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INTERNATIONAL
JOURNAL OF CURRENT
RESEARCH
International Journal of Current Research
Vol. 9, Issue, 05, pp.50646-50650, May, 2017

ISSN: 0975-833X
RESEARCH ARTICLE

ONLAY PREPARATION TECHNIQUES - CLINICAL PRACTICE GUIDELINES

*Dr. Rubeena. A. Azeem and Dr. Nivedhitha Malli Sureshbabu


Dept. Conservative Dentistry & Endodontics, Saveetha Dental College & University, Chennai, India

ARTICLE INFO ABSTRACT

Article History: Aim: The aim of this clinical practice guideline is to help dental
Received 08th February, 2017 Received in revised form practitioners make decisions regarding appropriate materials
10th March, 2017 Accepted 29th April, 2017 and techniques for onlay restorations.
Published online 23rd May, 2017 Background: Onlay restorations are an excellent choice for the
clinicians to restore structurally compromised posterior teeth.
Key words: These restorations are bonded directly to the tooth using resin
Collection Development of Libraries, Evaluative, Comparative. cement and can actually increase the strength of a tooth by up
to 75%. Many techniques have been suggested for the
preparation of onlays. Advances in adhesive system and
esthetic dental materials such as composite resins and
ceramics have enabled clinicians to use conservative
preparations to place restorations that also reinforce the
remaining tooth structures. In addition, these restorations
satisfy the increasing patient expectations for a natural or
enhanced appearance. More technologically developed
systems with fiber - reinforced materials which can be placed in
a single - visit provides optimism for the future application of
these restorations to the daily clinical practice.

Copyright©2017, Dr. Rubeena. A. Azeem and Dr. Nivedhitha Malli Sureshbabu. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Citation: Dr. Rubeena. A. Azeem and Dr. Nivedhitha Malli Sureshbabu. 2017. “Onlay preparation techniques - clinical practice guidelines”,
International Journal of Current Research, 9, (05), 50646-50650.

INTRODUCTION necessary (Christensen, 2012 and Jackson, 1994).Composite


resin onlay restorations have gained popularity since 1980s.
The most commonly placed partial coverage extracoronal The direct composite onlay restoration is formed in the cavity;
restoration would be an onlay where weakened tooth structure after an initial cure, it is removed from the cavity and
can be protected without further extensive tooth removal. A postcured in a heat-and-light oven. Improved mechanical and
common indication for an onlay would be a root-filled posterior physical properties are expected compared with direct light-
tooth where cuspal protection is required. Root canal treatment cured-only composite, mainly due to the overall increase in
in molars and premolars is usually the result of caries conversion. Higher stress relaxation and improved marginal
and restorative procedures and, as such, these teeth are adaptation is also expected. Shrinkage is limited to a thin
extensively broken down and have weakened cusps. The access luting composite resin layer (Wendt, 2012).
cavity for a root treatment removes the roof of the pulp Indirect laboratory-processed composite onlay
restorations also have
chamber, weakening the tooth further, and can leave a limited gained increased popularity over the last decade. Heat,
amount of buccal and lingual tooth tissue which might be pressure, and nitrogen atmospheric treatment may be
completely removed if prepared for a crown. Preservation of combined to form a relatively void-free well-polymerized
some part of the buccal and lingual tooth helps to retain the core resin matrix, in an attempt to improve the wear resistance of
and reduces the need to consider a post, especially in composite resin.
premolar teeth (Christensen, 2012 and Jackson, 1994). Bonding However, the basic chemistry remains similar to that of the
materials (including gold) to a tooth, using adhesive cements, direct materials (Swift, 2001).Recently, fiber-reinforced
reduces some of the need for conventional principles of composite has been introduced as a dental restorative
retention. Onlays can be considered when there is no or little composite resin. These single-visit restorations are intended to
intracoronal shape to the preparation and where retention is be used in stress bearing areas since it has the ability to form
a
poor. Despite the retention provided by adhesive cement, conventional concepts of tooth preparation for retention should
not be ignored and, where possible, should be incorporated into strong and reinforcing sub-structure. It can be used as a for the
the design of the preparation; routine use of adhesive cements to restoration of cavities where inlays and onlays would be
achieve retention poses problems if retrieval is ever indicated (Garoushi, 2013; Garoushi, 2007 and Garoushi,
2008). Long-term clinical studies reported no difference in
*Corresponding author: Dr. Rubeena. A. Azeem, clinical and mechanical properties between direct and direct
Dept. Conservative Dentistry & Endodontics, Saveetha Dental College heat-treated composite resin inlay/onlay restorations (Wassell,
& University, Chennai, India. 2000).
50647 Dr. Rubeena. A. Azeem and Dr. Nivedhitha Malli Sureshbabu, Onlay preparation techniques - Clinical practice guidelines

Overview of various onlay preparation ● Make impressions and pour casts of the prepared onlay.
(Fig. 6)
techniques Tooth preparation for the onlay
● Try the castings on the tooth, adjust the proximal
contacts, evaluate occlusal relationship, and cement the
casting
casting. Use one or two 5/8 inch “metal center” fine
This technique was given by Dr. Jack G. Seymour in 1987.
Most posterior teeth can be restored garnets to finish the exposed margins. After the
conservatively with a type
II gold by using a minimal number of instruments in an complete set of the cement, review the
occlusal surface
organized manner. The instruments needed are No. 1157, again (Seymour, 1987).
No. 17OL, and No. 282-010 carbide burs and a ½ inch fine
emery
disk with No. 80-7-14 and No. 10-7-14 trimmers (Seymour, gingival marginal
1987).

● Place depth penetration grooves on the occlusal surface,


develop axial surfaces, and establish the traditional
outline form with a No. 1157 carbide bur. Remove
existing restorations and excavate caries. This may
modify the conventional outline. (Fig. 1, Fig. 2, Fig. 3)

Fig. 5.
Fig. 6
To
ot
h
pr
ep
ar
ati
on
fo
r
est
he
tic
on
la
y

The principles of cavity preparation for esthetic inlays or


onlays differ from those for gold restorations. For esthetic
Fig. 1. Fig. 2. inlay or onlay restorations, bevels and retention
forms are not needed. Resistance form is generally
not necessary but may be
required in very large onlay restorations. Cavity walls are
flared 5 degrees to 15 degrees in total (10 degrees to 12
degrees ideal), and the gingival floor can be prepared with a
butt joint. The internal line angles are rounded, the minimum
isthmus width is 2 mm, and the minimum depth thickness is
1.5 mm (Christensen, 2012 and Jackson, 1994).

Fig. 7.

For onlay restorations, nonworking and working cusps


Fig. 3.
are
● Place the retentive grooves in ¾ crowns and prepare
proximal boxes and occlusal offset for onlays with the
use of a No. 170 L carbide bur. (Fig.4)
covered with at least 1.5 mm and 2 mm of material,
Fig. 4. ● Prepare the gingival bevel, buccal and lingual flares, and
occlusal offset with the No. 282-010 bur. (Fig. 5)
● Use a fine emery disk on the proximal aspect of the respectively. If the cusp to be onlayed shows in the patient’s
preparation to finish the flares and slight hollowing that smile, a more esthetic blended margin is achieved by a
develop during use of the No. 282-010 bur. further 1- to 2-mm reduction with a 1-mm chamfer
● Define the proximal box and refine the reverse gingival (Christensen, 2012 and Jackson, 1994). When the occlusal
bench with hand instruments No. 80-7-014 and 10-7-14. aspect of the cavity is prepared, undercuts should not be
eliminated by removing healthy tooth structure, which
compromises the conservatism of this approach. The
objective is to establish divergence in the enamel, then block
out all undercuts. This is possible using bonded resin or a
resin-modified glass ionomer. For cemented castings it is
generally best to overlay a working cusp when the
50648 International Journal of Current Research, Vol. 9, Issue, 05, pp.50646-50650, May, 2017

cavosurface margin is more than 50% up the incline of the finishing bur to remove any adhesive that may have flowed
cusp. The cavosurface margin can extend onto these surfaces. After preparation, an impression is
up to 75% up the
cuspal incline of a nonworking cusp before overlaying of the obtained using an accurate re-pourable material. This is sent
cusp is considered. Studies have investigated the use of bonded to the laboratory with any additional models, records, or
inlay or onlay restorations for this area, but no clinical information needed to fabricate the restoration. The level of
consensus on when to remove a cusp has been reached. esthetics achieved with this restoration is directly proportional
Because these restorations reinforce the remaining tooth to the level of communication between
the clinician and
structure, the traditional guidelines for overlaying a cusp as in laboratory technician. Consequently, the color prescription
cast gold onlays have been modified. must contain the occlusal base shade of the restoration, the
gradient of shade from central fossa to cavosurface margin,
the degree and color of the desired pit and fissure stains, and
any
maverick highlights present. The shade is taken before
preparation to avoid the misleading effects produced in a
desiccated tooth. Once this diagnostic information has been
obtained, a direct provisional restoration is placed while the
definitive restorations are fabricated in the laboratory.

A good deal of science is documented in studies over the past


20 years. Significant evidence details the effectiveness of the
enamel bonds in terms of both bond strength and durability.
For esthetic inlays or onlays, evidence supports the
effectiveness of these enamel bonds with regard to tooth
reinforcement. The literature lists tooth reinforcement
Fig. 8. numbers that indicate that when there are significant enamel
bond surfaces, tooth reinforcement is achieved, even up to
When there is no dentin support directly underneath the cusp 70% to 80% of the original strength of the tooth. Clinical
tip, onlay restorations can be done. The palatal or working cusp evidence also supports the longevity of these restorations. A
is onlayed, even with dentin support if the margin is within 1 significant number of patients show longevity greater than 10
mm of the cusp tip. When the margin is beyond 1 mm from the years (Christensen, 2012 and Jackson, 1994). Tooth
cusp tip, the cusp gains dentin support and bond strength preparation for intra- and extra-coronal restorations follows
increases. The horizontal lines depict the direction of the the similar concepts as used for indirect restorations. The
enamel rods. At the cusp tip the enamel rods are almost vertical preparation should avoid undercuts between opposing walls
and etching would be on their sides. As the margin moves away within the cavity. All-ceramic restorations depend upon the
from the cusp tip the ends become etched, which has been luting cement for most of the retention, therefore a slightly
shown to increase bond strength (Christensen, 2012 and over-tapered cavity is acceptable provided there are no
Jackson, 1994). The non-working or buccal cusp is not onlayed undercuts. However, gold restorations gain most of their
in this diagram even when the margin is at the cusp retention from the cavity shape and are therefore more near
parallel preparations can be
tip. If the posterior teeth are discluded in lateral jaw done for these restorations. Inlay and onlay restorations
movements, there are no forces applied to this cusp. It is not preserves tooth tissue to retain the core. If existing cavities
uncommon to find cracks on the pulpal floor under cusps when contain undercuts they can be blocked out with composite or
removing amalgams that have been in place for some time, glass ionomer cements to provide the necessary cavity
particularly moderate-sized ones. Whether the teeth exhibit pain shape.Tapered burs provide the most convenient shape to
on chewing (e.g., cracked tooth syndrome) or are asymptomatic, prepare onlays and reduce the chance of creating undercuts. If
these cusps should be overlayed. A popular an onlay preparation is to be cut, occlusal clearance/ reduction
technique, called immediate dentin sealing (IDS), first described will be required consistent with the material chosen. The
by Paul and Scharer in 1997, this technique has been clinically marginal configuration (shoulder, chamfer or deep chamfer)
popularized by Dr Pascal Magne. The technique is based on the depends on the material planned (Christensen, 2012 and
logic that the strongest dentin bond is achieved when dentin is Jackson, 1994).
bonded immediately after being cut and before becoming
contaminated, such as occurs during the provisional Technique for placing tooth-colored onlays
phase. Besides the pulpal protection afforded by this
procedure, the patient has more comfort while the provisional ● Anesthetize the tooth if necessary
is in place. Finally, early data show that the ultimate bond of ● Clean the tooth preparation with flour of pumice and
the restoration and the marginal integrity over time are water on a rubber cup
improved. ● Selectively place phosphoric acid gel on just the enamel
portions of the margins and perform a standard acid etch
This technique requires placement of a self-etching adhesive of the enamel; this is the so-called selective etching
followed immediately after curing by a very thin layer of technique
very- low-viscosity flowable composite resin. Any undercuts ● Seat the onlay with a self-etching resin cement
are blocked out simultaneously with the flowable resin. After ● Minimally cure the resin cement residue around the
curing, it is necessary to remove the air- soaked margins and remove it cure
inhibited layer. This can be done by
wiping the surface with a cotton pledget
before making the final light
in alcohol. An alternative technique is to cover the surface ● Floss the contact areas before providing a full light cure
with a glycerin product and light curing again. After washing of the restoration to avoid difficulty in clearing cement
and drying, the vertical enamel walls are prepared again with from the contact areas
a
50649 Dr. Rubeena. A. Azeem and Dr. Nivedhitha Malli Sureshbabu, Onlay preparation techniques - Clinical practice guidelines

● Finish and polish the margins and


correct any high using composite finishing and
occlusal areas polishing kit. Hence, these direct
restorations can be placed in a single
RECENT ADVANCES visit and allows for maximum
preservation of tooth structure as well
Direct fiber-reinforced composite as strengthens remaining tooth
onlay structure. (Fig. 9-14: Clinical pictures
of direct fiber-reinforced composite
onlay restorations with 3 year follow-
up – by Dr. Rubeena)

ecently, short fiber reinforced composite resin was introduced CAD-CAM approach
as a dental restorative composite resin. These direct composite
restorations are now intended to be used in high stress bearing The computer-assisted design and computer-assisted manufac-
areas especially in molars. The results of the laboratory turing (CAD-CAM) approach is a valid procedure for
mechanical tests revealed substantial improvements in the load fabricating esthetic inlays or onlays. Many of the ceramic
bearing capacity, the flexural strength and fracture toughness of inlays or onlays ordered by dentists today are fabricated in the
dental composite resin reinforced with short E glass fiber laboratory using milling machines. The two machines
available
fillers in comparison with conventional particulate filler in the marketplace today are the CEREC (Sirona Dental
composite resin. The short fiber composite resin has shown Systems, Charlotte, North Carolina) and the E4D (D4D
control of the polymerization shrinkage stress by fiber Technologies, Richardson, Texas). The quality of the
orientation and, thus, marginal micro leakage was reduced restorations that can be fabricated with these milling machines
compared with conventional particulate filler composite resins in the dental office today is as good as that of
laboratory-
(Garoushi, 2012; Garoushi,f, 2007 and Garoushi, 2008). For fabricated indirect resin or ceramic restorations with respect to
direct composite restorations, quadrant isolation is done using fit and function. Both approaches depend on the commitment
rubber dam sheet. The tooth to be restored is cleaned with and skill of the operator. This can be the dentist or a dental
pumice-water slurry in a rubber cup to remove salivary pellicle auxiliary who actually does the design and operates the
and any remaining dental plaque. milling equipment.

Fig. 9 – 14.

Onlay preparation is done using high-speed burs. Caries


Summary and conclusion
removed with low-speed burs and spoon excavator leaving
discolored but hard dentin at the cavity floor. The preparations Advances in tooth-colored materials and adhesive technology
are done according to the principles of minimally invasive have expanded the scope of restorative dentistry. Onlays are a
dentistry. In cases where the cavity is deep, MTA Plus can be cured according to an incremental technique. All restorations
given (PREVEST Denpro). The prepared tooth is restored using are fully covered with a layer (1-2 mm) of hybrid composite
sectional matrix system (Triodent) that is stabilized using resin (Gaenial Posterior, GC). Occlusion is carefully adjusted
anatomical wedges. The bonding procedure begins with the using articulating paper. Finishing and polishing procedures are
application of self-etch adhesive (Gaenial Bond, GC) to the carried at same visit after occlusal adjustment
prepared walls. The application and placement of bonding agent
is done according to manufacturer’s instructions. The fiber-
reinforced composite (EverX Posterior, GC) is placed and light
more conservative restorative option than are crowns. The
results of research are positive regarding onlays’ service
potential. Numerous well-proven, as well as some new,
materials such as ceramics and fiber – reinforced composite
make the use of tooth-colored onlays a viable procedure.

REFERENCES
Christensen, G.J. 2012. The case for onlays versus tooth-
colored crowns. The Journal of the American Dental
Association. 2012 Oct 1;143(10):1141–4.
Frankenberger, R., Petschelt, A., Krämer, N. 2000. Leucite-
reinforced glass ceramic inlays and onlays after six years.
Part I: Clinical behavior, Oper Dent 25:459-465.
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