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2023 Clinical Guidelines For Posterior Restorations Based On Coverage, Adhesion, Resistance, Esthetics, and Subgingival Management
2023 Clinical Guidelines For Posterior Restorations Based On Coverage, Adhesion, Resistance, Esthetics, and Subgingival Management
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Tissue loss and occlusal load usually needs to reach the dentin to ensure
resistance minimal restorative thickness, contrary to
anterior teeth where enamel preparation
The concept that tooth resistance is in can be minimized.4 Posterior teeth also de-
directly proportional to tissue loss, the fact mand more resistant restorative materials
that restorations are never lifelong and may than those required for anterior teeth. For
need replacement, and the favorable clin- example, layered feldspathic porcelain does
ical evidence of adhesive procedures sup- not guarantee acceptable long-term results
port minimally invasive approaches. How in cusp coverage restorations in posterior
ever, the relationship between tissue loss teeth, whereas it does in anterior teeth. In
and resistance compromise does not follow the posterior region, more resistant, re
the same proportional correlation in poster inforced glass-ceramics should be used as
ior and anterior teeth. For example, an en- adhesive materials.5
dodontic access cavity associated with the
loss of one palatal ridge in an anterior tooth Materials for posterior partial
may not pose a high fracture risk, and the adhesive restorations
need for a full-coverage strategy is debat
able. However, there seems to be sufficient Some review studies show significantly
evidence for the need for a full-coverage higher long-term survival for ceramics com-
restoration in an anterior tooth with palatal pared with composites. A recent review and
endodontic access and the loss of both meta-analysis suggested a survival rate for
marginal palatal ridges.3 In vitro studies partial ceramic and composite restorations
show that similar lesions in posterior teeth of about 90% at 5 years.6 The 10-year sur-
significantly benefit from partial or com- vival rate for ceramic restorations seems to
plete cusp coverage, with a preparation that be around 85%,6 but this rate probably drops
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Table 1 Structural factors and clinical context to consider when deciding on preventive cusp coverage
Central cavity depth • The most decisive factor seems to be the combination of cavity
depth versus wall thickness
• Cavities deeper than 4 mm (as in ETT) will significantly benefit
Interaxial from cusp coverage if remaining walls have 3 mm or less
dentin • In shallow cavities (up to 3 mm), the walls need to be less than
STRUCTURAL FACTORS
the restoration
• Increased caries risk will favor decisions to include more marginal ridges/
Carious risk contact points to minimize the need for future restorative revision and repair
due to interproximal secondary caries
• Clinical history and signs of increased erosive risk will lead to the inclusion of
Erosive risk more dental surfaces in the restoration in the areas more exposed to the
erosive agent
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All remaining walls ≥ 1 mm Some remaining walls < 1 mm Some remaining walls ≤ 3 mm
All remaining walls
(≥ 2 mm for high functional risk) (< 2 mm for high functional risk) OR high funcional risk
> 3 mm
NO cracks OR cracks OR cracks
GINGIVECTOMY GINGIVECTOMY
DEEP SUBGINGIVAL
OSSEOUS
MARGIN ELEVATION
SUPRA-
VERTICAL PREPARATION
EXTRUSION
EXTRUSION ASSUME FRACTURE AS
OSSEOUS
INFRA-
VERTICAL PREPARATION
OSTEOTOMY
OSTEOTOMY
Fig 2 Decision chart for posterior teeth for cusp coverage, axial extension, and subgingival management.
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a b
c d
Fig 3 (a) Initial situation with caries on premolars and first molar. (b) Removal of carious tissue, removal of
unsupported enamel, absent or shallow central cavities with remaining walls thicker than 1 mm – therefore, a direct
adhesive restoration was performed. (c) Result at 3 years. (d) Radiographs of initial situation (top) and at the 3-year
follow-up (bottom).
teeth – and is associated with marginal ridge Selective or complete cusp coverage?
loss, then cusp coverage needs to be con- It is generally accepted that indirect pos
sidered, even for teeth with remaining walls terior restorations can be classified as inlays
of 3-mm thickness. In these deeper cavities, (no cusp is covered), onlays (at least one
the volume of interaxial dentin loss is signifi- cusp covered), and overlays (all cusps are
cantly higher, and more stress is present in covered). The choice for maintaining some
the preserved walls (Fig 2).17 cusps (onlay restoration) or covering all
It is worth mentioning the suggestion of cusps (overlay restoration) depends, again,
some authors to use fiber or short fiber- on structural and functional factors (Fig 2).
reinforced direct composites in large cavities There can be structural factors indicating a
as a possible alternative to more complex need for coverage in the mesial cusps
indirect restorative treatment. The idea be- (deeper cavity, thinner walls or ridge loss in
hind this is that the improved biomechanic- the mesial area) but not in the distal area.
al and physical properties of these direct Tissue preservation would be the obvious
materials may reduce the need for cusp advantage of maintaining some cusps, but
coverage in large cavities, including ETT, as there are some disadvantages, depending on
is shown in some in vitro studies.26 However, the situation. In patients with a high caries
other in vitro studies show that fiber-rein- risk, the interproximal area that has been
forced composites cannot replace the need preserved may develop a lesion in the fu-
for cusp coverage.27 ture. A revision treatment might be simple if
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the previous restoration is a resin since a wall height is more coronal to the tooth
predictable adhesive repair protocol can be equator, there seems to be no biomechan-
performed.28 If the previous restoration is a ical reasons for additional axial preparation,
ceramic, some difficulties regarding repairs as explained later in this article. This design
can be expected. Even though bonding of is also possible when there are no esthetic
ceramics with a thin luting resin agent shows demands to cover a buccal wall in a dis-
excellent long-term behavior, in the present colored tooth, for example.15 The occlusal
authors’ experience, repairing ceramic frac- reduction should be concave following the
tures with higher volumes of composite natural concavity of the posterior occlusal
resin does not seem to produce the same surfaces (Fig 4). This anatomical preparation
predictable clinical results, probably due has been shown to be significantly benefi-
to different elastic moduli. An additional cial as it ensures adequate thickness in the
perspective is that tooth–restoration inter- central sulcus.32 Although no further axial
faces on the occlusal surface in teeth that preparation is needed, there are still a few
are highly susceptible to deflective forces possibilities regarding the peripheral finish-
may also present a weak point for margin ing line on this type of preparation. A simple
degradation.28 Therefore, before deciding to 90-degree butt joint would be the simplest
preserve some cusps, the clinician should margin to perform. However, preparing the
consider the age, carious and functional risk enamel parallel to its prisms is not ideal.
of the patient, and management of secondary Bonding strength to a surface that is parallel
caries or fractures. to enamel prisms can be half of what can be
achieved in surfaces that are perpendicu-
How much vertical reduction is needed for lar.32 Therefore, the proposition by some au-
cusp coverage? thors to use a light chamfer or a bevel at the
Studies suggest between 1 to 2 mm as margin may have benefits in terms of mar-
the minimum vertical reduction for cusp ginal integrity and the maximal enamel sur-
coverage, depending on material choice. face for adhesion (Fig 4).33 Yet, it is most dif-
CAD/CAM composite resin and lithium di- ficult with these conservative margins to
silicate-reinforced glass-ceramics seem to optically hide a transition of the restorative
need less reduction (around 1 mm),29 while interface. In esthetic situations, such as in
CAD/CAM feldspathic and leucite-reinforced the case of maxillary premolars, a different
glass-ceramics need more occlusal volume approach might be needed, as discussed
(closer to 2 mm; Fig 4).30 When the enamel later in this article.
is preserved on the occlusal surface, such
as in cases with a raised vertical dimension When should marginal ridges and the
where occlusal reduction is not needed, the contact point be included?
material thickness can be reduced due to A common question is when to include the
the higher stiffness of the substrate.29 marginal ridge and/or the contact point in
the restoration. A lost marginal ridge will ob-
Occlusal preparation design for cusp viously be included if a decision is made to
coverage cover its adjacent cusps. The doubt usually
Cases of complete cusp coverage, where arises when a decision is made to cover the
no additional axial preparation is performed, cusps adjacent to a marginal ridge that is in-
have been referred to in the literature as tact with its contact point. In most cases, it
overlay ‘table tops’ or ‘occlusal veneers.’31 In is recommended to include it in the restor-
these cases, where most of the remaining ation, especially when the remaining
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PREPARATION PRINCIPLES
ADHESIVE RESTORATIONS
CONSERVATIVE ESTHETIC RESTORATION CONTACT
MARGIN MARGINS THICKNESS POINT
1–2 mm
marginal ridge is less than 1-mm thick (ab- When should retentive designs be
sence of DEJ), presents cracks or the inter- added to ‘occlusal veneer’ or ‘table
face will be in an opposing occlusal contact top’ overlays?
(Figs 2 and 4). Inclusion of the contact point
also depends on its vertical location in the When to perform an ‘occlusal veneer’ or
interproximal area. In younger patients, ‘table top’ only? When to further prepare?
there can be enough space to ensure a How to provide more volume to the restor-
minimum of 1.5 mm for restorative thick- ation in order to restore more extensive
ness, which can include the marginal ridge structural damage? Not only are these com-
in the restoration but still not reach the con- mon decision points, they also frame the
tact point. However, in worn teeth, the con- issue in a simple, logical, and clinically rele-
tact point is usually more occlusal, and in vant context. The easy answer is that these
order to ensure a minimal restorative thick- decisions are related to the remaining tooth
ness, the contact point needs to be includ- structure, namely the enamel. The difficulty,
ed in the preparation. Deciding to preserve however, is how to relate the structural loss
a marginal ridge and/or contact point can to a specific preparation design.
pose the same risks as when some cusps It is accepted that restorations cannot
are preserved – secondary caries, restora- rely solely on micromechanical adhesion,
tive fracture or marginal ridge fracture due especially if enamel is absent since adhe-
to thin volumes. sion to dentin is not predictable in the long
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term.34 The more the remaining walls are on the clinical decision. Apically to this area,
compromised vertically, the less enamel is the enamel thickness starts to significantly
present, and a higher vectorial result in hori- reduce below 1 mm (Fig 2).35 With this refer-
zontal loads is induced in the adhesive inter- ence in mind, but knowing that this should
face. An extreme example would be a com- be seen more as a thought process than a
pletely flat preparation at the gingival level strict guideline, the present authors can
that would be likely to fail due to two fac- suggest three grades that will have a clinical
tors: a) The high vertical restoration volume impact on the restorative decision, based
would subject the bonding interface to a on the amount of remaining wall height per
more intense tensile load; and b) The re- tooth periphery:
duced enamel thickness in the gingival area • Mild tissue loss: Remaining walls with
would result in less predictable bonding. enamel above half the height of the clin-
Therefore, it is logical to establish a minimal ical crown (> 3 mm) in more than two
height of the remaining walls, below which thirds of the tooth’s periphery.
the restoration must rely not only on adhe- • Moderate tissue loss: Remaining walls
sion (the ‘table top’) but also on grasping, with enamel above half the height of the
splinting or somehow introducing addi clinical crown (> 3 mm) between one third
tional mechanisms of resistance. However, and two thirds of the tooth’s periphery.
there are no studies that objectively address • Severe tissue loss: Remaining walls with
this decision, only expert recommendations. enamel above half the height of the clin-
In the literature to date, the decision to go ical crown (> 3 mm) in less than one third
from a ‘table top’ to a ‘veneerlay’/‘vonlay’ of the tooth’s periphery.
(overlay with additional buccal coverage) is
justified by either the esthetic need to cover In cases with mild tissue loss, the restora-
the visible buccal surface or by a subjective tive technique can be a simple cusp cover-
recommendation regarding more ‘extensive’ age according to the criteria stated above,
damage. without any additional design – a ‘table
In order to overcome the lack of clarity top’ or ‘occlusal veneer.’ There is still a
regarding this decision, the present authors large peripheral enamel extension above
propose the use of a grading division for the the equator line, thicker than 1 mm. Adhe-
minimal peripheral height that will dictate sion will provide the restoration with the
clinical decisions. It is important to note that micro mechanical stability to prevent it
this evaluation is performed after caries re- from dislodging along the insertion path
moval and the clearance of unsupported (retention) or another oblique path
enamel as well as after the vertical re (resistance; Fig 5).
duction of thin walls until a minimum of Cases with moderate tissue loss have less
1-mm thickness is reached, as stated earlier. surrounding vertical structure and enamel
A reasonable and practical evaluation thresh- thickness for adhesion, and the present
old for wall height can be around the equa- authors believe that these situations de-
tor. Although it has some variability, it is lo- mand an additional adhesive area and/or
cated roughly around half the clinical crown, complementary resistance measures. These
2 to 3 mm coronal to the cementoenamel measures can include (Fig 2):
junction in posterior teeth in the buccal and 1. Axial preparation (shoulder/chamfer/
lingual areas. This criterion can be import- long bevel) of the walls, allowing the res-
ant for the predictability of adhesive reten- toration to partially or completely brace
tion to enamel and, consequently, impact the tooth structure – also referred to as a
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a b
c d
Fig 5 (a) Initial situation of a vital maxillary right first molar showing clinical signs of infiltration on the restoration margin. The central cavity
was 3-mm deep, with remaining walls of < 1 mm in some areas. The history and clinical examination revealed signs of centric bruxism, and
there were visible cracks in the interproximal walls. A full cusp coverage restoration was planned. (b) The previous restoration was redone and
a gingivectomy was performed under rubber dam isolation on the subgingival area for better marginal finishing. Adequate remaining walls in
more than two thirds of the periphery were present; therefore, a simple ‘table top’ indirect restoration was indicated without the need for
additional preparation for retention. Contact points were included in the preparation/restoration since the existing enamel cracks were
removed. A conservative margin was selected as it was a less visible molar and no discoloration was present. A CAD/CAM-milled and stained
lithium disilicate ‘table top’ was fabricated. (c) Restoration after bonding. (d) Initial (top) and 3-year postoperative (bottom) radiographs.
‘long wrap overlay’ or a full contour ‘ad- still present.36 The amount of remaining
hesive crown,’ respectively. tooth structure to which a restoration can
2. The use of the pulp chamber in cases bond or engage around (‘ferrule’ effect)
of endodontically treated teeth – an seems to be more important than the use of
endocrown. a post.37 Therefore, posts may eventually be
3. Both of the above – an endocrown with more indicated for build-up reconstructions
peripheral axial preparation. prior to full-contour resistance form crowns,
where more extensive tissue losses com-
The use of posts does not seem to provide promise tooth flexural strength. However,
benefits in partial adhesive posterior restor no fundamentalist doctrines for or against
ations when cusp coverage is performed the use of posts have been clearly support-
since enough remaining structure is usually ed by scientific evidence. In borderline cases,
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even in adhesive restorations, the clinician present. However, when an axial prepar
may decide that the buildup needs addition- ation is added to the occlusal reduction –
al retention/resistance, and a post may be a so-called ‘vonlay’ or ‘veneerlay’ or a full
used according to certain considerations adhesive ‘crown’ – the material is subject to
(discussed in Parts II and III of this article different tensile forces. For monolithic cer
series). amics in the posterior area, the literature
In cases of severe tissue loss, endo- seems to favor keeping the ceramic thick-
crowns can be considered. However, when ness adequate and allowing some prepar
adhesion is not predictable, resistance-form ation into the dentin in the axial areas,41
preparations for full-contour crowns (dis- while trying to maintain some enamel at
cussed in Part II of this article series) may least in the margins when the preparation
have a better prognosis. needs to extend below the equator for
structural or esthetic reasons. Therefore,
Which resistance measures can be added cervical lesions should be covered by the
to partial adhesive restorations? Peripheral ceramic restoration, ensuring that a previ-
axial preparation or using the pulp cham- ous direct composite is performed to re-
ber (endocrown)? duce lesion depth, preventing undercuts
and unnecessary tooth preparation. How
Peripheral axial preparation for additional ever, in premolar teeth, especially in restor
adhesive area and resistance ations mainly for esthetic reasons, it seems
Shoulders and chamfers as a form of peri reasonable for the preparation to remain in
pheral axial preparation have been asso the enamel, using the same strategy as for
ciated with higher long-term survival of veneers in anterior teeth.
onlays.38 A marginal design in silica-based Another important consideration is that
ceramic materials demands particular atten- the buccal or lingual axial preparation mar-
tion since these materials are more prone to gin should extend into the interproximal
marginal chipping than composite resins.39 zones to gradually connect to the finishing
However, as discussed initially, lithium disili- line in that area whenever marginal ridges
cate seems to be the most reasonable cer have been reduced, so that the contact point
amic material to consider for posterior ad- is included within the restoration (Fig 6).
hesive restorations since thinner preparation
designs have been providing good clinical Endocrown – use of the pulp chamber for
results. The shoulder may provide a safer additional adhesive area and resistance
marginal design biomechanically than a While in the case of an onlay or overlay the
bevel,40 and 1 mm can be considered the pulp chamber is previously restored with a
minimum thickness for the material in the direct restoration, the ‘endocrown’ uses the
axial area.41 Since thickness of enamel drops pulp chamber for additional adhesive area
below 1 mm apically to the equator level,35 and resistance of the indirect restoration it-
a common doubt exists: a) Should the self (Figs 2, 7, and 8). Recent reviews reveal
axial preparation be limited to enamel and high long-term success rates of endocrowns,
compromise ceramic thickness, especially comparable with post and crown restor
below the equator level?; or b) Should the ations for molars and premolars.42 Although
ceramic thickness be maintained, irrespec- promising, this modality needs to be con-
tive of the loss of some of the enamel area? sidered carefully due to the limited number
The thickness of monolithic ceramics can of available clinical studies. It is not clear
be reduced in the occlusal area if enamel is whether adding a peripheral axial ‘ferrule’
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a b
c d
e f
MARGIN
ELEVATION
INDIRECT
RESTORATION
g h
Fig 6 (a) Initial situation: buccal view. (b) Initial situation: occlusal view. (c) Implant placement and soft tissue graft to
increase buccal volume on tooth 15. Removal of existing restoration and evaluation of remaining vertical walls above
the equator and its presence in between one and two thirds of the periphery on tooth 14. An adhesive indirect
restoration with peripheral axial preparation was selected. A previous direct restoration was performed to elevate the
future interproximal margins and core buildup. (d) Final preparation for the adhesive restoration, creating axial
preparation for esthetics, additional retention, and adequate margin elevation for a correct emergence profile and
contact point of the restoration with the adjacent teeth. An indirect monolithic lithium disilicate restoration was
bonded. (e) 7-year follow-up: buccal view showing minimally stained ceramic margin. (f) 7-year follow-up: occlusal
view showing normal signs of wear on tooth 14 (with monolithic lithium disilicate), probably less wear than that shown
on the monolithic zirconia implant crown on tooth 15. (g) Initial radiograph. (h) Final radiograph at the 7-year
follow-up showing the tooth structure, margin elevation, and ceramic restoration interfaces with apparent stability.
The mesial contact point of the implant has been lost due the mesial migration of the teeth with age, which is a
well-known phenomenon.
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Fig 7 Preparation
principles for
PREPARATION PRINCIPLES
‘FERRULE’ BUTT JOINT EXTENSION INTO
endocrowns. DESIGN OR MARGINS PULP CHAMBER
1 mm
2 mm
1 mm 3 mm 6–12
2 mm degrees
ENDOCROWNS
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of composite resin (flowable or packable). in the tooth structure (creating a ‘ferrule’ de-
This will prevent dentin contamination and sign) that is mainly responsible for the res-
hypersensitivity during temporization and toration resistance.48 These types of resist-
dissipate the polymerization tension of the ance form preparations, tra d
itionally
adhesive interface while bonding, thus in- referred to as ‘crowns,’ are fully d
iscussed in
creasing immediate dentin bond strength, Part II of this article series.
compared with adhering the restoration dir
ectly onto the dentin without previous seal- Esthetics
ing.46 Besides a few in vitro studies, data are
lacking regarding long-term clinical advan- Posterior teeth are less visible and are there-
tages of dentin sealing, except that it seems fore less of an esthetic concern. However,
to increase long-term restoration survival this is not true for all patients, as some have
when the dentin occupies more than 50% higher esthetic expectations and may not
of the surface for anterior veneers.47 accept or understand an esthetic compro-
mise in favor of tissue conservation. For this
When should the transition be made reason, in order to manage these expecta-
from an adhesive restoration to a tions, it is important that clear explanations
resistance-form crown in the clinical and good communication is developed
decision? before the start of treatment.
Esthetics in posterior teeth can involve:
Using the same pragmatic logic of remain- a) Blending of the optical properties of par-
ing vertical height per tooth periphery, in tial restorations between the restored and
cases of severe tissue loss – remaining walls preserved areas within a tooth in more
above half the tooth’s height (> 3 mm), in visibly exposed buccal/occlusal areas; and
less than one third of the tooth’s periphery – b) Blending of the optical properties between
the amount of enamel available for adhe- the restored and adjacent teeth.
sion is significantly limited. As previously Regarding optical integration in partial
stated, there are promising clinical data restorations, what needs to be considered is
concerning the long-term performance of that, in vital teeth, a successful immediate
adhesive endocrowns in cases with a limit- optical blending of the restorative material
ed amount of peripheral enamel. Given the with the remaining structure will probably
good clinical results, even in cases without a be maintained in the long term. However,
‘ferrule’ design, endocrowns can be consid- uncovered areas in nonvital teeth are very
ered in teeth with severe tissue loss; for ex- likely to become progressively discolored
ample, when all the walls are less than 3 mm with time.49 While some patients may accept
while still supragingival, exhibiting a thin but this color contrast and understand the con-
fully present enamel layer throughout the servative advantage, others may be dissatis-
periphery. Although there have been prom- fied, even in areas that seem less exposed
ising studies for the clinical performance of during smile. Moreover, the preparation
endocrowns, a traditional high-strength res- depth/restorative thickness needs to be ad-
torative material with a resistance-form prep- dressed in case of discoloration. Heavier
aration (crown) still has important long-term discolorations may need a preparation that
scientific support that justifies its use in se- goes into the dentin and might demand a
verely damaged teeth. When adhesion is not subgingival margin. This can eventually
reliable (limited or absent enamel), it is the change the conservative/adhesive restora-
crown engagement, grasping or embrasure tive decision that was exclusively based on
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Clinical Research
A B C A B C
D D
Fig 9 Fluorescence behavior of different ceramics: natural vital and nonvital teeth. The lithium disilicate on tooth
25 has almost no fluorescent behavior, even though the composite used to bond it can express some of it through
the restoration. Non-fluorescent materials provide a less natural result, especially in different light conditions.
remaining tooth structure into a more re- remaining enamel and reducing bonding
sistance form approach as enamel is re- performance.47 For this reason, these situ
moved. Therefore, options should be dis- ations may also demand additional resistance
cussed with a patient to find a balance form measures – or even the decision for a
between a conservative approach and es- full-contour resistance form preparation –
thetic satisfaction (Figs 4 and 6). and for the adhesive option to be discarded.
In terms of optical integration with adja- Internal bleaching can also be performed,
cent teeth, especially relevant in maxillary analyzing risks and potential benefits, always
premolars, it is important to realize that the considering that color stability in the long
use of monolithic ceramics is far from being term is not predictable.47
as predictable regarding the match with nat- Fluorescence is a critical but often neg
ural teeth as layered ceramics. However, lected part of the optical result that will pro-
monolithic multilayered blocks can be help- vide better metameric behavior (less vari
ful to mimic different translucencies within ability in different light conditions) and will
the restoration. Monolithic restorations that result in less shadowed cervical areas, espe-
are stained or minimally layered in nonfunc- cially in dark substrates. It can increase value/
tional areas need to be mastered in order to brightness without affecting translucency,
create optical illusions of depth, translu- especially important to nonvital teeth that
cency, and value/brightness, especially if the lose fluorescence properties. Lithium di
adjacent teeth are natural and the patient is silicate and zirconia, for example, have a
young. In heavily discolored teeth, the need very low fluorescence and brightness/value
to hide the substrate may require a prepar compared with natural vital teeth (Fig 9).50
ation depth of more than 1 mm, removing For these reasons, implementation of
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