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Ceramic Inlays: A Case Presentation and Lessons Learned From The Literature
Ceramic Inlays: A Case Presentation and Lessons Learned From The Literature
ABSTRACT
Ceramic dental restorative materials offer an esthetic alternative to dental amalgam or gold.
There is uncertainty relative to the longevity of ceramic inlay restorations. Recently published
long-term research studies reveal general clinical performance trends. These trends are discussed
while presenting a ceramic inlay case. Successful clinical use of ceramic inlay materials is abso-
lutely dependent on the creation of an uncompromised adhesive tooth/ceramic interface.
Ceramic inlay restorations perform well in terms of long-term retention, color match, and ana-
tomic contour stability. These restorations all experience limited margin deterioration that does
not predispose to marginal discoloration or secondary caries. Patients rarely suffer from post-
operative sensitivity secondary to ceramic inlay placement.
Ceramic inlays fail predominantly as a result of crack propagation from material flaws
leading to bulk fracture. Some superficial ceramic defects may be repaired with composite
resin. Internal material flaws are minimized by industrial production of indirect pressable glass-
ceramic materials or ceramic blocks designed for computer-aided design/computer-assisted
manufacturing (CAD/CAM). External surface flaws are limited by careful polishing techniques.
Strategic placement of ceramic inlays in teeth that are not subject to heavy occlusal loading will
result in more predictable long-term performance. Preparation design to prevent flexure of
ceramic inlay materials is essential.
CLINICAL SIGNIFICANCE
Use of ceramic inlays to restore defects in posterior teeth requires careful attention to detail.
Placement of ceramic inlay materials in high-stress areas may result in less predictable long-
term performance. Ceramic inlays are advantageous for restoring moderately sized defects
when optimal control of restoration contours and esthetics is desired.
(J Esthet Restor Dent 21:77–88, 2009)
INTRODUCTION disease, which in the case of dental has solved many of the esthetic
*Assistant professor, University of North Carolina School of Dentistry, Chapel Hill, NC, USA
†
Associate professor, University of North Carolina School of Dentistry, Chapel Hill, NC, USA
tooth structure, and are therefore external surface.2,3 Conventional standardization led to the develop-
subject to the durability of that sintered feldspathic porcelain inlays ment of the much-used United
interface. In addition to depen- are prone to fracture, and methods States Public Health Service
dence on an adhesive interface, to reinforce the porcelain have (USPHS) criteria to allow consis-
these restorative materials have been developed. Industrial produc- tent assessment of the various clini-
unique characteristics that must be tion of ceramic blocks for CAD/ cal parameters that define how
considered when restoring stress- CAM helps minimize the inclusion these materials perform over time.
bearing areas of the oral cavity. of internal flaws in the ceramic.3 A key ingredient to successful stan-
Ceramics that have an increase in dardization is the calibration of the
Enamel, as a substrate, is mini- the crystalline phase of the ceramic researcher(s) conducting the study.5
mally variable from patient to have greater resistance to fracture.2 Short-term studies of ceramic inlay
patient and tooth to tooth. The One strategy to limit fracture performance have been carefully
durability of the adhesive interface propagation is to increase the evaluated, and a need for improved
with enamel is very predictable. leucite crystal content in the felds- study design quality was observed.6
Dentin, however, as a substrate pathic porcelain (IPS Empress and
varies greatly within each tooth ProCAD, Ivoclar Vivadent, This decade has seen the publica-
and from patient to patient. Hence, Amherst, NY, USA). In these prod- tion of clinical research on ceramic
the adhesive attachment to dentin ucts, larger leucite crystals inter- inlay restorative materials with
is not as predictable. Tooth-colored rupt fractures that form in the evaluation times ranging from 8 to
restorative systems are, therefore, amorphous phase and resist frac- 15+ years. The goal of these
technique sensitive and require ture propagation. Another method studies has been to identify the
greater attention to detail than is to heat-treat leucite-reinforced long-term clinical performance.
restorative systems that do not ceramic such that the leucite crys- Modified USPHS criteria have fre-
require an adhesive interface. It is tals begin to convert into the sani- quently been employed in these
incumbent upon the dentist to dine crystal polymorph of feldspar various long-term clinical research
understand this variability and (Vita Mark II, Vita Zahnfabrik, reports (randomized clinical trials,
create the conditions necessary for Brea, CA, USA). Upon cooling, the controlled clinical trials, and case
a successful adhesive bond to both sanidine crystals contract more reports).7–12 The type and level of
enamel and dentin. than the original leucite crystals, calibration of the examiners has
resulting in a net compressive force rarely been reported.8,10 Most of
Current tooth-colored restorations in the ceramic block with a the published long-term clinical
made of composite resin perform resultant increased resistance to evaluation of ceramic inlays are
much like amalgams when atten- fracture propagation.4 case series studies.7,9,11,12 Studies
tion to detail is maintained.1 Less with a greater amount of control
is known about the clinical perfor- Research has been undertaken to lack strength because of low
mance of tooth-colored ceramic assess how well dental restorative sample size8,10 or uneven sample
restorations. Ceramic restorations, materials perform over time. Com- population (either male/female
in general, fail from cyclic loading, paring the various clinical studies ratios or premolar/molar ratios).8–10
material flexure, and subsequent of these materials has proven to be In all the published studies evalu-
propagation of fractures inherent difficult because of a lack of ated in this article, the specific
in the ceramic material and on the standardization. The need for patient sex (male or female) and
A B
Figure 1. A fractured MOL amalgam in the maxillary right first molar (A). Common esthetic clinical presentation of
the first maxillary molar restored with amalgam (B).
Figure 3. Isolation with rubber dam and removal of defective Figure 4. Divergent walls were created and
restoration to assess the size of the cavitation. Narrow isthmus cavosurface margins adjusted to allow
areas that would prevent adequate porcelain thickness were maximum bulk of ceramic at the interface.
identified (a, b, and c). Clearance with the adjacent tooth was
established to allow interproximal finishing.
Margins were maintained in enamel for
maximum bond predictability.
reported as a concern, provided Ease of isolation and greater pre- A CEREC 3D system (Sirona, The
that appropriate attention is given dictability of enamel bonding dic- Dental Company, Charlotte, NC,
to isolation and establishment of tates the placement of ceramic USA) was used to generate the
the adhesive interface.15 restoration margins in enamel MOL inlay for this individual.
whenever possible (Figure 4). Every attempt to ensure a small
The preparation design will It has been unclear whether marginal gap was made (Figure 6).
also need to be modified to allow gingival margins placed in dentin It is now possible to consistently
for ceramic bulk at the margins are more prone to recurrent have ceramic inlays with marginal
(Figures 4 and 5). Ceramic inlays caries. Long-term studies of gaps less than 100 micrometers
develop a self-limiting loss of ceramic inlays report no (mm). Early CAD/CAM systems
marginal integrity at the cavosur- associated increase in caries created marginal gaps of 150 mm
face adhesive interface over when margins are placed on or more. Long-term studies with
time.7–9,11,12 Long-term studies dentin.7–10,12 The potential various CAD/CAM and pressed
report no increase in caries adverse effects of polymerization glass-ceramic systems report no
as a result of the marginal shrinkage are minimized because detected adverse effects at the
deterioration.7–10,12 Three of these of the thin cement layer. Therefore, marginal interface, even with
studies utilized radiographs to it may be that the bond to the larger marginal gaps.7,9–12
assess for caries in interproximal dentin is relatively more protected
areas that may be difficult to than it would be if direct compos- The restoration occlusal anatomy
detect clinically.8,10,12 ite were used. was adjusted to recreate appropriate
A B
Figure 5. Images (A and B) used during ceramic inlay computer-assisted design (CEREC 3D). Sharp transitions have
been removed to limit areas of stress concentration. The wall divergence was designed to allow fitting, retention form,
and protection of the adhesive interface.
A B
Figure 6. The CAD/CAM unit generated a ceramic inlay with satisfactory fit of a dental stone die (A) as well as fit in
the upper maxillary first molar (B). Slight submargination was present at the lingual margin.
A B
Figure 7. Staining and glazing of ceramic inlays is optional but can aid in the elimination of surface flaws that may
predispose the inlay to fracture (A). An image of the ceramic inlay immediately after initial seating (B). Predictable
clinical performance depends on the establishment of the adhesive interface.
cuspal inclines and marginal ridge seconds, between the etch-and-bond cementation to limit potential
heights. Surface characterization steps, and excess fluid was evapo- flaw propagation.
was added in the process of glazing rated with a light airstream. The
(Figure 7A). The Vita Mark II inlay restoration was completely seated Careful attention to the placement
was etched with 9% hydrofluoric with controlled pressure using a of even functional stops on the
acid and treated with fresh silane. A ball burnisher. Excess cement was occlusal surface, which are in addi-
light-emitting diode curing light immediately removed with caution tion to natural tooth functional
(DEMI, sdsKERR, Orange, CA, as to not remove cement from the stops, will limit excessive cyclic
USA) was used for all light-curing margin interface. Initial light-curing loading of the ceramic material.
steps. The adhesive interface was was accomplished while maintain- Once the occlusion is perfected,
created by closely following the ing controlled seating pressure on careful attention to surface polish-
manufacturer’s instructions the inlay. Careful compliance with ing becomes essential (Figure 8).
included with the 3M ESPE Rely-X the manufacturer’s instructions for Areas that are adjusted with rotary
ARC (St. Paul, MN, USA) adhesive use of any particular adhesive instrumentation are more prone to
resin cement system (Figure 7B). system cannot be overemphasized. develop marginal ridge or bulk
This system includes the 3M ESPE Long-term studies reported the use fractures.9 Removal of surface
Scotchbond etchant and the Adper of various luting systems, but no defects/flaws (which increase the
Single Bond Plus Adhesive. strong statements can be made with likelihood of ceramic fracture)
GLUMA Desensitizer (Heraeus regard to relative adhesive cement cannot be overemphasized.2,9 The
Kulzer, South Bend, IN, USA) was effectiveness.7–12 The occlusion final polish is accomplished with
applied to the dentin for 30 was checked and adjusted after rubber instruments, followed by
various amounts of postoperative son of the performance of pressed Ceramic inlays are a highly esthetic
sensitivity experienced were rarely glass-ceramic inlays with CAD/ restorative option. Their use should
a substantial patient concern.7,9,10,11 CAM-produced ceramic inlays. be limited to vital teeth that are
Ceramic inlay materials are very Analysis of the various long-term not under heavy occlusal loading.
esthetic and can return the appear- studies reveals that, in general, Attention to detail in every step is a
ance of a restored tooth to near ceramic inlays have greater longev- prerequisite to long-term success.
normal (Figure 9). A 1-year ity in premolars than in Establishment of an excellent adhe-
follow-up evaluation reveals molars.7,8,11,12 Careful thought sive interface, an adequate ceramic
ongoing achievement of esthetics, should be given to the level of thickness, and a highly polished
A B
Figure 9. One-month follow-up images (A and B) revealing optimal esthetic and functional clinical performance of the
ceramic inlay restoration.
A B
Figure 10. One-year follow-up image revealing optimal clinical performance (A). One-year follow-up bitewing
radiograph with normal radiographic appearance (B).
6. Overcontour of ceramic to close large interproximal areas may 5. Bayne SC, Schmalz G. Reprinting the
predispose to early failure.9 classic article on USPHS evaluation
7. Absolute isolation is essential. Use whatever method works best.7,9,10,12 methods for measuring the clinical
research performance of restorative mate-
8. Careful attention to adhesive technique and preparation design will help rials. Clin Oral Investig 2005;9:209–14.
insure predictable retention of ceramic inlays.7–12,15
9. Ceramic inlays develop a self-limiting loss of marginal integrity at the 6. Hayashi M, Wilson NHF, Yeung CA,
Worthington HV. Systematic review of
cavosurface adhesive interface over time.7–9,11,12
ceramic inlays. Clin Oral Investig
10. Ceramic inlay marginal deterioration does not appear to increase 2003;7:8–19.
likelihood of caries.7–10,12
11. Subgingival ceramic inlay margins has not been associated with an 7. Otto T, De Nisco S. Computer-aided
direct ceramic restorations: a 10-year
increase in recurrent caries.7–10,12 prospective clinical study of CEREC
12. The size of the marginal gap of ceramic inlays fabricated using various CAD/CAM inlays and onlays. Int J Pros-
CAD/CAM and pressed glass-ceramic systems has not been reported to thodont 2002;15:122–8.
have an adverse effect on restoration longevity.7,9–12 8. Sjogren G, Molin M, van Dijken JWV. A
13. Surface flaws of ceramic inlays must be carefully removed (by polishing) 10-year prospective evaluation of CAD/
to avoid crack propagation that may lead to marginal ridge or bulk CAM-manufactured (CEREC) ceramic
inlays cemented with a chemically cured
fractures.9 or dual-cured resin composite. Int J Pros-
14. Ceramic inlays maintain anatomic contour over time.7–9,12 thodont 2002;17:241–6.
15. Ceramic inlays gradually develop rough and pitted surface texture over
time.7–10,12 9. Kramer N, Frankenberger R. Clinical per-
formance of bonded leucite-reinforced
16. Fracture is the primary mode of failure of ceramic inlays.7–12 glass ceramic inlays and onlays after eight
17. Premolar ceramic inlays have more longevity than molar ceramic years. Dent Mater 2005;21:262–71.
inlays.7,8,10,12
10. Thordrup M, Isidor F, Horsted-Bindslev
P. A prospective clinical study of indirect
and direct composite and ceramic inlays:
ten-year results. Quintessence Int
2006;37:139–44.
restoration surface helps to prevent whose materials are included in
fracture propagation and failure. this article. 11. Reiss B. Clinical results of CEREC inlays
in a dental practice over a period of 18
When used in the correct circum- years. Int J Comput Dent 2006;9:11–22.
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