The Area of

Adhesive Continuity:
A New Concept for
Bonded Ceramic
Restorations
Oswaldo Scopin de Andrade, DDS, MS, PhD'
Gilberto Antonio Borges, DDS, MS, PhD'
Marcelo Kyrillos, DDS 3
Marcelo Moreira, DDS 3
3 LuisCalcho,DS
Lourenco Correr-Sobrinho, DDS, MS, PhD'

eramic laminate veneers (CLVs) offer an es- statistical analysis. The criteria commonly used in the

C thetic and functional oral rehabilitation with

well-documented favorable success rates. 1-6
Generally, the assessment of restorative success is
based on established clinical criteria and associated
'Director, Advanced Program in Implant and Esthetic Dentistry,
Senac University, Sao Paulo, Brazil.
2 Assistant
Professor, Restorative Dentistry, Uberaba University,
Uberaba, Brazil.
3 Atelie Oral Clinic, Sao Paulo, Brazil.
4 Professor,Department of Restorative Dentistry, Dental Materials
Division, School of Dentistry, Campinas State University,
Piracicaba, Sao Paulo, Brazil.
Correspondence to: Dr Oswaldo Scopin de Andrade, Rua Barao
de Piracicamirim 889 #61, Piracicaba-SP, Brazil CEP 13.416-005.
Email: osda@terra.com.br
literature include the United States Public Health Ser-
vice criteria, modified California Dental Association
criteria, and variations thereof. 3,6,7 These systems allow
for uniform measurements and facilitate tabulation of
data for analysis. In this way, an index of success can
be assigned to a given restorative treatment. These
evaluations are well accepted in the literature and can
be used to assess the efficacy of a wide variety of treat-
ment options.
When it comes to the replacement of missing tooth
structure using any type of restorative material, the
question is always the same: What is the longevity of
this treatment? Scientifically, there are several meth-
ods of measuring the quality of a restoration, including
direct or indirect 8-1 ° and objective or subjective evalu-
ations of a variety of different parameters.

QDT 2013 9
SCOPIN DE ANDRADE ET AL
Objective parameters are the most well-accepted
assessments in the dental literature." ,12 Objective pa-
rameters may include the following:
• Marginal adaptation
• Marginal degradation
• Signs of leakage
• Secondary or recurrent caries
• Color maintenance
• Surface texture
• Chipping or fracture
In contrast, subjective parameters account for per-
sonal feelings and opinions obtained from the patient
and/or clinician via questionnaires and interviews: 8 ' 84 '
Subjective parameters include patient satisfaction and
patients' opinions regarding maintenance and color
stability.
Today, dental restorative sciences are focused on
conservative techniques, ie, the preparation of less
tooth structure. Thanks to the development of new ad-
hesive materials, tooth preparation for indirect restora-
tions can be restricted to enamel and superficial den-
tin. With maximum enamel preservation and carefully
executed adhesive procedures, problems such as sec-
ondary caries and leakage do not occur as frequently
for indirect restorations luted using conventional ce-
ments as for those luted using acid-based cements: 3 ' 14
For CLVs, longitudinal studies have shown excellent
results in terms of esthetics and stability of the restora-
tion margins. The data from these studies are generally
presented as success or survival rates; however, due to
the limited number of pages and images available in a
published article, clinicians reading these studies may
not be sure how to evaluate their own CLVs intraorally.
In other words, while published studies often report
the results of clinical evaluations, they rarely provide a
clear understanding of how to perform clinical evalu-
ations. Clarification of this issue would help clinicians
who are not researchers determine the quality of their
own treatments.
Therefore, this article aims to describe an additional
method to assess the quality and longevity of CLVs us-
ing scanning electron microscopy (SEM) and esthetic
parameters based on digital photography.
QDT 2013
Both marginal adaptation and cement film thickness
play crucial roles in the long-term success of conven-
tional crown preparations. 15-1 ' When fabricating an in-
direct restoration, every step of the process is aimed at
achieving perfect marginal adaptation. 18 For example,
clinical guidelines for tooth preparation attempt to
create the proper path of insertion to allow for minimal
cement film thickness. 19 In the laboratory, the methods
used to pour the molds and fabricate the restorations
are likewise based on perfect marginal adaptation, ie,
providing a minimal gap between the restoration and
tooth structure.
Traditional crown preparation often requires ex-
tensive removal of sound dental tissue. 2° Conversely,
CLV treatment can be provided using minimally inva-
sive techniques. 21-23 If properly planned and executed,
CLVs can be bonded to the tooth structure without any
preparation. As a result, the restoration will not have
a well-defined margin. 23-26 This can make it impossi-
ble to determine the location of the finishing line for
the CLV. In addition, bonding usually extends beyond
the margins of the restoration to properly seal the
surrounding dental structures. 2227 Thus, conservative
bonded restorations are dissimilar to cemented resto-
rations. For this reason, the authors suggest describing
the junction between the bonded restoration and the
tooth not as a "line of marginal adaptation" but as an
" area of adhesive continuity" (AAC).
THE ACC: A PARADIGM SHIFT FOR
INDIRECT BONDED RESTORATIONS
Research has shown that a marginal fit of approximate-
ly 100 pm is acceptable for most indirect procedures, 28
andivtrosuehabindmrgalftsoe
than 100 pm in controlled laboratory tests. 29-31 Intra-
oral measurements of marginal adaptation are rare in
the dental literature; indeed, it is extremely difficult to
 The Area of Adhesive Continuity: A New Concept for Bonded Ceramic Restorations
evaluate marginal adaptation intraorally. For example,
it is challenging to directly measure around the entire
circumference of a crown and precisely determine the
mean marginal fit. It is also impossible to evaluate all
areas of an indirect restoration. However, it is possible
to evaluate select areas that will provide the best avail-
able information."
When using a laminate veneer as an indirect resto-
ration, the criteria for clinical longevity must include
marginal adaptation as one of the important param-
eters for long-term success. Because CLVs involve a
conservative and additive procedure, the veneer may
not have a well-defined finishing line; in other words,
the transition between the CLV and tooth structure
is totally different from the marginal adaptation of a
crown. For veneers without preparation and partial ve-
neers, the ceramist often leaves a slight overcontour to
facilitate proper insertion and positioning of the resto-
ration. The overcontoured area is then removed only
after final bonding using specific ceramic-polishing
wheels. In this manner, the AAC is created, forming a
hybrid interface of different structures that have been
bonded together: the tooth (enamel or dentin), bond-
ing system, resin cement, and ceramic.
Clinical Protocol
The clinical success of CLVs depends on four majors
factors: enamel preservation, material selection (etch-
able ceramic), the bonding procedure, and careful
occlusal adjustment. 21 To achieve excellence in all of
these parameters, detailed treatment planning must
be carried out, including the following:
1. Diagnostic digital photography protocol including
both facial and intraoral views. These photographs
will help to determine the extent of treatment, the
number of teeth to be included, and whether peri-
odontal plastic surgery is necessary.
2. Initial additive wax-up made on a cast obtained us-
ing polyvinyl siloxane (PVS) impression material. The
wax-up will guide all esthetic treatments. 24
3. Treatment mock-up. In this phase, the patient and
dental team determine realistic parameters for the
final restoration. Any alterations must be done at
this stage. 24-26
After the treatment plan is defined, the clinical pro-
cedures must be carefully executed to preserve as
much of the tooth structure as possible. Tooth prepara-
tion should be kept mainly to enamel. Further, proper
impression taking and provisionalization are essential
from a clinical perspective. The ceramic material can
be bonded to the tooth structure using resin cement
or preheated composite resin.
Maintenance Protocol
Every dental material undergoes thermal variation, mas-
ticatory loading, and contact with abrasive substances
that may damage or alter the surface. For this reason, a
maintenance program must be implemented.
As already mentioned, adhesive restorations gener-
ally do not have a well-defined finishing line; rather,
they have an AAC. This area is exposed to a variety of
harmful elements, including abrasion caused by tooth-
brushing and eating. Chemical abrasion due to the
consumption of acidic beverages is particularly com-
mon and may result in staining of the exposed resin
cement. Wear of the resin cement and consequent
loss of material can lead to an unsupported ceramic
margin. 32 However, if a maintenance protocol is care-
fully followed, it is possible to prevent these problems
or at least to detect them in their early stages. Such
defects can then be resolved via finishing and polish-
ing. 3,26 When only the resin cement has been stained,
it is possible to repair or even polish this superficial
defect in areas accessible for instrumentation. Indeed,
CLVs usually provide easy access because they tend to
be conservative restorations with supragingival margins.
In some cases, the margin of a CLV may be placed
on dentin due to the presence of preexisting restora-
tions or gingival recession. Clinicians should be aware
that placement of the restoration margin in this area
requires special care.
The clinical maintenance protocol should include
the following:
1. Careful evaluation of any preexisting restorations.
Periapical radiographs may be useful in this stage.
2. Patient hygiene instruction and support. Bleaching
toothpastes should be avoided for patients with
CLVs. Although there is a lack of scientific data on
this topic, many bleaching toothpastes appear to
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 SCOPIN DE ANDRADE ET AL
be extremely abrasive and may remove the surface
polish of the ceramic.
3. Occlusal maintenance at the end of treatment. The
canine anterior guidance must protect the anterior
segment during lateral movements. For extensive
modifications, an occlusal guard can be delivered
on the day of final cementation.
4. Adjustments and repairs, as necessary. Small frac-
tures and chipping may occur, and repair is more
conservative than replacement. The repair protocol
is executed as follows: (1) medium-coarse diamond
bur with water irrigation or air abrasion with alumi-
num oxide particles at 40 psi (PrepStart H 2 0, Dan-
ville, San Ramon, California, USA), (2) light-curing
block-out resin (Ultradent, South Jordan, Utah, USA)
may be used for enamel protection, (3) 9% hydro-
fluoric acid for 20 seconds on ceramic surface to
be repaired (wash, dry, and remove the LC block-
out resin), (4) 35% phosphoric acid for 60 seconds
on enamel and ceramic surfaces (wash, dry, apply
a silane-coupling agent for 2 minutes, and dry), (5)
air-thinned hydrophobic adhesive (no photocuring),
(6) composite resin (applied gently with a brush), (7)
photocuring followed by application of glycerin jelly
and light activation again to remove the oxygen in-
hibited layer, and (8) polishing with ceramic and/or
composite resin rubber wheels. If a large area is af-
fected by fracture, a partial veneer can be placed
over the veneer to avoid damage to the enamel.
The maintenance protocol should be explained to
the patient before treatment, and an agreement form
should be signed.
SEM ANALYSIS: CASE REPORTS
Clinicians have generally believed that a perfect indi-
rect restoration should have almost no luting or cement
line; however, when long-term crowns and veneers are
12 QDT 2013
evaluated under SEM and measured in vivo, a different
scenario becomes evident. 33 ' 34
SEM has been used for many years to analyze dental
structures and materials."' 36 SEM analysis can be used
to reveal surface details that would be almost impos-
sible to detect using an optical microscope. In some
cases, a minimum magnification of x100 is necessary
to correctly evaluate the outcome of an adhesive res-
toration. Of course, this may not be feasible for every
clinical case. Nonetheless, the information collected
from a single image is valuable to better understand
and predict novel adhesive bonding techniques.
For this analysis, several cases were evaluated. All
patients analyzed had been wearing their CLVs for
more than 5 years. Some patients were treated more
than 10 years prior. The adhesive procedures were per-
formed under a strict bonding protocol under magnifi-
cation (x2.5). All patients were included in a controlled
maintenance program every 6 months.
Select areas from each case were subjected to SEM
analysis to help assess the CLV margins. For the SEM
evaluation, a PVS impression was taken, and a replica
of each area of interest was created with an epoxy
resin—based material. The restoration margins of the
epoxy resin die were sputter coated with gold (Balzers-
SCD 050, Oerlikon Balzers, Balzers, Liechtenstein) for
180 seconds at 40 mA and analyzed under SEM (LEO
435 VP, LEO, Cambridge, England) at 20 kV by the
same operator.
All CLVs were made using the refractory die tech-
nique with a high-content fluorapatite glass-ceramic
(IPS d'Sign, Ivoclar Vivadent, Schaan, Liechtenstein).
For bonding, a light-curing resin cement (Variolink II,
Ivoclar Vivadent) was used in conjunction with a hy-
drophobic adhesive (Heliobond, Ivoclar Vivadent) for
enamel or a hydrophilic adhesive (Single Bond, 3M
ESPE, St Paul, Minnesota, USA) for exposed dentin.
Every case analyzed followed the clinical protocol de-
scribed above. Facial, extraoral, and intraoral photo-
graphs were taken of all patients (Fig 1).
 The Area of Adhesive Continuity: A New Concept for Bonded Ceramic Restorations

la lc

ld le if

1h

Figs la to 1I Example of the photographic protocol used for all cases to document the preoperative situation (a, d to f),
immediate posttreatment (b, g to i), and long-term follow-up (c, j to I).

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SCOPIN DE ANDRADE ET AL

CASE

Fig 2a Intraoral view of the evaluated region.

Fig 2b Close - up view of the CLVs on the central incisors.

Fig 2c SEM image of the cervical area of the right central incisor (magnification x18).

Fig 2d SEM image showing the AAC on the right central incisor (magnification x70). RC = resin cement.

Case 1 Clinical analysis revealed a small pigmented margin

This case involved periodontal plastic surgery from
maxillary first molar to first molar and placement of
CLVs from maxillary second premolar to second pre-
molar. The central incisors were selected for analysis.
The restorations had been in situ for 7 years (Figs 2a
and 2b).
in the mesial/cervical region of the right central incisor.
This was likely caused by either adhesive failure or the
presence of an air bubble inside the resin cement. In
such cases, the enamel finishing line usually prevents
tooth sensitivity.
It was possible to observe the AAC using SEM anal-
ysis (Figs 2c and 2d). The resin cement appeared worn
down without damage to the CLV.

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 The Area of Adhesive Continuity: A New Concept for Bonded Ceramic Restorations

CASE 2
Fig 3a CLV on the right lateral incisor. Note the visibly
different texture of the restoration.

Fig 3b SEM photomicrograph showing the CLV in-

terface (arrows) as seen in the area marked on Fig 3a
(magnification X42).

Fig 3c SEM image showing the CLV interface (arrows)

at higher magnification. Even at this magnification, it
is possible to see a well-adapted AAC (magnification
x165).

3a

2000 Detector = SE1

Detector = SE1 Mag = 165X
Date 2 Mar 2012 ENT = 20.00 kV Date 2 Mar 2012

3c

the right lateral incisor (Fig 3a). Surface irregularities at

Case 2
For this case, the treatment included periodontal plas-
tic surgery from the maxillary right second molar to the
left first molar, placement of CLVs at the lateral incisors
and left first and second premolars, and placement of
partial veneers at the right first and second premolars.
The CLVs at the lateral incisors were selected for analy-
sis. The restorations had been in situ for 7 years.
Clinical analysis revealed changes in texture and
shade occurring at the midfacial surface of the CLV on
the AAC were also evident (Fig 4a).
SEM analysis revealed a perfect and continuous mar-
gin (Figs 3b and 3c). One possible explanation for the
difference between the clinical and SEM images is that
debonding occurred after years of function, creating
the interface separation seen clinically. At higher mag-
nifications (Figs 4b and 4c), the restorations showed a
continuous margin, despite an area of resin cement abra-
sion (no clinical relevance). A few areas showed some
indentation marks, possibly due to finishing procedures.

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 SCOPIN DE ANDRADE Er AL
Detector = SE1
Date 2 Mar 2012
Case 3
CLVs were placed from maxillary canine to canine and
mandibular canine to canine. The CLV on the maxillary
right canine was selected for analysis. This restoration
received a partial veneer after fracture of the ceramic
on the canine and lateral incisor due to an accident.
Clinical analysis revealed discrete marginal staining.
The margin of the partial veneers was visible (Fig 5a).
16 QDT 2013
Fig 4a CLV on the left lateral incisor. Minor irregularities
in the AAC can be observed.
Fig 4b The irregularities in the AAC become more evi-
dent under SEM (magnification x41).
Fig 4c SEM image showing the CLV interface (red
arrows). Yellow arrows show the edges of the ceramic
structure. The area around the resin cement shows
irregularities, possibly due to abrasion. The orange
arrows show a possible scratch caused by the finishing
procedures (magnification x209). RC = resin cement;
E = enamel.
4c
SEM analysis revealed the presence of the AAC. A
better view of the margin was achieved by using re-
traction cord during tissue displacement (Figs 5b and
5c). At higher magnification (Fig 5d), an area of abra-
sion was evident; however, the AAC was still clinically
acceptable. Figures 5e and 5f show the area where the
partial veneer was bonded to fix the CLV.
 The Area of Adhesive Continuity: A New Concept for Bonded Ceramic Restorations

(2 Resin cement

Mag = 750 X 111, Detector = SEt

EMT = 20.00 NV Date 2 Mar 2012

Fig 5a CLV on the right canine. Marginal staining is evident at the AAC.
Fig 5b SEM image showing the AAC. The image was obtained with the help of retraction cord placed in
the sulcus (magnification x40).
Fig 5c SEM image of the area marked in Fig 5b (magnification x61).
Fig 5d The AAC clearly shows no signs of deep abrasion. It is possible to see the difference between
the three structures of the AAC: enamel, resin cement (RC), and ceramic (magnification x750).
Fig 5e SEM image showing the interface between the CLV and partial veneer (arrows). Scratches on the
ceramic surface probably resulted from abrasion caused by toothpaste and food (magnification X40).
Fig 5f SEM image showing the AAC in the repaired area (magnification x750).

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 SCOPIN DE ANDRADE ET AL

CASE 4

6a 6b

6d
6c

Fig 6a CLVs on the central incisors showing an excellent AAC.

Fig 6b SEM view showing the interface between the CLV and tooth structure on the central incisors. Note that the
interface is easier to detect under SEM than in the clinical image (magnification x25).

Fig 6c A crack was found on the CLV at the left central incisor (magnification x25).

Fig 6d Higher-magnification view of the crack (magnification x650).

Case 4
This case involved periodontal plastic surgery and
placement of CLVs from maxillary second premolar
to second premolar. The CLVs on the central incisors
and right first and second premolars were selected for
analysis.
Clinical analysis revealed a smooth surface at the
AAC between the central incisors (Fig 6a). For the
modified CLVs at the second premolars, no damage

18 QDT 2013
 The Area of Adhesive Continuity: A New Concept for Bonded Ceramic Restorations

7d

Fig 7a Occlusal view of the modified CLV on the right second premolar.

Fig 7b SEM image showing the AAC on the occlusal surface (magnification x25). RC = resin cement.

Fig 7c At higher magnification, the AAC shows an area of abrasion on the enamel, with no signs of leakage (magnifi-
cation x55).

Fig 7d Additional magnification reveals minor irregularities or bubbles on the ceramic surface (magnification x150).
RC = resin cement.

was evident despite the location of the margin in the
occlusal area (Fig 7a).
SEM analysis of the central incisors revealed an AAC
with no severe modifications (Fig 6b). A fissure was
found in the CLV (Figs 6c and 6d), which did not cause
any shade alterations. This finding is common for CLVs. 24
SEM analysis of the second premolars helped to eluci-
date the behavior of the AAC when anterior canine
guidance is provided and careful occlusal adjustments
are made (Fig 7b). An area of enamel abrasion was ob-
served (Figs 7c and 7d). The behavior of enamel and
ceramic seems to be similar.

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SCOPIN DE ANDRADE ET AL
CASE 5
Case 5
CLVs were placed from maxillary canine to canine, and
partial veneers were placed at the maxillary first and
second premolars. The canines and left central incisor
were selected for analysis.
Clinical analysis of the left central incisor revealed
staining of the margin (Fig 8a). The canines showed
clinically acceptable margins (Fig 9a).
QDT 2013
Fig 8a CLVs on the central and lateral incisors.
Fig 8b SEM view of the area marked in Fig 8a. No fail-
ures or bubbles are evident (magnification x25).
Fig 8c Higher magnification of the area marked in Fig
8b. There are still no visible irregularities at the surface
of the AAC (magnification x140).
SEM analysis of the central incisor showed an ideal
AAC (Figs 8b and 8c). Figures 9c to 9e show the SEM
images of the right canine. Chipping due to a fracture
of the ceramic margin or an irregularity caused by fin-
ishing procedures was observed. At the left canine,
the margin of the CLV was visible (Figs 9f to 9h).
 The Area of Adhesive Continuity: A New Concept for Bonded Ceramic Restorations

9a

Fig 9a CLV on the right canine. The AAC is visible.

Fig 9b SEM image of the AAC further highlighting the

smooth surface of the ceramic (magnification x25).

Fig 9c SEM image of the mesial area (magnification

x25).

Fig 9d As seen under high magnification, it is

possible for the resin cement (RC) area to be greater
than 100 pm without damaging the interface
(magnification x120).
 SCOPIN DE ANDRADE ET AL

9f

Fig 9e SEM image showing minor chipping on the ceramic side of the AAC on the right canine (magnification X 190).

Fig 9f SEM view of the left canine (magnification x25). Arrows show the area analyzed in Figs 9g and 9h.

Fig 9g The arrow shows a bubble on the resin cement. Circled area is shown at higher magnification in Fig 9h.
(Magnification x25). RC = resin cement.

Fig 9h At high magnification, overcontouring of the resin cement (arrows) is evident (magnification X 190).

Fig 9i Artistic photography of the patient. Reprinted from Arquitetura do Sorriso (Quintessence Ed, Sao Paulo, Brazil,
2012.)

IMS QDT 2013

 The Area of Adhesive Continuity: A New Concept for Bonded Ceramic Restorations

9i

QDT 2013 23
 SCOPIN DE ANDRADE ET Al

10a 10b

Fig 1 Oa CLV on the left lateral incisor.

Fig 10b SEM image showing minor chipping at the CLV interface (arrows) (magnification x18).

Fig 10c The chipped area shows irregularities at the AAC (magnification x33).

Fig 10d At higher magnification, the ceramic surface reveals an irregular area likely caused by the finishing proce-
dures (magnification x90).

Case 6 Using SEM, the ceramic surface of the left lateral

CLVs were placed on the maxillary lateral incisors and
canines. The lateral incisors were selected for analysis.
Clinical analysis revealed a clinically acceptable mar-
gin at both the left lateral incisor (Fig 10a) and right
lateral incisor (Fig 11a).
incisor presented a marginal irregularity, possibly due
to finishing and/or polishing procedures (Figs 10b to
10d). The right lateral incisor showed minor chipping
at the CLV margin (Figs llb to 11d).

24 QDT 2013
 The Area of Adhesive Continuity: A New Concept for Bonded Ceramic Restorations

llb

11c lid

Fig 11 a CLV on the right lateral incisor.

Fig 11 b SEM image showing the AAC (magnification X18).

Fig 11 c Clinically acceptable AAC with a measure of more than 100 pm (magnification x220). RC = resin cement.

Fig 11 d SEM image showing area of minor chipping (arrows) in the ceramic side of the AAC (magnification x370).

CONCLUSIONS ment, and ceramic. This intricate interface highlights

The AAC is a new concept for the analysis of bonded
restorations. The AAC forms a hybrid interface of dif-
ferent structures that have been bonded together: the
tooth (enamel or dentin), bonding system, resin ce-
the need for clinicians to evaluate adhesive restorations
differently from conventional cemented restorations.
Understanding the concept of the AAC is essential to
improving the longevity of bonded ceramic restorations.

QDT 2013 25
 SCOPIN DE ANDRADE ET AL
ACKNOWLEDGMENTS
The authors would like to express their gratitude to the Atelie Oral
Clinic team in S5o Paulo, Brazil. The artistic photography of the pa-
tient on page 23 was taken by Andre Schiliro for the book Arquite-
tura do Sorrisso, published in 2012 by Quintessence Ed, Sao Paulo,
Brazil.
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