A

esthetic inlays and onlays have become viable

restorative alternatives for moderately broken down
posterior teeth and an integral means of rendering restora-
tive treatment.
1- 8
Advances in adhesive technology and
aesthetic dental materials (eg, composite resins and
ceramics) have enabled clinicians to utilize conserva-
tive preparations for the placement of restorations that
reinforce the remaining tooth structure.
9
These restora-
tions also satisfy increasing patient expectations for a
natural or enhanced appearance.
The directly placed resin restoration is clearly the
most conservative posterior restoration in contemporary
dentistry. While this technique only requires the removal
and replacement of diseased tooth structure, direct resin
is subject to shrinkage when it is light cured. This can
result in stress on the bond or the tooth and potentially
cause postoperative sensitivity and/or microleakage if
it is not relieved by elastomeric flow in the resin. Although
this phenomenon is less problematic in smaller Class II
cavities and can to a degree be controlled or
limited by technique, it is of greater concern with more
extensive cavities.
10
Aesthetic inlay/onlay restorations are
an attempt to minimize this inherent property of light-cured
resins, since only the thin layer of luting resin is subject
to polymerization shrinkage.
It can also be arduous to establish a predictable,
quality proximal contact when placing a Class II direct
resin restoration particularly for a moderately broken
down tooth. In addition, it is often difficult to routinely
achieve adequate contacts in teeth with compromised
arch position or malalignment. Finally, the amount of
tooth structure being replaced can be a factor during
treatment planning when the ease of placement and qual-
ity of the definitive result are considered. When a large
cavity (ie, with one or more cusps missing) requires
restoration, a higher level of aesthetics and enhanced
occlusion can often be achieved by laboratory techni-
cians working on models in comparison to directly placed
resin restorations.
INDIRECT RESIN INLAY AND
ONLAY RESTORATIONS:
A COMPREHENSIVE CLINICAL OVERVIEW
Ronald D. Jackson, DDS*
Pract Periodont Aesthet Dent 1999;11(8):891-900
Figure 1A. Diagram demonstrates occlusal view of premolar inlay
preparation. 1B. Premolar inlay preparation as observed from the
proximal view.
*Private practice, Middleburg, Virginia.
Ronald D. Jackson, DDS
204 E. Federal Street
Middleburg, VA 20118
Tel: 540-687-6363
Fax: 540-687-6733
Advances in adhesive technology and aesthetic dental
materials have permitted clinicians to perform conserv-
ative preparation of the dentition for inlay/onlay restora-
tions. The use of adhesive indirect procedures provides
numerous advantages (eg, aesthetics, reinforcement, ade-
quate seal) to conventional restorative techniques. This
article describes the indications/contraindications and
material properties of aesthetic indirect restorations. It
also highlights the preparation, bonding, and finishing
procedures utilized to achieve an aesthetic indirect resin
restoration and demonstrates the techniques with a series
of case presentations.
Key Words: indirect, inlay/onlay, posterior, adhesive, resin
891
J
A
C
K
S
O
N
O
C
T
O
B
E
R
11
8
C O N T I N U I N G E D U C A T I O N 2 9
90- 120
2 mm
min.
1.5 mm
5- 15
divergence
A B
Figure 3A. Illustration of amalgam removal, which is performed without cutting enamel. 3B. Caries is removed in conventional
manner. At this phase, enamel is only removed for access to caries. 3C. If the cavity is large, the occlusal portion is prepared
with the larger, tapered flat-ended diamond bur. The line angle of this bur is rounded. 3D. Diagram illustrates the use of the
smaller occlusal preparation bur on less extensive cavities. 3E. The large proximal bur is used to achieve proper taper in cavi-
ties that permit access. 3F. The smaller proximal bur is used to taper proximal areas with compromised access. 3G. Diagram
demonstrates undercuts being blocked out. 3H. The finishing bur is utilized to achieve a smooth finish and cutback of the
block out material. 3I. The end-cutting bur is occasionally necessary to establish a smooth butt joint gingival margin without
damaging the adjacent tooth.
Figure 2A. Diagram illustrates occlusal view of molar onlay
preparation. 2B. Molar onlay preparation, proximal view.
Note: A step or deep chamfer for an onlaid cusp will
enhance aesthetics.
892 Vol. 11, No. 8
Practical Periodontics & AESTHETIC DENTISTRY
It has been postulated that laboratory- fabricated
resin inlays/onlays with an accurate fit may have an
advantage over directly placed composite resins in the
reduction of microleakage.
11-13
Although significant
advances have occurred in the development of dentin
bonding agents (DBAs), the complete elimination of
microleakage remains elusive when the margin is below
the cementoenamel junction.
14,15
While laboratory- fabricated composite resins can
be polymerized with heat and pressure, the majority of
these systems are light polymerized and subsequently
subjected to heat treatment. Heat polymerization or treat-
ment imparts greater physical properties to the resin than
would be possible through light curing alone. This is
reportedly due to the higher rate of conversion of mono-
mers to polymers. The literature indicates that certain
material properties may be improved by this process,
A B C
D E F
G H I
2 mm 1 mm
minimum minimum
1.5 mm
to 2 mm
A B
Materials and Systems
In recent years, the physical properties and clinical per-
formance of laboratory-fabricated resin materials have
been significantly improved (Table). One of these systems
(Concept, Ivoclar Williams, Amherst, NY) has been in
existence for 13 years and has proven clinical efficacy.
6
Although controversy exists with regard to which mate-
rial provides the optimum long-term, durable aesthetic
restoration, the author has successfully used each of these
systems. Numerous factors constitute a quality restoration,
and each has to be examined with respect to the mate-
rial, fabrication process, and clinical technique. Clearly,
indirect composite materials are being fabricated with
enhanced durability, wear resistance, and fit.
8,20
As with
any laboratory- fabricated restoration, however, the ulti-
mate success and longevity are functions of the materials
used, the technique used by the clinician and the labo-
ratory technician, and the patients care.
In comparison to ceramic materials, inlay/onlay
restorations composed of composite resin can generally
be fabricated with greater ease in the laboratory. Resins
also demonstrate improved wear compatibility against
opposing tooth structure and can be repaired intra-
orally.
21-24
In 1996, the popularity of indirect resin for
aesthetic inlay/onlay restorations surpassed ceramic
materials in the United States.
25
Clinical Procedures
Preparation
The principles of cavity preparation for aesthetic inlays/
onlays differ from those for gold restorations (Figures 1
and 2).
1,26
For aesthetic inlay/onlay restorations, bevels
and retention forms are unnecessary. While resistance
Figure 4. If the enamel lacks dentin support anywhere
from the cusp tip to the pulpal floor, or if the cavosurface
margin is within 1 mm of a working cusp tip, the cusp
should be overlaid.
P P A D 893
Jackson
Figure 5. If the cavosurface margin is greater than 1 mm
from a working cusp tip, the cusp does not need to be
overlaid. For a nonworking cusp, the cavosurface margin
can extend to the cusp tip and still not be overlaid if
dentin support is evident.
but others may not.
16-19
In larger cavities or teeth sub-
jected to greater functional demand (ie, patients with
bruxism), the enhanced physical properties of laboratory-
fabricated inlay/onlay restorations appear to be advan-
tageous to direct resin restorations.
Indications/Contraindications
Aesthetic inlay/onlay restorations are characterized by
two primary indications. The first occurs when the patient
desires a nonmetal restoration and is essentially patient
driven. The second depends primarily on restorative con-
siderations determined by the clinician. These restora-
tions are ideal for the moderately broken down tooth
where: 1) the cavity is too large or the tooth is sub-
jected to functional demands that contraindicate the
placement of a posterior amalgam or direct resin restora-
tion; and 2) placement of a full-coverage crown would
be unnecessarily aggressive. This consideration is becom-
ing increasingly important as patients are educated on
the benefits (eg, aesthetics, conservation of tooth struc-
ture, proper seal, tooth reinforcement) of modern adhe-
sive dentistry. When they understand the reduction of the
natural tooth involved in crown restorations, patients often
select treatment with aesthetic inlay/onlay restorations to
preserve the tooth structure.
Similar to all adhesive restorations, inlay/onlay
restorations are contraindicated when isolation and con-
trol of saliva, crevicular fluid, or blood contamination
cannot be achieved. Consideration should also be given
to second molar restorations and restorations in patients
with bruxism or who clench. In these situations, it may
be prudent to overengineer the restoration by placing
a crown rather than a large multisurface onlay.
Palatal
Onlay
cusp
Onlay
cusp
Do not
onlay
cusp
Do not
onlay
cusp
Buccal Palatal Buccal
1 mm
> 1 mm
Undercuts
blocked out
form is generally not necessary, it may be required in
large onlay restorations. The walls of the cavity are flared
between 5 and 15, and the gingival floor can be pre-
pared with a butt joint. The internal line angles are
rounded, the minimum isthmus width is 2 mm, and the
minimum depth thickness is 1.5 mm. For onlay restora-
tions, nonworking and working cusps should be covered
with a minimum of 1.5 mm and 2 mm of material, respec-
tively. Bur kits (eg, Esthetic Inlay/Onlay, Brasseler USA,
Savannah, GA) can be utilized to prepare the proper
cavity form (Figure 3). When the occlusal aspect of the
cavity is prepared, it is important not to eliminate under-
cuts by removing healthy tooth structure, which would
negate the conservatism of this approach. The objec-
tive is to merely establish divergence in the enamel and
to subsequently block out all undercuts, which can be
accomplished with bonded resin or a resin-modified glass
ionomer. The latter is simpler since it generally does
not require etching or placement of a DBA. Bases and
liners are unnecessary on the floor of the pulp and are
contraindicated. Optimal support for the restoration will
be the hybridized dentin established at insertion. Although
the dentin is etched and sealed with a DBA by some
clinicians at the preparation phase, this rationale is not
universally accepted at present. Additional studies are
necessary to verify that there is no effect on subsequent
bond strength when the restoration is placed.
For cemented castings, it is generally recommended
to overlay a working cusp when the cavosurface margin
is located more than 50% up the incline of the cusp. The
cavosurface margin can extend up to 75% of the cuspal
incline of a nonworking cusp before the overlaying of
the cusp is considered.
27,28
Although studies have been
performed in this area for bonded inlay/onlay restorations,
a clinical consensus on when a cusp requires removal
remains to be determined.
9,29
Since these restorations
Figure 7. Postoperative occlusal view. The second molar
and premolar have been restored with direct composite
resin; the first molar has been restored with indirect
composite resin.
894 Vol. 11, No. 8
Practical Periodontics & AESTHETIC DENTISTRY
Table
Commercial Systems
Product Name Product Name Processing Method
Previous Generation New Generation New Generation Company
VisioGem SinFony Light Espe (Norristown, PA)
Charisma Artglass Light and heat Heraeus Kulzer (Irvine, CA)
Concept* Targis

Light and heat Ivoclar Williams (Amherst, NY)

Conquest Sculpture Light and heat Jeneric/Pentron (Wallingford, CT)
(nitrogen atmosphere)
Herculite Lab belleGlass HP Light, heat, and pressure Kerr/Sybron (Orange, CA)
(nitrogen atmosphere)
*Concept is known as Isosit SR Inlay/Onlay outside North America.

Targis (hybrid resin) is not technically a new generation of Concept (microfill resin) but is marketed as an additional option with
different properties.
Figure 6. Case 1. Preoperative view of second molar with
leaking amalgam filling, first molar with cracks and exten-
sive proximal caries mesially and distally, and second
premolar with early generation direct composite resin.
reinforce the remaining tooth structure, the traditional
guidelines as to when a cusp should be overlaid have
been modified. In the authors experience, the cavosur-
face margin can extend virtually to the tip of a nonworking
cusp if the enamel has dentin support from the cusp tip
to the pulpal floor. A working cusp is overlaid when
the cavosurface margin is within 1 mm of the cusp tip
(Figures 4 and 5). If the working cusp is not overlaid
when the cavosurface margin is this high on the cuspal
incline, marginal integrity cannot be maintained. This is
due to the relatively high functional demand on this cusp
and enamel rods that run more vertically toward the cusp
tip, which increases the difficulty of etching this layer.
These guidelines must be modified for patients with para-
functional habits (eg, bruxism or clenching), for whom
the cusps should be overlaid more aggressively.
The authors experience in treating teeth with sympto-
matic cusps (ie, cracked tooth syndrome) has demon-
strated that these cusps should be overlaid. In teeth with
asymptomatic cracks, however, it is more difficult to deter-
mine a proper treatment plan. These cracks can often be
observed in the pulpal floor once preexisting amalgam
restorations are removed. In these circumstances, the
decision to onlay is more subjective.
30,31
If substantial tooth
structure remains and the patient does not have exces-
sive parafunctional habits, the cusp can be left intact. If
these conditions do not exist, or if cracks are observed
below two cusps, the cusp or cusps must be overlaid.
Following preparation, an impression is obtained
with an accurate repourable material and forwarded to
the laboratory with any additional models, records, or
information necessary to fabricate the restoration. The
level of aesthetics achieved with this restoration is directly
proportional to the level of communication between the
clinician and the laboratory technician. Consequently,
it is essential for the color prescription to contain the
occlusal base shade of the restoration, the gradient of
shade from central fossa to cavosurface margin, the
degree and color of the desired pit and fissure stains,
and any maverick highlights present. For onlay restora-
tions in the aesthetic zone, the base shade at the facial
margin must be communicated to the laboratory techni-
cian. This information can be supplied in a detailed color
prescription. A color photograph that includes a shade
tab in the picture may also be a useful adjunct. The shade
is taken prior to preparation to avoid the misleading
effects that can occur through desiccation of the tooth.
Once this diagnostic information has been obtained, a
direct provisional restoration (eg, E-Z Temp Inlay/Onlay,
Cosmedent, Chicago, IL; Fermit, Ivoclar Vivadent, Amherst,
NY) is placed while the definitive restorations are fabri-
cated in the laboratory.
Bonding
Following the removal of the provisional restoration, a
rubber dam is placed to ensure isolation and moisture
control. If a rubber dam cannot be placed, a cemented
(rather than an adhesive) restoration should be consid-
ered.
32
The tooth is cleansed with a brush (eg, ICB,
Ultradent Products, South Jordan, UT) and a mixture of
pumice and chlorhexidine gluconate (eg, Consepsis
Figure 9. Postoperative view 8 years following placement
of indirect composite resin (Concept, Ivoclar Vivadent,
Amherst, NY). Note restorations do not exhibit visible
wear and are color stable.
Figure 8. Case 2. Preoperative occlusal view of a quadrant
of amalgam fillings.
Figure 10. Case 3. Preoperative occlusal view of molar
with mesiolingual cusp fractured.
P P A D 895
Jackson
Scrub, Ultradent Products, South Jordan, UT). Once it has
been washed, the tooth is further disinfected and scrubbed
with 2% chlorhexidine gluconate. The restoration is tried
in and evaluated for complete seating. The contacts are
examined with floss and adjusted as necessary. Prior to
bonding, a handle (eg, Pic- N- Stic, Pulpdent Corp.,
Watertown, MA; True-Grip, Clinicians Choice, New
Milford, CT) is placed to facilitate convenient placement.
The indirect resin restoration is sandblasted by the
technician with 50 m aluminum oxide particles prior to
its return to the clinician. Since all the laboratory-
fabricated resins are highly polymerized, the adhesion
of the resin cement is created by the micromechanical
retention provided by sandblasting. In the rare event that
the internal surface has been adjusted by the clinician, it
should be resandblasted. As this internal surface becomes
contaminated during try-in procedures, it is advisable to
clean it by applying a 32% to 40% phosphoric acid to
the surface for 10 seconds. Once the acid has been
rinsed away, silane and/or a wetting agent (specified
by the manufacturer) is applied to the cleaned internal
surface and the restoration is set aside. A matrix band
is placed around the tooth and adapted tightly to the
gingival margin. This prevents inadvertent etching of the
adjacent tooth and even more importantly prevents
the accidental etching and bonding of the resin cement
apical to the gingival margin.
The total-etch bonding technique can be utilized
with fourth or fifth generation universal bonding agents,
although it is essential to precisely follow the manufac-
turers directions. Numerous dual-cure resin cements of
various viscosities are presently available and while mate-
rial selection is essentially based upon personal prefer-
ence, it is necessary to use a translucent or neutral shade.
This cement is mixed and applied to the internal surface
of the restoration. Although cement can also be applied
to the prepared tooth, this is generally unnecessary if it
has been properly blocked out. The matrix band is sub-
sequently removed, and the restoration is seated into the
tooth and held in place with light pressure from a plas-
tic instrument or a ball burnisher.
Excess cement is removed with a metal instrument
or a rubber tip. Since a brush can occasionally remove
cement from the margins and leave deficiencies, its use
is not recommended. The utilization of metal instruments
or rubber tips leaves excess cement at the occlusal mar-
gins, which can be beneficial. Excess resin cement at
this margin can preclude the use of glycerin to prevent
air inhibition, as it occurs in the unpolymerized excess.
A pigtail explorer is used to remove cement interproxi-
mally, and the gingival margin is cleaned by sweeping
floss through the contact occlusogingivally. This process
Figure 11. Postoperative occlusal view. The conservative
indirect resin onlay restoration (Concept, Ivoclar Vivadent,
Amherst, NY) has been in function for 6 years.
Figure 12. Case 4. Occlusal view of tooth #3(16) following
removal of amalgam and preparation for an indirect
resin inlay. External enamel cracks are left intact on the
marginal ridges.
Figure 13. Postoperative occlusal view. The bonded resin
inlay restoration reinforces the weakened marginal ridges
and may prevent further crack propagation. The cracks
are sealed by the luting resin.
896 Vol. 11, No. 8
Practical Periodontics & AESTHETIC DENTISTRY
eliminates excess cement from the margin and minimizes
the need to finish this area. The floss remains in place
while the restoration is light cured at the buccal and lin-
gual interproximal areas as well as the occlusal surface
for a minimum of 40 seconds at each site. The duration
of the curing period may be a function of the type of
light source utilized. While resin cements are generally
The rubber dam is removed, and the occlusion is
verified with articulating paper. Any necessary adjust-
ments can be performed with carbide finishing burs and
repolished with rubber cups, points, or wheels. The appli-
cation of a resin sealer has not demonstrated any benefit
to the luting resin.
35
Since laboratory-fabricated compos-
ite materials generally require little finishing, it is unlikely
that the application of a surface sealant would have a
similarly beneficial effect on the inlay/onlay restoration
as is noted for direct posterior resin restorations.
Case Presentations
Case 1
A 37-year-old female patient presented with cracks in
both marginal ridges in tooth #3(16) (Figure 6). Leakage
in these cracks had allowed caries to initiate interproxi-
mally. The amalgam restoration in tooth #2(17) had
open margins and leakage was suspected. The restora-
tion in tooth #4(15) had been placed several years pre-
viously with a macroparticle direct resin material and
exhibited leakage at the margins. Since the first molar
restoration was relatively large and the tooth was under
high functional demand, an indirect resin (Concept,
Ivoclar Vivadent, Amherst, NY) restoration was placed.
The cavities in the adjacent teeth were small and restored
with a contemporary direct resin and the total -etch tech-
nique (Figure 7). Since these restorations reinforce and
seal the teeth, long-term performance can be expected.
Case 2
This 39-year-old female patient exhibited bruxism and
had experienced fractured cusps in several posterior teeth
that had been replaced with full-coverage crown restora-
tions (Figure 8). The patient was dissatisfied with the
appearance of the amalgam and, upon learning of the
potential benefits of conservative adhesive tooth-colored
materials, requested replacement with inlay/onlay restora-
tions. The patient was satisfied with the improved aes-
thetic result and has not experienced subsequent tooth
fracture (Figure 9). Although cusp fracture is less likely to
occur with adhesive restorations, long-term investigations
have yet to verify the maintenance of this bond.
Case 3
A 48-year-old female patient presented with a fracture
of the mesiolingual cusp of tooth #30(46) (Figure 10).
Traditional restorative dentistry would have presumably
necessitated a larger possibly pin retained amalgam
or cemented cast- gold onlay restoration for this patient.
The use of pins has always entailed potential compli-
cations, and the placement of a larger amalgam restora-
tion could have predisposed the tooth to a full - coverage
P P A D 897
Jackson
Figure 14. Case 5. Preoperative occlusal view of asympto-
matic amalgam restorations that require replacement
(From J Esthet Dent with permission).
Figure 15. Following removal of the amalgam in the
molar, a crack was evident at the axial-pulpal line angle
of the mesiobuccal cusp. The preparation is complete and
undercuts are blocked out.
Figure 16. Five-year postoperative occlusal view of the
indirect resin inlay and onlay restorations in the premolar
and molar, respectively.
dual cured, polymerization is greater for light curing.
33,34
Once the floss is removed, any cement along the inter-
proximal aspect can be eliminated with a #12 blade
on a scalpel or a carving knife (CR21 Esthetic Carving
Knife, Hu-Friedy, Chicago, IL). The gingival margin can
be further finished and polished with narrow aluminum
oxide finishing strips if necessary.
crown restoration. Although cast gold has a clinical his-
tory of long-term success that surpasses the 13-year results
of indirect resin restorations, the patient elected treatment
with the latter (Figure 11).
Case 4
A 46- year-old female patient presented with an occlusal
amalgam restoration that required replacement (Figure 12).
While enamel cracks were evident in both marginal
ridges, no clinically detectable proximal caries was
observed, and the radiograph indicated that the proxi-
mal enamel surfaces were intact. If the tooth was to be
re-restored with amalgam, typical preparations would
require mesial and distal box forms. This would convert
the cavity to an MODL preparation and sacrifice signif-
icant tooth structure. Consequently, an occlusolingual indi-
rect resin inlay restoration was placed without removing
proximal tooth structure. The cracks were sealed and the
marginal ridges were reinforced with an adhesive restora-
tion (Figure 13). Should proximal caries develop in the
future, a conservative box preparation and direct resin
would be used to treat it without necessitating the removal
of the aesthetic inlay restoration.
Case 5
Upon removal of an amalgam restoration in tooth #3(16)
of a 44- year- old female patient (Figures 14 and 15), a
crack was discovered at the axial pulpal line angle of
the mesiobuccal cusp. The tooth was asymptomatic, only
one crack was evident, substantial tooth structure
remained, and the patient had no excessive parafunc-
tional habits. The cusp was retained and reinforced by
the placement of a bonded indirect resin inlay/onlay
restoration (Concept, Ivoclar Vivadent, Amherst, NY). If the
tooth was to be restored with amalgam or gold, the cusp
would be considered too weak to support normal occlusal
loads and would have to be removed and overlaid.
Since classification is based upon cavity size rather than
restorative material and technique, the aesthetic adhe-
sive restoration is classified as an onlay rather than an
inlay. It should be noted that the slight ditching that is
occasionally evident at the margins of older restorations
is self-limiting and of no clinical significance (Figure 16).
36
Case 6
A 49-year-old female presented with pain upon masti-
cation, which the patient had identified as originating
from tooth #3(16) (Figure 17). Following clinical exam-
ination, a preliminary diagnosis of cracked tooth syn-
drome was determined, and each cusp was sequentially
tested. The mesiofacial cusp elicited sharp pain when
subjected to occlusal pressure. Since inconsistent results
Figure 20. Postoperative view 12 years following
replacement with indirect composite resin
(Concept, Ivoclar Vivadent, Amherst, NY).
Figure 17. Case 6. Patient presented with
cracked tooth syndrome of the mesiobuccal cusp
of the maxillary first molar.
Figure 18. Postoperative occlusal view. The
symptomatic cusp was removed and an indirect
composite resin onlay restoration was placed.
Figure 19. Case 7. Preoperative occlusal view in
which the amalgam filling in the molar is cracked,
and the restoration in the premolar is leaking.
898 Vol. 11, No. 8
Practical Periodontics & AESTHETIC DENTISTRY
have been achieved when such cusps are retained, the
cusp was aggressively removed and overlaid with an
aesthetic indirect resin restoration (belleGlass HP, Kerr/
Sybron, Orange, CA) (Figure 18).
Case 7
This 65-year-old female patient presented with a frac-
tured amalgam restoration in tooth #31(47) and leak-
ing margins around the amalgam in tooth #29(45)
(Figure 19). The patient indicated that the area between
the teeth had always trapped food. It appeared that the
patient had lost the first molar at a young age and that
the second molar had tipped mesially into the space,
which made it clinically difficult to place amalgam or
direct resin and achieve a quality contact. Inlays were
proposed as a means of restoring the teeth and improv-
ing periodontal health. Although the patient was also
offered treatment with cast gold, which offered pre-
dictable long-term function, aesthetic inlay restorations
were selected despite the relatively unknown (at time of
placement) longevity of this material (Concept, Ivoclar
Vivadent, Amherst, NY) (Figure 20).
Case 8
A 50-year-old female patient fractured off the buccal
cusp of tooth #13(25), which exposed the underlying
pulp. Following endodontic treatment, the tooth was
restored with a bonded resin onlay (Concept, Ivoclar
Vivadent, Amherst, NY) that extended into the pulp
chamber (Figures 21 through 23). Traditional dentistry
would have required the use of a post and core with a
full- coverage crown restoration to treat this condition. If
the occlusion is not excessive, a conservative aesthetic
restoration can be delivered using adhesive dentistry and
laboratory- fabricated resin (Figure 24).
Conclusion
The development of adhesive materials and technology
has revolutionized the scope of restorative dentistry. Since
amalgam has low technique sensitivity and expense,
however, clinicians may be reluctant to incorporate adhe-
sive procedures into their practices. The principal limi-
tation of amalgam as a restorative material is that it does
not support the remaining tooth structure. In fact, amal-
gam often acts as a wedge,
37,38
which is believed to be
involved with internal crack development. Since patients
are living longer and expecting to maintain the integrity
of their teeth, it is increasingly important for clinicians to
utilize adhesive procedures.
39
The biomechanics of adhesive resin restorations,
which can actually serve as intracoronal splints, are the
opposite of those for amalgam dentistry. The clinical
Figure 24. Postoperative buccal view of the indi-
rect resin restoration, which is integrated with
the existing dentition.
Figure 21. Case 8. Occlusal view of the die
demonstrates the completed preparation.
Figure 22. Proximal view illustrates the exten-
sion of the one-piece indirect resin restoration
into the pulp chamber.
Figure 23. Occlusal view of the definitive
restoration 2 years postoperatively.
P P A D 899
Jackson
900 Vol. 11, No. 8
Practical Periodontics & AESTHETIC DENTISTRY
techniques are also vastly different from those used to
place amalgam. In order to achieve a successful result,
a clinician must possess comprehensive knowledge of
the resin systems, adhesive technology, and become tech-
nically proficient in exacting procedures. Although clin-
icians receive extensive university training in amalgam
placement, these techniques cannot be used for adhe-
sive dentistry. Modifying the professions restorative
approach will not be easy and will not occur immedi-
ately, particularly at the university level.
40
Such change
is inevitable, however, especially when the advantages
of adhesive dentistry are considered. Bonded, tooth-
colored restorations seal and reinforce teeth, require less
removal of sound tooth structure, and are clearly aesthetic.
Direct resin, indirect intracoronal, and partial-coverage
onlay restorations have the potential to bank tooth struc-
ture and postpone or prevent the progression of medium
and large amalgam restorations to full-coverage crowns
via the wedge effect. This feature, combined with the
durability and aesthetics of the inlay/onlay restoration,
is critical to patients and will continue to direct the nature
of restorative dentistry.
Acknowledgment
The author is the developer of E-Z Temp and retains a
royalty interest. He further acknowledges his participa-
tion in the design of the Esthetic Inlay/Onlay bur kit, but
accrues no benefits from its sale.
The indirect resin restorations featured in this article
were fabricated by William Campbell, CDT, Ronald
Ferguson, CDT, Orrin King, CDT, and Gregg Vesely, CDT.
References
1. Jackson RD. Esthetic inlays and onlays. Curr Opin Cosmet Dent
1994:30-39.
2. Garber D, Goldstein R. Porcelain & Composite Inlays & Onlays.
Carol Stream, IL: Quintessence Publishing, 1994.
3. Christensen G. Restoration or crown? J Am Dent Assoc 1997;
128(6):771-772.
4. Dietschi D, Spreafico R. Adhesive Metal-Free Restorations. Carol
Stream, IL: Quintessence Publishing, 1997.
5. van Dijken JW, Hrstedt P. Marginal breakdown of 5-year-old
direct composite inlays. J Dent 1996;24(6):389-394.
6. Donly K, Jensen M, Triolo P, et al. A clinical comparison of
resin composite inlay and onlay posterior restorations and cast
gold at 7 years. Quint Int 1999;30:163-168.
7. Touati B, Aidan N. Second generation laboratory composite
resins for indirect restorations. J Esthet Dent 1997;9(3):108-118.
8. Lutz FU, Krejci I, Oddera M. Advanced adhesive restorations:
The post-amalgam age. Pract Periodont Aesthet Dent 1996;8(4):
385-394.
9. Lopes LM, Letlao JG, Douglas WH. Effect of a new resin
inlay/onlay restorative material on cuspal reinforcement. Quint
Int 1991;22(8):641- 645.
10. Pearson GJ, Hegarty SM. Cusp movement of molar teeth with
composite filling materials in conventional and modified MOD
cavities. Br Dent J 1989;166(5):162-165.
11. Hasegawa EA, Boyer DB, Chan DC. Microleakage of indirect
composite inlays. Dent Mater 1989;5(6):388-391.
12. Milleding P. Microleakage of indirect composite inlays: An in
vitro comparison with the direct technique. Acta Odontol Scand
1992;50(5):295-301.
13. Llena Puy MC, Forner Navarro L, Faus Llacer VJ. Composite resin
inlays: A study of marginal adaptation. Quint Int 1993;24(6):
429-433.
14. Dietschi D, Scampa U, Campanile G, Holz J. Marginal adapta-
tion and seal of direct or indirect Class II composite resin restora-
tions: An in vitro evaluation. Quint Int 1995;26(2):127-138.
15. Wendt SL, Leinfelder KF. The clinical evaluation of heat-treated
composite resin inlays. J Am Dent Assoc 1990;120(2):177-181.
16. Kanca J. The effect of heat on the surface hardness of light-
activated composite resins. Quint Int 1989;20(12):899- 901.
17. McCabe JF, Kagi S. Mechanical properties of a composite inlay
material following post-curing. Br Dent J 1991;171(8):246-248.
18. DeGee A, Pallar P, Werner A, Davidson CL. Annealing as a
mechanism of increasing wear resistance of composites. Dent
Mater 1990;6:266-270.
19. Mante F, Saleh N, Mante M. Softening patterns of post-cure
heat-treated dental composites. Dent Mater 1993;9(5):325-331.
20. Mitchem JC, Wagner PC, Ferracane JL. Marginal adaptation
of the concept inlay system. Am J Dent 1994;7(5):232-234.
21. Burgoyne AR, Nicholls JI, Brudvik JS. In vitro two-body wear of
inlay-onlay composite resin restorations. J Prosthet Dent 1991;
65(2):206-214.
22. Ratledge DK, Smith BG, Wilson RF. The effect of restorative mate-
rials on wear of human enamel. J Prosthet Dent 1994;72(2):
194-203.
23. Gregory WA, Berry S, Duke E, Dennison JB. Physical proper-
ties and repair bond strength of direct and indirect composite
resins. J Prosthet Dent 1992;68(3):406- 411.
24. Turner CW, Meiers JC. Repair of an aged, contaminated indi-
rect composite resin with direct, visible-light-cured composite
resin. Oper Dent 1993;18(5):187-194.
25. Trends in dentistry: A survey. Dent Prod Rep 1997; Apr:25.
26. Jackson RD. Aesthetic inlays and onlays: A clinical technique
update. Pract Periodont Aesthet Dent 1993;5(3):18- 27.
27. Gilmore HW. Textbook of Operative Dentistry. St. Louis, MO:
CV Mosby, 1977.
28. Shillingburg H, Jacobi R, Bracket S. Fundamentals of Tooth Prepa-
rations. Carol Stream, IL: Quintessence Publishing, 1987:237.
29. Burke F, Wilson N, Watts D. The effect of cuspal coverage on
the fracture resistance of teeth restored with indirect composite
restorations. Quint Int 1993;24:875-880.
30. Liebenberg WH. Use of resin-bonded partial coverage ceramic
restorations to treat incomplete fractures in posterior teeth: A clin-
ical report. Quint Int 1996;27(11):739-747.
31. Behle CA. Conservative direct and indirect resin posterior restora-
tive alternatives for cracked dentition. Pract Periodont Aesthet
Dent 1997;9(4):130-135.
32. Barghi N, Knight GT, Berry TG. Comparing two methods of
moisture control in bonding to enamel: A clinical study. Oper
Dent 1991;16(4):130-135.
33. El-Bardrawy W, El-Mowafy O. Chemical versus dual-curing of
resin inlay cements. J Prosthet Dent 1995;73:515-524.
34. Darr AH, Jacobsen PH. Conversion of dual-curing luting cements.
J Oral Rehabil 1995;22(1):43-47.
35. Shinkai K, Suzuki S, Leinfelder KF, Katoh Y. Effect of surface-
penetrating sealant on wear resistance of luting agents. Quint Int
1994;25(11):767- 771.
36. ONeal SJ, Miracle RL, Leinfelder KF. Evaluating interfacial gaps
for esthetic inlays. J Am Dent Assoc 1993;124(12):48-54.
37. Davis MW, Nesbitt WE. The wedge effect: Structural design
weakness of Class II amalgam. AACD J 1997;Fall:62-68.
38. Davis MW. Cuspal fracture with conventional Class II amalgam.
Dent Today 1998;Dec:42-49.
39. Christensen GJ. The future of dentistry? Treatment shifts to the
older adult. J Am Dent Assoc 1992;123(5):89-90.
40. Mjr IA, Wilson NH. Teaching Class I and Class II direct com-
posite restorations: Results of a survey of dental schools. J Am
Dent Assoc 1998;129(10):1415-1421.
1. Aesthetic inlay/onlay restorations are indicated
in all of the following situations EXCEPT when:
a. The patient desires an aesthetic posterior
restoration.
b. Isolation and saliva control are not achieved.
c. There still exists a moderate amount of healthy
tooth structure.
d. The lesion is large and/or under heavy
occlusal stress.
2. Which of the following statements about
preparation design is not true?
a. The minimum material thickness is 1.5 mm.
b. The wall can be flared 5 to 15.
c. Cavosurface margins are beveled.
d. The gingival floor can be a butt joint.
3. When preparing the occlusal apsect of the
cavity for a resin bonded inlay, how should
undercuts be treated?
a. They should be blocked with bonded resin
or resin modified glass ionomer.
b. They should be removed and proper box form
established.
c. They can be left for the technician to block
them out on the die.
d. They should be etched and a dental bonding
agent placed.
4. It is usually necessary to protect the pulp for
inlay/onlay preparations. Bases and liners
should be placed on the pulpal floor for
inlay/onlay preparations.
a. Both statements are true.
b. Both statements are false.
c. The first statement is true and the second false.
d. The first statement is false and the second true.
5. When external enamel cracks are present in a
relatively intact poterior tooth without proxi-
mal caries, how should the tooth be treated?
a. The cusps should be removed and a gold
crown restoration performed.
b. The tooth should be restored with a large
amalgam.
c. The cracks should be sealed and marginal
ridges reinforced with an adhesive resin.
d. With a conservative box preparation and
a direct resin inlay/onlay.
6. When luting an indirect posterior resin
restoration:
a. Placement of a matrix band helps to control
the acid etchant.
b. Use of rubber dam isolation is optional.
c. The luting resin is an opaque neutral shade.
d. Etching and bonding of the resin cement
apical to the gingival margin occurs.
7. How should a tooth be treated when it is
symptomatic and has been diagnosed with
cracked tooth syndrome?
a. The cusps should be removed and the tooth
crowned.
b. The tooth should be endodontically treated
prior to restoration.
c. The cracked cusp should be overlaid.
d. The cracks should be sealed with an adhesive
resin.
8. A cusp should be onlayed when:
a. The cusp is a working cusp and the cavo-
surface margin is within 1 mm of the cusp tip.
b. Adequate dentin support is present directly
under the cusp tip.
c. The working cusp and the cavosurface margin
are within 2 mm of the cusp tip.
d. The cavosurface margin is low on the cuspal
incline.
9. A tooth that has received endodontic
treatment can be restored with a bonded resin
onlay under what conditions?
a. In any case in which a post and core
restoration could be used.
b. When the occlusion is not excessive.
c. When there is not enough tooth structure for
a pin amalgam.
d. When a gold crown is not desired.
10. Indirect resin inlay/onlay restorations:
a. Are still considered experimental.
b. Have demonstrated unreliable performance
ratings.
c. Can virtually act as an intracoronal splint.
d. Perform similarly to those in amalgam
dentistry.
902 Vol. 11, No. 8
To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and
complete as follows: 1) Identify the article; 2) Place an X in the appropriate box for each question of each exercise; 3)
Clip answer sheet from the page and mail it to the CE Department at Montage Media Corporation. For further instruc-
tions, please refer to the CE Editorial Section.
The 10 multiple-choice questions for this Continuing Education (CE) exercise are based on the article Indirect resin inlay
and onlay restorations: A comprehensive clinical overview by Ronald D. Jackson, DDS. This article is on Pages 891-900.
Learning Objectives:
This article provides a comprehensive review of aesthetic inlay/onlay restorations. Indications/contraindications are
addressed and highlighted with case presentations. Upon reading and completing this exercise, the reader should have:
Improved ability to prepare, cement, and finish aesthetic inlay/onlay restorations.
Enhanced understanding of the benefits of adhesive procedures.
CONTINUING EDUCATION
(CE) EXERCISE NO. 29
C
E
CONTINUING EDUCATION
29
NEW YORK UNIVERSITY
College of Dentistry
Center for Continuing Dental Education
New York City, NY