RestorativeDentistry/FixedProsthodontics Enhanced CPD DO C

Richard J Ibbetson

Ian R Jones

All-Ceramic Inlays and Onlays for

Posterior Teeth
Abstract: The increasing requirement for aesthetic restorations has been matched by the continuing improvements in dental materials
and fabrication techniques. These factors have resulted in the development of newer ways of making tooth-coloured restorations for
posterior teeth. The value of preserving tooth tissue is widely appreciated and the use of partial coverage restorations can assist this
aim. The use of porcelain inlays and onlays etched with hydrofluoric acid together with improved composite resin-luting agents offers
the dentist and patient the option of a conservative and aesthetic restoration for more extensively damaged posterior teeth. The paper
describes the indications and clinical procedures for the use of these restorations.
CPD/Clinical Relevance: Porcelain inlays and onlays offer a predictable alternative to full coverage crowns and should be part of the
clinician’s armamentarium.
Dent Update 2019; 46: 610–624

There is no clearly defined point at which it
is better to provide an indirect rather than
a direct restoration. There is a number of
factors which influence the decision:
 The quantity of missing tooth structure;
 The location of the tooth structure that
remains;
 The status of the dental pulp;
 The nature of the occlusion;
 The wishes of the patient;1
 The preference of the operator.
Direct intra-coronal
restorations for posterior teeth
The impact of the loss of tooth
Richard Ibbetson, BDS, MSc, FDS
RCS(Eng), FDS RCS(Ed), FFGP(UK) FFD
RCSI, FRCA, Professor of Restorative
Dentistry (email: richardjibbetson@gmail.
com) and Ian R Jones, BDS, MSc MBA,
FInstLM, MFDS RCPS(Glasg), Clinical
Senior Lecturer, Institute of Dentistry,
University of Aberdeen, Scotland.
610 DentalUpdate July/August 2019
tissue on the strength of that which remains
can be significant. Vale in 1956 was one
of the first investigators to describe the
weakening of the tooth resultant from Class
II cavity preparations.1 This has been verified
by numerous researchers over the years,
but it cannot easily be related to clinical
outcomes. The point at which the risk of
fracture becomes likely has never been
clearly defined, although it is evident that
root-treated posterior teeth are particularly
at risk unless the final coronal restoration
does something to protect the remaining
tooth tissue.2 The continued development
in adhesive materials and the decline in
dental caries have encouraged a more
conservative approach to cavity preparation
which has both pulpal and structural
benefits. The ability to produce adhesion
between a restorative material and tooth
structure is potentially a key element in
developing or retaining strength in what
remains of the tooth. However, this has not
been quantified clinically, but there can be
little argument that the principle is correct.
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Where the loss of tooth
structure has been significant, there may
be benefits in considering the use of an
indirect restoration in order to protect the
tooth structure that remains. Under these
circumstances it is clearly highly desirable
that minimal further loss of tooth structure
should take place whilst good tooth
preparation requires high quality manual
skills in order to create the best conditions
for the final restoration. However, research
has failed to link the quality of the
performance of the dentist and the dental
technician to the outcome but there is an
inescapable logic in doing so.
Two relatively recent systematic
reviews report that success rates for silver
amalgam restorations remain higher than
those for direct resin composite when
used to restore posterior teeth.3,4 However,
continued materials’ development and
increasing usage leading to improvements
in clinical techniques have produced
change, with studies now reporting
higher success rates for direct composite

restorations than for silver amalgam.5,6
This trend is likely to continue with the
increasing emphasis on minimally invasive
techniques and the reduction in the use
of silver amalgam. The material of choice
for restoring small to moderate-sized
cavities in posterior teeth is direct resin
composite, notwithstanding the need
for good isolation and careful operative
technique. There is no absolute definition
or description of what constitutes an
extensively damaged posterior tooth,
and the term remains one dependent
on clinical opinion. The damage is often
described in terms of loss of marginal ridges
or cuspal elements. However, perhaps a
more significant descriptor is the amount
of dentine remaining at the base of the
cusps. It is the cuspal bases that provide
the support for the coronal parts of the
tooth or the restoration. This is one major
reason for recommending that when a
tooth is considered to be so damaged that
an indirect restoration is required, it is good
practice to remove the existing coronal
restoration in order to be able to evaluate
the quantity of tooth remaining at the
cuspal bases. This is also important when a
tooth requires a core to support a crown as
it allows retention for the core to be created
in areas that will be less affected by the
crown preparation itself.
The principles of restoration for
the extensively damaged posterior tooth
should be to:
 Preserve as much useful tooth structure
as possible;
 Protect the tooth structure that remains;
 Control the loads upon the restoration
and tooth.
Preservation of tooth structure
This means keeping as many
reasonably intact surfaces as possible.
It seems reasonable that a tooth with
relatively small amounts of missing tooth
structure should be restored with an
adhesive direct composite resin restoration.
This can apply even to teeth where a
significant amount of tooth structure
has been lost internally, ie following root
canal treatment. It is the adhesive nature
of restoration that is important, despite
there being only weak data to support this
approach7,8 Figure 1 shows a maxillary first
premolar which had been root-treated and
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RestorativeDentistry/FixedProsthodontics
a
b
Figure 1. Occlusal view of a root-filled maxillary
first premolar: the disto-occlusal cavity has been
restored with direct resin composite.
where there was a disto-occlusal cavity
that required restoration. Given the
amount of tooth tissue evident externally,
it would appear grossly destructive to
provide a crown for this tooth even
Figure 2. (a) Occlusal view of a large mesio-
though that is what the literature might
occlusal cavity in a root-filled maxillary first
recommend as best practice.
molar. (b) The completed direct composite resin
However, the ability of the restoration in the maxillary first molar.
operator, the size of the cavity and
the long-term performance of the
restorative material have relevance in
reaching this decision. Whilst Figure 1
occlusal form is poor. The relevance of the
shows a reasonable approach because latter has frequently been ignored. The
the direct restoration is relatively small, reasons for needing good occlusal form
the situation is not the same as the are to provide stability, ie tooth contacts
restoration becomes larger. Under these that do not change very much with time
circumstances greater requirements are and also to ensure that the likelihood of
placed on the adhesive, the restorative the development of occlusal interferences
material and the clinical expertise of can be minimized. These criteria are linked
the operator. Figure 2a shows a large with the intention that loads between
MO cavity in a root-treated maxillary opposing teeth in any mandibular-maxillary
first molar which was then restored relationships are minimized. This also
with a directly placed composite resin requires stability in the restorative material,
(Figure 2b). This might seem like a no wear of the antagonist tooth and
reasonable approach but, as the form of effective occlusal contacts from the time
the restoration shows, the result is less of placement. It is evident from clinical
than ideal. The proximal contact is too observation that this is more difficult when
broad, with inevitable consequences the size of a direct restoration made in
for the interdental papilla,9 whilst the composite resin increases.
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 RestorativeDentistry/FixedProsthodontics
a c
b
Indirect restorations
It is not possible to specify
when a tooth should be restored with
an indirect restoration. It has been
recommended that when a cavity
becomes too large for directly-placed
composite resin to be advisable, an
indirect composite resin inlay might be
used. Construction of the restoration
away from the oral cavity gives the
opportunity to control the form of
612 DentalUpdate July/August 2019
Figure 3. (a) Worn MOD direct composite resin
restorations in the first and second right maxillary
premolars. (b) The cavities prepared for indirect
composite resin inlays: undercuts have been
blocked out with a glass ionomer cement.
(c) The indirect composite resin inlays following
cementation and minor finishing.
restoration better and to increase the
degree of cure of the composite material.
With the composite resin being cured
before cementation, the stresses affecting
the tooth produced by polymerization
shrinkage are limited to the composite
luting agent used to cement the
restoration. The use of indirect inlays
requires a cavity without undercuts,
although modest amounts of blocking
out with a resin-modified glass ionomer
cement would seem to be appropriate if
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necessary. The challenge in using indirect
composite inlays is that there is little
data which suggest that they perform
better than those placed directly.10,11
Their occlusal form will undoubtedly be
better, which improves the prospects
for control of the occlusal contacts and
therefore loading, but there appears to
be no translation from the theoretical
benefits into improved outcomes.
Consequently, it is difficult to recommend
indirect composite inlays for regular use
in larger intra-coronal cavities in posterior
teeth. Figures 3a−c show two maxillary
premolar teeth where worn MOD direct
composite resin restorations were
replaced by indirect composite inlays.
A more suitable material for
a non-metallic indirect restoration for
an extensively damaged tooth may be
dental porcelain. It offers better physical
properties than resin composite and can
be fabricated to provide excellent fit and
good aesthetics. Porcelain inlays were
described as early as 1857;12 these inlays
were made of feldspathic porcelain fired
on a platinum foil burnished into a replica
of the cavity preparation. Construction
was challenging, and good fit was
difficult to achieve. Historically, these
restorations would have been cemented
with a silico­phosphate cement which
retained the restoration mechanically
rather than adhesively. The subsequent
development of adhesion, the ability to
etch the fitting surface of the restoration
with hydrofluoric acid, improved
fabrication techniques and developments
in dental ceramics have made these
restorations useful and predictable.
Etching of porcelain with
hydrofluoric acid was first described
by Calamia in 1983 to facilitate the
cementation of porcelain veneers with
composite resin.13 A major development
in the available porcelain materials
suitable for use as inlays and onlays for
posterior teeth has been the introduction
of leucite-reinforced ceramic that makes
use of either a lost-wax technique and
pressing of the ‘green’ ceramic or through
milling and CAD-CAM processes. Other
porcelains are available, including
traditional feldspathic porcelain, which
now has little indication for use in
posterior teeth due to its limited physical
strength: zirconia is a further option with

a d
b is only partially possible when an inlay is
c
good mechanical properties but presents
challenges in achieving a predictable bond
with composite-luting agents.
Inlay or onlay
The principle for the restoration
of an extensively damaged posterior
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RestorativeDentistry/FixedProsthodontics
Figure 4. (a) A maxillary first molar which had
symptoms of a mild reversible pulpitis.
(b) Transillumination of the maxillary first molar
showed evidence of a crack mesially. (c) The
maxillary first molar prepared for a porcelain
inlay. (d) The maxillary first molar following
cementation of a leucite-reinforced ceramic inlay.
tooth is protection of the remaining tooth
structure whilst preserving as much useful
tooth structure as possible. In traditionally
cemented fixed prosthodontics, this has
required reduction of the cuspal elements
of the tooth and their coverage by the
restorative material. Such extra-coronal
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restorations have been demonstrated to
control stresses within the remaining tooth
structure more effectively than when an
inlay is used.14 However, these principles
were developed before adhesion to tooth
structure and the ceramic restoration could
be achieved with composite resin.
An onlay is not only able to
limit stresses but permits full control of
the form of the occlusal surface, which
used. However, there may be instances
where much of the occlusal surface and the
resultant tooth contacts are satisfactory and
simply to replace what is missing becomes
an attractive conservative option when
the restoration can also be bonded to the
cavity. Figure 4a shows a maxillary first
molar which had developed a reversible
pulpitis and transillumination (Figure
4b) followed by removal of the amalgam
restoration revealing a crack mesially (Figure
4c). Given the reasonable occlusal form and
the acceptable occlusal contacts, both in
the intercuspal position and on excursive
mandibular movements, it was decided to
restore the tooth with an indirect pressed
ceramic inlay. The cavity was modified to
allow a path of withdrawal although the
axial wall taper was maintained at a low
value of less than ten degrees. There was
already sufficient depth to allow adequate
strength for the porcelain with a minimum
of 2 mm in the area of the central fossa
being considered appropriate. The proximal
boxes were provided with flares in order
to release undercuts present cervically.
The completed preparation shown in
Figure 4c demonstrates good retention
and resistance form: this might seem
unnecessary when the mode of attachment
of the inlay to the tooth is adhesive.
However, the presence of retention and
resistance may reduce the stresses placed
on the adhesive bond. Whilst the latter
has proved generally predictable and
long lasting, there is evidence that the
adhesive bond undergoes degradation with
time,15,16 therefore minimizing stresses at
the restoration-tooth structure interface
would represent good practice. Following
fabrication of the leucite-reinforced ceramic
inlay and try-in, the fitting surface of the
inlay was etched with hydrofluoric acid,
cleaned and then silanated before being
cemented under rubber dam isolation
using a multi-stage etching and bonding
 RestorativeDentistry/FixedProsthodontics

a c procedure with a composite luting agent.

Very minor finishing was required following
a small amount of occlusal refinement
and the surface of the restoration was
re-polished using abrasive rubber points
under a water spray. The final restoration is
shown in Figure 4d.
The decision whether to make
a porcelain inlay or onlay should be based
on information derived from the literature,
although at present this is difficult to do.
The majority of the published papers do
not differentiate between ceramic inlays
and onlays in terms of their survival and
complications. For both types, survival
is approximately 90% at 10 years. The
major causes of failure are fracture of the
ceramic and marginal discoloration whilst
the incidence of recurrent caries is low.17,18
Therefore, the choice between an inlay and
an onlay is clinically based and relates to
the factors outlined earlier.

Ceramic onlays
The requirements for a ceramic
onlay preparation are the creation of
sufficient occlusal reduction which, for
b pressed ceramic, should be a minimum of
2 mm, but is increased to 2.5 mm over the
supporting (functional) cusp. The finish
line on the axial surface adjacent to the
supporting cusp should be a heavy chamfer
of just under 1.0 mm width and located
beyond the site of any occlusal contact. The
finishing line on the axial surface adjacent
to the non-supporting cusp should be as
close to a right angle as possible whilst still
maintaining the form of the cuspal inclines.
d The palatal/lingual and buccal finish lines
should blend into the proximal boxes which
should present flat floors and buccal and
lingual flares. There should be no sharp
angles in the preparation, although good
parallelism in the isthmus and internally
within the proximal boxes is advisable.
Figures 5a−c show an early preparation for
a ceramic onlay. The patient had presented
with fracture and loss of the palatal cusp
of the maxillary second premolar (Figure
5a) and the tooth had previously been
restored with an MOD amalgam restoration:
the tooth was pulpally vital and free from
Figure 5. (a) A maxillary second premolar where the palatal wall had fractured. (b) The maxillary dental caries whilst the occlusion appeared
second premolar prepared for a ceramic onlay. (c) The occlusal view of the maxillary second premolar stable and there was no evidence of
restored with a ceramic onlay fabricated in feldspathic porcelain. (d) The buccal view of the maxillary
parafunctional activity. The options for
second premolar following restoration with a ceramic onlay.
treatment were to place a core and make a
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 RestorativeDentistry/FixedProsthodontics

partial coverage gold veneer or a porcelain a d

fused to metal crown. The patient did not
wish for any display of metal, whilst the
operator wished to avoid a metal-ceramic
crown preparation which would have
removed most of the intact buccal wall of
the tooth, leaving little coronal dentine.
The decision was made to make a porcelain
onlay and this procedure took place in
the early 1990s with feldspathic porcelain
being the only ceramic possibility. The
completed preparation is shown in Figure
5b. The amalgam restoration was removed
and the buccal and palatal cuspal inclines
on the occlusal surface reduced to create
2 mm of clearance from the opposing
tooth. The patient had group function on
a working mandibular movement and, in
order to provide sufficient strength for the
onlay, 2 mm of space was created over
the buccal cusp. Palatally, a supporting
cusp bevel was made giving 2.5 mm of
inter-occlusal space before creating a
wide chamfer of 1 mm at the termination
of the palatal fracture line: the palatal b
chamfer blended mesially and distally
into the proximal boxes. The proximal
boxes were modified to provide a path of
insertion and some resistance form before
flaring their buccal and palatal margins
and blending these into the palatal and
buccal finish lines. Any undercuts in the
isthmus area and parts of the proximal
boxes were blocked out with glass ionomer
cement, although currently resin-modified c
glass ionomer cement is the material of Figure 6. (a) A mandibular right first molar
choice for this purpose as its physical to be restored with a ceramic onlay due to a
properties are better. In Figure 5b showing symptomatic dentine crack. (b) Buccal view of
the completed preparation, it should be the completed onlay preparation using a concept
noted that the junctions between the of minimal resistance form and rounded internal
reduced buccal cusp and the mesial and angles. (c) Lingual view of the completed onlay
distal boxes are sharper than would be preparation. (d) The cemented MOD pressed
currently recommended if stresses are to be ceramic onlay.
minimized and the laboratory fabrication
not made more difficult. Figures 5 c and d
show the etched and cemented onlay, the An example of such a preparation of a simply reducing the cuspal height. Such
buccal finishing line is just visible on close mandibular right first molar is shown in a design of preparation is attractive as it
inspection.
Figures 6 a–d. In this instance, there is is relatively simple to execute and also
Given the lack of clinical data
appropriate occlusal reduction and the facilitates the fabrication process for the
linking preparation design to outcome, it is
functional cusp bevel has been created, dental technician. However, as there is little
not surprising that variations are described.
The most significant of these is based on but there is no isthmus and the proximal geometric retention and resistance form, it
the principle that, because retention is boxes are rounded in form. These blend places great reliance on the bond between
achieved by the composite luting agent, buccally into the 1 mm chamfer at the the composite-luting agent, the etched
stresses will be minimized and fabrication termination of the functional cusp bevel porcelain and the tooth structure which is
facilitated by making preparations which and lingually into the reduced lingual cusp predominantly dentine. Given the questions
have greatly reduced resistance form. where the finishing line was created by remaining over the stability of the bond to
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 RestorativeDentistry/FixedProsthodontics

dentine, the use of a preparation design a

with greater resistance form seems to be
prudent.
Onlays can appear to be
aggressive preparations but it is important
to bear in mind that it is the dentine at
the base of the cusps which is important
in maintaining strength of the tooth.
If the diagrams in Figures 7a and b are
compared, it is easy to conclude that the
full crown preparation removes more
tooth structure, both axially and cervically,
and that that is likely to have an adverse
effect on the strength of the remaining
coronal tissues, particularly when there is
a core present. In the onlay preparation
more dentine is retained cervically in
the region of the cuspal bases. Ceramic
onlays are of particular use for premolars
which require an indirect restoration and
success rates are higher for these teeth
than for molars. Figures 8a and b show
the maxillary and mandibular arches of a b
patient who required a full reconstruction
at an increased occlusal vertical dimension.
The patient was content with the proposal
that gold veneers were used for the molar
teeth but requested that no metal be
visible on the premolar teeth. Full metal-
ceramic or all-ceramic crowns would have
been unnecessarily destructive so pressed
ceramic onlays were used. All the premolars
were restored with leucite-reinforced
ceramic onlays, the post-restoration occlusal
views of both arches are shown in Figures
8c and d. The right maxillary premolars are
shown in Figure 9a, the onlay preparations
are illustrated in Figures 9b and c. The
occlusal and buccal views of the onlays are
shown in Figures 9d and e.
The clinical limitations of
porcelain onlays are not completely
established. The risk of fracture of the Figure 7. (a) Diagrammatic representation of a metal-ceramic crown preparation of a maxillary
porcelain is clear but it is a benefit that, premolar which also has an intra-coronal MOD restoration. (b) Diagrammatic representation of root-
filled maxillary first molar showing a preparation for a ceramic onlay.
under these circumstances, re-restoration of
the tooth is likely to be feasible. Figure 10a
shows a maxillary first molar following root
canal treatment. The intra-coronal amalgam restoration removed, if the imaginary of a mesio-distal crack was noted: it was
restoration is large and a final restoration outline form of a metal-ceramic crown concluded that a crown preparation would
which protects the remaining tooth
preparation is superimposed on the tooth. remove a significant amount of the useful
structure and controls the occlusal contacts
It can be concluded that virtually nothing remaining tooth structure so that the tooth
is required. In making an assessment
of the type of restoration indicated, it will remain of the buccal cusps whilst, not was prepared for a pressed ceramic onlay.
was necessary to remove the amalgam only are the proximal surfaces extensively The gutta percha in the pulp chamber was
restoration to evaluate the quantity and damaged, but the disto-palatal cusp has sealed with resin-modified glass ionomer
location of the remaining tooth structure. also been lost. This tooth was clearly cement and the weakened buccal wall
Figure 10b shows the tooth with the extensively damaged, and the presence had been reduced in height until it was
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 RestorativeDentistry/FixedProsthodontics

a a c

b d

e
d

Figure 8. (a) Pre-treatment occlusal view of the

maxillary arch. (b) Pre-treatment occlusal view of Figure 9. (a) Pre-operative view of UR4 and UR5.
the mandibular arch. (c) Post-treatment occlusal (b) Occlusal view of ceramic onlay preparations
view of the maxillary arch where the premolars of UR4 and UR5. (c) Buccal view of the ceramic
have been restored with leucite-reinforced onlay preparations of UR4 and UR5. Note the
porcelain onlays. (d) Post-treatment occlusal view preservation of the form of the buccal cusp. (d)
of the mandibular arch where the premolars have Occlusal view of the cemented pressed ceramic
been restored with leucite-reinforced porcelain onlays. (e) Buccal view of UR4 and UR5 restored
onlays. with the ceramic onlays.

considered to have sufficient thickness to apical to the supporting cusp bevel, a wide and resistance form were developed by
minimize the chances of fracture (Figure chamfer finishing line was placed with maintaining minimal taper between the
10c). Palatally, occlusal reduction and a the buccal and palatal finish lines being buccal and palatal walls internally. The
supporting cusp bevel were made and, blended into the proximal boxes. Retention completed preparation is shown in
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 RestorativeDentistry/FixedProsthodontics

a d f

b
e
g

Figure 10. (a) Occlusal view of a maxillary first

molar following root canal treatment. (b) The
occlusal view with the amalgam restoration
removed: the pulp chamber was sealed with a
resin-modified glass ionomer cement. (c) The
buccal cusp reduced at right angles to the path
of insertion until the remaining tooth structure
was considered strong enough to support the
c onlay. (d) Occlusal view of the completed onlay
preparation – note the mesio-distal crack across
the floor of the preparation. (e) Occlusal view
with the temporary onlay removed showing the
inflamed inter-dental papilla. (f) Occlusal view of
the cemented leucite-reinforced ceramic onlay.
(g) Buccal view of the restored maxillary first
molar.

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Figure 10d. The vulnerability for the final
restoration in this tooth must be the floor of
the distal box which is no longer in enamel
but in dentine/cementum. This constitutes
a risk factor for adhesively retained
restorations.15,16 This risk is not mitigated by
building up the floor of the proximal box with
composite resin or a resin-modified glass
ionomer cement as the interface with the
dentine/cementum will still be vulnerable
Temporization of teeth prepared
for ceramic onlays is challenging as a good
temporary restoration is required for patient
comfort and stability both occlusally and
proximally whilst its form should facilitate
plaque control procedures. The clinician
would like the temporary to be both stable
and easy to remove. In addition, temporary
cements containing eugenol should be
avoided otherwise these will contaminate
the tooth structure and will interfere with
the curing of the composite luting agent.
A decision must also be made about the
need for dentine sealing prior to making the
impression.19 A stable temporary restoration
can be made from a bisacrylic temporary
crown and bridge material as long as a
silicone matrix made either from a diagnostic
wax-up or directly from the tooth prior to
preparation is used. The temporary onlay
is trimmed, adjusted and polished prior to
cementation. It can be cemented with an
eugenol-free temporary cement, although
sometimes this may not provide sufficient
retention. An alternative is to cement
the temporary restoration with flowable
composite resin on the unetched and
unsealed dentine and enamel. This method
retains the temporary onlay effectively and,
on removal of the restoration, the flowable
composite comes away cleanly from the
tooth being better attached to the bisacrylic. research has been reported which seeks to
Cementation is an important part of
the procedure and good isolation is essential,
with the use of rubber dam being necessary.
Figure 10e shows the maxillary first molar
after removal of the temporary onlay: it can
be seen that the interdental papilla between
the first and second molars is inflamed. It
is hard to see how the restoration can be
bonded and cemented effectively unless a
rubber dam is placed. The tooth is cleaned
with a pumice and water slurry prior to
cementation to ensure that any biofilm is
removed. The fit, contour, proximal contacts
and the occlusion will all have been verified
prior to placement of the rubber dam and
July/August 2019 DentalUpdate 623
RestorativeDentistry/FixedProsthodontics
the fitting surface of the leucite-reinforced
onlay etched with hydrofluoric acid and
silanated prior to cementation. The tooth
structure is etched and the adhesive
applied, preferably using a multi-stage
system. The etched and silanated fitting
surface of the onlay is coated with the
luting cement and the restoration carefully
seated, with an instrument being used
occlusally to avoid coronal rebound. The
excess cement is removed with a disposable
brush or sponges before initiating the final
curing process with the manufacturer’s
recommendation being followed. The
presence of the rubber dam makes removal
of the cured cement easier from all areas
as the excess cement remains on the oral
side of the rubber dam. Once the excess
cement has been removed, the rubber dam
is also removed and the occlusion verified,
together with any further minor finishing
being carried out. The final pressed ceramic
onlay is shown in Figures 10f and g; the
occlusal form is broader than would be
considered optimal which leads to a flatter
occlusal surface.
The full crown
The ceramic onlay represents
a suitable method for restoring both
moderately and more extensively damaged
teeth but has limitations when there is
insufficient tooth structure for adhesion,
and when higher levels of loading are
anticipated, such as those patients who
demonstrate parafunctional activity
or where contacts between opposing
posterior teeth are significantly reduced.
There can be no clearly defined point
when a crown becomes a better option:
develop a tooth restorability index,20 but no
useful correlation has been demonstrated
between the amounts of tooth structure
remaining and clinical outcomes. However,
it is important to bear in mind that it is
the tooth structure that provides support
for the restoration. As a core beneath an
indirect restoration becomes larger, it
has to take on an increasingly structural
role in supporting the final restoration.
Clinicians have a tendency to assume that,
once a core has been placed, the tooth is
essentially ‘as good as new’. This is clearly
not the case as all materials used for cores
have inferior physical properties when
Downloaded from magonlinelibrary.com by 131.172.036.029 on August 4, 2019.
compared with tooth structure.
The full crown, whilst providing
protection for what remains, causes loss of
additional tooth structure and increased risk
of pulpal damage. The traditional, by some
considered old-fashioned, three-quarter
gold veneer is a demanding preparation
but is able to fulfil more completely the
requirements for a satisfactory protective
restoration as compared with a full
coverage crown, particularly those made
of metal-ceramic or all-ceramic. Despite
all the advances in alternatives to metal
restorations, it remains the case that, if
maximum predictability is required, cast
gold restorations providing either partial or
full coverage continue to be the restoration
of choice from the perspective of oral
health.21 However patients’ demands and
dentists’ inclinations have resulted in the
partial metal veneer becoming virtually
obsolete.
The principles of preparation
for crowns are well established.22 The
clinician should bear these in mind, but just
as importantly must remember that the
support for the restoration is derived from
the remaining tooth structure. A crown is
broadly only indicated for teeth that are
extensively damaged and therefore will
usually have relatively large cores which
are used to replace the missing tooth
structure and to provide a foundation for
the final restoration. The design of the
crown preparation should take into account
the amount and location of the remaining
tooth structure and also where retention for
the core may be obtained. The use of silver
amalgam as a core material has declined,
with composite resin becoming the popular
choice: with composite resin, use should be
made of adhesion, but it should be borne in
mind that the majority of the tissue which
remains once the preparation is completed
will be dentine. Adhesion to dentine is
less predictable than to enamel,15,16 it is
therefore advisable to provide mechanical
retention for the core as well as making use
of adhesive techniques.
Crowns receive loading in
function and therefore stresses within
the restoration, the tooth structure and
the cement are inevitable. One particular
location for the concentration of stress is
at the margins of restorations and this will
include both the core and also the finishing
line of the crown preparation. It is therefore
 RestorativeDentistry/FixedProsthodontics
Figure 11. A maxillary root-treated second molar
prepared for a porcelain-fused-to-metal crown.
Note the position of the finishing line beyond the
margin of the amalgam core.
important that the margin of the crown
preparation is placed apical to the
termination of the core (Figure 11). This
was termed the ferrule effect by Sorensen
in 1990.23 A similar finding was made in a
lesser known study by Hoag and Dwyer24
where, with large cores, placement of
the margin of the crown 2 mm apical
to a core resulted in greater resistance
to failure in their laboratory tests on
extracted extensively damaged teeth.
The larger the core, the more important
this principle, as it better transfers the
stresses to the tooth structure rather than
allowing them to be concentrated within
the core.
Conclusions
The reduction in dental caries,
developments in dental materials and the
increasing requirements of patients for
aesthetic restorations have changed the
pattern of dental delivery. There is a range
of options for the restoration of more
extensively damaged posterior teeth. The
use of indirect ceramic partial coverage
restorations provides a predictable
restoration which is able to restore form,
is conservative of structurally important
dentine and will protect the remaining
tooth structure whilst satisfying patients’
aesthetic requirements.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
624 DentalUpdate July/August 2019
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