropol polishers Fig. 9: A cavity difficult to restore with regularviscosity composite Fig. 10: Tetric EvoFlow has the ability of filling in even very narrow cavity angles. The flowable composite ensures a perfect marginal seal in these areas which cannot be achieved with regular-viscosity composite (magnified section of Figure 9) Fig. 11: The hard-to-reach area was completely filled in/wetted with Tetric EvoFlow Fig. 12: The flowable composite was applied in circles along the cavity walls and matrix band Page 10

11 13 14 Fig. 13: Tetric EvoFlow is a standard restorative for Class I, II and V restorations in deciduous teeth Fig. 14: The use of the self-etching AdheSE Bonding system is recommended. This provides the advantage of not having to apply phosphoric acid, which can be problematic in deciduous teeth due to the proximity of the pulp Fig. 15: Provisional restoration Fig. 16: Removal of the provisional restoration Very small cavities Small and very small cavities are difficult to restore with regular-viscosity composite, as due to their small dimensions, the usual sculpting and contouring instruments cannot be used (Fig. 9). The occlusal view clearly shows that the angle between the cavity margin and the matrix is very narrow. Thus the clinician can hardly achieve a tightly sealed restoration margin when using regular-viscosity composite. Figure 10 shows that this hard-to-reach area was completely filled in/wetted with Tetric EvoFlow. The cavity should not be filled vertically starting from the cavity floor, but the flowable composite should be applied in circles along the cavity walls and matrix band (Fig. 11). By working from the outside towards the centre, a Class II cavity is first converted into a Class I cavity and then filled completely. For that purpose, three or more layers are usually required which need to be cured separately. However, time is not a problem when using bluephase 16i. By using this procedure, a complete cure of the restoration is ensured and polymerization shrinkage maintained at a tolerable level. Due to the material s improved wear behaviour, Tetric EvoFlow is suitable for the restoration of small Class II cavities. 5. Restoration of deciduous teeth Tetric EvoFlow is a standard restorative for Class I, II and V restorations in deciduous teeth (Fig. 13). It is superior to amalgam or glass ionomer cement, as no loss of material occurs. As the restorations are invisible, small patients and their parents are usually enthusiastic about the final outcome. Moreover, the material cures in only 10 seconds when using the bluephase 16i curing unit. There is no need to wait until the material can be condensed or until self-curing material has polymerized. I recommend using the AdheSE bonding system, because it is self-etching and there is no need to apply phosphoric acid (Fig. 14). This is particularly advantageous in deciduous teeth, as the pulp is usually very close. Applying AdheSE requires sixty seconds which are definitely worthwhile, because the adhesive helps prevent the loss of Tetric EvoFlow restorations. 6. Creation of an auxiliary cavity (endodontics) The effective prevention of bacteria penetration into the root canal is a decisive factor in the success or failure of endodontic therapy. This is particularly true if the endodontic disease was caused by secondary caries. Especially in cases with extensive loss of tooth structure, a tight seal of the root canal system is crucial. When treating gangrene and apical periodontitis, for example, the creation of an auxiliary cavity is indispensable to enable the long-term application and exchange of root canal dressings. After having removed the temporary filling, an auxiliary cavity is created which enables the root canal to be accessed from the occlusal aspect. For that purpose, a circular matrix band (e.g. GoMat) is placed which allows tight proximal contacts to be produced (Figs. 15 and 16). Page 11

12 17 18 Fig. 17 and 18: Creation of an auxiliary cavity which enables the root canal to be accessed from the occlusal aspect. A circular matrix band is placed which allows tight proximal contacts to be produced Fig. 19: Finished auxiliary cavity Abb. 20: With the Tetric EvoFlow Luer-Lock syringe, even hard-to-reach areas can be accessed To build up the cavity walls, circular increments of Tetric EvoFlow are applied along the matrix band and individually light-cured (Fig. 17). Tetric EvoFlow is offered in eight enamel shades (A1 to A4, B3, IVA5 and IVA6), the dentin shade A3.5, the highly translucent incisal shade T and the bleach shades XL, L, I, M. A root canal dressing can be applied to the auxiliary cavity and left in place for as long as necessary or changed as often as required until the apical periodontitis has completely healed. The coronal opening is tightly sealed with glass ionomer cement (Fig. 18). The auxiliary cavity made of composite remains fully functional and does not entail any disadvantages for the patient (Fig. 19). After successfully completing the endodontic therapy, the auxiliary cavity is adhesively filled and the tooth restored correspondingly. Delivery forms Tetric Flow was the first flowable composite to be offered in Cavifils. This boosted the material s popularity ten years ago. The new Tetric EvoFlow is available in both Cavifils and syringes. The Luer-Lock syringe features a tip with a diameter of 1.1 mm and bent at a 30-degree angle, so that it allows even hard-to-reach areas to be accessed. Tips with a diameter of 0.9 mm can also be used (Fig. 20). Conclusion Flowable composites are no longer considered to be exotic, but have become standard materials used routinely in the daily practice. Modern dentistry is unthinkable without flowable composite. My material of choice is Tetric EvoFlow, because it is a further developed version of Tetric Flow, which has been thoroughly researched, documented and demonstrated to be clinically successful for more than ten years. For me, this means improved processing properties and the reassurance of creating long-lasting restorations that offer patients the highest possible benefit. For easier recognition of the flowable, low-viscosity version, light-grey was chosen as the colour for the syringes and Cavifils. Dark-grey syringes and Cavifils mean regular-viscosity Tetric EvoCeram. The shelf life expiry date is indicated on the syringe label and is now also imprinted on each Cavifil. Dr. Jan-W. Harders Neutorstr , Emden Germany info@dr-harders.de Page 12

13 (R)evolution among flowable composites Minimally invasive restorations with the new Tetric EvoFlow Dr. Dr. Christian Hammerer, Vienna/Austria The current distinct trend towards minimally invasive dentistry entails a demand for appropriate restorative materials. Excellent flow properties and the possibility of selective, precise application are fundamental prerequisites to ensure gapfree adaptation of restoratives to the walls of small cavities. Moreover, properties such as good radiopacity are indispensable these days, as they are highly relevant from a clinical point of view. The new Tetric EvoFlow is a further developed version of the flowable hybrid composite Tetric Flow, which has proven its exceptional qualities in more than 10 years of clinical use. It is predominantly employed in conjunction with conservative cavity preparation techniques using micro-grinding tools, ultrasonic instruments or micro-air abrasion. Even though the flowable nano-hybrid composite offers a limited indication range compared to conventional, sculptable composite due to its reduced filler content, it is ideally suited for restoring microinvasive Class I and II cavities in low-stress areas, extended fissure sealing in premolars and molars, the filling of anterior teeth (Class III) and Class V cavities (cervical caries lesions, wedge-shaped defects). Further indications of the material include the cementation of composite and ceramic restorations and repair of composite and ceramic veneers. In addition, it can be used as a cavity liner under Class I and II restorations to create an intimately adapting initial composite layer under conventional, sculptable composites particularly in the proximal box and provide a flat cavity floor on which to build high-quality restorations. Due to the reduced filler content (silicon dioxide and finely ground glass/quartz fillers), the material features a lower viscosity and enhanced flow properties. This ensures excellent surface affinity and allows the composite to be adapted to the cavity surfaces without any bubbles or voids. Simultaneously, the material exhibits high tensile and compressive strength as well as wear resistance. Another important clinical feature of Tetric EvoFlow is its exceptionally high radiopacity, which facilitates diagnosis of secondary caries and the detection of material excess. Below is a case study which demonstrates the easy handling properties of this flowable composite. In a young female patient, pit and fissure caries was diagnosed in teeth # 34 and 35 during a dental checkup (Fig. 1). After brief cleaning, the tooth shade was determined while 1 2 Fig. 1: Pre-operative situation: Pit and fissure caries in teeth # 34 and 35 Fig. 2: OptraDam in place Fig. 3: Occlusal view of teeth # 34 and 35 prior to preparation Fig. 4: Teeth # 34 and 35 after removal of carious tissue 3 4 Page 13

14 5 6 Fig. 5: The teeth are etched with 37 % phosphoric acid 7 8 Fig. 6: The etchant gel is rinsed off. OptraDam effectively protects the mucous membrane Fig. 7: Single-component, light-curing bonding agent (Excite) Fig. 8: Flowable nano-hybrid composite is applied Fig. 9: The composite is light-cured in a completely dry environment Fig. 10: Composite restorations after light-polymerization Fig. 11: The restorations are polished with Astrobrush (special fibres with integrated silicon carbide as the polishing medium) Fig. 12: Completed restorations after polishing and application of topical fluoride the teeth were still moist. A rubber dam was placed to ensure a dry operating field (Figs. 2 and 3). Next, the carious lesions were removed preserving as much tooth structure as possible. The cavities were rinsed with water spray and then dried (Fig. 4). Following this, the prepared teeth were conditioned with 37 % phosphoric acid using the total-etch technique (Figs. 5 and 6). Then a light-curing single-component dentin/enamel adhesive was applied (Fig. 7). Subsequently, composite material of the selected shade was applied to the cavities using Cavifils. The restorations were pre-contoured with a small condenser and then light-cured (Figs. 8 to 10). After light-polymerization, fine-grit diamonds were used to finish the restorations and polishing was performed. After removal of the rubber dam, the occlusion was verified and fluoride was applied topically to the teeth (Figs. 11 and 12). Dr. Dr. Christian Hammerer Bernhard-Gottlieb Universitätszahnklinik Wien Währingerstr. 25A, 1090 Vienna/Austria christian.hammerer@zahnklinik-wien.at Page 14

15 Composite layering technique for anterior teeth using Tetric EvoCeram Dr. Iñaki Gamborena, San Sebastián/Spain Highly aesthetic results are not only achieved with ceramic restorations. We have a responsibility to our patients to fabricate restorations that are just as aesthetic as those produced in the dental laboratory using composite resin. For this purpose, we need materials whose light scattering is similar to that of natural teeth. Furthermore, we must use a straightforward working technique to correctly apply the different materials, taking into account their shade, opalescence, and fluorescence, to name only a few of the most important properties. I have been using Tetric EvoCeram as a restorative material for the past two years. As a result, I can confirm that it is suitable for fabricating monochromatic restorations in posterior teeth as well as polychromatic restorations in anterior teeth. The product comprises a number of materials in different degrees of opacity, translucency and brightness. These materials can be polished to a high gloss finish. Therefore, the restorations show heightened stability and resistance to pigmentation and decolouration. The material s chameleon effect which allows it to adapt to the colour of the surrounding tooth structure is attributed selected according to their properties. For example, I can choose different materials from the Tetric EvoCeram assortment for the basic dentin shade, the dentin shade saturation and the mean opacity / translucency. In accordance with the characteristics of the tooth in need of restoration, I can reinforce certain areas with a dentincoloured material, which nevertheless has a higher opacity. This effect can be observed in the following opaque dentin materials: Dentin A3.5, Dentin A4 and Dentin B2. I have a choice between various translucent materials (T, Bleach L, Bleach M und Bleach I) for imitating the shine and translucency of dental enamel. The Tetric EvoCeram assortment includes a material called Bleach XL, which if used properly and applied in very thin increments allows me to increase the brightness of the restoration or to accentuate very bright areas to enhance the adaptation of the restoration to the remaining tooth structure (Fig.1). Clinical case: step-by-step description of the technique A young male patient presented to the practice with two fractured central incisors resulting from accidental trauma. The pulp remained undamaged (Fig. 2). On the basis of a dental impression, I fabricated a plaster cast, on which I created a study model in wax. In the process, I paid special attention to the palatal surfaces and the incisal edges. Next, I examined the colour characteristics of the teeth in question. It is important to conduct this step before the appearance of the teeth changes when they become dehydrated during the subsequent treatment steps. When I had finished this analysis, I filled in a colour diagram in which I indicated the different materials that I wanted to use in specific areas. Fig. 1: Tetric EvoCeram shade guide to the microfine particles and the nano-optimized filler technology used in the material. In addition, nano-pigments contribute to this special characteristic. In order to ensure the smooth integration of the restoration into the surrounding dentition, the adjacent teeth have to be thoroughly analyzed and the suitable materials have to be Fig. 2: Preoperative situation Page 15

16 3 4 Fig. 3: Application of bevels 5 6 Fig. 4: Build-up of palatal enamel Fig. 5: Application of the opaque Dentin B2 Fig. 6: Application of Tetric EvoCeram shade A2 between the mamelons Fig. 7: Application of Tetric EvoCeram Bleach XL to increase the brightness value Fig. 8: Tetric EvoCeram Bleach L on the labial surface Fig. 9: Finishing and polishing with Astropol Fig. 10: Final polishing with Astrobrush Fig. 11: Application of Tetric EvoCeram T to simulate palatal enamel Fig. 12: Application of Tetric EvoCeram B2 Dentin and A Page 16

17 13 14 Fig. 13: Final result of both the restored teeth Fig. 14: Smooth integration of the restorations into the surrounding tooth structure It is of utmost importance that both teeth are beveled to create the basis for a smooth transition between the composite resin and the dental tissue (Fig. 3). After having etched the tooth structure and applied the corresponding adhesive (Excite ), I placed the different Tetric EvoCeram materials. With the help of a silicone matrix and the translucent material (T) I built up the palatal enamel (Fig. 4). This technique enabled me to closely imitate nature. Therefore, I did not apply a Dentin material as the surface layer to the palatal surface. The silicone matrix allowed me to apply the material in suitable form and to avoid time-consuming adjustments as well as subsequent contouring of the palatal surface. Next, I used the opaque Dentin B2 to reproduce the shade and saturation of the underlying dentin. In addition, this material allowed me to create the mamelons (Fig. 5). In order to achieve optimal masking and improve the transition of opaque Dentin B2 to the mamelon, I applied shade A2 between the mamelons. This material has a high translucency and therefore makes the restoration look more lifelike. I maintained a distance of 1 mm to the enamel edge (Fig. 6). very much. The system has polishers of decreasing grit sizes. Subsequently, I used Soflex (3M) polishing discs and finally the Astrobrush polishing system, which allowed me to achieve an outstanding high-gloss polish (Figs. 9 and 10). I restored Tooth #21 in the same sequence: Enamel shade (T) palatal, Dentin B2 for reproducing the mamelons, A2 and Bleach L (Figs. 11 and 12). Figure 13 shows the completed restorations. The mentioned chameleon effect is one of the salient features of Tetric EvoCeram. Because of this effect, completed restorations blend in smoothly with the surrounding dentition (Fig. 14). Conclusion As discussed at the beginning, the highly aesthetic reconstruction of teeth, which is essential to restoring the wellbeing of our patients, requires that we use suitable materials and the correct technique. Because of its outstanding optical and physical properties, Tetric EvoCeram offers dental professionals a convenient solution for fabricating quality restorations. A silicone matrix additionally facilitates the use of the different materials and provides a reliable basis for achieving an aesthetically pleasing result. If the brightness value of the restoration is too low, it can be heightened by applying a very thin layer of Bleach XL to the dentin region (Fig. 7). I used the translucent Bleach L to complete the restoration and recreate the labial enamel. I covered the entire restoration including the incisal edge with this material (Fig. 8). The final appearance of the restoration not only depends on the application of the individual layers but also on the shape and structure of the surface. I used diamond instruments for this purpose. For finishing and final polishing, I used the three-step polishing system with silicone polishers (Astropol ), which I like Dr. Iñaki Gamborena Resurrección Maria de Azkue 6, San Sebastián, Spain gambmila@telefonica.net Page 17

18 Restorations with Tetric EvoFlow and Artemis Dr. Ali H. Özoglu, Adana/Turkey The user report below gives an account of how two upper incisors were restored with Tetric EvoFlow and Artemis. Fig. 1: Two fractured upper central incisors of an 8-year-old patient Fig. 2: Fractured piece of one of the two teeth Clinical examination revealed that both teeth were vital and showed no signs of periodontal injury. Therefore, it was decided to restore the fractured central incisors with Artemis using a direct restorative procedure after having bonded the fractured piece to the tooth with Tetric EvoFlow. The shades selected for these restorations were Artemis A2 Dentin and Artemis A2 Enamel. Moreover, the shade Artemis Clear was chosen to ensure a natural rendering of the translucent intermamellon area. Prior to starting the treatment, OptraDam, which I believe is an innovative and practical rubber dam, was placed into the patient's mouth. The purpose of using OptraDam was to isolate the fractured incisors and prevent the risk of possible contamination. Case presentation An 8-year-old patient with two fractured upper central incisors was referred to our clinic (Fig. 1). One of the fractured tooth pieces was brought along to the clinic by the patient s father (Fig. 2). Wave bevelling was the only preparation needed on the labial surfaces of the fractured teeth. It was done to achieve higher retention, invisibility and consequently a better aesthetic result (Fig. 3). All the prepared surfaces were acid-etched with 37% Total Etch phosphoric acid. Then the one-bottle adhesive Excite, which was used as the bonding agent, was applied. The same procedure was applied to the fractured tooth piece (Figs. 4 to 6). The next step involved attaching the broken piece to the corresponding tooth using Tetric EvoFlow. This was followed by placing a layer of Artemis A2 Dentin on the crack line (Fig. 7). In order to restore the palatal wall of the left central incisor, the forefinger of the left hand was positioned on the palatal surface to serve as a matrix. Then Artemis A2 Enamel and Clear shades were used to build up the palatal wall. Artemis A2 Enamel was also utilized to build the proximal ridges. A transparent matrix strip was used to contour and shape the proximal areas. Subsequently, A2 Dentin shade was applied to reconstruct the dentin layer and the mamellons. A touch of Tetric Color White was painted onto the incisal edge to mimic the natural halo effect and Clear shade was added between the A2 Dentin mamellons to reproduce the natural translucency of dentition in a young patient (Figs. 8 to 11) Finally, Artemis A2 Enamel was applied to the entire restoration. Then the restorations were given their final shape and surface texture using diamond burs and fine diamond finishers. Following this, polishing strips and discs were used to finish and polish the interproximal surfaces. High-gloss polishing was performed with the Astropol polishing system and Astrobrush (Figs. 12 and 13). Dr. Ali H. Özoglu Ataturk Cd. Ogrt. Sit. Cigdem Apt. K:1 D:3, Adana Turkey aliozoglu@yahoo.com Page 18

19 3 4 Fig. 3: Isolation of the fractured incisors using OptraDam and wave bevelling of the fractured margins 5 6 Figs. 4 to 6: The prepared surfaces were acid-etched with 37% phosphoric acid. Subsequently, the one-bottle adhesive Excite was applied. The same procedure was used for the fractured tooth piece. Fig. 7: The broken piece was attached to the corresponding tooth with Tetric EvoFlow. Then a layer of Artemis A2 Dentin was placed on the crack line. Fig. 8: The palatal wall of the left central incisor was restored with Artemis A2 Enamel and Clear. Artemis A2 Enamel was used to restore the marginal ridges. A2 Dentin was applied to reconstruct the dentin layer and the mamellons. Fig. 9 to 11: Clear shade was added between the mamellons to reproduce the natural translucency of dentition in a young patient. Finally, Artemis A2 Enamel was applied to the entire restoration. Fig. 12: High-gloss polishing was performed with the Astropol/Astrobrush polishing system Page 19

20 Morphological aspects of aesthetic anterior tooth restorations Dr. Ulf Krueger-Janson, Frankfurt am Main/Germany In order to create anterior tooth restorations that blend well with the surrounding dentition, several parameters need to be taken into account. Every effort has to be made to ensure a true-to-nature rendering of the tooth shape, surface texture and tooth shade. Based on the patient case below, it will be shown how light-optical phenomena can be utilized to achieve natural shaping. Moreover, the most suitable means of imparting a lifelike appearance to restoration surfaces will be presented. The restorative treatment described below involved the use of Tetric EvoCeram and Tetric EvoFlow composite materials from Ivoclar Vivadent. Anamnesis and formulation of the treatment plan The patient was considerably bothered by the asymmetrical shape of her anterior arch and the heavily stained (devitalized) lateral incisors. She did not want to undergo orthodontic treatment because of the time involved. A close-up view of the situation (Fig. 1) reveals the difference in shade between the lateral and central incisors. Moreover, teeth # 12 and 13 were twisted und the central incisors slightly rotated towards the mesial aspect, so that the distal portions fanned out and had a very dominant appearance. Due to a slightly overbuilt, defective restoration in the cervical region, the gingival tissue mesial to tooth # 12 showed signs of inflammation. In addition, anterior crowding had led to the rotation of the mesial portion of tooth # 12 towards the labial aspect. Figure 2 shows that two teeth can look very different from different viewing angles due to light reflection effects, even though they may appear very similar when viewed from the front. While the surface of tooth # 11 appears streaky, tooth # 21 has a predominantly smooth and uniform appearance. The perikymata are easy to identify. They are even partly visible on the vertical curvature. The surface is composed of a combination of more or less pronounced vertical and horizontal bulges which overlap. Preparation and composite layering Details of the case: Figure 3 shows the triangular embrasure between teeth # 22 und # 23 and the initial discolouration of the devitalized tooth # 22. By conducting an internal bleaching procedure using 30% H 2 O 2 and sodium perborate, a shade level comparable to that of the surrounding dentition was achieved (Fig. 4a). After reducing the labial enamel portion, the lateral incisors were protected with Teflon tape and etched. Then bonding agent was applied. The silicone matrix, which had been fabricated with the mock up in place, was positioned on the palatal side to provide an outline of the desired dimensions (Fig. 4b). First, an opaque dentin layer Tetric EvoCeram A3.5 Dentin in this case was applied mesially and adapted to the previously etched and bonded tooth # 23 to give it more width. The same material was then used to build on this base layer, except in the labial portion, where A3.5 Enamel material was applied. After completing the build-up, tooth # 23 was protected with Teflon tape (Fig. 5a). In tooth # 22, A2 Enamel material was applied as a first layer. This material is very convenient to process. Due to its outstanding thixotropy, it stays where it is placed and does not run or bleed. Then the tooth was successively built to full contour in a targeted fashion. Only as much material had to be applied as was actually needed. Light-curing of the individual increments is recommended to fix them in place and maintain intermediate shape results. Following this, a layer of Teric EvoFlow was applied. Shade A2 was again used for this purpose (Fig. 5b). The layering technique presented here involves building a stable core with universal composite und subsequently covering it with a layer of flowable composite to take advantage of the favourable surface properties of this material. Due to its nonslump consistency, the flowable composite is easy to place exactly where you need it and stays there. Even larger portions can be applied to the tooth directly from the syringe. Thanks to its gel-like consistency, it can be easily spread and pulled into position with a probe. This simple procedure ensures homogeneous and void-free layering of the composite. In addition, the material features an exceptionally high surface gloss which becomes noticeable as early as during application of the composite. Following this, Tetric EvoFlow Bleach I was used to build the tooth to full contour (Fig. 5c). The gel-type consistency Page 20

21 1 2 Fig. 1: Starting situation: Asymmetrical anterior arch with severe discolouration 3 4a+4b Fig. 2: Different light reflections and viewing angles of the anterior teeth Fig. 3: Triangular embrasure between teeth # 22 and # 23 and initial discolouration of the devitalized tooth # 22 Fig. 4a: Tooth # 22 after bleaching treatment Fig. 4b: Following reduction of the labial enamel portion enables soft rounded shapes to be created in the interdental area. A void-free, homogeneous appearance of the restoration surface is ensured, so that intricate, complex surface structures can be designed. Due to the material s excellent stability, the interdental areas can be built up and contoured in small individual steps. Small quantities of Tetric EvoFlow can be applied with a probe and spread as required. This technique allows the interdental areas to be shaped and contoured in a simple, quick and efficient fashion without having to use matrices or other auxiliary aids. Shaping and contouring The blue lines have been drawn to outline the basic shape and mark the transition of the labial surface to the interdental area between the teeth. The proximal curvature in this area is represented by hatched lines (Fig. 6a). A flameshaped diamond finisher (Komet, Gebr. Brasseler) was used to contour the interdental area (Fig. 6b). The transition from the labial surface to the interdental area was slightly relocated in this case. By exposing the transition area and shifting it more towards the anterior, the tooth obtains a more pronounced three-dimensional appearance as a larger part of the lateral surface becomes visible. The position and direction of the light-guiding ridges are determined accordingly. We recommend using polishing strips (3M) for finishing the interdental surfaces. Make sure to slide the already used portion through the proximal contact area while using the more abrasive part for shaping the curvature towards the front. The picture on the right (Fig. 6b) shows that a shallow concavity was prepared on the mesial aspect of the labial surface. A coarse-grit, torpedo-shaped finishing instrument (Komet, Gebr. Brasseler) was used for this purpose. By fabricating a diagnostic mock-up and consistently using the information it provides as to the final dimensions of the restoration (via the silicone matrix), finishing and polishing is considerably facilitated. In addition to being quick, efficient and target-oriented, the procedure helps save material. Creation of surface texture To reproduce the topography of the labial surfaces of the central incisors, the perikymata need to be accurately mimicked. The transverse, wavy lines projected onto the tooth surface in Figure 7a are supposed to outline them. When texturizing surfaces, it has to be kept in mind that natural teeth are exposed to (age-related) wear resulting from food ingestion and the polishing media contained in tooth paste. If you aim to achieve a true-to-nature reproduction of surface texture, you should make sure to apply the desired degree of age-related levelling using finishing and polishing instruments. The wavy structure is achieved by creating grooves on the tooth surface with the tip of a flame-shaped diamond bur (Fig. 7b). By varying the depth of the grooves, a natural interplay of light reflections and projections is achieved. When performing this procedure, the grinding direction should be constantly changed to avoid the creation of uniform structures. Page 21

22 5a 5c 7a+7b 5b 6a+6b 8a+8b Fig. 5a: Interdental protection with Teflon tape Fig. 5b: Application of a Tetric EvoFlow layer Fig. 5c: Application of the final Tetric EvoFlow Bleach I layer Fig. 6a: The transition between the labial surface and the interdental area has been outlined Fig. 6b: Representation of the proximal curvature by hatched lines Fig. 7a: Profile of the light-guiding ridges and proximal curvature Fig. 7b: The wavy structure is achieved with the tip of a flame-shaped diamond bur Fig. 8a: The projections outline the areas and structures to be worked on Fig. 8b: Levelling of the surface Fig. 9a: Final polishing with Astrobrush Fig. 9b: High-gloss polishing with cotton wheels and diamond polishing paste Fig. 10a: Outlined shape and surface characteristics Fig. 10b: Lifelike, anatomically correct surface texture after polishing 9a+9b 10a+10b Author s note: In Figures 6a-9b, both the instruments and drawings have been incorporated directly into the pictures for reasons of simplification and to achieve a better understanding. In Figure 8a, the perikymata have again been projected onto the surface to give a clear picture as to which areas of the tooth surface have to be worked on and which surface structures have to be created. This is followed by smoothing of the entire surface, which is one of the most important working steps of the entire procedure. In the process, care needs to be taken not to eliminate the previously applied surface structures (Fig. 8b). The more delicate the structures are, the easier it is to smooth out the surface. I prefer to use OptraPol polishers for that purpose. They are coordinated with the filler particle sizes used in composite resin, which simplifies and accelerates the procedure. By gently running over the surface exerting low pressure and performing a slight brushing motion, a surface with a relatively homogeneous appearance is achieved. A certain roughness should, of course, be maintained. The edges will be softened during the high-gloss polishing procedure and eventually impart the restoration with a very natural appearance. Page 22

23 11 12 Fig. 11: Harmonious appearance of the adjusted anterior arch Fig. 12: Completed restoration: harmonious incisal line and perfect integration into the surrounding dentition Fig. 13: Patient prior to starting the treatment Fig. 14: Patient after completion of the treatment As flowable composites feature a considerably lower filler content than universal composites, they are usually easier to work on. It is important to keep this in mind, as finishing of the restoration needs to be performed very cautiously. However, they give you the advantage of achieving aesthetically appealing results more easily. After pre-treating the surface as mentioned, either dry or wet final polishing can be performed with the silicon carbide-impregnated Astrobrush (Fig. 9a). When polishing with dry brushes, excessive heat generation should be avoided by placing a suction device in such a way that an air draught is generated on the palatal side, while simultaneously conveying air onto the operating field with the universal syringe from the labial side. The brush is applied with a pumping motion at low speed to penetrate the transverse grooves. This results in an irregular abrasion pattern which lends a vital appearance to the tooth. The less pressure is applied, the better is the polishing effect achieved. Another "trick is to additionally use polishing paste. Cotton wheels are appropriate tools to achieve a high-lustre finish when used in conjunction with diamond polishing paste (OptraFine HP Polishing Paste from Ivoclar Vivadent in this case) (Fig. 9b). However, the right direction of rotation needs to be chosen. When polishing labial build-ups, it is usually advisable to polish from the interdental and cervical aspects towards the centre of the labial surface. The only exception to this rule is the incisal region, where polishing should be performed towards the incisal edge. Polishing at high speed and applying a successively reduced level of pressure leads to excellent results. Figures 10 a and b show the reflective areas relevant from a light-optical viewpoint in detail. The result The final outcome of the treatment: The entire anterior arch has a very harmonious appearance and the restored tooth shows light-optical effects similar to those of the adjacent teeth. Moreover, any unfavourable tooth positions have been adjusted (Fig. 11). Both lateral incisors have been adjusted to optically blend into the surrounding dentition. Due to the way the mesial edge of tooth # 23 and the incisal edges of the central incisors have been designed, a harmonious incisal line and a perfect integration of tooth # 12 is attained. A harmonious, aesthetic overall appearance has been achieved which equally satisfies both the patient and the dental team (Fig. 12). Figures 13 and 14 give a direct comparison between the starting situation and the final outcome. Dentist Ulf Krueger-Janson Stettenstraße 48, Frankfurt/Main Germany ulf.krueger-janson@t-online.de Page 23