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Universidade Federal de Pelotas

Faculdade de Odontologia
Programa de Pós-Graduação em Odontologia

Tese

Resina composta restauradora pré-aquecida como agente de cimentação

adesiva de restaurações indiretas

Rogério Luiz Marcondes

Pelotas, 2021
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Rogério Luiz Marcondes

Resina composta restauradora pré-aquecida como agente de cimentação

adesiva de restaurações indiretas

Tese apresentada ao Programa de Pós-

Graduação em Odontologia da Faculdade
de Odontologia da Universidade Federal de
Pelotas, como requisito parcial à obtenção
do título de Doutor em Odontologia, área de
concentração Biomateriais e Biologia Oral,
ênfase Materiais Odontológicos.

Orientador: Prof. Dr. Rafael Ratto de Moraes

Co-orientador: Prof. Dr. Marco Aurélio de Carvalho

Pelotas, 2021
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Rogério Luiz Marcondes

Resina composta restauradora pré-aquecida como agente de cimentação adesiva de

restaurações indiretas

Tese apresentada, como requisito parcial para obtenção do grau de Doutor em

Odontologia, Programa de Pós-Graduação em Odontologia, Faculdade de
Odontologia, Universidade Federal de Pelotas.

Data da defesa: 01/10/2021

Banca examinadora:

Prof. Dr. Rafael Ratto de Moraes (Orientador)

Doutor em Materiais Dentários pela Universidade Estadual de Campinas

Prof. Dr. Gregori Franco Boeira

Doutor em Odontologia (Dentístics) pela Universidade Federal de Pelotas

Prof. Dr. Leandro Augusto Hilgert

Doutor em Dentística pela Universidade Federal de Santa Catarina

Prof. Dr. Tiago Veras Fernandes

Doutor em Odontologia (Dentística) pela Universidade Norte do Paraná

Profa. Dra. Giana da Silveira Lima (Suplente)

Doutora em Odontologia (Dentística) pela Universidade Federal de Pelotas

Profa. Dra. Priscilla Cardoso Lazari (Suplente)

Doutora em Clínica Odontológica (Prótese Dental) pela Universidade Estadual de
Campinas
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DEDICATÓRIA

À minha querida esposa, Carolina dos Santos Marcondes, o grande amor da

minha vida e meu porto seguro.
Aos meus dois filhos, Guilherme e Gabriel, pessoas que me fazem aprender e
crescer dia a dia e enriquecem minha vida intensamente, com eles aprendi a amar
incondicionalmente.
À memória de meu irmão, Ricardo Kochinski Marcondes, um exemplo fraterno de
inteligência e tranquilidade. Meu irmão, saudades eternas!
Ao meu pai, Genilton Luiz Marcondes, um pai presente e dedicado a vida dos filhos
À minha mãe, Anísia Kochinski Marcondes, pessoa que me inspira e acima de tudo,
sempre MÃE.
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Agradecimentos

À Universidade Federal de Pelotas e ao Programa de Pós-Graduação em

Odontologia (PPGO) pela oportunidade de aprimorar minha formação.
Ao meu orientador, Prof. Dr. Rafael Ratto de Moraes, pela incansável
dedicação. Muito obrigado mestre, sua ajuda tornou simples até as fases mais
complexas. E mesmo quando eu estava desistindo, me deu força para seguir em
frente e, só por isso, foi possível a realização deste trabalho.
Ao meu co-orientador, Prof. Dr. Marco Aurélio de Carvalho, pela oportunidade
de aprender contigo. Um verdadeiro mestre no conhecimento e na simplicidade. Muito
obrigado pelas discussões que enriqueceram a elaboração teórica e pela ajuda nas
tarefas descritivas deste trabalho. Meu grande amigo e professor., te considero muito!
A Profa. Dra. Giana da Silveira Lima, pela ajuda em diversas disciplinas e por
ajudar a instigar em mim a vontade, já adormecida, dentro da didática aplicada à
odontologia. Obrigado, mais uma vez, por esta oportunidade de aprender contigo.
Aos demais professores do PPGO, por todos os conhecimentos divididos.
Aos alunos do PPGO, Verônica Lima, Fabíola Barbon, Matheus Kinalski e
Peterson Boeira pela ajuda nos ensaios no laboratório, assim como à pós-doutoranda
Cristina Isolan.
Aos colegas Dr. Tiago Veras Fernandes, Dr. Adriano Lima, Dr. Fabricio Ogliari,
Dra. Aline Ogliari, Dr. Jefferson Ricardo Pereira e Dr. Gregori Boeira pelo apoio e ajuda
nessa jornada.
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Notas Preliminares

A presente tese foi redigida segundo o Manual de normas UFPel para trabalhos
acadêmicos de 2019, adotando o Nível de Descrição em Capítulos não convencionais,
descrito no Apêndice C do manual (último acesso em 28/08/2021)
<https://wp.ufpel.edu.br/sisbi/files/2019/06/Manual.pdf>. O projeto de pesquisa que
originou esta tese foi submetido a exame de qualificação em 19/10/2018 e aprovado
pela banca examinadora composta pelos professores doutores Rafael Ratto de
Moraes, Aline Oliveira Ogliari e Gregori Franco Boeira.
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Resumo

MARCONDES, Rogério Luiz. Resina composta restauradora pré-aquecida como

agente de cimentação adesiva de restaurações indiretas. Orientador: Rafael Ratto
de Moraes. 2021. 68f. Tese (Doutorado em Odontologia) – Programa de Pós-
Graduação em Odontologia, Universidade Federal de Pelotas, Pelotas, 2021.

O uso de resina composta restauradora pré-aquecida para cimentação adesiva de

restaurações indiretas como alternativa aos tradicionais cimentos resinosos é cada
vez mais popular. No entanto, ainda há espaço para melhorar a técnica clínica,
entender como selecionar o compósito corretamente e reduzir a espessura de
película, bem como relatar resultados clínicos de longo prazo. Essa tese abordou o
tema por meio de três estudos. O primeiro estudo foi uma investigação in vitro dos
efeitos do pré-aquecimento a 69°C sobre viscosidade, espessura de película e perda
de temperatura de 10 compósitos contemporâneos, além do efeito da energia do
ultrassom na espessura do filme resultante. Este estudo mostrou que materiais com
formulações distintas reagem de forma diferente ao pré-aquecimento, afetando
viscosidade e espessura do filme. O tempo de trabalho ideal dos compósitos pré-
aquecidos foi curto, sugerindo que clínicos devem adequar a sequência de
cimentação para aproveitar as temperaturas mais altas encontradas nos primeiros 15s
após o pré-aquecimento. Além disso, observou-se que a aplicação do ultrassom foi
eficaz na redução da espessura de película e pode ajudar resinas compostas
restauradoras a alcançar películas abaixo de 50μm. O segundo estudo foi uma técnica
clínica relatando a cimentação de facetas laminadas cerâmicas com composto pré-
aquecido, descrevendo um procedimento passo a passo que pode ser utilizado por
clínicos em sua rotina de trabalho, incluindo aplicação de ultrassom sobre a cerâmica
para otimizar a espessura do filme. O terceiro estudo foi um relato de caso de
tratamento clínico no qual os laminados cerâmicos foram cimentados adesivamente a
dentes superiores anteriores de uma paciente utilizando resina composto pré-
aquecida e mostrou excelente desempenho clínico e notável integridade marginal
após 123 meses de acompanhamento. Uma transição marginal suave entre cerâmica,
agente de cimentação e dente (área de continuidade adesiva) e a ausência de lacunas
marginais e valamento indicaram que o compósito restaurador foi capaz de suportar
os desafios abrasivos e superficiais impostos pelo ambiente oral em longo prazo. Em
geral, esta tese mostra que resina composta pré-aquecida para a cimentação de
restaurações indiretas pode ser considerado uma excelente opção clínica e que o
desempenho geral da técnica clínica depende da seleção adequada de um compósito
que responde adequadamente ao pré-aquecimento. Ainda há espaço para estudos
clínicos controlados sobre o tema.

Palavras-chave: Cimentação. Resinas compostas. Restauração dentária permanente.

Ultrassom.
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Abstract

MARCONDES, Rogério Luiz. Preheated restorative resin composite as adhesive

luting agent of indirect restorations. Advisor: Rafael Ratto de Moraes. 2021. 68p.
Thesis (PhD in Dentistry) – Graduate Program in Dentistry, Universidade Federal de
Pelotas, Pelotas, 2021.

The use of restorative preheated resin composite for adhesive luting of indirect
restorations as an alternative to traditional resin-based cements is increasingly
popular. However, there is still room for improving the clinical technique, understanding
how to select the composite properly and reduce film thickness, as well as on reporting
long-term clinical results. This thesis addressed the topic by means of three studies.
The first study was an in vitro investigation of the effects of preheating at 69°C on
viscosity, film thickness, and temperature loss of 10 contemporary resin composites,
in addition to the effect of ultrasound energy on the resulting film thickness. This study
showed that materials with distinct formulations react differently to preheating, affecting
viscosity and film thickness. Optimal working time of the preheated composites was
short, suggesting that clinicians should adequate the luting sequence to take
advantage of higher temperatures found in the first 15s after preheating. In addition, it
was observed that application of ultrasound energy was effective in reducing film
thickness and may aid restorative resin composites to achieve films below 50µm. The
second study was a clinical technique reporting the luting of ceramic laminate veneers
with preheated composite, describing a step-by-step procedure that may be used by
clinicians in their working routine, including the application of ultrasound energy over
the ceramic to optimize film thickness. The third study was a case report of a clinical
treatment in which ceramic laminate veneers were adhesively luted to maxillary
anterior teeth of a patient using preheated resin composite and showed excellent
clinical service and remarkable marginal integrity after 123 months of follow up. A
smooth marginal transition between ceramic, luting agent, and tooth (area of adhesive
continuity) and the absence of marginal gaps and ditching indicated that the restorative
resin composite was able to withstand the abrasive and surface challenges imposed
by the oral environment in the long term. In general, this thesis shows that preheated
resin composite for luting indirect restorations may be considered an excellent clinical
option and that the overall performance of the clinical technique depends on proper
selection of a resin composite that responds properly to preheating. There is still room
for further controlled clinical studies on the topic.

Keywords: Cementation. Composite resins. Dental restoration, Permanent.

Ultrasonics.
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Sumário

1 Introdução ..................................................................................................... 09

2 Capítulo 1 – Viscosity and thermal kinetics of 10 preheated restorative

resin composites and effect of ultrasound energy on film thickness ........ 13

3 Capítulo 2 – Preheated restorative composite for luting ceramic

laminate veneers: A technique report ........................................................... 33

4 Capítulo 3 – Ceramic laminate veneers luted with preheated resin

composite: A 10-year clinical report .............................................................. 43

5 Considerações finais ................................................................................... 54

Referências ...................................................................................................... 56

Apêndices ........................................................................................................ 61

Anexos .............................................................................................................. 66
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1 Introdução

A alta demanda social por estética dentofacial tem implicações significantes na

prática clínica de dentistas, aumentando consideravelmente os tratamentos com
restaurações indiretas, especialmente facetas cerâmicas, também conhecidas como
laminados cerâmicos ou lentes de contato dentárias. As facetas de cerâmica oferecem
uma modalidade de tratamento previsível e bem-sucedida, proporcionando ótima
preservação de estrutura dentária sadia (D’ARCANGELO et al., 2012). No intuito de
diminuir os efeitos da intervenção restauradora, os preparos tendem a ser pouco
invasivos, aproveitando a efetividade de materiais adesivos e obtendo margens
íntegras, o que favorece a saúde periodontal e a longevidade dos trabalhos protéticos
(HELVEY, 2009; MAGNE e DOUGLAS, 1999). O sucesso e sobrevivência no
tratamento com facetas cerâmicas depende de diversos fatores, incluindo
planejamento, preparo, moldagem, cimentação adesiva, acabamento e proservação
entre fatores-chave para o sucesso e longevidade estética em longo prazo (AHMAD,
2010; D’ARCANGELO et al., 2012; MAGNE et al. 2002).
O sucesso a longo prazo das facetas pode também estar relacionado às
propriedades do material escolhido para confeccionar a restauração (BAGHERI et al.,
2007; BOVERA, 2016; FERRACANE, 2006; MCLAREN e WHITEMAN, 2010;
PETRIDIS e MALLIARI, 2012) e agentes cimentante utilizados (KAWAI et al., 1994;
MANHART et al., 2004). Outros são o desenho do preparo do dente, a condição
funcional e morfológica do dente suporte e a adaptação marginal da restauração
(PEUMANS et al., 2000). A deterioração da linha de cimentação adesiva deve a ser
considerada no sucesso clínico de restaurações indiretas, sendo um dos elos fracos.
A descoloração severa de margem já foi reportada em uma metanálise como uma
importante causa de insucesso, com incidência de 2% (MORIMOTO et al., 2016). Uma
revisão sistemática mostrou que a taxa de descoloração marginal inaceitável foi de
2,8% em 5 anos e 5,4% em 10 anos para restaurações cerâmicas. Os autores
associaram a descoloração marginal ao valamento da margem (degradação marginal)
associado à pigmentação extrínseca.
Neste sentido, pode ser observada na literatura uma busca por melhor
adaptação marginal e menores linhas de cimentação em restaurações indiretas. A
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maioria dos autores sugere uma linha de cimentação de no máximo 120 micrômetros
(GOUJAT et al., 2019). No entanto, a espessura da linha de cimentação já foi avaliada
clinicamente com valores que vão de 100 a 315 micrômetros (AKIN et al., 2015;
KARAGÖZOĞLU et al., 2016; YUCE et al., 2019). Essa discrepância observada
clinicamente em margens pode favorecer o valamento marginal, visto que o cimento
resinoso, agente tradicionalmente usado para cimentar restaurações indiretas, pode
sofrer desgaste por abrasão (KAWAI et al., 1994). Além disso, com o tempo, o cimento
exposto na margem estará sujeito à sorção de água e fluidos (FERRACANE, 2006),
degradação superficial (BAGHERI et al., 2007) e desgaste, que podem acelerar o
valamento e descoloração marginal (MANHART et al., 2004), o que pode ocasionar
falhas clínicas, especialmente por questões estéticas.
Tradicionalmente os cimentos resinosos são os mais utilizados para a
cimentação adesiva de restaurações indiretas, como facetas cerâmicas, devido à
simplicidade de aplicação associada à sua baixa viscosidade, que facilita o
assentamento rápido da peça. No entanto, resinas compostas restauradoras têm sido
utilizadas para procedimentos de colagem desde a introdução das restaurações
indiretas parciais não-retentivas (BELSER et al., 1997; CHRISTENSEN, 1985;
D’ARCANGELO et al., 2012; DARONCH et al., 2006; FRIEDMAN, 1998; HELVEY,
2009; SCHULTE et al., 2005). As possíveis vantagens que justificariam o uso de
resinas compostas como agente de cimentação estão relacionado ao potencial menor
valamento marginal por ser um material mais resistente ao desgaste, maior
estabilidade de cor e maior resistência mecânica (BARBON et al., 2019; COELHO et
al., 2019; DONG et al., 2016; DUARTE et al., 2011; GRESNIGT et al., 2017;
GUGELMIN et al., 2020; SCHNEIDER et al., 2020; SPAZZIN et al., 2017; TOMASELLI
et al., 2019; VAN DEN BREEMER et al., 2021).
Resinas compostas restauradoras são mais viscosas que cimentos resinosos
e, dessa forma, normalmente são pré-aquecidas antes da cimentação para aproveitar
o ganho de fluidez obtido no aquecimento, que pode ser feito até ~70°C (DA COSTA
et al., 2009; FRÓES-SALGADO et al., 2010; HELVEY, 2009; LOHBAUER et al., 2009).
Assim, uma característica da técnica que usa resinas composta não fluidificada
corretamente como agente de cimentação é a maior espessura do agente cimentante
na comparação da técnica com cimento resinoso (AL-DWAIRI et al., 2019; SAMPAIO
et al., 2017). Esta informação poderia levar a uma contraindicação precoce do uso de
resinas compostas como agente cimentante, visto que a margem é o elo fraco
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atualmente das restaurações indiretas (SAMPAIO et al., 2017). De fato, o uso de

resinas compostas restauradoras que apresentam alta viscosidade mesmo após o
aquecimento deve ser evitado, por poderem criar filmes muito grandes, chegando a
mais de 300 micrômetros (SAMPAIO et al., 2017). Da mesma forma, devem ser
evitadas técnicas de aquecimento que não permitam adequado controle da
temperatura do material e procedimentos clínicos de fotopolimerização do agente
cimentante sem uso de pressão.
Apesar das resinas compostas restauradoras não compartilharem das
propriedades mecânicas inerentes aos cimentos resinosos que os fazem mais
susceptíveis à degradação marginal (DA COSTA et al., 2010; DUARTE et al., 2011;
SHINKAI et al., 2001) maiores espessuras de linha de cimentação podem gerar
maiores ajustes clínicos. No intuito de se diminuir a linha de cimentação, o fluxo ideal
para cimentação adesiva com resina composta restauradora envolve pelo menos a
correta seleção da resina apropriada, aquecimento previsível da resina e técnica de
cimentação adesiva com a resina aquecida. O aquecimento de algumas resinas
compostas restauradoras com propriedades reológicas ideais favorece a diminuição
da viscosidade do material, possibilitando o uso previsível do mesmo para colagem
de laminados cerâmicos finos (MAGNE et al., 2018; MARCONDES et al., 2020).
Espera-se que esse compósito aquecido possa ser utilizado como agente de
cimentação sem perder suas propriedades de resistência mecânica (NIKOLAOS-
STEFANOS, 2019).
Há ainda dúvidas clínicas sobre quais resinas seriam mais indicadas para a
técnica de cimentação adesiva com resina composta termomodificada (RTM),
principalmente se há alguma correlação da viscosidade após aquecimento com a
composição de matriz orgânica e partículas de carga. Não se sabe se a reologia das
resinas compostas restauradoras é influenciada pela quantidade de partícula de carga
na sua composição, por exemplo. A dinâmica de perda de calor e diminuição da
temperatura com aumento da viscosidade após cessar o aquecimento de diferentes
resinas também é um fator importante no procedimento de cimentação e faltam dados
na literatura acerca deste aspecto. Além do tipo de resina e do aquecimento, o uso de
energia ultrassônica tem sido recomendado para facilitar a remoção de excessos e
melhorar o assentamento de restaurações indiretas (PEUTZFELDT, 1994;
SCHMIDLIN et al., 2005; WALMSLEY e LUMLEY, 1995, 1999). No entanto, ainda não
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se sabe do efeito de associar o aquecimento de diferentes resinas compostas com

energia ultrassônica para diminuição de espessura de filme.
Há muitas formas de se aquecer resina composta restauradora para
cimentação adesiva que vão desde do banho-maria, ao uso de um dos aparelhos
específicos para aquecimento controlado. Há poucas informações sobre as diferentes
técnicas e os benefícios e limitações do fluxo clínico de cada uma. Muitas vezes o
cirurgião-dentista não sabe selecionar o melhor fluxo para cimentação com RTM para
sua realidade. Além disso, poucos são os relatos de caso na literatura que mostram a
sobrevivência e sucesso de restaurações cimentadas com RTM. Sendo assim o
objetivo desta tese foi avaliar o comportamento reológico de várias resinas compostas
restauradoras e cimentos resinoso após aquecimento, o efeito do uso do ultrassom
da diminuição de filme, a perda de calor após aquecimento (capítulo 1); relatar o fluxo
clínico da técnica de cimentação adesiva com RTM (capítulo 2) e exemplificar, por
meio de relato de caso, o acompanhamento clínico de restaurações cimentadas com
RTM após 10 anos (capítulo 3).
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2 Capítulo 11

Viscosity and thermal kinetics of 10 preheated restorative resin composites and effect
of ultrasound energy on film thickness

Rogério L. Marcondes1, Verônica P. Lima1, Fabíola J. Barbon1, Cristina P. Isolan1,

Marco A. Carvalho2, Marcos V. Salvador3, Adriano F. Lima3, Rafael R. Moraes1

1Graduate Program in Dentistry, Federal University of Pelotas, Brazil

2Graduate Program in Dentistry, Anápolis University Center (Unievangélica), Anápolis,
Brazil
3Dental Research Division, Paulista University (UNIP), São Paulo, Brazil

Corresponding author:
Prof. Rafael Moraes
Graduate Program in Dentistry, Federal University of Pelotas
Rua Gonçalves Chaves 457 room 505, 96015-560, Pelotas, RS, Brazil
Tel/Fax: +55 53 32602831 ([email protected])
ORCID: 0000-0003-1358-5928

Acknowledgements: This study was financed in part by the Coordenação de

Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil (Finance Code 001).
The sponsor had no role in study design, collection, analysis or interpretation of data,
writing the report, or decision to submit for publication. V.P.L., F.J.B., C.P.I., and M.V.S.
are grateful to CAPES/Brazil for scholarships.

Declarations of interest: None.

1 Artigo publicado no periódico Dental Materials (Anexo A).

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ABSTRACT
Objectives: This study investigated viscosity and thermal kinetics of 10 selected
preheated restorative resin composites and the effect of ultrasound energy on film
thickness.
Methods: A range of different resin composites was tested: Charisma Diamond, IPS
Empress Direct, Enamel Plus HRi, Essentia, Estelite Omega, Filtek Z100, Filtek Z350
XT, Gradia, TPH Spectrum and VisCalor. A flowable resin composite (Opallis Flow)
and two resin cements (RelyX Veneer, Variolink Esthetic LC) also were tested.
Viscosity (Pa.s) was measured at 37ºC and 69ºC (preheating temperature) using a
rheometer. Film thickness (µm) was measured before and after application of
ultrasound energy. Temperature loss within resin composite following preheating
(°C/s) was monitored. Data were statistically analyzed (α=0.05).
Results: Viscosity at 69ºC was lower than at 37°C for all materials except the flowable
resin composite. Preheating reduced viscosity between 47% and 92% for the
restorative resin composites, which were generally more viscous than the flowable
materials. Film thickness varied largely among materials. All preheated resin
composites had films thicker than 50 µm without ultrasound energy. Application of
ultrasound reduced film thickness between 21% and 49%. Linear and nonlinear
regressions did not identify any relationship between filler loading, viscosity, and/or film
thickness. All materials showed quick temperature reduction following preheating,
showing maximum temperature loss rates after approximately 10 s.
Significance: Distinct restorative resin composites react differently to preheating,
affecting viscosity and film thickness. The overall performance of the preheating
technique depends on proper material selection and use of ultrasound energy for
reducing film thickness.

Keywords: luting, temperature, flowability, ultrasonics, resin cement, flowable resin

composite.

1. INTRODUCTION
Use of preheated restorative resin composite as luting agent for veneers and
other thin indirect restorations is increasingly popular. The topic has been investigated
in clinical and laboratory studies [1–9]. When compared to photopolymerizable resin
cements and flowable resin composites, potential advantages of preheated restorative
 15

resin composites may include increased shade availability, lower cost, less
polymerization shrinkage and marginal degradation, and improved mechanical
performance due to their higher filler content [8–19].
Preheating intends to reduce viscosity and increase flowability of restorative
resin composite pastes [20], but thicker films compared to resin cements are commonly
observed [3,6,7]. It has been reported that a poor marginal fit of indirect restorations
could lead to resin cement dissolution and marginal discoloration [21–24]. There is still
no consensus, however, for limits of clinically acceptable film thickness. As a laboratory
screening method, the ISO 4049 standard considers 50 µm as a limit for resin-based
luting agents [25]. Most authors suggest that films should be thinner than 120 µm in
the clinics [26–28], whereas clinical studies indicate that average marginal
discrepancies in indirect restorations may vary between 100 and 315 µm [29–31]. The
film thickness yielded by different preheated restorative resin composites should be
evaluated in order to aid the proper selection of an adequate material for the technique.
A new resin composite claiming a ‘thermoviscous technology’ (VisCalor, Voco,
Cuxhaven, Germany) was recently introduced. VisCalor is primarily a bulk-fill
restorative, but perhaps it could generate a thin film if used as luting agent. Recent
reports observed that preheating reduced up to 66% the force required to extrude
VisCalor from its compule, whereas the degree of C=C was not affected [32] and no
adverse effect of premature polymerization was observed [33]. Another alternative to
reduce film thickness, raised in previous work [3], is the use of ultrasound energy,
which could increase flowability of the restorative resin composite if applied over the
ceramic restoration [34–36].
Several restorative resin composite options are available in the market. Since
most materials are not primarily intended to be preheated, chances are that dentists
will choose anyone at hand. However, a recent study [3] reported that different
formulations of resin composites may react differently to preheating, affecting viscosity
and film thickness, and ultimately influencing the mechanical performance of luted
ceramic structures. Thermal loss after preheating is ceased will likely play a role on
those aspects. Since not all clinical preheating techniques may provide adequate
working time, the cooling patterns of different resin composites should be further
studied. The best-case scenario would be understanding how a range of restorative
resin composites react to preheating and the resulting flowability and film thickness,
guiding proper material selection and the clinical procedures.
 16

This study investigated the effects of preheating on viscosity, film thickness, and
temperature loss of 10 contemporary restorative resin composites. The effect of
ultrasound energy application on film thickness also was investigated. Two resin
cements and a flowable resin composite were included for comparison. The
hypotheses tested were: (i) film thickness, viscosity and thermal loss would be material
dependent, (ii) use of ultrasound would reduce film thickness.

2. MATERIALS AND METHODS

2.1. Study design and materials tested
This in vitro study evaluated the effect of preheating different restorative resin
composites on their viscosity and film thickness as primary response-variables. Ten
restorative resin composites (Table 1) were selected considering their range in
classifications, formulations, and manufacturers. Dentins shades A1, A2, or similar
were tested. A flowable resin composite and two resin cements were tested for
comparison, and are herein referred as flowable materials. A 69ºC temperature was
used as clinical desired temperature for luting with preheated restorative resin
composites. The effect of ultrasound energy application on film thickness was also
tested. Thermal kinetics within resin composite increments following preheating was
monitored, with temperature loss and cooling rates as response-variables.

2.2. Viscosity
Viscosity (n=5) was measured using a dynamic oscillation rheometer (R/S-
CPS+; Brookfield, Middleboro, MA, USA). Two temperatures were tested: 69ºC, as the
initial temperature obtained clinically after preheating on the specific heater device
used here (HotSet; Technolife, Joinville, SC, Brazil), and 37ºC (body temperature) as
final temperature, simulating the clinical condition after seating the restoration. It was
not possible to test the materials at 25ºC because some resin composites were too
viscous at room temperature and exceeded the rheometer measuring range. The resin
composites were taken from their original packages (i.e. syringe or compule) with a
spatula and placed in a half-circle mold for standardizing a 0.5 mL volume. The test
material was dispensed on the lower plate of the rheometer and positioned with a 0.05
mm gap between the plates. Heating was provided by the rheometer itself. Viscosity
(Pa.s) was measured until reaching the designated temperature and for additional 45
 17

s, at a constant shear rate of 2 s-1. The flowable resin composite and resin cements
were also tested in both temperatures.

2.3. Film thickness

Film thickness (n=3) was measured based on the ISO 4049 standard [25]. Only
restorative resin composites were preheated in this analysis. Two optically flat, square
glass plates with 200 mm2 contact surface area were used. The combined thickness
of the two glass plates stacked in contact was measured with a digital caliper (Mitutoyo,
Tokyo, Japan) with 1 µm accuracy. Increments of restorative resin composites were
preheated to 69ºC for 10 min in order to achieve and stabilize this temperature before
testing [37]. The increment was placed directly on the preheating device using a
spatula. A standard 0.1 mL volume of the preheated material was dispensed on the
center of a glass plate and the other plate was placed on top. A 150 N force was
centrally and vertically applied via the upper plate using a loading device (Odeme
Dental Research; Joaçaba, SC, Brazil). After 180 s, the loading system was released
and the combined thickness of the two glass plates was measured again. Film
thickness was calculated as the difference between the two readings. Three different
specimens were tested for each material. The thickness of each specimen was read
three times and the average value was recorded as the film thickness for that
specimen. No light-polymerization was carried out because the same specimen was
used next for testing the effect of ultrasound energy, in accordance with the clinical
workflow of seating indirect restorations [35]. The ultrasound energy was applied
through the upper glass plate for 30 s using a polyacetal tip. The tip was positioned
statically at the center of the glass plate with slight hand pressure, the ultrasound
equipment operated at 40% power (DentSurg Pro; CVdentus, São José dos Campos,
SP, Brazil). It should be highlighted that the resin composite between the glass plates
was not warm anymore during the ultrasound application step, simulating what
happens in the clinical scenario when luting indirect restorations with pre-heated resin
composite. Film thickness after ultrasound application was measured anew.

2.4. Thermal kinetics

Resin composite increments (2 mm in thickness, mass ~130 mg) were placed
over a polyester stripe and inside the preheating device. The preheating device has
spaces that allowed the increments to be placed without overflowing during preheating.
 18

This was important to avoid reduction in increment thickness that could affect the
temperature measurements. A type-K thermocouple was used (TM902C, Yarboly,
China), the tip (diameter = 1 mm) was inserted within the increment to monitor
temperature. When it reached 70±1ºC, the polyester stripe with increment was
removed from the preheating device and placed over the bench at room temperature
(25ºC). Temperature (ºC) within the increment was recorded every second for 2 min
after placing the resin composite over the bench (n=3). This time was enough for all
resin composites to approximately reach room temperature. Plotted temperature vs.
time data were adjusted by curve fitting (R2 > 0.997) and temperature loss rates were
calculated using these fitted plots.

2.5. Statistical analysis

Viscosity data were submitted to a Two-Way Analysis of Variance – ANOVA
(material vs. temperature). Viscosity data were transformed to ranks before the
analysis. Data for film thickness without use of ultrasound were analyzed using One-
Way ANOVA. Film thickness data of restorative resin composites including the use of
ultrasound were analyzed using Repeated Measures ANOVA (one factor repetition).
All pairwise multiple comparison procedures were carried out using the Tukey method.
Regression analysis were used to investigate the relationship between filler load (wt%
and vol%), viscosity, and/or film thickness. Significance level was set at α=0.05 for all
analyses. Thermal loss within resin composite and cooling rates were analyzed
descriptively.

3. RESULTS
Results for viscosity at 37ºC and 69ºC are shown in Figure 1. Materials are listed
in ascending order of viscosity at 69ºC (top to bottom). Average reductions in viscosity
by preheating (%) are presented. Both factors and their interaction were statistically
significant (p<0.001). The viscosity at 69ºC was significantly lower than at 37°C for all
materials (p≤0.027) except the flowable resin composite (p=0.45). Significant
differences in viscosity were observed in almost all comparisons between materials,
including at 69°C (Table 2). In either temperature, all restorative resin composites were
significantly more viscous than the flowable resin composite and Variolink Esthetic LC
resin cement. When preheated, four resin composites had lower viscosity compared
with RelyX Veneer resin cement (at room temperature): Essentia, Gradia, VisCalor,
 19

and Estelite Omega. Filtek Z350 XT showed remarkably higher viscosity than all other
materials in both temperatures tested. At 69ºC, Filtek Z350 XT showed viscosity
around 14 kPa.s, whereas all other preheated materials were at least 3-fold less
viscous. Preheating also reduced viscosity of the resin cements. VisCalor (92%), TPH
Spectrum (82%), and Essentia (81%) showed the highest viscosity reductions by
preheating.
Figure 2 presents the results for film thickness before and after use of ultrasound
energy. Materials are listed in ascending order of film thickness after ultrasound
application (top to bottom). Average reductions in film thickness by use of ultrasound
(%) also are shown. The dashed line indicates the 50-µm film thickness limit defined
by ISO 4049 standard. The statistical analysis revealed significant differences between
groups (p<0.001) and the results varied largely among materials. In the regular test
(no ultrasound), all preheated restorative resin composites had films thicker than 50
µm, and all flowable materials thinner than the ISO limit (Table 2). The use ultrasound
energy significantly reduced film thickness (p<0.001), the reductions varied between
21% and 49%. Five restorative resin composites had film thicknesses below or
approximate 50 µm after use of ultrasound: Estelite Omega, Filtek Z100, Enamel Plus
HRi, VisCalor, and Gradia. Two resin composites showed films thicker than 70 µm
even after ultrasound: Filtek Z350 XT and TPH Spectrum. Linear and nonlinear
regression analyses were not able to identify any trend or relationship between filler
loading, viscosity, and film thickness of the materials tested. Figure 3 presents plots
for linear regression analyses of filler load (wt%) vs. viscosity at 69°C (Fig.3A), filler
load vs. film thickness without ultrasound (Fig.3B), and viscosity vs. film thickness
(Fig.3C). The coefficients of determination (R2) were below 0.2.
Results for the thermal analysis are presented in Figure 4 (temperature loss)
and Figure 5 (cooling rate). The materials were separated in higher viscosity and lower
viscosity restorative resin composites in these figures. All materials showed quick
temperature reduction after placed in the bench. Cooling rate analysis showed that, for
most higher viscosity materials, maximum temperature loss rates were reached 7 to 8
s after the heating was ceased. Lower viscosity resin composites took slightly longer
(about 10 s) to reach maximum temperature loss rates. Table 2 shows the temperature
within resin composite increments 15, 30, and 60 s after preheating. Fifteen seconds
after the heating was ceased, all resin composites had average temperature within
increment below 50°C, with temperature losses varying between 45% and 61%. This
 20

calculation considers that the temperature loss is 100% when the increment reaches
room temperature. The average temperature within the increments was below 37°C
after 30 s (average 84% temperature loss), and below 29°C for all resin composites
after 60 s (average 96% loss).

4. DISCUSSION
The first hypothesis was accepted as film thickness, viscosity and thermal loss
were material dependent. The 10 restorative resin composites tested have distinct
formulations, including monomers and fillers, which affect their response to preheating
as each component has a specific heat capacity. The resin phase is less thermal
conductive than filler particles but it is expected to react most to preheating by
increasing monomer mobility. The filler particles play an important role on thermal
conductivity as well [38]. A study with dental resin composites [39], for instance,
showed a nonlinear increase in the system enthalpy by increasing the concentration
of fillers. In this study, no relationship was observed between filler content, viscosity,
and/or film thickness. This may have occurred because not only filler content but also
particle type, shape, size, nature of particle surface, and filler spatial arrangement
within the resin composite are relevant aspects for thermal conductivity [38,39]. Those
features are expected to differ among the tested resin composite materials. Since
manufacturers do not disclose formulation details, experimental materials should be
used in future studies for further understating how different monomers and filler
features might influence the resin composite reaction to preheating.
Characteristics of the inorganic particles may also influence flowability.
Preheating to 69°C was able to reduce between 47% and 92% the viscosity of
restorative resin composites in comparison to 37°C. Another study reported that
preheating increased between 23% and 55% the flowability of four restorative resin
composites [40], also showing a negative correlation between filler content and
flowability. In the present study, preheated resin composites hardly showed viscosity
values in the range of flowable composite and resin cements. This is likely a result of
the higher filler content leading to increased filler-to-filler interactions and interfacial
friction between fillers and resin matrix, affecting flowability. Findings of the present
study suggest that viscosity at preheating temperature (69°C) or change in viscosity
upon preheating (%) are not adequate parameters for selecting a restorative resin
composite for luting purposes. This can be illustrated by the behavior of VisCalor, a
 21

resin composite designed by the manufacturer to be preheated. VisCalor showed the

highest reduction in viscosity at 69°C among all materials tested (92%), but it was not
able to yield films thinner than 50 µm without the use of ultrasound. Essentia is another
good example, as it showed low viscosity after preheating but generated thicker films
than other materials with higher viscosity.
It has been reported that preheating restorative resin composites may reduce
their film thickness between 4% and 77% depending on the tested material [41]. The
same authors observed no significant correlation between either weight or volume of
fillers and film thickness. Similarly, the thinning of preheated restorative resin
composite films was not a result of their filler content alone. In addition, this study
demonstrates that use of ultrasound energy significantly reduced film thickness
(between 21% and 57%). Thus, the second hypothesis also was accepted. For most
materials, an optimal film thickness may be achieved by combining preheating and
ultrasound application. The influence of ultrasound is more evident as its application
occurred at least 3 min after preheating, when the resin composite was already at room
temperature. During the clinical luting of indirect restorations, application of ultrasound
occurs specifically after restoration seating and removal of major excesses. Therefore,
the temperature of the luting agent during ultrasound use is lower than in the initial
seating step [35]. The glass plates used in the test also are thicker than indirect
restorations, thus the use of ultrasound energy could be even more beneficial in the
clinical scenario. However, the glass plates are flat and smooth, whereas the intaglio
surface of indirect restorations may not be. Although ultrasound energy has been
previously used by clinicians to reduce film thickness [34–36], this is the first study to
evaluate the effect of ultrasound on a variety of restorative resin composites. Finally,
considering the relevant film thinning observed with ultrasound energy even at room
temperature, the working time may not be a significant issue when preheated resin
composite is used as luting agent. Provided that ultrasound is applied afterwards,
clinicians can take their time for proper excess removal before final seating and light
polymerization.
Different from clinical luting procedures, the method used here to evaluate film
thickness requires the simulated luting load to be released before measurements. In
addition, the materials were not light polymerized, whereas a reduction in film thickness
after light polymerization has been reported [4]. In the clinical scenario, it is suggested
that indirect restorations should be maintained under slight hand pressure during light
 22

polymerization. This would avoid possible restoration displacement arising from the
viscoelastic response of the resin composite in the event pressure is removed. The
use of ultrasound is also important in the control of film thickness, although there is no
consensus on the limits for clinically acceptable film thicknesses. Perhaps the 50 µm
value defined by ISO 4049 should not be considered a limit when restorative resin
composite is the luting agent, especially because up to 6 times higher marginal
discrepancy values have been reported for indirect restorations in clinical studies [29–
31]. In addition, resin composites are direct restorative materials designed to withstand
intraoral challenges; a thicker film may not be of clinical significance provided that it
does not interfere with adaptation of the indirect restoration.
The restorative resin composites presented a rapid temperature reduction in the
cooling rate analysis. Therefore, clinicians have between 10 to 15 s of ideal working
time with preheated resin composites, when temperature and viscosity are still optimal.
This working time should be taken into consideration in the selection of a proper luting
sequence. Several techniques are available, some requiring less time from the
moment the preheated composite is removed from the heating device until it is placed
at the prepared tooth [37]. Warm water bath has been used for preheating resin
composites, but a study reported an up to 2-fold increase in film thickness compared
to flowable materials [6]. This is likely explained by the water bath technique being
more time consuming, which may have affected flowability and film thickness. Other
quicker luting sequences have been proposed, including preheating compules already
attached to delivery syringes [37], or placing the resin composite into the intaglio
surface of indirect restorations and preheating them simultaneously [14]. These two
latter techniques seem to take more advantage of the optimal working and flowability
of preheated resin composites. Placing the preheated resin composite over the bench
before luting is not advised.
Taking all results of the present study into account, it seems reasonable to
suggest that Charisma Diamond, Essentia, Filtek Z350 XT, and TPH Spectrum should
not be used as luting agents since these resin composites yielded films with ~70-80
µm in average even when preheating was associated with ultrasound. This study
shows that there are better resin composite options for the preheating luting technique.
Gradia and IPS Empress Direct showed intermediary results. However, it should be
noted that a thicker film of resin composite may not be a clinical issue because this
material is designed to have color stability and abrasion resistance, as shown in
 23

laboratory and clinical studies [10,42,43]. In addition, recent studies [3,11] raised the
question whether thicker films could have a positive effect on the strengthening of thin
feldspar ceramic structures. Finally, clinicians could consider other aspects they find
relevant for resin composites, including handling, stickiness and cost, which will
depend on the selected resin composite brand.

5. CONCLUSIONS
Within the limitations of this in vitro study, the following conclusions can be
drawn:
• Restorative resin composites with distinct formulations react differently to
preheating, affecting viscosity and film thickness;
• Optimal working time of preheated composite is short and clinicians should
adequate the luting sequence to take advantage of higher temperatures found in
the first 15 s;
• Application of ultrasound energy is effective in reducing film thickness and may aid
restorative resin composites to achieve films below 50 µm;
• The overall performance of the preheating resin composite technique depends on
proper material selection.

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 28

Table 1. Characteristics and formulation of the resin-based agents tested as informed by manufacturers
Materials tested Type Manufacturer Formulation
Restorative resin Resin phase Filler wt% (vol%)
composites
Charisma Diamond Nanohybrid Kulzer, Hanau, Germany Bis-GMA, UDMA, TEGDMA, TCD-DI- 77
HEA
IPS Empress Direct Nanohybrid Ivoclar Vivadent, Schaan, Bis-GMA, UDMA, TCDDMA 60 or 79.6*
Liechtenstein
Enamel Plus HRi Nanohybrid Micerium, Avegno, Italy Bis-GMA, UDMA, BDDMA 80 (63)
Essentia Microhybrid GC, Tokyo, Japan Bis-GMA, UDMA, TEGDMA, Bis-EMA, 81 (65)
Bis-MEPP
Estelite Omega Supranano Tokuyama, Tokyo, Japan Bis-GMA, TEGDMA 82 (78)
Filtek Z100 Microhybrid 3M ESPE, St. Paul, MN, USA Bis-GMA, TEGDMA 80 (66)
Filtek Z350 XT Nanohybrid 3M ESPE Bis-GMA, UDMA, Bis-EMA, PEGDMA, 72.5 (55.6)
TEGDMA
Gradia Microhybrid GC UDMA 80
TPH Spectrum Nanohybrid Dentsply Sirona, York, PA, USA Bis-GMA, Bis-EMA, TEGDMA 75 (57)
VisCalor Nanohybrid Voco, Cuxhaven, Germany Bis-GMA, aliphatic dimethacrylate 83

Resin cements
RelyX Veneer Light-cured 3M ESPE Bis-GMA, TEGDMA 66
cement
Variolink Esthetic LC Light-cured Ivoclar Vivadent UDMA, DDMA (38)
cement

Flowable resin composite

Opallis Flow Microhybrid FGM, Joinville, SC, Brazil Bis-GMA, TEGDMA, Bis-EMA 72
Bis-GMA, bisphenol-A glycidyl dimethacrylate; UDMA, urethane dimethacrylate; TEGDMA, triethylene glycol dimethacrylate; TCD-DI-HEA, Bis-
(acryloyloxymethyl) tricyclodecane; TCDDMA: tricyclodocane dimethanol dimethacrylate; BDDMA: 1,4-butandiol dimethacrylate; Bis-EMA,
bisphenol-A ethoxylated dimethacrylate; Bis-MEPP, bisphenol-A polyethoxy methacrylate; PEGDMA, polyethylene glycol dimehacrylate;
DDMA: 1,10-decandiol dimethacrylate. *Including prepolymer as filler.
 29

Table 2. 95% confidence intervals for viscosity at 69°C (n=5) and film thickness after
use of ultrasound (n=3), and means ±standard deviations for temperature within resin
composite increments with time following preheating (n=3)
Material Viscosity, Film thickness, Temperature within
kPa.s µm increment, °C
15 s 30 s 60 s
Charisma Diamond 2.91–3.01 c 48–106 ab 43 ±2 35 ±4 28 ±2
IPS Empress Direct 2.45–2.48 e 37–83 bc 42 ±8 30 ±2 25 ±1
Enamel Plus HRi 2.85–2.91 c 40–54 bc 49 ±9 37 ±5 29 ±3
i ab
Essentia 0.34–0.36 61–119 43 ±3 33 ±4 27 ±2
Estelite Omega 0.71–0.73 g 30–44 c 45 ±4 29 ±1 25 ±1
Filtek Z100 2.59–2.63 d 25–60 bc 41 ±9 29 ±7 26 ±2
Filtek Z350 XT 14.0–14.3 a 71–109 ab 41 ±2 31 ±2 25 ±1
h cd
Gradia 0.41–0.43 13–61 45 ±4 33 ±1 28 ±1
TPH Spectrum 3.77–3.80 b 71–123 a 46 ±3 31 ±1 27 ±2
VisCalor 0.43–0.47 h 30–64 bc 43 ±9 31 ±4 27 ±2
RelyX Veneer* 0.92–1.01 f 15–39 cd - - -
j d
Variolink Esthetic LC* 0.22–0.24 6–20 - - -
Opallis Flow* 0.12–0.14 k 14–38 cd - - -
*Viscosity at 37°C; in film thickness analysis, ultrasound was not applied for these
materials.
Different letters in same column indicate statistical differences between materials
(α=0.05).
 30

Figure 1. Means + standard deviations for viscosity at 37ºC and 69ºC (n=5). Materials
are listed in ascending order of viscosity at 69°C (top to bottom). Change in viscosity
by preheating (%) is shown for each material.

Figure 2. Means + standard deviations for film thickness with and without use of
ultrasound energy (n=3). Materials are listed in ascending order of film thickness after
use of ultrasound (top to bottom). Note that only restorative resin composites were
preheated and subjected to ultrasound energy. Change in film thickness by ultrasound
application (%) is shown for each material. Dashed line indicates 50-µm film thickness
limit defined by ISO 4049 standard.
 31

Figure 3. Plots for linear regression analyses of filler load (wt%) vs. viscosity at 69°C
(A), filler load vs. film thickness without ultrasound (B), and viscosity vs. film thickness
(C). The coefficients of determination (R2) were below 0.2. These and other linear or
nonlinear regressions were not able to identify any trend or relationship between filler
load, viscosity, and film thickness of the materials tested.

Figure 4. Temperature reduction within resin composite increments placed on bench

following preheating (n=3). Restorative resin composites were separated in higher
viscosity (left hand) and lower viscosity (right hand). Dashed lines indicate 15- and 30-
second marks.
 32

Figure 5. Cooling rates following preheating (n=3). Restorative resin composites were
separated in higher viscosity (left hand) and lower viscosity (right hand). Maximum
rates of temperature loss were typically achieved up to 10 s after preheating.
 33

3 Capítulo 22

Preheated restorative composite for luting ceramic laminate veneers: A

technique report

Rogério L. Marcondes, DDS, MSc, PhD candidatea,b, Marco A. Carvalho, DDS, MSc,
PhD,c Rafael R. Moraes, DDS, MSc, PhDb, and Jefferson R. Pereira, DDS, MSc, PhDd

a Private Practice, Curitiba, PR, Brazil

b Graduate Program in Dentistry, Universidade Federal de Pelotas, RS, Brazil
c Postgraduate Program in Dentistry, Evangelic University of Goias, GO, Brazil
d Postgraduate Program in Health Sciences, University of Southern Santa Catarina,
Tubarão, SC, Brazil

Abstract
Resin cements are traditionally used to lute ceramic laminate veneers due to their lower
viscosity, which facilitates a fast restoration seating. However, resin cements have
lower wear resistance than restorative composites. Thus, restorative composite resin
is an alternative luting agent with lower marginal degradation as a potential advantage
for clinical longevity. This article presents an application of preheated restorative
composite resin for adhesive luting of laminate veneers with a predictable clinical
technique for seating and marginal quality.

Introduction
Bonding of indirect restorations, known as adhesive cementation, comprises one
of the most critical steps of adhesive treatment and responds to the majority of clinical
failures reported in literature.1-3 The main causes of failure reported for indirect
restorations are marginal discoloration, marginal degradation, and debonding of the
restoration.4-6 Thus, there is a constant need for better marginal adaptation while

2 Artigo que será enviado para potencial publicação no periódico The Journal of Prosthetic Dentistry.
 34

attaining film thickness below 120 µm,7 although clinical studies found marginal
discrepancies in indirect restorations between 100 and 315 µm.8,9
The gap between indirect restorations and tooth surfaces filled by luting
material is known as area of adhesive continuity.10 A thick line of exposed cement could
over time be subject to sorption11, surface degradation,12 and wear, leading to marginal
ditching and discoloration.13 Even tooth brush abrasion can lead to marginal ditching
influenced by dentifrice abrasiveness,14 tooth brushing force,15 and direction of the
bristles.16 When subject to tooth brushing, resin cements with larger filler particles have
shown increased wear than those with smaller particles.14,17 In addition, resin cements
showed greater marginal degradation than resin composites. 18
Resin cements are traditionally used for luting indirect restorations due to the
simplicity of application associated with their lower viscosity, which enables fast
restoration seating. However, restorative composite resins have been increasingly
used for bonding non-retentive partial restorations.19-25 The benefits that would justify
the use of composites are related to lower marginal degradation, greater color stability,
and improved mechanical strength.26-33 Preheating of restorative composites with
appropriate rheological properties enables its predictable use for bonding indirect
restorations.34-36 Associated with preheating, the use of ultrasonic devices favors a
faster excess removal during the seating of restorations and may aid in reducing the
luting agent film.
Considering the clinical evidence that the adhesive interface between the
dental substrate and restoration is the weak link of adhesive indirect restorations,
bonding the restoration with pre-heated restorative composite resin may provide an
interface filled with a restorative resin material presenting optimized mechanical
properties. Therefore, an area of adhesive continuity that is more resistant to
degradation and staining is expected to provide improved restoration prognosis. This
article reports a clinical technique for luting ceramic laminate veneers with preheated
composite.

Technique
Figure 1 to 8 illustrate the technique, which was carried out using the following
clinical steps:
1. Ceramic laminate veneers were prepared for ten maxillary teeth to recover
incisal length and esthetic enhancement of the smile.
 35

2. Removal of provisional restorations, dry and wet try-in of the laminate veneers
on the prepared teeth.
3. The operative field was isolated with rubber dam for moisture control.
4. Dry try-in of the laminate veneers after rubber dam isolation to assess correct
restoration seating even with a clamp;
5. For luting, the intaglio feldspar ceramic surfaces (Creation CC; Willi Geller
International GmbH, Meiningen, Austria) were etched with 9.5% hydrofluoric
acid for 60 seconds (Porcelain Etchant; Bisco, Schaumburg, IL), cleaned with
35% phosphoric acid for 15 seconds (Ultra Etch; Ultradent, South Jordan, UT),
silanated (Bis-Silane; Bisco), and filled with hydrophobic adhesive (OptiBond
FL; Kerr, Brea, CA).
6. Enamel was etched with 35% phosphoric acid gel for 30 seconds and the same
adhesive was used.
7. Compules of restorative composite resin Estelite Omega, shade BL2
(Tokuyama, Tokyo, Japan) were preheated to 156°F/69°C for 10 minutes
(HotSet warmer, Technolife; Joinville, SC, Brazil) and used as luting material.
The composite was applied to the veneers with Centrix syringe. Restorations
were positioned on prepared teeth, and seating by hand pressure was applied.
8. Initial removal of composite resin excesses.
9. Ultrasonic activation applied over ceramic with ultrasonic unit and polyacetal tip
at 40% power (Dentsurg; CVDentus, São José dos Campos, SP, Brazil) to
further increase composite flowability and reduce film thickness. More excesses
are removed on this stage.
10. Light-curing under pressure for 60 seconds on each face (20 seconds × 3, with
intervals of 10 seconds between applications);
11. Additional 10 seconds marginal light-curing using water-soluble gel to reduce
oxygen-inhibited layer;
12. Finishing with scalpel blades and polishing with diamond polishers (D.Fine;
Clinician's Choice, New Milford, CT).

Summary
This article proposes a predictable clinical sequence for using preheated
restorative composite resin to lute indirect restorations. This technique may reduce
 36

degradation, wear, ditching, and discoloration at the restorative margins by improving

the mechanical properties of the luting material at the adhesive interface.

Discussion
Preheated restorative composite resin may be considered an excellent clinical
option for luting ceramic laminate veneers due to its improved mechanical properties, 26-
33 but care should be taken when choosing this technique as it needs training and
adequate apparatus, and sequence to achieve a temperature (156°F/69°C) for
decreasing viscosity and allowing predictable seating. Preheating approaches that do
not provide predictable seating of the restoration should be avoided. Wrong composite
resin selection and/or not reaching the ideal temperature could jeopardize the quality
of the restorative composite resin flowability. Associated with the preheating of the
composite, the use of ultrasonic device over the ceramic allows more accurate fitting of
these restorations, reducing film thickness, thus this instrument should be considered
when using the technique.34 To ensure the final restoration seating, initial
photopolymerization should be carried out under pressure. This ensures that the
restoration will not dislocate, which would generate marginal misfit and greater need
for occlusal adjustments.36
Choosing a composite with poor response to preheating may prevent optimal
flowability and proper seating of restorations. Some restorative composites have been
shown to be contraindicated as luting agent, as they provide unacceptable film
thickness.34,36 In contrast, there are composites resins with a high amount of inorganic
fillers, excellent mechanical and optical properties that could be indicated for the luting
technique using preheated composite. A proper selection would not compromise the
restoration seating35, provide adequate film thicknesses34 and could be beneficial to
lute an indirect restoration, reaching lower marginal degradation, greater color stability,
and greater mechanical strength.26-33

References
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feldspathic porcelain veneers: accounting for clustering. Int J Prosthodont.
2012;25(6):604–12.
2. Rinke S, Bettenhäuser-Hartung L, Leha A, Rödiger M, Schmalz G, Ziebolz D.
Retrospective evaluation of extended glass-ceramic ceramic laminate veneers
 37

after a mean observational period of 10 years. J Esthet Restor Dent. 2020 May
25;30(4):329–37.
3. Aljazairy YH. Survival Rates for Porcelain Laminate Veneers: A Systematic
Review. European Journal of Dentistry. 2020.
4. Rinke S, Bettenhäuser-Hartung L, Leha A, Rödiger M, Schmalz G, Ziebolz D.
Retrospective evaluation of extended glass-ceramic ceramic laminate veneers
after a mean observational period of 10 years. J Esthet Restor Dent. 2020 May
25;30(4):329–37.
5. Mushashe AM, Farias IC, Gonzaga CC, Cunha LF da, Ferracane JL, Correr GM.
Surface Deterioration of Indirect Restorative Materials. Braz Dent J. 2020
Jun;31(3):264–71.
6. Morimoto S, Albanesi RB, Sesma N, Agra CM, Braga MM. Main Clinical
Outcomes of Feldspathic Porcelain and Glass-Ceramic Laminate Veneers: A
Systematic Review and Meta-Analysis of Survival and Complication Rates. Int J
Prosthodont. 2016;29(1):38–49.
7. Goujat A, Abouelleil H, Colon P, Jeannin C, Pradelle N, Seux D, et al. Marginal
and internal fit of CAD-CAM inlay/onlay restorations: A systematic review of in
vitro studies. J Prosthet Dent 2019;121:590-597.e3.
8. Yuce M, Ulusoy M, Turk AG. Comparison of Marginal and Internal Adaptation of
Heat-Pressed and CAD/CAM Porcelain Laminate Veneers and a 2-Year Follow-
Up. J Prosthodont. 2019 Jun;28(5):504–10.
9. Akın A, Toksavul S, Toman M. Clinical Marginal and Internal Adaptation of
Maxillary Anterior Single All-Ceramic Crowns and 2-year Randomized Controlled
Clinical Trial. J Prosthodont. 2015 Jul;24(5):345–50.
10. Andrade OS de, Borges GA, Kyrillos M, Moreira M, Calicchio L, Correr–Sobrinho
L. The Area of Adhesive Continuity: A New Concept for Bonded Ceramic
Restorations. In: Duarte, Sillas J, editor. Quintessence of Dental Technology
(QDT) Vol 36. Quintessence Publishing; 2013..
11. Ferracane JL. Hygroscopic and hydrolytic effects in dental polymer networks.
Dent Mater. 2006 Mar;22(3):211–22.
12. Bagheri R, Tyas MJ, Burrow MF. Subsurface degradation of resin-based
composites. Dent Mater. 2007 Aug;23(8):944–51.
13. Manhart J, Chen H, Hamm G, Hickel R. Buonocore Memorial Lecture. Review of
the clinical survival of direct and indirect restorations in posterior teeth of the
 38

permanent dentition. Oper Dent. 2004;29(5):481–508.

14. da Costa J, Adams-Belusko A, Riley K, Ferracane JL. The effect of various
dentifrices on surface roughness and gloss of resin composites. J Dent. 2010;38
Suppl 2:e123-8.
15. Heintze SD, Forjanic M, Ohmiti K, Rousson V. Surface deterioration of dental
materials after simulated toothbrushing in relation to brushing time and load. Dent
Mater. 2010 Apr;26(4):306–19.
16. Belli R, Pelka M, Petschelt A, Lohbauer U. In vitro wear gap formation of self-
adhesive resin cements: a CLSM evaluation. J Dent. 2009 Dec;37(12):984–93.
17. Shinkai K, Suzuki S, Katoh Y. Effect of filler size on wear resistance of resin
cement. Odontology. 2001 Nov;89(1):41–4.
18. Duarte S, Sartori N, Sadan A, Phark J-H. Adhesive Resin Cements for Bonding
Esthetic Restorations: A Review. Quintessence Dent Technol. 2011;34:40–66.
19. Schulte AG, Vöckler A, Reinhardt R. Longevity of ceramic inlays and onlays luted
with a solely light-curing composite resin. J Dent. 2005 May;33(5):433–42.
20. Daronch M, Rueggeberg F a., Moss L, de Goes MF. Clinically relevant issues
related to preheating composites. J Esthet Restor Dent. 2006 Nov;18(6):340–50;
discussion 351.
21. Helvey G a. Porcelain Laminate Veneer Insertion Using a Heated Composite
Technique. Insid Dent. 2009;5(4):2–6.
22. D’Arcangelo C, de Angelis F, Vadini M, D’Amario M. Clinical evaluation on
porcelain laminate veneers bonded with light-cured composite: Results up to 7
years. Clin Oral Investig. 2012;16(4):1071–9.
23. Belser UC, Magne P, Magne M. Ceramic laminate veneers: Continuous evolution
of indications. J Esthet Restor Dent. 1997;9(4):197–207.
24. Friedman MJ. A 15-year review of porcelain veneer failure--a clinician’s
observations. Compend Contin Educ Dent. 1998 Jun;19(6):625–8, 630, 632
passim; quiz 638.
25. Christensen GJ. Veneering of teeth. State of the art. Dent Clin North Am. 1985
Apr;29(2):373–91.
26. Duarte S, Sartori N, Sadan A, Phark J-H. Adhesive Resin Cements for Bonding
Esthetic Restorations: A Review. Quintessence Dent Technol. 2011;34:40–66.
27. Tomaselli L de O, Oliveira DCRS de, Favarão J, Silva AF da, Pires-de-Souza F
de CP, Geraldeli S, et al. Influence of Pre-Heating Regular Resin Composites
 39

and Flowable Composites on Luting Ceramic Veneers with Different

Thicknesses. Braz Dent J. FapUNIFESP (SciELO); 2019 Oct;30(5):459–66.
28. Schneider LFJ, Ribeiro RB, Liberato WF, Salgado VE, Moraes RR, Cavalcante
LM. Curing potential and color stability of different resin-based luting materials.
Dent Mater. 2020 Oct;36(10):e309–15.
29. Coelho NF, Barbon FJ, Machado RG, Boscato N, Moraes RR. Response of
composite resins to preheating and the resulting strengthening of luted feldspar
ceramic. Dent Mater. Elsevier BV; 2019 Aug;35(10):1430–8.
30. Dong XD, Wang HR, Darvell BW, Lo SH. Effect of Stiffness of Cement on Stress
Distribution in Ceramic Crowns. Chin J Dent Res. 2016;19(4):217–23.
31. Spazzin AO, Bacchi A, Alessandretti R, Santos MB, Basso GR, Griggs J, et al.
Ceramic strengthening by tuning the elastic moduli of resin-based luting agents.
Dent Mater. The Academy of Dental Materials; 2017;33(3):358–66.
32. Van den Breemer CRG, Buijs GJ, Cune MS, Özcan M, Kerdijk W, Van der Made
S, et al. Prospective clinical evaluation of 765 partial glass-ceramic posterior
restorations luted using photo-polymerized resin composite in conjunction with
immediate dentin sealing. Clin Oral Investig. 2020 Aug 12;
33. Gresnigt MMM, Özcan M, Carvalho M, Lazari P, Cune MS, Razavi P, et al. Effect
of luting agent on the load to failure and accelerated-fatigue resistance of lithium
disilicate laminate veneers. Dent Mater. The Academy of Dental Materials; 2017
Dec;33(12):1392–401.
34. Marcondes RL, Lima VP, Barbon FJ, Isolan CP, Carvalho MA, Salvador M V, et
al. Viscosity and thermal kinetics of 10 preheated restorative resin composites
and effect of ultrasound energy on film thickness. Dent Mater. 2020 Sep
1;36(10):1356–64.
35. Magne P, Razaghy M, Carvalho MA, Soares LM. Luting of inlays, onlays, and
overlays with preheated restorative composite resin does not prevent seating
accuracy. Int J Esthet Dent. 2018;13(3):318–32.
36. Sampaio CS, Barbosa JM, Cáceres E, Rigo LC, Coelho PG, Bonfante EA, et al.
Volumetric shrinkage and film thickness of cementation materials for veneers: An
in vitro 3D microcomputed tomography analysis. J Prosthet Dent. Editorial
Council for the Journal of Prosthetic Dentistry; 2017;117(6):784–91.
 40

Figure Legends

Fig. 1. Dry try-in test is performed to assess the fitting of laminate veneers, including
marginal adaptation and insertion axis of each restoration.

Fig. 2. Feldpar ceramic laminates on the preheating tray. Veneers were previously acid-
etched, silanated and treated with adhesive.

Fig. 3. Ceramic laminate veneer was loaded with composite resin before preheating to
69°C/156°F for 10 minutes.
 41

Fig 4. Application of adhesive system on teeth surfaces, excesses should not be

removed at this stage and adhesive should not be photopolymerized.

Fig. 5. Removal of restorative composite excesses right after initial seating of the
veneer. Excess removal is easy to perform because the preheated composite acquires
higher viscosity within seconds after seating.

Fig. 6. Use of ultrasound polyacetal tip applied from incisal edge to cervical as an
auxiliary mean to improve flowability of the restorative composite resin and reduce
luting agent film thickness.
 42

Fig. 7. Photopolymerization of composite resin using hand pressure to ceramic veneer

to ensure best seating.

Fig. 8. Finishing with scalpel blades followed by polishing of restorative composite resin
at margins using diamond polishers.
 43

4 Capítulo 33

Ceramic laminate veneers luted with preheated resin composite: A 10-year clinical
report

Running title: Ceramic veneers luted with preheated composite

Marcondes, Rogério L., DDS, PhD candidatea,b

Lima, Verônica P., DDS, MS, PhD candidateb
Isolan, Cristina P., DDS, MS, PhDb
Lima, Giana S., DDS, MS, PhDb
Moraes, Rafael R., DDS, MS, PhDb

aPrivate practice, Curitiba, PR, Brazil

bGraduate Program in Dentistry, Federal University of Pelotas, RS, Brazil

Corresponding author:
Prof. Rafael R. Moraes, Graduate Program in Dentistry, Federal University of Pelotas,
Rua Gonçalves Chaves 457 sala 505, 96015-560, Pelotas, RS, Brazil
Tel/Fax: +55 53 32602831 ([email protected])
ORCID: 0000-0003-1358-5928

Abstract
Background: Resin cement and preheated restorative resin composite may be used
for luting laminate veneers. Main advantage of resin composite is increased wear
resistance, which could lead to better marginal performance in long term.
Setting: This article reports a clinical treatment with feldspar laminate veneers luted to
maxillary teeth with preheated resin composite in a private practice. Case was finalized
in May, 2009 and followed by 10 years.

3 Artigo aceito para publicação no periódico Contemporary Clinical Dentistry (Anexo B).
 44

Results: Excellent clinical service and remarkable long-lasting marginal integrity were
observed after 123 months. Scanning electron microscopy analysis showed no wear,
gaps, or ditching at the margins. Restorative margins showed smooth transition
between ceramic and tooth with no signs of degradation.
Conclusion: Preheated resin composite for luting ceramic laminate veneers may be
considered an excellent clinical option.

Keywords: dental veneers; dental porcelain; resin composites; longevity; scanning

electron microscopy.

Introduction
Ceramic laminate veneers are widely used for esthetic restorations. Clinical
studies report survival rates above 80 % in up to 20 years of follow up.[1-3] In addition
to ceramic cracking, chipping and fractures, main reported reasons for failures of
ceramic laminate veneers are related to marginal adaptation, integrity, and/or
discoloration. [1-3] It is known that patient specific risks and variables influence the
success of laminate veneers. For instance, smoking and the presence of endodontic
treatment have been associated with increased marginal discoloration. [1,4] Marginal
failures also could be associated with the resin-based luting agent used. A recent
prospective trial of laminate veneers up to 11 years reported low rates of marginal
failures. [4} It is speculated that such a finding is explained by the use of preheated resin
composite to lute the laminate veneers, but that was not the focus of the study. The
report by Friedman[5] is likely the first on the use of restorative resin composite as luting
agent, but no preheating was described by the author. Preheating is necessary to
reduce viscosity and film thickness,[6] which are of particular importance for thin
restorations. As compared with resin cements, restorative composites have the
advantage of increased filler loading, wear resistance and mechanical strength. Less
marginal ditching has also been suggested.[7] These characteristics, in the long term,
could reflect in less marginal problems and staining. The objective of this article is to
report a clinical treatment in which ceramic laminate veneers were luted to maxillary
anterior teeth with preheated resin composite and showed excellent clinical service
and remarkable marginal integrity after 123 months of follow up.
 45

Clinical Report
The CARE guideline was used for this report.[8] A 28-years old female patient
had a complaint about esthetics in her maxillary anterior teeth. The six maxillary
anterior teeth had complete or partial resin composite veneers including a diastema
closure (Fig. 1A). Restorations had problems of chipping and minor fractures, staining,
surface roughness and texture, and loss of surface gloss (Figs. 1B, 1C). The
anamnesis appointment took place in May 2009. The patient reported that the
treatment had been finalized six months before and asked for longer-lasting
restorations. Use of ceramic laminate veneers was proposed for eight maxillary teeth
to widen the buccal corridor and because the first premolars had gingival recession.
Potential risks were discussed with the patient, who agreed with the treatment. A
double impression technique with polyvinylsiloxane – PVS (Panasil Putty and Light,
Kettenbach, Eschenburg, Germany) was made for obtaining stone cast models, from
which the occlusion was analyzed on articulator and a diagnostic waxing was created.
Tooth preparation was carried out with K0082 Magne bur system (Brasseler,
Georgetown, GA) over the direct resin composites with little (if any) extension into the
underlying enamel. Refining was carried out ultrasonically with diamond tips (T9 and
T10; Sonicflex, KaVo, Biberach, Germany). Figure 1D shows the definitive teeth
preparations. A double impression with PVS (Panasil) was made. Mockup and
provisional restorations were created with acrylic resin (New Outline; Anaxdent,
Stuttgart, Germany).
Feldspar laminate veneers (IPS d.SIGN; Ivoclar Vivadent, Schaan,
Liechtenstein) with thicknesses between 0.2 and 0.4mm were created by using a
layering technique (Figs. 2A, 2B). For luting, the intaglio ceramic surfaces were etched
with 9.5 % hydrofluoric acid for 60 seconds (Porcelain Etchant; Bisco, Schaumburg,
IL), cleaned with phosphoric acid for 15 seconds (Ultra Etch; Ultradent, South Jordan,
UT), silanated (Bis-Silane; Bisco), and filled adhesive from a 3-step system (OptiBond
FL; Kerr, Brea, CA) was applied. The operative field was isolated by using a modified
rubber dam technique. Enamel was etched with phosphoric acid gel for 30 seconds
and the same adhesive used. Compules of resin composite Filtek Z250, shade A1 (3M
ESPE, St. Paul, MN) were preheated to 68 °C for 10 minutes (Calset warmer; AdDent,
Danbury, CT) and used as luting material. The composite was applied to the veneers
with Centrix syringe, restorations were positioned on prepared teeth, and seating hand
pressure applied. Excess resin composite was removed and photoactivation was
 46

carried out for 60 seconds with a LED unit (Radii 2; SDI, Bayswater, Australia).
Finishing was carried out with scalpel blades and polishing with diamond polishers
(D.Fine; Clinician's Choice, New Milford, CT). Figures 3A and 3B show clinical pictures
after luting (same day).
After 21 days, occlusion was rechecked and the treatment was finalized. The
patient returned for follow up appointments after every 18 to 24 months. The last follow
up visit was in June 2019, 123 months the treatment was finalized. Pictures and a PVS
impression were made (Elite Putty and Regular; Zhermack, Badia Polesine, Italy). The
mold was poured with epoxy resin (Fiberglass, Porto Alegre, Brazil) for observation of
the restorations by using scanning electron microscopy – SEM (JSM6610; Jeol, Tokyo,
Japan). The biological, esthetic, and mechanical success of the treatment was
clinically evident (Figs. 4A, 4B). Figure 5 presents an overlapping between clinical and
SEM pictures to show that the restorative margins had no gaps nor signs of
deterioration, marginal ditching, wear, or staining 2. SEM images of the laminate
veneer bonded to maxillary right central incisor (Figs. 6A, 6B) show the integrity of
tooth-composite-ceramic interface after 123 months of clinical service. No wear, gaps,
or any signs of degradation were observed at the margins, which showed a smooth
transition between substrates. A cone-beam computed tomography image of the same
tooth (Fig. 6C) showed excellent adaptation of the laminate veneer; one can also notice
the thickness of resin composite layer at the bonded interface. Both patient and dentist
were well satisfied with the excellent, long-lasting results. The patient signed an
informed consent term to allow reproduction of images.

Discussion
Reports on the use of preheated resin composite as luting agent for laminate
veneers are available, but this is the first with a clinical follow up time longer than 5
years and with a close analysis on marginal integrity. Exceptional long-term biological,
esthetic, and mechanical results were observed, notably regarding the absence of any
marginal deterioration and maintenance of a smooth ceramic-tooth transition. The
same could happen for other restoration types, provided that the restoration allows
adequate light transmission for photopolymerization. Benefits of resin composites over
resin cements as luting agents include more shades available, lower polymerization
shrinkage/stress, and improved mechanical strength.
 47

The main shortcoming usually reported for preheated resin composites is higher
film thickness. A recent study showed that selection of resin composite should consider
its response to preheating since viscosity, flowability, and even the reinforcing effect
provided to thin ceramic structures are material dependent.[6] Since that information
was not available at the time the present treatment was conducted, perhaps the resin
composite used was not the best in terms of response to preheating. That did not
preclude an excellent marginal and internal adaptation, and a long-lasting clinical
service. One should note that an optimal preheating temperature (68°C) and time (10
minutes) were used, different preheating approaches could lead to distinct results.
Maintaining the temperature and gained flowability is a challenge because heat
dissipation occurs fast after preheating is ceased. Heating devices also offer the
possibility of warming up the ceramic laminate veneers, which could reduce heat
dissipation. In addition, up-to-date clinical luting approaches with preheated resin
composite include an ultrasonic activation step to further increase flowability and
reduce film thickness. Taking all into account and considering the excellent long-term
clinical service reported here, preheated resin composite may be considered an
excellent clinical option for luting ceramic laminate veneers.

Conclusion
Preheated resin composite for luting ceramic laminate veneers may be
considered an excellent clinical option since no signs of marginal degradation or
staining were observed after 10-years of clinical service. The smooth marginal
transition between ceramic, luting agent, and tooth and the absence of marginal gaps
and ditching indicate that the restorative resin composite was able to withstand the
abrasive and surface challenges imposed by the oral environment in the long term.

References
1. Beier US, Kapferer I, Burtscher D, Dumfahrt H. Clinical performance of porcelain
laminate veneers for up to 20 years. Int J Prosthodont 2012;25:79-85.
2. Fradeani M, Redemagni M, Corrado M. Porcelain laminate veneers: 6- to 12-year
clinical evaluation--a retrospective study. Int J Periodontics Restorative Dent
2005;25:9-17.
3. Guess PC, Stappert CF. Midterm results of a 5-year prospective clinical
investigation of extended ceramic veneers. Dent Mater 2008;24:804-813.
 48

4. Gresnigt MM, Cune MS, Schuitemaker J, van der Made SA, Meisberger EW,
Magne P, et al. Performance of ceramic laminate veneers with immediate dentine
sealing: An 11 year prospective clinical trial. Dent Mater 2019;35:1042-1052.
5. Friedman M. Multiple potential of etched porcelain laminate veneers. J Am Dent
Assoc 1987; Spec No:83E-87E.
6. Coelho NF, Barbon FJ, Machado RG, Boscato N, Moraes RR. Response of
composite resins to preheating and the resulting strengthening of luted feldspar
ceramic. Dent Mater 2019;35:1430-1438.
7. Duarte Jr S, Sartori N, Sadan A, Phark J-H. Adhesive resin cements for bonding
esthetic restorations: A review. Quintessence Dent Tech 2011; 34:40-66.
8. Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D, et al. The CARE
Guidelines: Consensus-based clinical case reporting guideline development. Glob
Adv Heal Med 2013;2:38-43.
 49

Figure 1. A, Patient had complete or partial resin composite veneers in maxillary

anterior teeth including diastema closure. Restorations had problems including
chipping, fractures, staining, surface roughness and texture, and loss of surface gloss.
B, Patient smile with lips and cheeks retracted. C, Maxillary teeth with a black
background. D, Low-invasive teeth preparations.

Figure 2. A, Laminate feldspar ceramic veneers (IPS d.SIGN) with thicknesses

between 0.2 and 0.4 mm were created by using layering technique. B, Translucent,
thin aspect of restoration.
 50

Figure 3. A, Clinical aspect of ceramic laminate veneers after luting to prepared teeth
with preheated resin composite (same day of luting). 3. B, Maxillary teeth with black
background.
 51

Figure 4. A, Ceramic laminate veneers showed remarkably good clinical performance

and aspect after 123 months of clinical service, with no signs of marginal deterioration,
marginal ditching, or staining. B, Maxillary teeth with black background. C, Palatal view
of maxillary anterior teeth.
 52

Figure 5. Overlapping between clinical and scanning electron microscope images

(×12). Restorative margins showed no gaps nor signs of deterioration, wear, ditching,
or staining during 123 months of clinical service.
 53

Figure 6. A, Scanning electron microscope images of ceramic veneer bonded to

maxillary right central incisor after 123 months of clinical service. B, Tooth-resin
composite-ceramic interface had no wear, gaps or any sign of degradation, with
smooth transition between substrates. Original magnification A, ×10; B, ×50. C, Cone
beam computed tomography image of same tooth showing excellent adaptation of
ceramic veneer.
 54

5 Considerações Finais

Os resultados dos estudos aqui apresentados fornecem uma visão inicial sobre
a possibilidade da utilização de resinas compostas de uso convencional como agente
cimentante de restauros indiretos. Embora alguns pontos ainda possam ser uma
incógnita para decisão de qual o melhor material restaurador pode ser utilizado como
material cimentante de restaurações indiretas, o nosso estudo verificou em três fases
tanto os materiais mais adequados, como também realizamos a descrição da técnica
e o relato de caso clinico de long prazo.
O primeiro artigo deste estudo investigou a viscosidade (reologia), a cinética
térmica de 10 resinas compostas restauradoras pré-aquecidas selecionadas e o efeito
da energia do ultrassom na espessura do filme, concluindo que resinas compostas
restauradoras com formulações distintas reagem de forma diferente ao pré-
aquecimento, afetando a viscosidade e a espessura do filme. Isso sugere a
necessidade de cuidado na escolha do material. Também identificamos que o tempo
ideal de trabalho do compósito pré-aquecido é curto e devemos adequar a sequência
de cimentação para aproveitar as altas temperaturas encontradas nos primeiros 15 s.
Sobre a aplicação de ultrassom, percebemos que é eficaz na redução da espessura
do filme e pode auxiliar resinas compostas restauradoras a obter filmes abaixo de 50
µm. Assim, entendemos que o desempenho geral da técnica de resina composta de
pré-aquecida depende da seleção adequada do material e que é aplicável como
material cimentante, assim como da técnica de aplicação.
Para isso, no segundo artigo descrevemos as fases clínicas da cimentação com
material resinoso restaurador, identificando os principais pontos que diferem da
aplicação com cimentos resinosos comumente utilizados para cimentação de
restauros indiretos. Espera-se que este relato de técnica possa auxiliar dentistas que
estão iniciando o uso da técnica, abordando aspectos relevantes da sequência clínica
de aplicação. Já no terceiro artigo, realizamos um estudo clinico de avaliação
longitudinal de 11 anos de uma paciente que possui 10 laminados cerâmicos que
foram cimentados com material restaurador, avaliamos não somente a estética dos
restauros, como também as margens da intersecção entre dente, material cimentante
e restauro indireto através de uma analise de superfície com microscopia eletrônica
 55

de varredura. Embora seja um relato de caso, indica que a técnica pode gerar uma
linha de cimentação e adaptação marginal resistentes ao desgaste clínico em longo
prazo, sendo o relato mais antigo presente na literatura. De forma geral, os estudos
apresentados nesta tese abordam aspectos e dúvidas relevantes na aplicação
contemporânea de resinas compostas pré-aquecidas como material de cimentação,
abrindo espaço para futuros estudos laboratoriais e clínicos para ajudar na
consolidação da técnica.
 56

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 61

Apêndices
 62

Apêndice A – Nota da Tese

Resina composta restauradora pré-aquecida como agente de cimentação

adesiva de restaurações indiretas

Preheated restorative resin composite as adhesive luting agent of indirect

restorations

O dia-a-dia de dentistas envolve restaurar dentes de seus pacientes por motivos

diversos, como cárie, fraturas e estética. Uma das opções de material para
restauração são materiais cerâmicos, conhecidos como porcelanas. Para unir a
porcelana aos dentes são usados materiais resinosos fluidos, que podem sofrer
desgaste na boca. Este trabalho estudou a possibilidade de trocar esses materiais
fluidos por materiais mais resistentes para aprimorar os resultados clínicos. Estes
materiais mais resistentes precisam ser aquecidos antes de seu uso para que
fiquem fluidos também e possam ser usados na colagem da porcelana. Este
trabalho mostrou que esta técnica diferente é uma excelente opção para dentistas,
mas que a escolha do material para colagem precisa ser feita com cautela pois nem
todos ficam bem fluidos quando aquecidos, o que pode atrapalhar o procedimento.

Campo da pesquisa: Odontologia restauradora.

Candidato: Rogério Luiz Marcondes, cirurgião-dentista pela Pontifícia Universidade

Católica do Paraná (1997).

Data da defesa e horário: 01/10/2021 às 14h

Local: Ambiente virtual Google Meet.

Membros da banca: Prof. Dr. Rafael Ratto de Moraes, Prof. Dr. Gregori Franco
Boeira, Prof. Dr. Leandro Augusto Hilgert, Prof. Dr. Tiago Veras Fernandes, Profa.
Dra. Giana da Silveira Lima (Suplente) e Profa. Dra. Priscilla Cardoso Lazari
(Suplente)

Orientador: Prof. Dr. Rafael Ratto de Moraes

Co-orientador: Prof. Dr. Marco Aurélio de Carvalho

Informação de contato: Rogério Luiz Marcondes, Email:

[email protected].
 63

Apêndice B – Súmula do currículo do candidato

Súmula do currículo

Rogério Luiz Marcondes nasceu em 16 de julho de 1973, em Curitiba, Paraná. Cursou

o ensino médio no Colégio Dom Bosco, na mesma cidade. Em 1993 ingressou na
Faculdade de Odontologia da Pontifícia Universidade Católica do Paraná (PUC-PR),
tendo sido graduado como cirurgião-dentista em julho de 1997. Durante o período de
graduação, foi monitor das disciplinas Dentística I e II durante 3 semestres. Entre 1999
e 2000, frequentou como estudante convidado o programa de Fellowship em
Reabilitação Oral da Universidade Estadual de Ohio, EUA sob orientação do Professor
Stephen Rosenstiel, em 2006 finalizou o aperfeiçoamento em próteses sobre implante
no Instituto Latino Americano de Pesquisa e Ensino Odontológico, Brasil. Em 2008,
concluiu especialização em dentística restauradora pela Força Aérea Brasileira. Em
2013, tornou-se Presidente da Sociedade Brasileira de Odontologia Estética. No ano
de 2017, ingressou no doutorado no Programa de Pós-Graduação em Odontologia da
Universidade Federal de Pelotas e desenvolveu trabalhos na linha de pesquisa com
materiais resinosos aquecidos e utilização de aparatos ultrassónicos com
coadjuvantes no assentamentos de restauros indiretos.

Publicações:

Artigos
MARCONDES, R. L.; CALGARO, M. O desafio estético com próteses anteriores
unitárias: o planejamento com integração clinico-laboratorial. REVISTA DENTAL
PRESS DE ESTÉTICA (MARINGÁ), v. 5, p. 31-71, 2008.
MARCONDES, R. L.; Bocutti, J. Lentes de Contato: Uma técnica minimamente
invasiva. REVISTA DENTAL PRESS DE ESTÉTICA (MARINGÁ), v. 09, p. 18-29,
2012.
MARCONDES, R. L.; PIRES, H. ; Bocutti, J. Escaneamento Intra-oral para confecção
de coroas unitárias anteriores em zirconia. Do desafio a resolução. Revista da APCD,
v. 01, p. 26-42, 2012.
 64

MARCONDES, R. L.; PIRES, H. ; Bocutti, J. Lamina cerâmica unitária sobre substrato

escurecido: protocolo clinico/laboratorial com estratificação em duas camadas.
REVISTA DENTAL PRESS DE ESTÉTICA (MARINGÁ), v. 9, p. 29-44, 2012.
MARCONDES, R. L.; Bocutti, J. ; PIRES, H. . Back to the Future. REVISTA DENTAL
PRESS DE ESTÉTICA (MARINGÁ), v. 10, p. 22-50, 2013.

MARCONDES, ROGÉRIO L.; LIMA, VERÔNICA P. ; BARBON, FABÍOLA J. ; ISOLAN,

CRISTINA P. ; CARVALHO, MARCO A. ; SALVADOR, MARCOS V. ; LIMA, ADRIANO
F. ; MORAES, RAFAEL R. Viscosity and thermal kinetics of 10 preheated restorative
resin composites and effect of ultrasound energy on film thickness. DENTAL
MATERIALS, v. 36, p. 1356-1364, 2020.

MARCONDES, ROGÉRIO L.; MORAES, RAFAEL R. . Ceramic laminate veneers luted

with preheated resin composite: A 10-year clinical report. CONTEMPORARY
CLINICAL DENTISTRY, aceito para publicação.

Capítulos de livros:
MARCONDES, R. L.; Bocutti, J. Laminados, lentes de contato e coroas de porcelana:
integrando biomecânica e estética. In: Nocchi, Ewerton. (Org.). Visão horizontal:
Odontologia Estética para Todos. 1ed.Maringa: Dental Press, 2012, v. 2, p. 01-400.

MARCONDES, R. L.; PIRES, H. ; Bocutti, J. O desafio das próteses unitarias

anteriores. In: Morita, D. ; Aranha, C.. (Org.). A Busca da excelencia estética no
laboratorio de protese e clinica dentaria. 1ed.nova odessa: Napoleao, 2013, v. 01, p.
45-78.

PIRES, H. ; MARCONDES, R. L. ; Bocutti, J. Resina Termicamente Modicficada -

RTM. In: Callegari, Andre. (Org.). Beleza do Sorriso - Vol. 02 - Especialidade em foco.
1ed.nova odessa: Napoleao, 2014, v. 2, p. 01-496.

MARCONDES, R. L.; HOLANDA, C. E. A. Abordagem Biomimética para a

reconstrução parcial coronária de dentes posteriores com cerâmicas feldspáticas. In:
Marcelo Fonseca. (Org.). Estética Contemporanea - SINERGIA DESING
TECNOLOGIA. 01ed.Sao Paulo: Quintessence Editora, 2016, v. 01, p. 99-131
 65

MARCONDES, R. L.; SILVEIRA, F. ; FREITAS, E. ; MACIEL, J. R. ; FERNANDES, T.

V. ; EVANGELISTA, O. ; GIORDANI, M. . Sorriso Perfeito - conheça as etapas, passo
a passo de um tratamento estético odontológico. 01. ed. Belo Horizonte: FanDesign,
2017. v. 01. 26p.

VERAS, T; MARCONDES, R. Full Reshaping – uma abordagem estética /

reabilitadora com resina composta (Org). The Aesthetics Yearbook – Anuário Oficial
Da SBOE – Volume 2. In: Fonseca, M ; et al. Ed. Napoleao , 2019.
 66

Anexos
 67

Anexo A – Capa do artigo oriundo do Capítulo 1

 68

Anexo B – Capa do artigo oriundo do Capítulo 3