6
Composite Resin: Indirect
Technique Restorations
Ross Nash and Richard D. Trushkowsky
BASIC CONCEPTS
In some situations indirect composite resin restorations offer
distinct advantages over direct composite resin restorations.
When a composite resin is polymerized, polymerization
shrinkage occurs in the resin matrix. With the direct tech-
nique, such shrinkage can cause a marginal gap where the bond
strength is the weakest, such as at the dentin-composite resin in-
terface. When composite resin is polymerized in the laboratory
by light, heat, or other methods, the shrinkage occurs before the
restoration is bonded into place, thus only a thin layer of luting
composite resin is subject to shrinkage at the tooth-restoration
interface. This results in less marginal gap, which reduces the
likelihood of marginal leakage, sensitivity, recurrent decay, and
staining. In addition, studies have shown that some laboratory
techniques (such as those that use pressure or vacuum plus heat
or light catalysts and those that use heat processing after or
simultaneously with light) produce a greater degree of polymer-
ization than that achieved with light alone.1-4 Thus the physical
properties of tensile strength and hardness may be improved,
providing for longer lasting and stronger restorations.5
Indirect techniques allow the dentist to incorporate the skills
of the cosmetic dental laboratory technician. The rapid advances
in composite resin technology have produced materials that can
rival the beauty of porcelain, and solve some of the problems as-
sociated with this time-proven material. For example, porcelain
is harder than tooth structure and can cause it to wear during
function. Composite resin does not cause accelerated wear of
opposing natural tooth structure. Also, after porcelain has been
bonded into place, it is difficult to return the surface to the origi-
nal luster after an adjustment. Composite resin can be adjusted
and repolished easily. Laboratory-processed composite resin can
be repaired with light-cured composite resin.
Compared with other techniques, indirect techniques may
allow better control over interproximal contours and contacts;
and, although meticulous attention to detail is important, indi-
rect composite resin procedures may be less technique sensitive
than direct ones.
BASIC CHEMISTRY
All composite resins are composed of filler particles in a resin
matrix. The filler particles may range in size from 0.04 mm to
over 100 mm. They provide the strength, and the resin matrix
binds them together and bonds them to the tooth structure. The
filler material may be very small silica particles, as in microfilled
composite resins, or larger quartz or glass particles, as in small
particle composite resin and hybrid composite resins. The resin
matrix may be composed of bisphenol A diglycidyl ether meth-
acrylate resin (introduced by Ray Bowen in 1962), urethane
dimethacrylate, or similar polymers. Many combinations of
resin and filler particles have been tried. In general, the higher
the filler content (expressed as a percentage of weight), the
greater the strength, and the smaller the filler particles, the
greater the surface polishability.6,7
COMPOSITE RESIN SYSTEMS
Three types of composite resin material are available for use in
indirect techniques: microfilled composite resins, small particle
composite resins, and hybrid composite resins (Table 6-1). All
show excellent wear resistance, but small particle composite
resins and hybrid composite resins can be etched to produce
micromechanical retention. They also can be silanated to en-
hance the bond strength. None of the current systems has
proved superior to the others, and all produce good results when
used properly.
In the mid 1990s a new category of processed composite
resin was introduced. Polymer-glass, polymer-ceramic, and
109
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PART 3     E s t h e t i c M a t e r i a l s a n d Te ch n i q u e s

Table 6-1  ​Composite Resin Systems

Composite Curing Type of
Name Manufacturer type Resin type method fabrication Use

Sinfony 3M ESPE Ultra-fine particle Mixture of aliphatic Light Indirect Crowns, inlays, onlays, laminate veneers,
hybrid composite and cycloaliphatic veneers on metal substructure, glass-
monomers fiber reinforced bridges

Gradia GC America, Inc. Micro-fine, Urethane Light Indirect Crowns, inlays, onlays, laminate veneers,
ceramic/ dimethacrylate veneers on metal substructure, glass-
pre-polymer filler fiber reinforced bridges

Tescera Bisco, Inc. Microhybrid Heat, light and Indirect Crowns, inlays, onlays, laminate veneers,
ATL pressure veneers on metal substructure, glass-
under water fiber reinforced bridges

Ceramage Shofu Dental Zirconium silicate UDMA resin Light Indirect Crowns, inlays, onlays, laminate veneers,
Corp. micro ceramic veneers on metal substructure, glass-
PFS (Progressive fiber reinforced bridges
Fine Structure)

cercomer (ceramic-optimized polymer) are all terms used to
describe these materials. In reality, they are all composite resins
with improved properties. Several systems also have incorpo-
rated fiber reinforcement to allow fabrication of metal-free fixed
partial dentures.
Premise Indirect
Premise Indirect (Kerr Corp.) dual cure indirect polymer-
ceramic is a low-wear, high-strength microhybrid for inlays,
onlays, anterior veneers, implants, full coverage crowns, metal-
free fixed partial dentures, long-term provisional restorations, or
splints. The opalescence of Premise Indirect is reported to
achieve optimal shade matching capabilities. Trimodal curing
(light, heat, and pressure) achieves over 98% material conversion
as compared to 60% to 70% achieved with light-cure only mate-
rials. The material is a combination of large prepolymerized
filler particles, 0.4 micron structural filler, and small silica
nanoparticles that allow higher filler loading, improved physical
properties, optimized handling, higher surface gloss, and
reduced polymerization shrinkage. The coefficient of thermal
expansion is similar to natural dentin and the wear rate over a
5 year period was similar to that of tooth structure. A reinforcing
fiber material of woven polyethylene braids coated with a reac-
tive monomeric solution that allows the product (Connect, Kerr
Corp.) to be bonded to a resin based crown and fixed partial
denture substructure by the application of heat is recommended
for use in metal-free fixed partial dentures made with Premise
Indirect.
Sinfony
Sinfony (3M ESPE), an ultrafine particle composite resin (or ul-
trafine particle hybrid composite resin) contains two kinds of filler:
macrofiller (strontium aluminum borosilicate glass with a mean
particle diameter of 0.5 to 0.7 mm; 40% by wt.) and microfiller
(pyrogenic silica; 5% by wt.), which can flow into the gaps between
the macrofiller particles. The Sinfony monomer system contains
no Bis-GMA or TEGDMA. It is used as an indirect laboratory
composite resin that combines strength, beauty, and versatility.
Indirect restorations created from Sinfony indirect laboratory
composite resin offer excellent esthetics, translucency, natural vital-
ity, amber opalescent effect, and fluorescence. Composite resin is
excellent for inlays/onlays, veneers, and full crowns. A completely
new feature is the addition of a special glass ionomer (5% by wt.),
which influences the surface potential of Sinfony so that plaque
accumulation is minimized. At the same time this additive does
not change the other favorable composite resin properties includ-
ing color and acid stability.
GC Gradia (GC America)
GC Gradia (GC America Inc.) is a light-cured high strength mi-
crohybrid (Microfill reinforced composite [MFR] formulation)
that can be used for inlays/onlays, veneers. and crowns. GC
Gradia couples a microfine ceramic/prepolymer filler with a ure-
thane dimethacrylate matrix to produce a superior ceramic com-
posite resin with exceptionally high strength, wear resistance, and
superior polishability. GRADIA is biocompatible and kind to
opposing teeth with excellent polishability, high wear resistance,
but kind to the opposing dentition. The Foundation Opaque and
Opaque shades can be used to mask discoloration effectively.
Polymerization doesn’t affect color so that the lab technician can
visualize the definitive restoration. The system consists of a vari-
ety of opaques, intensive colors, enamel shades and translucent
materials so that the restorations can be built up like porcelain. In
addition to tooth colored composite resins, GC Gradia Gum
provides a variety of natural gingival shades with good adaptation
to the GC Gradia composite resin system. It is also a microfilled
composite resin with high strength and wear resistance. Oxygen
also plays an important role in the apparent translucency or opac-
ity of the polymerized resin restoration. Oxygen also plays an
important role in the apparent translucency or opacity of the
polymerized resin restoration. Removing all of the air causes the
restoration to become considerably more translucent.
TESCERA ATL
TESCERA ATL (Bisco, Inc.) is a dual-cured microhybrid com-
posite resin that is provided in every Classic Vita shade. The
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C H A P T E R 6     C o m p o s i t e R e si n : I n d i re c t Te c h n i q u e R e s t o r a t i ons
incremental layers are condensed with pressure and then polym-
erized to prevent delamination and keep the restoration free of
voids. Final polymerization occurs in an oxygen-free environ-
ment to achieve a high-gloss–free surface to reduce staining.
Tescera Opaceous Dentin composite resins emulate the most
dense and most opaque area of the tooth; it will also reflect light
resulting in optimal aesthetics. Tescera Opaceous Dentin com-
posite resins emulate the most dense and most opaque area of
the tooth; it will also reflect light resulting in optimal aesthetics.
TESCERA U-BEAM is a U-shaped, unidirectional, prestressed,
quartz fiber reinforced beam for fixed partial dentures. It is resis-
tant to twisting and flexing because of its I-beam effect.
Rods: Unidirectional, pretensed quartz fiber reinforcement
bars are used for posterior and anterior fixed partial dentures
Signum Heraeus Kulzer
Signum ceramic is a glass-ceramic composite resin with micro-
fine filler particles, which was specifically developed for the
requirements of metal-free restorations; its particularly high
intrinsic durability (E-modulus) makes the restoration more
durable, even if high levels of stress are encountered.
Ceramage Shofu
Ceramage is a zirconium silicate integrated indirect restorative
for both anterior and posterior regions. A progressive fine struc-
ture filling of more than 73% plus an organic polymer matrix
delivers superior flexural strength, elasticity, and excellent polish-
ability. It has flexural and compressive strength beyond 140 MPa,
excellent abrasion resistance of opposing dentition, transmission
and diffusion of light with a refractive index similar to natural
teeth, and superior color stability over 5 years.
ANTERIOR COMPOSITE RESIN
LAMINATE VENEERS
Many composite resins wear much like natural tooth structure
and do not cause iatrogenic wear of the opposing dentition.
Indirect composite resin laminate veneers are the treatment of
choice in many situations:
• Darkly stained teeth. Indirect composite resin can cover
dark color without opaquing agents while retaining a vital
appearance.
• Conservation of tooth structure. Tooth preparation for com-
posite resin laminate veneers can be more conservative than
that for porcelain alternatives because composite resin does
not require 0.5 mm thickness, as does porcelain. Composite
resin can be much thinner in spots and still function well.
• Fabrication alternatives. Indirect composite resin laminate
veneers can be fabricated either in the office or in the dental
laboratory. They can be polymerized or processed. They can
be made of microfilled, small particle, or hybrid composite
resin. The glass in the small particle or hybrid composite
resin can be etched with hydrofluoric acid, which provides
micromechanical retention rivaling that of etched porcelain.
• Chairside repairs. These restorations can be repaired at the
chairside with light-cured composite resins.
The technique described below is for a light-cured hybrid
composite resin that is heat tempered, etched with 10% hydro-
fluoric acid gel, and treated with silane. The silane chemically
bonds to the remaining glass particles and then to the luting
111
composite resin, which is used to attach the laminate veneer to
the etched enamel surface of the tooth. (Note that techniques
may vary among manufacturers.)
Armamentarium.
• Mirror
• Explorer
• Metal “plastic” instrument (e.g., Hu-Friedy, Inc.)
• #12 surgical blade
• Bard parker handle
• Anterior scaler (U-15 Towner, Hu-Friedy, Inc.)
• Medium grit flame or chamfer diamond bur
• Vinyl polysiloxane impression material
• Irreversible hydrocolloid impression material
• Maxillary and mandibular full arch impression trays
• Die stone
• Hybrid composite resin
• Light-cured or dual-cured luting composite resin (see
Chapter 12)
• Toaster oven or Coltene oven
• 12- and 30-fluted carbide finishing burs (e.g., ET Esthetic
Trimming, Brasseler USA)
• Fine finishing diamond burs (e.g., ET Esthetic Trimming,
Brasseler USA)
• Rubber composite resin polishing cups (see Chapter 5)
• Composite resin finishing disks (see Chapter 5)
• Composite resin polishing paste (see Chapter 5)
• 10% hydrofluoric gel
• 37% phosphoric acid gel(see Chapter 5)
• Dentin-enamel bonding resin (see Chapter 3)
• Silane coupling agent
• Intraoral light-curing unit (e.g., Demi Plus LED Dental
Curing Light, Kerr Corp.)
• Oil-free pumice
Clinical Technique.
1. Clean the tooth and the neighboring teeth with pumice.
2. Select the desired shades of composite resin while the teeth
are wet with saliva.
3. Determine the desired alignment of the teeth.
4. Prepare the eight maxillary anterior teeth by removing small
amounts of enamel with a medium grit flame or chamfer
diamond bur. If only minimum preparation is necessary to
improve alignment and increase facial contour, remove only
0.25 to 0.50 mm of enamel from the facial area and none
from the incisal area (Fig. 6-1A). If incisal reduction is neces-
sary, remove 1 to 1.5 mm (Fig. 6-1B).
CLINICAL TIP
Preparation dimensions may vary depending on the manufac-
turer’s recommendations and the amount of desired color change.
CLINICAL TIP
Preparation dimensions may vary depending on the manufac-
turer’s recommendations and the amount of desired color change.
5. Make a full arch impression of the prepared teeth with a
vinyl polysiloxane impression material. No retraction cord is
needed because the margins are placed at the gingival crest.
6. Make a full arch irreversible hydrocolloid opposing impression.
7. Place a provisional restoration if needed (see Chapter 7)
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PART 3     E s t h e t i c M a t e r i a l s a n d Te c h n i q u e s
8. Pour stone casts of both the prepared and the opposing arches.
Laminate veneers can be fabricated on the stone cast by using
a separating medium or on a flexible cast as described below.
9. After the stone is fully set, soak the cast of the prepared
arch in water for 10 minutes and make an irreversible
hydrocolloid impression of the cast.
CLINICAL TIP
Soaking the stone in water before making the irreversible
hydrocolloid impression prevents the irreversible hydrocolloid
from adhering to the stone.
10. Inject a vinyl polysiloxane impression material (medium to
heavy viscosity) into the irreversible hydrocolloid impres-
sion and form a flexible cast (Fig. 6-1C). This technique was
first developed by Dr. K. Michael Rhyne for use in indirect
composite resin inlay fabrication.
CLINICAL TIP
A flexible working cast does not require a separating medium,
nor is it susceptible to breakage. The chance of chipping the
restoration upon removal from the working cast is slight.
11. On the flexible cast, fabricate composite resin veneers using
a technique similar to that described for direct intraoral
application (Fig. 6-1D).
CLINICAL TIP
To achieve a vital, natural appearance, apply layers of dentin,
enamel, and incisal shades and polymerize each layer for
40 seconds (Fig. 6-1E).
1 2. Remove the laminate veneers from the flexible cast.
13. Contour and polish the laminate veneers using 12- and
30-fluted finishing carbide burs in a high-speed handpiece
or porcelain contouring and polishing wheels on a lathe.
CLINICAL TIP
Fabricating every other laminate veneer to completion before
fabricating the adjacent laminate veneer allows for good
interproximal contours and contacts.
14. Place the laminate veneers on the original stone cast to check
the fit and margins; adjust further if necessary (Fig. 6-1F).
15. Heat treat the laminate veneers in boiling water or a heat
device, such as the Coltene unit, for 10 minutes to achieve
the heat-curing benefits.
16. Acid etch the lingual side of the laminate veneers with 10%
hydrofluoric acid gel for 30 seconds (Fig. 6-1G) or lightly
sandblast with a microetcher or air abrasion unit and rinse
thoroughly.
CLINICAL TIP
Handle hydrofluoric acid carefully because it is caustic.
17. Evaluate the internal surfaces of the laminate veneers to
ensure that an etched surface has been achieved (Fig. 6-1H).
18. Clean the teeth with No. 4 fine pumice in a prophylaxis cup,
rinse, and dry with water-free and oil-free air.
CLINICAL TIP
At the delivery appointment, use cheek and lip retractors
to isolate the teeth. With this technique no cotton rolls or
rubber dam is needed.
19. Clean the teeth with No. 4 fine pumice in a prophylaxis cup,
rinse, and dry with water-free and oil-free air.
20. Use 37% phosphoric acid for 15 seconds to etch the enamel
and remove the smear layer from any exposed dentin sur-
face of the first central incisor (Fig. 6-1I).
21. Rinse thoroughly.
22. Leave the tooth surface slightly moist for wet bonding.
23. Using a brush, apply silane coupling agent to the internal
surface of the laminate veneers and air dry.
CLINICAL TIP
Silane is generally indicated for hybrid, microhybrid, and
nanohybrid composite resins and generally contraindicated
for microfilled composite resins. Check the manufacturer’s
recommendation.
24. Liberally coat the etched surfaces with a hydrophilic primer
from a fourth generation dentin and enamel bonding agent
(Fig. 6-1J) and dry the primer with oil-free and water-free
air until the surface appears glossy without being wet. This
indicates that the “hybrid” layer has been established in the
dentin and the enamel is thoroughly coated with the resin
in the primer.
25. Paint a thin layer of bonding resin onto the internal surface
of the laminate veneers.
26. Apply a luting composite resin to the internal surface of one
of the laminate veneers. Place the laminate veneer on the
prepared tooth and remove excess luting composite resin
with a brush dipped in bonding agent (Fig. 6-1K).
27. Polymerize for 40 seconds on the facial and lingual surfaces
of the tooth (Fig. 6-1L).
28. Remove excess polymerized luting composite resin with a
#12 surgical blade or a scaler (Fig. 6-1M).
29. Place the other laminate veneers in the same fashion.
30. Finish the margins with 12- and 30-fluted carbide finishing
burs, fine diamonds, rubber polishing cups, finishing disks, or
other composite resin finishing techniques (Fig. 6-1N-P).
PREFABRICATED COMPOSITE RESIN
LAMINATE VENEERS
Componeers (Coltene Whaledent)
Componeers direct composite resin laminate veneers are polym-
erized, prefabricated composite resin enamel shells made of a
nanohybrid composite resin in order to combine the advantages
of direct composite resin with laboratory fabricated laminate
veneers. The laminate veneers are 0.3 mm in thickness so that
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C H A P T E R 6     C o m p o s i t e Re s i n : I n d i re c t Te c h n i q u e R e s t o r a t i ons 113

0.2 – 0.5mm

0.2 – 0.5mm

A B 1.0 – 1.5mm

C D

E F

G H
FIGURE 6-1  ​A, Anterior preparation without incisal reduction. Preparation dimensions may vary
(see Clinical Tip). B, Anterior preparation with incisal reduction. Preparation dimensions may vary
(see Clinical Tip). C, Vinyl polysiloxane is injected into an irreversible hydrocolloid impression of a
stone cast of prepared teeth. D, On the flexible cast, fabricate composite resin veneers using a tech-
nique similar to that described for direct intraoral application. E, Composite resin veneer is polymer-
ized. F, Eight indirect composite resin laminate veneers on a stone cast. G, Hydrofluoric acid gel (10%)
is applied for 30 seconds. H, Etched internal surface of the hybrid composite resin laminate veneer.
Continued
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PART 3     E s t h e t i c M a t e r i a l s a n d Te c h n i q u e s

I J

K L

Enamel
Bonding resin
Luting composite resin
Bonding resin
Silane
Veneer

M N

O P
FIGURE 6-1, cont’d  I, Enamel surface is etched with 37% phosphoric acid. J, Bonding resin is
applied to the etched enamel. K, Excess luting composite resin is removed with a brush dipped in
bonding agent. L, Luting composite resin is polymerized. M, Excess polymerized luting composite
resin is removed with a #12 surgical blade. N, Final anterior restoration with various layers
displayed. Silanation may be contraindicated. Refer to the manufacturer’s recommendations. 
O, Preoperative view of tetracycline-stained teeth. P, Postoperative view of eight indirect compos-
ite resin laminate veneers.
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C H A P T E R 6     C o m p o s i t e R e s i n : I n d i re c t Te c h n i q u e R e s t o r a t i o ns
minimal preparation is usually required. They are available in
different sizes and are then directly customized by the clinician
at the time of placement. They possess a microretentive inner
surface to increase wettability and allow a more durable bond.
No special conditioning is necessary. No impressions or the use
of a dental laboratory are required.
Armamentarium.
• Standard prefabricated composite resin laminate veneer setup
• Mirror
• Explorer
• Metal “plastic” instrument (e.g., Hu-Friedy, Inc.)
• #12 surgical blade
• Bard parker handle
• Anterior scaler (U-15 Towner/, Hu-Friedy, Inc.)
• Medium grit flame or chamfer diamond bur ( Brasseler
USA)
• 12- and 30-fluted carbide finishing burs (e.g., ET
Esthetic Trimming—Brasseler USA)
• Fine finishing diamond burs (e.g., ET Esthetic Trimming—
Brasseler USA)
• Rubber composite resin polishing cups (see Chapter 5)
• Composite resin finishing disks (see Chapter 5)
• Composite resin polishing paste (see Chapter 5)
• Intraoral light-curing unit (e.g., Demi Plus LED Dental
Curing Light, Kerr Inc.)
• Oil-free pumice
• Componeers Accessory Set/(Coltene Whaledent) includes
• MBS modeling instrument
• Etchant Gel S
• One coat Bond
• Synergy D6/Synergy D6 Flow/Synergy D6 connect
• Holder
• Holder caps (black)
• Placer (white)
• Placer adapter (white)
• Placer adapter (red)
• Application needles
• Brush holder (black)
• Brushes
• Shade guide Componeer Synergy D6
• Componeer Contour guide
Clinical Technique.
1. The correct componeer shade and size are selected with the
template provided. The Componeer Contour guide (a blue
transparent guide) aid in selection of the correct tooth shape.
Thirty different shapes with 6 sizes per shape.
2. The teeth are then prepared as needed for the Componeer
laminate veneer. Usually minimal preparation is needed. The
Componeer Modeling Instrument MB5 is sharp and can
be used to remove excess composite resin.
3. Bonding resin of choice is placed on the tooth and then the
Componeer Holder (a specially designed tweezers to aid in
shape correction of the Componeer as well as placement of
the bond) is used for reshaping as required and placement of
the bonding resin. The interchangeable holder caps protect
the Componeer. Conventional microhybrid composite resin
and polymerized.
4. Place the Compomer cement on the tooth (Fig. 6-2A)
5. The Componeer placer is used to align and position the
laminate veneers (Fig. 6-2B and C). The Componeer Casting
Instrument MB5 is sharp and can be used to remove excess
composite resin.
115
6. The Componeer is light cured as per manufacturer’s guide-
lines (Fig. 6-2D).
7. The Componeer is trimmed with carbide finishing burs
(Fig. 6-2E) and excess cement is removed with finishing
strips (Fig. 6-2F).
8. The laminate veneers are polished (Fig 6-2G).
Edelweiss Composite Laminate Veneers
(Ultradent Products Inc.)
Edelweiss Composite Laminate Veneers (Ultradent Products,
Inc.) are composite resin laminate veneers which are laser sintered
so that the laser particles are fused together to provide a high
gloss, uniform surface, and a thermally tempered base. The lami-
nate veneer filler ratio is 82% by weight and 65% by volume. The
variation of inorganic filler particle is between 0.02 and 0.03 mm.
Armamentarium.
• Standard prefabricated composite resin laminate veneer setup
• Edelweiss composite laminate veneers kit
Clinical Technique.
1. Clean each tooth, including the mesial and distal aspects,
with Consepsis Scrub or a fluoride-free flour of pumice.
2. Placing the transparent laminate veneer sizing guide over the
teeth, select the size. Slight adjustments to the shape of the
laminate veneer can be made with a rough disk at slow speed.
3. Determine the shade on a moist, non-dehydrated tooth
using natural daylight conditions.
4. Isolate the treatment area with a rubber dam, if possible.
5. Prepare the tooth surface with as minimal an amount of re-
duction as possible. Use retraction cord and hemostatic agents
where needed to control tissue, bleeding, and moisture.
6. Clean each tooth again, including the mesial and distal aspects,
with Consepsis Scrub or a fluoride-free flour of pumice.
7. Securely place a thin, transparent matrix band or Teflon tape
interproximally.
Pretreatment of the Enamel Shell.
1. Using a rough surface disk at low speed with no water, adjust
the fit of the laminate veneer.
2. To improve adhesion, the internal surface may be roughened
by micro abrading with 25 or 50 mm aluminum oxide or a
diamond bur.
3. Apply 37% phosphoric acid for 5 seconds, rinse, and dry to
cleanse the surface.
4. Brush a coat of bonding agent onto the prepared surface.
5. Blow air using half pressure to thin and remove solvents. The
surface will appear shiny.
6. Polymerize for 10 seconds with a curing light. For lights with
outputs less than 600mW/cm2, polymerize for 20 seconds
or for lights with output greater than 600mW/cm2, polym-
erize for 10 seconds.
Pretreatment of the Prepared Teeth.
1. Apply 37% phosphoric acid to the tooth surface for 20 seconds,
rinse thoroughly for 5 seconds and dry lightly leaving the
surface slightly damp.
2. Place a puddle coat of bonding agent with a microbrush onto
the prepared surface and gently agitate for 10 seconds.
3. Thin/dry for 10 seconds using quarter to half pressure. The
surface will appear slightly shiny.
4. Polymerize for 10 seconds with a curing light. For lights with
output less than 600mW/cm2, polymerize for 20 seconds or
for lights with output greater than 600mW/cm2, polymerize
for 10 seconds.
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A E

B F

C G

F I G U R E 6 - 2  ​A, The Compomer cement is placed on the

tooth. B, The Componeer is placed on the tooth. C, The Com-
poneer placer can be used to align the laminate veneer. D, The
Componeer is light cured. E, Carbide finishing burs are used to
trim the Componeer. F, Finishing strips are used to remove ex-
D
cess interproximal cement. G, The completed restorations.
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C H A P T E R 6     C o m p o s i t e R e s i n : I n d i re c t Te c h n i q u e R e s t o r a t i ons
5. Amelogen Plus (Ultradent) can be used as it flows under
pressure. Conventional laminate veneer cements are not rec-
ommended.
POSTERIOR INLAYS AND ONLAYS
Composite resin inlays and onlays are an excellent choice for
teeth with wide proximal occlusal cavities8:
• Esthetic considerations. A bonded restoration can provide
esthetics and function of high quality and may be a long-
lasting alternative to full coverage or the porcelain or direct
composite resins counterparts.
• Structural considerations. A bonded restoration returns
nearly all the original strength to the tooth and holds the
remaining tooth structure together.9
• Abrasion considerations. Because some composite resins
have been shown to wear at about the same rate as natural
tooth structure, they are an excellent choice of material for
restorative purposes. However, newer ceramic materials such
as E Max (Ivoclar Vivadent) are a viable alternative.
• Conservation of tooth structure. Onlay preparations have
the advantage of requiring the removal of less tooth struc-
ture than for a full crown.
• Supragingival margins. Onlay preparations have supragingi-
val margins and therefore infringe less on the periodontal
apparatus than restorations with subgingival margins.
• Chairside repairs. These restorations can be repaired at the
chairside with light-cured composite resins.
With the advent of strong bonding agents and appropriate
restorative materials, indirect composite resins can provide
long-lasting alternatives to full crowns or conventional cast
onlays.
Direct/Indirect Technique: Fabrication
Armamentarium.  ​The armamentarium is the same as that
listed for anterior laminate veneers.
Clinical Technique.
1. The preparation is similar to that for a gold inlay or onlay;
however, the divergent walls must have rounded angles and
no sharp corners (Fig. 6-3A).
CLINICAL TIP
No retentive cuts or parallel walls are needed, because the
restoration will be bonded into place (Fig. 6-3B).
2. Provide at least 1.5 mm of clearance on the prepared occlusal
surface.
3. No bevels are needed, and slightly tapering or butt joint
margins should be used.
4. Areas prepared closer than 0.5 mm to the pulp should be
lined with calcium hydroxide, and undercuts should be filled
with an appropriate liner or base.
CLINICAL TIP
Do not use solutions containing eugenol, which can interfere
with the chemistry of the resins.
117
CLINICAL TIP
Undercuts in the preparation make removal impossible;
carefully inspect the preparation before placing composite
resin and block out or remove undercuts.
5 . Apply a separating medium or glycerin to the entire tooth.
6. Place a light-cured hybrid composite resin directly into the
prepared tooth using normal direct placement technique.
7. Remove the restoration from the tooth using a large spoon or
other instrument.
8. Heat treat the inlay or onlay.
9. Place the inlay or onlay according to the placement technique
described later.
Indirect Technique: Flexible Cast
Fabrication
A completely indirect technique that can be performed in one
appointment and that does not require a provisional restoration
can be accomplished using a flexible cast technique.
Armamentarium.  ​The armamentarium is the same as that
listed for anterior laminate veneers.
Clinical Technique.
1. The first four steps are identical to those given in the preced-
ing section on direct/indirect technique.
2. Make an irreversible hydrocolloid impression that captures
all of the margins of the preparation.
3. Inject a firm-setting vinyl polysiloxane impression material
into the irreversible hydrocolloid impression to form a flexi-
ble cast (Fig. 6-3C).
4. Fabricate a composite resin inlay using light-cured hybrid
composite resin (Fig. 6-3D).
5. Heat treat the restoration.
6. Place the inlay or onlay according to the placement technique
described below (Fig. 6-3E).
Indirect Technique: Laboratory Fabrication
Composite resin inlays and onlays can be fabricated by the labo-
ratory technician The preparation is identical to those described
in the first four steps in the earlier section on direct/indirect
technique. If desired, immediate dentin sealing can be incorpo-
rated prior to provisionalization to minimize or eliminate sensi-
tivity. An impression is made with an impression material which
would be suitable for any laboratory fabricated single tooth
restoration. A provisional restoration must then be fabricated
and placed until the definitive restoration is placed during a
subsequent office visit.
Dentin Sealing Before Impressioning (Optional).
Bisco Pro V.
Armamentarium.
• Oil-free pumice
• Cavity cleanser
• Bonding Agent (ex ALL-BOND SE or All Bond 3 (Bisco,
Inc.)
• Provisional Restorative system (ex PRO-V COAT, PRO-V
FILL, PRO-V FLO, Bisco, Inc.)
• Mirror
• Explorer
• Metal “plastic” instrument (e.g., Hu-Friedy, Inc.)
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PART 3     E s t h e t i c M a t e r i a l s a n d Te c h n i q u e s

1.5 mm
2 mm

A B

C D

E
FIG U R E 6 - 3   ​A, Posterior onlay preparation. Note the rounded line angles designed to reduce
internal stress. B, Tooth prepared for indirect composite resin veneer. C, Vinyl polysiloxane is
injected into an irreversible hydrocolloid impression. D, Fabrication of the composite resin inlay.
E, Composite resin inlay bonded into place.

• Anterior scaler (U-15 Towner/, Hu-Friedy, Inc.)
• 12- and 30-fluted carbide finishing burs (e.g., ET Esthetic
Trimming—Brasseler USA)
• Fine finishing diamond burs (e.g., ET Esthetic Trimming—
Brasseler USA)
• Intraoral light-curing unit (e.g., Demi Plus LED Dental
Curing Light, Kerr Inc.)
Clinical Technique—ALL-BOND 3—Total Etch Method.
1. Thoroughly clean the preparation with pumice slurry or
Cavity Cleanser (Bisco), which should dwell for 30 seconds
and excess blotted.
2. Etch the dentin for 5 to 10 seconds using UNI-ETCH with
benzalkonium chloride and rinse thoroughly. Remove excess
water using a foam pellet or with a high volume suction, leav-
ing the preparation visibly moist.
CLINICAL TIP
Use of an air syringe may desiccate the dentin. A high vol-
ume suction or foam pellet to remove excess water followed
(if needed) with a dry cotton pellet in a blotting motion will
leave the dentin slightly moist.
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C H A P T E R 6     C o m p o s i t e R e s i n : I n d i re c t Te c h n i q u e R e s t o r a t i ons
3. Dispense an equal number of drops of ALL-BOND 3 Parts
A & B (1:1) into a mixing well. Immediately replace the caps.
CLINICAL TIP
The caps should be replaced immediately to prevent evapora-
tion of the solvent. Evaporation would change the consistency
and the chemical composition of the components.
4. Using a brush, mix ALL-BOND 3 Parts A & B in the well
for 5 seconds.
5. Immediately apply 1 to 2 coats to the moist preparation.
6. Gently but thoroughly air dry until there is no visible move-
ment of the material.
7. The surface should appear shiny; otherwise apply addi-
tional coats and air dry.
a. Polymerize for 10 seconds at 500mW/cm2.
8. Apply 1 thin coat of ALL-BOND 3 RESIN. Air thin if
necessary and polymerize for 10 seconds at 500mW/cm2.
9. Block out existing undercuts with a flowable composite
resin, according to the manufacturer’s instructions.
10. Redefine the preparation, including the enamel margins.
11. Remove the oxygen inhibited layer of the freshly bonded
surfaces with an alcohol moistened cotton pellet or gauze.
CLINICAL TIP
The surface with an oxygen inhibited layer will leach more
monomer, has inferior properties, and should be removed.
1 2. Make an impression.
13. Dispense 1 to 2 drops of PRO-V COAT into a mixing well.
Immediately replace the cap on the bottle.
CLINICAL TIP
The caps should be replaced immediately to prevent evapora-
tion of the solvent. Evaporation would change the consis-
tency and the chemical composition of the components.
14. Using a brush, apply 1 to 2 coats of PRO-V COAT to the
entire preparation.
15. Gently air dry (from 8-10cm from the prep) for 10 to
15 seconds to evaporate the solvent.
16. Proceed with provisionalization. (See section on PROVI-
SIONAL INLAYS AND ONLAYS.
Using ALL-BOND SE—Self Etch Method
Armamentarium.
• Standard prefabricated composite resin laminate veneer
setup
• Unfluoridated pumice paste
• Intraoral air abrasion unit (e.g., Microetcher ERC Sand
Blaster Danville Engineering) (optional)
• Aluminum Oxide—50 Micron (Danville Materials Abrasive
and Polishing Material) (optional)
• Cavity Cleaner (e.g., Cavity Cleanser, Bisco Inc.)
• Bonding Agent (e.g., ALL-BOND SE, Bisco Inc.)
119
• Flowable composite resin (e.g., Renamel Flowable, Cosme-
dent Inc.)
• Impression material (e.g., Reprosile, Dentsply)
• Separating agent (e.g., PRO-V COAT, Bisco, Inc.)
Clinical Technique.
1. Thoroughly clean the preparation with unfluoridated pumice
paste, or a microetcher with 25 micron aluminum oxide or
Cavity Cleanser (Bisco), which should dwell for 30 seconds
and excess blotted.
2. Gently dry to remove excess moisture from the tooth
preparation and then dispense an equal number of drops
of ALL-BOND SE Parts I & II (1:1) into a mixing well.
Immediately replace the caps.
CLINICAL TIP
The caps should be replaced immediately to prevent evapora-
tion of the solvent. Evaporation would change the consis-
tency and the chemical composition of the components.
3. Using a brush, mix ALL-BOND SE Parts I & II until uni-
formly pink. Apply 1 to 2 coats of ALL-BOND SE to the
dry preparation and then agitate for at least 10 seconds.
4. Gently but thoroughly air dry until there is no visible move-
ment of the material. The surface should appear shiny; other-
wise, apply additional coats of ALL-BOND SE and air dry.
5. Polymerize for 10 seconds at 500mW/cm2.
6. Apply one thin coat of ALL-BOND SE LINER. Air thin
if necessary and polymerize for 10 seconds at 500mW/cm2.
7. Block out existing undercuts with a flowable composite,
according to manufacturer’s instructions.
8. Redefine the preparation, including the enamel margins.
9. Remove the oxygen inhibited layer of the freshly bonded
surfaces with an alcohol moistened cotton pellet or gauze.
10. Make an impression
11. Dispense 1 to 2 drops of PRO-V COAT into a mixing well.
Immediately replace the cap on the bottle.
CLINICAL TIP
The caps should be replaced immediately to prevent evapora-
tion of the solvent. Evaporation would change the consis-
tency and the chemical composition of the components.
12. Using a brush, apply 1 to 2 coats of PRO-V COAT to the
entire preparation. Gently air dry (from 8-10 cm from the
prep) for 10 to 15 seconds to evaporate the solvent.
13. Proceed with provisionalization.
PROVISIONAL INLAYS AND ONLAYS
Provisional restorations are an important and necessary part of
any reconstruction. Besides temporarily restoring the tooth/
teeth, they serve other important functions including:
• Covering exposed dentin to prevent tooth sensitivity, plaque
buildup, cavities, and pulp problems
• Preventing unwanted tooth movement
• Enabling patients to eat and speak normally
• Serving as a diagnostic tool
• Maintaining the health and contours of the periodontal tissue
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PART 3     E s t h e t i c M a t e r i a l s a n d Te c h n i q u e s
Provisional inlays and onlay systems are designed with spe-
cific properties that are optimized for quick and easy removal.
Ideally they should:
• Be light curable
• Cure to a semi-hard state
• Maintain enough flexibility for easy removal
• Have the ability to be placed without a matrix
• Be easy to carve and clean up
• Be eugenol free to allow for the use of resin cements for final
cementation.
• Have excellent retention without cementation
• Encourage healing of gingival tissue
Fabrication of a Provisional Restoration
Armamentarium.
• Bis-Acryl materials such as
• Telio CS Inlay and Telio CS Onlay (Ivoclar Vivadent)
• Luxatemp Ultra (DMG)
• Integrity Multi-Cure (Dentsply/Caulk)
• Venus Temp 2 (Heraeus)
• Protemp Plus (3M ESPE)
• Tuff-Temp (Pulpdent)
• Structur 2 SC (Voco America)
• PRO-V FILL and PRO-V Flow (Bisco, Inc.)
• Silicone finishing burs (e.g., Astropol F) or tungsten carbide
finishing burs for grinding and excess removal
• Scalpel (may also be used to remove excess material)
Clinical Technique.
1. Place PRO-V Flow initially to adapt to the internal aspect of
the preparation.
2. Place PRO-V FILL in 2- to 3-mm increments. Polymerize
each increment for 10 seconds at 500mW/cm2.
3. Place the last incremental layer of PRO-V FILL and adjust
the occlusion with instruments.
4. After the final adjustment, polymerize for 20 seconds at
500mW/cm2.
5. If desired, apply a liquid polish such as BisCover LV. Dis-
pense 1 or 2 drops of BisCover LV into a mixing well. Dip
the brush into the BisCover LV. Wipe excess from the
brush onto the side of the mixing well. The brush does not
need to be saturated; it should be only wet enough to apply
one thin coat.
6. Apply one thin coat of BisCover LV in one direction with a
smooth stroke. Do not agitate the brush during application.
CLINICAL TIP
It is very important to allow 15 seconds dwelling time for
evaporation of solvent after application. Do not air thin be-
cause this will disperse the material unevenly causing ripples
on the surface.
7. BisCover LV uses the following curing lights and curing
times to initiate polymerization:
a. LED Lights: Using an LED curing light with a minimum
output of 500mW/cm2, polymerize for 30 seconds at
close range (0-2 mm)
b. Halogen Lights: Using a halogen curing unit, such as VIP
junior, with a minimum output of 500mW/cm2, polym-
erize for 30 seconds at close range (0-2 mm)
CLINICAL TIP
If the light intensity is lower and/or curing occurs at a dis-
tance (10 mm), polymerize for greater than 30 seconds.
c. PAC (Plasma Arc) Lights: Using a PAC light, polymerize
for 10 seconds at close range (0-2 mm).
CLINICAL TIP
Insufficient curing will leave an air-inhibited layer on the
surface of BisCover LV. Upon curing, BisCover LV may
produce a brief exothermic reaction, which is minimized by
applying in a thin layer. Do not cure on soft tissue.
8. If a second coat is desired, repeat steps 1 to 6.
Removal of the Provisional Restoration
Armamentarium.
• Standard prefabricated composite resin laminate veneer setup
Clinical Technique.
1. Insert a suitable sharp instrument (probe/scaler) into the
material and remove in the line of draw.
2. Proceed with the definitive bonding protocol.
Placement of the Definitive Inlay or Onlay
The placement of inlays or onlays is identical whether they are
fabricated in the office or at the dental laboratory using the com-
mercial processes described.
Armamentarium.  ​The armamentarium is the same as that
listed for anterior laminate veneers.
Clinical Technique.
1. Remove the provisional restorations (Fig. 6-4A).
2. Place the definitive restorations on a clean, dry surface
(Fig. 6-4B).
3. Place a rubber dam.
4. Thoroughly clean the prepared tooth with pumice.
5. Use 37% phosphoric acid to etch the enamel margins
(Fig. 6-4C) and to remove the smear layer from the pre-
pared dentin surfaces. Rinse thoroughly and leave the tooth
surfaces moist to allow wet bonding.
6. Liberally coat the etched surfaces with a hydrophilic primer
from a fourth generation dentin and enamel bonding agent
(Fig. 6-4D) and dry the primer with oil-free and water-free
air until the surface appears glossy without being wet. This
indicates that the “hybrid” layer has been established in the
dentin and the enamel has been thoroughly coated with the
resin in the primer.
7. Apply a dual-curing bonding resin to the dentin and enamel
surfaces and the internal surface of the onlay (Fig. 6-4E).
8. Mix a dual-cured luting composite resin and apply it to the
inner surface of the restoration or to the surface of the pre-
pared tooth (Fig. 6-4F).
9. Place the restoration and remove excess luting composite
resin with a brush dipped in bonding agent (Fig. 6-4G).
10. While the onlay is held in place with an instrument, run
dental floss through the proximal areas, pulling in the facial
or lingual direction to remove excess resin.
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C H A P T E R 6     C o m p o s i t e Re s i n : I n d i re c t Te c h n i q u e R e s t o r a t i ons 121

A B

C D

E F

G H
FIGURE 6-4  ​A, Prepared teeth. B, Internal surfaces of laboratory-fabricated composite resin
onlays. C, Enamel margins are etched with 37% phosphoric acid gel. D, Dentin primer is applied.
E, Bonding resin is applied to the internal surface of the onlay. F, Mixing of the dual-cured luting
composite resin. G, Excess luting composite resin is removed with a brush dipped in bonding agent.
H, Luting composite resin is polymerized with a visible light source. Continued
122 |
PART 3     E s t h e t i c M a t e r i a l s a n d Te c h n i q u e s

Dentin
Dentin primer
Bonding resin
Composite resin
Bonding resin
Silane
Inlay
2 mm

I
J

K L

M N

O
FIGURE 6-4, cont’d  I, Final posterior restoration with various layers displayed. J, Excess po-
lymerized luting composite resin is removed with a #12 surgical blade. K, Occlusion is adjusted
with a carbide finishing bur. L, Composite resin onlays are polished with composite resin polishing
paste. M, Completed onlays. N, Preparation of the mandibular arch for two inlays and one onlay.
O, Finished restorations.
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C H A P T E R 6     C o m p o s i t e R e s i n : I n d i re c t Te c h n i q u e R e s t o r a t i ons
11. Polymerize the restoration for 40 seconds on the occlusal,
facial, and lingual surfaces (Figs. 6-4H and 6-4I).
12. Excess polymerized luting composite resin can be removed
with a surgical blade (Fig. 6-4J), a scaler, or carbide finish-
ing burs.
CLINICAL TIP
The dual-cured luting composite resin will continue to cure,
but finishing can begin 4 minutes after light curing.
13. Adjust the occlusion with carbide finishing burs (Fig. 6-4K).
14. Polish the finished and adjusted surfaces with normal com-
posite resin polishing techniques, including the use of final
polishing paste (Fig. 6-4L-O).
THE FUTURE
Composite resins have a promising future in dentistry. The
technology has progressed over the years, and bonding agents
will ensure strong, long-lasting adhesion to tooth structure.
However, ceramic materials such as E Max and monolithic
Zirconia provide viable alternatives. Newer materials such as
Lava Ultimate CAD/CAM Restorative a resin nano ceramic
material combine resin and ceramic materials.
BIBLIOGRAPHY
Berge M: Properties of prosthetic resin-veneer materials processed in commercial laborato-
ries, Dent Mat 5:77, 1989.
Bonner P, Kanca J: Dentist reveals methods for fabricating the direct resin inlay, Cosmet
Dent Gen Pract 5:1, 1989.
123
Christensen GJ: Tooth-colored inlays and onlays, J Am Dent Assoc 4:12E, 1988.
Dimberio RD: A new crown and bridge veneering material, Quintessence Dent Tech 4:27,
1979.
First International Symposium on the Clinical Applications of Laboratory Light Cured
Composites, December 13, 1984, Valley Forge, PA.
Gallegos LI, Nicholls JI: In vitro two-body wear of three veneering resins, Quintessence Int
20:259, 1989.
Gallegos LI, Nicholls JI. In vitro two-body wear of three veneering resins, J Prosthet Dent
Aug; 60(2):172-8,1988.
Gross J, Malacmacher L: Posterior composite resins: the technique, Dentique 1:1, 1985.
James DF: An esthetic inlay technique for posterior teeth, Quintessence 14:725, 1983.
Jones RM, Moore BK: A comparison of the physical properties of four prosthetic veneering
materials, Prosthet Dent 61:38, 1989.
Kanca J: The single visit heat processed indirect composite resin inlay, J Esthet Dent 1:13,
1988.
Lappalainen R, Yli-Urpo A, Seppa L: Wear of dental restorative and prosthetic materials
in vitro, Dent Mat 5:35, 1989.
Michl RJ: Isosit, a new dental material, Quintessence Int 9:1, 1978.
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Nash R: Hybrid composites: excellent for veneers, Lab Man Today 4:34, 1988.
Nash R: Restorative options for good aesthetics, Dent Today 3:1, 1987.
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1. Wendt SL: Time as a factor in the heat curing of composite resins, Quintessence Int
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the inlay composite material resulting from different curing conditions, September 1-13,
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3. Duke ES, Norling BK: Vacuum curing of light activated composite resin veneering resin,
USAF Medical Center and University of Texas HSC published report, San Antonio,
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4. Wendt SF: The effect of heat used as a secondary cure upon the physical properties of
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Class II restorations, J Dent Res 62:761, 1983.
8. Geurtsen W, García-Godoy F. Bonded restorations for the prevention and treatment of
the cracked-tooth syndrome, Am J Dent 12(6):266-270, 1999.
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Class II restorations, J Dent Res 62:761, 1983.