KEY WORDS Learning objectives author

Treatment planning, indirect • Revise clinical workflows in daily Dr Mahul Patel

restorations, tooth preparation,
conventional cementation, adhesive
bonding
general practice for provision of
indirect restorations
• Understand current material
properties that allow the clinician
to provide indirect restoration of
abutment teeth
• Understand the preparation and
restoration design in relation to the
materials used for the production
of indirect restorations
BDS, MJDF RCS (Eng), MSc RDP,
MSc ConsDent, MPros RCS (Ed)
Private practice, London; Specialty Dentist in
Prosthodontics, King’s College Dental Hospital;
Senior Clinical Teaching Fellow, UCL Eastman
Dental Institute; Senior Clinical Teacher, King’s
College London

Mahul Patel
Prim Dent J. 2019;8(3):48-63

Evolution of indirect restorations

for fixed prosthodontics: planning,
preparation and cementation
ABSTRACT
The provision of indirect restorations utilising contemporary materials for single or
multiple abutment units in primary health care is an essential requirement for all
general dental practitioners to ensure predictable patient outcomes. This paper
highlights the important considerations for comprehensive planning and adept
treatment execution and delivery that can enhance the patient’s dental experience
and outcome. A selection of clinical cases highlighting established and novel
restorative materials utilising conventional and adhesive clinical techniques is
presented and discussed.

Introduction patient are based upon the general

The aesthetic expectations of our
patients must be met by the required
clinical demands, and therefore,
dental restorations should be made to
optimum biomechanical functionality
but be conservative to the recipient
dental hard tissues. With the advent of
modern restorative materials, indirect
restorations may be used as the
preferred treatment of choice where
units are extensively damaged, and
the restorative correction is extensive.
The use of full veneer crowns may
be declining due to an increased
awareness of treatment approaches
utilising partial coverage restorations
and improved adhesive protocols.
Abutment tooth and indirect restoration
survival are symbiotic, and it is
assumed that the interventions for the
and local factors that determine tooth
prognosis and treatment success. It
is therefore essential that the treating
practitioner is aware of the current
material and treatment options with
regards to the indirect provision of
satisfactory aesthetic and functional
restorations as to ensure a treatment
delivery for long-term survival. This
may be challenging; it is therefore the
intention of this article that the reader
be given an insight into the planning
considerations for the restoration of
abutment teeth with indirect restorations.
It will present a decision-making
pathway for the provision of an
indirect restoration (Figure 1), highlight
available restorative material options
and describe contemporary treatment
techniques that may be utilised for
predictable treatment outcomes.

48 p r i m a r y d e n ta l j o u r n a l
 figure 1
DecisioN making pathway
Material selection
Metal restoration Patient’s wishes/clinician’s choice Tooth coloured restoration

Direct Indirect Indirect Semi-direct Direct

Amalgam COMPOSITE
Tooth Tooth
structure structure

CONVENTIONAL CONVENTIONAL
ADHESIVE ADHESIVE
Retention and HYBRID Retention and HYBRID
Resin bonding Resin bonding
resistance form resistance form

RESTORATION or RESTORATION or
PREPARATION PREPARATION
DESIGN DESIGN

Crown Onlay Crown Onlay Crown Onlay Crown Onlay

FVC PVC M.O.D FVC PVC M.O.D FVC PVC M.O.D FVC PVC M.O.D
no grooves
Gold Gold Gold Gold Gold Gold PFM PFM PFM LDS
PFM PFM PFM PFM Zirconia LDS RNC
COMPOSITE COMPOSITE
ZIRCONIA ZIRCONIA
Key:
FVC: Full Veneer Crown; PVC: Partial Veneer Crown (7/8 or 3/4); M.O.D: Mesial.Occlussal.Distal (any combination);
LDS: Lithium Disilicate; RNC: Resin nano ceramic

The provision of an indirect restoration
is divided into four stages as listed in
Table 1. It is outside the remit of this
article to describe provisional restoration
and impression techniques.
1 Treatment planning
Clinical and radiographic examinations
to determine periodontal, endodontic
and prosthodontic prognosis of the
proposed abutment units are undertaken
to aid forming a treatment plan. Factors
that influence decision making that
need to be considered include: the
patient’s preference; time and financial
commitment; condition and restoration
of other teeth; aesthetic requirements;
functional occlusal factors; operator skill;
clinical experience; and knowledge of the
dental literature with regards to material
properties and current treatment protocols.
The combination of these forms the basis
of evidence-based dentistry. The clinician
should be able to give an indication of
the likely outcome of the proposed
treatment that will include its benefits,
risks, time and financial implications
and alternative treatment options.
Figure 1: Decision making pathway
for the treatment planning of an
abutment tooth to receive an indirect
restoration. It allows the clinician to
follow the clinical journey from the
top of the pathway to the end at
the bottom. It highlights restorative
material choices and the restoration
design that are relevant to these
based upon available tooth structure
and cementation protocol

Vol. 8 No. 3 autumn 2019 49

 Evolution of indirect restorations for fixed prosthodontics:
planning, preparation and cementation
Ta b l e 1
Stage and considerations required for
the provision of indirect restorations
Stage
1 Treatment planning
2 Restorative material choice
3 Tooth preparation
4 Restoration cementation
50
Considerations
• Discussion with patient
• Laboratory diagnostic procedures
• Discussion with patient
• Knowledge of current material choice
• Knowledge of laboratory material system options
• Diagnostic instruments and materials
• Preparation burs and handpieces
• Intra-oral digital scanning
• Conventional preparation
• Adhesive preparation
• Occlusal reduction and functional requirements
• Finish line design
• Taper and convergence angle – total occlusal
convergence (TOC)
• Axial reduction
• Auxiliary features
• Knowledge of current material choice
• Abutment tooth preparation geometry
• Conventional cementation
• Adhesive bonding
• Restoration intaglio surface treatment
Figure 2: Deconstruction and
investigation of teeth before restoration
In the case of treating either single or
multiple abutment units, the investigation
of specific teeth to receive an indirect
restoration will involve removing the
existing restorative material and caries
(Figure 2) and examining the thickness
of the existing peripheral axial walls
(Figure 3). The amount of tooth tissue
available will influence the design
and type of restoration prescribed.
The Tooth Restorability Index (TRI)1
and the Dental Practicality Index (DPI)2
are examples of published indices that
may be used to assess the restoration
of teeth. The practitioner can make
treatment decisions that are tailored
to the presenting case. The overall
prognosis of the tooth determines
to restore the tooth provisionally or
definitively, utilising direct or indirect
methods. Direct restoration methods of
heavily broken down or heavily restored
teeth are preferred as a provisional
phase of treatment (Figure 4), or if the
prognosis of the tooth is of question
or the intervention utilising an indirect
restoration is aggressive, considering
the patient’s age. A referral should be
made to an appropriate specialist or
secondary care setting if restoration of
the case may be out of the clinical scope
for the managing clinician. Diagnostic
Figure 3: Measuring peripheral axial
wall thickness with an Iwanson Calliper
p r i m a r y d e n ta l j o u r n a l
considerations on mounted study casts
may be required for intra-oral testing.
This may be planned utilising analogue
or digital workflows – analogue/
digital wax up and gypsum/3D printed
casts (Figures 5 and 6). The diagnostic
form outline of the intended restoration
across all its external contours must
be determined prior to commencing
treatment.

2 Restorative material choice

The use of classic materials such as
Type III gold alloy and porcelain fused
to metal (PFM) for both conventional
and adhesive restorations is still
popular amongst clinicians. However,
the provision of all-ceramic restorations
in prosthodontics has increased Figure 5: Analogue diagnostic waxing on mounted
to meet the aesthetic demands of gypsum study casts for diagnostic intra-oral testing
patients (Figure 7). Dental ceramics
are unsurpassed for matching the
complex aesthetics of a human
tooth in terms of colour, surface
texture and translucency3,4 (Figures
8,9 and 10). An ideal all-ceramic
restoration is one that demonstrates
biocompatibility, good fit, high strength
and is aesthetically pleasing.5 Their
prosthetic advantages are that they
are: biocompatible and chemically
inert; colour stable; have a low thermal
conductivity; are strong in compression;
have high hardness and are wear

Figure 6: Digital diagnostic waxing on mounted 3D

printed study casts for diagnostic intra-oral testing

Figure 4: Direct composite resin

restoration of heavily restored teeth
as a provisional phase of treatment

Vol. 8 No. 3 autumn 2019 51

 Evolution of indirect restorations for fixed prosthodontics:
planning, preparation and cementation
7 resistant. Their disadvantages include
8 (feldspathic, leucite, lithium disilicate)
9 strengths attributed to glass and alumina
Figure 7: Posterior type III gold alloy,
PFM and all-ceramic (zirconia)
crown restorations
Figure 8: Anterior all-ceramic (Lithium
Dislicate) crown restorations
10
Figure 9: Anterior all-ceramic (Lithium
Dislicate) crown restorations in-situ
Figure 10: Translucent zirconia
monolithic full anatomical contour
crown restorations
Figure 11: CAD-CAM milling of
restoration from a pre-fabricated
Resin nano ceramic block
11
Figure 12: Preparations and cementation
of Resin nano ceramic adhesive
onlay restorations. Geometric features
of the abutment preparation do not
allow adequate mechanical
retention and resistance form
12
52
that they are: brittle in tension; have
a less than ideal marginal adaptation
due to shrinkage; exhibit low fracture
toughness and tensile strength; are
technique-sensitive in production; are
susceptible to fracture and are difficult
to repair when fractured.6 All-ceramic
restorations using glass ceramics
and polycrystalline ceramics (alumina
and zirconia), have been utilised
for both single and multiple tooth
replacement. Luecite (e.g. Empress 1)
and alumina materials (e.g. Procera)
have been superseded by lithium
disilicate and zirconia materials
for clinical use as the low fracture
toughness, lower tensile and flexural
ceramics have increased the efforts in
the research and development of these
higher strength ceramics.5,7
In the 1980s, computer-aided design
and computer-aided manufacturing
(CAD-CAM) was introduced in
Europe. CAD-CAM systems use a
scanning and machining process
to allow the rapid production of
restorations from a pre-fabricated
ceramic block8 (Figure 11).
Feldspathic ceramic (glass) exhibits low
flexural strength and is indicated for use
in single units and posterior bridge unit
abutments when applied as an aesthetic
and functional layer over a high strength
coping substructure material. They can
also be used as a stand-alone material
for anterior veneers when bonded
to enamel due to its excellent optical
properties.
Lithium disilicate ceramic (glass) is one
of the most used ceramic systems in the
world. It is indicated for use in single
units and posterior bridge unit abutments
of up to three units. IPS e.max (Ivoclar
Vivadent) was introduced in 2006,
and can be milled (IPS e.max CAD)
or pressed (IPS e.max Press). Initially
developed as a substructure material,
it has gained popularity for its use as
a monolithic restoration due to its high
p r i m a r y d e n ta l j o u r n a l
strength and good aesthetic properties
(see Figures 8 and 9).
Zirconia ceramic (polycrystalline) is
indicated for full crowns, telescopic
copings, fixed partial dentures (FPDs),
posts, implants and implant abutments.
Zirconia crown restorations commonly
comprise a zirconia coping combined
with a veneering feldspathic porcelain.
This serves with the advantage that a
more life-like restoration is produced
by masking the inferior aesthetics of
the zirconia coping. However, the
overlying veneering surface is liable to
mechanical failure, exhibiting cracking
and chipping.9,10 This problem has
been addressed by either modifying the
design of the zirconia coping or milling
translucent cubic zirconia restorations
to full anatomical contour (monolithic)
without the requirement for the veneering
surface11,12 (see Figure 10).
Resin nano ceramic (hybrid) e.g.
LavaTM Ultimate, primarily are ceramics
integrated with a mixture of nano-resin
composite. It is indicated for use as
inlays, onlays and veneers (Figures 11
and 12). The manufacturer states that the
fracture toughness of the hybrid material
is greater than feldspathic porcelain and
direct composite resin materials while
being less brittle than feldspathic glass
ceramics, and therefore it is less prone to
cracking during try-in and function. They
offer the benefits of ease of handling
and repair similar to composite materials
and high surface gloss and finish of
glass-ceramics.
The comparative strengths of ceramic
and hybrid materials are shown in
Table 2.
3 Tooth preparation
The three main considerations regarding
the design of a dental restoration are
biological, mechanical and aesthetic.13
All three factors must balance against
one another for producing an ideal
clinical outcome. Tooth preparation
should conserve as much tooth tissue as
possible to preserve pulpal health and
the structural integrity of the underlying
Vol. 8 No. 3 autumn 2019
Ta b l e 2
Ceramic material strengths
Flexural strength Fracture toughness
Material MPa MPa m0.5
Resin nano ceramic (hybrid)
• Enamic (Vita) 150 1
• Lava Ultimate (3M ESPE) 200 2
Lithium disilicate (glass)
• IPS e.max – Press (Ivoclar Vivadent) 400 2.5-3
• IPS e.max – CAD (Ivoclar Vivadent) 360 2-2.5
Zirconia (polycrystalline)
• LavaTM (3M ESPE) 1272 8 -12
tooth whilst remaining consistent with
mechanical and aesthetic principles.14
As such, partial preparations (e.g.
onlay and partial crown) for posterior
teeth, should be considered over full
preparations to address this. Over-
preparation can compromise pulp
vitality15,16 but benefits from a resultant
thicker restoration that will be more
resistant to physical forces acting
upon it. Under-preparation benefits
the conservation of tooth structure but
can result in inadequate emergence
profile and contour of the restoration,
subsequent plaque retention, unaesthetic Figure 13: Tungsten Carbide bur
restorations and occlusal issues. and planar occlusal reduction.
Note dentine wall thickness
The resultant restoration if made
to the correct profile would be too
thin and be structurally compromised
from mechanical forces. As such, the
primary objective of tooth preparation
is to remove precisely the exacting
amount of abutment tooth tissue to
create space for the thickness of the
chosen veneering restorative material
about a given path of insertion. This
space should allow the restoration
to be thick enough for mechanical
durability and allow appropriate
gingival emergence profile and
aesthetic contour. It follows that
successful abutment preparation
is dependent upon the knowledge
of restorative material properties
and their requirements for optimum
performance of the desired restoration.
53
 Evolution of indirect restorations for fixed prosthodontics:
planning, preparation and cementation

14

15

Figure 14: Full veneer crown preparation using a Tungsten

Carbide bur. Note supra and equi-gingival finish lines

Once this is determined, the clinician

is able to choose the appropriate
armamentarium to allow themselves to
perform this operative work to a high
standard.

A variety of bur materials (diamond,

tungsten carbide, Arkansas white stone)
grit sizes, geometric shapes and width
may be used (Figures 13,14,15 and
16). Disposable single use diamond
burs are of preference due to their cost
effectiveness and efficiency compared
to multiuse burs.17,18 Ultra-sonic diamond
instruments may also be used to achieve
smooth surfaces19 (Figure 17).

Key parameters of abutment preparation

contributing to restoration success include
occlusal reduction, finish line design
and taper. Definitions of classic features
of crown preparation taken from the
Glossary of Prosthodontic Terms20 can Figure 15: Various bur materials and
be seen in Table 3. General preparation shapes; coarse and fine grit diamond
guidelines for preparing posterior and White (Arkansas) Stone used for
abutment teeth for various restorative preparing abutment teeth
materials highlighting these parameters
are shown in Table 4. 16

Depth cuts and silicone putty reduction

guides based on diagnostic waxing are
useful methods to gauge preparation
depths (Figures 16 and 18), but the
advent of intra-oral digital scanning
and novel digital measuring techniques
(e.g. PrepCheck, Dentsply Sirona)
has facilitated detailed measuring of
such parameters such as occlusal and
axial reduction depths, axial surface
smoothness, analysis of undercut, finish Figure 16: Round medium grit
line configuration and smoothness, diamond used for depth cutting

54 p r i m a r y d e n ta l j o u r n a l
 Ta b l e 3
Definitions of classic features of crown
preparation taken from The Glossary of
Prosthodontic Terms 20
Features of crown
preparation Definition
Retention form The feature of a tooth preparation that resists dislodgment of
a crown in a vertical direction or along the path of placement
Resistance form The features of a tooth preparation that enhance the stability
of a restoration and resist dislodgment along an axis other than
the path of placement
Taper The angle, measured in degrees as viewed in a given plane,
formed between an external wall and the path of placement of
a tooth preparation or machined surfaces on a metal or ceramic
material when prepared for fixed dental prosthesis.
Convergence angle The total angle of convergence, measured in degrees as viewed
– total occlusal in a given plane, formed by opposing axial walls when a Figure 17: Ultra-sonic diamond
convergence (TOC) tooth or machined surfaces of a metal or ceramic material instruments for rounding off sharp
is prepared for a fixed dental prosthesis preparation corners and refining
finish lines

taper and total convergence angle/ A posterior indirect restoration must

total occlusal convergence values
(see Figures 19, 20 and 21). The
benefit of this educational information
is that immediate quantitative digital
feedback is given to the operator
such that corrections can be made to
the preparation before committing to
restoration fabrication. This will only
enhance the skill development of the
clinician and improve treatment delivery
to the patient.
be able to withstand the occlusal
forces of approximately 800N.21
Inadequate abutment reduction will
lead to premature restoration wear and
fracture. A planar occlusal reduction
that follows the buccal and palatal
cuspal inclines will allow increased
resistance form of the restoration (Figure
13). The intra-coronal engagement
and extra-coronal axial extension wrap
for full veneer, partial veneer or onlay

Ta b l e 4
General guidelines for posterior tooth preparations and cementation
protocols based upon restorative materials used
Taper and convergence Restoration
angle – total occlusal cementation
Material Occlusal reduction Finish line convergence (TOC) protocol
Gold alloy • 1mm • Chamfer 0.5mm • 3° • Conventional
• 1.5mm (functional cusp bevel) • 6° (TOC) • Adhesive
Porcelain fused to • 1.5mm • Rounded shoulder 1mm • 3° • Conventional
metal • 2mm (functional cusp bevel) • Chamfer 0.5mm • 6° (TOC) • Adhesive
Lithium disilicate • 1.5mm • Chamfer 1mm • 6° • Adhesive
(glass) • Rounded shoulder 1mm • 12° (TOC)
Zirconia • 1mm • Feather-edge 0.3mm • 6° • Conventional
(polycrystalline) • 1.5mm (functional cusp bevel) • Chamfer 1mm • 12° (TOC) • Adhesive
• Rounded shoulder 1mm
Resin nano ceramic • 1.5mm • Chamfer 1mm • 6° • Adhesive
(hybrid) • Rounded shoulder 1mm

Vol. 8 No. 3 autumn 2019 55

 Evolution of indirect restorations for fixed prosthodontics:
planning, preparation and cementation

restorations may then be considered. PFM conventional retained restorations

Figure 18: Silicone putty reduction
guide based on diagnostic waxing
in conjunction with a BPE probe to
gauge preparation depth for a
veneer preparation
The biomechanical principles of
retention and resistance form employed
in traditional tooth preparation must be
considered in relation to their effects
upon dentine wall thickness (Figure 13).
This may be quite destructive at times,
all-ceramic crown preparations can
be invasive and result in the removal
of 63-72% (by weight) coronal tooth
structure.22 The axial wall reduction
will depend upon tooth rotation (Figure
22), bulbosity and the chosen path of
draw for the restoration (which may
or may not coincide with the long axis
of the tooth). It will also depend upon
the finish line depth at the cervical
portion and the degree of taper given
to that wall. Near parallel axial walls
for a full veneer abutment preparation
(Figure 23) are technically difficult to
achieve, there is a tendency to over
taper to avoid proximal undercuts.
This may be also enhanced by a
combination of incorrect bur shape
choice, undeveloped manual dexterity,
restricted operative area access, soft
tissue obstruction and fear of damage
to adjacent hard teeth. A 3° taper
(TOC of 6°) – or less for gold alloy and
– is advocated in the literature.14,23-25
Outside this range there is a decrease
in retention and resistance, significantly
with a 20° taper (TOC of 40°) or
over.23,25 It is important to note that
the gingival portion of the abutment
preparation provides the greatest
retention26,27 and that preparation
height and diameter are also both
vital to resistance and retention form,
their relationships being linear.27,28
(Figure 22).
One may consider auxiliary preparation
features as a means of increasing
resistance form in the presence of short
clinical crown height. This may include
the placement of boxes and grooves on
interproximal surfaces that interfere with
rotational axis in functional movement
that would contribute to the decementing
of restorations. However, these features
may only slightly contribute to the
improvement in retention form.29-31
They are implemented especially when
utilising a conventional partial coverage
restorations e.g. 3/4 or 7/8 gold alloy
crowns or onlays (Figures 24-27). These
box and groove preparation features are
inappropriate for all-ceramic restorations
and should have rounded corners and
smooth undulating flowing transitions
(Figure 28).

Finish line configuration and depth

Figure 19: Intra-oral digital scanning and novel digital measuring
techniques (e.g. PrepCheck, Dentsply Sirona) facilitating detailed
measuring of preparation reduction parameters
for restoration margins must respect
periodontal health and where possible
be placed supragingival or equigingival
(Figures 14 and 22). Violation of
biological width with subgingival
restoration margins will compromise
periodontal health, mediating an
inflammatory response.32,33 Numerous
designs of finish lines have been used in
tooth preparation for crown restorations
and are all modifications of the
chamfer and shoulder.34 For cast metal
restorations, the chamfer is regarded
as the finish line of choice35 as it allows
the sufficient thickness for strength for
the desired acute margin of metal and
the rounded line angle produces lower
stress concentrations within the cement
film.13, 36,37 Chamfer or rounded shoulder

56 p r i m a r y d e n ta l j o u r n a l
finish line configurations for all-ceramic
systems are recommended38 (Figures 23
and 29). There is no current consensus
as to the ideal marginal design for
zirconia crowns. The use of feather-
edge margins for zirconia restorations
has been reported39-42 (Figures 29-31).
“Feather-edge” is a term that has been
described in several ways (and is used
interchangeably in the literature with
the terms “knife-edge,” “chisel-edge,”13
“shoulderless,”13,43 “slice-form”44 and
“vertical”.42 This finish line was popular
in the 1960s and 1970s before the
development of high-speed cutting
instruments and accurate impression Figure 20: Intra-oral digital
materials.14,22,45 The feather-edge scanning and novel digital
finish line can be viewed as a vertical measuring techniques (e.g.
preparation as opposed to a horizontal PrepCheck, Dentsply Sirona)
one41,46 as there is no defined end facilitating detailed measuring of
point to the preparation, as is seen with preparation reduction parameters

Figure 21: Intra-oral

digital scanning and
novel digital measuring
techniques (e.g.
PrepCheck, Dentsply
Sirona) facilitating
detailed measuring of
preparation reduction
parameters

Vol. 8 No. 3 autumn 2019 57

 Evolution of indirect restorations for fixed prosthodontics:
planning, preparation and cementation

the chamfer and shoulder finish lines.

Figure 22: Quadrant full veneer crown
preparations highlighting cross-sectional
outline form in the presence of rotations.
Note supra and equi-gingival finish lines,
preparation height and diameter vital to
resistance and retention form
The cut surface is near parallel to the
path of insertion35 and it is difficult to
follow on both tooth and die (Figures
29-31). The most likely result of this
type of finish line is overcontouring of
the fabricated restoration14,39,47 (Figure
30). Indications of using feather-edge
finish lines include: the preparation
of periodontally involved teeth with
acute cervical contours and mandibular Figure 24: Auxiliary preparation
incisors where deeper preparation features, interdental grooves for ¾ gold
would involve the pulp39,48 in vital alloy crown. Clinical abutment and 3D
teeth in young individuals and teeth printed die
where the endodontic prognosis is of
concern,11,41 teeth affected by cervical
caries, erosion or abrasion,40,48 and
subgingival tooth fracture.48 The
advantages of using this design is that
there is an increase in gingival thickness
and stability of the gingival margin;
less biological cost is incurred to the
prepared tooth; it is easier to prepare;
the final impression is simplified in that
there is no longer a finish line, but a
finishing area in the gingival sulcus and Figure 25: Auxiliary preparation
that relining and finishing a provisional features, interdental grooves for ¾ gold
restoration is easier and faster.39,42,46,48 alloy crown. Clinical abutment, 3D
printed die and gold alloy restorations
The disadvantages of the feather-
edge preparation are that achieving
a definite finishing line is difficult
and crown fabrication is problematic
as the margins are indistinct on the
impression and die.46 If the junction
between restoration and tooth were
not properly formed, then a horizontal
overhang is created.39 Overcontoured Figure 26: Auxiliary preparation
restorations are produced to provide features, box and grooves for gold alloy
sufficient bulk of restorative material to onlay. Clinical abutment and gypsum die
ensure functional rigidity45,46 which can
be damaging to the periodontal tissues
due to bacteria and plaque retention.
The consensus from Gardner’s review
of marginal configurations was that
feather-edge margins were not the most
acceptable and that bulky margins with
subtle line angles are best.49

Preparations for adhesive restorations

Figure 23: Near parallel axial walls for
a full veneer abutment preparation and
deep chamfer finish line
may be defect orientated and bonded
directly to tooth without the requirement
for a core material, consequently
this may allow more abutment tooth
tissue to be retained50 (Figure 32).
Figure 27: Digital scan of quadrant full
veneer and onlay preparations. Auxiliary
preparation features, box and grooves
for gold alloy onlay and 3D printed die

58 p r i m a r y d e n ta l j o u r n a l
Immediate dentine sealing with a fourth
or eighth generation bonding agent
is advised to be used in conjunction.
This allows infiltration and sealing
of freshly cut dentine such that the
dentine bond develops without stress
during the provisional restoration
stage. The sealed dentin is protected
from bacterial infiltration during the
provisional restoration stage, thus Figure 28: Gypsum die of glass-ceramic onlay preparation
decreasing dentine contamination showing undulating flowing transitions. Geometric features of
and postoperative sensitivity. Other the abutment preparation do not allow adequate mechanical
advantages include significantly retention and resistance form
improved microtensile dentine bond
strengths and reduced marginal
leakage.51 A composite resin material
may then be used at this stage in order
to build a core, block out undercuts and
relocate or elevate peripheral margins
(cervical margin relocation/deep
Feather-edge Chamfer Deep-chamfer
margin elevation)52-54 (Figure 33).

4 Restoration cementation Figure 29: Various finish line configurations for all-ceramic
The indication of cement choice is systems. Note feather-edge (vertical) finish line
dependent upon the restoration material
and the geometric configuration of the
prepared abutment tooth. If the features
of the preparation are significant to
aid retention and resistance form of
the restoration, a conventional luting
cement may be used (Figures 13,14,19,
22-27, 29, 30, 31, 34). If not, a resin
composite cement may be utilised to
adhesively bond the restoration in place.

Conventional cementation with Figure 30: Feather-edge (vertical) finish lines and
conventional cements (e.g. zinc overcontoured emergence profile of proposed crown
phosphate, glass-ionomer cement and restoration in cross-section (red line)
resin modified glass-ionomer cement)
can be used for gold alloy, PFM
and zirconia restorations. Zirconia
restorations can be cemented using
conventional cements because of their
high flexural strength10,55-57 which has
been reported not to affect their load
at fracture values.10,57-59 In each case
the restoration and abutment must
be cleaned, dried and a crown fill
technique used (Figure 34).

Adhesive cementation with adhesive

resin composite cements may be
employed where the restorative material
used indicates (gold alloy, PFM, zirconia Figure 31: Deep chamfer versus Feather-edge
and glass ceramic restorations), and (vertical) finish line comparison on gypsum dies

Vol. 8 No. 3 autumn 2019 59

 Evolution of indirect restorations for fixed prosthodontics:
planning, preparation and cementation

Figure 32: Defect orientated preparation
on a root canal treated abutment tooth
to receive a glass-ceramic restoration
and Lithium Disilicate restoration in-situ
after adhesive bonding
where the geometric features of the
abutment preparation are compromised
(Figures 12, 28 and 35). It may be
challenging to utilise this form of
cementation modality due to lack of
adequate isolation of the abutment
tooth and control of the moisture in
the operating environment. Flaws and
tensile stresses are highest at the internal
surfaces of ceramic restorations, therefore
adhesive bonding provides strengthening
of the tooth-restoration interface via
physicochemical interaction between the
ceramic surface, the adhesive and the
adhesive cement which allows greater
transmission of force to the abutment
tooth.60 This reduces the occurrence of
crack propagation within the ceramic
and therefore probability of restoration
failure. The cementation process for a
glass-ceramic restoration is highlighted
and described (Figure 36). The intaglio
surface is cleaned after try-in and treated
with a 5-10% hydrofluoric acid61,62 for
10-20 seconds. After removing surface
precipitates from the dissolution of
the silica with isopropyl alcohol, the
conditioned surface can be primed
with a silane coupling agent that soaks
into the porous ceramic surface and
provides enhanced micromechanical
interlocking and chemical adhesion
with the ceramic and bonding resin
cement.63 Restorative resin composite
may be used as an alternative to a
dedicated resin composite cement. The
advantage of the higher filler content
will improve compressive strength and
excess clean-up is easier due to the
lower viscosity of the material (Figures
37 and 39). Viscosity can be influenced
by heating the resin composite material
to allow it to flow at the time of seating
the restoration.

Figure 33: Immediate Dentine Sealing workflow and placement of composite

resin base and Lithium Disilicate restoration in-situ after adhesive bonding

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Figure 34: Zirconia crown conventional cementation with resin-modified glass-

ionomer cement. Treatment of the intaglio surface of the restoration is shown

Enamel substrate allows both Figure 35: Adhesive cementation of

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Vol. 8 No. 3 autumn 2019 61

 Evolution of indirect restorations for fixed prosthodontics:
planning, preparation and cementation

IPSe.max HF Isopropyl Air dry Silane Compos-

acid etch alcohol application ite resin

Figure 36: Treatment of the intaglio surface of a glass-ceramic restoration

attained by the use of sectioned matrix particles; tribochemical silica coating

band strips, matrix bands or PTFE tape68
(Figures 35 and 39).
The highly crystalline surface of zirconia
ceramics is not amenable to hydrofluoric
acid etching as their microstructure does
not contain a silicon dioxide (silica) or
any substantial glassy phase. However,
the bonding of zirconia restorations
to tooth structure with resin cements
may be possible10,69,70 and various
methods employed have given mixed
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increase bond strengths. These include
sandblasting with aluminium oxide
(Rocatec and CoJet systems; 3M Figure 37: Cement choice of either,
ESPE, Germany); and modifications a composite resin cement system or
to primers with phosphoric acid a heated restorative composite resin
and vapour-phase deposition of
chlorosilane.70,71,72,73 Bond strengths
of sandblasted zirconia surfaces to
10-Methacryloyloxydecyldihydrogen
phosphate (10-MDP) have been shown
to be higher than other resin cements
and techniques70. However, one study
reports that the retention of zirconia
crowns with adhesive cements showed
no difference when compared to
conventional cements.56
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utilising conventional and adhesive preparation to clean remnant temporary
based treatment protocols is shown in cement from abutment tooth before
Figure 40. substrate treatment for adhesive bonding

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62 p r i m a r y d e n ta l j o u r n a l
 Figure 39: Substrate treatment
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bonding of a Lithium Disilicate
restoration with restorative
composite resin. Note use
of PTFE tape as a barrier

Summary
A number of patient, abutment tooth
and restorative material factors should be
carefully considered before any definitive
decisions are made as to the technique
employed in which an abutment tooth
is restored in an indirect fashion. The
decision-making pathway will guide the
clinician with regards to this.

Whilst established traditional

analogue techniques are bedrock,
efficient digital workflows involving
novel software are available,
improving clinical and laboratory
efficiency. Clinicians have to decide
for themselves which workflow is best
suited and applicable for their specific
clinical case. Ultimately, clinicians
and dental technicians will follow
digital protocols adhering to analogue
principles to allow indirect restorations
to be delivered that are biologically
sound, optimised functionally and
Figure 40: Multidisciplinary case using gold alloy, PFM, Zirconia highly aesthetic to allow a favourable
and Lithium Disilicate restorations on abutment teeth and implants, long-term prognosis to the recipient
utilising conventional and adhesive based treatment protocols abutment tooth.

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