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Michael J. Koczarski, DDS* Amy Lynn Mitchell, RDH

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Although glass inserts have enabled the use of direct restorative procedures for the placement of inlays and onlays, these techniques are often unable to address elementary patient concerns (ie, aesthetics, fit, expense). The advent of a novel process that standardizes preparation design and facilitates the use of advanced restorative materials may provide an alternate means of providing acceptable treatment. This article highlights the use of a sonic preparation system with ceramic inserts to develop aesthetic direct inlay restorations that demonstrate the qualities traditionally exhibited by indirect ceramic materials.

Learning Objectives: This article highlights a clinical technique that features the preparation and ceramic insert technology utilized to perform direct inlay restorations in the posterior segment. Upon reading this article, the reader should have: Increased knowledge of ceramic insert technology. Improved understanding of the application of sonic preparation tips.

Key Words: composite, posterior, strength, layer, preparation

* Codirector, Pacific Aesthetic Continuum, University of the Pacific, San Francisco, California; Director, Northwest Aesthetic Continuum, University of Washington, Seattle, Washington; private practice, Woodinville, Washington. Private practice, Woodinville, Washington. Michael J. Koczarski, DDS, 17000 140th Avenue NE, Ste. 202, Woodinville, WA 98072 Tel: 425-486-2200 Fax: 425-481-8561 E-mail:

Pract Proced Aesthet Dent 2007;19(9):A-G




Practical Procedures & AESTHETIC DENTISTRY

ue to the increasing patient demand for aesthetic, biocompatible restorations, materials that exhibit a natural appearance, strength, and durability have been developed. Researchers have explored several alternatives for achieving this objective, including the use of inlay or onlay restorations fabricated of direct composite resin, ceramic, and ceramic optimized polymer (Ceromer) materials. The advancements associated with CAD/CAM and milled restorations have further increased the clinician's ability to deliver predictable, durable restorations. While direct Class II composite restorations can provide clinical advantages with regard to aesthetics, reduced patient expense, and efficiency,1 clinicians must simultaneously address several material and procedural limitations (eg, polymerization shrinkage, microleakage, postoperative sensitivity).2 Although conventional ceramic or Ceromer inlays and onlays are clinically superior to direct composite restorations, these modalities increase treatment expense and require multiple visits to facilitate placement.3 The use of direct inlays or glass insert restorations was introduced in the early 1980s in the form of Beta Quartz glass inserts.4,5 Utilizing this technology, sites prepared for direct composite resin restorations were megafilled with prepolymerized glass inserts to reduce polymerization shrinkage and impart strength to the definitive restorations. Sites treated in this manner have exhibited a sevenfold lower coefficient of thermal expansion as compared to amalgam, and have demonstrated the ability to reduce polymerization shrinkage by 50% to 70%.2,4,5 Use of the inserts is intended to improve the wear characteristics of composite restorations by providing a solid surface for contact against the opposing dentition, and also permits them to function as an acceptable megafiller for composite resin.2,4,5 The glass inserts, however, are also characterized by clinical deficiencies that include the poor aesthetic blending of the insert and composite materials, and marginal failure due to the gap that often forms between the insert and the restorative margins. With the advent of a sonically driven preparation system (eg, SONICSYS, Ivoclar Vivadent, Amherst, NY; KaVo, Lake Zurich, IL), many of the original limitations of insert technology have been resolved. This sonic system consists of single-sided, diamond-coated tips (40 m to 50 m coating) that facilitate conservative preparation of mesial and distal surfaces without causing damage to adjacent teeth. The tipsdesigned for three Class II preparation sizes attach to an oscillating air scaler unit.6 The appropriate tip should be selected based on the size of the preparation required

Figure 1. Preoperative occlusal view of defective amalgam restorations on teeth #2 and #3 in the right maxillary posterior segment.

Figure 2. A caries indicator reveals remaining decay on the interproximal and occlusal aspects of the teeth.

for complete decay removal and finishing of the inlay restoration. The system also contains ceramic inserts fabricated from a leucite-reinforced glass ceramic material similar to that of a pressed ceramic (ie, IPS Empress, Ivoclar Vivadent, Amherst, NY)that are precisely shaped to correspond to the assorted preparation tips. The objective of the technique is to establish a preparation of predictable size and shape to one of the three inserts, thus achieving an inlay type restoration in the interproximal region of the tooth. The definitive result is a prefabricated ceramic inlay with marginal tolerance of 81 m to 108 m in the interproximal area, and 12 m to 21 m in the gingival bevel areas,7 which significantly reduces the deficiencies (eg, microleakage, postoperative sensitivity) of conventional direct composite restorations that are typically associated with polymerization shrinkage.1 The gingival inclination of the sonically driven preparation instrument is 45, which is optimal for the acid-etch technique in cervical enamel.8 If the proximal preparation margin extends into the dentin, the preparation is completed as soon as the dentinal

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incline ridge, are indicated for an onlay restoration. Additional parameters (eg, occlusal function, position of the tooth in the arch, and degree of enamel support) should also be considered.11,12 The smallest preparation instrument that covers the marginal regions and provides axial wall beveling should be selected. Sonic technology, which cuts less aggressively than rotary instruments, is ideal for finishing and standardization of the proximal box to ensure proper fit of the ceramic inlay. Upon completion of the milled and precise interproximal preparation site, the appropriately sized ceramic insert is selected. Accepted isolation protocols should be followed to eliminate moisture, which may compromise the conventional bonding procedures employed for direct resin restorations.13 The ceramic insert is subsequently placed into the interproximal preparation and luted with flowable and conventional microhybrid Ceromers (eg, Tetric Flow; Tetric Ceram, Ivoclar Vivadent, Amherst, NY). The inserts increase depth of cure by conducting the curing light within the composite material,14 and their light transmission produces a cohesive stress that is directed toward the insert rather than the surface of the restoration. Once complete curing of the dentin layer has been performed, pit and fissure stains are incrementally applied to the surface along with an enamel layer of a reinforced microfill composite resin. Final occlusal adjustments, finishing, and polishing are accomplished in order to complete the aesthetic and functional direct resin/composite inlay restoration.

Figure 3. Occlusal view of the proximal box form required for the use of the sonic preparation system and ceramic insert technology.

Figure 4. Utilizing the total-etch technique, the enamel layer was initially rimmed with 37% phosphoric acid for five seconds.

gingival margin is smooth. Beveling the gingival margin in the dentin does not provide decisive strength advantages for bonding strength.9 This article demonstrates a clinical protocol that features the preparation and ceramic insert technology utilized to perform direct inlay restorations in the posterior segment.

Case Presentation
A 28-year-old male patient presented with a failing conservative amalgam restoration and interproximal decay on tooth #3(16) (Figure 1). Direct pressure to the mesiobuccal cusp of this tooth resulted in pain associated with cracked tooth syndrome. Although tooth #2(17) was asymptomatic, it also exhibited recurrent decay upon radiographic examination. It was determined that treatment required the placement of a restorative material capable of providing strength and cuspal support to the undermined structure of tooth #3. A conventional composite resin restoration was planned for tooth #2. The base shade, which was to be utilized for the internal and base portions of the restoration, was obtained from the buccocervical third using a shade selection system (ie, Chromascop, Ivoclar Vivadent, Amherst, NY). An enamel shade was planned for the occlusal half and margins of the restoration in order to develop a natural transition from enamel to resin. Shade

Clinical Protocol
Following proper case selection, diagnosis, and treatment planning for direct inlay restorations, a strict clinical protocol should be followed in order to achieve predictable results. Preparation design utilizing sonic technology and predictable cavity size contributes to the success of the restoration with the ceramic insert. When selecting the design of the inlay or onlay preparation, the One-Half Rule can be applied by the clinician.10 Instances in which the width of the isthmus is equal to or greater than one half of the buccolingual intercuspal distance, or in which the preparation finish line falls on or above the halfway point of the cuspal


Practical Procedures & AESTHETIC DENTISTRY

selection occurred prior to actual preparation and possible dehydration of the dentin, which could have altered the process. Details of pit and fissure staining were also mapped at this time. Once anesthesia had been administered, the maxillary right quadrant was isolated with a rubber dam. The defective amalgam restoration and interproximal decay were removed with conventional rotary instruments and a carbide bur. A caries indicator was applied to facilitate removal of all infected tooth structure (Figure 2). Preparation of the proximal area of tooth #3 was completed utilizing a large sonic preparation tip (eg, SONICSYS approx, Ivoclar Vivadent, Amherst, NY; KaVo, Lake Zurich, IL) (Figure 3). Since the gingival margin was located entirely in enamel, a 45 bevel was established on the gingival floor to enhance bond strengths in this area.8 The proximal box was completed by beveling the axial walls with the sonic preparation tip under light pressure and water irrigation. When the proximal preparation was complete, the occlusal cavity margins were finished with conventional 30 m finishing diamonds. A matrix band was placed and tightly secured with a wedge at the gingival margin. Positive pressure was applied during wedging in order to adequately separate the preparations, thus ensuring optimal contact for the definitive restorations. The preparations were etched with 37% phosphoric acid for 10 to 15 seconds using the total-etch technique to promote proper bond strengths.15 The enamel was initially rimmed with acid and etched for 5 seconds (Figure 4); the remainder of the preparation was then acid-etched for 10 seconds, which resulted in 10 and 15 seconds of total etching for the dentin and enamel, respectively. An antibacterial

Figure 6. Occlusal view of the placement of the ceramic insert in the proximal box prior to photopolymerization.

Figure 7. Application of ochre tinting to the Ceromer (ie, Tetric Ceram, Ivoclar Vivadent, Amherst, NY) pit and fissure anatomy.

Figure 5. Occlusal view of the flowable composite resin, which is placed into the interproximal box until it is two-thirds full.

solution (ie, Tubulicid Red, Global Dental, North Bellmore, NY) was then applied as a rewetting agent, and excess liquid was removed.16 A single-component dentin primer/bonding resin (ie, Syntac Single Component, Ivoclar Vivadent, Amherst, NY) was applied and allowed to penetrate the dentin tubules for 20 seconds. Excess carrier residue was subsequently air thinned for 15 seconds, and the surface of the preparation was cured with an argon laser (ie, Premier Laser Systems, Irvine, CA) for 10 seconds. A ceramic insert was removed from the container with the inlay holder, and a thin layer of bonding resin was applied to its entire pre-etched and presilanized surface. Care was exercised not to contaminate the conditioned surface of the insert. The primer was allowed to penetrate the ceramic surface for 30 seconds and was then gently air thinned. The bonding resin on the insert was not photopolymerized at this time. Two-thirds of the proximal box preparation was filled with a flowable Ceromer (ie, Tetric Flow, Ivoclar Vivadent, Amherst, NY) (Figure 5). In order to prevent

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Upon completion, the fissures were shaded with a composite tint (Kolor Plus, Kerr/Sybron, Orange, CA) that spanned approximately 0.5 mm beyond the grooves, and light cured (Figure 7). A thin layer of brown stain was applied into the depths of the pits and fissures with a fine explorer to enhance blending with the adjacent natural dentition (Figure 8). In order to enhance the aesthetics of the definitive restoration, a layer of translucent material was selected for the final enamel layer. The enamel anatomy of each cusp was carefully built and light cured in an incremental manner. The restoration was filled to final contour to limit mechanical finishing and destruction of the natural tooth anatomy. Glycerin gel (ie, De-Ox, Ultradent Products, South Jordan, UT) was applied at all margins to prevent the formation of an oxygen-inhibition layer and enhance the composite cure at the cavosurface margins.17 Final curing was accomplished with an argon laser for 10 seconds per surface for each restoration. The matrix band and wedge were removed to permit finishing of the interproximal margins (Figure 9). Excess composite material at the margins was removed with a curet, a carbide finishing bur, or a diamond bur. Remaining excess composite in the interproximal areas was removed with an interproximal scaler, #12 scalpel blade, or an interproximal metal strip. The handle of the insert was removed with a 30 m diamond finishing bur, and any excess composite resin at the cavosurface margins was also removed (Figure 10). Final polishing was accomplished using polishing cups and paste (Figure 11). The rubber dam was subsequently removed, and occlusion was verified and adjusted; centric and lateral excursions were also verified. The restorations

Figure 8. A fine bead of brown stain is applied to the pits and fissures to further enhance morphology.

Figure 9. Formed matrix band removed. Note that minimal interproximal finishing is required.

air entrapment, the tip of the resin syringe was placed into the gingival floor and flowable resin was injected along the axial walls. The inlay was seated into the proximal box, which allowed the excess flowable resin to escape up and over the ceramic insert (Figure 16). The insert carrier was removed prior to 10 seconds of photopolymerization with an argon laser. An initial layer of flowable composite resin was placed to line the first 0.5 mm of the pulpal floor and light cured. A dentin-shaded hybrid composite material (ie, Tetric Ceram, Vivadent, Amherst, NY) was selected and placed to incrementally build up the internal cuspal portions of the restoration. The layering of the dentinshaded composite did not make contact with the enamel walls, but extended to the fissures only. Consequently, shrinkage did not result in polymerization stress at the restoration margins. The composite material was light cured through the buccal and lingual walls of the restoration to further limit internal polymerization stresses.1 The internal pit and fissure morphology was then reproduced within the dentin layers of the composite resin.

Figure 10. The cavosurface margins of the restoration are finished with a football-shaped 30 m diamond bur.


Practical Procedures & AESTHETIC DENTISTRY

Figure 11. Once any necessary occlusal adjustments have been completed, polishing pastes and cups are utilized to render the luster of the definitive restorations.

Figure 12. Magnified view of the posterior restoration. Note the natural harmony of the ceramic insert with the composite material (ie, Heliomolar, Ivoclar Vivadent, Amherst, NY).

were then etched and resealed with a surface sealer (ie, OptiGuard, Kerr/Sybron, Orange, CA) to ensure prolonged longevity (Figure 12). The definitive restoration exhibited natural aesthetics, color, and contour and returned the posterior teeth to consummate anatomical form without discomfort upon occlusal function.

1. Peters MCRB, Sakaguchi RL, Nelson SR, et al. Polymerization contraction stresses in composite resins. J Dent Res 1991;70(special issue):Abstract. 2. Rada RE. Class II direct composite resin restorations with betaquartz glass-ceramic inserts. Quint Int 1993;24(11):793-797. 3. Dietschi D, Magne P, Holz J. Recent trends in esthetic restorations for posterior teeth. Quint Int 1994;25(10):659-677. 4. Burbach GE. BetaQuartz restorative module system clinical guideline from Lee Pharmaceuticals. 5. Bowen RL, Eichmiller FC, Marjenhoff WA. Glass-ceramic inserts anticipated for megafilled composite restorations. Research moves into the office. J Am Dent Assoc 1991;122(3):71-75. 6. Hugo B, Stassinakis P, Klaiber B. Development of a new preparation method for defect-related restoration of proximal carious lesions. Dtsch Zahnarztl Z 1996;51(9):518-523. 7. Hugo B, Stassinakis P, Klaiber B. Reproducible preparation of standardized Class II cavities. Dtsch Zahnarztl Z 1995;50(11): 832-835. 8. Cheung GS. A scanning electron microscope investigation on the acid-etched cervical margin of Class II cavities. Quint Int 1990;21(4):299-302. 9. Lutz F, Imfeld T, Barbakow F, Iselin W. Optimizing the marginal adaptation of MOD composite restorations. International Symposium on Posterior Composite Resin Dental Restorative Materials. Peter Sculo Publishing; 1985:405-419. 10. Koczarski MJ. Utilization of Ceromer inlays/onlays for replacement of amalgam restorations. Pract Periodont Aesthet Dent 1998;10(4):405-412. 11. Liebenberg WH. SONICSYS Approx: An innovative addition to the restorative condition. Pract Periodont Aesthet Dent 1998;10(7):913-922. 12. Hugo B, Stassinakis A. Preparation and restoration of small interproximal carious lesions with sonic instruments. Pract Periodont Aesthet Dent 1998;10(3):353-359. 13. 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. 14. Losche AC. Verbesserung der randqualitat von kompsitfullengen durch lichtletende und lichstreuende glaskeramikeinsatze. Berlin, Germany: 1991. Dissertation. 15. Bertolotti RL. Total etchThe rational dentin bonding protocol. J Esthet Dent 1991;3(1):1-6. 16. Kanca J III. Improving bond strength through acid etching of dentin and bonding to wet dentin surfaces. J Am Dent Assoc 1992;123(9):35-43. 17. Bergmann P, Noack MJ, Roulet JF. Marginal adaptation with glass-ceramic inlays adhesively luted with glycerine gel. Quint Int 1991;22(9):739-744.

This article has presented the use of a sonic-driven preparation system, ceramic inserts, and advanced composite materials for the restoration of Class II cavities in the posterior segment. Utilizing this modality, the authors were able to achieve the desirable characteristics of indirect restorations without the expense or extended treatment duration associated with such restorations. Consequently, this treatment is an optimal posterior alternative to conservative direct inlay restorations. While the use of a preformed insert allowed the authors to enhance the strength of the restoration with an ideal proximal contact, the preparation design was modified in order to match the insert. Contemporary technologies such as CAD/CAM systems may further allow clinicians to deliver a more minimally invasive preparation design; the restoration is then milled to fit that preparation design. As technologies continue to advance and increase the restorative armamentarium, a variety of options can, therefore, be utilized when providing aesthetic, durable restorations with success and predictability.

Thie author wishes to express his gratitude to Ronald D. Jackson, DDS, of Middleburg, VA, for guidance in the concepts presented in this article.

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please refer to the CE Editorial Section.



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 instructions,

The 10 multiple-choice questions for this Continuing Education (CE) exercise are based on the article Direct inlay restorations: Utilization of sonic preparation technology in conjunction with ceramic inserts, by Michael J. Koczarski, DDS and Amy Lynn Mitchell, RDH. This article is on Pages 000-000.

1. Which of the following is/are requisite for modern aesthetic restorations? a. Natural appearance. b. Adequate strength. c. Long-term function. d. All of the above. 2. According to the author, alternative posterior restorative materials include: a. Direct composite materials. b. Ceramic inlay restorations. c. Ceromer onlay restorations. d. All of the above. 3. Early deficiencies of glass inserts included: a. Compromised aesthetic results. b. Marginal failure. c. Both a and b. d. None of the above. 4. Ceramic or Ceromer inlay/onlay restorations are not clinically superior to direct composite restorations. a. True. b. False. 5. Which of the following statements describe glass insert technology? a. It is used to reduce polymerization. b. It is used to increase the strength of the definitive restoration. c. It has a lower coefficient of thermal expansion than does amalgam. d. All of the above.

6. Direct Class II restorations exhibit limitations that include: a. Reduced polymerization shrinkage. b. Decreased postoperative sensitivity. c. Microleakage. d. All of the above. 7. The restorative system described requires which of the following? a. Ceramic inserts. b. Composite resin. c. Sonic preparation tips. d. All of the above. 8. The sonic preparation tips have a gingival inclination that measures: a. 45. b. 40. c. 35. d. 30. 9. Which of the following must be completed to ensure restorative success? a. Proper isolation of the site. b. Conventional bonding procedures. c. Sterile placement of the inlay restoration. d. All of the above. 10. The sonic preparation and material technology offer what restorative benefit(s)? a. Reduced treatment duration. b. Improved durability. c. Optimal aesthetics. d. All of the above.

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