The Esthetic Impact
Inside Dentistry (ID): What does adhesive dentistry allow you to do cosmetically with indirect restorations?
Amanda N. Seay, DDS (AS): Adhesive dentistry has revolutionized patient care and the available treatment options in cosmetic dentistry. In dental school, I was taught that when a direct restoration exceeded a certain size, the standard treatment protocol dictated that a full-coverage crown be placed. These crowns typically followed conventional preparation designs, and if they were porcelain-fused-to-metal crowns, they often required subgingival margin placement to conceal the unesthetic interface between the tooth and porcelain. However, with the advancements in adhesive dentistry and the introduction of newer, stronger, and more esthetic ceramic options, these traditional protocols have been completely transformed. Modern adhesive dentistry facilitates the use of more conservative, minimally invasive procedures that result in restorations that seamlessly blend with the natural tooth structure, enhancing esthetics. It allows me to deliver truly minimally invasive restorations without the need for any "standard" preparation.
ID: How about in regard to direct restorations?
AS: I have a deep appreciation for composite artistry, and adhesive dentistry has consistently provided me with the predictability that I've needed to effectively work with composites. However, what has truly evolved over the years is the variety of procedures for which we can rely on adhesive dentistry. Nowadays, I contemplate how to phase treatment, adjust vertical dimensions, and tackle complex cases using direct bonding in the posterior region—all while leveraging the predictability of modern adhesive techniques. This paradigm shift has undeniably been a game-changer for me.
ID: When you are educating, do you often hear from dentists who are reluctant to practice adhesive dentistry?
AS: Yes. Surprisingly, some clinicians are hesitant to embrace adhesive dentistry. Concerns often revolve around restorations debonding; however, when debonding occurs, it is typically due to improper technique. It's essential for practitioners to recognize that investing in training to refine their technique is in the best interest of their patients, particularly regarding remaining as conservative as possible. Adhesive dentistry has become indispensable in modern dental practice, and mastering its principles is a crucial component of providing optimal patient care.
ID: Can the bonding technique used have any impact on esthetics?
AS: Although the bonding technique used may not directly influence esthetics, an improper bonding technique can lead to sensitivity, low bond strength, and functional issues. Even seasoned dentists can benefit from revisiting the fundamental techniques to ensure optimal outcomes. Understanding each step of the bonding technique that will be used and closely adhering to the manufacturer's instructions for the chosen bonding agent are key to avoiding complications and achieving superior results.
ID: Do you prefer a total-etch, self-etch, or selective-etch technique?
AS: Universal adhesives can be used with various etching techniques; however, studies have demonstrated that the best results are achieved when they are used in a selective-etch approach. Personally, I prefer a selective-etch technique because it offers better control and minimizes the risk of over-etching dentin, which results in less sensitivity. Given the minimally invasive nature of much of my work, I prioritize enamel preservation while I'm ensuring excellent bonding.
ID: Do you believe that immediate dentin sealing is effective?
AS: I had to think about this because in the past, before I had the option of in-office milling, I would have to place a provisional restoration while waiting for the final restoration from the laboratory. If I was going to place a provisional restoration, I always applied flowable composite to either block out undercuts or as part of a core buildup. In addition, air abrasion has always been an essential component of my bonding protocol. Since incorporating in-office milling for final restorations, my approach to how I treat the tooth hasn't changed. I find myself applying similar principles, just with a more streamlined process that isn't interrupted by a provisionalization phase. Essentially, my answer is that there are no drawbacks for clinicians to adopt immediate dentin sealing in their practices, particularly if they are placing provisional restorations.
ID: Do you feel that universal adhesives are truly universal, or do you use different adhesives for different situations?
AS: I utilize universal bonding agents but always with a selective-etch technique. They can be used with various etching techniques, but that is my preference. I believe that understanding the specific requirements for bonding each restorative material is essential for success. Treating each surface accordingly, whether it's glass ceramic, lithium disilicate, zirconia, metal, or composite, is critical to producing reliable bonds and achieving optimal outcomes.
ID: Which restorative materials do you bond?
AS: I bond a variety of materials, but I mostly use glass ceramics and lithium disilicate for their esthetic qualities. However, I also bond zirconia, when necessary, which can be done predictably provided that the correct bonding protocol is followed. Understanding the nuances of how to bond all of the different materials that you use is essential to ensuring long-lasting, durable restorations.
About the Expert
Amanda N. Seay, DDS, is the founder, CEO, and clinical director of Expertise Dental in Mount Pleasant, South Carolina. She is also a fellow of the American Academy of Cosmetic Dentistry, Inside Dentistry's restorative section editor, and the director of outreach and engagement for the Seattle Study Club.
