Q U I N T E S S E N C E I N T E R N AT I O N A L

A new design for all-ceramic inlay-retained fixed

partial dentures: A report of 2 cases
Stefan Wolfart, Dr Med Dent1/Matthias Kern, Dr Med Dent, PhD2

In a previous clinical study, all-ceramic resin-bonded 3-unit inlay-retained fixed partial den-
tures (IRFPDs) had a significantly worse outcome in the posterior region than did crown-
retained 3-unit FPDs made from the same material. Debonding or fractures were causes
of failure. To improve the clinical outcome of IRFPDs, a new framework design was devel-
oped: (1) The inlay retainers were made out of CAD/CAM-manufactured zirconia ceramic
to improve fracture resistance, and additional veneering of the inlays was omitted. (2) The
inlay retainers were completed with a shallow occlusal inlay (1-mm minimum thickness)
and an oral retainer wing (0.6-mm minimum thickness). The wings were designed to
reduce stress on the inlay retainer caused by torsion forces when the FPD is loaded non-
axially and to increase the enamel adhesive surface area. The pontic was circumferentially
veneered with feldspathic porcelain. The clinical and laboratory procedures of this new
treatment modality are described, and 2 exemplary clinical cases are presented. This new
preparation and framework design might improve the clinical outcome of all-ceramic resin-
bonded IRFPDs. However, adequate evidence of long-term safety and efficacy is required
before this new design can be recommended for general clinical practice. (Quintessence
Int 2006;37:27–33)

Key words: adhesive, all-ceramic restoration, CAD/CAM, fixed partial dentures,

inlay-retained, preparation, zirconia

The use of all-ceramic materials for fixed
restorations in dentistry has become more
and more important for patients and clini-
cians in the last decades. Since the first felds-
pathic crown was inserted in 1886,1 recent
1
Assistant Professor, Department of Prosthodontics,
Propaedeutics and Dental Materials, School of Dentistry,
Christian-Albrechts University at Kiel, Kiel, Germany.
2
Professor and Chair, Department of Prosthodontics,
Propaedeutics and Dental Materials, School of Dentistry,
Christian-Albrechts University at Kiel, Kiel, Germany.
Reprint requests: Dr Stefan Wolfart, Department of
Prosthodontics, Propaedeutics and Dental Materials, School
of Dentistry, Christian-Albrechts University, Arnold-Heller-
Strasse 16 D-24105 Kiel, Germany. Fax: + 49-431-597-2860.
E-mail: swolfart@proth.uni-kiel.de
progress in material technology and manu-
facturing procedures has extended the indi-
cations for these materials. In 19902 the IPS
Empress system (Ivoclar Vivadent) was intro-
duced to the dental community and became
a popular all-ceramic system for pressed
glass-ceramic inlay, onlay, and veneer
restorations. To increase the mechanical
strength of all-ceramic restorations, different
core materials were used. They were made
either from glass-infiltrated alumina ceramic
(In-Ceram Alumina, Vita Zahnfabrik),3 pure
alumina ceramic (Procera, Nobel Biocare),4
or lithium disilicate-based glass-ceramic (IPS
Empress 2). However, the highest fatigue
fracture strength so far is achieved by the
core material zirconia ceramic.5

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Fig 1a (left) The maxillary right second premolar and sec-

ond molar after preparation (patient A).

Fig 1b (above) Epoxy cast with plotted outline of prepara-

tion of the second premolar. Preparations of an oral retainer
wing (white asterisk) and a shallow occlusal inlay (black aster-
isk) are performed (patient A).

Irrespective of which type of ceramic clini-
cians use, a crown preparation is always a
risk to pulp vitality and may lead to pulpal
reactions in the long term.6 About 63% to
73% of the coronal tooth structure is
removed when teeth are prepared for all-
ceramic crowns.7 Given these facts, it
seemed desirable to adapt the type of abut-
ment preparation to the extent of sound tooth
structure after caries removal, not only for a
single-tooth restoration but also for fixed par-
tial denture (FPD) abutment preparations.
Therefore, if a patient rejects an implant treat-
ment and if enough sound tooth structure is
available, it would be desirable to restore a
missing tooth with an inlay-retained FPD
(IRFPD) instead of a crown-retained FPD.
However, clinical evaluations showed a fail-
ure rate of 10% after 9 months (Empress 2)8
and 13% after 37 months (IPS e.max Press,
Ivoclar Vivadent)9 for inlay-retained 3-unit
FPDs. In both studies, the failure was evoked
by debonding or a combination of both
debonding and fracture. Compared to
crown-retained FPDs, these failure rates
appear to be much too high to recommend
this treatment strategy. To improve the out-
come of IRFPDs, 2 strategies look promising.
On the one hand, the core material has to be
improved to demonstrate a higher fracture
resistance, and on the other hand, the design
of the IRFPDs has to be reconsidered to min-
imize the risk of debonding.
The aim of this article is to describe a new
design of inlay-retained FPDs that will (1)
increase the adhesive strength by maximiz-
ing the bonding area and (2) minimize tor-
sion forces on the inlay retainers when the
FPDs are loaded nonaxially. Because of its
very high static and fatigue fracture strength,
the use of a zirconia ceramic material
seemed reasonable.
METHODS AND MATERIALS
Patients
Two patients referred to the Department of
Prosthodontics of Christian-Albrechts Univer-
sity at Kiel, Germany, with the indication for 3-
unit FPDs, were selected for this new type of
restoration. Patient A was a 33-year-old man
missing the maxillary right first molar. The
tooth gap corresponded to the typical size of
a maxillary molar and had already been treat-
ed 22 months earlier with an all-ceramic resin-
bonded IRFPD (experimental ceramic).
Because of debonding of the inlay retainer at
the second molar after 22 months, the FPD

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*
Fig 1c (left) Resin framework and the
enlarged milled framework (patient A).

Fig 1d (center) Framework in situ (patient A).

Fig 1e (above) Proximal inlay with oral retain-

er wing (white asterisk) and shallow occlusal
inlay (black asterisk) of the second premolar
(patient A).

Fig 1f (above) The second premolar before cementation, with rubber

dam and etched preparation surface (patient A).

Fig 1g (right) Resin-bonded inlay-retained FPD in situ 1 month after

cementation (patient A).

had to be removed. The inlay retainer of the
second premolar was still in situ. The patient
rejected implant treatment and again chose
an all-ceramic IRFPD. Figures 1a to 1g show
the treatment procedures step-by-step.
Patient B was a 46-year-old man missing
the maxillary right second premolar. The
tooth gap corresponded to the typical size of
a maxillary premolar. The maxillary right first
premolar had a small carious lesion distally,
and the first molar had an insufficient mesial-
occlusal-palatal-buccal restoration. Figures
2a to 2g show the treatment procedures
step-by-step.

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Fig 2a (left) The maxillary right first premolar and first molar before treatment (patient B).

Fig 2b (center) Epoxy cast showing the final preparation (patient B).

Fig 2c (right) Framework modeled in resin and wax (patient B).

Fig 2d (above) Inlay-retained FPD before cementation (patient B).

Fig 2e (right) Protection of the veneering ceramic in the pontic

area with silicone for the airborne-particle abrasion procedure
(patient B).

Both patients were healthy and had an
almost complete dentition. All abutment
teeth were vital. The bone level of the abut-
ment teeth corresponded to the upper third
of the root length with no signs of active bone
resorption or periapical pathology. Oral
hygiene was very good, and caries activity
was low. All abutment teeth showed no
mobility, and probing depths ranged from 2
to 3 mm. Extreme bruxism or a conspicuous

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Fig 2f (left) Occlusal view of the resin-bonded inlay-retained FPD

1 month after insertion (patient B).

Fig 2g (above) Buccal view of the resin-bonded inlay-retained

FPD 1 month after insertion (patient B).

medical or psychological history could be in height and 4 mm in length. The occlusal

excluded. Patients were informed about the
risks of the proposed therapy and its alterna-
tives such as insertion of a crown-retained
FPD or single implant placement.
Prosthodontic procedures
The abutment teeth were prepared accord-
ing to their defects. For patient A, the maxil-
lary right second premolar was prepared
with a distal inlay and the second molar with
a mesial inlay (see Fig 1a). For patient B, the
maxillary right first premolar was prepared
with a distal inlay and the first molar with a
preparation for a partial crown (see Fig 2b).
Inlay preparation procedures were per-
formed in accordance with general princi-
ples for ceramic inlay restorations.10 Box-
shaped inlay cavities were prepared with fine
(30- to 40-µm-grained) diamond instruments,
and additional undercuts were set at the
edges of the boxes (patient A). The finishing
line was a shoulder; no bevels were used. A
shallow occlusal inlay (size 3
3 mm, mini-
mum thickness 1 mm) was added, and an
oral retainer-wing bevel preparation was per-
formed (Fig 1b). For this preparation, the
enamel was reduced about 0.2 to 0.5 mm
parallel to the insertion direction of the boxes
to achieve a plain enamel area about 3 mm
inlay and the oral retainer-wing preparations
were performed only in enamel; no dentin
was exposed. All preparations were finished
by rounding sharp angles. Figure 1b shows
the outline of the completed preparation
of the maxillary right second premolar
(patient A).
After abutment preparation, impressions
were made with a simultaneous dual-mix
technique using polyether material (Perma-
dyne, 3M Espe). In the laboratory, the impres-
sions were cast with epoxy (Diatan, Völker
Dental-Produkte) (Fig 2b). Afterward, the
framework was modeled in resin (Pattern
Resin, GC) consisting of the inlay retainer,
onlay retainer, and oral retainer wing for the
first premolar abutment, the second premo-
lar pontic, and the first molar partial crown
(patient B, Fig 2c). Next, the framework was
scanned and milled out of zirconia ceramic
(Vita In-Ceram YZ Cubes, Vita Zahnfabrik)
using a computer-aided design/computer-
assisted manufacture (CAD/CAM) system
(Cerec Inlab, Sirona Dental Systems). The
original framework made from resin and the
enlarged milled framework are shown in Fig
1c. For patient B, the color of the framework
was individualized using an infiltration tech-
nique (Vita Coloring lLiquid, Vita Zahnfabrik).

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The enlarged green-state framework was
then sintered at 1,530°C using a special fur-
nace (Thermostar, Vita Zahnfabrik). After the
sintering process, minor adjustments to seat
the castings on their dies were completed
under a light microscope (magnification

20) if necessary. Additionally, the marginal
fit of the framework was checked intraorally
with a silicone indicator paste (Fit Checker,
GC) and an explorer (Fig 1d). The marginal fit
of the restorations was accepted when the
silicone indicator paste showed a thin and
homogeneous thickness.
Adjustments were made if necessary. Vita
VM9 (Vita Zahnfabrik) was used for veneer-
ing the pontic circumferentially (see Fig 2d).
The minimum ceramic thickness was 3 mm
for the box retainer, 1 mm for the occlusal
inlay, and 0.6 mm for the oral retainer wings
(see Fig 1e). For the proximal connector, the
minimal dimensions were 4 mm in height
and 4 mm in width (16 mm2).
Both FPDs were cemented adhesively.
The surfaces of the inlay retainer and oral
retainer wings were airborne-particle abrad-
ed (50 µm Al2O3) for 10 seconds with 2.5 bar
pressure, which is an essential step for reli-
able bonding of zirconia ceramic.11 To pro-
tect the remaining parts of the FPD (ie, the
veneered pontic area), the other ceramic sur-
faces were protected with silicone during air-
borne-particle abrasion (see Fig 2e). Then
the FPDs were bonded to the abutment teeth
with a phosphate monomer–containing
adhesive system (ED-primer and Panavia 21
TC, Kuraray). Rubber dam was used during
adhesive cementation. Figure 1f shows the
second premolar of patient A after etching
with phosphoric acid. The etched enamel
surface relating to the oral retainer wing and
the occlusal inlay is visible.
Figures 1g, 2f, and 2g show the IRFPDs of
both patients 1 month after placement. After
an observation time of 9 months (patient A)
and 7 months (patient B), the outcome of
both restorations was successful. Within the
observation time there was no need for
repairs or retreatment other than mainte-
nance procedures, including oral hygiene
and prophylaxis. During the latest follow-up
examination, both patients reported that they
are highly satisfied with the IRFPDs.
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DISCUSSION
In a previous study, short-span crown-retained
3-unit FPDs made from a new glass-ceramic
(IPS e.max Press) had a significantly better
outcome up to 5 years than inlay-retained 3-
unit FPDs made from the same material.9 The
failures in IRFPDs were evoked by debonding
or a combination of debonding and fracture
at the isthmus of 1 abutment, ie, the connec-
tion between the occlusal part and the proxi-
mal box of the inlay.
High stress on the luting cement because
of different kinds of torsion forces on the
inlay retainers and a high percentage of
dentin instead of enamel at the interface
between tooth and luting cement have been
suggested as causes for debonding. The
newly designed IRFPDs address these main
weak points found in the latter study: (1) A
CAD/CAM-manufactured zirconia-ceramic
framework was used for the new IRFPDs
because the use of this kind of framework
resulted in a significantly higher static and
fatigue fracture strength of 3-unit inlay-
retained posterior FPDs than did lithium disil-
icate–based glass-ceramic.12 (2) By prepar-
ing oral retainer wings and shallow occlusal
inlays, the size of the enamel adhesive bond-
ing area was increased, and therefore the
bond strength of the IRFPD should be
improved significantly.
Similar types of retainer wings have
already been described for cantilevered all-
ceramic resin-bonded FPDs.13 When these
FPDs were made in the anterior region from
high-strength oxide ceramics, they showed a
promising long-term outcome after a mean
observation time of 52 months.14 It is further
assumed that the oral retainer wings will
reduce the effect of torsion forces on the
inlay retainers when the FPDs are loaded
nonaxially, and in this way, will reduce the
stress at the adhesive interfaces.
The minimal preparations for the oral
retainer wing and for the occlusal inlay are
performed only within enamel, because the
bond strength is much higher and more
durable between luting cement and enamel
than between luting cement and dentin.15,16
Therefore, the bond strength in these areas is
very strong, provided that adequate luting pro-
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cedures are used.11,17,18 However, a problem of
these minimal preparations is that the ceram-
ic of the restoration is relatively thin in the cor-
responding areas (thickness between 0.6 to 1
mm). Therefore, this IRFPD design should be
performed only with a high-strength core
material such as zirconia ceramic.5
Unfortunately, only a few CAD/CAM sys-
tems so far are able to produce the complex
framework structure suggested for this new
IRFPD design. Disadvantages of the new
design are that the fragile parts of the IRFPD
show inadequate color matching because
they are made completely out of zirconia
ceramic (ie, the inlay retainer, partial crown,
occlusal inlay, and oral retainer wings) (Fig
1d). The color matching of the framework can
be improved but will not be fully satisfying with
the color-infiltration technique (ie, using color-
ing liquid, as for patient B) (Figs 2f and 2g). In
addition, because of a suggested minimum
thickness of 0.6 mm for the oral retainer wings
and the very thin preparation in this area, the
wings are oversized and bulge out slightly
(around 0.1 to 0.3 mm) at the tooth contour
(Figs 1g and 2f).
CONCLUSIONS
The new preparation form and framework
design presented in this article are consid-
ered to improve the clinical outcome of resin-
bonded all-ceramic inlay-retained FPDs. The
new design improves the inlay-retained FPDs
at their weakest points—the adhesive bond-
ing interface and the connection between
the occlusal part and the proximal box of the
inlay. However, adequate evidence about
their long-term safety and efficacy is required
before this new design can be recommend-
ed as acceptable for general clinical practice.
ACKNOWLEDGMENTS
The authors are grateful to the patients for their kind
cooperation and to the dental technicians B. Schlueter
and R. Gerhardt (Department of Prosthodontics,
Propaedeutics, and Dental Materials, School of
Dentistry, Christian-Albrechts University at Kiel).
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