Shiono and Koizumi

Int Chin J Dent 2003; 3: 100-104.

Clinical performance of a premolar jacket crown made of a highly
loaded indirect composite and seated with an adhesive luting agent: Aclinical report
Hideaki Shiono, DDS, PhD, and Hiroyasu Koizumi, DDS, PhD
Department of Crown and Bridge Prosthodontics, Nihon University School ofDentistry, Tokyo, Japan
This clinical report evaluates the clinical performance of a tooth-colored composite restoration made of ahighly filled prosthodontic composite (Estenia) and bonded with a composite luting agent (RelyX ARC), inconjunction with the longevity of an adjacent conventional full cast restoration cemented with aresin-modified glass-ionomer material (RelyX luting cement). After an observation period of 36 months,
both restorations are functioning satisfactorily, indicating that the jacket crown seated with the RelyX ARC
material can be used as an alternative to a cast restoration for restoring pulpless mandibular premolars.
(Int Chin J Dent 2003; 3: 100-104.)
Key Words: adhesive, composite, jacket crown, resin-modified glass-ionomer.

Introduction
Porcelain-fused-to-metal (PFM) restorations have been successfully used for more than 40 years for bothanterior and posterior teeth.

A number of all-ceramic and all-composite restorative systems havemeanwhile been developed, and some of the manufacturers claim that the metal-free system is available as
an alternative to PFM systems. Composite material is generally considered to be less wear resistant thanporcelain and inferior to ceramics in color stability. The wear resistance and mechanical properties ofindirect composite materials have been improved considerably by increasing the inorganic filler loading.1-5
The Estenia light- and heat-polymerized composite6 (Kuraray Medical, Tokyo, Japan) contains more than
90% inorganic filler. It is also important for the clinician to select an adequate luting agent for seating
tooth-colored restorations in order to facilitate color stability, marginal integrity, and fracture resistance. In
addition to representative inorganic luting cements, a growing number of resin adhesives andresin-modified glass-ionomer materials have been introduced.7-13 Although a number of researchers haveevaluated the in vitro properties of composite restoratives and resin-based luting agents, limited information
is available about the clinical performance of the restorative-cement system. This clinical report comparesthe 3-year clinical performance of a jacket crown and a full-cast restoration seated with different lutingagents.

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Int Chin J Dent 2003; 3: 100-104.

Clinical Report
A 48-year-old female patient was examined; her chief complaint was food impaction between her rightmandibular second premolar and first molar. The examination revealed a considerable amount of space,more than 200 µm, with gingival inflammation between these teeth. The patient preferred a tooth-coloredrestoration for replacement of the premolar rather than a cast metallic restoration. Several treatment
methods were proposed to the patient, including metal-ceramic restoration, porcelain jacket crown, andcomposite restoration. Considering the service period, appearance, restorative strength, and cost of thetreatment, the patient selected a composite jacket crown for the premolar and cast restoration for the molar.
Old restorations were removed and root canal treatment of the second premolar was completed. A cast
dowel core made from a silver-palladium-copper-gold alloy (Ag-Pd-Cu-Au, Castwell M.C. 12, GC Corp.,
Tokyo, Japan) was fabricated and cemented with a conventional glass-ionomer material (Fuji I, GC Corp.).
Shoulder preparation of 1 mm width was selected for the premolar abutment in order to achieve sufficientmarginal thickness as well as strength of the restoration. For the first molar, chamfer preparation wasperformed (Fig. 1). An impression was made with a silicone elastomeric material, poured with die stone,
and a working die was prepared. A cast metallic molar restoration was made from the Ag-Pd-Cu-Au alloy.
A composite jacket crown was next fabricated from a highly filled indirect composite material (Estenia,Kuraray Medical Inc., Tokyo, Japan) according to the manufacturer’s specifications (Fig. 2). An opaquecomposite was used to hide the metallic color of the abutment. At the patient’s next visit, the restorations
were tried-in, occlusion and articulation were adjusted, and the restorations were seated with different
luting agents. The cast molar restoration was seated with a resin-modified glass-ionomer material (RMGI,RelyX luting cement, 3M Espe, St. Paul, MN, USA), whereas the RelyX ARC system (3M Espe) was usedfor bonding the premolar jacket crown.
After try-in, the inner surface of the jacket crown was treated with a 35% phosphoric acid gel(Scotchbond Etchant, 3M Espe), rinsed with water, air-dried, and a silane coupling agent (RelyX CeramicPrimer, 3M Espe) was applied. The abutment was etched with the 35% phosphoric acid gel for 15 s, rinsed
with water for 10 s, and blot-dried. Next, two consecutive coats of a proprietary bonding agent (SingleBond Adhesive, 3M Espe) was applied to the abutment, dried for 5 s, and light-cured for 10 s. The RelyX
ARC cement was dispensed, and was spatulated for 10 s. The crown was seated and the marginal area wasexposed to light for 5 s, followed by the removal of excess material (Fig. 3). The luting agent was thenlight-polymerized through the restoration for 40 s per surface (Fig. 4).
The patient entered into a check-up program and oral examination was continued once or twice a year
(Figs. 5-8). After an observation period of 36 months, the restorations are functioning satisfactorily without
fracture, dislodgement, discoloration or gingival recession, although slight occlusal wear as well as matted
facial appearance have been recognized. In addition, wear of the antagonists was not distinct and thepatient was satisfied with the clinical result. Occlusal wear appeared to be comparable between themetallic molar restoration and the premolar jacket crown.

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Int Chin J Dent 2003; 3: 100-104.

1Fig. 1. Abutments after build-up.
Fig. 2. Premolar jacket crown fabricated with the Estenia Composite.

23Fig. 3. Removing the RelyX ARC material after 5 s light exposure.
Fig. 4. Occlusal view after the seating of the restorations.

45Fig. 5. Buccal view 2.5 years after the seating of the restorations.
Fig. 6. Occlusal view after 2.5 years. A slightly frosty appearance can be detected.

6Discussion
The longevity of tooth-colored restorations substantially depends upon the mechanical properties ofrestorative materials and the bonding characteristics of luting agents. A highly loaded composite material(Estenia) was selected for the current premolar restoration on the basis of laboratory evaluation results.1-5
The restoration did demonstrate a favorable clinical course, except for a slight loss of smoothness.

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Int Chin J Dent 2003; 3: 100-104.

78Fig. 7. Radiograph after root canal treatment of the premolar.
Fig. 8. Radiograph after the cementing of the restorations. Outline of the dowel core can be seen
through the jacket crown.
However, the roughened appearance vanished after polishing with a diamond paste used together with arotary felt instrument. In addition, the premolar Estenia restoration did not grind the antagonists during thethree-year observation period. This is probably due to the sufficient polishing performed on the restoration
surface. Suzuki et al.5 reported a remarkable loss of antagonist enamel surface when the Estenia material
was subjected to the three-body wear simulation system. This paper, however, does not examine theinfluence of variations in composite surface characteristics on antagonist wear. The authors speculate that
the Estenia material does not negatively affect the wear behavior of the antagonists so much, as long as theEstenia restoration surface has been properly polished. During the observation period of three years, thesmoothness of the Estenia surface was reduced. Continuous check-up regarding the surface roughness ofEstenia restorations is necessary as compared with the ceramic restoratives.
The surface preparations of adherends as well as the type of luting agent are critical factors for theprognosis of restorations. Due to the considerable amount (more than 90%) of inorganic filler contained in
the Estenia composite, the authors used the RelyX ARC ceramic-to-tooth bonding system for seating thecomposite jacket crown to the abutment. This is based on the fact that the bond strength of the RelyX ARC
system is excellent for bonding both dentin and ceramics.8-13 Although the long-term in vitro bonding
characteristics between the Estenia composite and the RelyX ARC material have not been evaluated, theEstenia jacket crown bonded with the RelyX ARC system is a viable alternative to the conventional jacket
crown as a mandibular premolar tooth-colored restorative.

References
1. Sekiya K, Okamoto A, Fukushima M, Iwaku M. In vivo wear pattern of experimental composite resins containing
different filler components. Dent Mater J 1994; 13: 36-46.
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visible light-cured composite resin veneering materials. J Oral Rehabil 1995; 22: 857-63.
3. Tanoue N, Matsumura H, Atsuta M. Wear and surface roughness of current prosthetic composites after
toothbrush/dentifrice abrasion. J Prosthet Dent 2000; 84: 93-7.

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4. Kawano F, Ohguri T, Ichikawa T, Matsumoto N. Influence of thermal cycles in water on flexural strength oflaboratory-processed composite resin. J Oral Rehabil 2001; 28: 703-7.
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partial denture with a highly filled indirect composite. J Prosthet Dent 2002; 88: 636-9.
7. Braga RR, Cesar PF, Gonzaga CC. Mechanical properties of resin cements with different activation modes. J OralRehabil 2002; 29: 257-62.
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88: 277-84.
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ceramic inlays in MOD class II cavity preparations. Int J Prosthodont 2003; 16: 64-9.
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restorations with a modified resin luting agent. J Prosthet Dent 2003; 89: 381-7.
11. Witzel MF, Braga RR, Singer Jde M, Azevedo CL. Bond strength between polymer resin-based cement andporcelain-dentin surfaces: influence of polymerization mode and early cyclic loading. Int J Prosthodont 2003; 16: 145-9.
12. Mota CS, Demarco FF, Camacho GB, Powers JM. Tensile bond strength of four resin luting agents bonded to bovine
enamel and dentin. J Prosthet Dent 2003; 89: 558-64.
13. Spohr AM, Sobrinho LC, Consani S, Sinhoreti MA, Knowles JC. Influence of surface conditions and silane agent on thebond of resin to IPS Empress 2 ceramic. Int J Prosthodont 2003; 16: 277-82.

Reprint request to:
Dr. Hiroyasu Koizumi
Department of Crown and Bridge Prosthodontics
Nihon University School of Dentistry
1-8-13, Kanda-Surugadai, Chiyoda-ku, Tokyo 101-8310, Japan
FAX: +81-3-3219-8351 E-mail: koizumi@dent.nihon-u.ac.jp
Received on August 1, 2003. Revised on October 21, 2003. Accepted on October 31, 2003.
Copyright ©2003 by the Editorial Council of the International Chinese Journal of Dentistry.

International Chinese Journal of Dentistry 2004 Outstanding Article AwardInternational Chinese Journal of Dentistry announces the third Outstanding Article Award.
Award:A cash prize of US$ 600 and a certificate of commendation are awarded for the most outstanding article published in
the International Chinese Journal of Dentistry.
Criteria:
Original articles, clinical reports, and dental technology articles published in the Journal between issue 1 and issue 4
are considered for the award. The winning article will be selected by a committee on the basis of scientific impact on
the dental professional communities, and interest to the readers. The 2004 Award is sponsored by the International
Chinese Journal of Dentistry and the following award sponsors.
Award Sponsors:
GC Corporation, Tokyo, Japan, http://www.gcdental.co.jp
Kuraray Medical Inc., Tokyo, Japan, http://www.kuraray.co.jp/dental
Shofu Inc., Kyoto, Japan, http://www.shofu.co.jp
Sun Medical Co., Ltd., Moriyama, Japan, http://www.sunmedical.co.jp
Toho Dental Products, Saitama, Japan
Tokuyama Dental Corp., Tokyo, Japan, http://www.tokuyama-dental.co.jp
3M Health Care Limited, Sagamihara, Japan, http://www.3m.com/espe/

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