Ceramic inlays and onlays

indications and contraindications of ceramic inlays and onlays
Difference between cast gold and ceramic inlay/onlay tooth preparation

1. CERAMIC INLAYS AND ONLAYS Presented by : Neha Deshpande

2. CONTENTS Introduction History Indications and contraindications Advantages and Disadvantages Clinical procedures : INLAYS AND ONLAYS Difference between ceramic and cast metal inlays and onlays Impression Try-in and cementation Finishing and polishing Inlays onlays using Different ceramic systems Common problems and solutions Repair of ceramic inlays and onlays Conclusion

3. INTRODUCTION Dental ceramics are nonmetallic , inorganic structures, primarily containing compounds of oxygen with one or more metallic or semi-metallic elements ( aluminum , boron, calcium, cerium, lithium, magnesium, phosphorus, potassium, silicon, sodium, titanium, and zirconium). Ceramic inlays offer an aesthetic alternative to metal class I or II restorations. Their primary use is in compromised posterior teeth with intact buccal and lingual walls. These restorations offer the opportunity to conserve tooth structure while taking advantage of the mechanical benefits of modern adhesive technology, which can strengthen the compromised tooth According to Sturdevant , an onlay caps all cusps; an inlay may cap none or may cap all but one cusp.

4. HISTORY Late 1700s : Ceramic materials were first used in dentistry to fabricate porcelain denture teeth 1887 : Charles H Land, a dentist from Detroit, MI, USA, fabricated the first ceramic crown Early 1970s : Duret pioneered the use of computer-aided design/manufacturing (CAD/CAM) in dentistry. 1980s : Mörmann et al developed the first chair-side economical restoration of aesthetic ceramics (CEREC) system, which allowed inlays to be machined from prefired ceramic blocks in the dental office. 1980s : the concept of acidetching porcelain to permit use of resin composite for luting porcelain restorations was developed. At about the same time, castable glass ceramics were introduced

5. INDICATIONS

6. 1. SMALL TO MODERATE CARIOUS LESIONS Garber DA, Goldstein RE. Porcelain & composite inlays & onlays : esthetic posterior restorations. Chicago: Quintessence; 1994 Jan.

7. 2. LARGE CARIOUS OR TRAUMATIC LESIONS Garber DA, Goldstein RE. Porcelain & composite inlays & onlays : esthetic posterior restorations. Chicago: Quintessence; 1994 Jan.

8. 3. ENDODONTICALLY COMPROMISED TEETH Garber DA, Goldstein RE. Porcelain & composite inlays & onlays : esthetic posterior restorations. Chicago: Quintessence; 1994 Jan.

9. 4. Teeth where it is difficult to develop retention form Garber DA, Goldstein RE. Porcelain & composite inlays & onlays : esthetic posterior restorations. Chicago: Quintessence; 1994 Jan.

10. 5. When metal allergy is a factor 6. The restoration of teeth in an arch opposed by already present porcelain restorations Garber DA, Goldstein RE. Porcelain & composite inlays & onlays : esthetic posterior restorations. Chicago: Quintessence; 1994 Jan.

11. CONTRAINDICATIONS Parafunctional habits Aggressive wear of dentition Although technique-sensitivity is itself not a contraindication, difficulty to maintain a dry operative field and obtaining precisely fabricated restorations, with attention to detail in placement, can make this contraindication a reality. Garber DA, Goldstein RE. Porcelain & composite inlays & onlays : esthetic posterior restorations. Chicago: Quintessence; 1994 Jan.

12. ADVANTAGES Improved physical properties Variety of materials and techniques Wear resistance Reduced polymerization shrinkage Support of remaining tooth structure More precise control of contours and contacts Biocompatibility and good tissue response Increased auxiliary support Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.

13. DISADVANTAGES Increased cost and time Technique sensitivity Difficult try-in and delivery Brittleness of ceramics Wear of opposing dentition and restorations Short clinical track record Low potential for repair Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.

14. CLINICAL PROCEDURE

15. Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.

16. Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.

17. Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.

18. TOOTH PREPARATION The principles of cavity preparation for esthetic inlays or onlays differ from those for gold restorations. For esthetic inlay or onlay restorations , bevels and retention forms are not needed. Resistance form is generally not necessary but may be required in very large onlay restorations. Retention form is not as critical due to the bonded nature of the restoration, and bevels are contraindicated. Freedman GA. Contemporary Esthetic Dentistry-E-Book. Elsevier Health Sciences; 2011 Dec 15. Hopp CD, Land MF. Considerations for ceramic inlays in posterior teeth: a review. Clinical, cosmetic and investigational dentistry. 2013;5:21.

19. Thompson MC, Thompson KM, Swain M. The all‐ceramic, inlay supported fixed partial denture. Part 1. Ceramic inlay preparation design: a literature review. Australian dental journal. 2010 Jun 1;55(2):120-7.

20. Thompson MC, Thompson KM, Swain M. The all‐ceramic, inlay supported fixed partial denture. Part 1. Ceramic inlay preparation design: a literature review. Australian dental journal. 2010 Jun 1;55(2):120-7.

21. Freedman GA. Contemporary Esthetic Dentistry-E-Book. Elsevier Health Sciences; 2011 Dec 15.

22. Garber DA, Goldstein RE. Porcelain & composite inlays & onlays : esthetic posterior restorations. Chicago: Quintessence; 1994 Jan.

23. CLASS III CERAMIC INLAY

24. CLASS IV CERAMIC INLAY

25. RULE FOR CUSP CAPPING Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.

26. If cusps must be capped, they should be reduced 1.5 to 2 mm and should have a 90-degree cavosurface angle. When capping cusps, especially centric holding cusps, it may be necessary to prepare a shoulder to move the facial or lingual cavosurface margin away from any possible contact with the opposing tooth, either in maximum intercuspal position or during functional movements. Such contacts directly on margins can lead to premature deterioration of marginal integrity. The axial wall of the resulting shoulder should be sufficiently deep to allow for adequate thickness of the restorative material and should have the same path of draw as the main portion of the preparation Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.

27. For onlay restorations, nonworking and working cusps are covered with at least 1.5 mm and 2 mm of material, respectively. If the cusp to be onlayed shows in the patient’s smile, a more esthetic blended margin is achieved by a further 1- to 2-mm reduction with a 1-mm chamfer

28. Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.

29. Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.

30. CERAMIC INLAYS AND ONLAYS CAST METAL INLAYS AND ONLAYS THICKNESS/ BULK More bulk needed , more clearance Less bulk needed OCCLUSAL BEVELS Bevels contraindicated Bevels necessary GINGIVAL BEVELS Not necessary Needed to achieve minimal marginal gap CERVICO-OCCLUSAL DIVERGENCE 6 to 7 degrees of occlusal divergence 2 to 5 degrees per wall MARGINAL ADAPTATION Rely on adhesion between tooth structure/resin cement/porcelain to create a gap-free Rely on close adaptation (20um);lack of adhesion between tooth structure/cement/metal interface : gingival bevels are thus needed

31. CERAMIC INLAYS AND ONLAYS CAST METAL INLAYS AND ONLAYS PULPAL FLOOR Need not be flat and perpendicular to the long axis of the tooth; If the cavity is shallow , pulpal floor should be indented in central fossa region parallel to the cuspal inclines. Flat and perpendicular to the long axis of the tooth INTERNAL LINE ANGLES Rounded internal line and point angles Well-defined internal line and point angles CAVOSURFACE ANGLE 90 Degrees butt joint 140 to 150 degrees( 30 to 40 degree marginal metal) CUSP REDUCTION Functional cusp: 1.5mm-2mm Non-functional cusp : 1.5 mm Functional cusp: 1mm-1.5 mm Non-functional cusp : 1mm

32. Impression Tooth- colored inlay or onlay systems require an elastomeric or optical impression of the prepared tooth and the adjacent teeth and interocclusal records, which allow the restoration to be fabricated on a working cast in the laboratory. With chairside CAD/CAM systems, no working cast is necessary. Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.

33. PROVISIONAL Restoration For exceptionally nonretentive preparations, or when the temporary phase is expected to last longer than 2 to 3 weeks, zinc phosphate or polycarboxylate cement can be used to increase retention of the provisional restoration. Resin-based temporary cements are also available (e.g., TempBond Clear, Kerr Corporation, Orange, CA)

34. Try-in and Cementation Try-in and bonding of tooth-coloured inlays or onlays are more demanding than those for cast gold restorations because of (1) the relatively fragile nature of some ceramic materials, (2) the requirement of near-perfect moisture control, and (3) the use of resin cements. Occlusal evaluation and adjustment generally are delayed until after the restoration is bonded, to avoid fracture of the ceramic material

35. Preliminary Steps The use of a rubber dam is strongly recommended to prevent moisture contamination of the conditioned tooth or restoration surfaces during cementation and to improve access and visibility during delivery of the restoration. After removing the provisional restoration, all of the temporary cement is cleaned from the preparation walls. Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.

36. Restoration Try-in and Proximal Contact Adjustment Passing thin dental floss through the contact reveals tightness and position of the proximal contact, signifying to the experienced operator the degree and location of excess contact. Articulating paper also can be used successfully to identify overly tight proximal contacts. Abrasive disks or points are used to adjust the proximal contour and contact relationship. While adjusting the intensity and location of the proximal contacts, increasingly finer grits of abrasive instruments are used to polish the proximal surfaces because they will be inaccessible for polishing after cementation.

37. Marginal fit is verified after the restoration is completely seated. Ceramic inlays and onlays typically have slightly larger marginal gaps than comparable gold restorations. Slight excesses of contour can be removed, if access allows, using fine-grit diamond instruments or 30-fluted carbide finishing burs. These adjustments are done preferably after the restoration is bonded so that marginal fractures are avoided. Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.

38. MECHANISM OF BONDING Bonding of ceramic CAD/CAM restorations is a critical step in achieving good long-term results. Ceramic restorations are bonded to tooth structure by Etching enamel to increase the bondable surface area Etching, priming, and applying the bonding agent to dentin (when appropriate) Etching ( by hydrofluoric acid ) and then priming ( silanating ) the restoration cementing the restoration with composite cement Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.

39. Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.

40. Ceramic restorations (with the exception of aluminous-core porcelains , such as In-Ceram High Strength Ceramic [Vita Zahnfabrik / Vident , Bäd Säckingen , Germany] and zirconia -core porcelain such as Lava [3M ESPE, St. Paul, Minn ]) must be etched internally with 6% to 10% hydrofluoric acid for 1 to 2 minutes to create retentive microporosities analogous to those that occur in enamel on etching with phosphoric acid. Hydrofluoric acid must be rinsed off carefully with running water for at least 2 minutes. Sandblasting with aluminum oxide particle can be done in the internal surface of the restoration. Mean bond strengths decrease, however, when hydrofluoric acid etching is not used. Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.

41. The bonding of traditional glass-containing ceramics or silica based ceramics utilizes mechanical and adhesive way Mechanical bonding assumed micromechanical interlocking between the resin cement and roughen surface of silica-based ceramics. Phosphoric acid or hydrofluoric acid etching is the method commonly used for roughening the silica-based ceramics surfaces Chemical adhesion of glass ceramic and resin cements is achieved with use of bi-functional compounds, silanes that promote connection between dissimilar organic and inorganic counterparts. Also, silanes could influence increasing surface energy and wettabiliy of ceramic surfaces, which enhances both mechanical and chemical bonding Obradović-Đuričić K, Medić V, Dodić S, Gavrilov D, Antonijević Đ, Zrilić M. Dilemmas in zirconia bonding: A review. Srpski arhiv za celokupno lekarstvo . 2013;141(5-6):395-401.

42. Blatz MB, Sadan A, Kern M. Resin-ceramic bonding: a review of the literature. Journal of Prosthetic Dentistry. 2003 Mar 1;89(3):268-74.

43. Acid etching Acid etching with solutions of hydrofluoric acid (HF) or ammonium bifluoride can achieve proper surface texture and roughness. The glassy matrix is selectively removed, and crystalline structures are exposed. HF solutions between 2.5% and 10% applied for 2 to 3 minutes seem to be most successful Blatz MB, Sadan A, Kern M. Resin-ceramic bonding: a review of the literature. Journal of Prosthetic Dentistry. 2003 Mar 1;89(3):268-74.

44. The well known methods of mechanical and chemical bonding used on glass-ceramics are not applicable for use with zirconia . The most important reason for this is the absence of silica in the zirconia microstructure which ignores the viability of etching as a roughening method essential for mechanical bonding, as well as nullified the use of silanes , forming surfaces hydroxyls and developing the chemical bond Obradović-Đuričić K, Medić V, Dodić S, Gavrilov D, Antonijević Đ, Zrilić M. Dilemmas in zirconia bonding: A review. Srpski arhiv za celokupno lekarstvo . 2013;141(5-6):395-401.

45. DIFFERENT APPROCHES IN ZIRCONIA/CEMENT BONDING Surface abrasion or roughening Application of a tribochemical silica coating Silica coating techniques Chloro-silane treatment Selective infiltration etching (SIE) Nanostructured alumina coating Surface treatments : Hot chemical etching solution, Laser application, Zirconia ceramic powder coating, Application of phosphate ester primers and phosphate modified resin cements, Gas-phase fluorination process Obradović-Đuričić K, Medić V, Dodić S, Gavrilov D, Antonijević Đ, Zrilić M. Dilemmas in zirconia bonding: A review. Srpski arhiv za celokupno lekarstvo . 2013;141(5-6):395-401.

46. Application of a tribochemical silica coating This is a technique which uses alumina particles modified with silica for air abrasion at 0.28 MPa and embedding silica particles in the ceramic surface. Silica particles create a base for micromechanical bonding and interlocking in ceramic. The next step is application of a silane which enables chemical adhesion between ceramic and resin cement. Ex. silica – coated 30 µm aluminum oxide particles , commercial product : Cojet , Rocatec 3M ESPE Obradović-Đuričić K, Medić V, Dodić S, Gavrilov D, Antonijević Đ, Zrilić M. Dilemmas in zirconia bonding: A review. Srpski arhiv za celokupno lekarstvo . 2013;141(5-6):395-401.

47. For intraoral silica-coating applications, the following can be mentioned: CoJet and Rocatector , Dento -Prep, and Microetcher Matinlinna JP, Vallittu PK. Bonding of resin composites to etchable ceramic surfaces–an insight review of the chemical aspects on surface conditioning. Journal of oral rehabilitation. 2007 Aug 1;34(8):622-30.

48. Silica coating techniques Chloro-silane treatment Actually, chloro-silane combined with vapor phase technique allowed pretreatment that deposits a silica-like layer on the zirconia substrate. The result is very thin coating (till 2.6 nm) which increased the number of chemical binding sites (Si x O y ) for the subsequent organ-saline primer, used in conventional adhesive technique. Application of the chloro-silane film increases the bond strength to resin cements enabling the values of microtensile bond strength similar to clinically common bonding technique. Obradović-Đuričić K, Medić V, Dodić S, Gavrilov D, Antonijević Đ, Zrilić M. Dilemmas in zirconia bonding: A review. Srpski arhiv za celokupno lekarstvo . 2013;141(5-6):395-401.

49. Selective infiltration etching (SIE) SIE is based on inter-grain metastable tetragonal grains, created during thermal pre-stressing of the surface grains using a specific thermal regime. Due to this procedure, the bonding zirconia surface is ready to accept the adhesive resin which infiltrates and „interlocks“ the bond SIE transforms dense, nano -retentive, relatively smooth and low energy surface of zirconia to highly active and well bonding surface In SIE method the surface of zirconia is coated with a glass-containing conditioning agent silica (65% wt), alumina (15% wt), sodium oxide (10% wt), potassium oxide (5% wt) and titanium oxide (5% wt) with closely-matched thermal expansion coefficient to zirconia . Obradović-Đuričić K, Medić V, Dodić S, Gavrilov D, Antonijević Đ, Zrilić M. Dilemmas in zirconia bonding: A review. Srpski arhiv za celokupno lekarstvo . 2013;141(5-6):395-401.

50. Later on, the material is heated above glass transition temperature, until the optimal grain boundary diffusion is achieved. After cooling to room temperature, the glass is dissolved in an acidic bath to eliminate all traces of conditioning agent. The cooling and heating rates are controlled by a computer-calibrated induction furnace The resultant effect is of a sealed interface of modified zirconia surface, which is capable to resist the nano -leakage during artificial aging. Obradović-Đuričić K, Medić V, Dodić S, Gavrilov D, Antonijević Đ, Zrilić M. Dilemmas in zirconia bonding: A review. Srpski arhiv za celokupno lekarstvo . 2013;141(5-6):395-401.

51. Nanostructured alumina coating Nanostructured alumina coating is presented as a new approach which is able to provide a strong and durable resin bond to Y-TZP. It is based on the idea of a rapid precipitation of aluminium hydroxides that originate from the hydrolysis of AlN (aluminium nitride) powder in a diluted aqueous suspension . The result is heterogeneous nucleation of lamellar boehmite ( γAlOOH ) onto the surface of the immersed Y-TZP substrate. The nanostructured coatings consist of 6 nm thick and 240 nm long interconnected polycrystalline γAlOOH lamellas that grow perpendicular to the zirconia surface. During a heat treatment up to 900°C, these coatings are transformed into transient alumina, but without any change in the morphology. This non-invasive process can be classified as chemical pretreatment method that increases the surface area and penetrates the lamellar network, implying good wetting

52. Nanostructured alumina coating ADVANTAGES : It does not create any flaws that can decrease the strength of zirconia ceramics. Functionalization of zirconia surface is more effective compared to air abraded and polished surface, even after thermo cycling procedures. T echnique is simple and can be easily transferred to dental laboratories

53. Application of phosphate ester primers and phosphate modified resin cements This is promising and chair-side method to create a relatively stable bond zirconia /tooth structure, but alone insufficient to stand long-term intraoral conditions The adhesive functional monomers are believed to have the ability to form chemical hydrogen bonds with metal oxides at the resin/ zirconia interface, improving the wettability . On the other hand, the composition of resin cement, for example, large filler size and high viscosity could affect the wettability significantly. The most frequent phosphate monomer groups used in resin cement or metal primers are the following: 10-methacryloyl oxydecyl dihydrogen phosphate, MDP (the adhesive monomer in Panavia F 2.0, Alloy Primer, Clearfil SE Bond/Porcelain Bond activator, Clearfil Ceramic primer), methacrylated phosphoric ester (adhesive monomer in RelyX Unicem ), and phosphoric acid acrylate (the adhesive monomer of multilink automix )

54. The purpose of this study was to assess the surface topography of 6 different ceramics after treatment with either hydrofluoric acid etching or airborne aluminum oxide particle abrasion. Five copings each of IPS Empress, IPS Empress 2 (0.8 mm thick), Cergogold (0.7 mm thick), In-Ceram Alumina, In-Ceram Zirconia , and Procera (0.8 mm thick) were fabricated following the manufacturer’s instructions. Each coping was longitudinally sectioned into 4 equal parts by a diamond disk. Borges GA, Sophr AM, De Goes MF, Sobrinho LC, Chan DC. Effect of etching and airborne particle abrasion on the microstructure of different dental ceramics. Journal of Prosthetic Dentistry. 2003 May 1;89(5):479-88.

55. The resulting sections were then randomly divided into 3 groups depending on subsequent surface treatments: Group 1, specimens without additional surface treatments, as received from the laboratory (control); Group 2, specimens treated by use of airborne particle abrasion with 50-µm aluminum oxide for 5 seconds at 4-bar pressure; and Group 3, specimens treated with 10% hydrofluoric acid etching (20 seconds for IPS Empress 2; 60 seconds for IPS Empress and Cergogold ; and 2 minutes for In-Ceram Alumina, In-Ceram Zirconia , and Procera ) Airborne particle abrasion changed the morphologic surface of IPS Empress, IPS Empress 2, and Cergogold ceramics. The surface topography of these ceramics exhibited shallow irregularities not evident in the control group. Borges GA, Sophr AM, De Goes MF, Sobrinho LC, Chan DC. Effect of etching and airborne particle abrasion on the microstructure of different dental ceramics. Journal of Prosthetic Dentistry. 2003 May 1;89(5):479-88.

56. For Procera , the 50-m aluminum oxide airborne particle abrasion produced a flattened surface. Airborne particle abrasion of In-Ceram Alumina and In-Ceram Zirconia did not change the morphologic characteristics and the same shallows pits found in the control group remained. For IPS Empress 2, 10% hydrofluoric acid etching produced elongated crystals scattered with shallow irregularities. For IPS Empress and Cergogold , the morphologic characteristic was honeycomb-like on the ceramic surface. The surface treatment of In-Ceram Alumina, In-Ceram Zirconia , and Procera did not change their superficial structure. They concluded that hydrofluoric acid etching and airborne particle abrasion with 50-m aluminum oxide increased the irregularities on the surface of IPS Empress, IPS Empress 2, and Cergogold ceramics. Similar treatment of In-Ceram Alumina, In-Ceram Zirconia , and Procera did not change their morphologic microstructure. Borges GA, Sophr AM, De Goes MF, Sobrinho LC, Chan DC. Effect of etching and airborne particle abrasion on the microstructure of different dental ceramics. Journal of Prosthetic Dentistry. 2003 May 1;89(5):479-88.

57. The purpose of this study was to compare the dentin bond strengths of 2 different ceramic inlay systems after cementation with 3 different techniques and 1 bonding system One hundred twenty freshly extracted caries- and restoration-free molar teeth used in this study were stored in saline solution at room temperature. Standardized Class I preparations were made in all teeth. Each preparation had a length of 6 mm, a width of 3 mm, a depth of 2 mm, and 6-degree convergence of the walls. Teeth were randomly assigned to 2 groups of 60 each to evaluate the bonding of 2 ceramic systems, Ceramco II (Group I) and IPS Empress 2 (Group II), to dentin. Each of the 2 groups were further divided into 3 cementation technique groups of 20 each (Group I A, B, and C and Group II A, B, and C). Ozturk N, Aykent F. Dentin bond strengths of two ceramic inlay systems after cementation with three different techniques and one bonding system. Journal of Prosthetic Dentistry. 2003 Mar 1;89(3):275-81.

58. Groups I A and B and Groups II A and B used dentin bonding agent (DBA) Clearfil Liner Bond 2V, and resin cement ( Panavia F). Groups I C and II C served as control groups and used Panavia F without the dentin-bonding agent. In Groups I A and II A, the DBA was applied immediately after the completion of the preparations (D-DBA). Impressions were then made, and the ceramic inlays were fabricated according to the manufacturers’ guidelines. In Groups I B and II B the DBA was applied just before luting the inlay restorations (I-DBA). In Groups I C and II C, no bonding agent was used before the cementation of the inlay restorations (No DBA). Cementation procedures followed a standard protocol. After cementation, specimens were stored in distilled water at 37° C for 24 hours. Ozturk N, Aykent F. Dentin bond strengths of two ceramic inlay systems after cementation with three different techniques and one bonding system. Journal of Prosthetic Dentistry. 2003 Mar 1;89(3):275-81.

59. The teeth were sectioned both mesial -distally and buccal-lingually along their long axis into three 1.2 1.2 mm wide I-shaped sections. The specimens were then subjected to microtensile testing at a crosshead speed of 1 mm/min, and the maximum load at fracture (in kilograms) was recorded. Two-way analysis of variance and Tukey honestly significant difference tests were used to evaluate the results Scanning electron microscopy analysis was used to examine the details of the bonding interface. The fractured surfaces were observed with a stereomicroscope at original magnification to identify the mode of fracture. The tensile bond strength in the D-DBA technique (40.27 MPa ) was significantly higher than both the I-DBA (30.20 MPa ) and No-DBA techniques (32.43 MPa ) for 2 different ceramic systems. Also, fracture surfaces of each specimen examined under stereomicroscopy demonstrated that 98% of the failures were adhesive in nature. In SEM examination, a distinct and thicker hybrid zone with longer and more resin tags were found in the D-DBA technique than in the I-DBA and No-DBA techniques. Ozturk N, Aykent F. Dentin bond strengths of two ceramic inlay systems after cementation with three different techniques and one bonding system. Journal of Prosthetic Dentistry. 2003 Mar 1;89(3):275-81.

60. As a result of scanning electron microscopy analysis, a distinct and thicker hybrid zone with more, and longer resin tags were found in specimens treated with the D-DBA technique than with the other 2 techniques. Most failures (353 of 360) were adhesive in nature at the bonding resin/dentin interface. Only 7 specimens showed cohesive failure within the bonding resin. They concluded that, the cementation of the ceramic inlays tested with the D-DBA technique used resulted in higher bond strengths to dentin Ozturk N, Aykent F. Dentin bond strengths of two ceramic inlay systems after cementation with three different techniques and one bonding system. Journal of Prosthetic Dentistry. 2003 Mar 1;89(3):275-81.

61. The preparation surfaces are etched and treated with the components of an appropriate enamel/dentin bonding system Typically , the final step of the bonding system (e.g., an unfilled resin) also is applied to the internal surfaces of the restoration previously etched and silanated . (Self-adhesive, resin based cements have been introduced in recent years, but whether they are appropriate with tooth- colored inlays/ onlays remains unproven .) A dual-cure composite cement is mixed and inserted into the preparation with a paddle-shaped instrument or a syringe. The internal surfaces of the restoration also are coated with the composite cement , and the inlay is immediately inserted into the prepared tooth, using light pressure. A ball burnisher applied with a slight vibrating motion is usually sufficient to seat the restoration Excess composite cement is removed with thin-bladed composite instruments, brushes, or an explorer Cementation

62. Cementation

63. This review describes the potential of adhesive luting procedures with respect to (1) material characteristics and classifications, (2) film thickness, (3) overhang control, (4) bonding to different inlay materials, (5) adhesion to tooth substrates and the problem of hypersensitivities, (6) wear of luting composites, and (7) clinical performance. A literature review of relevant studies of various in vitro and in vivo studies enables an overview of possibilities and limitations of adhesively luted indirect restorations. They concluded that : (1 ) Resin-based composites are the material of choice for adhesive luting . Both material properties and wear behavior of fine particle hybrid-type resin-based composites are superior to other materials. The use of compomers is questionable due to hygroscopic expansion and possible crack formation as proven for IPS Empress caps in vitro and in vivo . Krämer N, Lohbauer U, Frankenberger R. Adhesive luting of indirect restorations. American Journal of Dentistry. 2000 Nov;13(Spec No):60D-76D.

64. (2 ) Recent luting cements exhibit excellent flow characteristics with mean film thicknesses ranging between 8 microm and 21 microm . The ultrasonic insertion technique is recommended for viscous luting composites or conventional restorative composites utilizing their thixotropic properties . (3) For successful overhang control, good fit of the restoration (during luting ) and high radiopacity of the cement (after luting ) are indispensable. Overhang control is estimated easier when the ultrasonic insertion technique is applied. ( 4) The pre-treatments of ceramic inlays using hydrofluoric acid or silica coating result in effective bonding; for pre-treatment of resin-based composite inlays, silica coating is promising as well. ( 5) Bonding to enamel and dentin is proven clinically acceptable, but it should be performed with multi-step systems providing separate primers and bonding agents producing a perfect internal seal with almost no hypersensitivities. Dual-cured multi-step bonding agents provide the most promising potential.

65. (6) The viscosity and filler content of the resin composite used for luting does not influence the wear characteristics within the marginal luting area in vivo. However, the ultrasonic insertion technique involving high viscosity materials provides enhanced handling characteristics for luting of tooth- colored inlays. ( 7) Clinical results with tooth- colored inlays and veneers are promising over periods of up to 10 yrs, including use in severely destroyed teeth.

66. Finishing and Polishing Procedures After light-curing the cement, the plastic matrix strips and the wedges (if used) are removed, and the setting of the resin cement is verified. All marginal areas are checked with an explorer tine

67. Feldspathic Porcelain Inlays and Onlays

68. Feldspathic Porcelain Inlays and Onlays Advantages : Low startup cost. The ceramic powders and investments are relatively inexpensive, and the technique is compatible with most existing ceramic laboratory equipment such as firing furnaces. Disadvantages :technique sensitivity, both for the technician and the dentist. Inlays and onlays fabricated with this technique must be handled gently during try-in and bonding to avoid fracture. Feldspathic porcelains are weak, so even after bonding, the incidence of fracture can be relatively high

69. Pressed Glass-Ceramics In 1984, the glass-ceramic material Dicor (DENTSPLY International, York, PA) was patented and became a popular ceramic for dental restorations. A major disadvantage of Dicor was its translucency, which necessitated external application of all shading Dicor restorations were made using a lost-wax, centrifugal casting process. Newer leucite -reinforced glass-ceramic systems (e.g., IPS Empress, Ivoclar Vivadent , Amherst, NY) also use the lost-wax method, but the material is heated to a high temperature and pneumatically pressed, rather than centrifuged, into a mold

70. Pressed Glass-Ceramics After tooth preparation, an impression is made, and a working cast is poured in die-stone. A wax pattern of the restoration is made using conventional techniques After spruing , investing, and wax pattern burnout, a shaded ceramic ingot and aluminum oxide plunger are placed into a special furnace The shade and opacity of the selected ingot are based on the information provided by the clinician, specifically the desired shade of the final restoration and the shade of the prepared tooth. At approximately 2012°F (1100°C), the ceramic ingot becomes plastic and is slowly pressed into the mold by an automated mechanism.

71. After being separated from the mold , the restoration is seated on the master die and working cast for final adjustments and finishing. To reproduce the tooth shade accurately, a heavily pigmented surface stain is typically applied. The ceramic ingots are relatively translucent and available in a variety of shades, so staining for hot pressed ceramic inlay and onlay restorations is typically minimal.

72. Pressed Glass-Ceramics The advantages of leucite -reinforced pressed ceramics are their similarity to traditional “wax-up” processes excellent marginal fit moderately high strength surface hardness similar to that of enamel. Although pressed ceramic inlays and onlays are stronger than porcelain inlays made on refractory dies, they are still somewhat fragile during try-in and must be bonded rather than conventionally cemented.

73. Lithium Disilicate Lithium disilicate (e.max, Ivoclar Vivadent Inc., Amherst, NY), is available in both pressed (IPS e.max Press) and machinable (IPS e.max CAD) forms, and either can be used to fabricate inlays and onlays . The two forms of e.max are slightly different in composition, but lithium disilicate is a moderately high-strength glass ceramic that also can be used for full crowns or ultra-thin veneers. In vitro testing of this ceramic material has shown very positive results, and it has become a highly popular alternative for inlays and onlays . However, because the material is relatively new, long-term clinical studies to demonstrate superior performance are lacking.

74. Computer-Aided Design/Computer-Assisted Manufacturing Inlays and Onlays Generation of a chairside CAD/CAM restoration begins after the dentist prepares the tooth and uses a scanning device to collect information about the shape of the preparation and its relationship with the surrounding structures This step is termed optical impression. The system projects an image of the preparation and surrounding structures on a monitor, allowing the dentist or the auxiliary personnel to use the CAD portion of the system to design the restoration. The operator must input or confirm some of the restoration design such as the position of the gingival margins

75. After the restoration has been designed, the computer directs a milling device (CAM portion of the system) that mills the restoration out of a block of high-quality ceramic or composite in minutes The restoration is removed from the milling device and is ready for try-in, any needed adjustment, bonding, and polishing

76. Several different types of ceramics are available for chairside CAD/CAM restoration fabrication. These include the feldspathic glass ceramics Vitablocs Mark II ( Vident , Brea, CA) and CEREC Blocs ( Sirona , manufactured by Vita Zahnfabrik , Bad Säckingen , Germany). The ceramic blocks are available in various shades and opacities, and some are even layered to mimic the relative opacity or translucency in different areas of a tooth. Two leucite -reinforced glass ceramics are available—IPS Empress CAD ( Ivoclar Vivadent ) and Paradigm C (3M ESPE). Lithium disilicate also is available in machinable form as IPS e.max CAD blocks. Although newer materials are stronger than the original ceramics, less is known about their long-term clinical performance

77. Ceramic Reconstruction System (CEREC-1) The Ceramic Reconstruction System (CEREC-1; Siemens, Germany) was the first commercially available CAD/CAM system used in dentistry. An intraoral video camera images the tooth preparation and the adjacent tooth surfaces. Elevations of the imaged surfaces are calculated by Moiré fringe displacement. Features of the tooth preparation are used to define the limits of the restoration.

78. External surfaces of the restoration are estimated as distances to adjacent tooth structure in the computer view. Occlusal surfaces are designed from a preexisting shape library and information about the occlusion. CEREC-3 displays an extremely high level of sophistication and can fabricate inlays, onlays , crowns, and veneers. It can be operated chairside , but also is being used with remote milling units in dental laboratories for two-appointment procedures. All other current CAD/CAM systems are employed in dental laboratories to fabricate a wide range of ceramic restorations

79. CEREC AC (A) and E4D (B) computer-aided design/ computer-assisted manufacturing (CAD/CAM) devices. These chairside units are compact and mobile

80. Hopp CD, Land MF. Considerations for ceramic inlays in posterior teeth: a review. Clinical, cosmetic and investigational dentistry. 2013;5:21.

81. Hopp CD, Land MF. Considerations for ceramic inlays in posterior teeth: a review. Clinical, cosmetic and investigational dentistry. 2013;5:21.

82. Common Problems and Solutions The most common cause of failure of tooth- colored inlays/ onlays is bulk fracture. Bulk fracture can result from placing the restoration in a tooth where it should not have been indicated, such as in bruxers and clenchers , or from lack of appropriate restoration thickness derived from lack of tooth preparation. If bulk fracture occurs, replacement of the restoration is almost always indicated.

83. Microtensile bond strength ( microTBS ) evaluation and fractographic analysis were used to compare four luting systems in the cementation of resin-based composite (RBC) and ceramic disks to dentin. Forty freshly-extracted molars were transversally sectioned to expose flat, deep dentin surfaces. Forty cylindrical specimens (5-mm diameter and 10-mm height), consisting of 20 RBC disks and 20 leucite -based glass ceramic disks, were produced. The ceramic disks were conditioned with 9.5% hydrofluoric acid gel and silane application. All the disks were then bonded to dentin surfaces according to the luting cements to be used: two etch-and-rinse luting agents (XP bond/ CoreXFlow ; Dentsply [XP]) ( Enabond / EnaCem HF; Micerium [ENA]), a self-etch luting system (ED Primer II A+B/ Panavia F2.0; Kuraray-Dental [PAN]) and a self-adhesive luting agent ( RelyX Unicem ; 3M ESPE [UNI]).

84. The adhesive/ luting cement systems were applied according to the manufacturers' instructions. The specimens were sectioned perpendicular to the adhesive interface to produce multiple beams, approximately 1 mm2 in area. The beams were tested under tension at a crosshead speed of 0.5 mm/minute until failure. The microTBS data were analyzed by two different one-way-ANOVA and multiple comparison Tukey tests (alpha = 0.05). All the fractured beams were observed using a Scanning Electron Microscope (SEM) at 200x magnification for fracture mode determination D'arcangelo C, De Angelis F, D'amario M, Zazzeroni S, Ciampoli C, Caputi S. The influence of luting systems on the microtensile bond strength of dentin to indirect resin-based composite and ceramic restorations. Operative Dentistry. 2009 May;34(3):328-36.

85. Type 1: Cohesive failure in dentin • Type 2: Adhesive failure at the luting -dentin interface • Type 3: Mixed adhesive failure and cohesive failure in dentin • Type 4: Cohesive failure in the luting agent • Type 5: Mixed adhesive failure and cohesive failure in RBC (or ceramic) • Type 6: Adhesive failure at the luting -RBC (or ceramic) interface D'arcangelo C, De Angelis F, D'amario M, Zazzeroni S, Ciampoli C, Caputi S. The influence of luting systems on the microtensile bond strength of dentin to indirect resin-based composite and ceramic restorations. Operative Dentistry. 2009 May;34(3):328-36.

86. Repair Of CERAMIC Inlays and Onlays Before initiating any repair procedure, the operator should determine whether replacement rather than repair is the appropriate treatment A small fracture resulting from occlusal trauma might indicate that some adjustment of the opposing occlusion is required. The repair procedure is initiated by mechanical roughening of the involved surface. Although a coarse diamond may be used, a better result is obtained with the use of air abrading or grit blasting with aluminum oxide particles and a special intraoral device

87. For ceramic restorations, the initial mechanical roughening is followed by brief (typically 2 minutes ) application of 10% hydrofluoric acid gel . Hydrofluoric acid etches the surface, creating further microdefects to facilitate mechanical bonding . The next step in the repair procedure is application of a silane coupling agent . Silanes mediate chemical bonding between ceramics and resins and may improve the predictability of resin-resin. After the silane has been applied, a resin adhesive is applied and light cured. A composite of the appropriate shade is placed, cured, contoured, and polished

88. This systematic review and meta-analysis aimed to evaluate the survival rate of ceramic and resin inlays, onlays , and overlays and to identify the complication types associated with the main clinical outcomes In the present study, the pooled estimated survival rate was 95% for 5 y of follow-up and the survival rate decreased to 91% after 10 y of follow-up (93% for glass-ceramics and 91% feldspathic porcelain), yet this was not a significant difference. One explanation for the similar performance of glass-ceramics and feldspathic porcelain could be the adhesive cementation that likely compensated for the mechanical differences between the 2 ceramic materials This meta-analysis indicates that the survival rate of inlays, onlays , and overlays remains high, irrespective of the follow-up time (5 y and 10 y) and regardless of the ceramic material, study design, and study setting . Thier results indicate that fractures remain the most frequent type of failure . The type of tooth does not seem to affect survival rates, but restorations survived longer on vital teeth Morimoto S, Rebello de Sampaio FB, Braga MM, Sesma N, Özcan M. Survival rate of resin and ceramic inlays, onlays , and overlays: a systematic review and meta-analysis. Journal of dental research. 2016 Aug;95(9):985-94.

89. Morimoto S, Rebello de Sampaio FB, Braga MM, Sesma N, Özcan M. Survival rate of resin and ceramic inlays, onlays , and overlays: a systematic review and meta-analysis. Journal of dental research. 2016 Aug;95(9):985-94.

90. The objectives of this study were to: (1) compare the fracture resistance of metal-ceramic inlays with that of all-ceramic inlays; (2) determine the correlation between the degree of preparation taper and fracture resistance; and (3) determine the correlation between marginal gap width and fracture resistance. Inlay preparations were made on 60 Dentoform teeth, with 30 teeth allocated for metal-ceramic inlays and 30 teeth for all-ceramic inlays. Each group was further subdivided into 5-, 10-, and 20-degree taper preparations . Metal-ceramic inlays were fabricated using Goldtech Bio 2000 metal and Ceramco porcelain extending to the margin, while all-ceramic inlays were made from Empress II ceramic. Marginal gap widths were measured at six critical areas after fabrication. The load at failure was measured using an Instron Universal Testing Machine . Esquivel-Upshaw JF, Anusavice KJ, Reid M, Yang MC, Lee RB. Fracture resistance of all-ceramic and metal-ceramic inlays. International Journal of Prosthodontics . 2001 Mar 1;14(2).

91. The mean fracture load for all-ceramic inlays and metal-ceramic inlays at 5, 10, and 20 degrees was 70+/-40 N, 48+/-37 N, 33+/-7 N, and 40+/-23 N, 29+/-22 N, and 14+/-4 N, respectively. The mean gap width was 105 microm and 126 microm for all-ceramic and metal-ceramic inlays, respectively. They concluded that the mean fracture load for Empress inlays was significantly higher than that for metal-ceramic inlays. Inlays with a 5-degree taper were significantly more fracture resistant than those with a 20-degree taper. There was no relation between marginal gap width and fracture resistance. Esquivel-Upshaw JF, Anusavice KJ, Reid M, Yang MC, Lee RB. Fracture resistance of all-ceramic and metal-ceramic inlays. International Journal of Prosthodontics . 2001 Mar 1;14(2).

92. CONCLUSION

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