QUI NTESSENCE I NT ERNAT I ONAL
PROSTHODONTICS
Minimally invasive treatment options in fixed
prosthodontics
Daniel Edelhoff, Prof Dr med dentVAnja Liebermann, Dr med dentVFIorian Beuer, Prof Dr med dent, MME1
Michael Stimmelmayr, PD Dr med dentVJan-Frederik Guth, PD Dr med d en t 4*
Minimally invasive treatment options have become increas­
ingly feasible in restorative dentistry, due to the introduction
of the adhesive technique in combination with restorative
materials featuring translucent properties similar to those of
natural teeth. Mechanical anchoring of restorations via con­
ventional cementation represents a predominantly subtractive
treatment approach that is gradually being superseded by
a primarily defect-oriented additive method in prosthodon­
tics. Modifications of conventional treatment procedures have
led to the development of an economical approach to the
removal of healthy tooth structure. This is possible because
Key words: adhesive technique, all-ceramics, diagnostic template, high-density polymers, minimally invasive
preparation, occlusal onlays, resin-bonded FDPs, veneers, wax-up
A t present, c o n v e n tio n a l tre a tm e n t m e th o d s using
m etal-based crow ns and fixed dental prostheses (FDPs)
are considered to be th e g o ld standard re g a rd in g c lin ­
ical survival and success.1 H ow ever, th e e xte n sive
rem oval o f to o th stru ctu re associated w ith th e crow n
and a b u tm e n t preparation fo r these restorations is seen
1Director and Chair, Department of Prosthodontics, Ludwig-Maximilians Univer­
sity, Munich, Germany.
2Assistant Professor, Department of Prosthodontics, Ludwig-Maximilians Univer­
sity, Munich, Germany.
d ire c to r and Chair, Department o f Prosthodontics, Charitd University Medicine
Berlin, Berlin, Germany.
4Associate Professor, Department o f Prosthodontics, Ludwig-Maximilians Univer­
sity, Munich, Germany-
Correspondence: Prof Dr med dent Daniel Edelhoff, Department of
Prosthodontics, Ludwig-Maximilians University, GoethestraBe 70,
80336 Munich, Germany. Email: daniel.edelhoff@med.uni-muenchen.de
VOLUME 47 ■ NUMBER 3 ■ MARCH 2016
Daniel Edelhoff
3/
2
the planned treatment outcome is defined in a wax-up before
the treatment is commenced and this wax-up is subsequently
used as a reference during tooth preparation. Similarly, res­
in-bonded FDPs and implants have made it possible to pre­
serve the natural tooth structure of potential abutment teeth.
This report describes a number of clinical cases to demon­
strate the principles of modern prosthetic treatment strategies
and discusses these approaches in the context of minimally
invasive prosthetic dentistry. (Quintessence Int2016;47:207-216;
doi: 10.3290/j.qi.a35115; Originally published in Quintessenz
2014;65(5)589-600)
as a disadvantage. A retrospective clinical study showed
th a t th e 15-year survival p ro b a b ility o f vita l p u lp was
81.2% in m etal-ceram ic single crow ns and 66.2% in FDP
a b u tm e n ts .2 Foster3 d e te rm in e d a 21% e n d o d o n tic
c o m p lic a tio n rate fo r FDP a b u tm e n ts a fte r 6 years. An
in itia l q u a n tific a tio n o f hard tissue rem oval in relation
to d iffe re n t preparation co n fig u ra tio n s revealed th a t up
to 70% o f th e clinical crow n is rem oved in co m p le te
coverage cro w n preparations, regardless o f w h e th e r
th e p re p a ra tio n was in th e a n te rio r o r p o s te rio r
re g io n .45 These fin d in g s have re ce n tly been co n firm e d
in a stu d y using m o d e rn m easuring te c h n o lo g y 6 and
are increasingly a ffe ctin g tre a tm e n t decisions. Several
in -v itro studies on e n d o d o n tic a lly tre a te d te e th have
show n th a t a h igh vo lu m e o f re m a in in g natural to o th
207
QUI NTESSENCE I N T E R N A T I ON A L
Edelhoff et al
Fig la Palatal view of the preoperative situation: agenesis of the
lateral maxillary incisors
structure has a significantly positive effect on fracture
resistance, independent o f the type o f to oth.7'8 Up to
45% more to oth structure can be saved by opting for a
partial rather than a com plete coverage crown when
restoring an e nd od on tically treated m olar.9 Similar
results were found in relation to the preparation of
retainers fo r resin-bonded FDPs and attachm ents.10
It is notew orthy th a t clinical studies on all-ceramic
partial coverage crowns showed either no11 or a very
low endodontic com plication rate12 after observation
periods between 7 and 12.6 years, compared to studies
on m etal-ceram ic com plete coverage crowns.2 In
veneer restorations, the rate o f endodontic complica­
tions was as low as 2.51% after an observation period of
20 years.13 Hence, a less invasive preparation and res­
toration design appear to have a favorable effect on
the vita lity o f restored teeth. Against this background,
fixed prosthodontics have been undergoing a para­
digm shift towards less invasive treatm ent m ethods in
recent years.11'14-17 A few treatm ent methods offering
substantial reductions in the removal o f to oth structure
are described and discussed below.
Resin-bonded anterior FDPs
Resin-bonded anterior FDPs were first described in the
1970s.18 Today they are used as an alternative to
im plant-supported restorations in single teeth if:
• im plant treatm ent is contraindicated
• extensive surgical interventions should be avoided
• the space available is inappropriate fo r im plant
treatm ent
208
Fig lb Palatal view after restoration with two-retainer res­
in-bonded FDPs made of base metal alloy and zirconia placed in
the course of a randomized prospective clinical study (CDT Max
Kurzmeier, University Munich, Germany).
• the patient is o f an inadequate age, or
• an im plant is sim ply not w anted.19
Most modern resin-bonded FDPs are manufactured on
the basis o f frameworks made o f materials featuring a
high modulus o f elasticity such as base metal alloys or
zirconia ceramics (Fig 1). A rem oval rate between
0.5 mm and 0.7 mm is recommended for the preparation
o f the retentive wings. Additional requirem ents are
healthy abutm ent teeth th a t are prim arily free o f both
caries and fillings, sufficient interocclusal space (approx­
imately 0.8 mm), and sufficient amounts o f enamel.19
In a long-term clinical study (literature review), adhe­
sive FDPs comprising tw o w ing retainers showed a sig­
nificantly poorer survival probability than full crown
abutm ent FDPs over a period o f 10 years.1 However, it is
im portant to bear in m ind th a t anterior maxillary teeth
are considered to be particularly vulnerable to vitality
loss if they are used as abutments in conventional FDPs.2
Additionally, a retentive preparation geometry has been
shown to play an essential and determining factor for the
success o f resin-bonded FDPs and should by all means
be considered in the preparation design together w ith
the properties o f the ceramic or metal being used.10'20
W ith the in tro d u c tio n o f metal-based single-re­
tainer adhesive FDPs in the 1980s, the level o f invasive­
ness was once more lowered and the need for unphys-
iolo gic s p lin tin g of th e a b u tm e n t te e th was
elim inated.21 In the 1990s, glass-infiltrated alum inum
oxide ceramic was used fo r the first tim e in a clinical
study to manufacture all-ceramic adhesive FDPs w ith
VOLUME 4 7 • NUMBER 3 ■ MARCH 2016

Fig 2a Single-retainer resin-bonded FDP made o f lithium-disil-
icate ceramic to replace a mandibular right lateral incisor (tooth
42 according to FDI notation; CDT Oliver Brix, Bad Fiomburg).
tw o retainers. In the further course of the study, zirco-
nia-based single-retainer adhesive FDPs appeared to be
advantageous.19 The data available from the clinical
long-term study indicate a survival probability of 94.4%
for the single-retainer zirconium oxide-based adhesive
FDPs after a clinical service time of 10 years. In certain
cases, lithium disilicate ceramics might be suitable as
the framework material for single-retainer adhesive
FDPs (Fig 2).22
All-ceramic anterior veneers
Given their favorable long-term results, excellent
esthetic properties, and low level of invasiveness, res­
in-bonded veneers23 offer an attractive alternative to
conventional single crowns in many cases.17'24 Silicate
ceramic materials are considered to be the material of
choice to replace lost natural enamel due to their favor­
able optical and mechanical properties.25'26 However,
minimally invasive veneer preparation, provisionaliza-
tion, and adhesive bonding set higher demands on the
skills of the operator compared with complete cover­
age crown preparation and conventional cementation.
Enamel preservation represents an essential and
determining factor for the success of a veneer restor­
ation.27'28 Therefore, veneers should be designed using
VOLUME 47 • NUMBER 3 • MARCH 2016
QUINTESSENCE I NTERNATI ONAL
E d el h o f f et al
Fig 2b Single-retainer resin-bonded FDP made of lithium-disil-
icate ceramic after adhesive cementation. Given the low w idth of
the extension unit 42 (short cantilever) and the large vertical
extension o f the connector, glass-ceramics m ight be used for this
particular indication in the anterior mandibular region.
a mostly exclusively additive technique. Well-defined
principles apply to the preparation for veneers; none­
theless, these principles can offer a high degree of
flexibility in the design of the restoration, depending
on the clinical situation (tooth position, degree of
destruction, occlusal conditions, periodontal surround­
ings, etc).29'30This is true for both the incisal design and
interproximal extension.30'31 Preparing a palatal cham­
fer offers the highest degree of freedom for the pos­
itioning of the incisal edge, which is particularly import­
ant if a large amount o f tooth structure has been
lost.29'30 Similar considerations apply to the interproxi­
mal extension of the preparation.2531
If the popular medium wrap design is used, the
contact area and therefore the width of the existing
tooth are maintained and, consequently, the height is
determined by the defined width-to-length ratio. By
contrast, the long wrap design leads to the elimination
of the contact areas due to the deep interproximal
extension and therefore offers considerably more
scope for variation with regard to the shape and pos­
ition of the restoration (Fig 3). The long wrap design is
therefore particularly advantageous in the treatment of
severe discolorations, diastemas, extensive shape mod­
ifications, black triangles, and large fillings. Further-
209
QUI NTESSENCE I NT ERNAT I ONAL
E d el h of f et al
Fig 3a Misalignment of the teeth and severe wear of the man­
dibular anterior teeth in a 59-year-old woman. Malocclusion
resulted in severe functional problems, which were redressed in
a 12-month splint therapy. Upon completion of the therapeutic
phase, the patient was complaint-free and the resulting occlusion
was to be transferred to the final prosthetic solution.
Fig 3c The veneers (IPS d.SIGN, Ivoclar Vivadent) were layered
on refractory dies and then inserted using an adhesive technique.
A clear change in length can be observed. Crowding was clearly
reduced, a result that was achieved w ithout using substantially
more invasive full crown preparation (CDT Oliver Brix, Bad Hom-
burg, Germany).
more, the long wrap design is recommended for
veneers that are located in the immediate vicinity of
crowns, as this allows the contact area between the
two restorations to be created in ceramic (Fig 4).
Interproximal preparation can be conveniently
accomplished with oscillating preparation instruments
(eg, Sonicflex micro tip no. 28 or 29, diamond coating
D25, half torpedo shape REF 0.571.6741/0.571.6731;
KaVo Dental) and Soflex disks (2382 M, 3M Espe)
(Fig 5a). In periodontally compromised situations, the
long wrap design may be combined with a horizontal
insertion axis.32This method eliminates the need for an
extensive reduction of the coronal tooth structure. Fur­
thermore, distance C (cervical) can be designed to be
smaller than distance D (dentin) (Fig 5b). Substantial
amounts of tooth structure can be preserved if this
configuration is used (Fig 5b). On the downside, how­
210
Fig 3b Veneer preparation o f the mandibular anterior teeth to
achieve a long wrap design. Prior to perform ing the double
impression technique, metal matrices were applied to the contact
areas of the prepared teeth to avoid having to cut the master
model.
Fig 3d Incisal view after placement o f the veneers. A primarily
additive procedure was followed (see mandibular left central
incisor). A full crown preparation m ight have required the end­
odontic treatment of the mandibular right central incisor to the
left lateral incisor.
ever, the clinical and technical implementation of this
technique is considered to be challenging.
In certain indications, the design may seamlessly
evolve into a full coverage crown (Fig 6). A circular
preparation design (360 degrees), also known as a full
wrap veneer design, is particularly indicated for com­
plex cases that necessitate an increase in the occlusal
vertical dimension to close the resultant free space on
the palatal side of the maxillary anterior teeth. As an
alternative, the three-step technique described by
Vailati and Belser16 may be followed. If this technique is
applied, the palatal space is first built up with compos­
ite before restoring the labial surface with a res­
in-bonded veneer (so-called sandwich technique).
Essentially, a diagnostic template or silicone mold
should be created from the wax-up and used as a guide
during tooth preparation to reduce the amount of tooth
VOLUME 47 • NUMBER 3 ■ MARCH 2016

Fig 4a Preoperative situation in a patient with a deep overbite
and minimal overjet (Angle Class II, division 2).
Fig 5a Long wrap veneers sintered on refractory dies, designed
for periodontally compromised anterior maxillary teeth (MDT Otto
Prandtner, Munich, Germany).
i ••
0 ih
^w MlS |
Fig 6a Situation after having removed a third generation of
veneers in a 54-year-old patient. The palatal surfaces o f the anter­
ior maxillary teeth: extensive composite restorations with second­
ary caries.
structure being removed by taking into account the pre­
viously defined outer contour o f the future veneer.26'2833
If severe discoloration is present, the preparation depth
may be slightly extended to allow the dental technician
sufficient scope to mask the to oth structure.34
VOLUME 47 • NUMBER 3 ■ MARCH 2016
QUINTESSENCE INTERNATIONAL
Edelhoff et al
Fig 4b Situation after splint therapy for 12 months and transfer
of the resulting situation into the dental prosthesis. The implants
in the posterior mandibular region were restored with macro-re­
tentive veneer crowns, which allow the veneering to be replaced
(Schweiger et al,47 University of Munich, Germany).
Fig 5b The veneer preparation was designed to allow a horizon­
tal path of insertion. In this way, distance "C" can be designed to be
smaller than distance "D" (seen as an undercut area if viewed from
the vertical). Compared with a conventional full crown preparation
design, approximately 40% more tooth structure was preserved.
Fig 6b Try-in o f the full-wrap veneers (hybrid crowns) using try-
in pastes. As required by the patient, the most tooth-conserving
preparation configuration possible was selected. As a result, cir­
cular (360 degree) veneers, sintered on refractory dies, were used
for the final restoration (MDT Hubert Schenk, Munich, Germany).
Silicate ceramic veneers present a predictable and
successful treatm ent m odality. In a recently published
retrospective 10-year cohort study, these veneers have
been shown to offer a 93.5% survival probability.13The
first results o f a 7-year prospective clinical study on full
211
QUINTESSENCE INTERNATI ONAL
E d el h o f f et al
Fig 7 Minimally invasive restorations made of lithium-disilicate
press ceramic using the layering technique in the anterior region
(IPS e.max Press LT and IPS e.max Ceram), while the monolithic
technique was used for the posterior restorations (IPS e.max Press
HT) (CDT Oliver Brix, Bad Homburg, Germany).
veneers are promising;35 however, sufficient data are as
yet unavailable fo r either long wrap veneers or full
wrap veneers.35 Bruxism, insufficient enamel support,
and endodontically treated teeth are seen as essential
risk factors for the success o f veneers.13'23'27'28
All-ceramic occlusal onlays
Adhesive all-ceramic partial coverage restorations are
also considered to be a reliable treatm ent option for
the posterior region.12'36 In this context, it should be
borne in m ind th a t the m ajority o f clinical long-term
studies are based on leucite-reinforced glass-ceramics,
whereas today considerably stronger ceramic materials
based on lithium disilicate are available (Fig 7).11'37'38 As
they perm it a defect-oriented preparation m ethod and
elim inate the need fo r a retentive preparation design,
all-ceramic onlays offer a sensible treatm ent option to
avoid conventional invasive trea tm en t m ethods.15-39
The Fourth German Oral Health Study (DMS IV)
revealed a high prevalence o f root caries and non-cari-
ous defects, on the basis o f which it is expected that the
need for single-tooth restorations w ill increase in the
future.40 Young patients affected by severe abrasion-
and/or biocorrosion-induced changes o f the dentition
may particularly benefit from a durable, m inim ally inva­
212
sive treatm ent m odality as their pulps are much larger
than in the adult population (Fig 8a). In addition to
elim inating the abrasion- and biocorrosion-inducing
causes, restoring the esthetic and functional properties
and reconstructing the biomechanical properties o f the
affected teeth are considered th e main trea tm en t
objectives. Furtherm ore, any restorative measures
should be aimed at preventing any further pathologic
wear in the long run.
Compared w ith conventional silicate ceramics, lith ­
ium-disilicate ceramic materials (IPS e.max Press or IPS
e.max CAD, Ivoclar Vivadent) offer enhanced flexural
strength and fracture toughness. Since the introduction
o f lithium disilicate, the recom m ended preparation
depths fo r glass-ceramic onlays have been reduced
significantly. Today, a m inim um occlusal thickness of
1 mm is recom m ended fo r m o n o lith ic restorations
(staining technique). Currently a further reduction in
the layer thickness is brought to discussion if appropri­
ate enamel support is present.14'15-37
Glass-ceramic onlays appear to be ideally suited for
rebuilding abraded and eroded posterior teeth because
they offer enamel-like properties and an optim al inter­
face behavior.39They perm it a particularly gentle prep­
aration of the tooth structure as long as the preparation
does not extend beyond the equator into the infra
bulge (Fig 8b). Consequently, these onlays can be used
to circum navigate conventional prosthetic procedures
th a t are substantially more invasive. It is o f essential
importance for the preparation margins to be predom ­
inantly located in the enamel. In in-vitro studies, exten­
sive silicate ceramic onlays displayed a favorable stress
pattern and almost pure compression at the interface,
which is o f advantage for the ceramic.39 However, all
transitions should be soft and rounded to prevent
stress peaks w ithin the restoration (Figs 8b and 8c).41
It is generally useful to distinguish between pure
onlays (involving o nly the occlusal surface) and
onlay-veneers (involving both the vestibular and occlu­
sal surfaces). The latter is indicated if a m ajor m odifica­
tion o f the shade in the esthetic region (premolar) is
required.42 In a controlled prospective clinical study, the
silicate ceramic onlays showed satisfactory long-term
VOLUME 4 7 • NUMBER 3 ■ MARCH 2016
 QUI NTESSENCE I NT ERNAT I ONAL
E d el h of f et al

results after 12 years and are also suited for use in con­
junction w ith extensive tooth structure defects.36
Another clinical study over an observation period of
12.6 years revealed a failure rate of 20.9% in vital teeth
and 39% in endodontically treated teeth.12

Restorations made of CAD/CAM polymers

Modern manufacturing technologies enable the use of
industrially prefabricated polymers or acrylates, which
offer material qualities that are clearly superior to the
qualities of direct temporary restorations. As these
Fig 8a Extensive abrasion-/biocorrosion-induced defects on the
occlusal surfaces o f the posterior maxillary teeth caused a lower­
ing in the vertical dimension o f occlusion (VDO) in this 28-year-old
female patient.

high-performance polymers are polymerized under

industrial conditions, they feature a highly homoge­
nous structure and therefore offer numerous advan­
tages. They exhibit increased long-term stability, better
biocompatibility and a more favorable wear behavior
than manually produced polymers. Furthermore, they
offer more favorable computer-aided design/comput-
er-assisted manufacture (CAD/CAM) processing charac­
teristics and can be used in thinner thicknesses than Fig 8b Try-in o f the m onolithic occlusal onlays made of IPS
e.max Press with an occlusal thickness of 1 mm. The occlusal
ceramic materials.38’43’44
plateau was smoothed and a 0.5-mm chamfer was prepared above
Complex rehabilitations represent a particular chal­ the equator of the tooth. This was the only preparation done.
lenge for the restorative team, especially if the vertical
dimension of occlusion (VDO) needs to be recon­
structed or redefined. The introduction of high-density
polymers has enabled a significant extension of the
pretreatment phase to establish the esthetic and func­
tional aspects of the reconstruction. If the adhesive
technique is applied correctly, these materials can be
used on both natural teeth and existing restorations.
This allows clinicians to evaluate the treatment objec­ Fig 8c View o f the occlusal onlays after placement w ith a
tive over an extended period of time and therefore light-curing adhesive (Syntac, Total Etch, Variolink II Base, Mono­
bond Plus; Ivoclar Vivadent).
generates a high predictability of the definitive rehabil­
itation.
High-density polymers are currently especially indi­ careful airborne particle abrasion of the restoration's
cated for single-tooth restorations. Basically, we can bonding surface (Rocatec Soft, 3M Espe; grain size
distinguish between polymethyl methacrylate (PMMA)- 33 pm, 1 bar pressure) followed by the application of a
based, mostly unfilled materials for long-term provi- bonding agent is recommended to establish a durable
sionalizations (eg, Telio CAD, Ivoclar Vivadent; or Vita adhesive bond.45
CAD-Temp, Vita Zahnfabrik) and materials, featuring a Using an intraoral silicoating system (eg, CoJet, 3M
high inorganic filler content for final restorations (eg, Espe) is advocated for the intraoral bonding of CAD/
Lava Ultimate, 3M Espe; or Vita Enamic, Vita Zahnfabrik). CAM polymers to existing restorations. It is advisable to
Except for Vita Enamic (etchable with hydrofluoric acid), use a thermoplastic foil and to selectively perforate it to

VOLUME 47 ■ NUMBER 3 • MARCH 2016

213
QUI NTESSENCE I NT ERNAT I ONAL
Edelhoff et al
Fig 9a Occlusal onlays can also be used on existing restorations
for occlusal height corrections, similar to a permanent splint.
expose exactly those areas that should be surface
treated. This measure ensures that only the bonding
areas are silicoated. By using an especially designed
silicoating powder agent (Rocatec Soft), the surfaces of
the existing restorations are cleaned, roughened, acti­
vated, and silicoated all in one step. Upon completion
of the silicatization process, the protective foil is care­
fully peeled off and any remaining particles are
removed from the bonding surfaces with the help of an
air syringe (Fig 9). Currently, clinical studies are being
carried out to assess the suitability of high-density poly­
mers for permanent restorations.46 Against this back­
ground, special attention should be given inter alia to
the wear resistance and behavior of these materials
when they are in direct contact with the opposing den­
tition.
The use of high-density polymers allows clinicians to
increasingly explore interesting new treatment options
and fields of applications.47 For instance, less invasive
restorative procedures to treat periodontally damaged
teeth may be developed, because polymers are charac­
terized by a low modulus of elasticity and are therefore
less susceptible to fracture than ceramic materials if
they are used in delicate configurations (Fig 10). Addi­
tional advantages result from the superior CAD/CAM
processing characteristics compared with ceramic ma­
terials. Higher edge stability, in particular, enables clin­
icians to use purely additive procedures for certain
indications w ithout sacrificing any tooth structure.
214
Fig 9b Occlusal veneers applied to existing restorations. Upon
successful completion of the splint therapy, the functionally validat­
ed occlusal position was transferred to long-term provisional restor­
ations made of PMMA-based CAD/CAM polymer. For this purpose,
the existing metal-ceramic restorations were tribochemically treat­
ed (CoJet), cleaned, and coated with bonding agent (Monobond
Plus) (CDT Josef Schweiger, University Munich, Germany).
DISCUSSION
Reliable resin bonding to natural enamel and silicate
ceramics has ushered in a shift in preparation designs
towards considerably more conservative methods in
the last few decades.4'5 Minimally invasive restorations
are considered to be beneficial because they reduce
the risk of devitalization, are kind to the tooth structure,
and offer a high esthetic potential. Whilst these possi­
bilities inspire a great deal of euphoria, we should bear
in mind that the methods described above involve a
high degree of technique sensitivity with regard to
preparation (mainly in the enamel), adhesive bonding,
and final fine-tuning of the static and dynamic occlu­
sion.27'4850 Adhering to the defined guidelines during
the various clinical and technical treatment phases
presents a key factor for achieving clinical long-term
success.51 While numerous clinical long-term stud-
j e s 13,23,36,48,52 are available on minimally invasive restora­
tive treatment methods with ceramic materials, valid
clinical data on the long-term behavior of minimally
invasive final restorations made of CAD/CAM polymers
are still lacking.53'54
So far the authors of this report have had excellent
experiences with long-term temporary single-tooth
restorations made of PMMA-based CAD/CAM polymers.
A prospective controlled clinical study using highly
filled CAD/CAM polymers as the material for the final
restoration in patients with generalized loss of tooth
VOLUME 4 7 - NUMBER 3 - MARCH 2016

Fig 10a Preoperative view of a 52-year-old patient. Periodon-
tally compromised anterior teeth impaired the functional and
esthetic properties of the dentition.
structure was initiated at the Department of Prostho-
dontics at the University of Munich recently (Project No
541-12). In the meantime, more than 12 patients have
been treated and, w ithout a single exception, they all
responded enthusiastically to the predominantly addi­
tive treatm ent modality, as most of these complex
cases could be treated with no, or hardly any, prepar­
ation. However, as the observation period of this study
is still short, a scientifically valid conclusion cannot yet
be drawn.
CONCLUSION
Dentists performing prosthetic treatments have a vast
array of alternative treatment options at their disposal,
which they can use instead of conventional and essen­
tially more invasive procedures. Many treatment modal­
ities are already backed up by valid long-term data.
With regard to the material class of ceramics these
treatment options are considered to be scientifically
validated for numerous indications. Long-term results
on the use of CAD/CAM polymers in permanent restor­
ations are not yet available. Generally, the methods
described above are considered to be highly tech­
nique-sensitive and therefore require the clinician and
technician to have well-founded skills and experience
to carry them out.49 Furthermore, the present report has
only touched on a small section of the spectrum of min­
imally invasive treatment options currently available.
VOLUME 4 7 • NUMBER 3 ■ MARCH 2 0 /6
QUINTESSENCE INTERNATIONAL
E d el h of f et al
Fig 10b A long wrap preparation design w ith a horizontal path
of insertion (see Fig 5b) was selected to avoid excessive removal
of tooth structure.
Fig 10c Try-in of the experimental veneers made of highly-filled
CAD/CAM polymer in the course o f a prospective clinical study
(MDT Otto Prandtner, Munich, Germany).
REFERENCES
1. Pjetursson BE, Lang NP. Prosthetic treatment planning on the basis o f scien­
tific evidence. J Oral Rehabil 2008;35:72-79.
2. Cheung GS, Lai SC, Ng RP. Fate o f vital pulps beneath a metal-ceramic crown
or a bridge retainer. Int Endod J 2005;38:521-530.
3. Foster LV. Failed conventional bridge work from general dental practice: clin­
ical aspects and treatment needs o f 142 cases. Br DentJ 1990;168:199-201.
4. Edelhoff D, Sorensen JA. Tooth structure removal associated w ith various
preparation designs for anterior teeth. J Prosthet Dent 2002;87:503-509.
5. Edelhoff D, Sorensen JA. Tooth structure removal associated w ith various
preparation designs for posterior teeth. Int J Periodontics Restorative Dent
2002;22:241-249.
6. Al-Fouzan AF, Tashkandi EA. Volumetric measurements o f removed tooth
structure associated w ith various preparation designs. Int J Prosthodont
2013;26:545-548.
7. Chun YH, Raffelt C, Pfeiffer FI, et al. Restoring strength o f incisors w ith veneers
and full ceramic crowns. J Adhes Dent 2010;12:45-54.
8. Soares PV, Santos-Filho PC, Martins LR, Soares G . Influence o f restorative
technique on the biomechanical behavior o f endodontically treated maxillary
premolars. Part I: fracture resistance and fracture mode. J Prosthet Dent
2008;99:30-37.
9. Murphy F, McDonald A, Petrie A, Palmer G, Setchell D. Coronal tooth structure
in root-treated teeth prepared for complete and partial coverage restorations.
J Oral Rehabil 2009;36:451-461.
10. Kern M. Adhesive bridges today. Quintessenz 1990;41:1145-1157.
11. Guess PC, Selz CF, Steinhart YN, Stampf S, Strub JR. Prospective clinical split-
mouth study o f pressed and CAD/CAM all-ceramic partial-coverage restor­
ations: 7-year results. Int J Prosthodont 2013;26:21—25.
215
QUI NTESSENCE I NT ERNAT I ONAL
Edelhoff et al
12. Van Dijken JW, Hasselrot L. A prospective 1S-year evaluation o f extensive den­
tin-enamel-bonded pressed ceramic coverages. Dent Mater 2010;26:929-939.
13. Beier US, Kapferer I, Burtscher D, Dumfahrt H. Clinical performance o f porce­
lain laminate veneers for up to 20 years. Int J Prosthodont 2012;25:79—85.
14. Cortellini D, Canale A. Bonding lithium disilicate ceramic to feather-edge
tooth preparations: a minimally invasive treatment concept. J Adhes Dent
2012;14:7-10.
15. Fradeani M, Barducci G, Bacherini L, Brennan M. Esthetic rehabilitation o f a
severely worn dentition w ith minimally invasive prosthetic procedures
(MIPP). Int J Periodontics Restorative Dent 2012;32:135-147.
16. Vailati F, Belser UC. Full-mouth adhesive rehabilitation o f a severely eroded
dentition: the three-step technique. Parts 1-3. Eur J Esthet Dent 2008;3:30-
44,128-146,236-257.
17. Walls AW. The use o f adhesively retained all-porcelain veneers during the
management o f fractured and worn anterior teeth: Part 2. Clinical results after
5 years o f follow-up. Br Dent J 1995;178:337-340.
18. Rochette AL. Attachment o f a splint to enamel o f lower anterior teeth. J
Prosthet Dent 1973;30:418-423.
19. Sasse M, Kern M. All-ceramic rein-bonded fixed dental prostheses: Treatment
planning, clinical procedures, and outcome. Quintessence Int 2014;45:291 —297.
20. Aggstaller H, Beuer F, Rammelsberg P, Edelhoff D, Gernet W. Long-term clin­
ical performance of resin bonded fixed dental prostheses with retentive
preparation geometry in anterior and posterior areas. J Adhes Dent
2008;10:301-306.
21. Flopkins C. An immediate cantilevered Rochette bridge. Br Dent J
1981;151:292-295.
22. Sailer I, Bonani T, Brodbeck U, Hammerle Chi. Retrospective clinical study of
single-retainer cantilever anterior and posterior glass-ceramic resin-bonded
fixed dental prostheses at a mean follow-up o f 6 years. Int J Prosthodont
2013;26:443-450.
23. Peumans M, van Meerbeek B, Lambrechts P, Vanherle G. Porcelain veneers: a
review of the literature. J Dent 2000;28:163-177.
24. Belser UC, Magne P, Magne M. Ceramic laminate veneers: continuous evolu­
tion of indications. J Esthet Dent 1997;9:197-207.
25. Magne P, Douglas WH. Porcelain veneers: dentin bonding optimization and
biomimetic recovery of the crown. Int J Prosthodont 1999;12:111-121.
26. Magne P, Douglas WH. Interdental design o f porcelain veneers in the pres­
ence o f composite fillings: finite element analysis o f composite shrinkage and
thermal stresses. Int J Prosthodont 2000;13:117-124.
27. Burke FJ. Survival rates for porcelain laminate veneers with special reference
to the effect o f preparation in dentin: a literature review. J Esthet Restor Dent
2012;24:257-265.
28. Gurel G, Sesma N, Calamita MA, Coachman C, Morimoto S. Influence o f enam­
el preservation on failure rates o f porcelain laminate veneers. Int J Periodon­
tics Restorative Dent 2013;33:31-39.
29. Magne P, Douglas WH. Design optimization and evolution o f bonded ceram­
ics for the anterior dentition: a finite-element analysis. Quintessence Int
1999;30:661-672.
30. Schmidt KK, Chiayabutr Y, Phillips KM, Kois JC. Influence o f preparation design
and existing condition o f tooth structure on load to failure o f ceramic lami­
nate veneers. J Prosthet Dent 2011;105:374—382.
31. Rouse JS. Full veneer versus traditional veneer preparation: A discussion of
interproximal extension. J Prosthet Dent 1997;78:545-549.
32. Magne P, Belser U. Chapter 4: Evolution of indications for anterior bonded
porcelain restaorations. Major morphologic modifications. In: Magne P, Belser
U. Bonded Porcelain Restorations in the Anterior Dentition. Chicago: Quintes­
sence, 2002:140-142.
33. Rieder CE. The use o f provisional restorations to develop and achieve esthetic
expectations. Int J Periodontics Restorative Dent 1989;9:122-139.
216
34. Edelhoff D, Seiffert A, Giith J-F. Light-transmission o f lithium disilicate in rela­
tion to the translucency. Quintessenz Zahntech 2013;39:22-26.
35. Guess PC, Selz CF, Voulgarakis A, Stampt S, Stappert CF. Prospective clinical
study o f press-ceramic overlap and full veneer restorations: 7-year results. Int
J Prosthodont 2014;27:355-358.
36. Frankenberger R, Taschner M, Garcia-Godoy F, Petschfelt A, Kramer N.
Leucite-reinforced glass ceramic inlays and onlays after 12 years. J Adhes Dent
2008;10:393-398.
37. Ma L, Guess PC, Zhang Y. Load-bearing properties o f minimal-invasive mono­
lithic lithium disilicate and zirconia occlusal onlays: finite element and theo­
retical analyses. Dent Mater 2013;29:742-751.
38. Schlichting LH, Maia HP, Baratieri LN, Magne P. Novel-design ultra-thin CAD/
CAM composite resin and ceramic occlusal veneers for the treatment of
severe dental erosion. J Prosthet Dent 2011 ;105:217-226.
39. Magne P, Belser U. Porcelain versus composite inlays/onlays: effect of
mechanical loads on stress distribution, adhesion, and crown flexure. Int J
Periodontics Restorative Dent 2003;23:543-555.
40. Schiffner U, Hoffmann T, Kerschbaum T, Micheelis W. Oral health in German
children, adolescents, adults and senior citizens in 2005. Community Dent
Health 2009;26:18-22.
41. Ahlers MO, Morig G, Blunck U, Hajto J, Probster L, Frankenberger R. Guidelines
for the preparation o f CAD/CAM ceramic inlays and partial crowns. Int J Corn-
put Dent 2009;12:309-325.
42. Edelhoff D, Beuer F, Schweiger J, Brix O, Stimmelmayr M, Guth JF. CAD/
CAM-generated high-density polymer restorations fot the pretreatment of
complex cases: a case report. Quintessence Int 2012;43:457-467.
43. Jakob F, Jungbauer G, Schneider J, et al. Biocompatibility o f new CAD/
CAM-machinable materials for provisional long-term restorations. 45th IADR
Meeting, Barcelona 2010, Abstr 134462.
44. Stawarczyk B, Ozcan M, Trottmann A, Schmutz F, Roos M, Hammerle C. Two-
body wear rate o f CAD/CAM resin blocks and their enamel antagonists. J
Prosthet Dent 2013;109:325-332.
45. Bahr N, Keul C, Edelhoff D, et al. Effect of different adhesives combined with
tw o resin composite cements on shear bond strength to polymeric CAD/
CAM materials. Dent Mater J 2013;32:492-501.
46. Guth J-F, Ihloff H, Edelhoff D, Mast G. Complete mouth rehabilitation after
transposition osteotomy based on intraoral scanning: An experimental ap­
proach. J Prosthet Dent 2014;112:89-93.
47. Schweiger J, Neumeier P, Stimmelmayr M, Beuer F, Edelhoff D. Macro-reten­
tive replaceable veneers on crowns and fixed dental prostheses: a new ap­
proach in implant-prosthodontics. Quintessence Int 2013;44:341-349.
48. Beier US, Kapferer I, Dumfahrt H. Clinical long-term evaluation and failure char­
acteristics o f 1,335 all-ceramic restorations. Int J Prosthodont 2012;25:70-78.
49. Frankenberger R, Reinelt C, Petschelt A, Kramer N. Operator vs. material influ­
ence on clinical outcome o f bonded ceramic inlays. Dent Mat 2009;25:960-
968.
50. Van Dijken JW, Hasselrot L, Ormin A, Olofsson A-L. Restorations with extensive
dentin/enamel-bonded ceramic coverage. A 5-year follow-up. Dent Mater
2001;109:222-229.
51. D'Arcangelo C, de Angelis F, Vadini M, d'Amario M. Clinical evaluation on
porcelain laminate veneers bonded w ith light-cured composite: results up to
7 years. Clin Oral Investig 2012;16:1071-1079.
52. Kern M, Sasse M. Ten-year survival o f anterior all-ceramic resin-bonded fixed
dental protheses. J Adhes Dent 2011 ;13:407-410.
53. Fasbinder DJ, Dennison JB, Heys DR, Lampe K. The clinical performance of
CAD/CAM-generated composite inlays. J Am Dent Assoc 2005;136:1714—1723.
54. Vanoorbeek S, Vandamme K, Lijnen I, Naert I. CAD/CAM-composite resin
versus ceramic single-tooth restorations: a 3-year clinical study. Int J Prostho­
dont 2010;23:223-230.
VOLUME 4 7 - NUMBER 3 - MARCH 2016
Copyright of Quintessence International is the property of Quintessence Publishing Company
Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.