INDIRECT AESTHET IC RESTORATIONS IN ......Indirect composite restorations such as inlays, onlays and overlays can be made with both dental office and laboratory composites, without

1

In recent years, the progress made in operational

techniques and the continuous improvement of the

physical, chemical and mechanical characteristics

of reconstruction materials have made it possible

for dentists to focus their attention on the constant

pursuit of the best aesthetic restoration results.

Patients asking for aesthetic restorations want

them to integrate with their natural teeth. Dentists,

therefore, should not only rely on scientifically

validated techniques to restore dental biology but

also be guided by their sense for aesthetics in

order to reproduce the polychromatic and

anatomical characteristics of teeth, so that

restorations are ultimately unnoticeable.

In philosophical terms, the word ‘aesthetics’

indicates the “science of beauty, liberal arts and

gnoseology, closely related to logics”, i.e. the

beauty and outward appearance of something. In

dentistry, a restoration is aesthetic when it best

matches the color, shape and function of what it

replaces.

The physiological behavior of teeth, in fact, is the

result of a close interaction between mechanical,

biological, functional and aesthetic properties. This

is where composite inlays come into play.

INDIRECT AESTHETIC

RESTORATIONS

IN CONSERVATIVE

DENTISTRY DAILY PRACTICE

DR. ALBERTO PUJIA

ODT. PAOLO RICCIONI

FIGURE 1 INITIAL QUADRANTS

INTRODUCTION

INDIRECT AESTHETIC RESTORATIONS IN CONSERVATIVE DENTISTRY DAILY PRACTICE DR. ALBERTO PUJIA & ODT. STEFANO RICCIONI

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The current composite resin

formulations have improved the

characteristics of materials through

the size, shape, concentration and

type of filler used.

Shrinkage caused by curing has

been reduced while tensile and

flexural strength as well as

resistance to abrasion and long

term color stability have increased.

Add to all this the benefits of high

power curing lights, in combination

with heat and pressure, that

improve the quality of the

polymerization reaction.

In recent years, two factors, at

least, have contributed to the

development of aesthetic inlays

and onlays:

o continuous innovation in

enamel and dentin adhesives,

which provide a high bond

strength of the composite to

dentin and enamel

o increased and constant request

for aesthetic restorations on

the part of patients.

Composite offers several

advantages: it does not require

large thicknesses, it provides a

good marginal precision and the

possibility to correct shape and

color, it is easy to repair, and lab

MATERIALS AND

METHODS

FIGURE 2 INITIAL QUADRANT 1

FIGURE 3 RUBBER DAM ISOLATION

FIGURE 4 IMPRESSION TAKING

FIGURE 5 INLAYS IN THE STONE CAST


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procedures are not complex.

Indeed, it (almost) matches

several of the most significant

qualities of ceramic materials

(resistance to wear, long-term

aesthetics, high stability) while

offering remarkable advantages in

terms of lower investment and less

complex laboratory procedures, the

possibility to perform intraoral

corrections and repair, a more

conservative cavity preparation,

effective polishing, and a lower

frailty and tendency to fracture. In

particular, the modulus of elasticity

(a body’s rigidity or flexure),

resilience (the ability to absorb

stress up to the breaking/failing

point) and fatigue strength

(rupture after dynamic stress is

applied) are the mechanical

properties that, unlike with ceramic

systems, make it possible to work

with lower thicknesses of

composite material, which is also

less subject to breakage.

Indirect composite restorations

such as inlays, onlays and overlays

can be made with both dental

office and laboratory composites,

without distinction.

Composite has three phases:

matrix, filler and bonding agent.

The most commonly used organic

phase in composite materials

mainly consists of Bis-GMA and/or

UDMA together with other resins

with a lower molecular weight.

Fillers are those substances that

are added to increase the strength

FIGURE 6 PROSTHETIC ARTIFACTS

FIGURE 7 TRY-IN OF INLAYS

FIGURE 8 JUST CEMENTED INLAYS

FIGURE 9 3 MONTH FOLLOW UP


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of the resin:

o macro particles (8-25 microns)

o fine particles (1-8 microns)

o micro particles (0.04-0.2 microns)

The composite used for this clinical

case was Estelite Sigma Quick by

Tokuyama Dental.

Estelite Sigma Quick is a light-

curable and radiopaque,

submicron-filled composite resin,

containing 82% by weight (71% by

volume) of composite filler and

zirconia/silicate filler. Thanks to

these filler particles, shrinkage

caused by curing is reduced. Each

inorganic particle in the composite

is submicronic (average size of the

particles is 0.2 µ, in a range from

0.1 to 0.3 µm) and this preserves

brightness and resistance to wear

to a very high degree. The

monomeric matrix contains Bis-

GMA and triethylene glycol

dimethacrylate.

Knowledge of the fundamental

principles of adhesive dentistry is a

prerequisite when working with

composite in order to obtain good

levels of aesthetic-functional

integration of the restoration and

long-term duration.

Adhesive cavities do not foresee

retentions, internal sharp edges

CAVITY

PREPARATION


FIGURE 11 INLAYS IN THE STONE CAST




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shall be avoided and a rounded

cavity has to be prepared to

facilitate the flowing of composite

cement. When preparing the cavity

for indirect adhesive restorations,

the principle of maximum tissue

preservation shall be observed and

the shape of the cavity depends on

the extension of the caries or the

presence of pre-existing

restorations to be replaced.

The clinical procedure includes two

sessions: the first one to prepare

and take the impression, and the

second one to cement the

composite restoration.

Ideally, cavity preparation entails

that the lateral walls converge

towards the bottom of the cavity

by approx. 15-18 degrees, that

minimum thickness is approx. 1.5-

2 mm, that there is an approx. 2

mm wide isthmus, that the

cavosurface angle is not beveled

and that enamel prisms are regular.

When the general design of the

cavity is predetermined, as when

replacing old restorations, the

cavity preparation has to be

adapted to adhesive techniques.

Adhesive restorations require a

conical shape with clear-cut

margins and the filling of any

undercuts with composite material,

in order to avoid excessively

invasive preparations. After

finishing the preparation, the

dentinal substrate is properly

treated to protect tooth vitality, if



FIGURE 16 ETCHING



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any. Then, after removing the

rubber dam, an impression is taken

of both the arch to be rehabilitated

and of the opposite arch, and the

intermaxillary relationship is

recorded with wax and face bow,

which is what the dental technician

needs to subsequently mount the

casts on the articulator.

Preparations can now be

provisionalised with light-curable

Eugenol-free provisional cement.

At the cementation stage, the

artifacts delivered by the

laboratory have already been

subjected to a post-polymerization

cycle which, thanks to the

combination of light, heat and

pressure, provides the inlay with

physical and mechanical

characteristics which are absolutely

superior to those of direct

restorations.

The already sandblasted and

silanized inlays are then cleansed

and conditioned with an enamel-

dentin adhesive. After removing

provisional cement and placing the

rubber dam, cavities are cleaned

and cleansed so as to remove all

residues of dental and cavity

surfaces; congruity of artifacts is

then checked and cementation

procedure is started.

CEMENTATION


FIGURE 19 IMPRESSION

FIGURE 20 ETCHING



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Cavities are sandblasted with particles having a size of 30 microns, at 2 bar pressure, for

approximately 10 seconds; etching is performed with 36.5-37.5% orthophosphoric acid for approx.

40 seconds; cleansing with 0.2% chlorhexidine is carried out to inhibit metalloproteinase and after

applying the primer/bonding agent (EnaBond, Micerium). A uniform layer of pre-heated composite

(37-39 degrees C) is then placed into the cavity, after which the inlay/onlay is seated and kept in

situ by exerting constant pressure. Excess cement is removed before its polymerization, and

dental floss is used to remove it also from interproximal areas. Curing with UV radiation is

performed on all sides for at least 2 minutes per side, while exerting constant occlusocervical

pressure on the prosthetic artifact. Once curing is complete, coarse composite residues on the

margins are removed and 40 micron diamond burrs and silicone trimmers are used for finishing.

After checking marginal congruity, occlusion is also checked, followed by finishing and polishing.

In another session, final polishing and glossing can be performed under a rubber dam.

FIGURE 22 INITIAL QUADRANT AND FINAL CHECK

BEFORE

AFTER


8

° Liebler M, Devigus A, Randall RC,

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BIBLIOGRAPHY

FIGURE 23 INITIAL UPPER AND LOWER ARCHES

FIGURE 24 UPPER AND LOWER ARCHES,

FINAL CHECK AFTER 1 YEAR

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INDIRECT AESTHET IC RESTORATIONS IN ......Indirect composite restorations such as inlays, onlays and overlays can be made with both dental office and laboratory composites, without