FUNDAMENTAL RESEARCH In Vitro Evaluation of Marginal and Internal Adaptations of Ceramic Inlay Restorations Associated with Immediate vs Delayed Dentin Sealing Techniques Linah M. Ashy, BDS, DMSc ‘DRBBA Research Group, Department of Oral and Maxillofacial Prosthodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia Hanadi Marghalani, BDS, MSc, PhD , ‘DRBBA Research Group, Operative and Esthetic Dentistry Division, Restorative Dentistry Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia Nikolaos Silikas, BSc, FADM, MPhil, PhD Schoo! of Dentist, The University of Manchester, Manchester, United Kingdom, Purpose: To investigate the marginal and internal adaptations of ceramic inlay restorations placed with immediate dentin sealing (DS) vs delayed dentin sealing (DDS) procedures. Materials and Methods: Mesial and distal Class Il cavities were prepared in 12 extracted molar teeth, which were randomly allocated into six groups of 2 teeth each. Lava Ultimate inlays were fabricated and luted to the cavities using All-Bond Universal adhesive system and eCEMENT dual-curing resin cement folowing IDS/immediate cementation (control groups 1 and 2), 1DS/delayed cementation (groups 3 and 4), or DDS/delayed cementation (groups 5 and 6) protocols. Teeth in groups 2,4, and 6 were subjected to thermacycling of 500 cycles between 5°C and 58°C after inlay cementation. Following staining with siver nitrate solution, the marginal and internal gap volumes were determined using microcomputed tomography images. Statistical analyses were conducted Using independent t test and one-way analysis of variance followed by Tukey post hoc test (P< 05). Results: Marginal gap volume for DDS (1.856 £ 0.323 mrn?) was significantly higher than that of IDS immediately after inlay cementation (0.891 0.281 mm?) (P = .025). Following thermocyciing, the internal gap volume for DDS (0.838 + 0.248 mm) was significantly higher than that for IDS (0.098 + 0,066 mm®) (P = .000), but the marginal gap volume of DDS (1.964 + 0.956 mm?) was not significantly different from that of IDS (1.426 0.725 mms) (P= .622). Conclusion: Luted ceramic inlays have a superior marginal adaptation right after cementation and a superior internal adaptation after thermocycling when using the IDS technique compared to the DDS technique. However, marginal adaptation after thermocycling was not significantly different between the two techniques. Int J Prosthodont 2020;33:48-55. doi 10.11607ijo.6372 mmediate dentin sealing (IDS) has been described as the sealing of dentinal tubules with filed adhesive resin immediately after tooth preparation.’ This procedure involves the application of a dentin bonding agent to freshly cut dentin directly after tooth preparation and prior to impression-making for indirect restorations. Alternatively, delayed dentin sealing (DDS) includes the application of a dentin bond- reece Detinh Ay ing agent to a previously cut dentin surface at the time of luting the indirect restora~ SeeminensOvlend ton, 1DS has been assumed 1 result in superior bond strenath, less gap formation, Mesto te decreased bacterial leakage, and reduced dentin sensitivity when compared to DDS. Kgs ey ‘The potential benefits of the IDS protocol have been described in several studies.» 7 Jeotah 21589, Saudi Arabia In two studies on extracted molar teeth, the tensile bond strength was reported to eae aposteate be significantly improved following the IDS protocol regardless of the ceramic inlay system (Ceramco 2 or IPS Empress 2°) or the adhesive system (total-etch ar self-etch Samide 22.208 adhesives) used. Another study evaluated fracture under shear force using different ate by Gurucacre types of dentin bonding agents and concluded that IDS showed higher shear bond Publting Cone strength when compared to DDS." ‘The International Journal of Prosthodontics © 2019 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER,Table 1_ Materials Used Ashy etal Material Product name Composition Manufacturer CADICAM la Utimate _Nanoceramic resin ceramic (80%), Bi-GMA, UDMA, BisEMA, TEGDMA with 3M ESPE restorative block slica nanomers (20 nm), ztconia nanomers (411 nm), nantocuste parties ‘derived from the nanomers (06-10 ym), and silane coupling agents Temporary ‘Systempiinlay __Monofunctional ethyl riycol methacrylate, pohester urethane methacrylate; oclar restorative material prepolymerges dimethacryates, pyrogenic sci acd fils, catalyst, abies, Vivadent trclosan 0.3 < 19, and mequindl 0.1 < 0.3% Etchant Select HV etch 35% phosphoric acid with Benzalkonium chlorde isco. Dentin bonding _AllBond Universal 209%-50%e bisphenol Agcy! methacyate, 30%-50% ethanol, Isc. adhesive stem 5%-259% MDP, 5%-25% 2-hyronyethy! methacrylate silane Porcelain Primer Coupling agent isco Resin cement ___eCEMENT Dualcuring resin cement asco Several other studies have investigated the mar- ginal integrity at the dentin-resin interface after a resin-coating procedure whereby the dentin is cov- ered with a bonding system and a low-viscosity com- posite immediately after tooth preparation and before impression-making for indirect ceramic restorations." Schenke demonstrated that when luting ceramic inlays, the resin coating technique using Panavia resin cement with Clearfil SE Bond and Protect Liner F resin coating (Kuraray) resulted in a lower marginal leakage at the dentin-resin interface than a conventional luting tech- nique, although the marginal seal of the self-adhesive resin cement RelyX Unicer (3M ESPE) was reported to be the best." Consistently, Kitamaya reported in 2011 that a resin coating technique using a combination of a hydrophobic dentin bonding system (Clearfil Protect Bond, Kuraray) and a flowable resin composite (Clearfil Majesty Flow, Kuraray) with cementation using Clearfil Esthetic Cement was effective in reducing microleakage at the tooth-resin interface of Class Il computer-aided design/computer-assisted manufactured (CAD/CAM) ceramic inlays, whether loaded or unloaded? To the authors’ knowledge, comparative data on the marginal and internal adaptations associated with IDS vs DDS techniques for indirect ceramic inlays are scarce, Therefore, the aim of this study was to further investi- gate the marginal and internal adaptations of the ce- ramic inlay restoration with IDS vs DDS techniques using microcomputed tomography (UCT) technology. The null hypothesis tested was that the IDS and DDS techniques would result in the same extent of marginal and internal gap formation at the tooth-resin interface of all ceramic inlay restorations. The specific objectives were 1. To compare marginal and internal gap formation at the tooth-ceramic inlay restoration interface immediately following inlay cementation between the IDS and DDS techniques 2.To compare marginal and intemal gap formation at the tooth-ceramic inlay restoration interface after a period of thermocycling between the IDS and DDS techniques 3. To compare marginal and internal gap formation at the tooth-ceramic inlay restoration interface in both IDS and DDS techniques before and after a period of ‘thermocycling MATERIALS AND METHODS Sample Preparation Twelve freshly extracted human molars were included in this study. The teeth were extracted at the oral surgery department of the Faculty of Dentistry at King Abdu- laziz University after the patients signed an adequate in- formed consent (048-04-17). After debriding the teeth from soft tissue and hard calculus, they were ultrasoni- cally cleaned for 5 minutes, and half of the roots were cut using a low-speed diamond saw ('somet Buehler Samples were then stored in distilled water. Cavity Preparation Two Class Il cavities of approximately 4-mm buccolin- gual width, 4-mm occluso-gingival height, and 3-mm mesio-distal depth (considering 2-mm depth at the Gingival seat) were prepared separately on the mesial and distal aspects of each tooth using a high-speed handpiece with a cylindrical rounded-end diamond bur (Brasseler. Inlay Fabrication Cavities were digitally scanned using CEREC Bluecam chairside digital scanner (Dentsply Sirona), and inlays were milled from Lava Ultimate resin nanoceramic CAD/ CAM blocks (REF no:3312AI-HT, 3M ESPE) using CEREC MC XL in-office miling machine (Dentsply Sirona). The materials used in this study are listed in Table 1. Volume 33, Number 1, 2020 49 © 2019 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER,Fundamental Research © Mesial and distal cavity preparation > Dentin sealing * Ceramic inlay restoration * Provisional restoration td Thermocyciing Control groups 105 groups DS groups Group _Group 2 | Group3 Group | Group 5 Group 6 6g =i oc) od i 1 Siver nitrate staining + microcomputed tomography scanning Fig 1 lusration of study protocol study Groups Teeth were randomly allocated into six groups of two teeth each. For con- trol group 1, dentin sealing and cementation of Lava Ultimate inlays were performed immediately after cavity preparation. For control group 2, the same technique was followed, in addition to thermocycling after inlay ce- mentation. For group 3 (IDS group), dentin sealing was performed imme- diately after cavity preparation, while the cementation of inlays was carried out after thermocycling. For group 4, the same technique as in group 3 was followed, in addition to thermocycling after inlay cementation. For group 5 (ODS group), both dentin sealing and the cementation of inlays were per- formed after thermocycling. For group 6, the same technique as in group 5 was followed, in addition to thermocycling after inlay cementation. For ‘groups 3 through 6, temporary restorations (Systemp inlay, Lot No: U17750, Ivoclar Vivadent) were placed in the prepared cavities during the period of time before cementation of the ceramic inlay restorations. The protocol of the study is illustrated in Fig 1 Dentin Sealing and Inlay Cementation For dentin sealing, whether immediate or delayed, total etching of the cavi- ties was performed with 35% phosphoric acid etchant for 15 seconds, fol- lowed by rinsing with water for 30 seconds and a brief air flushing. Then, ‘two coats of All-Bond Universal dentin bonding agent (BISCO) were ap- plied and scrubbed with a microbrush for 10 to 15 seconds, air dried for 10 seconds, and then light cured with Elipar LED curing unit (3M ESPE) of 1,200 mWiem? for 10 seconds and calibrated by an external light meter (Pujing, DCO2). For temporization, cavities were gently air dried. Liquid- strip glycerine gel (lvoclar Vivadent) was applied to the cavity to isolate the sealed dentin, an adequate amount of Systemp.inlay temporary material ‘was placed into the cavity, excess material was removed, and the filing was contoured and then light cuted for 10 seconds. This temporary material is highly elastic; therefore, it was easily removed after curing in one piece by inserting a probe into the material and pulling it out of the cavity without, 50 The international Journal of Prosthodontics damaging it. For luting the Lava Ultimate ceramic inlays, one coat of porcelain silane primer (BISCO) was applied to the fitting surface of each restoration and allowed to settle for 30 seconds before air dry- ing for 5 seconds. Then, eCEMENT adhesive dual-curing resin cement (Lot No: 1500007181, BISCO) was applied to the fitting surface, after which the inlay was placed into its corresponding cavity and the excess cement was removed. The cement was cured for 40 seconds from each aspect for a total time of 120 sec ‘nds for each inlay. Each luted res- ‘oration was then finished with fine diamond burs (Brasseler) and pol- ished using a polishing rubber cup. Thermocycling Thermocycling was performed for groups 2 through 6 after inlay ce- mentation (Fig 1). Thermocycling ‘of 500 thermal cycles between 5°C and 55°C was carried out in a wa ter-bath thermocycler (THE-1100, SD Mechatronik) with a dwell time of 15 seconds in each bath and a transfer time of 5 seconds, Mounting and Sealing of Teeth The roots of the teeth were mounted in an acrylic resin mount (Orthodon- tic Resin Caulk, Dentsply) prepared by Using a custom-made rubber silicon mold (Exafast putty, GC America). The coronal part of the samples was covered with nail polish (Revlon), leaving a distance of ~1 mm around the tooth-restoration interface. This allowed the siver nitrate to pen- ‘trate the interface through the in- terfacial gap and not through other ‘cracks on the crown surface. Silver Nitrate Staining Toallow a siler nitrate stain to pen- trate into possible interfacial gaps at the tooth-inlay interface, samples were submerged in a 50 wt% silver nitrate solution (AgNO, 50% by weight) for 24 hours. Ammonical silver nitrate was prepared by dis- solving 25 g of silver nitrate crystals © 2019 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER,(Sigma Chemical) in 25 ml of distilled water. A concen- trated (28%) ammonium hydroxide Gigma Chemical) solution was used to titrate the black solution until it became clear as ammonium ions complexed the silver into diamine silver ions ([Ag (NH,),}4). This solution was diluted to 50 mL with distilled water, giving a 50 wt% solution (pH = 9.5). The time point of AgNO, staining is presented in Fig 1 UCT and Image Analyses Samples were scanned after submersion in the silver nitrate solution (Fig 1). Scanning of samples was per- formed using SkyScan 1172 CT scanner (Bruker ri- croCT, Kartuizersweg 38). The scanning parameters used were: 100 kV, 100 uA, 830 ms of exposure, angle of rotation = 0.600 degrees, 720 projections, and 2 frames per projection. The total scanning time for each sample was approximately 2 hours and 30 minutes. NRecon (version 1.6.7.2; SkyScan) and Data Viewer soft- ware (version 1.5.2.4 64-bit, SkyScan) (Bruker, Microt) were used for the 3D reconstruction of acquired CT images and image visualization, respectively. Microleakage and Internal Void Volume Measurement To segment the silver nitrate stain, multi-level threshold- ing feature in 3D was applied to the dataset to identify different density phases with a high gray level for high- density subjects. The 3D volume of the internal voids and the silver nitrate penetrant at the interface between the inlay restoration and its corresponding cavity sur- face were calculated using CT-analyzer software. Statistical Analyses The data were analyzed using independent t test and one-way analysis of variance (ANOVA) followed by post hhoc multiple comparisons Tukey test using IBM SPSS Statistics version 22 software. The level of statistical sig- nificance for both was set at P <..05. RESULTS The means and standard deviations (SDs) for the vol ume of silver nitrate penetrant (the marginal gap vol- lume) and the volume of internal voids (the internal gap volume) for different adhesion techniques are present- ed in Table 2. P values for comparisons between differ- ent adhesion techniques for marginal and internal gap volumes are presented in Table 3. UCT images of luted Ceramic inlays are shown in Fig 2. Marginal and internal Gap Volumes Immediately After Inlay Cementation Marginal gap volume for DDS/delayed cementa- tion (group 5) was significantly higher than both IDS/ Ashy etal Table 2 Marginal and internal Gap Volumes for Different Adhesion Techniques Marginal gap Internal gap volume (mm'), volume (mm), Study groups. mean SD ‘mean # SD Group 1 (SAC) VoI2s0632 035120176" Group 2(DSACITC) —1.54420.684° 0,240 20.152" Group 3 (09/0C) 0891 +0281" 0.063 + 0.075" Group 4 (DSCC) 1.42620.725 0,098 + 0.066" Group S(ODSOC) 1185620323" 0323 20.193" Group 6(ODSIOCITC) _1.96420.956 0838 + 0.248" Superscipt tars nicate homogenous subsets withn which P> 05) ‘ere comparison as been mage with expect testy OUP IDs =immedate dentin sealing: Ic = inmedate cementation delayed dentin Seng, DC = delayed ceretationT hermocyting SD =standard dora. Table 3. P Values for Comparisons Between Different Adhesion Techniques for Marginal and Internal Gap Volumes ‘Marginal gap Study group volume: Groups 15355 os" Groups 2 v5 4¥5 6 622 Groups 1 vs2 297 Groups 3 vs4 218 Groups 5 56 Bai 015" Pe 05 immediate cementation (group 1) (P = .057) and IDS/ delayed cementation (group 3) (P = .031), Internal gap volume, on the other hand, did not differ significantly among groups 1, 3, and 5 (P= .059) (Fig 3). Marginal and internal Gap Volumes After Thermocycling Marginal gap volume after thermocycling was not sig- nificantly different between the different adhesion techniques; however, the internal gap volume for DDS/ delayed cementation/thermocycling (group 6) was signif- icantly higher than that of !DS/immediate cementation! thermocycling (group 2) (P = .002) and IDS/delayed ce- mentation/thermocycling (group 4) (P = .000) (ig 4). Effect of Thermocycling on Marginal and Internal Gap Volumes There was no statistically significant difference be- tween the marginal and internal gap volumes before and after thermocycling for the IDS/immediate cemen- tation technique (group 1 vs 2) (Fig 5) or for the IDS/ delayed cementation technique (group 3 vs 4) (Fig 6). However, a statistically significant difference was found in the internal gap volume for the DDS/delayed cemen- tation technique (group 5 vs 6; P = .015) (Fig 7). Volume 33, Number 1, 2020, © 2019 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER, 5152 restoration (0 Group 3 ID! dimensional yCT images of luted ceramic inlay restorations showing the marginal and internal gaps atthe up 1 immediate dentin sealing []DSVimmediate cementation IC). (b) Group 2(IDS/C/thermocycing I (Group 4 (IDS/IC/TC).) Group 5 (delayed dentin sealing [DDS/0C). (9 Group 6 (D enti, The adhesive layer may contain a vod (solid arow) or ser stain precipitation or deposits (dotted arro interface, TC). ln = inlay rs entation I enamel: Dn celayed ca tration; En f the indirect restoration all performed at the same visit. IDS groups imitate 2 clinical situation The rationale behind the different groups in this study where the patient is provided with cavity preparation, was to simulate distinct clinical settings. Control groups dentin sealing, and a provisional restoration in a single simulate a clinical situation where the patient is pro- visit, then the permanent indirect restoration is luted vided with a cavity preparation, dentin sealing, and on a following visit. Finally, DDS groups represent a ‘The Intemational Journal of Prosthodontics © 2019 BY QUINTESSENCE PUBLISHING CO, INC, PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER,Ashy etal Hiviarsina gap ivircial gap [Binternal void Biinterna void 25 35 e 30 20. £ = 2s z's a 220 Zio Bis | z 210 Sos: Bos ‘ . ° ° 1osic vos/oc Dose TDsic7Te SNC _pDSIBCITE Adhesion technique Adhesion technique Fig 3 Mean and standard deviation volume of marginal gap and intemal vod volume for afferent adhesion techniques post-inlay cementation. *P <.05 between groups. Fig 4 Mean and standard deviation volume of marginal gap and internal vod volume for alifferent adhesion techniques post-ilay thermocyclng. *P<.05 between groups. Wi viarial oap Wiviacinal oop Bivacial oop DBimernal void [Bineral void [Bireral void 25 25 35 € . 30 E20 $20 < £ £ a2 es Es £20 310 310. Bis + 5 3 gio Gos Bos Bs : ° ° °. rosie iosnete isc IoS/C/TE Dosoc _DDS/DC/TE Adhesion technique Adhesion technique Adhesion technique Fig5 Mean and standard deviation vol- tume of marginal gap and internal void for immediate dentin sealing (D5Yimmediate cementation ((C) before and after thermo- oycing 10), ing (70), common clinical practice whereby the patient is treated with a cavity preparation and a provisional restoration in the first visit followed by a second visit for dentin sealing and cementation of the indirect restoration. The required sample size here was calculated based on the reported mean and SD of mean microleakage vol- ume (mm) among microhybrid composites, preheated microhybrid composites, and flowable composites in Zavattini et a Assuming an alpha of .05 and a power of 80%, the sample size required for this study was a total of 12, The current study indicates that luted ceramic in- lays have a superior marginal adaptation right after cementation and a superior internal adaptation after Fig6 Mean and standard deviation vol- ume of marginal gap and internal void for immediate dentin sealing (DSivielayed ce- mentation (DC) before and after thermocy- Fig7 Meanand standard deviation volume (of marginal gap and internal void volumes for delayed dentin sealing (ODSVdelayed cementation (DC) before and after thermo- cycing (TC). #°< 05 between groups ‘thermocycling when using the IDS technique compared to the DDS technique. Although no studies were found in the literature inspecting the adaptation of indirect res- ‘orations using IDS vs DDS techniques except for reports on fracture mode after cyclic loading,'*-" the results of this study on the improved marginal and internal adap- tation of the IDS technique can be supported by several previous studies reporting on the improved microtensile bond strength’®-%" and shear bond strength?" associ- ated with the IDS technique. Moreover, while control groups 1 and 2 showed larger gap volume values than those of the IDS groups 3 and 4, respectively (Table 2), this difference was not statistically significant, and so a superior seal in the IDS groups over the control groups Volume 33, Number 1, 2020. 53 © 2019 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER,Fundamental Research cannot be concluded. Therefore, comparable marginal and internal gap volumes between these respective ‘groups is suggested for the current sample size. This study also concludes that the marginal adapta- tion after thermocycling was not significantly different between IDS and DDS techniques, emphasizing the ef- fect of the aging process on the reduction of the dif- ference between these tested groups. In line with this result, a report by Ferreira-Filho et al has shown that the rmicrotensile bond strength is largely related to the dura- tion of aging of luted samples, as IDS groups presented higher bond strength than the DDS group only within 7 days of water storage but did not differ significantly after 3 months of the same condition 2? Thetmocycling was performed to simulate the ther- mal effect of the oral environment on the restorations during the provisional phase and after cementing the indirect restoration. Changes in temperature during the process of thermocycling will result in dissimilar dimen- sional changes of the resin cement filers and matrix phases, creating intemal stresses and possible micro- cracking.25 In the present investigation, a significant increase in the internal void volume was detected in the DDS group as a consequence of thermocycling. Several previous studies have demonstrated the negative effect of thermocycling aging on resin cements.27-29 A recent study by de Oliveira et al concluded that thermocycling significantly reduced the microtensile bond strength of CADICAM fiber-reinforced composite using a conven- tional three-step adhesive system, All-Bond 3, with C&B self-curing adhesive resin cement.2° Another study by Nalcaci and Ulusoy showed that thermocycling aging of 10,000 cycles can significantly increase the micro- leakage of resin composites (hybrid resin composite Feltik 2250 and flowable resin composite Feltik flow) bonded to dentin surfaces." Nevertheless, in the pres- ent study, thermocycling of 500 thermal cycles between 5°C and 55°C did not result in a significant change in the before-and-after marginal and internal gap volumes of luted inlays in the IDS group. This could be related to the frequency of cycles used in the present study, which \was probably insufficient for producing a significant dif- ference in the IDS groups. Consistent with this rational- ization, a study by Leesungbok et al demonstrated that a minimum of 7 days of 1,500 thermal cycles for an im- mediately sealed dentin surface is needed to decrease the mean bond strength of IPS Empress ceramic discs bonded to a dentin surface with All-Bond 2 adhesive system and Duo-Link resin cement. 22 The current investigation includes some shortcom- ings. First, the sample size could have been increased to detect reliable significant differences among groups Second, the number of thermal cycles could have been amplified and implemented under cyclic loading to bet- ter represent the actual clinical situation 54 The international Journal of Prosthodontics CONCLUSIONS Within the limitations of the present in vitro investiga~ tion, the following can be concluded: * The IDS technique results in a smaller marginal gap volume at the tooth-restoration interface than the DDS technique immediately after cementation, but not after thermocycling of the luted indirect ceramic restoration. * Thermocycling results in a bigger internal gap formation with the DDS technique than with the IDS technique. + Thermocycling does not result in a significant increase of either the marginal or internal gaps with the IDS technique. * Thermocycling results in a significant increase of the internal gaps but not the marginal gaps with the DDS technique. ACKNOWLEDGMENTS This project was funded by the Deanship of Scientific Research (DSR) at King Abdulazic University, Jeddah, under orant no. (RG-1-165-37) ‘The authors, therefore, acknowiedge with thanks DSR for technical {and financial support. The authors do not have any financial interest in ary product, service, andor company included inthis arti REFERENCES 1. Bestschinge , Pau, ath H SchirerP.Dua application of dentin bonding agers fect on bond strength. Am | Dent 19963:115-119. 2. Faull Scharer The dual bonding teceique: A mostied method to improve adhese luting procedzes, nt) PeridontisRestorave Dent 1997 17536-545, |. Jayasora Pr, Perera PN, Niksido Turow MF, Tagan. Te effect of ‘sin coating onthe interfacial adaptation of cps inlays. Oper Dent 2003:28:28-35, 4, Magne immediate dentin sealing: fundamental procedure for ind rect bonded testrations, J Esthet Restor Dent 200517 144-154, 5. anungoA, Aras MA, Chive V Mysore A, Ain B, Dasani SR. Immed- ‘ate dertn sealing for indvec bonded restorations. rsthodont Res 2016;60240-249, 6 Magne P. Kim TH, CascioneD, Donovan TE. Immediate dentin sea ing improves bond strength of indirect restorations. | rsthet Dent 200598511-519, 7. Hu, Zhu Q.ffect of immediate dentin sealing on preventive veatment {or postementtin hypersenstty Int] Pesthosont 2010734952 {8 Oaturk Hi Aykert Dentin bond strengths of two ceramic inlay systems ‘after cementation wth three eiferent techriques and one bonding system. J Prosthet Dent 2003:89275-281 9. Duarte, de reas CR Sad IR, Sadan A. The effec of immedate ‘entn sealing onthe margral adaptation and bord strengths af toa ‘ch and seltetch adhesves. J Prosthet Dent 2009,1025-9, 10, Chai ¥5, Chol An effect of mmecate dentin eling onthe shear bond stength of ren cement a porcelain restraton | Ad rostho sont 20102 38-48, 11, Schenk, ilrk, Schmat , Feder M. Magna ntgrty of partial ‘ceramic crows tin dentin wth ferent tng techninues and mate fils Oper Den 200833 516-525, © 2019 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER,Ashy etal 12. Kitayama 5, Nasser NA, Packie al: lect of sn coating and 22, Leesungbok Lee SM, Pak), e a. The effet of DS immediate den- ‘occa loading an mioleskage of Clas comnpueaided des tin sealing on detn bond strength under various thermocying ‘computer-aided manufacturing fabreated ceramic restorations periods. 1 Ad Prosthodo: 20187224-232, ‘confocal mioscopc study. Acta Odontol cand 201,69182-192. 23, Fear RC, €lyC, Amaral RC, et al Effect of diferent adhesive 13, Zatti MancinM, Higginson |, osc Pasquatoni G, Mangan systems use for imimedat dentin sealing on bond sength of se F Mico-comtes tonogtnhy evaluation of mioleakage of Clas dahesve ein cement to dentin, Oper Dent 20183 391-397, composite estrations An vivo study Eu Jen 2018.12 368-374, 24. Blumer L_ Schmid WeigeR Fischer A systematic approach stan 14 Daly Elakwa A, Mil 8, Marin FE. Inluence of immediate dn dardice aici aging of sn composite cements. Dent Mater 2015;31 ‘inseaing on the shear bond stength of pressed ceramic luted to dentin 855-63, with sete resin cement nt J Dent 2012:2012 310702, 25, Kono, OhguiT,Ievkawe T, Masumoto lence of thea 15, Gresigt Ml, Cure MS, de Roos 1G, Oxcon M. ect of immediate es in water on fexaal stenah of abort processed compasite and delayed dentin sealing onthe fracture strength, ale type 2nd resn, | Oral Rehabil 2001 28:703-707, \Wetbul characters of Ithum dicate laminate veneers, Dent Mater 25, Vers A Douglas WH, Sakaguchi RL Thermal expansion cetficen of 2016;32473-«81, dental composites measured vith stain gauges, Dent Mater 199612: 16, Santana VB, de Alexandre RS, Rodiques A, Ely, Res AF. eects of 290-254 Immediate dentin eng and pulpal pressure on vesin cement bond _-27.-RohN Fischer. Efecto aging andcuing mode on the compressive strength and nanoeskage. Oper Dent 20164:189-199, and nrect tere stength of resin compost cements, Head Face Med 17, Murata Mase T, Nara. fect of immediate dentin sealing appca- povta2. ‘ons on bonding of CADICAMA ceramic onay restoration Dent Mater) 28, omar N, Saburan P, Chifoush N, Karaaloré Mi, Hashemkaman- 201837928-9, gar. tect of themocyeing an surface resent on repair bond 18. Ishi Masel, Nara . Bonding tate of meta iee CADICAM onlay Strength of compost) Clin Exp Dent 2017, 92948-e951 restraton after jcc loosing wth and without immetiat dertn seal- 29, Bedrande-Castro AK, Perera PN, Penta LA, Thompson J. fect of ‘ng, Dent Mater 2017:36357-367, thermal and mechanical load cycling on microtensle Bond strength ofa 19, Hionaka NGL, Ubaliin ALM, at, Garin, Teada RSS, Pascotto toualetch adhesive system Oper Det 2004.28 150-156, AC. Influence of immediate dann sesing andinteimcementation 30, de lier Lino, Machado CM, de Pala VG, eta. ect of aging and con the adhesion of rec restorations with dt polmerng resin testing method on bond strength of CADYCAN fiber reinforced compos Cement | Prosthet Dent 20181191678 e1-678 8 ite to dentin Dent Mater 2018 34:1680-170, 20, BrgaG30 VC, Bare LD, Goncaes KAS, et al Etec of interim cement 31, alae A, UlsoyN fect of themacycling on microlakage of sn application on bond sength between resin cements and dent m= composts polmenzed with LED curing techniques. Quintessence It ‘mediate and detajed dentin sealing J Prosthet Dent 2017117792798 2007;380433-0439. 21. Rou T Hoang Thal HA, Ceti, lash R.Comparson between shes forces applied on the overy-deta tse nerface sing oi ferent bonding tectniques: An nwt sty. nan Presthodent Soc 2018 18212-218 Literature Absvact Clinical Performance of Occlusal Onlays Made of Lithium Disilicate Ceramic in Patients with Severe Tooth Wear up to 11 Years ‘The aim ofthis study was to evaluate the sunival and complication rates of monolithic occlusal onlays made of lithium disiicate ceramic in patients with severe tooth wear for up 10 11 year of clinical sence. ina prospective nonrandomized clinical study, seven patients (four men, three women; median age 44.3 « 6.56 years old) underwent full-mouth restoration with 2 total of 103 adhesively bonded occlusal ‘onlays made of lithium dslicate ceramic (IPS e max Press, locarVivaden), Al restorations were examined during annual recall ists using Periodontal parameters (marginal discoloration; secondary cafes; marginal integrity surface texture; restoration fracture; and occlusal, wear) according tothe modified United States Public Health Service criteria ratings of Alpha, Bravo, and Charlie over an observation Period of up to 11 years (68 to 139 months; median 94:9 + 26.1 months). Data were statstically analyzed using Kaplan-Meter estimation. Monolithic lithium dsiicate occlusal onlays presented a 100% survival rate. Four restorations within one patient (3.9%) presented marginal discoloration, one after 60 and thre after 108 months (all rated Bravo). One restoration (195) showed a marginal crack formation (technical complication) after 120 months rated Bravo. No biologic complications, debonding, or secondary caries could be found, and tested periodontal parameters showed excellent results. Based on the analyzed data from up to 11 years, monolithic occlusal onlays made of lithium dislicate ceramic can be considered a reliable treatment option for full- mouth rehabilitation in patients with severe tooth wear. Edelhoff 0, Gth If ErdeltK, Brix O, Liebermann A. Dent Mater 2019;35 1319-1330, References 44, Reprints: A. Liebermann, anjallebermanntmedun-muenchen de Steven Sadowsy, USA Volume 33, Number 1, 2020. 55 © 2019 BY QUINTESSENCE PUBLISHING CO, INC. 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