Professional Documents
Culture Documents
Evidence Based Concepts For Bonded Inlays and Onlays. PartI. History-Dietschi2015
Evidence Based Concepts For Bonded Inlays and Onlays. PartI. History-Dietschi2015
E-mail: didier.dietschi@unige.ch
2
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
DIETSCHI ET AL
3
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
CLINICAL RESEARCH
4
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
DIETSCHI ET AL
Adhesive layer
Composite Base /
Lining
a: Shallow cavity
b: Deep cavity &
supra or juxta-gingi-
val cervical margin
c: Deep cavity &
intra-crevigular
a b c margin
Fig 1 Diagrammatic representation of the different layers in the application of the Dual Bonding (DB),
Cavity Design Optimization (CDO), and Cervical Margin Relocation (CMR) procedures. This modern treat-
ment approach alleviates all complications encountered in indirect posterior restorations, providing reli-
ability and increased success. (a) shallow; (b) deep; (c) intracrevicular cavities.
5
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
CLINICAL RESEARCH
Table 1 Development of concepts for adhesive inlays and onlays, with original references
Cavity Design Optimization Application of an adhesive base/ Dietschi and Spreafico, 1997
(CDO) liner to: Dietschi and Spreafico, 1998
• optimize cavity geometry Dietschi et al, 2003
• fill undercuts
• harmonize and limit restoration
thickness
• protect exposed dentin during
temporary phase
• improve restoration adaptation
Cervical Margin Relocation Displace supragingivally an intrac- Dietschi and Spreafico, 1998
(CMR) revicular cervical margin to facili- Dietschi et al, 2003
tate and improve:
• impression procedures
• cementation procedures
• cleaning and finishing of margins
• restoration adaptation
• rubber dam placement
(for cementation)
Controlled Adhesive Cementa- Luting partial restorations with Besek et al, 1995
tion (CAC) highly filled, light-curing restorative Dietschi and Spreafico, 1998
composite to: Dietschi et al, 2003
• reduce luting cement wear
• control excess removal of cement
• extend working time
6
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
DIETSCHI ET AL
Fig 2a Preoperative view of teeth 35 and 36 with Fig 2b A rubber dam is placed and amalgam res-
defective amalgam restorations and a fracture of the torations removed (note the deep cervical margins,
mesiolingual cusp of the first molar. particularly on the mesial aspect of the first molar).
Figs 2c and 2d A full matrix is placed around both preparations, ensuring perfect closure of deep
cervical and lingual margins. Ideally, the matrix emergence profile should be divergent to allow for the
development of better restoration anatomy.
7
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
CLINICAL RESEARCH
Fig 2f 3D model of the two restorations created Fig 2g Both restorations (Lava Ultimate, 3M) are
by the CEREC CAD/CAM system, prior to milling inserted and checked for occlusion and fit.
procedure.
Fig 2i A rubber dam is again placed, to help con- Fig 2j Final restorations following the revised
trol the working-field dryness and ensure optimal preparation and cementation protocol that ensures
conditions for cementation. predictability and simplification, showing good es-
thetic and functional integration.
8
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
DIETSCHI ET AL
9
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
CLINICAL RESEARCH
er consistency and large particle size ary phase) through the systematic
(prepolymerized particles or clustered use of a rubber dam and extensive
nanoparticles). The results of research water spray, and by isolating the
studies on the possibility of bringing dentin immediately after preparation
sufficient light into the cementing space with a thick layer of DBA and adhe-
for optimal composite conversion and sive base/liner.
mechanical properties have shown that The long-term function and resist-
proper light polymerization is feasible, ance of the teeth due to the use of
and in some conditions is superior, to wear-resistant, strong, and rigid re-
what can be achieved with a dual-cur- storative materials (both restoration
ing material in the absence of light; in and cement).
fact, proper light propagation within the Strong and durable adhesive inter-
luting interface is highly recommended faces between the materials and
for both types of composites (light- or substrate (dentin-enamel to adhe-
dual-curing).5-18 The CDO procedure sive, adhesive to base/liner, base/
also helps to reduce and optimize the liner to composite cement, and com-
restoration thickness, and therefore fa- posite cement to restoration).
vors proper light transmission within the
luting interface. An additional benefit of The treatment procedures discussed in
this technique is that, due to the dentin this article have been extensively evalu-
remaining fully protected by the base/ ated in vitro, and there is strong positive
liner, anesthesia during cementation pro- evidence in favor of this revised treat-
cedures is virtually no longer required. ment protocol.21-27 In vivo, the nature of
These procedures have to be used base/liners and their influence on res-
for both semidirect (chairside intraoral or toration longevity and success have
extraoral and CAD/CAM techniques) or not been specifically investigated (no
indirect clinical procedures (in-lab com- comparative, prospective, randomized
posite or ceramic)5,6,19,20 (Figs 1 to 3). clinical trial has taken place). However,
Table 2 summarizes the comprehen- these procedures have been success-
sive changes made to the advanced fully used by the authors and by many
clinical protocol for bonded inlays and other clinicians. Long-term follow-up
onlays and compares them to conven- will be presented in Part II of this article,
tional procedures. The procedures and which may then be considered as fac-
principles described in Table 2 (revised tual clinical evidence.
protocol) feature the following clinical
advantages:
The absence of tissue removal for Biosubstitution
the sake of convenience, the proper-
ties of materials, or the limitations of The principles discussed in this article
technology. imply major differences between na-
The gentle treatment of the pul- ture’s model and an adhesively restored
podentinal complex during the prep- tooth. First, the various restoration layers
aration (and eventually the tempor- and interfaces do not share the same
10
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
DIETSCHI ET AL
Fig 3a Preoperative view of tooth 45 with defec- Fig 3b Following removal of the restoration, the
tive cast gold onlay (cervical recurrent decay). cervical margin appears juxta-gingival and no
enamel is present.
Fig 3c The cavity is therefore modified (as shown in Fig 1) with dentin sealing, using the DB, CMR and
CDO techniques.
11
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
CLINICAL RESEARCH
Fig 3d Following these procedures, the cavity is Fig 3e After placement of a clear full matrix, the
isolated using Rubber Sep (Kerr) to avoid any bond- restoration is fabricated in-mouth using a composite
ing between the resinous base/liner and restorative mass for the proximal and occlusal surfaces in ad-
composite. dition to the central dentin increment.
Fig 3f The central groove is characterized with a Fig 3g The inlay is luted with the same restora-
brown-effect shade and, following polymerization, tive composite (light-curing enamel mass) to en-
the restoration can be moved out of the cavity for sure optimal working time and complete removal of
margin refinements and luting preparation. excesses.
12
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
DIETSCHI ET AL
Table 2 Description of the major differences between the conventional and the revised preparation and
cementation protocols for indirect adhesive class II restorations (according to Dietschi and Spreafico, 1997
and 1998)
13
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
CLINICAL RESEARCH
Fig 4a Preoperative view showing defective Fig 4b A rubber dam is placed before removing
amalgam (teeth 46 and 47) and composite (teeth the bulk of the restorations.
44 and 45) restorations. The sextant also needs to
be realigned to create a better curve of Spee.
Fig 4c Preparations show deep proximal margins with no cervical enamel (teeth 44 to 46), including
many undercuts. Impression taking, control of restoration proximal adaptation, and removal of excesses
would complicate the next steps if such cavity configuration were to remain.
14
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
DIETSCHI ET AL
Fig 4d Thereafter, cervical margins are relocated Fig 4e Trial of composite restorations made of a
on teeth 44 to 46 (CMR), and all retentive areas are highly filled composite material (homogenous nano-
filled up with flowable composite to improve overall hybrid: Inspiro, EdelweissDR).
cavity design (CDO). Note that an opaque com-
posite shade is chosen for tooth 46 to cover the
discolored dentin.
Fig 4f Restorations are cemented one by one, using a light-curing restorative enamel, usually a micro-
hybrid (eg, Tetric, Ivoclar) or a homogenous nanohybrid (eg, Inspiro, EdelweissDR). Avoid selecting a
conventional nanohybrid material (which contains large clusters or prepolymerized particles). This allows
better control of placement and removal of excesses before curing (CAC).
15
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
CLINICAL RESEARCH
Fig 4g Restoration insertion starts with manual Fig 4h Light-curing is performed for 40 to 60 s (on
pressure only until firm resistance is attained. There- each restoration surface) through the tooth substrate
after, restoration seating is achieved in a second and inlay/onlay. Not only is the light-curing efficacy
step, using a sonic or ultrasonic handpiece and a shown to be sufficient, it allows for a superior quality
special plastic cementation tip (KaVo or EMS). of the physical properties of the luting material.
16
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
DIETSCHI ET AL
17
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
CLINICAL RESEARCH
fore impression taking, providing (when the increased rigidity and reinforcement
needed) a relocation of deep cervical potential of rigid, high-strength modern
margins and leading to a more conserv- ceramics appears advantageous. This
ative, predictable, and improved treat- latter point will be discussed in the sec-
ment outcome. At this point in time, no ond article in this series (Part II).
material has systematically proven itself Finally, practical reasons exist to limit
to be the most feasible or reliable regard- the complexity of restorative procedures
ing its physicochemical and handling (material combinations), so that it is best
characteristics. Therefore, both compos- to speak of biosubstitution until such
ites and ceramics can be successfully time as true, evidence-based bioemu-
used for bonded inlays and onlays on lated solutions are available for class II
vital teeth. For non-vital teeth, however, restorations.
References
1. Rocca GT, Krejci I. Bonded tooth-colored posterior res- 12. Magne P, Spreafico R. Deep
indirect restorations for torations. Pract Periodontics margin elevation: a possible
posterior teeth: from cavity Aesthet Dent 1998;10:47–54. adjunct procedure to imme-
preparation to provision- 7. Paul SJ, Schärer P. The diate sealing. Am J Esthet
alization. Quintessence Int dual bonding technique: a Dent 2012;2:86–96.
2007;38:371-379. modified method to improve 13. Dietschi D, Monasevic M,
2. Gyorkos TW, Tannenbaum adhesive luting procedures. Krejci I, Davidson C. Mar-
TN, Abrahamowicz M, et al. Int J Periodontics Restorative ginal and internal adaptation
An approach to the develop- Dent 1997;17:536–545. of class II restorations after
ment of practice guidelines 8. Dietschi D, Herzfeld D. In immediate or delayed com-
for community health inter- vitro evaluation of marginal posite placement. J Dent
ventions Can J Public Health and internal adaptation of 2002;30:259–269.
1994;85(suppl 1):S8–S13. class II resin composite res- 14. Dietschi D, Olsburgh S,
3. Bazos P, Magne P. Bio- torations after thermal and Krejci I, Davidson C. In vitro
emulation: biomimetically occlusal stressing. Eur J Oral evaluation of marginal and
emulating nature utilizing a Sci 1998;106:1033–1042. internal adaptation after
histo-anatomic approach; 9. Magne P. Immediate dentin occlusal stressing of indirect
structural analysis. Eur J sealing: a fundamental pro- class II composite restor-
Esthet Dent 2011;6:8–19. cedure for indirect bonded ations with different resin-
4. Roulet JF, Degrange M (eds). restorations. J Esthet Restor ous bases. Eur J Oral Sci
Adhesion: the silent revolu- Dent 2005;17:144–154. 2003;111:73–80.
tion in dentistry. Chicago: 10. Magne P, Kim TH, Cascione 15. Besek M, Mörmann WH,
Quintessence Publishing, D, Donovan TE. Immedi- Persi C, Lutz F. [The curing
2000. ate dentin sealing improves of composites under Cerec
5. Dietschi D, Spreafico R. Indi- bond strength of indirect inlays]. Schweiz Monatsschr
rect techniques. In: Adhesive restorations. J Prosthet Dent Zahnmed 1995;105:1123–
metal-free restorations – cur- 2005;94:511–519. 1128.
rent concepts for the esthetic 11. Stavridakis MM, Krejci I, 16. Dietschi D, Marret N, Krejci
treatment of posterior teeth. Magne P. Immediate dentin I. Comparative efficiency of
Berlin: Quintessence Pub- sealing of onlay preparations: plasma and halogen light
lishing, 1997. thickness of pre-cured Dentin sources on composite micro-
6. Dietschi D, Spreafico R. Bonding Agent and effect of hardness in different cur-
Current clinical concepts surface cleaning. Oper Dent ing conditions. Dent Mater
for adhesive cementation of 2005;30:747–757. 2003;19:493–500.
18
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015
DIETSCHI ET AL
17. Park SH, Kim SS, Cho YS, vitro performance of Class 25. Lefever D, Gregor L, Bor-
Lee CK, Noh BD. Curing I and II composite restor- tolotto T, Krejci I. Supragin-
units’ ability to cure restora- ations: a literature review on gival relocation of subgin-
tive composites and dual- nondestructive laboratory givally located margins for
cured composite cements trials – part I. Oper Dent adhesive inlays/onlays with
under composite overlay. 2013;38:E166–181 [epub different materials. J Adhes
Oper Dent 2004;29:627– ahead of print 5 June 2013]. Dent 2012;14:561–567.
635. 22. Dietschi D, Argente A, 26. Rocca GT, Gregor L, Sand-
18. Gregor L, Bouillaguet S, Krejci I, Mandikos M. In oval MJ, Krejci I, Dietschi D.
Onisor I, Ardu S, Krejci I, vitro performance of Class In vitro evaluation of mar-
Rocca GT. Microhardness I and II composite restor- ginal and internal adaptation
of light- and dual-polymer- ations: a literature review on after occlusal stressing of
izable luting resins polymer- nondestructive laboratory indirect class II composite
ized through 7.5-mm-thick trials – part II. Oper Dent restorations with different
endocrowns. J Prosthet Dent 2013;38:E182–200 [epub resinous bases and interface
2014;112:242–248 [epub ahead of print 31 May 2013]. treatments. “Post-fatigue
ahead of print 22 April 2014]. 23. Roggendorf MJ, Krämer N, adaptation of indirect com-
19. Dietschi D, Magne P, Holz Dippold C, et al. Effect of posite restorations”. Clin Oral
J. Recent trends in esthetic proximal box elevation with Investig 2012;16:1385–1393.
restorations for poste- resin composite on marginal 27. Zaruba M, Göhring TN,
rior teeth. Quintessence Int quality of resin compos- Wegehaupt FJ, Attin T. Influ-
1994;25:659–677. ite inlays in vitro. J Dent ence of a proximal margin
20. Magne P, Dietschi D, Holz 2012;40:1068–1073. elevation technique on mar-
J. Esthetic restorations for 24. Frankenberger R, Hehn ginal adaptation of ceramic
posterior teeth: practical and J, Hajtó J, et al. Effect of inlays. Acta Odontol Scand
clinical considerations. Int proximal box elevation with 2013;71:317–324.
J Periodontics Restorative resin composite on marginal
Dent 1996;16:104–119. quality of ceramic inlays
21. Dietschi D, Argente A, in vitro. Clin Oral Investig
Krejci I, Mandikos M. In 2013;17:177–183.
19
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 1 • SPRING 2015