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Operative Dentistry

Aesthetic inlays in the dental practice

Dr. G. Goracci1 - Dr. M. Andreasi Bassi2

INTRODUCTION
Aesthetic considerations are becoming always more important in Operative Dentistry even for the restoration of posterior teeth. Aesthetic inlays (AI) represent an heterogeneous family of tooth colored restorations for the permanent restoration of posterior teeth and joined by the presence of a composite cement interposed between the restoration and the tooth cavity. AI are the most suitable solution for restoration of large defects. Their advantage is that most of the composite used is displaced by an inert body. Thus, the amount of composite polymerized in the oral cavity is minimal1. This reduces the problem of the polymerization shrinkage to insignificant levels. AI require a particular uppercut cavity preparation with a 10-1 5 taper without beveled enamel margins7,17. They also require a meticulous use of an adhesive technique which produces a micromechanical and chemical bond between both, luting composite and tooth cavity as well as between composite and inlay. Therefore inlays inserted with adhesive techniques always

Abstract Many of the studies conducted in the field of Restorative Dentistry aim to obtaining an ideal filling material. Amalgam alloy still remains the most widely used material for restoration of posterior teeth, but this pattern of practice is changing as a result of materials and techniques developed in recent years. There has been an increased demand for aesthetic restoration and also a growing concern about biocompatibility, raising questions regarding the safety of mercury in amalgam, both for the dentist and the patient. Aesthetic inlays are a valid alternative to direct restorations in the case of large defects in posterior teeth. The purpose of this paper is to provide the practicing dentist with a panoramic view and a systematic step by step technique for the adhesive luting of such kind of restorations.

show an excellent margin behaviour and no marginal openings13. Normally, when the cavities do not interest the cusps, it is correct to speak of inlays, while when the cavity preparation involves one or more cusps, such restorations are called onlays7. Depending on the material used AI can be initially divided into two groups: Ceramic inlays and Composite inlays.

1 MSD, DDS, Professor and Director, Department of Operative Dentistry, University of Rome La Sapienza, Italy. 2- DDS, Ph. D., Department of Operative Dentistry, University of Rome La Sapienza, Italy.

Correspondence address: Guido Goracci. Via Tagliamento, 50, 00198 Rome, Italy. Tel.: 396+ 8548260 Fax: 396+ 841 4218

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Aesthetic inlays in the dental practice

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Operative Dentistry
Ceramic Inlays
Since their introduction, in 1839 by John Murphy12, numerous techniques have been adopted both to increase the accuracy of fit of these restorations and to improve and simplify their methods of production. Ceramic materials have many excellent properties, particularly in terms of biocompatibility, chemical durability, and optical and aesthetic properties. Ceramic inlays, however, have never been adopted for routine and large use because of the complexity of the technique, time-consuming methods and consequential costs of fabrication12. According to their method of construction they can be classificated as: plaited ceramic inlays; preshaped ceramic inlays; fired feldspathic ceramic inlays; glass-ceramic inlays. Plaited ceramic inlays are performed using blocks of ceramic material which are plaited in the correct shape by means of a particular plaiting-machine. Two systems are available: Cerec 2 (Siemens) and Celay (Mikrona). The Cerec 2 system uses CAD/CAM technique to produce the inlay. After cavity preparation an optical imprint of the cavity is taken by means of a small video camera. The cavity must be previously coated with a thin layer of titanium dioxide to eliminate light reflections. Then the inlay is plaited with a computer assisted plaiting-machine in 5-10 minutes13,14. The Celay system uses a particular copy plaiting-machine13. A removable dark blue composite inlay (proinlay) is made directly in the patients mouth or indirectly in the dental laboratory. This inlay is then manually traced with a stylus. The stylus reads the surface of the pro-inlay and has a fixed relation to a turbine which plaits the inlay out of a ceramic bloc. Both Cerec 2 and Celay systems plait the ceramic blocks with diamond burs, producing initially rough surfaces which have to be polished by the dentist with abrasives (aluminum dioxide and diamond particles) and rotary instruments (flexible discs, felt cones and abrasive silicon points) to avoid the wear of opposite teeth13, 16. inserts. The commercial system is called Cerafill (Komet). The limit of this technique is that often the caries is larger or smaller than the inserts and the corresponding diamond burs; for this reason, in smaller caries a sacrifice of healthy tissue is required and in bigger lesions a larger quantity of composite must be polymerized in the oral cavity, which limits their beneficial effect1,13. Fig. 1: The amalgam restoration of tooth 36 will be replaced by a fired feldspathic ceramic inlay. Fired feldspathic ceramic inlays are preferred by dental technicians, because they may be performed using conventional porcelain furnaces. These inlays are fired on phosphate-bondedinvestment-replicas of the master model. This is possible because modern ceramics have a lower sintering temperature and because the thermal expansion of both refractory die and ceramic material are very near. However, refitting the fired inlay on the master model is often difficult and time consuming and the fit of such restorations is highly dependent on the patience and the skill of the dental technician. Anyway, the esthetic result is excellent because the dental technician can layer the ceramic material with different opacities/translucencies and colors to match the anatomical form of the tooth13.

Fig. 2: The rubber dam is placed.

Fig. 3: The tooth after cavity preparation.

Fig. 5: The tooth temporarily filled.

Fig. 4: Silicon impression of the tooth. Preshaped ceramic inlays are standardized ceramic inserts performed by the manufacturer to fill tooth cavities cut with especially made diamond burs which have the same dimension of the

Fig. 6: Master model of the prepared tooth.

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DENTAL NEWS, Volume VI, Number 2, 1999.

Aesthetic inlays in the dental practice

Operative Dentistry
use it as a core material only. Therefore, the Dicor system in some way faded out, also due to the high costs of equipment. Only few dental technicians are still offering this material13. The Empress system has proved to be a better way to produce full ceramic restorations, because the technique is quite simple and the necessary equipment is inexpensive and the process requires only one step. After the casting, the ceramic is subjected to a heat procedure by controlled cooling of the furnace. In this phase leucite crystals grow within the ceramic, producing its high strength13. Kulzer inlay system (Kulzer), in which the inlays are secondary cured in high intensity light in an enclosed light-activating unit attachment with internal mirrored surfaces7,13.

Fig. 7: The ceramic inlay.

Fig. 1 Acid etching of the tooth cavity. 0:

Composite Inlays
Composite inlays have been proposed for the first time in 1982 with the aim to resolve the problem of excessive shrinkage of direct composite fillings. The idea was to compensate the polymerization shrinkage and the consequent gap formation by means of a composite cementum interposed between restoration and cavity. Polymerization shrinkage occurs during the performance of the inlay, and any subsequent shrinkage can occur only during the setting of the luting agent. Such a kind of restoration has better mechanical properties and wear resistance than direct composite restoration due to its complete polymerization performed in suitable furnaces2,3,7,9,18. Composite inlays may be classified according to their performing technique in: direct inlays; indirect inlays; direct/indirect inlays. Direct composite inlays: the tooth cavity is isolated with glycerin and filled with a posterior composite resin which is then lightcured. In class II cavities metal, matrixes and wedges are required for a proper performing of proximal contacts. A plastic pin is then bonded to the chewing surface of the inlay for its removal. The restoration is then extraorally completely cured (postcuring) before being adhesively luted in the tooth cavity11,13. Examples of this technique are the Brillant Aesthetic Line inlay/onlay system (Coltene) where the inlays are postcured in high light intensity at up to 1 20C for 7 minutes and the

Fig. 8: The inner surface of the inlay is etched with hydrofluoric acid.

Fig. 1 Ceramic inlay immediately 1: after insertion.

Fig. 9: The inner surface of the inlay is silanized. Glass ceramic inlays are performed by means of the well known lost wax method; they are called also castable ceramic inlays. The commercially available materials are Dicor (Dentsply International) and Empress (Ivoclar). The Dicor inlays are cast from special glass ingots. In a second process, the glass inlay is partially recrystallized to form a glass ceramic. During this thermal process mica crystals grow within the glass phase conferring the Dicor ceramic high strength. Dicor was initially produced as a crown material. However, problems arose with the staining technique, because the material is uncolored have induced dental technicians to

Fig. 1 The restored tooth after rub2: ber dam removal. Indirect composite inlays: in this case the dental technician performs the inlay with posterior composite resin based on an impression taken by the dentist6,7,13,15. An example of this technique is the SRIsosit inlay/onlay system (Ivoclar) where the inlays are cured at 1 20 C at 6 bar of pressure in watery environment. The esthetic result with indirect composite inlays are excellent because the dental technician can layer the composite material copying the nat ural aspect of the tooth in the same manner of fired feldspathic ceramic inlays13.

DENTAL NEWS, Volume VI, Number 2, 1999.

Aesthetic inlays in the dental practice

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Operative Dentistry
Direct/indirect composite inlays: this technique is basically an indirect technique; however the single steps are so fast and simple that may be done chairside, while the patient is waiting for the restoration to be made. An example of this technique is the EOS system (Vivadent) not anymore in commerce due to the low quality of the inlays performed with this system as compared with indirect composite inlays (7,8). However, this technique has been recently reviewed and improved and presently allows to obtain composite inlays with a better marginal adaptation and the same aesthetic and mechanical properties as indirect composite inlays4.

Operative technique for adhesive luting of aesthetic inlays


Independently from the material or the technique of performance adopted, the AI inlays can be adhesively luted to cavities by means of the same technique. First of all the rubber dam is placed. After a preliminary control of the correct inlay fitting into the cavity and checking the proximal contacts with dental floss, the inner surface of inlay and tooth cavity can be prepared for the adhesive luting. The preparation of the tooth cavity includes total etching, with phosphoric acid gel (37 %) for 1 seconds, produc5 ing microporosities on both enamel and dentin surfaces. Acid etching also involves exposition of collagen fibers on the dentin and consequently creates a resin impregnated hybrid layer when the resin primer is applied on it. In order to obtain an optimal bond between resin primer and collagen fibers, the cavity must not be dried completely after acid removal by water, in order to avoid the collapse of such fibers, warranting in this way a complete penetration of the primer into the collagen network5. As to

the inner surface of the inlay, the following procedure is recommended: Ceramic inlays: 1- degrease with acetone; 2- etch with hydrofluoric acid (10%) for 1 seconds; 3- rinse for 60 20 seconds; 4- dry with air; 5- application of silane for 30 seconds; 6- dry gently with air blast or, if possible, apply hot air (ca. 100 C) for 30 seconds13. Composite inlays: 1- sand blasting with aluminum dioxide; 2- silane application for 30 seconds; 3- dry gently with the air blast or, if possible, apply hot air (ca. 100 C) for 30 seconds5,10,13. Tooth and inlay are coated with a thin layer of bonding resin. The luting composite is mixed and applied into the cavity. The inlay is positioned and inserted into the cavity. Then the excess of composite material must be removed from the interproximal areas, first by an explorer and then by a dental floss. Occlusally the composite excess is best removed by a spatula, followed by a nylon paintbrush. To avoid oxygen polymerization-inhibition on the surface layer, the composite is covered with glycerin gel. For a complete hardening, composite is then lightcured for 60 seconds for each surfaces5,13. The rubber dam is now removed. Occlusion is checked in centric relation and in eccentric movements. Finishing is done with fine grit diamond burs on the occlusal surface and with aluminum dioxide-coated discs for the interproximal regions. The inlay is then polished with abrasives (aluminum dioxide and diamond particles) and rotary instruments (flexible discs, felt cones and abrasive silicon points)16.

Fig. 1 The composite restoration of 3: tooth 1 will be replaced by an indi6 rect composite inlay.

Fig. 1 The rubber dam is placed. 4:

Fig. 1 Silicon impression of the tooth. 6:

Fig. 15: The tooth after cavity preparation.

Fig. 1 The tooth temporarily filled. 7:

Fig. 1 Composite inlays performed 8: on plaster model immediately before of its postcuring.

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DENTAL NEWS, Volume VI, Number 2, 1999.

Aesthetic inlays in the dental practice

Operative Dentistry
cations and their placement is more time consuming compared to direct restorations. They also require much more effort and skill on dentists part and the assistance of a dental technician is often involved. For this reason they are more expensive than direct restorations and less used in daily practice12,13. However, their use is very satisfying for the dentist and the patients, due to the high aesthetic results which are possible to obtain with them.

References
1- BAUSH J.R., DE LONG K., DAVIDSON C.L.: Clinical significance of polimerization shrinkage of composite resins. J. Prosth. Dent.; 48: 59-67; 1982. 2- BIANCHI S., PAROLI R., RIVA R.: Intarsi in resina composita: caratteristiche fisiche. Dental Cadmos, 10: 56-82; 1994. 3- BURKE F.J.T., WATTS D. C., WILSON N.H.F., WILSON M.A.: Current status and rationale for composite inlays and onlays . Brit. Dent. J., 6: 269-273; 1996. 4- CITO C., ANDREASI BASSI M:, MORI G., GORACCI G.: Evaluation of a photo-activation technique in indirect composite inlays using a transparent silicon model J. Dent. Res. 77(5): 1 262 Abstr. no. 443; 1998. 5- GORACCI G., MORI G.: La cementazione adesiva. In: CAROSSA S., PERA M.: Ricostruzioni coronali parziali. Ed. Masson, Milano; 1997. 6- FERRARI M., MASON P.M.: Adaptability and microleakage of indirect resin inlays: an in vivo investigation. Quint. Int.; 1 861-865; 1993. 2: 7- GORACCI G., E. ACCARISI, M. CORIGLIANO: Otturazioni estetiche nei quadranti posteriori: intarsi in composito. In Tema di Odontoiatria e Cultura; 1: 29-44; 1991. 8- GORACCI G., M. CORIGLIANO: Nuova metodica per la realizzazione di intarsi in composito. In Tema di Odontoiatria e Cultura; 5: 19-31; 1992. 9- KREJCI I., GLAUSER R., SAGESSER M., HICKEL R.: Marginale adaptation und verschleissfestigkeit eines feinhybridkomposit-inlays in vitro. Schwez Monatsschr. Zahnmed.; 103: 973-978; 1993. 10- LATTA M. A., BARKMEIER W.W.: Bond strength of a resin cement to a cured composite inlay material. J. of Prost. Dent., 72(2): 189-193; 1994. 1 LEUNG R., FAN P., JOHNSON W.: Post irradia1tion polymerization of visible light-activated composite resin. J. Dent. Res.; 62: 363-65; 1983. 1 QUALTRHOUGH A., WILSON N., SMITH G.: 2The porcelain inlay: a historical view. Oper. Dent., 1 61-70; 1990. 5: 1 ROULET JF.: Esthetic posterior restorarions. 3In: DONDI DALLOROLOGIO G., FUZZI M., PRATI C.: Adhesion in restorative dentistry pp.27-47. Ed. Valbonesi, Forl; 1996. 1 SCHMALZ G., FEDERLIN M., REICH E.: Effect 4of dimension of luting space and luting composite on marginal adaptation of class II ceramic inlay. J. Prosthet Dent.; 73: 392-9; 1995. 1 VAN DIJKEN J.V.W.: A 6-year evalutation of a 5direct composite resin inlay/onlay system and glass ionomer cement-composite resin sandwich restorations . Acta Odontol. Scand., 52: 368-376; 1994. 16- VANINI L., DEVOTO W.: Rifinitura e lucidatura dei restauri in composito. Il Dentista Moderno, 5: 5-1 1997. 3; 1 WASSEL R.W., Mc CABE J.F., MURRAY J.J.: 7Cavity convergence angles for direct composite inlays. J. Dent.; 20(5): 294-7; 1992. 18- WENDT S.L.: Effetti del calore come fonte secondaria di polimerizzazione sulle propriet fisiche di tre compositi. I Parte: resistenza diametrale alla trazione, resistenza alla compressione e stabilit dimensionale marginale. Quintessence Inter., 5: 395-403; 1987.

Fig. 1 The inner surface of the inlay 9: is silanized.

Fig. 22: Composite inlay immediately after insertion. Fig. 20: Acid etching of the tooth cavity.

Fig. 23: The composite excess is removed by a nylon paintbrush. Fig. 21: The adhesive is applied to the cavity.

Conclusions
The increasing demand by patients for aesthetic restorations and the search for substitutes of metal restorations (amalgam and gold) focused the attention of the researcher and the dental manufacturers on new operative techniques and materials. Aesthetic inlays are the outcome of this endeavor. However, this kind of restoration has only limited appli-

Fig. 24: The restored tooth after rubber dam removal.

DENTAL NEWS, Volume VI, Number 2, 1999.

Aesthetic inlays in the dental practice

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