Considerations for ceramic inlays in posterior teeth: a review

Introduction

Ceramic inlays offer an aesthetic alternative to metal class I or II restorations. Their primary use is in
compromised posterior teeth with intact buccal and lingual walls. These restorations offer the opportunity
to conserve tooth structure while taking advantage of the mechanical benefits of modern adhesive
technology, which can strengthen the compromised tooth. Ceramic inlays offer a viable alternative to
amalgam or cast-gold restorations, both of which have enjoyed long histories of clinical success.

Ceramic inlays, by contrast, allow the practitioner to achieve an excellent shade match with surrounding
natural tooth structure. Provided that the appropriate shade is selected and the restoration is fabricated
with proper translucency, ceramic inlays can be almost indistinguishable from the tooth being restored.
They have improved physical properties in comparison to direct posterior composite resin restorations,
and when preparation margins are situated in enamel, ceramic inlays offer the potential of reduced
microleakage by comparison to either amalgam or gold. However, the current adhesive systems have not
completely eliminated microleakage when cervical margins are located in dentin.

Use of ceramic inlays

Ceramic inlay indications include most of the typical indications for cast-metal inlays, with the added
requirement for a tooth-colored restoration. Ceramic inlays can be conservative of tooth structure, and
permit preservation of much coronal tissue. They can be used in lieu of a metal-casting or amalgam
restoration in patients who require a class II restoration where buccal and lingual walls remain intact, and
offer a viable alternative where excessive isthmus width may preclude the use of a direct posterior
composite restoration. Ceramic inlays are stronger than direct posterior composite resins, offering
superior physical properties than the latter, as the limited degree of polymerization conversion of direct
posterior composites limits their strength. However, the advantage of the ceramic inlay over the
composite resin may be limited by the possible need for an additional appointment, the greater skill level
required to deliver the treatment, and the higher cost associated with the materials used.

Contraindications for ceramic inlays exist in dentitions of patients with poor plaque control or active
decay. Since porcelain fracture has been reported as a primary reason for ceramic inlay failure, heavy
loading should be avoided.26 Under those circumstances, the brittle nature of the ceramic makes these
restorations a higher risk. In the presence of an unfavorable occlusion, a group-function occlusal
arrangement, or in patients exhibiting evidence of parafunctional activity such as bruxism or clenching,
prudence is advised.

Consideration should be given to alternative restorations when faced with the inability to maintain a dry
field precluding proper luting procedures. Accordingly, preparations with deep cervical subgingival
extensions, and other clinical situations where excellent isolation is problematic, may constitute a
contraindication.
 Preparation design

Preparation design is influenced by the selected restorative material (weaker materials requiring
additional bulk), the fabrication method, and the ability to bond the restoration. Clinicians must further
consider aesthetics, fracture resistance, and edge-strength capabilities of the selected restorative material.
The potential advantages of enamel bonding versus dentin bonding should also be taken into
consideration, as well as the variance in bonding to different qualities of dentin and the possibility of
limited retentive form.

Ceramics are brittle. Though significant progress has been made in the development of new and improved
materials, the inherent brittleness remains a limiting factor that can be minimized through proper
preparation design.

Preparation guidelines for ceramic inlays differ from those for cast gold . Retention form is not as critical
due to the bonded nature of the restoration, and bevels are contraindicated. Cavosurface angles of 90° are
preferred, and the preparation must have smooth-flowing margins to facilitate the fabrication of the
restoration. The bulk of ceramic must be established in areas of potential contact from adjacent and
opposing teeth, and good visual access to all prepared surfaces facilitates optical capture and subsequent
fabrication.

There appears to be a reasonable consensus about minimally required dimensions for all ceramic posterior
inlay preparations. Generally, a minimum of 1.5–2 mm of pulpal floor depth, 1–1.5 mm of axial
reduction, and 2 mm of isthmus width define minimally adequate preparation dimensions. Such isthmus
width minimizes fracture risk by stresses resulting from occlusal forces.47 Insufficient material thickness
will result in fracture.47,48 Without adequate reduction, isthmus width, and smooth 90° cavosurface
margins, the ceramic material will not be able to withstand the significant loads to which it is subjected
posteriorly.49

Inlay preparations may be modified in part to overlay a compromised or weakened cusp. If in that manner
a cusp is to be overlaid, occlusal reduction of at least 2 mm is recommended to allow sufficient occlusal
ceramic thickness to predictably withstand occlusal forces without fracture.47

In a pulpal direction, axial reduction in proximal boxes should be a minimum of 1–1.5 mm deep. Such
allows for conservation of tooth structure and the reduced need for bulk of ceramic due to a lack of direct
occlusal forces while considering the minimal bulk needed to create a 90° cavo-surface margin.

The minimum dimensions cited above are suggested for commonly used ceramics, such as leucite-
reinforced porcelain or lithium disilicates

Ceramic inlays can be fabricated from a number of materials, each of which has unique advantages and
disadvantages. Current choices include feldspathic porcelains, leucite-reinforced, lithium disilicates, and
glass-infiltrated ceramics . A limiting property of feldspathic ceramics is their inherent weakness in
comparison to alternative material choices.
 Strengthening of ceramics

All ceramics contain fabrication defects and surface cracks, from which fracture can initiate. Porosity in
dental ceramics is an inherent by-product of the condensation procedures used during fabrication.
Clinically failed glass-ceramic restorations have been shown to initiate fracture from internal
porosities.66 Leucite (potassium aluminosilicate) raises the coefficient of thermal expansion of dental
porcelain, and results in increased hardness.67 Leucite-strengthened ceramics develop microcracks during
the cooling phase, caused by the deliberate mismatch in coefficients of thermal expansion between the
leucite crystals and the surrounding glassy matrix.68

The increased demand for stronger materials spurred the search for new materials and methods to
strengthening existing glass ceramics. Strengthening methods for improved performance of dental
ceramics include thermal tempering, chemical strengthening, crystalline reinforcement, and stress-
induced transformation. Thermal tempering can result in compressive stress profiles that extend deeper
than chemically derived stresses, but may have limited dental applications because cooling rates are
difficult to control for objects that have complex shapes.69
 Aesthetic considerations

The clinical choice to select a material for restoration of a posterior tooth, whether amalgam, composite,
gold, or ceramic, is influenced by multiple factors. If patients demand an “aesthetic” restoration, options
are limited to composite or ceramic. When the most economical option is desired, the choice typically is
between amalgam or composite. If the longest service record is sought, many dentists would respond with
a gold restoration. In a survey of dentists’ preferences for the restoration of their own molar teeth, it was
found that most dentists did not replace traditional metallic restorations with aesthetic alternatives, and
still chose nonaesthetic options for a significant number of their own restorations.

Each material appears to have a niche, however, as newer and further-improved aesthetic material choices
become available, such as the relatively recent introduction of the lithium disilicates. The exact place
where ceramic inlays fit into the overall selection has continued to morph.

For aesthetic restorations, the question becomes, under what circumstances does a direct composite best
fulfill the treatment needs, and when is an indirect ceramic inlay a more appropriate choice?

The versatility of layered porcelains permits the knowledgeable ceramist and clinician to mimic the
chroma, shade, hue, translucency, and surface finish of natural teeth. Improvement of their aesthetic
qualities and physical properties has served as a constant catalyst to the further development of aesthetic
materials.

Several authors report that patients were satisfied with the aesthetic results of both direct composites and
ceramic inlays.79,80 However, one study reported lower color match scores for the ceramic inlays (85%)
than for the composite inlays (100%) at baseline due to their monochromatic nature, and even lower
scores after 3 years (58.8% for ceramics and 86.5% for resin),79 while another study reported no
significant difference in aesthetic scores after 10 years of clinical function. Thus, from a patient’s
perspective, if aesthetic differences are not a major factor, the question becomes why investment in the
ceramic restoration might be preferable over a direct composite. The logical next consideration, then, is
which material will provide the longest service to the patient. Stress distribution and bonding are
significant factors contributing to restoration longevity.

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Stress distribution

A number of studies have evaluated differences in stress distribution and flexure between ceramic and
composite inlays. Finite-element modeling suggests that composite restored teeth exhibit increased
coronal flexure, whereas ceramic inlays result in increased coronal rigidity. Compared to ceramics,
composite with a low modulus of elasticity exhibits increased tension at the dentin-bonding agent
junction, suggesting that porcelain inlays have a lower risk of debonding.80

In vitro studies suggest that ceramic inlays may perform better than composite resin inlays in terms of
adaptation to dentin, marginal adaptation, and cusp stabilization.81–83 In vivo, ceramic inlays have been
shown to exhibit superior restoration integrity and anatomic form.84
Logically, one might conclude that because of these advantages, the comparative long-term performance
of the ceramic inlay should be superior. If so, less frequent need to replace the restoration would in fact
result in improved longevity, making the ceramic inlay the more economical choice.

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Luting considerations

The use of traditional acid-based reaction cements such as zinc phosphate and glass ionomer results in
ceramic inlays that are more prone to fracture in comparison to an adhesively bonded ceramic inlay.85

The use of resin-modified glass ionomer luting agents gained some popularity in practice largely because
of comparatively superior strength compared with traditional glass ionomer, and potential release of
fluoride. The clinical significance of the latter is questionable, because the actual fluoride release is of
fairly short duration,86 and the cohesive strength of resin-modified ionomers remains lower than for
composite resins.87

The use of dual-cured cements has been advocated for luting ceramic inlays because of the varied ceramic
thickness through which light must pass in order to activate the polymerization reaction.92 When using
dual-cured resin cements, the ultimate hardness is a function of light exposure, and marked differences
have been shown between various materials in terms of the ratio of chemical and light-activated
catalysts.93 In a comparative in vitro study of five dual-cure cements, typical 40-second exposure time, as
recommended by the manufacturer, was shown to be insufficient to compensate for light attenuation
through a 4 mm thickness of porcelain.94 Dual-cure resin luting agents require visible light exposure to
reduce risk of discoloration, and exposure time should be as long as possible, taking light attenuation into
consideration as a function of restoration thickness.95 The durability of the resin bond is affected by the
amount of light the luting agent is exposed to.96 97 Ceramic inlays are superior to composite resin inlays
in terms of light transmission,98 which aids achieving a higher degree of conversion.

Longevity

When evaluating the longevity of any dental restoration, it is prudent to analyze the technological
advancements that occur throughout the evaluation period. For ceramic inlays in particular, the rapid
evolution of the available materials, methods, and associated technologies make this a challenge. Over the
course of the last decade, significant improvements have been developed in ceramics, bonding, and
technology used in the manufacturing process.101

A number of variables are unpredictable and uncontrollable: the quality of tooth structure the restoration
is bonded to, the applied load, and oral hygiene; all impact clinical longevity. Among the variables the
clinician can control are tooth-preparation design, the type of restorative material selected, and the
bonding technique used.

It has been reported that ceramics appear to have similar short-term survival rates to other materials on
posterior teeth.102 A 2003 study in which ceramic inlay longevity was compared to that of other posterior
restorations concluded that no strong evidence base existed to support any performance difference,
reporting an 11% failure rate after 5 years.103 One retrospective study evaluated 141 two-surface inlays
and 155 three-surface inlays with a mean observation period of almost 9 years, and reported a 12-year
inlay survival of 89.6%, with increased failure rates in nonvital teeth. The author concluded that ceramic
inlays are a viable restoration for posterior teeth, but do not provide comparable longevity to the posterior
cast-gold inlays.104 In contrast, CEREC inlays have been reported to have 89% survival at 10 years, with
clinical failure rates being comparable to those of cast gold.105

Porcelain fracture has been reported as a primary reason for restoration failure.106,107 Therefore, it
appears prudent to avoid excessive loading of porcelain inlays. Over an 11.5 year observation period of
183 inlays, porcelain inlay survival rate for premolars was 99% in comparison to 95% for molars.108 In
this study, all preparation margins had been placed in enamel, and the prepared teeth were isolated under
rubber dam during the luting procedure.

Summary

When a posterior tooth is compromised, eg, because of wide isthmus preparations, ceramic inlays offer
advantages over direct composite resin restorations. They offer an aesthetic long-lasting alternative with a
predictable degree of clinical success. The physical properties of ceramics have improved dramatically in
recent years, and with improvements in CAD/CAM technologies, internal and marginal adaptation of
milled restorations continues to improve. Due to the inherently brittle nature of ceramic materials,
adequate tooth reduction is necessary to provide sufficient bulk for the ceramic to withstand functional
loads. Preparation margins should ideally be located in enamel, which will result in a strong and durable
bond when resin luting agents are used. By comparison, resin bonding to margins located on dentin
exhibits greater potential for microleakage.

Ceramic inlay luting procedures require excellent isolation, etching of the ceramic, the use of a silane
coupling agent, and etching of the prepared tooth. A careful technique will ensure delivery of a
predictable, long-lasting, aesthetic ceramic inlay restoration.