1.

2.

The part of a fixed partial denture which unites the abutment(s) to the remainder of restoration. It is a crown or any restoration that is cemented to the abutment. Retainers can be Extra coronal retainers-they cover the entire occluding surface of the tooth e.g. full veneer crowns, partial veneer crowns. Intra coronal retainers

small metallic extensions that are cemented onto the tooth. E g: inlay, onlay.

INLAY

ONLAY

An inlay is an indirect restoration(filling) consisting of a solid substance (as gold or porcelain) fitted to a cavity in a tooth and cemented into place. Sometimes the decay or fracture is so extensive that a direct restoration,such as amalgam or composite, would compromise the structural integrity of the restored tooth or fail to bear occlusal (i.e., biting) forces. In such situations, an indirect gold or porcelain inlay restoration may be used. They are usually used when tooth destruction is less than half the distance between cusp tips.

An onlay is an indirect restoration which incorporates a cusp or cusps by covering or onlaying the missing cusps. When decay or fracture incorporate areas of a tooth that make amalgam or composite restorations inadequate, such as cuspal fracture or remaining tooth structure that undermines walls of a tooth, an onlay might be used. Onlays are fabricated outside of the mouth and are typically made out of gold or porcelain.

A inlay can be used instead of amalgam for patients with a low caries rate who require a small class II restoration in a tooth with ample supporting dentin. Least complicated cast restoration to make. Durable if done carefully.

An onlay allows the damaged occlusal surface to be restored with a casting in the most conservative manner. Restoration of a severely worn dentition with minimally damaged teeth or for replacement of an MOD amalgam restoration when sufficient tooth structure remains for retention and resistance form.

As these rely on intra coronal(wedging) retention, contraindicated unless there is sufficient bulk to provide resistance and retention form. MOD inlays may increase the risk of cusp fracture and are avoided. Extensive onlays, where caries extend beyond the facial or lingual line angles, are contraindicated unless pins are used to supplement retention and resistance.

Long lived because of excellent mechanical properties of gold alloys. Low creep and corrosion. Esthetics. Absence of tooth discoloration as with amalgam. Resistance to occlusal forces. Protection against recurrent decay. Marginal integrity. Precision of fabrication. Proper contouring for gingival health. Ease of cleansing. An onlay can support the cusps, reducing the risk of tooth fracture. If the onlay or inlay is made in a dental laboratory, a temporary is fabricated while the restoration is custom-made for the patient.

For small carious lesion, an inlay is not very conservative. To achieve cavity preparation without undercuts and to permit access for impression making additional tooth removal is necessary. This extension may lead to additional display of metal and gingival encroachment which affects periodontal health. Inlays rely on buccal and lingual cusps for resistance and retention form. Due to wedging from inlay high occlusal force may fracture the cusp. Very costly.

Carbide burs are usually used for inlay or onlay preparations, but diamonds can be substituted if preferred: 1. Tapered carbide burs 2. Round carbide burs 3. Cylindrical carbide burs 4. Finishing stones 5. Mirror 6. Explorer and periodontal probe 7. Chisels 8. Hatchet 9. Gingival margin trimmers 10. Excavators 11. High- and low-speed hand pieces 12. Articulating film

Occlusal Analysis 1. Carefully assess the occlusal contact relationship and mark it with articulating film. The margins of the restoration should not be too close (<1.0 mm) to a centric contact; otherwise, there will be damaging stresses at the gold-enamel junction. 2. Apply rubber dam.

Outline Form 3. Penetrate the central groove just to the depth of the dentin (typically about 1.8 mm) with a small, round or tapered carbide bur held in the path of withdrawal of the inlay. Generally this will be perpendicular to an imaginary line connecting the buccal and lingual cusps, not necessarily perpendicular to the occlusal plane. For example, on mandibular premolars it will be angled toward the lingual.

4. Extend the occlusal outline through the central groove with the tapered carbide. The bur should be held in the same path of withdrawal and kept at the same depth just into dentin. The buccolingual extension should be conservative to preserve the bulk of the buccal and lingual cusps. Resistance to proximal displacement is achieved with a small occlusal dovetail or pinhole. The outline should avoid the occlusal contacts.

5. Extend the outline proximally,Undermining the marginal ridge, and stop it at the height of contour of the ridge. 6. Advance the bur cervically to the carious lesion and then lingually and buccally. There should be a thin layer of enamel remaining between the side of the bur and the adjacent tooth to prevent accidental damage. The bur should move parallel to the original unprepared proximal surface, creating a convex axial wall in the box as the opposing buccal and lingual walls provide retention.

It should be held in the path of withdrawal throughout. The width of the gingival floor of the box should be about 1.0 mm (mesiodistally). Correct cervical,lingual, and buccal extension is just beyond the proximal contact area. A minimum of 0.6 mm of proximal clearance required to allow an impression to be made. Sharp line angles are rounded at this time

 Caries

Excavation 7. Identify and remove any caries left, using an excavator or a round bur in the low-speed handpiece. 8. Place a cement base to restore the excavated tissue in the axial wall and/or pulpal floor. If necessary, the preparation can be extended buccally or lingually.

Axiogingival Groove and Bevel Placement 9. Prepare a small, well-defined groove at the junction of axial and gingival walls at the base of the proximal box to enhance resistance form and prevent distortion of the wax pattern during manipulation. It is easily placed with a gingival margin trimmer held in contact with the axial wall to prevent creating an undercut.

10. Place a 45-degree gingival margin bevel with a thin, tapered carbide or fine-grit diamond. Correct orientation is achieved by holding the instrument parallel to the gingival one third of the proximal surface of the adjacent tooth. The bur should not be tilted buccally or lingually to the path of withdrawal; otherwise, an undercut will be created at the corners of the box.

11. Prepare proximal bevels on the buccal and lingual walls with the tapered bur oriented in the path of withdrawal. There should be a smooth transition between the proximal and gingival bevels. 12. Place an occlusal bevel to improve marginal fit and allow finishing of the restoration.

When the cuspal anatomy is steep, a conventional straight bevel will create too little gold near the margin for strength and durability. A hollow-ground bevel or chamfer is normally preferred and can be conveniently placed with a round bur or stone. 13. As a final step, smooth the preparation where necessary, specially the margins.

The MO inlay preparation. A, Depth hole extending just into the dentin. B, An occlusal outline is prepared following the central groove. C, The outline is extended proximally and then gingivally, undermining the marginal ridge and removing caries.

D, Unsupported enamel is removed, and the walls of the proximal box are defined. This is easily done with hand instruments. E, Proximogingival bevels can be placed with tapered or flame-shaped carbides and hand instruments. F, An occlusal bevel or chamfer complete the preparation. G, Occlusal view of the completed preparation.

Preparation of a mandibular molar tooth for an MO inlay. A, Occlusal outline. B, Proximal box initiated. C, Proximal box extended to remove contact. D, Completed preparation.

The occlusal outline and proximal boxes of an onlay preparation are similar to those of an inlay. The additional steps are the Occlusal reduction and a functional(centric)cusp ledge. Outline Form 1. Prepare the occlusal outline with a tapered carbide bur just beyond the enamel-dentin junction (approximately 1.8 mm deep) and extend it through the central groove, incorporating any deep buccal or lingual grooves. Existing amalgam restorations are removed.

2. Extend the outline both mesially and distally to the height of contour of the marginal ridge. As with an inlay, the boxes are prepared by advancing the bur gingivally and then buccally and lingually, always holding it in the precise path of withdrawal of the preparation. There should be a thin section of proximal enamel remaining as the bur advances, to prevent damage to the adjacent tooth.

A minimum clearance of 0.6 mm is needed for impression making. Sometimes existing restorations or caries require a box to be extended beyond optimal so the preparation will have little resistance form, and an alternative restoration such as a complete crown should be considered.

Preparing the boxes is a key step when fabricating an onlay. The tapered bur should be held precisely in the planned path of withdrawal throughout. Tilting should be avoided. 3. Round sharp line angles between the occlusal outline and proximal boxes.

Caries Excavation 4. Remove any remaining caries using an excavator or a round bur in the low-speed hand piece. 5. Place a cement base to restore the excavated tissue. Ensure that adequate sound dentin is present on the axial walls to provide retention and resistance.

Occlusal Reduction 6. Place depth grooves on the centric (functional) cusps. To give additional clearance at the cusp tip, the bur must be oriented more horizontally. The grooves should be 1.3 mm deep, allowing 0.2 mm for smoothing. 7. Place 0.8 mm grooves on the non centric cusps. On non centric cusps, the bur is oriented parallel to the cuspal inclines.

8. Connect the grooves to form the occlusal reduction maintaining the general contour of the original anatomy. 9. Prepare a 1.0-mm centric cusp ledge with the cylindrical carbide bur. This will give the restoration bulk in a high-stress area, preventing deformation during function. The ledge should be placed about 1 mm apical to the opposing centric contacts.

10. Round any sharp line angles, particularly at the junction of the ledge and occlusal surface. 11. Check for adequate occlusal reduction by having the patient close into soft wax and measuring with a thickness gauge.

Margin Placement 12. Establish a smooth, continuous bevel on all margins. The gingival bevel is placed, as for an inlay, with the thin carbide or diamond held at 45 degrees to the path of withdrawal, or approximately parallel to the adjacent tooth contour. This will blend smoothly with the buccal and lingual bevels.

13. Bevel the noncentric and centric cusps. Where additional bulk at the margin is needed, a chamfer should be substituted for the straight bevel. This can be placed with a round-tipped diamond. 14. Complete the preparation by rechecking the occlusal clearance in all excursions and assessing for smoothness.

The MOD onlay preparation. A, An occlusal outline is prepared to follow the central fossa, and the marginal ridges are undermined. B, The proximal boxes are refined.They should extend just beyond the proximal contact area. C, Depth grooves are placed for occlusal reduction-0.8 mm on the noncentric cusp and 1.3 mm on the centric cusp. D, Notethe lingual functional cusp bevel as part of the completed occlusal reduction. A lingual shoulderis prepared, approximately at the level of the occlusal isthmus.

E, Continuous bevel completes the preparation. The bevel on the Lingual shoulder makes a smooth transition into the proximal bevel of the box. A small contrabevel is placed on the buccal cavosurface margin. F, Occlusal view of the completed preparation

Preparation of a mandibular molar tooth for an MOD onlay. A, Preparation outline. B, Proximal boxes extended to remove contacts. C, Occlusal reduction grooves. D, Centric cusp ledge placed for distal half. E and F, Completed preparation.

For patients demanding esthetic restorations, ceramic inlays and onlays provide a durable alternative to posterior composite resins. The ceramic restoration can be bonded to the prepared tooth with hydrofluoric acid and the use of a silane coupling agent.

Used for patients with a low caries rate requiring a Class II restoration and wishing to restore the tooth to its original appearance. It is the most conservative ceramic restoration and enables most of the remaining enamel to be preserved.

Because these restorations are time consuming and expensive, contraindicated in patients with poor oral hygiene or active caries. Because of their brittle nature, contraindicated in patients with excessive occlusal loading, such as bruxers.

Esthetic restorations. The restoration wear is not a problem. Marginal leakage associated with polymerization shrinkage and high thermal coefficient of expansion of the resin is reduced, because the luting layer is very thin.

Accurate occlusion difficult to achieve. Rough porcelain is extremely abrasive of the opposing enamel. Wear of the composite resin-luting agent can be a problem, leading to marginal Finishing of the margins can be difficult in interproximal areas. Resin flash or overhangs can initiate periodontal disease. Bonded ceramic inlays are a relatively new concept, and long-term clinical performance is hard to judge.

As for metal inlays, carbide burs are used in the preparation, but diamonds may be substituted: Tapered carbide burs Round carbide burs Cylindrical carbide burs Finishing stones Mirror Explorer and periodontal probe Chisels Gingival margin trimmers Excavators High- and low-speed handpieces Articulating film

Rubber dam isolation. Before applying the dam, mark and assess the occlusal contact relationship with articulating film. To avoid chipping or wear of the luting resin, the margins of the restoration should not be at a centric contact.

Outline Form 1. Prepare the outline form- broadly similar to that for conventional metal inlays and onlays Axial wall undercuts can be blocked out with resin-modified glass ionomer cement, preserving additional enamel for adhesion. However, undermined or weakened enamel should always be removed.

The central groove reduction (typically about 1.8 mm) follows the anatomy of the unprepared tooth. The outline should avoid occlusal contacts. Areas to be onlayed need 1.5 mm of clearance in all excursions to prevent ceramic fracture.

2. Extend the box to allow a minimum of

0.6 mm of proximal clearance for impression making. The margin should be kept supra gingival, which will make isolation easier and will improve access for finishing.

If necessary, electrosurgery or crown lengthening can be done. The width of the gingival floor of the box should be approximately 1.0 mm.

3. Round all internal line angles. Sharp angles lead to stress concentrations and increase the likelihood of voids during the luting procedure.

Caries Excavation 4. Remove any caries not included in the outline form preparation with an excavator or a round bur in the lowspeed handpiece. 5. Place a resin-modified glass ionomer cement base to restore the excavated tissue in the gingival wall.

Margin Design 6. Use a 90-degree butt joint for ceramic inlay margins. Bevels are contraindicated because bulk is needed to prevent fracture. A distinct heavy chamfer is recommended for ceramic onlay margins.

Finishing 7. Refine the margins with finishing burs andhand instruments, trimming back any glass ionomer base. Smooth, distinct margins are essential to an accurately fitting ceramic restoration.

Occlusal Clearance (for Onlays) 8. Check this after the rubber dam is removed. A 1.5-mm clearance is needed to prevent fracture in all excursions. This can be easily evaluated by measuring the thickness of the resin provisional restoration with a dial caliper.

Maxillary first molar preparation for an MOD ceramic inlay. A, Defective restoration. B, The restoration and caries removed. C, Unsupported enamel removed and glass ionomer base placed. D, The completed ceramic restoration.