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Inlays-Onlays-Dietschi 1
Inlays-Onlays-Dietschi 1
E-mail: didier.dietschi@unige.ch
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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.
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Table 1 Development of concepts for adhesive inlays and onlays, with original references
Dual Bonding (DB) - Dentin sealing and protection Paul and Schärer, 1997
before impression and provision- Dietschi and Spreafico, 1997
alization Dietschi and Spreafico, 1998
- Improved bond strength and ad- Dietschi and Herzfeld, 1998
hesive interface quality Dietschi et al, 2002
Cavity Design Optimization Application of an adhesive base/ Dietschi and Spreafico, 1997
(CDO) liner to: Dietschi and Spreafico, 1998
tPQUJNJ[FDBWJUZHFPNFUSZ Dietschi et al, 2003
tmMMVOEFSDVUT
tIBSNPOJ[FBOEMJNJUSFTUPSBUJPO
thickness
tQSPUFDUFYQPTFEEFOUJOEVSJOH
temporary phase
tJNQSPWFSFTUPSBUJPOBEBQUBUJPO
Cervical Margin Relocation Displace supragingivally an intrac- Dietschi and Spreafico, 1998
(CMR) revicular cervical margin to facili- Dietschi et al, 2003
tate and improve:
tJNQSFTTJPOQSPDFEVSFT
tDFNFOUBUJPOQSPDFEVSFT
tDMFBOJOHBOEmOJTIJOHPGNBSHJOT
tSFTUPSBUJPOBEBQUBUJPO
tSVCCFSEBNQMBDFNFOU
(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
tSFEVDFMVUJOHDFNFOUXFBS
tDPOUSPMFYDFTTSFNPWBMPGDFNFOU
tFYUFOEXPSLJOHUJNF
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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.
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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.
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consistency and large particle size (pre- ary phase) through the systematic
polymerized particles or clustered nano- use of a rubber dam and extensive
particles). The results of research stud- water spray, and by isolating the
ies on the possibility of bringing sufficient dentin immediately after preparation
light into the cementing space for optimal with a thick layer of DBA and adhe-
composite conversion and mechanical sive base/liner.
properties have shown that proper light The long-term function and resist-
polymerization is feasible, and in some ance of the teeth due to the use of
conditions is superior, to what can be wear-resistant, strong, and rigid re-
achieved with a dual-curing material in storative materials (both restoration
the absence of light; in fact, proper light and cement).
propagation within the luting interface Strong and durable adhesive inter-
is highly recommended for both types faces between the materials and
of composites (light- or dual-curing).5-18 substrate (dentin-enamel to adhe-
The CDO procedure also helps to re- sive, adhesive to base/liner, base/
duce and optimize the restoration thick- liner to composite cement, and com-
ness, and therefore favors proper light posite cement to restoration).
transmission within the luting interface.
An additional benefit of this technique The treatment procedures discussed in
is that, due to the dentin remaining fully this article have been extensively evalu-
protected by the base/liner, anesthesia ated in vitro, and there is strong positive
during cementation procedures is virtu- evidence in favor of this revised treat-
ally 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
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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.
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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.
Fig 3h Completed
restoration.
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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)
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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.
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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).
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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.
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Fig 4k Fig 4l
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