CLINICAL RESEARCH

Indirect adhesive restorations

subsequent: updated instructions and
preparation technique based on the
morphology
Marco Veneziani,DDS
Private practice, Vigolzone (PC), Italy

Visiting Professor, University of Pavia, 2007-2012

Active member, Italian Academy of Conservative Dentistry

Active member, Italian Academy of Aesthetic Dentistry

Active member of the International Academy of Digital Dental Medicine.

Correspondence to: Dr. Marco Veneziani

Via Roma 57, 29020 Vigolzone (PC), Italy

Correo electrónico: marco.veneziani@nesh.biz ; veneziani.mar@gmail.com

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Abstract since they are less conservative, incompatible with the

adhesive procedures and imply an exposure
The objective of this article is to identify the indications unnecessary of the dentin. The clinical advantages of this
from the adhesively cemented restorations and new "anatomical" preparation design is 1) to improve
provide a correct step-by-step protocol for the the quality of the adhesion (optimizing the cutting of the
doctors. The new principles of preparation of the prisms of enamel and increasing the surface of
cavity is based on morphological considerations in available enamel); 2) minimize exposure of the
geometry terms (maximum profile line and dentin; 3) maximize the preservation of hard tissue (the
inclination of the lines of the peaks) and structure The cavity is designed for cementation with resins.
(concavity of the dentin and convexity of the enamel). In reinforced composites, flow improvement and elimination
in this article, we analyze preparation concepts from excess material); 4) optimization of integration
previous ones that were not designed exclusively for aesthetics due to the design of the inclined plane, which
adhesive restorations and, therefore, they were not the allows for a better combination in the transition area
neither sufficiently conservative nor suitable for between the tooth and the restoration. These principles of
adhesive procedures. The new way of cavity preparations can be effectively used for all the
it consists of inclined flat cavity margins adhesively cemented restorations, both according to
continuous (hollow chamfer or concave bevel) on walls traditional concepts (inlay, onlay, overlay) as
axial, as long as they are coronal to the equatorial line new (additional overlay, occlusal veneer, overlay-veneer,
of the tooth. A preparation of the joint is performed to large wrap overlay, adhesive crown). From this
top of 1.2 mm thickness in the interproximal box and in how a balance is created between restoration and prosthesis,
the axial walls when the margins are apical to which is characterized by a more conservative approach.
the equatorial line. The occlusal surface is prepared
anatomically, free of grooves and angles. The
the author's suggestion is to avoid preparing the line
of the shoulder meta around peaks, grooves
occlusal and pins,

(Int. J. Esthet Dent 2017; 12:2– 28)

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Introduction with different techniques: direct, semi-direct (intraoral and

extraoral) and indirect. The decision-making criteria that guide
In modern restorative dentistry, the development to doctors in the choice of materials and techniques
from adhesive procedures has led to a can be divided into general and local parameters. The
important cultural and methodological revolution. general parameters include the patient's age,
Likewise, the evolution of restorative materials and oral hygiene, motivation, risk assessment of
adhesive systems have influenced the approach to the caries, dietary habits, functional activity,
restoration of the posterior teeth, modifying ergonomics and economic resources; The parameters
considerably the treatment plan.1 The need locales include cavity shape, thickness of the
to perform adhesive restorations of teeth remaining walls, position of the margins
later is not only linked to aesthetic purposes, but cervicals, presence of cervical lesions, presence of
also to early bioeconomic principles, as well as to the possible cracks, tooth position, evaluation of the element in
biomechanical strengthening of the dental structure preprosthetic function and presence of pulp disease
remaining.2 or periodontal lesions.

Microhybrid and nanoparticle composites

they are the most suggested materials for all types of
cavities in posterior teeth.3However, the Current guidelines for restorations
technical problems of composites that are still not
adhesive cemented.
they are the remedy for contraction and adhesion
from the dentin, and the clinical problems are related to Direct techniques are traditionally indicated in
the clinician's ability to manage isolation and the small and medium size class I restorations
tooth adhesion, as well as restoring the morphology and II with cervical enamel. In these clinical situations, the
These problems are particularly the first option is the direct technique, which allows
challenging when the restorations are extensive and it is high-level, predictable and repeatable results with a
necessary to cover one or more peaks. This has conservative approach and excellent longevity. The
led to the development of semi-direct techniques and limitations of direct techniques, mentioned in the
indirect messages, which allow for the complete healing of the literature from the mid-90s
composite restoration before the procedures of
cementation.4,5
They have been reviewed and discussed in many studies
published in the 2000s
13th of what can be deduced that direct techniques

Recently, the aesthetic restoration and they would be effective even in cases of partial coverage of
rehabilitation of posterior teeth and arches the peaks, obtaining a clinical result similar to the
Completes has created, out of necessity, a new indirect techniques. Furthermore, the mere lack of enamel
paradigm and balance between operative dentistry cervical would no longer represent an indication for the
"restorative" and prosthodontics. indirect technique.

According to the Geneva School Classification of 1994, there is

they could use five composite resins for the However, the direct technique on teeth that have
back teeth. suffered an important

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The loss of hard tissue presents a series of The advantages of cemented restorations
clinical problems: resistance to mandibular wear; adhesively compared to a direct technique
control of contraction stresses; possible consist of creating an ideal anatomy of the surfaces
postoperative hypersensitivity; predictability of the occlusal, with excellent control of the points of
dentin adhesion; Difficulty of the restoration contact and emergency profiles, and the possibility of a
morphological, with special attention to the occlusal surface, evaluation of occlusion with an articulator. Likewise,
the contact points and the emergency profile. this technique strongly decreases the contraction of
consequence, in large cavities with coverage of cured that is produced outside the cavity, improving the
peaks, it is clinically more favorable to use a marginal sealing. The only contraction of curing that
adhesively cemented restoration as the first it is in the thin layer of resin cement.
treatment option.5 In addition, the photothermal treatment (130°C for 7
improves the conversion rate of the composite and the
physicochemical properties of restoration. 18-20 Another
An 'indirect adhesive restoration' has been defined an advantage is the possible use of ceramic materials such as,
like a partial crown restoration made of for example, vitroceramics reinforced with disilicate
composite or complete ceramic, which must be settled lithium.
passively and adhere adhesively in a
cavity characterized by specific attributes. The
The objective of this article is to define criteria for a
new cavity design for restorations
cemented and analyze the different types of
restorations, comparing cavity shapes Operational procedures
conventional and new concepts.
for the indirect technique

The current guidelines for restorations According to the author's experience (since 1994) and the data
adhesively bonded could be summarized as: from literature, 4, 5, 21, 22 It suggests a procedure
simple and clear for indirect adhesive restorations.
Wide class II cavity with cusp cover. The chronological sequence of clinical steps is:
age (one or more).
Restoration of large occlusal surface.
compromised by wear and/or biocorrosion. 1. Hard silicone mold to print the anatomy of
the affected teeth (when the anatomy is
sufficiently preserved).
These indications are reinforced by some 2. Opening of cavities or removal of previous restoration and
cofactors, including the presence of cervical enamel in removal of carious lesions.
small amount (< 1 mm in height, 0.5 mm of
size), or even its absence; cervical concavity; the 3. Evaluation of the thickness of enamel and dentin and, in
need to perform multiple restorations in several consequence, reduction of non-tissues
quadrants with modification of the entire occlusion; and the supported.
need to restore or increase the dimension 4. Reconstruction of composite with immediate sealing of
vertical. dentin (IDS) and, if necessary, relocation of
cervical margin (CmR).

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5. Preparation and finishing of the cavity according to new 2. Amount of enamel that is not supported by the
modified principles (preparation technique underlying dentin. The wall must be reduced to
based on the morphology - mDPT. that there is enough dentin for
support the enamel.
6. Final printing with elastomers (for elements
singular, even with double arch technique 3. Thickness of the enamel. Measurement of the cusp
through bite control). the remaining is not enough to determine its
resistance; Both the thickness must be considered
7. Completion of the permanent restoration (composite or of the enamel like that of the dentin.
ceramics) in the laboratory or in the office.
4. The importance of functional occlusal tension during
8. Verification of the adaptation of the restoration before chewing.
from the application of the rubber dam.
After the occlusal reduction, the following should be done
9. Application of rubber dam and procedure of reconstruction for the following reasons:
adhesive cementation with composite
heated photopolymerizable. "Obey the fundamental principle of
10. Finishing, polishing and occlusal control. IDS.23IDS has demonstrated bond strength.
improved microtensile compared to sealing
dentin retard (DDS). "" To fill the
Assessment of the remaining thickness and of the undermining that inevitably
they are formed during the removal of the decay.
accumulation of adhesive.
Provide a correct cavity geometry.
Since indirect restorations are indicated to produce an optimal restoration
in wide cavities characterized by a loss material thickness to allow a conversion
significant hard tissue, a critical thickness of the correct of the photo-polymerizable composite
remaining walls influence the decision to maintain the preheated used for adhesive cementation.
wall or not, particularly because the walls a 24,25

they are undermined and need restoration

suitable (recreation or blocking). Additionally, it is possible to cement without anesthesia, because the

exposed dentin has already been hybridized and covered by a

The reduction of the remaining unsupported tissue is the preliminary layer of composite. The first-rate material
next step, but before the accumulation of election for the reconstruction are miniparticles
adhesive, so that a better assessment is possible highly reinforced composite hybrids used
of the wall thickness and, consequently, the doctor with the modified double bond technique.26 When the
may avoid the exposure of non-hybridized dentin Interocclusal free space is scarce, a ______ is indicated.
after the preparation. mini reconstruction with only a thin layer of
composite fluid.
The reduction of occlusal tissue depends on four
points:
minimum thickness of the material (either composite or In case of deep cervical margins without
lithium disilicate) of at least 1.0 to 2 mm. violation of biological width, is clinically
convenient to move the margin

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Figure 1 New morphology-based preparation technology. Figure 2 Indirect composite restorations after adhesion.
unique (mDPT) in two upper molars. siva cementation.

gins coronally, applying a layer of The width of the occlusal isthmus must
highly reinforced composite fluid 27-29 (1 to 1.5 mm of to be≥ 2 mm for composite ceramic glass and
thickness). When the position of the cervical margins lithium disilicate.
does not allow for proper isolation with a rubber dam, or Presence or absence of marginalized.
there is a violation of the biological width, it is necessary a crests and, consequently, presence of cash
surgical approach.30 interproximal evaluated in three spatial planes.9,36

Thickness of the material for the roof of the peak.

Principles of preparation for restoration The size must be≥ 1 to 1.5 mm. 22, 37, 38
for composite and lithium disilicate (pressed or CAD/
indirect.
CAm), and≥ 2 to 2.5 mm for feldspathic ceramic and
Conventional principles would suggest a cavity with a leucite-reinforced glass-ceramic. "" The highlight
divergent wall of 6 to 10 degrees, internal angles interproximal must be possible.
rounded, enamel finish with margins
sharp and not bevelled, smooth and well-defined walls and bly≤ 2 mm. The risk of crest fracture
a flat overall design. The margins of the restored margin increases when the highlight is
restoration does not have to coincide with the too big.4
occlusal contacts.
New cavity design (technique of
The following parameters that influence and guide the
preparation based on morphology) (Figs. 1
design of the cavity.4,21,31,32
y 2)
they are essential:
Thickness of the remaining walls (in order The principles of traditional cavity design are
to maintain them) it has to be≥ 2.0 mm in teeth they derived from preparations intended for restorations
vital, 4 (the latest articles report values of 1 non-adhesive indirects. These were characterized by a
mm22), y≥ 3.0 mm in treated teeth cavity design that ensured retention by
endodontically.33-35 del

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MAXILLARY
OLD CONVENTIONAL MANDIBULAR ADHESIVE PREPARATIONS

Fig. 3 Clinical examples of old and conventional adhesive preparations of upper and lower molars.
and premolars.

NEW MODIFIED ADHESIVE PREPARATIONS

figure 4 Clinical examples of new mDPT for adhesive restorations of upper and lower molars and
premolars.

shoulder placement, occlusal grooves and He entrusts to the doctors the task of preparing them for
eventually nails, which could expose the dentin agreement with your clinical experience. Furthermore, the design

you have a significant loss of structural tissue Traditional cavity is not completely suitable.
(Fig. 3). Aside from this, conventional preparations for adhesive cementation due to the presence of
they did not consider the morpho-structural course and isthmuses, shoulders, and rounded angles. In addition, the

real histo-anatomy of the tooth crown. Furthermore, not width of the shoulders and the onlays themselves seems
clear data is reported in the literature about the level excessive and leads to an inadequate degree of conversion
correcting the shoulders on the axial walls, leaving of the cementation composite.

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The principles of mDPT (Fig. 4) aim to

achieve these improvements:

To minimize as much as possible the

Loss of healthy dental tissue when reducing areas of
exposure of the dentin. "" To guide the reduction
tissue of the lesion
Clusial surface with depth cuts or, better
still, with a silicone index for thickness control.

To reduce the width of the margins.

prepared as a palette, where indicated.
Fig 5 maxillary premolar, endodontically treated
with a moderately deep cavity. A complete coverage is necessary.
Define a margin design that can ridge to preserve it from fracture.

improve the quality of adhesion, optimizing the

cutting of the enamel prisms and creating a
greater enamel surface.

To improve the smooth insertion of

restoration during cementation. "" To improve
the aesthetics of transition
junction area between the tooth and the restoration. In
chronological order, the sequence of preparation is the
preparation of the interproximal box, the reduction
anatomy of the occlusal surface and the definition of
the margins on the axial walls. The definitions
the margins differ in the maxillary teeth and
mandibulars. The design of the axial margins
figure 6 New mDPT for indirect adhesive overlay
varies according to the residual healthy tissue, the position of the
restoration.
margin, the morphology of tilt and slope of
the apex and the maximum contour line of the tooth
(Ecuador). The preparation ultimately depends on
instance of the anatomical and structural morphology of
the teeth. 1.2 mm, max 1.5 mm) and rounded interior angles,
obtained with conical diamond burrs of grit
medium (diameter 14) for preparation and milling
fine grain diamond for finishing. The need for
defining a reduced depth box has as
objective to obtain an indirect restoration of thickness
MDPT principles for premolars and molars regular to ensure resistance and at the same time
(Figs. 5 to 9) allow proper conversion of light.
1) Preparation of the joint to the limit in the box
interproximal (ideal thickness: 1 to

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Maxillary premolars and molars

Joint at maximum (1.2–1.5 mm)

- Interproximal box: always
- Axial walls: apically up to
the maximum contour line.

Anatomical reduction
from the occlusal surface

Divergent walls
(6 to 10 degrees)

Inclined planes m–D, V–P (bevel)

- Axial walls, coronal up to

the maximum contour line.

figure 7 New mDPT scheme for upper premolars and molars.

curing adhesive and composite resin material

used for cementation.
Divergent interior walls of 6 to 10 degrees, with
sharp margins with rounded inner angles.
Residual axial walls require a
precise preparation of the occlusal margin, since the
creation of beveled inlays towards occlusal
in itself susceptible to the risk of margin fracture.

figure 8 New mDPT for indirect adhesive coating and Reduction of the occlusal anatomy following the
Overlay restorations.
direction of the crack and the resulting proportion of the
peaks, with conical diamond end mills
(diameters 14 and 18). The extent of the reduction is a function
of the resistance parameters of the material of
restoration, so it is recommended from 1.0 to 2.0 mm.
The occlusal slots are not necessary; in fact,
should

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Mandibular molars and premolars

Top joint (1.2–1.5 mm)

- Interproximal box: always
- Axial walls: apically up to
the maximum contour line.

Anatomical reduction
from the occlusal surface

Diverging walls
(6 to 10 degrees)

Inclined planes m–D, V–P (chamfer)

- Axial walls, coronal up to

the maximum contour line.

figure 9 mDPT scheme for mandibular molars and premolars.

to be avoided. It is desirable to perform occlusal reduction. premolars. This preparation of the margins allows:
guided by the depth of the cuts or, whenever it may be
possible, by correctly cut silicone indices and maximum preservation of sound reproduction.
detected in the tooth before preparation. lateral tissue;
a geometrically induced increase of
4a) Preparation of axial walls with sloping plane the usable area of enamel for procedures
(hollow chamfer). In the mesiodistal directions and adhesives without exposure of dentin areas;
For the bucopalatina, a "hollow chamfer" or bevel should be drawn.

concave with cylindrical chamfered strawberries, using only more favorable margin configuration
the tip of the strawberry. This design is indicated in areas For adhesion through enamel prisms
of cusp coating on axial walls cutting almost perpendicular to its longitudinal axis.
coronals to the maximum contour line of the tooth. By 39,40 (unlike the drawing of sharp margins, which

geometric and structural reasons, this occurrence is it would cause a cut of the prisms parallel to their axis
more frequent at the level of the buccal and palatine walls mayor) (Fig. 10);
from the upper molars and premolars, and in the walls
buccal surfaces of the mandibular molars and premolars. apical displacement of the finish line
(along the inclined plane), with a reduction of
the level differences between the vertex peaks to
cover and the

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Preparation of precise margins Preparation of hollow chamfer

Enamel prisms parallel to the long axis Perpendicular to the long-axis enamel prisms.

Cavity-Surface Angle Cavity-surface angle

< 90 degrees ≥ 90 degrees
180 degrees 90 degrees

Fig 10 More favorable margin configurations (hollow chamfer) for adhesion through enamel cut.
prisms perpendicular to their longitudinal axis.

bottom of the box, by creating 'ways and premolars due to a different geometry of the
of access own surfaces (Figs. 8 and 9).
cervical of the interproximal box must be created a
curved line that continues on the axial wall, which
descends backwards to then connect with the Justification of the new cavity design
opposing interproximal box; modified
The basis of the described cavity design
previously it is the morphological analysis of the teeth
"a more gradual transition between posteriors, with some differences between the teeth
preparation margins and restoration for maxillary and mandibular, and with considerations
obtain a better imitation, aesthetics, and combination geometric and structural elements that justify its use.
of transition colors of the restoration.

upper molars and premolars (Fig. 10)

4b) Preparation of axial walls, butt joint. Geometric considerations: the representations
type. In some cases, when the margin of the cavity graphs extracted from marseillier41,42 (Fig. 11) show
is apical or in the equatorial line as a result of a that the maxillary elements have axial walls
substantial loss of tissue involving the third buccal and coronal definitely inclined and
cervical cusp, it is advisable to prepare a margin converging in the coronal direction, with the line of
sharp (with the characteristics mentioned in step 1) maximum contour (or dental equator) positioned in the
that matches in the apicocoronal direction with the level of cervical third of the respective walls. When the
the cutting peak. This occurrence is more frequent in tooth requires cusp coverage, a sharp cut
the lingual surfaces of the lower molars. it would certainly produce an oblique section of

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MDPT: Maxillary molars and premolars preparation

Inclined plane
(hollow chamfer)
Buccal Palatal

Anatomical
Together to the maximum
reduction of the
maximum contour line
occlusal surface
apical third of the tooth
1-1.2 mm
maximum contour line
Access routes
(apical third of the tooth)
Inclined plane
hollow chamfer
≥ 1.5 mm
≥ 1.5 mm
Inclined plane
Inclined plane (hollow chamfer)
(hollow chamfer)

Figure 11 Preparation scheme with mDPT for upper molars and premolars.

the prisms of enamel and an inadequate restoration The profile (chamfer) is indicated because it fits well with the
of the sharp edge (Fig. 12), while the coverage of inclination of the axial walls from a point of
the peaks with a full joint preparation would give geometric or biological view (enamel prisms)
as a result, a substantial loss of healthy tissue cut transversely to its major axis.
associated with dentin exposure. It is evident that,
as long as the margin design is coronal to the At the interproximal level, the walls converge
Ecuador, a concave shaped enamel cut apically and the maximum contour line is positioned
in the occlusal area.

MORPHOLOGY
GEOMETRIC CONSIDERATIONS

maxillary molars and premolars

Figure 12 Geometric considerations (for upper molars and premolars) underlying the mDPT.
images of: Marseillier E. The Morphology of Human Teeth. Gauthier-Villars, 1967.

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Morphology
STRUCTURAL CONSIDERATIONS

maxillary molars and premolars

Bazos P, Magne P. Bioemulation: biomimetically emulating nature using a histoanatomical approach; structural analysis. Eur J
Esthet Dent 2011;6:8–19.

Figure 13 Structural considerations (for upper molars and premolars) underlying the mDPT.

third. Therefore, the margin design can only be Structural considerations (Fig 13): from a
to be a rounded shoulder with defined margins. three-dimensional structural analysis of human teeth
Any inclined or beveled plane is contraindicated. It can be observed that the contours of the surface
because it would displace the margin apically, reducing The convex edges of the enamel match the concave profiles.
thus the thickness of the cervical enamel. and the sharp body dentin (sigmoid).

MDPT: Mandibular molars and premolars preparation

Inclined plane
(hollow chamfer) Maximum meeting Oral Linguistic
≥ 1.5 mm
Interior preparation line ≥ 1.5 mm
maximum contour line
Exterior preparation line ≥ 1.0 mm
(apical third of the tooth)

maximum contour line

(apical third of the tooth)

Figure 14 mDPT: different configuration of the buccal margins (inclined plane) and lingual (full articulation) of
mandibular molar, according to the maximum contour line of the tooth.

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MORPHOLOGY
GEOMETRIC CONSIDERATIONS STRUCTURAL CONSIDERATIONS

Mandibular molars and premolars

Bazos P, Magne P. Bioemulation: biomimetically emulating nature using a histoanatomical approach; structural analysis. Eur J
Esthet Dent 2011;6:8–19.

Fig 15 Geometric and structural considerations (for mandibular molars and premolars) that underlie
the mDPT. [Original images from: Marseillier E. Human Teeth morphology. Gauthier-Villars, 1967.]

curve). The concavity of the dentin surface is action of the cases in which a significant loss of
particularly evident and is located tissue has eroded the wall up to the cervical third. The
topographically in the middle third and coronal to the The margins on the lingual side are usually represented
Ecuador. Consequently, it is obvious that, focusing on through a shoulder, because of the tissue loss that it induces
on oral and buccal surfaces, the gold standard the coverage of the cusp usually affects the occlusal third and
for the design of cavities constitutes a design of middle of the peak, with margins located below the line
edge with a beveled concave inclined plane that equatorial.
cut the convexity of the enamel, following the concavity
from the dentin without exposing it.

Structural considerations (Fig 15): Even from

From the structural point of view, a convexity is highlighted.
of the enamel with a strong concavity of the dentin in
mandibular molars and premolars (Fig. 14) the middle and occlusal thirds of the buccal walls. In the
lingual side, a morphology of the enamel slightly
Similar considerations must be applied to the teeth. convex (on average) corresponds to a
mandibular posteriors. more linear dentin surface. Consequently,
Geometric considerations (Fig 15): The surfaces based on these considerations, the justification is
buccal surfaces are inclined with occlusal convergence, with selection of sharp shoulder margins on the side
a maximum contour line located in the third lingual. A concave margin can only be prepared and
cervical. The lingual surfaces, however, are more to end in cases where structural deficits
verticals, with the equatorial lines located in the constitute an indication of a sudden cut in the
occlusal third. For this reason, the buccal margin coronal third of the lingual cusp at the equatorial level.
it is frequently represented by a chamfer
concave, with the exception of

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Adhesive restorations (conventional and

recently developed)

The new preparation principles listed

previously can be effectively applied to all kinds
of traditional adhesive restorations (inlay, onlay,
overlay) and help to define a set of
recently developed restorations (overlay
adicional, carilla oclusal, carilla superpuesta, envoltura
large). overlap, adhesive crown).

Figure 16 Inadequate amalgam and composite resin.

Tornations with evidence of recurrent deterioration.
Conventional indirect restorations in inlay, onlay
and overlay, the adhesively cemented restorations
they are traditionally classified according to their type.

Inlays (Figs 16 to 18) are restorations without

cusp coverage, and they would be indicated for teeth
with preserved vitality in medium class II cavities
at large (mO/ OD, mOD), with buccal walls and
well-preserved buccals. Composite is the material
ideal. Currently, this type of restoration usually
to be carried out with a direct technique, thus obtaining the
the same predictability as a more conservative approach.

Figure 17 Medium class II mO/OD cavities restored

with composite inlays without cusp coverage.
overlays (Figs. 19 to 21) are restorations that
they partially cover the peaks, but not all of the
occlusal surface. They are indicated for class II cavities
large dimensions with side walls
partially supported without dentin fissures. In the
in the case of endodontically treated teeth, it is required
the presence of at least one marginal ridge and two
well-supported axial walls in continuity with the
own marginal crest. It can be used for both composite
like ceramics.44,45

Overlays are cover restorations

total of cusps, indicated in class II cavities of
large dimensions with unsupported axial walls
Figure 18 Clinical follow-up of 11 years, which shows
Good morphological, functional, and aesthetic maintenance. and absence of both marginal ridges. The presence of
cracks in

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Figure 19 Inadequate pre-existing restoration with Fig 20 Preparation of the onlay cavity with partial cut.
material fracture and notable marginal infiltration. Quick coverage after a deep cleaning of the cavity and the
accumulation of adhesive.

Figure 21 8-year follow-up with excellent preservation. Figure 22 Extensive restoration of inadequate amalgam.
tion of morphology, function, aesthetics, and marginal integrity. with residual and recurrent caries. The tooth was asymptomatic.

Figure 23 Deep cleaning of cavities with vitality Figure 24 Accumulation of adhesive and preparation of overlaps.
Tooth maintenance without pulp exposure. Action with joint to circumferential limit (all the edges of the cavity)
they are below the maximum contour line).

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Fig 25 Final restoration after finishing and polishing.

ing, with appropriate morphological and aesthetic integration. The choice of
composite as a restoration material facilitates a possible
future reinvention (e.g., for endodontic reasons).

a b

Figure 26 Upper first molar with dental fissure syndrome, previously restored with silver amalgam. The
The thickness of the wall is good, but there are enamel-dentin cracks. (b) General cut of the buccal and palatal cusps. Cracks are noticeable at the base of
the peaks.

Figure 27 Definition of the cavity design (after the adhesive). Figure 28 Monolithic lithium, hot pressed and painted.
reconstruction) for overlap, with inclined wall planes Overlay of disilicate (IPS e.max Press, Ivoclar Vivadent) after
axials and ramp connection with box (mDPT). Direct restoration with adhesive cementation in an isolated field with a rubber dam. The
composite in tooth 15. total coverage of the crowns with porcelain significantly hardens
the crown and increases the stabilization of the peaks.

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the enamel and dentin (in vital teeth), and the absence
from a marginal crest in treated teeth
endodontically, it requires full coverage, even
in the presence of residual walls of thickness
suitable. Composite can be used (Figs. 22 to 25) or
ceramics. The ceramic (lithium disilicate glass-ceramic)
it is the first choice material in the case of
multiple restorations with broad coverage. In addition,
due to its greater resistance and capacity to
stabilize the apex, ceramics is the first option
for teeth affected by tooth syndrome
cracked, using it with a total coating of the Fig 29 Restoration in the oral cavity with excellent
functional and aesthetic morphological integration, and complete remission of the
peaks. 21,46-48 (Figures 26 to 29).
symptoms associated with dentin cracks.

Recently developed indirect restorations Additional superposition (Figs. 30 to 35): It is about a

This new group of restorations is capable of fulfilling partial coverage restoration or more
with the criteria of maximum preservation of healthy tissue frequently, complete, carried out without any
and aesthetic, and helps to establish new boundaries between the dental preparation. It is indicated in cases of
conservative practices and prosthetics, with changes anatomical restoration of teeth with tissue loss
substantial in the treatment plan of the region for erosion/abrasion or in cases of increased
posterior. These restorations can be classified as occlusal vertical dimension. The reference material is the
in the following way: ceramic (lithium disilicate), although it is also possible
use composite.

Fig 30 Deep skeletal and dental bite. Implant- Figure 31 Carry out the rehabilitation of sectors 1 and
Prosthetic replacement of the upper right molar after elevation 4 easier, and to partially compensate for the deep bite, it
From the breast. The opposing molars are extruded and require remodeling. increased the vertical dimension with the execution of overlays
of the occlusal plane. additional on the back teeth and additional palatal veneers on the
front teeth.

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Figure 32 Teeth without any prior preparation. Figure 33 Adhesive cementation of the completely indirect.

the adhesive cementation. additional restorations.

Occlusal surface (or 'board'): It is about a

preparation of partial occlusal coverage for posterior
thin adhered (1 to 1.2 mm) with a non-design
retentive. It is indicated, above all, in previous erosion.
from the occlusal surface or in cases of clinical restoration
where it is necessary to increase the vertical dimension. 6,7
(Figures 36 to 43). An in vitro study of fatigue 37,38
they concluded that resin occlusal veneers
superfine composites (0.6 mm) CAD/CAM had a
significantly greater fatigue resistance in
comparison with ceramic occlusal veneers.
Figure 34 A detail of teeth 26 and 27 with an excellent
It provided functional morphological aesthetic integration.

Layered veneer (or 'veneerlay') (Figs. 44 to 49): It

used in the case of a restoration that involves the
occlusal surface that extends to the entire surface
aesthetic considerations or
functional. It is indicated for teeth located in areas
aesthetics (typically upper premolars) with
significant loss of hard tissue, very discolored and
bleaching resistant. The reference material
it is the ceramic (lithium disilicate).

Fig 35 The maxillary arch after rehabilitation.

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Figs 36 and 37 maxillary and mandibular arches before treatment. There is a clear need for
rehabilitate the arches due to inadequate restorations, abrasions, wear and discoloration of the teeth.

Fig 38 Encapsulated diagnosis of the maxilla and Fig 39 First phase of jaw rehabilitation.
mandibular arches. Subsequently, a adhesive model will be made. arch ular on the lateral-posterior side with occlusal coating of the
directly in the mandibular arch, increasing the vertical dimension. teeth 34, 35, 44, 45, and 46. Tooth 36 is a metal-free crown on a
implant.

Fig 40 Details of minimally invasive procedures. Figure 41 The ultra-fine pressed lithium disilicate is found
Clusal crown (IPS e.max Press) of quadrant 4 after cementation
adhesive.

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Figure 42 The mandibular arch after the complete Figure 43 The maxillary arch after a complete adjustment
Adhesive rehabilitation, with ceramic occlusal veneer in all Hesive rehabilitation, with partial pressed ceramic restorations and
anterior and posterior teeth. Two lithium disilicate crowns on the totals in the front and back teeth.
teeth 36 and 37.

Figure 44 maxillary premolar with previous composition Fig 45 Vestibular side with inadequate aesthetics.
Restoration of ite and signs of occlusal wear. integration.

Figure 46 Partial preparation

ration with a covered appearance Figure 47 lithium distillation
occlusal and buccal in isolated field. Pressed superimposed sheet (IPS
e.max Press).

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Figure 48 Restoration after adhesive cementation. Fig 49 Restoration with morphological and functional aspects.
with aesthetic restoration of the oral appearance. optional occlusal reconditioning.

Long superposition: This restoration involves the axial walls to detect the presence of lesions
complete occlusal surface. It extends to the walls extensive cavities, abrasions, biocorrosions or fractures
vestibular and/or palatal-lingual axials, depending on the that affect the external surfaces. The material of
loss of hard tissue regardless of the profile election is ceramic (lithium disilicate), although the
of the soft tissue. It is indicated for teeth that require composite can only be indicated as a compromise
a complete extended cuspidate coverage to less expensive (Figs. 50 to 52).

Fig 50 Preparation of long wrap overlay according to Figure 51 Anatomical preparation of the occlusal.
to the MDPT principles. Oral aspect: the anatomical reduction of the tooth surface.
After the root canal treatment and reconstruction, it is evident.

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Figure 52 Indirect restoration with composite after adhesive cementation with good aesthetics, morphological,
and functional integration.

Adhesive crown49,50(Figs. 53 to 59): This restoration tissue and periodontal tissue with a complete crown
completely covers the tooth, with margins conventional. With this restoration, the elongation
supragingival that follows the contour of the soft tissue surgical crown is usually avoidable because it is not
marginal, and which is adhesively cemented afterwards necessary to gain endurance and maintain fitness, which
isolation of the rubber dam. It is indicated in teeth it is essential when performing restorations
with a significant loss of tissue that requires a conventional prosthetics. The chosen material is the
total preparation. The adhesive approach enables the clinician lithium disilicate.
be more conservative regarding poor quality
dental residual.

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Figure 53 maxillary premolar treated endodontically Figure 54 Pre-prosthetic adhesive reconstruction

with a significant loss of dental tissue. composite made with a fiber pole.

Fig 55 The oral aspect shows a minimum of inter-

occlusal thickness that would require an apical positional flap in the case of
a traditional crown.

a b

Figure 56 Preparation for the adhesive crown. (a) Occlusal view. (b) Buccal view. Slightly supragingival.
The margin allows for the isolation of the field with a rubber dam.

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Conclusions

Modern restorative dentistry is

substantially adhesive. The conservative spirit
it should permeate all procedures. Preserve
healthy tissue (not only dental but also pulp and
periodontal) has become the priority. With this
focus, indirect adhesive restorations are
indicated in large cavities associated with coverage
cuspids with reduced or absent amounts of
cervical enamel
Figure 57 Pressed adhesive crown of lithium disilicate
(IPS e.max Press) on galvanized stone model.
The reason for this study was to review the concepts of
design of cavities taken from ancient patterns for
non-adhesive restorations, which are outdated,
they are not conservative and inadequate for
adhesive procedures. This new cavity design
allows the following clinical advantages:

Definition of a margin design that

acts to improve the quality of adhesion through
the optimization of the enamel cut and the creation of
a greater surface area of enamel provided.

minimum exposure of the dentin, avoiding

Figure 58 Adhesive cementation with preheating.
wide shoulders, occlusal grooves, and pits.
composite material.

maximum preservation of health

residual tissue, adapting the design of the cavity to
the adhesive cementation procedures with
composite resins and improving material flow
surplus. "Optimization of aesthetic performance."

performance, which allows for a better combination in the

transitional zones.

The new preparation principles discussed in this

the article can be effectively applied to all types of
traditional adhesive restorations (inlay, onlay,
overlay) and help to define a set of
Figure 59 Oral aspect of the restoration after
cementation with good aesthetic and functional integration.
recently developed restorations (overlay
additional

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occlusal veneer, overlay veneer, superposition of Expressions of gratitude

wide wrap and adhesive crown). The different types
restorations constitute a proportion Dr. F. De Fulvio (Moricone, Rome, Italy) for his invaluable help in the
drafting of the article; Dr. N. Scotti (TO, Italy) for the translation and review;
significant of the available treatment options
to the dental technicians for their excellent work: A. Pozzi (PR, Italy), F.
for the rehabilitation of the posterior teeth, and us Pozzi, A. Quintavalla (PR, Italy) and m. Svanetti (BS, Italy).
they allow to define a new line between treatments
conservatives and prosthetists, in favor of a more approach
conservative.

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