CLINICAL RESEARCH

Evidence-based concepts and

procedures for bonded inlays
and onlays. Part II. Guidelines for
cavity preparation and restoration
fabrication
Giovanni Tommaso Rocca, DMD
Senior lecturer, Division of Cariology and Endodontology,
University Clinic of Dental Medicine, Geneva, Switzerland

Nicolas Rizcalla, DMD

Senior lecturer, Division of Cariology and Endodontology,
University Clinic of Dental Medicine, Geneva, Switzerland

Ivo Krejci, Prof, DMD,PD

President, University Clinic of Dental Medicine, Geneva, Switzerland
Director, Department of Preventive Dental Medicine and Primary Dental Care,
Head, Division of Cariology and Endodontology,
University Clinic of Dental Medicine, Geneva, Switzerland

Didier Dietschi, DMD, PhD, PD

Senior lecturer. Division of Cariology and Endodontology,
University Clinic of Dental Medicine, Geneva, Switzerland
Adjunct Professor, Department of Comprehensive Dentistry,
Case Western University, Cleveland, Ohio
Private Education Center, The Geneva Smile Center, Geneva, Switzerland

Correspondence to: Giovanni Tommaso Rocca, DMD

School of Dentistry, Faculty of Medicine, University of Geneva, 19 rue Barthlmy-Menn, 1205 Geneva, Switzerland;

E-mail:giovanni.rocca@unige.ch

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Abstract after a multifactorial analysis, which in-

cludes cavity dimensions and the result-
The second part of this article series pre- ing tooth biomechanical status, as well
sents an evidence-based update of clin- as occlusal and esthetic factors. The clin-
ical protocols and procedures for cavity ical impact of the modern treatment con-
preparation and restoration selection for cepts that were outlined in the previous
bonded inlays and onlays. More than article Dual Bonding (DB)/Immediate
ever, tissue conservation dictates prep- Dentin Sealing (IDS), Cavity Design Op-
aration concepts, even though some timization (CDO), and Cervical Margins
minimal dimensions still have to be con- Relocation (CMR) are described in de-
sidered for all restorative materials. In tail in this article and discussed in light of
cases of severe bruxism or tooth fra- existing clinical and scientific evidence
gilization, CAD/CAM composite resins for simpler, more predictable, and more
or pressed CAD/CAM lithium disilicate durable results. Despite the wide choice
glass ceramics are often recommend- of restorative materials (composite resin
ed, although this choice relies mainly on or ceramic) and techniques (classical or
scarce in vitro research as there is still CAD/CAM), the cavity for an indirect res-
a lack of medium- to long-term clinical toration should meet five objective cri-
evidence. The decision about whether teria before the impression.
or not to cover a cusp can only be made (Int J Esthet Dent 2015;10:392413)

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 CLINICAL RESEARCH

Introduction has the potential to resolve most of the

clinical difficulties usually encountered
The first part of this series of articles was during the preparation, isolation, impres-
presented as a comprehensive, revised sion taking, and cementation of tooth-
treatment rationale and as clinical pro- colored inlays and onlays, while improv-
cedures for bonded inlays and onlays, ing treatment quality and longevity.
based on scientific and long-term clin-
ical evidence. The most relevant princi-
ples reported were the absence of tissue Occlusal considerations
removal following materials properties
and tooth preparation
or technical requirements, and the ef-
fective preparation of dental tissues fol- Restoration material choice
lowing Dual Bonding (DB)/Immediate
Dentin Sealing (IDS) concepts,1-8 Cav- Regarding the restorative material used
ity Design Optimization (CDO), and Cer- for inlays and onlays, ceramics (pressed
vical Margins Relocation (CMR),   or fired) were traditionally preferred, as
depending on the clinical situation and they were thought to be stronger and
needs. The aforementioned procedures more reliable than their composite coun-
aim to avoid any additional tooth prep- terpart. However, the referred literature
aration and tissue removal required to never clearly confirms the advantage of
create the geometry for indirect pos- ceramics, especially taking into consid-
terior restorations and to protect the eration disparate testing environments
pulpodentinal structures from any con- for both restorative materials.14-16 Ac-
tamination/disturbance during the tem- tually, the patient selection and clinic-
porary phase, as well as to stabilize and al environment were manifestly more
improve the adhesive interface quality. favorable to ceramic restorations, as
When needed, the CMR technique (also indirect ceramic restorations were nei-
known as Deep Margin Elevation DME) ther placed in social clinics nor in pa-
helps to raise deep cervical margins to a tients with severe bruxism, while such
visible and accessible level (supragingi- restrictions did not normally apply (or
vally), easing impression and cementa- did not apply as strictly) to composite
tion procedures. Moreover, due to an studies. Despite this, composite resins
even cavity design, the CDO and CMR have been widely used for the fabrica-
techniques facilitate the placement of tion of inlays and onlays due to a simpler
temporary restorations (non-cemented) manufacturing process (and thus lower
and the restoration fabrication. Regard- cost), as well as their excellent esthet-
ing cementation, the use of a highly ics and easier reparability. A more re-
filled, light-curing restorative material is cent and increasingly used alternative
recommended instead of a dual-curing is CAD/CAM restoration, made in either
composite cement because of its super- ceramic or composite resin blocks (ie,
ior mechanical properties and wear re- IPS Empress or e.max CAD, Ivoclar
sistance, as well as its practicality. 
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Overall, this updated clinical protocol this large choice with regard to materials

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 ROCCA ET AL

and fabrication methods, the tooth prep- ment of the in vivo performance of new
aration for all kinds of modern bonded monolithic ceramic restorations in a criti-
restorations relies on similar specific cal biomechanical environment.
principles, which differ from those for
traditional cast-gold inlays and onlays, Preparation extent and restoration
and even the first generation of fired thickness
porcelain restorations, whose limited
mechanical resistance imposes more All tooth-colored materials (composite
demanding and invasive preparations. resin or ceramic) used for the fabrica-
The occlusal environment has to be tion of posterior indirect restorations are
evaluated, as it plays an important role submitted to high occlusal functional
in restoration longevity and can also stresses; consequently, their inherent
influence material choice. Extensive vulnerability needs to be compensated
restorations with generally large and for by restoration thickness and proper
deep cavities (mainly non-vital teeth) adhesive cementation. Although the res-
in high load-bearing areas (especially torations should therefore be as thick as
the second molars) associated with an possible, this approach is tempered by
unfavorable occlusal context (such as the fundamental principles of minimal
patients with bruxism) have to be con- invasiveness.29 Moreover, an unconsid-
sidered biomechanically vulnerable and ered sacrifice of enamel and dentin could
more susceptible to failure. In the latter also directly weaken the tooth. For exam-
unfavorable situation, only the strong- ple, Fennis and co-workers have dem-
est materials should be chosen, based onstrated that thick overlay restorations
mainly on their superior mechanical show higher static fracture strength com-
properties. Today, new CAD/CAM com- pared to conservative ones, although
posite resin blocks (ie, Lava Ultimate, they present more drastic and irrevers-
.
&OBNJD
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PS
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based restorations (ie, IPS e.max Press be stronger but simultaneously imply
or CAD, Ivoclar Vivadent) are preferred, thinner and weaker dental tissues under-
the former option having some interest- neath them. At the same time, extremely
ing stress-absorbing properties,17 while thin material is not systematically and un-
requiring simpler procedures when a conditionally recommended. If one takes
surface modification or repair is need- into consideration that a few tenths of a
ed.18 Recent in vitro studies on the frac- millimeter can considerably strengthen a
ture and fatigue resistance of direct and restoration, the best compromise would
indirect restorations of a severely eroded be between material resistance and the
tooth model demonstrated the favorable clinical situation. We should therefore
behavior of CAD/CAM composite ma- move away from the blind application of
terials.17,19-24 Apart from the non-vital minimally invasive dentistry to a more
tooth configuration, the aforementioned realistic concept of minimally hazard-
findings are well supported by clinical ous dentistry, which is particularly per-
trials.25-28 However, less information is tinent to large and deep cavities and to
available to date regarding the assess- non-vital teeth.

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 CLINICAL RESEARCH

ials, including composite resins, pressed

ceramics, and CAD/CAM blocks (apart
from traditional feldspathic and leucite-
reinforced ceramics), while the stabil-
ity and impact of thinner material lay-
ers on restoration longevity is still under
evaluation. Moreover, it is important to
note that minimal material thicknesses
should be limited to monolithic/mono-
laminar restorations, as a layering pro-
cedure could mean including imperfec-
Fig 1 Oscillating selectively coated diamond in- tions in the narrow available space, thus
struments for the finishing of the interproximal zone.
weakening the system. Finally, esthetic
considerations will also have an impact
on restoration thickness (see Esthetic
considerations below).
In conclusion, a good compromise
between tissue preservation and a suita-
The minimal occlusal thickness al- ble restoration thickness has to be found
lowed for a material depends on its in- and adapted to each case or tooth-spe-
trinsic mechanical features (static and cific occlusal and esthetic context.
dynamic reaction to stresses) and is
therefore material- and even brand- Clinical guidelines
dependent. Thus, usual recommenda-
tions based on clinical experience and It follows, then, that while the cavity de-
in vitro testing suggest to attain at least sign and extent is largely dictated by
1 mm thickness for composite resins, conservation principles, together with
and 2 mm for low-strength ceramics, occlusal and esthetic parameters, the
such as feldspathic (eg, Vita Mark II, overall cavity design is related to the
Vita) and leucite-reinforced (IPS Em- pathology and presence of decayed tis-
press I, Ivoclar Vivadent) ceramics. sues rather than the need for macrore-
For new lithium disilicate-reinforced ce- tention or friction.
ramics (ie, IPS e.max Press or CAD), Practically, preparation starts with the
the minimal recommended thickness removal of the existing restoration and
seems to be closer to that recommend- decayed tissues without initially finishing
ed for composite resin, ie, between 1 the enamel margins. In less accessible
and 1.2 mm.   The presence of areas (usually interproximally), oscillat-
enamel under these thin ceramic res- ing, selectively diamond-coated instru-
torations has also been recently proven ments (ie, PCS, EMS or Sonicsys, KaVo)
to yield a certain positive effect.   facilitate the preparation and finishing
Overall, a restoration thickness between of cavities (Fig 1). When cavity margins
1.0 and 1.5 mm seems to be advisable violate the biological width, a crown-
for all modern white restorative mater- lengthening procedure may be needed,

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while for subgingival/intracrevicular cer- to follow aforementioned conservation

vical margins (a more frequent condi- principles, thin and undermined cavity
tion), a conservative CMR is advised. walls can be maintained and reinforced
The decision to use a specific technique with composite resin during the adhe-
depends less on ultra-strict biological sive resin lining of the cavity. The au-
width considerations and more on the thors recommend a minimum of 1 mm
future accessibility of the margins to se- as minimal wall width/thickness before
cure the clean and dry environment nec- reinforcement. In cases where the mini-
essary for proper adhesive techniques. mal residual thickness is below this
Fissures (in dentin or enamel) should measurement, cusp coverage is indi-
ideally be included in the preparation, cated (this guideline seems to be the
considering potential bacterial leakage accepted general clinical consensus
or structural weakening, although their nowadays). The aim is to have a more
extension in inaccessible zones often homogeneous biting force distribution
prevents these flaws from being fully and offer a protective effect for the un-
eliminated. derlying weakened tooth structure. The
resulting invasiveness could, howev-
Thin cavity walls and occlusal er, increase the risk of irreversible tooth
fracture (below the cementoenamel
coverage
junction CEJ), as is shown in vitro by
Little is known scientifically about the Fennis et al, although such clinical ob-
minimal thickness needed to maintain servation is extremely rare in vital teeth.
thin tooth walls and what is to be con- Finally, the systematic occlusal cover-
sidered totally safe and conservable, age of functional and/or non-function-
knowing that a multitude of parameters al cusps is not yet advocated, as it is
will impact such a decision process. The seemingly not proven to increase the
presence of thin walls around an exten- final strength of the tooth-restoration
sive cavity is, in any case, considered a system, both for composite resins40 and
strong indication for indirect restorations ceramics.41-44
rather than direct fillings, as polymeriza- In conclusion, occlusal coverage is
tion might deform the remaining facial recommended for cavity walls of 1mm
and lingual tooth structures, potentially or thinner, while for intermediate thick-
inducing cracks due to the inward cusp ness (1 to 2 mm), the occlusal context
movement that follows. The cavity including tooth position, presence of
size and design (C-factor), as much as parafunctions, and the kind of lateral
the stratification technique, will impact guidance (canine or group guidance)
such stresses on residual tooth struc- should be taken into account when mak-
ture. This is why indirect techniques ing the therapeutic decision. The cavity
are generally preferred, because poly- configuration, and in particular the pres-
merization shrinkage is confined to the ence or absence of the marginal ridges,
thin layer of luting resin cement. can also play a role in the final strength
Different options are available with an of the residual walls, especially in endo-
indirect approach. First, in an attempt dontically treated teeth.45

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 CLINICAL RESEARCH

Fig 2 The smile space of two different patients. The visibility of the treated tooth during smile has to be
verified before cavity preparation. The patients lips can act as a curtain behind which the toothrestoration
transition can be hidden.

Esthetic considerations esthetic zone is generally unknown. As

the removal of undermined, fissured or
For restorations extending into the buc- thin buccal cusps could bring the res-
cal-esthetic zone (the virtual space be- toration into a visible and more critical
tween the upper and lower lips during esthetic zone, this occurrence must be
full smile), margin positioning plays an taken into account and a shade selec-
important role (Fig 2). Actually, the sim- tion systematically performed before the
plest and most ideal situation is for the preparation. Otherwise, tissue dehydra-
restoration margins to be located in the tion will prevent the clinician from later
incisal or cervical thirds. In both situa- choosing a precise and reliable shade
tions, a good esthetic integration of the registration because it only takes a few
restoration can easily be achieved due seconds of tissue dehydration to impact
to a simpler tissue arrangement; practi- shade perception.
cally, almost only one tissue is present
enamel in the incisal third, and dentin Shade selection
in the cervical third. This makes the es-
thetic integration of the restoration tech- Additionally, metallic and temporary res-
nically and optically more predictable torations, caries, and in general any
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discolored, decayed tissue may alter
low, margins can be left elsewhere on dentin and enamel shades; thus, they
the buccal cusp, depending only on the should be removed beforehand under
restorative needs. water spray, to preserve tissue hydra-
While the esthetic impact of the res- tion. As an alternative, tooth shade can
toration should theoretically be analyzed be recorded and crossed-matched with
before the cavity preparation, the final a non-restored, contralateral or neigh-
extent of the restoration in the buccal- boring tooth.

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 ROCCA ET AL

Fig 3 Guidelines for buccal cusp coverage. (a) Ultraconservative buccal cusp coverage. (b) Conven-
tional buccal cusp coverage. (c) Full buccal cusp coverage. In (a) and (c), the restoration has to mimic
practically only one tissue, with only one set of optical properties enamel (blue) in the incisal third, and
dentin (yellow) in the cervical third. Thus, esthetic outcomes are more predictable.

There are various techniques used boratory via a simple schematic drawing
to make a shade selection, depending (Fig 4) or an intraoral photograph of the
on the material (composite or ceramic), tooth. In the specific case of the buccal
which usually make use of brand-specif- cusp, enamel shades should be pre-
ic shading systems and shade guides. ferred for a minimally invasive occlusal
For ceramic restorations, particularly in DPWFSBHF
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guide (Vita) is the most widely used sys- QSFQBSBUJPOT
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tem for monolithic ceramic or mono- part of the restoration.
laminar composite restorations (those
following the VITA shading concept). For
layered composite restorations, more ef-
fective alternatives exist, with either a bi-
laminar shade guide, including specific
dentin and enamel color selection (ie,
Inspiro, EdelweissDR; Miris 2, Coltene
Whaledent),46,47 or, for other brands,
customized shade tabs produced free-
hand or with a mold (My Shade Guide,
Smile Line).
In addition to the basic information
about dentin and enamel shade, any
other details or characteristics to be re-
produced on the buccal and occlusal
surfaces (white spots, stains on fissures, Fig 4 Example of a schematic drawing for com-
etc) should be communicated to the la- munication with the dental laboratory.

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 CLINICAL RESEARCH

Table 1 Clinical step-by-step protocol for the cavity preparation of bonded indirect posterior restorations

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t Dual Bonding (DB)/Immediate Dentin Sealing (IDS). Seal whole dentin with an adhesive system
following manufacturers instructions. This procedure also involves thin subgingival enamel margins,
if present

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t Cavity Design Optimization (CDO) and Cervical Margins Relocation (CMR). Apply a thin layer of
composite resin to cover whole dentin, fill the retentions, and relocate margins supragingivally, if
necessary

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composite margins too, if present

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1. Detailed sharp margins
2. Absence of undercuts

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4. Absence of contact between the cavity and the adjacent teeth
5. (After rubber dam removal) Adequate interocclusal space in centric and during lateral movements

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For monolithic CAD/CAM ceramic or tion of esthetically demanding cases.

composite resin blocks, porcelain stains For CAD/CAM or pressed lithium dis-
or resin paint-on-colors should be used ilicate ceramic restorations, apart from
for a more detailed color characteriza- surface staining, low-fusing ceramic

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 ROCCA ET AL

a b

Figs 5a and b Rubber dam isolation is facilitated by placing a metallic matrix and interproximal wedges.

veneering is possible, although it may or base, as previously described. This

affect overall restoration strength.48 step should be performed under rubber
dam isolation. In case of subgingival/in-
tracrevicular margins, the placement of
Adhesive procedures and a pre-shaped metallic matrix will prevent
the rubber dam from covering deeper
cavity treatment before
margins, making adhesive and liner ap-
impression
plication easier (Figs 5a and 5b).
To obtain an optimal substrate for
Dual Bonding/Immediate Dentin
further adhesive procedures enamel
Sealing
and composite only attention should
One of the main objectives of the prep- be given to enamel thickness. When it is
aration session is to leave the cavity thin and inconveniently located (typically
with only two substrates until cementa-
tion, these being mechanically finished
enamel, and composite (Table 1). All
the dentinal surfaces should be prop-
erly sealed. Once the cavity is prepared,
the next step is the sealing of the dentin
and thin subgingival enamel margins,
if present, using a multistep adhesive
system. An etch-and-rinse or self-etch
system can be used. The early sealing
of dentin provides many benefits, as has
been described by several authors (see
Part I of this article series).2,4,5,8,49,50
Fig 6
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Early sealing is also necessary as an
shown in this image has to be avoided when enamel
adhesive pretreatment, allowing for is thin, typically in a subgingival situation. There is a
the placement of the composite liner high risk of dentin over-etching.

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 CLINICAL RESEARCH

a a

b b

c c

Fig 7 Dual Bonding (DB) or Immediate Dentin Fig 8 DB or IDS with a self-etch adhesive system.
Sealing (IDS) with an etch-and-rinse adhesive sys- This procedure also involves the thin subgingival
tem. This procedure also involves the thin subgingi- enamel margins, if present. (a) The cavity before
val enamel margins, if present. (a) Orthophosphoric the adhesive treatment. (b) Application of the self-
acid etching of dentin and thin interproximal enamel etching primer on dentin and thin enamel. (c) Ap-
for 5 to 10 s. (b) Primer application on dentin. (c) plication of the bonding resin. The resin is then po-
Bonding resin application on dentin and thin enam- lymerized for 20 s.
el. The resin is then polymerized for 20 s.

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in a juxta- or subgingival situation), dif- Cavity Design Optimization and

ficulties will arise; for instance, it will be Cervical Margin Relocation
a lot more demanding to finish enam-
el margins before impressions without Once bonding resin is polymerized, a
contacting/exposing dentin and without layer of composite is normally applied
damaging gingiva, or obtain perfect im- over all sealed dentin surfaces to create
pression taking, or quick, effective rub- an optimal cavity design, unless restor-
ber dam placement. In this case, the ation thickness restricts the placement of
cervical margin comprising both enamel such a layer, as is the case with overlays
and dentin is likely to be covered by the used for the treatment of tooth wear. In
composite liner. Then, adhesion to this this particular situation, a filled adhesive
thin subgingival enamel is established system is normally preferred (ie, Opti-
at the same time as the dentin sealing. Bond FL, Kerr), which plays the role of
If an etch-and-rinse system is used, it both adhesive and cavity liner.54,55
is important to respect conditioning As has been mentioned, the cavity
times. Indeed, the etch-and-rinse tech- lining plays multiple roles, including the
nique, based on highly concentrated or- reinforcement of cavity walls. It simulta-
thophosphoric acid action, implies the neously eliminates undercuts and saves
conditioning of dentin and enamel for tooth structure, the leveling of the cavity
different time intervals, ie, 5to 10s, and floor, and, if needed, the occlusal relo-
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cation of cervical margins. Finally, it of-
enamel is thin, selective enamel etch- fers a physical and biological protection
ing is difficult to achieve without the risk during the temporary phase (eliminating
of inadvertently over-etching the neigh- virtually all possible biological compli-
boring dentin (Fig 6).51 The proposed cations, such as tooth sensitivity and
clinical compromise is then to con- bacterial leakage), leading to a mark-
dition such thin enamel, together with edly improved protocol, compared to
dentinal tissue, for a limited time of 5 to the traditional approach for adhesive
10 s (Figs 7a to 7c). As an alternative, indirect restorations (Table 2). At the
a two-component self-etch system can time of cementation, it will also act as
be used, without prior selective enamel a physical barrier against the mechani-
acid etching (Figs 8a to 8c).  cal surface treatment (sandblasting) of
the cavity, preserving the integrity of the
sealed dentin surfaces (Fig 9).7

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Table 2 Comparison between the conventional and updated clinical protocol for bonded inlays and onlays

Clinical steps Conventional Updated

Preparation With suction Under rubber dam

Dentin sealing application At cementation Just after preparation

Base/liner Optional Mandatory

Luting material Dual-curing resin cement Light-curing restorative materials

Insertion Manual Assisted by sonic/ultrasonic energy

In CAD/CAM restorations, the exact With regard to CMR, the amount/

same objectives must be attained, al- thickness of composite (either flowable
though the software can easily ignore or restorative) is limited to the minimum
undercuts. However, despite the lack needed to bring the preparation suprag-
of any interference during insertion/ce- ingivally (usually about 1 to 1.5 mm),
mentation, larger cementing gaps may in order to both control polymerization
be created in all retentive areas, which stresses and optimize marginal adapta-
will induce higher polymerization stress- tion, while creating a proper restoration
es due to the wall-to-wall contrac- emergence profile. A curved matrix, full
tion.56 As a result, gap formation and/ or sectional, is recommended for this
or postoperative sensitivity could occur. procedure (eg, MetaFix, Kerr; Palodent,
The latter approach is therefore not rec- Dentsply).
ommended.

Fig 9 SEM image showing the

effect of sandblasting on IDS. In
the left part of the image, dentin
has been sealed with Adhese Uni-
versal (Ivoclar Vivadent). In the
right part, dentin has been sealed
with Adhese Universal (Ivoclar Vi-
vadent), sandblasted with 27-m
aluminum oxide particles (5 mm
distance) for 1 s and then etched
with orthophosphoric acid for 10 s.
The large presence of dentinal tu-
bules on the right part of the dentin
surface means that the adhesive
layer has been widely removed by
the sandblasting.

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Material selection (flowable vs fill up the pulp chamber suggests the

restorative consistency) use of a restorative composite instead
of a flowable one.
While the clinical advantages of a com- Highly filled flowable composite res-
posite liner/base underneath indirect ins (usually 65% to 75% filler weight)
bonded inlays and onlays have been otherwise offer obvious practical advan-
clearly shown and discussed by several tages due to their ease of use, and are
authors,1,5,9,10,55 there is, however, no indicated in all cases which necessitate
consensus regarding what resin-based a normal composite liner thickness
material is ideal. The choice between (less than 1.5 mm thickness), which
highly filled hybrid or flowable com- corresponds to the majority of inlay or
posites is still debated today because onlay cavities, including those with lim-
the few existing scientific studies have ited interocclusal space. Due to their in-
failed to demonstrate any difference in herent physicochemical characteristics
terms of marginal adaptation between (slightly inferior mechanical strength
both materials, at least when used in and higher polymerization shrinkage,
thin layers (1 to 1.5 mm), in particular although not always higher polymeriza-
for CMR.10,57-59 tion stress), flowable composites should
Overall, classical restorative hybrid not be used in thick layers, regardless of
composites present better mechani- the simpler application technique.
cal properties compared to flowable Practically, the composite liner/base
ones, apart from higher hydrophobic- (either flowable or restorative consist-
ity and wear resistance,60 although for ency) is normally light-cured separately
the latter this advantage is rather in- for 20 s per area. The final or single in-
significant in this specific application. crement will be cured, protected by a
Restorative materials do, however, have thick layer of glycerine gel (K-Y Jelly,
a practical shortcoming, as they require Personal Products Co) placed into the
additional finishing, during which dentin cavity after a first 5 s period and left until
areas covered by thin layers of mater- complete liner/base polymerization. The
ial and adhesive are re-exposed, mak- aim of the glycerine gel is to eliminate
ing a second dentin sealing procedure the superficial oxygen inhibition layer,
necessary. Moreover, when relocating which can interfere with the setting of
deep cervical margins, the matrix can some impression materials.61 Finishing
be displaced during the placement of a and cleaning of enamel margins and
firmer material when the use of a wedge excesses of composite resin liner with
is impossible due to deep proximal mar- fine diamond instruments is the last step
gin position. Then, a restorative, highly before impression taking, to obtain well-
filled composite (usually 75% to 85% defined margins. One should, however,
filler weight) is recommended in ex- be careful not to expose dentin again
tensive cavities that require more than during this step; if this accidentally oc-
one single increment of material (over curs, resealing of exposed dentin would
1.5 mm).59 For endocrowns, the more be required.
important volume of material needed to

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 CLINICAL RESEARCH

Impression procedures CAD software will also be able to cut

the working model easily. The inter-
Checklist before impression proximal surfaces of adjacent teeth
must be polished before impression.
When the cavity is ready for impression They can also be slightly reduced so
taking, five objective criteria should be as not to invade the normal proximal
met (Figs 10a to 10e): volume of the restoration.
1) Detailed sharp margins. All cavity 5) Adequate interocclusal space. The
margins must be clearly visible and suitable interocclusal space for the
sharp, granting optimal impression selected restorations material (see
quality (including readability by the Preparation extent and restoration
CAD/CAM camera system), as well thickness above) is checked after
as restoration quality and fit. Finish- rubber dam removal in centric and in
ing enamel margins of the cavity after lateral movements.
adhesive coating/composite lining is
mandatory to obtain these well-de- The preparation checklist and guide-
fined and sharp margins before the lines are identical for both classical in-
impression of the cavity. lab or CAD/CAM restorations.
2) Absence of undercuts. Undercuts
must be eliminated or filled with com- Impression technique
posite (restorative or flowable) during
the composite lining. Once the five above-mentioned criteria



Accessibility of subgingival margins. have been met, impression will definitely
Margins of the cavity, especially cervi- become uncomplicated. For a conven-
cal ones, must be relocated occlusally tional approach, the use of an elasto-
(at least 0.5mm over the free gingival mer material such as polyvinylsiloxane
margin) to facilitate impression and (VPS) or polyether is recommended,
rubber dam application. Do not over- although polyether materials are rather
elevate the margins in order to obtain sensitive to the possible persistence of
an optimal, natural proximal emer- an oxygen-inhibited layer, which may af-
gence profile of the future restoration. fect their setting reaction.61 A two-step
4) Absence of contact between the cav- technique is suggested, including both
ity and the adjacent teeth. This should a syringe and a tray material (Figs 11a to
guarantee good flow of the impres- 11e). A metallic half-bite tray, also know
sion material in the interproximal ar- as triple tray, will ease the impression
eas, and make optical impression re- technique while limiting the slight inac-
cording easier. The technician or the curacy of full-arch impressions.

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 ROCCA ET AL

a b

c d

Fig 10 Checklist before impression. (a, b, c)

Cavities of these images have detailed sharp mar-
gins, no undercuts, accessibility of subgingival mar-
gins, and no contact with adjacent teeth. (d) Pala-
tal view of the restoration. Note the optimal mesial
proximal emergence profile. (e) The interocclusal
space needed for the restoration can be checked
with a 1.5 mm-thick pink wax (Ruscher Belladi). e

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 CLINICAL RESEARCH

a b

c d

Fig 11 Impression of the cavity. (a) The half-bite

metal tray, also known as a triple tray. (b) The putty
material is first inserted in the tray. (c) The flowable
impression material is injected successively in the
cavity. (d) The setting of the impression materials
while the patient is in occlusion. (e) Details of the
e impression.

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 ROCCA ET AL

Provisional restoration
Following the impression, cavities will be
temporarily restored with, preferably, a
non-cemented semi-rigid light-curing
resin (eg, Teliotemp, Ivoclar Vivadent)
(Figs 12a to 12c). Practically, the cavity
first needs to be isolated with Vaseline
at the periphery and over the axial walls,
leaving a small central area at the cavity
a
floor without isolation (the size of which
depends on the cavity design and re-
tentiveness) to provide semi-adhesion
between the composite liner and provi-
sional material, granting temporary re-
tention. Then, an adequate amount of the
light-curing material is inserted into the
cavity before occlusion by the patient,
who then proceeds with anterior and lat-
eral movements in order for the tempor-
ary restoration to be shaped functionally.
b
Thereafter, interproximal, buccal, and
lingual/palatal excesses are removed
and the resin is light cured in occlusion.
Limited interproximal excesses contrib-
ute to temporary stabilization. The place-
ment of such temporaries is both simple
and fast, assuming adequate protection
of the preparation, teeth stabilization,
and the patients functional comfort. Due
to the very short time that it remains in
the mouth, the presence of triclosan as
an antimicrobial agent in the temporary c
material (ie, Teliotemp) and the related
Fig 12 Temporization of the cavity. (a) The soft
issues that have been raised about this resin is inserted into the cavity with a finger tech-
disinfectants potential side effects, is nique. As the provisional resin is not cemented, it
needs to be hardened inside the mesial and dis-
limited or insignificant. 
tal interproximal spaces. The use of interproximal
A classical provisional restoration wedges limits gingiva bleeding and material over-
made out of acrylic resin is not recom- filling against the papilla. (b) The resin is photopo-
mended any longer due to its time-con- lymerized while the patient is in occlusion. (c) The
provisional resin after the polymerization (note the
suming procedure (compared to semi-
interproximal rinsing tunnels).
rigid light-curing resin), as well as the

409
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 CLINICAL RESEARCH

a b

Figs 13a and b
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practical shortcomings relating to the sue conservation principles. Despite

isolation of lined cavities and the need the wide choice of restorative materials
for a temporary cement, which contami- with dissimilar properties, preparation
nates either the liner or dentin surfac- design should be similar for all options,
es.64,65 with sealed dentin, detailed and over-
gingival margins, and a recommended
minimum restoration thickness of 1 to
Adhesive luting of the res- 1.5 mm. Modern in vitro research has
shown that new CAD/CAM composite
toration
resins and pressed CAD/CAM lithium
The indirect restoration is fabricated disilicate glass ceramics should be
in-lab or milled from a CAD/CAM block preferred in cases of severe bruxism
'JHT

B
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C

%VSJOH
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pointment, the intaglio surface of the there are no medium- to long-term clin-
restoration and the tooth cavity are ad- ical studies to confirm this recommen-
hesively treated, and the restoration is dation.
luted with a conventional light-cured mi- The cavity preparation techniques
crohybrid resin composite (Figs 14a and for tooth-colored bonded indirect res-
14b). A comprehensive description and torations presented in this article fol-
discussion of the adhesive cementation low the adhesive philosophy rigorously
procedures will be presented in a future and are different from the principles
article in this series. used for metal restorations or crown
preparation. They allow for a more con-
servative and esthetic dentistry, and
Conclusions are a prerequisite for good cavity seal-
ing and for minimizing postoperative
Modern preparation concepts and sensitivity, marginal discoloration, and
guidelines are chiefly influenced by tis- secondary caries.

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 ROCCA ET AL

a b

Figs 14a and b The onlays 1 week after luting.

restorations. J Prosthet Dent sources on composite micro-

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7FSTMVJT
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3%
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