INTRODUCTION
From the time I became a dentist 3 decades ago to the present, dentistry has undergone dramatic changes in many ways. One of the most important ones is the development of advanced dental materials, including adhesives. Three decades ago, most restorations had to be retained by friction and mechanical retentive features. Dentists had to be very diligent and spend considerable time cutting tooth preparations with the correct amount of taper, parallelism, or undercut to ensure the restorations would stay on the tooth. Geometric preparations require healthy tooth structure to be removed in order to achieve these geometric designs; understandably, additional tooth removal sometimes leads to more postoperative sensitivity and the possibility of root canal procedures. Also, older dental materials, like amalgam, require a certain thickness to have sufficient strength or to be layered on top of the metal coping to gain strength, needing more space like a PFM restoration needing a minimum of 1.5 to 2 mm of thickness; this necessitates more healthy tooth structure removal. Dental cements were mostly luting agents without the ability to adhere strongly to the tooth or restorative material, reinforcing the need for geometric preparation. On badly damaged teeth, complicated and time-consuming buildups using pins and posts were needed to ultimately achieve the desired geometry. Additionally, older-generation porcelains were weak and with limited aesthetic flexibility, sometimes requiring time-consuming buildups to improve aesthetic results. Looking back at the dark ages of dentistry, the net result was time-consuming, complicated, and unpredictable dental procedures, which required excessive tooth removal, leading to post-op sensitivity and occasionally unplanned root canals. The power of adhesive dentistry makes all of the above null!
In this enlightened time in dentistry, where most of the old dental materials have been replaced with sophisticated and technologically advanced adhesives; cements; super strong and highly aesthetic porcelains; and composites, can we honestly say that dentistry is faster, easier, less painful, prettier, problem-free, and more durable than in former times? In my observation, the answer is usually no, mainly because adhesive dentistry is not being used correctly or to its maximum capacity. In my opinion, there are 3 things holding dentistry back from universally benefiting from adhesive dentistry: (1) the lack of trust and understanding of adhesion; (2) subgingival margins and adherence to old preparation principles; and (3) groups teaching extremely complicated techniques that have turned dentists away from adhesive dentistry, like the biomimetic group. Two clinical cases will demonstrate how adhesive dentistry magic can and should make dentistry easier for the patient and the clinician while also faster, prettier, and more durable.
The Enemies of Adhesive Dentistry
First, the lack of trust and understanding in adhesive dentistry undermines the ability of dentists and patients to benefit from the power of adhesives. A good analogy of not benefiting from adhesives would be drilling a hole in the wall and buying and using an anchor or finding a stud to hang a frame/picture when we can use a 3M Command strip that can be applied to the wall in seconds and hold a frame with ease. Similarly, a dentist can spend 30 minutes drilling away healthy tooth structure to create resistance, retention, undercuts, boxes, ferrules, or buildups for mechanical retention when adhesives can instantly replace all of the above.
Second, many dentists have stories of bonded restorations falling off or leaking, and this has turned them away from adhesive restoration, plunging them back into the mechanical retention era. The number one enemy of adhesive dentistry is bleeding1 and contamination, which severely affects adhesion and seal. Using supragingival techniques will prevent bleeding gums and make adhesive dentistry a breeze.2 Having a clean, uncontaminated tooth means using a proper protocol for tooth preparation, tooth cleaning, and proper isolation; it does not mean that the use of a rubber dam is mandatory,3 which leads me to No. 3.
Third, it is my personal belief that adhesive dentistry is far less popular because some well-known institutes and academics, striving for perfection, have made adhesive dentistry very demanding, convoluted, and time-consuming, thus turning many dentists away from it. Demands like mandatory rubber dam isolation, ultrasonic tools to create perfect bevels, excessive increments and inserts to fill a cavity, immediate dentin sealing, and other demanding and marginally useful procedures that the academics consider “indispensable to achieve the absolute best results” are unrealistic. “The absolute best” is an elusive, unnecessary, and often unattainable mission. Do we all need to walk around with 10 lbs of Nikkon SLR cameras and special lenses and take 2 hours to stage the perfect setting to get “the absolute best photo” when we can use our iPhone 13 and take almost identical photos in seconds? It is usually a matter of ego.
The Benefits of Adhesive Dentistry
Just like adhesion and technology have made it much faster and easier to hang a frame or take a photo, when properly used, adhesive dentistry should make dentistry easier, faster, more predictable, and less painful. Adhesive dentistry results in less collateral damage than traditionally mechanically retained dentistry, which benefits clinicians and patients. The following 2 cases illustrate these facts.
CASE REPORTS
Case 1
A 75-year-old female patient presented with a crown fractured off of a mandibular second molar (Figure 1). Her multiple health conditions made her very apprehensive about receiving anesthesia and more hypersensitive about long, painful dental procedures. The patient was reassured that by using adhesive dentistry, we would have to do so little tooth drilling that we could do it without anesthesia. The treatment offered was a fully adhesive, 5-surface onlay without any mechanical retention. The patient accepted the treatment.
Figure 1. The crown fractured off almost at the gum level.
This procedure perfectly exemplifies the advantages of adhesive dentistry. Without the need for resistance, retention, or ferrules, the preparation was limited to caries removal and ensuring clearance for the chosen material: IPS e.max HT (Ivoclar). Understanding that the standard of care in dentistry is to do minimally invasive caries removal,4 we used Caries Detector (Kuraray) to evaluate if there was any highly demineralized dentin or enamel (Figure 2), and no caries were identified. This can be followed by impression with Panasil (Kettenbach). But, in this particular case, it was scanned using a 3Shape Scanner. No provisional was made as the tooth was not sensitive, the patient was used to not having a tooth, and not much movement was expected as the crown had been gone for a while. Nevertheless, to minimize any tooth movement or loss of space, we requested the restoration to be done in a rush. It is important to highlight that the supragingival, minimally invasive approach avoids subgingival margins,5 making adhesive cementation very simple.
Figure 2. Caries Indicator (Kuraray) was used to uncover highly demineralized dentin and enamel.
The final restoration was fabricated by Prestige Dental Lab (Studio City, Calif) and the cementation procedure was almost as simple as the preparation. After ensuring the contacts were correct, the intaglio surface of the restoration was etched with Porcelain Etch buffered 9% hydrofluoric acid (Ultradent Products) for 20 to 25 seconds, thoroughly washed with water, and made bone-dry. This step was followed by coating the intaglio with MDP-containing Ceramic Primer (Kuraray). No additional steps were needed for the porcelain. Because the tooth had been exposed to the mouth environment, excellent cleaning was essential. First, we cleaned impurities using Consepsis Scrub (Ultradent Products) and a rubber cup. Additionally, I like to use my course diamond to scratch or lightly sand the surface and, in some cases, remove remnant temporary cement. After the tooth was properly cleaned, the enamel was selectively etched using Ultra-Etch etchant 35% phosphoric acid (Ultradent Products) for 10 seconds, thoroughly washed with water, and dried until the enamel looked frosted.
Immediately after washing and drying, we avoided saliva contamination by immediately inserting multiple cotton rolls for isolation. If we are prepared and have a well-trained dental assistant, the following cementation steps will take approximately 2 minutes total, diminishing the time we must maintain the isolation. On a well-isolated dry tooth, we will apply the primer or first bottle of CLEARFIL SE Protect (Kuraray) for 20 to 25 seconds, agitating the dentin but applying it over the entire area to be bonded, including enamel, followed by proper evaporation of the solvent using dry air. The second bottle or bond will then be painted thinly over the enamel and dentin but not cured yet. Resin cement (Panavia V5 [Kuraray]), will be generously applied over the restoration, and the restoration will then be seated. Gross cement excess should be removed, followed by a half cycle of light curing on the facial and the same on the lingual. The intention is to avoid over-curing so that cement removal is simple. Also, partial light curing of the resin cement decreases polymerization shrinkage,6 an important enemy of adhesion. Attention should be placed on ensuring the cement is hard before starting the cement removal process, and if need be, one more partial cure should be done. My favorite instrument for removing cement is the No. 12 blade, as it removes the cement at the margin level without taking chunks, as a scaler could do. If the floss doesn’t go through, I will use CeriSaw (DenMat), an indispensable instrument when using resin cements, as it goes through the contacts in seconds but does not damage them. After entirely removing the excess cement, a final cure is essential. I use KY jelly as an oxygen inhibitor.
Figure 3. Immediately after cementation of the supragingival restorations (notice the lack of bleeding).
The final step is proper bite adjustment using the 3 Golden Rules of Occlusion.7 The patient was delighted with the results and appearance of the restoration, although it was in a place where appearance is less critical (Figure 3). Based on my experience and the literature,8 this restoration will last for many years, if not decades.
Case 2
A 47-year-old female presented with a crown fractured off of her right maxillary central. She did not have the crown—she swallowed it. As evident in the preoperative photo and x-ray (Figures 4 and 5), there was very little remaining tooth structure and lingual enamel. It is worth mentioning that this is a recurring problem when dentists prepare the teeth for crowns and remove all or most of the enamel. The teeth are left weak, and with years of use, the dentin fractures, leaving the patient with challenging options. The recommendation was a bonded crown. She accepted.
Figure 4. Fractured crown with minimum remaining tooth structure.
Figure 5. X-ray showing the severity of the fracture.
Taking full advantage of the power of adhesive dentistry, no additional tooth removal, preparation, or buildup was done. Some academics may insist on doing extensive buildups, which in my opinion have no purpose. First, bonding porcelain directly to the tooth will always give higher adhesion and retention than a flexible composite buildup, and the idea of doing a bonded buildup to create a mechanical retentive preparation is just counter to reason. Secondly, a composite buildup to achieve better color is unnecessary if we understand that advanced modern porcelains like IPS e.max have color characteristics that allow for considerable tooth color masking with a little more than 0.5 mm thickness and, at the same time, offer the appearance of translucency, allowing for simple and beautiful results. An exception to this would be a severely dark tooth.
Figure 6. A lingual view of the fracture showing the very minimal amount of enamel that remained.
Figure 7. Demonstrating how compression eliminates bleeding and it has no time limit.
Because the previous crown had been prepared with subgingival margins, cord was placed to allow the cavo-margins of the facial preparation to be fully visible by the 3Shape scanner. Because the patient presented without a tooth and with no time for a wax-up, a chairside provisional was made using OMNICHROMA (Tokuyama). OMNICHROMA, with its easy handling and color, allowed for the full reconstruction of the tooth to be done in 2 simple increments: a blocker for the lingual surface and OMNICHROMA for the rest of the tooth. No adhesive was used to allow for easy removal at the time of cementation. The final restoration was made out of IPS e.max MT (Ivoclar) and created by Prestige Dental Laboratory. Because this case had subgingival margins, we had to deal with some papilla bleeding (Figure 6). Compression is usually a great way to manage a bleeding papilla. It can be accomplished either by compression with the finger or an instrument, and it is usually better than a cord or laser as it has no time limit and is very predictable (Figure 7). The bonding and porcelain protocol used was almost identical to the previous case except that I used RelyX Veneer Cement (3M) shade A1, which has been my preferred veneer cement for many years. The patient was very satisfied (Figure 8).
Figure 8. The final IPS e.max (Ivoclar) restoration cemented.
CONCLUSION
Using adhesive dentistry to its fullest capacity completely revolutionizes dentistry. It provides the patients and the dentist with endless benefits; makes procedures easier, better, faster, and less painful; and results in less collateral damage. I have yet to have a patient complain that the procedure was done too quickly or too painlessly. As in the 2 cases above, the patients are usually very happy, with no post-op pain or complications.
REFERENCES
- Ruiz JL. Supragingival dentistry using metal-free restorations. Dent Today. 2008;27(10):104–9.
- Ruiz JL. Anterior and posterior partial-coverage restorations using supra-gingival dentistry. J Mass Dent Soc. 2012;61(2).
- Reich SM, Wichmann M, Rinne H, et al. Clinical performance of large, all-ceramic CAD/CAM-generated restorations after three years: a pilot study. J Am Dent Assoc. 2004;135(5):605–12. doi:10.14219/jada.archive.2004.0248
- Dhar V, Pilcher L, Fontana M, et al. Evidence-based clinical practice guideline on restorative treatments for caries lesions: A report from the American Dental Association. J Am Dent Assoc. 2023;154(7):551—66. doi:10.1016/j.adaj.2023.04.011
- Ruiz JL. Avoiding subgingival margins for healthier dentistry: using a supragingival preparation protocol. Dent Today. 2015 Oct;34(10):82–6.
- Yoshikawa T, Burrow MF, Tagami J. The effects of bonding system and light curing method on reducing stress of different C-factor cavities. J Adhes Dent. 2001;3(2):177–83
- Ruiz JL. The three golden rules occlusion. Dent Today. 2010;29(10):92–3.
- Malament KA, Natto ZS, Thompson V, et al. Ten-year survival of pressed, acid-etched e.max lithium disilicate monolithic and bilayered complete-coverage restorations: Performance and outcomes as a function of tooth position and age. J Prosthet Dent. 2019;121(5):782–90. doi:10.1016/j.prosdent.2018.11.024
ABOUT THE AUTHOR
Dr. Ruiz is the founder of the Los Angeles Institute of Clinical Dentistry, former course director of the University of Southern California’s Esthetic Dentistry Continuum, associate instructor at Gordon J. Christensen Practical Clinical Courses in Utah, and an independent evaluator for Clinicians Report. He is the author of Supra-Gingival Minimally Invasive Dentistry with Dr. Ray Bertolotti and of many research and clinical articles. He has been named as one of Dentistry Today’s Leaders in CE since 2006. He is also in private practice in the Studio District of Los Angeles. He can be reached at drruiz@drruiz.com.
Disclosure: Dr. Ruiz reports no disclosures.
