Ceramic Inlays Clinical Assessment and Survival Rate

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Ceramic Inlays: Clinical Assessment andSurvival Rate

Massimo FuzziVGiorgio Rappellib

Purpose This study evaluates th e olinical behavior of oeramic inlays piaced during the past deca de.Materials and Methods One hundred eighty-two inlays were examined in 66 patiehts. The interval be-tween placement and assessment was oh average 5.9 years 2.7, ranging from 2 to 11.7 years. Restora-tions still present at the time of evaluation were clinically assessed according to modified USPHS criteria.Kaplan-Meier statistical analysis was used to assess the survival rate.

Results According to USPHS criteria, good results were obtained for color match, marginal discoloration,recurrent caries, contour, and marginal integrity. Six inlays failed: four for endodontic reasons, one due torecurrent caries, and the other due to fracture. The results indicate that a success rate of 95% could bepredicted at 11.5 years.

Conclusion The lack of recurrent canes, the ohiy slight changes ih marginal discoloration and colormatch, combined with the excellent longevity prove that ceramic inlays are a valuable tool for the restora-tion of posterior teeth.J Adhesive Dent 1999; 1; 71-79. Submitted for publication: 0 6.10 98 : accepted for publicai/on: 05.11,98.

he challenge of repro duc ing natural e stheticshas been present for several decades, with a

nstant improvement of restorative materials andiicatjon techniques.

Since 1882, when Herbst introduced the first ce-mic in iays ,2^ grea t progress has been ma de.

ay, than ks to improv em ents in adhe sion tech-ues and mater ia l character is t ics , indi rec t ce-

mic restorations are one of the ai ternatives toalgam, particularly in large cavities, enabling the

hetic demands of patients to be met for theirte rior teeth.2.7.11.25.26 j ^ j g typ e of re sto ra tio no strengthens the tooth structure and preservestai tissue to a large extent.^

ate practice. Bologna, Itaiy.vate practice, Osimo (An), itaiy

nt requests Dr Massimo Fuzzi 7 Piazza P.ta Mascareila.8 Boiogna. Itaiy Fax: ++39 051 240513; E-mail: SAOS FUZZimasianet.it

Porcelain remains the materiai of choice for nat-urai-looking, esthetic restorations, due to its excel-lent optical qualities, indirect fabrication process,and favorable bioiogical response. However, investi-gations on the longevity and ciinical behavior of ce-ramic inlays are insuffioient.

in 1992, Mrmann and Krejct^^ estimated a suo-cess rate with the Cerec system of 75% after 5years. That same year, Studer et aiô reported asurvival rate of 98% based on 130 iPS Empress in-lays, examined at 186 months. In 1994, Reiss^êxamined 1000 Cerec-type inlays and, using the Ka-pian-Meier survivai analysis, found a success rateof 9 1 % after 6 years. In 1994, Moaci< and Rouietiêxam ined porcelain inlays piaced by studen ts andfound a survivai rate of 75% after 4 years. In 1995,Roule t ts assessed 123 in iays wi th the Kapian-iVleier analysis and found a success rate of 76% at6 years. The failures were due to fractures and en-dodo ntic causes, partiy related to extended applica-t ions. Studer and coworkers^^ published data in19 96 on 13 0 IPS-Empress iniays, reporting a sur-

vivai rate of 97.5% after 2 years, in 1996, Qual-t roug h and Wilson ^ obta ine d a success ra te of


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Fig 1 The margins of the prepa ration are placed on theenamel. The dentin side, when neoessary, is reoonstruotedwith a glass-ionomer photooured base.

Fig 2 The impression w ith poiyether ma teriai reprothe de tails of the prepa ration, A fluid m steriai (Pbiue, ESPE, See feid, Germany) is applied to the thioi^er m aterial [Imp regum , ESPE, See feid, Germaplied to the tray.

8 2% from 50 ceramic inlays examined at 3 years.In 1997, Fradeani et ai^ reported a 96% successrate over 125 iPS-Empress inlays examined at 4.5years. That same year, Roulet^* reported a 4% an-nual faiiure rate of Dicor porcelain inlays.

The present study assesses the survival rate andciinicai condit ion of porcelain inlays provided byone of the authors in his ciinicai practice over theperiod 1986 to 1996,

M TERI LS ND METHODS

One hundred eighty-two porcelain inlays were exam-ined in 66 patients, 41 female and 26 male. Pa-tient age ranged from 23 to 50 years. The iniaysincluded occiusai restorations (11), mesio-occlusal(35), occluso-distal (45), mesio-occlusal-distal (63)and cus pal-cove rage restora tions (28), Cavity pre pa-rations with ai i margins iocated in enamei werecompleted in each tooth using Cerinlay diamondburs (Intensiv, Viganelio-Lugano, Switzeriand) (Fig1) , Fuil-arch impressions including the preparationswere taken using a polyether impression material(Impregum, FSPF, Seefeid, Germany) (Fig 2), whilethe opposing arch was replicated with an algnatei m p r e s s i o n . F e r m i t a c r y l i c ( I v o c i a r, Vi v a d e n t ,Schaan, Liechtenstein) or a reiated material wasused to make temporary restorations.All restorations w ere made by the same techn icianusing Microbond Natural f ired ceramics (Austenal

Dental-Austenal Internationai Inc, Chicago, IL, USA)

in the period from 1986 to 1990 and Fortucera mic s (W illiam s-lvociar, Am hers t, New USA) from 1 9 9 1 to 1 99 6. L uting was carwith a rubber dam in place, Cavex Protect (Cavex, Haarlem, Holland, by Kuraray Co Ltdwas used to protect the external part of theduring luting; the varnish was applied withand removed with alcohol after luting the (Fig 3). The fitting surface of the ceramic tions was etched with hydrofiuoric acid (HF the t echn ic i an a f t e r t ry- in . S i ianiza t ion wSilane (3IVI De ntal Produc ts D ivision , St PUSA) was carried out by the dentist just being. Enamel and dentin were etched and The adh esiv e used in the pe r iod f ro m 1

1992 was Scotchbond 2 (3M Dental Produsion, St Paul, MN , USA); en am el w as etch37% p hosphoric acid for 30 s, rinsed, and bonding agent was used to achieve adhesion

1993 to 1996, Scotchbond MP (3M Dentucts Division, St Paui, MN, USA) was useadhesive . A 10% maie ic ac id or 37% phoacid was applied to the enamei for 30 s andden tin for 15 s; after rins ing and ge ntly dthin layer of primer w as appiied to the de ntbonding agent was used to achieve adhesioluting materials used were dual-cured comUltra-Bond (Den Mat Corp, Santa Maria, Cfrom 1986 to 1990 and indirect PorceiainDentist Bo nding (3M Dental P roducts DivPaul, M N, USA) in the period from 1 9 9 1 Following restoration placement, excess lu


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3 A varnish is applied to the external surface of the prepa-ion to faciiitate the removal of the composite after polymer-tion. A transp arent st icky wax is applied to the occlusalt to facilitate the manipulation of the inlay.

ig 4 The finished case, 1 year after completion.

ial was removed with sponge pellets, brush, andper floss. The luting composite was light curedm all aspects (5 min totai). The varnish, rubber

m, and excess lu ting m aterai were removed. Oc-usion was then checked and adjusted. Diamondishing burs and rubber points were used for fin-

hing margins (Fig 4).Ali patients were enroiied in a 3-to 6-month peri-

ontai maintenance program consisting of remoti-t ion , r e ins t ruc t ion o f o ra l hyg iene measures ,ofessional tooth cleaning, and fiuoridation. Thisre was provided by a dental hygienist.The restorations still present at the time of as-ssment were evaiuated clinically by a suitablyined operator using modified USPHS cri teria^iable 1). The margins were checked with a Hu-iedy XP 23/OW (Hu-Friedy, Chicago iL, USA] ex-orer. Color was assessed under Siroiux iliumina-n (Siemens AG, Bensheim, Germany). The time

apsed from the date of luting until the iast checks 2 to 11.7 years.

The oiinicai variables (color match, marginal dis-loration, recurrent caries, contour, marginal in-ri ty) were tabled using the stat is t ical programS for W indows, ve rs ion 6 .08.2- ' A con di t ion al

aiysis of the iniays and onlays still intact at thet observation was performed on those variableswhich several values of bravo or worse had

en recorded. To reconstruct the changes in theiables, the med ian dura tion (5 years and 13 2

ys) was used to create two subgroups: recent vs.er restorations. The subgroup recent included

89 and the subgroup older 87 inlays. The frequencyof alph a vaiues in the two groups was comp aredby means of the exact analogue of the chi-squaretest . i^ A iarger percentage of alpha in the group ofmore recent restorations was interpreted as a trendtowards better values over time, without necessarilyproviding an explanation ofthe cause.

Those inlays no longer present at the time of as-

sessment were considered failures. Failures werec la s s i f i ed accord ing to cause : a ) f r ac tu res ; b )caries: c) endodontic reasons: d) unacceptable es-thetics; e] periodontal problems.

To display the life expectancy of the inlays andonlays, Kaplan-Meier survivai curves were piotted,both for the whole sample and separateiy for per-manen t mola r s and p remola r s . The s t a t i s t i ca lprogram SOLC 4,0 for D0S22 was used for calcu-lations .i^ For the whole sample, 95% confidence in-tervals were constructed by multiplying by 1.96 the

estimated standard error of the probabiiity of sur-vival at the time of each failure.

R SULTS

Assessment of USPHS criteria showed 100% alphaconcerning recurrent caries. Color match analysisof older restorations yielded 57% alpha and 43%bravo: recent restorations were rated 8 1 % alphaand 19% bravo (Fig 5), Marginal disc olora tion in

older restorations was rated 83% alpha and 17%bravo, whiie recent restorations scored 94% alpha


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Table Criteria for the clinical evaluation of the inlays

Category Rating Characteristic

Color matoh Alpha

Bravo

Charlie

Marginaldisoo oration

Recurrentcaries

Marginalintegrity

Oscar

Aipha

Bravo

Alpha

Bravo

Alpha

Chariie

Alpha

The restoration appears to match the shade ahd transiucehcyof adjaoent tooth tissues.The restoration does hot m atch the shade and transiuoency ofadjacent tooth tissues, but the mismatch is within the normairange of tooth shades.The restoration does hot match the shade and transiucehcy ofadjacent tooth structure, ahd the mismatch is outside the hor-mal range of tooth shades and transiucency.The restoration cannot be examined without using a mouthmirror.There is no visual evidence of marginal discoloration differentfrom the color of the restorative m atenai and from the coior ofthe adjacent tootli structure.There is visuai evidence of marginai discoloration at the junc-tion of the tooth structure and the res toration, but the disool-oration has not penetrated aiongthe restoration in a puipai di-rection.There is visual evidence of marginai discoioration at the junc-tion of the tooth structure and the restoration tha t has pene-trated aiongthe restoration in a puipai direction.There is no visual evidence of dark, deep discolorationadjacent to the restoration.There is visual evidenoe of dark, deep discoioration adjacentto the restoration but not directly associated with cavosurfaoemargins).The restoration is a continuation of existing anatomic form oris siightiy fiattene d. When the side of the explorer is piacedtangentiaiiy aoross the res toration, it does not touch two op-posing oavosurface line angles at the sam e time .Asur faoeoo noavity is evident. When the side of an expiorer isplaced tangen tiaiiy aoross a restoration, the explorer touchestwo opposing oavosurface iine angies at the same time, but

the dentin or base is not exposed.There is a ioss of restorative subs tance so th at a surface con-cavity S evident and the base and/or dentin is exposed.

The expiorer does not catch w hen drawh across the surface ofthe restoration toward the too th, or, if the explorer doesoatoh,there is no visible crevice aion gth e periphery of the restora-tion.The expiorer catches and there is visibie evidence of a orevice,into whioli the explorer penetrates, indicating th at the edge ofthe restoration does not adapt ciosely to the tooth struc ture.The dentin is not exposed, and the restoration is not m obiie,Tlie expiorer penetrates a orevice defect tha t extends to thedentin-enamei junc tion.

and 6 bravo (Fig 6, Marginal integrity was rated

alpha in all restorations except five assessed as

bravo. Contour received bravo scores in 2 cases

and alpha in all others (Tab 2 and Tab 3) (Figs 7, 8),

Of the 182 iniays examined, 6 fai led. Of these

fai lures, 4 were caused by endodontic probiems

and occurred during the first 6 months after ce-

mentation. One failure occurred after 3 years due

to fracture, and another was caused by recurrent

caries after 8 years. Five fai lures took piace in mo-

iars and one in a premolar. Using the Kaplan-Meier

analysis, the survivai index at 11.5 years was 95 ,

and the values, calculated with a 95 confidence

interval (CI), ranged from 86.5 to 98, 1 (Fig 9).

Separating the results of the premoiars from those

of the mol ars, the survivai rate of the premolar

restorations was 99 , while the survival rate of the

molar restorations was 90,2 after 11,5 years

(Fig 10),


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5 A ciinicai exam ple of 3 ceramic restorations after 11ars. The onlays on teeth 16 and 15 have been evaiuated asavo for color match, while the restoration on tooth 14 hasen evaluated as aipha.

i 6 The marginal discoloration of two iniays after 4 years ina patient who smotes. Some points of the occlusal and proxi-mai margins of tooth 14 are stained.

7 MOD iniays on tooth 36 anO 37, OD inlay on tooth 35.te the good ohromatic and marginai adap tation.

i 8 Radiographie verifications of the previous case. Noticethe absence of overhangs and the good marginal adaptation.

Table 2 Results of the clinical evaluation of 3ll 176 inlays examined

Recurrent canesMarginal integrityContourMarginal discolorationColor match

176176176176176

176 (100 ) (0 )171 [97.2 | 5 (2.8 )174 (98.4 ) 2 (1.6 )15 6 88.6 ] 20 (11.4 ]122(89 .3 ) 54(30 .7 )

Table 3 Marginal discoioration and coior match of recent < 5 y) vsolder {> 5 y) restorations; 0.05 ChiMest)

Marginal discoloration Cclor match

Recent restorationsOlder restorations

Aipha Bravo Alpha Bravo84 (94 ) 5 (6 ) 72 (81 ) 17 (19 )72(83 ) 15(17 ) 50(57 ) 37(43 )


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Kstill intact

ss%9S

9 2

9 0

8fl%

86

T - . , .,

1' 1 2

sjrviMlrBtt

: 3

0 2 4 S 8 10 12 Ye a r s Fig 9 Kaplan-Meier survivuated for the totai number and 9 5% con fidence interv

%sl i l l i n l ac l190% -|

98 %

9B %

94%

92%

90%

r

0 2 4 6 a 10 12

S4iii>lars

-38 premolars

Fig 10 Kapian-Meier survrestorations in premolars a< 0.05).

D I S C U S S I O N

All the inlays assessed were found to be clinicaiiysatisfactory. Exampies are shown in Figures 11a-l l d . No recurrent caries was observed, which is in

aooordance with the findings of Stenberg and Mats-son,28 Tidehagand and Gunne,^ berg et al,25 andKrejci e t a l . "

The oontour was assessed as alpha in 98.4% ofthe oa ses. The same results were obtained by Cavelet al," who, however, examined 31 inlays only 6months after luting, and Krejci et al .^ ' ' who as-sess ed 1 0 iniays at 1 8 mo nths . Stude r et aP*^ ex-amined 130 inlays at 18 months (6 months) andassessed the contour of 87% of the restorations asalpha. Cerutti and ooworkers^ reported 84% alpha

contours on 109 Cerec CAD/CAM inlays 6 yearsafter luting.

Marginai integrity was assessed as oases and alpha in ail the others. Romarginai gaps in 14% of inlays. Krejci an important difference between the interproximai margins. We did not obs

ference, aithough our assessment was clinical examination with the expiorer,cas were made for a scanning eieotronexamination.

The quality of the color matoh decrcantly as a function of time (Tabie 3).not expect ceramics to change color ovfact might be due both to the experitechnician in choosing the coior of tand to the dentist 's choice of the iutinBetter resuits on coior match were

Studer et a l^f and Krejci e t ai . l ' Bess iiVIolin,3 who found 54% of assessed i


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g l i a Initiai case of the right upper qua drant. The gold in-ys had interproxim ai overhangs , therefore preventing correotai hygiene.

ig l i b The view of the oeramic iniays 1 mo nth after plment.

g l i e An ooclus ai view after 5 years ig l i d An occiusai view after 13 years.

n acceptab le color ma tch, attributes this resultocciusal adjustment conducted after cementing;Dicor-type inlays, this is assumed to remove the

ost superficial layer of colored ceramics, exposinge bulk ceramic.

The values for marginal discoloration were alsognificantiy different, depending on whether thestorations were oider or more recent (Tabie 3), Itnot known, however, if this discrepancy is due to

technical improvement or to a deterioration of thementing oomposite which supposedly occurs with

me.Using Kaplan-Meier analysis, the inlays' 11,5 yrvivai rate was 95%, Other studies, conducted onsim iiar nu m ber of resto ratio ns, have aiso re-rted favorable findings.29-30 Molin and Karisson^^

amined 20 5 Optec inlays after 1 to 32 mon ths.our restorations were lost and 3 had fractured. In

a study by berg et a\ ^ the influence of the lutingmaterial on the longevity of ceramic inlays wasvestigated. After a 3-year observation period, thelays luted with composite resin showed significafewer failures (2 failures out of 59 restoratio

than those cemented with glass-ionomer cementfailures out of 59). Van Dijken et aP^ evaluated fired felspathic ceramic inlays luted with glionomer cement and composite cement afteryears. As with berg et al. Van Dijken et al foubetter results forthe inlays cemented with compite (93% success rate) than the inlays luted wglass-ionomer cement (76%), Rouiet^s found 9failures among 123 Dicor inlays over a period to 82 months, failures being due to fracture (7),dodontic problems (4), and postoperative pain

No differences were found between the luting mrials (three different luting composites). Premo


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Fuzzi/Rappeiii

tended to show a better success rate; however, the

difference was not statistically significant, Molin

and Karisson '' reported a 90 success rate after 3

years: this was obtained by calculating the survival

rates of iniays performed by 10 dentists who pre-

sented very different results. This finding empha-

sizes the sensitivity of the ceramic iniay technique

and the dependence on personal operator skill andclinical experience. Operator ability and care in ap-

plying the technique can be the main factors infiu-

encing the success rate.

In many studies, the main reason for failure

seems to be the fracture of inlays. Quaitrough and

Wiison,20 examining 50 cerami c iniays after 3

years, found 18 failures due to fracture. All fail-

ures reported by Fradeani et al were due to frac-

ture. Isidor and Brondum^s obtained even less

favorabie results after 57 months with 12 failures

out of 25 inlays, 10 of which were fractures. The se-

lection of cases, particulariy if bruxism patients are

invoived, must also be taken into account when

evaluating the mechanicai properties of ceramics.

It shouid also be noted that 4 of the 6 failures re-

ported in the present study occurred in the same

patient for endodontic reasons (puipitis), and that

these restorations were carried out 11.5 years ago,

when iess oiinicai information was avaiiabie about

the adhesive technique and microleakage controi.

CONCLUSIONS

Taking into account that this single-center study

was conducted without using a control group, the

following conclusions may be drawn:

1 . Within the observation time (up to 11,5 years),adhesively luted oeramic inlays showed no recur-

rent caries.

2 . The slight occurrence of marginal discolorationover ti me (17 bravo for inlays older than 5

years) is still clinically acceptable.

3. The color match of the ceramic inlays was found

to be better in the recent restorations subgroup

than in the older restorations subgroup.

4 . After 11.5 years, a survival rate of 95 of all theceramic inlays must be considered as excellent.

5. The survival rate of premolar inlays (99 ) was

superior to that of molar inlays (90 ).

REFERENCES

1. berg CH, Van D ijken JWV. Olofsson AL. Threson of fired ceramic inlays cemented with coglass ionomer cement. Acta Odontol Scan149.

2. Banks RG. Conservative posterior ceramic rerature review. J Prosthet Dent 1990;B3;619-6

3. Bessihg C, Molin M. An in vivo study of glass ceraminiays. Acta Odontol Scand 1990 :48:351 -35

4. Cavei WT, Keisey WP, Barkmeier WW, et a l. A pilothe clinicai evaiuation of castabie ceramic inlayscure resin cement. Quintessence Int 1988:1

5. Gerutti A, Vehturi G. Putignano A, Prati C. Six-yeaevaiuation of 109 Cad/C am inlays. Ma drid: lstract 29 5|, 1997.

6. Cvar J and Ryge G. Criteria for the Ciihical Etai Restorative Materials, USPHS PublicatiSan Francisco: U.S. Government Printing Of

7. Dietschi D Holz J, Restauration des dents posSuisse Odontostom 1990:10 0:1325-1 332.

8. Douglas WH. Methods tc improve fracture reteeth, in: Vanherie G, Smith DC {eds). PosterResm Dentai Restorative Materiais. Proc 3MNetherlands: Peter Szulc Pubi Co, 1985: 4 3 3

9. Fradeani M, Aqu ilano A, Bassein L. Longitudinpressed glass-ceramic inlays for four and half yethet Dent 1997;78:346-353.

10 . Fu ii M. Porcelain bonded restoration. In: DG. Fuizi M, Prati C (eds). Adhesion in RestorativeProceedings ofthe International Symposium87-97.

11. Garber DA, Goldstein RE. Porcelain and comonlays. Chicago: Quintessence, 1 99 4.

12. Hihtze JL. SOLO S tatistical system BMDP SCork, ireland, 1991 (Survivai Anaiysis Modu

13 . Isidor F, Brondum K, A ciinjcal evaiuation of porceiJ Prosthet Dent 1995:74:140-144.

14. Krejci i, Krejci D, Lutz F. Ciinicai evaiuation of a newgiassed ceramic iniay material over 1.5 years. Quint 1992:23:181-186.

15 . Mehta C, Patel N Statxact Turbo, StatisticaiExact Non param etric inference. U ser s Maware Corporation, Cambridge, MA, 1992 .

16 . Molin M, Karisson S. A clinical evaluation of the Osystem. Acta Odontol Scand 1992:50:227-2

17. Molm M, Karisson S. A 3 year clinical follow-upramic (Optec) inlay system. Acta Odont54:145-149.

18 . Mrmann W, Krejci i. Computer-designed inlaysin situ: clinical performance and scanning scopic evaluation. Quintessence Int 199 2:23:109

19 . Noack MJ, Rouiet JF, Survivai rates and m of Dicor iniays after 4 yea r s | abs t rac t759] . J D1994;73:196,

20. Quaitrough AJE, Wilson NHF, A 3-year ciinporceiaih iniay system. J Dent 1 996 :24:3 17-

21. Quaitrough AJE, Wilson NHF, Smith GA. TAn historical view. Oper Dent 19 90:1 5:61 -7

22. Reiss B, Kiinische Langzeiterfahrungen mit 1994:38:30-33.


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Rouiet JF. The longevity of giass ceramic iniays [abstract 3 6],J Dent Res 1995:74:405,Roulet JF, Longevity of giass ceramic iniays and am aigam -re-sults up to 6 years. Clin Orai Invest 19 97 :1 :40 ^6 ,Rouiet JF, Degrange M Ihlay restorations, J Caiif Dent Assoc1996:24:48-62,

Roulet JF, Herder S, Bonded ceramio inlays, Chicago: Quintes-sence , 19 91 .SAS institute Inc., SAS Procedures Guide, Version 6 ThirdEdition, Second p nnting, Gary, NC, 199 2 .Stenberg R Matsson L Ciinical evaiuation of giass oeramicinlays Dicor), Aota Odontoi Scand 1993 :51:91-97.Studer S, Lehner C, Brodbecii U Scharer P, Short term re-sults of IPS-Empress ihlays and oniays , J Pros thodont1996:5:277-287,Studer S, Lehner C, Schrer P. Glass-ceramic iniays and on-lays made by IPS em press: first clinicai resuits, J Dent Res1992:71:658,Tidehag P, Gunne J, A 2-year ciinic ai foilow-up study of iPSEmpress ceramic inlays, IntJ Prosthcdont 1995:8:456-460.

Van Dijken JWV, Aberg HC, et al. Five year evaluation of oe-ramic inlays [abstract 72]. J Dent Res 1996:75:13 02 ,

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Ceramic Inlays Clinical Assessment and Survival Rate