Fixed Prosthodontics: Inlays & Onlays

Fixed prosthodontics in dentistry is a technique used to restore teeth, using fixed restorations
(also referred to as indirect restorations), which include crowns,bridges, inlays, onlays,
and veneers. Prosthodontists are specialist dentists who have undertaken training recognized
by academic institutions in this field. Fixed prosthodontics can be used to restore single or multiple teeth,
spanning areas where teeth have been lost. In general, the main advantages of fixed prosthodontics
when compared to direct restorations is the superior strength when used in large restorations, and the
ability to create an aesthetic looking tooth. As with any dental restoration, principles used to determine the
appropriate restoration involves consideration of the materials to be used, extent of tooth destruction,
orientation and location of tooth, and condition of neighboring teeth.

Inlays

Sometimes, a tooth is treatment planned to be restored with an intracoronal restoration, but the
decay or fracture is so extensive that a direct restoration, such as amalgam or composite, would
compromise the structural integrity of the restored tooth by possibly undermining the remaining tooth
structure or providing substandard opposition to occlusal (i.e. biting) forces. In such situations, an indirect
gold or porcelain inlay restoration may be indicated. The following documents the indirect (out of the
mouth) fabrication of a gold inlay. When an inlay is used, the tooth-to-restoration margin may be finished
and polished to such a super-fine line of contact that recurrent decay will be all but impossible. It is for this
reason that some dentists recommend inlays as the restoration of choice for pretty much any and all filling
situations. While these restorations might be ten times the price of direct restorations, the superiority of an
inlay as a restoration in terms of resistance to occlusal forces, protection against recurrent decay,
precision of fabrication, marginal integrity, proper contouring for gingival (tissue) health, ease of cleansing
and many other aspects of restorative quality offers an excellent alternative to the direct restoration. For
this reason, some patients request inlay restorations so they can benefit from its wide range of
advantages even when an amalgam or composite will suffice. The only true disadvantage of an inlay is
the higher cost.

Onlays

Additionally, when decay or fracture incorporate areas of a tooth that make amalgam or
composite restorations essentially inadequate, such ascuspal fracture or remaining tooth structure that
undermines perimeter walls of a tooth, an "onlay" might be indicated. Similar to an inlay, an onlay is an
indirect restoration which incorporates a cusp or cusps by covering or onlaying the missing cusps. All of
the benefits of an inlay are present in the onlay restoration. The onlay allows for conservation of tooth
structure when the only other alternative is to totally eliminate cusps and perimeter walls for restoration
with a crown. Just as inlays, onlays are fabricated outside of the mouth and are typically made out of gold
or porcelain. Gold restorations have been around for many years and have an excellent track record. In
recent years, newer types of porcelains have been developed that seem to rival the longevity of the gold.
Either way, if the onlay or inlay is made in a dental laboratory, a temporary is fabricated while the
restoration is custom made for the patient. A return visit is then required to deliver the final prosthesis.
Inlays and onlays may also be fabricated out of porcelain and delivered the same day utilizing techniques
and technologies relating to CAD/CAM Dentistry.

Inlays that are billed as onlays have direct cost impact on insurers, dentists, purchasers
and patients. The cost impact for all insurers may not be significant today due to the low overall
utilization of inlays and onlays relative to other types of restorations. However, many dental
benefit plans are starting to feel the cost impact and utilization of these services is expected to
increase as more dentists introduce CAD-CAM technology into their practices. This trend could
potentially place all insurers at risk for increased claims cost. Increases in the cost of care may
subsequently be passed on to purchasers in the form of premium increases. Dentists are also
negatively impacted particularly if they are given potentially misleading information by CAD-
CAM company representatives that may cause them to adopt suspect billing patterns. In addition
to the possible cost impact to dentists are issues regarding quality concerns related to
overtreatment. Ultimately though, patients may be the ones at highest risk for cost impact as they
may be left to pay for procedures that have been upcoded, not covered because of benefit
exclusions, or not necessary in the first place to restore the tooth to an appropriate level of
function.
In addition to insurers, dentists, purchasers and patients, other key stakeholders include
the ADA, whose CDT dictates the definition of procedures, others in organized dentistry such as
the Boards of Dental Examiners, regulators, purchasers, fraud and abuse investigators and, of
course, groups such as the AADC. Improved communication is needed between all the key
stakeholders as well as agreement on definitions and concepts in order to establish consistency in
the interpretation of the definitions of inlays and onlays.
An inlay/onlay differs from an inlay in that it offers cuspal protection similar to a crown
during excursions of the mandible involved in the dynamics of occlusion.
Since an inlay is a centric stop restoration only, any involvement with the dynamics of
occlusion must not be classified as an inlay unless the clinician also addresses the onlay
component beyond the basic inlay outline form. Since it is necessary to cover a cusp to involve
the tooth in the dynamics of occlusion, the onlay component must be classified accordingly. An
onlay does have to involve full coverage of a cusp or cusps.
Dentists may be interpreting the involvement of 80% or more of the cuspal incline as the
benchmark for fulfilling the criteria for an onlay. This interpretation appears to be in conflict
with the requirement for overlaying of a cusp or cusps in an onlay, as noted in all other sources
consulted, and may be contributing to the recent trend in upcoding of inlays to onlays.
Inlays and onlays can be made from porcelain, gold or composite resin. Once fabricated,
they are securely bonded to the tooth.
Advantages of inlays and onlays:
o Since they can be fabricated from tooth-colored materials, inlays and
onlays are aesthetically pleasing. Unlike traditional metal fillings, the
restoration is virtually invisible.
o Less removal of the tooth structure is required to achieve optimal results.
o They do not cause excessive wear and tear to opposing tooth structures.
o Inlays and onlays prevent the need for more significant treatment in the
future.
The process for placing inlays and onlays generally requires two or more office visits.
Initially, once the decay is removed, your prosthodontist will take an impression of the tooth. A
temporary restoration is placed until the custom made inlay/onlay is manufactured in a
laboratory.
Following a proper oral hygiene regimen daily, ensures the success and longevity of your
new restoration.