Scientifically Based Rationale and Protocol for Use

of Modern Indirect Resin Inlays and Onlays

J E F F T. BLANK, D M D '

ABSTRACT
The desire to place esthetically pleasing, conservative, functionally stable, posterior restorative
materials has steadily increased over the past 20 years. The creation of successful dentin bonding
adhesives and appropriate resin luting cements has paved the way for the development of a
myriad of indirect resin-based restorative materials. These materials have been specifically
designed to overcome the negative attributes of their porcelain counterparts, and to simplify fab-
rication, insertion, and post-delivery adjustments. Possibly like no other product before, these
restorative materials have met with instant clinical acceptance by many practitioners, and con-
cern exists that these materials have not been sufficiently studied to warrant such widespread
acceptance. This article presents an overview of the history and development of resin-based,
esthetic, indirect systems, and offers the clinician a review of the literature supporting their role
in posterior restorative dentistry. Additionally, a scientifically based protocol for preparation,
impressing, provisionalization, and subsequent cementation and adjustment of indirect laboratory-
processed resin inlays and onlays is presented.
CLINICAL SIGNIFICANCE
This article reviews the history of indirect laboratory-processed resin restorations, reviews avail-
able literature supporting their use, and presents a scientifically based protocol for their place-
ment and use as a viable alternative for conservative reconstruction of posterior teeth.
( J Esthet Dent 12:195-208,2000)

T he search for the ideal restora-

tive material in dentistry has
been undertaken by many pioneers
over the past two centuries. Numer-
ous materials and techniques have
been documented, and many are
well-accepted as standards by which
current and prospective materials
are evaluated. Although it is not
expected that any single material
can meet the demands of every
clinical situation, it is generally
agreed that the ideal restorative
material should fulfill the following
basic functions:'
1. Permit the most conservative
approach to cavity preparation
2. Optimally restore the morphol-
ogy and the original mechanical
resistance of the tooth to allow
it to resume proper function
3. Ensure external and internal
adaptation and seal of the
restoration, to prevent recurrent
decay, pulpal injuries, and denti-
nal sensitivity
4. Be biologically compatible with
the underlying vital substrate
5. Provide satisfactory longevity
Historically, interest in the
appearance of the restoration,
particularly in posterior teeth, has
been secondary to the aforemen-
tioned criteria.

"Private Practice, Rock Hill, South Carolina.

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 SCIENTIFICALLY B A S E D RATIONALE A N D PROTOCOL FOR
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It is only natural that practitioners
and patients are interested in restor-
ing all teeth, including posteriors,
to their original function, strength,
and beauty. By definition, the act of
restoration should employ methods
that reconstruct the damaged tooth
to its original form. This entails the
use of appropriate synthetic materi-
als that not only reestablish struc-
tural integrity but also replicate the
original appearance of the damaged
or missing portion.
Such interest in recreating the
anatomic appearance of posterior
teeth has been longstanding.
Whereas the popularity of tooth-
colored posterior filling materials
has increased with recent advances
in adhesive and material science,
the technology dates back as long
as 150 years. Hoffman-Axthelm
has been credited with using pre-
fabricated ceramic inlays sealed
with gold foil as early as 1856;
his work was refined by Herbst,
Land, and others in the mid
1 8 8 0 ~ .Bruce
~ , ~ later published
these methods in the Dental
Record, in 1891.4 It is interesting
to note that this article was pre-
sented 4 years before G.V. Black’s
landmark publication on the
proper protocol for dental amalgam
use in 1895. Nonetheless, most
tooth-colored inlay techniques
were abandoned because of the
lack of an appropriate luting
medium sufficient to support the
brittle ceramic inserts.
196 J O U R N A L OF ESTHETIC DENTISTRY
MATERIAL A N D T E C H N I Q U E are a direct function of width and
SELECTION
location. Simply stated, direct resins
Selecting the appropriate technique of any formulation can be expected
and material to restore posterior to perform less than optimally
teeth can be difficult with the array when used in large-diameter prepa-
of choices available to modern rations on teeth positioned distally
practitioners. When patients demand in the arch.7 The literature confirms
an esthetically pleasing restorative that directly placed posterior com-
material, dentists must follow basic posites are ideal for insipient lesions
guidelines for making recommenda- with minimal occlusal contact, in
tions to patients. First and foremost, small to moderate Class I and I1
the long-term prognosis of the cavity preparations, where incre-
tooth and the restoration must take mental filling techniques can be
precedence over any other f a ~ t o r . ~ used.8 When these criteria cannot
Second, the restorative material be met, direct placement strategies
chosen should permit the most con- should be abandoned and an indi-
servative preparation possible to rect restorative procedure should be
accomplish the restoration.6 Adhe- treatment planned.
sive technology has progressed
recently to permit more conserva- INDIRECT ESTHETIC POSTERIOR
tive preparations that modify con- IN LA Y S A N D O N L A Y S
ventional retention and resistance The indications for conservative
forms. Preparations described best adhesive indirect posterior restora-
as tunnel preparations, box prepa- tions include wide Class I or 11 and
rations, microcavities, and selective partial coverage preparations; serial
ameloplasty have replaced conven- restorations in the same arch to be
tional G.V. Black designs when treated simultaneously; more dis-
lesions are superficial and direct tally located, stress-bearing teeth;
resin is the material of choice (Fig- and in circumstances where the
ure 1).Third, when large defective residual enamel is less than 0.5 mm
amalgams or extensive decay dic- thick or totally absent.*v9Addition-
tate more aggressive cavity designs, ally, indirect fabrication of these
it is imperative that the clinician restorations permits greater control
assess the opposing occlusion and over occlusal and proximal con-
determine the point of centric con- tacts; avoids the extended chairtime
tact and the width of the antagonis- necessary for multiple, large direct
tic cusp, so that the appropriate composites; reduces the negative
restorative material can be deter- effects of polymerization shrinkage;
mined.’ It is well accepted that the achieves superior marginal seal;
wear rate and long-term survival of and permits the use of materials
directly placed posterior composites better suited for long-term success
 BLANK

Figure 1. A, Example of a highly conservative, direct composite preparation; B, such “microcavities” are easily and estheti-
cally restored with direct composite.

(Figure 2).’O Most importantly,
modern adhesive technology
affords the use of these restorations
as a means to cohesively unite the
retaining walls of the preparation,
and permits the reinforcement of
weakened areas more conserva-
tively than could be accomplished
with traditional metal or porcelain-
metal restorations.
Choosing the appropriate material
for indirect esthetic inlays and
onlays can be difficult, given the
recent developments of esthetic
indirect materials. Although por-
celain as an esthetic restorative
material is acknowledged to be
highly biologically compatible,
wear resistant, color stable, and
esthetic,11J2 its shortcomings are
significant. Clinically, ceramic
restorations can be extremely
brittle; they cannot be reliably
repaired in the mouth, are highly
rigid, and distribute occlusal stress
to the underlying tooth structure;
they are nearly impossible to pol-
ish intraorally, are often more
expensive to fabricate compared
to their composite counterparts,
and show a high propensity to
abrade the opposing dentition.’?”
In an effort to overcome these
significant disadvantages, manu-
facturers have introduced numer-
ous indirectly processed resin
restorations over the past 10 to
15 years.

Figure 2 . A, By using an indirect technique, an entire quadrant can be prepared at one visit. B, Postoperative results of the
placement of four indirect laboratory-processed resin restorations (belleGlass, Belle de St. ClairelKerr, Orange, California).

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BRIEF H I S T O R Y O F L A B O R A T O R Y -
PROCESSED INDIRECT RESINS
Prior to the early 1980s, little com-
mercial interest existed in manufac-
turing indirectly processed inlay
materials, because of the lack of a
suitable bonding medium to
exposed dentin. With the introduc-
tion of relatively successful third-
generation dentin bonding agents,
pioneers began to expand the use of
resins to indirect posterior applica-
tions. Mormann, Touati, and Pissis,
are just a few of the clinicians who
recognized the benefit of laboratory-
processing resin formulations, and
they were among the first to pub-
lish literature on their use, in the
mid 1 9 8 0 ~ . ’ Manufacturers
~-~~ took
note, and the first generation of
laboratory-processed resins, such
as Dentacolor (Kulzer, Irvine,
California), SR Isosit N (Ivoclar
North America Inc., Amherst,
New York), and Visio-Gem (ESPE,
Norristown, Pennsylvania) were
produced. All these were microfill
resin systems that explored a vari-
ety of curing mechanisms but pos-
sessed low flexural strength and
wear characteristics, because of the
low filler content and high percent-
age of exposed resin.16
Second-generation laboratory-
processed restorations, produced in
the late 1980s and throughout the
1990s, were characterized by an
increase in filler loading, increased
flexural strength, and resistance to
wear similar to enamel. Examples of
198 J O U R N A L OF ESTHETIC DENTISTRY
Herculite Lab (KerrLybron, Orange,
California), Tetric Lab (Vivadent),
Conquest (JeneridPentron,
Wallingford, Connecticut), ArtGlass
(Kulzer), Targis (Ivoclar), Sculpture
(JenericPentron), belleGlass HP
(Belle de St. ClaireKerr, Orange,
California), Cristobal (Dentsply/
Ceramco, York, Pennsylvania), and
Sinfony (ESPE). With the exception
of Concept (Ivoclar), which is a
microfill, all of the second-generation
materials are variations of submi-
cron hybrid resin systems. It was
during this period of evolution that
manufacturers began using multi-
functional resin monomers with
more double-bonding sites and
manipulating their positions in the
carbon chain to permit greater
crosslinking.” This technology was
further enhanced by developments
in the modes of polymerization
used for each system. By using com-
binations of heat, various wave-
lengths and intensities of visible
light, pressure, and the exclusion of
oxygen, manufacturers are able to
increase the percentage of conver-
sions of available bonding sites to
nearly 100% and significantly
improve strength, wear, hardness,
and color stability.18-20
One system, belleGlass HP, employs
heat, pressure, and the additional
use of a nitrogen bell to eliminate
oxygen from the curing environ-
ment. Whereas heat multiplies the
rate of polymerization, it also
increases the volatility of the
reduces the vapor pressure of the
monomer and minimizes porosity.
Conducting the polymerization
process in a nitrogen environment
eliminates oxygen, which is known
to compete at the carbon double-
bonding sites, and can limit the
degree of conversion and minimize
the physical properties of the poly-
mer. In this environment, few if any
voids exist in the polymer, and the
result is an increase in light diffu-
sion and better optical properties.12
ADVANTAGES A N D DISADVANTAGES
OF U S I N G M O D E R N L A B O R A T O R Y -
P R O C E S S E D R E S I N SYSTEMS
The primary impetus behind the
development of indirect resin systems
was the desire to overcome the previ-
ously mentioned negative attributes
of other esthetic materials, such as
porcelain. Advantages of using these
materials over their porcelain coun-
terparts include the following:12~*6J8
They have lower elastic moduli
and are less brittle.
They easily and reliably can be
repaired in the mouth.
They are less rigid and transmit
less functional stress to the
underlying tooth structure.
They are easily adjusted and
polished intraorally.
They are simpler to produce
and less expensive than most
porcelain restorations, and are
less likely to abrade the oppos-
ing dentition.

It also has been suggested that
when compared to the preparations
required to ensure adequate bulk
of ceramics, indirect resins may
permit more conservative prepara-
tion designs that preserve more
tooth
Ongoing laboratory and clinical
research provides data that suggest
that the wear rate of second-
generation indirect resin systems
may be comparable to that of natural
enamel. In an unpublished 5-year
clinical study at the University of
Alabama, the average annual wear
rate of belleGlass HP was only 1 pm
per year more than that of adjacent
enamel.22Another study, in 1998, at
Oregon Health Sciences University,
testing in vitro wear, found that
Targis, Artglass, and belleGIass HP
had an average of 20.9 pm of abra-
sion after 50,000 cycles with a
synthetic abrasive grit to simulate
a food bolus.12 Additionally, Clinical
Research Associates (CRA) is con-
ducting a multi-year clinical study
of all aspects of clinical performance
of Targis, Artglass, and belleGlass
HP. After 1 year, they state, “filled
polymer crowns have promising
clinical p e r f ~ r m a n c e . ” ~ ~
Another advantage of these materi-
als is their ability to be reinforced
with either silanated glass fibers or
cold gas plasma-treated polyethy-
lene fibers. Such fiber reinforcement
increases the physical properties of
these materials and permits their use
in conservative fixed bridge^.^^,^^
The primary disadvantage of labo-
ratory-processed resin materials is
the lack of sufficient clinical data. in
the literature. Although many stud-
ies are underway, the unique prob-
lem exists in that this technology is
evolving so fast that new products
are introduced, existing products are
modified, and other products are
removed from the market before the
results can be determined and pub-
lished. Although many noted prac-
titioners have worked with these
systems for years, even prior to their
introduction to the market, and are
experiencing clinical success, these
reports are merely anecdotal. Quan-
titative scientific data concerning
the longevity of indirect laboratory-
processed resins is still forthcoming.
In these circumstances, clinicians
must rely on data extrapolated from
in vitro studies and be forthright
with patients as to the anticipated
performance of these materials.
Another apparent disadvantage of
indirect resin systems stems from the
fact that all composites are inher-
ently more porous than ceramics.
Therefore, there is a greater
propensity for these materials to
stain or lose their color over time
and to accumulate plaque. Addi-
tionally, one published report has
demonstrated the importance of
meticulous laboratory techniques
during construction of these materi-
als. Critical factors, such as general-
ized wear, surface pitting, and
localized separation between resin
layers and various reinforcing sub-
BLANK
structures, are significantly affected
by improper laboratory fabrication
methods.25 Specific recommenda-
tions to overcome these problems
suggest that laboratories should
avoid the addition of thin layers of
material; pay close attention to
occlusal contacts during fabrica-
tion, thereby reducing the need for
chairside adjustment; and achieve
the highest surface finish possible in
the laboratory, to avoid possible
failures due to accelerated wear and
delamination in the mouth.
To date, there are few indications
that indirect laboratory-processed
resins are not viable replacements
for currently used materials, and
most reports indicate that they
show great promise for successful
clinical use. Fortunately, most of
the potential problems identified to
date can be avoided with proper
case selection and scrupulous labo-
ratory and clinical technique. As
with all burgeoning restorative con-
cepts, clinicians, laboratory techni-
cians, researchers, and manufactur-
ers ‘mustwork together to share
information, so that indirect labo-
ratory-processed resins can be
recommended with confidence.
CLINICAL P R O T O C O L FOR
PLACING LABORATORY-PROCESSED
RESIN INLAYS A N D ONLAYS:
CASE STUDY
A 37-year-old male presented for
the treatment of defective amal-
gams in his lower right quadrant
(Figure 3 ) . Since the restoration on
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the mandibular molar was small,
not wider than two-thirds the inter-
cuspal width, and the majority of
the centric holding area could be
retained on the oblique ridges of
the natural tooth, a directly placed
posterior composite was treatment
planned for this tooth. The second
premolar and first molar had larger
restorations that violated the two-
thirds rule and involved the centric
holding areas and the majority of
the occlusal contact. Replacement
of these restorations required the
additional wear resistance afforded
by indirect laboratory-processed
restorations that permitted precise
control over the interproximal
contacts, embrasure spaces, and
emergence profile.
Before the patient was anesthetized
and the rubber dam was placed,
the preoperative shade of the teeth
to be restored was determined.
The author has found that the com-
bined use of the Vita Shade Guide
(Vita Zahnfabrik, Bad Sackingen,
Figure 3. Preoperative view demonstrating large, failing
amalgams.
200 JOURNAL OF ESTHETIC DENTISTRY
Germany) and the Mosaic Posterior When preparing teeth for conserva-
Shade Guide (Dental Illusions, tive indirect resin inlays or onlays,
Woodland Hills, California) permits clinicians should be mindful to
the most accurate communication to provide adequate bulk to ensure
the laboratory. The Vita shades com- strength of the restorative material,
municate the basic hue, value, and while taking care not to violate
chroma of the teeth to be restored, minimal thicknesses of retaining
and the Mosaic guide provides tooth structure. Dietschi and
details, such as the cusp translucency, Spreafico have recommended a
degree of pit and fissure staining, minimal pulpal floor depth of 2 mm
and the level of hypocalcification. (measured from the apex of the
opposing cusp in centric), 2 mm
Once the teeth were isolated, the of occlusal cusp clearance, and
existing amalgam restorations were 10-degree tapered walls, with an
removed and a tentative outline form isthmus of at least 2 to 3 mm, when
was established, to eliminate decay. A laboratory-processed resins are to
caries-indicating die (Seek, Ultradent, be used.l If the remaining buttress
South Jordan, Utah) was used to of tooth structure is less than 2 mm,
assist in the detection and subsequent some clinicians advise reduction
removal of the remaining carious and coverage of these areas to pre-
lesions (Figure 4). The restoration in vent potential fracture either during
the second premolar was replaced the provisionalization phase or dur-
with a hybrid composite, using the ing function po~toperatively.',~~,~~
total-etch technique, a single-bottled, Small undercuts present in the lat-
dentin-enamel adhesive, and incre- eral walls of the preparation should
mental filling. The rubber dam was be eliminated by placement of suit-
removed, the occlusion adjusted, able restorative materials, such as
and the restoration polished. resin-reinforced glass ionomers,
compomers, or composite resin.
Preparations, should be devoid of
sharp internal angles, and cavo-
surface margins should be obtuse,
without bevels, and end in enamel
when at all possible (Figure 5).
Proper tissue management is essen-
tial for any indirect procedure, and
the judicious use of retraction cord
and hemostatic agents is advisable.
The use of buffered 20% ferric
sulfate solutions, such as Viscostat

Figure 4. Isolation with rubber dam, demonstrating caries
access and disclosure with a caries-indicating dye.
(Ultradent, South Jordan, Utah),
as a tool to control crevicular fluid
flow and inadvertent hemorrhage
can yield exceptional results.2s
Disposable quadrant triple trays
have been advocated for use in
impressing single teeth with conser-
vative preparations, but full arch
trays are recommended when mul-
tiple teeth, involving numerous
centric contacts and functional
cusps, are to be restored. Impression
materials, such as addition reaction
silicones and polyethers, yield the
best results for indirect resin inlay
systems, because they allow ade-
quate sterilization and can be
poured multiple times, enabling the
technician to predictably produce
multiple working and refractory
dies.29These materials traditionally
come in varying consistencies and
allow the clinician to capture the
fine detail of each preparation in a
light bodied “wash” material, while
maintaining tray stability and cap-
turing the surrounding dental struc-
tures in a heavier bodied “tray”
material. One product, Aquasil
(Dentsply/Caulk,Milford, Delaware),
offers an extra low-viscosity material
that may be appropriate for captur-
ing the highly complex geometry of
these preparations.
The goals of provisionalization for
indirect laboratory-processed resin
restorations include protection of
the underlying tooth, prevention of
tooth drift, maintenance of centric
holding areas, and restoration of
Figure 5. Mandibular right second molar conservatively
restored with a direct posterior composite and the final
preparations of the second premolar and molar for indirect
laboratory-processed resins.
BLANK
sufficient anatomy to permit rea-
sonable occlusal function during
the interim p e r i ~ d . A~ variety
~ ? ~ ~of
materials exists for the fabrication
of provisionals, ranging from tradi-
tional methylmethacrylates and
modern bis-acryl composites to
“soft-setting” proprietary formula-
tions that permit ease of placement
and removal without cementation.
It is the author’s preference to use a
light-cured provisional composite
material for provisionalization of
indirect resin inlays and onlays.
This material offers the advantage
of a full range of shades and pos-
sesses a thick viscosity that permits
freehand sculpting directly in the
preparation with traditional com-
posite instruments. It can be either
cemented with a eugenol-free provi-
sional cement or sealed in place
using a simplified technique. This
technique involves first, the applica-
tion of a commercially available,
non-fluoride-containing, desensitiz-
ing agent (Gluma Desensitizer,
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 SCIENTIFICALLY B A S E D RATIONALE AND PROTOCOL FOR
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Heraeus Kulzer, South Bend,
Indiana) over all exposed dentin
surfaces for 20 seconds and thor-
oughly air-dried. The purpose of
this step is to provide at least a
transient barrier to sensitivity by
the precipitation of plasma proteins
and d i ~ i n f e c t i o n .This
~~?~ step
~ may
increase comfort and does not
affect subsequent bonding steps at
~ e m e n t a t i o nIn
. ~the
~ case presented
here, Triad (Dentsplymrubyte) pro-
visional composite material was
pressed into the preparation, with
brief manipulation into centric
occlusion. Upon opening, the excess
material was carved away, and
additional anatomic refinement
was accomplished (Figure 6). Since
the material is light-cured and
has a stiff consistency, intimate
adaptation can be achieved prior
to light-curing. After photocuring,
additional occlusal and anatomic
refinement can be accomplished
with rotary composite finishing
instruments and silicone polishing
points and cups. Care must be
taken to avoid alteration of the
cavosurface margins during this final
adjustment. The final step was to
seal the open cavosurface margins
created by polymerization contrac-
tion of the composite with a highly
filled bonding resin (Permaquick
Resin, Ultradent) or low-viscosity
flowable composite. Without etch-
ing, the resin material was painted
into all cavosurface margins, which
may serve to seal the provisional
and add a secondary element of
retention (Figure 7). This technique
is advantageous in that it is quickly
and easily accomplished, it preserves
the interproximal and occlusal rela-
tions of the teeth, it permits reason-
able function during the interim
period with little to no discomfort,
it is highly retentive, and can readily
be removed in minutes by sectioning
with a nonend-cutting finishing bur,
at the delivery appointment.
In this case, belleGlass HP was
chosen as the restorative material.
Laboratory requirements included
preoperative selection of appropri-
ate tooth shades, creation of a full-
arch addition reaction silicone
impression, and fabrication of an
opposing model and silicone bite
index. Additionally, the author
prefers to have the laboratory cre-
ate the cavosurface margins in
translucent enamel material, which
facilitates a “chameleon” effect,
drawing in color from the sur-
rounding tooth. This additional
step facilitates invisible margins,
even with difficult, polychromatic
teeth (Figure 8 ) .
At the delivery appointment, the
patient is anesthetized and the pro-
visionals are removed with a com-
posite finishing bur (Midwest 7214)
under water spray. This process
involves sectioning the provisional in
blocks without completing the cut
to the cavosurface walls. The sec-
tioned pieces are “flexed” out with
a small spoon excavator (Figure 9).
This usually can be accomplished in
minutes without alteration of the
preparation, and for most patients,
it can be done comfortably while
the anesthetic is taking effect. To

Figure 6. Initial increment of the light-cured provisional Figure 7. Immediate postoperative view of the composite
material is sculpted into the preparations after placement of provisional restorations.
a desensitizing agent.

202 J O U R N A L OF ESTHETIC D E N T I S T R Y
 BLANK

Figure 8. belleGlass HP onlays demonstrating the clear cavo- Figure 9. A t the delivery appointment, the provisionals are
surface margins. sectioned and removed.

ensure proper isolation of the internally with rotary diamonds to c o l l e a g ~ e sand

bonding area, a rubber damn is
placed. Proper clamp selection is
imperative, and the retaining tines
must not impede the seating of any
of the restorations. Inverting the
rubber dam with individual tooth
ligation further enhances marginal
visualization, and provides the
maximum barrier to contaminating
fluids. The preparations are then
sandblasted with an intraoral
sandblaster and 50 micron alumi-
nous oxide, to physically remove
any contaminates from the
bonding surfaces.
ensure complete seating. The con-
tacts and embrasures are inspected,
and proper emergence profile is
confirmed (Figure 10). Each
restoration is then removed,
rinsed, dried, sandblasted, and
cleaned with a 37% phosphoric
acid solution to activate the inter-
nal surface. Silane is applied
liberally to the bonding surfaces
to potentiate a hydroxyl group
chemical bridge between the glass
filler particles and the luting
resins. This protocol is consistent
with the findings by Hummel and
, ~ ~ is believed to
generate the most reliable bond
between luting resins and laboratory-
processed hybrid restorations,
such as belleGlass HP.
The cementation procedure is the
most critical step in the process
and requires precise attention to
detail. Numerous bonding resin
systems exist, and each has its
own distinct guidelines for proper
cementation protocol. Several
important issues concerning proper
luting of indirect resin inlays and
onlays must be addressed.

The restorations are tried in with-

out a try-in paste, to facilitate ade-
quate visualization of each margin
and to ensure proper fit and contour.
The use of the Pic-N-Stic (Pulpdent,
Watertown, Massachusetts) or
Vivastick (Vident) is indispensable
for handling small restorations such
as these, and these can be angled to
simplify repeated insertions. Any
discrepancy is identified, and the Figure 10. The restorations are tried in dry to inspect accu-
restorations may be adjusted racy o f f i t .

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 SCIENTIFICALLY B A S E D RATIONALE AND PROTOCOL F O R
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First and foremost, clinicians must indirect restorative materials. Intro- products must have film thicknesses
select a resin cement that has a duction of cytotoxic materials into low enough to permit complete
chemistry compatible with the the pulp can produce sequelae that seating of the restoration, and that
dentin and enamel bonding agents range from transient pulpal inflam- their chemistry must be compatible
used. For instance, it is well docu- mation to complete and irreversible with the chosen resin cement system.
mented that self-curing primer sys- pulpitis. Additionally, even if cyto-
tems may accelerate the setting time toxic materials never reach the pulp, In the case presented here, all
of self-cure and some dual-cure it can be postulated that unpoly- surfaces of the preparations were
resin cement systems, owing to the merized adhesives may be forced treated with a 37% phosphoric acid
presence of residual tertiary amine into opened tubules by the pressure gel for 20 seconds. This concentra-
on the surface of the rimer.^^,^' created in seating an indirect tion permits proper dissolution
However, this can be prevented if restoration. This could disrupt the of enamel for mechanical retention
the appropriate decelerators are natural pressure gradient within the between exposed enamel prisms,
used. Additionally, some single-bot- pulpal fluid, and upon resin poly- and effectively removes the smear
tled primer and resin systems have merization, could seal these tubules layer and demineralizes 2 to 20
either inferior bond strengths or no in a suspended state of pressure. microns of the inorganic component
bond strength at all to self-curing Such prolonged pressure in the of the dentin substrate.s0-s2The gel
and dual-curing resin cement sys- dentinal tubules could be related to is rinsed vigorously from the teeth
t e m ~ .At ~ least
~ , ~one
~ novel system a variety of postoperative problems, with a combination of air and
has created a dual-cure additive ranging from thermal and pressure water spray for at least 5 seconds.
that, when mixed with the single- sensitivity, to more ominous condi-
bottled primer and resin, modifies tions, such as irreversible pulpitis. The benefits of “wet bonding” are
its chemistry and successfully bonds well established, and with certain
with most available resin cements. One study suggests that it may be adhesive systems, it is imperative
prudent to use adhesive systems that the dentin remain hydrated
Second, the efficacy and viability of that permit the complete polymer- prior to the application of an
the total-etch technique and its use ization of the primer and adhesive amphiphilic m o n ~ m e r . ~This
~J~
in conjunction with the application complex prior to crown place- hydration serves several functions.
of bipolar monomers and subsequent m e r ~ tThis, . ~ ~ in essence, would Collagen fibrils exposed during the
resins are well d ~ c u m e n t e d . ~ O > ~ ~ ensure that the tubules opened dur- demineralization process must be
However, some controversy exists ing the etching step would be sealed suspended in water to permit
as to the role of the hydraulic forces completely prior to the hydraulic proper resin infiltration between
created upon seating indirect loading pressure created during the fibrils of the intertubular
restorations, and the potential for restoration placement. Therefore, the dentin, and into the tubules and
unset monomers, particularly use of fourth-generation materials between the fibrils of the peritubu-
HEMA, to be forced into the pulpal that use a self-curing primer that lar dentin.s6s7 Such penetration
tissues of teeth that have undergone sets prior to the introduction of the into the perifibrillar spaces permits
total This can be clini- resin cement, or a fifth-generation adaptation of these bipolar
cally significant in adhesive and lut- product that permits complete monomers to microporosities cre-
ing resin selection for the placement light-curing prior to seating the ated by acidic demineralization of
of indirect laboratory-processed restoration, may be advantageous. the inorganic dentin substrate.s8
resin restorations, as well as other It must be reemphasized that these Additionally, recent studies indicate

204 J O U R N A L O F ESTHETIC D E N T I S T R Y

that solvents, such as acetone,
achieve the greatest depth of pene-
tration into these areas when the
dentin substrate is kept moist and
bond strengths are significantly
e n h a n ~ e d .Furthermore,
~~.~~ avoid-
ing dessication of the dentin allows
fluid in the dentinal tubules to be
kept in a relaxed state. This equilib-
rium must be maintained during the
entire adhesive process to prevent
the fixation of an unfavorable pres-
sure gradient within the tubules and
the subsequent stimulation of nerve
fibers postoperatively.61
Following the rinsing of the acid
etchant, proper hydration of dentin
can be accomplished by a variety of
procedures.62Regardless of the
method chosen, it is imperative that
the clinician inspect the dentin to
ensure that it is visibly moist but
does not have significant pools of
water. The “overwet” phenomenon,
as described by Tay and colleagues,
can significantly dilute the primer
and adversely affect the bond
interfa~e.~~
In this case, Prime and Bond NT
was chosen as the primer-adhesive.
This material is a dual-cured,
primer and adhesive combination
that, when combined with the Dual
Cure Additive (DentsplyKaulk),is
compatible with most self-cured
and dual-cured resin cements.38
Prime and Bond N T is an acetone-
based system that is approximately
2.5% filled by volume with a
nanoscale functionalized filler.64
With an ultralow film thickness of
5 to 8 microns, this material can be
completely light-cured on dentin
and enamel surfaces without com-
promising the complete seating of
an indirect r e ~ t o r a t i o nAs
. ~ ~men-
tioned, it is imperative to seal the
etched dentin surface completely, to
minimize the negative effects of the
hydraulic pressure created during
cementation. Three drops of Prime
and Bond N T were mixed with
three drops of Dual Cure Additive,
mixed with a microbrush, and
placed until saturation of the dentin
and enamel surfaces. After 30 sec-
onds, the adhesive layer was
thinned, using moisture- and oil-
free air. After close inspection to
ensure that there was no pooling in
the line angles of the preparations,
the primer resin layer was cured for
30 seconds with a halogen light
(Figure 11).Simultaneously, the
primer-adhesive and activator mix-
ture was applied to the bonding
surfaces of the onlays, and air-
thinned, but not cured.
Figure 11. The preparations have been etched, rinsed, and
lightly dried, and the dual-cured primer-adhesive has been
thinned and light-cured prior to cement loading.
BLANK
The resin cement chosen for this
procedure was Calibra (Densply/
Caulk). A dual-cured resin cement
with a film thickness of approxi-
mately 20 to 25 microns, Calibra
comes in five shades and can be
mixed with either of two viscosities
of dual-cure catalyst. The author
recommends using the translucent
shade base mixed with equal por-
tions of the low-viscosity catalyst.
Since most laboratory-processed
resin materials are opacious and
have thicknesses up to 5 mm, it is
nearly impossible to modify the
shade of the restoration by using a
shaded resin cement. Additionally,
the translucent shade is the most
sensitive to light initiation, and the
best choice for cementation for
onlays of this type. The low-viscosity
catalyst is recommended because
this consistency permits the best
adaptation to the complex geometry
of onlay preparations.
Equal portions of the catalyst and
base are mixed with a spatula and
V O L U M E 1 2 , N U M B E R 4, 2 0 0 0 205
 S C I E N T I F I C A L L Y B A S E D R A T I O N A L E A N D P R O T O C O L FOR
U S E O F MODERN I N D I R E C T R E S I N I N L A Y S A N D O N L A Y S
loaded into a Centrix tube and plug
cartridge (Centrix Inc., Shelton,
Connecticut). The cartridge is
loaded into the Centrix gun, and
the material is injected into the
preparations (Figure 12).This tech-
nique allows for uniform distribu-
tion of the cement within the
preparations, ensuring the best
adaptation to all aspects of the cav-
ity walls. The onlays are then
seated completely, and the bulk of
excess cement is removed with a
rubber-tipped instrument. The ini-
tial polymerization is initiated by
3 to 5 seconds of light polymeriza-
tion. During this period, the resin
cement begins to gel, and the
remaining excess can be removed
by a sharp curette, floss, or a No.12
disposable scalpel (Figure 13).Once
the restorations have been com-
pletely cleared of excess luting
resin, a generous coat of glycerin is
painted over all exposed margins
and subsequently light-cured from
all angles for 1 to 2 minutes to
eliminate the air-inhibited layer.
Figure 12. The dual-cured resin cement is applied via a Cen-
trix tube to ensure proper coverage.
206 ,JOURNAL OF ESTHETIC DENTISTRY
The rubber dam is then removed,
and any necessary occlusal adjust-
ments are accomplished with
rotary composite finishing instru-
ments. Margination of the onlays
and the final polish is best per-
formed with silicone points and
cups and composite polishing
pastes. As a final step, the entire
restoration and marginal surfaces
should be etched and sealed with
an unfilled resin sealant, to fill in
all microcracks created during the
adjustment process.6s
It has been suggested that such
treatment may significantly reduce
the wear values of most indirect
resin systems. Figure 14 demon-
strates the restorations at the 1-year
recall. Note that the color, form,
and fit of the onlays and the direct
posterior composite demonstrate
exceptional clinical results. The
patient has not reported any post-
operative sensitivity, and the success
of these restorations appears
promising.
Figure 13. The restorations are seated and “tacked” into
place with minimal halogen light exposure, and initial excess
cement removal is accomplished.
CONCLUSIONS
Historically, there has been signifi-
cant interest in using materials that
allow dentists not only to conserva-
tively restore badly broken-down
posterior teeth but also to return
them to their original appearance.
Recent advances in adhesive technol-
ogy, as well as in material science,
have opened the door to a myriad
of alternatives to accomplish that
goal. Modern indirect laboratory-
processed resin restorations not only
are capable of meeting the esthetic
demands of both patients and practi-
tioners but also meet most of the cri-
teria for an ideal restorative material.
Indirect laboratory-processed resin
restorations permit a conservative
approach to cavity design; optimally
restore the morphology and the
original mechanical resistance of the
tooth; can be adequately adapted to
the preparation to ensure an ade-
quate seal that will prevent recur-
rent decay, pulpal injuries, and
dentinal sensitivity; and when prop-

Figure 14. The restorations at the 1 -year recall.
erly processed, can be biologically
compatible with the underlying
substrate and surrounding tissues.
Unfortunately, indirect resins have
yet to be clinically proven to pro-
vide satisfactory longevity, owing to
their recent introduction to the pro-
fession. Early reports from ongoing
in vivo studies indicate that indirect
laboratory-processed resin restora-
tions are likely to be successful.
This, of course, is corroborated
with numerous in vitro tests.
Though no one material can be rec-
ommended for every clinical circum-
stance, with proper case selection
and technique, indirect laboratory-
processed resin restorations can be
a successful adjunct to existing
posterior restorative techniques.
DISCLOSURE A N D
ACKNOWLEDGMENT
The author thanks Greg Vesley,
CDT, of Gold Dust Dental
Laboratory, Tempe, Arizona, for
the fabrication of the laboratory-
processed resin restorations
described in this article.
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