Journal

of
Dentistry
Journal of Dentistry 28 (2000) 299–306
www.elsevier.com/locate/jdent

Direct resin composite inlays/onlays: an 11 year follow-up

J.W.V. van Dijken*
Department of Odontology, Dental School Umeå, Umeå University, 901 87 Umeå, Sweden
Received 9 August 1999; received in revised form 8 November 1999; accepted 4 January 2000

Abstract
Objectives: The aim of this study was to present an 11-year assessment of direct resin composite inlays/onlays.
Methods: One-hundred Class II direct resin composite inlays and 34 direct resin composite restorations were placed in 40 patients. The
restorations were evaluated clinically, according to modified USPHS criteria, annually over a 11-year period.
Results: Of the 96 inlays/onlays and 33 direct restorations evaluated at 11 years, 17.7% in the inlay/onlay group and 27.3% in the direct
restorations group were assessed as unacceptable. The differences in longevity were not statistically significant. The main reasons for failure
for the inlays/onlays and direct restorations were fracture (8.3 and 12.1%, respectively), occlusal wear in contact areas (4.2 and 6.1%,
respectively) and secondary caries (4.2 and 9.1%, respectively). Eight of the non-acceptable inlays/onlays and five of the direct restorations
were replaced, while the other ones were repaired with resin composite. Unacceptable wear was observed in occlusal contact areas of six
restorations, in patients who were severe bruxers. For the other restorations occlusal wear was not found to be a clinical problem and no
difference was observed between the inlays/onlays and direct composite restorations. The marginal adaptation of the inlays/onlays was still
good at the end of the study. Ditching was only observed in a few inlays. A higher failure rate was observed in molar teeth than in premolar
teeth.
Conclusions: Good durability was observed for the direct resin composite inlay/onlay technique. Excellent marginal adaptation and low
frequency of secondary caries in patients with high caries risk were shown. No apparent improvement of mechanical properties was obtained
by the secondary heat treatment of the inlays. Also, the difference in failure rate between the resin composite direct technique and the inlay
technique was not large, indicating that the more time-consuming and expensive inlay technique may not be justified. The direct inlay/onlay
technique is recommended to be used in Class II cavities of high caries risk patients with cervical marginal placed in dentin. 䉷 2000 Elsevier
Science Ltd. All rights reserved.
Keywords: Adhesion; Resin composite; Clinical; Caries

1. Introduction
The need for amalgam alternatives and the growing
demand for more esthetic restorations has led to increased
popularity of resin composite restorations in posterior teeth.
The recently developed resin composites are superior to the
earlier versions in regard to wear resistance and color stabi-
lity, but the main shortcoming of the composites, i.e. the
polymerization, shrinkage of the resin still remains [1–3]. In
posterior cavities, especially with the cervical margin situ-
ated in dentin, the mass to be polymerized is so large that the
shrinkage forces win out, producing marginal defects and
gaps despite careful application [4,5]. This facilitates micro-
leakage, which can cause secondary caries, pulpal irritation,
postoperative sensitivity and marginal discoloration [6–8].
In order to enhance the adaptation in Class II cavities, reduc-
* Tel.: ⫹ 46-90-7856034; fax.: ⫹ 46-90-135074.
E-mail address: jan.van.dijken@odont.umu.se (J.W.V. van Dijken).
0300-5712/00/$ - see front matter 䉷 2000 Elsevier Science Ltd. All rights reserved.
PII: S0300-571 2(00)00010-5
tion in the in situ resin composite mass has been suggested.
Several new restorative techniques have been introduced
during the last years to minimize the development of stres-
ses, such as multiple increment techniques, replacement of
the dentin with a glass ionomer cement in the sandwich
technique or the use of ceramic inserts [9,10]. However,
these techniques still suffer from imperfections and are
very technique-sensitive.
A promising method introduced to reduce the shrinkage
problem was the resin composite inlay/onlay technique
[11–13]. The form of the inlay can be established by either
a direct or an indirect method. The first commercial direct
resin composite inlay system was introduced on the market
in 1987. Based on a light-cured resin composite, the restora-
tion was formed directly in the inlay cavity. Following an
initial cure and removal of the inlay from the cavity, the
inlay was post-cured in a heat and light oven at 110⬚C. The
post-curing at a high temperature resulted in a higher stress
relaxation and conversion compared to the direct-placement
300 J.W.V. van Dijken / Journal of Dentistry 28 (2000) 299–306
light-cured-only composite [14–20]. Related to the overall
increase in conversion, improved mechanical and physical
properties have been reported a secondary-cured resin
composites, such as improved diametral tensile strength,
elastic modulus, fracture toughness, flexural strength and
hardness [14,19,21–24]. However, this was not confirmed
for all resin composite materials [25].
In the inlay/onlay technique, the amount of shrinkage is
limited to the thin luting resin composite layer. Improved
marginal adaptation and seal of the inlays have been
reported [26–28]. Peutzfeldt and Asmussen [29] showed
that contraction gap formation around resin composite
inlays could be prevented. Excellent marginal quality has
been reported initially and after in vivo aging [28,30,31].
The clinical potential of the inlays/onlays was shown in a
few short-term studies [31–38]. In a previous report, direct
resin composite inlays/onlays were found to have a failure
rate of 12% after 6 years [33]. The aim of this study was to
present the 11-year assessment of these inlays/onlays and
direct composite restorations.
2. Materials and methods
2.1. Resturation placement
In 40 patients, 24 men and 16 women, with a mean age of
48 years (range, 27–70 years), a total of 100 Class II direct
resin composite inlays/onlays were placed [33]. The inlays
which were evaluated (54 2-surface, 28 3-surface and 18
onlays), were distributed as follows: in the lower arch 50
premolars and 10 molars; and in the upper arch 34 premolars
and 6 molars. All teeth were in occlusion and had at least
one proximal contact with an adjacent tooth. The resin
composite material used for production of the inlays (Bril-
liant DI, Coltène AG, Altstätten, Switzerland) was a hybrid
small-particle resin composite with an average particle size
of 1 mm. The material contained barium glass and had a
filler load of 78.5% by weight. All restorations were repla-
cements of Class II amalgam fillings because of secondary
caries, fracture, or esthetic reasons. The cavities were
prepared with slightly conical cavity walls and without
bevels. Forty percent of the restorations had a gingival
margin below the cement-enamel junction. After placement
of rubber dam, the cavities were cleaned with a surface-
active cavity cleanser (Tubulicid, Dental Therapeutics Ltd,
Ektorp, Sweden) and a glass ionomer cement base (GC
Lining, GC Ind. Corp., Tokyo, Japan) was placed to elim-
inate undercuts in deep areas of the cavities. After place-
ment of a transparent matrix band and wooden wedges, a
separating liquid (Coltène AG), was applied to the cavity.
The cavity was filled incrementally and each increment was
light-cured for 40 s. The restoration was removed from the
cavity after curing and post-cured in the DI-500 light- and
heat-curing oven (Coltène AG) for 7 min at 120⬚C. After
trial of the inlay fit in the cavity, the enamel cavity margins
were acid etched for 15–20 s, followed by thorough spray-
ing with water for 20 s and gentle air drying. A dual-cured
enamel-bonding agent (Brilliant Duo Bond) was then
applied and thinned with a gentle stream of compressed
air and not light-cured. After reapplication of the matrix
band and wedges, the dual-cure luting resin composite
cement (Brilliant Duo Cement) was applied to the cavity
and/or the inside of the inlay with a disposable brush. The
cement was identical to the restorative except for a lower
filler load. No conditioning or pretreatment of the inner
surface of the inlay was performed neither was a dentin
bonding agent used. The inlays were quickly inserted with
pressure and excess cement was removed. Light-curing
periods of 60 s were used from occlusal and proximal
sides. The occlusion was then carefully checked.
In addition, 34 direct resin composite restorations (Fulfil,
DeTrey/Dentsply, Konstanz, Germany) were placed with a
glass ionomer cement base (GC Lining, GC Ind. Corp.) [33].
The restorations were placed in 20 premolars and 14 molars,
18 two-surface and 16 three-surface restorations. The
cement was placed in a thickness of 1–2 mm and covered
all dentin (closed sandwich restoration) [10]. The enamel
margins were not beveled. They were etched for 15–20 s
with 35% phosphoric acid, rinsed with water and air dried.
A layer of enamel bonding agent (DeTrey/Dentsply) was
applied. The resin composite was placed incrementally in
2 mm layers and cured for 40 s, except for the first cervical
layer which was cured for 60 s. All restorations were placed
by the author.
2.2. Evaluation
Each inlay was evaluated directly after the final finishing
(baseline), at 6 months and thereafter annually for 11 years.
A slight modification of the USPHS criteria was used to
evaluate the quality of the restorations (Table 1) [33,39].
The inlays were evaluated by two calibrated observers,
with disagreement being resolved by consensus. A predic-
tion of the caries risk, expressed as the potential caries
activity, was carried out for each patient during the first
part of the study and 45% of the patients were considered
as high risk patients [33]. The evaluated characteristics of
the restorations were described by descriptive statistics,
using frequency distribution of the scores. The longevity
of the restorations was analyzed with the Fisher’s exact
test for difference of proportions at a significance level of
0.05.
3. Results
Thirty-seven patients with 96 inlays/onlays and 33 direct
placed restorations were evaluated yearly for 11 years. Five
teeth, four inlays and one direct composite restoration, were
extracted for periodontal reasons during the period of the
study. A cumulative rate of 17 inlays (17.7%) and nine
direct composite restorations (27.3%) were recorded as
 J.W.V. van Dijken / Journal of Dentistry 28 (2000) 299–306 301

Table 1
Criteria for direct clinical evaluation

Category Score Criteria

(acceptable/unacceptable)

Anatomical form 0 The restoration is contiguous with tooth anatomy

1 Slightly under- or over-contoured restoration; marginal ridges slightly undercontoured;
contact slightly open (may be self-correcting); occlusal height reduced locally
2 Restoration is undercontoured, dentin or base exposed; contact is faulty, not self-correcting;
occlusal height reduced; occlusion affected
3 Restoration is missing partially or totally; fracture of tooth structure; shows traumatic
occlusion; restoration causes pain in tooth or adjacent tissue
Marginal adaptation 0 Restoration is contiguous with existing anatomic form, explorer does not catch
1 Explorer catches, no crevice is visible into which explorer will penetrate
2 Crevice at margin, enamel exposed
3 Obvious crevice at margin, dentin or base exposed
4 Restoration mobile, fractured or missing
Color match 0 Very good color match
1 Good color match
2 Slight mismatch in color, shade or translucency
3 Obvious mismatch, outside the normal range
4 Gross mismatch
Marginal discoloration 0 No discoloration evident
1 Slight staining, can be polished away
2 Obvious staining can not be polished away
3 Gross staining
Surface roughness 0 Smooth surface
1 Slightly rough or pitted
2 Rough, cannot be refinished
3 Surface deeply pitted, irregular grooves
Caries 0 No evidence of caries contiguous with the margin of the restoration
1 Evidence of superficial caries, no operative treatment necessary.
2 Caries is evident contiguous with the margin of the restoration, operative treatment indicated.

unacceptable. Six inlays, four molars and two premolars, between the two techniques were not statistically significant
showed partial fracture or total loss of the resin composite p ˆ 0:45†: For both the inlay technique and the direct
material. One of the molars with a partial fracture had to be composite restorations, a higher frequency of mechanical
treated endodontically because of pulp necrosis. Two other failures was found in molar teeth compared to premolars,
premolar inlays were replaced by other dentists, probably namely for inlays 50 and 11.9%, respectively, and for direct-
because of partial fractures. One premolar tooth showed a placement restorations 41.7 and 18.2%, respectively. The
buccal tooth fracture. Secondary caries, of superficial type cumulative frequencies for unacceptable inlays and direct
as observed during the operative treatment, was found composite restorations during the 11-years follow-up are
contiguous to four inlays (four premolars). Four inlays,
one premolar and three molar teeth, showed severe occlusal Table 2
wear in contact areas. One inlay was replaced because of Relative cumulative frequencies (%) unacceptable resin composite inlays
suspected caries based on a radiographic diagnosis, but no and direct restoration during the 11-year evaluation
secondary caries was found after operative treatment.
Years Inlays Direct restorations
Another six inlays (6.3%) showed minor defects, four
with small marginal ridge chip fractures and two with 1 0 0
pores. Eight of the unacceptable inlays were replaced, 2 1.1 2.9
while the others were repaired with resin composite. All 3 2.1 2.9
4 3.1 5.9
the fractured inlays and wear defects occurred in patients
5 7.3 5.9
with moderate to severe parafunctional habits. 6 11.5 14.7
Five of the failed direct resin composite restorations were 7 12.5 18.1
replaced because of isthmus fracture (6.1%), and secondary 8 12.5 21.2
caries (9.1%). The carious lesions were of intermediate and 9 14.6 24.2
10 16.7 27.3
deep type. Four other restorations, two with severe occlusal
11 17.7 27.3
wear and two with fractures were repaired. The differences
302 J.W.V. van Dijken / Journal of Dentistry 28 (2000) 299–306

Table 3
The scores for the evaluated criteria at the 11 year recall (%)

0 1 2 3 4
a
Anatomical form Inlay/onlay 83.3 3.1 4.2 9.4
Direct composite restoration 63.6 18.2 6.1 12.1
Marginal adaptation a Inlay/onlay 41.7 42.7 2.1 4.2 9.4
Direct composite restoration 18.2 45.5 18.2 6.1 12.1
Color match Inlay/onlay 4.5 70.5 25.0 0 0
Direct composite restoration 0 71.4 28.6 0 0
Marginal discoloration Inlay/onlay 93.2 6.8 0 0
Direct composite restoration 64.3 21.4 14.3 0
Surface roughness Inlay/onlay 77.3 18.2 0 4.5
Direct composite restoration 42.9 42.9 7.1 7.1
Caries a Inlay/onlay 95.8 0 4.2
Direct composite restoration 90.9 0 9.1
a
Cumulative scores.

shown in Table 2. Table 3 shows the scores of the 11-year
evaluations with the modified USPHS criteria, expressed as
frequencies of restorations available at 11 years or as cumu-
lative frequencies for the factors which include unaccepta-
ble restorations. The acceptable inlays showed in most cases
excellent marginal adaptation and surface structure.
The marginal wear of the inlay/onlay material and the
luting material was rather similar and ditching was not a
clinical problem during the evaluation. Only in four of the
unacceptable inlays, in patients with severe parafunctional
habits, was occlusal wear of the resin composite severe,
while for the other inlays occlusal wear was not a clinical
problem. One inlay patient complained about a low degree
of post-operative sensitivity to masticatory forces during the
first two years. Three direct composite restoration patients
observed sensitivity to masticatory forces during the first
weeks after placement.
4. Discussion
The resin composite inlay/onlay technique is an attempt
to overcome the main disadvantage of polymerization
shrinkage of the direct resin composite restoration. The
larger the volume of resin composite to be cured, the larger
the shrinkage, which will generate internal stress in the
material and the bonding layer. This stress may cause adhe-
sive or cohesive failures and interfacial gap formation, or if
adhesion is maintained, deformation of tooth structure may
occur. If the forces of stress are larger and/or develop earlier
than the bond to the cavity margins, debonding and marginal
opening will occur. Roulet [40] concluded, based on in vitro
data, that indications for Class II posterior composite
restorations are limited, unless the operator is willing to
accept marginal openings with all their negative conse-
quences. Beside the initial contraction stress on the bond,
the post-cure polymerization of the composite filling
continues to stress the bond during the days following
placement.
The secondary cure of the composite inlay, at a tempera-
ture above the lower glass transition temperature of the resin
composite, improved the degree of conversion and allowed
the initial polymerization contraction and the following
post-cure stress to occur before insertion [17]. The
decreased stress on the bonding surface resulted in an
improved bond and seal [11,26,41–46]. Good quality of
the marginal adaptation was also observed in the clinic
and by SEM after long term wear in vivo [28,47]. A reduced
postoperative sensitivity has been reported for inlays
compared to direct composite fillings, explained by the
better sealing [34,37,48,49]. The decreased stress of the
composite material after the additional cure also signifi-
cantly increased the resistance to cusp flexure and cusp
fracture, which was also shown in this study, there being
only one tooth fracture despite the fact that all inlays were
placed as replacement of large amalgam fillings [20,33–55].
Another advantage of the secondary cure, which is
discussed seldom, but is nonetheless very important for
biocompatibility reasons, is the considerable decrease of
the quantity of released monomers from resin composite
materials and the potentially decreased cytotoxic effect
[50,51].
Few clinical evaluations examined the long-term durabil-
ity of composite inlays/onlays. Short-term studies showed
no or low failure rates [31–34,37,52–55]. Most of the
studies evaluated the indirect inlay system. (Table 4). In
only four studies the resin composite inlay was compared
intra-individually with the direct composite restorations.
Gerbo et al. [55] exhibited significant better marginal adap-
tation, no caries or fractures for inlays. No difference in
wear was observed. Wassel et al. [38,58] evaluated modified
“open sandwich” inlays and direct restorations. In the Class
II cavities included, they placed a glass cermet cement as
base material in both groups so that the gingival portion of
the restoration consisted of 1–3 mm of base exposed to the
oral cavity. After 5 years, they recalled 65 pairs and
observed an failure rate of 12 inlays (19%) and 5 fillings
(8%). Pallesen and Qvist [59] found, after 8 years, a fracture
 J.W.V. van Dijken / Journal of Dentistry 28 (2000) 299–306 303

Table 4
Overview of clinical evaluations, with failure rates and reasons for failure, of direct and indirect processed resin composite inlays

Author Time (year) No. inlays D (direct) I (indirect) inlays No. failures (%) Main reasons for failure if
(material) indicated (%)

O’Neal et al. [53] 1 60 D (Occlusin) 0 –

Krejci et al. [31]
Thordrup et al. [35]
Scheibenbogen et al. [76]
Motokawa et al. [78]
Pallesen and Qvist [32]
Scheibenbogen et al. [77]
Alhadainey et al. [52]
Triolo et al. [36]
Gerbo et al. [55]
Wendt and Leinfelder [37]
Frederickson et al. [54]
Wassell et al. [38]
Kreulen et al. [34]
Pfeiffer et al. [79]
Wassell et al. [58]
Thordrup et al. [80]
van Dijken [33]
Krämer et al. [81]
Hannig [57]
Donly et al. [56]
Pallesen and Qvist [59]
Present study
30
1 29
1 15
14
1 47
2 50
2 84
2 39
2 42
2.5 27
3 30
3 60
3 46
3 71
4 180
4 223
5 65
5 15
11
6 100
6 118
7 40
7 36
8 81
11 96
I (P50) 2 Caries (2.2%)
I (Prisma APH) 0 –
D (Brilliant) 1 Caries (6.7%)
I (Estilux) 1 Sensitivity (7.1%)
I (Tetric, Blend a Lux, Pertac H) 3 Caries (4.3%) endodontic (2,1%)
I (P30) 4 Fracture (8%)
I (Brilliant, Estilux, Isosit) 2 Fracture (2.4%)
I (Tetric, Blend a Lux, Pertac H) 4 Caries (5.1%) endodontic (2.5%)
fracture (2.5%)
I (EOS) 1 Loss (2.4%)
I (Concept) 0 –
D (Brilliant) 0 –
D (Occlusin) 0 –
I (Concept) 2 Fracture 4.3%)
D (Brilliant Dentin) 8 Sensitivity (5.6%) fractures
(4.2%) tooth fracture (1.4%)
I 2 Fracture
I (Charisma) 4 Fracture (0.5%) endodontic
(1.5%)
D (Brilliant Dentin) 12 Sensitivity (6.2%) endodontic
(3.1%) fracture (3.1%) tooth
fracture (4.6%) caries (1.5%)
D (Brilliant) 2 Caries (13.3%)
I (Estilux) 1 Sensitivity (6.7%)
D (Brilliant) 12 Fracture (6%)
I (Visio-Gem) 15 Sensitivity fracture marginal
failures
I (Isosit) 23 Fracture (15%) marginal
discoloration (8%)
I (Concept) 25 Caries, fracture
I (Brilliant, Estilux and Isosit) 17 Fracture (6.2%) tooth fracture
(2,5%) caries (6.2%)
D (Brilliant) 17 Fracture (8.3%) caries (4.2%)
wear (4.2%) tooth fracture
(1.2%)

rate of 11% for the direct restorations and 17% for the
indirect inlays. The overall assessment showed no signifi-
cant difference between the techniques. In the present study,
results after 6 years showed a significantly better clinical
longevity for the direct inlay/onlay system, and the results
after 11 years were not more significant [33]. The lower
failure rates observed for the direct inlay/onlay technique
as shown in several clinical studies [33,37,53,55] demon-
strate the advantage of the direct method compared to the
indirect technique.
Clinical wear of the inlays, as assessed by the modified
Ryge criteria, and tooth fracture was not a clinical problem
in the present study [60]. Only in four of the inlays, deep
wear defects were observed, and which occurred in severe
bruxing patients. The direct fillings showed also good wear
resistance, confirming the results of Wendt et al. [37].
Numerous studies have described the effect of heat treat-
ments on the mechanical properties of the resin composite
inlay/onlay material. Increase in properties like diametral
tensile strength, elastic modulus, flexural strength and hard-
ness have been reported, while others only found minimal or
no improvement [14,18,21–23,61–64]. It has been ques-
tioned whether the slight improvements in properties
would have any significant effect on clinical durability
[62,65]. The clinical reports of heat-treated inlays do not
confirm the suggested superior mechanical strength. It has
recently been shown that the improvements of some of the
properties were only of short-time benefit and decreased due
to weakening of the polymer by water uptake in the same
way as for light-cured-only resin composites [18,61,65].
Partial fracture was the principal reason of failure for
inlays/onlays in many clinical evaluations. No difference
in clinical mechanical failure rates could be observed
between direct resin composite restorations and heat-treated
inlays/onlays in many of the reported studies. It seems that
the major benefit of the inlay/onlay system is found in the
improvement of the marginal adaptation due to minimiza-
tion of contraction stresses.
304 J.W.V. van Dijken / Journal of Dentistry 28 (2000) 299–306
It has been stated that wear of the luting agent is the weak
link of inlay systems, which can jeopardize the marginal
adaptation and durability of the restoration. Cement wear
or ditching, has been reported in most clinical evaluations of
ceramic inlays [49]. Pallesen and van Dijken [66] reported
that in spite of efforts made during the luting procedure of
Cerec inlays, wear of the dual cement was already detect-
able at the 8-month recall, but only by the indirect evalua-
tion technique, which was in accordance with the findings of
Heymann et al. [67]. Several inlay studies investigated the
influence of type of resin luting agent or the widths of the
margin on the degree of ditching. In some studies microfiller
resin composites showed a superior clinical wear resistance,
while others found no difference [67–69]. It has been
suggested that the marginal wear is self-limiting and that
the depth of cement wear would not exceed the width of the
cement margin. Berg and Dérand [70] found, however, no
correlation between the width and the depth of ditches. Van
Dijken et al. [49] showed that the extent of the wear was
limited after 3–4 years due to the sheltering effect of the
inlay and enamel. This was confirmed in other long-term
investigations of ceramic inlays [67,70]. Marginal adapta-
tion of resin composite inlays has been reported to be super-
ior to direct fillings showing less microleakage and better
marginal quality [5,27,71]. In the present study, ditching
was hardly observed for the majority of the inlays/onlays
after the 11-year period. In an SEM evaluation of the
marginal adaptation of the resin composites inlays at 5
years, we showed that more than 84% of the total investi-
gated length of the margins revealed gap free margins [28].
Hannig [57] reported a marginal imperfection frequency of
68% after 7 years for Isosit inlays, which are subjected to
heat and pressure polymerization. In the clinical evaluation
composite inlays show clearly less ditching than ceramic
inlays. A larger difference in wear is found between the
ceramic inlay and the resin luting resin, while, as observed
by SEM replica technique, the composite inlay and the
cement showed a similar degree of wear in more than
50% of the evaluated marginal length [28,47,49]. The high-
est frequency marginal defects were observed for the cervi-
cal margins, which is in accordance with findings of
microleakage in the literature. The marginal quality of the
inlays was far better than for direct composite restorations.
A review of ceramic inlay studies showed a low secondary
caries rate in most of the evaluations [9,49]. Also, in evalua-
tions of composite inlays, no or a low caries frequency was
observed [33,36–38,53,55,56]. Despite the high frequency
of patients with a high caries risk (45%) which participated
in this study, only four caries lesions contiguous with the
inlay margins were recorded during the 11-year follow-up.
A difference in caries penetration depth with the caries
around composite fillings was also observed. All inlay
lesions were of more superficial or moderate depth. A higher
secondary caries rate (6%) was reported by Pallesen and
Qvist after 8 years [59]. It can be suggested that due to
the good seal of the resin composite inlays, one of the
main clinical advantages of the resin composite inlay/
onlay technique will be found in deep cavities, especially
in patients with high caries risk.
The composite inlays in this study were luted, as in many
of the reviewed clinical evaluations, without the use of an
efficient dentin bonding system. The more effective amphi-
philic systems were not available at the start of the studies.
With the newer more hydrophilic dentin bonding systems
improved bond strength can be obtained by the formation of
a micro-mechanical bond to the etched dentin. No pretreat-
ment of the fitting surface of the composite inlay was
performed after the post-curing. Pretreatment of the inlay
by sandblasting, etching with phosphoric acid and hydro-
fluoric acid or silanization have previously been proposed to
optimize the wettability of the surface and increase the bond
strength [72–75]. However, the low frequency of lost inlays
observed in this study and in other long-term evaluations
seem to indicate that an extra treatment step of the fitting
surface not necessary to improve retention. The use of an
amphiphilic dentin bonding system can probably improve
the cervical seal of the restoration. The clinical advantage is
not easy to predict and will depend also on the caries risk of
the individual patient. For the low caries risk patient the
optimizing of the seal will probably make no difference,
whereas in a high risk patient the better interfacial adapta-
tion can be a very important factor to prevent secondary
caries.
5. Conclusion
It can be concluded that the evaluated direct resin compo-
site inlay/onlay technique showed a promising clinical long-
evity, with improved marginal adaptation and a low
incidence of secondary caries. The mechanical properties
of the composite material apparently were not improved
by the secondary cure. Fracture tendency and wear rate
was equal to that of direct resin composite restorations.
The direct inlay, which facilitated the direct chairside place-
ment of the inlay in one appointment, not requiring an
impression or temporary restoration, seems to result in a
better clinical longevity then the indirect inlay. Taking
into account the increased treatment time and cost to
produce the inlays, the advantage of the technique will
therefore be found especially in the high caries risk patient
in Class II cavities with the cervical margins located in
dentin.
Acknowledgements
This study was partly supported by the County Council of
Västerbotten, the Swedish Dental Association and the
Swedish Medical Research Council.
 J.W.V. van Dijken / Journal of Dentistry 28 (2000) 299–306
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