The first time I repaired a broken anterior tooth with a bonded class IV composite was in the late 80s, in dental school. I was worried it wouldn’t last, and the professors appeared equally skeptical. Sadly, a few weeks later, the composite failed, and I was instructed to cut the remaining healthy enamel and considerable dentin away to make room for a PFM crown; it was a sobering experience.
Almost 20 years earlier, engineer Ray Bertolotti was working on developing ceramics that would eventually be bonded to rockets for heat insulation, protecting the lives of American astronauts. During my first few years as a dentist, I listened to many of the star educators of the time talk with excitement about adhesive restorations, direct and indirect, always considering them for only selected cases and with many contraindications, and always suggesting to include some mechanical retentive features, “just in case.” In the early 90s, still a wide-eyed young dentist, I remember listening to now Dr. Bertolotti speak about adhesion with the confidence of a man who fully understood it and trusted in it (Figure 1). I remember going back to my office to duplicate the novel techniques he taught and finding they worked. His influence sparked in me, as it did with thousands of dentists, the love for adhesive dentistry. In time, I discovered how properly used adhesive dentistry would permit supra-gingival minimally invasive restorations, which became my passion and led me to launch the LA Institute of Clinical Dentistry in 2005, where we teach workshops on advanced adhesive restorative dentistry.
In this article, cases 1 and 2 demonstrate how using bonded composite with absolute trust in adhesion, combined with the proper materials and techniques, can turn extremely complex cases into simple bonded procedures for the benefit of dentists and patients.
As discussed in a previous article for Dentistry Today,1 minimally invasive bonded bridges could easily replace the use of implants as the first choice of treatment for missing anterior and posterior teeth because they are less invasive and current research shows impressive durability, possibly surpassing that of implants.2-4 Success with bonded bridges greatly depends on the ability to bond to zirconia reliably. While the profession continued to struggle with the idea of bonding to zirconia, many believing it is not possible or predictable, Dr. Bertolotti continued to develop clever tools and materials needed to perform better adhesive dentistry (he ultimately founded Danville Engineering, which he later sold to Zest Dental Solutions). Dr. Bertolotti has been teaching predictable techniques to bond to zirconia for decades, again with the understanding of a man who knows how it works. Case No. 3 exemplifies how bonded bridges can be a better choice than an implant in certain cases, and finally, case No. 4 demonstrates how advanced adhesion can turn a complex case into a simple adhesive case.
CASE 1
A male in his early 50s, who, due to fear and cost, has allowed his dentition to deteriorate to the point that he is extremely unhappy about his appearance, making him become reclusive and depressed. The patient is a mailman with good insurance but limited out-of-pocket funds. He has been told he needs root canals, posts, and crowns, plus some crown lengthening on most of his teeth, with a cost of tens of thousands, which he couldn’t afford (Figure 2). A local dentist referred the patient to me, knowing that I tend to have simple alternatives to complex problems. After proper records and diagnosis, I treatment planned direct composite restorations, with basically no preparation or root canals needed. Bonded porcelain restorations with absolutely minimal preparation were also offered as the ideal, more durable option, but the patient accepted direct composite due to cost. The case required opening the vertical dimension, and the patient was offered the option of long-term onlay temporary restorations to delay posterior restoration, which could be done slowly using his insurance. As of today, this case is almost 10 years old, and the referring dentist reports that the restorations are still in his mouth (Figure 3). The step-by-step process of the bonded composite restorations will be shown in case No. 2. The importance of this case is to demonstrate how trust in adhesion, combined with proper technique, can provide simple solutions to complex problems.
CASE 2
A male in his 60s was seeking to improve his smile, but again, cost was an issue. He wished to close the diastemas and improve the color (Figure 4). Direct composite veneers were diagnosed and approved. Our protocol calls for smile design5 and occlusal analysis6 to ensure durable results that the patient will love, and a wax-up constructed to those specifications. Study models were made using a hydrophilic alginate substitute, Silginat (Kettenbach). Building 6 direct composite veneers freehand with accurate incisal edge position, ideal lingual surfaces, and good occlusion is a daunting task and can easily take several hours; thus, an LA Institute design silicon matrix was fabricated from the ideal wax-up, using Panasil Putty (Kettenbach) only wrapping 1 mm up the incisal edge (Figure 5). Using this matrix accelerates the procedure, as the shape of the lingual surfaces, incisal length, position, and occlusion will be established with the matrix.
OMNICHROMA (Tokuyama Dental America) is a highly sophisticated material with multiple benefits. Its chameleon effect design allows for an unreal color match, with ideal consistency for sculpting, and it is designed to give clinicians time to sculpt even with ambient light. Because of the large diastema, the silicon matrix was used as a guide for minimal preparation while breaking contacts needed for symmetry (Figure 6). All 6 teeth were etched for 25 seconds using Ultra-Etch 35% phosphoric acid (Ultradent) (Figure 7), washed and dried until enamel looked frosted, then primed and bonded all 6 teeth at the same time using Clearfil SE Protect (Kuraray America). OMNICHROMA was used to build the entire missing tooth, including incisal edges, and was applied directly to the silicon matrix, estimating how much material would be needed. The matrix was seated on the mouth, and all teeth were built simultaneously using the matrix as a guide. The matrix allows for an accurate formation of the lingual surfaces, interproximal and incisal edge in a few minutes. The trick is partial curing of the composite, allowing the composite to get hard without maximum hardness, which permits separation of the teeth using a CeriSaw (DenMat) (Figure 8). The facial finishing and interproximal repairs are more artistic and take the longest. After building the entire tooth with OMNICHROMA, which closely matched the color of the patient’s natural teeth, I used a very thin layer of Estelite A1 (Tokuyama Dental America) to lighten the shade a bit. Usually, a 6 direct veneer case should be done in 1.5 hours using this system that was developed and taught at the LA Institute. The patient was extremely satisfied (Figure 9).
CASE 3
A 24-year-old male had an implant placed by a periodontist, which unfortunately failed, causing severe periodontal loss, leaving the left maxillary central with 50% bone loss and mobility of 2+ (Figure 10). The patient was referred to me wearing a stay plate, but the patient wanted a fixed solution without implant surgery. A cantilever bonded bridge with the retention wing on the left maxillary canine as abutment was presented and accepted. The preparation design developed by Kern7 asks for a minimum of 0.7 mm thick retention pad with a retention surface of a minimum of 30 mm² and a connector of a minimum of 2 mm by 3 mm when using 3Y zirconia. Additionally, he recommended that a depression be created on the proximal areas where the connector will be, which can function as both a positioning feature and a means of reenforcing the connector. I like to draw the outline with a pencil, ensuring proper connector size to avoid facial exposure of the zirconia (Figure 11). This is followed by using a No. 2 round bur at a 45° angle to give me an approximately 0.7-mm depth, followed by horizontal depth groves. Finally, a large diamond (6856-025 Brasseler) is used to connect all the depth groves. This preparation can be done without anesthesia as the preparation is mostly on enamel. The patient does not need a temporary restoration and will use the stay plate.
The bonded cementation of the bridge is equally simple. Once the bonded bridge has been tried in the mouth, verifying good fit and the patient’s aesthetic approval, the APC concept8 for zirconia adhesion will be used. The “a” in APC stands for air abrade with 30µm to 50µm aluminum oxide, in my case, using the MicroEtcher (Danville/Zest Dental Solutions) (Dr. Bertolotti’s invention). The “p” is for prime the zirconia using an MDP primer (Ceramic Primer [Kuraray America]) and the “c” stands for resin cement. We can use any dual-cure resin cement if we use a MDP containing primer on the zirconia. I used Panavia V5 (Kuraray America). The patient was very satisfied with the results; the bonded bridge has been in the mouth for 3 years with zero complications (Figure 12).
CASE 4
A 32-year-old male from South America presented with a desire to enhance his smile and would consider porcelain veneers. Three things made this case complicated. He was congenitally missing laterals, and his canines were moved orthodontically into the lateral position, but the canine space was not closed. In the right maxillary canine position, he had an unaesthetic implant-supported crown. He was unaware of the implant brand and his dentist in South America was unreachable. Plus, based on my research, the parts are not available in the United States. Finally, on the left canine site, he had convergent roots as a consequence of orthodontics. Thus, an implant was impossible, so he had a direct composite bonded bridge which, according to the patient, didn’t last long (Figure 13). He was referred to me by a local dentist who found the case complicated. This case exemplifies how adhesive dentistry makes complex cases simple. After proper records for diagnosis were done, I presented porcelain veneers on 4 teeth, including veneering the implant crown and a 3-unit bonded bridge with a facial veneer retention wings design from the left lateral to the first premolars. After simple veneer preparation on all teeth, a slight modification was made to the surfaces proximal to the pontic. The proximal surface must be flattened, thus extending the cavo-margin of the retention wing to the proximal-lingual transitional line to allow for the maximum connector size and to draw with the other abutment (Figure 14). Additionally, the canine had to be made narrower to appear to be a lateral. Provisional restorations were fabricated using a silicon matrix (Panasil Putty) made from the wax-up and using Visalys Temporary material (Kettenbach), a very strong and aesthetic provisional material.
All restorations were made out of IPS e.max Press MT (Ivoclar), my usual choice with anterior cases. Attention must be placed on having thick connectors to avoid fractures, which I have not experienced on any of my restorations to date. The protocol for preparing IPS e.max porcelain for adhesion is a 20-second hydrofluoric Porcelain Etch (Ultradent) of the intaglio surface. The IPS e.max etch surface is then primed using Ceramic Primer (Kuraray America), the same primer as zirconia because, guided by technical advice from Dr. Bertolotti, Kuraray developed a ceramic primer capable of priming all ceramics. Based on my research on the tooth surface, I selectively etch the enamel for 5 seconds using Ultra-Etch (Ultradent) and Clearfil SE Protect (Kuraray America) as the bonding system.9 In this case, I used 3M Veneer Cement shade A1 (Solventum). The only significant variation in this case was the cementing of a veneer on top of an implant crown. Because the crown was a layered PFM, I used Porcelain Etch for 60 seconds, followed by EtchArrest (Ultradent), an etch neutralizer so that we could wash the etch without risks or water contamination. After washing and drying the etch, the porcelain will look chalky (Figure 15), apply Ceramic Primer (Kuraray) to that surface, followed by cementing the restoration. Note that the intraoral porcelain adhesion is extremely strong. To date, this case has been in the mouth for 5 years with zero complications (Figure 16).
CONCLUSION
Adhesion works. If it fails, additional training may be needed. But when used correctly, it makes restorative dentistry more minimally invasive, supra-gingival, faster, more predictable, and more beautiful. Dr. Ray Bertolotti is a pioneer in the field of adhesive dentistry influencing the profession and thousands of dentists as he did me. This article is meant to honor his many contributions.
REFERENCES
1. Ruiz JL, Bertolotti R. Minimally invasive bonded bridges vs implants. Dent Today. 2023;42(1):72–5.
2. Froum SJ. Chapter 1: Implant complications: scope of the problem. In: Froum SJ, ed. Dental Implant Complications. Wiley-Blackwell; 2010: 1-6.
3. Derks J, Schaller D, Håkansson J, et al. Effectiveness of implant therapy analyzed in a Swedish population: prevalence of peri-implantitis. J Dent Res. 2016;95(1):43–9. doi:10.1177/0022034515608832
4. Kern M, Passia N, Sasse M, et al. Ten-year outcome of zirconia ceramic cantilever resin-bonded fixed dental prostheses and the influence of the reasons for missing incisors. J Dent. 2017;65:51–5. doi:10.1016/j.jdent.2017.07.003
5. Ruiz JL. Achieving optimal esthetics in a patient with severe trauma: using a multidisciplinary approach and an all-ceramic fixed partial denture. J Esthet Restor Dent. 2005;17(5):285–91; discussion 292. doi:10.1111/j.1708-8240.2005.tb00131.x
6. Ruiz JL. Achieving longevity in esthetics by proper diagnosis and management of occlusal disease. Contemp Esthet. 2007;11(6);24-30.
7. Kern M. Resin-Bonded Fixed Dental Prostheses: Minimally invasive – esthetic – reliable. Quintessence Publishing; 2018
8. Blatz MB, Alvarez M, Sawyer K, et al. How to bond zirconia: the APC concept. Compend Contin Educ Dent. 2016;37(9):611–7.
9. Endo T, Finger W, Ruiz JL. Conventional and self-etching adhesive effects on retention of luting resins. Presented at: 2005 IADR/AADR/CADR General Session; March 12, 2005; Baltimore, MD. https://iadr.abstractarchives.com/abstract/2005Balt-58298/conventional-and-self-etching-adhesive-effects-on-retention-of-lut
ing-resins
ABOUT THE AUTHORS
Dr. Ruiz is 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 in addition to 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.
Dr. Bertolotti received his DDS degree from the University of California, San Francisco, after working as a PhD metallurgical and ceramic engineer at Sandia National Laboratories. He is perhaps best known for introducing “total etch” to North America in 1984. He also introduced Panavia in 1985, tin plating in 1989, self-etching primers in 1992, and HealOzone in 2004. He is the co-founder of Danville Materials (now part of Zest Dental Solutions) and was director of research at the company. The sectional Contact Matrix System, MicroPrime B, MicroEtcher sandblasting, and intraoral tin plating are also his developments. He is a well-known international lecturer, having presented at invited lectures in more than 30 countries. He can be reached via email at rbertolott@aol.com.
Disclosure: The authors report no disclosures.
FREE CE WEBINAR
Dr. Ruiz will be hosting a webinar that will expand on this article.
It’ll happen on August 21 at 7 PM (Eastern Time).
