The double-inlay technique: A new concept and improvement in design

Bruno Dailey, DDS,a Philippe Gateau, DDS,b and Laurent Covo, DDS, MSc
Faculty of Dentistry, University of Paris, Paris, France
Gold and ceramic have long been used in prosthetic dentistry. In the posterior region, it is possible
to use both materials with the double-inlay technique to add the strength of metal to the esthetics
of ceramic. The problem, however, remains the volume of tooth reduction required to avoid
ceramic fracture. This article describes a modification of the double-inlay technique that makes use
of a pin system. This modified technique permits good retention while avoiding excessive tooth
reduction. (J Prosthet Dent 2001;85:624-7.)

atient concerns about esthetics have increased the

use of indirect porcelain inlays for restoring Class II
and Class III cavities. Some studies have shown that, if
used under stringent clinical conditions, these restorations may have a satisfactory survival rate of more than
5 years.1-3 Inlays fabricated with new laboratory composite materials such as Targis-Vectris (Ivoclar, Schaan,
Liechtenstein) have shown good results4,5 but still
need to be tested for longer time intervals.
When choosing a restorative material, the clinician
should consider which material will result in minimal
destruction of the tooth; display morphology and
mechanical properties similar to the tooth; create a seal
that guards against recurrent decay, pulpal disease,
and/or dentinal sensitivity; and be biocompatible with
the intraoral tissues. A material that meets these criteria
should increase the longevity of the restorations.6
Many cosmetic inlays are constructed for use in the
posterior region, and for many reasons, premolars are
good candidates for these techniques.7 Esthetics are
more obvious in the anterior than the molar area, and
occlusal wear is less damaging in the premolar
region.8,9 Moreover, easy access to this region allows
the clinician to maintain better control of the technique. The use of ceramic inlays for restoring posterior
cavities is considered an adequate treatment by many
clinicians. However, these restorative materials and the
techniques used to bond them have limitations, which
include the following: (1) A wide diastema between 2
teeth often results in excessive unsupported ceramic
and increases the risk of ceramic fracture. (2) Cervical
margins, located at or slightly underneath the marginal gingiva, are poor candidates for bonding. It has
been shown that a large enamel surface is superior for
composite bond strength.10 (3) It has been demonstrated that there is a better bond strength to crown
dentin than to root dentin.11 (4) The use of a rubber
aConsultant,

Department of Prosthodontics.
Professor, Deparment of Prosthodontics.
cFormer Assistant Professor, School of Dentistry, Marquette
University, Milwaukee, Wis.
bAssistant

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dam is mandatory for proper results with bonding

techniques. Saliva, blood, or sulcular fluid may interfere with the cementation procedure if the preparation
is located in the subgingival area.12 (5) Patients with
parafunctional occlusal habits (grinding, clenching,
and bruxomania) are poor candidates for ceramic
restorations.13
For these different reasons, the authors have suggested combining gold and porcelain for posterior inlay
construction.13-15 With a double-material inlay technique, 2 treatment options are possible: a 1-piece inlay
containing ceramic fused to gold in the laboratory13,14
and a 2-piece inlay with a cemented metal base overlaid
by a bonded porcelain inlay.15 The major problem with
the double-inlay technique is the amount of tooth
reduction needed to avoid ceramic fracture. A cavity
preparation of 2.5 mm is mandatory because of the volume required for the 2 inlay components.
This article describes a modification of the doubleinlay technique. The modified technique involves less
tooth reduction and decreases the risk of fracture in
Class II and III cavities. The treatment presented was
performed on a Class II double-inlay restoration on
the first maxillary premolar of a 27-year-old female
patient. The alternative treatment was root canal therapy and a prosthetic crown.

PROCEDURE
1. Prepare the occlusal cavity as a classic ceramic
inlay box-shaped preparation with an appropriate
bur (835-016, Komet, Berlin, Germany). The
isthmus should be as large as possible, and sharp
angles should be avoided.
2. Unlike other techniques, a minimal depth of only
1.5 mm for the occlusal cavity is needed because
the floor will not be covered by the metal structure.
3. Prepare the proximal box for receiving the metal
base substructure (Fig. 1). The cavity preparation
should be extended until the proximal contact
with the adjacent tooth is completely open, with a
minimum thickness of 1 mm on all sides. Bevel
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Fig. 1. Preparation design of double inlay.

Fig. 3. Master die of first maxillary premolar preparation for

double inlay and first premolar for gold-ceramic crown.

Fig. 2. Preparation before impression with plastic pin in

place in pit.

Fig. 4. Disto-occlusal double inlay on master die with type

IV gold.

only the gingival margin to ensure the best fit of

the metal casting portion at this critical area. Also
prepare a 1.5- to 2.0-mm dentinal pit at the floor
of the proximal cavity, parallel to the pulp chamber and to the long axis of the root. This allows
precise 3-dimensional placement and aids in
retention of the metal base. We suggest replacing
the horizontal part of the metal base covering the
cavity floor and the vertical grooves described in
the other techniques with the Vertical Parallel Pin
system (Whaledent, Mahwah, N.J.).
Place the 0.7-mm calcinable pin into the prepared
pin hole, and make an impression with an appropriate impression material (Permadyne Garant 2:1
and Penta, ESPE, Seefeld, Germany) (Fig. 2).
Select the shade of porcelain.
Fabricate and cement the provisional restoration
with a noneugenol cement (Fermit, Vivadent,
Schaan, Liechtenstein).
In the laboratory, pour the impression in die stone

(Fuji Rock, GC, Bruxelles, Belgium) (Fig. 3).

Fabricate both components with the same working cast. Cast the metal base with ceramic gold
type IV (Estheticor royal, Cendres et Metaux,
Bienne, Switzerland) (Fig. 4). The gold-ceramic
joint must be built above the gingival margin to
ensure accurate bonding and proper polishing.
8. Place a ceramic opaque porcelain to cover the
occlusal portion of the inlay surface (Fig. 5). The
opaque increases the bonding strength16 and also
decreases black shadow by masking the metal of
the ceramic inlay. Fabricate the ceramic inlay conventionally with the IPS Empress system (Ivoclar)
(Fig. 6).
9. At the second clinical appointment, place a rubber
dam to avoid any contamination. Both inlays
should be evaluated for accuracy and color in a
clean cavity.
10. Cement the gold inlay first with a glass ionomer
cement (Ketac Cem, ESPE) (Fig. 7) or conven-

4.

5.
6.

7.

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DAILEY, GATEAU, AND COVO

Fig. 5. Ceramic opaque glaze covering occlusal inlay surface.

Fig. 7. Cemented gold inlay portion.

Fig. 6. Block-inlay over metal structure.

Fig. 8. Ceramic inlay porcelain bonded to dental tissue and

over metal piece.

tional zinc phosphate cement. Remove excess

with a sharp explorer (Hu-Friedy, Chicago, Ill.).
11. Evaluate the ceramic inlay after the sealing procedures to ensure the fit. Then apply bonding
agents on the metal and tooth structure. Apply
37% phosphoric acid for 60 seconds (Uni-Etch,
Bisco, Schaumburg, Ill.), and activate the ceramic
with a silane agent (Silane, Ultradent, South
Jordan, Ill.). Select an appropriate bonding system
with a dual-polymerizing resin cement (Allbond
II and Choice, Bisco) that enhances bonding to
ceramic and metal structures.17
12. After light polymerization, evaluate the occlusion
and conduct final polishing with finishing burs,
silicon burs, and diamond paste (Dia-Finish,
Renfert, Illzingen, Germany) (Figs. 8 and 9).

SUMMARY
Previously used techniques may have increased
destruction of the tooth structure, primarily because
vertical grooves were needed to enhance retention and
secondarily because the cavity floor had to be covered
to allow precise placement of the inlay. The double626

Fig. 9. Final aspect of double-inlay restoration. Note small

amount of visible metal.

inlay technique presented in this article combines the

advantages of gold and ceramic restorative materials
and makes use of a parallel pin system, which allows
less tooth structure removal and permits retention and
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perfect adaptation of the restoration. A 5-year patient

treatment that made use of this technique showed
encouraging results.
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11. Shono Y, Ogawa T, Terashita M, Carvalho RM, Pashley EL, Pashley DH.
Regional measurement of resin-dentin bonding as an array. J Dent Res
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14. Sewitch T. Resin-bonded metal-ceramic inlays: a new approach. J
Prosthet Dent 1997;78:408-11.
15. Hannig M, Schmeiser R. Esthetic posterior restorations utilizing the double-inlay technique: a novel approach in esthetic dentistry. Quintessence
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16. Suh BI. All-Bondfourth generation dentin bonding system. J Esthet
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Reprint requests to:
DR LAURENT COVO
37, AVENUE VICTOR HUGO
75116 PARIS
FRANCE
FAX: (33)40-67-7282
E-MAIL: lcovo@club-internet.fr
Copyright 2001 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2001/$35.00 + 0. 10/1/115651

doi:10.1067/mpr.2001.115651

New product news

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