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Adhesive Restoration in Posterior Teeth using Semidirect Technique

Adhesive Restoration in Posterior Teeth using

Semidirect Technique
Maciel E da Silva Júnior, 2Gabriela Ohata, 3Mateus R Tonetto, 4Edson A de Campos, 5Marcelo F de Andrade

ABSTRACT conservative treatments have been proposed and are

Aim: The aim of this article was to present a detailed case based on minimally invasive dentistry with minimal
report of semidirect composite restoration in tooth #36 and its healthy dental tissue removal.
anatomical and esthetic reestablishments. Semidirect restor- Direct restoration using composite resins is indicated
ative technique is an alternative with many advantages for both when tooth destruction is not large, such as small–
clinicians and patients. It can improve esthetics with minimal
dental tissue removal, reduce polymerization contraction, medium cavity with proximal walls slightly divergent to
improve marginal sealing, reduce infiltration and postoperative proximal.1 However, composite resin restorations present
sensitivity, and enhance the restoration longevity. Moreover, it limitations, such as polymerization shrinkage (causing
is a low-cost technique and carried out in a single session. A cracks at tooth–restoration interface and increasing mar-
female patient reported with sensitivity and discomfort in tooth
ginal leakage risk), and in addition, it is not indicated in
#36 region; clinical evaluation showed marginal infiltration and
restoration loss, and thus, semidirect restoration technique large dental destruction with proximal walls and cusps
was recommended. The impression was carried out using involvement; thus, to solve those problems, indirect
precision alginate, and a semirigid addition silicone model adhesive restorations are indicated.
was obtained. Semidirect restoration was performed using a
Indirect adhesive restorations require more than one
model outside the mouth. Semidirect restoration is a viable
alternative improving dental esthetics with conservative treat- clinical session and a laboratory step. Clinicians send the
ment, reducing polymerization shrinkage, improving marginal preparation and antagonist teeth impressions to a dental
sealing, reducing infiltration and postoperative sensitivity, and laboratory, and then the technician makes an indirect
enhancing restoration quality. restoration. An alternative method to indirect technique
Clinical significance: Semidirect restoration is a low-cost is the semidirect restoration, which uses both direct and
technique with advantages, such as polymerization control, indirect restoration principles.2
esthetic refinement, and facilitating of occlusal and contact
Semidirect restoration is accessible, a simple technique
point adjustments.
with restorative quality, and mainly depends on the clini-
Keywords: Dental esthetics, Esthetic dentistry, Indirect–direct cian’s ability. The treatment time is higher than direct res-
toration; however, semidirect restoration is performed in
How to cite this article: da Silva Júnior ME, Ohata G, Tonetto MR, a single session. This principle of this technique provides
de Campos EA, de Andrade MF. Adhesive Restoration in Pos-
an adhesive restoration without a laboratory step and
terior Teeth using Semidirect Technique. World J Dent 2017;
8(5):413-416. high-cost inlays and/or onlays restorations. Therefore, the
aim of the present case report was to describe a detailed
Source of support: Nil
semidirect restoration confection in tooth #36 and its
Conflict of interest: None anatomical esthetic reestablishment using a semirigid die.


The search for beauty standards has increased the concept A female patient reported with sensitivity and discom-
of esthetic values among people. Moreover, an esthetic fort in tooth# 36 region, and clinical evaluation showed
smile has also been considered important and demanded marginal infiltration and restoration loss (Fig. 1).
by patients in dental surgeries. Nowadays, esthetic After evaluation, the semidirect restorative technique
was the chosen treatment. First, tooth preparation was
carried out using diamond burs at high speed under irri-
Department of Restorative Dentistry, School of Dentistry gation (Fig. 2). Semidirect restoration technique follows
Universidade Estadual Paulista, Araraquara, São Paulo, Brazil some indirect restoration principles, such as expulsive
Department of Dentistry, University of Cuiabá, Cuiabá, Mato preparation with smooth wall and an occlusal box pre-
Grosso, Brazil senting 1.5 to 2 mm depth, rounded internal angles and
Corresponding Author: Maciel E da Silva Júnior, St. Humaitá sharp external angles, or presenting a 90° angle.
Street, 1680, Araraquara, São Paulo, Brazil, 14801903, e-mail: After tooth preparation, an impression was carried
out using a Hidrogum V (Zhermack, Badia Polesine,
World Journal of Dentistry, September-October 2017;8(5):413-416 413
Maciel E da Silva Júnior et al

Fig. 1: Tooth 36 initial view showing defective composite Fig. 2: Defective restoration removal followed by semidirect
resin restoration restoration preparation using diamond bur #3098 at high speed
under water cooling

Fig. 3: Partial impression using Hidrogum V Fig. 4: Tooth #36 die was obtained from condensation
high-precision alginate silicone base

Italy) high-precision alginate (Fig. 3), and semirigid addi-

tion silicone (Die Silicone – Voco, Cuxhaven, Germany)
cast was obtained. During the cast, 36 region was kept
smooth, and retentions were performed underneath the
adjacent teeth. Glycerin-based insulation was applied in
36 region. A barrier made of condensation silicone was
placed around silicone model to provide stability during
tooth #36 separation using a scalpel blade #11 to obtain
a die (Fig. 4).
After obtaining the die model, mesial–occlusal–distal
restoration was performed using composite resin (Gran-
diOSO-VOCO, Cuxhaven, Germany) and light cured for Fig. 5: Restoration was performed through several composite
40 seconds for every 2 mm thickness at each increment resin increments
(Fig. 5). The semidirect restoration was light-cured in
both internal and external faces. Then, restoration was acid etched with 37% phosphoric acid (FGM Produ-
tried and adjusted in the mouth. tos Odontológicos Ltda., Joinville, SC, Brazil) for 30
Afterward, luting procedure was performed follow- seconds (enamel) and 15 seconds (dentin) and rinsed;
ing three steps: Internal rough surface and decontamina- after that, an adhesive system was applied according
tion, prophylaxis and hybridization, and luting. to manufacturer’s instructions and light cured using
Internal restoration surface was prepared using a light-emitting diode system (LED Bluephase; Ivoclar
diamond bur to obtain a rough surface. After that, the Vivadent, Schan, Liechtenstein, AL) with 1.200 mW/cm2
surface was decontaminated using 37% phosphoric acid light intensity.
for 1 minute and then rinsed. Semidirect restoration was luted using a dual-cure
Adhesive luting protocol was followed, absolute cement (Allcem FGM, Joinville, Brazil). After its inser-
isolation was carried out, and prophylaxis tooth was tion into the cavity, excesses were removed and cement


Adhesive Restoration in Posterior Teeth using Semidirect Technique

times are reduced; composite resin material can be

added to enhance proximal contacts; and there is the
possibility to obtain better surface smoothness and
esthetic result since finishing and polishing proce-
dures are performed outside the mouth providing
better adaptation and marginal sealing;
• However, it also presents some disadvantages: It
requires longer working time than direct technique;
preparation must be homogeneous and expulsive;
more materials are required; the technique is more
Fig. 6: Semidirect restoration final image after finishing and
difficult and depends on the ability of the clinicians;
polishing procedures and dental structure wear and treatment session time
are higher than direct technique.
Both semi-direct and indirect restorations follow the
was light-cured. Occlusal and proximal contacts were
same technical principles. When restorations need to
adjusted, and semidirect restoration was submitted to
be changed, e.g., amalgam restoration replacement, the
final polishing (Fig. 6).
cavity has already been performed, and the preparation
must be adapted to semi-direct and indirect restorations.
Hydrogum 5 high-precision alginate is the choice
Composite resin has been widely used since it provides material for the impression of semidirect tooth restora-
an esthetic and conservative treatment. Many studies tions. Semirigid addition silicones can be employed to
have been conducted to improve composites’ mechanical obtain an immediate model (Die Silicone, VOCO) similar
behavior, reduce polymerization shrinkage, and polish to the present study.
maintenance. Polymerization shrinkage may cause An additional polymerization can be performed
marginal gaps or even cracks in dental structure or res- after the last increment light curing. This additional
toration due to internal stress occurrence when internal step is carried out to improve the composite mechani-
forces exceed tooth restoration–interface bond strength. cal properties. Some in vitro studies4 have reported that
Moreover, polymerization shrinkage is an important the composite resin hardness and wear resistance were
factor to be considered during restorative technique improved after that additional step. It can be performed
selection, since shrinkage controlling will minimize using maximum light curing on all faces, or after pho-
some postoperative problems, such as sensitivity, pain, tothermal treatment at 120°C for 7 minutes, or thermal
and discomfort.3 postpolymerization using an autoclave or microwave
Semidirect technique is indicated to minimize polym- oven.5,6 Magne7 suggests the use of an oven at 220° for a
erization shrinkage and also when posterior teeth access few minutes. In the same article, the author states that the
is difficult, large dimensions cavities, or limited number esthetic potential and anatomy of extraoral composites
of teeth.1 are greatly improved by the possibility of performing
Therefore, semidirects restorations are recommended more sophisticated layering than can be accomplished
for: Teeth with expulsive cavities, avoiding unnecessary intraorally. In addition to improving restoration adapta-
cavity preparation; large cavities with preserved ana- tion and seal because the main polymerization shrinkage
tomical references, such as cusp tips; defective restoration is achieved without stress on the adhesive interface, the
replacements, mainly indirect ones; limited number of initial goals of semidirect techniques were also to facili-
teeth; posterior tooth with difficult access; low-cost res- tate clinical procedures and improve occlusal anatomy,
torations; and when a single session is needed and does contact points, and related function.
not require a temporary crown confection. Tonetto et al8 indicate this kind of restorative treat-
• Semidirect technique has advantages: Incremental ment for cases in which the rehabilitations with full
technique is not used similar to direct restorations; covering with ceramics for reanatomizations are contra-
thus, air bubbles are not included; polymerization indicated, as in the use in children and adolescents. The
process is improved and polymerization shrinkage authors believe that semidirect restorations are a viable
occurs outside the mouth; it improves physical prop- alternative because of the low cost, the advantage of
erties of material, reducing marginal gaps and post- extraoral polymerization, advantage of extraoral polym-
operative sensitivity; it is low in cost in comparison erization, and esthetic refinement as they are prone to be
with indirect techniques; intra- and extraoral session repaired easily.

World Journal of Dentistry, September-October 2017;8(5):413-416 415

Maciel E da Silva Júnior et al

Related to durability, Spreafico et al9 evaluated the point and a marginal adaptation performed in a single
clinical performance and marginal adaptation of direct session.
and semidirect class II composite restorations in a split-
mouth design over 3.5 years, and the clinical results ACKNOWLEDGMENT
exhibited a retention rate of 100% after 3.5 years. No frac- Authors would like to thank the Araraquarense Foun-
tures were observed or even sensitivity compared with dation of Teaching and Dental Research (FAEPO).
an equal number of restorations done directly (22 resto-
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