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Posterior indirect adhesive restorations:

updated indications and the Morphology
Driven Preparation Technique

Article in The international journal of esthetic dentistry · January 2017


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Marco Veneziani
Università degli Studi di Torino


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Clinical Research

Posterior indirect adhesive

restorations: updated indications
and the Morphology Driven
Preparation Technique
Marco Veneziani, DDS
Private practice, Vigolzone (PC), Italy
Visiting Professor, University of Pavia, 2007–2012
Active member, Accademia Italiana di Conservativa
Active member, Italian Academy of Esthetic Dentistry
Active member, International Academy for Digital Dental Medicine

Correspondence to: Dr Marco Veneziani

Via Roma 57, 29020 Vigolzone (PC), Italy; Tel/fax: +39 0523 870362; Mobile: +39 3351 435187;


VOLUME 12 • NUMBER 2 • Summer 2017

Abstract as they are less conservative, incompat-

ible with adhesive procedures, and in-
The aim of this article is to identify the volve unnecessary dentin exposure. The
indications for adhesively cemented clinical advantages of this new “anatom-
restorations and to provide a correct ic” preparation design are 1) improving
step-by-step protocol for clinicians. adhesion quality (optimizing the cutting
New cavity preparation principles are of enamel prisms, and increasing the
based on morphological considerations available enamel surface); 2) minimiz-
in terms of geometry (maximum profile ing dentin exposure; 3) maximizing hard
line and inclination of cusp lines), and tissue preservation (the cavity being de-
structure (dentin concavity and enamel signed for cementation with reinforced
convexity). In this article, we discuss composite resins, improvement of flow,
previous preparation concepts that were and removal of excess material); 4) op-
not designed purely for adhesive restor- timization of esthetic integration due to
ations and were therefore not conserva- the inclined plane design, which permits
tive enough or suitable for adhesive pro- a better blending at the transition area
cedures. The novel cavity shape consists between tooth and restoration. These
of continuous inclined plane cavity mar- preparation principles may be effec-
gins (hollow chamfer or concave bevel) tively used for all adhesively cemented
on axial walls, whenever they are coro- restorations, both according to tradition-
nal to the equatorial tooth line. A 1.2 mm- al concepts (inlay, onlay, overlay) and
thick butt-joint preparation is performed new ones (additional overlay, occlusal-
in the interproximal box and on the axial veneer, overlay-veneer, long-wrap over-
walls when the margins are apical to lay, adhesive crown). Thus, a balance
the equatorial line. The occlusal surface between restoration and prosthodontics
is anatomically prepared, free of slots is created, which is characterized by a
and angles. The author’s suggestion is more conservative approach.
to avoid shoulder finish line preparation
around cusps, occlusal slots, and pins, (Int J Esthet Dent 2017;12:2–28)

VOLUME 12 • NUMBER 2 • Summer 2017
Clinical Research

Introduction with different techniques: direct, semi-

direct (intraoral and extraoral), and in-
In modern restorative dentistry, the de- direct. Decision criteria that guide clin-
velopment of adhesive procedures has icians in the choice of materials and
led to an important cultural and method- techniques can be divided into general
ological revolution. Likewise, the evolu- and local parameters. General param-
tion of restorative materials and adhesive eters include the patient’s age, oral hy-
systems has influenced the approach to giene, motivation, caries risk assess-
restoring posterior teeth, modifying the ment, dietary habits, functional activity,
treatment plan considerably.1 The need ergonomics, and financial resources;
to perform adhesive restorations of pos- local parameters include cavity shape,
terior teeth is not only linked to esthetic thickness of remaining walls, position of
purposes, but also to bioeconomic prin- cervical margins, presence of cervical
ciples, as well as to the possible bio- lesions, presence of cracks, position of
mechanical strengthening of the remain- the tooth, evaluation of the element in
ing tooth structure.2 preprosthetic function, and presence of
Microhybrid and nanoparticle com- pulp disease or periodontal lesions.
posites are the materials most often sug-
gested for all kinds of cavities in posterior Current indications for adhesive
teeth.3 However, the technical problems cemented restorations
of composites that are not yet solved are
curing shrinkage and dentin adhesion, Direct techniques are traditionally indi-
and the clinical problems relate to the cated in small- and medium-sized class
clinician’s ability to manage the tooth I and II restorations with cervical enam-
isolation and adhesion, as well as re­ el.8 In these clinical situations, the first
establish the original morphology. These choice is the direct technique, which
issues are particularly challenging when allows for high-level, predictable, and
the restorations are wide, and the cov- repeatable results with a conservative
erage of one or more cusps is neces- approach and excellent longevity. The
sary. This has led to the development of limitations of direct techniques, pointed
the semidirect and indirect techniques, out in the literature of the mid-90s,5,8
which allow for the complete curing of have been reviewed and discussed in
the composite restoration before the lut- many studies published in the 2000s,9-
ing procedures.4,5 13 from which it can be deduced that di-
Recently, the esthetic restoration and rect techniques would be effective even
rehabilitation of posterior teeth and full in cases of partial cusp coverage, ob-
arches has, through necessity, created taining a clinical outcome similar to indi-
a new paradigm and balance between rect techniques. Furthermore, the mere
operative “restorative” dentistry and lack of cervical enamel would no longer
prosthodontics.6,7 represent an indication for the indirect
According to the Geneva School technique.
Classification of 1994, five composite However, the direct technique on
resins could be used for posterior teeth teeth that have suffered a significant

VOLUME 12 • NUMBER 2 • Summer 2017

loss of hard tissue presents a number The advantages4,5 of adhesively ce-

of clinical issues: mandibular wear re- mented restorations compared to a di-
sistance; control of shrinkage stresses; rect technique consist in creating an
possible postoperative hypersensitivity; ideal anatomy of occlusal surfaces,
predictability of dentin adhesion; diffi- with excellent control of contact points
culty of morphological restoration, with and emergence profiles, and the pos-
particular attention to occlusal surface, sibility of an occlusion evaluation with
contact points, and emergence pro- an articulator. Likewise, this technique
file.5,14-17 Consequently, in large cavi- strongly decreases the curing shrinkage
ties with cusp coverage, it is clinically that occurs outside the cavity, improving
more favorable to use an adhesively ce- the marginal sealing. The only remain-
mented restoration as the first treatment ing curing shrinkage is in the thin layer
choice.5 of resin cement. Moreover, photothermal
An “adhesive indirect restoration” has treatment (130°C for 7 min) improves the
been defined as a partial crown restor- degree of conversion of the composite
ation made in composite or full ceramic, and the physiochemical properties of
which has to be seated passively, and the restoration.18-20 A further benefit
adhesively cemented in a cavity char- is the possible use of ceramic mater-
acterized by specific attributes. The aim ials such as lithium disilicate-reinforced
of this article is to define criteria for a glass-ceramics.
new cavity design for luted restorations,
and to analyze the different kinds of res- Operative procedures
torations, comparing conventional and for the indirect technique
new concept cavity shapes.
Current indications for adhesively ce- According to the author’s experience
mented restorations could then be sum- (since 1994) and data in the litera-
marized as: ture,4,5,21,22 a simple and clear procedure
„„Wide class II cavity with cusp cover- is suggested for indirect adhesive res-
age (one or more). torations. The chronological sequence of
„„Restoration of large occlusal surface the clinical steps is:
compromised by wear and/or bio- 1. 
Hard silicone matrix to impress the
corrosion. anatomy of involved teeth (when the
anatomy is sufficiently preserved).
These indications are strengthened by 2. 
Opening of cavities or removal of
some cofactors, including the presence previous restoration and carious le-
of cervical enamel in a small quantity sion removal.
(< 1 mm height, 0.5 mm large), or even 3. 
Evaluation of enamel and dentin
its absence; cervical concavity; the thickness, and consequently reduc-
necessity of performing multiple res- tion of unsupported tissues.
torations in several quadrants with the 4. 
Composite build-up with immedi-
modification of the entire occlusion; and ate dentin sealing (IDS), and, if nec-
the need to reestablish or increase the essary, cervical margin relocation
vertical dimension. (CMR).

VOLUME 12 • NUMBER 2 • Summer 2017
Clinical Research

5. Preparation and finishing of the cav- 2. Enamel quantity that is not support-
ity according to new modified prin- ed by underlying dentin. The wall
ciples (morphology driven prepar- must be reduced until there is a suf-
ation technique – MDPT). ficient quantity of dentin to support
Definitive impression with elasto- the enamel.
mers (for singular elements, even 3. 
Enamel thickness. Measurement of
with a dual-arch technique through the remaining cusp is not enough to
a bite check). determine its resistance; both enam-
Carrying out of the final restoration el and dentin thicknesses must be
(composite or ceramic) in the la- considered.
boratory or chairside. 4. 
The importance of occlusal func-
Verification of restoration adaption tional strain during chewing.
before the application of rubber
dam. After occlusal reduction, the build-up
9. Application of rubber dam, and ad- must be performed for the following rea-
hesive cementation procedure with sons:
heated light-curing composite. „„To obey the fundamental principle of
Finishing, polishing, and occlusal IDS.23 IDS has shown an improved
control. microtensile bond strength compared
to delayed dentin sealing (DDS).
Evaluation of remaining thickness „„To fill the undercuts that inevitably

and adhesive build-up form during caries removal.

„„To provide a correct cavity geometry.
Since indirect restorations are indicat- „„To produce an optimal restoration ma-
ed in wide cavities characterized by a terial thickness so as to permit a cor-
significant loss of hard tissue, a critical rect conversion of the light-curable,
thickness of remaining walls influences preheated composite used for adhe-
the decision to maintain the wall or not, sive cementation.24,25
particularly as the walls are often under-
cut and need proper restoration (build- Furthermore, it is possible to cement
up or block-out). without anesthesia, because exposed
The reduction of unsupported remain- dentin has already been hybridized and
ing tissue is the following step, but prior covered by a pre-layer of composite.
to adhesive build-up, so that a better The first-choice material for the build-up
evaluation of wall thickness is possi- is hybrid highly reinforced mini particles
ble, and the clinician can consequently of composite used with the modified du-
avoid exposure of non-hybridized dentin al-bonding technique.26 When interoc-
after the preparation. clusal free space is poor, a mini build-up
Occlusal tissue reduction depends with only a thin layer of flowable com-
on four points: posite is indicated.
1. Minimal thickness of material (either In case of deep cervical margins
composite or lithium disilicate) of at without biological width violation, it is
least 1.0 to 2 mm.22 clinically convenient to move the mar-

VOLUME 12 • NUMBER 2 • Summer 2017

Fig 1    New morphology driven preparation tech- Fig 2    Indirect composite restorations after adhe-
nique (MDPT) in two maxillary molars. sive cementation.

gins coronally, applying a layer of highly „„Width of occlusal isthmus has to

reinforced flowable composite27-29 (1 to be ≥ 2 mm for composite and lithium
1.5-mm thick). When the position of cer- disilicate glass-ceramic.
vical margins does not allow for the cor- „„Presence or absence of marginal
rect isolation with rubber dam, or there ridges, and, consequently, presence
is a biological width violation, a surgical of interproximal box evaluated on
approach is necessary.30 three space planes.9,36
„„Thickness of material for cusp cov-
Preparation principles for indirect erage has to be ≥ 1 to 1.5 mm22,37,38

restoration for composite and lithium disilicate

(pressed or CAD/CAM), and ≥ 2 to
Conventional principles4 would suggest 2.5 mm for feldspathic ceramic and
a cavity with a 6- to 10-degree divergent leucite-reinforced glass-ceramic.
wall, internal rounded angles, finishing „„Interproximal overjet has to be possi-
of enamel with sharp and not beveled bly ≤ 2 mm. The fracture risk of the re-
margins, smooth and well-defined walls, stored marginal ridge increases when
and a general plain design. Restoration the overjet is too large.4
margins do not have to coincide with oc-
clusal contacts. New cavity design (Morphology
The following parameters that influ- Driven Preparation Technique)
ence and lead the cavity design4,21,31,32
(Figs 1 and 2)
are essential:
„„Thickness of remaining walls (in order The principles of traditional cavity design
to maintain them) has to be ≥ 2.0 mm were derived from preparations meant
in vital teeth,4 (latest articles report for indirect non-adhesive restorations.
values of 1  mm22), and ≥ 3.0 mm in These were characterized by a cav-
endodontically treated teeth.33-35 ity design that ensured retention by the

VOLUME 12 • NUMBER 2 • Summer 2017
Clinical Research


Fig 3    Clinical examples of old, conventional adhesive preparations of maxillary and mandibular molars
and premolars.


Fig 4    Clinical examples of new MDPT for adhesive restorations of maxillary and mandibular molars and

placement of shoulders, occlusal slots, clinicians the task of preparing them ac-
and eventually pins, which could expose cording to their clinical experience. Fur-
sound dentin with a significant loss of thermore, the traditional cavity design
structural tissue (Fig 3). Apart from this, is not completely suitable for adhesive
conventional preparations did not con- cementation because of the presence of
sider the real morphostructural and his- isthmuses, shoulders, and rounded an-
toanatomical course in the tooth crown. gles. Also, the width of the shoulders and
Moreover, no clear data are reported in of the onlays themselves seems to be
the literature about the correct level of excessive, and leads to an inadequate
the shoulders on the axial walls, leaving degree of luting composite conversion.

VOLUME 12 • NUMBER 2 • Summer 2017

The principles of MDPT (Fig 4) are

intended to achieve these improve-
„„To minimize as much as possible the
loss of healthy tooth tissue by reduc-
ing the areas of dentin exposure.
„„To guide tissue reduction of the oc-
clusal surface with depth cuts or, bet-
ter still, with a silicone index for thick-
ness control.
„„To reduce the width of the margins
prepared as a shoulder, where indi-
Fig 5   Maxillary bicuspid, endodontically treated
cated. with a deep MOD cavity. There is a need for a com-
„„To define a margin design that could plete cuspal coverage to preserve it from fracture.

improve the quality of the adhesion,

optimizing the cutting of the enamel
prisms and creating a greater surface
of enamel.
„„To improve the smooth insertion of the
restoration during cementation.
„„To improve the esthetics of the transi-
tion zone between the tooth and the
restoration. In chronological order,
the preparation sequence is the prep-
aration of the interproximal box, the
anatomical reduction of the occlusal
surface, and the definition of the mar-
gins on the axial walls. The margin
Fig 6   New MDPT for indirect adhesive overlay
definitions differ in maxillary and man-
dibular teeth. The design of the axial
margins varies according to the resid-
ual sound tissue, the margin position,
the inclination and slope morphology
of the cusp, and the maximum tooth 1.2 mm, max 1.5 mm) and rounded in-
contour line (equator). The prepar- side angles, obtained with a truncated
ation is ultimately guided by the ana- conical medium-grit diamond bur (diam-
tomical and structural morphology of eter 14) for the preparation, and fine-grit
the teeth. diamond burs for finishing. The need to
define a box of reduced depth is intend-
Principles of the MDPT for premolars ed to obtain an indirect restoration of a
and molars (Figs 5 to 9) regular thickness so as to guarantee the
1)  Butt-joint preparation in the in- resistance and at the same time allow
terproximal box (ideal thickness: 1 to for the adequate conversion of the light-

VOLUME 12 • NUMBER 2 • Summer 2017
Clinical Research

MAXILLARY bicuspid and molars

Butt joint (1.2–1.5  mm)

› Interproximal box: always
› Axial walls: apically to
maximum contour line

Anatomical reduction
of the occlusal surface

Divergent walls
(6–10 degrees)

Inclined planes M–D, V–P

› Axial walls, coronal to
maximum contour line

Fig 7    Scheme of new MDPT for maxillary bicuspid and molars.

curing adhesive and composite resin

material used for luting.24
2)  Interior walls diverging 6 to 10 de-
grees, with sharp margins with rounded
inside angles. The residual axial walls
require a sharp preparation of the oc-
clusal margin, as the creation of inlays
beveled to occlusal would themselves
be susceptible to the risk of margin frac-
Fig 8    New MDPT for indirect adhesive onlay and 3)  Occlusal anatomy reduction follow-
overlay restorations.
ing fissure direction and the resulting
proportion of the cusps, with diamond
conical truncated burs (diameters 14
and 18). The extent of the reduction is
a function of the strength parameters
of the restorative material, thus 1.0 to
2.0 mm is recommended. Occlusal slots
are not necessary; indeed, they should

VOLUME 12 • NUMBER 2 • Summer 2017

MANDIBULAR molars and premolars

Butt joint (1.2–1.5  mm)

› Interproximal box: always
› Axial walls: apically to
maximum contour line

Anatomical reduction
of the occlusal surface

Divergent walls
(6–10 degrees)

Inclined planes M–D, V–P

› Axial walls, coronal to
maximum contour line

Fig 9    Scheme of MDPT for mandibular molars and premolars.

be avoided. It is desirable to perform the premolars. This preparation of the mar-

occlusal reduction guided by the depth gins allows for:
of cuts or, when possible, by properly „„maximum preservation of sound re-
cut silicone indices detected on the sidual tissue;
tooth before preparation. „„a geometrically induced increase of
4a)  Preparation of axial walls with in- the usable area of enamel for adhe-
clined plane (hollow chamfer). In the sive procedures without exposure of
mesiodistal and buccopalatal direc- dentin areas;
tions, a “hollow chamfer” or concave „„margin configuration more favorable
bevel must be drawn with cylindrical for adhesion through cutting enamel
chamfer burs, using only the tip of the prisms almost perpendicular to their
bur. This design is indicated in cuspal longitudinal axis39,40 (unlike the draw-
covering areas on axial walls coronal to ing of sharp margins, which would
the line of maximum contour of the tooth. cause a cut of prisms parallel to their
For geometrical and structural reasons, long axis) (Fig 10);
this occurrence is more frequent at the „„apical displacement of the finish line
level of the buccal and palatal walls of (along the inclined plane), with a re-
maxillary molars and premolars, and the duction of level differences between
buccal walls of mandibular molars and cuspal vertices to be covered and the

VOLUME 12 • NUMBER 2 • Summer 2017
Clinical Research

Sharp margin preparation Hollow chamfer preparation

Parallel to long axis enamel prisms Perpendicular to long axis enamel prisms

Cavity-surface angle Cavity-surface angle

< 90 degrees ≥ 90 degrees
180 degrees 90 degrees

Fig 10   Margin configurations (hollow chamfer) more favorable for adhesion through the cut of enamel
prisms perpendicular to their longitudinal axis.

bottom of the box, through the crea- and premolars due to a different geom-
tion of “slip roads” curved without cor- etry of the surfaces themselves (Figs 8
ners. Starting from the cervical margin and 9).
of the interproximal box, a curved line
that continues on the axial wall must Rationale of the new modified cavity
be created, which descends back to design
then link with the opposite interproxi- The rationale of the cavity design de-
mal box; scribed above is the morphological
„„a more gradual transition between the analysis of posterior teeth, with some
preparation margins and the restor- differences between maxillary and man-
ation to obtain better mimicry, esthet- dibular teeth, and with geometrical and
ics, and transitional color blending of structural considerations justifying its use.
the restoration.
Maxillary molars and premolars (Fig 10)
4b)  Preparation of axial walls, butt-joint Geometric considerations: the graphi-
type. In some cases, when the cavity cal representations drawn from Marseil-
margin is apical or at the equator line lier41,42 (Fig 11) show that the maxillary
as a result of substantial tissue loss that elements have buccal and coronal axial
involves the third cervical cusp, it is con- walls definitely inclined and converging
venient to prepare a sharp margin (with in the coronal direction, with the maxi-
the characteristics mentioned in step 1) mum contour line (or dental equator)
that coincides in the apicocoronal direc- positioned at the cervical third of the re-
tion with the level of the cutting cusp. spective walls. When the tooth requires
This occurrence is most frequent at the cusp covering, a sharp cut would cer-
lingual surfaces of mandibular molars tainly produce an oblique sectioning of

VOLUME 12 • NUMBER 2 • Summer 2017

MDPT: MAXILLARY molars and premolars PREPARATION

Inclined plane
(hollow chamfer)
Buccal Palatal

reduction of the
Butt joint Maximum contour line
occlusal surface
(apical third of the tooth)
1–1.2  mm Maximum contour line
“Slip roads”
(apical third of the tooth)
Inclined plane
(hollow chamfer)
≥ 1.5  mm
≥ 1.5  mm
Inclined plane
Inclined plane (hollow chamfer)
(hollow chamfer)

Fig 11    Scheme of preparation with MDPT for maxillary molars and premolars.

the enamel prisms and an inadequate profile (chamfer) is indicated because

acute margin restoration (Fig 12), while it fits well with the inclination of the axial
cusp coverage with butt-joint prepara- walls from either a geometrical or bio-
tion would result in a substantial loss of logical (enamel prisms cut transversely
sound tissue associated with dentinal to their long axis) point of view.
exposure. It is evident that, whenev- At the interproximal level, the walls
er the margin design is coronal to the converge apically, and the maximum
equator, an enamel cut with concave contour line is positioned in the occlusal


MAXILLARY molars and bicuspids

Fig 12    Geometric considerations (for maxillary molars and bicuspids) that underlie the MDPT. [Original
images from: Marseillier E. Les Dents Humaines Morphologie. Gauthier-Villars, 1967.]

VOLUME 12 • NUMBER 2 • Summer 2017
Clinical Research


MAXILLARY molars and bicuspids

Bazos P, Magne P. Bioemulation: biomimetically emulating nature utilizing a histo-anatomic approach;

structural analysis. Eur J Esthet Dent 2011;6:8–19.

Fig 13    Structural considerations (for maxillary molars and bicuspids) that underlie the MDPT.

third. Thus, the margin design can only Structural considerations (Fig 13):
be a rounded shoulder with sharp mar- from a three-dimensional structural
gins. Any inclined or beveled plane is analysis of human teeth43 it can be ob-
contraindicated because it would shift served that the contours of the convex
the margin apically, thereby reducing surface of enamel match concave pro-
the cervical enamel thickness. files and sharp body dentin (sigmoid


Inclined plane
(hollow chamfer) Butt joint Buccal Lingual
≥ 1.5  mm
Inner preparation line ≥ 1.5  mm
Maximum contour line
Outer preparation line ≥ 1.0  mm
(apical third of the tooth)

Maximum contour line

(apical third of the tooth)

Fig 14   MDPT: Different configuration of the buccal (inclined plane) and lingual (butt-joint) margins of the
mandibular molar, according to the tooth maximum contour line.

VOLUME 12 • NUMBER 2 • Summer 2017


MANDIBULAR molars and premolars

Bazos P, Magne P. Bioemulation: biomimetically emulating nature utilizing a histo-anatomic approach;

structural analysis. Eur J Esthet Dent 2011;6:8–19.

Fig 15    Geometric and structural considerations (for mandibular molars and premolars) that underlie
the MDPT. [Original images from: Marseillier E. Les Dents Humaines Morphologie. Gauthier-Villars, 1967.]

curve). The concavity of the dentin sur- tion of cases where a significant tissue
face is particularly evident and topo- loss has undermined the wall up to the
graphically located in the middle third, cervical third. The margins on the lingual
and coronal to the equator. Consequent- side are more often represented by a
ly, it is obvious that, focusing on buccal shoulder, because a loss of tissue that
and oral surfaces, the gold standard for induces a cusp cover often involves the
cavity design constitutes a margin de- occlusal and middle third of the cusp,
sign with a beveled concave inclined with margins positioned under the equa-
plane that cuts the enamel convexity, tor line.
following the dentin concavity without Structural considerations (Fig 15):
exposing it. Even from a structural point of view, an
enamel convexity with a strong dentin
Mandibular molars and premolars concavity in the middle and occlusal
(Fig 14) thirds of the buccal walls is highlighted.
Similar considerations should be ap- On the lingual side, a slightly convex
plied to the mandibular posterior teeth. morphology of the enamel (on aver-
Geometric considerations (Fig 15): age) corresponds with a more recti­linear
The buccal surfaces are inclined with dentin surface. Consequently, based
occlusal convergence, with a maximum on these considerations, the choice of
contour line located at the cervical third. sharp shoulder margins is justified on the
The lingual surfaces, however, are more lingual side. A concave margin can only
vertical, with the equator lines localized be prepared and finished in cases where
to the occlusal third. For this reason, the structural deficits constitute an indication
buccal margin is frequently represented for a sharp cut in the coronal third of the
by a concave chamfer, with the excep- lingual cusp at the equatorial level.

VOLUME 12 • NUMBER 2 • Summer 2017
Clinical Research

Adhesive restorations (conven-

tional and newly developed)

The new principles of preparation listed

above can be applied effectively to all
types of traditional adhesive restorations
(inlay, onlay, overlay) and help to define
a set of newly developed restorations
(additional overlay, occlusal-veneer,
overlay-veneer, long-wrap overlay, ad-
hesive crown).
Fig 16    Inadequate amalgam and composite res-
torations with evidence of recurrent decay.
Conventional indirect restorations
In inlay, onlay and overlay, the adhesive-
ly cemented restorations are traditionally
classified according to their type.
Inlays (Figs 16 to 18) are restorations
without cusp coverage, and would be
indicated in teeth with preserved vitality
in medium to large class II cavities (MO/
OD, MOD), with well-preserved buccal
and oral walls. Composite is the ideal ma-
terial. Currently, this type of restoration is
often performed with a direct technique,
thus obtaining equal predictability with a
more conservative approach.
Fig 17   Medium class II MO/OD cavities restored
with composite inlays without cuspal coverage.
Onlays (Figs 19 to 21) are restorations
that partially cover cusps, but not the en-
tire occlusal surface. They are indicated
in class II cavities of large dimensions
with lateral walls partially supported
without dentin cracks. In the case of en-
dodontically treated teeth, the presence
of at least one marginal ridge, and two
well-supported axial walls in continu-
ity with the marginal ridge itself, are re-
quired. Both composite or ceramic can
be used.44,45
Overlays are total cusp-coverage res-
torations, indicated in class II cavities of
large dimensions with unsupported ax-
Fig 18   11-year clinical follow-up, which shows
good morphological functional and esthetic main- ial walls and the absence of both mar-
tenance. ginal ridges. The presence of cracks in

VOLUME 12 • NUMBER 2 • Summer 2017

Fig 19    Inappropriate pre-existent restoration with Fig 20    Onlay cavity preparation with partial cus-
fracture of the material and noticeable marginal in- pid coverage after thorough cleansing of the decay
filtration. and adhesive build-up.

Fig 21    8-year follow-up with excellent preserva- Fig 22   Wide inadequate amalgam restoration
tion of the morphology, function, esthetics, and mar- with residual and recurrent caries. The tooth was
ginal integrity. asymptomatic.

Fig 23   Thorough caries cleansing with vitality Fig 24   Adhesive build-up and overlay prepar-
maintenance of the tooth without pulp exposure. ation with circumferential butt joint (the cavity mar-
gins are all under the maximum contour line).

VOLUME 12 • NUMBER 2 • Summer 2017
Clinical Research

Fig 25    Final restoration after finishing and polish-

ing, with adequate morphological and esthetic inte-
gration. The choice of composite as restoration ma-
terial makes a possible future re-intervention easier
(eg, for endodontic reasons).

a b

Fig 26    (a) First maxillary molar with tooth crack syndrome, previously restored with silver amalgam. The
wall thickness is good but there are enamel-dentin cracks. (b) Overall buccal and palatal cusps cut. Cracks
at the base of cusps are noticeable.

Fig 27   Cavity design definition (after adhesive Fig 28   Monolithic, heat-pressed, painted lithium
build-up) for overlay, with inclined planes of the axial disilicate (IPS e.max Press, Ivoclar Vivadent) over-
walls and connection on ramp with box (MDPT). lay after adhesive cementation in isolated field with
Direct composite restoration on tooth 15. rubber dam. Total cusp coverage with porcelain
significantly stiffens the crown and increases cusp

VOLUME 12 • NUMBER 2 • Summer 2017

enamel and dentin (in vital teeth), and

the absence of a marginal ridge in en-
dodontically treated teeth, requires to-
tal coverage, even in the presence of
residual walls of adequate thickness.
Composite (Figs 22 to 25) or ceramic
can be used. Ceramic (lithium disilicate
glass-ceramic) is the first-choice mater-
ial in the case of multiple restorations
with wide coverage. Furthermore, due
to its greater strength and ability to stabi-
lize the cusp, ceramic is the first choice Fig 29   Restoration in oral cavity with excellent
morphological functional and esthetic integration,
for teeth affected by cracked tooth syn-
and complete symptoms remission associated with
drome, using it with a total cusps cover- dentinal cracks.
ing21,46-48 (Figs 26 to 29).

Newly developed indirect restorations Additional overlay (Figs 30 to 35): This

This new group of restorations is able to is a partial or, more frequently, complete
meet the criteria of maximum preserva- coverage restoration performed without
tion of healthy tissue and esthetics, and any tooth preparation. It is indicated in
helps to establish new boundaries be- cases of anatomic restoration of teeth
tween conservative practices and pros- with loss of tissue due to erosion/abrasion
thetics, with substantial changes in the or in cases of occlusal vertical dimension
treatment plan of the posterior region. increase. The gold standard material is
These restorations can be classified as ceramic (lithium disilicate), although it is
follows: also possible to use composite.

Fig 30   Skeletal and dental deep bite. Implant- Fig 31    To make the rehabilitation of sectors 1 and
prosthetic replacement of the maxillary right molar 4 easier, and to partially offset the deep bite, the
after sinus lift. The opposing molars are extruded vertical dimension was increased with the execution
and require occlusal plan remodeling. of additional overlays on the posterior teeth, and ad-
ditional palatal veneer on the anterior teeth.

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Clinical Research

Fig 32    The teeth without any preparation before Fig 33   Adhesive cementation of the all-indirect
the adhesive cementation. additional restorations.

Occlusal-veneer (or “table-top”): This

is a thin (1 to 1.2 mm) bonded posterior
occlusal partial-coverage preparation
with a non-retentive design. It is indicat-
ed, above all, in advance erosion of the
occlusal surface or in clinical restora-
tive cases where the vertical dimension
needs to be increased6,7 (Figs 36 to 43).
An in vitro fatigue study37,38 concluded
that CAD/CAM superthin (0.6 mm) com-
posite resin occlusal veneers had sig-
Fig 34    A detail of teeth 26 and 27 with an excel- nificantly higher fatigue resistance when
lent morphological functional esthetic integration.
compared to ceramic occlusal veneers.
Overlay-veneer (or “veneerlay”)
(Figs 44 to 49): This is used in the case
of a restoration that involves the oc-
clusal surface that extends to the entire
buccal surface due to either esthetic
or functional considerations. It is indi-
cated in teeth positioned in esthetic ar-
eas (typically maxillary premolars) with
significant loss of hard tissue, heavily
discolored, and resistant to bleaching.
The gold standard material is ceramic
(lithium disilicate).

Fig 35    The maxillary arch after the rehabilitation.

VOLUME 12 • NUMBER 2 • Summer 2017

Figs 36 and 37   Maxillary and mandibular arches before treatment. There is a clear need to completely
rehabilitate the arches because of inadequate restorations, abrasions, wear, and tooth discoloration.

Fig 38   Diagnostic wax-up of the maxillary and Fig 39    First phase of rehabilitation of the mandib-
mandibular arches. Thereafter, a direct adhesive ular arch on the lateral-posterior side with occlusal
mock-up will be performed in the mandibular arch, veneer of teeth 34, 35, 44, 45, and 46. Tooth 36 is a
increasing the vertical dimension. metal-free crown on an implant.

Fig 40    Detail of minimally invasive preparations. Fig 41    The ultra-thin lithium disilicate pressed oc-
clusal veneer (IPS e.max Press) of quadrant 4 after
adhesive cementation.

VOLUME 12 • NUMBER 2 • Summer 2017
Clinical Research

Fig 42    The mandibular arch after the complete Fig 43   The maxillary arch after complete ad-
adhesive rehabilitation, with ceramic occlusal ve- hesive rehabilitation, with partial and full-pressed
neer on all the posterior and anterior teeth. Two ceramic restorations on the posterior and anterior
lithium disilicate crowns on teeth 36 and 37. teeth.

Fig 44   Maxillary bicuspid with previous compos- Fig 45   Vestibular side with inadequate esthetic
ite restoration and signs of occlusal wear. integration.

Fig 46    Partial prepa-

ration with coverage of Fig 47   Lithium disili-
occlusal and buccal as- cate pressed overlay ve-
pect in insulated field. neer (IPS e.max Press).

VOLUME 12 • NUMBER 2 • Summer 2017

Fig 48   Restoration after adhesive cementation Fig 49    Restoration with morphological and func-
with esthetic restoration of the buccal appearance. tional occlusal reconditioning.

Long-wrap overlay: This restoration in- axial walls for the presence of extensive
volves the complete occlusal surface. It carious lesions, abrasions, biocorrosions
extends to either the buccal and/or pala- or fractures involving the external sur-
tal-lingual axial walls, depending on hard faces. The material of choice is ceramic
tissue loss and regardless of soft tissue (lithium disilicate), although composite
profile. It is indicated in teeth that require can be indicated only as a less-expen-
complete cuspal coverage extended to sive compromise (Figs 50 to 52).

Fig 50    Long-wrap overlay preparation according Fig 51   Anatomical preparation of the occlusal
to the MDPT principles. Buccal aspect: the anatomi- surface.
cal reduction of the tooth after root canal treatment
and build-up is apparent.

VOLUME 12 • NUMBER 2 • Summer 2017
Clinical Research

Fig 52    The indirect composite restoration after adhesive cementation with good esthetic, morphological,
and functional integration.

Adhesive-crown49,50 (Figs 53 to 59): tissue and periodontal tissue than with a

This restoration completely covers the conventional complete crown. With this
tooth, with supragingival margins that restoration, surgical crown lengthening
follow the contour of the marginal soft tis- is usually avoidable because it is not
sue, and which is adhesively cemented necessary to gain resistance and retain
after rubber dam isolation. It is indicated form, which is fundamental when con-
in teeth with a major loss of tissue requir- ventional prosthetic restorations are per-
ing a total preparation. The adhesive ap- formed. The material of choice is lithium
proach allows the clinician to be more disilicate.
conservative on the poor residual dental

VOLUME 12 • NUMBER 2 • Summer 2017

Fig 53   Maxillary bicuspid endodontically treated Fig 54   Preprosthetic adhesive reconstruction

with a significant loss of dental tissue. made of composite with a fiber post.

Fig 55    The buccal aspect shows minimum inter­

occlusal thickness that would require an apical po-
sitional flap in the case of a traditional crown.

a b

Fig 56    Preparation for the adhesive crown. (a) Occlusal view. (b) Buccal view. Slightly supragingival
margin allows for the insulation of the field with rubber dam.

VOLUME 12 • NUMBER 2 • Summer 2017
Clinical Research

Modern restorative dentistry is substan-
tially adhesive. The conservative spirit
should pervade all procedures. Preserv-
ing healthy tissue (not only dental, but
also pulpal and periodontal) has be-
come the priority. With this approach,
indirect adhesive restorations are indi-
cated in large cavities associated with
cuspal coverage with absent or reduced
Fig 57    Lithium disilicate pressed adhesive crown amounts of cervical enamel.
(IPS e.max Press) on galvanized stone model.
The rationale of this study was to re-
vise cavity design concepts borrowed
from old patterns for non-adhesive res-
torations, which are outdated, not con-
servative, and unsuitable for adhesive
procedures. This new cavity design al-
lows for the following clinical advantag-
„„Definition of a margin design which
acts to improve adhesion quality
through the optimization of the enam-
el cutting and the creation of a greater
surface of enamel provided.
„„Minimal dentin exposure, avoiding
Fig 58   Adhesive cementation with preheated
wide shoulders, occlusal slots, and
composite material.
„„Maximum preservation of healthy
residual tissue, adapting the cavity
design to adhesive cementation pro-
cedures with composite resins, and
improving the flow of excess material.
„„Optimization of the esthetic perfor-
mance, which allows for better blend-
ing in the transition zones.

The new principles of preparation dis-

cussed in this article can be applied ef-
fectively to all types of traditional adhe-
sive restorations (inlay, onlay, overlay),
Fig 59    Buccal aspect of the restoration after
cementation with good esthetic and functional in- and help to define a set of newly de-
tegration. veloped restorations (additional overlay,

VOLUME 12 • NUMBER 2 • Summer 2017

occlusal-veneer, overlay-veneer, long- Acknowledgments

wrap overlay, and adhesive crown). The
different types of restorations constitute Dr F. De Fulvio (Moricone, Roma, Italy) for his invalu-
able assistance in drafting the article; Dr N. Scotti
a significant proportion of treatment
(TO, Italy) for the translation and review; the dental
options available for the rehabilitation technicians for their excellent work: A. Pozzi (PR,
of the posterior teeth, and allow us to Italy), F. Pozzi, A. Quintavalla (PR, Italy), and M.
Svanetti (BS, Italy).
define a new line between conservative
and prosthetic treatments, in favor of a
more conservative approach.

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