J fô O A
CLINICAL REPORTS
CAD-CAM ceramic inlays and onlays:
a case report after 3 years in place
Werner H. Mormann, DMD, PhD; Marco Brandestini, PhD;
Felix Lutz, MD, DMD, PhD; Fred Barbakow, BDS, HDD, MSc;
Thom as Gotsch, DMD
A t least three d ifferent techniques are
available fo r preparing computer-aided
designed (C A D ) a n d c o m p u te r-a id e d
manufactured (CAM) inlays and veneers.
T h is p a p e r d eta ils a c lin ic a l case in
which 13 Cerec CAD-CAM inlays have
been functioning for 3 years. Advantages
an d lim ita tio n s o f th is system are
discussed.
ig h -te c h in d e n ta l offices is
H mainly lim ited to practice m an­
ag em en t an d d ata storage.
However, com puters also record p e ri­
odontal findings, occlusal interferences,
and during the last 15 years have been
used in restorative dentistry to m ap cavity
p re p a ra tio n s as well. In itia l w ork in
this field began in the 1970s,13 but since
the 1980s the Duret (H ennson Interna­
tional), Minnesota, and Cerec (Siemans)
systems have evolved, and reviews of
these three systems have recently been
published.4’7
Currently, the Cerec system is the only
commercially available CAD-CAM system
w hich fabricates in lay s, onlays, an d
veneers. T h e Cerec system (ceram ic
rec o n stru ctio n ) con sists of a self-
Fig 1 ■ T h ree-d im en sio n al in tra o ra l cam era
over a mesio-occlusodistal cavity displayed on
the mobile u n it’s video screen.
contained mobile unit with a m iniature decided to offer tooth-colored posterior
three-dimensional intraoral video camera, restorations in stress-bearing areas on
a m onitor, keyboard, and a computer an experimental basis.
th at co n tro ls the three-axis diam ond- Indications and contraindications of
coated m illing device (Fig 1). the various methods available at the time
Three-dim ensional data of the cavity were e x p lain e d to the p a tie n t. T hese
preparation are recorded when the camera methods included chairside-m ade com ­
snaps the “optical im pression,” using posite inlays; laboratory-made composite
the p rin c ip le of active tria n g u la tio n . inlays; laboratory-m ade glass ceram ic
Additional data related to the restoration inlays (D icor, C o rn in g G lass W orks);
o u tlin e s are fed m an u a lly in to the laboratory-m ade porcelain inlays; and
co m p u ter, p ro d u cin g the view on the Cerec system, chairside-m ade ceram ic
m onitor shown in Figure 2. All the stored in la y s .1114 (In fo rm ed co n sen t was
data are subsequently used to direct the o b ta in e d to replace the 13 a m alg am
m illin g process, w hich is carried o u t
by a rotating diamond-coated disk (Fig
3). T he inlay is milled from a hom og­
en o u s, q u a lity -c o n tro lle d , factory-
restorations with Cerec inlays and one
onlay.)
Figure 4 (top) shows the left and right
bitewing radiographs taken at the onset
p re p a re d stan dardized ceram ic block of treatm ent. T h irteen Cerec system
w ithin 4-7 minutes; the margins are then
checked and the occlusal surface manually
ground in. T he inlay and enamel margins
are acid-etched, and the restoration is CfREC 3 1 /0 1 /1 9 8 8
cemented w ith either a light-curing or
a dual-curing posterior composite resin.
Preferably, Cerec Inlays are cem ented
w ith d u a l-c u rin g p o sterio r com posite
resin because of its im proved c u rin g
ability.7' 10
T his paper describes the first case in
which all the amalgam restorations were
rep laced by Cerec inlays an d onlays.
These restorations have been in place
for 3 years.
Report of case
A 32-year-old fem ale p a tie n t came to
the departm ent of cariology, periodon-
tology, and preventive dentistry, Zurich
University, December 1985. She requested
the rep lacem en t of all her am algam
restorations w ith natural tooth-colored
material for esthetic reasons. Her general
Fig 2 ■ T hree-dim ensional appearance of the
m edical history was n o n co n trib u to ry ,
m esio-occlusodistal cavity show ing the m esial
and as the p a tie n t’s oral hygiene and and distal restoration margins on the video screen.
gingival condition were excellent, it was
JADA, Vol. 120, May 1990 ■ 517
CLINICAL REPORTS
ceramic inlays were placed during five
visits w ithin 3 months. Cavity walls were
essentially prepared parallel to each other,
but the enamel m argins were not bevelled.
The gingival and lateral proxim al enamel
m argins were short-bevelled by 45° to
form adhesive margins for the bonding
procedure. Occlusal enamel margins were
not short-bevelled, thus n o t extending
the cem entation interfaces reducing the
potential loss of cem enting com posite
resin. T h e in la y s were m illed from
homogenous and almost porefree ceramic
blocks (V ita-C erec, V ita Z ahnfabrik).
T he ceramic and enamel m argins were
etched w ith 5% H F (C erec-E tch, Vita
Z ah n fab rik ) an d 35% H 3P 0 4 (E sticid-
Gel, Kulzer), respectively. In this case,
the inlays were finally cemented using
lig h t-c u rin g co m p o site (H e lio m o la r,
V ivadent), lig h t tra n s m ittin g wedges,
and transparent m atrix bands.15’16
Figures 5 and 6, respectively, show
details of the Cerec restorations in the
m a x illa a n d m a n d ib le 3 years after
p lacem ent. F ig u re 4 (bottom ) depicts
the left and right bitewing radiographs
3 years after the Cerec ceram ic inlays
were placed. T he 13 Cerec ceramic inlays
were subjectively evaluated by an inde­
p en d en t clin ical assistan t (TG ) using
US Public H ealth Service criteria mod­
ified to assess stre ss-b e a rin g ceram ic
inlays.17 T he modified criteria are pres­
ented in Table 1 and the results of this
clinical assessment are listed in T able
2.
D is c u s sio n
T his is the first reported case in which
all the a m alg am re sto ra tio n s were
F ig 3 ■ M illin g of th e ceram ic block in the
cham ber seen in Figure 1 on the u n it’s lower
left.
518 ■ JADA, Vol. 120, May 1990
Fig 4 ■ B itew ing rad io g rap h s d e ta ilin g the clin ical s itu a tio n w ith am algam resto ratio n s in
the p a tien t’s left and rig h t sides respectively (top) in January 1986. T he patien t’s left side and
rig h t side (bottom ) b itew in g rad io g ra p h s show the 13 Cerec ceram ic inlays after 3 years in
place in June 1989.
replaced with Cerec CAD-CAM ceramic
inlays. T h e p a tie n t is on a 12-m onth
recall, has m a in ta in e d ex cellent oral
hygiene during the 3 years, and considers
the “experiment” totally successful. The
subjective clinical assessment after 3 years
is excellent (Table 2). T he Bravo type
of defects along the cavity margins were
minim al, appearing equally as overhangs
an d u n d erfilled m argins, p artic u larly
on the occlusal surfaces. T h e co lo r
matches recorded after 3 years of function
were the same as those noted at cemen­
tation as only a m inim al range of colors
were available at that time. Currently,
closer color m atching is possible. Also,
a proto ty pe u n it was used to prepare
the inlays, and a lth o u g h extensive in
vitro testing had been done at that point,
o u r clinical experience with the Cerec
system was limited.
Five visits were required to prepare,
cement, and polish the 13 inlays. T he
currently available Cerec units are more
efficient than the prototypes. T he time
required to scan the cavity, design, mill,
finish, cement, and polish Cerec inlays
and onlays has been recorded by clinicians
d o in g field studies. T h e average time
recorded in practice to place one-surface
inlays (N = 27) was 3 2 + 1 1 min, two-
surface inlays (N = 106) was 39 ± 9 min,
three-surface inlays (N = 104) was 46
± 12 m in, and four-surface inlays (N
= 35) was 5 7 + 1 1 min.
The demand for esthetic tooth-colored
stress-bearing posterior restorations is
increasing. Several m aterials and tech­
niques are available to meet this demand,
but problems related to polymerization
shrinkage, secondary caries, insufficient
resistance to w ear, an d chem ical d is­
integration still persist. Ceramic inlays,
in c o n tra st to com posite types, have
physical and chemical properties similar
to those of enamel. As the only CAD-
CAM system available to practitioners,
the Cerec System fabricates restorations
from high-grade, quality controlled Vita-
Cerec ceram ic blocks and m achinable
glass ceramic blocks (Cerec Dicor MGC-
blocks, C aulk). A lth o u g h the various
materials used to fabricate indirect inlays
are factory-standardized, their subsequent
use by chairside assistants, clinicians,
and te c h n icia n s has n o t alw ays been
uniform.
Etched ceramic bonds well to etched-
enam el u sin g resin-based com posite
cements.810’1418 20 The net polymerization
shrin k ag e and net therm al expansion
of composite resin cement are low; only
a thin layer of composite cement is needed
between ceramic and enamel, producing
m in im a l w all-to -w all te n sio n .21 Tw o
types of H eliom olar were used in this
case: one w ith and one w ith o u t ra d i­
opaque material as shown in postop­
erative ra d io g ra p h s (Fig 4, bottom ).
N either ceramic nor composite cement
overhangs were detected clin ically or
rad io lo g ically . T h e earlier com posite
cem ents were less successful than the
types presently used which combine light-
and chemical-curing modes, for example,
Cerec Cement (Kulzer), Di-Cement (Col-
tene AG), or Dual Cement (Ivoclar AG).
The chemically cured component facil-
 CLINICAL REPORTS

itates the cu rin g in those parts of the

cavity inaccessible to the light.
Regardless of cavity size, simple box­
shaped preparations suffice for the Cerec
system. Undercuts, which retained am al­
gams, need not be converted to divergent
walls for Cerec inlays, thus conserving
maximum amounts of enamel and dentin.
In fact, the Cerec camera ignores under­
cuts when taking the “optical im pres­
sion.” Generally, am algam cavity m ar­
gins need only refinishing, and undercut
areas are filled in w ith c e m en tin g
composite resin during cementation.

Cerec system advantages

The advantages of Cerec inlays include

long-lasting esthetic appearance and at
least a 3-year material stability, as shown
in this case. A yet u n p u b lish e d study
has recently been com pleted, d etailing
the clinical findings of 81 other Cerec
inlays in another 29 patients, which have
also been in service for 3 years. Further,
no abrasion of the o p p o sin g teeth by
the ceramic material has been clinically
detected. Im pressions of cavity p rep a­
rations are unnecessary and laboratory
procedures are not needed. In addition,
as the restorations are cemented in one
visit, the p la c in g of tem porary resto ­
rations is unnecessary. T he unit is fully
mobile from one dental office to another,
and the num ber and duration of visits
are less for the placement of Cerec inlays
compared with other conventional direct
and indirect inlay systems.

Cerec system disadvantages

System-related restrictions include the

initial investment of the Cerec unit and
the 2-day intensive training course needed
to m aster the Cerec system . D entists
enrolled for these courses have found
the handlin g of the three-dim ensional
camera and the management of the cavity
design steps rath er ch allen g in g in the
m ultifaceted clinical situations. Initial
le a rn in g phases are stressful an d are
considered a system-related restriction.
According to a m an u factu rer’s report,
Swiss and West G erm an d e n ta l p ra c ­
titioners indicate that they feel totally
comfortable with the system after placing
50 to 100 ceramic restorations.

Summary
Cumulated laboratory data710-22 indicate
that the Cerec CAD-CAM system is ready
for use in d en tal offices. In a d d itio n ,
Fig 5 ■ Overview of the six Cerec inlays in the Fig 6 ■ Overview of the seven Cerec inlays in
m axilla (top) detailing the p atien t’s m axillary the m a n d ib le (to p ) d e ta ilin g th e p a tie n t’s
left (middle) and right (bottom) quadrants. m a n d ib u la r left (m iddle) and rig h t (bottom )
quadrants.

M ormann : CAD-CAM CERAMIC INLAYS AND ONLAYS ■ 519

CLINICAL REPORTS

Dr. Lutz is professor and chairman, department

of preventive dentistry, periodontology, and cari­
ology; Dr. Barbakow is senior research associate;
Table 1 ■ Criteria and methods used to assess the quality of the Cerec CAD-
and Dr. Gotsch is clinical associate, Dental Institute,
CAM ceramic inlays (modified from the USPHS system).
University of Zurich. Address requests for reprints
C ontour (using m irror and probe) to Dr. M o rm an n , U niversity of Z urich, D ental
Institute, PO Box 138, CH-8028, Zurich, Switzerland.
Alfa Surface m orphology correct, perhaps overcontoured
Bravo Surface m orphology incorrect, perhaps undercontoured
Charlie Defective restoration, exposed dentin, or base material 1. A ltschuler BR. H olodontograph y : an in tro ­
duction to dental laser holography: SAM-TR-73-
Margin quality: mesial, occlusal, distal (using m irror and probe) 4 Report, No. AD 758191 Texas, Brooks AFB, USAF,
Alfa No catches at cavity margin; if present, overhangs and underfilled margins are School of Aerospace Medical Div (AFSC). 1973;78:235.
invisible 2. Swinson WE. Dental fitting process. US Patent
Bravo Probe catches at cavity margin, visible overhangs and underfilled margins; no No. 3,861,044:1973.
exposed dentin or base material 3. M ushabac DR. Dental probe, US P aten t no.
Charlie Probe catches at cavity margin, visible overhangs and underfilled margins; exposed 4,182,312; 1980.
dentin or base material, immobile and uncracked filling 4. Rekow ED. Computer-aided design and m anu­
Delta Fractured or missing filling facturing in dentistry: a review of the state of the
art. J Prosthet Dent 1987;58:512-6.
Surface texture (using m irror and probe) 5. D uret F, B louin JL , D uret B. CAD-CAM in
Alfa Visual smooth surface, no tactile roughness dentistry. JADA 1988;117:715-20.
Bravo Visual and tactile surface roughness, no pitting or craters, unpolished fissures 6. M orm ann WH, Brandestini M, Lutz F, Bar­
Charlie Pitted or cratered surface, overall insufficient polish bakow F. Chairside com puter-aided direct ceramic
inlays. Quintessence Int 1989;20:329-39.
Color m atching (using mirror) 7. M o rm an n W, B ran d estin i M. Die CEREC
Alfa No apparent color change retaining a shiny surface com puter reconstruction. Inlays, onlays und veneers.
Bravo M inim al loss of translucency, but within the range of normal tooth color Berlin: Quintessence, 1989.
Charlie Severe surface dulling, not within the range of norm al tooth color 8. B randestini M, M orm ann W, Ferru A, Lutz
F, Krejci I. C om puter m achined ceram ic inlays:
In vitro marginal adaptation. J Dent Res (Abstract
Table 2 ■ Clinical assessm ent of the Cerec CAD-CAM ceram ic inlays using no. 305) 1985;64:208.
9. M orm ann W, B randestini M, Ferru A, Lutz
criteria characterized in Table 1.
F, Krejci I. M arginale A daptation von adhesiven
Margin quality P o rz ellan -in lay s in vitro. Schweiz M onatsschr
T ooth no. and Surface Color Zahnmed 1985;95:1118-29.
restoration Contour Mesial Occlusal Distal texture matching 10. M orm ann W, Jans H , Brandestini M, Ferru
A, Lutz F. Com puter m achined adhesive porcelain
4 OD* At A B A A inlays: m arg in al a d a p ta tio n after fatig u e stress.
5 M O DÏ A A A A A A J Dent Res (Abstract no. 339) 1986;65:763.
13 MOD A A A A A B 11. Fullem ann J, Lutz F. Direktes Kompositinlay.
14 MOD A A A A A B Das neve Verfah fen und Seine In-vitro Testresultat.
15 MOD A A A A B A Schweiz Monatsschr Zahnmed 1988;98:758-64.
18 MO A A B - A A 12. Jam es DF. An esthetic inlay technique for
19 MOD A A A A A A posterior teeth. Quintessence Int 1983;14:725-31.
20 OD A A A A B 13. Adair PJ, Grossman DG. T he castable ceramic
28 OD A A A A A crown. Int J Periodont Res Dent 1984;4:32-46.
29 MOD A A A A A A 14. Je n sen ME. A tw o-year clin ical study of
30 MOD A A A A A A posterior etched-porcelain resin-bonded restorations.
31 MO A A B - B B Am J Dent 1988;1:27-33.
15. Lutz F, Krejci I, Luscher B, Oldenburg TR.
* = Distocclusal.
t A = Alfa, B = Bravo.
Im proved p ro x im a l m arg in a d a p ta tio n of Class
X - M e s i o - o c c lu s o d i s t a l .
II co m p o site resin re sto ra tio n s by use of lig h t-
reflectin g wedges. Q uintessence Int 1986; 17:659-
64.
the Cerec system is already integrated 12 Cerec inlays and one Cerec onlay. 16. Lutz F, Krejci I, Oldenburg TR. Elim ination
into the undergraduate operative dentistry T his paper describes the clinical appear­ of polymerization stresses at the margins of posterior
co m p o site resin resto ratio n s. A new resto rativ e
course at the Zurich University Dental ance of these CAD/CAM resto ratio n s
technique. Quintessence Int 1986;17:777-84.
Institute. According to the manufacturer, that have been in function for 3 years. 17. Leinfelder KF, Lemons JE. Clinical restorative
350 units have been placed since becom­ m a te ria ls an d tech n iq u es. P h ila d e lp h ia : Lea 8c
in g available in E urope in June 1988. ----------------------------J 'A O A ---------------------------- Febiger; 1988:201-21.
T he Cerec system was accepted by the 18. N a th an so n D, H assan F. Effect of etched
porcelain thickness on resin-porcelain bond strength.
US Food an d D rug A dm inistration in T h e au th o rs th an k the p a tie n t for perm ission J Dent Res (Abstract no. 1107) 1987;66:245.
Ju n e 1989. Of the 207 units placed by to publish this case and Msses. L. Brandenberger 19. S heth J, Je n sen M. L u tin g interfaces and
Ju ly 1989, 161 are in W est G erm any, and B. Muller for photographic assistance. m a te ria ls for etched p o rcelain resto ratio n s. Am
14 in Italy, 11 in Sw itzerland, five in J Dent 1988;1:225-35.
In fo rm a tio n a b o u t the m an u factu re rs of the 20. T aleghani M, Leinfelder KF, Land J. Posterior
D enm ark , 4 each in A u stria an d the
products mentioned in this article may be available porcelain bonded inlays. Com pend C o n tin Educ
United States, three in Sweden and one from the authors. T he American Dental Association Dent 1987;8:420-5.
each in Belgium, Canada, France, H ol­ has no com m ercial interests in the p ro d u cts 21. Gotsch T , Krejci I, Lutz F, Reich T. Defor­
land, an d J a p a n (perso n al c o m m u n i­ mentioned. mation of cavity walls induced by different composite
cation, Siemens Co, 1989). restorative techniques. J Dent Res (A bstract no.
Dr. M ormann is associate professor, departm ent 1282) 1989;68:342.
In 1985, a 32-year-old female patient of preventive dentistry, periodontology and cariology, 22. Fett HP, Mormann W, Lutz F, Krejci I. Margin
had 13 amalgam restorations. They were Dental Institute, University of Zurich. Dr. Brandestini adaptation of com puter machined Cerec inlays in
removed and the cavities refilled with is president of Brains Inc in Zollikon, Switzerland. vitro. J Dent Res (Abstract no. 1141) 1989;68:324.

520 ■ JADA, Vol. 120, May 1990