QUI NTESSENCE I NT ERNAT I ONAL

PROSTHODONTICS

Daniel Edelhoff

Minimally invasive treatment options in fixed

prosthodontics
Daniel Edelhoff, Prof Dr med dentVAnja Liebermann, Dr med dentVFIorian Beuer, Prof Dr med dent, MME1
3/
2
Michael Stimmelmayr, PD Dr med dentVJan-Frederik Guth, PD Dr med d en t 4*

Minimally invasive treatment options have become increas­ the planned treatment outcome is defined in a wax-up before
ingly feasible in restorative dentistry, due to the introduction the treatment is commenced and this wax-up is subsequently
of the adhesive technique in combination with restorative used as a reference during tooth preparation. Similarly, res­
materials featuring translucent properties similar to those of in-bonded FDPs and implants have made it possible to pre­
natural teeth. Mechanical anchoring of restorations via con­ serve the natural tooth structure of potential abutment teeth.
ventional cementation represents a predominantly subtractive This report describes a number of clinical cases to demon­
treatment approach that is gradually being superseded by strate the principles of modern prosthetic treatment strategies
a primarily defect-oriented additive method in prosthodon­ and discusses these approaches in the context of minimally
tics. Modifications of conventional treatment procedures have invasive prosthetic dentistry. (Quintessence Int2016;47:207-216;
led to the development of an economical approach to the doi: 10.3290/j.qi.a35115; Originally published in Quintessenz
removal of healthy tooth structure. This is possible because 2014;65(5)589-600)

Key words: adhesive technique, all-ceramics, diagnostic template, high-density polymers, minimally invasive
preparation, occlusal onlays, resin-bonded FDPs, veneers, wax-up

A t present, c o n v e n tio n a l tre a tm e n t m e th o d s using as a disadvantage. A retrospective clinical study showed

m etal-based crow ns and fixed dental prostheses (FDPs) th a t th e 15-year survival p ro b a b ility o f vita l p u lp was
are considered to be th e g o ld standard re g a rd in g c lin ­ 81.2% in m etal-ceram ic single crow ns and 66.2% in FDP
ical survival and success.1 H ow ever, th e e xte n sive a b u tm e n ts .2 Foster3 d e te rm in e d a 21% e n d o d o n tic
rem oval o f to o th stru ctu re associated w ith th e crow n c o m p lic a tio n rate fo r FDP a b u tm e n ts a fte r 6 years. An
and a b u tm e n t preparation fo r these restorations is seen in itia l q u a n tific a tio n o f hard tissue rem oval in relation
to d iffe re n t preparation co n fig u ra tio n s revealed th a t up
1Director and Chair, Department of Prosthodontics, Ludwig-Maximilians Univer­
sity, Munich, Germany. to 70% o f th e clinical crow n is rem oved in co m p le te
2Assistant Professor, Department of Prosthodontics, Ludwig-Maximilians Univer­ coverage cro w n preparations, regardless o f w h e th e r
sity, Munich, Germany.
th e p re p a ra tio n was in th e a n te rio r o r p o s te rio r
d ire c to r and Chair, Department o f Prosthodontics, Charitd University Medicine
Berlin, Berlin, Germany. re g io n .45 These fin d in g s have re ce n tly been co n firm e d
4Associate Professor, Department o f Prosthodontics, Ludwig-Maximilians Univer­ in a stu d y using m o d e rn m easuring te c h n o lo g y 6 and
sity, Munich, Germany-
are increasingly a ffe ctin g tre a tm e n t decisions. Several
Correspondence: Prof Dr med dent Daniel Edelhoff, Department of
in -v itro studies on e n d o d o n tic a lly tre a te d te e th have
Prosthodontics, Ludwig-Maximilians University, GoethestraBe 70,
80336 Munich, Germany. Email: daniel.edelhoff@med.uni-muenchen.de show n th a t a h igh vo lu m e o f re m a in in g natural to o th

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Edelhoff et al

Fig la Palatal view of the preoperative situation: agenesis of the Fig lb Palatal view after restoration with two-retainer res­
lateral maxillary incisors in-bonded FDPs made of base metal alloy and zirconia placed in
the course of a randomized prospective clinical study (CDT Max
Kurzmeier, University Munich, Germany).

structure has a significantly positive effect on fracture • the patient is o f an inadequate age, or
resistance, independent o f the type o f to oth.7'8 Up to • an im plant is sim ply not w anted.19
45% more to oth structure can be saved by opting for a
partial rather than a com plete coverage crown when Most modern resin-bonded FDPs are manufactured on
restoring an e nd od on tically treated m olar.9 Similar the basis o f frameworks made o f materials featuring a
results were found in relation to the preparation of high modulus o f elasticity such as base metal alloys or
retainers fo r resin-bonded FDPs and attachm ents.10 zirconia ceramics (Fig 1). A rem oval rate between
It is notew orthy th a t clinical studies on all-ceramic 0.5 mm and 0.7 mm is recommended for the preparation
partial coverage crowns showed either no11 or a very o f the retentive wings. Additional requirem ents are
low endodontic com plication rate12 after observation healthy abutm ent teeth th a t are prim arily free o f both
periods between 7 and 12.6 years, compared to studies caries and fillings, sufficient interocclusal space (approx­
on m etal-ceram ic com plete coverage crowns.2 In imately 0.8 mm), and sufficient amounts o f enamel.19
veneer restorations, the rate o f endodontic complica­ In a long-term clinical study (literature review), adhe­
tions was as low as 2.51% after an observation period of sive FDPs comprising tw o w ing retainers showed a sig­
20 years.13 Hence, a less invasive preparation and res­ nificantly poorer survival probability than full crown
toration design appear to have a favorable effect on abutm ent FDPs over a period o f 10 years.1 However, it is
the vita lity o f restored teeth. Against this background, im portant to bear in m ind th a t anterior maxillary teeth
fixed prosthodontics have been undergoing a para­ are considered to be particularly vulnerable to vitality
digm shift towards less invasive treatm ent m ethods in loss if they are used as abutments in conventional FDPs.2
recent years.11'14-17 A few treatm ent methods offering Additionally, a retentive preparation geometry has been
substantial reductions in the removal o f to oth structure shown to play an essential and determining factor for the
are described and discussed below. success o f resin-bonded FDPs and should by all means
be considered in the preparation design together w ith
Resin-bonded anterior FDPs the properties o f the ceramic or metal being used.10'20
Resin-bonded anterior FDPs were first described in the W ith the in tro d u c tio n o f metal-based single-re­
1970s.18 Today they are used as an alternative to tainer adhesive FDPs in the 1980s, the level o f invasive­
im plant-supported restorations in single teeth if: ness was once more lowered and the need for unphys-
• im plant treatm ent is contraindicated iolo gic s p lin tin g of th e a b u tm e n t te e th was
• extensive surgical interventions should be avoided elim inated.21 In the 1990s, glass-infiltrated alum inum
• the space available is inappropriate fo r im plant oxide ceramic was used fo r the first tim e in a clinical
treatm ent study to manufacture all-ceramic adhesive FDPs w ith

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Fig 2a Single-retainer resin-bonded FDP made o f lithium-disil- Fig 2b Single-retainer resin-bonded FDP made of lithium-disil-
icate ceramic to replace a mandibular right lateral incisor (tooth icate ceramic after adhesive cementation. Given the low w idth of
42 according to FDI notation; CDT Oliver Brix, Bad Fiomburg). the extension unit 42 (short cantilever) and the large vertical
extension o f the connector, glass-ceramics m ight be used for this
particular indication in the anterior mandibular region.

tw o retainers. In the further course of the study, zirco- a mostly exclusively additive technique. Well-defined
nia-based single-retainer adhesive FDPs appeared to be principles apply to the preparation for veneers; none­
advantageous.19 The data available from the clinical theless, these principles can offer a high degree of
long-term study indicate a survival probability of 94.4% flexibility in the design of the restoration, depending
for the single-retainer zirconium oxide-based adhesive on the clinical situation (tooth position, degree of
FDPs after a clinical service time of 10 years. In certain destruction, occlusal conditions, periodontal surround­
cases, lithium disilicate ceramics might be suitable as ings, etc).29'30This is true for both the incisal design and
the framework material for single-retainer adhesive interproximal extension.30'31 Preparing a palatal cham­
FDPs (Fig 2).22 fer offers the highest degree of freedom for the pos­
itioning of the incisal edge, which is particularly import­
All-ceramic anterior veneers ant if a large amount o f tooth structure has been
Given their favorable long-term results, excellent lost.29'30 Similar considerations apply to the interproxi­
esthetic properties, and low level of invasiveness, res­ mal extension of the preparation.2531
in-bonded veneers23 offer an attractive alternative to If the popular medium wrap design is used, the
conventional single crowns in many cases.17'24 Silicate contact area and therefore the width of the existing
ceramic materials are considered to be the material of tooth are maintained and, consequently, the height is
choice to replace lost natural enamel due to their favor­ determined by the defined width-to-length ratio. By
able optical and mechanical properties.25'26 However, contrast, the long wrap design leads to the elimination
minimally invasive veneer preparation, provisionaliza- of the contact areas due to the deep interproximal
tion, and adhesive bonding set higher demands on the extension and therefore offers considerably more
skills of the operator compared with complete cover­ scope for variation with regard to the shape and pos­
age crown preparation and conventional cementation. ition of the restoration (Fig 3). The long wrap design is
Enamel preservation represents an essential and therefore particularly advantageous in the treatment of
determining factor for the success of a veneer restor­ severe discolorations, diastemas, extensive shape mod­
ation.27'28 Therefore, veneers should be designed using ifications, black triangles, and large fillings. Further-

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Fig 3a Misalignment of the teeth and severe wear of the man­ Fig 3b Veneer preparation o f the mandibular anterior teeth to
dibular anterior teeth in a 59-year-old woman. Malocclusion achieve a long wrap design. Prior to perform ing the double
resulted in severe functional problems, which were redressed in impression technique, metal matrices were applied to the contact
a 12-month splint therapy. Upon completion of the therapeutic areas of the prepared teeth to avoid having to cut the master
phase, the patient was complaint-free and the resulting occlusion model.
was to be transferred to the final prosthetic solution.

Fig 3c The veneers (IPS d.SIGN, Ivoclar Vivadent) were layered Fig 3d Incisal view after placement o f the veneers. A primarily
on refractory dies and then inserted using an adhesive technique. additive procedure was followed (see mandibular left central
A clear change in length can be observed. Crowding was clearly incisor). A full crown preparation m ight have required the end­
reduced, a result that was achieved w ithout using substantially odontic treatment of the mandibular right central incisor to the
more invasive full crown preparation (CDT Oliver Brix, Bad Hom- left lateral incisor.
burg, Germany).

more, the long wrap design is recommended for ever, the clinical and technical implementation of this
veneers that are located in the immediate vicinity of technique is considered to be challenging.
crowns, as this allows the contact area between the In certain indications, the design may seamlessly
two restorations to be created in ceramic (Fig 4). evolve into a full coverage crown (Fig 6). A circular
Interproximal preparation can be conveniently preparation design (360 degrees), also known as a full
accomplished with oscillating preparation instruments wrap veneer design, is particularly indicated for com­
(eg, Sonicflex micro tip no. 28 or 29, diamond coating plex cases that necessitate an increase in the occlusal
D25, half torpedo shape REF 0.571.6741/0.571.6731; vertical dimension to close the resultant free space on
KaVo Dental) and Soflex disks (2382 M, 3M Espe) the palatal side of the maxillary anterior teeth. As an
(Fig 5a). In periodontally compromised situations, the alternative, the three-step technique described by
long wrap design may be combined with a horizontal Vailati and Belser16 may be followed. If this technique is
insertion axis.32This method eliminates the need for an applied, the palatal space is first built up with compos­
extensive reduction of the coronal tooth structure. Fur­ ite before restoring the labial surface with a res­
thermore, distance C (cervical) can be designed to be in-bonded veneer (so-called sandwich technique).
smaller than distance D (dentin) (Fig 5b). Substantial Essentially, a diagnostic template or silicone mold
amounts of tooth structure can be preserved if this should be created from the wax-up and used as a guide
configuration is used (Fig 5b). On the downside, how­ during tooth preparation to reduce the amount of tooth

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Edelhoff et al

Fig 4a Preoperative situation in a patient with a deep overbite Fig 4b Situation after splint therapy for 12 months and transfer
and minimal overjet (Angle Class II, division 2). of the resulting situation into the dental prosthesis. The implants
in the posterior mandibular region were restored with macro-re­
tentive veneer crowns, which allow the veneering to be replaced
(Schweiger et al,47 University of Munich, Germany).

Fig 5a Long wrap veneers sintered on refractory dies, designed Fig 5b The veneer preparation was designed to allow a horizon­
for periodontally compromised anterior maxillary teeth (MDT Otto tal path of insertion. In this way, distance "C" can be designed to be
Prandtner, Munich, Germany). smaller than distance "D" (seen as an undercut area if viewed from
the vertical). Compared with a conventional full crown preparation
design, approximately 40% more tooth structure was preserved.

i ••

0 ih
^w MlS |
Fig 6a Situation after having removed a third generation of Fig 6b Try-in o f the full-wrap veneers (hybrid crowns) using try-
veneers in a 54-year-old patient. The palatal surfaces o f the anter­ in pastes. As required by the patient, the most tooth-conserving
ior maxillary teeth: extensive composite restorations with second­ preparation configuration possible was selected. As a result, cir­
ary caries. cular (360 degree) veneers, sintered on refractory dies, were used
for the final restoration (MDT Hubert Schenk, Munich, Germany).

structure being removed by taking into account the pre­ Silicate ceramic veneers present a predictable and
viously defined outer contour o f the future veneer.26'2833 successful treatm ent m odality. In a recently published
If severe discoloration is present, the preparation depth retrospective 10-year cohort study, these veneers have
may be slightly extended to allow the dental technician been shown to offer a 93.5% survival probability.13The
sufficient scope to mask the to oth structure.34 first results o f a 7-year prospective clinical study on full

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sive treatm ent m odality as their pulps are much larger

than in the adult population (Fig 8a). In addition to
elim inating the abrasion- and biocorrosion-inducing
causes, restoring the esthetic and functional properties
and reconstructing the biomechanical properties o f the
affected teeth are considered th e main trea tm en t
objectives. Furtherm ore, any restorative measures
should be aimed at preventing any further pathologic
wear in the long run.
Compared w ith conventional silicate ceramics, lith ­
ium-disilicate ceramic materials (IPS e.max Press or IPS
e.max CAD, Ivoclar Vivadent) offer enhanced flexural
strength and fracture toughness. Since the introduction

Fig 7 Minimally invasive restorations made of lithium-disilicate o f lithium disilicate, the recom m ended preparation
press ceramic using the layering technique in the anterior region depths fo r glass-ceramic onlays have been reduced
(IPS e.max Press LT and IPS e.max Ceram), while the monolithic
significantly. Today, a m inim um occlusal thickness of
technique was used for the posterior restorations (IPS e.max Press
HT) (CDT Oliver Brix, Bad Homburg, Germany). 1 mm is recom m ended fo r m o n o lith ic restorations
(staining technique). Currently a further reduction in
veneers are promising;35 however, sufficient data are as the layer thickness is brought to discussion if appropri­
yet unavailable fo r either long wrap veneers or full ate enamel support is present.14'15-37
wrap veneers.35 Bruxism, insufficient enamel support, Glass-ceramic onlays appear to be ideally suited for
and endodontically treated teeth are seen as essential rebuilding abraded and eroded posterior teeth because
risk factors for the success o f veneers.13'23'27'28 they offer enamel-like properties and an optim al inter­
face behavior.39They perm it a particularly gentle prep­
All-ceramic occlusal onlays aration of the tooth structure as long as the preparation
Adhesive all-ceramic partial coverage restorations are does not extend beyond the equator into the infra
also considered to be a reliable treatm ent option for bulge (Fig 8b). Consequently, these onlays can be used
the posterior region.12'36 In this context, it should be to circum navigate conventional prosthetic procedures
borne in m ind th a t the m ajority o f clinical long-term th a t are substantially more invasive. It is o f essential
studies are based on leucite-reinforced glass-ceramics, importance for the preparation margins to be predom ­
whereas today considerably stronger ceramic materials inantly located in the enamel. In in-vitro studies, exten­
based on lithium disilicate are available (Fig 7).11'37'38 As sive silicate ceramic onlays displayed a favorable stress
they perm it a defect-oriented preparation m ethod and pattern and almost pure compression at the interface,
elim inate the need fo r a retentive preparation design, which is o f advantage for the ceramic.39 However, all
all-ceramic onlays offer a sensible treatm ent option to transitions should be soft and rounded to prevent
avoid conventional invasive trea tm en t m ethods.15-39 stress peaks w ithin the restoration (Figs 8b and 8c).41
The Fourth German Oral Health Study (DMS IV) It is generally useful to distinguish between pure
revealed a high prevalence o f root caries and non-cari- onlays (involving o nly the occlusal surface) and
ous defects, on the basis o f which it is expected that the onlay-veneers (involving both the vestibular and occlu­
need for single-tooth restorations w ill increase in the sal surfaces). The latter is indicated if a m ajor m odifica­
future.40 Young patients affected by severe abrasion- tion o f the shade in the esthetic region (premolar) is
and/or biocorrosion-induced changes o f the dentition required.42 In a controlled prospective clinical study, the
may particularly benefit from a durable, m inim ally inva­ silicate ceramic onlays showed satisfactory long-term

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results after 12 years and are also suited for use in con­
junction w ith extensive tooth structure defects.36
Another clinical study over an observation period of
12.6 years revealed a failure rate of 20.9% in vital teeth
and 39% in endodontically treated teeth.12

Restorations made of CAD/CAM polymers

Modern manufacturing technologies enable the use of
industrially prefabricated polymers or acrylates, which Fig 8a Extensive abrasion-/biocorrosion-induced defects on the
occlusal surfaces o f the posterior maxillary teeth caused a lower­
offer material qualities that are clearly superior to the ing in the vertical dimension o f occlusion (VDO) in this 28-year-old
qualities of direct temporary restorations. As these female patient.

high-performance polymers are polymerized under

industrial conditions, they feature a highly homoge­
nous structure and therefore offer numerous advan­
tages. They exhibit increased long-term stability, better
biocompatibility and a more favorable wear behavior
than manually produced polymers. Furthermore, they
offer more favorable computer-aided design/comput-
er-assisted manufacture (CAD/CAM) processing charac­
teristics and can be used in thinner thicknesses than Fig 8b Try-in o f the m onolithic occlusal onlays made of IPS
e.max Press with an occlusal thickness of 1 mm. The occlusal
ceramic materials.38’43’44
plateau was smoothed and a 0.5-mm chamfer was prepared above
Complex rehabilitations represent a particular chal­ the equator of the tooth. This was the only preparation done.
lenge for the restorative team, especially if the vertical
dimension of occlusion (VDO) needs to be recon­
structed or redefined. The introduction of high-density
polymers has enabled a significant extension of the
pretreatment phase to establish the esthetic and func­
tional aspects of the reconstruction. If the adhesive
technique is applied correctly, these materials can be
used on both natural teeth and existing restorations.
This allows clinicians to evaluate the treatment objec­ Fig 8c View o f the occlusal onlays after placement w ith a
tive over an extended period of time and therefore light-curing adhesive (Syntac, Total Etch, Variolink II Base, Mono­
bond Plus; Ivoclar Vivadent).
generates a high predictability of the definitive rehabil­
itation.
High-density polymers are currently especially indi­ careful airborne particle abrasion of the restoration's
cated for single-tooth restorations. Basically, we can bonding surface (Rocatec Soft, 3M Espe; grain size
distinguish between polymethyl methacrylate (PMMA)- 33 pm, 1 bar pressure) followed by the application of a
based, mostly unfilled materials for long-term provi- bonding agent is recommended to establish a durable
sionalizations (eg, Telio CAD, Ivoclar Vivadent; or Vita adhesive bond.45
CAD-Temp, Vita Zahnfabrik) and materials, featuring a Using an intraoral silicoating system (eg, CoJet, 3M
high inorganic filler content for final restorations (eg, Espe) is advocated for the intraoral bonding of CAD/
Lava Ultimate, 3M Espe; or Vita Enamic, Vita Zahnfabrik). CAM polymers to existing restorations. It is advisable to
Except for Vita Enamic (etchable with hydrofluoric acid), use a thermoplastic foil and to selectively perforate it to

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Edelhoff et al

Fig 9a Occlusal onlays can also be used on existing restorations Fig 9b Occlusal veneers applied to existing restorations. Upon
for occlusal height corrections, similar to a permanent splint. successful completion of the splint therapy, the functionally validat­
ed occlusal position was transferred to long-term provisional restor­
ations made of PMMA-based CAD/CAM polymer. For this purpose,
the existing metal-ceramic restorations were tribochemically treat­
ed (CoJet), cleaned, and coated with bonding agent (Monobond
Plus) (CDT Josef Schweiger, University Munich, Germany).

expose exactly those areas that should be surface DISCUSSION

treated. This measure ensures that only the bonding
areas are silicoated. By using an especially designed Reliable resin bonding to natural enamel and silicate
silicoating powder agent (Rocatec Soft), the surfaces of ceramics has ushered in a shift in preparation designs
the existing restorations are cleaned, roughened, acti­ towards considerably more conservative methods in
vated, and silicoated all in one step. Upon completion the last few decades.4'5 Minimally invasive restorations
of the silicatization process, the protective foil is care­ are considered to be beneficial because they reduce
fully peeled off and any remaining particles are the risk of devitalization, are kind to the tooth structure,
removed from the bonding surfaces with the help of an and offer a high esthetic potential. Whilst these possi­
air syringe (Fig 9). Currently, clinical studies are being bilities inspire a great deal of euphoria, we should bear
carried out to assess the suitability of high-density poly­ in mind that the methods described above involve a
mers for permanent restorations.46 Against this back­ high degree of technique sensitivity with regard to
ground, special attention should be given inter alia to preparation (mainly in the enamel), adhesive bonding,
the wear resistance and behavior of these materials and final fine-tuning of the static and dynamic occlu­
when they are in direct contact with the opposing den­ sion.27'4850 Adhering to the defined guidelines during
tition. the various clinical and technical treatment phases
The use of high-density polymers allows clinicians to presents a key factor for achieving clinical long-term
increasingly explore interesting new treatment options success.51 While numerous clinical long-term stud-
and fields of applications.47 For instance, less invasive j e s 13,23,36,48,52 are available on minimally invasive restora­

restorative procedures to treat periodontally damaged tive treatment methods with ceramic materials, valid
teeth may be developed, because polymers are charac­ clinical data on the long-term behavior of minimally
terized by a low modulus of elasticity and are therefore invasive final restorations made of CAD/CAM polymers
less susceptible to fracture than ceramic materials if are still lacking.53'54
they are used in delicate configurations (Fig 10). Addi­ So far the authors of this report have had excellent
tional advantages result from the superior CAD/CAM experiences with long-term temporary single-tooth
processing characteristics compared with ceramic ma­ restorations made of PMMA-based CAD/CAM polymers.
terials. Higher edge stability, in particular, enables clin­ A prospective controlled clinical study using highly
icians to use purely additive procedures for certain filled CAD/CAM polymers as the material for the final
indications w ithout sacrificing any tooth structure. restoration in patients with generalized loss of tooth

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Fig 10a Preoperative view of a 52-year-old patient. Periodon- Fig 10b A long wrap preparation design w ith a horizontal path
tally compromised anterior teeth impaired the functional and of insertion (see Fig 5b) was selected to avoid excessive removal
esthetic properties of the dentition. of tooth structure.

structure was initiated at the Department of Prostho-

dontics at the University of Munich recently (Project No
541-12). In the meantime, more than 12 patients have
been treated and, w ithout a single exception, they all
responded enthusiastically to the predominantly addi­
tive treatm ent modality, as most of these complex Fig 10c Try-in of the experimental veneers made of highly-filled
CAD/CAM polymer in the course o f a prospective clinical study
cases could be treated with no, or hardly any, prepar­ (MDT Otto Prandtner, Munich, Germany).
ation. However, as the observation period of this study
is still short, a scientifically valid conclusion cannot yet
be drawn.
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216 VOLUME 4 7 - NUMBER 3 - MARCH 2016

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