Case Report

___________________________________________________ ____________________
J Res Adv Dent 2014; 3:2s:72-77.

All Ceramic Inlay: A Case Report

Priti D Desai1* Pathik P Patel2 Khyati Shah3 Pankaj N Patel4

1Professor, Department of Conservative Dentistry, Gurunanak Institute of Dental Science and Research, Kolkata, WB, India.
2Post Graduate Student, Department of Conservative Dentistry, Karnavati School of Dentistry, Gandhinagar, Gujarat, India.
3Private Consultant, Prosthodontics, Kalol, Gandhinagar, Gujarat, India.
4Private Practitioner, Conservative Dentistry and Endodontics, Kalol, Gujarat, India.

ABSTRACT

Introduction: Esthetic restoration is a prime concern for everyone in todays’ world. Dentists are in search of a
durable and tooth coloured restorative material. All ceramics with high strength are better alternative to
composite, amalgam and gold for posterior tooth restoration.

Case description: A patient comes for restoration of carious lesion involving proximal contact on mesial side of
maxillary first molar. The cavity was prepared, rubber base was taken and all ceramic inlays were prepared with
e max –cad material (Ivoclar vivadent). After preparation, it was cemented with resin cement (U1003M ESPE).
Follow up was done after seven days, one month, three months, six months uptil two years respectively.

Discussion: All ceramic inlays showed better esthetic and marginal adaptation immediately after restoration
and after 7 days, one month and three months, six months, one year and two years. The patient is comfortable
with restoration. There were no marginal deterioration, no crack formation, and no discoloration after two years.
All ceramic restorations overcome the weakness of other esthetic restorative material and give good esthetic as
well as function.

Conclusion: All ceramic inlays are better alternatives as esthetic restoration for medium to large size carious
lesion, among different all ceramic material cad cam inlay is best for marginal adaptation and function of
restoration.

Keywords: Inlay, All ceramic, IPS e-max.

INTRODUCTION are in search of a durable and restorative tooth

Aesthetic treatment is one of the most
required dental treatments coming after pain
related treatments in conservative dentistry.
Aesthetics is playing an increasingly important role
in the choice of dental restorations. Re-creating the
original tooth as faithfully as possible is a
challenging task for both the operator and the
dental material. Colour, shape and the surface
texture are very important in aesthetic
characterization and personalizing a smile. Dentists
colour material for teeth.
Various materials used are Glass ionomer
cement, Composite resin, ceramic bonded to metal
and All Ceramic. All ceramic material with high
strength is becoming popular as aesthetic
restoration. As the aesthetic aspect of dental care
becomes increasingly important to patients, the
dental practitioner should be aware of the
applications and limitations of the various tooth-

_______________________________________________________________________________________

Copyright ©2013
Fig 1: Carious lesion preoperatively. Fig 4: After preparing inlay.

Fig 2: Preoperative radiograph. Fig 5: Cement for cementation.

Fig 3: After cavity preparation. Fig 6: Immediately after restoration.

73
Fig 7: Postoperative radiograph. Fig 10: After one month of restoration.

Fig 8: Postoperative view in occlusion Fig 11: After 6 months of restoration.

Fig 9: After seven days of restoration. Fig 12: After 2 years of restoration

74

Fig 13: Post operative radiograph after 2 years
coloured restorative systems available for
the restoration1.
Introduction of ceramic material for
aesthetic is limited due to its abrasiveness to
natural tooth structure which may accelerate the
wear of natural enamel. Once a vivo study was
conducted to quantify the wear of natural enamel
opposing three ceramic materials as influenced by
ceramic. It was concluded that equivalent wear
occurs between ceramic/enamel and
enamel/enamel pairs and ceramics offer a
restorative option.2 The survival rate of Ceramic
restoration and ceramic inlay onlay shows 94 % for
4-5 years and 91 % up to 7 years.3
All ceramic based inlays provide aesthetics
and durability as restoration. It maintains a better
anatomic forms, exhibits a better marginal integrity,
and colour stability in oral cavity. All Ceramic-based
inlays also reinforce the remaining dental hard
tissue as they bond to the tooth with adhesive
cement.4
All ceramic material with high strength is a
better alternative to composite, amalgam and gold.
All ceramic inlay and onlay is recently most useful
for moderate to large size restorations. Various type
of all ceramic material are available, among them
IPS e-max is recently introduced with high strength
and excellent aesthetic. Herewith we would like to
report case treated with IPS e max inlay observed
for two years.
CASE REPORT
A 30 year old male patient came to private
dental clinic for treatment of broken composite
restoration in 26 with no pain and sensitivity in
tooth. Patient was interested in aesthetical durable
restoration, it was decided to give all ceramic inlay
as restoration. Cavity preparation was done with
the principle of cavity preparation. After the cavity
preparation impressions were made and send to
laboratory, where IPS e.max CAD Ceramic inlay was
prepared. In laboratory –Image was scanned from
the cast and dye cut was prepared, milling of
ceramic inlay was done with IPS e.max CAD block
(Ivoclar vivadent, Europe). After preparing the
inlay, it was etched and silanated and cemented
with RelyXTMU100 self-adhesive Universal Resin
Cement. (3M ESPE USA).
The patient was observed clinically after 7
days, one months, six months and two year for
restoration for pain, sensitivity, marginal
adaptation, crack formation, fracture and
discoloration. Clinical photograph and radiographs
were done to correlate clinical and radiographic
evaluation. (Figure – 1, 2, 3, 4, 5, 6, 7, 8)
RESULT
Result showed that there was no pain, no
sensitivity, no marginal deterioration, no crack
formation, no fracture and no discoloration even
after two years of restoration. Radiographs after 7
days, one month, six months and two year of
restoration also shows there is no development
marginal gap and secondary caries around the
restoration. (Figure - 9, 10, 11, 12, 13)
DISCUSSION
As the aesthetic aspect of dental care
becomes important to patients, aesthetics is playing
an increasingly important role in their choice for
dental restorations. There are various options of
aesthetic restoration for anterior teeth but aesthetic
restoration for posterior teeth is a challenge for
dental practitioner. Various aesthetic materials for
posterior teeth include direct composite
restoration, indirect composite restoration, metal
ceramic restoration, all ceramic restoration.
Direct composite is generally used for small
to medium size preparation and can be placed in
75
one appointment but there are certain reasons like
difficulty in placement, improper marginal
adaptation, difficulty in finishing & in developing
contour and contacts, chances of voids which leads
to weakening of the restoration, chances for
microleakage and post-operative sensitivity. So it
becomes difficult to use in day to day practice.
Indirect composite restorations provide
good color match, easy to finish, intra oral repair is
possible but there are chances of poor marginal fit,
marginal failure, require laboratory support,
technique sensitive, adhesion to tooth may be
weak.
Metal ceramic restorations for small to
medium size carious lesion in posterior teeth are
difficult to fabricate and do not provide good
aesthetics. Metal ceramic is generally used for full
coverage restoration.
All ceramic material with high strength
provide good restorative alternative to moderate to
large size carious lesion. Cavity preparation is also
simple for example the line angles and point angles
are rounded, floor and gingival sheet area is smooth
and flat, cavo-surface angle is 900, walls are
diverging, isthmus is wide, if any undercuts are
present can be blocked with glass-ionomer cement,
0.5mm clearance from adjacent teeth and all cavity
walls should have the same path to draw.
In one study clinical assessment and
survival rate ceramic inlay showed that the lack of
recurrent caries, the only slight changes in marginal
discoloration and colour match, combined with the
excellent longevity prove that ceramic inlays are a
valuable tool for the restoration of posterior teeth.5
Evaluation of clinical performance of ceramic inlay
and composite inlay proved that posterior tooth-
colour inlays exhibited a success rate of 100% for
ceramic inlays and 90% for composite inlays even if
placed by relatively inexperienced but supervised
student operators.6 One
systematic review of ceramic inlays had assessed
the quality of published clinical studies, and
determines the clinical effectiveness of
ceramic inlays compared to other forms of posterior
restorations. They wrote that many study result
indicates no significant differences in longevity or
postoperative sensitivity between ceramic and
other posterior restorations over assessment
periods of up to 1 year and concluded.7
Evaluation the performance of Class
II Cerec inlays after 10 years of clinical service
found that patient satisfaction with and acceptance
of the Cerec inlays were high, and the performance
after 10 years of clinical service was acceptable.8
Another study regarding clinical performance of
bonded leucite-reinforced glass ceramic inlays and
onlays after eight years proved that IPS Empress
inlays and onlays demonstrated to be successful
even in large defects. Neither the absence of enamel
margins, nor cuspal replacement significantly
affected the quality of the restorations.9
A Longitudinal clinical evaluation of
bonded composite inlays shows that composite
inlay gives high success rate in clinical practice that
not related to size of lesion or tooth type. These
proves that bonded restoration always helps in
strengthens of remaining tooth structure and
increase survival rate of tooth (Barone A et al,
2008)10. Clinical study by R. T. Lange showed that
indirectly manufactured Evopress ceramic inlays
performed better than direct Filtek Z250 composite
restorations in marginal adaptation, colour match
and anatomic form.11
The monolithic leucite and lithium
disilicate glass ceramic systems have shown
promising laboratory and clinical results for small
restoration such as inlay, onlay, crown and
laminates.12
IPS e.max (Ivoclar vivadent) newly
developed glass ceramic material containing the
lithium disilicate (LS2) shows that esthetics and
strength can be successfully combined. It has high
strength up to 400 Mpa. For single-tooth
restorations, this innovative ceramic produces good
esthetic as well as offers a flexural strength that is
2.5 times higher than that of other glass-ceramics. It
is available as pressable ceramic blocks and CAD
CAM blocks. Self-adhesive or conventional
cementation methods can be used for it.
In large carious lesion or in replacement of
failed restoration cavity preparations significantly
weaken the remaining tooth structure. Acid etching
76
and adhesive technique do reinforce dental
structures in a way that stiffness values of restored
teeth approximate the value of sound teeth. There
are certain limitations of ceramic inlay restoration
like it requires 2-3 appointments, good laboratory
support, difficult to repair and somewhat costly.
CONCLUSION
All ceramic restorations overcome the
weakness of other esthetic restorative materials like
Glass ionomer, composite resin and give good
esthetic as well as function. Ceramic inlay is a better
alternative as esthetic restoration compared to
direct and indirect composite resin restoration for
medium to large size carious lesion. Among
different All ceramic material IPS e.max CAD inlay is
best for marginal adaptation and function. More
studies are required to know long term
performance of IPS e.max CAD All ceramic inlay.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this
article was reported.
REFERENCES
1. Burke EJ, Qualtrough AJ. Aesthetic inlays:
composite or ceramic? Br Dent J 1994
176:53–60.
2. Clelland NL, Agarwala V, Knobloch LA,
Seghi RR. Wear of enamel opposing low-
fusing and conventional ceramic
restorative materials. J Prosthodont 2001
10:8–15.
3. El-Mowafy O, Brochu JF (2002). Longevity
and clinical performance of IPS-Empress
ceramic restorations—a literature reviews.
J Can Dent Assoc 68:233–237.
4. Fradeani M, Aquilano A, Bassein L (1997).
Longitudinal study of pressed glass-ceramic
inlays for four and a half years. J Prosthet
Dent 78:346–353.
5. Fuzzi M, Rappelli G (1999). Ceramic inlays:
clinical assessment and survival rate. J
Adhes Dent 1:71–79.
6. Manhart J, Scheibenbogen-Fuchsbrunner A,
Chen HY, Hickel R. A 2-year clinical study of
composite and ceramic inlays. Clin Oral
Investig. 2000 Dec; 4(4):192-8.
7. Hayashi M, Wilson NH, Yeung CA,
Worthington HV . Systematic review of
ceramic inlays. Clin Oral Investig 2003 7:8–
19.
8. Sjögren G, Molin M, van Dijken JW. A 10-
year prospective evaluation of CAD/CAM-
manufactured (Cerec) ceramic inlays
cemented with a chemically cured or dual-
cured resin composite. Int J Prosthodont
2004 17:241–246.
9. Krämer N, Frankenberger R (2005). Clinical
performance of bonded leucite-reinforced
glass ceramic inlays and onlays after eight
years. Dent Mater 21:262–271.
10. Barone A, Derchi G, Rossi A, Marconcini S,
Covani U. Longitudinal clinical evaluation of
bonded composite inlays: a 3-year study.
Quintessence Int. 2008 Jan; 39(1):65-71.
11. R. T. Lange and P. Pfeiffer, Clinical
Evaluation of Ceramic Inlays Compared to
Composite Restorations. Operative
Dentistry: May 2009, Vol. 34, No. 3, pp. 263-
2.
12. Petra C Guess and Stefan schultheis et al. all
ceramic systems: Laboratary and clinical
performance .Dent. Clinics of north America
55 (2011) 332-352.
77