journal of prosthodontic research 62 (2018) 10–23

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Journal of Prosthodontic Research

journal homepage: www.elsevier.com/locate/jpor

Review

All-ceramic inlay-retained fixed dental prostheses for replacing

posterior missing teeth: A systematic review
Raquel Castillo-Oyagüea,* , Rocío Sancho-Espera , Christopher D. Lynchb ,
María-Jesús Suárez-Garcíaa
a
Department of Buccofacial Prostheses, Faculty of Dentistry, Complutense University of Madrid, Pza. Ramón y Cajal, s/n, 28040 Madrid, Spain
b
University Dental School & Hospital, Wilton, Cork, Ireland, UK

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: To evaluate the current status of all-ceramic inlay-retained fixed dental prostheses (CIR-FDPs)
Received 15 December 2016 for the replacement of posterior teeth.
Received in revised form 14 April 2017 Study selection: Screening of titles and abstracts, full-text analysis for inclusion eligibility, quality
Accepted 28 June 2017
assessment, data extraction and evaluation of the scientific evidence were performed independently by
Available online 20 July 2017
two reviewers. The electronic databases MEDLINE/PubMed, EMBASE, Cochrane Central Register of
Controlled Trials, and Compludoc were searched with no restriction to publication date or language. The
quality of the studies was evaluated through: the original ‘QDP’ (‘Questionnaire for selecting articles on
Dental Prostheses’) (for research papers); the ‘Guidelines for managing overviews’ of the Evidence-Based
Medicine Working Group (for reviews); the Cochrane risk of bias tool; and the GRADE scale for grading
scientific evidence.
Results: This review started with 4942 articles, which were narrowed down to 23 according to the
selection criteria. The data was not statistically treated because of the heterogeneity of the studies.
Zirconia-based CIR-FDPs may be recommended for restoring posterior single missing teeth, although the
prosthesis/tooth bonded interface has yet to be improved. The addition of lateral wings to the classical
inlay preparation seems promising. The weakest parts of CIR-FDPs are the connectors and retainers,
while caries and endodontic problems are the most common biological complications. The fabrication of
CIR-FDPs with monolithic zirconia may eliminate chipping problems.
Conclusions: A three-unit CIR-FDP is a viable treatment option for replacing a posterior missing tooth.
Appropriate case selection, abutment preparation and luting procedures may be decisive for clinical success.
© 2017 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction
The treatment of choice for replacing a missing posterior tooth
with healthy adjacent teeth is usually a dental implant-supported
restoration [1–5]. However, clinical contraindications (such as
smoking patients, uncontrolled diabetes, or several cancer
therapies) and other surrogate situations (such as economic
problems or fears of surgery) may be encountered [4–7]. The first
option in these cases has traditionally been crowning the adjacent
teeth for a three-unit fixed dental prosthesis (FDP). Nevertheless,
when preparing teeth for a full coverage, approximately 63–73% of
the dental structure has to be removed [3,8]. Irreversible pulpitis
and pulpal necrosis have been reported to occur in 15.6% of the
* Corresponding author. Fax: +34 913942029.
E-mail addresses: raquel.castillo@ucm.es, siete_rosas.rc@hotmail.com
(R. Castillo-Oyagüe).
teeth treated with single crowns and in 32.5% of the teeth restored
with FDPs after 10 years of oral service [9–11].
In the last decades, the use of inlays for retaining a three-unit
FDP has increasingly been considered [5,12]. This alternative has
been defined as ‘a minimally invasive treatment modality for
replacing posterior single missing teeth, which uses box-shaped
cavities as retainers and might include existing fillings made of gold,
composite, ceramic, or other materials that are luted to the adjacent
teeth’ [13]; thus preserving the dental structure and the integrity of
the periodontal tissues [5,14–17].
Inlay-retained FDPs were introduced in 1960s and were
originally made out of noble metals [2,3,18]. This allowed for a
conservative preparation and facilitated a proper load and stress
distribution [12,19,20]. Nonetheless, in addition to the aesthetic
inconvenience [21], the detachment of the retainers was a
common problem, and often led to the development of secondary
caries [22,23]. Mean failure rates of 46.4% have been reported for

http://dx.doi.org/10.1016/j.jpor.2017.06.007
1883-1958/ © 2017 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.
 R. Castillo-Oyagüe et al. / journal of prosthodontic research 62 (2018) 10–23
this type of restorations after 2.5–9 years [3]. Although nearly
parallel-sided box configurations with frictional retention seem to
increase their clinical success until 96.1% at 5 years of follow-up
[24] it still remains unknown whether such positive outcome is
confirmed in the long-term [3].
In order to avoid these problems, glass fiber-reinforced
composites (FRCs) and dental ceramics were proposed for the
fabrication of inlay-retained FDPs [21,25]. These restorations,
which are bonded to the abutment teeth and require simpler and
minimally invasive preparations [26–28], may be used as definitive
treatments instead of implants in the presence of scarce bone or
other anatomical, medical, or economical constrains [29,30]; and
also in juveniles as temporary solutions that can be readily
replaced or modified [29–31]. Decementation has been rated as the
most common failure type of resin-bonded FDPs [32]. Other typical
events are secondary caries on the abutments [30], chipping of the
veneering material [33], and/or fracture at the connectors and
retainers [34]. The long-term success of these prostheses, which
range from 59% to 100% at 5 years, mainly depends on the
mechanical properties of the materials used, the preparation
configuration [29,35], the occlusal loads, the presence of parafunc-
tional habits [5,26,36], and the quality of the adhesion at the tooth/
restoration interface [29,35]. The geometry of the inlay cavity must
offer favourable conditions for adhesive cementation. The location
of the margins should allow a rubber dam to be placed for ensuring
a complete isolation [37] thus preventing contamination with
saliva or sulcus fluid [38]. Moreover, the increased inclusion of
enamel promotes the bond to dentin, which still needs to be
enhanced [37,39].
Glass fiber-reinforced composites were presented as universal
dental aesthetic restorative materials when they were introduced
to Dentistry in the late 1990s [12,21,40]. FRCs are composed of a
core material made of fiber composite and an external veneer
surface of hybrid or microfilled particulate filler composites (PFC)
[41,42]. The physiological stiffness of the structure, resilience,
satisfactory immediate aesthetics, and proper adhesion of the
composite luting agent to the framework are their main
advantages [5,40,43,44]. Nevertheless, they are limited by their
low fracture toughness, high wear of the veneering composite that
may lead to fiber exposure, degradation of marginal integrity, and
discoloration compared to other materials [3,4,28,45,46]. Their
survival rates have been observed to drop considerably below 80%
after 5 years [47], so that this material has mostly been relegated to
temporary solutions [48,49]. However, the reinforcing effect of the
fiber restorations depends, in turn, on the characteristics of the
fibers, matrix, and polymer; the quantity of fibers and their
location, direction, construction, and distribution; the impregna-
tion of the fibers in the resin; the adhesion of the fibers to the
matrix; the elastic modulus of the supporting substructure; the
features of the luting agent; the thickness of the restoration; and
the preparation design [5,21,43,44]. For instance, the shape of the
framework (i.e., parallel vs. parallel and woven fibers) has been
reported to affect the fracture resistance, being higher for parallel
fibers [50]. Also, when the structure is fabricated without the
recommended dimensions, the excessive frame flexibility may
increase the microfractures of the aesthetic veneering [51].
Ceramics are the material of choice for guaranteeing durable
aesthetic results [17,37,52]. Each situation must be particularly
evaluated to determine whether the case complies with the ideal
number of teeth lost and location; edentulous space (20 mm or less
between the remaining teeth); integrity and periodontal health of
the abutment teeth [3,4,17,21]; favourable occlusal loads, and
absence of parafunctions [5,26,36].
Yttria partially stabilised CAD/CAM zirconium-oxide ceramic
(YPSZ) has been proved to have excellent mechanical performance
as core material for all-ceramic fixed dental prostheses. The
11
zirconia surface is usually coated with glass-ceramic layers to
optimise the aesthetic appearance [38,53]. However, these
rehabilitations are prone to failure primarily by chipping of the
veneering ceramic [33], which might be circumvented by the use of
monolithic zirconia [3].
High-strength heat-pressed lithium-disilicate ceramics may be
used as well for all-ceramic structures [53]. The outstanding
aesthetic features of these tooth-coloured systems, which repre-
sent their main advantage, must be attributed to their high
translucency [37]. However, their mechanical properties are
questionable [37,53,54].
Additionally, industrially sintered homogeneous ceramics
(e.g., sanidine-reinforced feldespathic ceramic, leucite-reinforced
glass-ceramic, zirconium-oxide or lithium-disilicate reinforced
trial glass-ceramic), and even resin-based composite block
materials, can be chosen for production of CAD/CAM-generated
inlay-fixed restorations directly at the chairside [2] but require
further investigation before being recommended for widespread
use.
Actually, the impact of both the porcelain material and the
prosthesis design on the clinical performance of three-unit resin-
bonded ceramic inlay-retained FDPs (hereafter called ‘CIR-FDPs’)
has not been rigorously evaluated with an evidence-based
approach. The aim of this paper was, therefore, to systematically
review the literature and provide updated evidence stemming
from prospective clinical trials, laboratory experiments, and finite
element analyses. Comparison results relied on materials,
manufacturing techniques, preparation designs, survival/failure
rates; mechanical and functional outcomes, cementation, biologi-
cal complications, and aesthetic behaviour of this type of
restorations. This may enable the identification of gaps in the
knowledge base thus setting the direction of future research.
2. Material and methods
2.1. Search methods for identification of studies
An electronic search of MEDLINE/PubMed, EMBASE, Cochrane
Central Register of Controlled Trials, and Compludoc databases
(24.10.2016) were conducted. No restriction to publication date or
language was considered. Different combinations of the following
Medical Subject Headings (MeSH)/key-terms were utilised: ‘fixed
dental prostheses’; ‘FDPs’; ‘prosth*’; ‘restorations’; ‘inlay-
retained’; ‘inlay-supported’; ‘resin-bonded’; ‘adhes*’; ‘bond’;
‘cement*’; ‘lut*’; ‘ceramic’; ‘all-ceramic’; ‘porcelain’; ‘zirconia’ ‘Y-
TZP’; ‘glass-ceramic’; ‘lithium-disilicate’; ‘edent*’; ‘posterior’;
‘random*’; ‘clinical trial’; ‘in vivo’; ‘in vitro’; ‘lab*’; and ‘FEA’. To
increase the yield of relevant results, a direct search (up until
October 2016) was made in the directory of generic and prosthetic-
related journals listed in the ‘Dentistry, Oral Surgery & Medicine’
category of the Journal Citation Reports (J.C.R.).
2.2. Selection criteria
Before starting the study, a series of inclusion and exclusion
criteria were established. Abstract texts were not admitted [55].
The inclusion criteria were: (a) articles describing clinical
studies, preferably randomised controlled clinical trials (RCTs) on
partially edentulous humans restored with three-unit CIR-FDPs in
the maxillary and/or mandibular posterior region (replacing a
missing premolar or molar); (b) articles published in peer-
reviewed international journals; (c) literature reviews, in vivo, or
ex-vivo prospective studies involving any of the search terms
listed; and (d) in vitro experiments, including finite element
analyses (FEA).
12 R. Castillo-Oyagüe et al. / journal of prosthodontic research 62 (2018) 10–23
The exclusion criteria were: (a) articles that did not comply with
the inclusion criteria; (b) articles about anterior CIR-FDPs; (c)
articles that described CIR-FDPs replacing two or more teeth; (d)
articles focused on the use of CIR-FDPs exclusively as provisional
treatments; (e) case reports/series/studies with less than ten
patients restored with posterior CIR-FDPs; (f) data being repeated
or updated in other included articles; (g) review/technique articles
with no clinical applicability/extrapolability; and (h) articles that
were vague in protocol design, did not provide the required data, or
did not allow the extraction of relevant information about CIR-
FDPs [56].
2.3. Data collection and analyses
Each phase was independently accomplished by two reviewers.
Any disagreement was resolved first by collegial debate, and then
by consulting a third author for arbitration [57]. Corresponding
authors were e-mailed seeking clarification of unclear or missing
information when necessary.
2.3.1. Selection of studies and full-text evaluation
The titles and abstracts of the retrieved articles were screened
based on the selection criteria. Additional papers found in the
bibliographies of the eligible manuscripts were considered. The
WHO International Clinical Trials Registry Platform Search Portal
was consulted for ongoing investigations.
The full text of all pre-selected papers was in-depth evaluated.
The articles that did not meet the inclusion criteria were excluded.
2.3.2. Quality assessment
A customised form containing 15 questions was applied to all
pre-selected papers, as such items represent good scientific
practise (GSP) [55,58]. This original questionnaire, named ‘QDP’
(‘Questionnaire for selecting articles on Dental Prostheses’) was
designed by the research team of the Master of Buccofacial
Prostheses and Occlusion of the Complutense University of Madrid
(Faculty of Dentistry, UCM, Spain), under the coordination of the
first and last co-authors, to assess the scientific quality of dental
prosthesis-related articles. This new scale, which has not been
published before in any form or any language, is inspired on the
Critical Appraisal Skills Programme (CASP) tools [59,60]; on the
methodology of the Grading Recommendations Assessment and
Development (GRADE) working group for the evaluation of the
cumulative evidence [57]; on the criteria of the University of
Oxford’s Centre for Evidence Based Medicine for scoring the levels
of evidence [61]; on the Methodological Index for Nonrandomized
Studies (MINORS criteria) [62]; and on the researchers’ experience.
The QDP index has two preliminary/eliminatory questions that
must be answered affirmatively to continue. The possible item
responses were ‘0’ (negative) or ‘1’ (positive). With this scale, the
study quality may be classified as ‘poor’ (<8/15), fair (9–11/15), or
good (12/15). Table 1 displays the QDP scores of the pre-selected
papers. Only in vivo or in vitro articles having ‘good quality’ were
finally included (Appendix A).
To evaluate the scientific adequateness of review articles, the
‘Guidelines for managing overviews’ published by the Evidence-
Based Medicine Working Group in 1994 [63] were strictly
followed.
2.3.3. Graduation of risk of bias and scientific evidence
The Cochrane Collaboration tool for assessing risk of bias was
applied to the pre-selected papers [64]. Articles with ‘high risk’
were rejected.
The quality of the scientific evidence of the papers with low risk
of bias was rated on a four-point scale consistent with GRADE
[65,66]. The following scores were used:
1. High quality (++++): Further research is very unlikely to change
our confidence in the estimate of effect.
2. Moderate quality (+++0): Further research is likely to have an
important impact on our confidence in the estimate of effect and
may change the estimate.
3. Low quality (++00): Further research is very likely to have an
important impact on our confidence in the estimate of effect and
is likely to change the estimate.
4. Very low quality (+000): Any estimate of effect is very uncertain.
Those studies with low/very low quality were eliminated from
the analysis and, thus, the final list of titles was reached.
2.3.4. Data extraction and definition of concepts
The two independent reviewers extracted the data from each
included study using a customised data collection form [29]. To
ensure consistency, both examiners had conducted calibration
exercises before starting the review. Data extracted included
methodology (principally concerning materials, manufacturing
techniques, and preparation designs [67]), demographic infor-
mation, sample size, treatment groups, randomisation, variables
analysed, and comparison and outcome details (including
survival/failure rates, follow-up time, mechanical and functional
outcomes, cementation, biological complications, and aesthetic
results).
In this review, ‘success’ was defined as the CIR-FDP remaining in
place without modification during the observation period; ‘failure’
was the debonding/detachment or complete fracture of any
component of the CIR-FDP (or even the fracture of one or both
abutment teeth) that required the replacement of the restoration.
Contrasting with previous definitions for crown-retained prosthe-
ses [68],‘complication’ was described as the introduction of an
unexpected and undesired event during treatment, such as some
types of biological-related problems, which did not require
substitution of the CIR-FDP.
3. Results
3.1. Pre-selection of studies by their title and abstract
A flow chart showing the results of the literature search and the
outcome of the selection procedures is presented in Fig. 1.
Electronic searches retrieved 4942 non-duplicate records, out
of which only 47 titles were initially applicable to the review. The
evaluation of their abstracts led to a total of 36 articles for full-text
analysis. Therefore, 4906 papers were excluded on the basis of
their title and abstract. The main reasons for exclusion were
reporting on anterior CIR-FDPs or being case reports/series/studies
with less than ten patients.
3.2. Evaluation of the studies’ adequacy to the review
Full-text articles were downloaded for the 36 publications that
were obtained until this stage. A careful manual search of citations
from these 36 articles led to the addition of six more papers (Fig. 1).
No results were achieved from the WHO International Clinical
Trials Registry Platform Search Portal.
Nineteen manuscripts were excluded from the final analysis
after an in-depth evaluation of the 42 full-text papers according to
the selection criteria, the QDP questionnaire, the ‘Guidelines for
managing overviews’ [63], the Cochrane Collaboration tool for
assessing risk of bias [64], and the GRADE scale [65] (Fig. 1).
All of the selected research papers attained good scientific
quality as scored by the QDP questionnaire (with punctuations
12/15 (Table 1)), while the two reviews that were included
complied with the ‘Guidelines for managing overviews’. No articles
Table 1
Qualitative data of the 23 articles that were finally included in the review (ordered by year of publication).

Article/year of publication QDP score Type of study Nature of the study Information on randomisation Variable(s) assessed Ideal inlay design Type of cementation
Edelhoff et al., 2001 [37] 12/15 In vivo Prospective (3 years) No specified information Clinical success Yes Adhesive
Kolbeck et al., 2002 [76] 14/15 In vitro (ex-vivo) Laboratory experiment No specified information Fracture strength Yes Adhesive
Magne et al., 2002 [45] 15/15 In vitro FEA – Stress distribution Modified design Adhesive
(interproximal slots)
Bindl et al., 2003 [2] 14/15 In vitro Laboratory experiment No specified information Fracture load Modified design (slot- Not cemented
inlay FDPs)
Rosentritt et al., 2003 [72] 13/15 In vitro (ex-vivo) Laboratory experiment No specified information Fracture strength Yes Adhesive
Kiliçarslan et al., 2004 [15] 14/15 In vitro Laboratory experiment No specified information Fracture load Yes Provisional
Ohlmann et al., 2005 [16] 14/15 In vitro Laboratory experiment No specified information Fracture load Yes Adhesive
Monaco et al., 2006 [39] 15/15 In vitro (ex-vivo) Laboratory experiment Random assignment of samples to Marginal adaptation and Yes (mesial-occlusal- Adhesive
groups retention distal (MOD) inlay in the
premolar and 2-cusp
covering onlay in the

R. Castillo-Oyagüe et al. / journal of prosthodontic research 62 (2018) 10–23

molar)
Wolfart et al., 2007 [73] 14/15 In vitro Laboratory experiment No specified information Quasi-static and fatigue Yes (different connector Adhesive
fracture strength dimensions)
Ohlmann et al., 2008 [38] 14/15 In vivo Prospective (1 year) No randomisation: the extension of Clinical success Yes Adhesive
caries removal determined the type of
restoration. Only the cementation
procedure was randomised
Puschmann et al., 2009 [74] 14/15 In vitro Laboratory experiment No specified information Quasi-static load-bearing Yes (different connector Adhesive
capacity dimensions)
Harder et al., 2010 [54] 14/15 In vivo Prospective (8 years) No randomisation: the amount of tooth Clinical success Yes Adhesive
structure determined the type of
restoration
Mehl et al., 2010 [10] 14/15 In vitro Laboratory experiment No randomisation: consecutive Centric and eccentric Yes Adhesive
sampling procedure quasi-static and fatigue
fracture strength
Mohsen, 2010 [52] 14/15 In vitro Laboratory experiment No specified information Fracture resistance Yes (different abutment Adhesive
preparations)
Thompson et al., 2010 [67] Literature review
Thompson et al., 2011 [70] 14/15 In vitro FEA – Stress distribution Modified design (broader Unavailable data
gingival embrasure)
Field et al., 2012 [71] 15/15 In vitro FEA – Stress distribution and Yes Unavailable data
bone remodelling
Kermanshah et al., 2012 [9] 15/15 In vitro FEA – Stress distribution and Yes Unavailable data
flexural strength
Möllers et al., 2012 [69] 15/15 In vitro FEA – Stress distribution and Yes Unavailable data
failure resistance
Saridag et al., 2012 [75] 15/15 In vitro (ex-vivo) Laboratory experiment Random assignment of samples to Fracture strength and Yes Adhesive
groups amount of bending
Chaar and Kern, 2015 [53] 14/15 In vivo Prospective (5 years) No randomisation: consecutive Clinical success Modified design (short Adhesive
sampling procedure (variation of the retainer-wing bevel
missing tooth) buccal and oral
preparations)
Chaar et al., 2015 [3] Literature review
Zhang et al., 2016 [77] 15/15 In vitro FEA – Fracture behaviour Yes Adhesive
(fracture load and crack
path)

*FEA: Finite Elements Analysis.

13
14 R. Castillo-Oyagüe et al. / journal of prosthodontic research 62 (2018) 10–23
were disregarded for having ‘high risk’ of bias after the pertinent
clarifications made by the corresponding authors about the
unclear and/or missing data. Consistent with the GRADE scale
[65], the scientific evidence of all included papers was of high/
moderate quality.
3.3. Description of the selected studies
The systematic review finally comprised 23 articles from which
quantitative and qualitative data were extracted and evaluated
(Fig. 1, Tables 1–4). Two of them were literature reviews [3,67]; four
were non-randomised prospective clinical studies [37,38,53,54];
and 17 were in vitro investigations [2,9,10,15,16,39,45,52,69–77]
(Fig. 1, Table 1). No randomised controlled clinical trials (RCTs)
meeting the selection criteria were found (Table 1). All of the
selected papers have been published from 2001 onwards: most of
which (15/23) during the recent 10-year period (Tables 1–4).
Information about materials tested, sample size, replaced teeth
with space in mm, follow-up time, and survival rates registered in
the in vivo investigations are outlined in Table 2. All of them were
prospective trials that analysed the clinical success of CIR-FDPs
made out of different ceramic materials after periods of observa-
tion that range from one year [38] to eight years [54].
For the in vitro studies, the variables and restorations’ designs
assessed, materials tested, number of specimens (in laboratory
experiments), and replaced teeth with the space in mm are detailed
in Tables 3 and 4. With the aim to facilitate the interpretation of the
results, the Finite Elements Analyses have been separated in Table 3,
while the laboratory in vitro articles are included in Table 4. Six in
vitro papers were FEA studies [9,45,69–71,77] that mainly focused
on the stress distribution [9,45,69–71], and on the fracture
behaviour of CIR-FDPs [77] (Tables 1 and 3). The remaining 11 in
Fig. 1. Study flow diagram.
*QDP: Questionnaire for selecting articles on dental prostheses.
vitro papers were laboratory experiments (seven about fracture-
strength/fracture load/fracture resistance [2,15,16,52,72,75,76],
two of quasi-static and fatigue fracture strength [10,73], one of
quasi-static load-bearing capacity [74], and one of marginal
adaptation and retention of CIR-FDPs) [39] (Table 4). Among the
in vitro papers, four were ex-vivo investigations in which extracted
human premolars and molars instead of pre-fabricated models
were used as retainer abutments [39,72,75,76] (Table 1).
A complementary review yielded 62 papers of background,
general concepts, historic evolution, performance of adhesive
dental prostheses, and evidence-based dentistry.
3.4. Organisation and interpretation of the data extracted
All of the co-authors participated actively in the extraction,
organisation, and interpretation of the data from the finally selected
articles. To set up a rigorous and exhaustive summary of the study
subject, the information extracted has been distributed according to
the next order under each subheading of Section 3: data from review
papers, data from prospective clinical trials, data from finite element
analyses, and data from laboratory experiments. Overall, the key
findings of current systematic are summarised in Tables 1–4. The
variables assessed in each study are depicted in Table 1.
Although the differences in study protocols and outcome
variables sometimes make it difficult to compare the results across
studies, some patterns emerged which appear reasonably robust
and are profiled in both Sections 3 and 4.
3.4.1. Restorative material and manufacturing technique
Regarding the review papers, only the article of Chaar et al. [3]
evaluated the behaviour of different core materials for manufactur-
ing inlay-retained FDPs. In their reviewed studies, lithium-
 R. Castillo-Oyagüe et al. / journal of prosthodontic research 62 (2018) 10–23 15

Table 2
Description of the reviewed prospective in vivo studies: authors, year of publication, materials tested, sample size, replaced teeth, follow-up period, and survival rates.

Authors Year of Materials tested Sample size Replaced teeth (mm) Follow-up Survival
publication period rates
Edelhoff 2001 IPS Empress 2, Ivoclar (lithium-disilicate ceramic) 23 (groups Premolar (9 mm; pressed 3 years 90.09%
et al. [37] of 11/12) ceramic)
Molar (12 mm; FRC)
Vectris (frame: preimpregnated/silicoated glass fibers
in resin matrix)/Targis, Ivoclar (veneer: highly filled
composite)

Ohlmann 2008 IPS e.max ZirCAD (frame: zirconia)/IPS e.max ZirPress, 27 Molar (not more than 1 year 90%
et al. [38] Ivoclar (veneer: pressable fluorapatite glass-ceramic) 16 mm)

Harder 2010 IPS e.max Press, Ivoclar (heat pressed lithium- 45 Premolar or molar 8 years 57% (5 years)
et al. [54] disilicate glass-ceramic) (The mm are not 38% (8 years)
provided)

Chaar and 2015 Vita In-Ceram YZ-Cubes (frame: zirconia)/Vita VM 9 30 Premolar or molar (The 5 years 95.80%
Kern [53] (veneer: feldespathic ceramic) mm are not provided)

*FRC: Fiber-Reinforced Composite.

disilicate ceramic showed failure rates from 20% (at 9.9 months) to
43% (at 62 months); FRC from 0% (at 15.3 months) to 31% (at
62 months); noble metal alloys from 3.9% (at 62 months) to 20% (at
72 months); and zirconia of 6% (at 60 months) and 10% (at
12 months).
Half of the clinical studies included in this systematic review
reported on the use of veneered zirconia structures [38,53], while
the other half tested CIR-FDPs made out of lithium-disilicate
ceramic [37,54] (Table 2). The most common failures for zirconia-
based restorations were chipping of the veneer and debonding of at
least one inlay retainer [38,53]. The most frequent failures of
lithium-disilicate rehabilitations were debonding, fracture, or a
combination of debonding and fracture at the isthmus of one inlay
retainer [37,54].
Edelhoff et al. [37] compared FRC and lithium-disilicate ceramic
inlay-prostheses (Table 2). One of the 12 FRC restorations tested

Table 3
Description of the Finite Element Analysis (FEA) studies included in the review: authors, year of publication, variables and restorations’ designs assessed, materials tested, and
replaced teeth (mm).

Authors Year of Variables and restorations’; designs assessed Materials tested Replaced teeth
publication (mm)
Magne 2002 Stress distribution within the tooth/restoration complex depending on Au–Pd alloy, Olympia Molar
et al. [45] the restorative material and the abutment preparation (interproximal
slots vs. 2-surface [MO, DO] vs. 3-surface [MOD])
Vita InCeram Alumina (12 mm)
Vita InCeram Zirconia
IPS Empress 2, Ivoclar (lithium-disilicate ceramic)
Vectris (frame: preimpregnated/silicoated glass
fibers in resin matrix)/Targis, Ivoclar (veneer: highly
filled composite) (FRC)

Thompson 2011 Stress distribution depending on the inlay preparation geometry and All-ceramic zirconia-based inlay-retained Molar
et al. [70] on the sizes of the gingival embrasure radii and the bridge connectors restorations (the ceramic trademark was not (The mm are not
specified, as it was not relevant for the FEA study) provided)

Field et al. 2012 To evaluate and compare the bone remodelling consequence and the All-ceramic zirconia-based inlay-retained Molar
[71] mechanical stress distribution within two possible configurations: restorations (the ceramic trademark was not (The mm are not
inlay and onlay FDPs specified, as it was not relevant for the FEA study) provided)

Kermanshah 2012 Stress distribution and flexural strength IPS Empress 2, Ivoclar (lithium-disilicate ceramic) Molar
et al. [9]
IPS Empress 2 with cosmopost (zirconia post) (The mm are not
inserted longitudinally in the centre of the bar provided)
IPS Empress 2 with the cosmopost inserted
longitudinally at the bottom of the bar

Möllers 2012 Stress distribution and failure resistance depending on the loading and All-ceramic zirconia-based inlay-retained Molar
et al. [69] bearing conditions of the teeth restorations (the ceramic trademark was not (The mm are not
specified, as it was not relevant for the FEA study) provided)

Zhang 2016 Fracture behaviour (fracture load and crack path depending on the Zirconia (the ceramic trademark was not Molar
et al. [77] loading position and on the restoration design: inlay vs. onlay) specified, as it was not relevant for the FEA study) (The mm are not
provided)

*FRC: Fiber-Reinforced Composite. MO: mesial-occlusal. DO: distal-occlusal. MOD: mesial-occlusal-distal.

16 R. Castillo-Oyagüe et al. / journal of prosthodontic research 62 (2018) 10–23

Table 4
Description of the laboratory in vitro experiments included in the review: authors, year of publication, variables and restorations’ designs assessed, materials tested, number
of specimens, and replaced teeth (mm).

Authors Year of Variables and restorations’; designs assessed Materials tested Number of Replaced
publication specimens teeth (mm)
Kolbeck et al. 2002 Fracture strength of posterior inlay FDPs Connect (frame: woven, not impregnated 40 Molar
[76]
polyethylene fiber)/BelleGlass, SDS Belle (8 per (10 mm)
group)
Orange (veneer: microhybrid composite)
FibreKor (frame: unidirectional glass fibers in
ethoxydimethacrylate matrix)/Conquest Sculpture,
Jeneric/Pentrom (veneer: polycarbonate
dimethacrylate matrix)
Vectris (frame: preimpregnated/silicoated glass fibers
in resin matrix)/Targis, Ivoclar (veneer: highly filled
composite)
EverStick, Stick Tech Ltd. (frame: unidirectional
preimpregnated glass fiber)/Sinfony, 3 M (veneer:
microhybrid composite)
IPS Empress 2, Ivoclar (lithium-disilicate ceramic,
layering technique)

Bindl et al. [2] 2003 Fracture load of CAD/CAM-generated slot-inlay Mk II, Vita (sanidine-reinforced feldespathic ceramic) 90 Molar
FDPs
ProCAD, Ivoclar (leucite-reinforced glass-ceramic) (15 per (14 mm)
group)
Glass-ceramic 1, Vita (zirconium-oxide reinforced trial
glass-ceramic)
Glass-ceramic 2, Ivoclar (lithium-disilicate reinforced
trial glass-ceramic)
Composite 1, 3 M (microfilled polymer ceramic Bis-
GMA, milled blocks)
Composite 2, GC (microfilled composite CAD/CAM
blocks)

Rosentritt et al. 2003 Fracture strength of 3-unit FDPs and inlay FDPs Vectris (frame: preimpregnated/silicoated glass fibers 40 (10 per Molar (10 mm)
[72] after thermal and mechanical cycling that in resin matrix)/Targis, Ivoclar (veneer: highly filled group)
simulated 5 years of oral service composite)
IPS Empress 2, Ivoclar (lithium-disilicate ceramic,
layering technique)
Vectris preform/IPS Empress 2, Ivoclar (lithium-
disilicate ceramic)
Zirkon, Lava (frame: zirconia)/Sinfony, 3 M (veneer:
low viscous composite)

Kiliçarslan et al. 2004 Fracture load of posterior FDPs and inlay- Ni-Cr-based alloy, Wirolloy (frame: metal)/IPS.d. 32 Molar
[15] retained resin-bonded FDPs SIGN, Ivoclar (veneer: ceramic)
(*2 groups: FDPs and inlay-retained FDPs) (8 per (10 mm)
group)
IPS Empress 2, Ivoclar (lithium-disilicate ceramic,
layering technique)
Cercon (frame: zirconia)/CerconCeramS, Degudent
(veneer: leucite-free porcelain)

Ohlmann et al. 2005 Fracture load of bi-layered inlay retained FDPs Industrial prefabricated Y-TZP (frame: zirconia)/ 64 Premolar (7 mm)
[16] depending on the material, and on the span Artglass, Heraeus Kulzer (veneer: polymer glass) (groups of
length/localization of the frame 7/8)
Industrial prefabricated Y-TZP (frame: zirconia)/IPS. e. Molar (12 mm)
max ZirPress, Ivoclar (veneer: experimental press
ceramic)
Premolar + Molar
(19 mm)

Monaco et al. 2006 Marginal adaptation and retention of inlay fixed SR Adoro-Vectris, Ivoclar (frame: FRC)/Silica-based 18 (6 per Molar (10 mm)
[39] FDPs after thermal cycling and mechanical ceramic (veneer) group)
loading that approximately simulated 5 years of
oral service
Cercon, Degudent (frame: zirconia)/Silica-based
ceramic (veneer)
DC-Leolux, DCS Dental (frame: magnesia partially
stabilized zirconia)/Silica-based ceramic (veneer)
 R. Castillo-Oyagüe et al. / journal of prosthodontic research 62 (2018) 10–23
Table 4 (Continued)
Authors Year of Variables and restorations’; designs assessed
publication
Wolfart et al. 2007 Quasi-static and fatigue fracture strength
[73] depending on the material used and the
connectors’ dimensions
Puschmann 2009 Quasi-static load-bearing capacity of resin-
et al. [74] bonded 3-unit inlay-retained FDPs with two
different connector dimensions, with and
without fatigue loading
Mehl et al. [10] 2010 Centric and eccentric quasi-static and fatigue
fracture strength of resin-bonded 3-unit inlay-
retained FDPs
Mohsen [52] 2010 Fracture resistance of inlay-retained FDPs
depending on the abutment preparation
(occlusal-proximal inlay + proximal box, occlusal-
proximal inlay, or proximal box-shaped)
Saridag et al. 2012 Fracture strength and amount of bending of
[75] inlay-retained FDPs
*FRC: Fiber-Reinforced Composite.
exhibited a fracture within the connector to the pontic at 11 months
of follow-up that required the replacement of the prosthesis; this
being the unique failure in the study.
Among the FEA investigations, four papers [69–71,77] tested
zirconia as the unique core material; one study compared zirconia
with gold–palladium, alumina, lithium-disilicate ceramic, and FRC
[45]; and one article evaluated lithium-disilicate ceramic with
zirconia posts inserted longitudinally in the centre or at the bottom
of the bar [9] (Table 3).
Magne et al. [45] stated that the use of composites for inlay-
retained FDPs resulted in insufficient strength and fracture
toughness. However, these authors observed that the unidirec-
tional FRC materials tested had a resilient component that
favoured the transference of stress within the tooth/restoration
complex when compared to gold and ceramics. Accordingly,
Kermanshah et al. [9] found that the inclusion of zirconia bars in
the structure of lithium-disilicate ceramic decreased the stress
concentration at the connector area.
Most of the laboratory in vitro experiments tested zirconia-
based CIR-FDPs [2,10,15,16,39,52,72–75]. Four of them exclusively
analysed this type of restorations [10,16,52,74], while the remain-
ing studies evaluated diverse core materials for CIR-FDPs, such as
lithium-disilicate ceramic [2,72,73,75,76], feldespathic ceramic
[2], FRC [39,72,75,76], composite [2,76], and resin matrices with
glass fibers [76]. Pertinent comparisons of zirconia with some of
these materials were performed by some authors [15,39,72,73,75]
(Table 4). Their mechanical, functional, and biological outcomes
are detailed in the subsequent subsections.
3.4.2. Restoration design
Overall, the inlay cavities used in the included studies followed
the ideal design described by Thompson et al. in their literature
review [67]: cavity depth of 1.5–2 mm; maximum isthmus width
of one-third of the total intercuspal width; total occlusal
convergence angle of 20 , and all of the internal line angles
17
Materials tested Number of Replaced
specimens teeth (mm)
IPS e.max Press, Ivoclar (heat pressed lithium- 32 (8 per Molar (11 mm)
disilicate glass-ceramic) group)
Cercon base 30 (frame: zirconia)/CerconCeramS,
Degudent (veneer)
Vita In-Ceram YZ-Cubes (frame: zirconia)/Vita VM 9 24 (6 per Molar (10 mm)
(veneer: feldespathic ceramic) group)
Industrially prefabricated zirconia, Gapless (frame)/ 42 Molar (10.5 mm)
thin layer of feldespathic ceramic and microhybrid (groups of
composite resin (veneer) 16/8/12/6)
ICE Zirkon, Zirkonzahn (zirconia) 30 (10 per Premolar (7 mm)
group) Molar (11 mm)
IPS e.max Press (frame: lithium-disilicate ceramic)/IPS 40 (10 per Molar (11 mm)
e.max Ceram, Ivoclar (veneer: glass-ceramic) group)
ICE Zirkon (frame: zirconia)/ICE Ceramik, Zirkonzahn
(veneer: glass-ceramic)
EverStick, Stick Tech (frame: glass-fiber)/Solidex,
Shofu (veneer: indirect resin composite)
Vectris (frame: glass-fiber)/Adora, Ivoclar (veneer:
indirect resin composite)
rounded and smoothed to reduce stresses (Table 1). However,
Thompson et al. [67] stated that the preparation geometry must be
adapted to the specific features of the ceramic materials used for
manufacturing inlay-retained restorations.
As for the in vivo studies, Edelhoff et al. [37] observed more
failures of CIR-FDPs with reduced connectors. Ohlmann et al. [38]
found no significant effect of the abutment preparation on the
occurrence of complications or failures. Harder et al. [54] tested
hybrid FDPs, which combined an inlay and a full-crown as
retainers. These prostheses reached rates of 100% at 5 years that
decreased to 60% after 8 years of follow-up. Chaar and Kern [53]
used a modified inlay cavity design with additional short retainer-
wings both at the buccal and oral sides, and recorded survival rates
of 100% and 95.8% after follow-up periods of 20 months and
5 years, respectively.
Four of the FEA investigations utilised the ideal inlay design
[9,69,71,77] (Table 1). Magne et al. [45] also introduced
interproximal slots and considered different cavity extensions
(occlusal-proximal and mesial-occlusal-distal). All their tooth
preparations exhibited similar stress patterns, with a definite
compressive area at the occlusal side of the pontic, a tensile zone
at the gingival portion of the pontic, and tensile stress peaks at
the connector areas. Thompson et al. [70] demonstrated that a
broadening of the gingival embrasure facilitated the distribution
of the forces derived from mastication. Comparing CIR-FDPs with
onlay-retained prostheses, Field et al. [71] and Zhang et al. [77]
confirmed that a preparation for an inlay preserves more tooth
tissue than a preparation for an onlay, but generates higher
mechanical stress.
Most of the in vitro studies used an average space of 10–12 mm
for replacing a missing molar with a CIR-FDP [10,15,39,52,72–76];
while Bindl et al. [2] suggested 14 mm as the space required.
Moreover, Ohlmann et al. [16] and Mohsen [52] considered a
missing premolar with 7 mm of space as adequate for a CIR-FDP
restoration (Table 4).
18 R. Castillo-Oyagüe et al. / journal of prosthodontic research 62 (2018) 10–23
The majority of the laboratory experiments also used the
recommended parameters for the preparation of the inlay cavities
[10,15,16,39,52,72,75,76] (Table 1). Seven of the laboratory in vitro
investigations described occlusal-proximal cavities [15,16,52,72–
75]; three evaluated box-shaped inlay-preparations [2,10,76]; and
one tested a mesial-occlusal-distal (MOD) inlay cavity in the
premolar and a 2-cusp partial covering onlay cavity in the molar
(Table 1). Particularly, Bindl et al.[2] tested slot inlay FDPs.
Various authors tested connectors of 16 mm2 in their in vitro
investigations [15,52,73,75]. Rosentritt et al. [72] utilised con-
nectors of 9 mm2; Ohlmann et al. [16] of 9–12 mm2, and Monaco
et al. [39] of 12.25 mm2. No scientific justification was provided in
any case. Wolfart et al. [73] did not detect significant differences
between 9 and 16 mm2-sized connectors when zirconia was used
as the frame material, while lithium-disilicate ceramic required
16 mm2 at least. Puschmann et al. [74] reported that connectors of
zirconia-based CIR-FDPs should be larger than 6 mm2, since, with
this size, the load-bearing capacity experiments a significant
reduction. Finally, Melh et al. [10] recommended connector sizes of
4.7 mm2 for their CIR-FDPs of industrially prefabricated zirconia
covered with a thin layer of feldespathic ceramic and microhybrid
composite resin.
3.4.3. Survival/failure rates
The same exclusion criteria (presence of periodontal disease
and parafunctions) coincided in the four clinical trials
[37,38,53,54]. The average follow-up period was 4.25 years,
ranging from 1 year in the investigation of Ohlmann et al. [38],
to eight years in the study of Harder et al. [54].
Different survival rates have been reported for CIR-FDPs
[37,38,53,54]. Concerning the two studies on zirconia restorations
included in our systematic review, Chaar and Kern [53] registered a
5-year survival rate of 95.8%, since 1 CIR-FDP had to be replaced
because of repeated debonding. Ohlmann et al. [38] confirmed
survival rates of 90% after 1 year of clinical use, as three inlay-
retained FDPs had to be changed because of framework fracture.
Conversely, four delaminations of the veneering material and six
decementations registered in their study did not require the
substitution of the restorations.
As regards the researches on lithium-disilicate ceramics,
Edelhoff et al. [37] recorded a 3-year survival rate of 90.09%, with
a sole failure consisting of a fractured connector. Harder et al. [54]
obtained 5- and 8-year survival rates of 57% and 38%, respectively.
Different complications and failure types, such as caries, end-
odontic problems, fracture or debonding at either the retainer,
pontic, or both, were registered. The hybrid-retained lithium-
disilicate restorations tested in the same investigation attained
survival rates of 100% after 5 years, which dropped to 60% after
8 years of follow-up.
3.4.4. Mechanical and functional outcomes
The failures reported by the clinical studies were mainly due to
mechanical, functional, and technical problems [37,38,53,54]. The
most frequent failures were debonding [38,53,54], chipping
[38,53], and framework breakage, which usually occurred at the
isthmus that connects the occlusal and proximal inlay boxes of the
abutments [37,54]. Ohlmann et al. [38] observed that the location
of the retainers did not influence the longevity of veneered zirconia
CIR-FDPs. Furthermore, Edelhoff et al. [37] explained that the core
material was very difficult to remove from the inlay cavity after
failure due to the ceramic hardness and the almost indistinguish-
able transition between material and tooth structure.
The most common type of failure registered by the FEA
investigations was the rupture at the connector area [9,45,69–
71,77]. Thompson et al.[70] reported that full-crown supported
FDPs display a more favourable stress distribution pattern largely
due to the added bulk material available being better able to absorb
and distribute stress; the open torsion box-like nature of the full
crowns; and the support gained from the crowns’ margins. This
adds considerably to the rigidity of the structure, leading to less
deflection, and, thus, more suitable stress distribution. Field et al.
[71] found that onlay-supported FDPs generated much lower
mechanical stresses than did inlay-retained structures. Nonethe-
less, they stated that FDP designs with similar flexural modulus
(which is largely determined by the geometry of abutments and
pontics) result in a comparable effect on the bone remodelling-
response. Among the three configurations of CIR-FDPs evaluated
by Magne et al. [45], i.e., 2-surface [MO or DO] vs. 3-surface
[MOD]; only the DO design showed almost pure compression at
the interface. Nonetheless, all groups exhibited a definite
compressive area at the occlusal side of the pontic, a tensile zone
at the gingival portion of the pontic, and tensile stress peaks at the
abutment/pontic connection areas (as previously described).
Magne et al. [45] reported better results for unreinforced
composite structures than for tough isotropic materials (i.e., gold,
alumina, zirconia), as the resilience of the composite proved
favourable in terms of stress transfer to the adhesive interface
under functional loading. For all other materials, the interfacial
stresses showed a characteristic pattern that switched from
compressive mode at the horizontal walls to tensile mode at the
vertical walls of the inlay preparations [45]. To improve the stress
distribution, the inclusion of extremely tough fibbers within the
composite [45], or the inclusion of zirconia bars in the structure of
lithium-disilicate ceramic [9] have also been proposed. Möllers
et al. [69] encountered a significant effect of the tooth mobility on
the stress distribution in the case of zirconia-based CIR-FDPs, so
that the resilience of the periodontal ligament was interpreted to
have a great influence on the maximal tensile stresses of these
restorations and also on their responses to loads. Zhang et al. [77]
observed that small perturbations of the loading position caused
the fracture load and crack pattern to vary considerably. Thus, the
fracture origins of inlay fixed FDPs changed from the bucco-
gingival aspect of the molar embrasure to the premolar embrasure
when the indenter force location was slightly shifted from mesial
to distal.
As for the laboratory investigations, those of Kiliçarslan et al.
[15], Monaco et al. [39], Wolfart et al. [73], Puschmann et al. [74],
Saridag et al. [75], and Kolbeck et al. [76], found that either in
zirconia or lithium-disilicate CIR-FDPs, the connector and the
retainer areas were, on the whole, the weakest parts.
In the study of Kiliçarslan et al. [15] zirconia-based inlay-
retained restorations exhibited the highest fracture resistance
when compared to metal-ceramic and lithium-disilicate CIR-FDPs
(which achieved the lowest values). However, for Kolbeck et al. [76]
different recently-marketed lithium-disilicate ceramic and com-
posite materials demonstrated sufficient fracture strength to be
considered for metal-free inlay-retained prostheses, with the
exception of the FibreKor (frame: resin matrix with glass fibers)/
Conquest Sculpture (veneer: polycarbonate dimethacrylate ma-
trix) combination (Table 4), which were recommended to be
regarded as a long-term provisional solution for inlay dentures.
The failures of their FRC inlay-retained FDPs were attributed to
chipping or delaminations of the facing materials [76]. This is in
agreement with the investigation of Saridag et al. [75], who
recorded higher bending values for FRC restorations than for
zirconia-based CIR-FDPs. The results of Bindl et al. [2] may
somewhat contribute to explain these findings, as their particular
slot-inlay FDP design behaved analogously to the ceramic, but not
to the composite, in terms of flexural strength. Rosentritt et al. [72]
registered the significantly highest fracture resistance for their
fibre-reinforced-based ceramic-veneered inlay FDPs, while their
zirconia/composite inlay FDPs showed significantly superior
 R. Castillo-Oyagüe et al. / journal of prosthodontic research 62 (2018) 10–23
fracture results when compared to those of lithium-disilicate
ceramics (Table 4).
The influence of the restoration design on the mechanical-
functional outcomes was also evaluated by several laboratory
studies. Puschmann et al. [74] confirmed that the mechanical
fatigue reduced the load-bearing capacity of zirconia-based CIR-
FDPs regardless of the connector size being 9 mm2 or 6 mm2.
Nevertheless, a further reduction to 6 mm2 resulted in a significant
decrease of the load-bearing capacity. Mohsen [52] found that
restorations with retainers prepared as occlusal-proximal inlay +
proximal boxes showed the highest fracture resistance for
replacing missing premolars and molars; while those with box-
shaped preparations disclosed the lowest fracture resistance.
Overall, the FDPs constructed for replacing molars attained lower
fracture resistance despite their design [52]. In line with this,
Ohlmann et al. [16] encountered acceptable fracture resistance
values for replacing a premolar or a molar with a polymer-
veneered zirconia-based CIR-FDP, but not for greater span lengths
(mainly up to 19 mm).
Finally, Mehl et al. [10] advised to remove any contact point in
eccentric, static, or dynamic occlusion, since the mean loading
cycles until fracture were significantly higher for centric loading
compared to eccentric loading in their study (performed with
industrially prefabricated zirconia veneered with a thin layer of
feldespathic ceramic and microhybrid composite).
3.4.5. Cementation
In all of the clinical papers included in the present review the
restorations were adhesively bonded [37,38,53,54]. Edelhoff et al.
[37] did not specify the type of luting cement utilised; Harder
et al. [54] used Bis-GMA-based resin cement; Chaar and Kern [53]
used phosphate monomer-containing (MDP)-based resin cement;
and Ohlmann et al. [38] compared MDP-based vs. Bis-GMA-based
dual-cure resin cements, finding no significant effect on failure
rates.
Before luting the restorations, the inner ceramic surfaces of the
inlay-retainers were submitted to different conditioning methods.
On their zirconia-based CIR-FDPs, Ohlmann et al. [38] used
tribochemical silico-coating plus silane; while Chaar and Kern [53],
used air-abrasion. Edelhoff et al. [37] and Harder et al. [54] pre-
treated their lithium-disilicate prostheses with hydrofluoric acid
etching plus silanization.
The tooth surfaces of the abutments were also pre-treated in
the in vivo studies. Most of them applied selective [37,38] or total
orthophosphoric acid etching [53] and/or dentin bonding/adhesive
[37,38,53,54]. A rubber dam was placed in those patients with
supragingival margins [37,38,53,54]. If fixation of a rubber dam was
impossible, cotton rolls and retraction cords were placed [38].
With respect to the FEA analysis, only the models of Magne et al.
[45] and Zhang et al. [77] considered the adhesion of the
restorations.
Finally, most of the laboratory in vitro investigations used Bis-
GMA-based resin cements [10,16,52,72–76]. Bindl et al. [2] did not
lute the restorations, while Kiliçarslan et al. [15] utilised eugenol-
free provisional cement.
A wide variety of surface conditioning methods were identified
in these studies regardless of the ceramic type. Zirconia-based CIR-
FDPs were submitted to sandblasting plus hydrofluoric acid
etching and silanization [39]; were pre-treated with sandblasting
plus MDP [73,74] or not-MDP [10] containing primers; or were
etched, silanated and applied a bonding agent [75]. Lithium-
disilicate-based restorations were etched with a special gel and
then treated with resin monomer [76]; were sandblasted and
treated with MDP containing primer [73]; or were etched,
silanized and applied a bonding agent [75].
19
The surfaces of the extracted teeth used in the four ex-vivo
studies [39,72,75,76] were also pre-treated with acid etching [76];
acid etching plus primer and adhesive [75]; dentin adhesive [72];
or sandblasting with alumina particles [39].
In all of the reviewed studies, the authors declared that the
luting procedures were carried out according to the manufacturers’
instructions.
3.4.6. Biological complications
Chaar et al. [3] reported low frequencies of secondary caries in
their revised articles. In the clinical papers of our systematic
review, caries [53,54] and endodontic problems [54] were the most
common biological complications registered, so that no included
investigations reported the absence of caries in any of the
abutment teeth after the follow-up period [37,38,53,54]. Chaar
and Kern [53] and Harder et al. [54] confirmed that their
restorations continued in function after the treatment of the
carious lesions, which occurred in less than 9% of their CIR-FDPs.
Harder et al. [54] performed an endodontic treatment
17 months after cementation in one abutment tooth, and the
restoration continued in function afterwards.
In most articles, the gingival conditions were generally good
[38,53,54]. Even though sealing the dentin was performed by many
authors [37–39,53,54,72,75], failures due to hypersensitivity have
not been clearly documented.
3.4.7. Aesthetics
As for the literature reviews, Chaar et al. [3] concluded that the
introduction of more translucent zirconia materials may enhance
the aesthetic properties of monolithic zirconia-based CIR-FDPs, so
that visible framework portions would not be opaque anymore. On
the whole, the clinical papers included in our systematic review
confirmed satisfactory aesthetic results for CIR-FDPs [37,38,53].
Edelhoff et al. [37] observed that the transition between the
prosthesis and the tooth structure was almost indistinguishable in
CIR-FDPs fabricated with pressed ceramic. Although this transition
was more evident in FRC restorations, their failure rates were
related to other, non-aesthetic aspects. The clinical investigation of
Harder et al. [54] was the only that did not inform about aesthetic
outcomes.
Neither the FEA, nor the laboratory experiments reported on
aesthetics.
4. Discussion
Inlay-retained FDPs allow for a minimally invasive prepara-
tion for replacing posterior missing premolars or molars [13].
Diverse aesthetic materials, such as zirconia, lithium-disilicate
ceramic, composite or FRC have recently been proposed for
fabricating this type of restorations. Undoubtedly, the impor-
tance of aesthetic factors such as minimising the appearance of
margins and the display of metal for achieving clinical success in
fixed prostheses implies a change in techniques and in treatment
philosophy [67].
The present systematic review aimed to synthesise the
available knowledge about all-ceramic posterior inlay-retained
FDPs. With this purpose, 23 studies were selected from 4942 origi-
nal articles; another 19 papers, which most published in 1990s
and 2000s, obtained QDP scores 11/15, had low/very low quality
according to the GRADE scale [65], were vague in study design, or
were updated in posterior investigations, and, therefore, were
excluded from the final analysis (Fig. 1). Meta-analysis was not
attempted due to the lack of RCTs, to the assorted design of the
papers (i.e., literature reviews, clinical trials, finite element
analyses, and laboratory experiments), and also to the
20 R. Castillo-Oyagüe et al. / journal of prosthodontic research 62 (2018) 10–23
heterogeneity detected within both the clinical and the in vitro
researches, which followed very different study protocols.
Concerning the material used, mostly researchers from the
literature reviewed have reported suitable results for zirconia-
based CIR-FDPs [2,9,10,15,16,38,39,45,52,53,69–75,77] when com-
pared with metal-ceramic [15], or lithium-disilicate ceramic
[15,72] in terms of fracture resistance. Zirconia-based CIR-FDPs
have demonstrated high survival rates ranging from 90% to 95% in
the mid-term [38,53], and the reported complications in the
included investigations (i.e., chipping, delaminations, and/or
decementations), did not require the replacement of the prosthe-
ses [38,53]. Nevertheless, their long-term successes must be
evaluated.
Notwithstanding that the selection of the most appropriate
zirconia system is multifactorial and case-sensitive; the improve-
ment of the zirconia translucency may allow fabricating CIR-FDPs
in monolithic pieces [3]. Although this could represent a proper
achievement to avoid the chipping problem thus preserving the
aesthetics [3], more studies are needed to reach enough scientific
evidence before recommending monolithic zirconia-based CIR-
FDPs for routinely use.
On the contrary, the clinical outcomes obtained for lithium-
disilicate ceramic discouraged the use of this material [37,54] for
constructing inlay-retained prostheses. In addition, the failures
described in the reviewed studies (such as ceramic delamination or
breakage of the structure) often required the substitution of the
rehabilitation [37,54]. Accordingly, a laboratory experiment
recommended lithium-disilicate CIR-FDPs only for patients with
low biting forces [73]. Nevertheless, given that these investigations
started in the 2000s [37,54], further research on CIR-FDPs
constructed with recently improved lithium-disilicate materials
and enhanced bonding methods should be conducted to redefine
these conclusions [78].
As a result of this systematic review, it can be concluded that the
reinforcement of apparently contraindicated materials with
infiltrations of though substrates may result in promising
combinations that optimise the stress distribution for an inlay-
retained configuration [9,45,72,76]. Some examples that deserve
further research are composite with extremely though fibbers
[45,76]; lithium-disilicate ceramic with zirconia bars [9]; or even
the mixture of ceramics and composite [72]. However, to date,
there is still insufficient evidence to draw firm conclusions in this
respect. Moreover, not only the type of material and its associated
mechanical properties, but other relevant factors, such as
treatment plan, case selection, tooth preparation, good under-
standing of the adhesive technology, and use of adequate surface
conditioning methods, would influence the longevity of the
restorations [3].
Despite the existing consensus on the ideal cavity design for the
inlay retainers [67], clinically, preparations tend to be wider and
often deeper than desired due to the volume of the previous
restorations and caries [67], which may have affected the results of
the reviewed clinical studies to some extent. In some of the in vivo
[53], FEA [45], and laboratory included investigations [2], a
modified configuration of the CIR-FDPs with additional slots was
used and demonstrated suitable results. This type of preparation,
which was first introduced by Wolfart and Kern in 2006 [79],
extends the bond surface in enamel and minimises the torsion
forces on the inlay retainers when the pontics are non-axially
loaded [2,45,53]. A FEA study [70] also concluded that a
broadening of the gingival embrasure would facilitate the
distribution of the forces derived from mastication to levels
within the strength range of current ceramics (situated around
700 N; which coincides with the average maximum posterior bite
forces) [80,81].
The connector was the weakest part of the restoration in this
systematic review [9,15,37,39,45,54,69–71,73–77]. This may be
explained because of the stress concentration generated at the
union between the occlusal and proximal areas of a CIR-FDP as a
consequence of the occlusal forces [9,37,73,77]. In fact, reduced
connectors resulted in higher failure rates [37]. Given that the
connectors’ dimensions were empirically established in the
included studies [10,15,16,39,52,72–75], further research should
be conducted, as the ideal size of the connectors may be a relevant
factor for the long-term success of CIR-FDPs. In this regard, just one
laboratory study recommended a minimum connector size of
6 mm2 [74].
Although the influence of the abutment preparation on the
clinical success of CIR-FDPs was not always demonstrated [38],
hybrid FDPs having an inlay and a full-crown as retainers were not
a reliable treatment option after 8 years of oral service as shown in
one of the reviewed in vivo articles [54]. Moreover, comparing CIR-
FDPs with onlay-retained prostheses, two finite element analyses
[71,77] confirmed that a preparation for an inlay preserves more
tooth tissue but generates higher mechanical stress because of its
lower structural attributes. Actually, as explained by these authors
[71,77], the choice of the abutment preparation largely came down
to a decision regarding its mechanical strength, and the preserva-
tion of tooth structure and periodontal health. The size of the
pontic should be also considered, since restorations replacing
premolars showed higher fracture resistance than those substi-
tuting molars in a laboratory experiment [52]; which should be
further evaluated.
Most of the included investigations combine ceramic surface
conditioning methods with adhesive cementation. However,
regardless of the ceramic type (zirconia or lithium-disilicate),
the reviewed articles show a lack of standardization concerning
the pre-treatment and luting procedures; which makes compar-
isons very difficult. Actually, resin bonding to dental ceramic is
still quite unpredictable and decreases over time [82,83]. Some
authors used silanization of silica-coated zirconia surfaces to
improve bond strength [38]; while others applied the silane after
etching their lithium-disilicate FDPs with hydrofluoric acid
[37,54]. During clinical function, inter-abutment forces would
also stress the retainer frameworks and adhesive interfaces,
causing possible detachment [38,84]. Also the eccentrically
loading of the pontics has been described to have an influence
in decementation [10,53,54]. Accordingly, most fracture and/or
debonding failures reported by one of the included studies [54]
were attributed to mandibular restorations replacing first molars.
Although this might be explained by the higher distortion of the
mandible and the superior chewing stresses in this area, such
affirmations should be corroborated in future investigations.
Moreover, the relatively small area bonded to enamel and the
large portion bonded to dentin usually found in these prostheses
might contribute to the loss of retention [53].
Despite all this, in light of the results recently obtained by Chaar
et al. in their review [3] and according to an update on bonding to
zirconia ceramic [3,85], the application of airborne particle
abrasion at a moderate pressure followed by MDP primers and/
or luting resins seem to provide long-term durable bonding to
zirconia ceramic under humid and stressful oral conditions. This
procedure was followed in one included in vivo paper; achieving a
high success rate [53].
Only one study included in our systematic review [38] assessed
the influence of the luting agent (MDP-based vs. Bis-GMA-based
resin cements) on the clinical success of zirconia-based CIR-FDPs;
but no significant effect on failure rates was observed. Nonetheless,
these preliminary results (at 1 year of follow-up) should be taken
with caution until they are confirmed in the long-term.
 R. Castillo-Oyagüe et al. / journal of prosthodontic research 62 (2018) 10–23
Overall, most authors agree in that the prosthesis/tooth bonded
interface has yet to be improved [82,83,85]. Therefore, more
investigation is needed before clinical use of CIR-FDPs can be
recommended without reservation.
From the biologic perspective, all of the included in vivo studies
registered the presence of carious lesions in some of the abutment
teeth [37,38,53,54]. Similarly to that occurred with the endodontic
problems detected, the viability of the restorations was not
compromised [54]. In addition, the use of CIR-FDPs preserves the
gingival and pulpal integrity. On the one hand, their preparation
causes reduced invasiveness in the surrounding tissues [37]. On
the other hand, the dentin is often sealed with adhesive and/or a
thin coat of a low-viscosity composite prior to bonding the
restoration in order to prevent contamination, hypersensitivity
and microfiltrations [37–39,53,54,72,75].
Despite that no restrictions to publication date or language
were applied, and that a wide variety of in vivo and in vitro studies
were evaluated in order to reach a complete update of the
reviewed topic; the short follow-up time (mean: 4.25 years) and
the relatively low evidence level of the clinical investigations
included were the two main limitations of this systematic review.
The failure rates of CIR-FDPs might increase in the long-term,
consistently with the results of one reviewed study on lithium-
disilicate ceramic [54]. No RCTs on the use of CIR-FDPs were
available in the literature and only four prospective cohort studies
fitted the inclusion criteria. The differences in materials used,
restoration designs, bonding techniques, and operators’ variability
and experience may have affected the results in a different manner
among the included studies. Therefore, even though zirconia-
based CIR-FDPs seem to offer better outcomes than other aesthetic
inlay-retained restorations, further long-term RCTs should be
performed before they can be recommended for general clinical
implications without restrictions [53].
5. Conclusion
On the basis of the reviewed literature, it can be concluded that
a three-unit CIR-FDP is a conservative and viable treatment option
for replacing a posterior missing tooth. The weakest points of CIR-
FDPs are: connectors, retainers, and bonded interfaces. A careful
case selection along with appropriate abutments’ preparation and
luting procedures may be decisive for the clinical success of a CIR-
FDP. Nonetheless, more investigation is still needed before
recommending their regular use in dental practice.
Appendix A. ‘Questionnaire for selecting articles on dental
prostheses’ (‘QDP’)
Eliminatory questions
1. Has the main purpose of the article direct clinical applicability?
2. Is the methodology reproducible and adequate for the rationale
of the study?
Introduction
3. Is the theoretical background well described and justified with
pertinent and updated references?
4. Are the aim(s) of the study and the null hypothesis(es) clear
enough and well formulated?
a) Materials and methods
5. Are the variables of the study well defined?
6. Regarding the tested groups:
21
a) For in vitro experiments: Is there a sufficient number of
specimens per group? Have they been randomly distributed?
b) For clinical trials: Is the sample size (n) adequate? Are the
inclusion and exclusion criteria well described? Have the
patients been randomly assigned to the groups?
7. Concerning the assessment of the study variables:
a) For in vitro experiments: Is the measuring method adequate?
b) For clinical trials: Are both the follow-up period and the
protocol of evaluation appropriate?
8. Have the potential confounding variables been kept under
control?
9. Is the statistical method suitable?
Results
10. Have the results been objectively enounced and accompanied
by appropriate figures and/or tables?
11. Do they report on statistical significance?
Discussion
12. Is there a sufficient contrast with the scientific evidence?
13. Have the differences with other studies been justified from the
methodological point of view?
14. Have the limitations and potential bias or confounding factors
been discussed?
Conclusions
15. Do they clearly answer to the null hypothesis(es), disclosing the
clinical significance and stating the possible extrapolation of the
findings?
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