Inlays, Onlays and Veneers Flashcards
Indirect Restorations
Restorations fabricated outside the mouth by a technician in a laboratory
Examples: • Crowns • Post and cores • Bridgework • Inlays and Onlays • Veneers
direct restorations
made by operator chairside
Pre operative assessment for indirect restorations
Full history and exam - CO - HPC - PMH - PDH - FM - SH - EO - IO Oral hygiene Caries, fractures - Restorable? Periodontal condition
special investigations for indirect restorations
Radiographs
- Caries
- Periodontal condition
- Peri-radicular/Peri-apical lesions
- Previous RCT- Quality
Sensibility testing
- Ethyl chloride
- Electric pulp test (EPT)
Mounted study models
- Semi- or fully adjustable articulator
Diagnostic wax-up
- Aesthetics
- Occlusion – both static and dynamic when pt absent
- Communication with patient and lab- patients can make educated decision- Show lab what you and/or patient want.
- Achievability
indirect restorations conventional clinical stages (4)
- Preparation
- Temporisation
- Impressions and occlusal records
- Cementation
chair-side indirect restorations use
CAD-CAM computer aided design , computer aided manufacture
Restorations milled from block of ceramic
- Quick - just one visit for pt
- No conventional impression or temporary needed
???Questions over accuracy???
inlays
Intra-coronal restorations made in lab – fillings made outside the mouth
types of inlays (5)
Composite
Gold
Ceramic
Porcelain
Ceromeric – porcelain and ceramic combination
uses of inlays (4)
Occlusal cavities
Occlusal/interproximal cavities
Replace failed direct restorations
Minor bridge retainers
- not advised now
indications for inlays (5)
Premolars or molars
occlusal
mesio-occlusal or disto-occlusal restoration
MOD restoration
- If kept narrow
- If not – consider onlay
cusps would be thin, create a wedge and cause cusps to fracture off
Low caries rate
MOD restoration when to use inlay Vs onlay
- If kept narrow
- If not – consider onlay
cusps would be thin, create a wedge and cause cusps to fracture off
advantages of inlays (2)
Superior materials and margins
Won’t deteriorate over time
disadvantages of inlays (2)
time
cost
inlay preparation - tools/armamentarium
Handpiece
Burs - No. 170L - No. 169L - Coarse-grit flame diamond - Flame (H4BL-010) - Ready made bur kits chamfer or shoulder burs mainly
Fine tuning
- enamel hatchets
- Binangle chisel
- Gingival margin trimmers
inlay
pulpal floor
flat
even depth (approx. 1.5 mm)
inlay
isthmus
sufficient width for materials
inlay
Undercuts?
none
- need to be blocked out if they exist
inlay
taper?
slight taper
Slide in and seat with retention
- Improve path of insertion - Go in one way and out one way
Not over tapered – reduce retention
inlay
line angles
Rounded line angles – can fracture if sharp cliff edge
inlay preparation for ceramic/composite
Isthmus: 1.5 - 2mm 1.5 mm depth proximal box: 1.5-2mm 1mm (min) shoulder or chamfer margin - SHOULDER FOR CERAMIC
Margins clear of occlusal contact points
Flat pulpal floor
Even-depth
Perpendicular to path of insertion
4-6 degree Tapered walls
- No undercuts
No bevels at occlusal aspect
- (thin porcelain -> fracture)
Butt-joint cavosurface margins
- Brittle in thin section so don’t want to break
Clear of adjacent tooth contact points
(Supra-gingival) Shoulder or chamfer margin
inlay preparation for composite/ceramic measurements
Isthmus: 1.5 - 2mm 1.5 mm depth proximal box: 1.5-2mm 1mm (min) shoulder or chamfer margin - SHOULDER FOR CERAMIC
inlay preparation for gold
Isthmus: 1mm
1.5mm depth
1mm proximal box (min)
0.5 mm chamfer margin
Margins clear of occlusal contact points
Flat pulpal floor
- Even-depth
- Perpendicular to path of insertion
4-6 degree Tapered walls
- No undercuts
15-20 degree bevel upper 1/3 of isthmus wall
- Stronger in thin section
- Nicer fit
Clear of adjacent tooth contact points
- buccal-lingual
- apical depth
Occlusal key/Dovetail
(Supra-gingival) Shoulder or chamfer margins
- chamfer
If proximal box required – keep margins clear of adjacent tooth contact points
Consider internal accessory retention features (e.g. grooves)
inlay preparation gold measurements
Isthmus: 1mm
1.5mm depth
1mm proximal box (min)
0.5 mm chamfer margin
bevel
for gold inlay
15-20 degree bevel upper 1/3 of isthmus wall
- Stronger in thin section
- Nicer fit
tapered walls
for gold and ceramic/composite inlay
4-6 degree Tapered walls
- No undercuts
inlays - temporisation and impression
Make temporary restoration
Impressions and occlusal records
- Send to lab for restoration fabrication
- 2 weeks
Fit temporary restoration
alternative to inlays
Direct temporary materials
Kalzinol
- not recommended – decrease dentine bonding to resin based cements)
Clip
GI
- May overly bond – need to cut back out thus modifying preparation that impression is off
communication with lab for inlay
Lab prescription - Pour impressions – state stone - Mount casts - Articulator – state type Occlusal record – e.g. JetBite, waxbite Facebow
Construct restoration - Tooth (FDI notation) - Material - Thickness - Characteristics fissure patterns, staining, disguise tooth as another tooth e.g. An E as a 5, white spots, wear facelts -Shade
inlay cementation for ceramic inlays
Weak when not cemented
- Don’t check occlusion as May fracture
Adhesive systems
- NX3 (Nexus)
- ABC
- RelyX Unicem self adhesive resin cement- Self etching, self priming resin based adhesive system
Place matrix strips interproximally or PTFE tape over adjacent teeth
inlay cementation for gold inlays
- AquaCem
- Panavia
- RMGI (RelyX)
Place matrix strips interproximally or PTFE tape over adjacent teeth
onlays
Extra-coronal restorations made in lab
Like inlays but with cuspal coverage
Height of cusps need to be reduced during preparation
Less destructive alternative to crowns
types of onlays (3)
Gold
Composite
Porcelain
indications for onlays (2)
Sufficient occlusal tooth substance loss
- Buccal and/or palatal/lingual cusps remaining
Remaining tooth substance weakened
- Caries
- pre-existing large restoration e.g.MODs with wide isthmuses; Thin cusps
cast metal inlays/onlays preferable to amalgam when
Higher strength needed
Significant tooth recontouring required
- Easier to do outhwith pt mouth (esp wear cases
uses of onlays (5)
Tooth wear cases
- Increase OVD
Fractured cusps
Restoration of root treated teeth
Replace failed direct restorations
Minor bridge retainers (not recommended)
- insufficient retention to successfully resist additional forces placed on abutment tooth by bridge
Less destructive alternative to crowns
onlay preparation - the tools/armamentarium
Handpiece
Burs
- No. 170L
- No. 169L
- Coarse-grit flame diamond
- Flame (H4BL-010)
Enamel hatchets
Binangle chisel
Gingival margin trimmers
onlay preparation measurements
porcelain
non working cusp: 1.5mm reduction
working cusp: 2mm reduction
Margins: 1mm shoulder/chamfer
onlay preparation measurements
gold
non working cusp: 0.5mm reduction
working cusp: 1mm reduction
Margins: 0.5mm chamfer
onlay preparation measurements
proximal box
if needed
1mm for gold
2mm for ceramic
onlay preparation
ceramic/composite
Margins clear of occlusal contact points
4-6 degree Tapered walls
- No undercuts
Flat pulpal floor
- Even-depth
- Perpendicular to path of insertion
Proximal box (if required): 1mm width
Supra-gingival Shoulder or chamfer margins: 1mm
Rounded internal line angles
Occlusal reductions;
- Non working cusp – 1.5mm reduction
- Working cusp – 2mm reduction
onlay preparation gold
Same as for composite/ceramic onlay expect:
Occlusal reductions
- Non working cusp – 0.5mm reduction
- Working cusp – 1mm reduction
Shoulder or chamfer margins: 0.5 mm
- Supra-gingival
Avoid cutting sound tooth tissue – use composite to block out undercuts
undercuts in onlay
none
Avoid cutting sound tooth tissue – use composite to block out undercuts
cusp reduction for onlay
Working cusp or non working cusp
Porcelain
- non working – 1.5mm
- working - 2mm
Gold
- non – 0.5
- Woking 1.5mm
onlays - temporisation and impressions
Make temporary restoration
Take impressions and occlusal records
- Send to lab for restoration fabrication
- 2 weeks
Fit temporary restoration
communication with lab for onlays
Lab prescription
- Pour impressions – state stone type
Mount casts
- Articulator -state type
Occlusal record – e.g. JetBite, waxbite
Facebow
Construct restoration - Tooth (FDI notation) - Material - Thickness - Characteristics fissure patterns, staining, disguise tooth as another tooth e.g. An E as a 5. - Shade
onlay cementation - ceramic
Weak when not cemented
- Don’t check occlusion
May fracture
Adhesive systems
- NX3 (Nexus) – ceramic onlays
- ABC
- RelyX Unicem self adhesive resin cement- Self etching, self priming resin based adhesive system
best
- NX3 (Nexus) – ceramic onlays
Place matrix strips interproximal or PTFE tape over adjacent teeth
onlay cementation - gold
- AquaCem (GI)
- Panavia (Composite with 1—MDP) metals to stick, often with bridge
- RMGI (RelyX)
Best
- AquaCem (GI)
Place matrix strips interproximal or PTFE tape over adjacent teeth
inlay/onlay alternatives (3)
Large direct restorations
- Amalgam
- Composite
- GI
Crowns - ¾ crown (Gold) - Full crown (Gold shell crown (GSC) Metal-ceramic (MCC) Porcelain (PJC))
Extraction
Inlays/onlays 1st appointment
LA (if not RCT)
make putty index ->
impression for temporary ->
tooth preparation ->
make temporary ->
Sufficient clinical time
- impressions, bite registration and record shade
If insufficient time
- cement temporary
inlays/onlays 2nd appointment
remove temporary ->
isolate, clean, dry prepared tooth ->
try in, assess fit, adaptation, occlusion etc
HAPPY -> cement
NOT HAPPY -> address issues
finally: minor occlusal adjustments (if needed)
veneers a.k.a
Porcelain laminate veneer (PLV), Laminate veneer
veneer
A laminate veneer is a thin layer of cast ceramic that is bonded to the labial or palatal surface of a tooth with resin.
veneer types
Ceramic - labial
Composite - labial
Gold – palatal, tooth wear cases
indications for veneers (3)
Improve aesthetics
Enamel defects
Discolouration – decipher cause, aid Tx
intrinsic discolouration causes (8)
Non-vital teeth
Ageing
Trauma
Medications (tetracycline)
Fluorosis
Hypoplasia or hypomineralisation
Amelogenesis imperfecta
Erosion and abrasion
extrinsic discolouration causes
Staining not amenable to bleaching
aesthetic issues addressed by veneers
If considerable changes – use diagnostic wax ups or composite mock-ups
Change teeth shape and/or contour
- Correct peg-shaped laterals
Reduce or close proximal spaces and diastemas
Align labial surfaces of instanding teeth
- wider labial palatal direction, can charactered incisal edge
contraindications to veneers (10)
Poor OH
High caries rate
- Interproximal caries and/or unsound restorations
Gingival recession
Root exposure
High lip lines – see margins more, so if Tx not great can be seen
If extensive prep needed (>50% of surface area no longer in enamel)
- Consider alternatives – PJC, DBCs MCCs
- Chemically bond to enamel?
Labially positioned, severely rotated and overlapping teeth
Extensive TSL/insufficient bonding area
Heavy occlusal contacts – substantial loads cause porcelain to fracture
Severe discolouration – degree of translucency
preparation needed for veneers
None in some cases
Use putty index and depth cut burs
- keep putty index
- 0.5mm grooves into tooth then normal bur to match
If prep required:
- Incisal edge reduction (if required): 1 – 1.5mm
material dependant bevel edge
- Midfacial reduction: 0.5mm
Within enamel, sufficient porcelain thickness
- Cervical reduction: 0.3mm (thinner enamel, want to stay within enamel)
Slight chamfer margin
Within enamel
Supragingival or slightly subgingival (0.5mm)
preparation for veneers
incisal edge reduction (if needed)
1 – 1.5mm
material dependant bevel edge
preparation for veneers
Midfacial reduction
0.5mm
Within enamel, sufficient porcelain thickness
Preparation for veneers
cervical reduction
0.3mm (thinner enamel, want to stay within enamel)
Slight chamfer margin
Within enamel
Supragingival or slightly subgingival (0.5mm
4 veneer types
a) Feathered incisal edge
b) Incisal bevel
c) Intra-enamel (window)
d) Overlapped incisal edge
dictated by pt occlusion. Don’t want to bite on veneer – will fracture, But overlap needed for aesthetics
minimal preparation veneer technique
Gurel Technique
diagnostic wax up with putty index on top
can see spaces between index and tooth
- Where porcelain goes
- assess thickness and preparation requirements
Mock up
- Fill with protemp – can check aesthetics, occlusal contact points
veneers temporisation and impression
May not need temporary – as remaining in enamel
- Prime and bond cured on top can be used for minimal sensitivity
BUT if necessary…make temporary restoration
- Take impressions and occlusal records
- Send to lab for restoration fabrication (2 weeks)
- Fit temporary restoration
Alternative – spot bonded composite
- No etch
- Small spot of primer and adhesive
(stick better in centre but strong enough for 2 week period and can be flicked off with prove)
- Directly apply composite to build veneer shell
veneers communication with lab
Lab prescription
- Pour impressions
Mount casts
- Articulator
Occlusal record – e.g. JetBite, waxbite
Facebow
Construct restoration
- Tooth (FDI notation)
- Material
- Thickness
- Characteristics
- Shade
- Translucency – opaquer (severe discolouration or change shade)
veneers cementation
Adhesive systems
- NX3 (Nexus) composite based cement as porcelain based
- ABC
- RelyX Unicem
Matrix strip or PTFE tape - interproximal surfaces (time consuming, can damage veneer)
- Remove excess before cement sets
- Microbrushes/probes/floss
veneers alternatives (4)
No treatment
Micro-abrasion
Direct composite restorations
Crowns
veneer 1st appointment
tooth prep required?
YES
- LA
- make putty index
- impression for temporary
- make temporary
after this and if NO tooth prep needed
- impressions, bite registration and record shade
(cement temporary if needed)
veneers 2nd appointment
remove temporary (if provided)
isolate, clean, dry prepared tooth
try-in, assess fit, adaptation and occlusion
HAPPY - cement
NOT HAPPY - address problems
chamfer margins for (3)
metal
gold
palatal MCC
shoulder margin for (1)
ceramic
MCC crown margins
shoulder on labial
palatal has chamfer margin as just metal there
