Ceramic Inlavs and Onlavs:

Clinical Procedures for Predictable Results

J

A L F R E D 0 M E Y E R F I L H O , DDS, MS'
L U I Z C L O V I S C A R D O S O VIEIRA, DDS, MS, P H D ~
6 L I T O A R A U J O , DDS, MS, PHD*
L U I Z N A R C I S O BARATIERI, DDS, MS, P H D ~

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.

v Esthet Restor Dent 15:338-352,2003)

T"

e restoration of posterior
teeth with tooth-colored materials is not a new trend in restorative 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 porcelains yielded less than optimal
resu1ts.l In the early 1980s Simonsen
and Calamia reported on the technique of resin composite adhesion
to porcelain by means of acid etch-

ing the porcelain surface with

hydrofluoric acid.2 The strong bond
afforded by this technique allowed
the first adhesive porcelain restorations to be made on anterior teeth,
as reported by Horn in 1983.3The
use of dental ceramics to restore
posterior teeth was a logical consequence of the success of these first
adhesive porcelain restorations. In
addition, the introduction in 1985
of specific dental ceramics for use
in posterior teeth: as well as the

continuous development of ceramic

materials with improved mechanical properties, allowed these materials to be used free of metal.5
New processing methods of dental
ceramics include fabrication techniques such as the lost wax technique and centrifugal casting
(castable glass-ceramic), the pressure injection of ceramic ingots
(pressable ceramics), and the
computer-aided design and manu-

*Graduate student, Department o f Operative Dentistry, and associate professor, Department of Dental
Clinics, Universidade Federal de Santa Catarina, Floriandpolis, Santa Catarina, Brazil
f Professor, Department of Operative Dentistry, Universidade Federal de Santa Catarina, Floriantjpolis,
Santa Catarina, Brazil
$Professor, Department o f Dental Clinics, Universidade Federal de Santa Catarina, Floriandpolis, Santa
Catarina, Brazil
338

J O U R N A L OF E S T H E T I C A N D RESTORATIVE D E N T I S T R Y

M E Y E R F I L H O ET A I ,

facturing (CAD/CAM) of premanufactured ceramic b l o ~ k s .These

~,~
innovations have resulted in an
esthetic revolution and a heightened interest of dentists and
patients in the use of dental ceramics for posterior restorations.
DIRECT VERSUS INDIRECT
RESTORATIONS

are to be done, particularly in the

same quadrant, it is easier, faster,
and more economic to fabricate
them indirectly.

were restored with resin composite.

Notwithstanding this indication in
less favorable situations, ceramic
inlays showed better clinical performance than did composite^.^^

Indirectly made resin-based composite inlays/onlays have achieved a INDICATIONS AND

CONTRAINDICATIONS
high level of technologic development. This improvement in physical Ceramic inlays and onlays are
indirect esthetic restorations that
and mechanical properties has
involve part of the clinical crown
made choosing between the use of
of
the tooth. Inlays involve occlusal
resin composite or ceramic more
and proximal tooth surfaces only,
difficult.16,20,21 Ceramics possess
whereas
onlays are extended to
distinct advantages when compared
involve the cusps either partially or
with resin composites. Generally
totally. They are indicated where
ceramics exhibit incomparable
esthetics and structural reinforceesthetics, superior wear resistance,
ment become primary requisites
and exceptional bond strength to
tooth structure when bonded adhe- and tooth preparation goes beyond
sively. Ceramic materials are similar the recommended limits for direct
application of resin composites.
to tooth structure and best mimic
This is particularly true in cases
the natural tooth, allowing posteinvolving complex restorations or
rior teeth with extensive structural
mesio-occlusodistal preparations in
loss to recuperate up to 100% of
the original rigidity of c ~ s p i d s . ~ ~which
> ~ ~the isthmus width covers half
or more of the distance between
This strengthening is due primarily
cusp
Onlays are also indito the reinforcement imparted by
the strong adhesion between etched cated to restore optimal occlusion
in caries-free teeth.26
ceramic and the tooth structure.

Thanks to the development of

improved adhesives and resin-based
restorative systems, resin composites
have become predictably successful
in the restoration of posterior
teeth.*-1 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 application^.^^-^^
Posterior teeth weakened owing to
wide mesio-occlusodistal preparations should ideally be restored
with materials capable of providing
structural support,14 which cannot
be achieved totally with directly
placed resin composites.15 In such
cases indirect restorations often are
indicated owing to their superior
mechanical qualities and improved
Scheibenbogen and colleagues
contour, anatomy, marginal adapta- evaluated processed resin compostion, interproximal contact, and
ite and ceramic inlays in posterior
surface t e x t ~ r e . ~Also,
~ J ~with an
teeth.24 The decision to restore
indirect technique, there is less
using either of the two materials
polymerization shrinkage and, con- was influenced by the size of the
sequently, reduced microleakage. l8
isthmus. Preparations with an isthAnother important criterion when
mus width greater than two-thirds
selecting the appropriate type of
of the intercuspal distance (large
material and restorative technique
preparations) were restored with
is the number of teeth to be
ceramics. Those with an isthmus
r e ~ t 0 r e d . lFor
~ example, in cases
width smaller than two-thirds of
the distance between the cuspid tips
where multiple large restorations

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
gross wear or having insufficient
dental structure for bonding also
are contraindicated, as are cases in
which adequate moisture control

V O L U M E 15, N U M B E R 6 , 2 0 0 3

339

CERAMIC I N L A Y S A N D O N L A Y S : C L I N I C A L P R O C E D I J R E S FOR P R E D I C T A B L E R E S U L T S

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.25Teeth requiring conservative classes I or I1 restorations
involving little extension also are
not indicated for ceramic inlays or
onlays and should be restored more
conservatively with direct resin
composites. The preparation for an
indirect restoration would remove
too much sound tooth structure to
provide the needed divergence.
For patients who exhibit parafunctional activity (bruxism), ceramic
restorations should not be considered at
unless the patient is
willing to use an occlusal biteguard.25If the 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 incidence of ceramic inlay fracture when
placed in patients who exhibit bruxism. A study published in 1994 by
Aberg and colleagues reported that
63.6% of fractured ceramic inlays
occurred in patients with signs of
active b r ~ x i s m . ~ ~
BASE A N D F I L L I N G M A T E R I A L S :
T H E INTERNAL BUILDUP

An important factor to be considered 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-

340

tistry for several reasons, such as

to protect the pulp and as a filling
material to eliminate internal
undercuts. Mat and Cheung recommend the use of a layer of glass
ionomer cement in vital teeth to
protect the exposed dentin and
minimize the possibility of postoperative sensitivity.28However, other
authors consider this application
an unnecessary procedure when
an effective adhesive system is
employed in association with adhesive cement^.^^.^^ In addition, glass
ionomer is not adequate for use as
a substrate for all-ceramic restorations owing to its low compressive
strength. Therefore, its use should
preferably be limited to the correction of small irregularities and
undercuts in the p r e p a r a t i ~ n . ~ ~
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 different elastic moduli, the larger part
of stress is absorbed by the material
of greatest rigidity.32If the substrate
has low compressive strength,
fracture of the ceramic restoration
directly supported by that substrate
might occur when the critical tension limit of this material (0.1% of
flexure) is reached. The compression load generated on the occlusal
surface is turned into tensile stresses
on the inferior surface of the restoration, and if the substrate yields, the

JOURNAL OF ESTHETIC A N D RESTORATIVE DENTISTRY

ceramic fails. This failure mechanism

has been confirmed by Tsai and
colleagues in a study conducted to
analyze fracture modalities of glassceramic disks of various thicknesses
supported by dentin-simulating
materials.33 Results confirmed the
initial hypothesis: when glassceramic disks are supported by a
material having an elastic modulus
similar to that of dentin (lower than
that of enamel), the fracture starts
at the inferior surface that is in contact with the substrate. Scherrer
and de Rijk have observed that the
resistance to fracture offered by a
ceramic restoration became significantly increased when the elastic
modulus of the support substrate to
which the restoration was attached
also was increased.34In other words,
the more flexible the substrate,
the smaller the load necessary to
fracture the ceramic restoration
supported by this substrate.
According to Moscovich and colleagues, glass ionomer cements
currently available do not offer the
ideal mechanical properties to act
as a base for ceramic restoration^.^^
The authors suggest that resin composites should be used as bases
under ceramic restorations owing to
their greater modulus of elasticity.
SELECTION OF T H E CERAMIC
SYSTEM

Various ceramic systems have been

developed in the past few years in
an effort to improve the physical
and mechanical properties of these
materials. The majority of these

M E Y E R FILHO E T A L

materials are variations of tradiGermany) have greater flexural

The criteria for selection of approtional feldspathic porcelain reinstrength but are more 0paque.~~33~ priate ceramic systems should be
forced with the addition of metal
They also are acid resistant owing
based on a combination of clinical
oxides or by induced cry~tallization.~to their significant crystalline
requirements and material properAfter firing, porcelain exhibits one
composition and the small amount
ties. Three criteria are traditionally
or more crystalline phases, usually
of glass matrix available for
considered: marginal adaptation,
made up of small alumina, leucite,
acid etching5
esthetics, and ~ t r e n g t h . ~
or mica crystals, embedded in a
noncrystalline amorphous matrix.
The demand for esthetic restoraMarginal Adaptation
These small crystals dispersed in the tions keeps growing, and consider- Longevity of ceramic restorations is
able research has been oriented
ceramic structure are responsible
largely determined by resistance to
for the enhanced strength of the
toward improving the properties
fracture, marginal adaptation, and
material; they retard the propagaof ceramics. To select the ceramic
wear resistance of the luting agent.
tion of cracks, which usually begin
system best indicated for each
A direct relationship exists between
as a flaw in the material.36 Unfortu- clinical situation, the dentist
initial poor marginal adaptation
nately, although the increased num- should be familiar with the various and dissolution of cement (with
ber of crystals dispersed in the glass types available. Four types of
resultant microleakage). Thus, in
matrix gives it greater strength, it
ceramic systems are now used,
selecting a ceramic system one must
also lessens the ceramic transluincluding conventional feldspathic
consider which will provide the best
cency. Ceramic materials with an
porcelains (fired ceramic), castable adaptation (and smaller marginal
essentially crystalline structure
ceramics, machinable ceramics
gap) possible.3942 Interestingly,
such as the In-ceram System@
(CAD/CAM), and pressable
however, recent studies indicate
(Vita Zahnfabrik, Bad Sackingen,
ceramics (Table 1).
that the ceramic-resin interface is
TABLE 1. ALL-CERAMICS SYSTEM CLASSIFICATION TO PRODUCE INLAYS AND ONLAYS.

lechniquea

Fired ceramic

Procedums

Layering technique; restoration is

built up on refractory die using
powder-water slurry

Examples

TYW

Optec HSP@(Jeneriflentron,
Wallingford, CT, USA)

Leucite-reinforced
feldspathic porcelain

Duceran LFC@(Degussa,
Bloomfield, CT, USA)

Hydromineral low-fusing
porcelain

Castable
ceramic

A glass made by lost-wax technique

and centrifugal casting, subsequently
heat treated under controlled
crystallization (ceramming)

Dicor (Dentsply)

Mica-reinforcedglass
ceramic

Machinable
ceramic

Milling ceramic ingot by computer

control

Cerec@Vitablocs Mark I and II

(Vident, Brea, CA, USA)
Dicor MGC@(Dentsply)

Feldspathic porcelain

Pressable
ceramic

Pressing molten ceramic into a lost

wax mold

Mica-reinforced
feldspathic glass ceramic

Optec O P P UeneridPentron)
IPS Empress

Leucite-reinforced
feidspathic porcelain
Leucite-reinforced
feidspathic porcelain

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341

CERAMIC I N L A Y S A N D O N L A Y S : C L I N I C A L P R O C E D L T R E S F O R P R E D I C T A B L E R E S U L T S

particularly fragile when the cement devitrification with a heat treatment (ceramming) to convert them
is too thin; it has been proposed
into a stronger crystalline body
that a 50 to 100 pm marginal gap
that possesses high translucency.6
is ideal to prevent wear of the
Surface staining is used to obtain
marginally exposed resin cement
and to preserve the a d h e ~ i o n . ~ ~ >the
~ ~final shade and characterization. If there is a need for occlusal
Marginal adaptation of this magnitude can be considered excellent for adjustment after inlay/onlay
cementation, these surface stains
adhesively cemented ceramic
can be lost, resulting in comprorestorations and can be obtained
mised esthetics.
with any of the currently used
ceramic system^.^^^^^ This factor
The conventional manufacturing
was confirmed in a study by Aberg
of ceramic restorations by fusing
and colleague^.^^ No secondary
porcelain in a refractory cast procaries was detected on adhesively
duces the most esthetic dental
cemented onlays in spite of 46%
restorations. However, this is a
of the considered patients being of
high caries risk. The authors attrib- technique-sensitive procedure that
requires a skilled dentist and techniuted this positive result to shrinkcian to produce a high-quality result.
age and microleakage reduction
The IPS Empress@system (Ivoclar
afforded by the indirect technique
Vivadent, Schaan, Liechtenstein)
owing to the fine cement film and
produces equally esthetic restorafavorable marginal fit of these
tions in a simpler way through a
ceramic restorations.
lost-wax technique of fabrication.
This simplicity in fabrication is
Esthetics
largely responsible for the resurMachinable ceramics (CAD/CAM
gence in popularity of all-ceramic
systems) available as colored prefired blocks make it possible to pro- restorations in recent years.
duce restorations with satisfactory
Strength
esthetics in posterior teeth; however, they require special equipment Studies conducted with various
ceramic systems point to fracture as
and can be quite ~ o s t l y . 4 ~
the main cause of ceramic restoration f a i l ~ r e . Fracture
~ ~ - ~ ~ resistance
Castable ceramics (Dicor@,
Dentsply/Caulk, Mildford, DE,
of a dental ceramic is one of the
USA), supplied in the form of
most important factors for success
for inlays/onlays. Fracture resisshaded glass ingots, produce
ceramic restorations that are initance depends on the ability of the
material to inhibit crack initiation
tially made as a glass by the lostand propagation. Crack initiation is
wax technique and centrifugal
casting. They subsequently undergo controlled by the surface condition

342

JOURNAL OF ESTHETIC A N D RESTORATIVE DENTISTRY

of the material, whereas resistance

to propagation of the defect is
determined by the inner structure of
the materiaLs4 Strength tests are
often employed but are highly influenced by the fabrication process of
the sample and by the methodology
used, and do not always simulate
the clinical mode of f a i l ~ r e . ~ ~ . ~ ~
Thompson and colleagues obtained
stress failure resistance values in
vivo of approximately half those
reported for in vitro tests with the
same material (Dicor glassceramic).57The 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 potential to initiate crack formation as
a result of the sintering process.6
These porosities can be minimized
through restoration fabrication
processes involving casting in place
of ~intering.~
Even so, cast ceramic
systems such as the Dicor glassceramic that require subsequent
ceramming might still experience
porosities as a consequence of this
p r o c e ~ sCAD/CAM
.~
ceramic systems using premanufactured and
precerammed blocks do not have
these fabrication problems.58
In the IPS Empress system, glassceramic is supplied in the form of
ingots, similarly precerammed and

M E Y E R F I L H O ET AL

preshaded. The restoration is produced with the lost-wax technique

and pressure injection of the melted
ceramic. Subsequent heat processes
for surface pigmentation or lamination do not produce porosities and,
in addition, increase the strength of
this material.s9
Understanding the multiple factors
that interfere with the clinical performance of a ceramic restoration is
important in ensuring its success. In
addition to material properties and
failures induced by restoration fabrication, other factors also must be
considered to reduce stress and fracture of ceramic restorations. Among
such factors are the elastic modulus
of the base material, ceramic thickness, cavity preparation design,
cement selection, adhesion procedures, and surface polishing.60
CLINICAL PROCEDURES

Tooth Preparation
Correct tooth preparation for
ceramic inlays and onlays is critical
to achieving a lasting restoration.
Ceramic restorations are extremely
fragile before adhesion. Consequently, the principles guiding this
procedure are different from those
for gold restorations.
Because of the inherent fragility
exhibited by this material, three primary requirements are important
when preparing a tooth for ceramic
restorations of this type: (1) avoidance 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 prepared surface and by rounding
internal line a n g l e ~ . ~ OCeramic
-~~
strength is proportional to its thickness but only up to a certain point.
A study has shown that ceramic
thickness > 2 mm increases the
risks of pulp damage (deeper preparation) without significantly
enhancing the restoration fracture
strength.62 Therefore, a uniform
2.0 mm occlusal thickness is considered ideal for ceramic inlays and
also for onlays involving functional
cusps.25>60-63
The occlusal preparation floor must present a shallow
V shape following the anatomy of
that surface.64Axial reduction
allowing a uniform thickness of
1.5 mm for the restoration is sufficient for any of the currently used
ceramic systems.65 Passive insertion
axis is determined by the inclination of the preparation walls, which
must be more inclined than those of
gold inlay~/onlays.~~
It is important
to remember that the ceramic
restoration does not bend or give
during the seating for try-in. A
divergence between opposing walls
of about 10" is sufficient to attain
this requisite without the unnecessary removal of sound tooth struct ~ r eIn. addition,
~ ~
cavosurface
angles must be 90,with the cervical margin ending in a deep chamfer or a butt joint. Occlusal bevels
should be avoided since they reduce
porcelain thickness in a region

where the restoration is subject to

strong occlusal stress.66In cases in
which the cusps are weakened, the
preparation must cap these cusps to
reduce the risk of postoperative
porcelain or cusp fra~ture.60361,~'
Cement Selection and
Bonding Procedures
As already noted, fracture strength is
the most important factor affecting
longevity of ceramic inlays/onlays.
All ceramic restorations luted with
zinc phosphate cement are subject
to stress concentrations in localized
areas during function, creating a
fracture potential of the material.
The use of adhesive cements capable of adhering tooth structure
and ceramic results in a strongly
bonded restoration that is much
more resistant to fracture.
Hydrofluoric acid is used to selectively dissolve the glass matrix, creating microporosities around the
leucite crystals. Low-viscosity adhesive resins applied to this conditioned surface fill these microscopic
areas, creating a strong micromechanical bond between resin and
p o r ~ e l a i n . 3Silane
~ > ~ ~coupling
agents are adhesion promoters
capable of forming chemical bonds
with organic and inorganic surfaces. 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 , 2003

343

CERAMIC I N L A Y S A N D O N L A Y S : C L I N t C A L P R O C E D U R E S FOR P R E D I C T A B L E R E S U L T S

fact that it penetrates microscopic

cemented with glass ionomer
between the silanol group (Si-OH)
irregularities
such as around
cements compared with resin
of the ceramic surface and the
cements, particularly for inlays fab- leucite crystals allows it to create a
silanol group of the hydrolyzed
strong micromechanical bond that
ricated with feldspathic porcelain
silane molecule, creating a siloxane
increases fracture resistance of
(fired ceramic); they are therefore
bond (Si-0-Si)and producing a
, ~ ~tooth and
water molecule (H20) b y p r ~ d u c t . ~ not
~ r e ~ o m m e n d e d . ~ ~ , ~ ~ , ~ ~both
Silanes also enhance porcelain-resin
Resin cements are divided into
Resin-modified glass ionomer
bonds by promoting the wetting of
three groups: light, chemical, and
cements have been used as an
the ceramic surface, thus making
dual activated. Light-activated
the penetration of the resin into the alternative to conventional glass
agents can be used for cementing
ionomer cements because of their
microscopic porosities of the acidindirect restorations if the light cursuperior mechanical properties.
conditioned porcelain more coming time is extended.81 However,
Recent short-term clinical studies
~lete.~O
The use of the hydrofluoric
on posterior ceramic restorations,
found the clinical performance of
acid and a silane coupling agent
thickness, color, and opacity level
enhances this union and constitutes resin-modified glass ionomer
make polymerization difficult
cements to be similar to that of
the most effective ceramic surface
and, consequently, may negatively
resin-based
However,
treatment, allowing maximum
affect the cement microhardness
another study revealed a lower
adhesive p ~ t e n t i a l . ~ OThis
- ~ ~adheowing to the limitations in light
sion mechanism associated with the cohesive strength compared with
penetrati~n.~~-~~
that of composite resin cements.76
development of new resin cements,
Regarding fluoride release, it is
dental adhesive systems, and
Dual-cured resin-based cements are
important to mention that the
ceramic materials has significantly
the most frequently used to cement
effective period of fluoride release
improved the clinical success of
ceramic inlayslonlays (Table 3).80
may be too short to have clinical
ceramic inlays/onlays.
This preference is explained by the
imp~rtance.~~
fact that these materials have the
Adhesive cements commonly used
Table 2 summarizes the requisites
for ceramic restorations include
of an ideal adhesive cement for
conventional or resin-modified
TABLE 2. REQUISITES OF AN IDEAL
LUTING CEMENT.
inlays/onlays. If no material can be
glass ionomer cements, and dualfound exhibiting the desirable propcured or chemically cured resinAdhesion to tooth structure and to
the restorative material
erties listed in Table 2, the adhesive
based cements. Glass ionomer
cement selection must take into
Sufficient resistance not to be
cements offer some apparent
dislodged by functional loads
consideration
the
most
important
advantages, such as chemical bond
Adequate film thickness
properties affecting the specific
to enamel and dentin, relatively
Insolubility in oral fluids
clinical
~ituation.'~
low solubility in the oral environment, and release of fluoride.27
Optical properties similar to those
of dental tissues
Resin-based
composite
cement's
However, bond strengths between
ability to adhere to multiple subAdequate viscosity
glass ionomer cements and acidstrates,
biocompatibility,
high
etched ceramics are lower than
Biocompatibdity
strength, insolubility in the oral
those found between resin cements
Anticariogenic potential
and ceramics.53Clinical and labora- environment, and esthetic potential
Easy to handle
make it the best choice for use with
tory studies point to a low fracture
Adapted from Cnrdash HS a al."'
ceramic inlay don lay^.^^ Also, the
strength of ceramic restorations

344

J O U R N A L OF E S T H E T I C A N D R E S T O R A T I V E D E N T I S T R Y

MEYER F I L H O ET A L

T A B L E 3 . F R A C T U R E I N D E X FOR C E R A M I C I N L A Y S A N D O N L A Y S .
~

S t W (Yd

No.of InlayslOnlayr Fracture (%)

EvaluationPerlod

CemmWLutIng Element

3 Y'

Mirage@(Chameleon Dental
Products, Kansas City,
KS, USA)/Dual RC
MiragelGIC
DicorDual RC
CeredDual RC
Miragemual RC
IPS EmpresdDual RC
Mirage/Dual RC
Dicor/Dual RC
CeredDual RC
CeredDual RC
CeredChemical RC
Microbond (Austenal
Dental-Austenal International Inc,
Chicago, IL, USA)/Dual RC
Fortune (Williams-Ivoclar,
Amherst, NY, USA)/Dual RC
MiragefDual RC
MiragdGIC
IPS EmpresdDual RC
IPS EmpresdDual RC
CereJDual RC
CeredDual RC
MiragefDual RC
IPS EmpresdDual RC

Aberg CH et aIz7(1994)

Roulet JF" (1995)

Gladys S et a139( 1 995)
Qualtrough AJE, Wilson NHF49(1996)
Fradeani M et also (1997)
Fried1 KH et aI9l (1997)
Roulet Jp2
(1997)
Berg NG, DCrand T 93 (1997)
Sjogren G et a15' (1998)

4-82 mo
3 Yr
3 Y'
4.5 yr
4 Yr
6 Yr
5 Yr
5 'Y

Fuzzi M, Rappelli G9' (1998)

4 mo-10 yr

Van Dijken JWV et alSZ(1998)

6 Yr

Kramer N et
(1999)
Studer S et
(1998)
Pallesen U, van Dijken JWVs3(2000)
Molin MK, Karlsson SL9' (2000)

4 Yr
7 Yr
8 Yr
5 Y'

59

3.4

59
116
2s

15.3

so
125
96
123

115
33
33
183

58
57
96
163
32
30
30
30

6.0
0.0
16.0
3.2
0.0
5.7
2.6
9.1
0.0
0.6

5.1
26.5
4.2
5.5
9.4
3.3
0.0

13.3

CIC = glass ionomer cement; RC = resin composite.

capacity to polymerize, even in

areas not totally reached by the curing light.85,86Dual-activated luting
cements also allow greater working
time when compared with the
chemically activated ones, making
it easier to remove cement excesses
before complete polymerization
occurs. In addition, they present
faster dental adhesion strength,
notwithstanding that masticatory
efforts should not be applied to the
restoration soon after ~ementation.~'

Cementing Procedures
Clinical procedures for cementing
ceramic inlays/onlays as suggested
by Ritter and Baratieri include the
foll~wing~~:

1. Test the restoration fit in the

mouth.
2. Ensure complete field isolation
and moisture control (use of a
rubber dam is preferable).
3 . Clean the preparation
completely.

4. Internally etch the restoration

with 8 to 12% hydrofluoric acid
for 1 (IPS Empress) to 3 minutes
(feldspathic porcelain), to be
followed by an air-water rinse.
5. Apply a silane coupling agent
to the ceramic etched surface,
following the manufacturer's
instructions.
6. Etch the preparation with 35%
phosphoric acid for 15 seconds.
Rinse with an air-water spray
and remove excess water with a

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CERAMIC INLAYS A N D ONLAYS: C L I N I C A L P R O C E D U R E S FOR P R E D I C T A B L E R E S U L T S

damp cotton pellet leaving the

substrate slightly moist.
7. Apply a thin layer of the adhesive system to both substrates
(restoration and preparation) in
accordance with instructions
given by the manufacturers of
the resin cement.
8. Apply the resin-based cement to
both the restoration and the
preparation; seat the restoration
with slight pressure.
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 mW/cm2. A clear glycerinbased gel may be applied to all
accessible margins to prevent
the occurrence of the oxygeninhibited resin layer.
11. Remove residual excess cement,
using either a probe or a no. 12
blade held in a Bard Parker surgical handle.
Occlusal Adjustment and Polishing
Ceramic restorations frequently
need 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 polishing can be achieved with intraoral
instrumentation using diamondimpregnated finishing points and
uolishing
gels.88Addine
glaze to
""
""

346

surfaces has been found to make

the restoration. more resistant to
fracture; however, this step is not
possible when occlusal adjustment
must be made.89
CASE R E P O R T

This clinical case illustrates the

potential of the described inlay/onlay
ceramic techniques in generating a
natural-looking restoration in a
compromised posterior tooth. The
patient was a young female with a
large mesio-occlusodistal 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 undercuts, 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-occlusodistal 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 carious
tissue are removed.

J O U R N A L OF ESTHETIC A N D RESTORATIVE DENTISTRY

Figure 3. The selected hybrid resin is

applied in increments.

MEYER FILHO ET A L

the definitive restoration was fabricated in the laboratory. The temporary restoration was cemented with
a eugenol-free temporary cement
(TempBond NE@,Kerr Corporation,
Orange, CA, USA).

Figure 4. Tooth preparation is performed with a diamond bur.

with silicone material (Express@,

3M ESPE), and a direct provisional
Voco, Cuxrestoration (Clip P,
haven, Germany) was placed while

Two weeks later the ceramic inlay

(IPS Empress) was received from
the technician. The restoration was
carefully positioned to check marginal adaptation, shape, and shade,
with completely satisfactory results.
After placement of the rubber dam,
cementing procedures were initiated.
The ceramic surface to be bonded
was conditioned with 9.5% buffered
hydrofluoric acid (Porcelain Etch,
Ultradent Products, Provoh, UT,
USA) for 1 minute, rinsed with
water, and air dried. A silanecoupling agent (Rely X@Ceramic
Primer, 3M ESPE) was applied with

a 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 hydrofluoric 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).
SingleBond* (3M ESPE) was
applied in two coats on both substrates with a microbrush (Figure 8)
and gently air dried for 5 seconds.
The adhesive was applied to the
preparation and light cured for
10 seconds (Figure 9). A dual-cured

Figure 5. A, The ceramic inlay is prepared for cementation. B, The internal ceramic surface is conditioned with 9.5% buffered
hydrofluoric acid. Note the ground glass appearance produced by 1 minute of hydrofluoric acid etching on the internal
ceramic surface. C, A silane coupling agent is applied with a minibrush on the internal surface o f the ceramic inlay after
hydrofluoric acid etching.

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resin cement (Rely X ARC@,3M

ESPE) was used (Figure 10).
The final view of the restoration
before occlusal adjustments is presented in Figure 11. Figure 12
shows the restoration at a 1-month
follow-up appointment. A direct
resin-based composite restoration
Figure 6. A rubber dam is placed and
the cavity is cleaned.

was performed in the

left second molar.

Figure 7. Enamel and dentin are etched

with 35% phosphoric acid gel.

CONCLUSION

Considering patients growing

demands for esthetic restorations,
the 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 biocompatible, capable of resisting occlusal
forces, and exhibit favorable wear
characteristics. Bonded ceramic
restorations represent an excellent
alternative for restoring posterior
teeth esthetically.
Figure 8. Adhesive is applied on the
prepared teeth with a microbrush.

Figure 10. Dual-cured resin cement is used as the

cementation medium.

348

Figure 9. The adhesive is light cured.

Figure 11. The final restoration prior to occlusal

adjustments is seen.

J O U R N A L OF ESTHETIC A N D RESTORATIVE DENTISTRY

M E Y E R FILHO ET A L

16. Shellard E, Duke ES. Indirect composite

resin materials for posterior applications.
Compendium 1999; 20:1166-1171.
17. Scheibenbogen A, Manhart J, Kremers L,
et al. Two-year clinical evaluation of direct
and indirect composite restorations in posterior teeth. J Prosthet Dent 1999; 82:
391-397.
18. Robson P, More B, Swartz M. Comparison of microleakage in direct and indirect
restorations in vitio. Oper Dent 1987;
12:113-1 16.

Figure 12. Illustrated is the restoration at the 1-month

follow-up appointment. Note also a direct resin-based
composite restoration in the mandibular left second molar.

DISCLOSURE A N D
ACKNOWLEDGMENT

The authors thank Edson Araiijo,

DDS, MS, for assistance in the
operatory procedures shown here,
Skrgio Araiijo, CDT, for the use of
IPS Empress, and Andrk Ritter, DDS,
MS, and Harald Heymann, DDS,
MEd, for their editorial assistance.
The authors do not have any financial interest in any of the materials
discussed in the manuscript.
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Reprint requests: Alfredo Meyer Filho, DDS,

MS, Av. Rio Branco 405, Torre 1, Sala 204,
Cenho, Florian6polis, Santa Catarina,
8801 5-200, Brazil; e-mail: alfredo.meyer@
bol.com. br
02003 BC Decker lnc

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COMMENTARY
C E R A M I C I N L A Y S A N D O N L A Y S : C L I N I C A L P R O C E D U R E S F O R P R E D I C T A B L E RESULTS

Ariel J. Raigrodski, DMD, MS

Clinical studies have demonstrated high success rates for ceramic onlays and inlays. The ongoing evolution in bonding
techniques, adhesive systems, and cements plays a major role in the success of these metal-free restorations. With the
various techniques and materials available for restoring an intracoronal carious lesion with a tooth-colored material,
selecting the appropriate one may prove to be challenging in many clinical situations. Therefore, clinicians often find
themselves pondering the following: Which is the appropriate technique-the direct or the indirect one? What are the
indications for and limitations of each? Which is the appropriate material--ceramics or composite resin?
This article provides a contemporary comprehensive review of all aspects related to ceramic inlays and onlays and thus
provides clinicians with recommendations and guidelines based on current scientific literature. By identifying all aspects
related to ceramic inlays and onlays and discussing their indications and limitations compared with each other and
with indirect and direct composite resin restorations, the authors answer many questions affecting the decision-making
process in the diagnosis, treatment planning, and materials and technique selection for tooth-colored intracoronal
restorations. The authors nicely review general criteria, such as marginal fit, mechanical properties, and esthetics, which
are all factors that are key to the success of other types of indirect tooth-colored restorations, and how these criteria
specifically apply to indirect intracoronal restorations.
The authors discuss in detail preparation design and the rationale for selection of adhesion and cementation materials,
which are critical to the long-term success of these types of restorations, while emphasizing the concepts of ceramic
etching and silanation and the use of dual-cured composite resin cements. They also recommend a cementation
sequence with a step-by-step procedure and describe finishing procedures. Finally, the case report illustrates well the
concepts previously described.
In summary, this article comprehensively reviews the literature to address in depth many aspects of ceramic inlays and
onlays. The sawy clinician will find this article a handy reference for the foreseeable future.
SUGGESTED READING
Barghi N, Berry TG. Clinical evaluation of etched porcelain onlays: a 4-year report. Compend Contin Educ Dent 2002; 23:657-674.

Frankenberger R, Petxhelt A, Kramer N.Leucite-reinforced glass ceramic inlays and onlays after six years: clinical behavior. Oper Dent 2000;
25:459-465.
Manhart J, Chen HY,Neuerer P, et al. Three-year clinical evaluation of composite and ceramic inlays. Am J Dent 2001; 14:95-99.
Thordrup M, Isidor F, Horsted-Binslev P. A 5-year clinical study of indirect and direct composite and ceramic inlays. Quintessence Int 2001;
32:1999-2005.

Diplomate of the American Board of Prostbodontics, assistant professor, Department of Prostbodontics, Louisiana State University, New
Orleans, LA, USA

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