BIOMATERIALS

Update

Neimar Sartori, DDS, MS, PhD1

Reham Alsamman, BDS2
Leonardo Bocabella, CDT3
Victor Clavijo, DDS, MS, PhD4
Jin-Ho Phark, DDS, Dr Med Dent5
Maria Manuela Lopes, PhD6
Sillas Duarte, Jr, DDS, MS, PhD7

Assistant Professor and Assistant Director, Advanced Program in Operative and Adhesive
1

Dentistry, Division of Restorative Sciences, Herman Ostrow School of Dentistry, University

of Southern California, Los Angeles, California, USA.
Resident, Advanced Program in Operative and Adhesive Dentistry, Master of Science
2

Candidate in Craniofacial Biology, Herman Ostrow School of Dentistry, University of

Southern California, Los Angeles, California, USA.
Dental Technician, Campinas, São Paulo, Brazil.
3

Visiting Professor, Advanced Program in Operative and Adhesive Dentistry, Division of

4

Restorative Sciences, Herman Ostrow School of Dentistry, University of Southern

California, Los Angeles, California, USA.
Assistant Professor, Advanced Program in Operative and Adhesive Dentistry, Division of
5

Restorative Sciences, Herman Ostrow School of Dentistry, University of Southern

California, Los Angeles, California, USA.
Unit of Investigation and Biomedical Sciences, Faculty of Dental Medicine, University of
6

Lisbon, Lisbon, Portugal.

Associate Professor and Chair, Division of Restorative Sciences, Director of the Advanced
7

Program in Operative and Adhesive Dentistry, Herman Ostrow School of Dentistry,

University of Southern California, Los Angeles, California, USA.

Correspondence to: Dr Sillas Duarte Jr, Division of Restorative Sciences, Herman

Ostrow School of Dentistry, University of Southern California, 925 W 34th Street,
Los Angeles, CA, 90089-0641, USA. Email: [email protected]

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 The Adhesive Restorative Complex
(ARC) Concept

T ENAMEL-GUIDED TOOTH
he ultimate goal of a bonded restoration is to attain
long-term intimate adaptation of the restorative
material with tooth structures. This is extremely dif-
PREPARATION
ficult because a multitude of structures/materials of differ-
ent compositions are involved in the bonding process on a Enamel thickness varies according to the tooth and region
given bonded restoration.1 Enamel, dentin, and restorative where it is located (Fig 1). For maxillary central incisors,
materials, such as ceramics and composites, have dedicat- the average thickness of enamel is 300 μm (0.3 mm) at
ed bonding mechanisms that are very technique sensitive the gingival third (1.0 mm above the cementoenamel junc-
and can lead to success or failure of a restoration. tion [CEJ]), 500 μm (0.5 mm) at the middle third (3.0 mm
There are four possible theoretical mechanisms of above the CEJ), and 700 to 800 μm (0.7 to 0.8 mm) at
bonding to tooth structures: (1) penetration of resin and sub­ the incisal third (5.0 mm above the CEJ).2 For molars, the
sequent formation of resin tags; (2) precipitation of sub- average thickness of enamel is 200 to 800 μm (0.2 to 0.8
stances on dental surfaces to which monomers can bond mm) at the cervical third (1.8 mm above the CEJ), 500
mechanically or chemically; (3) chemical bonding to the to 1,400 μm (0.5 to 1.4 mm) at the middle third (2.5 mm
inorganic component (hydroxyapatite); and (4) chemical above the CEJ), and 1,100 to 2,400 μm (1.1 to 2.4 mm)
bonding to the organic components of dentin or enamel. at the occlusal third (1.0 mm cervically from the cusp tip).3
Thus, structural modification is required for an adhesive There are still controversies as to the exact enamel
procedure. Tooth structures can be modified by the appli- thickness of natural dentition. Interproximal enamel and
cation of an etch-and-rinse, self-etch, or self-adhesive bond- gingival enamel are where most discrepancies in thick-
ing system, whereas restorative materials such as ceramics ness are found. The proximal enamel thickness increases
can have their surface structure modified by airborne progressively from incisor (averaging 620 µm or 0.62 mm
abrasion and/or etching, followed by chemical bonding with mandibular; 810 µm or 0.81 mm maxillary) to the first mo-
silane. lar (averaging 1,390 µm or 1.39 mm mandibular; 1,420 µm
With the advances in adhesive technology and a better or 1.42 mm maxillary) (Graphs 1 and 2).4 Another study
understanding of its benefits and limitations, novel ultra- showed the thickness of enamel at the gingival third might
conservative adhesive restorative concepts that rely on reach 410 μm (0.41 mm) on the maxillary central incisor
tooth preservation can now be safely indicated. The aim and 367 μm (0.36 mm) on the maxillary lateral incisor.5
of this article is to describe new concepts for biologically Considering the thickness of natural tooth enamel, tra-
guided tooth preparation and their implications on the ad- ditional crown preparations—which recommend 1.0 mm of
hesive restorative complex (ARC). reduction at the gingival margin and 1.5 mm of reduction

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 SARTORI ET AL

Fig 1  Thickness of enamel in different regions of the tooth.

Note the difference in thickness between the facial and lingual
surfaces.

Graph 1  Mean
maxillary proximal
enamel thickness
(in mm).4

Central Lateral Canine First Second Molar

incisor incisor premolar premolar

Graph 2  Mean
mandibular proximal
enamel thickness
(in mm).4

Central Lateral Canine First Second Molar

incisor incisor premolar premolar

axially—would deplete a tooth from most of its enamel, more conservative restorations.10–17 Full-coverage minimally
leaving only dentin for adherence. The main concern of bond­ invasive preparations can produce a clinically acceptable
ing to exposed dentin is the longevity of the bonded inter- outcome only if the restorations are bonded to tooth struc-
faces and potential for bonding degradation over time.6–9 ture.18–21 To preserve enamel, ultrathin bonded ceramic
Thus, preserving dental enamel is of paramount impor- restorations, with 100 μm (0.1 mm) to 300 μm (0.3 mm)
tance for the longevity of bonded indirect restorations. of thickness, can be fabricated and bonded to the remain-
Different minimally invasive dental preparations or re- ing enamel.13,22–28 To achieve such delicate preparation,
storative approaches have been suggested to produce the clinician should start with a mock-up, followed by the

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 The Adhesive Restorative Complex (ARC) Concept

Fig 2a  Enamel-guided tooth

preparation guidelines for an
anterior tooth. (left) Mesial
0.2–0.3 mm
view. (right) Facial view.
0.2–0.3 mm 0.2–0.3 mm
0.2–0.3 mm

0.2–0.5 mm 0.2–0.5 mm
0.2–0.5 mm 0.2–0.5 mm
Max 0.6 mm Max 0.6 mm
Max 0.6 mm Max 0.6 mm

Fig 2b  Enamel-guided tooth

preparation guidelines for a
posterior tooth. (left) Mesial
view. (right) Facial view. 0.2–0.3 mm

0.2–0.3 mm
0.2–0.3 mm
0.5–0.7 mm 0.2–0.3 mm
0.5–0.7 mm
Max 1.0 mm Max 1.0 mm
0.5–0.7 mm 0.5–0.7 mm
Max 1.0 mm Max 1.0 mm

use of extrafine diamond burs or polishing instruments The novel enamel-guided tooth preparation guidelines
(ie, ceramic polishing kits, aluminum oxide discs) rather for adhesive full-coverage restorations are as follows (Figs
than coarse high-speed diamond burs. Determining the 2a and 2b):
path of insertion of the adhesive restoration is performed
mainly with polishing instruments to impart control over the •  Anterior Tooth. The gingival enamel must be protected,
amount of tooth structure removed. For ultraconservative thus minimal reduction of 0.2 to 0.3 mm at the gingival
preparations, the gingival finish line is modified from the margins is made, whereas axially 0.2 to 0.5 mm of reduc-
traditional chamfer to a supragingival feather-edge margin. tion with a maximum of 0.6 mm of reduction should be
Feather-edge margins are an acceptable finish-line op- the aim to maintain enamel.
tion for monolithic lithium disilicate single-unit restorations •  Posterior Tooth. The gingival enamel must be protected,
if the restorations are adhesively bonded to enamel.29–31 thus minimal reduction of 0.2 to 0.3 mm at the gingival
The gingival margins of any adhesive preparation must be margins is made, whereas axially 0.5 to 0.7 mm of reduc-
protected by the presence of an enamel rim. Should prepa- tion with a maximum of 1.0 mm of reduction should be
rations extend over 1.0 mm, there is a high probability of the aim to maintain enamel.
dentin exposure and long-term bonding may be compro-
mised. Thus, guidelines for adhesive indirect restorations If due to circumstances beyond clinician control (ie, caries,
should be reconsidered based on the average enamel erosion, tooth wear) the preparation extends beyond the
thickness of different teeth in order to provide maximum thicknesses described above, dentin will be exposed and
preservation of enamel. the clinician should be aware of bonding techniques that
would enhance the longevity of bonding to dentin.

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 SARTORI ET AL

3a 3b

3c 4

Fig 3a  Complex hierarchical structure of enamel, dentin-enamel junction (DEJ), and dentin, which allows support of all oral and mas-
ticatory functions without damaging the tooth.
Fig 3b  Outer enamel showing prisms relatively straight and aligned parallel to one another (original magnification ×2,500).
Fig 3c  Inner enamel showing decussation (original magnification ×350).
Fig 4  DEJ complex (original magnification ×10,000).

IMPORTANCE OF PRESERVING enamel can promote crack deflection, resulting in reduc-

tion of the stress intensity at the crack tip while, simultane-
INNER ENAMEL AND DENTIN- ously, extrinsic mechanisms such as bridging by ligaments
ENAMEL JUNCTION and organic matrix within helps in crack closure.33,35 This
process dissipates the intensity of the fracture and averts
Enamel possesses a highly complex hierarchical structure cracks from extending toward the dentin-enamel junction
that allows support of all oral and masticatory functions (DEJ) and dentin.33 Thus, the majority of cracks initiated
without damaging the tooth (Fig 3a). In the outer enamel in enamel are nucleated and the DEJ prevents the cracks
(Fig 3b), the region nearest the tooth surface, the enamel from propagating into the dentin.
prisms are relatively straight and aligned parallel to one an- The DEJ complex is a 100- to 150-µm-wide interface
other, while in inner enamel the prisms are decussated (Fig region that unites the brittle enamel and softer dentin (Fig
3c) and are arranged in layers with oblique orientations 4).36 With an average width of 12 µm, the DEJ has its own
to one another.32,33 This complex gradient system allows complex biological and mechanical characteristics that are
crack growth resistance and fracture toughness of enam- essential for the long-term survival of any tooth.37 One of
el.34 The decussation of the enamel prisms in the inner these characteristics is its elastic-plastic behavior, which

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 The Adhesive Restorative Complex (ARC) Concept

5 6

Fig 5  High magnification of the DEJ showing the transition between enamel (E) and dentin (D), where the collagen fibrils (c) extend
from dentin to enamel and hydroxyapatite crystals (e) (original magnification ×30,000).
Fig 6  Scalloped microstructure of DEJ (original magnification ×3,000).

accommodates fracture stresses by deflecting the crack bonded interfaces allows the clinician to have better con-
path and preventing any damage from reaching dentin and trol over the adhesive restoration.
pulp.36,38 The DEJ contains 80- to 120-nm parallel type I When enamel is etched with phosphoric acid, hydroxy-
collagen fibrils, extending from the dentin into enamel, that apatite is selectively removed and the adhesive permeates
assist its mechanical behavior (Fig 5).39 The DEJ complex and diffuses into the etched surfaces. It is important to at-
also includes inner aprismatic enamel and mantle dentin.40 tain interprismatic penetration and intraprismatic enamel
It is organized into three levels of microstructure: scallops hybridization to ensure appropriate bond strengths (Figs
varying in size and location, microscallops within each scal- 7a and 7b).42 Usually, deeper enamel interprismatic resin
lop, and a nanometric structure within the microscallops (Fig penetration is observed with phosphoric acid etching com-
6).41 Without the DEJ and its inherited properties, even a pared with that of self-adhesive or self-etching systems.
small fracture or structural flaw would result in catastrophic Deep interprismatic penetration averaging 2 to 3 μm with
failure of the tooth. Thus, given the importance of the DEJ well-defined intraprismatic hybridization (2 to 3 μm) can
on tooth mechanical behavior, it should be preserved at all be obtained when enamel is acid etched with phosphoric
costs during any restorative approach. acid (Fig 8a).43 The microporosities created by acid etch-
ing ensure longevity for the bonded restoration because of
micromechanical retention (Fig 8b).
Self-etch adhesive systems create shallow interpris-
THE ADHESIVE RESTORATIVE matic penetration (0.2 to 0.5 μm) with shallow and rare
COMPLEX CONCEPT intraprismatic hybridization (0.5 μm), and self-adhesive
resin cements reveal inconsistent interprismatic penetra-
Ultraconservative tooth preparations rely on preservation tion with intraprismatic hybridization occurring in small
of enamel throughout the entire preparation. With protec- areas.43 Although some articles have indicated that self-
tion of the inner enamel and consequently the DEJ, crack etching systems may have appropriate bonding to enamel,
propagation is minimized and absorbed within the ARC. they only observe its effect on direct restorations.44–46 For
The ARC is composed of multiple bondable surfaces: full-coverage or partial-coverage indirect bonded restora-
etched ceramic, silane, resin cement, adhesive layer, and tion, the present authors strongly recommend treatment or
enamel hybrid layer. These surfaces create three distinct pretreatment of enamel with phosphoric acid before the
adhesive interfaces: the ceramic–resin cement interface, application of any dental adhesive or self-adhesive system.
resin cement–adhesive layer interface, and adhesive layer– If dentin exposure during the tooth preparation is un-
enamel hybrid layer interface. Minimizing the number of avoidable, the dentin must be carefully and effectively

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 SARTORI ET AL

7a 7b

8a 8b

9 10

Fig 7a  Complex arrangement of the hydroxyapatite crystallites within the intact enamel (original magnification ×6,000).
Fig 7b  Enamel etched with phosphoric acid for 30 seconds (original magnification ×3,000).
Fig 8  Different adhesive interfaces on a bonded ceramic restoration to enamel: (a) adhesive interface between the enamel adhe-
sive layer (A) and resin cement (R). HL = enamel hybrid layer; E = enamel (original magnification ×3,000). (b) Adhesive interface
between the enamel adhesive layer (A) and enamel hybrid layer (HL) (original magnification ×6,000).
Fig 9  Dentin etched with phosphoric acid for 15 seconds (original magnification ×5,000).
Fig 10  Adhesive interface on dentin showing the interface between the dentin adhesive layer (A) and dentin hybrid layer (HL).
RT = resin tags.

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 The Adhesive Restorative Complex (ARC) Concept

11a 11b

Fig 11a  Etched lithium disilicate glass-ceramic with 5% hydro-

fluoric acid (original magnification ×20,000).
Fig 11b  Microstructure of an amine-free resin cement (RelyX
Ultimate, 3M) showing the differences in filler size and shape
(original magnification ×7,000).
Fig 11c  Adhesive interface between the etched lithium disili-
cate ceramic (C) and resin cement (RC) (original magnification
×5,000).

11c

hybridized only during the delivery of the restoration. At than bonding to enamel due to the many factors that can
that stage, the application of an acid to dentin removes negatively affect the integrity of the dentin bond.
the dentin smear layer, demineralizes dentin up to 5 to 8 As previously mentioned, minimizing the amount of
μm, widens dentin tubuli, and exposes collagen fibers (Fig adhesive interfaces within the ARC facilitates bonding
9). Hydrophilic monomers then permeate the small spaces procedures and enhances the longevity of bonded restora-
created within the dentin collagen network, resulting in tions (Figs 8 and 11). Conversely, as more different bioma-
resin-enveloped collagen fibrils and formation of a resin- terials are added to the ARC, the less control the clinician
dentin interdiffusion zone or dentin hybrid layer (Fig 10).47 has over the different properties of each interface created.
Alternatively, self-etch adhesive systems demineralize and Mismatch between the thermal expansion coefficients of
infiltrate the dental substrate simultaneously. The etching different restorative materials and the tooth results in dif-
characteristics are dependent on the pH of the acidic so- ferential expansion and contraction during intraoral tem-
lutions, which range from ultramild (pH > 2.5) and mild perature changes.49,50 Thermal stress, particularly caused
self-etching (pH ≈ 2.0) to strong self-etching adhesives by cold exposure, may increase the potential for crack
(pH < 1.0).48 Intertubular collagen is exposed and hydroxy- initiation at the gingival region.49 The ARC must be kept
apatite is replaced by resin monomers, creating microme- as simple as possible with the least number of adhesive
chanical interlocking within the collagen interstices, while interfaces, since each different interface may be subject
the smear layer is impregnated by acidic monomers. Self- to stress, which will decrease the overall longevity of the
adhesive systems partially dissolve the smear layer without restoration.
removing the smear plug within the dentinal tubules and Figures 12 to 29 depict a full-mouth rehabilitation using
promote chemical adhesion by chelating the calcium ions the ARC concept.
of the hydroxyapatite. Dentin bonding is far more complex

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 SARTORI ET AL

12a 12b 12c

13a 13b 13c

14a 14b 14c

15

Figs 12a to 12c  Preoperative views of a patient rehabilitated with composite resin 10 years ago.
Figs 13a to 13c  Preoperative view of the maxillary dentition. Observe the lack of appropriate dental anatomy and flattened occlusal
surfaces caused by composite wear.
Fig 14a to 14c  Preoperative view of the mandibular dentition, also depicting lack of appropriate dental anatomy and flattened occlu-
sal surfaces caused by composite wear.
Fig 15  Additive composite resin additions were made over the existing composite resin restorations to correct the vertical dimension
of occlusion.

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 The Adhesive Restorative Complex (ARC) Concept

16a 16b 16c

17a 17b 17c

18a 18b 18c

18d

Figs 16a to 16c  Ultraconservative maxillary tooth preparations were carefully performed to ensure maximum preservation of
enamel. Feather-edge margins were adopted on the buccal to preserve the cervical enamel, whereas a light chamfer was placed on
the working cusps to provide thickness for the restoration.
Figs 17a to 17c  Lithium disilicate glass-ceramic (IPS e.max CAD, Ivoclar) restorations before crystallization. The preparations were
scanned, restorations designed digitally (CEREC, Sirona), and lithium disilicate glass-ceramic milled.
Figs 18a to 18d  Lithium disilicate glass-ceramic restorations after finishing and glazing. Monolithic restorations were made for the
posterior teeth, and restorations for the anterior teeth were microlayered.

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 SARTORI ET AL

19a 19b 19c

19d 19e

19f 19g

Fig 19a  Ultraconservative tooth preparations were made for the mandibular teeth for maximum preservation of enamel.
Fig 19b  Preparations were scanned and the final monolithic restorations digitally designed.
Figs 19c to 19e  Occlusal, buccal, and lingual views of the translucent digital design and preparations for the mandibular teeth.
Fig 19f  CAD/CAM milled mandibular molar ultrathin crown.
Fig 19g  Ultrathin gingival margin displaying 0.15 mm (150 μm) thickness. Note the ultraconservative preparations and milled
CAD/CAM restorations made for maximum preservation of enamel.

20a 20b 20c

Figs 20a to 20c  Lithium disilicate glass-ceramic restorations before crystallization. Monolithic restorations were made for the poste-
rior teeth, and the restorations for the anterior teeth were microlayered.

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 The Adhesive Restorative Complex (ARC) Concept

21a 21b 21c

21d 21e

22a 22b 22c

22d

Figs 21a to 21e  Ultraconservative preparations for the maxillary anterior teeth: (a) Preoperative view of the worn composite res-
torations. (b) A mock-up with the final tooth shape was made and lightly bonded to the existing composite restorations. (c) After the
patient agreed to the shape of the teeth, the mockup and existing composite restorations were carefully removed to preserve the
underlying tooth structure. (d) Teeth after removal of the old composite restorations. (e) Instead of traditional preparation, which would
deplete the teeth from enamel, retraction cords were placed and only the path of insertion was created with intraoral ceramic polish-
ing burs and aluminum oxide discs, allowing preservation of enamel for bonding. Feather-edge supragingival margins were adopted
since the restorations would be adhesively bonded to the teeth.
Figs 22a to 22c  Preparations were scanned and the restorations were digitally designed.
Fig 22d  Ultrathin anterior CAD/CAM restoration with ultraconservative gingival margins of 0.15 mm (150 μm) thickness.

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 SARTORI ET AL

23a 23b 23c

Figs 23a to 23d  Microlayering of CAD/

CAM restorations: (a) Lithium disilicate
glass-ceramic restorations were milled.
(b) A 1.0-mm incisal reduction was made
to create mamelons and a better esthetic
outcome. (c) Feldspathic porcelain was
added to the incisal edge and to the line
angles. (d) CAD/CAM lithium disilicate
glass-ceramic restorations after polishing
and glazing.
23d 24 Fig 24  Final bonded maxillary restora-
tions using the ARC concept.

25a 25b

25c

Figs 25a to 25c  Final maxillary CAD/CAM ultraconservative adhesive restorations bonded to teeth using the ARC concept.

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 The Adhesive Restorative Complex (ARC) Concept

26a 26b

26c

27

Figs 26a to 26c  Final mandibular CAD/CAM ultraconservative adhesive restorations bonded to teeth using the ARC concept.
Fig 27  Maxillary and mandibular arches ultraconservatively restored using the ARC concept.

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 SARTORI ET AL

Figs 28a to 28c  Views of the full-mouth adhesive

reconstruction of the vertical dimension of occlusion using
ultraconservative preparations and the ARC concept.

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 The Adhesive Restorative Complex (ARC) Concept

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 SARTORI ET AL

CONCLUSIONS 11. Edelhoff D, Sorensen JA. Tooth structure removal associated with
various preparation designs for posterior teeth. Int J Periodontics Re-
storative Dent 2002;22:241–249.
Maximum preservation of tooth structure can be obtained 12. Edelhoff D, Sorensen JA. Tooth structure removal associated with
if modified ultraconservative preparation techniques are various preparation designs for anterior teeth. J Prosthet Dent
used. Enamel preservation is of paramount importance for 2002;87:503–509.
13. Clavijo V, Sartori N, Phark J, Duarte S Jr. Novel guidelines for bonded
the success of bonded restorations. Thus, ultrathin resto- ceramic veneers: Part 1. Is tooth preparation truly necessary? Quin-
rations should be made to ensure maximum preservation tessence Dent Technol 2016;39:7–25.
of enamel, especially at the gingival third. Additionally, the 14. Tsitrou EA, van Noort R. Minimal preparation designs for single pos-
terior indirect prostheses with the use of the Cerec system. Int J
number of adhesive interfaces within bonded restorations Comput Dent 2008;11:227–240.
should be minimized in order for the clinician to reduce the 15. Vailati F, Belser UC. Full-mouth adhesive rehabilitation of a severely
complexity of delivering bonded restorations as well as to eroded dentition: The three-step technique. Part 3. Eur J Esthet Dent
2008;3:236–257.
control the various properties of different adhesive bioma-
16. Vailati F, Belser UC. Full-mouth adhesive rehabilitation of a severely
terials. The ARC concept has been introduced to improve eroded dentition: The three-step technique. Part 2. Eur J Esthet Dent
the longevity of bonded restorations and for clinicians and 2008;3:128–146.
patients who will benefit from future ultraconservative 17. Vailati F, Belser UC. Full-mouth adhesive rehabilitation of a severely
eroded dentition: The three-step technique. Part 1. Eur J Esthet Dent
bonded restorations. 2008;3:30–44.
18. Bacherini L, Brennan M, Bocabella L, Viagiani P. Esthetic rehabilita-
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