Class I and II

Indirect Tooth-Colored Restorations

Most indirect restorations are made on a replica of
the prepared tooth in a dental laboratory by a
trained technician. Tooth-colored indirect systems
include laboratory-processed composites and
ceramics, such as porcelain fired on refractory dies
or hot pressed glasses.
In addition, chairside computer-aided
design/computer-assisted manufacturing
(CAD/CAM) systems are currently available and
are used to fabricate ceramic restorations.
Indications
* Esthetics.
* Large defects or previous restorations.
* Economic factors: Some patients desire the best
dental treatment available, regardless of cost.
Contraindications
* Heavy occlusal forces
* Inability to maintain a dry field.
* Deep subgingival preparations.
Advantages
* Improved physical properties: A wide variety
of high-strength tooth-colored restorative
materials, including laboratory-processed and
computer-milled composites and ceramics, can
be used with indirect techniques.
* Variety of materials and techniques: Indirect
tooth-colored restorations can be fabricated with
either composites or ceramics using various
laboratory processes or CAD/CAM methods.
* Wear resistance: Ceramic restorations are more
wear-resistant than direct composite restorations,
an especially critical factor when restoring large
occlusal areas of posterior teeth. Laboratory-
processed composite restorations wear more than
ceramics, but less than direct composites in
laboratory studies .
* Reduced polymerization shrinkage:
Polymerization shrinkage and its resulting
stresses are a major shortcoming of direct
composite restorations.
* Ability to strengthen remaining tooth structure:
Tooth structure weakened by caries, trauma, or
preparation can be strengthened by adhesively
bonding indirect tooth-colored restorations.
* More precise control of contours and contacts:
Indirect techniques usually provide better contours
(especially proximal contours) and occlusal contacts
than direct restorations because of the improved access
and visibility outside the mouth.
* Biocompatibility and good tissue response:
Ceramic materials are considered the most
chemically inert of all materials.
* Increased auxiliary support: Most indirect
techniques allow the fabrication of the
restoration to be totally or partially delegated to
dental laboratory technicians.
Disadvantages
* Increased cost and time: Most indirect techniques
require two patient appointments, plus fabrication of
a temporary restoration.

These factors, along with laboratory fees, contribute

to the higher cost of indirect restorations relative to
direct restorations.
* Technique sensitivity: Restorations made
using indirect techniques require a high
level of operator skill.
* Brittleness of ceramics: A ceramic restoration
can fracture if the preparation does not provide
adequate thickness to resist occlusal forces or if
the restoration is not appropriately supported by
the cement medium and the preparation.
* Wear of opposing dentition and restorations:
Ceramic materials can cause excessive wear of
opposing enamel or restorations.
* Resin-to-resin bonding difficulties: Laboratory-
processed composites are highly cross-linked, so
few double bonds remain available for chemical
adhesion of the composite cement.
* Short clinical track record: Indirect bonded
tooth-colored restorations have become
relatively popular only in recent years and are
still not placed by many practitioners.
* Low potential for repair: Indirect restorations,
particularly ceramic inlays/onlays, are difficult to
repair in the event of a partial fracture.
* Difficult try-in and delivery: Ceramics are
more difficult to polish because of potential
resin-filled marginal gaps and the hardness of the
ceramic surfaces.
Laboratory-Processed Composite
Inlays and Onlays
Processed composite restorations are
indicated when:
(1) maximum wear resistance is desired
from a composite restoration,
(2) achievement of proper contours and
contacts would otherwise be difficult, and
(3) a ceramic restoration is not indicated because
of cost or concerns about wear of the opposing
dentition. Regarding the last-mentioned, the
indirect composite would likely cause less wear
of the opposing dentition than a similar ceramic
restoration.
The fabrication steps for one
representative system can be
summarized as follows:
1. The indirect composite restoration is
initially formed on a replica of the
prepared tooth.
2. The composite is built up in layers,
polymerizing each layer with a brief
exposure to a visible light-curing unit.
3. After it is built to full contour, the
restoration is coated with a special gel to
block out air and thus prevent formation of
an oxygen-inhibited surface layer.
4. Final curing is accomplished by inserting
the inlay into an oven-like device that
exposes the composite to additional light
and heat, in some cases, pressure.
5. The cured composite inlay is
trimmed, finished, and polished in the
laboratory.
Ceramic Inlays and Onlays
Among the ceramic materials used are
feldspathic porcelain, hot pressed ceramics, and
machinable ceramics designed for use with
CAD/CAM systems.
The physical and mechanical properties of
ceramics come closer to matching those of
enamel than do composites.

They have excellent wear resistance and a

coefficient of thermal expansion very close to
that of tooth structure.
Feldspathic Porcelain Inlays and Onlays
 The fabrication steps for fired ceramic
inlays and onlays can be summarized as follows:
Master cast for MOD ceramic inlay. Die
spacer is usually applied to axial walls
and pulpal floor before duplication
Master die is impressed, then a
duplicate die is poured with refractory
investment
 Inlay is cleaned of all investment, then seated
on master die for final adjustments and
finishing. Ceramic inlay is now ready for
delivery
Dental porcelains are added and fired in
increments until inlay is the correct shape.
Hot Pressed Glass-Ceramics
The fabrication steps for one type of leucite-
reinforced hot pressed ceramic restoration
are summarized as follows:
Wax pattern for ceramic inlay
Wax pattern on sprue base, ready to be
invested
 Ceramic inlay as pressed and before
Device for pressing heated ceramic
surface characterization
Inlay following surface characterization
Computed-Aided Design/Computed-
Assisted Manufacturing: CAD/CAM
Rapid improvements in technology have
spawned several computerized devices that can
fabricate ceramic inlays and onlays from high-
quality ceramics in a matter of minutes.
Some CAD/CAM systems are very
expensive laboratory-based units requiring
the submission of an impression or working
cast of the prepared tooth.
The CEREC system
The CEREC system was the first commercially
available CAD/CAM system developed for the
rapid chairside design and fabrication of ceramic
restorations.

The 2005 version of this device is the CEREC 3.

A B

CEREC 2 (A) and CEREC 3 (B) CAD/CAM devices.

These chairside units are compact
and mobile.
Generation of a CEREC 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.
An optical impression is made by
placing a small video camera or
scanner over the prepared tooth.
 The restoration is designed on
the computer screen by drawing
position of gingival margins and
proximal contacts.
 A, Computer-driven software
controls two small, diamond-
coated milling devices that cut
the restoration out of a block of
high-quality ceramic. B, The
ceramic block rotates as the
diamond cutting instruments
move as needed to generate the
B restoration.
A major advantage is the quality of the restorative
material. Manufacturers make blocks of
"machinable ceramics" or "machinable composites"
specifically for computer-assisted milling devices.

Because these materials are fabricated under ideal

industrial conditions, their physical properties have
been optimized.
The major disadvantages of CAD/CAM
systems are high cost and the need for extra
training.

However, CAD/CAM technology is changing

rapidly, with each new generation of devices
having more capability, accuracy, and ease of
use.
CLINICAL PROCEDURES
Tooth Preparation
By definition, an onlay caps all cusps; an
inlay may cap none, or may cap all but
one cusp.
 As a first clinical step:

1- The patient is anesthetized and the area

isolated, preferably using rubber dam.
2- The compromised restoration (if present)
is completely removed, and all the caries is
excavated.
3- If necessary, the walls are restored to a
more nearly ideal form with a light-cured
glass-ionomer liner/base or a composite
restorative material.
Preparations for indirect tooth-colored inlays and
onlays are designed to provide adequate thickness
for the restorative material and simultaneously a
passive insertion pattern with rounded internal
angles and well-defined margins.
1- All margins should have a 90- degree
cavosurface angle to ensure marginal strength of
the restoration.
2- All line and point angles, internal and external,
should be rounded to avoid stress concentrations
in the restoration and tooth, reducing the potential
for fractures.
The carbide bur or diamond used for tooth
preparation should be a tapering instrument that
creates occlusally divergent facial and lingual
walls.
The occlusal step should be prepared 1.5 to
2 mm in depth. Most composite and ceramic
systems require that any isthmus be at least 2
mm wide to decrease the possibility of fracture
of the restoration.
The pulpal floor should be smooth and
relatively flat.
The facial, lingual, and gingival margins of the
proximal boxes should be extended to clear the
adjacent tooth by at least 0.5 mm.

These clearances will provide adequate

access to the margins for impression material
and for finishing and polishing instruments.
For all walls, a 90-degree cavosurface
margin is desired because composite and
ceramic inlays are fragile in thin cross-
section.
The gingival margin should be extended as
minimally as possible because margins in enamel
are greatly preferred for bonding, and because
deep gingival margins are difficult to impress
and to isolate properly during cementation.
A cusp usually should be capped if the
extension is two thirds or greater than the
distance from any primary groove to the
cusp tip.
Impression
Most tooth-colored indirect inlay/onlay systems
require an impression of the prepared tooth and
the adjacent teeth as well as interocclusal
records, which allow the restoration to be
fabricated on a working cast in the laboratory
Temporary Restoration
A provisional restoration is necessary when
using indirect systems that require two
appointments.

The temporary restoration protects the pulp-

dentin complex in vital teeth, maintains the
position of the prepared tooth in the arch, and
protects the soft tissues adjacent to prepared
areas.
Temporary restorations for porcelain-fused-to-
metal and cast gold restorations typically are
cemented with eugenol-based temporary
cements.
Eeugenol is believed to interfere with resin
polymerization, however, and potentially could
reduce the adhesion of the permanent composite
cement to tooth structure.

Use of a noneugenol temporary cement is

recommended.
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 temporary restoration.
Computer-Aided Design/Computer-
Assisted Manufacturing (CAD/CAM)
Techniques
Using the CEREC system, an experienced
dentist can prepare the tooth, fabricate an inlay,
and deliver it in approximately 1 hour. This
system eliminates the need for a conventional
impression, temporary restoration, and multiple
patient appointments.
 B

A, CEREC inlay being milled. B, Completed inlay

Try-in and Cementation
The inlay or onlay is placed into the
preparation using very light pressure to
evaluate its fit. If the restoration does not
seat completely, the most likely cause is an
overcontoured proximal surface.
A, Initial try-in of CEREC inlay. Proximal contacts are too
tight and must be adjusted.
B, Inlay seated after contact adjustment. Proximal surfaces
of the inlay must be polished before cementation.
Cementation
For most laboratory-processed composite inlays/
onlays, the resin matrix has been polymerized to
such an extent that few bonding sites are
available for the composite cement to chemically
bond to the internal surfaces of the restoration.
For ceramic inlays and onlays, hydrofluoric acid
usually is used to etch the internal surfaces of the
restoration.
Chairside ceramic etching is done with a 2-
minute application of 10% hydrofluoric acid on
the internal surfaces of the inlay/onlay.
After etching, the ceramic is treated with a
silane coupling agent to facilitate chemical
bonding of the composite cement.
Clear plastic matrix strips may be applied in
each affected proximal area and wedged.

The inlay/onlay can be tried in again and

checked for fit.
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.
A dual-cure composite cement is mixed and
inserted into the preparation.

The internal surfaces of the restoration are also

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
The operator must be careful not to remove
composite from the marginal interface between
the tooth and the inlay.

The cement is now light-cured from occlusal,

facial, and lingual directions for a minimum
exposure of 60 seconds from each direction.
A, Enamel and dentin are etched with phosphoric acid. B,
Dual-cured composite cement is applied to inlay. C, After
application of the adhesive system, cement is applied to the
preparation. D, CEREC ceramic inlay is seated into
preparation.
Cont'd E and F, Before curing, excess
composite cement is removed with
explorer, brushes, and IPC carver. G,
The composite cement is light-cured
from occlusal, facial, and lingual
directions.
Finishing and Polishing Procedures
 A, Slender, fine-grit, flame-shaped, diamond
instruments are used to remove flash along facial and
lingual margins of CEREC ceramic inlay. B, 30-fluted
finishing burs are used to smooth areas that were
adjusted with diamonds.
A, Removing excess composite cement using a surgical blade. B,
Smoothing the interproximal area with abrasive finishing strip.
 Polishing sequence for ceramic inlays. A, After using fine-grit diamonds
and 30-fluted carbide finishing burs to adjust contours and margins,
rubber abrasive points and cups of successively finer grits are used at
slow speed. B, Final polish imparted by porcelain polishing paste applied
with bristle brush. C, Occlusal view of polished ceramic inlay.
Common Problems and Solutions
The most common cause of failure of tooth-colored
inlays and onlays is bulk fracture.

If bulk fracture occurs, replacement of the

restoration is almost always indicated.
Repair of Tooth-Colored
Inlays and Onlays
For composite and ceramic inlays, the
repair procedure is initiated by mechanical
roughening of involved surface.
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.
Although many indirect composites contain
etchable glass filler particles, hydrofluoric
acid treatment of composites is neither necessary
nor recommended.

However, a brief application of phosphoric

acid may be used to clean the composite surface
after roughening.
The next step in the repair procedure is application
of a silane coupling agent.

Silanes mediate chemical bonding between

ceramics and resins and also may improve the
predictability of resin-resin repairs.
After the silane has been applied, a resin
adhesive agent is applied and light cured.

A composite of the appropriate shade is placed,

cured, contoured, and polished.