Indirect Esthetic Restorations

ILOs:
1. Describe the indication, types, advantage and methods of construction for the
indirect esthetic restorations.
2. Select the most appropriate restorative material used in different clinical
situations.
3. Identify different surface pretreatments for indirect restorations
The search for the ideal restorative material continues, though the fact that amalgam
alloy still remain the most widely used restorative for posterior teeth, but there has
been increased demands for esthetic restoration and also growing concern about
biocompatibility and strength of existing restorations. Simplicity of restorative
dentistry dictates direct approach including cavity preparation and immediate
restoration of any tooth defect. Yet, in some cases indirect restoration may be the only
successful resort for restoration of anatomical and functional relation of the offending
tooth.
General indications for indirect Esthetic restorations:
The indications for Class I and II indirect tooth-colored restorations relate to a
combination of esthetic demands and size of the restoration and include the following:

1-Esthetics: Indirect tooth colored restorations are indicated for Class I and II
restorations located in areas of esthetic importance for the patient.

2-Large defects or previous restorations: Indirect tooth colored restorations should

be considered for restoration of large Class I and II defects or replacement of large
compromised existing restorations, especially those that are wide faciolingually and
require cusp coverage. Large preparations are best restored with adhesive restorations
that strengthen the remaining tooth structure. The contours of large restorations are
more easily developed when using indirect techniques. Indirect tooth colored
restorative materials are more durable than direct composites when placed in large

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occlusal posterior restorations, especially in regard to maintaining occlusal surfaces
and occlusal contacts. The wear resistance provided by indirect materials is especially
important in large posterior restorations that involve most or all of the occlusal contacts
without sufficient bulk, however, an extensive indirect ceramic or composite
restoration might fracture under occlusal loading, particularly in the molar region.

3-Economic factors: Some patients desire the best dental treatment available,
regardless of cost. For these patients, indirect tooth-colored restorations may be
indicated not only for large restorations, but also for moderate-sized restorations that
otherwise might be restored with a direct restorative material (usually composite).

Contraindications for indirect tooth-colored restorations include the following:

1-Heavy occlusal forces: Ceramic restorations can fracture when they lack sufficient
bulk or are subject to excessive occlusal stress, as in patients who have bruxing or
clenching habits. Heavy wear facets or a lack of occlusal enamel are good indicators
of bruxing and clenching habits.

2-Inability to maintain a dry field: Despite some research suggesting that modern
dental adhesives can counteract certain types of contamination, adhesive techniques
require near-perfect moisture control to ensure successful long-term clinical results.

3-Deep subgingival preparations:Although this is not an absolute contraindication,

preparations with deep subgingival margins should be avoided. These margins are
difficult to record with an impression and are difficult to finish. Additionally, bonding
to enamel margins is greatly preferred, especially along gingival margins of proximal
boxes.

Advantages:

1-Improved physical properties: A wide variety of high strength tooth-colored

restorative materials, including laboratory-processed and computer-milled com-

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posites and ceramics, can be used with indirect techniques. Indirect restorations have
better physical properties than direct composite restorations because they are
fabricated under relatively ideal laboratory conditions. Also, although CAD/CAM
restorations generally are fabricated chairside, the materials themselves are
manufactured under nearly ideal industrial conditions.

2-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.

3-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.

4-Reduced polymerization shrinkage: Polymerization shrinkage and its resulting

stresses are a major shortcoming of direct composite restorations. With indirect
techniques, the bulk of the preparation is filled with the indirect tooth-colored
restoration, and stresses are reduced because little composite cement is used during
cementation. Although shrinkage of composite in thin-bonded layers can produce
relatively high stress, studies indicate that indirect composite restorations have fewer
marginal voids, less microleakage, and less postoperative sensitivity than direct
composites.

5-Ability to strengthen remaining tooth structure: Tooth structure weakened by

caries, trauma, or preparation can be strengthened by adhesively bonding indirect
tooth-colored restorations. The reduced polymerization shrinkage stress associated
with the indirect technique also is desirable when restoring such weakened teeth.

6-More precise control of contours and contacts: Indirect techniques usually provide
better contours (especially proximal contours) and occlusal contacts than direct

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restorations because of the improved access and visibility outside the mouth.

7-Biocompatibility and good tissue response: Ceramics are considered chemically

inert materials with excellent biocompatibility and soft tissue response. The pulpal
biocompatibility of the indirect techniques is related more to the adhesive composite
cements than to the ceramic materials used.

8-Increased auxiliary support: Most indirect techniques allow the fabrication of the
restoration to be delegated totally or partially to dental laboratory technicians. Such
delegation allows for more efficient use of the dentist’s time.

Disadvantages

1-Increased cost and time: Most indirect techniques, excluding chair side
CAD/CAM methods, 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. Although indirect tooth-colored
inlays and onlays are more expensive than direct restorations (amalgams or
composites), they are usually less costly than more invasive esthetic alternatives such
as all-ceramic or porcelain- fused-to-metal crowns.

2-Technique sensitivity: Restorations made using indirect techniques require a high

level of operator skill. A devotion to excellence is necessary during preparation,
impression, try-in, cementation, and finishing the restoration. Diligence is required
during all stages of the process to obtain a high-quality restoration.

3-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. Fractures can
occur either during try-in or after cementation, especially in patients who generate
unusually high occlusal forces.

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 4-Wear of opposing dentition and restorations: Ceramic materials can cause
excessive wear of opposing enamel or restorations. Improvements in ceramics have
reduced this problem, but ceramics, particularly if rough and unpolished, can wear
opposing teeth and restorations.

5-Resin-to-resin bonding difficulties: Laboratory-processed resins are highly cross-

linked, so few double bonds remain available for chemical adhesion of the composite
cement. The composite restoration must be mechanically abraded or chemically treated
to facilitate adhesion of the cement. The bond between the indirect composite
restoration and the composite cement is the weak link in the system. Bonding of
composite cements to properly treated ceramic restorations is not a problem.

6-Short clinical track record: Indirect bonded tooth-colored restorations have

become popular only in recent years, and relatively few controlled clinical trials are
available, although these are increasing in number. The long-term clinical
performance, although expected to be good, is not well documented.

7-Low potential for repair: Indirect restorations, particularly ceramic inlays/onlays,

are difficult to repair in the event of a partial fracture. If the fracture occurs in the
restoration, an indirect composite inlay or onlay can be repaired using an adhesive
system and a light-cured restorative composite. The bond strengths of indirect
composite repair and direct composite repair seem to be similar. When a partial fracture
occurs in a ceramic inlay/onlay, repair is usually not a definitive treatment. The actual
procedure (mechanical roughening, etching with hydrofluoric acid, and application of
a silane coupling agent before restoring with an adhesive and composite) is relatively
simple. Because some ceramic inlays/onlays are indicated in areas where occlusal
wear, esthetics, and resistance are important, however, direct composite repairs
frequently are not suitable because the composite might be exposed to a challenging
environment.

8-Difficult try-in and delivery: Indirect composite restorations can be polished

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intraorally with the same instruments and materials used to polish direct com- posites,
although access to some marginal areas can be difficult. Ceramics are more difficult to
polish because of potential resin-filled marginal gaps and the hardness of the ceramic
surfaces.

Classification of indirect esthetic restorations:

According to material:
 Indirect resin composite
 Ceramics
According to technique:
a. Direct/indirect (semidirect) technique. For indirect resin composite restorations
only
b. Indirect technique (laboratory processed). For indirect resin composites and
ceramics
C. Flexible model techniques. For indirect resin composite restorations only
D. Machinable. For indirect resin composites and ceramics
Tooth preparation for esthetic inlays:
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. All margins should
have a 90-degree butt-joint cavosurface angle to ensure marginal strength of the
restoration. 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 tapered
instrument that creates occlusally divergent facial and lingual walls. Gingival-

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occlusal divergence allows for passive insertion and removal of the restoration The
junction of the sides and tip of the cutting instrument should have a rounded design to
avoid creating sharp, stress-inducing internal angles in the preparation. Although the
optimal gingival-occlusal divergence of the preparation is 5-15 degrees, it should be
greater than the 2 to 5 degrees per wall recommended for cast metal inlays and onlays.
Divergence can be increased because the tooth-colored restoration is adhesively
bonded and because very little pressure can be applied during try-in and cementation,
(Fig 1).

Throughout preparation, the cutting instruments used to develop vertical walls are
oriented to a single path of draw, usually the long axis of the tooth crown. Most
composite and ceramic systems require that any isthmus be at least 2mm wide to
decrease the possibility of fracture of the restoration. Facial and lingual walls should
be extended to sound tooth structure and should go around the cusps in smooth curves.
Ideally, there should be no undercuts that would prevent the insertion or removal of
the

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 •

Fig 1 the optimal gingival-occlusal divergence of the preparation is 5-15 degrees divergence
, the isthmus has to be at least 2mm width, the contacts is completely freed. the cavosurface
angle is 90 degrees
When extending through or along cuspal inclines to reach sound tooth structure, 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 (If cusps must be capped, they should be
reduced 1.5 to 2mm and should have a 90-degree cavosurface angle. When capping
cusps, especially centric holding cusps, it may be necessary to prepare a shoulder to
move the facial or lingual cavosurface margin away from any possible contact with the
opposing tooth, either in maximum intercuspal position or during functional
movements. Such contacts directly on margins can lead to premature deterioration of
marginal integrity. The axial wall of the resulting shoulder should be sufficiently deep
to allow for adequate thickness of the restorative material and should have the same
path of draw as the main portion of the preparation. (Fig 2)

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 Cavity lining for indirect esthetic restorations:
If a compromised restoration (if present) is completely removed, and all caries is
excavated. The cavity lining is performed. The reason for cavity lining of esthetic inlay
preparations is not the same for amalgam and gold preparations.

The objectives for lining are:

1. Removal of all cavity undercuts. It is not necessary to cut away all undercuts
providing that they can be removed by blocking them by suitable liner.
2. The liner should provide pulp protection.
Fig 2: Mesioocclusal,distofacial,and distolingual Inlay preparation on
maxillary right first molar. Distofacial, mesiolingual, and distolingual cusps are
reduced. A, Occlusal view. B, Facial view.

Mesio-occlusal,distofacial,anddistolingualinlaypreparationonmaxil- lary
right first molar. Distofacial, mesiolingual, and distolingual cusps are reduced.

A, Occlusal view. B, Facial view.

3. The lining material adjacent to outer tooth walls should not block light
transmission.
4. It must be compatible with the resin material and the luting cement.

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 The best lining materials are:
I. Resin modified glass ionomer.
2. Visible light cured composite resin.

Indirect resin composite restorations

Resin composite inlays were developed to overcome some of the problems
encountered by clinicians during fabrication of direct composite resin in posterior
teeth. Moreover, they solved most of the clinical problems of direct composite resin
restorations including marginal leakage, increased wear, and improper restoration of
contact relations of the inaccessible areas.
Techniques for fabrication of resin composite inlays:
The fabrication techniques for the composite resin inlays depend on the specific
system of materials being used. Three different fabrication techniques are available
namely the combined direct/indirect (semi-direct) technique, the indirect technique on
stone die, the indirect flexible model technique and machinable techniques
I) Direct/indirect (Semi-direct) technique:
The rationale of the semi-direct approach is to provide the patient with the benefits of
luted restorations without the cost of indirect lab-made inlays or onlays.
Steps for fabrication:
l) Lubrication of the Inlay Preparation: Once the inlay preparation has been completed,
the tooth and cavity preparation are liberally painted with a lubricant on a disposable brush.
This lubricant is compatible with the hybrid composite resin inlay restorative material and will
allow inlay removal after intra-oral light curing.
2) Matrix and Wedge Placement: A retrainerless contoured, clear matrix is placed and
clear reflecting wedges are placed at the interproximal gingival margin. The wedges are firmly
placed to create rapid separation of the teeth, compensating for thickness of the Mylar matrix
band and allowing for the interproximal contact between the inlay and adjacent teeth. The
lubricant is lightly thinned with a gentle air stream.

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 3) Resin Composite Inlay material Placement: The hybrid resin composite is placed
into the inlay preparation by taking the high-viscosity resin paste, placing it into the
proximal box, and gently condensing it with a ball burnisher. After the composite resin
has been placed in the proximal box, the occlusal portion of the preparation is
completely filled and gently condensed with a ball burnisher that has been lightly
coated with a resin adhesive to avoid the composite resin from sticking to the end of
the burnisher. Once again, firm pressure is placed on the reflecting wedges to guarantee
rapid separation of the teeth and to avoid creating gingival excess of the composite
resin inlay material. The end of a curved light-curing tip is placed firmly on the end of
the reflecting wedge and the interproximal area is cured for 60 seconds. The
interproximal surfaces are cured from the facial and lingual aspects; then the occlusal
surface is cured for 60 seconds also.
4) Inlay Removal: After the completion of light curing, the inlay must be removed
from the preparation. A scaler is gently placed on an interproximal surface, taking care
to avoid injury of the margins. The inlay is gently teased out of the inlay preparation.
If the inlay resists removal, a loop of dental floss can be placed in a small increment
of the composite resin material, and that small amount of composite resin is placed in
the central fossa area of the inlay and light cured. This will act as a handle for engaging
an instrument to remove the inlay along the preparation's path of draw.
5) Oven Tempering: Separator lubricant is painted on all the inlay surfaces. This will
act to exclude air and will allow the inlay to completely cure without an air-inhibited
layer. The air-inhibited layer is the soft surface layer of composite resin and should be
excluded whenever possible. The inlay is then light cured for an additional 60 seconds.
The composite resin inlay must now be tempered in a special tempering oven. The
inlay may be heat cured at 1100c for 7 minutes. The combined light and heat curing
ensures complete polymerization of the material, which guarantees an increased
hardness and provides potential for increased wear-resistance of the inlay. Therefore,
the direct-indirect inlay technique eliminates the need for an impression of the
preparation and the inlay can be finished in a single visit.

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 II) Indirect Technique
The alternative method of composite resin inlay fabrication is to make an impression
of the prepared tooth and fabricate the inlay on a die. The indirect inlay technique can
be performed as either a one- visit or two-visit method. The one-visit method involves
making an impression with a vinyl polysiloxane material and pouring the impression
with a fast-setting die stone, which will set within 5 minutes. The inlay is fabricated
by the practitioner or trained staff personnel and should be bonded within
approximately 30 minutes. The two-visit method involves sending the impression to
a laboratory for fabrication and provides for bonding at a subsequent patient visit. The
following description applies to both one-visit and two-visit methods. The difference
is in the sequence of the fabrication and whether it takes place in the office or the
laboratory.
Steps of construction:
1) Impression Making: Impression should be made with either a polyether or a vinyl
polysiloxane impression material. These materials can be poured in stone immediately
and also will remain stable if the impression is sent to a dental laboratory. The
impression is then poured up in a die stone for inlay fabrication. For the in-office
technique, a fast-setting stone should be used.
2) Provisionalization: The aim of temporariztion is to protect the pulpo-dentinal
complex from any bacterial, mechanical, and thermal aggression and to stabilize
relations with proximal and antagonizing teeth, as well as maintain an acceptable
occlusion and function. However, these temporaries have to stay in the mouth for a
short period because it is advisable to proceed with the cementation of definitive
restorations as soon as possible, generally within a week of impression taking.
Technique of provisionalization:
a) The rubber dam is removed for the fabrication of the provisional restoration. For
an inlay, the provisional restoration can be constructed directly on the prepared tooth
in the patient's mouth.
b) A light coat of the patient's own saliva may be painted into the preparation to act
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as a lubricant.
c) Two drops of monomer liquid are placed into a dappen dish and enough powder is
added to form a runny mix of acrylic resin. When the mix acquires slightly less flow,
a disposable brush is used to paint some of the acrylic resin into the tooth preparation,
covering the gingival wall. When the mix becomes doughy, it is placed into the cavity
preparation with an angled flat plastic instrument.
d) The patient should close into maximum intercuspation and go through all
mandibular excursive movements to establish the parameters of an occlusal form.
After polymerization, the acrylic resin restoration is removed from the tooth. The
excess acrylic resin is trimmed with acrylic resin burs or abrasive disks.
e) After the finishing stage, the restoration is placed back into the tooth preparation
to evaluate the fit and marginal adaptation of the restoration. Articulating paper is used
to check the occlusion and make any adjustments that are necessary to maintain the
occlusion and proximal contacts. The surface of the provisional inlay is then glazed
with a light cured glazing resin. The restoration is cemented with a non-eugenol-based
temporary cement.
3) Cast Preparation: Once the die stone is set, the cast should be mounted and
sectioned for preparation for the inlay fabrication. Care should be taken when the cast
is sectioned, so that the gingival contacts remain intact; this should be done even at the
expense of the adjacent tooth. The impression can be poured a second time if
an additional cast is desired for better evaluation for the proximal contact area and the
path of removal.
4) Inlay Fabrication: The preparation margins are outlined with a red pencil. A
separating medium is applied to the internal surface of the die as well as to
the surrounding and opposing teeth. One or two drops are placed into the cavity
preparation and spread over the tooth so that each margin is well coated. The
separating medium is then dried with a gentle air stream.
The composite resin of the correct shade is dispensed onto a pad. This material is
sensitive to light exposure and will cure while it is being worked with, so it is necessary
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to work quickly. It is advisable to use the material within 5 minutes. The composite
resin can be built up in two layers if shading of dentin and enamel is desired. The
hybrid composite resin has a high viscosity for ease in sculpting and will hold its shape
until light-cured. Instruments made specifically for composite resin materials should
be used. Proximal and occlusal anatomy should be developed at this stage. Light curing
should then be completed; each surface is irradiated for 40 seconds. After light curing,
the inlay is removed from the die by pressing on the proximal surface in an occlusal
direction.
5) Heat Treatment: The resin inlay is heat treated in an oven for 15 minutes at 100°C
in a heat-curing oven. This oven can maintain the curing temperature over the curing
time for multiple restorations. The unit is very compact and requires little bench-top
space.
6) Finishing and polishing: After heat treatment, the inlay is carved on the die with
fine diamonds and mounted abrasive stones. The inlay is then polished with composite
polishing paste on a buff wheel.
7) Characterization: The inlay is thoroughly cleaned ultrasonically in a water bath.
It can then be characterized by applying one of the resin-based colorants to the surface
of the inlay. This characterizing stain is applied to pits and fissures with a brush. The
stain is then light cured for 40 seconds. Stain may also be applied when the composite
resin is being layered into the preparation to develop internal characterization. At this
stage the inlay is ready for bonding and cementation to the tooth preparation.

III)Flexible Model Technique:

The flexible model technique is an alternative to using the natural tooth as the die
for inlay fabrication.
Steps for fabrication:
1) The technique starts by making a polyvinyl- siloxane impression of the
preparation. After the impression is made, a silicone-releasing agent is sprayed onto
this impression.
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 2) A heavy-bodied polyvinyl-siloxane is now placed into the impression to make the
flexible-working model. Although many techniques can be used, preferred injecting a
heavy bodied (high viscosity) material into the preparation impression, followed
immediately with a putty material. The dental assistant mixes the putty while the
dentist injects the heavy-bodied material into the impression and is used to force the
less viscous heavy body material into the details of the impression.
3) This is allowed to set for the manufacturer's recommended time and the
impressions are separated. The use of the silicone releasing agent facilitates separation,
if this agent were not used, the two silicone impression materials would bond together.
4) The resin inlay is now fabricated as with the direct technique. Many clinicians
find the flexible model technique easier because it provides greater control
extraorally. To aid in proximal contouring, the model can be partially sectioned.
Curing time and finishing procedures are all identical to those used with the direct
composite inlay technique described previously.
This technique has utilized many times, many clinicians prefer the ease and accuracy
of the direct resin inlay utilizing the natural tooth as the working die. When a larger
restoration is required or if the preparation involves cuspal coverage, the flexible
model technique facilitates contour of the restoration.
Advantages of Flexible Model Technique:
1. There is less inconvenience, less trauma and less time consumption for the
patient because a separate second appointment is eliminated. The dentist, an
in-house laboratory technician, or a capable assistant can make the restoration.
2. Provisional restoration is not needed, reducing time and cost and eliminating
contamination of tooth preparation by provisional cement debris.
3. Polymerization shrinkage of resin occurs on the die and not on the tooth.
4. The technique requires minimal clinical time (it is possible to seat the
restoration 20 minutes after impression).
5. Ability to achieve improved contours, improved esthetic results and minimal
finishing times.
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 The drawbacks of this technique may be summarized as follows:
1. The time needed for impression material to set and possible deformation of the
original impression when making the flexible die.
2. Tooth preparation should not have thin, weak cusps because the accuracy of
the die is compromised as a result of the flexibility of the die silicone.
3. The opposing reference is not available because the restoration is generated on
a single base from a single-quadrant impression. There is a high incidence of
occlusal discrepancy when complex restorations are built up with the adjoining
teeth as the only reference. Cusps and occlusal contacts are at best estimated
during resin composite build up and then reduced or augmented at seating to
achieve the optimal interocclusal relationship.

CERAMIC INLAYS
The word ceramic is derived from the Greek "Keramos" i.e. pertaining to pottery as
an art. Porcelain is defined as a fine kind ware-earthen having a translucent body and
a transparent glaze. The history of porcelain inlays goes back to more than 100 years
ago. Porcelain inlays have been used since this time but did not gain popularity due to:
I. Problems attributed to the exacting technique.
2.The inherent brittle nature of porcelain.
3.Microleakage and cement failure.
4.Poor fit and luting difficulties.
These problems have now largely been overcome by the introduction of "shrink-free"
porcelains which may be etched and bonded to resin composite luting cement, with the
chemical bonding being enhanced by silanization of the fitting surface of the inlay.
Types of ceramic inlays:
1.Ceramic inlays produced on refractory die material.
2.Castable and pressed ceramic inlays.
3.Ceromers inlays.

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 1. Ceramic inlays produced on refractory die material (Feldspathic technique).
The refractory die technique uses a direct build-up of porcelain onto an investment
model whose coefficient of thermal expansion is similar to that of ceramic material.

Steps for construction:

a. Generating of the refractory die: the entire master cast is covered with a clear
mold that contains several large holes in its top surface and is attached to the
underlying base. A vinyl polysiloxane impression material is poured through one hole
in the top of the model. The die of the prepared tooth is removed from the impression.
This specific portion of the impression is repoured in a refractory investment
b. Porcelain buildup: The margins of the preparation are marked with a special
refractory marker. At least three firings are necessary before final glaze is applied.
2. Castable and pressed ceramics: They are fabricated by the lost wax technique.
Theoretically, the lost wax technique improved fit compared with refractory die
technique.
A. Castable ceramic inlay fabrication:
I. Following tooth preparation and impression making, accurately indexed working
cast with individual dies is developed.
2. Wax pattern is formed to reproduce the desired tooth anatomy and relations.
3. The wax pattern is invested using phosphate- bonded investment, which is a
specific type for this technique.
4. Wax elimination: once the investment has set, the casting ring is placed in burnout
furnace and held at a temperature of 350°C for 30 to 45 minutes. Then the temperature
is increased to 900°C, the casting temperature of castable ceramics.
5. Centrifugal casting technique for ceramic material into the mould to produce an
accurate casting is done.
6. Ceraming process: which converts the casting to a partially crystalline state
through a controlled heat treatment in which nucleation and growth of the crystals
occur (mica crystals) which are responsible for strength of the inlay. The ceraming
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process takes about 6 hours.
Advantages of castable ceramics:
1. Increased fit more than conventional ceramic inlays.
2.Less predicted wear than conventional porcelain.
3.The thermal coefficient of expansion is close to that of enamel.
4. Higher flexural strength is reportedly greater than that for conventional porcelain.
Disadvantages:
1. Lack of surface staining hence any grinding of the restoration leaves an unaesthetic
opaque white area.
2. The whole procedure is a technique-sensitive.
B. Pressed ceramics:
It is considered as a development of the castable ceramic in which glass ceramic into
the mould by a pneumatic pressure system. However, surface staining is recommended
for both systems. Each stain firing lasts for at least two minutes.
Advantages of pressed ceramic system:
1.Relatively simple and accurate procedure.
2.The precerammed porcelain has a high degree of flexural strength.
3. It can be used in restoration with very thin sections (about one millimeter).
4. The lost wax technique and ceramic injection allow for accurate fit.

3. Ceromers inlays
They are ceramic optimized polymers where ceramic fillers are incorporated to
substitute the quartz fillers. They are claimed to improve the wear resistance of the
material and its esthetic properties. Wear is said to be comparable to that of enamel
tissue. The material is available for both direct and indirect composite resin inlay
techniques. Silanated fibers may be added for the indirect technique for reinforcement.
Technique:
1) Removal of defective restoration and cavity preparation.

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 2) Impression taking using alginate impression material.
3) Fabrication of positive replica using vinyl polysiloxane rubber base impression
material.
4)Base formation.
5)Incremental building up of the inlay with light curing.
6) Post curing using high performance curing unit.

Machined restorations (for both ceramics and composites):

1. CAD/CAM (Computer Aided Designed/ Computer Aided Manufacturing)
restorations.
2. Celay type inlays.
3.Prefabricated size-matching inserts (Sonicsyst).

1. CAD/CAM (Computer Aided Design-Computer Aided Manufacturing):

Restorations that are constructed from solid blocks of porcelain milled into the correct
shape and dimensions utilizing a computer driven milling machine. The CEREC
(ceramic reconstruction) machine was the first introduced system and it comprises a
miniature camera for optical impression, computerized designer and milling machine
with a self-contained water supply. They are machined from modified porcelain or
special fluoroalumino-silicate compositions with excellent wear resistance. The
materials being machined are pore-free and generally have both crystalline and non-
crystalline phase. A two phase composition permits differential etching of internal
restoration walls for micromechanical retention using bonding agents and/or luting
cements. Recently composite blocks are available in the dental market
Technique:
Optical impression: The miniature intra-oral camera maps the cavity contours after
coating the tooth with a thin dusted layer of titanium oxide to eliminate light reflection.
However recent versions from the intraoral camera donot require the use of the

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titanium oxide dust. It is essential to position the camera over the long axis so that the
computer can read all internal walls and cavosurface margins equally.
Computer generated restoration design: The restoration is designed from the image
shown on the computer screen by using a series of icons or symbols. Once the
restoration has been designed, the computer develops a three-dimensional image of the
inlay, onlay or veneer.
Milling procedure: The milling is accomplished by a three-axis of rotation cutting
machine which mills the restoration from prefabricated ceramic blocks with different
shades, which generally takes 4 to 7 minutes to complete the procedure. Final occlusal
adjustments are done in the patient's mouth. The weak link with these Systems is the
cement gap along occlusal surfaces that may be wider than desired. Minimizing this
gap depends on the computer digitization, design and manufacturing steps being
sufficiently accurate. The clinical longevity of these restorations is difficult to predict,
because only relatively short term clinical research information is available.
Advantages of the Cerec system:
1. Single appointment.
2. No conventional impression technique
3. Wear hardness is similar to enamel.
4. Excellent polishing characteristics.
5. Less fracture because it is milled from homogeneous blocks.
6. The whole procedure is accomplished in 1- 1.5 hours

2. Copying Machines: Celay

The Celay is a well-known hand-operated system that represents an interesting
alternative to CAD/CAM systems for the dental laboratory. In a first step, a pro-inlay
is produced in the patient's mouth or on a model. The pro-inlay, made of composite
resin, is fixed on the scanning side of the machine. Hand scanning and machining are
then executed simultaneously. Ceramic and composites inlays, onlays, copings, and
even three-unit bridge substructures can be fabricated. The manufacturer of Celay
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machine tried to overcome the difficult technology of Cerec system and designed a
simplified high precision milling machine.
Technique:
Proinlay: A removable, dark blue composite inlay is made directly in the patient's
mouth or indirectly on an accurate model.
Tracing: The blue inlay is manually traced with a stylus. A thin coating of white
powder is used to control the tracing. Contact of the stylus with the boundaries of the
Proinlay will remove the white powder and the blue color becomes visible.
Milling: The stylus has a fixed relation to a turbine, which mills the inlay out of a
ceramic block using diamond points to produce a finely worked surfaces' especially
the occlusal anatomy.
Advantages of Celay system:
1. A precisely fit ceramic restoration can be done in one visit.
2. No need for laboratory technician.
3 .The processing time is very Short, complete inlay in 12-13 minutes.

3- Prefabricated size matching ceramic inlays (Sonicsys)

It is a recently introduced ceramic inlay system to provide easier and less costly
prefabricated ceramic restorations for proximal cavities of posterior teeth. The system
is composed of: Varying sizes of ultrasonic abrasive tips with the abrasive particles
are bounded to all surfaces except the surface facing the adjacent tooth to avoid injury
during cavity drilling. Standardized ceramic inserts size matching the corresponding
abrasive tips. They are cemented to tooth as other ceramic and composite inlays. If
occlusal caries does exist, a conservative cavity and direct ceromer or composite resin
material could be used for occlusal restoration.

Cementation of composite and ceramic inlays:

A- treatment of the fitting surface of the inlay:

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 For proper adhesive bonding, the internal surface of the inlay/onlay must be treated
before cementation. The techniques and materials vary, depending on the specific
restorative system used. For most laboratory-processed composite inlays/onlays, the
resin matrix has 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. To
improve the bond of the cement to the processed composite restoration, some systems
recommend sandblasting (air abrading) the inside of the composite restoration with
aluminum oxide abra- sive particles to increase surface roughness and surface area for
bonding. For ceramic inlays/onlays, hydrofluoric acid usually is used to etch the
internal surfaces of the restoration . Such acid etching increases surface relief and not
only increases the surface area, but also results in micromechanical bonding of the
composite cement o the ceramic restoration. Hydrofluoric acid etching usually is done
by the laboratory. The clinician should check the internal surface of the restoration,
however, to confirm the etching, which is evident by a white- opaque appearance
similar to acid-etched enamel. 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

B-Treatment of the tooth structure

1. Isolation: preferably by the application of rubber dam.

2. Cleaning and drying of the cavity: to remove any traces of temporary
restoration Matricing: It is advisable to apply matrix to prevent gingival flow
of excess cement.
3. Etching, washing, drying, and application of the bonding system according to
manufacturer's instructions.
4. Cementation: Apply either chemically activated or dual activated composite
resin cement to the fitting surface of the inlay and the prepared cavity.
5. Seating of the inlay: Gentle seating of the inlay is done by finger pressure or
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 by a ball burnisher applied with a slight vibrating followed by steady pressure
from the opposing teeth. The excess luting cement is then removed with a
sponge pellet or with with thin-bladed composite instruments, brushes, or an
explorer.

6. Curing: Visible light curing to initiate the polymerization reaction of the dual
cured resin cement.
7. Removal of rubber dam.
8. Finishing & polishing: The margins are finished using flexible discs or
diamond burs while polishing is done by composite polishing discs, white
rubber cups or porcelain polishing kits.
References:

1. Kidd EAM et al. Pickard’s manual of operative dentistry. Oxford University

Press,2003.
2. Summit JA. Fundamentals of operative dentistry: a contemporary approach.
Quintessence Pub. Co, 3rd edition, 2006

3. Zaghloul H, Elkassas DW and Haridy MF . Effect of incorporation of silane

in the bonding agent on the repair potential of machinable esthetic blocks Eur
J. Dent Vol 8 ;1,2014.

4. Sturdevant's Art and Science of Operative Dentistry, Elsevier/Mosby, 7th

edition, 2016.

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