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Recent advances in direct reinforced restorations for vital teeth

Article in Advances in Human Biology · January 2022

DOI: 10.4103/aihb.aihb_104_21

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Review Article

Recent Advances in Direct Reinforced Restorations for Vital

Teeth
Karan Bhargava, Chaitra Mastud1, Santosh Kumar Mastud2, Deepak M Vikhe3, Pooja Newase, Prasad Nanasaheb Mhaske4
Departments of Conservative Dentistry and Endodontics, 1Orthodontics and 2Oral Medicine and Radiology, Faculty of Dentistry, Dr. D. Y. Patil Vidyapeeth, Dr. D. Y. Patil
Dental College, Pune, 4Department of Prosthodontics, Bharati Vidyapeeth (Deemed to be) University Dental College and Hospital, CBD Belapur, Navi Mumbai,
3
Department of Prosthodontics, Faculty of Dentistry, Rural Dental College, Loni, Maharashtra, India

Abstract
The conservative option depends mainly on the ability of the bonded restoration to strengthen the enamel in the same way that dentine gives
strength and supports the enamel. In order for a dental material to reinforce the vital tooth, it must bond to dentine. As such, an essential
attribute of a good dentine adhesive system is the ability of the adhesive to wet and infiltrate the dentine. In restorative dentistry, numerous
studies have demonstrated coronal reinforcement of the vital tooth through bonded restorations. Six bonded amalgams and resin composites
have all been shown to reinforce the remaining vital tooth structure by bonding to dentine and enamel.

Keywords: Bonded amalgam, reinforced composites, restorative materials

Introduction
Traditionally, more extensive restorations on vital teeth were
performed using non‑adhesive techniques. The materials of
choice were gold, porcelain and metallic ceramics. These
were placed either intra‑ or extra‑coronally and relied on the
preparation having near‑parallel walls, assisted by a luting
cement to fill the marginal gap and help with the retention
process. With the development of new materials and techniques
for bonding to the vital tooth, there has been a blurring of the
methods used, and often restorations rely on a multitude of
factors for retention, which incorporates both mechanical and
adhesive principles.[1]
Loss of dentine, including anatomic structures such as cusps,
ridges and arched roof of the pulp chamber, may result in
tooth tissue fracture after the final restoration. Therefore,
intra‑coronal strengthening of teeth to protect them against
fracture is important, particularly in posterior teeth, where
stresses generated by forces of occlusion can lead to fracture
of unprotected cusps.[2‑5]
Replacement of Lost Coronal Tooth Structure
Indirect restorations are frequently placed on teeth that have
lost substantial amounts of vital tooth structure. Retention
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and resistance forms are lost as the height of the tooth
preparation is reduced in relation to the intended occlusal
surface position of the final restoration.[6,7] A foundation or
core build‑up restoration may be required to supplement
retention and resistance form. The strength required of a
foundation restoration will vary, depending on the location of
the vital tooth in the dental arch, as well as on the design of
the surrounding tooth preparation.[8‑10]
Apart from acting as a transitional restoration in the
management of a damaged tooth, a core build‑up restoration
must withstand crown preparation and impression taking
and contribute to the retention and support of a provisional
crown before the definitive crown restoration is placed. When
retention and resistance depend significantly on the core
build‑up, the strength of the foundation restoration and its
retention to the underlying tooth tissue can directly influence
Address for correspondence: Dr. Santosh Kumar Mastud,
Department of Oral Medicine and Radiology, Faculty of
Dentistry, Dr. D. Y. Patil Vidyapeeth, Dr. D. Y. Patil Dental College, Pimpri,
Pune, Maharashtra, India.
E‑mail: drsantoshkumar.mastud@gmail.com
Submitted: 12‑Jul‑2021 Revised: 31-Mar-2022
Accepted: 30‑Apr‑2022 Published: 13-May-2022
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

DOI: How to cite this article: Bhargava K, Mastud C, Mastud SK, Vikhe DM,
10.4103/aihb.aihb_104_21 Newase P, Mhaske PN. Recent advances in direct reinforced restorations
for vital teeth. Adv Hum Biol 2022;12:120-6.

120 © 2022 Advances in Human Biology | Published by Wolters Kluwer - Medknow

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Bhargava, et al.: Direct reinforced restorations for vital teeth
the survival of the restoration.[11] Some core materials lack
sufficient strength and/or adhesion to vital tooth tissues to serve
this function. Posterior vital teeth are exposed to greater forces
than anterior vital teeth, and the direction of load differs.[12,13]
Vital teeth that have to serve as abutments for fixed or
removable prostheses are subject to increased stress. Almost
one‑quarter of all posterior crowns were provided with a
pin‑ or post‑retained core. The restoration of severely broken
down vital teeth is an increasing problem for the restorative
dentist, as more patients retain their natural teeth into older
age.[14‑18] Clinical studies demonstrate an increased incidence of
vital tooth fractures in teeth with large restorations compared
with sound or minimally restored teeth. Whilst advances in
adhesive restorative materials and techniques may result in
more predictable retention of restorations with compromised
retention, the success of these techniques is still to be confirmed
by clinical trials.[19,20]
Such techniques may be operator sensitive as the success of
an indirect restoration depends on the ability of the cement or
resin lute to prevent dislodgement of the restoration from the
tooth preparation; the latter must possess adequate retention
and resistance form. While resistance form is considered more
critical than retention form, and it is impossible to separate
these two features.[21] Retention will prevent dislodgement
of the restoration along a direction parallel to its path of
insertion, whilst resistance prevents dislodgement in any
other direction. Minimal taper and maximum preparation
heights are critical features for good retention. The fit of the
restoration, any surface treatments which facilitate adhesion
and the nature of the cement lute are also important variables. If
adequate retention and resistance form can be developed from
natural tooth structure, the strength of any core or foundation
restoration is less critical and minor depressions or undercuts
in the vital tooth preparation can be restored with adhesive
restorative materials.[22‑26]
Choice of Core Material
Clinically, there are times when the remaining tooth structure
is so reduced that the margins of the crown must be placed
at or just below the core. It is under these conditions that the
choice of core material may be critical. Core build‑up materials
for direct placement include:
• Dental amalgam
• Resin composite
• Reinforced glass‑ionomer cement
• Resin‑modified glass ionomers/compomers
(polyacid‑modified resin composites).[27]
Gold alloys and ceramics have been used as indirect core
build‑up materials. Each candidate core material has
advantages and disadvantages.
Desirable properties for a restorative material to be used in
complex restorations:
• Compressive strength to resist intraoral forces
Advances in Human Biology ¦ Volume 12 ¦ Issue 2 ¦ May‑August 2022
• Flexural strength to prevent core dislodgement during
function
• Biocompatibility with surrounding tissues
• Ease of manipulation
• Ability to bond to tooth structure, pins and posts
• Capacity for bonding with luting cement or having
additions made to it
• Coefficient of thermal expansion conductivity similar to
dentine
• Dimensional stability
• Minimal water absorption
• Short setting time to allow tooth preparation and
co‑replacement to be carried out during the same visit
• No adverse reaction with temporary crown materials or
luting cement
• Cariostatic potential
• Low cost
• Contrasting colour to tooth tissue unless being used for
anterior cores.[28]
Dental treatment procedures are increasingly governed by
factors such as biocompatibility of restorative materials,
patients’ demands for aesthetics and a conservative approach
to minimise loss of vital tooth structure.[29,30] Following
the traditional Black’s principles for cavity preparation, all
undermined enamel should be removed even for marginal
ridges composed of healthy, sound and caries‑free undermined
enamel.[31] This could be attributed to the brittle nature of the
undermined enamel and the inability of the conventional cast
inlays and amalgam restorations to strengthen the remaining
tooth structure.[32‑34]
However, the increased use of resin composites in posterior
teeth violates these principles. Restoring vital teeth with
minimal sacrifice of sound tooth structure depends mainly
on adhesives that provide strong and durable bonding to the
remaining sound enamel and dentine. Laboratory reports
have proven that modern adhesives do effectively bond to
tooth tissue in the short term. However, clinically, marginal
deterioration of composite restorations remains problematic
in the long term and still forms the major reason to replace
adhesive restorations.[35]
When resin composite is bonded to tooth structure using
adhesives, the initial and residual polymerisation stresses that
are present along the cavity walls may result in gap formation,
leakage, recurrent caries and pulp irritation. The detrimental
effect of marginal gap formation cannot be offset even with the
use of fluoride‑releasing adhesives or restorative materials that
prevent demineralisation along cavity margins. Thus, only the
hermetic sealing of restorations guarantees clinical success.
The purpose of restorative material is not only to restore
the decayed or defective tooth and provide an effective seal
between the restoration and the tooth but also to strengthen
the tooth.[36]
Studies showed that strength of the vital teeth was significantly
reduced after cavity preparation; others, however, report no
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Bhargava, et al.: Direct reinforced restorations for vital teeth
significant difference between fracture resistance of intact
teeth and the teeth that were prepared but unrestored. Morin
showed that the mean relative deformation and stiffness values
for acid‑etched bonded teeth resemble the mean relative
deformation and stiffness values for sound teeth. Simonsen
showed that teeth restored with resin composite were stronger
than those restored with amalgam when tested at cusp inclines.
An important clinical controversial condition is the presence of
undermined marginal ridge of the full thickness of enamel after
cavity preparation. The clinician either leaves the undermined
marginal ridge and restores the tooth or removes the thin
enamel preparing Class II and restores the tooth.[37‑39]
The conservative option depends mainly on the ability of the
bonded restoration to strengthen the enamel in the same way
that dentine gives strength and supports the enamel. In order
for a dental material to reinforce the vital tooth, it must bond
to dentine. As such, an essential attribute of a good dentine
adhesive system is the ability of the adhesive to wet and
infiltrate the dentine. In restorative dentistry, numerous studies
have demonstrated coronal reinforcement of the vital tooth
through bonded restorations. Six bonded amalgams and resin
composites have all been shown to reinforce the remaining
vital tooth structure by bonding to dentine and enamel.
Recent Advances
Ormocers
Ormocers, a word originally derived from organically
modified ceramic, were originally developed for science and
technology (e.g. for special surfaces such as protective coatings,
non‑stick surfaces, anti‑static coatings and non‑reflective
coatings). In contrast to conventional composites, the ormocer
matrix is not only organic but also inorganic. Therefore,
monomers are better embedded in the matrix, which reduces
the release of monomers.[40]
Ormocers basically consist of three components – organic and
inorganic portions and polysiloxanes. The proportions of those
components can affect the mechanical, thermal and optical
qualities of the material:
1. The organic polymers influence the polarity, the ability
to crosslink, hardness and optical behaviour
2. The glass and ceramic components (inorganic constituents)
are responsible for thermal expansion and chemical
stability
3. The polysiloxanes influence the elasticity, interface
properties and processing
4. The inorganic components are bound to the organic
polymers by multifunctional silane molecules.
After polymerisation, the organic portion of the methacrylate
groups forms a three‑dimensional network.[41] In spite of all
efforts to create a better restorative material using ormocers,
their performance (cervical and occlusal marginal adaptation)
was significantly worse when compared to today’s hybrid
composites after cyclical loading in a laboratory test. However,
no significant differences were found in a 5‑year clinical
122
comparison of AdmiraR (ormocer) and TetricCeramR (hybrid
composite).[42]
At the same filler content, ormocers have a reduced
polymerisation shrinkage compared to hybrid composites, or
at a lower filler content of the ormocer, the polymerisation
shrinkage is equal to that of a conventional composite.[43]
Ramsey PH et al. investigated the ‘in vivo’ quality of ormocer
restorations in a clinical trial over 1 and 2 years. The clinical
application was acceptable, but there were concerns about the
marginal adaptation and the indication for Class V restorations
due to poor adhesion. In contrast, another study found no
difference in the longevity of restorations between ormocers
and Bis‑GMA‑based systems. However, the 5‑year control
showed a much stronger tendency to discolouration with one of
the two ormocer materials compared to the other materials.[44]
Another 1‑year study found that an ormocer (DefiniteR) failed
to meet the requirements for restoration longevity compared
to a conventional composite resin for Class II restorations.
Numerous restorations had to be replaced within the 1st year.
Hayashi M et al. examined the cytotoxicity of three different
filling materials and their flowables (AdmiraR, Z250R,
TetricCeramR). The ormocer material (AdmiraR) had the
highest cytotoxicity in the standard composites but the
lowest regarding flowables. This has been rejected by another
study, which showed that an ormocer (CeramXR) released
significantly less monomers such as Bis‑GMA, TEGDMA or
UDMA compared to either a nanohybrid composite (Filtek
Supreme XTR) or a self‑curing composite (ClearfilCoreR).[45]
With respect to microhardness, the ormocers are comparable
with hybrid composites, but their wear resistance is lower.
This contradicts other studies, which have shown less wear
for ormocers.[46]
Compomer
The word ‘compomer’ comes from composite and glass
ionomer. The material itself is a polyacrylic/polycarboxylic
acid‑modified composite. Compomers are composed of
composite and glass‑ionomer components. It is an attempt
to take advantage of the desirable qualities of both materials:
The fluoride release and ease of use of the glass ionomer
is one advantage and other one is the superior material
qualities and aesthetics of the composites. In addition to the
various polymerisable monomers (e.g. UDMA), the material
also contains dicarboxylic acids, which in contrast to those
composite and glass -ionomers, in traditional glass ionomers
that have polymerisable double bonds.[47]
The reactive fluoro‑aluminium silicate glasses from the
glass‑ionomer technology are found in compomers. The
particle size of fillers in these products varies from 0.2 μm up
to 10 μm. Compomer restorations have been shown to have
insufficient retention without pre‑treatment of the dental hard
tissue with an adhesive system.
The composition and properties of these adhesives do not
differ fundamentally from adhesives used for composites. The
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Bhargava, et al.: Direct reinforced restorations for vital teeth
setting reaction of the compomer is based primarily on the
polymerisation of acidic monomers.[48] The acid‑base reaction,
which starts only after water absorption, is limited to the
superficial layers. Although, for a narrow range of indications,
certain coloured compomer materials (Comp naturR) may
be of interest for use in adults, compomers are most suitable
for restorations in the deciduous dentition due to their low
abrasion resistance.[49]
In cervical restorations, compomer restorations performed
better than resin‑modified glass ionomers but not as well
as hybrid composites. The fluoride release of compomers
increased quickly initially (24 h) but decreased equally quickly.
The ability of compomer to be recharged with fluoride from
its environment resulting in long‑lasting caries prevention has
been discussed.[50] An in situ experiment showed that caries
development next to compomer restorations (DyracteXtraR)
was lower than next to composite restorations (Spectrum TPHR).
The fluoride release over 28 days had an inhibitory effect on
caries development in the adjacent tooth. It has also been shown
that fluoride release into saliva was less for young permanent
teeth than for deciduous teeth. It is assumed, therefore, that
young permanent teeth can store more ions in the enamel.
However, a clinical study showed no difference in new caries
development in children who received compomer restorations
compared to those who had amalgam restorations. The fluoride
regeneration is mainly determined by the glass component and
the hydrogel layer.[51]
The hydrogel layer is, in turn, dependent on the acid‑base
reaction. Therefore, both the fluoride release and the
fluoride re‑uptake are greatest in glass ionomers followed
by compomers and then by composites. The increased water
absorption of the compomer compared to conventional
composite results in marginal discolouration interfering with
aesthetics, particularly in the anterior teeth. Compomers are
also contraindicated for large core build‑ups due to their poor
abrasion resistance.[52]
Silorane
The name of this material class refers to its chemical
composition from siloxanes and oxiranes. This product class
aims to have lower shrinkage, longer resistance to fading and
less marginal discolouration. The silorane monomer ring differs
obviously from the chain monomers of hybrid composites.
The hydrophobic properties of the material are caused by
siloxanes. Exogenous discolouration and water absorption
are reduced. The oxirane rings are responsible for the physical
properties and the low shrinkage. Siloranes are polymerised
by a cationic reaction in contrast to methacrylates, which
crosslink via radicals.[53] The photoinitiator system is based
on three components: light‑absorbing camphor, an electron
donor (e.g. amine) and an iodonium salt. The camphor Chinon
is excited and reacts with the electron donor, which reduces
the iodonium salt to an acidic cation in the process. This starts
the opening process of the oxirane ring. The opening of the
oxirane rings during the polymerisation process compensates
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to some degree for the polymerisation shrinkage. The fillers
in FiltekSiloraneR, the only silorane material on the market
at the moment, consist of 0.1–2.0 μm quartz particles and
radiopaque yttrium fluoride.[54]
A comprehensive study of FiltekSiloraneR was carried out by
Heyman HO et al.: it confirms the low shrinkage (<1%) and
found that the light stability of the silorane was seven times
longer than for methacrylates. The silorane low shrinkage
leads to lower contraction stress. The silorane‑based filling
material was shown to have both low water absorption and
water solubility. The adhesion of streptococci observed on
the surface of silorane restorations was low, maybe because
of its hydrophobic properties. Siloranes have been shown to
have good storage stability in various media, and compared to
conventional composites, they are less susceptible to changes
if stored in ethanol. FiltekSiloraneR has good polishing
characteristics. The material showed little colour change after
artificial ageing, and the surface gloss was retained.[55‑57]
The clinical application of these materials is limited to the
posterior teeth because few low translucent colours are
available.
Because of the hydrophobic properties, the appropriate
adhesive system must be used for silorane restorations. Dentists
both value and recognise the challenge of the relatively
high viscosity. At the moment, the weak radiopacity is a
disadvantage since the limitations of the restoration are difficult
to recognise on radiographs.[58]
Ceromer
Due to the increasing patient demand for aesthetic,
biocompatible restorations, materials that exhibit a natural
appearance, strength and durability have been developed.
Researchers have explored several alternatives for achieving
this objective, including the use of inlay or onlay restorations
fabricated of direct composites in ceramic and ceramic optimised
polymer (ceromer) materials. The advancements associated
with computer‑aided design/computer‑aided manufacturing
and milled restorations have further increased the clinician’s
ability to deliver predictably durable restorations.[39,34] Whilst
direct Class II composite restorations can provide clinical
advantages with regard to aesthetics, reduced patient expense
and efficiency, clinicians must simultaneously address several
materialistic and procedural limitations (e.g. polymerisation
shrinkage, microleakage and post‑operative sensitivity).
Although conventional ceramic or ceromer inlays and onlays
are clinically superior to direct composite restorations, these
modalities increase treatment expense and require multiple
visits to facilitate placement.
The use of direct inlays or glass insert restorations was
introduced in the early 1980s in the form of Beta Quartz
glass inserts. After utilising this technology, sites prepared
for direct composite resin restorations were mega filled
with pre‑polymerised glass inserts to reduce polymerisation
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Bhargava, et al.: Direct reinforced restorations for vital teeth
shrinkage and impart strength to the definitive restorations.
Sites treated in this manner have exhibited a sevenfold lower
coefficient of thermal expansion as compared to amalgam
and have demonstrated the ability to reduce polymerisation
shrinkage by 50%–70%. The use of the inserts is intended to
improve the wear characteristics of composite restorations
by providing a solid surface for contact against the opposing
dentition and also permits them to function as acceptable
megafiller for composite resin.[39] The glass inserts, however,
are also characterised by clinical deficiencies that include the
poor aesthetic blending of the insert and composite materials
and marginal failure due to the gap that often forms between
the insert and the restorative margins.
After the advent of a sonically driven preparation system
(e.g. SONICSYS, Ivoclar Vivadent, Amherst, NY; KaVo,
Lake Zurich, IL), many of the original limitations of insert
technology have been resolved. This sonic system consists of
single‑sided, diamond‑coated tips (40 μm–50 μm coating) that
facilitate conservative preparation of mesial and distal surfaces
without causing damage to adjacent teeth. The tips – designed
for three Class II preparation sizes – attach to an oscillating
air scaler unit.[59]
The appropriate tip should be selected based on the size of the
preparation required for complete decay removal and finishing
of the inlay restoration. The system also contains ceramic
inserts – fabricated from a leucite‑reinforced glass‑ceramic
material similar to that of a pressed ceramic (i.e., IPS Empress,
Ivoclar Vivadent, Amherst, NY) – that are precisely shaped to
correspond to the assorted preparation tips. The objective of
the technique is to establish a preparation of predictable size
and shape to one of the three inserts, thus achieving an ‘inlay’
type restoration in the interproximal region of the tooth. The
definitive result is a prefabricated ceramic inlay with marginal
tolerance of 81 μm–108 μm in the interproximal area, and
12 μm–21 μm in the gingival bevel areas, which significantly
reduces the deficiencies (e.g. microleakage and post‑operative
sensitivity) of conventional direct composite restorations
that are typically associated with polymerisation shrinkage.
The gingival inclination of the sonically driven preparation
instrument is 45°, which is optimal for the acid‑etch technique
in cervical enamel.[60]
If the proximal preparation margin extends into the dentine,
the preparation is completed as soon as the dentinal gingival
margin is smooth. Bevelling the gingival margin in the dentine
does not provide decisive strength advantages for bonding
strength. This article demonstrates a clinical protocol that
features the preparation and ceramic insert technology utilised
to perform direct inlay restorations in the posterior segment.
Clinical protocol
Following proper case selection, diagnosis and treatment
planning for direct inlay restorations, a strict clinical protocol
should be followed in order to achieve predictable results.
Preparation design utilising sonic technology and predictable
cavity size contributes to the success of the restoration with
124
the ceramic insert. When selecting the design of the inlay or
onlay preparation, the ‘One‑Half Rule’ can be applied by the
clinician. 1 Instances in which the width of the isthmus is
equal to or greater than one half of the buccolingual intercuspal
distance, or in which the preparation finish line falls on or above
the halfway point of the cuspal incline ridge, are indicated for
an onlay restoration. Additional parameters (e.g. occlusal
function, the position of the tooth in the arch and degree of
enamel support) should also be considered. The smallest
preparation instrument that covers the marginal regions and
provides axial wall bevelling should be selected.[61]
Sonic technology, which cuts less aggressively than rotary
instruments, is ideal for finishing and standardisation of the
proximal box to ensure proper fit of the ceramic inlay. Upon
completion of the milled and precise interproximal preparation
site, the appropriately sized ceramic insert is selected. Accepted
isolation protocols should be followed to eliminate moisture,
which may compromise the conventional bonding procedures
employed for direct resin restorations. The ceramic insert
is subsequently placed into the interproximal preparation
and luted with flowable and conventional microhybrid
ceromers (e.g. Tetric Flow; Tetric Ceram, Ivoclar Vivadent,
Amherst, NY).[62] The inserts increase the depth of cure by
conducting the curing light within the composite material,
and their light transmission produces cohesive stress that
is directed towards the insert rather than the surface of the
restoration. Once complete curing of the dentine layer has been
performed, pit and fissure stains are incrementally applied to
the surface along with an enamel layer of a reinforced microfill
composite resin. Final occlusal adjustments, finishing and
polishing are accomplished in order to complete the aesthetic
and functional direct resin/composite inlay restoration.[63]
Whisker composites
Ceramic whiskers were used as fillers in dental resins.
Nanometre‑sized silica particles were fused onto the whiskers
to facilitate silanization is the covering of a surface with
organofunctional alkoxysilane molecules. mineral components
like glass and metal oxide surface can all be silanized, minimise
whisker entanglement and enhance whisker retention in
the resin matrix by roughening the whisker surfaces. These
whisker composites demonstrated flexural strength and fracture
toughness values nearly twofold those of currently available
dental composites.[64] They showed superior performance in
thermal cycling between 5°C and 60°C water baths up to
105 cycles, long‑term water ageing for 2 years and three‑body
wear. An in vitro biocompatibility study showed that the
whisker composites were non‑cytotoxic and supported cell
attachment and proliferation.
The most promising work in composites with modified fillers
for both enhanced mechanical properties and remineralising
potential by virtue of calcium and phosphate release has
been the work with fused silica whiskers and dicalcium or
tetracalcium phosphate nanoparticles. These composites
may be stronger and tougher, but the optical properties are
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Bhargava, et al.: Direct reinforced restorations for vital teeth
not ideal, and their opacity requires them to be self‑cured or
heat‑processed at this point.[65]
The reinforcement mechanisms for the whisker composites
are said to be whiskers pinning and bridging the cracks. The
whiskers have a tensile strength of about 50 GPa, compared
with 2.6 GPa of glass fibres. The fracture toughness of silicon
carbide is also higher than glass. Therefore, compared with
the conventional glass fillers, the whiskers are more effective
in resisting the cracks and less likely to be cut through by
the cracks. The whiskers increased the elastic modulus of the
monocalcium phosphate monohydrate–whisker composite to
more closely mimic the elastic modulus of natural dentine.
Fibre or whisker reinforcement has produced very significant
enhancements in toughness, but not to the range of high
toughness ceramics or casting alloys, and this may be what is
required to render the materials essentially fracture‑resistant
under all oral conditions.[66]
Conclusion
From this information obtained during the patient evaluation,
the operator must envision the restoration replacing lost tooth
structure being subjected to functional loading and then try to
plan the best tooth preparation to both retain this restoration
and make it resistant to these loads.[67]
Complex restorations are clinically rewarding, but they do
require careful treatment planning to ensure their longevity in
the mouth. This aspect of restorative dentistry ensures that the
patient has a vital functional restoration that is mechanically
sound but also biologically compatible. Many factors need to
be considered, including the aesthetic desires of the patient,
functional requirements of the material, tooth colour, core or
abutment being restored, condition of the tooth, whether the
restoration is anterior or posterior and whether the dentist
prefers cementing or bonding the definitive restoration.
Optimal functional capacity and stability of occlusal
relationships are major considerations in every phase of
restorative dentistry.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Ayad MF, Rosenstiel SF, Farag AM. A pilot study of lactic acid as an
enamel and dentin conditioner for dentin‑bonding agent development.
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2. Black GV. G.V. Black’s Classification of dental caries. 7th ed. Chicago:
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