Journal of Oral Rehabilitation 1997 24:646-651
Marginal adaptation of a sintered ceramic inlay system
before and after cementation
D. G E M A L M A Z , M. OZCAN, A.B. YORUg*
Urtiversity of Marmara. Istanbul and *Faculty of Chemistry and Metallurgy. Yildiz Technical University. Istanbul.
SUMMARY The long term clinical performance of
porcelain inlays depends on a number of factors and
the marginal adaptation is one of significant interest.
The purpose of this in vitro study was to evaluate
the marginal integrity of a sintered inlay technique
(Ducera®), hefore and after cementation. MOD
cavities without bevels were prepared on 10 human
mandibular molar teeth and porcelain inlays were
fabricated according to the manufacturer's
instructions. Inlays were evaluated microscopically
for their adaptation to the occlusal and approximal
margins of the tooth by means of a replica technique.
Inlays were cemented with a dual-cured hybrid
composite luting material (Enforce®). After
polishing, each tooth was sectioned in buccal/lingual
and mesial/distal directions following the same
Introduction
The use oi aesthetic materials is becoming more popular
due to the increased interest in tooth appearance.
Patients are demanding improved aesthetics and even
in the posterior regions of the mouth, insistence on
tooth-coloured restorations has generated great interest
in the developmeiii: o{ beuer alternatives to amalgam.
Despite the improved qualities of the posterior
composites, they still show a relatively high poly-
merization shrinkage, low resistance to clinical wear
and a high coefficient of thermal expansion (Feilzer,
DeGee & Davidson, 1989; Wohlwerd, 1990; Burgoyne.
NichoUs &• Brudvik. 1991). Since ceramic inlays offer
more wear-resistance and biocompatihle posterior
& H.N. ALKUMRU Faculty of Dentistry.
Turkey
procedure in the sectioning of replicas. The marginal
gap and the thickness of exposed cement were
measured at each section. The mean marginal gap
of 71-83 ± 8-93 (lm recorded for the occlusal margin
before cementation was significantly smaller than
that of 105-6 ± 39-33 |im calculated attheapproximal
margin. Following the cementation, the adaptation
of the inlays at the occlusal margin was also found
to he superior to that of the approximal margin.
Comparison of mean gap values before and after
cementation revealed that the marginal gap
increased by 6 94 tim and 23-25 ^m at the occlusal
and approximal margins, respectively. Although
polishing was performed after cementation, excess
luting material was still observed, tbat caused an
increase in the width of the exposed luting cement.
restorations, they are viable alternatives to composite
inlays.
The long term clinical performance ot ceramic inlays
depends on a number of factors with marginal
adaptation being one of significance. Several in vitro
studies (Hickel & Kunzelmann, 1990; Rose, Platzer &•
Roth, 1990; Sturdevant et ai, 1991; Federlin, Schmaiz
&• Reich, 1992; Inokoshi etal. 1992; Thordrup, Isidor
& Horsted-Bindslev, 1992; Moiin & Karlsson, 1993;
Thordrup, Isidor & Horsted-Bindslev, 1994; Sertgoz
et al.. 1995), exist in the literature in relation to the
marginal integrity of ceramic inlays. However, the
marginal integrity values reported were related only to
either before cementation or after cementation.
Therefore, a need for a comparison of the initial fit with
© 1997 Blackwell Science Ltd

the final adaptation of the ceramic inlays seems to be
essential to achieve a basis for the evaluation of marginal
integrity studies.
The aim of the present in vitro study was to evaluate
the marginal integrity of a sintered ceramic inlay
technique, before and after cementation.
Materials and methods
Ten newly extraaed noncarious human mandibular
molar teeth were used*. After cleaning and scaling,
MOD inlay preparations with 90° cavosurface margins
were made on all of the teeth. The preparation was
performed with a standard bur sefl". The base oi the
cavity was placed at a depth of 2-3 mm. and the
proximal gingival margins were placed in the enamel.
After preparation of the cavities, the teeth were
cleaned with an air-water spray and dried thoroughly.
An impression of each inlay cavity was taken using an
additional silicone material*. Stone dies were poured
within one hour. A ceramic inlay was manufactured
for each inlay cavity in accordance with the working
instructions of the Ducera®^ Low Fusing Ceramic inlay
technique. An inlay preparation is more irregular with
a great number of angles that necessitated internal
adjustment of the restoration for accurate seating. For
this purpose, the inlays were adjusted first on the stone
dies and subsequently on the abutment teeth by using
a control paste*".
When the inlays were completed, replicas of the
intermediate space between the inner surface of the
inlay and the tooth cavity surfaces were made. This was
achieved by coating the tooth cavity walls with a thin
layer of light-body additional silicone material, after
which the inlay was placed onto the looth and finger
pressure was applied. After the impression material was
set the inlay was removed leaving a thin film of light-
body material adhering to the die, representing the
discrepancy between the inlay and the tooth. For the
purpose of stabilization, a medium-body material was
applied, adhering with the light-body film dressing the
cavity. This procedure made it possible to remove and
handle the intermediate replica of the light-body
material. The replica specimens were sectioned with
d foi rthodontic
+Imensiv, Lugano. Switzerland.
^Extrude®, Kerr, Romulus, MI, USA.
^Diicera®, Rosbach, Germany.
llPS Empress, ivoclar, Scbaan. Liechtenstei
) 1997 Blackwell Science Ltd, Journal of Oral Rehabilitation 24; 646-^5!
SINTERED INLAY T E C H N I Q U E S 647
a scalpel in two axial directions, buccolingually and
mesiodistally. Five sections were made buccolingually
and two sections were made mesiodistaiJy. The five
sections in the buccolingual direction enabled a total of
10 measurements from occlusa! margins whereas the
two mesiodistal sections supplied measurements of
approximal margins in 4 different locations. The
marginal fit was assessed microscopically under a
transmitting tight microscope at a 1 50 X magnification.
After initial assessment of marginal adaptation, the
inlays were cemented with a dual-cured composite resin
luting material**. First, the inlays were etched for
2 min with hydrofluoric acid'*^ and coated with a silane
solution**, necessary to restore the bond strength.
During the conditioning of the inlay, the enamel margins
of the cavities were etched for 20 s with 37% phosphoric
acid. After thoroughly spraying with water for 20 s and
drying with compressed air, the cavities were covered
with a dentine bonding agent, Probond®^^ primer.
While holding for 30 s, Probond® adhesive was applied
over the entire surface of the preparation. The bonding
agent was thinned using compressed air for 1 5 s and
the adhesive was light-cured for 10 s using a visible
light-curing unit'^''. Equal amounts of resin cement base
and catalyst paste were mixed for 15 s and applied to
the internal surfaces of the restorations. The inlays were
immediately inserted with gradual pressure using a
blunt instrument to assure final seating. Gross resin
excess was removed from all the marginal areas and a
constant vibratory motion was applied by using an
ultrasonic sealer to insure optimal seating. After light
aaivation was completed, final finishing and polishing
was accomplished by using a porceJain polishing kit***.
The teeth were embedded in separate acrylic blocks
in order to facilitate the sectioning procedure with a
low speed sawing machine. Each tooth was sectioned
in buccal/lingual and mesial/distal directions with the
same procedure being followed for the sectioning of
replicas. The following parameters were assessed
microscopically under a transmitting light microscope
at 150 X magnification: (a) the marginal gap, defined
as the smallest distance between the inlay and the tooth
'^Enforce, Dentsply, Milford, DE. USA.
^"•tCeramco, Burlingame, NJ, USA.
**Mc)nobond S. Ivoclar. Schaan. Liechtenstein.
S^Enforce, Dentspiy, Milford, DE, U.S.A.
•"Vivadent, Scbaan, Liechtensiein.
***Edema Porcelain Veneer Kit, Edenia AG dentalprodukte,
Switzerland.
648 D . GEM ALMA Z
Fig. 1. Photomicrograph of the occlusal margin oi an inlay, (a)
Marginal gap. (b) Thickness of the exposed luting cement. I, inlay;
T, tooth; C, Luring composite.
Fig. 2. Photomicrograph of the approximal margin of an inlay,
(al Marginal (inish line of the inlay, (b) Marginal finish iinc of
the tooth cavily. h, horizonial discropancy: 1. inlay; T. looth; C,
Luting composite.
structure (Fig. 1); (b) the thickness of the exposed luting
cement (Fig. 1); (c) the horizontal discrepancy, both
over and undercontours observed for the approximal
margins (Fig. 2).
The tnarginal fit values recorded for the ceramic inlays
al occlusal and proximal margins before and after
cementation were recorded and analysed statistically
using two way analysis of variance at a confidence level
of 0-95 (a = 0-05). In order to visualize the marginal
adaptation of the inlays after cementation and exposed
© 1997 Blat-kw
luting composites, SEM observation* was performed on
sectioned specimens at 100 X and 150 x magnifications.
Results
The mean marginal gap values {before and after
cementation), luting composite thicknesses and
horizontal discrepancy recordings at both the occlusal
and the approximal margins are shown in Table 1.
Table 2 summarizes the analysis of variance results for
various comparisons of the recorded differences. When
the marginal gap values helore cementation were
compared, ihe mean marginal gap of 71 83 jim recorded
for the occiusal margin was significantly smaller than
the 105-6 nm recorded for the approximal margin
(P < 0-05). Following the cementation, the adaptation
of the inlays at the occlusal margin (78'77 |am), was
also found to be superior to the adaptation of the
approximai margins (128-85 |im) (? < 0 05).
The observed differences between before and after
cementation marginal gap values of occlusa! and
approximal margins were 6'94 (im and 23-25 |am,
respectively, which were not statistically significant
(Table 2).
Comparison of the marginal gap values after
cementation and exposed luting composite thicknesses
revealed that the exposed luting composite thicknesses
were significantly higher than those of the marginal gap
values observed at both the occiusai and the approximal
margins (Tables 1 &• 2).
A wide range of horizontal discrepancy
nieasurcmenis, expressed in levms oi" standard
deviation, was observed. The mean discrepancy was
79-74 [i.m with a range ot-142-6 [im (undercontoured)
to 343-8 M-m (overcontoured), indicated that the inlays
were generally overcontoured at the approximal
margins.
Discussion
Several in vitro studies have reported that the marginal
fit of ceramic inlays is inferior to that of gold inlays
(Fett et aL, 1989; Shortall, Baylis 8- Grundy, 1989; Hung
et at., 1990; Qualtrough et al., 1991; Molin &- Karlsson,
1993). The marginal interface is said to be compensated
ior by the use of a bonded dual-cured composite resin
luting agent. However, in the long term, this could
*Jeol, Tokyo, Japan.
tal of Oral Rehabilitation 24; 646-651
 SINTERED INLAY TECHNIQUES 649

Table 1. Marginal gap, luting composite and horizontal discrepancy values (Mm)

Measuring poini

Ocdusai margin Approximdl margin

Range Range

Marginal gap 59-196-4

After cementation 78'77 14.85 63-44-104-56 128-85 34 34 74-4-196-73
Luting composite 197-54 64-64 140-4-313-6 165-69 17-20 148 2-204-13
Horizontal discrepancy 79-74 139-18 -1426-343-8

s.d., standard deviation.

Table 2. ANOVA results

Source of variance d.f. Sum of squai

Occlusal marginal gap before cementation 1 5701-389 7-01 0-016

X Approximal marginal gap before cementation
Occlusal marginal gap after cementation 1 12540-03 17-91 0-001
X Approximal marginal gap after cemeniaiion
Occlusal marginal gap before cementation ! 241-0957 t-6 0-221
X Occlusal marginal gap after cementation
Approximal marginal gap before cementation 1 2704'208 1-98 0'176
X Approximal marginal gap after cementation
Occlusal luting composite thickness I 5072-495 2-27 0-149
X Approxima! luting composite thickness
Occlusa! marginal gap after cementation 1 70532-99 32-06 0-000
X Occlusal Luting composite thickness
Approximal marginal gap after cementation I 6785-928 919 0-007
X Approxima] luting composite thickness

d.i., degrees of Ireedom.

be a serious drawback promoting the failure of the
restoration due to dissolution and leakage,
discolouration and excessive wear of the luting agent.
Although an ideal range for the marginal gap of luting
composite cements has not yet been reported, some
authors (Leinfelder, Isenberg &• Essig, 1989; Federlin
etai. 1992; Van Meerbeeker<j/.. 1992; Schmalz, Federlin
& Reich. 1995). suggested that the maximum width of
exposed luting cement should not exceed 100 \xm.
In the present study, the mean gap values calculated
for occlusal and approximal margins were 78-77 ^.m
and 128-85 uni, respectively. Although, the mean value
of occlusa] marginal fit did noi exceed the limit of
100 fim, the approximal marginal tit was over 100 jim
by approximately 30 |im.
Since a great variation in marginal adaptation was
observed within all the samples and even within the
different locations of the same inlay, the clinical
acceptability of the marginal adaptation of an inlay
system cannot be determined only by considering the
mean value. Thus, it would not be appropriate to state
that the approximal marginal fit of Ducera inlays is
clinically unacceptable. However, the use of high
viscosity resins coutd be recommended for luting, as
Schmalz elal. (1995) claimed that luting spaces greater
than 100 ^.m could partially be compensated by the
viscosity ol the luting cement.
It has been reported that the viscosity of a luting
agent might have an influence on the minimum film
thickness that can he obtained in sectioning the inlay
(Lambrechts et al., 1991). Comparison of the mean gap
values before and after cementation revealed that dual-

) 1997 Biackwell Science Ltd. Journal of Oral Rehabililai

650 D.GEM ALMAZ et al.

Fig. 3. Photomicrograph of the occlusal margin of an inlay. The Fig. 4. Photomicrograph of one of various shaped occlusal marginal
extensions of the luting composite over bolh enamel and ceramic finish lines.
inlay are indicated by ihc arrows. 1, inlay; T. tooth; C, Luting
composite-
cured composite resin did not have a significani effect
on the adaptation of the inlays. It is highly probable
that the very low viscosity of the luting cement and its
long working time enabled us to work for a wide range
of time without causing any seating problem.
Exposed luting composite thicknesses were higher
than the marginal gap values at both the occlusal and
approximal margins. The SEM observations revealed
that although polishing was performed excess luting
material still remained that caused an increase in the
width of the exposed luting cement (Fig. 3). In the long
term, occlusa! wear will occur in both the excess luting
material and the ceramic inlay. However, the rate of "ograpli of one ol various shaped occlusaJ marginal
wear will be more in the composite luting material
which might predispose to submargination that could
result in microcracks at the marginal edges of the The definition of marginal fit varies among the studies
ceramic inlays (van Meerbeek et at,, 1992). mentioned above and this makes it difficult to compare
The marginal fit of the cemented restorations may directly the results from the different studies.
be estimated by invasive or non-invasive techniques Furthermore, the various shaped marginal finish lines
(Rouiet, 1994). The invasive methods are based on (Figs 1, 3-5) which occur, cause uncertainty in
sections. The multiple sectioning technique used in interpretation of measuring points. Thus, stan-
this study offers an advantage over the more simple dardization of such measurements seems to be essential
procedure of bisectioned satnples. According to Hung to achieve a basis for the in vitro evaluation of marginal
et at. (1990) the multiple section technique is not only integrity in inlay restorations.
more precise than the non-invasive method, but also
results in statistically significant higher values. A
Acknowledgments
possible explanation might be that the absolute marginal
discrepancy appears better defined on a section The authors gratefully acknowledge the contribution of
compared to an intact surface and thus easier to the Enforce® dual-cured composite resin luting material
detertnine. by Dentsply International for this study. Particular

© 19«7 Blackwtl! Science Ltd. Journal of Oral Rehabilih


appreciation is expressed to Professor Adnan Tekin for
his help with the SEM observations. Appreciation is
also expressed to Mr Eren Tor and Mr Sunay Rodoplu for
their assistance in preparing the experimental samples.
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