CONTINUING EDUCATION 2

INDIRECT COMPOSITE RESIN RESTORATIONS

Adhesive Cementation of Indirect Composite

Inlays and Onlays: A Literature Review
Camillo D’Arcangelo, DDS; Lorenzo Vanini, MD, DDS; Matteo Casinelli, DDS; Massimo Frascaria, DDS, PhD;
Francesco De Angelis, DDS, PhD; Mirco Vadini, DDS, PhD; and Maurizio D’Amario, DDS, PhD

LEARNING OBJECTIVES

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sive systems has been to learn more about increased bond strength and simpli- .!/%*ƫ!)!*0ƫ#.+1,/ƫ
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necessary to obtain high survival and success rates of indirect composite resin.
Each step of the clinical and laboratory procedures can have an impact on longevity and the esthetic results of
indirect restorations. Cementation seems to be the most critical step, and its long-term success relies on ad-
herence to the clinical protocols. The authors concluded that in terms of survival rate and esthetic long-term
outcomes, indirect composite resin techniques have proven to be clinically acceptable. However, the correct
management of adhesive cementation protocols requires knowledge of adhesive principles and adherence to
the clinical protocol in order to obtain durable bonding between tooth structure and restorative materials.

T
he proliferation of resin composites and adhesive sys-
tems has met the increasing demand for esthetic resto-
rations in both anterior and posterior teeth.1 Depending
on the respective clinical indication, resin composite
materials are suitable for both direct and indirect res-
torations.2 Although direct resin composites have replaced other
restorative options, there are a number of issues associated with
their use in the posterior region. These include: high polymeriza-
tion shrinkage; gap formation; poor resistance to wear and tear;
color instability; and insufficient mechanical properties.3 Direct
restorations can result in contact area instability, difficulty in gener-
ating proximal contour and contact, lack of marginal integrity, and
postoperative sensitivity.4 All of these factors impact the longevity
and clinical success of restorations.5-7 Despite efforts to reduce the
issue of marginal infiltration associated with direct techniques, to
date, no method has produced acceptable results.8,9
Posterior indirect restorations are widely used in modern re-
storative dentistry to overcome the problems resulting from direct
techniques.2 The adhesive concepts that have been used for direct
restorative procedures are now being applied to indirect restora-
tions and have been incorporated into daily practice.10 Indirect
composites offer an esthetic alternative to ceramics for posterior
teeth.10,11 The clinical performance of composite resin restora-
tions is comparable to ceramic restorations, but the relatively low
cost associated with composites has resulted in increased use of
composite resin-based indirect restorations in the posterior re-
gion.12-14 Ceramic materials exhibit a very high elastic modulus, thus
they cannot absorb most of the occlusal forces. Since polymeric

566 COMPENDIUM September 2015 Volume 36, Number 8

materials absorb a significant amount of occlusal stress, they should
be considered the material of choice.10,15
The success of adhesive restorations depends primarily upon the
luting agent and adhesive system.16 Several authors investigated the
properties of resin luting materials such as bond strength, degree of
conversion, and wear, in order to predict their clinical behavior.17-22
Among the parameters that may influence the clinical success of
indirect restorations is a proper degree of polymerization of the
resin luting agent, which should be taken into account.23 Moreover,
successful adhesion depends on proper treatment of the internal
surfaces of the restoration as well as the dentinal surface.2,16
This article discusses materials and techniques used in adhesive
cementation for indirect composite resin restorations.
The Adhesive Systems
A Historical Overview
Because the microscopic structure of two different contact surfaces
presents irregularities, an adherent is necessary. The introduction
of adhesive materials as alternatives to traditional retentive tech-
niques has greatly revolutionized restorative dentistry.24 In the
development of dental adhesives, the ultimate goal is to achieve
strong, durable adhesion to dental hard tissues.25 In 1955, Buono-
core showed how the treatment of enamel with phosphoric acid
increases the exposed enamel surface by producing micro-irregu-
larities on it, resulting in improved adhesion potential. The modern
concept of enamel bonding can be traced to his published findings.26
In 1965, Bowen formulated the first generation of dentinal ad-
hesive.27 The increasing interest in adhesion in dentistry led to the
development of four generations of adhesive systems, with the 4th
generation achieving good results for dentin bonding in the 1990s.28
Modern Adhesive Systems
The modern formulation of an enamel-dentin adhesive system
includes the following three components29:
Ċŋ Etchant—an organic acid with the function of demineralizing the
surface, dissolving hydroxyapatite crystals, and increasing free
surface energy.
Ċŋ Primer—an amphiphilic compound that increases the wettabil-
ity of the hydrophilic substrate (dentin) to a hydrophobic agent
(bonding or resin).
Ċŋ Bonding agent—a fluid resin used to penetrate the etched and primed
substrate and, after curing, to create a real and stable adhesive bond.
In order to obtain an optimal infiltration of enamel and den-
tin substrates, the ideal features of an adhesive material are: low
viscosity; high superficial tension; and effective wettability. The
fundamental requisite is wettability, which depends on the intrinsic
properties of fluid and dental substrate.30
The classification of the respective adhesive systems is based on
their etching characteristics and the number of steps they require.31
Etch-and-Rinse Systems—The etch-and-rinse technique is char-
acterized by the etching of the enamel and/or dentin with an acid
agent (orthophosphoric acid at 35% to 37%), which needs to be sub-
sequently washed away. The etch-and-rinse adhesive systems can be
www.compendiumlive.com
further classified into three-step and two-step systems. Three-step
systems require separate etching, priming, and bonding. Two-step
adhesives are instead characterized by an application of an etching
compound and then an agent that combines a primer and a bonding.
The etching application removes the smear plugs, demineralizes the
dentin, and exposes the intertubular dentin collagen fibers, obtaining
an ideal micromechanical anchor for the adhesive.32,33
Self-Etch Systems—Self-etch refers to an adhesive system that
dissolves the smear layer and infiltrates it at the same time, without
a separate etching step.31 The self-etch adhesives have been further
classified into two-step systems and one-step systems, which simul-
taneously provide etching, priming, and bonding.34
Self-Adhesive Systems—In the past few years, new resin cements,
so-called “self adhesives,” have been introduced. This particular
resin cement needs only to be applied on tooth substrate, without
any etching, priming, or bonding phases.35
Tooth Preparation
After caries and/or failed restoration removal, a cavity with slightly
occlusal divergent walls (5° to 15°) and round internal angles is
prepared by using decreasing grit (from 60–70 µm to 15–20 µm grit)
cylindrical round-ended diamond burs. Preparation margins are not
bevelled but prepared via butt joint.2 After cavity preparation and
before cavity finishing, adhesive procedures are performed36 using
a rubber dam in order to achieve an immediate dentin sealing.37,38
In keeping with rubber dam placement for subsequent restoration
placement, the interproximal margin must be supragingival. To
avoid a dual marginal leakage, no direct composite is used for gingi-
val margin rebuilding.39 If any deep subgingival margin persists after
cavity preparation—thus precluding proper rubber dam placement—
the feasibility of a surgical crown-lengthening procedure and/or an
orthodontic extrusion must be considered.40 A light-curing compos-
ite filling material is used to block out defect-related undercuts.2,41
The finishing phases are performed with diamond burs with a slight
taper and with silicone points (Table 1). The teeth are protected with
temporary eugenol-free restorations after impression making.42
TABLE 1
Tooth Preparation Phases for
Indirect Composite Resin
TOOTH PREPARATION
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September 2015 COMPENDIUM 567
CONTINUING EDUCATION 2 |  ƫ
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Dentin Treatments
Research on adhesive systems is focused mainly on increasing bond
strength and simplifying application. The application of phosphoric
acid increases the surface energy of the dentin by removing the
smear layer and promoting demineralization of surface hydroxy-
apatite crystals. The resin monomers, by means of the primer
agent’s amphiphilic properties, infiltrate the water-filled spaces
between collagen fibers, which results in a “hybrid layer” composed
of collagen, resin, residual hydroxyapatite, and traces of water. It
results in an ideal micromechanical anchor substrate for adhesive
systems on dentin.16,43,44
Immediate dentin sealing (IDS) is a strategy in which a dentin
bonding agent is applied to freshly cut dentin and polymerized
before making an impression.45 The recommended technique fo-
cuses on the use of the “etch-and-rinse” systems. Etching should
extend slightly over enamel to ensure the conditioning of the entire
dentin surface. The use of either two-step or three-step dentin
bonding agents is equally effective. Self-priming resins, however,
generate a more excess resin layer, which may extend over the
margin and require additional bur corrections. IDS can be imme-
diately followed by the placement of composite in order to block
out eventual undercuts and/or build up deep cavities, reducing
restoration thickness and ensuring the light-cured polymerization
of the luting agent. Finally, enamel margins are usually reprepared
before final impression to remove excess adhesive resin and pro-
vide ideal taper.45
When the preparation exposes no dentinal areas—eg, in
TABLE 2
Suggested Treatment for the Internal
Surfaces of Indirect Restorations
COMPOSITE RESTORATION SURFACE TREATMENTS
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veneered indirect restorations—neither immediate dentin seal-
ing nor primer agent applications are necessary, since the etching
and bonding phases ensure an optimal bond for enamel adhesion.46
Immediate dentin sealing should be followed by air blocking and
pumicing to generate ideal impressions.47 In-vitro studies have
shown increased bond strength for IDS versus delayed dentin
sealing (DDS) techniques.48-52 The IDS technique also eliminates
any concerns regarding the film thickness of the dentin sealant and
protects dentin against bacterial leakage and sensitivity during
the provisional phase of treatment.45 Moreover, it was suggested
that multiple adhesive coatings can improve the quality of resin-
dentin bonds.53
Surface Treatments for Composite Restorations
Several techniques have been suggested for increasing bond
strength, involving treating the internal surfaces of indirect res-
torations (Table 2).54,55 The surface treatments aim not only to
achieve a high retentive bond strength of the restoration, but also
to avoid any microbiological leakage.56 Composite surface treat-
ments are necessary for adhesion of indirect composite restora-
tions.57 Acid-etching with phosphoric acid, acidulated phosphate
fluoride, or hydrofluoric (HF) acid is one of the treatments reported
in literature.58-60
The internal surfaces of indirect restorations can be abrad-
ed with aluminium oxide, using an intraoral sandblasting de-
vice.58,59,61-63 Also, silane coupling agents are used as adhesion pro-
moters.64,65 Another method, the tribochemical coating, forms a
silica-modified surface as a result of airborne-particle abrasion
with silicon dioxide (SiO2)-coated aluminium particles. The sur-
face becomes chemically reactive to the resin by means of silane
coupling agents.63,66,67
Many studies show that Er:YAG laser treatment enhances bond
strength between composite and resin cement.68,69 Other studies
demonstrate no influence of laser treatment on bond strength.67,70
Roughening the composite area of adhesion, sandblasting, or
both sandblasting and silanizing can provide statistically significant
additional resistance to tensile load. Acid-etching with silane treat-
ment does not reveal significant changes in tensile bond strength.
Sandblasting treatment is the main factor responsible in improv-
ing the retentive properties of indirect composite restorations.57
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wTABLE 3
Recommended Clinical Protocol, According to Review Outcomes

DENTIN SURFACE COMPOSITE SURFACE CEMENTATION

TREATMENT
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568 COMPENDIUM September 2015 Volume 36, Number 8

Cementation
Resin cements are divided into three groups according to polym-
erization process: chemically activated cements, light-cured ce-
ments, and dual-cured cements.16,71 Of the three, light-cured resin
cements have the clinical advantages of longer working time and
better color stability, but curing time, restoration thickness, and
overlay material significantly influence the microhardness of the
resin composites employed as luting agents.46,72
Dual-cured resin cements have the advantages of controlled
working time and adequate polymerization in areas that are inac-
cessible to light. Conversely, they are relatively difficult to han-
dle.23,73,74 Photoactivation increases the degree of conversion and
surface hardness of dual-cured cements.75
Optimal luting of indirect restorations is dependent on the light
source power, irradiation time, and dual-cure luting cement or
light-curing composite chosen. Curing should be calibrated for
each material to address high degrees of conversion. Preheating
light-cured filled composites allows the materials to reach optimal
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fluidity.76-78 The suggested temperature for composite preheating
is 39°C.79 The necessary working time for positioning the indirect
restorations and removing the excess cement can be extended at
the discretion of the clinician, using a light-curing composite as
luting agent, thus overcoming the relatively restricted working
time allowed by dual-cure cements.2
Total-etching of dentin substrate is recommended as the first
step for the two- and three-step adhesive systems.80 To reduce the
number of operative steps and to simplify the clinical procedures,
self-etching adhesive systems, which do not require a separate
acid-etching step, have been introduced.81 Literature reports dem-
onstrate that multi-bottle systems with simultaneous etching and
rinsing show superior in-vitro and in-vivo activities compared to
the new all-in-one systems.44,82
The self-adhesive resins may be considered an alternative for
luting indirect composite restorations onto non-pretreated dentin
surfaces,83 even if bond strengths are lower than etch-and-rinse
systems.84,85 The etch-and-rinse technique provides more reliable
Fig 2.
Fig 4.
September 2015 COMPENDIUM 569
CONTINUING EDUCATION 2 |  ƫ
 ƫ ƫ
 

bonding compared to self-etch luting agents and self-adhesive An appropriate treatment of the fitting surface of the resin com-
luting agents when used to bond indirect composite restorations posite restoration and dentin substrate is necessary to establish
to dentin.22,86-88 a strong and durable bond.57
The constant use of rubber dam isolation is necessary for the It is recommended that the freshly cut dentin surfaces be sealed
cementation protocol with adhesive systems. Removing residual with a dentin bonding agent immediately following tooth prepa-
cement using explorers, scalpels, and floss before complete polym- ration, before taking impression.45 Immediate dentin sealing re-
erization, and a 15c scalpel after polymerization, is recommended sults in a high bond strength for total-etch and self-etch adhesives;
in order to avoid compromising restoration marginal accuracy, however, the microleakage is similar to that with conventional
compared to the use of burs, discs, or strips (Table 3).2 cementation techniques.49
When following a protocol of cementation using an adhesive
Discussion and Conclusions system, constant rubber dam isolation and careful hand finish-
Resin-based composites give predictable results in teeth res- ing are necessary to provide predictable clinical results (Figure
toration with respect to both mechanical and 1 through Figure 4).2
esthetic properties when they are used as indi- Supragingival margins facilitate impression
rect restoration materials.2 Indirect composites Resin cements are making, definitive restoration placement, and
make it possible to overcome some shortcom- divided into three detection of secondary caries.94 In addition,
ings of direct techniques. Indirect restorations— some studies have demonstrated that subgin-
ie, those created outside of the mouth—result groups according to gival restorations are associated with higher
in better proximal and occlusal contacts, better polymerization levels of gingival bleeding, attachment loss, and
wear and marginal leakage resistance, and en- gingival recession than supragingival restora-
hancement of mechanical properties compared process: chemically tions.95,96 Therefore, in all cases where rubber
to direct techniques. 6,85
activated cements, dam cannot be adequately placed, surgical
Since the dentin substrate has a high organic crown lengthening or orthodontic extrusion
content, tubular structure variations, and the light-cured cements, should be taken into account. Otherwise, tra-
presence of outward fluid movement, bonding and dual-cured ditionally cemented restorations are preferable
to dentin is a less reliable technique when com- to the use of adhesive procedures.
pared to enamel bonding.89,90 Bonding composite cements. Sandblasting of the composite surfaces has
restorations to tooth structure involves the den- been recommended as a predictable means for
tin/adhesive-cement interface and composite enhancing the retention between resin cements
restorations/cement interface.22 and indirect composite restorations.57,97 The ap-
Each step of the clinical and laboratory procedures can have plication of an appropriately selected adhesive material with proper
an impact on the esthetic results and longevity of indirect resto- technique will ensure predictable results and successful long-term
rations.91 Cementation is the most critical step and involves the clinical outcomes.
application of both the adhesive system and resin luting agent.92,93 Modified United States Public Health Service criteria are the
most complete and commonly used assessment techniques in clini-
Fig 5. cal trials on indirect composite restorations.37,98
XƫD’Arcangelo, et al, 2014 Ă QƫManhart, et al, 2001 āĀĀ
ƫBarone, et al, 2008 ć
Oƫeirskar, et al, 1999 āĀā As shown in Figure 5, restorations were evaluated at baseline and
VƫHuth, et al, 2011 ĊĊ ƫScheibenbogen-Fuchsbrunner, et al, 1999 102 after a follow-up period for secondary caries, marginal adaptation,
marginal discoloration, color match, anatomic form, surface rough-
100
 O  ness, endodontic complications, fracture of the restoration, fracture
90 X of the tooth, and retention of the restoration.2,6,99-102 In many of the
80 V reported follow-up studies, indirect restorative procedures were
70 carried out by dental students,99-102 and the main reasons for fail-
60 ures during the observation period seemed to be secondary caries,
50 endodontic complications, and fractures.1,2
The literature sources support the clinical acceptability of
40
indirect composite resin techniques regarding survival rate and
30
esthetic outcomes at up to 10 years’ follow-up.1,103 Adhesive cemen-
20 tation is a complex procedure that requires knowledge of adhesive
10 principles and adherence to the clinical protocol in order to obtain
0% durable bonding between tooth structure and restorative material.
24 months 36 months 48 months 60 months
DISCLOSURE
Fig 5. 1.2%2(ƫ.0!ƫ+"ƫ%* %.!0ƫ+),+/%0!ƫ.!/0+.0%+*/ƫ.!,+.0! ƫ%*ƫ
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0$!ƫƫ.%0!.%ċƫ The authors had no disclosures to report.

570 COMPENDIUM September 2015 Volume 36, Number 8

 ABOUT THE AUTHORS .+3*/Čƫ* ƫ.% #!/ċƫGen DentċƫĂĀĀćĎĆąĨĆĩčăāĀġăāĂċ
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Department of Restorative Dentistry, School of Dentistry, University G. D’Annunzio - .%(ƫ $!/%+*ċƫJ Prosthet DentċƫĂĀāĀĎāĀăĨąĩčĂĂāġĂĂĈċ
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Lorenzo Vanini, MD, DDS
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572 COMPENDIUM September 2015 Volume 36, Number 8

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Adhesive Cementation of Indirect Composite Inlays and Onlays: A Literature Review

Camillo D’Arcangelo, DDS; Lorenzo Vanini, MD, DDS; Matteo Casinelli, DDS; Massimo Frascaria, DDS, PhD;
Francesco De Angelis, DDS, PhD; Mirco Vadini, DDS, PhD; and Maurizio D’Amario, DDS, PhD

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1. Issues associated with the use of direct resin composites in the 6. After cavity preparation and before cavity finishing, adhesive
posterior region include: procedures are performed using a rubber dam in order to:
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ƫ ċƫ ƫ((ƫ+"ƫ0$!ƫ+2! ƫ ċƫ ƫ %//+(2!ƫ0$!ƫ$5.% ƫ(5!.ċ

2. While the clinical performance of composite resin restorations is 7. The application of phosphoric acid increases the surface
comparable to ceramic restorations, increased use of composite energy of dentin by removing the what and promoting
resin-based indirect restorations in the posterior region is a demineralization of surface hydroxyapatite crystals?
result of: ƫ
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ƫ ċƫ ƫƫ('ƫ+"ƫ,+/0+,!.0%2!ƫ/!*/%0%2%05ƫ//+%0! ƫ3%0$ƫ+),+/%0!/ċ
8. Immediate dentin sealing (IDS) is a strategy in which a dentin
3. An adherent is necessary because the microscopic structure of bonding agent is applied to freshly cut dentin and
two different contact surfaces presents: polymerized before:
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ƫ ċƫ ƫƫ(!*Čƫ/)++0$ƫ/1."!ċ ƫ ċƫ ƫ).#%*ƫ,.!,.0%+*ċ
ƫ ċƫ ƫƫ100ƫ&+%*0ċ ƫ ċƫ ƫ(/!.ƫ0.!0)!*0ċ

4. What is an organic acid that demineralizes the surface, dissolves 9. What is the main factor responsible in improving the retentive
hydroxyapatite crystals, and increases free surface energy? properties of indirect composite restorations?
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ƫ ċƫ ƫ(%#$0ġ1.! ƫ+),+/%0!ƫü((%*#ƫ)0!.%( ƫ ċƫ ƫ,1)%%*#

5. What refers to an adhesive system that dissolves the smear layer and 10. Light-cured filled composites can reach optimal fluidity by
infiltrates it at the same time, without a separate etching step? doing what to them?
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ƫ ċƫ ƫ!0$ġ* ġ.%*/! ƫ ċƫ ƫ,.!$!0%*#ƫ0$!)
ƫ ċƫ ƫ/!(!0%2!ġ!0$ ƫ ċƫ ƫ%.ƫ(+'%*#ƫ0$!)

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574 COMPENDIUM September 2015 Volume 36, Number 8