Porcelain Inlay and Onlay

Preparation and Restoration

Dr. Ignatius Lee

Restorative Options - Direct

1970s
Posteriors: amalgam Anteriors: composite

2000s
Posteriors: amalgam (material specific), composite (lesion specific) Anteriors: composite

Evolution of Cavity Preparation Design for Posterior Composite

Taking into consideration the differences in the physical properties between the two materials (amalgam vs composite); and based on the rationale of the cavity preparation design for amalgam Questions were asked: Do we need convergent walls? retention grooves? Worry about unsupported enamel? Extension for prevention? Do we need bulk? New cavity preparation design for posterior composite was created; it was based on specific characteristic of the material.

Why are we talking about amalgam/composite

Example of utilizing the skill/knowledge we acquired in using a specific material/procedure (amalgam restoration) and applying it on a new material/procedure (composite restoration) Preparation skills should be easily transferable. Knowledge on the rationale of cavity preparation will allow us to adapt to the new material based on the materials specific characteristic. Answer to your question on why are we still teaching cast gold inlay/onlay? - when only a few dentists are doing these kinds of procedures in their offices.

Restorative Options - Indirect

1970s
Cast gold inlay/onlay, 3/4 crown, full cast crown, PFM

2000s
Cast gold inlay/onlay, 3/4 crown, full cast crown, PFM Porcelain/composite inlay/onlay

Differences between gold and porcelain restorations

Physical properties - porcelain more brittle Mode of retention - bonding vs mechanical retention Concept of margin

Based on these differences, can we design a cavity preparation for using porcelain intra-coronally??

Starting with cavity preparation design for cast gold inlay/onlay, what features do we have to modify for porcelain????

Physical Properties

What cavity preparation features do we need to modify?

Bulk - more occlusal clearance Reinforcement - bonding Bevels contraindicated

Mode of Retention
Cast gold preparation rely on 6 to 7 degree of divergent walls and sharp internal line angles. Porcelain rely on the bonding process, no need for 6 to 7 degree divergent wall and sharp internal line anlges.

Marginal Adaptation

Cast gold - rely on close adaptation (20u); lack of adhesion between tooth structure/cement/gold interface

Porcelain - rely on the adhesion between tooth structure/resin cement/procelain to create a gap free continuous margin. No gingival bevels needed to minimize the gap.

Empress Procelain System

All procelain restoration used for inlay, onlay, full crown Castable Adequate marginal fit Better wear characteristic than conventional procelain Similar to cast gold inlay/onlay in terms of cavity preparation design

Porcelain Fused to Metal Crown vs Empress: Similarities

Highly esthetic Wear Brittle - reinforced through the bonding process

Composite vs Empress: Similarities

Mode of retention - dentinal bonding agent Apply skills you learn for composite on the bonding process.

Mechanism of Adhesion

Etched Porcelain

Etched Tooth

Silane Coupling agent Dentinal Bonding Agent

Resin Adhesive

Dentinal Bonding Agent

Porcelain etched with hydrofluoric acid (micromechanical) Bond between etched tooth and DBA identical to composite/tooth Silane coupling agent chemical bond

Summary of Characteristics
Highly esthetic Acceptable marginal fit Conservation of tooth structure Less occlusal wear Highly technique sensitive

Indications

High esthetic demand Replace moderate to large existing restoration Fractured tooth/restoration Moderate to large primary caries

Contraindiations

Unable to adequately isolate the field Parafunctional habits - bruxing, clenching, excessive wear

Empress vs Gold Inlay/Onlay Empress

Advantages ESTHETIC Conservation of tooth structure (gold onlay vs porcelain inlay) Less complicated cavity design?? Disadvantages Expensive Technique sensitive - bonding process Abrasive to occluding dentition

Empress vs PFM Empress

Advantages Conservative cavity preparation Foundation restoration may not be necessary Less abrasive to occluding dentition No metal collar Disadvantages Expensive Technique sensitive

Cavity Preparation Design

1. Occlusal Depth/Cusp Reduction Occlusal Depth = 1.5 to 2.0 mm Cusp Reduction:Functional cusp = 1.5-2.0mm Nonfunction cusp = 1.5 mm 2. Internal/External Line Angles Rounded

Cavity Preparation Design

3. Draw Degree of draw = approximately 12 to 15 degree
4. Bevel No bevel

Mn first premolar- DO amalgam with fractured lingual cusp, deep pulpal floor

Existing amalgam removed, making all walls divergent, smoothed all cavosurface margins

Mx first molar - MOD amalgam with deep pulpal floor (4mm)

Existing amalgam removed

Proximal walls and gingival seats extended, occlusal wall divergent, clinical judgement was made to cover DL cusp (with shoulder)

No cavosurface bevel on shoulder

MOB amalgam on Mx first molar with deep pulpal floor

Existing amalgam removed, make all walls divergent and smoothed all cavosurface margins

Occl amalgam on Mn first molar, normal pulpal depth; patient complaining about pain on functionDx: DB cusp fractured

Patients occlusion

Existing amalgam removed, DB cusp reduced by 2mm, all walls divergent

No shoulder on DB cusp WHY???

MOD amalgam on Mn second molar with fractured Li cusp. Normal pulpal depth; all amaglam removed

Proximal box divergent, Li cusp - smoothed cavosurface margin

MOD amalgam on Mn first molar - occlusal fractured

Shade selection BEFORE rubber dam; need dentin shade (match shade at gingival third) and overall shade

Finished preparation; rubber dam removed; ready for impressioning; proximal box divergent, cusp reduction, buccal cusp with heavy bevel (no shoulder)

Buccal view

Wax up on working cast

Special die for shade matching/staining - reason for taking the dentin shade

Restoration on die/working cast

Trying in under rubber dam; adjust proximal contact; do not adjust occlusal contact

Cementation under rubber dam using resin cement; excess cement removed using cotton tip

Excess resin cement removed from proximal/gingival margins using an explorer

Rubber dam removed following cementation

Adjust occlusion using fine diamond in high speed hand piece

Laboratory Exercise - Mn first molar,

MOD onlay preparation for porcelain

Finished Preparation - MOD porcelain onlay preparation

Restoration on die, back from laboratory

Restoration seated under rubber dam

Bu view after cementation

Restoration on die, back from laboratory

Restoration seated under rubber dam