2. Contents
Introduction
History
Indications and contraindications
Advantages and Disadvantages
Clinical procedures : INLAYS AND ONLAYS
Difference between ceramic and cast metal inlays and onlays
Impression
Try-in and cementation
Finishing and polishing
Inlays onlays using Different ceramic systems
Common problems and solutions
Repair of ceramic inlays and onlays
Conclusion
3. INTRODUCTION
• Dental ceramics are nonmetallic, inorganic structures, primarily
containing compounds of oxygen with one or more metallic or
semi-metallic elements (aluminum, boron, calcium, cerium,
lithium, magnesium, phosphorus, potassium, silicon, sodium,
titanium, and zirconium).
• According to Sturdevant, an onlay caps all cusps; an inlay may cap
none or may cap all but one cusp.
4. HISTORY Late 1700s
Ceramic materials were
first used in dentistry to
fabricate porcelain
denture teeth
1887
Charles H Land, a dentist
from Detroit, MI, USA,
fabricated the first
ceramic crown
Early 1970s
Duret pioneered the use
of computer-aided
design/manufacturing
(CAD/CAM) in dentistry.
1980s
Mörmann et al
developed the first chair-
side economical
restoration of aesthetic
ceramics (CEREC) system,
which allowed inlays to
be machined from
prefired ceramic blocks
in the dental office.
1980s
the concept of
acidetching porcelain to
permit use of resin
composite for luting
porcelain restorations
was developed. At about
the same time, castable
glass ceramics were
introduced
9. TEETH WHEREIT IS DIFFICULT TO DEVELOP RETENTION FORM
Garber DA, Goldstein RE. Porcelain & composite inlays & onlays: esthetic posterior restorations.
Chicago: Quintessence; 1994 Jan.
10. • When metal allergy is a factor
• The restoration of teeth in an arch opposed by alreadypresent porcelain restorations
11. CONTRAINDICATIONS
Parafunctional habits
Aggressive wear of dentition
In dentitions of patients with poor plaque control or active decay. Since porcelain
fracture has been reported as a primary reason for ceramic inlay failure, heavy
loading should be avoided.
preparations with deep cervical subgingival extensions, and other clinical
situations where excellent isolation is problematic, may constitute a
contraindication.
Although technique-sensitivity is itself not a contraindication, difficulty to
maintain a dry operative field and obtaining precisely fabricated restorations,
can make this contraindication a reality.
Garber DA, Goldstein RE. Porcelain & composite inlays & onlays: esthetic posterior restorations. Chicago: Quintessence; 1994 Jan.
12. ADVANTAGES
Improved physical
properties
Variety of
materials and
techniques
Wear resistance
Support of
remaining tooth
structure
More precise
control of contours
and contacts
Biocompatibility
and good tissue
response
Increased auxiliary
support
Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.
13. DISADVANTAGES
Increased cost
and time
Technique
sensitivity
Difficult try-in and
delivery
Brittleness of
ceramics
Wear of opposing
dentition and
restorations
Short clinical
track record
Low potential for
repair
Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.
15. As a first clinical step, the
patient is anesthetized and the
area isolated, preferably using
rubber dam.
The compromised restoration (if
present) is completely
removed, and all caries is
excavated.
If necessary the walls are
restored to a more nearly ideal
form with a light-cured glass-
ionomer liner/base or a
composite restorative material
Occlusal step should be
prepared 1.5 to 2 mm in depth.
The carbide bur or diamond
used for tooth preparation
should be a tapered
instrument that creates
occlusally divergent facial
and lingual walls
Isthmus be at least 2 mm
wide to decrease the
possibility of fracture of the
restoration.
Ideally, there should be no
undercuts that would prevent
the insertion or removal of the
restoration. Small undercuts,
if present, can be blocked out
using a glass- ionomer liner
Facial and lingual walls
should be extended to sound
tooth structure and should go
around the cusps in smooth
curves.
The facial, lingual, and
gingival margins of the
proximal boxes should be
extended to clear the
adjacent tooth by at least 0.5
mm.
.
16.
17. Thompson MC, Thompson KM, Swain M. The all‐ceramic, inlay supported fixed partial denture. Part 1. Ceramic inlay preparation design: a
literature review. Australian dental journal. 2010 Jun 1;55(2):120-7.
18. Thompson MC, Thompson KM, Swain M. The all‐ceramic, inlay supported fixed partial denture. Part 1. Ceramic inlay preparation design: a
literature review. Australian dental journal. 2010 Jun 1;55(2):120-7.
21. RULEFORCUSPCAPPING
Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.
22. RULEFORCUSPCAPPING
Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.
• If cusps must be capped, they should be reduced 1.5 to 2 mm 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
23. RULEFORCUSPCAPPING
Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.
• For onlay restorations, nonworking and working cusps are coveredwith at least 1.5 mm and 2
mm of material, respectively.
• If the cusp to be onlayed shows in the patient’s smile, a more esthetic blended margin is
achieved by a further 1- to 2-mm reduction with a1- mm chamfer
24. RULEFORCUSPCAPPING
Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.
25. CERAMIC INLAYS AND ONLAYS CAST METAL INLAYS AND ONLAYS
THICKNESS/BULK More bulk needed , more
Clearance
Less bulk needed
OCCLUSALBEVELS Bevels contraindicated Bevels necessary
GINGIVAL BEVELS Not necessary Needed to achieve
minimal marginal gap
CERVICO-OCCLUSAL DIVERGENCE 6 to 7 degrees of occlusal
divergence
2 to 5 degrees per wall
MARGINAL
ADAPTATION
Rely on adhesion
between tooth
structure/resin cement/porcelain
to create a gap-free
Rely on close adaptation
(20um);lack of adhesion
between tooth
structure/cement/metal
interface : gingival bevels are thus
needed
26. CERAMIC INLAYS AND ONLAYS CAST METAL INLAYS AND ONLAYS
PULPAL FLOOR Need not be flat and
perpendicular to the long axis
of the tooth; If the cavity is
shallow ,pulpal floor should be
indented in central fossa region
parallel to the cuspal inclines.
Flat and perpendicular to the
long axis of the tooth
INTERNAL LINE ANGLES Rounded internal line and
point angles
Well-defined internal line
and point angles
CAVOSURFACE ANGLE 90 Degrees butt joint 140 to 150 degrees( 30 to 40
degree marginal metal)
CUSP REDUCTION Functional cusp: 1.5mm- 2mm
Non-functional cusp : 1.5 mm
Functional cusp: 1mm-1.5 mm
Non-functional cusp : 1mm
27. IMPRESSION
• Tooth-colored inlay or onlay systems require an
elastomeric or optical impression of the prepared tooth
and the adjacent teeth and interocclusal records, which
allow the restoration to be fabricated on a working cast
in the laboratory.
• With chairside CAD/CAM systems, no working cast is
necessary.
28. PROVISIONAL
RESTORATION
• For exceptionally nonretentive preparations, or when the
temporary phase is expected to last longer than 2 to 3
weeks, zinc phosphate or polycarboxylate cement can be
used to increase retention of the provisional restoration.
• Resin-based temporary cements are also available (e.g.,
TempBond Clear, Kerr Corporation, Orange, CA)
29. TRY-IN AND
CEMENTATION
• Try-in and bonding of tooth-coloured inlays or onlays are more
demanding than those for cast gold restorations because of (1)
the relatively fragile nature of some ceramic materials, (2) the
requirement of near-perfect moisture control, and (3) the use
of resin cements.
• Occlusal evaluation and adjustment generally are delayed until
after the restoration is bonded, to avoid fracture of the ceramic
material
30. PRELIMINARY
STEPS
• The use of a rubber dam is strongly recommended to prevent
moisture contamination of the conditioned tooth or restoration
surfaces during cementation and to improve access and
visibility during delivery of the restoration.
• After removing the provisional restoration, all of the
temporary cement is cleaned from the preparation walls.
31. RESTORATION
TRY-IN AND
PROXIMAL
CONTACT
ADJUSTMENT
• Passing thin dental floss through the contact reveals tightness and
position of the proximal contact, signifying to the experienced operator
the degree and location of excess contact.
• Articulating paper also can be used successfully to identify overly tight
proximal contacts.
• Abrasive disks or points are used to adjust the proximal contour and
contact relationship.
• While adjusting the intensity and location of the proximal contacts,
increasingly finer grits of abrasive instruments are used to polish the
proximal surfaces because they will be inaccessible for polishing after
cementation.
• Slight excesses of contour can be removed, if access allows, using fine-grit
diamond instruments or 30-fluted carbide finishing burs. These
adjustments are done preferably after the restoration is bonded so that
marginal fractures areavoided.
.
32. MECHANISM
OF BONDING
Bonding of ceramic CAD/CAM
restorations is a critical step in
achieving good long-term
results.
Ceramic restorations are
bonded to tooth structure
by
Etching enamel to increase
the bondable surface area
Etching, priming, and
applying the bonding agent
to dentin (when
appropriate)
Etching (by hydrofluoric
acid) and then priming
(silanating) the restoration
cementing the restoration
with composite cement
33. Heymann HO, Swift Jr EJ, Ritter AV.Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.
34. Heymann HO, Swift Jr EJ, Ritter AV.Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar 12.
• Ceramic restorations (with the exception of aluminous-core porcelains, such as In-Ceram High Strength Ceramic [Vita
Zahnfabrik/Vident, Bäd Säckingen, Germany] and zirconia-core porcelain such as Lava [3M ESPE, St. Paul, Minn]) must
be etched internally with 6% to 10% hydrofluoric acid for 1 to 2 minutes to create retentive microporosities analogous
to those that occur in enamel on etching with phosphoric acid.
• Hydrofluoric acid must be rinsed off carefully with running water for at least 2 minutes.
• Sandblasting with aluminum oxide particle can be done in the internal surface of the restoration.
• Mean bond strengths decrease, however, when hydrofluoric acid etching is not used.
35. Obradović-Đuričić K, Medić V,Dodić S, Gavrilov D, Antonijević Đ, Zrilić M. Dilemmas in zirconia bonding: A review. Srpski arhiv za celokupno lekarstvo.2013;141(5-6):395-401.
• The bonding of traditional glass-containing ceramics or silicabased ceramics utilizes mechanical and adhesive way.
• Mechanical bonding assumed micromechanical interlocking betweenthe resin cement and roughen surface of silica-
basedceramics.
• Phosphoric acid or hydrofluoric acid etching is the method commonly used for roughening the silica-based ceramics
surfaces.
• Chemical adhesion of glass ceramic and resin cements is achieved with use of bi-functional compounds, silanes that
promote connectionbetween dissimilar organic and inorganic counterparts.
• Also, silanes could influence increasing surface energy and wettabiliy of ceramic surfaces, which enhances both
mechanical and chemical bonding
36. SURFACE
PREPARATION
Grinding
Abrasion with
diamond rotary
instruments
Airborne particle
abrasion with
aluminum oxide
Acid etching with
hydrofluoric acid
or phosphoric
acid or
ammonium
bifluoride
Blatz MB, Sadan A, Kern M. Resin-ceramic bonding: a review of the literature. Journal of Prosthetic Dentistry. 2003 Mar 1;89(3):268-74.
37. Obradović-Đuričić K, Medić V,Dodić S, Gavrilov D, Antonijević Đ, Zrilić M. Dilemmas in zirconia bonding: A review. Srpski arhiv za celokupno lekarstvo.2013;141(5-6):395-401.
• The well known methods of mechanical and chemical bonding used on glass-ceramics are not applicable for use with
zirconia.
• The most important reason for this is the absence of silica in the zirconia microstructure which ignores the viability of
etching as a roughening method essential for mechanical bonding, as well as nullified the use of silanes, forming surfaces
hydroxyls and developing the chemical bond
38. CEMENTATION
The preparation surfaces are etched and
treated with the components of an
appropriate enamel/dentin bonding
system
Typically, the final step of the bonding
system (e.g., an unfilled resin) also is
applied to the internal surfaces of the
restoration previously etched and
silanated. (Self-adhesive, resin based
cements have been introduced in recent
years, but whether they are appropriate
with tooth-colored inlays/onlays remains
unproven.)
A dual-cure composite cement is mixed
and inserted into the preparation with a
paddle-shaped instrument or a syringe.
The internal surfaces of the restoration
also are coated with the composite
cement , and the inlay is immediately
inserted into the prepared tooth, using
light pressure.
A ball burnisher applied with a slight
vibrating motion is usually sufficient to seat
the restoration
Excess composite cement is removed with
thin-bladed composite instruments,
brushes, or an explorer
41. FINISHING ANDPOLISHING PROCEDURES
All marginal areas are checked with an explorer tip
After light-curing the cement, the plastic matrix strips and the
wedges (if used) are removed, and the setting of the resin
cement is verified.
42.
43.
44.
45. FELDSPATHIC PORCELAIN INLAYS AND ONLAYS
After tooth preparation, an impression is made, and a “master” working cast is poured
of die stone
The die is duplicated and poured with a refractory investment capable of
withstanding porcelain-firing temperatures. The duplication method must result in
the master die and the refractory die being accurately interchangeable
Porcelain is added into the preparation area of the refractory die and fired in an
oven. Multiple increments and firings are necessary to compensate for sintering
shrinkage
The ceramic restoration is recovered from the refractory die, cleaned of all
investment, and seated on the master die and working cast for final adjustments
and finishing
46.
47. FELDSPATHIC PORCELAIN INLAYS AND ONLAYS
• Low startup cost
• The ceramic powders and investments are relatively inexpensive, and the technique is
compatible with most existing ceramic laboratory equipment such as firing furnaces.
Advantages :
• Technique sensitivity, both for the technician and the dentist
• Inlays and onlays fabricated with this technique must be handled gently during try-in and
bonding to avoid fracture.
• Feldspathic porcelains are weak, so even after bonding, the incidence of fracture can be
relatively high
Disadvantages :
48. PRESSED GLASS-CERAMICS
After tooth preparation, an
impression is made, and a
working cast is poured in die-
stone. A wax pattern of the
restoration is made using
conventional techniques
After spruing, investing, and
wax pattern burnout, a shaded
ceramic ingot and aluminum
oxide plunger are placed into a
special furnace
The shade and opacity of the
selected ingot are based on the
information provided by the
clinician, specifically the
desired shade of the final
restoration and the shade of
the prepared tooth.
At approximately 2012°F
(1100°C), the ceramic ingot
becomes plastic and is slowly
pressed into the mold by an
automated mechanism.
•After being separated from
the mould, the restoration is
seated on the master die and
working cast for final
adjustments and finishing.
•Toreproduce the tooth shade
accurately, a heavily pigmented
surface stain is typically
applied.
The ceramic ingots are
relatively translucent and
available in a variety of shades,
so staining for hot pressed
ceramic inlay and onlay
restorations is typically
minimal.
49. PRESSED GLASS-CERAMICS
The advantages of leucite-reinforced pressed ceramics are their
• similarity to traditional “wax-up” processes
• excellent marginal fit
• moderately high strength
• surface hardness similar to that of enamel.
Although pressed ceramic inlays and onlays are stronger than porcelain inlays made on
refractory dies, they are still somewhat fragile during try-in and must be bonded rather
than conventionally cemented.
50.
51. LITHIUM
DISILICATE
• Lithium disilicate (e.max, Ivoclar Vivadent Inc., Amherst, NY), is
available in both pressed (IPS e.max Press) and machinable (IPS
e.max CAD) forms, and either can be used to fabricate inlays and
onlays.
• The two forms of e.max are slightly different in composition, but
lithium disilicate is a moderately high-strength glass ceramic that also
can be used for full crowns or ultra-thin veneers.
• In vitro testing of this ceramic material has shown very positive
results, and it has become a highly popular alternative for inlays and
onlays.
• However, because the material is relatively new, long-term
clinical studies to demonstrate superior performance are lacking
52. COMPUTER-AIDED
DESIGN/COMPUTER-
ASSISTED
MANUFACTURING
INLAYS AND ONLAYS
• Generation of a chairside CAD/CAM restoration begins after thedentist
prepares the tooth and uses a scanning device to collect information about
the shape of the preparation and its relationship with the surrounding
structures
• This step is termed optical impression.
• The system projects an image of the preparation and surrounding structures
on a monitor, allowing the dentist or the auxiliary personnel to use the CAD
portion of the system to design therestoration.
• The operator must input or confirm some of the restoration design such as
the position of the gingival margins
• After the restoration has been designed, the computer directs a milling
device (CAM portion of the system) that mills the restoration out of a block
of high-quality ceramic or composite in minutes
• The restoration is removed from the milling device and is ready for try-in,
any needed adjustment, bonding, and polishing
53.
54. • Several different types of ceramics are available for chairside CAD/CAM restoration fabrication.
• These include the feldspathic glass ceramics Vitablocs Mark II(Vident, Brea, CA) and CEREC Blocs (Sirona,
manufactured by Vita Zahnfabrik, Bad Säckingen, Germany).
• The ceramic blocks are available in various shades and opacities, and some are even layered to mimic the relative
opacity or translucency in different areas of a tooth.
• Two leucite-reinforced glass ceramics are available—IPS EmpressCAD (Ivoclar Vivadent) and Paradigm C (3M ESPE).
• Lithium disilicate also is available in machinable form as IPS e.maxCAD blocks. Although newer materials are stronger
than the original ceramics, less is known about their long-term clinical performance
55. CERAMIC
RECONSTRUCTION
SYSTEM (CEREC-1)
• The Ceramic Reconstruction System (CEREC-1; Siemens,
Germany) was the first commercially available CAD/CAM
system used in dentistry.
• An intraoral video camera images the tooth preparation
and the adjacent tooth surfaces.
• Features of the tooth preparation are used to define the
limits of the restoration.
56. CERAMIC
RECONSTRUCTION
SYSTEM (CEREC-1)
• External surfaces of the restoration are estimated as distances
to adjacent tooth structure in the computer view.
• Occlusal surfaces are designed from a pre-existing shape
library and information about the occlusion.
• CEREC-3 displays an extremely high level of sophistication and
can fabricate inlays, onlays, crowns, and veneers.
• It can be operated chairside, but also is being used with
remote milling units in dental laboratories for two-
appointment procedures.
• All other current CAD/CAM systems are employed in
dental laboratories to fabricate a wide range of ceramic
restorations
57. CEREC AC (A) and
E4D (B) computer- aided design/
computer-assisted manufacturing
(CAD/CAM) devices
These chairside units are compact and mobile
58. COMMON
PROBLEMS &
SOLUTIONS
• The most common cause of failure of tooth-colored
inlays/onlays is bulk fracture.
• Bulk fracture can result from placing the restoration in a
tooth where it should not have been indicated, such as
in bruxers and clenchers, or from lack of appropriate
restoration thickness derived from lack of tooth
preparation.
• If bulk fracture occurs, replacement of the restoration
isalmost always indicated.
59. REPAIR OF
CERAMIC
INLAYS AND
ONLAYS
• Before initiating any repair procedure, the
operator should determine whether replacement
rather than repair is the appropriate treatment
• A small fracture resulting from occlusal trauma might
indicate that some adjustment of the opposing occlusion is
required.
• The repair procedure is initiated by mechanical roughening
of the involved surface. Although a coarse diamond may be
used, a better result is obtained with the use of air
abrading or grit blasting with aluminum oxide particles and
a special intraoral device
60. REPAIR OF
CERAMIC
INLAYS AND
ONLAYS
• For ceramic restorations, the initial mechanical roughening
is followedby brief (typically 2 minutes) application of 10%
hydrofluoric acid gel.
• Hydrofluoric acid etches the surface, creating further
microdefectsto facilitate mechanical bonding.
• The next step in the repair procedure is application of a
silanecoupling agent.
• Silanes mediate chemical bonding between ceramics and
resinsand may improve the predictability of resin-resin.
• After the silane has been applied, a resin adhesive is
applied and light cured.
• A composite of the appropriate shade is placed, cured,
contoured and polished
61. CONCLUSION
Ceramic inlays offer an aesthetic alternative to metal class I or
II restorations. Their primary use is in compromised posterior
teeth with intact buccal and lingual walls. These restorations
offer the opportunity to conserve tooth structure while taking
advantage of the mechanical benefits of modern adhesive
technology, which can strengthen the compromised tooth.
Ceramic inlays offer a viable alternative to amalgam or cast-
gold restorations, both of which have enjoyed long histories
of clinical success.
62. REFERENCE
• Garber DA, Goldstein RE. Porcelain & composite inlays & onlays: esthetic posterior restorations. Chicago: Quintessence; 1994 Jan.
• Heymann HO, Swift Jr EJ, Ritter AV. Sturdevant's Art & Science of Operative Dentistry-E-Book. Elsevier Health Sciences; 2014 Mar
12
• Freedman GA. Contemporary Esthetic Dentistry-E-Book. Elsevier Health Sciences; 2011 Dec 15
• Hopp CD, Land MF. Considerations for ceramic inlays in posterior teeth: a review. Clinical, cosmetic and investigational dentistry.
2013;5:21
• Thompson MC, Thompson KM, Swain M. The all‐ceramic, inlay supported fixed partial denture. Part 1. Ceramic inlay preparation
design: a literature review. Australian dental journal. 2010 Jun 1;55(2):120-7.
• Obradović-Đuričić K, Medić V, Dodić S, Gavrilov D, Antonijević Đ, Zrilić M. Dilemmas in zirconia bonding: A review. Srpski arhiv za
celokupno lekarstvo. 2013;141(5-6):395-401.
• Blatz MB, Sadan A, Kern M. Resin-ceramic bonding: a review of the literature. Journal of Prosthetic Dentistry. 2003 Mar
1;89(3):268-74.
