CLINICAL RESEARCH

Evidence-based concepts and

procedures for bonded inlays and
onlays. Part II. Updated 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,
University Clinic of Dental Medicine, Geneva, Switzerland
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 Barthélémy-Menn, 1205 Geneva, Switzerland;

E-mail:giovanni.rocca@unige.ch

2
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 ROCCA ET AL

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:XXX–XXX)

3
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 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),1-3,9,10 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 clinical
porary phase, as well as to stabilize and environment were manifestly more fa-
improve the adhesive interface quality. vorable to ceramic restorations, as in-
When needed, the CMR technique (also direct ceramic restorations were neither
known as Deep Margin Elevation – DME) placed in social clinics nor in patients
helps to raise deep cervical margins to a with severe bruxism, while such restric-
visible and accessible level (supragingi- tions did not normally apply (or did not
vally), easing impression and cementa- apply as strictly) to composite studies.
tion procedures. Moreover, due to an Despite this, composite resins have
even cavity design, the CDO and CMR been widely used for the fabrication of
techniques facilitate the placement of inlays and onlays due to a simpler manu-
temporary restorations (non-cemented) facturing process (and thus lower cost),
and the restoration fabrication. Regard- as well as their excellent esthetics and
ing cementation, the use of a highly easier reparability. A more “recent” and
filled, light-curing restorative material is increasingly used alternative is CAD/
recommended instead of a dual-curing CAM restoration, made in either ceramic
composite cement because of its super- or composite resin blocks (ie, IPS Em-
ior mechanical properties and wear re- press or e.max CAD, Ivoclar ­
Vivadent;
sistance, as well as its practicality.3,11-13 Lava Ultimate, 3M). Despite this large
Overall, this updated clinical protocol choice with regard to materials and fab-

4
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 ROCCA ET AL

rication methods, the tooth preparation regarding the assessment of the in vivo
for all kinds of modern bonded restor- performance of new monolithic ceramic
ations relies on similar specific princi- restorations in a critical biomechanical
ples, which differ from those for tradition- environment.
al cast-gold inlays and onlays, and even
the first generation of fired porcelain res- Preparation extent and restoration
torations, whose limited mechanical re- thickness
sistance imposes more demanding and
invasive preparations. All tooth-colored materials (composite
The occlusal environment has to be resin or ceramic) used for the fabrica-
evaluated, as it plays an important role tion of posterior indirect restorations are
in restoration longevity and can also submitted to high occlusal functional
influence material choice. Extensive stresses; consequently, their inher-
restorations with generally large and ent vulnerability needs to be compen-
deep cavities (mainly non-vital teeth) sated for by restoration thickness and
in high load-bearing areas (especially proper adhesive cementation. Although
the second molars) associated with an the restorations should therefore be as
unfavorable occlusal context (such as thick as possible, this approach is tem-
patients with bruxism) have to, in any pered by the fundamental principles
case, be considered biomechanically of minimal invasiveness.29 Moreover,
vulnerable and more susceptible to fail- an unconsidered sacrifice of enamel
ure. In the latter unfavorable situation, and dentin could also directly weaken
only the strongest materials should be the tooth. For example, Fennis and co-
chosen, based mainly on their super- workers have demonstrated that thick
ior mechanical properties. Today, new overlay restorations show higher static
CAD/CAM composite resin blocks (ie, fracture strength compared to conserva-
Lava Ultimate, 3M; Enamic, Vita) or lithi- tive ones,30 although they present more
um disilicate-based restorations (ie, IPS drastic and irreversible failures; ie, thick-
e.max Press or CAD, Ivoclar Vivadent) er restorations may be stronger but si-
are preferred, the former option having multaneously imply thinner and weaker
some interesting stress-absorbing prop- dental tissues underneath them. At the
erties,17 while requiring simpler proced- same time, extremely thin material is not
ures when a surface modification or re- systematically and unconditionally rec-
pair is needed.18 Recent in vitro studies ommended. If one takes into considera-
on the fracture and fatigue resistance tion that a few tenths of a millimeter can
of direct and indirect restorations of a considerably strengthen a restoration,
severely eroded tooth model demon- the best compromise would be between
strated the favorable behavior of CAD/ material resistance and the clinical situ-
CAM composite materials.17,19-24 Apart ation.31 We should therefore move away
from the non-vital tooth configuration, from the blind application of “minimally
the aforementioned findings are well invasive dentistry” to a more realistic
supported by clinical trials.25-28 Howev- concept of “minimally hazardous den-
er, less information is available to date tistry”, which is particularly pertinent to

5
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 CLINICAL RESEARCH

ness between 1.0  and 1.5  mm seems

to be advisable for all modern “white”
restorative materials, including compos-
ite resins, pressed ceramics, and CAD/
CAM blocks (apart from traditional felds-
pathic and leucite-reinforced ceramics),
while the stability and impact of thinner
material layers on restoration longevity
is still under evaluation. Moreover, it is
important to note that minimal material
thicknesses should be limited to mono-
Fig 1    Oscillating selectively coated diamond in- lithic/mono-laminar restorations, as a
struments for the finishing of the interproximal zone.
layering procedure could mean includ-
ing imperfections in the narrow availa-
ble space, thus weakening the system.
Finally, esthetic considerations will also
have an impact on restoration thickness
(see “Esthetic considerations” below).
large and deep cavities and to non-vital In conclusion, a good compromise
teeth. between tissue preservation and a suita-
The minimal occlusal thickness al- ble restoration thickness has to be found
lowed for a material depends on, among and adapted to each case or tooth-spe-
many other parameters, its intrinsic me- cific occlusal and esthetic context.
chanical features (static and dynamic
reaction to stresses) and is therefore Clinical guidelines
material- and even brand-dependent.
Thus, usual recommendations based on It follows, then, that while the cavity de-
clinical experience and in vitro testing sign and extent is largely dictated by
suggest to attain at least 1  mm thickness conservation principles, together with
for composite resins, and 2  mm for low- occlusal and esthetic parameters, the
strength ceramics, such as feldspathic overall cavity design is related to the
(eg, Vita Mark II, Vita) and leucite-rein- pathology and presence of decayed tis-
forced (IPS Empress I, Ivoclar Vivadent) sues rather than the need for macrore-
ceramics. For new lithium disilicate-re- tention or friction.
inforced ceramics (ie, IPS e.max Press Practically, preparation starts with the
or CAD), the minimal recommended removal of the existing restoration and
thickness seems to be closer to that decayed tissues without initially finishing
recommended for composite resin, ie, the enamel margins. In less accessible
between 1 and mm.21,22,31-33
1.2    The areas (usually interproximally), oscillat-
presence of enamel under these thin ing, selectively diamond-coated instru-
ceramic restorations has also been re- ments (ie, PCS, EMS or Sonicsys, KaVo)
cently proven to yield a certain positive facilitate the preparation and finishing
effect.31,32,34 Overall, a restoration thick- of cavities (Fig  1). When cavity margins

6
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 ROCCA ET AL

violate the biological width, a crown- Different options are available with an
lengthening procedure may be needed, indirect approach. First, in an attempt
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 following
width considerations and more on the the CDO. The authors recommend a
future accessibility of the margins to se- minimum of 1 mm as minimal wall width/
cure the clean and dry environment nec- thickness before reinforcement. In cas-
essary for proper adhesive techniques. es where the minimal residual thickness
Fissures (in dentin or enamel) should is below this measurement, cusp cover-
ideally be included in the preparation, age is indicated (this guideline seems
considering potential bacterial leakage to be the accepted general clinical con-
or structural weakening, although their sensus nowadays). The aim is to have
extension in inaccessible zones often a more homogeneous biting force dis-
prevents these flaws from being fully tribution and offer a “protective effect”
eliminated. for the underlying weakened tooth struc-
ture. The resulting “invasiveness” could,
Thin cavity walls and occlusal however, increase the risk of irrevers-

coverage ible tooth fracture (below the cemento-

enamel junction – CEJ), as is shown in
Little is known scientifically about the vitro by Fennis et al,30 although such
minimal thickness needed to maintain clinical observation is extremely rare in
thin tooth walls and what is to be con- vital teeth. Finally, the systematic occlus-
sidered totally safe and conservable, al coverage of functional and/or non-
knowing that a multitude of parameters functional cusps is not yet advocated,
will impact such a decision process. The as it is seemingly not proven to increase
presence of thin walls around an exten- the 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 1 mm
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.35-38 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.39 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

7
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 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 patient’s lips can act as a curtain behind which the tooth–restoration
transition can be hidden.

of the residual walls, especially in endo- While the esthetic impact of the res-
dontically treated teeth.45 toration should theoretically be analyzed
before the cavity preparation, the final
extent of the restoration in the buccal-
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
(Fig  3). Where esthetic requirements are 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-

8
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 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.

tion. As an alternative, tooth shade can other details or characteristics to be re-

be recorded and crossed-matched with produced on the buccal and occlusal
a non-restored, contralateral or neigh- surfaces (white spots, stains on fissures,
boring tooth. etc) should be communicated to the la-
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 o
­ cclusal
For ceramic restorations, particularly in
posterior areas, the classical VITA shade
guide (Vita) is the most widely used sys-
tem for monolithic ceramic or mono-
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 Fig 4    Example of a schematic drawing for com-
about dentin and enamel shade, any munication with the dental laboratory.

9
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 CLINICAL RESEARCH

Table 2    Clinical step-by-step protocol for the cavity preparation of bonded indirect posterior restorations

• Apply local anesthesia

• Check occlusal context and esthetic needs of the tooth

• Choose tooth shade

• Remove old restoration, excavate caries, and prepare but do not finish the margins of the cavity

• Check interocclusal space in centric and during lateral movement

• Isolate the cavity with rubber dam and, in case of subgingival margins, place metal matrix

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

• Light-cure bonding resin for 20 s

• 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

• Light-cure each increment of composite resin for 40 s

• Insulate cavity with a layer-forming glycerine gel and light-cure the resin again for 10 s

• Finish enamel margins with fine diamond instruments without exposing dentin. Do this with
composite margins too, if present

• Check the five criteria for cavity approval:

1.  Detailed sharp margins
2.  Absence of undercuts
3.  Accessibility of subgingival margins
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

• Take impression

• Insert the temporary resin material into the cavity, check the occlusion before the material sets,
remove excesses, and light-cure in occlusion for 30 s

coverage (see Fig  3a), while dentin For monolithic CAD/CAM ceramic

shades should be used for crown-like or composite resin blocks, porcelain
preparations (see Fig  3c) in the cervical stains or resin “paint-on-colors” should
part of the restoration. be used for a more detailed color char-

10
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 ROCCA ET AL

a b

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

acterization of esthetically demanding been described by several authors (see

cases. For CAD/CAM or pressed lithium Part I of this article series).2,4,5,8,49,50
disilicate ceramic restorations, apart Early sealing is also necessary as an
from surface staining, low-fusing ce- adhesive pretreatment, allowing for
ramic veneering is possible, although it the placement of the composite liner
may affect overall restoration strength.48 or base, as previously described. This
step should be performed under rubber
dam isolation. In case of subgingival/in-
Adhesive procedures and tracrevicular margins, the placement of
a pre-shaped metallic matrix will prevent
cavity treatment before
the rubber dam from covering deeper
impression
margins, making adhesive and liner ap-
plication easier (Figs  5a and 5b).
Dual Bonding/Immediate Dentin
Sealing
One of the main objectives of the prep-
aration session is to leave the cavity
with only two substrates until cementa-
tion, these being mechanically finished
enamel, and composite (Table  
2). All
the dentinal surfaces should be prop-
erly sealed, and are usually protected
by the liner. 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
Fig 6    Selective enamel etching for 30 to 45 s as
system. An etch-and-rinse or self-etch
shown in this image has to be avoided when enamel
system can be used. The early sealing is thin, typically in a subgingival situation. There is a
of dentin provides many benefits, as has high risk of dentin over-etching.

11
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 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.

12
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 ROCCA ET AL

To obtain an optimal substrate for Cavity Design Optimization and

further adhesive procedures – enamel Cervical Margin Relocation
and composite only – attention should
be given to enamel thickness. When it Once bonding resin is polymerized, a
is thin and inconveniently located (typi- layer of composite is normally applied
cally in a juxta- or subgingival situation), over all sealed dentin surfaces to create
difficulties will arise; for instance, it will an optimal cavity design, unless restor-
be a lot more demanding to finish enam- ation thickness restricts the placement
el margins before impressions without of such a layer, as is the case with over-
contacting/exposing dentin and without lays used for the treatment of tooth wear.
damaging gingiva, or obtain perfect im- In this particular situation, a filled adhe-
pression taking, or quick, effective rub- sive system is normally preferred (ie,
ber dam placement. In this case, the OptiBond FL, Kerr), which plays the role
cervical margin comprising both enamel of both adhesive and cavity liner. In this
and dentin is likely to be covered by the case only, the procedure is considered
composite liner. Then, adhesion to this to be a “cavity coating”.54,55
thin subgingival enamel is established As has been mentioned, the cavity
at the same time as the dentin sealing. lining plays multiple roles, including the
If an etch-and-rinse system is used, it reinforcement of cavity walls. It simulta-
is important to respect conditioning neously eliminates undercuts and saves
times. Indeed, the etch-and-rinse tech- tooth structure, the leveling of the cavity
nique, based on highly concentrated or- floor, and, if needed, the occlusal relo-
thophosphoric acid action, implies the cation of cervical margins. Finally, it of-
conditioning of dentin and enamel for fers a physical and biological protection
different time intervals, ie, 5 to 10 s, and during the temporary phase (eliminating
30 to 45 s, respectively. However, when virtually all possible biological compli-
enamel is thin, selective enamel etch- cations, such as tooth sensitivity and
ing is difficult to achieve without the risk bacterial leakage), leading to a mark-
of inadvertently over-etching the neigh- edly improved protocol, compared to
boring dentin (Fig  6).51 The proposed the “traditional” approach for adhesive
clinical “compromise” is then to con- indirect restorations (Table  
1). At the
dition such thin enamel, together with time of cementation, it will also act as
dentinal tissue, for a limited time of 5 to a physical barrier against the mechani-
10  s (Figs  7a to 7c). As an alternative, cal surface treatment (sandblasting) of
a two-component self-etch system can the cavity, preserving the integrity of the
be used, without prior selective enamel sealed dentin surfaces (Fig  9).7
acid etching (Figs 8a to 8c).52,53

13
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 CLINICAL RESEARCH

Table 1    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-µm
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.

14
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 ROCCA ET AL

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

15
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 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 restoration’s 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
3) Accessibility of subgingival margins. have been met, impression will definitely
Margins of the cavity, especially cer- become uncomplicated. For a conven-
vical ones, must be relocated occlus- tional approach, the use of an elasto-
ally (at least 0.5 mm over the free gin- mer material such as polyvinylsiloxane
gival margin) to facilitate impression (VPS) or polyether is recommended,
and rubber dam application. Do not although polyether materials are rather
over-elevate the margins in order to sensitive to the possible persistence of
obtain an optimal, natural proximal an oxygen-inhibited layer, which may af-
emergence profile of the future res- fect their setting reaction.61 A two-step
toration. technique is suggested, including both
4) Absence of contact between the cav- a syringe and a tray material (Figs  11a
ity and the adjacent teeth. This should to 11e). A metallic half-bite tray will ease
guarantee good flow of the impres- the impression technique while limiting
sion material in the interproximal ar- the slight inaccuracy of full-arch impres-
eas, and make optical impression re- sions.
cording easier. The technician or the

16
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 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

17
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 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.

18
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 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 patient’s 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-
disinfectant’s 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.62,63
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

19
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 CLINICAL RESEARCH

a b

Figs 13a and b    The in-lab composite resin onlays. Only A3–A2 shades and occlusal stains were used
for the in-lab stratification (Tetric EvoCeram A2–A3, Ivoclar Vivadent; Kolor + Plus, Kerr).

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- 1.2  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
(Figs  13a and 13b). During the next ap- or tooth structural weakening, although
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.

20
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 ROCCA ET AL

a b

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

References restorations. J Prosthet Dent

2005;94:511–519.
sources on composite micro-
hardness in different cur-
7. Stavridakis MM, Krejci I, ing conditions. Dent Mater
1. Spreafico R (ed). Adhesive Magne P. Immediate dentin 2003;19:493–500.
Metal-Free Restorations: sealing of onlay prepar- 13. Park SH, Kim SS, Cho YS,
Current Concepts for the ations: thickness of pre- Lee CK, Noh BD. Curing
Esthetic Treatment of Poste- cured dentin bonding agent units’ ability to cure restora-
rior Teeth: Quintessence Pub and effect of surface clean- tive composites and dual-
Co, 1997. ing. Oper Dent 2005;30:747– cured composite cements
2. Dietschi D, Spreafico R. 757. under composite overlay.
Current clinical concepts 8. Magne P, Spreafico RC. Oper Dent 2004;29:627–
for adhesive cementation of Deep margin elevation: A 635.
tooth-colored posterior res- paradigm shift. Am J Esthet 14. Huth KC, Chen HY, Mehl A,
torations. Pract Periodontics Dent 2012;2:86–96. Hickel R, Manhart J. Clinical
Aesthet Dent 1998;10:47– 9. Dietschi D, Monasevic M, study of indirect compos-
54;quiz 56. Krejci I, Davidson C. Mar- ite resin inlays in poste-
3. Paul SJ, Schärer P. The ginal and internal adaptation rior stress-bearing cavities
dual bonding technique: a of class II restorations after placed by dental students:
modified method to improve immediate or delayed com- results after 4 years. J Dent
adhesive luting procedures. posite placement. J Dent 2011;39:478–488.
Int J Periodontics Restorative 2002;30:259–269. 15. Manhart J. Direct compos-
Dent 1997;17:536–545. 10. Dietschi D, Olsburgh S, ite restorations in posterior
4. Dietschi D, Herzfeld D. In Krejci I, Davidson C. In vitro region: a case history using
vitro evaluation of marginal evaluation of marginal and a nanohybrid composite.
and internal adaptation of internal adaptation after Dent Today 2004;23:66,68–
class II resin composite res- occlusal stressing of indirect 70.
torations after thermal and class II composite restor- 16. Sahafi A, Peutzfeld A,
occlusal stressing. Eur J Oral ations with different resin- Asmussen E, Gotfredsen K.
Sci 1998;106:1033–1042. ous bases. Eur J Oral Sci Effect of surface treatment of
5. Magne P. Immediate dentin 2003;111:73–80. prefabricated posts on bond-
sealing: a fundamental pro- 11. Besek M, Mörmann WH, ing of resin cement. Oper
cedure for indirect bonded Persi C, Lutz F. The curing Dent 2004;29:60–68.
restorations. J Esthet Restor of composites under Cerec 17. Magne P, Knezevic A. Influ-
Dent 2005;17:144–54;dis- inlays [in German]. Sch- ence of overlay restorative
cussion 155. weiz Monatsschr Zahnmed materials and load cusps
6. Magne P, Kim TH, Cascione 1995;105:1123–1128. on the fatigue resistance
D, Donovan TE. Immedi- 12. Dietschi D, Marret N, Krejci of endodontically treated
ate dentin sealing improves I. Comparative efficiency of molars. Quintessence Int
bond strength of indirect plasma and halogen light 2009;40:729–737.

21
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 CLINICAL RESEARCH

18. Rocca GT, Bonnafous F, based composite restor- of minimal-invasive mono-

Rizcalla N, Krejci I. A tech- ations used to treat localised lithic lithium disilicate and
nique to improve the esthetic anterior tooth wear. Br Dent J zirconia occlusal onlays:
aspects of CAD/CAM com- 2003;194:566–72;discussion finite element and theo-
posite resin restorations. J 559. retical analyses. Dent Mater
Prosthet Dent 2010;104:273– 27. Gulamali AB, Hemmings KW, 2013;29:742–751.
275. Tredwin CJ, Petrie A. Sur- 35. Versluis A, Tantbirojn D, Pin-
19. Hamburger JT, Opdam NJ, vival analysis of composite tado MR, DeLong R, Doug-
Bronkhorst EM, Huysmans Dahl restorations provided las WH. Residual shrinkage
MC. Indirect restorations for to manage localised anterior stress distributions in molars
severe tooth wear: fracture tooth wear (ten year follow- after composite restoration.
risk and layer thickness. J up). Br Dent J 2011;211:E9. Dent Mater 2004;20:554–
Dent 2014;42:413–418. 28. Smales RJ, Berekally TL. 564.
20. Hamburger JT, Opdam NJ, Long-term survival of direct 36. Tantbirojn D, Versluis A,
Bronkhorst EM, Roeters JJ, and indirect restorations Pintado MR, DeLong R,
Huysmans MC. Effect of placed for the treatment of Douglas WH. Tooth deforma-
thickness of bonded com- advanced tooth wear. Eur tion patterns in molars after
posite resin on compressive J Prosthodont Restor Dent composite restoration. Dent
strength. J Mech Behav 2007;15:2–6. Mater 2004;20:535–542.
Biomed Mater 2014;37:42– 29. Beier US, Kapferer I, 37. Bicalho AA, Pereira RD, Zan-
47. Burtscher D, Giesinger JM, atta RF, et al. Incremental fill-
21. Magne P, Schlichting LH, Dumfahrt H. Clinical perfor- ing technique and composite
Maia HP, Baratieri LN. In vitro mance of all-ceramic inlay material – part I: cuspal
fatigue resistance of CAD/ and onlay restorations in deformation, bond strength,
CAM composite resin and posterior teeth. Int J Prostho- and physical properties.
ceramic posterior occlusal dont 2012;25:395–402. Oper Dent 2014;39:E71–82.
veneers. J Prosthet Dent 30. Fennis WM, Kuijs RH, 38. Bicalho AA, Valdívia AD,
2010;104:149–157. Kreulen CM, Verdonschot N, Barreto BC, Tantbirojn D,
22. Schlichting LH, Maia HP, Creugers NH. Fatigue resist- Versluis A, Soares CJ. Incre-
Baratieri LN, Magne P. ance of teeth restored with mental filling technique and
Novel-design ultra-thin CAD/ cuspal-coverage composite composite material – part
CAM composite resin and restorations. Int J Prostho- II: shrinkage and shrink-
ceramic occlusal veneers for dont 2004;17:313–317. age stresses. Oper Dent
the treatment of severe den- 31. Skouridou N, Pollington S, 2014;39:E83–92.
tal erosion. J Prosthet Dent Rosentritt M, Tsitrou E. Frac- 39. Kim ME, Park SH. Com-
2011;105:217–226. ture strength of minimally parison of premolar cuspal
23. Giannetopoulos S, van Noort prepared all-ceramic CEREC deflection in bulk or in incre-
R, Tsitrou E. Evaluation of the crowns after simulating 5 mental composite restor-
marginal integrity of ceramic years of service. Dent Mater ation methods. Oper Dent
copings with different 2013;29:e70–77. 2011;36:326–334.
marginal angles using two 32. Guess PC, Schultheis S, 40. Fonseca RB, Fernandes-
different CAD/CAM systems. Wolkewitz M, Zhang Y, Strub Neto AJ, Correr-Sobrinho L,
J Dent 2010;38:980–986. JR. Influence of preparation Soares CJ. The influence of
24. Hamburger JT, Opdam NJ, design and ceramic thick- cavity preparation design on
Bronkhorst EM, Kreulen nesses on fracture resist- fracture strength and mode
CM, Roeters JJ, Huysmans ance and failure modes of of fracture of laboratory-
MC. Clinical performance premolar partial coverage processed composite resin
of direct composite restor- restorations. J Prosthet Dent restorations. J Prosthet Dent
ations for treatment of severe 2013;110:264–273. 2007;98:277–284.
tooth wear. J Adhes Dent 33. Clausen JO, Abou Tara M, 41. Federlin M, Sipos C, Hiller
2011;13:585–593. Kern M. Dynamic fatigue KA, Thonemann B, Schmalz
25. Attin T, Filli T, Imfeld C, and fracture resistance of G. Partial ceramic crowns.
Schmidlin PR. Composite non-retentive all-ceramic full- Influence of preparation
vertical bite reconstructions coverage molar restorations. design and luting material on
in eroded dentitions after 5.5 Influence of ceramic mater- margin integrity – a scanning
years: a case series. J Oral ial and preparation design. electron microscopic study.
Rehabil 2012;39:73–79. Dent Mater 2010;26:533– Clin Oral Investig 2005;9:8–
26. Redman CD, Hemmings KW, 538. 17.
Good JA. The survival and 34. Ma L, Guess PC, Zhang Y. 42. Stappert CF, Guess PC,
clinical performance of resin- Load-bearing properties Gerds T, Strub JR. All-

22
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015
 ROCCA ET AL

ceramic partial coverage alization. Quintessence Int 59. Zaruba M, Göhring TN,
premolar restorations. Cavity 2007;38:371–379. Wegehaupt FJ, Attin T. Influ-
preparation design, reliabil- 51. Tjäderhane L, Nascimento ence of a proximal margin
ity and fracture resistance FD, Breschi L, et al. Strat- elevation technique on mar-
after fatigue. Am J Dent egies to prevent hydrolytic ginal adaptation of ceramic
2005;18:275–280. degradation of the hybrid inlays. Acta Odontol Scand
43. Soares CJ, Martins LR, layer – A review. Dent Mater 2013;71:317–324.
Fonseca RB, Correr-Sobrinho 2013;29:999–1011. 60. De Munck J, Van Lan-
L, Fernandes Neto AJ. 52. Peumans M, Kanumilli P, De duyt KL, Coutinho E, et al.
Influence of cavity prep- Munck J, Van Landuyt K, Fatigue resistance of dentin/
aration design on fracture Lambrechts P, Van Meerbeek composite interfaces with
resistance of posterior B. Clinical effectiveness of an additional intermediate
Leucite-reinforced ceramic contemporary adhesives: a elastic layer. Eur J Oral Sci
restorations. J Prosthet Dent systematic review of current 2005;113:77–82.
2006;95:421–429. clinical trials. Dent Mater 61. Magne P, Nielsen B. Interac-
44. Stappert CF, Abe P, Kurths 2005;21:864–881. tions between impression
V, Gerds T, Strub JR. Mas- 53. De Munck J, Van Landuyt K, materials and immediate
ticatory fatigue, fracture Peumans M, et al. A criti- dentin sealing. J Prosthet
resistance, and marginal cal review of the durability Dent 2009;102:298–305.
discrepancy of ceramic of adhesion to tooth tissue: 62. Garza ADG, Haraszthy
partial crowns with and methods and results. J Dent VI, Brewer JD, Monaco E,
without coverage of compro- Res 2005;84:118–132. Kuracina J, Zambon JJ. An
mised cusps. J Adhes Dent 54. Satoh M. How to use “Liner in vitro study of antimicrobial
2008;10:41–48. Bond System” as a dentin agents incorporated into
45. Rocca GT, Krejci I. Crown and pulp protector in indirect interim restorative materials.
and post-free adhesive res- restorations. Jap J Adhes Open J Somatology 2013.
torations for endodontically Dent 1994;12:41–48. doi:10.4236/ojst.2013.31017.
treated posterior teeth: from 55. Jayasooriya PR, Pereira PN, 63. Yazdankhah SP, Scheie AA,
direct composite to endo- Nikaido T, Burrow MF, Tagami Høiby EA, et al. Triclosan
crowns. Eur J Esthet Dent J. The effect of a “resin coat- and antimicrobial resist-
2013;8:156–179. ing” on the interfacial adap- ance in bacteria: an over-
46. Dietschi D, Ardu S, Krejci tation of composite inlays. view. Microb Drug Resist
I. A new shading concept Oper Dent 2003;28:28–35. 2006;12:83–90.
based on natural tooth color 56. Feilzer AJ, De Gee AJ, 64. Ribeiro JC, Coelho PG, Janal
applied to direct composite Davidson CL. Increased MN, Silva NR, Monteiro AJ,
restorations. Quintessence wall-to-wall curing contrac- Fernandes CA. The influence
Int 2006;37:91–102. tion in thin bonded resin lay- of temporary cements on
47. Magne P, Bruzi G, Carvalho ers. J Dent Res 1989;68:48– dental adhesive systems for
AO, Giannini M, Maia HP. 50. luting cementation. J Dent
Evaluation of an anatomic 57. Rocca GT, Gregor L, Sand- 2011;39:255–262.
dual-laminate composite oval MJ, Krejci I, Dietschi D. 65. Koch T, Peutzfeldt A,
resin shade guide. J Dent In vitro evaluation of mar- Malinovskii V, Flury S, Häner
2013;41(suppl 3):e80–86. ginal and internal adaptation R, Lussi A. Temporary zinc
48. Zhao K, Pan Y, Guess PC, after occlusal stressing of oxide-eugenol cement:
Zhang XP, Swain MV. Influ- indirect class II composite eugenol quantity in dentin
ence of veneer applica- restorations with different and bond strength of resin
tion on fracture behavior resinous bases and interface composite. Eur J Oral Sci
of lithium-disilicate-based treatments. “Post-fatigue 2013;121:363–369.
ceramic crowns. Dent Mater adaptation of indirect com-
2012;28:653-660. posite restorations”. Clin
49. Bertschinger C, Paul SJ, Oral Investig 2012;16:1385–
Lüthy H, Schärer P. Dual 1393.
application of dentin bond- 58. Medina AD, de Paula AB,
ing agents: effect on de Fucio SB, Puppin-Ron-
bond strength. Am J Dent tani RM, Correr-Sobrinho
1996;9:115–119. L, Sinhoreti MA. Marginal
50. Rocca GT, Krejci I. Bonded adaptation of indirect restor-
indirect restorations for ations using different resin
posterior teeth: from cavity coating protocols. Braz Dent
preparation to provision- J 2012;23:672–678.

23
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
VOLUME 10 • NUMBER 3 • AUTUMN 2015