Case Reports

Tooth-colored onlay restorations of cusp-fractured maxillary

premolars－cases report

WEN-CHIEH KUO YEN-HSIANG CHANG

Department of General Dentistry, Taoyuan Medical Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC.
College of Medicine, Chang Gung University, Taoyuan, Taiwan, ROC.

It is always a challenge for clinicians when a missing functional cusp of a maxillary premolar has to
be replaced. In the past, we used pins to retain the restoration, but the remaining cusp tended to become
weak and fractured during axial loading. With improvements in adhesive techniques and the
development of computer-aided techniques, we now offer more-conservative treatment for patients. The
CEREC system is the only chair-side treatment equipment currently available. It has several advantages
including a single-appointment finish, fine esthetic outcome, good clinical performance, preservation of
more tooth structure for better longevity, and several shades of ceramic blocks to choose from. In all 3
cases we present, we utilized the CEREC onlay to replace the palatal cuspal fracture which occurred in 3
maxillary premolars. In the first case, we utilized the CEREC onlay to replace the functional cusp of a
premolar and followed it up for more than 10 years. In the second and third cases, we used a CEREC
onlay to restore maxillary premolars which had been extensively destroyed. Clinical results of all 3 cases
were quite satisfactory, and the restorations have survived to the present. In this report, we present our
treatment experience and provide another treatment option for clinicians who might have come across
the same problem. （J Dent Sci, 3(1)：49-56 , 2008）

Key words: functional cusp fracture, cusp replacement, CEREC onlay, maxillary premolar.

The incidence of maxillary premolar tooth
fractures is quite common; it particularly occurs in
teeth with large intracoronal restorations1. The effects
of restorations are thought to be associated with
reduced amounts of dentin supporting the cusps of a
restored tooth. There have been several studies
analyzing different restorative materials for restoring
severely compromised teeth1-4. Segura et al.2 evaluated
the fracture resistance of 4 different restorations for
cuspal replacement on human extracted molars. Their
results revealed that composite resin restorations with
an adhesive had higher values of fracture resistance
Received: January 5, 2008
Accepted: March 18, 2008
Reprint requests to: Dr. Yen-Hsiang Chang, General Dentistry, De-
partment of Dentistry, Tao-Yuan Chang Gung
Memorial Hospital, No. 123, Ding-Hu Street, Kwei-
Shan, Taoyuan, Taiwan 33353, ROC.
than did other restorative techniques, while a
self-threading pin decreased the fracture resistance.
Macpherson2 also concluded that pin-retained
amalgam had less fracture resistance. Studies by
Pilo et al.3 showed that amalgam adhesives might
contribute to strengthening weakened cusps and
revealed good marginal adaptation. Qualtrough5
concluded that premolars prepared with extensive
compound preparation involving loss of the functional
cusp might have substantially weakened buccal cusps.
One has to minimize reductions in the buccal-palatal
width of the buccal cusp to prevent cusp fracture
and preserve the residual coronal tooth structure.
Therefore, a direct onlay restoration should be a better
choice than a crown. With improvements in dental
adhesive systems, bonded ceramic restorations are
recognized as an alternative to direct restorations6. To
the present, the CEREC system is 1 of the chair-side
applications of CAD/CAM technology for restorative
dentistry; using it, dentists can provide an esthetic

J Dent Sci 2008‧Vol 3‧No 1 49

W.C. Kuo and Y.H. Chang.
restoration in a single appointment. According to
many clinical studies6-8, it has shown good
performance and longevity with the direct placement
CAD/CAM technique. Some dentists have doubts
about its fitness and wear resistance. But in Harry et
al.’s study9, they concluded that the marginal gap of
CEREC II system was 85µm. Several clinical studies
have reported that CEREC restorations display greater
fit and marginal integrity than laboratory-fabricated
restorations. In addition, Leinfelder8,10 concluded that
CAD/CAM restorations demonstrate a yearly wear
rate of 20 µm, compared to a wear rates of 8~10 µm
for amalgam and 25~50 µm for composite resin. Reich
et al.10 found that CAD/CAM was able to successfully
restore severely decayed teeth, while preserving the
natural tooth structure as indicated by the pre-
ponderance of onlay restorations. Therefore, utilizing
the CEREC restoration to treat an extensively de-
cayed tooth is practicable, and its success can also be
predicted. But we should take many clinical
limitations into consideration such as isolation
requirements for a sound adhesive technique, occlusal
space limitations for proper preparation, and ceramic
volume design to meet clinical biomechanical de-
mands of clinical applications19. Careful examination
and case selection are also very important before
choosing the CEREC system for treatment.
In this report, we present 3 cases of a maxillary
premolar with a functional cusp fracture or extensive
damage. The premolars of these patients were all
replaced with a CEREC onlay and cemented with
resin adhesive. In 1 case, the patient has been
followed up for more than 10 years. Results of all of
the cases were satisfactory and have lasted to the
present. We present our experience with replacement
of functional teeth with a fractured cusp.
CASE PRESENTATION
All 3 cases in this report had a cusp fracture of a
functional maxillary premolar. The pulps were
healthy, and the buccal cusps remained intact. Under
these circumstances, an onlay restoration is an
appropriate option. At present there are mainly 3 kinds
of materials available: cast metal, ceramic, and resin
reinforcement. Cast metal is not applied to the
premolar area because of esthetic reasons. In com-
parison, the wear-resistance, flexural strength, and
color durability of ceramic are superior to those of
50
resin reinforcement18. Therefore, we chose ceramic
for onlay fabrication because of its durability,
performance, and precision.
Case 1
A 34-year-old female patient visited our dental
department in 1995 due to a fracture on the distal-side
marginal ridge of the left side maxillary second
premolar (#25). Through an electric pulp tester (EPT)
test, we determined that the vitality of this tooth was
positive, and she reported no discomfort. She only
complained of food impaction between the adjacent
teeth and hypersensitivity when consuming hot or cold
drinks. An x-ray examination of #25 revealed an old
amalgam filling on the mesial surface, and secondary
caries was found on the distal surface. The support-
ing bone was intact without periodontal ligament
widening or an apical lesion. After we removed all of
the old amalgam and carious tissue, the pulpal wall of
the cavity was very close to the pulp but not involved,
so indirect pulp capping with calcium hydroxide and
Copalite varnish was applied. Then we restored the
cavity with amalgam. After 6 weeks, we rechecked the
tooth by x-ray which revealed a good treatment result.
However, 2 years later (1997), she visited us again,
complaining that her left maxillary second premolar
palatal cusp had fractured. We found the fracture
extended even with the gingival margin (Figure 1A,B),
but the previous amalgam was still retained. After
removing the old amalgam, we found that the buccal
cusp was still sound. Based on conventional concepts,
a crown had to be fabricated, and a buccal cusp had to
be prepared, which was quite a pity. Under such
circumstances, if it was restored with pin-retained
amalgam or a composite resin, a tooth fracture was
likely to occur again. Another option was crown
construction, but more tooth structure would have to
be removed, and root canal treatment might be
required. Finally, the best option was CEREC onlay
restoration. With this method, we not only could
preserve the remaining buccal cusp structure and
maintain the vitality of tooth, but also achieved an
esthetic and durable restoration. We prepared the
cavity only along the original defect area, without
placing any mechanical undercutting to weaken the
tooth structure. All margins had a 90° butt-joint
cavosurface angle. All line and point angles were
rounded to avoid stress being concentrated on the
restoration and tooth. The CEREC onlay was
J Dent Sci 2008‧Vol 3‧No 1

cemented with an adhesive technique for greater
retention. Therefore, differing from the conventional
gold onlay, the CEREC does not need a bevel or
shoulder and can preserve more of the tooth structure.
After preparing the tooth, we evaluated the remaining
portion of the enamel to ensure that it had sufficient
bonding strength (Figure1C). We took an optical
impression of the prepared tooth and used CEREC 2
to design a restoration for this MOD+P cavity (Sirona,
CEREC 2). Finally, we fabricated the CEREC onlay
(ceramic blocks, Vitablocs Mark II, Vita Zahnfabrik,
Bad Sackingen, Germany) and cemented it with resin
cement (Variolink, Ivoclar Vivadent AG, Schaan,
Liechtenstein) under moisture control with rubber
dam isolation. The internal surface of the ceramic
restoration was etched with 4% hydrofluoric acid (IPS
Ceramic Etching Gel, Ivoclar Vivadent AG, Schaan,
Liechtenstein) for 5 minutes, silanated with Mono-
bond S (Variolink, Ivoclar Vivadent AG, Schaan,
Liechtenstein), and covered with Helibond (Variolink,
Ivoclar Vivadent AG, Schaan, Liechtenstein). The
cavities were etched with 37% phosphoric acid, and
we applied a dentin-bonding agent to the cavities
(Syntac classic, Ivoclar Vivadent AG, Schaan, Lie-
chtenstein). Then we inserted the ceramic restoration
using light pressure with a ball burnisher to seat it.
Excess composite resin was removed with a thin-
bladed composite instrument or an explorer. The
cement was light-cured from each direction for an
exposure of at least 60 seconds. We adjusted the
occlusion to obtain light contact on the palatal cusp
tips, and a flat cusp inclined plane. We polished and
finished the restorations using a series of fine diamond
instruments and 30-fluted carbide finishing burs under
air-water spray (Figure 1D). After treatment, we
followed-up the case at 2, 3, 7, and 10 years, and
results showed that this tooth was still in a healthy
condition and functioning very well (Figure1E, F).
Meanwhile, we found that marginal staining between
the CEREC onlay and tooth was detectable along the
cavosurface margin, but there were no secondary
caries or fracture.
Case 2
A 54-year-old female visited us to restore a
decayed right-side maxillary second premolar(#15)
(Figure 2A). Clinical examinations revealed that the
pulp was healthy, and an x-ray showed that the bone
structure was good (Figure 2B). But the palatal side
J Dent Sci 2008‧Vol 3‧No 1
Cusp replacement with a CEREC onlay
margin was level with the gingiva, and the mesial side
had extensive caries and was close to the pulp. After
we removed the carious lesion and retained the sound
sclerotic dentine, a CEREC onlay (ProCAD blocks)
was fabricated by CEREC 3 (Sirona, CEREC 3), and
all procedures were completed in 1 appointment.
Occlusion adjustment, polishing, and finishing were
performed using a diamond bur and a polishing kit
(Brassler ceramic polish kit, USA) (Figure 2C). Two
months later, we checked this restoration. She
complained of no pain or discomfort. The occlusal
function was normal, and the esthetics were accept-
able (Figure 2D).
Case 3
The right-side maxillary second premolar of this
26-year-old female patient had a large extensive cavity.
This cavity involved the marginal ridges on both
the mesial and distal sides (Figure 3A). Clinical
examinations revealed that the cavity margin extended
almost to the subgingival level, but an x-ray showed
that the periodontal ligament and supporting bone
were normal (Figure 3B). The tooth gave a positive
response to the electric pulp test. She felt no pain or
discomfort during percussion, palpation, or the biting
test. Therefore, we prepared the cavity for rounding
cavosurface and temporary restoration with inter-
mediate restorative material (IRM, Densply Caulk,
USA). It was very important for us to ensure that pulp
was still healthy before the treatment to prevent
restoration failure. One month later, we removed the
temporary restoration and again evaluated the pulp
vitality. Based on our previous experience, we decided
to use the CEREC onlay to restore this cavity. While
the cavity was being prepared, we found the cavity
margin had extended to the subgingival area, and the
resistance strength had been lost. So we designed a
mesial-to-distal side shoulder to increase the retention
and resistance strength in the buccal-palatal direction.
Finally, we restored the cavity with a CEREC onlay
and cemented it with resin adhesive (Variolink II resin
cement, Ivoclar Vivadent AG, Schaan, Liechtenstein).
However, we found it was hard to isolate the tooth
with a rubber dam for cementation because the margin
was subgingival. Instead of rubber dam application,
we placed a retainer with a metal band for isolation.
After cementation, we adjusted the occlusion and
polished the restoration (Figure 3C). After 1 week,
we followed-up this restoration and found mild
51
W.C. Kuo and Y.H. Chang.

1A 1B

1C 1D

1E 1F

1G 1H
Figure 1. (A) Photograph showing the old amalgam filling retained but a palatal cusp fracture with an
even gingival margin. (B) Periapical radiograph revealing a #25 palatal surface fracture before CEREC
onlay fabrication. (C) After removing the remaining amalgam and preparing the cavity. (D) Photograph
and radiograph after cementation and finishing. (E) After 10 years of follow-up, showing discoloration of
the margin but no evidence of secondary caries or tooth fracture. (F) Radiograph revealing surrounding
sound bone after 10 years.

52 J Dent Sci 2008‧Vol 3‧No 1

 Cusp replacement with a CEREC onlay

2A 2B

2C 2D
Figure 2. (A) Photograph showing the MOD and palatal cusp fractured decay. (B)
Radiograph revealing no apical lesion or periodontal problems. (C) Occlusal view of the
CEREC onlay restoration after cementation. (D) Photograph 2 months after cementation.

3A 3B

3C 3D
Figure 3. (A) Photograph showing the MOD+P decay after preparation. (B) Periapical
radiograph revealing the normal lamina dura. (C) Occlusal view of the CEREC onlay
restoration. (D) Periapical radiograph taken after 8 months by orthodontists which reveals the
healthy supporting structure.

J Dent Sci 2008‧Vol 3‧No 1 53

W.C. Kuo and Y.H. Chang.
gingivitis surrounding the onlay (Figure 3D). We
cleaned the residual resin cement and again checked
the occlusion.
DISCUSSION
It has been over 20 years since the CEREC
system was first applied to clinical treatment in 1985.
The method using this kind of optical impression has
been widely accepted. The CEREC has advanced
from the first to the third generation with great
improvements in material options and operating
interfaces13. Clinically CEREC has been widely used
by many dentists. In 2003, 3D imaging software was
incorporated into the CEREC system, making it easier
for dentists to operate it15. This simplified design
procedures, became more accurate, and allowed better
marginal adaptation14. It saved on chair time and
shortened the learning curve13-15. In fact, the CEREC
system has been widely used for inlays, onlays,
all-ceramic crowns, and veneers. A systematic review
of CEREC ceramic inlays by Martin et al.20 found that
the CEREC system had a mean survival rate of 97.4%
over a period of 4.2 years. Another studies by Otto21
and Reiss22 also showed the survival probability rate
of CEREC inlays and onlays reached 90.4% after 10
years. Thus, this is a reliable treatment option for
clinicians due to its predictable success.
In cases of large decay or loss of the entire cusp
(particularly in cases with a functional cusp), the
restorative procedure becomes more challenging1.
The choice of restorative material or technique might
influence the success or failure of the treatment5.
Ideally, when a multisurface cavity involves the entire
cusp, full coverage with a crown or onlay restoration
is the best choice6. In the first case, we restored the
MOD decay with amalgam but it failed after 2 years
because of cusp fracture. Amalgam, as a restorative
material, still offers good physical properties, minimal
wear, and fairly good advantages when restoring
multiple surfaces in posterior teeth. Michael et al.11
concluded that there was no difference in cusp fracture
rates between amalgam and resin-based composite
restorations. Studies by Qualtough et al.5 found that
different types of restorations may have ill effects on
the fracture resistance of the restored premolars.
Using amalgam alone or with pins for transitional
restorations in premolars may result in tooth structure
damage. Fortunately in our case, the margin of the
fractured cusp did not impinge on the root surface and
54
could be replaced with a CEREC onlay. If an adhesive
restoration had been chosen earlier, the risk of frac-
ture cusp would have been decreased or avoided.
Moreover, when a palatal cusp fracture of a premolar
occurs, one should evaluate the pulp vitality, the size
of the cavity, the occlusal relationships, and the
residual supporting tooth structure. It is important to
confirm the pulp vitality before the CEREC onlay
fabrication to prevent the necessity of root canal
treatment after restoration. In the third case, indirect
pulp capping was done and followed-up for 1 month.
When the positive pulp vitality was confirmed, the
CEREC restoration was fabricated.
In addition, margin adaptation is often deemed a
critical factor in the longevity of indirect restorations7.
Recently, the bond strength of resin cement has been
improved, and the margin adaptation of the CEREC
system has been verified. After a year, we found no
secondary caries or cement dissolution except some
stains on the margin.
Clinically, we have applied many CEREC re-
storations in inlays, onlays, all-ceramic crowns, and
veneers for anterior teeth. In our experience and other
reports6-8, the longevity and good performance of the
CAD/CAM technique can be predicted.7 In our 3 cases,
we prepared the cavity, fabricated the CEREC onlay
restoration, and cemented the restoration in the same
appointment. This not only saved chair time but also
prevented buccal cusp fracture and cavity conta-
mination during the temporal phase.
There are some factors which determine the
success of CAD/CAM restorations such as (1)
postoperative sensitivity, (2) moisture isolation, (3)
design of the cavity, and (4) occlusion adjustment. We
discuss each of these problems below.
Many dentists have received complaints of
postoperative sensitivity after performing adhesive
restorative procedures. Among our 3 cases, only 1
case complained of postoperative sensitivity within
the first week, but it improved after 1 week.
According to a study by Dennis7, posterior sensitivity
was resolved in 2 weeks during a 3-year study per-
iod. Use of a rubber dam can prevent moisture
contamination and produce a better operating field.
This procedure can reduce the incidence of pos-
toperative sensitivity6. Furthermore, the long-term
success of adhesive-bonded restorations is determined
by a precise and careful luting procedure. But
sometimes, the cavity containing extensively severe
destruction or the cavity margin extending to the
J Dent Sci 2008‧Vol 3‧No 1

subgingival area can lead to difficulty in applying a
rubber dam. In the third case, because the palatal
cusp fracture extended to the subgingival margin, we
separated the adjacent teeth with a thin metal band and
retainer to obtain optimal isolation during the
cementation procedure. However, an adhesive ce-
mentation procedure without a rubber dam is time-
consuming6.
In addition, in cases where the margin of the
tooth fracture is in a bad position or a severely
destroyed area, a mechanical form should be designed
to increase retention and resistance. In the third case,
we encountered this problem and tried to prepare a
shoulder to increase the stability and resistance of
restoration. Sometimes we might prepare a slot or box
to reinforce the retention. According to studies by Lin
et al.12, they thought that an additional reinforced slot
in proximal area can increase retention when a
restored tooth receives an axial occlusal load.
Nevertheless, we designed this mechanical component
in a safe area as far as away from the pulp chamber to
prevent pulp damage. The size and depth of the
additional mechanical component also depend on the
remaining tooth structure.
After cementing the CEREC onlay, appropriate
occlusal adjustment is a key point for success. We
checked the static and dynamic occlusal relationships
and again eliminated other risk indicators for cusp
fracture16,including bruxism and worn teeth, a steep
cuspal anatomy, traumatic occlusal relationships, etc.
Clinically, we evaluated the causes of tooth fracture,
prevented the risk factors from occurring, and expect
excellent long-term results. In our cases, we should
evaluate the occlusion before preparation to ensure
that the biting force will not concentrate on the
junction between the tooth and the restoration. Finally,
it is also important to follow-up the restoration a few
days after cementation and to recall the patient every 6
months17.
All 3 cases described above involved repairing a
functional cusp by utilizing a CEREC onlay. Either
it was a fracture caused by oversized fillings or
a defect caused by tooth decay. Our treatment
strategies were to preserve a sound tooth structure,
reduce tooth destruction, and avoid pulp damage. With
a crown prosthesis, either much dentin has to be
removed or intentional endodontic treatment has to be
carried out. Based on a conservative and noninvasive
treatment concept, it is better to use a CEREC onlay.
Meanwhile during restoration, the same problem of a
J Dent Sci 2008‧Vol 3‧No 1
Cusp replacement with a CEREC onlay
lack of mechanical design of sufficient retention and
fracture resistance must be faced. High-quality
adhesives should be used for these restorations.
Clinically, optimal isolation measures are needed
for better adhesive restoration. However, not every
clinical case is so easy. Under such conditions, we can
offer a modified method of isolation. In addition, in
order to avoid cusp fracture after restoration in the
first case, when preparing extensive caries, we use an
adhesive restoration as the first choice.
In summary, when faced with a tooth with
extensive destruction or a fractured cusp but intact
pulp, we may consider choosing the CEREC onlay for
restoration. However, careful case selection and
optimal clinical procedures are keys to success. There
are many advantages of utilizing the CEREC system,
such as preserving more tooth structure compared to a
crown, acceptable esthetic results, ideal retention and
fracture resistance, reducing the number and time of
chair-side treatments, preventing tooth contamination
during the temporal phase and the occurrence of
buccal cusp fracture, and predictable longevity and
performance of restorations. We present our treatment
experience of the 3 clinical cases, hoping to provide a
better alternative method for cases with a fractured
cusp.
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