Ceramic Inlays and Onlays:
Clinical Procedures for Predictable Resul
ALFREDO MEYER FILHO, DDS, MS*
LUIZ CLOVIS CARDOSO VIEIRA, DDS, MS, PHD!
ELITO ARAUJO, DDS, MS,
LUIZ NARCISO BARATIERI, DDS, MS, PHD!
ABSTRACT
‘The use of ceramics as restorative materials has increased substantially in the past two decades.
This trend can be attributed to the greater interest of patients and dentists in this esthetic and
long-lasting material, and to the ability to effectively bond metal-free ceramic restorations to
tooth structure using acid-etch techniques and adhesive cements, The purpose of this article is to
review the pertinent literature on ceramic systems, direct internal buildup materials, and adhesive
cements. Current clinical procedures for the planning, preparation, impression, and bonding of
ceramic inlays and onlays are also briefly reviewed. A representative clinical case is presented,
illustrating the technique,
CLINICAL SIGNIFICANCE
When posterior teeth are weakened owing to the need for wide cavity preparations, the success of
direct resin-based composites is compromised. In these clinical situations, ceramic inlays/onlays
can be used to achieve esthetic, durable, and biologically compatible posterior restorations.
(J Esthet Restor Dent 15:338-352, 2003)
the restoration of posterior ing the porcelain surface with continuous development of ceramic
teeth with tooth-colored mate-
rials is not a new trend in restora-
tive dentistry. Porcelain inlays were
used in the nineteenth century, but
the lack of an adequate adhesive
cementing medium along with the
poor esthetics of those early porce
lains yielded less than optimal
results! In the early 1980s Simonsen
and Calamia reported on the tech-
nique of resin composite adhesion
to porcelain by means of acid etch-
“Graduate student, Department of Operative Dentist
Glinies, Universidade Federal de Santa Catarina, Florin
Professor, Depa
hydrofluoric acid? The strong bond
afforded by this technique allowed
the first adhesive porcelain restora
tions to be made on anterior teeth,
as reported by Horn in 1983. The
use of dental ceramics to restore
posterior teeth was a logical conse-
quence of the success of these first
adhesive porce
addition, the introduction in 1985
in restorations. In
of specific dental ceramics for use
in posterior teeth,* as well as the
tment of Operative Dentistry, Unive
Santa Catarina, Brasil
Professor, Department of Dental Clinics, Universidade Federal de Santa Catarina, Floriandpolis, Santa
Catarina, Bras
JOURNAL OF ESTHETIC
AND RFSTORATIVE DENTISTRY
materials with improved mechani-
cal properties, allowed these mate-
rials to be used free of metal.’
New processing methods of dental
ceramics include fabrication tech-
niques such as the lost wax tech-
nique and centrifugal casting
(castable glass-ceramic), the pres-
sure injection of ceramic ingots
{pressable ceramics), and the
computer-aided design and manu-
and associate professor, Department of Dental
‘polis, Santa Catarina, Brasil
de Federal de Santa Catarina, Florianspolis, facturing (CAD/CAM) of premanu-
These
innovations have resulted in an
factured ceramic blocks
esthetic revolution and a height-
cened interest of dentists and
patients in the use of dental ceram
ics for posterior restorations,
DIRECT VERSUS INDIRECT
RESTORATIONS
Thanks to the development of
improved adhesives and resin-based
restorative systems, resin composites
have become predictably successful
in the restoration of posterior
teeth." However, even with the
demonstrable improvements in
physical and mechanical properties,
the use of resin composites in a
direct technique should be restricted
to selected clinical applications.!"-!3
Posterior teeth weakened owing to
wide mesio-occlusodistal prepara-
tions should ideally be restored
with materials capable of providing
structural support," which cannot
be achieved totally with directly
placed resin composites." In such
ses indirect restorations often are
\dicated owing to their superior
mechanical qualities and improved
contour, anatomy, marginal adapta-
tion, interproximal contact, and
surface texture."©!7 Also, with an
indirect technique, there is less
polymerization shrinkage and, con-
sequently, reduced microleakage."®
Another important criterion when
selecting the appropriate type of
material and restorative technique
is the number of teeth to be
restored.!” For example, in cases
where multiple large restorations
are to be done, particularly in the
same quadrant, it is easier, faster,
and more economic to fabricate
them indirectly
Indirectly made resin-based com-
posite inlays/onlays have achieved a
high level of technologic develop-
ment. This improvement in physical
and mechanical properties has
made choosing between the use of
resin composite or ceramic more
difficult.'62°21 Ceramics possess
distinct advantages when compared
with resin composites. Generally
ceramics exhibit incomparable
esthetics, superior wear resistance,
and exceptional bond strength to
tooth structure when bonded adhe-
sively. Ceramic materials are similar
to tooth structure and best mimic
the natural tooth, allowing poste-
rior teeth with extensive structural
loss to recuperate up t0 100% of
the original rigidity of cuspid:
This strengthening is due primarily
to the reinforcement imparted by
the strong adhesion between etched
ceramic and the tooth structure.
Scheibenbogen and colleagues
evaluated processed resin compos-
ite and ceramic inlays in posterior
teeth.2* The decision to restore
using either of the two materials
was influenced by the size of the
isthmus, Preparations with an isth-
mus width greater than two-thirds
of the intercuspal distance (large
preparations)
re restored with
ceramics. Those with an isthmus
width smaller than two-thirds of
the distance between the cuspid tips
MEYER PILIO ET aL
were restored with resin composite
Notwithstanding this indication in
less favorable situations, ceramic
inlays showed better cli
formance than did composites.2*
INDICATIONS AND
CONTRAINDICATIONS
Ceramic inlays and onlays are
indirect esthetic restorations that
involve part of the clinical crown
of the tooth. Inlays involve occlusal
and proximal tooth surfaces only,
whereas onlays are extended to
involve the cusps either partially or
totally. They are indicated where
esthetics and structural reinforce
ment bee«
primary requisites
and tooth preparation goes beyond
the recommended limits for direct
application of resin composites.
This is particularly true in cases
involving complex restorations ot
‘mesio-ocelusodistal preparations in
which the isthmus width covers half
or more of the distance between
cusp tips.!25 Onlays are also indi-
cated to restore optimal occlusion
in caries-free teeth,
Indications and contraindications
for ceramic inlays and onlays must
consider several factors, such as,
structural integrity of the tooth,
cusp load capacity, and localization
of occlusal contact points. Posterior
adhesive ceramic restorations are
contraindicated for patients with
poor oral hygiene. Teeth exhibiting,
ross wear or having insufficient
dental structure for bonding also
ate contraindicated, as are cases in
which adequate moisture control
NUMBER 6
339 Mo
CERAMIC INLAYS AND ONEAYS: CLIMEAL PROCEDL
cannot be achieved. Teeth needing,
significant color alterations also are
not candidates for ceramic onlays
when optimal esthetics is a requisite
since this degree of color change is
best obtained with all-ceramic
crowns. Teeth requiring conser-
vative classes I oF Il restorations
involving little extension also are
not indicated for ceramic inlays or
‘onlays and should be restored more
conservatively with direct resi
‘composites. The preparation for an
indirect restoration would remove
too much sound tooth structure to
provide the needed divergence.
For patients who exhibit parafune-
tional activity (bruxism), ceramic
restorations should not be consid-
cred at all,425 unless the patient is
willing to use an occlusal bite
guard2* Ifthe patient does not agree
to wear a biteguard, an indirect resin
composite restoration polymerized
in the laboratory would be a better
alternative considering the high inci-
dence of ceramic inlay fracture when
placed in patients who exhibit brux-
ism, A study published in 1994 by
Aberg and colleagues reported that
63.6% of fractured ceramic inlays
occurred in patients with signs of
active bruxism.2”
BASE AND FILLING MATERIALS:
THE INTERNAL NUILDUP
An important factor to be consid
ered when planning an all-ceramic
inlay or onlay is the selection of the
material to be used as a base or
internal buildup, if needed. Bases
are employed in restorative den-
JOURNAL OF ESTHETIC
FOR PREDICTABLE
tistry for several reasons, such as
to protect the pulp and asa filling
material to eliminate internal
undercuts, Wat and Cheung recom-
mend the use of a layer of glass
ionomer cement in vital teeth to
protect the exposed dentin and
minimize the possibility of postop-
erative sensitivity.¥ However, other
authors consider this application
an unnecessary procedure when
an effective adhesive system is,
employed in association with adhe-
In addition, glass
sive cements.
ionomer is not adequate for use as
a substrate for all-ceramic restora
tions owing to its low compressive
strength. Therefore, its use should
preferably be limited to the correc-
tion of small irregularities and
undercuts in the preparation.’!
Because of the brittle nature of
ceramic materials, they must be
bonded to a substrate capable of
supporting functional stress. For
this reason, base materials must
have high compressive strength.
When stress is applied to a system
composed of materials with differ-
ent elastic moduli, the larger part
of stress is absorbed by the material
of greatest rigidity.” Ifthe substrate
has low compressive strength,
fracture of the ceramic restoration
directly supported by that substrate
might occur when the critical ten-
sion limit of this material (0.1% of
flexure) is reached. The compres-
sion load generated on the occlusal
surface is turned into tensile stresses
on the inferior surface of the restora
tion, and if the substrate yields, the
AND RESTORATIVE DENTISTRY
ceramic fails, This failure mechanism
has been confirmed by Tsai and
colleagues in a study conducted to
analyze fracture modalities of glass-
ceramic disks of various thicknesses
supported by dentin-simulating
materials. Results confirmed the
initial hypothesis: when glass-
mic disks are supported by a
| having an elastic modulus
similar to that of dentin (lower than
thar of enamel), the fracture starts
at the inferior surface that is i
tact with the substrate, Scherrer
and de Rijk have observed that the
resistance to fracture offered by a
matei
con-
ceramic restoration became signifi-
cantly increased when the elastic
‘modulus of the support substrate to
which the restoration was attached
ed.™ In other words,
the more flexible the substrate,
also was incre:
the smaller the load necessary to
fracture the ceram
supported by this substrate.
restoration
According to Moscovich and col-
leagues, glass ionomer cements
currently available do not offer the
ideal mechanical properties to act
asa hase for ceramic restorations."
The authors suggest that resin com-
posites should he used as bases
under ceramic restorations owing to
their greater modulus of elasticity.
SELECTION OF THE CERAMIC
sysTEM
Various ceramic systems have been
dey
an effort co improve the physical
and mechanical properties of these
materials. The majority of these
Joped in the past few years in materials are variations of tradi-
tional feldspathic porcelain rein-
forced with the addition of metal
oxides or by induced crystallization.S
After firing, porcelain exhibits one
or more crystalline phases, usuall
made up of small alumina, leucite,
cor mica crystals, embedded in a
noncrystalline amorphous matrix.
‘These small crystals dispersed in the
ceramic structure are responsible
for the enhanced strength of the
‘material; they retard the propaga-
tion of cracks, which usually begi
asa flaw in the material. Unfortu-
nately, although the increased num-
ber of erystals dispersed in the glass
matrix gives it greater strength, it
also lessens the ceramic translu=
ceney. Ceramic materials with an
essentially crystalline structure
such as the In-ceram System®
(Vita Zahnfabrik, Bad Sickingen,
Germany) have greater flexural
strength but are more opaque."”"*
‘They also are acid resistant owing
to their significant crystalline
composition and the small amount
of glass matrix available for
acid etching.
‘The demand for esthetic restora-
tions keeps growing, and consider-
able research has been oriented
toward improving the properties
Of ceramics. To select the ceramic
system best indicated for each
clinical situation, the dentist
should be familiar with the various
types available. Four types of
ceramic systems are now used,
including conventional feldspathic
porcelains (fired ceramic), castable
ceramics, machinable ceramics
(CAD/CAM), and pressable
ceramics (Table 1).
MEYER PILWO ET aL
The criteria for selection of appro-
priate ceramic systems should be
based on a combination of clinical
requirements and material proper-
ties. Three criteria are traditionally
considered: marginal adaptation,
esthetics, and strength.”
Marginal Adaptation
Longevity of ceramic restorations is
largely ed by resistance to
fracture, marginal adaptation, and
wear resistance of the luting agent,
derert
A direct relationship exists between
initial poor marginal adaptation
and dissolution of cement (with
resultant microleakage). Thus, in
selecting a ceramic system one must
consider which will provide the best
adaptation (and smaller marginal
gap) possible. Interestingly,
however, recent studies indicate
shar the ceramic-resin interface is,
VOLUME 15, NUMBER 6, 2003
Mi CERAMIC INLAYS AND ONLAYS: CLINICAL PROCEDURES FOR PREDICTABLE RE
particularly fragile when the cement
is too thin; it has been proposed
that a 50 to 100 pm marginal gap
is ideal to prevent wear of the
marginally exposed resin cement
and to preserve the adhesion.
Marginal adaptation of this magni
tude can be considered excellent for
adhesively cemented ceramic
restorations and can be obtained
with any of the currently used
ceramic systems.!%6 This factor
was confirmed in a study by Aberg
and colleagues.2” No secondary
caries was detected on adhesively
cemented onlays in spite of 46%
of the considered patients being of
high caries risk. The authors attrib-
uted this positive result to shrink:
age and microleakage reduction
afforded by the indirect technique
owing to the fine cement film and
favorable marginal fit of these
ceramic restorations.
Esthetics
Machinable ceramics (CAD/CAM
systems) available as colored pre~
fired blocks make it possible to pro-
duce restorations with satisfactory
esthetics in posterior teet
ever, they require special equipment
and can be quite costly.”
Castable ceramics (Dicor®,
Dentsply/Caulk, Mildford, DE,
USA), supplied in the form of
shaded glass ingots, produce
ceramic restorations that are in
tially made as a glass by the lost
wax technique and centrifugal
casting. They subsequently undergo
JOURNAL OF ESTHETIC
devitrification with a heat treat-
ment (ceramming) to convert them
into a stronger crystalline body
that possesses high translucency.¢
Surface staining is used to obtain
the final shade and characteriza
tion. If there is a need for occlusal
adjustment after inlay/onlay
cementation, these surface stains
can be lost, resulting in compro-
mised esthetics.
The conventional manufacturing
of ceramic restorations by fusing
porcelain in a refractory cast pro-
duces the most esthetic dental
restorations. However, this is a
technique-sensitive procedure that
requires a skilled dentist and techni-
an to produce a high-quality result.
The IPS Empress? system (Ivoclar
Vivadent, Schaan, Liechtenstein)
produces equally esthetic restora-
tions in a simpler way through a
lost-wax technique of fabrication.
‘This simplicity in fabrication is
largely responsible for the resur
gence in popularity of all-ceramic
restorations in recent years.
Strength
Studies conducted with various
ceramic systems point to fracture as
the main cause of ceramic restora-
tion failure. Fracture resistance
of a dental ceramic is one of the
most important factors for success
for inlays/onlays. Fracture resis
tance depends on the ability of the
material to inhibit crack initiation
and propagation. Crack
controlled by the surface condition
tiation is
AND RESTORATIVE DENTISTRY
of the material, whereas resistance
to propagation of the defect is
determined by the inner structure of
the material. Strength tests are
often employed but are highly influ-
enced by the fabrica
the sample and by the methodology
used, and do not always simulate
the clinical mode of failure.’
‘Thompson and colleagues obtained
stress failure resistance values in
jon process of
vivo of approximately half those
reported for in vitro tests with the
same material (Dicor glass:
ceramic).‘” The development of
flaws at the time the ceramic is
processed or when the restoration is
placed in the mouth might reduce
resistance to fracture, meaning
smaller forces would be required to
cause failures.
Fired ceramic restorations present
porosities with the inherent poten-
tial to initiate crack formation as
a result of the sintering process.*
These porosities can be minimized
through restoration fabrication
processes involving casting in place
of sintering.* Even so, cast ceramic
systems such as the Dicor glass-
‘ceramic that require subsequent
ceramming might still experience
porosities as a consequence of this
process. CAD/CAM
ufactured and
tems using pren
precerammed blocks do not have
these fabrication problems.%*
In the IPS Empress system, glass-
ceramic is supplied in the form of
ingots, similarly precerammed and preshaded. The restoration is pro-
duced with the lost-wax technique
and pressure injection of the melted
ceramic. Subsequent heat processes
for surface pigmentation or lamina-
tion do not produce porosities and,
in addition, increase the strength of
this material.°?
Understanding the multiple factors
that interfere with the clinical per-
formance of a ceramic restoration is
important in ensuring its success. In
addition to material properties and
failures induced by restoration fab-
rication, other factors also must be
considered to reduce stress and frac
ture of ceramic restorations. Among,
such factors are the elastic modulus
of the base material, ceramic thick-
ness, cavity preparation design,
cement selection, adhesion proce
dures, and surface polishing."
CLINICAL PROCEDURES
‘Tooth Preparation
Correct tooth preparation for
ceramic inlays and onlays is critical
to achie
184 lasting restoration,
Ceramic restorations are extreme
fragile before adhesion. Conse-
‘quently, the principles guiding this
procedure
for gold restorations.
re different from those
Because of the inherent fragility
exhibited by this material, three pri-
mary requirements are important
when preparing a tooth for ceramic
restorations of this type: (1) avoid:
ance of internal stress concentration
areas, (2) provision for adequate
thickness of ceramic, and (3) creation
of a passive insertion axis, Internal
stress concentrations can be avoided
by eliminating undercuts of the pre-
pared surface and by rounding
internal line angles.6°-45
strength is proportional to its thick-
ness but only up to a certain point,
‘A study has shown that ceramic
Ceramic
thickness > 2 mm increases the
risks of pulp damage (deeper pre-
paration) without significantly
enhancing the restoration fracture
strength." Therefore, a uniform
2.0 mm occlusal thickness is con-
sidered ideal for ceramic inlays and
also for onlays involving functional
cusps.2563 The occlusal prepara-
tion floor must present a shallow
V shape following the anatomy of
that surface.* Axial reduction
allowing a uniform thickness of
1.5 mm for the restoration is suffi-
cient for any of the currently used
ceramic systems. Passive insertion
axis is determined by the inclina-
tion of the preparation walls, which
must be more inclined than those of
gold inlays/onlays.* It is important
to remember that the ceramic
restoration does not bend or give
during the seating for try-in, A
divergence herween opposing walls
of about 10° is sufficient to attain
this requisite without the unneces-
sary removal of sound tooth strue-
ture.’ In addition, cavosurface
angles must be 90°, with the cervi-
cal margin ending in a deep cham-
fer or a butt joint. Occlusal bevels
should be avoided since they reduce
porcelain thickness in a region
where the restoration is subject to
© In cases in
strong occlusal stress.
which the cusps are weakened, the
preparation must cap these cusps to
reduce the risk of postoperative
porcelain or cusp fracture.S6157
Cement Selection and
Bonding Procedures
As already noted, fracture strength is
the most important factor affecting
longevity of ceramic inlayvonlays.
All ceramic restorations luted with
zine phosphate cement are subject
to stress concentrations in localized
areas during function, creating a
fracture potential of the material
‘The use of adhesive cements
pable of adhering tooth structure
and ceramic results in a strongly
bonded restoration that is much
more resistant to fracture.
Hydrofluoric acid is used to selec~
tively dissolve the glass matrix, cre:
ating microporosities around the
leucite crystals. Low-viscosity adhe-
sive resins applied to this con
tioned surface fill these microscopic
areas, creating a strong microme
chanical bond between resin and
porcelain. Silane coupling
agents are adhesion promoters
capable of forming chemical bonds
with organic and inorganic sur-
faces. Bonding to the resin occurs
by an additional polymerization
reaction between methacrylate
‘groups of the matrix resin and the
silane molecule during curing of the
composite. The bond with ceramics
occurs via a condensation reaction
VOLUME 15, NUMBER 6
M3 344
CERAMIC INLAYS AND ONLAYS, CLINEML, PROCEDURES FOR PREDICTABLE
between the silanol group (Si-OH)
of the ceramic surface and the
silanol group of the hydrolyzed
silane molecule, ereating a siloxane
-O-Si) and producing a
water molecule (HzO) byproduct.”
bond (
Silanes also enhance porcelain-resin
bonds by promoting the wetting of
the ceramic surface, thus making
the penetration of the resin into the
microscopic porosities of the acid
conditioned porcelain more com-
) The use of the hydrofluoric
plete
acid and a silane coupling agent
enhances this union and constitutes
the most effective ceramic surface
treatment, allowing maximum
adhesive potential.” This adhe-
sion mechanism associated with the
development of new resin cements,
dental adhesive systems, and
Is has significantly
improved the clinical success of
ceramic inlays/onlays.
Adhesive cements commonly used
for ceramic restorations include
conventional or resin-modified
glass ionomer cements, and dual-
cured or chemically cured res
based cements. Glass ionomer
cements offer some apparent
advantages, such as chemical bond
to enamel and dentin, relative!
low solubility in the oral enviros
ment, and release of fluoride.
However, bond strengths between
glass ionomer cements and acid-
etched ceramics are lower than
those found between resin cements
and ceramics.* Clinical and labora-
tory studies point to a low fracture
strength of ceramic restorations
JOURNAL OF ESTHETIC
cemented with glass ionomer
cements compared with resin
cements, particularly for inlays fab-
ricated with feldspathic porcelain
(fired ceramic); they are therefore
not recommended.”
Resin-modified glass ionomer
cements have been used as an
alternative to conventional glass
ionomer cements because of their
superior mechanical properties.
Recent short-term clinical studies
found the clinical performance of
resin-modified glass ionomer
‘cements to be similar to that of
resin-based cements.’S However,
another study revealed a lower
cohesive strength compared with
that of composi
Regarding fluoride release, itis
resin cements,
important to mention that the
effective period of fluoride release
may be too short to have clinical
importance.”
‘Table 2 summarizes the requisites
of an ideal adhesive cement for
inlays/onlays. If no material can be
found exhibiting the desirable prop-
erties listed in Table 2, the adhesive
cement selection must take into
consideration the most important
properties affecting the specific
clinical situation.”
Resin-based composite cement’s
ability to adhere to multiple sub-
strates, biocompatibility, high
strength, insolubility in the oral
environment, and esthetic potential
make it the best choice for use with
Also, the
ceramic inlays/onlays.
AND RESTORATIVE DENTISTRY
RESULTS
fact that it penetrates microscopic
irregularities such as around
leucite crystals allows it to create a
strong micromechanical bond that
increases fracture resistance of
both tooth and ceramic.2*524?
Resin cements are divided into
three groups: light, chemical, and
dual activated. Light-activated
agents can be used for cementing
indirect restorations if the light cur-
ing time is extended.*! However,
on posterior ceramic restorations,
thickness, color, and opacity level
make polymerization difficult
and, consequently, may negatively
affect the cement microhardness
owing to the limitations in light
penetration.2-*
Dual-cured resin-hased cements are
the most frequently used to cement
ceramic inlays/onlays (Table 3).8°
This preference is explained by the
fact that these materials have the OEM OT
‘Study (| Evalution Period ———Ceramic/Luting Element No, of nlays/Onlays. Fracture (4)
Aberg CH et al?” (1994) 3yr Mirage® (Chameleon Dental 59 34
Products, Kansas City,
KS, USA)Dual RC
Mirage/GIC 59 153
Roulet JF* (1995) 4-82 mo Dicor/Dual RC 116 60
Gladys $ etal (1995) 3yr Cerec/Dual RC 25 00
Qualtrough AJE, Wilson NHE® (1996) 3 yr Mirage/Dual RC 50 160
Fradeani M et aP° (1997) 45 yr IPS Empress/Dual RC 12s 32
Fried! KH et al! (1997) aye Mirage/Dual RC 96 00
Roulet JF” (1997) 6yr Dicor/Dual RC 123 $7
Berg NG, Dérand T°3 (1997) Sye Ceree/Dual RC us 26
Sjogren G et al" (1998) Sye Cerec/Dual RC 33 94
Cerec/Chemical RC 3 00
Fuzzi M, Rappelli G™* (1998) 4 mo-10 yr ‘Microbond (Austenal 183, 06
Dental-Austenal International Inc,
‘Chicago, IL, USA)/Dual RC
Fortune (Williams-Wwoclas,
Amherst, NY, USAYDual RC
‘Van Dijken JWV et al? (1998) yr Mirage/Dual RC 58 SA
‘Mirage/GIC 57 265
Kramer N et al% (1999) Aye IPS Empress/Dual RC 96 42
Studer § et al* (1998) Ty TPS Empress/Dual RC 163 ss
Pallesen U, van Dijken JWV" (2000) 8 yr Cerec/Dual RC 32 94
Molin MK, Karlsson SL?” (2000) Syr Cerec/Dual RC 30 33
Mirage/Dual RC 30, 00
IPS Empress/Dual RC 30 133
GIC = glass ionomer cement, RC = resin composite
capacity to polymerize, even in renting Procedures 4. Internally etch the restoration
areas not totally reached by the cur- Clinical procedures for cementing with 8 10 12% hydrofluoric acid
ing light.8586 Dual-activated luting ceramic inlays/onlays as suggested for I (IPS Empress) to 3 minutes
cements also allow greater working by Ritter and Baratieri include the (feldspathic porcelain), to be
time when compared with the following? followed by an air-water rinse
chemically activated ones, making 5. Apply a silane coupling agent
it easier to remove cement excesses 1. Test the restoration fi in the to the ceramic etched surface,
before complete polymerization mouth. following the manufacturer's
occurs. In addition, they present 2. Ensure complete field isolation instructions.
faster dental adhesion strength, and moisture control (use of a6, Exch the preparation with
notwithstanding that masticatory
efforts should not be applied to the
restoration soon after cementation.”
rubber dam is preferable)
Clean the preparation
completely
phosphoric acid for 15 seconds,
Rinse with an air-water spray
and remove excess water with a 346
CERAMIC INLAYS AND ONLAYS: CLINICAL PROCEDURES FOR PREDICTABLE
damp cotton pellet leaving the
substrate slightly moist.
Apply a thin layer of the adhe
sive system to both substrates
(restoration and preparation) in
accordance with instructions
given by th
the r
facturers of
in cement,
8. Apply the resin-based cement to
both the restoration and the
prepa
with slight pressure.
ation; seat the restoration
9, Remove gross excesses of
cement from the margins with
a microbrush.
10. Cure the cement for 60 seconds
in each direction (facial, lingual,
and occlusal) using a light-curing
unit with a minimum power of
450 mWiem2. A clear glycerin
based gel may be applied to all
accessible margins to prevent
the occurrence of the oxygen:
inhibited resin layer.
LL. Remove res nt,
using either a probe or a no. 12
blade held in a Bard Parker sur-
ial excess c
gical handle,
Occlusal Adjustment and Polishing
Ceramic restorations frequently
‘occlusal adjustments following.
cementation, Unfortunately, this,
step introduces minor defects on
the restoration surface, increasing
the abrasion potential against
opposing tooth and introducing
flaws to the ceramic. Final polish-
ing can be achieved with intraoral
instrumentation using diamond-
impregnated finishing points and
polishing gels.%¥ Adding glaze to
JOURNAL OF ESTHETIC
surfaces has been found to make
the restoration more resistant to
fracture; however, this step is not
possible when occlusal adjustment
must be made.‘
CASE REPORT
This clinical case illustrates the
potential of the described inlay/onlay
ceramic techniques in ge
rating a
natural-looking restoration ina
compromised posterior tooth. The
patient was a young female with a
large mesio-ocelusodistal amalgam
restoration in her mandibular left
first molar. An occlusal amalgam
restoration was present in the left
second molar (Figure 1). After
placement of a rubber dam, the
amalgam restorations and carious
tissues were removed (Figure 2).
Structural reinforcement of the first
molar was a primary requisite; the
selection was made for a ceramic
inlay. To eliminate internal under
cuts, a hybrid resin composite
(Z250®, 3M ESPE, St. Paul, MN,
USA) was selected and applied in
increments (Figure 3). After internal
buildup was placed, the cavity was
prepared to the proper cavity form
(Figure 4). Impressions were made
Figure 1. Unsatisfactory large mesio-ocelusodistal amalgam
restoration on the mandibular left first molar; an occlusal
amalgam restoration is present on the second molar.
Figure 2. A rubber dam is installed, and
the amalgam restoration and car
tissue are removed.
Figure 3. The selected hybrid resin is
us applied in increments.
AND RESTORATIVE DENTISTRY with silicone material (Express®,
and a direct provisional
restoration (Clip F
any) was placed while
the definitive restoration was fabri:
cated in the laboratory. The tempo:
rary restoration was cemented with
a eugenol-free temporary cement
(TempBond NE
Orange, CA, USA).
Two weeks later the ceramic inlay
IPS Empress) was received from
the technician. The restoration was
carefully positioned to check mai
nal adaptati¢
shape, and shade,
After placement of the rubber dam,
cementing procedures were initiated,
The ceramic surface to be bonded
was conditioned with 9.5% buffer
hydrofluoric acid (Porcelain Etch
Ultradent Products, Provoh, UT,
USA) for 1 minute, rinsed with
water, and air dried. A silane
coupling agent (Rely X
4 ESPE
Ceramic
. Kerr Corporation,
1 minisponge, allowed to evaporate
for 3 minutes, and air dried for 30
seconds, Figure 5 shows the inlay
before and after hydrofluoric acid
etching, Note the ground glass
appearance produced by hydrofluo
ric acid etching of the IPS Empress
ceramic surface
In preparation for cementation, the
cavity was cleaned (Figure 6) and
the enamel and dentin were etched
with a 35% phosphoric acid gel for
15 seconds, rinsed with water for
20 seconds, and blot dried with a
moist cotton pellet (Figure 7)
3M ESPE
strates with a microbrush (Figure 8}
and gently air dried for 5 seconds.
preparation and light cured for
10 seconds € 9). A dual-cured X ARC®, 3M
ESPE) was used (Figure 10)
before occlusal adjustments is pre
sented in Figure 11. Figure 12
shows the restoration at a 1-month
follow-up appointment. A direct
resin-based composite restoration
was performed in the mandibular
Figure 6. A rubber dam
econd molar.
Considering patients’ growing,
demands for esthetic restorations,
he dentist of the new millennium
should be aware of the need for a
biomimetic” restorative material
such as dental ceramics. Restorative
materials of this type are bioc¢
patible, capable of resisting occlusal
alternative for restoring posterior
10, Dual-cured resin cement is used as th Figure 12. lMlustrated is the restoration at the I-month
follow-up appointment. Note also a direct resin-based
‘composite restoration in the mandibular left second molar
DISCLOSURE AND
ACKNOWLEDGMENT
The authors thank Edson Araijo,
DDS, MS, for assistance in the
operatory procedures shown here,
Sérgio Arajo, CDT, for the use of
IPS Empress, and André Ritter, DDS,
MS, and Harald Heymann, DDS,
MEd, for their editorial assistance.
The authors do not have any finan:
cial interest in any of the materials
discussed in the manuscript.
REFERENCES
1, Jones DW. Development of dental cera
ies. An historal perspective. Dent Clin
North Am 1985; 29:621-644,
Simonsen RJ, Calamia JR. Tensile bond
strength of etched porcelain, Dent Res
1983, 62:297, (Aber
3. Horn H, Porcelain laminate veneers
bonded to etched enamel. Dent Clin North
Amv 1983; 27:671-686,
4. Nasedkin JN, Porcelain posterior resin:
boned restorations: curent perspectives
con esthetic serorative dentistry: part I}
Can Dent Assoc 1988; 5449956,
5. Van Dijken JWV. Alleramic restorations
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