CLINICAL RESEARCH

Retrospective clinical evaluation of ceramic onlays placed by

dental students
Jennifer J. Archibald, DDS,a Gildo Coelho Santos, Jr, DDS, MSc, PhD,b and
Maria Jacinta Moraes Coelho Santos, DDS, MSc, PhDc

Indirect ceramic restorations ABSTRACT

have been considered an Statement of problem. Indirect restorations with partial or complete occlusal surface coverage
excellent treatment option for have been recommended to restore teeth with weakened walls in order to prevent cusp fracture.
patients with high esthetic The success of these restorations when performed by dental students is unknown.
demands, especially where the
Purpose. The purpose of this retrospective study was to evaluate the clinical performance of
size of the cavity preparation is adhesively bonded ceramic onlay restorations placed by third- and fourth-year dental students.
too large for direct restora-
tions.1 The development of Material and methods. Sixty-five ceramic onlays were placed in patients between 2009 and 2015.
The onlays were laboratory or chairside fabricated with a computer-aided design and computer-
high flexural strength ceramics
aided manufacturing (CAD-CAM) system, using either IPS e.max Press or IPS e.max CAD. An
has allowed the use of ceramic adhesive technique and luting composite resin agent were used to cement the restorations.
restorations on teeth with Thirty-seven onlays were evaluated clinically using the modified United States Public Health
higher functional loading.1,2 Service (USPHS) criteria. Data were statistically analyzed using the Cox proportional hazards
Manufacturers have been able model to compare tooth type and failures and the Fisher exact and McNemar tests to compare
to strengthen ceramics by the USPHS criteria for significant differences (a=.05). Survival probability was calculated using the
adding filler particles to the Kaplan-Meier algorithm.
base glass composition, such Results. Five onlays were considered to be failures and needed replacement. According to the
as leucite and lithium disilicate Kaplan-Meier analysis, the estimated survival rate was 96.3% after 2 years and 91.5% at 4 years. All 5
2
crystals. IPS e.max Press and of the failures occurred on molars (13.5%) and none on premolars (P=.025). A statistically significant
difference was found for marginal discoloration between onlays placed within 0 to 3 years and 3 to
IPS e.max CAD (Ivoclar Viva-
6 years (P<.05) but no differences between any other criteria.
dent AG) are examples of
particle-filled glass ceramics Conclusions. Ceramic onlays placed by dental students demonstrated acceptable long-term clinical
that contain high concentra- performance. (J Prosthet Dent 2018;119:743-8)
tions of lithium disilicate crys-
tals for enhanced mechanical properties.3 Ceramic materials are available for fabricating partial
Partial or complete coverage of the occlusal surface restorations by using different techniques.11-14 Among
has been recommended to restore teeth with weakened them, the IPS Empress system introduced in the early
walls and to prevent cusp fracture.4 Ceramic onlay res- 1990s combines heat and pressure in an injection
torations are able to provide cuspal protection while molding process by using presintered glass-ceramic
minimizing the extensive removal of sound tooth struc- blocks enriched with leucite crystals.2,15 The addition of
ture.5,6 Adhesive cementation is indicated for use with crystals in the glass phase helps to counteract the buildup
glass ceramic systems to create a strong bond between of tensile stresses, improving the flexural strength and
tooth and ceramic material.7-10 mechanical performance of the ceramic material.12,16

a
Predoctoral student, Schulich Medicine and Dentistry, Western University, London, Ont, Canada.
b
Associate Professor, Department of Restorative Dentistry, Schulich Medicine and Dentistry, Western University, London, Ont, Canada.
c
Associate Professor, Department of Restorative Dentistry, Schulich Medicine and Dentistry, Western University, London, Ont, Canada.

THE JOURNAL OF PROSTHETIC DENTISTRY 743

744
Clinical Implications
The results observed in this study showed that
ceramic onlay restoration is a successful treatment
option for patients. The advantages of these
conservative ceramic restorations include less tooth
removal and excellent esthetics.
More recently, IPS e.max Press has been introduced by
using a similar processing technique but using ceramic
blocks enriched with lithium disilicate crystals (SiO2-
Li2O) to improve mechanical properties and trans-
lucency.3,12,17 Furthermore, machinable ceramics such as
IPS e.max CAD have been developed for use with
computer-aided design and computer-aided manufacturing
(CAD-CAM) applications, either chairside or in the lab-
oratory.18 Ceramic blocks in a partially crystallized, soft,
state allow milling without excessive diamond tool wear
or damage to the ceramic material.
The long-term survival rates of adhesively bonded
ceramics restorations have been reported to range from
76% to over 90%,19-25 with bulk fracture and marginal
discoloration as the most common causes of failures.26-28
Although ceramic materials have been extensively used
for crowns, numerous studies have reported the successful
clinical behavior of partial ceramic restorations.29-39 The
longevity of CAD-CAM onlays has also been studied,
with marginal fit having a strong influence on success
rates.40-43
To assess the behavior of partial ceramic restorations
in a dental school environment, the present study aimed
to evaluate the clinical performance of adhesively bonded
ceramic onlay restorations placed by dental students
within the past 6 years.
MATERIAL AND METHODS
This study was carried out according to research guide-
lines involving human subjects and was independently
reviewed and approved by the Research Ethics Board for
Health Sciences Research Involving Human Subjects
(HSREB) for Western University, Ontario, Canada.
Sixty-five ceramic onlays were placed in 52 patients at
the Schulich Dental Clinic at Western University in the
past 6 years. These ceramic onlay restorations were
prepared and cemented by fourth-year predoctoral stu-
dents supervised by a faculty member in the Department
of Restorative Dentistry.
The following criteria have been adopted by the
dental school to determine the suitability of a tooth to
receive an onlay restoration using clinical and radio-
graphic examination: amount and quality of the
remaining tooth structure, occlusion, periodontal
assessment, pulpal or endodontic treatment evaluation,
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 119 Issue 5
amenability for rubber dam placement, and esthetic
requirement.
The tooth preparations followed the general princi-
ples for adhesive ceramic onlays, including isthmus width
between 1.5 and 2.5 mm; minimum occlusal reduction of
1.5 (nonfunctional cusps) to 2.0 mm (functional cusps);
1.25-mm modified shoulder margin around the prepa-
ration; round internal line angles; and divergence of walls
at approximately 10 to 15 degrees with no bevel.
After cavity preparation, interim restorations were
fabricated with an automixed methacrylate resin (Integ-
rity; Dentsply Sirona) and cemented with interim
cement (Temp Bond; Kerr Corp). The shade was selected
with the Vita Shade guide (Vita North America).
Impressions were made with light-body and heavy-body
polyvinyl siloxane materials (Aquasil; Dentsply Sirona),
and onlays were fabricated in the dental school’s labo-
ratory using IPS e.max Press or IPS e.max CAD (Ivoclar
Vivadent AG). Six onlays were produced chairside by
using the CEREC system (software 4.0; Dentsply Sirona).
The prepared teeth were sprayed with a thin layer of
powder spray (IPS Contrast Spray Labside; Ivoclar
Vivadent AG) for image capture with the BlueCam digital
scanner (BlueCam; Dentsply Sirona). The restorations
were milled in a CEREC MC XL machine by using pre-
sintered glass ceramic blocks (IPS e.max CAD; Ivoclar
Vivadent AG) and were polished with porcelain polishing
points (Dialite Intra-Oral Polishing System; Brasseler
USA).
During the cementation appointment, the teeth to be
restored were isolated with either rubber dam, displace-
ment cords, dry angles, or cotton rolls. Interim restora-
tions were removed, and the tooth was cleaned with
pumice slurry. The fit of the ceramic onlays was evaluated
before cementation, and minor adjustments were per-
formed if necessary. The ceramic onlays were placed
using the following cementation protocols: ceramic
onlay, etched with 10% hydrofluoric acid (Prosthetic
Etchant Gel; Dentsply Sirona) for 20 seconds, washed,
and dried; silane agent (Monobond S; Ivoclar Vivadent
AG) applied for 1 minute; prepared tooth, acid etched
with 35% phosphoric acid, rinsed with water, and gently
air dried; dentin bonding agent (Multilink Primer or
Excite DSC; Ivoclar Vivadent AG or Scotchbond Uni-
versal Adhesive; 3M ESPE) applied over dentin and
enamel. If Scotchbond was used, the silane agent was
omitted as Scotchbond Universal contains a silane agent.
The onlays were cemented with a dual-polymerizing
resin luting material (Variolink II; Ivoclar Vivadent AG
or RelyX Ultimate; 3M ESPE) according to the manu-
facturer’s instructions. The restorations were briefly
polymerized (5 to 10 seconds) with a light-emitting diode
light-polymerizing unit so that excess cement could be
easily removed with explorers, scalers, and dental floss
interproximally. Each surface was then polymerized for
Archibald et al
May 2018
Table 1. Clinical investigation results with modified USPHS criteria
Alfa Bravo Charlie
Criteria (%) (%) (%)
Postoperative sensitivity 91.2 8.8
Secondary caries 91.2 8.8
Anatomic form 76.5 20.6 2.9
Color match 32.4 67.6 0.00
Surface roughness 44.1 53.0 2.9
Marginal discoloration 47.1 52.9 0.00
Marginal adaptation 32.4 58.8 5.9
USPHS, United States Public Health Service.
20 seconds. Restorations were adjusted with diamond
finishing rotary instruments under water cooling and
polished with porcelain polishing points (Dialite Intra-
Oral Polishing System; Brasseler USA). Each patient
received a 48-hour follow-up appointment to re-evaluate
interproximal contacts, margins, and occlusion.
Patients of the Schulich Dental Clinic who had onlays
placed between January 2009 and March 2015 were
contacted by telephone, letter, or email and were invited
for a follow-up examination. After receiving information
about the research methodology, risks, and benefits of
their participation, a written informed consent was ob-
tained. Restorations were assessed with the modified
United States Public Health Service (USPHS) criteria
(Supplementary Table 1) by 2 independent investigators
(M.J.S., J.A.) calibrated in the use of the system.44 The
investigators worked as a team but evaluated the onlays
independently with mouth mirrors and dental explorers. A
joint examination was performed to resolve any dis-
agreements. The participants were also asked about their
satisfaction with the restoration and whether they had
experienced any sensitivity or discomfort after placement.
Clinical photographs were made of select participants.
Interexaminer reliability was determined to be above 0.85
for all criteria, demonstrating a high rate of agreement
between examiners. The date of placement and the date of
the last observation of the restoration were recorded for
statistical analysis. Time of failure was fixed at the end of a
4-month time period because the exact time of failure
could not be accurately determined for each participant.
Failures were established as being restorations that were
lost or had fractured prior to the evaluation or those that
required replacement because of poor marginal quality
(Charlie, Delta), secondary caries (Bravo), or endodontic
complications. The ratings Alfa (A) and Bravo (B) are
considered successful for most criteria.
Statistical graphing software (Prism 6; GraphPad
Software, Inc) was used to calculate survival probability
using the Kaplan-Meier algorithm. The Cox proportional
hazards model was used to compare tooth type (molar or
premolar) and failures. The Fisher exact and McNemar
statistical tests were used to compare the USPHS criteria
for significant differences (a=.05).
Archibald et al
745
Delta
(%)
2.9
Figure 1. Representative restoration scored Bravo for marginal
discoloration (clinically acceptable).
RESULTS
Among the 52 participants who received onlay restora-
tions, 22 could not attend an appointment at the school
because of work commitments, sickness, vacation, or
relocation to another city. Of the participants who could
not come into the clinic and were reached by telephone
or email, 18 reported no postoperative sensitivity or other
issues and overall patient satisfaction. One participant
reported that the onlay had been rebonded in the past.
However, information gathered from participants that
could not be clinically evaluated was not added to the
statistical analysis.
Thirty participants, 19 women and 11 men with a
median age of 52 years, (ranging from 24 to 80 years)
were evaluated in the clinic for a total of 37 onlays.
Fifteen onlays (40.5%) were placed on premolar teeth
and 22 onlays (59.5%) were placed on molars.
Of the 37 onlays evaluated clinically, 6 were fabricated
with IPS e.max Press, and 31 with IPS e.max CAD. Six of
the IPS e.max CAD onlays were produced chairside with
the CAD-CAM machine. At the time of clinical obser-
vation, 34 (91.9%) of these restorations were considered
clinically acceptable. The mean observation period for the
ceramic restorations was 3.5 years, with an observation
interval of up to 6 years.
Table 1 summarizes the results of the modified
USPHS criteria obtained at the recall appointments.
Some Alfa and Bravo findings are illustrated in Figures 1
to 3. Five restorations were considered failures (Table 2).
Two restorations received C/D scores for marginal
adaptation and/or B scores for secondary caries and
needed to be replaced. Three restorations could not be
evaluated as they had been replaced.
The Kaplan-Meier methodology was used to calculate
the survival probabilities (Fig. 4). The estimated survival
rate was 96.3% after 2 years and 91.5% at 4 years (n=37).
The sample size after 5 to 6 years was much smaller,
THE JOURNAL OF PROSTHETIC DENTISTRY
746 Volume 119 Issue 5

Figure 2. Representative restoration scored Bravo for marginal integrity Figure 3. Representative restoration scored Bravo for recurrent caries
(clinically acceptable). (not clinically acceptable).

Table 2. Data of failed restorations

Number Location Rating Time in Service (mo) Material Used Sex
1 Maxillary 1st molar Fracture 24 IPS e.max CAD Male
2 Mandibular 1st molar Fracture 48 IPS e.max CAD Male
3 Mandibular 1st molar Fracture 60 IPS e.max CAD* Female
4 Maxillary 1st molar Secondary caries 60 IPS e.max CAD* Female
5 Maxillary 1st molar Secondary caries 72 IPS e.max CAD* Female
*Chairside CEREC CAD-CAM.

reducing the survival rate. The mean survival rate after 6 100
years was 67.4% (95% confidence interval=62.3% to
72.5%). All 5 of the failures occurred on molars (13.5%) 90
Survival Probability (%)

and none on premolars (P=.025). Three of the 6 onlays

80
(50%) fabricated chairside with the CEREC machine
failed, compared with 2 of the 31 (6.5%) fabricated with 70
IPS e.max CAD in the laboratory. No IPS e.max Press
onlays failed. 60
The McNemar statistical test (n=34) revealed a sta- 50
tistically significant difference for marginal discoloration
between onlays placed within 0 to 3 years and 3 to 6 40
years ago (P<.05). No significant differences were found
30
for other criteria when time since placement (<3 years 0 20 40 60 80
and >3 years) and tooth location (molar or premolar) Time (mo)
were compared.
Figure 4. Kaplan-Meier survival analysis of all onlays examined clinically.

DISCUSSION
The longevity and clinical performance of adhesively
bonded ceramic onlays placed by dental students were
evaluated. Few studies12,19,25,29,30,32 have retrospectively
assessed ceramic onlays over more than 3 years, espe-
cially with the IPS e.max CAD and IPS e.max Press
systems. Another particularity of the present study is
related to the population analyzed, where the partici-
pants were from the community and represented to a
certain extent a cross section of the population. Hickel
et al45 have provided a practical approach for conducting
clinical trials, which considers that the results of a clinical
evaluation obtained from participants recruited from the
community may be more realistic than results obtained
from a select group with more awareness of dental hy-
giene and preventive measures. Furthermore, several
operators (fourth-year dental students) carried out the
clinical procedures following guidelines adopted by the
dental school for the preparation and cementation of
ceramic onlays.
A 4-year study20 reported success rates above 90%,
similar to the 91.5% survival rate calculated with Kaplan-
Meier statistics in the present study. Survival rate was
higher at 2 years (96.3%), similar to previous find-
ings.6,26,31 As expected, higher success rates were recor-
ded for recently placed restorations. In the present study,

THE JOURNAL OF PROSTHETIC DENTISTRY Archibald et al

May 2018
the sample size after 5 years of service was smaller,
causing the survival rate to decline. Due to the retro-
spective nature of this study in a dental school clinic
setting, the recall rate was lower than that of similar
studies. Success rates need to be verified by continual
follow-up investigations over a 5-year period with a
higher recall percentage.
The survival rate of posterior ceramic crowns ranges
between 84.4% and 95.5%. Recent studies on lithium
disilicate crowns generally report survival rates of 95%
over 5 years.22 Ceramic onlays have comparable survival
rates with crowns yet are able to preserve healthy tooth
structure. All the failures observed in the present study
occurred on molars, as heavy occlusal loads tend to occur
on molar teeth.26,32,33 Although a similar number of
premolar and molar onlays were evaluated, 15 onlays
(40.5%) on premolar teeth and 22 onlays (59.5%) on
molars, no failures were observed on premolars. Occlusal
forces are one of the main reasons for ceramic frac-
ture.1,19 This finding is consistent with previous studies
reporting great risk of failures on molars.26,32 Smales and
Etemadi33 found a higher percentage of failures in molar
onlays due to bulk fracture. Other studies, however,
found no differences in the survival rates of ceramic in-
lays or onlays between the premolar and molar areas.12
Three of the onlays failed because of fracture, which is
considered a common problem reported in clinical
studies.6,12,27,32,34 Fracture may have been caused by
excessive occlusal loads or insufficient ceramic thick-
ness.45 Cracks produced by finishing and polishing pro-
cedures can lead to fracture of the material by crack
propagation under excessive tensile stress.35 The treat-
ment records revealed that all 3 of these onlays were
adjusted with diamond rotary instruments and rubber
points during the delivery appointment. This finding
highlights the importance of careful finishing and pol-
ishing procedures in adjusting the restoration.
Two onlays were replaced before evaluation. These
failed onlays were from the same participant and had
been placed on opposing first molars. The first fracture
occurred at 2 years after placement, much earlier than the
other failures in this study. This participant was found to
be a bruxer with extensive wear facets on his dentition.
This finding is supported by another retrospective study,
which reported an early failure due to the patient’s
bruxism.28 Because of their brittle nature, ceramic resto-
rations should not be used in patients with excessive
occlusal loads.23,36
Two restorations received Charlie or Delta scores for
marginal adaptation, and one of them presented sec-
ondary caries. Both restorations failed after 56 months of
service. Although several studies have reported decreased
marginal adaptation over time,12,37 no significant statistical
differences for marginal adaptation were observed for
those onlays placed between 0 to 3 years of service
Archibald et al
747
compared with 3 to 6 years. However, few restorations
received an Alfa score for marginal adaptation (32.4%).
Previous studies have observed the deterioration of mar-
ginal quality because occlusal fatigue caused degradation
of the resin-based luting agent.37 Deterioration at the
margins may lead to recurrent caries and restoration
fracture.28 The low modulus of elasticity of the resin-based
luting agent compared with the high modulus of elasticity
of the ceramic materials, combined with the fatigue of the
adhesive luting agent under occlusal loading, are consid-
ered contributing factors for decreased marginal adapta-
tion of partial ceramic restorations.6,25
Marginal adaptation is closely related to marginal
discoloration. As such, statistically significant increased
marginal discoloration (P=.013) was observed in this
study as the restoration aged. Previous studies have
shown that discoloration increases over time as a result of
the wear of the luting resin cement.6,24,38 This finding is
also consistent with the study of Tagtekin et al,39 which
showed statistically significant marginal discoloration at
12- and 24-month recalls with IPS Empress ceramics.
Coelho Santos et al6 illustrated cement wear with
consequent marginal discoloration of the margins of
ceramic onlays with scanning electron micrographs.
Three of the 5 failures observed in the present study
occurred on the onlays fabricated using the CAD-CAM
CEREC machine in 2009, representing the oldest onlays
in the sample. One onlay fractured before evaluation,
and the other 2 received poor scores on marginal adap-
tation, leading to replacement because of secondary
caries and endodontic treatment. These results may be
attributed to the difficulty of digitally capturing sub-
gingival margins40 or to the limitations of the previous
software versions and milling machine.41 Posselt and
Kerschbaum42 reported a large percentage of CEREC
restorations with underfilled margins. Contrary to these
findings, several studies have reported survival rates for
CEREC manufactured onlays to be similar to those
fabricated using the hot pressed technique, with rates
over 90% for 10 years.42,43
The limited participant recall is a weakness of the
present study and is an inherent problem with clinical
studies.46 Follow-up by 32 of the 52 original participants
might have been biased because those more motivated
to receive an evaluation might have responded to the
study recruitment. Additionally, the use of an older
chairside CAD-CAM system to fabricate onlays in 2009
has some disadvantages compared with newer versions
developed to eliminate previous limitations of the system
and enhance marginal adaptation.47 Half of the chairside
CEREC ceramic onlays evaluated in this study failed
(3 of 6). Further long-term clinical studies should be
conducted to evaluate the performance of IPS e.max
CAD onlays fabricated chairside with newer software
versions.
THE JOURNAL OF PROSTHETIC DENTISTRY
748
CONCLUSIONS
Based on the findings of this clinical study, the following
conclusions were drawn:
1. Ceramic onlays placed by dental students demon-
strated acceptable clinical performance over a 4-year
period and are a successful treatment option for
selected patients in a dental school.
2. These results are relevant to daily practice as high-
quality indirect partial restorations can protect
compromised tooth structure without extensive
removal of sound dental tissue and with increased
patient satisfaction.
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Corresponding author:
Dr Maria Jacinta Moraes Coelho Santos
Department of Restorative Dentistry
Schulich School of Medicine & Dentistry
Western University
DSB Rm 0149, London, ON
CANADA
Email: jacinta.santos@schulich.uwo.ca
Acknowledgments
The authors thank Lisa Lyons for assistance in editing the manuscript.
Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.
Archibald et al
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Supplementary Table 1. Modified USPHS criteria for clinical evaluation of ceramic onlays
Characteristic Rating Criteria
Postoperative sensitivity Alfa No postoperative sensitivity.
Bravo Postoperative sensitivity.
Secondary caries Alfa No evidence of caries contiguous with margin of restoration.
Bravo Caries evident contiguous with margin of restoration.
Marginal discoloration Alfa No discoloration on margin between restoration and tooth structure.
Bravo Discoloration on margin between restoration and tooth structure.
Charlie Discoloration has penetrated along margin of restorative material in pulpal direction.
Surface roughness Alfa Smooth surface.
Bravo Slightly rough or pitted, can be refinished.
Charlie Rough, cannot be refinished.
Marginal Integrity Alfa No visible evidence of ditching along margin.
Bravo Visible evidence of ditching along margin not extending to DE junction.
Charlie Dentin or base is exposed along margin.
Delta Restoration is mobile, fractured or missing.
Color match Alfa No mismatch in color, shade, and translucency between restoration and adjacent tooth structure.
Bravo Mismatch between restoration and tooth structure within normal range of color, shade, and translucency.
Charlie Mismatch between restoration and tooth structure outside normal range of color, shade, and translucency.
Anatomic form Alfa Restorations continuous with existing anatomic form.
Bravo Restorations continuous with existing anatomic form, but not exposing cement material or dentin.
Charlie Sufficient material lost to expose cement material or dentin.

USPHS, United States Public Health Service.

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