Ceramic Inlays: Clinical Assessment and

Survival Rate
Massimo FuzziVGiorgio Rappellib

Purpose: This study evaluates the olinical behavior of oeramic inlays piaced during the past decade.
Materials and Methods: One hundred eighty-two inlays were examined in 66 patiehts. The interval between placement and assessment was oh average 5.9 years 2.7, ranging from 2 to 11.7 years. Restorations still present at the time of evaluation were clinically assessed according to modified USPHS criteria.
Kaplan-Meier statistical analysis was used to assess the survival rate.
Results: According to USPHS criteria, good results were obtained for color match, marginal discoloration,
recurrent caries, contour, and marginal integrity. Six inlays failed: four for endodontic reasons, one due to
recurrent caries, and the other due to fracture. The results indicate that a success rate of 95% could be
predicted at 11.5 years.
Conclusion: The lack of recurrent canes, the ohiy slight changes ih marginal discoloration and color
match, combined with the excellent longevity prove that ceramic inlays are a valuable tool for the restoration of posterior teeth.
J Adhesive Dent 1999; 1; 71-79.

Submitted for publication: 06.10 98: accepted for publicai/on: 05.11,98.

he challenge of reproducing natural esthetics

has been present for several decades, with a
constant improvement of restorative materials and
appiicatjon techniques.
Since 1882, when Herbst introduced the first ceramic iniays,2^ great progress has been made.
Today, thanks to improvements in adhesion techniques and material characteristics, indirect ceramic restorations are one of the aiternatives to
amalgam, particularly in large cavities, enabling the
esthetic demands of patients to be met for their
posterior teeth.2.7.11.25.26 j ^ j g type of restoration
aiso strengthens the tooth structure and preserves
dentai tissue to a large extent.^

Porcelain remains the materiai of choice for naturai-looking, esthetic restorations, due to its excellent optical qualities, indirect fabrication process,
and favorable bioiogical response. However, investigations on the longevity and ciinical behavior of ceramic inlays are insuffioient.

in 1992, Mrmann and Krejct^^ estimated a suocess rate with the Cerec system of 75% after 5
years. That same year, Studer et ai^o reported a
survival rate of 98% based on 130 iPS Empress inlays, examined at 186 months. In 1994, Reiss^^
examined 1000 Cerec-type inlays and, using the Kapian-Meier survivai analysis, found a success rate
of 9 1 % after 6 years. In 1994, Moaci< and Rouieti^
examined porcelain inlays piaced by students and
found a survivai rate of 75% after 4 years. In 1995,
Rouletts assessed 123 iniays with the KapianiVleier analysis and found a success rate of 76% at
6 years. The failures were due to fractures and en^ Private practice. Bologna, Itaiy.
dodontic causes, partiy related to extended applica' Private practice, Osimo (An), itaiy
tions. Studer and coworkers^^ published data in
1996 on 130 IPS-Empress iniays, reporting a surReprint requests: Dr Massimo Fuzzi, 7 Piazza P.ta Mascareila. vivai rate of 97.5% after 2 years, in 1996, Qual40128 Boiogna. Itaiy Fax: ++39 051 240513; E-mail: SAOS-FUZZim
trough and Wilson^" obtained a success rate of
maii.asianet.it

Vol 1, No 1,1999,,,

71

Fuzzi/Rappeili

Fig 1 The margins of the preparation are placed on the

enamel. The dentin side, when neoessary, is reoonstruoted
with a glass-ionomer photooured base.

Fig 2 The impression with poiyether materiai reproduces aii

the details of the preparation, A fluid msteriai (Permadyne
biue, ESPE, Seefeid, Germany) is applied to the tooth, A
thioi^er material [Impregum, ESPE, Seefeid, Germany) is applied to the tray.

82% from 50 ceramic inlays examined at 3 years.

In 1997, Fradeani et ai^ reported a 96% success
rate over 125 iPS-Empress inlays examined at 4.5
years. That same year, Roulet^* reported a 4% annual faiiure rate of Dicor porcelain inlays.
The present study assesses the survival rate and
ciinicai condition of porcelain inlays provided by
one of the authors in his ciinicai practice over the
period 1986 to 1996,

in the period from 1986 to 1990 and Fortune fired

ceramics (Williams-lvociar, Amherst, New York, NY,
USA) from 1 9 9 1 to 1996. Luting was carried out
with a rubber dam in place, Cavex Protect Varnish
(Cavex, Haarlem, Holland, by Kuraray Co Ltd, Japan)
was used to protect the external part of the cavity
during luting; the varnish was applied with a pellet
and removed with alcohol after luting the inlays^"
(Fig 3). The fitting surface of the ceramic restorations was etched with hydrofiuoric acid (HF 10%) by
the technician after try-in. Siianization with 3M
Silane (3IVI Dental Products Division, St Paul, MN,
USA) was carried out by the dentist just before luting. Enamel and dentin were etched and primed.
The adhesive used in the period from 1986 tc

MATERIALS AND METHODS

One hundred eighty-two porcelain inlays were examined in 66 patients, 4 1 female and 26 male. Patient age ranged from 23 to 50 years. The iniays
included occiusai restorations (11), mesio-occlusal
(35), occluso-distal (45), mesio-occlusal-distal (63)
and cus pal-cove rage restorations (28), Cavity preparations with aii margins iocated in enamei were
completed in each tooth using Cerinlay diamond
burs (Intensiv, Viganelio-Lugano, Switzeriand) (Fig
1), Fuil-arch impressions including the preparations
were taken using a polyether impression material
(Impregum, FSPF, Seefeid, Germany) (Fig 2), while
the opposing arch was replicated with an algnate
impression. Fermit acrylic (Ivociar, Vivadent,
Schaan, Liechtenstein) or a reiated material was
used to make temporary restorations.
All restorations were made by the same technician
using Microbond Natural fired ceramics (Austenal
Dental-Austenal Internationai Inc, Chicago, IL, USA)

72

1992 was Scotchbond 2 (3M Dental Products Division, St Paul, MN, USA); enamel was etched with
37% phosphoric acid for 30 s, rinsed, and dried, A
bonding agent was used to achieve adhesion. From
1993 to 1996, Scotchbond MP (3M Dental Products Division, St Paui, MN, USA) was used as the
adhesive. A 10% maieic acid or 37% phosphoric
acid was applied to the enamei for 30 s and to the
dentin for 15 s; after rinsing and gently drying, a
thin layer of primer was appiied to the dentin, and a
bonding agent was used to achieve adhesion. The
luting materials used were dual-cured composites:
Ultra-Bond (Den Mat Corp, Santa Maria, CA, USA)
from 1986 to 1990 and indirect Porceiain System
Dentist Bonding (3M Dental Products Division, St
Paul, MN, USA) in the period from 1991 to 1996,
Following restoration placement, excess luting ma-

The Journal of Adhesive Dentistry

Fig 3 A varnish is applied to the external surface of the preparation to faciiitate the removal of the composite after polymerization. A transparent sticky wax is applied to the occlusal
part to facilitate the manipulation of the inlay.

Fig 4 The finished case, 1 year after completion.

terial was removed with sponge pellets, brush, and

super floss. The luting composite was light cured
from all aspects (5 min totai). The varnish, rubber
dam, and excess luting materai were removed. Occlusion was then checked and adjusted. Diamond
finishing burs and rubber points were used for finishing margins (Fig 4).
Ali patients were enroiied in a 3-to 6-month periodontai maintenance program consisting of remotivation, reinstruction of oral hygiene measures,
professional tooth cleaning, and fiuoridation. This
care was provided by a dental hygienist.
The restorations still present at the time of assessment were evaiuated clinically by a suitably
trained operator using modified USPHS criteria^i"
(Table 1). The margins were checked with a HuFriedy XP 23/OW (Hu-Friedy, Chicago iL, USA] explorer. Color was assessed under Siroiux iliumination (Siemens AG, Bensheim, Germany). The time
elapsed from the date of luting until the iast check
was 2 to 11.7 years.

89 and the subgroup older 87 inlays. The frequency

of "alpha" vaiues in the two groups was compared
by means of the exact analogue of the chi-square
test.i^ A iarger percentage of alpha in the group of
more recent restorations was interpreted as a trend
towards better values over time, without necessarily
providing an explanation ofthe cause.
Those inlays no longer present at the time of assessment were considered failures. Failures were
classified according to cause: a) fractures; b)
caries: c) endodontic reasons: d) unacceptable esthetics; e] periodontal problems.
To display the life expectancy of the inlays and
onlays, Kaplan-Meier survivai curves were piotted,
both for the whole sample and separateiy for permanent molars and premolars. The statistical
program SOLC 4,0 for D0S22 was used for calculations.i^ For the whole sample, 95% confidence intervals were constructed by multiplying by 1.96 the
estimated standard error of the probabiiity of survival at the time of each failure.

The oiinicai variables (color match, marginal discoloration, recurrent caries, contour, marginal integrity) were tabled using the statistical program
SAS for Windows, version 6.08.2-' A conditional
anaiysis of the iniays and onlays still intact at the
last observation was performed on those variables
for which several values of "bravo" or worse had
been recorded. To reconstruct the changes in the
variables, the median duration (5 years and 132
days) was used to create two subgroups: recent vs.
older restorations. The subgroup recent included

Vol 1, No 1, 1 9 9 9 .

RESULTS
Assessment of USPHS criteria showed 100% alpha
concerning recurrent caries. Color match analysis
of older restorations yielded 57% alpha and 43%
bravo: recent restorations were rated 8 1 % alpha
and 19% bravo (Fig 5), Marginal discoloration in
older restorations was rated 83% alpha and 17%
bravo, whiie recent restorations scored 94% alpha
73

Fuzzi/Rappeii

Table 1 Criteria for the clinical evaluation of the inlays

Category

Rating

Characteristic

Color matoh

Alpha

The restoration appears to match the shade ahd transiucehcy

of adjaoent tooth tissues.
The restoration does hot match the shade and transiuoency of
adjacent tooth tissues, but the mismatch is within the normai
range of tooth shades.
The restoration does hot match the shade and transiucehcy of
adjacent tooth structure, ahd the mismatch is outside the hormal range of tooth shades and transiucency.
The restoration cannot be examined without using a mouth
mirror.
There is no visual evidence of marginal discoloration different
from the color of the restorative matenai and from the coior of
the adjacent tootli structure.
There is visuai evidence of marginai discoloration at the junction of the tooth structure and the restoration, but the disooloration has not penetrated aiongthe restoration in a puipai direction.
There is visual evidence of marginai discoioration at the junction of the tooth structure and the restoration that has penetrated aiongthe restoration in a puipai direction.
There is no visual evidence of dark, deep discoloration
adjacent to the restoration.
There is visual evidenoe of dark, deep discoioration adjacent
to the restoration (but not directly associated with cavosurfaoe
margins).
The restoration is a continuation of existing anatomic form or
is siightiy fiattened. When the side of the explorer is piaced
tangentiaiiy aoross the restoration, it does not touch two opposing oavosurface line angles at the same time.
Asurfaoeoonoavity is evident. When the side of an expiorer is
placed tangentiaiiy aoross a restoration, the explorer touches
two opposing oavosurface iine angies at the same time, but
the dentin or base is not exposed.
There is a ioss of restorative substance so that a surface concavity IS evident and the base and/or dentin is exposed.
The expiorer does not catch when drawh across the surface of
the restoration toward the tooth, or, if the explorer doesoatoh,
there is no visible crevice aiongthe periphery of the restoration.
The expiorer catches and there is visibie evidence of a orevice,
into whioli the explorer penetrates, indicating that the edge of
the restoration does not adapt ciosely to the tooth structure.
The dentin is not exposed, and the restoration is not mobiie,
Tlie expiorer penetrates a orevice defect that extends to the
dentin-enamei junction.

Bravo
Charlie
Oscar
Marginal
disoo i oration

Aipha

Bravo

Recurrent
caries

Alpha
Bravo
Alpha

Chariie
Marginal
integrity

Alpha

and 6% bravo (Fig 6, Marginal integrity was rated

alpha in all restorations except five assessed as
bravo. Contour received bravo scores in 2 cases
and alpha in all others (Tab 2 and Tab 3) (Figs 7, 8),
Of the 182 iniays examined, 6 failed. Of these
failures, 4 were caused by endodontic probiems
and occurred during the first 6 months after cementation. One failure occurred after 3 years due
to fracture, and another was caused by recurrent
caries after 8 years. Five failures took piace in mo-

74

iars and one in a premolar. Using the Kaplan-Meier

analysis, the survivai index at 11.5 years was 95%,
and the values, calculated with a 95% confidence
interval (CI), ranged from 86.5% to 9 8 , 1 % (Fig 9).
Separating the results of the premoiars from those
of the molars, the survivai rate of the premolar
restorations was 99%, while the survival rate of the
molar restorations was 90,2% after 11,5 years
(Fig 10),

The Journal of Adhesive Dentistry

Fuzzi/Rappelli

Fig 5 A ciinicai example of 3 ceramic restorations after 11

years. The onlays on teeth 16 and 15 have been evaiuated as
bravo for color match, while the restoration on tooth 14 has
been evaluated as aipha.

Fig 6 The marginal discoloration of two iniays after 4 years in

a patient who smotes. Some points of the occlusal and proximai margins of tooth 14 are stained.

Fig 7 MOD iniays on tooth 36 anO 37, OD inlay on tooth 35.

Note the good ohromatic and marginai adaptation.

Fig 8 Radiographie verifications of the previous case. Notice

the absence of overhangs and the good marginal adaptation.

Table 2 Results of the clinical evaluation of 3ll 176 inlays examined

Recurrent canes
Marginal integrity
Contour
Marginal discoloration
Color match

176
176
176
176
176

176 (100%)
171 [97.2%|
174 (98.4%)
156 88.6%]
122(89.3%)

0 (0%)
5 (2.8%)
2 (1.6%)
20 (11.4%]
54(30.7%)

Table 3 Marginal discoioration and coior match of recent (< 5 y) vs

older {> 5 y) restorations; P < 0.05 (ChiMest)

Recent restorations
Older restorations

Marginal discoloration

Cclor match

Aipha
84 (94%)
72(83%)

Alpha
72 (81%)
50(57%)

Bravo
5 (6%)
15(17%)

Bravo
17 (19%)
37(43%)

75

Fuzzi/Rap pe 11
Kstill intact

sjrviMlrBtt

T-

ss%
9S%

.,

'

92%
90%
8fl%
86%
0

10

12

Years

Fig 9 Kaplan-Meier survival curve evaiuated for the totai number of inlays (2)
and 95% confidence interval (1 and 3).

S4iii>lars
%slillinlacl

-38 premolars

190% -|

98%

9B%
94%
92% .
90% .

10

DISCUSSION
All the inlays assessed were found to be clinicaiiy
satisfactory. Exampies are shown in Figures 11al l d . No recurrent caries was observed, which is in
aooordance with the findings of Stenberg and Matsson,28 Tidehagand and Gunne,^! berg et al,25 and
Krejci e t a l . "
The oontour was assessed as alpha in 98.4% of
the oases. The same results were obtained by Cavel
et al," who, however, examined 3 1 inlays only 6
months after luting, and Krejci et al.^'' who assessed 10 iniays at 18 months. Studer et aP*^ examined 130 inlays at 18 months (6 months) and
assessed the contour of 87% of the restorations as
alpha. Cerutti and ooworkers^ reported 84% alpha
contours on 109 Cerec CAD/CAM inlays 6 years
after luting.

76

12

Fig 10 Kapian-Meier survival rates of

restorations in premolars and molars (P
< 0.05).

Marginai integrity was assessed as bravo in 5

oases and alpha in ail the others. Rouletts found
marginai gaps in 14% of inlays. Krejci et ai^''reports
an important difference between the occiusal and
interproximai margins. We did not observe this difference, aithough our assessment was limited to a
clinical examination with the expiorer, and no replicas were made for a scanning eieotron microscopic
examination.
The quality of the color matoh decreased significantly as a function of time (Tabie 3). Since we do
not expect ceramics to change color over time, this
fact might be due both to the experience of the
technician in choosing the coior of the porcelain
and to the dentist's choice of the iuting composite.
Better resuits on coior match were reported by
Studer et al^f and Krejci et ai.l'^ Bessing and
iVIolin,3 who found 54% of assessed inlays showing

The Journal of Adhesive Dentistry

Fig l i a Initiai case of the right upper quadrant. The gold inlays had interproximai overhangs, therefore preventing correot
orai hygiene.

Fig l i b The view of the oeramic iniays 1 month after placement.

Fig l i e An ooclusai view after 5 years

Fig l i d An occiusai view after 13 years.

an "acceptable" color match, attributes this result

to occiusal adjustment conducted after cementing;
in Dicor-type inlays, this is assumed to remove the
most superficial layer of colored ceramics, exposing
the bulk ceramic.
The values for marginal discoloration were also
significantiy different, depending on whether the
restorations were oider or more recent (Tabie 3), It
is not known, however, if this discrepancy is due to
a technical improvement or to a deterioration of the
cementing oomposite which supposedly occurs with
time.

a study by berg et a\,^ the influence of the luting

material on the longevity of ceramic inlays was investigated. After a 3-year observation period, the inlays luted with composite resin showed significantly
fewer failures (2 failures out of 59 restorations)
than those cemented with glass-ionomer cement (9
failures out of 59). Van Dijken et aP^ evaluated 118
fired felspathic ceramic inlays luted with glassionomer cement and composite cement after 5
years. As with berg et al. Van Dijken et al found
better results forthe inlays cemented with composite (93% success rate) than the inlays luted with
glass-ionomer cement (76%), Rouiet^s found 9,7%
failures among 123 Dicor inlays over a period of 4
to 82 months, failures being due to fracture (7), endodontic problems (4), and postoperative pain (1),
No differences were found between the luting materials (three different luting composites). Premolars

Using Kaplan-Meier analysis, the inlays' 11,5 y

survivai rate was 95%, Other studies, conducted on
a simiiar number of restorations, have aiso reported favorable findings.29-30 Molin and Karisson^^
examined 205 Optec inlays after 1 to 32 months.
Four restorations were lost and 3 had fractured. In

Vol 1, mi. 1999

77

Fuzzi/Rappeiii
tended to show a better success rate; however, the
difference was not statistically significant, Molin
and Karisson^'' reported a 90% success rate after 3
years: this was obtained by calculating the survival
rates of iniays performed by 10 dentists who presented very different results. This finding emphasizes the sensitivity of the ceramic iniay technique
and the dependence on personal operator skill and
clinical experience. Operator ability and care in applying the technique can be the main factors infiuencing the success rate.
In many studies, the main reason for failure
seems to be the fracture of inlays. Quaitrough and
Wiison,20 examining 50 ceramic iniays after 3
years, found 18% failures due to fracture. All failures reported by Fradeani et al^ were due to fracture. Isidor and Brondum^s obtained even less
favorabie results after 57 months with 12 failures
out of 25 inlays, 10 of which were fractures. The selection of cases, particulariy if bruxism patients are
invoived, must also be taken into account when
evaluating the mechanicai properties of ceramics.
It shouid also be noted that 4 of the 6 failures reported in the present study occurred in the same
patient for endodontic reasons (puipitis), and that
these restorations were carried out 11.5 years ago,
when iess oiinicai information was avaiiabie about
the adhesive technique and microleakage controi.

CONCLUSIONS
Taking into account that this single-center study
was conducted without using a control group, the
following conclusions may be drawn:
1. Within the observation time (up to 11,5 years),
adhesively luted oeramic inlays showed no recurrent caries.
2. The slight occurrence of marginal discoloration
over time (17% bravo for inlays older than 5
years) is still clinically acceptable.
3. The color match of the ceramic inlays was found
to be better in the recent restorations subgroup
than in the older restorations subgroup.
4. After 11.5 years, a survival rate of 95% of all the
ceramic inlays must be considered as excellent.
5. The survival rate of premolar inlays (99%) was
superior to that of molar inlays (90%).

78

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The Journal of Adhesive Dentistry

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HYBRIDIZATION O F
DENTAT, HARD TISSUES

HYBRIDIZATION OF DENTAL HARD TISSUES

Nobuo Nakabayashi and David H. Pashley
The hybridization of dentina process that creates a molecular-level mixture of adhesive polymers and dental hard tissuesgives clinicians a
versatile new material, useful in a wide array of
advanced dental treatments. As the first in-depth
exploration of the suhject, this book covers the
development, present understanding, and future
research areas of this multifunctional dental material, A thorough review of the current literature
rounds out the text.
Valuable for students, researchers, and clinicians seeking a greater understanding of resin
hybridization of tooth structure.

CONTENTS
! Evolution of Dendn-Resin Bonding
2 Properties of Dentin
3 Acid Conditioning and Hybridization of
Substrates
4 Characterization of the Hybrid Layer
5 The Quality of the Hybndized Dentin
6 Clinical Applications of Hybrid Layer
Formation
29 pp. 80 iHus some in coior!:
ISBN 0-87417-575-9 C3047; US S40

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