dentistry journal

Case Report
Restoring Large Defect of Posterior Tooth by Indirect
Composite Technique: A Case Report
Pei-Ying Lu 1 and Yu-Chih Chiang 2, *
1 Department of Restorative and Esthetic Dentistry, National Taiwan University, Taipei 100, Taiwan;
r05422016@ntu.edu.tw
2 Department of Restorative and Esthetic Dentistry, National Taiwan University and National Taiwan
University Hospital, Taipei 100, Taiwan
* Correspondence: munichiang@ntu.edu.tw; Tel.: +886-2-23123456 (ext. 67866, 66386)




Received: 20 September 2018; Accepted: 4 October 2018; Published: 7 October 2018


Abstract: Advances in adhesive dentistry have led to increased use of indirect restorations. In
some situations, indirect composite techniques are more advantageous than direct composite filling
techniques, such as establishing proper occlusal and interproximal anatomy, reducing polymerization
shrinkage stress, and promoting the degree of conversion. This article presents a case about restoring
the lower right first molar with extensive loss of tooth structure by the composite onlay to achieve
a proper anatomic form and rehabilitate chewing function. This one-year clinical case encourages
clinicians to manage large decay of posterior tooth conservatively. The given functional and esthetic
outcomes demonstrate the promising applicability of the indirect composite technique.

Keywords: indirect restoration; composite onlay; dental esthetics; composite resin; large cavity

1. Introduction
Owing to the evolution of adhesive technologies and restorative materials, approaches and
treatment plans for restoring posterior teeth have been considerably innovated [1]. Although amalgam
and gold have demonstrated persistent clinical success and biocompatibility, novel tooth-colored
restorations are increasingly replacing metal restorations not only for esthetic concerns but also for more
conservative preparations [2]. Considering biology, mechanics, function, and aesthetics, a harmonious
and successful restorative result could be achieved with these natural-looking restoration materials,
such as resin composite and ceramic. Differences in the mechanical properties of ceramic materials and
resin composites lead to the question as to which material is more durable than the other, especially in
load-bearing posterior regions of the mouth. Ceramic restorations are characterized by satisfactory
esthetic results and stronger physical properties. Studies on ceramic indirect restorations have revealed
a success rate of approximately 90% after 10 years. However, limited information is available on the
clinical survival of indirect resin composites. Previous reviews have revealed no conclusive evidence
showing that indirect ceramic inlays and onlays can survive longer than resin ones in the mouth [3,4].
Although resin composites are the trends among restorative options, several issues are still
associated with their properties, such as polymerization shrinkage, microleakage, marginal gap
formation, color instability, difficulties in rebuilding ideal proximal contour and contact, and
insufficient mechanical property [2,5,6]. The mentioned issues influence the clinical success and
longevity of composites resin restorations. The rehabilitation of decayed or fractured posterior teeth
through an indirect technique overcame some difficulties associated with direct composite filling,
resulting in better occlusion and a desired tooth form; in addition, complete curing and reduced
shrinkage of composite resins in the deepest regions can be achieved [6]. For large damaged posterior
teeth, the indirect technique is indicated [7]. This report presents a case involving the restoration of an

Dent. J. 2018, 6, 54; doi:10.3390/dj6040054 www.mdpi.com/journal/dentistry

Dent. J.
Dent. J. 2018,
2018, 6,
6, xx FOR
FOR PEER
PEER REVIEW
REVIEW 22 of
of 77
Dent. J. 2018, 6, 54 2 of 7
shrinkage of
shrinkage of composite
composite resins
resins in
in the
the deepest
deepest regions
regions can
can be
be achieved
achieved [6].
[6]. For
For large
large damaged
damaged posterior
posterior
teeth, the indirect technique is indicated [7]. This report presents a case involving the restoration
teeth, the indirect technique is indicated [7]. This report presents a case involving the restoration of of
extensive cavity
an extensive of
extensive cavity the
cavity of lower
of the
the lowerright
lower rightfirst molar
right first through
first molar
molar throughan indirect
through an composite
an indirect
indirect compositetechnique
composite techniqueand one-year
technique and
and one-
one-
an
follow-up
year of theofclinical
follow-up the outcome
clinical afterward.
outcome afterward.
year follow-up of the clinical outcome afterward.
2. Case Presentation
2. Case
2. Case Presentation
Presentation
A 22-year-old male student visited the department of restorative and esthetic dentistry of National
A 22-year-old
A 22-year-old male
male student
student visited
visited the
the department
department of of restorative and and esthetic dentistry
dentistry of of
Taiwan University Hospital for a dislodgement of lower rightrestorative
posterior tooth esthetic
restoration. He had
National Taiwan
National Taiwan University
University Hospital
Hospital forfor aa dislodgement
dislodgement of of lower
lower right
right posterior
posterior tooth
tooth restoration.
restoration.
received direct composite resin filling three years ago, but the old restoration was dislodged while
He
He had received
hadpopcorn
receivedtwodirect
direct composite
composite resin filling
resin filling three years
three years ago, but
ago, but the old restoration
theimpaction
old restoration was
was dislodged
dislodged
eating days earlier. Clinical examination revealed food over the large mesial
while eating popcorn
while popcorn twotwo days
days earlier.
earlier. Clinical
Clinical examination
examination revealed
revealed food
food impaction
impaction over
over the
the large
cavityeating
of the lower right first molar with gingival inflammation (Figure 1). The pulp vitalitylarge
test
mesial cavity
mesial cavity of
of the
the lower
lower right
right first
first molar
molar with
with gingival
gingival inflammation
inflammation (Figure
(Figure 1).
1). The pulp
pulp vitality
vitality
was normal with no symptoms or signs. Radiographic examination revealed a largeThe
mesial decay in
test was
test was normal
normal with
with no symptoms
symptoms or or signs.
signs. Radiographic
Radiographic examination
examination revealed aa largelarge mesial
mesial decay
decay
proximity to the pulpno horn while no obvious abnormal apical findingsrevealedwere noted (Figure 2). After
in proximity
in proximity toto the
the pulp
pulp horn
horn while
while nono obvious
obvious abnormal
abnormal apical findings
findings were noted
noted (Figure
(Figure 2).
2). After
After
oral hygiene reinforcement, we discussed with the patientapical
that compositewere onlay might be a choice for
oral
oral hygiene reinforcement,
hygiene and
reinforcement, we discussed
we discussed with the
with the patient that
patient of
that composite
composite onlay might
onlay might be a choice
be a choice for
for
his aesthetic financial concerns, and further possibility root canal treatment. A written informed
his aesthetic
his aesthetic and
and financial
financial concerns,
concerns, and and further
further possibility
possibility of
of root
root canal
canal treatment.
treatment. A A written
written
consent was obtained before the treatment, and patient gave permission for the related pictures and
informed consent
informed consent was
was obtained
obtained before
before thethe treatment,
treatment, and
and patient
patient gave
gave permission
permission forfor the
the related
related
radiographs to be published before submission.
pictures and radiographs to be published before
pictures and radiographs to be published before submission. submission.

Figure 1. Pre-operative
Figure 1.
Figure Pre-operative clinical
Pre-operative clinical picture of
clinical picture of lower
lower right
right first
first molar
molar with
with large
large cavity
cavity over
over mesial
mesial side.
side.

Figure 2.
Figure 2. Pre-operative periapical
periapical radiograph shows
shows caries in
in proximity to
to the
the pulp
pulp horn.
horn.
Figure 2. Pre-operative
Pre-operative periapical radiograph
radiograph shows caries
caries in proximity
proximity to the pulp horn.

At the
At the next
next appointment,
appointment, under
under block
block anesthesia
block anesthesia using
anesthesia using
using 2%2% lidocaine
2% lidocaine with
lidocaine with epinephrine
with epinephrine 1:100,000,
epinephrine 1:100,000,
1:100,000,
caries was removed by low speed carbide burs and sharpened spoon excavator
caries was removed by low speed carbide burs and sharpened spoon excavator under rubber dam under rubber dam
isolation (Figure
isolation (Figure 3).
3). The
The mesial
The mesial gingival
mesial gingival margin
gingival margin was
margin was located
was located approximately
located approximately
approximately 0.5 0.5 mm
0.5 mm subgingivally.
mm subgingivally.
subgingivally.
Therefore, gingival displacement was achieved using a retraction cord.
Therefore, gingival displacement was achieved using a retraction cord. The undercuts of The undercuts of the
the tooth
tooth
cavity were blocked out with a nano-hybrid
cavity were blocked out with a nano-hybrid composite
nano-hybrid composite resin
composite resin (Grandio,
resin (Grandio, shade
(Grandio, shade A3,
shade A3, Voco,
A3, Voco, Cuxhaven,
Voco, Cuxhaven,
Cuxhaven,
Germany), which served as a base material. The
Germany), which served as a base material. The cavity cavity was
cavity was prepared,
was prepared, and an alginate impression was
prepared, and an alginate impression was
taken after removal of the rubber
taken after removal of the rubber dam. A dam. A self-cured
A self-cured bis-acrylic
self-cured bis-acrylic resin
bis-acrylic resin (Structur
resin (Structur 2 SC,
(Structur 22 SC, Voco,
SC,Voco, Cuxhaven,
Voco, Cuxhaven,
Cuxhaven,
Germany) was
Germany) was used
used as
as a
a temporary
temporary filling
filling material
material before
before the
the next
next cementation
cementation
was used as a temporary filling material before the next cementation appointment. appointment.
appointment. A fast-
A fast-
setting
setting
A siliconesilicone
silicone
fast-setting die material
die material (GrandioSO
(GrandioSO
die material Inlay System,
Inlay
(GrandioSO System, Voco,
InlayVoco, Cuxhaven,
Cuxhaven,
System, Germany)
Voco, Germany)
Cuxhaven,was was injected was
injected
Germany) into
into
the
the alginate.
alginate.
injected During
into During the inter-appointment
the inter-appointment
the alginate. period, the onlay
period, the onlay
During the inter-appointment restoration
restoration
period, was
was
the onlay fabricated incrementally
fabricatedwas
restoration incrementally
fabricated
with aa light-cured
with light-cured composite
composite resin
resin (Grandio,
(Grandio, shades
shades A2,
A2, A3,
A3, and
and A3.5,
A3.5, Cuxhaven,
Cuxhaven, Germany)
Germany) (Figure
(Figure
Dent. J. 2018, 6, 54 3 of 7

Dent. J. 2018, 6, x FOR PEER REVIEW 3 of 7

Dent. J. 2018, 6, x FOR
incrementally withPEER REVIEW
a light-cured composite resin (Grandio, shades A2, A3, and A3.5, Cuxhaven, 3 of 7
Germany)
4), and
and each
each (Figure 4), and
layer was
was each layer for
polymerized was10polymerized
s with for 10 s withdiode
with aa light-emitting
light-emitting a light-emittingunitdiode
curing unit (Valo,curing unit
Ultradent,
4),
(Valo, layer
Ultradent, polymerized for 10 s diode curing 2 (Valo, Ultradent,
South Jordan,
South Jordan, UT,South
UT, USA) Jordan,
USA) with
UT,
with light
light USA) with
irradiance
irradiance of
lightmW/cm
of 1000
1000 irradiance
mW/cm
ofsculpting
2.. For
2 For 1000 mW/cm . For sculpting
the occlusal
sculptingridge
the occlusal morphology,
morphology,
the
occlusal morphology,
we determined
determined mesio-lingual we determined
mesio-lingual cusp cusp and mesio-lingual
and trianglular
trianglular ridge cusp
ridge by and
by referringtrianglular
referring to to the
the existing by referring
existing distolingual to
distolingual cusp the
cusp
we
existing distolingual cusp and neighboring teeth. In addition, the cast of the upper arch was used for
and neighboring
and neighboring teeth.teeth. InIn addition,
addition, the
the cast
cast of
of the
the upper
upper arch
arch was was used
used forfor adjusting
adjusting thethe occlusion.
occlusion.
adjusting
The final the occlusion.
final occlusal
occlusal anatomy Thewas
final occlusal anatomy
reconstructed was reconstructed
and incorporated
incorporated and
resinincorporated
with aa resin staining kit with acolor,
kit (Tetric
(Tetric resin
The
staining kit (Tetric anatomy
color, was Vivadent,
Ivoclar reconstructed and
Schaan, Liechtenstein), with
which was staining
used for internal color,
staining
Ivoclar Vivadent,
Ivoclar Vivadent, Schaan,
Schaan, Liechtenstein),
Liechtenstein), which
which waswas used
used for
for internal
internal staining
staining toto mimic
mimic thethe fissures
fissures
to mimic
of aa naturalthe fissures
natural tooth.
tooth. Afterof a natural
After finishing tooth.
finishing and After finishing
and polymerization,
polymerization, the and polymerization,
the composite
composite onlay the
onlay was composite
was removed onlay
removed fromfromwas the
of
removed from the silicone die and cured from the intaglio surface for 40 s. the
silicone die and cured from the intaglio surface
silicone die and cured from the intaglio surface for 40 s. for 40 s.

Figure 3.
Figure 3. Caries
Caries removal under rubber
removal under rubber dam
dam isolation.
isolation.

(a)
(a) (b)
(b)
Figure 4.
Figure 4. Composite
Composite onlay
onlay fabricated
fabricated on
on silicone
silicone die:
die: (a)
(a) occlusal
occlusal view;
view; and
and (b)
(b) mesial
mesial view.
view.
Composite (a)

At the
At the next
next appointment,
appointment, isolation
isolation was
was performed
performed with with rubber
rubber dam.
dam. Then,
Then, thethe onlay
onlay waswas tried
tried
in and
in and the
the fitness
fitness was
fitness was checked.
was checked. Before
checked. Before cementation,
cementation,
cementation, the the intaglio
the intaglio surface of
intaglio surface of restoration
restoration received
received
airborne-particle abrasion with
airborne-particle abrasion with 50 μm 50 μm alumina particles; subsequently, it was conditioned
µm alumina particles; subsequently, it was conditioned with 37.5% with 37.5%
phosphoric
phosphoric
phosphoric acid acid
acidgelgel (Gel
gel(Gel Etchant,
(GelEtchant, Kerr,
Etchant,Kerr, Orange,
Kerr,Orange,
Orange, CA,CA,
CA, USA)
USA)
USA) for
forfor 15
15 15 s. After
s. After
s. After the
thethe etchant
etchant
etchant gel
gel gel was
waswas rinsed,
rinsed, the
rinsed,
the composite
composite
the composite onlay
onlayonlay was
was cleaned cleaned with
with 75%
was cleaned 75%
withethanol ethanol in an
in an ultrasonic
75% ethanol ultrasonic bath
bath for bath
in an ultrasonic for
3 min.for 3 min.
Moreover, Moreover,
the tooth was
3 min. Moreover, the
the
tooth was
selectively selectively etched
etched withetched
tooth was selectively with 37.5%
37.5% phosphoric phosphoric
with 37.5% acid acid
gel (Gel acid
phosphoric gel
Etchant, (Gel Etchant,
Kerr,Etchant,
gel (Gel Kerr,
Orange, Kerr,
CA, USA) Orange,
for 15
Orange, CA,
CA, USA)
s, rinsed
USA)
for
with 15 s,
for 15water rinsed with
spray,with
s, rinsed water
and air spray,
dried.
water and
The and
spray, air dried.
self-etching
air dried. The
adhesive self-etching
and dual-cured
The self-etching adhesive
luting
adhesive and
and dual-cured
composite
dual-cured luting
(Multilink
luting
composite
N
composite (Multilink
system, Ivoclar
(Multilink N system,
Vivadent,
N system, Ivoclar
Schaan,Ivoclar Vivadent,
Liechtenstein)
Vivadent, wereSchaan,
used for
Schaan, Liechtenstein)
final cementation.
Liechtenstein) were Polymerization
were used for
used for final
final
cementation.
was performed
cementation. Polymerization was
for 40 s per surface
Polymerization performed for
(Figure 5).for
was performed 40
After s per surface
rubber
40 s per (Figure
dam(Figure
surface removal, 5). After rubber
the occlusal
5). After dam
rubbercontacts removal,
dam removal, were
the occlusal
adjusted
the occlusal contacts
andcontacts were
checkedwere adjusted
with adjusted and
articulating checked
andpaper with
(Figure
checked with6).articulating
Finally, the
articulating paper (Figure
restoration
paper (Figurewas 6). Finally,
finished the
6). Finally, the
by
restoration
fine-grained
restoration was was finished
diamond burs by
finished by fine-grained
andfine-grained diamond
polished by abrasive, burs and
diamondsilicon-impregnated polished
burs and polishedrubbers by abrasive, silicon-
(Jiffy, Ultradent,
by abrasive, silicon-
impregnated
South
impregnated rubbers
Jordan, rubbers
UT, USA) (Jiffy, Ultradent,
(Figure
(Jiffy, South Jordan,
7). A bitewing
Ultradent, South Jordan, UT, USA)
radiograph
UT, USA) (Figure
was taken
(Figure 7). A
A bitewing
to examine
7). bitewing
whether radiograph
any overhang
radiograph was
was
taken to
existed
taken toatexamine
examine
the gingivalwhether
margin
whether any (Figure
any overhang
overhang existed
8). existed at the
the gingival
At the one-year
at gingival margin
recall, margin (Figure 8).
the restoration
(Figure 8). At
At
still the one-year
one-year
maintained
the its
recall,
esthetic the
recall, the restoration
and still
chewing function
restoration maintained its
(Figure its
still maintained esthetic and chewing function
9). esthetic and chewing function (Figure 9).(Figure 9).
Dent. J. 2018,
Dent. 2018, 6, xx FOR
FOR PEER REVIEW
REVIEW 444 of
of 7
Dent. J.
J. 2018, 6,
6, x FOR PEER
PEER REVIEW of 77
Dent. J. 2018, 6, 54
Dent. J. 2018, 6, x FOR PEER REVIEW 44ofof77

(a)
(a) (b)
(b)
(a) (b)
Figure 5.
Figure (a) under
5. Cementation
Cementation under rubber
rubber dam
dam isolation:
isolation: (a)
(a) before (b) and
before cementation;
cementation; and (b)
(b) after
after
Figure 5. Cementation under rubber dam isolation: (a) before cementation; and (b) after
cementation.
cementation.
Figure Figure 5. Cementation
5. Cementation under rubber
under rubber dam isolation:
cementation.
dam isolation: (a) cementation;
(a) before before cementation;
and (b)and
after(b) after
cementation.
cementation.

Figure 6. Examining
Figure Examining the
Examining the occlusal contacts
the occlusal contacts after cementation.
cementation. The blue spots represent the centric
Figure 6.
6. Examining the occlusal contacts
occlusal contacts after
after cementation. The
The blue
The blue spots
blue spots represent
spots represent the
represent the centric
centric
occlusion,
occlusion, and the red spots represent the functional movements.
Figure 6. and
occlusion, and the
the red
red spots
Examining the represent
occlusal
spots the
the functional
contacts
represent movements.
movements.
after cementation.
functional movements.The blue spots represent the centric
occlusion, and the red spots represent the functional movements.

(a)
(a) (b)
(b)
(a) (b)
Figure 7.
Figure 7. After
After finishing (a)polishing:
finishing and
and polishing: (a)
(a) occlusal
occlusal view;
view; and
and (b) (b) view.
(b) mesial
mesial view.
Figure 7. After finishing and polishing: (a) occlusal view; and (b) mesial view.
Figure 7. After finishing and polishing: (a) occlusal view; and (b) mesial view.

Figure 8. Post-operation
Post-operationbite-wing radiograph
bite-wing shows
radiograph no obvious
shows overhang
no obvious or remaining
overhang excess resin
or remaining resin
Figure 8. Post-operation
Figure 8.
8. Post-operation bite-wing
bite-wing radiograph
radiograph shows
shows no
no obvious
obvious overhang
overhang or
or remaining
remaining excessexcess
excess resin
cement.
resin cement.
cement.
Figure
cement. 8. Post-operation bite-wing radiograph shows no obvious overhang or remaining excess resin
cement.
Dent. J. 2018, 6, 54 5 of 7
Dent. J. 2018, 6, x FOR PEER REVIEW 5 of 7

(a) (b)
9. Follow-up
Figure 9. Follow-up after
after 12
12 months:
months: (a)
(a) occlusal
occlusal view;
view; and
and (b)
(b) no
no obvious
obvious gap or marginal
marginal
discoloration.

3.
3. Discussion
Discussion
Interest
Interest in in bonded
bonded tooth-colored
tooth-colored restoration
restoration has has been
been increasing
increasing in in recent
recent years.
years. Although
Although the the
color stability and wear resistance of resin composites are not as good
color stability and wear resistance of resin composites are not as good as those of ceramic restorations,as those of ceramic restorations,
both
both areare routinely
routinely considered
considered by by clinicians
clinicians in in their
their daily
daily practice.
practice. Due Due to to the
the chemical
chemical compositions,
compositions,
ceramics
ceramics are harder and thus more wear resistant, but they can cause more wear than usual
are harder and thus more wear resistant, but they can cause more wear than usual to to the
the
opposing
opposing tooth. In addition, ceramics are brittle and more prone to facture than composites incase
tooth. In addition, ceramics are brittle and more prone to facture than composites in the the
of thin-layer thickness [8]. A 4–6-year clinical study indicated that
case of thin-layer thickness [8]. A 4–6-year clinical study indicated that bonded indirect resin bonded indirect resin composite
onlays
composite can onlays
achievecan clinical
achieve success in treating
clinical success painful,
in treating cracked
painful, teeth [9]. Cusp
cracked teethprotection
[9]. Cusp of bonded
protection
indirect
of bonded resin composite
indirect resin onlays
composite could provide
onlays couldresistance
providetoresistance
cuspal deflection
to cuspalregarding
deflection structurally
regarding
compromised teeth [10,11]. Moreover, using resin composites
structurally compromised teeth [10,11]. Moreover, using resin composites is easier for intra-oralis easier for intra-oral repairs in the
future by composite materials. From an economic perspective, composite
repairs in the future by composite materials. From an economic perspective, composite resins are a resins are a more attractive
option than costly
more attractive ceramic
option thanmaterials [9]. materials [9].
costly ceramic
Several factors, namely the
Several factors, namely the materials, materials, adhesive cementation
adhesive cementation and bonding procedures,
and bonding are relevant
procedures, are
in applications
relevant of indirect
in applications composite
of indirect restoration
composite [3]. The[3].
restoration resinThe composite used inused
resin composite this in
study
this was
study a
nano-hybrid with high filler content (87% w/w). The nanohybrid
was a nano-hybrid with high filler content (87% w/w). The nanohybrid composite not only provided composite not only provided high
polishability
high polishability with low
withsurface
low surfaceroughness
roughnessbut also
butpossibly
also possiblyenhancedenhanced the retention
the retentionof smoothness
of smoothness after
abrasion.
after abrasion. SomeSomein vitroin wear studies
vitro wear have revealed
studies have revealed that increased
that increased filler content enhances
filler content the wear
enhances the
resistance,
wear resistance, and nanohybrid composites may exhibit superior wear resistance comparedother
and nanohybrid composites may exhibit superior wear resistance compared with with
composite
other composite resins resins
[10,11].[10,11].
A
A restoration
restoration can can be be placed
placed either
either directly
directly or or indirectly,
indirectly, and and an an indirect
indirect restoration
restoration is is more
more
favorable for restoring the morphology and function of a compromised
favorable for restoring the morphology and function of a compromised tooth structure. The indirect tooth structure. The indirect
technique
technique was was used
used outside
outside the the oral
oral cavity,
cavity, taking
taking an an impression
impression and and fabricating
fabricating the the composite
composite
restoration on a die model. Internal buildup by resin composites before
restoration on a die model. Internal buildup by resin composites before tooth preparation can prevent tooth preparation can prevent
excessive loss of sound tissue, which is crucial in practice because the
excessive loss of sound tissue, which is crucial in practice because the goal of restorative dentistry goal of restorative dentistry is to
is
prepare the cavity as conservatively as possible. Using a quick-setting
to prepare the cavity as conservatively as possible. Using a quick-setting flexible silicone die, instead flexible silicone die, instead
of
of stone
stone die,
die, could
could allow
allow aa more more effective
effective treatment
treatment whichwhich couldcould be be performed
performed on on aa chair
chair side. Two
side. Two
recent systematic reviews regarding clinical performance with a follow-up
recent systematic reviews regarding clinical performance with a follow-up period of at least three period of at least three years
revealed
years revealedthat no significant
that no significant difference was observed
difference was observedbetween betweenthe direct and indirect
the direct methods
and indirect [2,7].
methods
The caution for such indirect composite restoration is the cementation
[2,7]. The caution for such indirect composite restoration is the cementation procedure. The luting procedure. The luting cement
may
cement adhere
maytoadhere
the composite onlay, which
to the composite cannot
onlay, whicheasily be detached
cannot easily be from the composite
detached from the surface
compositeafter
light cured. Occaisionally, we may encounter the challenge of occlusal
surface after light cured. Occaisionally, we may encounter the challenge of occlusal adjustment. Thus, adjustment. Thus, as a reference
by
as aa reference
study castby ofaopposing
study castteeth is also indicated.
of opposing teeth is alsoNevertheless, the indirect method
indicated. Nevertheless, couldmethod
the indirect reduce
the time
could of intraoral
reduce the time adjustment
of intraoral andadjustment
overcome some difficultiessome
and overcome of the direct method,
difficulties of theespecially
direct method,when
dealing with severely destroyed posterior tooth or with multiple cavities
especially when dealing with severely destroyed posterior tooth or with multiple cavities at the same at the same visit. Moreover,
this
visit.technique
Moreover, wasthisfavored over the
technique wasdirect technique
favored over because
the direct it could easily reconstruct
technique because it could the anatomy
easily
of tooth structure and enable a more appropriate occlusal and interproximal
reconstruct the anatomy of tooth structure and enable a more appropriate occlusal and interproximal contour [12]. Optimal
curing
contourfrom [12].allOptimal
directions curingand from
outsideallthe oral cavity
directions andcan also improve
outside the oral the degree
cavity canof conversion
also improveand the
then
degree enhance physical and
of conversion and mechanical
then enhance properties
physical[13].andFurthermore,
mechanical properties the indirect[13]. method might reduce
Furthermore, the
indirect method might reduce the polymerization shrinkage stress, resulting in a relatively ideal
Dent. J. 2018, 6, 54 6 of 7

the polymerization shrinkage stress, resulting in a relatively ideal marginal adaption and reduced
microleakage, which are the main factors responsible for the occurrence of secondary caries [12–14].
Several techniques have been suggested for treating the internal surface of an indirect composite
restoration to increase bond strength; examples of such techniques include acid-etching, air-abrasion,
silane coupling, tribochemical coating, and laser treatment [5]. Previous research showed that the effect
of surface treatment on the bond strength is dependent on the different compositions and aging of the
composites [15]. Hummel et al. discovered that airborne-particle abrasion with 50-µm alumina oxide
followed by conditioning with phosphoric acid produced a more irregular surface and significantly
greater bond strength of a hybrid composite [16].
One of the main purposes of reproducing the natural morphology of posterior tooth is to
enhance the mastication function. The restorations must fit into the pre-existing occlusal scheme,
where grinding paths are established. This can ensure that iatrogenic interference does not occur
because of dental treatment [17]. At the one-year recall in the case reported herein, the restoration
could potentially withstand physiological chewing force without fracture, debonding, or marginal
discoloration. Although the observation time was limited to only 12 months, this technique showed
satisfactory clinical performance; accordingly, it can enable dental clinicians to restore the tooth to
functional and esthetic outcomes. Further research, for example on clinical performances of ceramic
onlay and composite onlay, is encouraged.

4. Conclusions
Improvements in adhesive and restorative materials may enable the use of indirect composite
onlays to restore an extensively damaged posterior tooth. The indirect composite technique enhances
the esthetics and enables clinicians to achieve conservative tooth preparations. This technique also
overcomes difficulties of the direct composite technique, such as improper occlusal and interproximal
anatomy, polymerization shrinkage stress, and insufficient curing. The clinical success of this technique
at the one-year recall could be attributed to adequate occlusion reconstruction, well performing
adhesive systems and highly wear-resistant resin composites.

Author Contributions: Y.-C.C. conceived and designed the experiments; P.-Y.L. performed the experiments; and
Y.-C.C. and P.-Y.L. wrote the paper.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Veneziani, M. Posterior indirect adhesive restorations: Updated indications and the morphology driven
preparation technique. Int. J. Esthet. Dent. 2017, 12, 204–230. [PubMed]
2. Angeletaki, F.; Gkogkos, A.; Papazoglou, E.; Kloukos, D. Direct versus indirect inlay/onlay composite
restorations in posterior teeth. A systematic review and meta-analysis. J. Dent. 2016, 53, 12–21. [CrossRef]
[PubMed]
3. van den Breemer, C.R.G.; Ozcan, M.; Cune, M.S.; van der Giezen, R.; Kerdijk, W.; Gresnigt, M.M.M. Effect
of immediate dentine sealing on the fracture strength of lithium disilicate and multiphase resin composite
inlay restorations. J. Mech. Behav. Biomed. Mater. 2017, 72, 102–109. [CrossRef] [PubMed]
4. Morimoto, S.; Rebello de Sampaio, F.B.; Braga, M.M.; Sesma, N.; Ozcan, M. Survival rate of resin and
ceramic inlays, onlays, and overlays: A systematic review and meta-analysis. J. Dent. Res. 2016, 95, 985–994.
[CrossRef] [PubMed]
5. D’Arcangelo, C.; Vanini, L.; Casinelli, M.; Frascaria, M.; De Angelis, F.; Vadini, M.; D’Amario, M. Adhesive
cementation of indirect composite inlays and onlays: A literature review. Compend. Contin. Educ. Dent. 2015,
36, 570–577. [PubMed]
6. D’Arcangelo, C.; Zarow, M.; De Angelis, F.; Vadini, M.; Paolantonio, M.; Giannoni, M.; D’Amario, M.
Five-year retrospective clinical study of indirect composite restorations luted with a light-cured composite
in posterior teeth. Clin. Oral Investig. 2014, 18, 615–624. [CrossRef] [PubMed]
Dent. J. 2018, 6, 54 7 of 7

7. da Veiga, A.M.; Cunha, A.C.; Ferreira, D.M.; da Silva Fidalgo, T.K.; Chianca, T.K.; Reis, K.R.; Maia, L.C.
Longevity of direct and indirect resin composite restorations in permanent posterior teeth: A systematic
review and meta-analysis. J. Dent. 2016, 54, 1–12. [CrossRef] [PubMed]
8. Gresnigt, M.M.; Ozcan, M.; van den Houten, M.L.; Schipper, L.; Cune, M.S. Fracture strength, failure type
and weibull characteristics of lithium disilicate and multiphase resin composite endocrowns under axial and
lateral forces. Dent. Mater. 2016, 32, 607–614. [CrossRef] [PubMed]
9. Belli, R.; Geinzer, E.; Muschweck, A.; Petschelt, A.; Lohbauer, U. Mechanical fatigue degradation of ceramics
versus resin composites for dental restorations. Dent. Mater. 2014, 30, 424–432. [CrossRef] [PubMed]
10. Cao, L.; Zhao, X.; Gong, X.; Zhao, S. An in vitro investigation of wear resistance and hardness of composite
resins. Int. J. Clin. Exp. Med. 2013, 6, 423–430. [PubMed]
11. Moraes, R.R.; Gonçalves, L.S.; Lancellotti, A.C.; Consani, S.; Correr-Sobrinho, L.; Sinhoreti, M.A. Nanohybrid
resin composites: Nanofiller loaded materials or traditional microhybrid resins? Oper. Dent. 2009, 34,
551–557. [CrossRef] [PubMed]
12. Alharbi, A.; Rocca, G.T.; Dietschi, D.; Krejci, I. Semidirect composite onlay with cavity sealing: A review of
clinical procedures. J. Esthet. Restor. Dent. 2014, 26, 97–106. [CrossRef] [PubMed]
13. Torres, C.R.G.; Zanatta, R.F.; Huhtala, M.; Borges, A.B. Semidirect posterior composite restorations with a
flexible die technique: A case series. J. Am. Dent. Assoc. 2017, 148, 671–676. [CrossRef] [PubMed]
14. Papazoglou, E.; Diamantopoulou, S. The modified semidirect onlay technique with articulated elastic model.
Eur. J. Prosthodont. Restor. Dent. 2015, 23, 207–212. [PubMed]
15. Cura, M.; Gonzalez-Gonzalez, I.; Fuentes, V.; Ceballos, L. Effect of surface treatment and aging on bond
strength of composite resin onlays. J. Prosthet. Dent. 2016, 116, 389–396. [CrossRef] [PubMed]
16. Hummel, S.K.; Marker, V.; Pace, L.; Goldfogle, M. Surface treatment of indirect resin composite surfaces
before cementation. J. Prosthet. Dent. 1997, 77, 568–572. [CrossRef]
17. Kaidonis, J.A.; Ranjitkar, S.; Lekkas, D.; Brook, A.H.; Townsend, G.C. Functional dental occlusion: An
anthropological perspective and implications for practice. Aust. Dent. J. 2014, 59 Suppl 1, 162–173. [CrossRef]

© 2018 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).