A L F R E D 0 M E Y E R F I L H O , DDS, MS'
L U I Z C L O V I S C A R D O S O VIEIRA, DDS, MS, P H D ~
6 L I T O A R A U J O , DDS, MS, PHD*
L U I Z N A R C I S O BARATIERI, DDS, MS, P H D ~
ABSTRACT
The use of ceramics as restorative materials has increased substantially in the past two decades.
This trend can be attributed to the greater interest of patients and dentists in this esthetic and
long-lasting material, and to the ability to effectively bond metal-free ceramic restorations to
tooth structure using acid-etch techniques and adhesive cements. The purpose of this article is to
review the pertinent literature on ceramic systems, direct internal buildup materials, and adhesive
cements. Current clinical procedures for the planning, preparation, impression, and bonding of
ceramic inlays and onlays are also briefly reviewed. A representative clinical case is presented,
illustrating the technique.
CLINICAL SIGNIFICANCE
When posterior teeth are weakened owing to the need for wide cavity preparations, the success of
direct resin-based composites is compromised. In these clinical situations, ceramic inlays/onlays
can be used to achieve esthetic, durable, and biologically compatible posterior restorations.
T"
e restoration of posterior
teeth with tooth-colored materials is not a new trend in restorative dentistry. Porcelain inlays were
used in the nineteenth century, but
the lack of an adequate adhesive
cementing medium along with the
poor esthetics of those early porcelains yielded less than optimal
resu1ts.l In the early 1980s Simonsen
and Calamia reported on the technique of resin composite adhesion
to porcelain by means of acid etch-
*Graduate student, Department o f Operative Dentistry, and associate professor, Department of Dental
Clinics, Universidade Federal de Santa Catarina, Floriandpolis, Santa Catarina, Brazil
f Professor, Department of Operative Dentistry, Universidade Federal de Santa Catarina, Floriantjpolis,
Santa Catarina, Brazil
$Professor, Department o f Dental Clinics, Universidade Federal de Santa Catarina, Floriandpolis, Santa
Catarina, Brazil
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M E Y E R F I L H O ET A I ,
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CERAMIC I N L A Y S A N D O N L A Y S : C L I N I C A L P R O C E D I J R E S FOR P R E D I C T A B L E R E S U L T S
340
M E Y E R FILHO E T A L
lechniquea
Fired ceramic
Procedums
Examples
TYW
Optec HSP@(Jeneriflentron,
Wallingford, CT, USA)
Leucite-reinforced
feldspathic porcelain
Duceran LFC@(Degussa,
Bloomfield, CT, USA)
Hydromineral low-fusing
porcelain
Castable
ceramic
Dicor (Dentsply)
Mica-reinforcedglass
ceramic
Machinable
ceramic
Feldspathic porcelain
Pressable
ceramic
Mica-reinforced
feldspathic glass ceramic
Optec O P P UeneridPentron)
IPS Empress
Leucite-reinforced
feidspathic porcelain
Leucite-reinforced
feidspathic porcelain
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CERAMIC I N L A Y S A N D O N L A Y S : C L I N I C A L P R O C E D L T R E S F O R P R E D I C T A B L E R E S U L T S
particularly fragile when the cement devitrification with a heat treatment (ceramming) to convert them
is too thin; it has been proposed
into a stronger crystalline body
that a 50 to 100 pm marginal gap
that possesses high translucency.6
is ideal to prevent wear of the
Surface staining is used to obtain
marginally exposed resin cement
and to preserve the a d h e ~ i o n . ~ ~ >the
~ ~final shade and characterization. If there is a need for occlusal
Marginal adaptation of this magnitude can be considered excellent for adjustment after inlay/onlay
cementation, these surface stains
adhesively cemented ceramic
can be lost, resulting in comprorestorations and can be obtained
mised esthetics.
with any of the currently used
ceramic system^.^^^^^ This factor
The conventional manufacturing
was confirmed in a study by Aberg
of ceramic restorations by fusing
and colleague^.^^ No secondary
porcelain in a refractory cast procaries was detected on adhesively
duces the most esthetic dental
cemented onlays in spite of 46%
restorations. However, this is a
of the considered patients being of
high caries risk. The authors attrib- technique-sensitive procedure that
requires a skilled dentist and techniuted this positive result to shrinkcian to produce a high-quality result.
age and microleakage reduction
The IPS Empress@system (Ivoclar
afforded by the indirect technique
Vivadent, Schaan, Liechtenstein)
owing to the fine cement film and
produces equally esthetic restorafavorable marginal fit of these
tions in a simpler way through a
ceramic restorations.
lost-wax technique of fabrication.
This simplicity in fabrication is
Esthetics
largely responsible for the resurMachinable ceramics (CAD/CAM
gence in popularity of all-ceramic
systems) available as colored prefired blocks make it possible to pro- restorations in recent years.
duce restorations with satisfactory
Strength
esthetics in posterior teeth; however, they require special equipment Studies conducted with various
ceramic systems point to fracture as
and can be quite ~ o s t l y . 4 ~
the main cause of ceramic restoration f a i l ~ r e . Fracture
~ ~ - ~ ~ resistance
Castable ceramics (Dicor@,
Dentsply/Caulk, Mildford, DE,
of a dental ceramic is one of the
USA), supplied in the form of
most important factors for success
for inlays/onlays. Fracture resisshaded glass ingots, produce
ceramic restorations that are initance depends on the ability of the
material to inhibit crack initiation
tially made as a glass by the lostand propagation. Crack initiation is
wax technique and centrifugal
casting. They subsequently undergo controlled by the surface condition
342
M E Y E R F I L H O ET AL
Tooth Preparation
Correct tooth preparation for
ceramic inlays and onlays is critical
to achieving a lasting restoration.
Ceramic restorations are extremely
fragile before adhesion. Consequently, the principles guiding this
procedure are different from those
for gold restorations.
Because of the inherent fragility
exhibited by this material, three primary requirements are important
when preparing a tooth for ceramic
restorations of this type: (1) avoidance of internal stress concentration
areas, (2)provision for adequate
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CERAMIC I N L A Y S A N D O N L A Y S : C L I N t C A L P R O C E D U R E S FOR P R E D I C T A B L E R E S U L T S
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J O U R N A L OF E S T H E T I C A N D R E S T O R A T I V E D E N T I S T R Y
MEYER F I L H O ET A L
T A B L E 3 . F R A C T U R E I N D E X FOR C E R A M I C I N L A Y S A N D O N L A Y S .
~
S t W (Yd
EvaluationPerlod
CemmWLutIng Element
3 Y'
Mirage@(Chameleon Dental
Products, Kansas City,
KS, USA)/Dual RC
MiragelGIC
DicorDual RC
CeredDual RC
Miragemual RC
IPS EmpresdDual RC
Mirage/Dual RC
Dicor/Dual RC
CeredDual RC
CeredDual RC
CeredChemical RC
Microbond (Austenal
Dental-Austenal International Inc,
Chicago, IL, USA)/Dual RC
Fortune (Williams-Ivoclar,
Amherst, NY, USA)/Dual RC
MiragefDual RC
MiragdGIC
IPS EmpresdDual RC
IPS EmpresdDual RC
CereJDual RC
CeredDual RC
MiragefDual RC
IPS EmpresdDual RC
Aberg CH et aIz7(1994)
4-82 mo
3 Yr
3 Y'
4.5 yr
4 Yr
6 Yr
5 Yr
5 'Y
4 mo-10 yr
6 Yr
Kramer N et
(1999)
Studer S et
(1998)
Pallesen U, van Dijken JWVs3(2000)
Molin MK, Karlsson SL9' (2000)
4 Yr
7 Yr
8 Yr
5 Y'
59
3.4
59
116
2s
15.3
so
125
96
123
115
33
33
183
58
57
96
163
32
30
30
30
6.0
0.0
16.0
3.2
0.0
5.7
2.6
9.1
0.0
0.6
5.1
26.5
4.2
5.5
9.4
3.3
0.0
13.3
Cementing Procedures
Clinical procedures for cementing
ceramic inlays/onlays as suggested
by Ritter and Baratieri include the
foll~wing~~:
345
346
MEYER FILHO ET A L
the definitive restoration was fabricated in the laboratory. The temporary restoration was cemented with
a eugenol-free temporary cement
(TempBond NE@,Kerr Corporation,
Orange, CA, USA).
Figure 5. A, The ceramic inlay is prepared for cementation. B, The internal ceramic surface is conditioned with 9.5% buffered
hydrofluoric acid. Note the ground glass appearance produced by 1 minute of hydrofluoric acid etching on the internal
ceramic surface. C, A silane coupling agent is applied with a minibrush on the internal surface o f the ceramic inlay after
hydrofluoric acid etching.
347
CONCLUSION
348
M E Y E R FILHO ET A L
DISCLOSURE A N D
ACKNOWLEDGMENT
25. Ritter AV, Baratieri LN. Ceramic restorations for posterior teeth: guidelines for the
clinician. J Esthet Dent 1999;
11:1172-1185.
26. Yatani H, Watanbe EK, Kaneshima T, et
31. Etched-porcelain resin-bonded onlay
1technique for posterior teeth. J Esthet Dent
1998; 10:325-332.
27. 4berg CH, van Dijken JWV,Olofsson A-L.
rhree-year comparison of fired ceramic
,nlays cemented with composite resin or
:lass ionomer. Acta Odoniol Scand 1994;
52:140-149.
28. Wat PYP, Cheung GSP. Factors affecting
349
350
M E Y E R FILHO ET AL
80. Rosenstiel SF, Land MF, Crispin BJ. Dental luting agents: a review of the curent
literature. J Prosthet Dent 1998;
80:28&301.
84. Cardash HS, Bharav H, Pill0 R, BemHamar A. The effect of porcelain color
on the hardness of luting composite resin
cement. J Prosthet Dent 1993; 69:620-623.
85. El-Badrawy WA, El-Mowafy OM. Chemical versus dual curing of resin inlay
cements. J Prosthet Dent 1995; 73515-524.
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351
COMMENTARY
C E R A M I C I N L A Y S A N D O N L A Y S : C L I N I C A L P R O C E D U R E S F O R P R E D I C T A B L E RESULTS
Frankenberger R, Petxhelt A, Kramer N.Leucite-reinforced glass ceramic inlays and onlays after six years: clinical behavior. Oper Dent 2000;
25:459-465.
Manhart J, Chen HY,Neuerer P, et al. Three-year clinical evaluation of composite and ceramic inlays. Am J Dent 2001; 14:95-99.
Thordrup M, Isidor F, Horsted-Binslev P. A 5-year clinical study of indirect and direct composite and ceramic inlays. Quintessence Int 2001;
32:1999-2005.
Diplomate of the American Board of Prostbodontics, assistant professor, Department of Prostbodontics, Louisiana State University, New
Orleans, LA, USA
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