Community Dimitry Averin Maxim Belograd Via

COMMUNITY
INDIRECT POSTERIORS - COMMUNITY

DIMITRY AVERIN - MAXIM BELOGRAD
7052 Views - Nov 2015
Modern restorative techniques are driven by ultimate esthetics demand while maintaining maximum
amount of intact hard tissues.?
A community article by Dimitry Averin and Maxim Belograd
Page 1 of 14
www.styleitaliano.org - DIMITRY AVERIN - MAXIM BELOGRAD
Occlusal Veneers, Rationale for ultraconservative posterior restorations
Conservative ceramics in posteriors
Page 2 of 14
Initially in the anterior segment - minimally invasive bonded feldspathic and glass-ceramic veneers have
become the treatment of choice with proven long-term success 1,2. However, fracture of ultraconservative
ceramic restorations may cause a concern when considering the same treatment modality for posterior
region especially with restorations covering the entire occlusal surface - so called occlusal veneers.
To minimize the risk of ceramic fractures and withstand occlusal loads, the standard guidelines for lithium
disilicate occlusal veneers 3 recommended by the manufacturer (Ivoclar Vivadent) advocate at least 1,0-1,5
mm of occlusal clearance and chamfer preparation of 1mm. However, such requirement may be in conflict
with current minimally invasive concepts.
First and foremost, adhering to above mentioned recommendations may result in excessive removal of
dental structure ranging between 40-50% 4. Considering that the tooth may be already destroyed by
caries, attrition or erosion - maximum tooth preservation is of paramount importance. Previous studies
revealed that excessive preparation will cause noticeable decline of the remaining tooth structure strength
5. Moreover, available long-term clinical data on ceramic partial coverage restorations have demonstrated
Page 3 of 14
that ceramic may fracture even despite recommended thicknesses of at least 1.5 mm.6,7 It means that the
more the prep - the more the longevity of tooth-restoration complex is jeopardized. As a result, traditional
restorative protocols aiming to reinforce the tooth-restoration complex at the expense of removing
remaining tooth structure are self-contradictory and may lead to catastrophic failures.7 Finally, traditional
thickness demands are mostly based upon the results of laboratory tests with limited clinical evidence.8
Consequently, limited clinical application of such aggressive preparation guidelines made the dental
community seek for more ultraconservative alternatives. It should be emphasized that even Ivoclar
Vivadent company is supporting researches in the area of ultra thin restoration.9 Notwithstanding we have
sparse long-term clinical evidence in this field at the moment, the review will attempt to present state-of
-the-art concepts regarding ultra-thin restorations - both for ceramic and composite. ?In the first part, the
rationale for ultraconservative concept will be discussed, and protocol for teeth with preserved occlusal
enamel will be elaborated. While the second part will investigate indications for ultra-thin technique when
occlusal enamel is lost accentuating dentin as the main substrate for bonding. In that context distinct
contraindications and limitations will receive special attention.
BIOMIMETIC CONCEPT
In the restoration of teeth it is important to avoid primitivistic approaches concentrating solely on
characteristics of restorative materials - such as strength, hardness etc. The key to successful and simple
(not primitive!) restorative technique is to use the intact tooth as a guide to biomechanical and esthetic
reconstruction and utilize those principles through hard tissue bonding.
The backbone of tooth strength is its internal stress distribution mechanism. It is provided via dentino-
enamel junction (DEJ), which constitutes a superb lesson from nature on how to achieve strong, durable
bonding between significantly dissimilar materials: the hard, brittle outer layer of enamel and the softer,
but tougher dentine. In primitive biomimetic model, DEJ is often compared to adhesive layer in terms of
stress absorption. However, it is not completely correct. Adhesive layer poorly imitates DEJ. The reason is
that biomechanically DEJ should be seen as a graded band or interPHASE rather than a discrete
interFACIAL line. Namely gradual change in mechanical properties is the most important feature of the DEJ
10. Such graded transition from enamel to dentine may sustain higher loads than a direct bond between
two distinct adhesive layers and thus it stands in stark contrast to the adhesive interFACES between
Page 4 of 14
artificial dental restorative materials and dentine.
THE CORE CONCEPT - PRESERVE ENAMEL AND MINIMIZE FRACTURES

This fact leads us to the first lesson - in order to avoid fractures of ultra-thin restorations -manipulations
should be confined to the framework of enamel. It is well documented that not only adhesion but also
fracture resistance of ceramic restorations bonded with resin to enamel was higher than those bonded to
dentin. 11-14 And vice versa - when supported by enamel the fracture load of lithium disilicate onlay
becomes less sensitive to its thickness, especially in the thickness range from 0,6 mm.15
The second evident lesson - in terms of modulus of elasticity covering of enamel with a similar material is
essential. The latter is best represented by lithium disilicate. Otherwise, elastic modulus mismatch between
restorative material and the cement/tooth supporting structure may generate unfavorable stress
distribution and stimulate crack initiation.
Additionally, it highlights the importance of achieving ultra thin layer of adhesive cement, whose low
modulus of elasticity may change beneficial stress distribution between enamel and glass-ceramic. It is
especially actual for thin ceramic restorations, where fractures were shown to initiate from the
cementation surface. 16 On the flip side, minimized thickness of cement layer (20 microns) makes it less
sensitive to its low modulus of elasticity.
Adhesion is the prerequisite as only through bonding will the material behave as the genuine part of the
tooth, which is not actual for zirconia as an example.
Page 5 of 14
To sum up - confining your preparation primarily to enamel allows to significantly reduce restoration
thickness. Considering that in recent researches reduced ceramic thicknesses of 1.0 and 0.5 mm did not
impair the fracture resistance of pressable lithium-disilicate ceramic onlay restorations 9, reduced ceramic
thickness and ultraconservative preparation may be considered as an option for standard guidelines. This
means that in early and medium occlusal wear in a patient with low and medium load requirements prep
thickness of 0,5 mm instead of 1 mm can be used. The only prerequisites are both prep in enamel and
sound adhesive cementation.
However, for veneerlays reduced ceramic thicknesses should be recommended with caution due to
increased risk of fracture at regions of geometrical changes (the border between vestibular and occlusal
components).9,17
On the other hand, if restoration is adhesively fixed to enamel - possible fracture would most probably be
limited to the ceramic restoration without involvement of the underlying tooth substrate, while
catastrophic failures involving dentin and root may occur with standard thickness restorations. In terms of
Page 6 of 14
management of this failures, the former can be easily corrected by renewing the restoration 4; in contrast
the latter may entail endodontic treatment or even induce subgingival tooth fracture.
This highlights the advantage of minimally invasive strategies, preserving the structural integrity of teeth.
CLINICAL CHALLENGES.
ABFRACTION AND DENTINAL EXPOSURE
Frequently clinician face situations where cervical enamel is missing or lacking. In order to overcome this
challenge the combination of direct and indirect approaches is an option. Direct composite filling will allow
to place ceramic margin 1-2 mm supragingivally and stay in enamel while maintaining predictable stress
distribution patterns between enamel and ceramic.
Page 7 of 14
Page 8 of 14
Page 9 of 14
One should never prepare teeth - prep of veneers always starts from the preparation of mock-up.?
Bur selection is based on the necessity of achieving ultrathin tissue reduction ( here - 0,3 mm) and chamfer
margin.
Page 10 of 14
Appropriate consequence of burs, stones and polishers provide a finished preparation that is smooth and
has no sharp ?internal-line-angles which would result in areas of high stress ?concentration.
The preparation margin should allow an optimum adaptation of the final restoration so that creation of a
delicate chamfer is recommended.
Enamel should be etched for 30 seconds and rinsed with water. Tooth surfaces then have to be conditioned
with adhesive (here - Heliobond Ivoclar Vivadent) according to the manufacturers instructions. For e.max
restorations it is better to adhesively cement them with a dual- polymerizing composite resin (Variolink II;
Ivoclar Vivadent) or heated composite. Any excess composite resin must be removed and margins covered
with an air-inhibiting glycerine gel for photocuring.
Page 11 of 14
The intaglio surfaces of the restorations are etched with 4.9 % hydrofluoric acid (IPS ceramic etching gel;
Ivoclar Vivadent) for 20 seconds. Next etched surfaces are thoroughly rinsed with water and air dried.
Having that done, additional cleaning with Ivoclean may be performed to be sure that ceramic surface is
free of any organic contents (phospholipids present in saliva) which may decrease bond strength.
Subsequently a silane coupling agent is applied.
The cleaning step can also be done with orthophosphoric acid.
Final aspect of the restorations
Page 12 of 14
New smile of the patient
The key to the long-term stability of ceramic structures is the ability to effectively utilize the properties of
restorative materials and supporting structures.
In this section the special attention was given to enamel while in the next part the philosophy of
ultratrathin tabletops on dentin will be discussed. ?
References
1. Hahn P, Gustav M, Hellwig E (2000). An in vitro assessment of the strength of porcelain veneers
dependent on tooth preparation. J Oral Rehabil 27:1024-1029.
2. Troedson M, Derand T (1998). Shear stresses in the adhesive layer under porcelain veneers. A finite
element method study. Acta Odontol Scand 56:257-262.
3. Beier US, Kapferer I, Burtscher D, Dumfahrt H. Clinical performance of porcelain laminate veneers for up
to 20 years. The International Journal of Prosthodontics. 2012; 25:7985.
4. .Edelhoff D, Sorensen J. Tooth structure removal associated with various preparation design for posterior
teeth. Int J Periodontics Dent 2002;22:2149.
5. St-Georges AJ, Sturdevant JR, Swift EJ Jr. Thompson JY. Fracture resistance of prepared teeth restored
with bonded inlay restorations. J Prosthet Dent. 2003; 89:5517.
6. Naeselius K, Arnelund CF, Molin MK. Clinical evaluation of all-ceramic onlays: a 4-year retrospective
study. Int J Prosthodont. 2008; 21:404.
7. Murgueitio R, Bernal G. Three-Year Clinical Follow-Up of Posterior Teeth Restored with Leucite-
Reinforced IPS Empress Onlays and Partial Veneer Crowns. J Prosthodont. 2012; 21:3405.
8. Ahlers MO, Morig G, Blunck U, Hajto J, Probster L, Frankenberger R. Guidelines for the preparation of
CAD/CAM ceramic inlays and partial crowns. Int J Comput Dent. 2009; 12:30925.
9. Guess PC, Schultheis S, Zhang Y, Strub JR. Influence of preparation design and ceramic thicknesses on
fracture resistance and failure modes of premolar partial coverage restorations. The Journal of Prosthetic
Dentistry.
10. 1.White, S. N. et al. The dentino-enamel junction is a broad transitional zone uniting dissimilar bioceramic
composites. J. Am. Ceram. Soc. 83, 238240 (2000). ?11. Clausen JO, Abou Tara M, Kern M. Dynamic fatigue
and fracture resistance of non-retentive all- ceramic full-coverage molar restorations. Influence of ceramic
material and preparation design. Dental Materials. 2010; 26:5338.
12. Piemjai M, Arksornnukit M. Compressive fracture resistance of porcelain laminates bonded to enamel or
dentin with four adhesive systems. Journal of Prosthodontics. 2007; 16:45764.
13. Layton D, Walton T. An up to 16-year prospective study of 304 porcelain veneers. Int J Prosthodont.
2007;20(4):389-396.?14.Peumans M, De Munck J, Fieuws S, et al. A prospective ten-year clinical trial of
porcelain veneers. J Adhes Dent. 2004;6(1):65-76.
15. Li Ma, Petra C. Guess, and Yu Zhang Load-bearing properties of minimal-invasive monolithic lithium
disilicate and zirconia occlusal onlays: finite element and theoretical analyses. Dent Mater. 2013 July ; 29(7):
742751.
16. Zhang Y, Kim JW, Bhowmick S, Thompson VP, Rekow ED. Competition of fracture mechanisms in
monolithic dental ceramics: flat model systems. J Biomed Mater Res B Appl Biomater. 2009; 88:40211.
17. Quinn JB, Quinn GD. A practical and systematic review of Weibull statistics for reporting strengths of
dental materials. Dent Mater. 2010; 26:13547.
Page 13 of 14
Visit: http://www.styleitaliano.org/dimitry-averin
Page 14 of 14

Community Dimitry Averin Maxim Belograd Via

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Community Dimitry Averin Maxim Belograd Via

Uploaded by

Copyright:

Available Formats

COMMUNITY

INDIRECT POSTERIORS - COMMUNITY

A community article by Dimitry Averin and Maxim Belograd

Occlusal Veneers, Rationale for ultraconservative posterior restorations

Conservative ceramics in posteriors

artificial dental restorative materials and dentine.

THE CORE CONCEPT - PRESERVE ENAMEL AND MINIMIZE FRACTURES

The cleaning step can also be done with orthophosphoric acid.

Final aspect of the restorations

New smile of the patient

You might also like