FUNDAMENTAL

RESEARCH
In Vitro Evaluation of Marginal and Internal
Adaptations of Ceramic Inlay Restorations
Associated with Immediate vs Delayed
Dentin Sealing Techniques
Linah M. Ashy, BDS, DMSc
Department of Oral and Maxillofacial Prosthodontics, Faculty of Dentistry, King Abdulaziz University,
Jeddah, Saudi Arabia.

Hanadi Marghalani, BDS, MSc, PhD

DRBBA Research Group, Operative and Esthetic Dentistry Division, Restorative Dentistry Department,
Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia.

Nikolaos Silikas, BSc, FADM, MPhil, PhD

School of Dentistry, The University of Manchester, Manchester, United Kingdom.

Purpose: To investigate the marginal and internal adaptations of ceramic inlay restorations placed with
immediate dentin sealing (IDS) vs delayed dentin sealing (DDS) procedures. Materials and Methods: Mesial
and distal Class II cavities were prepared in 12 extracted molar teeth, which were randomly allocated into
six groups of 2 teeth each. Lava Ultimate inlays were fabricated and luted to the cavities using All-Bond
universal adhesive system and eCEMENT dual-curing resin cement following IDS/immediate cementation
(control groups 1 and 2), IDS/delayed cementation (groups 3 and 4), or DDS/delayed cementation (groups 5
and 6) protocols. Teeth in groups 2, 4, and 6 were subjected to thermocycling of 500 cycles between 5°C and
55°C after inlay cementation. Following staining with silver nitrate solution, the marginal and internal gap
volumes were determined using microcomputed tomography images. Statistical analyses were conducted
using independent t test and one-way analysis of variance followed by Tukey post hoc test (P < .05). Results:
Marginal gap volume for DDS (1.856 ± 0.323 mm3) was significantly higher than that of IDS immediately
after inlay cementation (0.891 ± 0.281 mm3) (P = .025). Following thermocycling, the internal gap volume
for DDS (0.838 ± 0.248 mm3) was significantly higher than that for IDS (0.098 ± 0.066 mm3) (P = .000),
but the marginal gap volume of DDS (1.964 ± 0.956 mm3) was not significantly different from that of IDS
(1.426 ± 0.725 mm3) (P = .622). Conclusion: Luted ceramic inlays have a superior marginal adaptation right
after cementation and a superior internal adaptation after thermocycling when using the IDS technique
compared to the DDS technique. However, marginal adaptation after thermocycling was not significantly
different between the two techniques. Int J Prosthodont 2020;33:48–55. doi: 10.11607/ijp.6372

I
Correspondence to:
Dr Linah Ashy
Department of Oral and
Maxillofacial Prosthodontics
Faculty of Dentistry,
King Abdulaziz University
P.O. Box 80209,
Jeddah 21589, Saudi Arabia
Email: lashy@kau.edu.sa
Submitted February 22, 2019;
accepted July 21, 2019.
©2020 by Quintessence
Publishing Co Inc.
mmediate dentin sealing (IDS) has been described as the sealing of dentinal tubules
with filled adhesive resin immediately after tooth preparation.1–4 This procedure
involves the application of a dentin bonding agent to freshly cut dentin directly
after tooth preparation and prior to impression-making for indirect restorations.1,4
Alternatively, delayed dentin sealing (DDS) includes the application of a dentin bond-
ing agent to a previously cut dentin surface at the time of luting the indirect restora-
tion. IDS has been assumed to result in superior bond strength, less gap formation,
decreased bacterial leakage, and reduced dentin sensitivity when compared to DDS.1
The potential benefits of the IDS protocol have been described in several studies.5–7
In two studies on extracted molar teeth, the tensile bond strength was reported to
be significantly improved following the IDS protocol regardless of the ceramic inlay
system (Ceramco 2 or IPS Empress 28) or the adhesive system (total-etch or self-etch
adhesives9) used. Another study evaluated fracture under shear force using different
types of dentin bonding agents and concluded that IDS showed higher shear bond
strength when compared to DDS.10

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 Ashy et al

Table 1   Materials Used

Material Product name Composition Manufacturer
CAD/CAM Lava Ultimate Nanoceramic resin ceramic (80%), Bis-GMA, UDMA, Bis-EMA, TEGDMA with 3M ESPE
restorative block silica nanomers (20 nm), zirconia nanomers (4–11 nm), nanocluster particles
derived from the nanomers (0.6–10 µm), and silane coupling agents

Temporary Systemp.inlay Monofunctional ethyl triglycol methacrylate, polyester urethane dimethacrylate; Ivoclar
restorative material prepolymerized dimethacrylates, pyrogenic silicic acid fillers, catalysts, stabilizers, Vivadent
triclosan 0.3 < 1%, and mequinol 0.1 < 0.3%

Etchant Select HV etch 35% phosphoric acid with Benzalkonium chloride BISCO

Dentin bonding All-Bond Universal 20%–50% bisphenol A-diglycidyl methacrylate, 30%–50% ethanol, BISCO
adhesive system 5%–25% MDP, 5%–25% 2-hydroxyethyl methacrylate

Silane Porcelain Primer Coupling agent BISCO

Resin cement eCEMENT Dual-curing resin cement BISCO

Several other studies have investigated the mar-
ginal integrity at the dentin-resin interface after a
resin-coating procedure whereby the dentin is cov-
ered with a bonding system and a low-viscosity com-
posite immediately after tooth preparation and before
impression-making for indirect ceramic restorations.11,12
Schenke demonstrated that when luting ceramic inlays,
the resin coating technique using Panavia resin cement
with Clearfil SE Bond and Protect Liner F resin coating
(Kuraray) resulted in a lower marginal leakage at the
dentin-resin interface than a conventional luting tech-
nique, although the marginal seal of the self-adhesive
resin cement RelyX Unicem (3M ESPE) was reported to
be the best.11 Consistently, Kitamaya reported in 2011
that a resin coating technique using a combination of
a hydrophobic dentin bonding system (Clearfil Protect
Bond, Kuraray) and a flowable resin composite (Clearfil
Majesty Flow, Kuraray) with cementation using Clearfil
Esthetic Cement was effective in reducing microleakage
at the tooth-resin interface of Class II computer-aided
design/computer-assisted manufactured (CAD/CAM)
ceramic inlays, whether loaded or unloaded.12
To the authors’ knowledge, comparative data on the
marginal and internal adaptations associated with IDS
vs DDS techniques for indirect ceramic inlays are scarce.
Therefore, the aim of this study was to further investi-
gate the marginal and internal adaptations of the ce-
ramic inlay restoration with IDS vs DDS techniques using
microcomputed tomography (µCT) technology. The null
hypothesis tested was that the IDS and DDS techniques
would result in the same extent of marginal and internal
gap formation at the tooth-resin interface of all ceramic
inlay restorations. The specific objectives were:
1. To compare marginal and internal gap formation
at the tooth-ceramic inlay restoration interface
immediately following inlay cementation between
the IDS and DDS techniques
2. To compare marginal and internal gap formation at
the tooth-ceramic inlay restoration interface after a
period of thermocycling between the IDS and DDS
techniques
3. To compare marginal and internal gap formation at
the tooth-ceramic inlay restoration interface in both
IDS and DDS techniques before and after a period of
thermocycling
MATERIALS AND METHODS
Sample Preparation
Twelve freshly extracted human molars were included in
this study. The teeth were extracted at the oral surgery
department of the Faculty of Dentistry at King Abdu-
laziz University after the patients signed an adequate in-
formed consent (048-04-17). After debriding the teeth
from soft tissue and hard calculus, they were ultrasoni-
cally cleaned for 5 minutes, and half of the roots were
cut using a low-speed diamond saw (Isomet Buehler).
Samples were then stored in distilled water.
Cavity Preparation
Two Class II cavities of approximately 4-mm buccolin-
gual width, 4-mm occluso-gingival height, and 3-mm
mesio-distal depth (considering 2-mm depth at the
gingival seat) were prepared separately on the mesial
and distal aspects of each tooth using a high-speed
handpiece with a cylindrical rounded-end diamond bur
(Brasseler).
Inlay Fabrication
Cavities were digitally scanned using CEREC Bluecam
chairside digital scanner (Dentsply Sirona), and inlays
were milled from Lava Ultimate resin nanoceramic CAD/
CAM blocks (REF no:3312A1-HT, 3M ESPE) using CEREC
MC XL in-office milling machine (Dentsply Sirona). The
materials used in this study are listed in Table 1.

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 Fundamental Research

damaging it. For luting the Lava

Mesial and distal cavity preparation Dentin sealing Ultimate ceramic inlays, one coat
Ceramic inlay restoration Provisional restoration
of porcelain silane primer (BISCO)
Thermocycling
was applied to the fitting surface
Control groups IDS groups DDS groups
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6
of each restoration and allowed to
settle for 30 seconds before air dry-
ing for 5 seconds. Then, eCEMENT
adhesive dual-curing resin cement
(Lot No: 1500007181, BISCO) was
applied to the fitting surface, after
which the inlay was placed into its
corresponding cavity and the excess
cement was removed. The cement
was cured for 40 seconds from each
aspect for a total time of 120 sec-
onds for each inlay. Each luted res-
toration was then finished with fine
Silver nitrate staining + microcomputed diamond burs (Brasseler) and pol-
tomography scanning
ished using a polishing rubber cup.
Fig 1   Illustration of study protocol.
Thermocycling
Thermocycling was performed for
groups 2 through 6 after inlay ce-
Study Groups mentation (Fig 1). Thermocycling
Teeth were randomly allocated into six groups of two teeth each. For con- of 500 thermal cycles between 5°C
trol group 1, dentin sealing and cementation of Lava Ultimate inlays were and 55°C was carried out in a wa-
performed immediately after cavity preparation. For control group 2, the ter-bath thermocycler (THE-1100,
same technique was followed, in addition to thermocycling after inlay ce- SD Mechatronik) with a dwell time
mentation. For group 3 (IDS group), dentin sealing was performed imme- of 15 seconds in each bath and a
diately after cavity preparation, while the cementation of inlays was carried transfer time of 5 seconds.
out after thermocycling. For group 4, the same technique as in group 3 was
followed, in addition to thermocycling after inlay cementation. For group 5 Mounting and Sealing of Teeth
(DDS group), both dentin sealing and the cementation of inlays were per- The roots of the teeth were mounted
formed after thermocycling. For group 6, the same technique as in group in an acrylic resin mount (Orthodon-
5 was followed, in addition to thermocycling after inlay cementation. For tic Resin Caulk, Dentsply) prepared by
groups 3 through 6, temporary restorations (Systemp.inlay, Lot No: U17750, using a custom-made rubber silicon
Ivoclar Vivadent) were placed in the prepared cavities during the period of mold (Exafast putty, GC America).
time before cementation of the ceramic inlay restorations. The protocol of The coronal part of the samples was
the study is illustrated in Fig 1. covered with nail polish (Revlon),
leaving a distance of ∼1 mm around
Dentin Sealing and Inlay Cementation the tooth-restoration interface. This
For dentin sealing, whether immediate or delayed, total etching of the cavi- allowed the silver nitrate to pen-
ties was performed with 35% phosphoric acid etchant for 15 seconds, fol- etrate the interface through the in-
lowed by rinsing with water for 30 seconds and a brief air flushing. Then, terfacial gap and not through other
two coats of All-Bond Universal dentin bonding agent (BISCO) were ap- cracks on the crown surface.
plied and scrubbed with a microbrush for 10 to 15 seconds, air dried for
10 seconds, and then light cured with Elipar LED curing unit (3M ESPE) of Silver Nitrate Staining
1,200 mW/cm2 for 10 seconds and calibrated by an external light meter To allow a silver nitrate stain to pen-
(Pujing, DC02). For temporization, cavities were gently air dried. Liquid- etrate into possible interfacial gaps
strip glycerine gel (Ivoclar Vivadent) was applied to the cavity to isolate the at the tooth-inlay interface, samples
sealed dentin, an adequate amount of Systemp.inlay temporary material were submerged in a 50 wt% silver
was placed into the cavity, excess material was removed, and the filling was nitrate solution (AgNO3, 50% by
contoured and then light cured for 10 seconds. This temporary material is weight) for 24 hours. Ammonical
highly elastic; therefore, it was easily removed after curing in one piece by silver nitrate was prepared by dis-
inserting a probe into the material and pulling it out of the cavity without solving 25 g of silver nitrate crystals

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 Ashy et al

(Sigma Chemical) in 25 mL of distilled water. A concen- Table 2   Marginal and Internal Gap Volumes for
trated (28%) ammonium hydroxide (Sigma Chemical) Different Adhesion Techniques
solution was used to titrate the black solution until it Marginal gap Internal gap
volume (mm3), volume (mm3),
became clear as ammonium ions complexed the silver Study groups mean ± SD mean ± SD
into diamine silver ions ([Ag (NH3)2]+). This solution was
Group 1 (IDS/IC) 1.012 ± 0.632a 0.351 ± 0.176a
diluted to 50 mL with distilled water, giving a 50 wt%
solution (pH = 9.5). The time point of AgNO3 staining is Group 2 (IDS/IC/TC) 1.544 ± 0.684a 0.240 ± 0.152a
presented in Fig 1. Group 3 (IDS/DC) 0.891 ± 0.281a 0.063 ± 0.075a
Group 4 (IDS/DC/TC) 1.426 ± 0.725a 0.098 ± 0.066a
µCT and Image Analyses Group 5 (DDS/DC) 1.856 ± 0.323a 0.323 ± 0.193a
Samples were scanned after submersion in the silver Group 6 (DDS/DC/TC) 1.964 ± 0.956a 0.838 ± 0.248b
nitrate solution (Fig 1). Scanning of samples was per-
Superscript letters indicate homogenous subsets (within which P > .05)
formed using SkyScan 1172 µCT scanner (Bruker mi- where comparison has been made with respect to the study groups.
croCT, Kartuizersweg 3B). The scanning parameters IDS = immediate dentin sealing; IC = immediate cementation;
DDS = delayed dentin sealing; DC = delayed cementation; T
used were: 100 kV, 100 µA, 830 ms of exposure, angle C = thermocycling; SD = standard deviation.
of rotation = 0.600 degrees, 720 projections, and 2
frames per projection. The total scanning time for each
sample was approximately 2 hours and 30 minutes. Table 3   P Values for Comparisons Between
NRecon (version 1.6.7.2; SkyScan) and Data Viewer soft- Different Adhesion Techniques for
Marginal and Internal Gap Volumes
ware (version 1.5.2.4 64-bit, SkyScan) (Bruker, Microt)
were used for the 3D reconstruction of acquired µCT Marginal gap Internal void
Study group volume volume
images and image visualization, respectively.
Groups 1 vs 3 vs 5 .025* .059

Microleakage and Internal Void Volume Groups 2 vs 4 vs 6 .622 .000*

Measurement
To segment the silver nitrate stain, multi-level threshold-
ing feature in 3D was applied to the dataset to identify
different density phases with a high gray level for high-
density subjects. The 3D volume of the internal voids
and the silver nitrate penetrant at the interface between
the inlay restoration and its corresponding cavity sur-
face were calculated using CT-analyzer software.
Statistical Analyses
The data were analyzed using independent t test and
one-way analysis of variance (ANOVA) followed by post
hoc multiple comparisons Tukey test using IBM SPSS
Statistics version 22 software. The level of statistical sig-
nificance for both was set at P < .05.
RESULTS
The means and standard deviations (SDs) for the vol-
ume of silver nitrate penetrant (the marginal gap vol-
ume) and the volume of internal voids (the internal gap
volume) for different adhesion techniques are present-
ed in Table 2. P values for comparisons between differ-
ent adhesion techniques for marginal and internal gap
volumes are presented in Table 3. μCT images of luted
ceramic inlays are shown in Fig 2.
Marginal and Internal Gap Volumes Immediately
After Inlay Cementation
Marginal gap volume for DDS/delayed cementa-
tion (group 5) was significantly higher than both IDS/
Groups 1 vs 2 .297 .380
Groups 3 vs 4 .218 .508
Groups 5 vs 6 .841 .015*
*P < .05.
immediate cementation (group 1) (P = .057) and IDS/
delayed cementation (group 3) (P = .031). Internal gap
volume, on the other hand, did not differ significantly
among groups 1, 3, and 5 (P = .059) (Fig 3).
Marginal and Internal Gap Volumes After
Thermocycling
Marginal gap volume after thermocycling was not sig-
nificantly different between the different adhesion
techniques; however, the internal gap volume for DDS/
delayed cementation/thermocycling (group 6) was signif-
icantly higher than that of IDS/immediate cementation/
thermocycling (group 2) (P = .002) and IDS/delayed ce-
mentation/thermocycling (group 4) (P = .000) (Fig 4).
Effect of Thermocycling on Marginal and Internal
Gap Volumes
There was no statistically significant difference be-
tween the marginal and internal gap volumes before
and after thermocycling for the IDS/immediate cemen-
tation technique (group 1 vs 2) (Fig 5) or for the IDS/
delayed cementation technique (group 3 vs 4) (Fig 6).
However, a statistically significant difference was found
in the internal gap volume for the DDS/delayed cemen-
tation technique (group 5 vs 6; P = .015) (Fig 7).

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 Fundamental Research

InR En
InR

Dn

En
En

a b

InR InR

Dn
En Dn

En

c d

En
InR
InR

Dn Dn
En

e f
Fig 2   Two-dimensional µCT images of luted ceramic inlay restorations showing the marginal and internal gaps at the tooth-restoration
interface. (a) Group 1 (immediate dentin sealing [IDS]/immediate cementation [IC]). (b) Group 2 (IDS/IC/thermocycling [TC]). (c) Group 3 (IDS/
delayed cementation [DC]). (d) Group 4 (IDS/IC/TC). (e) Group 5 (delayed dentin sealing [DDS]/DC). (f) Group 6 (DDS/DC/TC). InR = inlay res-
toration; En = enamel; Dn = dentin. The adhesive layer may contain a void (solid arrow) or silver stain precipitation or deposits (dotted arrow).

DISCUSSION cementation of the indirect restoration all performed

The rationale behind the different groups in this study
was to simulate distinct clinical settings. Control groups
simulate a clinical situation where the patient is pro-
vided with a cavity preparation, dentin sealing, and
at the same visit. IDS groups imitate a clinical situation
where the patient is provided with cavity preparation,
dentin sealing, and a provisional restoration in a single
visit, then the permanent indirect restoration is luted
on a following visit. Finally, DDS groups represent a

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 Ashy et al

Marginal gap Marginal gap

Internal void Internal void

2.5 3.5
*
3.0
Gap volume (mm3)

Gap volume (mm3)

2.0
* 2.5
1.5 2.0
*
1.0 1.5
*
1.0
0.5
0.5 *
*
0 0
IDS/IC IDS/DC DDS/DC IDS/IC/TC IDS/DC/TC DDS/DC/TC
Adhesion technique Adhesion technique

Fig 3   Mean and standard deviation volume of marginal gap and Fig 4   Mean and standard deviation volume of marginal gap and
internal void volume for different adhesion techniques post–inlay internal void volume for different adhesion techniques post–inlay
cementation. *P < .05 between groups. thermocycling. *P < .05 between groups.

Marginal gap Marginal gap Marginal gap

Internal void Internal void Internal void

2.5 2.5 3.5

3.0
Gap volume (mm3)

Gap volume (mm3)

Gap volume (mm3)

2.0 2.0
2.5
1.5 1.5 2.0
1.0 1.0 1.5
*
1.0
0.5 0.5 *
0.5
0 0 0
IDS/IC IDS/IC/TC IDS/DC IDS/DC/TC DDS/DC DDS/DC/TC
Adhesion technique Adhesion technique Adhesion technique

Fig 5   Mean and standard deviation vol-
ume of marginal gap and internal void for
immediate dentin sealing (IDS)/immediate
cementation (IC) before and after thermo-
cycling (TC).
Fig 6   Mean and standard deviation vol-
ume of marginal gap and internal void for
immediate dentin sealing (IDS)/delayed ce-
mentation (DC) before and after thermocy-
cling (TC).
Fig 7   Mean and standard deviation volume
of marginal gap and internal void volumes
for delayed dentin sealing (DDS)/delayed
cementation (DC) before and after thermo­
cycling (TC). *P < .05 between groups.

common clinical practice whereby the patient is treated
with a cavity preparation and a provisional restoration
in the first visit followed by a second visit for dentin
sealing and cementation of the indirect restoration.
The required sample size here was calculated based on
the reported mean and SD of mean microleakage vol-
ume (mm3) among microhybrid composites, preheated
microhybrid composites, and flowable composites in
Zavattini et al.13 Assuming an alpha of .05 and a power
of 80%, the sample size required for this study was a
total of 12.
The current study indicates that luted ceramic in-
lays have a superior marginal adaptation right after
cementation and a superior internal adaptation after
thermocycling when using the IDS technique compared
to the DDS technique. Although no studies were found
in the literature inspecting the adaptation of indirect res-
torations using IDS vs DDS techniques except for reports
on fracture mode after cyclic loading,14–16 the results of
this study on the improved marginal and internal adap-
tation of the IDS technique can be supported by several
previous studies reporting on the improved microtensile
bond strength16–20 and shear bond strength21,22 associ-
ated with the IDS technique. Moreover, while control
groups 1 and 2 showed larger gap volume values than
those of the IDS groups 3 and 4, respectively (Table 2),
this difference was not statistically significant, and so a
superior seal in the IDS groups over the control groups

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 Fundamental Research
cannot be concluded. Therefore, comparable marginal
and internal gap volumes between these respective
groups is suggested for the current sample size.
This study also concludes that the marginal adapta-
tion after thermocycling was not significantly different
between IDS and DDS techniques, emphasizing the ef-
fect of the aging process on the reduction of the dif-
ference between these tested groups. In line with this
result, a report by Ferreira-Filho et al has shown that the
microtensile bond strength is largely related to the dura-
tion of aging of luted samples, as IDS groups presented
higher bond strength than the DDS group only within
7 days of water storage but did not differ significantly
after 3 months of the same condition.23
Thermocycling was performed to simulate the ther-
mal effect of the oral environment on the restorations
during the provisional phase and after cementing the
indirect restoration. Changes in temperature during the
process of thermocycling will result in dissimilar dimen-
sional changes of the resin cement fillers and matrix
phases, creating internal stresses and possible micro-
cracking.24–26 In the present investigation, a significant
increase in the internal void volume was detected in the
DDS group as a consequence of thermocycling. Several
previous studies have demonstrated the negative effect
of thermocycling aging on resin cements.27–29 A recent
study by de Oliveira et al concluded that thermocycling
significantly reduced the microtensile bond strength of
CAD/CAM fiber-reinforced composite using a conven-
tional three-step adhesive system, All-Bond 3, with C&B
self-curing adhesive resin cement.30 Another study by
Nalcaci and Ulusoy showed that thermocycling aging
of 10,000 cycles can significantly increase the micro­
leakage of resin composites (hybrid resin composite
Feltik Z250 and flowable resin composite Feltik flow)
bonded to dentin surfaces.31 Nevertheless, in the pres-
ent study, thermocycling of 500 thermal cycles between
5°C and 55°C did not result in a significant change in
the before-and-after marginal and internal gap volumes
of luted inlays in the IDS group. This could be related to
the frequency of cycles used in the present study, which
was probably insufficient for producing a significant dif-
ference in the IDS groups. Consistent with this rational-
ization, a study by Leesungbok et al demonstrated that
a minimum of 7 days of 1,500 thermal cycles for an im-
mediately sealed dentin surface is needed to decrease
the mean bond strength of IPS Empress ceramic discs
bonded to a dentin surface with All-Bond 2 adhesive
system and Duo-Link resin cement.22
The current investigation includes some shortcom-
ings. First, the sample size could have been increased
to detect reliable significant differences among groups.
Second, the number of thermal cycles could have been
amplified and implemented under cyclic loading to bet-
ter represent the actual clinical situation.
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CONCLUSIONS
Within the limitations of the present in vitro investiga-
tion, the following can be concluded:
• The IDS technique results in a smaller marginal gap
volume at the tooth-restoration interface than the
DDS technique immediately after cementation, but
not after thermocycling of the luted indirect ceramic
restoration.
• Thermocycling results in a bigger internal gap
formation with the DDS technique than with the IDS
technique.
• Thermocycling does not result in a significant
increase of either the marginal or internal gaps with
the IDS technique.
• Thermocycling results in a significant increase of the
internal gaps but not the marginal gaps with the
DDS technique.
ACKNOWLEDGMENTS
This project was funded by the Deanship of Scientific Research (DSR)
at King Abdulaziz University, Jeddah, under grant no. (RG-1-165-37).
The authors, therefore, acknowledge with thanks DSR for technical
and financial support. The authors do not have any financial interest
in any product, service, and/or company included in this article.
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Literature Abstract

Clinical Performance of Occlusal Onlays Made of Lithium Disilicate Ceramic in Patients with Severe Tooth Wear up to 11 Years
The aim of this study was to evaluate the survival and complication rates of monolithic occlusal onlays made of lithium disilicate ceramic
in patients with severe tooth wear for up to 11 years of clinical service. In a prospective nonrandomized clinical study, seven patients (four
men, three women; median age 44.3 ± 6.56 years old) underwent full-mouth restoration with a total of 103 adhesively bonded occlusal
onlays made of lithium disilicate ceramic (IPS e.max Press, Ivoclar Vivadent). All restorations were examined during annual recall visits using
periodontal parameters (marginal discoloration; secondary caries; marginal integrity; surface texture; restoration fracture; and occlusal
wear) according to the modified United States Public Health Service criteria ratings of Alpha, Bravo, and Charlie over an observation
period of up to 11 years (68 to 139 months; median 94.9 ± 26.1 months). Data were statistically analyzed using Kaplan-Meier estimation.
Monolithic lithium disilicate occlusal onlays presented a 100% survival rate. Four restorations within one patient (3.9%) presented marginal
discoloration, one after 60 and three after 108 months (all rated Bravo). One restoration (1%) showed a marginal crack formation
(technical complication) after 120 months rated Bravo. No biologic complications, debonding, or secondary caries could be found, and
tested periodontal parameters showed excellent results. Based on the analyzed data from up to 11 years, monolithic occlusal onlays made
of lithium disilicate ceramic can be considered a reliable treatment option for full-mouth rehabilitation in patients with severe tooth wear.
Edelhoff D, Güth JF, Erdelt K, Brix O, Liebermann A. Dent Mater 2019;35:1319–1330. References: 44. Reprints: A. Liebermann,
anja.liebermann@med.uni-muenchen.de —Steven Sadowsky, USA

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