Evidence-Based Concepts and Procedures For Bonded Inlays and Onlays. Part III. A Case Series With Long-Term Clinical Results and Follow-Up
Evidence-Based Concepts and Procedures For Bonded Inlays and Onlays. Part III. A Case Series With Long-Term Clinical Results and Follow-Up
Evidence-Based Concepts and Procedures For Bonded Inlays and Onlays. Part III. A Case Series With Long-Term Clinical Results and Follow-Up
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How to cite
DIETSCHI, Didier, SPREAFICO, Roberto Carlo. Evidence-based concepts and procedures for bonded
inlays and onlays. Part III. A case series with long-term clinical results and follow-up. In: The
International Journal of Esthetic Dentistry, 2019, vol. 14, n° 2, p. 118–133.
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Case Report
any specific selection process other than The treatment rationale applied to all the
being part of a recall system, including year- restorations relied on distinctive basic pro-
ly or biyearly clinical and radiographic exam- cedures: the immediate, postpreparation
ination, and otherwise not presenting any placement of an adhesive base liner in the
severe, active carious and parafunctional form of a dentin coating using a thick layer
pathologies. of dentin bonding agent, preferably a filled
one, on its own for thin restorations (dual tion [CDO]),4 and, when necessary, the si-
bonding [DB]/immediate dentin sealing multaneous coronal relocation of deep
[IDS])3-5 or usually combined with a restora- cervical margins (cervical margin relocation
tive or flowable composite layer leveling all [CMR]).4,6 Overall, the resulting preparations
cavity irregularities and undercuts (alto- present an ideal geometry with slight diver-
gether known as cavity design optimiza- gence of all cavity walls and supragingival
Fig 2 Clinical
workflow for
semidirect extraoral
technique (chairside
method). This case
appears as no. 4 in
Table 1, with a 19-year
follow-up. (a) Preoper-
ative view showing a
large amalgam to be
replaced. (b) Prepar-
a b
ation with CDO
performed with a
multicomponent
adhesive and flowable
composite. (c) Chair-
side model fabricated
using hard, dual-vis-
cosity silicone
materials (Mach-2 and
Blu-Mousse, Parkell); a
condensation silicone c d
or alginate is used for
the impression. (d) The
restoration is built up
in composite using a
dentin shade of
adequate chroma,
effect shade, and
enamel shade.
(e) Completed
restoration using a
microhybrid resin
composite. (f) Post-ad- e f
hesive cementation.
margins. After tooth preparation following and occlusally using a few more enamel
the aforementioned procedures, the com- increments, as needed.
posite inlays or onlays were produced using 2. The semidirect intraoral technique (Fig 3)
one of three methods: which allows for the build-up of the res-
1. The semidirect extraoral technique toration directly on the tooth following
(Fig 2), which makes use of a dual-viscos effective, physical cavity isolation from
ity, hard, A-silicone model (ie, Mach-2 the IDS layer and composite base, using,
and Blu-Mousse, Parkell) on which the for instance, a thin layer of liquid latex
restoration is fabricated. The impression (Rubber Sep; Kerr). After application, the
is preferably done with an alginate or a isolation material is gently dried until it
soft-consistency C-silicone (ie, Speedex becomes transparent. A full-contoured
Medium; Coltène Whaledent). The res- matrix (ie, Lucifix; Kerr) is then placed
toration fabrication starts with the dentin around the tooth to allow for the place-
core and is then completed proximally ment and polymerization of the com-
Fig 4 Clinical
workflow for indirect
technique. This case
appears as nos. 20 to
22 in Table 1, with a
14-year follow-up.
(a) Preoperative view
showing large
amalgams to be
replaced. (b) Prepar-
ations with CDO and
a b
CMR performed with
a mutlicomponent
adhesive and
flowable composite.
(c) Laboratory made
composite restor-
ations on the hard
stone model. (d) Trial
of the restorations
fabricated with a
nanohybrid (inho- d
mogenous type).
(e) Post-adhesive
cementation.
c e
microhybrid – Tetric (Ivoclar Vivadent), Bel- being cured for a minimum of 20 s), fol-
leglass (Kerr), Miris (Coltène Whaledent), lowed by a heat (110°C) and light postcuring
and TPH (Dentsply) or nanohybrid (Miris 2; treatment in a specific oven (DI-500;
Coltène Whaledent) resin composites. The Coltène Whaledent). A highly filled, light-cur-
Belleglass system was the only laboratory ing restorative material was used as a luting
composite system that involved a special agent (usually the same enamel as the one
dual-polymerization method (light- and used to fabricate the surface of the restor-
heat-curing initiation) and nitrogen pressure ation for semidirect restorations); otherwise,
for complete resin conversion using a spe- a translucent shade of a microhybrid resin
cific curing oven. composite was used (ie, Tetric Transparent).
Apart from the Belleglass system, all oth- The viscosity of the luting material was re-
er composites were polymerized, first using duced by sonic/ultrasonic energy using a
a conventional halogen light-curing unit specific application tip (with plastic insert) –
(470 nm at > 750mW/cm2, each increment SONICflex cem (KaVo) or Sonocem Tip
(EMS), and/or material heating (55°C) (ie, two cases of > 20 years. Figure 5 presents
Calset; AdDent) to ease the complete res- the clinical overview of all the restorations,
toration insertion. with pre- and postoperative views (at treat-
The evaluation was performed on radio- ment completion and at the specific evalu-
graphs for the presence or absence of prox- ation period); a radiograph after the final
imal decays, clinical examination for the evaluation period completes this documen-
presence of occlusal decays or fractures, tation.
and intraoral photographs for the other None of the restorations observed
quality parameters. Three parameters (mar- showed recurrent decay or fractures; no re-
gin, anatomy, and color match) were used stored tooth surveyed underwent any pul-
to assess the restoration quality after any pal complication or required any endodon-
given observation period, with three possi- tic treatment. Among the 16 semidirect and
ble scores: A = ideal, B = satisfactory, and indirect restorations fabricated with micro-
C = insufficient. For instance, for the margin hybrid resin composites (Tetric, Belleglass,
parameter, a B score meant a discrete, par- Miris, and TPH), only three restorations pre-
tial discoloration and/or irregularity, while a sented a slight marginal discoloration and
C score meant noticeable, extended discol- degradation (B score); all the other restor-
oration or irregularity. In the case of recur- ations were considered optimal (A score) for
rent decay, restoration fracture or a C score, the three evaluated parameters (margin,
the restoration would be considered a fail- anatomy, and color match). Among the
ure, which would necessitate retreatment. nine semidirect or indirect restorations fab-
Otherwise, any restoration showing no de- ricated with an inhomogeneous nanohybrid
cay or fracture and with an A or B score was (Miris 2), four restorations presented a slight
deemed a success, with possible minor in- marginal discoloration and degradation,
terventions necessary (such as repolishing and seven presented discrete anatomical
or, in a worst case scenario, localized re- surface change. The analysis (shown in Ta-
pair). This clinical assessment method is bles 2 and 3; distribution of scores A and B)
similar to the modified United States Public did not suggest any impact of the follow-up
Health Service (USPHS) ranking method.20-22 time on the restoration quality, except for a
The quality assessment was crosschecked slightly better clinical behavior of classical
by both operators. Due to data heterogene- microhybrids (Tetric, Belleglass, TPH) com-
ity and the limited number of cases, no spe- pared with the nanohybrid (Miris 2). No oth-
cific statistical test/s other than clinical, er discriminative judgments could be made
technical, and qualitative descriptions could with the limited number of cases reviewed.
be carried out. The results are presented in
Table 1. Discussion and conclusions
Fig 5 Clinical
overview of the case
series. The left
column shows
restorations at t = 0,
the middle and right
columns show the Case 1 15Y
radiographic and
clinical findings at the
indicated follow-up
periods (see Table 1
for detailed clinical
data and assess-
ments). Case nos. 7,
8, and 10 are Case 2 19Y
presented at 6 years
in the left column,
instead of t = 0.
Case 9 18Y
Case 10 16Y
Case 11 16Y
Case 12 13Y
Case 13 13Y
Case 14 13Y
Case 15 14Y
Case 16 13Y
Case 17 13Y
Case 18 11Y
Case 19 9Y
Cases 20 to 22 14Y
Case 23 11Y
Cases 24 and 25 6Y
investigating the periodontal status of res- changes may thus not be justified). There-
torations placed with the CMR technique,23 fore, owing to the quality, quantity, and con-
which showed a slight increase in bleeding sistency of the results and evidence16-18 of
on probing (BoP) as the only adverse effect.. rigorous in vitro trials (and combinations of
This is partly due to the fact that well-struc- them), these trials are often the most ade-
tured, randomized, prospective studies are quate performance predictors for new re-
extremely demanding, and also because storative protocols while ultimate confirma-
the many confounding factors of in vivo tri- tion is awaited from clinical studies.
als impact their discriminative power (the This case series demonstrated the high
effort needed to evaluate only procedural success rate of composite inlays and onlays
Table 2 Summary
Margin quality Anatomy Color
Composite of restoration quality
A B Total A B Total A B Total assessment per
Belleglass (MH) 2 2 4 4 4 4 4 product (the number
for each score
Miris (MH) 6 6 6 6 6 6 indicates the number
Miris 2 (INH) 5 4 9 2 7 9 9 9 of samples per
designated product)
TPH (MH) 1 1 1 1 1 1
Tetric (MH) 4 1 5 5 5 5 5
Total 18 7 25 18 7 25 25 0 25
NB: Note that no restoration exhibited a C score.
Table 3 Summary
Follow-up Margin quality Anatomy Color
of restoration quality
in years A B Total A B Total A B Total assessment
6 2 2 2 2 2 2 according to
follow-up time (the
9 1 1 1 1 1 1 number for each
11 3 1 4 1 3 4 4 4 score indicates the
number of samples
13 3 3 3 3 3 3
per follow-up period)
14 1 3 4 1 3 4 4 4
15 1 1 1 1 1 1
16 1 1 2 2 2 2 2
17 1 2 3 3 3 3 3
18 1 1 1 1 1 1
19 1 1 1 1 1 1
21 2 2 2 2 2 2
Total 17 7 24 17 7 24 24 0 24
NB: Note that no restoration exhibited a C score.
made with either semidirect or indirect ations made with the nanohybrid compos-
techniques following extended periods of ite (Miris 2). This observation is partly
clinical service (6 to 21 years). The absence substantiated by published in vitro physico
of recurrent decay or pulpal complication chemical characteristics of various com-
has been another positive outcome of the posite types. Actually, some inhomogeneous
technique. In the absence of any restoration nanohybrids containing prepolymerized and/
failure, only minor restoration defects were or clusters of nanofillers (such as Miris 2)
observed such as slight anatomy change or have shown significantly inferior mechani-
partial marginal discoloration or irregularity. cal performance in either static (flexural or
These defects were mainly found in restor- compressive strength) or dynamic (fracture
toughness or flexural fatigue) tests. Flexural retrospective clinical evaluation and the low
strength is considered an influential value number of controlled restorations, the pres-
for material wear resistance, as fracture ent data – combined with the numerous
toughness could be for the incidence of positive in vitro findings regarding the clinic-
restoration fractures.24-26 Other studies using al protocols used here – support the contin-
staircase, dynamic mechanical loading (in uous use of resin composite and indirect
both a dry and moist environment) or test- techniques for restoring extensive decays.
ing for mechanical performance before and
after storage in saliva and water also sug- Acknowledgments
gested the inferior performance of inhomo-
geneous nanohybrid composites.27-29 How- We gratefully acknowledge the support of
ever, there is as yet no clinical data to Dr Enrico di Bella, statistician at the Depart-
confirm these in vitro findings. Interestingly, ment of Economics and Business Studies,
the present results suggest that material University of Genoa, Italy, for the analysis of
wear is not an issue for indirect, postcured results and data of this case series.
composite restorations in an ordinary pa-
tient population, and that the clinical appli- Disclaimer
cation of the CMR concept did not trigger
any recurrent proximal decay within the sur- The authors declare that they have no con-
veyed cases. Despite the known limits of a flict of interests.
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