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Cavity Configurations for Indirect Partial-Coverage

Adhesive-Cemented Restorations

Guido Fichera, DDS1


Walter Devoto, DDS2
Dino Re, MD, DDS3

I n d i rect esthetic adhesive restorations in


composite resin and ceramics belong to
the wider category of partial-coverage
crown restorations. As such, they require pre p a r a-
FACTORS AFFECTING STRUCTURAL
STRENGTH

N u m e rous studies on the biomechanical and


tion designs that leave a certain amount of intact structural analysis of a tooth’s intact healthy stru c-
clinical crown and generally have supragingival tures are available in the literature, especially from
margins.1 To guarantee the fracture resistance of a the era prior to the use of adhesive resins. From
p a rtial-coverage crown restoration over time, it is these re p o rts, it appears that the presence of the
necessary to determine which part of the clinical marginal ridge is fundamental4; if it is lacking, the
crown that has, by itself or in combination with the occlusocervical and mesiodistal depth, and the
buildup, appropriate structural characteristics and size of the proximal boxes must be taken into con-
sufficient biomechanical strength. This decision in- sideration,5–8 as well as the intercuspal width (and
fluences the clinical outcome of the restoration. thus, proximity to the tips of the cusps) and the
Respecting biologic principles and using a conser- depth of the occlusal isthmus,5–9 the thickness of
vative approach are the building blocks for a suc- the enamel-dentin layer at the base of each cusp,
cessful outcome. the depth of the base of the intact cusp,6 the ab-
For indirect tooth-colored adhesive-cemented sence or presence of the pulp chamber roof4 (ie,
restorations, the highest incidence of failure is vital or endodontically treated tooth), and the
f r a c t u re of the restoration material and intact thickness and depth of interaxial dentin. 7 – 1 0
tooth, together with secondary caries.2 To avoid Restoration is further complicated as these factors
fracture, cavity preparation should be considered must be related to the functional role of the tooth
as both a diagnostic and operative phase.3 in question (eg, position in the arch, biotype, oc-
clusal trauma, parafunctional habits, static and dy-
namic occlusion, condition of antagonistic teeth).
Private practice, Monza, Italy.
1 Clinical re s e a rch shows that the adhesive bond
Private practice, Sestri Levante (GE), Italy.
2
between dentin and resin composite will, over
Researcher, Department of Prosthodontics, University of
3
time, decrease in strength,11,12 and that the extent
Milan, Italy.
of this decrease is in proportion to the mechani-
Correspondence to: Dr Walter Devoto, Via E. Fico 106/8,
cal, thermal, hydrolytic, and enzymolytic stresses
16039 Sestri Levante (GE), Italy. E-mail: dewal@tele2.it to which the bond is subjected. It is also highly

QDT 2006 55
FICHERA ET AL

ic
ic
mr
ic ic
D mr M
D id
mr M
mr
id

ic pcr
ic

Fig 1 Occlusal view of structural model of the Fig 2 Buccolingual view of the structural model
tooth. id = interaxial dentin, ic = intact cusp, of the tooth. id = interaxial dentin, ic = intact
mr = marginal ridge. cusp, mr = marginal ridge, pcr = pulp chamber
roof.

p robable that weakening of the adhesive bond Central structures


over time is responsible for the mechanical failure
of direct and indirect tooth-colored adhesive- The central stru c t u res consist of the interaxial
cemented restorations for which the restoration- dentin and the pulp chamber roof. The interaxial
cavity interface is situated close to the tip of the dentin is the central core of the tooth. It may be
cusp, or the intact tooth wall is insufficiently thick. seen as the occlusocervical continuation of the
These failures cannot easily be explained except pulp chamber roof and, thus, occupies the area
by hypothesizing a failure over time of the adhe- c o rresponding to the projection of the pulp cham-
sive bond at the interface, where it is subjected to ber to the occlusal surface.13 The interaxial dentin
high physical and chemical stress. connects the axial walls, in particular the buccal
It is the authors’ opinion that for posterior teeth and lingual walls, and is the most important stru c-
it is important to place the margins of indire c t ture. When it is intact, the presence of other com-
tooth-colored adhesive-cemented restorations in p romised stru c t u res will not significantly under-
occlusal-axial areas subjected to lower mechanical mine the overall fracture resistance of the intact
s t ress. An analysis of the literature reveals four tooth.14–17
s t ru c t u res that determine the strength of intact Studies by Mondelli et al 14 and Larson et al 15
tooth: the interaxial dentin, the pulp chamber roof, have shown that the loss of the marginal ridge
the marginal ridge, and the intact cusp. For their (peripheral stru c t u re) does not produce signifi-
diagnostic and operative implications, these struc- cant structural weakening when the occlusal isth-
tures may be classified topographically as central mus (ie, interaxial dentin) remains intact. On the
or peripheral. The spatial relationship between the contrary, exclusive preparation of the interaxial
various structures is better clarified through a struc- dentin is associated with significant stru c t u r a l
tural model of the tooth (Figs 1 and 2). weakening. The structural significance of the

56 QDT 2006
Cavity Configurations for Indirect Partial-Coverage Restorations

marginal ridge is affected by any compromise of terms of the presence or absence of the pulp
the interaxial dentin.16,17 chamber roof and the thickness of the enamel-
The pulp chamber roof, contrary to common dentin complex at the adjacent intact cusp (it
belief, is less important than the marginal ridge. must be greater than1.5 to 2 mm in a vital
Reeh et al 4 demonstrated that loss of the pulp t o o t h 18 and 2.5 to 3 mm in an endodontically
chamber roof when both marginal ridges are treated tooth 13) and depth at the base.19 The na-
kept intact (ie, endodontic treatment re q u i r i n g t u re of the structural interdependence deter-
removal of some of the interaxial dentin and the mines whether or not it is necessary to cover the
pulp chamber roof) produces a less significant adjacent cusps. Articles by Linn et al20 and Pan-
structural weakening than maintenance of the itvisai et al21 on the relationship between the
pulp chamber roof when one or two marg i n a l marginal ridge and intact cusps in an endodonti-
ridges are missing (ie, vital tooth with Class 2 cally treated tooth demonstrate a structural and
cavity, occlusomesial, occlusodistal, and mesial- functional dependence of the intact cusp on the
occlusodistal). adjacent marginal ridge. Likewise, the articles
These considerations are important in making c o n f i rm the independent biomechanical be-
clinical choices based on the evaluation of healthy haviour among cusps as suggested by Sakaguchi
intact tooth structures and on scientific evidence, et al,22 and which has been clinically confirmed
and not simply on empirical or preconceived no- by numerous studies.5–12 The loss of one marginal
tions. The hierarchy of tooth structures is thus: (1) ridge in an endodontically treated molar, where
the interaxial dentin, ( 2 ) the marginal ridge, (3) the the other marginal ridge is intact and adjacent
roof of pulp chamber, and (4) the enamel-dentin cusps are well-supported, should be planned as
complex of the intact cusp. a restoration with partial cusp coverage; the
cusps adjacent to the lost marginal ridge are
covered, while the cusps adjacent to the intact
Peripheral structures marginal ridge are maintained.
The enamel-dentin complex of the intact cusp
The peripheral stru c t u res are the marginal ridge re p resents the most significant clinical factor in
and the enamel-dentin complex of each intact deciding whether to maintain or cover the cusp.
cusp. The marginal ridge is the peripheral stru c- Hood6 demonstrated that from the mechanical
t u re of the proximal wall, whereas the enamel- standpoint the enamel-dentin complex of the in-
dentin complex of the cusp is the peripheral stru c- tact cusp adjacent to a proximal box behaves
ture of the axial-buccal or palatolingual wall. The like a cantilever; the thickness and depth at the
marginal ridge, its underlying enamel-dentin com- base of the intact cusp are the most important
plex, and the interaxial dentin meet at the junc- parameters since they vary with the cube of the
tion of the buccal wall with the palatolingual wall. d e f o rmation and, in the final analysis, are re-
The thickness of enamel-dentin complex at the sponsible for the strength of the cusp. This is
base of each cusp does not participate in this why, with equal thickness and in the absence of a
structural junction but is rather the last support of m a rginal ridge, intact cusps of endodontically
the cusp itself. treated teeth flex more than those of vital teeth.
C o rrect evaluation of the marginal ridge must Keeping an intact cusp in a vital tooth is deter-
follow certain criteria. The loss of a marg i n a l mined by an enamel-dentin thickness gre a t e r
ridge signifies the presence of a proximal box. If than 1.5 to 2 mm,20 whereas in an endodontically
the interaxial dentin has been compromised and treated tooth the thickness must exceed 2.5 to 3
the presence of an occlusal isthmus is antici- m m .1 3
pated, the proximal box must be evaluated in

QDT 2006 57
FICHERA ET AL

ic
ic

D mr M
mr id

Fig 3 Structural model of the tooth, illustrating


ic
ic the transition area (red) between marginal ridge
and cusp, cusp and cusp, and interaxial dentin
and peripheral marginal ridge–cusp unit. id =
L interaxial dentin, ic = intact cusp, mr = marginal
ridge.

TRANSITION AREAS AND POSSIBLE (buccal and lingual) (Fig 4). Configurations 1 to 4
CAVITY CONFIGURATIONS (see Figs 4a to 4d) are characterized by the pre s-
ence of the marginal ridge, while configurations 5
After analyzing the peripheral and central stru c- to 8 (see Figs 4e to 4h) are characterized by the a b-
tures (ie, the marginal ridge, the intact cusp, and sence of the marginal ridge, and, therefore, by the
the interaxial dentin), it is possible, topographi- presence of a proximal box. These eight configura-
c a l l y, to outline the separation areas between tions cover all clinical possibilities for cavity design
each tooth structure. These areas are valuable in and cusp coverage in relation to the marginal ridge
diagnosing cavity configurations, since they repre- and account for half of the possibilities for a pre-
sent a line of transition between the restoration molar (eight configurations associated with the
and intracoronal and extracoronal cavity to be presence of the opposed marginal ridge and eight
outlined in partial-coverage crown preparation. configurations associated with its absence).
They also act as spatial re f e rences and help ac- By considering mirror images of the eight possi-
complish a rapid buildup that is stereoscopically ble configurations for a marginal ridge and adja-
c o rrect. cent cusps, it is possible to obtain every type of
Taking, for example, a maxillary first molar, cavity preparation for a partial-coverage crown—
three areas of transition can be outlined between inlays, onlays, and overlays—in any combination
the marginal ridge and cusp, between cusp and (Figs 5 and 6). A simple calculation of the combi-
cusp, and between the interaxial dentin and the nations shows that 64 types of cavity preparation
peripheral marginal ridge–cusp unit (Fig 3). Given are possible for a partial-coverage crown in a tooth
the anatomy of posterior teeth, two areas of tran- with four cusps. Thanks to the concept of principal
sition are associated with each marginal ridge: a transition areas, it is simple to standardize cavity
buccal transition, at the beginning of the adjacent design. Ascertaining the presence or absence of
buccal cusp; and a lingual transition, at the begin- the marginal ridge is sufficient to determ i n e
ning of the adjacent lingual cusp. whether the adjacent cusp should be maintained
A number of cavity designs are derived from the or covered. Following this decision, the geometry
possible combinations based on the absence or of the cavity configuration can be outlined with
presence of the marginal ridge and on the mainte- certainty.
nance or restoration of the two adjacent cusps

58 QDT 2006
Cavity Configurations for Indirect Partial-Coverage Restorations

Fig 4 Basic cavity configuration depending on presence or absence of marginal ridge and maintenance restoration
of adjacent cusps. bc = buccal cusp, lc = lingual cusp, mr = marginal ridge, pid = prepared interaxial dentin, cc =
cusp cover, pb = proximal box.

lc cc lc cc

mr pid mr mr pid mr pid


pid

bc bc cc cc

4a 4b 4c 4d

lc cc lc cc

pb pb pb pid pb pid
pid pid

bc bc cc cc

4e 4f 4g 4h

Fig 4a Cavity configuration 1: occlusal inlay. Fig 4e Cavity configuration 5: occlusodistal inlay.

Fig 4b Cavity configuration 2: onlay with lingual cusp Fig 4f Cavity configuration 6: occlusodistal onlay with
cover. lingual cusp cover.

Fig 4c Cavity configuration 3: onlay with buccal cusp Fig 4g Cavity configuration 7: occlusodistal onlay with
cover. buccal cusp cover.

Fig 4d Cavity configuration 4: onlay with lingual and Fig 4h Cavity configuration 8: occlusodistal onlay with
buccal cusp cover. lingual and buccal cusp cover.

L L

1-1 1-2 1-3 2-1 2-2 2-3

D M D M
1-4 1-5 2-4 2-5

1-6 1-7 1-8 2-6 2-7 2-8

B B
Fig 5 Mirror-image associations of mesial configuration Fig 6 Mirror-image associations of mesial configuration
1 with the 8 distal configurations. 2 with the 8 distal configurations.

QDT 2006 59
FICHERA ET AL

L marginal ridge
cusp cusp
occlusocervical
3.5 levels
mm
2 mm
D M
pu cu pu
B L
1.2 mm
1.2
mm B 3.5 mm
1.5-2 mm
mesiodistal
levels de me

Fig 7 Horizontal cross section of in- Fig 8 Frontal cross section of intact Fig 9 Diagnostic model for type of
tact tooth structure at a specific oc- tooth structure at a specific mesio- cusp cover facilitates analysis of
clusocervical level to identify distal level to identify enamel-dentin occlusocervical and mesiodistal
enamel-dentin thickness on the thickness on the occlusocervical line. enamel-dentin thickness of the intact
mesiodistal line. cusp. pu = peripheral unit, cu = cen-
tral unit, de = distal extremity, me =
mesial extremity, red grids = transi-
tion area.

TYPES OF CUSP COVER By definition, the thickness of the cusp wall is a


spatial attribute on the transversal and fro n t a l
As stressed in a previous publication,3 cusp cover- planes. For an overall evaluation, the enamel-
age in indirect esthetic adhesive restorations may dentin thickness should be considered at various
be accomplished by either shoeing or capping. The o c c l u s o c e rvical and mesiodistal levels. A transver-
diagnostic model for cusp cover outlines parame- sal section at a specific occlusocervical level pro-
ters of how to decide whether or not a cusp cover vides information on the thickness of the enamel-
is necessary and what type of cover is appropriate. dentin complex along the mesiodistal line (Fig 7).
To use the model requires analyzing the cusps in A frontal cross section at a specific mesiodistal
three planes: transversal, frontal, and sagittal. level provides information about the enamel-
The thickness of the enamel-dentin complex on dentin thickness along the occlusocervical line
the cusp dictates the need for cusp coverage. As (Fig 8). By combining the information concern i n g
p reviously indicated, the limit for enamel-dentin the enamel-dentin thickness at varying occlu-
thickness in a vital tooth must be around 1.5 or 2 s o c e rvical and mesiodistal levels, it is possible to
mm; if it is any less, the wall would be exclusively determine whether a cusp cover is required and
s u p p o rted by enamel and reinforcement provided the most appropriate type.
by the buildup would not be reliable. An endo- Transversal and frontal examination is effec-
dontically treated tooth requires greater enamel- tively supplemented by the diagnostic model for
dentin thickness; when the cusp has lost the adja- type of cusp cover, shown in lateral view (sagittal
cent marginal ridge, even if it is supported by an plane) with the start of the marginal ridge and the
enamel-dentin thickness greater than 1.5 or 2 mm, adjacent cusp. A grid of horizontal and vert i c a l
it has lost all structural links (interaxial dentin, pulp lines can be traced on the cusp, to represent the
chamber roof, and marginal ridge) to the opposite o c c l u s o c e rvical levels (spaced by approximately 2
marginal wall and, thus, behaves as a cantilever. In mm) and the mesiodistal levels (where the lines
this case, the cusp height becomes an essential coincide with the mesial and distal extremities of
factor, due to the loss of the pulp chamber roof. the transition area, between cusp and marg i n a l
Covering the cusp is strongly recommended, un- ridge, and between cusp and cusp) (Fig 9). These
less the intact cusp has a remarkable thickness lines produce a grid of structural units, which are
greater than 2.5 to 3 mm. valuable for ascertaining the enamel-dentin thick-

60 QDT 2006
Cavity Configurations for Indirect Partial-Coverage Restorations

cusp cusp
marginal ridge
1.5-2 mm

Figs 10a and 10b Structural defi-


ciencies in the occlusal 2 mm of in- B
tact cusps require cusp coverage pb buildup
by shoeing. The model is shown
on the left and the frontal cross
section on the right. pb = proximal
box, red grids = transition area.
10a 10b

ness of the cusp. A Johannson thickness gauge preparation. To simplify analysis of the model, it is
for metals may be used as a diagnostic aid. a p p ropriate to consider first the structural defi-
The structural units (nine in all) may be subdi- ciency of the enamel-dentin thickness in the 2-mm
vided into central3 and peripheral units (three on occlusal area of the cusp. This deficiency indicates
each side, ie, six per cusp). The peripheral stru c- the need for shoeing (Figs 10a and 10b). When the
tural units coincide with the mesial and distal perimeter of the intracoronal cavity is in proximity
halves of the transition area, and, as such, will be to or coincides with the tip of the cusp, shoeing is
the site of maintenance or restoration (ie, the pas- indicated. This is true for all situations in which the
sage of the cavity perimeter) depending on the occlusal isthmus is intact and conventional capping
clinical situation. is not considered a conservative enough ap-
By examining the various parts of this model, it proach. The lateral view shows the cusp cover with
is possible to obtain all the necessary diagnostic its mesiodistal extension, whereas the frontal cross
i n f o rmation related to cuspal coverage. Before an- section shows its conservative quality and the ease
alyzing the model, it is important to observe that of perf o rming this type of cusp cover.
a mesial and a distal extremity can be distin- Depending on the combination of mesial and
guished in the transition areas. For example, dur- distal extremities of the transition area, the shoe-
ing the preparation phase the cutting line may be ing will have four possible configurations; the most
traced through the transition area between cusp conservative approach does not involve the adja-
and marginal ridge, or between cusp and cusp, cent ridge or cusp, and the most extensive ap-
anywhere from the mesial to the distal extremity, proach involves both. There are schematic distinc-
ie, within a range of approximately 1.5 to 2 mm. tions between minimum-extension shoeing
Conceptually, wherever the cutting line runs within (re q u i red exclusively for a deficiency of a central
this range of 1.5 to 2 mm, the design of the gen- structure), intermediate-extension shoeing (for a
eral cavity shape (types 1 to 8) does not change deficiency of a central stru c t u re plus one periph-
(see Fig 4). If the transition line is located at the eral stru c t u re), and maximum-extension shoeing
mesial or distal extremity of the area, it will affect (for a deficiency of a central structure and both pe-
the type of cusp cover that is required. ripheral stru c t u res) (Figs 11a to 11f). Should the
Identifying transition areas and their extremities s t ructural deficiency in enamel-dentin thickness in-
limits the preparation line and avoids unnecessary volve the middle third as well as the occlusal band,

QDT 2006 61
FICHERA ET AL

cusp cusp
marginal ridge

11a 11b

cusp cusp
marginal ridge

11c 11d

cusp cusp
marginal ridge

11e 11f

Figs 11a to 11f Models (left) and occlusal views (right) of cusp cover by shoeing
with minimum (a and b), intermediate (c and d), and maximum (e and f) mesiodistal
extension. red grids = transition area.

capping will be required (Figs 12a and 12b). Four those in which an intact cusp is combined with a
combinations of capping are also possible, one s t ructural deficiency involving a missing adjacent
classic total capping and three partial capping of m a rginal ridge and an adjacent cusp re q u i r i n g
minimum to intermediate extension (Figs 13a to complete restoration (eg, 2-6,2-8,3-7,3-8 [see Figs
13f). A structural deficiency in the cervical third in- 5 and 6]). Such situations allow full exploitation of
volves the same combinations as outlined above, the operative space, due to the absence of transi-
the only clinical diff e rence being that the cervical tion areas adjacent to the cusp. Despite this, it is
margin will lie closer to the gingival margin, and, possible to re s o rt to maximum-extension cover in
consequently, the axial wall will be longer (Figs 14 the presence of adjacent marginal ridge and cusp.
and 15). By exploiting the transition areas bordering the in-
Out of the possible 64 cavity designs, configura- tact cusp and using a cavity perimeter that passes
tions with the greatest space for cusp coverage are through the more distant mesial and distal extremi-

62 QDT 2006
Cavity Configurations for Indirect Partial-Coverage Restorations

cusp cusp
marginal ridge
1.5-2 mm

Figs 12a and 12b Structural defi-


ciency in the middle and occlusal B
thirds of the intact cusp requires buildup
pb cusp coverage by capping the
middle third. The model is shown
on the left and the frontal cross
section on the right. pb = proximal
box, red grids = transition area.
12a 12b

cusp cusp
marginal ridge

13a 13b

cusp cusp
marginal ridge

13c 13d

cusp cusp
marginal ridge

13e 13f

Figs 13a to 13f Models (left) and occlusal views (right) of cusp cover by capping
the middle third with minimum (a and b), intermediate (c and d), and maximum
(e and f) mesiodistal extension. red grids = transition area.

QDT 2006 63
FICHERA ET AL

cusp cusp
marginal ridge
1.5-2 mm

Figs 14a and 14b Structural defi- B


pb ciency of the entire intact cusp re- buildup
quires cusp cover by capping the
cervical third. The model is shown
on the left and the frontal cross s e c-
tion on the right. red grids = transi-
tion area.
14a 14b

cusp cusp
marginal ridge

15a 15b

cusp cusp
marginal ridge

15c 15d

cusp cusp
marginal ridge

pb

15e 15f

Figs 15a to 15f Models (left) and occlusal views (right) of cusp cover by capping
the cervical third with minimum (a and b), intermediate (c and d), and maximum
(e and f) mesiodistal extension. pb = proximal box, red grids = transition area.

64 QDT 2006
Cavity Configurations for Indirect Partial-Coverage Restorations

cusp cusp
marginal ridge

Figs 16a to 16b Structural defi-


ciency of the central and lateral
structures of the entire distal intact
cusp and the occlusal third of the
mesial intact cusp requires cusp
cover by total capping and by
shoeing with maximum extension.
The model is shown on the left
and the occlusal view on the right.
red grids = transition area.
16a 16b

Fig 17 Diagnostic algorithm with flowchart.

Fig 18 Initial radiograph showing


distal secondary caries at the sec-
ond premolar and direct capping
of mesial pulpal horn at the first
molar, which is affected by pulpitis
and occlusal caries.

Fig 19 Radiograph showing endo-


dontic therapy.
18 19

ties, the minimum operative space needed to ac- simplify explanation of the model and clarify the
complish a maximum-extension cusp cover can be differences between various cusp covers. Clinical
obtained. Furt h e rm o re, understanding of the practice produces a wide range of possible com-
mesial and distal extremities of a transition are a binations (Figs 16a and 16b), but by following a
makes it possible to consider different designs for number of guidelines it is possible to make the
cusp coverage, provided that one or both transition best compromise between maximum conserva-
areas adjacent to the undermined intact cusp are tion of tooth stru c t u re and optimal biomechanics
not involved. Partial capping and minimum- and in- of the tooth restoration (Fig 17).
t e rmediate-extension shoeing, combine the biome- Furtherm o re, the grid and its central and pe-
chanical benefits of cusp covers with the advan- ripheral subdivisions allow a realistic evaluation of
tages of maximum conservation of tooth structure. buildup possibilities for re i n f o rcing the intact
Various combinations of enamel-dentin thick- enamel-dentin complex (Figs 18 to 33).
ness on the intact cusp have been illustrated to

QDT 2006 65
FICHERA ET AL

Fig 20 Examination of the first Fig 21 Placement of modified Fig 22 Etching.


molar, with intact healthy tooth glass-ionomer cement at canal en-
structure at and onlay treatment trances.
covering the mesiobuccal and
mesiolingual cusps.

Fig 23 Application of primer and Fig 24 Bright white chrome com- Fig 25 Application of fluid com-
bonding agent. posite facilitates potential endo- posite buildup.
dontic re-treatment and enhances
value of buildup.

Fig 26 Application of restoration Fig 27 Preparation of onlay cavity Fig 28 Sectional matrix, wedge, and
composite buildup. with cusp cover by shoeing of retractor ring for Class II occluso-
mesiolingual cusp and by capping mesial cavity at the second premolar.
middle third of mesiobuccal cusp.

Fig 29 Construction of mesial wall Fig 30 Direct resin composite Fig 31 Adhesive cementing of
of the second premolar. restoration of the second premolar. composite onlay to the first molar.
Field for adhesive cementing of
onlay to the first molar is placed
under rubber dam.

Fig 32 Direct resin composite Fig 33 Removal of dam, followed


restoration of the second molar. by finishing and polishing of the
restorations.

66 QDT 2006
Cavity Configurations for Indirect Partial-Coverage Restorations

CONCLUSION 7. Khera SC, Goel VK, Chen RCS, Gurusami SA. Parameters
of MOD cavity preparations: A 3-D FEM Study, Part II.
Oper Dent 1991;16:42–54.
By looking to biomechanical studies and a stru c- 8. Goel VK, Khera SC, Gurusami SA, Chen RC. Effect of cav-
tural model of the tooth, it is possible to standard- ity depth on stresses in a restored tooth. J Prostht Dent
ize the diagnosis of cavity configuration and the 1992;2:174–183.
9. Rees JS: The role of cuspal flexure in the development of
application of clinical and operative guidelines. abfraction lesions: A finite element study. Eur J Oral Sci
Determining the strength of the intact healthy 1998;6:1028–1032.
tooth stru c t u res re p resents the starting point for 10. Lin CL, Chang CH, Wang CH, Ko CC, Lee HE. Numerical
investigation of the factors affecting interfacial stresses in
all analysis. In examining the adequacy and defi- an MOD restored tooth by auto-meshed finite element
ciency of intact tooth stru c t u res, a clinician can de- method. J Oral Rehabil 2001;6:517–525.
t e rmine all biomechanically valid cavity configura- 11. Takahashi A, Inoue S, Kawamoto C, et al. In vivo long-
term durability of the bond to dentin using two adhesive
tions. Using a model of the enamel-dentin complex systems. J Adhes Dent 2002;2:151–159.
of the intact cusp, an analysis can provide indica- 12. Hashimoto M, Ohno H, Kaga M, Endo K, Sano H, Oguchi
tions for restoring any intact cusp, as well as the H. In vivo degradation of resin-dentin bonds in humans
over 1 to 3 years. J Dent Res 2000;6:1385–1391.
choice of type of cusp cover. This approach en-
13. Becciani R, Castellucci A. La biomeccanica del dente trat-
courages cavity configurations and types of cusp tato endodonticamente. Implicazioni cliniche. Dent Cad-
cover that offer structural strength and maximum mos 2002;1:15–32.
14. Mondelli J, Steagall L, Ishikiriama A, de Lima Navarro MF,
c o n s e rvation of the natural tooth.
Soares FB. Fracture strength of human teeth with cavity
preparations. J Prosthet Dent 1980;43:419–422.
15. Larson TD, Douglas WH, Geistfeld RE. Effect of prepared
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