1 Class I and II Indirect Tooth-Colored Restorations
2 Most indirect restorations are made on a replica of the prepared tooth in a dental laboratory by a trained technician. Tooth-colored indirect systems include laboratory-processed composites and ceramics, such as porcelain fired on refractory dies or hot pressed glasses.
3 In addition, chairside computer-aided design/computer-assisted manufacturing (CAD/CAM) systems are currently available and are used to fabricate ceramic restorations.
6 * Esthetics. * Large defects or previous restorations. * Economic factors: Some patients desire the best dental treatment available, regardless of cost.
8 * Heavy occlusal forces
9 * Inability to maintain a dry field. * Deep subgingival preparations.
11 * Improved physical properties: A wide variety of high-strength tooth-colored restorative materials, including laboratory-processed and computer-milled composites and ceramics, can be used with indirect techniques.
12 * Variety of materials and techniques: Indirect tooth-colored restorations can be fabricated with either composites or ceramics using various laboratory processes or CAD/CAM methods.
13 * Wear resistance: Ceramic restorations are more wear-resistant than direct composite restorations, an especially critical factor when restoring large occlusal areas of posterior teeth. Laboratoryprocessed composite restorations wear more than ceramics, but less than direct composites in laboratory studies.
14 * Reduced polymerization shrinkage: Polymerization shrinkage and its resulting stresses are a major shortcoming of direct composite restorations.
15 * Ability to strengthen remaining tooth structure: Tooth structure weakened by caries, trauma, or preparation can be strengthened by adhesively bonding indirect tooth-colored restorations.
16 * More precise control of contours and contacts: Indirect techniques usually provide better contours (especially proximal contours) and occlusal contacts than direct restorations because of the improved access and visibility outside the mouth.
17 * Biocompatibility and good tissue response: Ceramic materials are considered the most chemically inert of all materials.
18 * Increased auxiliary support: Most indirect techniques allow the fabrication of the restoration to be totally or partially delegated to dental laboratory technicians.
20 * Increased cost and time: Most indirect techniques require two patient appointments, plus fabrication of a temporary restoration. These factors, along with laboratory fees, contribute to the higher cost of indirect restorations relative to direct restorations.
21 * Technique sensitivity: Restorations made using indirect techniques require a high level of operator skill.
22 * Brittleness of ceramics: A ceramic restoration can fracture if the preparation does not provide adequate thickness to resist occlusal forces or if the restoration is not appropriately supported by the cement medium and the preparation.
23 * Wear of opposing dentition and restorations: Ceramic materials can cause excessive wear of opposing enamel or restorations.
24 * Resin-to-resin bonding difficulties: Laboratoryprocessed composites are highly cross-linked, so few double bonds remain available for chemical adhesion of the composite cement.
25 * Short clinical track record: Indirect bonded tooth-colored restorations have become relatively popular only in recent years and are still not placed by many practitioners.
26 * Low potential for repair: Indirect restorations, particularly ceramic inlays/onlays, are difficult to repair in the event of a partial fracture.
27 * Difficult try-in and delivery: Ceramics are more difficult to polish because of potential resin-filled marginal gaps and the hardness of the ceramic surfaces.
28 Laboratory-Processed Composite Inlays and Onlays
29 Processed composite restorations are indicated when:
30 (1) maximum wear resistance is desired from a composite restoration,
31 (2) achievement of proper contours and contacts would otherwise be difficult, and
32 (3) a ceramic restoration is not indicated because of cost or concerns about wear of the opposing dentition. Regarding the last-mentioned, the indirect composite would likely cause less wear of the opposing dentition than a similar ceramic restoration.
33 The fabrication steps for one representative system can be summarized as follows:
34 1. The indirect composite restoration is initially formed on a replica of the prepared tooth.
37 2. The composite is built up in layers, polymerizing each layer with a brief exposure to a visible light-curing unit.
39 3. After it is built to full contour, the restoration is coated with a special gel to block out air and thus prevent formation of an oxygen-inhibited surface layer.
40 4. Final curing is accomplished by inserting the inlay into an oven-like device that exposes the composite to additional light and heat, in some cases, pressure.
42 5. The cured composite inlay is trimmed, finished, and polished in the laboratory.
44 Ceramic Inlays and Onlays
45 Among the ceramic materials used are feldspathic porcelain, hot pressed ceramics, and machinable ceramics designed for use with CAD/CAM systems.
46 The physical and mechanical properties of ceramics come closer to matching those of enamel than do composites. They have excellent wear resistance and a coefficient of thermal expansion very close to that of tooth structure.
47 Feldspathic Porcelain Inlays and Onlays
48 The fabrication steps for fired ceramic inlays and onlays can be summarized as follows:
49 Master cast for MOD ceramic inlay. Die spacer is usually applied to axial walls and pulpal floor before duplication Master die is impressed, then a duplicate die is poured with refractory investment
50 Dental porcelains are added and fired in increments until inlay is the correct shape. Inlay is cleaned of all investment, then seated on master die for final adjustments and finishing. Ceramic inlay is now ready for delivery
54 Hot Pressed Glass-Ceramics
55 The fabrication steps for one type of leucitereinforced hot pressed ceramic restoration are summarized as follows:
56 Wax pattern for ceramic inlay Wax pattern on sprue base, ready to be invested
57 Device for pressing heated ceramic Ceramic inlay as pressed and before surface characterization
60 Rapid improvements in technology have spawned several computerized devices that can fabricate ceramic inlays and onlays from highquality ceramics in a matter of minutes.
61 Some CAD/CAM systems are very expensive laboratory-based units requiring the submission of an impression or working cast of the prepared tooth.
62 The CEREC system
63 The CEREC system was the first commercially available CAD/CAM system developed for the rapid chairside design and fabrication of ceramic restorations. The 2005 version of this device is the CEREC 3.
64 A B CEREC 2 (A) and CEREC 3 (B) CAD/CAM devices. These chairside units are compact and mobile.
65 Generation of a CEREC restoration begins after the dentist prepares the tooth and uses a scanning device to collect information about the shape of the preparation and its relationship with the surrounding structures.
66 An optical impression is made by placing a small video camera or scanner over the prepared tooth.
67 The restoration is designed on the computer screen by drawing position of gingival margins and proximal contacts.
68 B A, Computer-driven software controls two small, diamondcoated milling devices that cut the restoration out of a block of high-quality ceramic. B, The ceramic block rotates as the diamond cutting instruments move as needed to generate the restoration.
69 A major advantage is the quality of the restorative material. Manufacturers make blocks of "machinable ceramics" or "machinable composites" specifically for computer-assisted milling devices. Because these materials are fabricated under ideal industrial conditions, their physical properties have been optimized.
70 The major disadvantages of CAD/CAM systems are high cost and the need for extra training. However, CAD/CAM technology is changing rapidly, with each new generation of devices having more capability, accuracy, and ease of use.
71 CLINICAL PROCEDURES
72 Tooth Preparation
73 By definition, an onlay caps all cusps; an inlay may cap none, or may cap all but one cusp.
74 As a first clinical step: 1- The patient is anesthetized and the area isolated, preferably using rubber dam.
75 2- The compromised restoration (if present) is completely removed, and all the caries is excavated.
76 3- 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.
77 Preparations for indirect tooth-colored inlays and onlays are designed to provide adequate thickness for the restorative material and simultaneously a passive insertion pattern with rounded internal angles and well-defined margins.
78 1- All margins should have a 90- degree cavosurface angle to ensure marginal strength of the restoration.
79 2- All line and point angles, internal and external, should be rounded to avoid stress concentrations in the restoration and tooth, reducing the potential for fractures.
83 The carbide bur or diamond used for tooth preparation should be a tapering instrument that creates occlusally divergent facial and lingual walls.
85 The occlusal step should be prepared 1.5 to 2 mm in depth. Most composite and ceramic systems require that any isthmus be at least 2 mm wide to decrease the possibility of fracture of the restoration.
86 The pulpal floor should be smooth and relatively flat.
87 The facial, lingual, and gingival margins of the proximal boxes should be extended to clear the adjacent tooth by at least 0.5 mm. These clearances will provide adequate access to the margins for impression material and for finishing and polishing instruments.
88 For all walls, a 90-degree cavosurface margin is desired because composite and ceramic inlays are fragile in thin crosssection.
89 The gingival margin should be extended as minimally as possible because margins in enamel are greatly preferred for bonding, and because deep gingival margins are difficult to impress and to isolate properly during cementation.
90 A cusp usually should be capped if the extension is two thirds or greater than the distance from any primary groove to the cusp tip.
94 Most tooth-colored indirect inlay/onlay systems require an impression of the prepared tooth and the adjacent teeth as well as interocclusal records, which allow the restoration to be fabricated on a working cast in the laboratory
95 Temporary Restoration
96 A provisional restoration is necessary when using indirect systems that require two appointments. The temporary restoration protects the pulpdentin complex in vital teeth, maintains the position of the prepared tooth in the arch, and protects the soft tissues adjacent to prepared areas.
97 Temporary restorations for porcelain-fused-tometal and cast gold restorations typically are cemented with eugenol-based temporary cements.
98 Eeugenol is believed to interfere with resin polymerization, however, and potentially could reduce the adhesion of the permanent composite cement to tooth structure. Use of a noneugenol temporary cement is recommended.
99 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 temporary restoration.
101 Using the CEREC system, an experienced dentist can prepare the tooth, fabricate an inlay, and deliver it in approximately 1 hour. This system eliminates the need for a conventional impression, temporary restoration, and multiple patient appointments.
103 A, CEREC inlay being milled. B, Completed inlay B
104 Try-in and Cementation
105 The inlay or onlay is placed into the preparation using very light pressure to evaluate its fit. If the restoration does not seat completely, the most likely cause is an overcontoured proximal surface.
106 A, Initial try-in of CEREC inlay. Proximal contacts are too tight and must be adjusted. B, Inlay seated after contact adjustment. Proximal surfaces of the inlay must be polished before cementation.
108 For most laboratory-processed composite inlays/ onlays, the resin matrix has been polymerized to such an extent that few bonding sites are available for the composite cement to chemically bond to the internal surfaces of the restoration.
109 For ceramic inlays and onlays, hydrofluoric acid usually is used to etch the internal surfaces of the restoration.
111 Chairside ceramic etching is done with a 2- minute application of 10% hydrofluoric acid on the internal surfaces of the inlay/onlay.
112 After etching, the ceramic is treated with a silane coupling agent to facilitate chemical bonding of the composite cement.
113 Clear plastic matrix strips may be applied in each affected proximal area and wedged. The inlay/onlay can be tried in again and checked for fit.
115 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.
116 A dual-cure composite cement is mixed and inserted into the preparation. The internal surfaces of the restoration are also coated with the composite cement and the inlay is immediately inserted into the prepared tooth, using light pressure.
117 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
118 The operator must be careful not to remove composite from the marginal interface between the tooth and the inlay. The cement is now light-cured from occlusal, facial, and lingual directions for a minimum exposure of 60 seconds from each direction.
119 A, Enamel and dentin are etched with phosphoric acid. B, Dual-cured composite cement is applied to inlay. C, After application of the adhesive system, cement is applied to the preparation. D, CEREC ceramic inlay is seated into preparation.
120 Cont'd E and F, Before curing, excess composite cement is removed with explorer, brushes, and IPC carver. G, The composite cement is light-cured from occlusal, facial, and lingual directions.
121 Finishing and Polishing Procedures
122 A, Slender, fine-grit, flame-shaped, diamond instruments are used to remove flash along facial and lingual margins of CEREC ceramic inlay. B, 30-fluted finishing burs are used to smooth areas that were adjusted with diamonds.
123 A, Removing excess composite cement using a surgical blade. B, Smoothing the interproximal area with abrasive finishing strip.
124 Polishing sequence for ceramic inlays. A, After using fine-grit diamonds and 30-fluted carbide finishing burs to adjust contours and margins, rubber abrasive points and cups of successively finer grits are used at slow speed. B, Final polish imparted by porcelain polishing paste applied with bristle brush. C, Occlusal view of polished ceramic inlay.
126 Common Problems and Solutions
127 The most common cause of failure of tooth-colored inlays and onlays is bulk fracture. If bulk fracture occurs, replacement of the restoration is almost always indicated.
128 Repair of Tooth-Colored Inlays and Onlays
129 For composite and ceramic inlays, the repair procedure is initiated by mechanical roughening of involved surface.
130 For ceramic restorations, the initial mechanical roughening is followed by brief (typically 2 minutes) application of 10% hydrofluoric acid gel. Hydrofluoric acid etches the surface, creating further microdefects to facilitate mechanical bonding.
131 Although many indirect composites contain etchable glass filler particles, hydrofluoric acid treatment of composites is neither necessary nor recommended. However, a brief application of phosphoric acid may be used to clean the composite surface after roughening.
132 The next step in the repair procedure is application of a silane coupling agent. Silanes mediate chemical bonding between ceramics and resins and also may improve the predictability of resin-resin repairs.
133 After the silane has been applied, a resin adhesive agent is applied and light cured. A composite of the appropriate shade is placed, cured, contoured, and polished.
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