PROSTHODONTICS

Long-term outcomes of all-ceramic inlays and onlays

after a mean observation time of 11 years
Malin Strasding, Dr med dent/Eszter Sebestyén-Hüvös, Dr med dent/Stephan Studer, PD Dr med dent/
Christian Lehner, Dr med dent/Ronald E. Jung, Prof Dr med dent, PhD/Irena Sailer, Prof Dr med dent

Objectives: Long-term retrospective evaluation of the survival
rate and the technical and biologic outcomes of all-ceramic in-
lays and onlays in premolars and molars. Method and mater-
ials: Fifty-four patients treated as part of a prospective clinical
trial and having received 157 inlays and 27 onlays made out of a
leucite-reinforced glass-ceramic (IPS Empress) in premolars and
molars, were invited to the present follow-up examination. The
survival of the restorations was evaluated. The biologic out-
comes were assessed by measuring the pocket probing depth
(PPD), the Plaque Index (PI), and the Sulcus Bleeding Index (SBI).
The technical behavior was evaluated using modified US Public
Health Service criteria (modUSPHS). Finally, patient satisfaction
was recorded with a questionnaire. Data of patients and restored
teeth were analyzed descriptively, and continuous variables
were given in mean values and standard deviations. For the
analysis of the restoration survival over time, the Kaplan-Meier
survival estimate was calculated. The level of statistical signifi-
cance was set at P < .05. Results: Thirty-six patients (20 women,
16 men; mean age 50.9 years) with 132 restorations, 107 inlays
and 25 onlays, were examined after a mean observation time of
11.2 ± 4.3 years. The overall 11-year survival rate of the 132 res-
torations was 80.3%. Inlays exhibited an 11-year survival rate of
80.4% and onlays of 80.0%. Twenty-two technical complications
occurred. Ceramic fractures (10.6%) and chipping (2.3%) were
the most frequent complications. Six biologic complications oc-
curred (4.5%). Conclusion: Glass-ceramic inlays and onlays pre-
sented favorable long-term clinical survival and success rates.
Technical complications were predominant, and biologic prob-
lems remained rare. More clinical long-term data are needed.
(Quintessence Int 2020;51:566–576; doi: 10.3290/j.qi.a44631)

Key words: adhesive cementation, all-ceramic restoration, glass-ceramic, long-term, minimally invasive

In the last several years, there have been important develop-
ments in the field of dental restorative materials. Consequently,
dental ceramics are more frequently used in the fabrication of
inlays and onlays.1-4 Prior to the introduction of dental ceramics,
amalgam and gold were the materials of choice for inlay and
onlay types of restorations.5-8 Inlays and onlays made from these
metallic materials demonstrated good medium- to long-term
results with survival rates ranging between 76% and 100%
between 5 and 12 years follow-up in various studies.7-13 How-
ever, both amalgam and gold are esthetically dissimilar to natu-
ral dentition and thus may decrease overall patient satisfaction.
Today, a myriad of ceramic materials is available for inlay
and onlay restorations. Feldspathic porcelain has been used
with excellent esthetic appearance.14 In the early 1990s, trans-
lucent leucite-reinforced glass-ceramic became one of the rec-
ommended materials for inlays and onlays due to its improved
strength compared to the conventional feldspathic porce-
lain.2,4,15,16 Subsequently, lithium disilicate glass-ceramics were
introduced as a restorative material with strength superior to
the previously mentioned ceramics.1,3
In conjunction with the improvements of dental ceramics, the
evolution of adhesive luting methods has had a significant impact
in the dental field over the last several decades.17,18 Together,
these two advancements have stimulated new concepts in tooth
restoration. For both amalgam and gold restorations, a significant
amount of tooth structure had to be removed in order to satisfy
the geometric requirements of the cavity designs.19,20 The newer
esthetic materials, together with their adhesive cementation,

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Table 1 Overview of the four different luting agents used for the adhesive cementation of the restorations; dentin bonding agents VP 891 and
All Bond II (Bisco) were used in combination with Porcelite
Chemically curing adhesive resin cement Dual-curing adhesive resin cement
Porcelite (Kerr)
Panavia TC (Kuraray)
Dicor LA (Dentsply International)
allow for a more defect-oriented way to restore teeth: the restor-
ation can now be luted to tooth structures without the need for
geometric stabilization.4,20,21 Hence, less tooth preparation is
needed, ultimately resulting in a less invasive treatment.20,22
The modern, minimally invasive restorations show lower
rates of loss of abutment tooth vitality.21,23-26 In contrast, loss of
abutment tooth vitality was considered a predominant bio-
logic complication related to conventional single crowns and
fixed dental prostheses (FDPs), such as single crowns and mul-
tiple-unit FDPs.27-29 For this reason mainly, minimally invasive
treatment concepts are being established as the new “state of
the art” in restorative dentistry.19,20,30
While conventional treatment concepts including metallic
inlays and onlays, single crowns, and multiple-unit FDPs are
well documented in the literature,5,12,31-33 medium- to long-term
studies on the less invasive alternatives like ceramic inlays and
onlays remain scarce.26,34,35 In addition, very few studies with a
follow-up of more than 10 years exist for the less invasive
ceramic restorations.14,34,36-38
Therefore, the aim of this retrospective study was to assess
the long-term clinical results of leucite-reinforced glass-ceramic
inlays and onlays with a follow-up period of more than 10 years.
Method and materials
Study design and original population
For the present retrospective study, all patients who had partic-
ipated in a previous prospective clinical study,15 analyzing the
long-term behavior of inlays and onlays made of glass-ceramic
(IPS Empress), were included. The original prospective clinical trial
comprised 54 patients (34 woman, 20 men) with 157 inlays and
27 onlays placed on 71 premolars (39%) and 113 molars (61%).
All previously treated patients were invited to participate in
the present retrospective long-term examination. The study
protocol was developed according to the guidelines of the Hel-
QUINTESSENCE INTERNATIONAL | volume 51 • number 7 • July / August 2020
Strasding et al
Micro filler composite cement with a low vicosity
VP 891 (Ivoclar Vivadent)
sinki declaration. Patients were informed in detail about the
study purpose and procedures. The patients willing to partici-
pate gave informed consent. The detailed criteria and proced-
ures of the original prospective clinical trial were previously
published15 and are here only briefly summarized.
Initial inclusion criteria
Patients needing the change of dental fillings in one or more
posterior teeth were included. Further prerequisites comprised
good general medical condition and a healthy periodontium
with a Papillary Bleeding Index (PBI) of < 20.39
Exclusion criteria
Patients with active, non-treated periodontitis, and temporo-
mandibular joint (TMJ) problems were not included in the study.
Initial clinical procedures
Box-shape preparations were performed for the inlay restor-
ations. The onlay preparation shapes were designed in a
defect-oriented way. When possible, the aim was to leave all
preparation margins in enamel. The minimal preparation depth
was 1.5 mm, and the depth of the occlusal box was between
1.5 and 3.0 mm. The margins were prepared with 90-degree
angulated shoulders. Following the cavity preparation, conven-
tional impressions were taken using elastomer impression
material (Permadyne, 3M Espe).
The inlays/onlays were manually designed using wax on
plaster study casts and were then heat-pressed out of a leu-
cite-reinforced glass-ceramic (IPS Empress I, Ivoclar Vivadent)
using the lost-wax technique.40
All restorations were adhesively cemented with one of four
different composite cements according to the manufacturers’
recommendations (Table 1).
567
 PROSTHODONTICS

41
Table 2 for the retrospective clinical evaluation at follow-up after 11.2 ± 4.3 years

Characteristics
(USPHS) Rating Criteria
Abutment tooth Alpha Clearly positive; negative in case of endodontically treated tooth
vitality Beta Not clearly positive, positive with delayed response
Charlie Clearly negative; and no endodontic treatment
Color match Alpha Restoration hardly detectable, perfect match
Beta Minimal mismatch; 1 shade off (Vita shade guide)
Charlie Distinct difference in shade; 1.5 or more shades off
Surface texture Alpha Smooth surface, glazed, glossy
Beta Slightly rough surface, dull surface
Charlie Porous surface, rough, or with deep pores, unevenly distributed pits, cannot be refinished
Occlusion Alpha Ideal occlusion and articulation
Beta Slight difference in occlusion and articulation; easily solvable by little grinding
Charlie Severe difference in occlusion and articulation; transversal/sagittal slide > 1 mm
Occlusal wear Alpha No wear facets at the restoration and/or antagonist tooth detectable
Beta Small wear facets at the restoration and/or the antagonist tooth: diameter ≤ 2 mm
Charlie Large wear facets at the restoration and/or the antagonist tooth: diameter > 2 mm
Anatomical form Alpha Correct contour with tight proximal contacts (checked with waxed dental floss)
Beta Slightly under- or overcontoured, weak proximal contact
Charlie Distinct under- or overcontoured, missing proximal contact
Cement line Alpha Cement line’s width ≤ 50 μm, narrow line, with tooth-like color
Beta Cement line’s width > 50 μm, but no disintegration of cement
Charlie Cement line’s width > 50 μm, including disintegration of cement
Marginal Alpha No discolorations visible
discoloration Beta Slight discoloration visible, but polishable
Charlie Distinct discoloration visible, not polishable, unacceptable
Marginal Alpha No catch on probing
adaptation Beta Probe caught on inlay/onlay margin but no gap/chipping on probing, with enamel exposed, but polishable
Charlie Gap or chipping and dentin or liner exposed
Fracture of the Alpha No fracture
restoration Beta Chipping at the margin, polishable
Charlie Chipping not polishable, dentin exposed
Delta Partial fracture, fracture, luxation, or mobile restoration

After the cementation, ie at baseline, all restorations were
clinically evaluated according to the modified US Public Health
Service (modUSPHS) criteria.41,42 In addition, the following par-
ameters for the monitoring of the biologic outcomes were
assessed for the abutment teeth and untreated neighboring
control teeth: pocket probing depth (PPD; Michigan-o-Probe,
Hu-Friedy), Sulcus Bleeding Index (SBI),43 Plaque Index (PI),44
and position of the margin of the restoration (subgingival,
epigingival, supragingival). Radiographs of the abutment teeth
and photographs of all the restorations were taken.
Follow-up examinations were made at 1, 2, 3, 4, and 5 years.
Clinical examinations at the present follow-up
For the present retrospective evaluation, all participating pa-
tients were reexamined clinically and radiologically using the
same criteria and indices as in the initial examination.15 The
two involved investigators (ES, RV) obtained defined examin-
ation instructions by the two principal investigators of the
initial study (SS, CL). Three chosen patients were clinically and
radiologically examined by all four investigators following the
present protocol. The results of these examinations were
compared and discussed. The examinations were repeated in

568 QUINTESSENCE INTERNATIONAL | volume 51 • number 7 • July / August 2020

 Strasding et al

1 2 3

Fig 1 Clinical situation of three inlay res-
torations of two maxillary premolars and one
maxillary molar, that were clinically
reevaluated after 11 years in function. In the
first premolar, the fracture of the restoration
and the margin were polishable. In all three
abutment teeth, occlusal wear and marginal
discoloration were detected.
Fig 2 Clinical situation of one inlay res-
torations of a maxillary, second premolar
that was clinically reevaluated after 11 years
in function. Surface texture and marginal
adaptation were rated Beta, all other criteria
were rated Alpha.
Fig 3 Clinical situation of two inlay res-
torations of a mandibular first and second
molar, which were clinically reevaluated after
14.5 years in function. Color match, anato-
mical form, and marginal adaptation were
rated Beta, all other criteria were rated Alpha.

4 5

Fig 4 Clinical situation of two inlay restor-
ations of a mandibular second premolar and
a first molar, which were clinically reevalu-
ated after 15 years in function. Color match,
surface texture, occlusal wear, and marginal
discoloration were rated Beta in both restor-
ations. The marginal adaptation of the molar
was rated Charlie, whereas it was rated Beta
for the premolar. For the molar, the cement
line was rated Beta.
Fig 5 Radiographic bitewing of inlay res-
torations of maxillary and mandibular
second premolars and mandibular first
molar after 15 years in function. Clinically,
all inlays were rated Alpha or Beta for all
USPHS characteristics.

cases of disagreement. This calibration procedure was per-
formed until the evaluations corresponded to the previous
procedures.
The restorations were then clinically reevaluated according
to the modified US Public Health Service (USPHS) criteria.41,42
Radiographs of the abutment teeth were taken.
The marginal adaptation was checked with an intraoral den-
tal mirror and a new dental probe (Explorer EXS 546; Hu-Friedy).
Shimstock metal foil (8 μm) (Hanel Shimstock Foil, Coltene) was
used for the examination of the occlusion and dental floss for
the evaluation of the interproximal contact points.
The detailed overview of all parameters of the modified
USPHS criteria41,42 used for the clinical evaluation of the restor-
ations is presented in Table 2.
Restorations without any problems and, hence, no need for
corrections were rated Alpha (A). Restorations with minor de-
fects, but no need for further intervention were rated Beta (B).
Restorations with major, clinically unacceptable problems, re-
quiring either repair or replacement, were rated Charlie (C) or
Delta (D), respectively.
Figures 1 to 5 show the typical clinical and radiographic sit-
uation of restorations that were reevaluated after 11 to 15 years.

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 PROSTHODONTICS
Table 3 Criteria for patient questionnaire
Question Degree of satisfaction with the restoration
Patient satisfaction 1 Yes, I am satisfied; highly satisfied
with the restoration
2 I am somewhat satisfied, would do it again
3 I am not satisfied, would not do it again
Postoperative 1 No sensitivity at all to date
sensitivity
2 Minor sensitivity, still present at recall
3 Unbearable sensitivity (with pain); patient
asks for replacement
Patient satisfaction
Finally, patient satisfaction with the restoration was assessed
(Table 3). Patients indicated whether they were fully satisfied (1),
more or less satisfied for different reasons, yet, would choose this
treatment option again (2), or not satisfied at all (3) and would
not agree to ceramic inlays/ onlays as a posterior tooth restor-
ation. Furthermore, the patients specified whether they suffered
or not from postoperative abutment tooth hypersensitivity. If so,
the patients were asked if the pain disappeared over time.
Statistical analysis
Descriptive statistics were performed, and continuous vari-
ables were given in mean values and standard deviations.
The data were first evaluated on the restoration level with
respect to the survival of the restorations along with the techni-
cal and biologic outcomes at the follow-up periods. Kaplan-
Meier was applied for discrete predictors, and Cox regression was
applied for continuous predictors. Definitions were as follows:
■ Determination of the survival time: Time of insertion of the
restoration until the occurrence of a severe complication or
last follow-up examination.
■ Determination of the survival rate: All restorations which
had no complications (A) or minor complications (B) until
the last follow-up examination.
■ Determination of the failure rate: All restorations which
showed clinically unacceptable, major complications (C), or
fatal complications (D).
Furthermore, the influence of the following variables on the
outcomes was examined: gender, age of the patient at cemen-
tation time, smoker versus nonsmoker, patient with or without
570 QUINTESSENCE INTERNATIONAL | volume 51 • number 7 • July / August 2020
bruxism, maxilla versus mandible, molar versus premolar, inlay
versus onlay, and extension of the inlays.
The inlay extension was defined by the number of surfaces
of the inlays, differentiating between one, two, or three sur-
faces. The influence of vitality was not analyzed due to the lack
of nonvital abutment teeth (n = 1). The differences between
the groups were tested using the Breslow-Gehan-Wilcoxon
test. The level of significance was determined with P < .05.
Cox-regression was calculated for the predictors molar/pre-
molar and inlay/onlay.
Accordingly, the data were also analyzed at the patient
level. One restoration per patient was randomly selected. In
cases with multiple restorations in the same patient having one
failed restoration, the failed restoration was included in the
statistical analysis. In cases with more than one restoration fail-
ure in the same patient, one failed restoration was randomly
chosen for the statistical analysis.
Results
After a mean observation period of 11.2 ± 4.3 years, 132 restor-
ations, 107 inlays and 25 onlays, in 36 patients (20 women, 16 men,
with a mean age of 50.9 years) were clinically and radiographically
reexamined; 28 patients had received more than one restoration.
Overall, 36 restorations were inserted in maxillary molars,
28 in maxillary premolars, 45 in mandibular molars, and 23 in
mandibular premolars. Eighteen inlays had one single surface
(14%), 49 inlays had two surfaces (37%), and 40 inlays consisted
of three surfaces (30%) (Table 4).
Eighteen patients (14 women, 4 men) with 50 inlays and two
onlays could not be reexamined, resulting in a patient drop-out
rate of 33.3%. Four patients with eight restorations were not will-
ing to participate in the present retrospective study, while
12 patients with 41 restorations had moved and could no longer
be contacted. Two patients with three restorations reported that
the abutment teeth had to be extracted and were not willing to
be examined.
Survival of the inlays/onlays
The 11-year survival rate of all reexamined restorations was
80.3% (Table 5).
Overall data analysis
Inlays exhibited a survival rate of 80.4%, whereas onlays pre-
sented a survival rate of 80.0% at 11.2 years (± 4.3 years) (Table 5).
 Strasding et al

Table 4 Detailed information (n, %) of the 36 patients and of the 132 restorations at the 11.2-year follow-up

Follow-up at 11.2 years

Parameter Restorations (N = 132)
(no. of patients, N = 36)
Sex Male 16 (44%) 54 (41%)
Female 20 (56%) 78 (59%)
Extension of the Inlays, 1 surface 1 (3%) 18 (14%)
restoration
Inlays, 2 surfaces 13 (36%) 49 (37%)
Inlays, 3 surfaces 15 (42%) 40 (30%)
Onlays 7 (19%) 25 (19%)
Abutment tooth Premolars 16 (44%) 51 (39%)
region
Molars 20 (56%) 81 (61%)
Localization in the Maxilla 18 (50%) 64 (48%)
jaws
Mandible 18 (50%) 68 (52%)
Maxillary molars 8 (22%) 36 (27%)
Maxillary premolars 10 (28%) 28 (21%)
Mandibular molars 12 (33%) 45 (34%)
Mandibular premolars 6 (17%) 23 (18%)

Table 5 Information on the failures with respect to the extensions of the restorations

Extension of the restoration Total (n) Failures (n) Success (n) Success (%) Total success (%)
1-surface inlays 18 0 18 100.0%
2-surface inlays 49 12 37 75.5%
80.3%
3-surface inlays 40 9 31 77.5%
Onlays 25 5 20 80.0%

The estimated Kaplan-Meier survival rate at the restoration
level of all inserted inlays and onlays was 92.3% (95% confi-
dence interval [CI] 90.1% to 94.5%) after 10 years, and 83.8%
(95% CI 80.6% to 87.0%) after 14 years.
At the patient level, however, the estimated Kaplan-Meier
survival rate of the restorations amounted to 77.4% (95% CI
70.9% to 83.9%) after 10 years, and to 65.4% (95% CI 57.6% to
73.2%) after 14 years (Fig 6).
Interestingly, the failure rate correlated with the extension
of the inlays/onlays.
In detail, 12 inlays with two surfaces (11.2% of all inlays), and
9 inlays with three surfaces (8.4% of all inlays) failed, whereas no
inlay with only one surface failed (Table 5). There was, however,
no significant difference in the complication rates between the
more extended types of restorations.
Technical and biologic outcomes
A total of 106 of the reexamined 132 restorations were free of
complications. Twenty-two clinically unacceptable technical
complications occurred (Fig 7), resulting in a C- or D-rating ac-
cording to the USPHS criteria. The most frequent clinically un-
acceptable technical complications were ceramic fractures,
with an incidence of 14 fractures (10.6%). Three chippings of the
ceramic occurred (2.3%). Occlusal wear was found in two restor-
ations (1.5%), insufficient esthetics, insufficient marginal adap-
tation, and severe marginal discoloration was found in one res-
toration each (0.8%) (Fig 7). More than half of the fractured
restorations (n = 9; 64.3%) were cemented with Porcelite (Kerr).
In one fractured restoration (n = 1; 7.1%), VP 891 (Ivoclar Viva-
dent) was used as the composite cement. The remaining restor-

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 PROSTHODONTICS
100
Cumulative survival (%)
80
60
40
20
ive
0 2 4 6 8 10
Time (years)
6
Fig 6 Kaplan-Meier survival plot at patient level (n = 23).
The circular marks depict the timepoint of the failures.
ations that failed (n = 4; 28.6%) were cemented with an un-
known cement. Therefore, no correlation could be performed.
The following six clinically unacceptable biologic complica-
tions occurred: two abutment teeth presented secondary car-
ies (1.5%), two abutment teeth had endodontic problems
(1.5%), and two abutment teeth had periodontal problems
(1.5%) (Fig 7). In two restorations, both biologic and technical
unacceptable complications occurred. It was not possible to
determine which problem occurred first for these restorations.
All clinically unacceptable complications were rated as failures.
Furthermore, no correlation between the number of com-
plications and the following potentially confounding factors
was found; gender, age of the patient at cementation time,
smoker versus nonsmoker, patient with or without bruxism,
maxilla versus mandible, molar versus premolar. The number of
failures was equally distributed among all of these factors.
Patient satisfaction
The patient satisfaction was high (97.2%), and patients did not
report postoperative abutment tooth sensitivity. Only one
female patient was not satisfied with the restoration (2.8%).
This patient was not affected by any kind of complication or
failure yet would still have preferred crowns instead of inlays as
restoration type for an unknown reason.
572
Discussion
The present study demonstrated high survival rates of glass
ceramic inlays and onlays, both on premolars and molars after a
period of 11 years. Technical problems, notably extended
ceramic fracture and major ceramic chipping, were the predom-
inant reason for replacing the restorations. Biologic problems
were rarely detected, with only two abutment teeth losing vital-
ity during 11 years. Secondary caries or periodontal problems
occurred on four of the abutment teeth.
In general, only a few studies reported the long-term results
of all-ceramic inlay and onlay types of restorations, while numer-
12 14 16
ous short- to mid-term studies are available.26,45-52 The obtained
long-term outcomes of this study are in agreement with survival
rates of the other available long-term studies reporting the obser-
vation times of 8 years to 12.6 years. These studies reported sur-
vival rates ranging between 76% and 86%.14,34,37,53 In contrast, in
the short-term studies with an observation period of up to 2 years,
the survival rates of glass-ceramic inlays and onlays were higher
and ranged between 96.7% and 100%.45-47,52 These results are in
line with the published 2- and 6-year estimated survival rates of
the present patient cohort of 97.7% and 95.5%, respectively.15,54
The discrepancy between short-term and long-term survival
rates can be related to aging and degradation of the ceramics
over time. The influence of aging on the long-term performance
of dental ceramics has been previously demonstrated.55,56 Micro-
cracks increased the risk for complications and included superfi-
cial chipping as well as catastrophic fracture of the ceramic res-
torations.55-57
In comparison, alternative restorative options such as gold
inlays and onlays, and amalgam fillings, exhibited higher long-
term survival rates in clinical studies. Gold inlays and onlays pre-
sented an estimated survival rate of 96.1% at 10 years and 87.0%
at 20 years.12 Mid- to long-term survival rates of amalgam fillings
ranged between 87% to 96% over a period of 6 to 13 years.7,11,13
Conventional single crowns represent a well-documented
treatment alternative to ceramic onlays. A systematic review re-
ported on estimated survival rates of tooth-supported metal-
ceramic and all-ceramic single crowns of 92.1% up to 96.6% at
5 years.32 Furthermore, in a large clinical study, survival rates of
97.08% and 85.4% were reported for metal-ceramic single
crowns after 10 and 25 years, respectively.58
The long-term survival of a particular restorative modality is,
however, not the only criterion to consider when determining
the best treatment option. The rates of technical and biologic
complications, not necessarily leading to a need for restoration
replacement, may also influence the treatment decision.
QUINTESSENCE INTERNATIONAL | volume 51 • number 7 • July / August 2020

Fig 7 Overview of survival and types of
failures of the restorations. 7
The majority of complications for the ceramic inlays and
onlays in the present patient cohort was ceramic fractures
(10.6%), followed by ceramic chipping (2.3%). These complica-
tions are in accordance with the literature, where ceramic frac-
tures and chipping are the most often reported technical com-
plications for ceramic inlays and onlays.14,32,50,52,59,60 The fracture
rates of this study were comparable to the results of two similar
clinical studies of ceramic inlays and onlays, with fracture rates
ranging between 7% and 12.5%.36,37 Slightly higher fracture rates
of leucite-reinforced glass-ceramic (IPS Empress) inlays and
onlays were found by Frankenberger et al34 at a 12-year fol-
low-up. To reduce the risk of ceramic fractures, cavity design with
a minimum depth of 1.5 mm is suggested to provide sufficient
space for the necessary thickness of the chosen restoration.46,51
For gold restorations, the most common technical failures
were loss of retention (4.3%), followed by extensive abrasion
(1%).12 For amalgam restorations, fractures of the restorations
were the major technical complication (9.8%).7 Metal-ceramic
single crowns had low rates of mechanical failures, with no
framework fractures at all and only a small amount of porcelain
chipping (3.8%).58 A systematic review including metal-ceramic
and all-ceramic single crowns showed chipping of the ceramic
as one of the main technical complications, whereas frame-
work fractures occurred rarely on metal-ceramic crowns (0.03%
at 5 years) and more often on all-ceramic restorations (0.4% to
6.7% at 5 years), depending on the used ceramic material.32
These results indicate general differences in the technical per-
formance of ceramic-based restorations as compared to metal-
based restorations. Aging of a ceramic, a brittle material, is the
most probable reason for the observed differences.7,55
QUINTESSENCE INTERNATIONAL | volume 51 • number 7 • July / August 2020
Strasding et al
Besides the technical problems, different incidences of bio-
logic complications were reported for the different types of res-
torations. Interestingly, in the present study only six biologic
complications were observed: secondary caries (1.5%), loss of
abutment tooth vitality (1.5%), and periodontitis at the abut-
ment teeth (1.5%). Caries has been reported as an uncommon
reason for the loss of a restoration with ceramic inlays and
onlays in other studies.50,61,62 In the study of Van Dijken and Has-
selrot,37 secondary caries was found in 11 abutment teeth, cor-
responding to 4.8%. Other studies did not find any secondary
caries after 3 to 8 years observation period.26,63 In contrast, bio-
logic problems prevailed as the major cause of failure for gold
restorations. In a recent long-term study, out of the 303 reexam-
ined gold restorations reported on after 18.7 years of function,
more than half failed due to biologic problems.12 Secondary
caries was one of the main reasons for failure (5.6%), followed
by tooth fractures (1.3%;) and endodontic treatments (0.66%).12
For amalgam restorations, tooth fractures (1.8%) and end-
odontic problems (2.5%) were the main biologic complications
up to a 6-year follow-up period.7
For metal-ceramic crowns, the loss of abutment tooth vital-
ity was the most frequent biologic complication (1.8%), fol-
lowed by abutment tooth fracture (1.5 %) and secondary caries
(1%), at the 5-year observation period.32
These results indicate that there is a shift from biologic to
technical complications from the conventional to the less invasive
treatment options. The minimally invasive, defect-oriented prep-
arations were associated with fewer biologic problems, which is
crucial for the long-term survival of the abutment teeth.19,26 In the
future, treatment concepts with the minimally invasive types of
573
 PROSTHODONTICS

restorations should be preferred to the conventional FDPs, and onlays in the future. More clinical long-term data are needed to
research should focus on their further improvement. validate new ceramic materials and manufacturing procedures.

Conclusions
This study demonstrates that all-ceramic inlays and onlays
present favorable long-term clinical survival and success rates.
Overall, technical complications were predominant, character-
ized by a high fracture rate of the ceramic inlays and onlays.
Biologic complications were rare, which is beneficial for the
long-term survival of the abutment teeth.
The dental ceramic system used for the present study was a
forerunner of the dental glass-ceramic materials that are em-
ployed today. Current and forthcoming developments of stron-
ger dental ceramics and improved manufacturing procedures
will further improve the technical outcomes of ceramic inlays and
Acknowledgment
This manuscript summarizes the data of a study performed as
thesis of Dr Eszter Sebestyén at the University of Zurich for the
Dr med dent degree. The authors thank PD Dr Malgorzata Roos,
Biostatistician at the Epidemiology, Biostatistics and Prevention
Institute, University of Zurich, for help with the statistical
analysis of the data. The authors thank PD Dr Dobrila Nesic and
David Cornish for English language editing.
Declaration
The authors declare there are no conflicts of interest.

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 PROSTHODONTICS

Malin Strasding Eszter Sebestyén-Hüvös Private dental office, Zurich, Switzer-

land

Stephan Studer Private Docent, Private dental office, Zurich,

Switzerland

Christian Lehner Formerly private dental office, Winterthur,

Switzerland

Ronald E. Jung Professor, Center of Dental Medicine, Clinic of

Reconstructive Dentistry, University of Zurich, Zurich, Switzerland

Malin Strasding Senior Lecturer, Division of Fixed Prosthodon- Irena Sailer Professor, Head of Department, Division of Fixed
tics and Biomaterials, University Clinics of Dental Medicine, Univer- Prosthodontics and Biomaterials, University Clinics of Dental Med-
sity of Geneva, Geneva, Switzerland icine, University of Geneva, Geneva, Switzerland

Correspondence: Prof Dr Irena Sailer, Division of Fixed Prosthodontics and Biomaterials, University Clinics of Dental Medicine, University
of Geneva, 1 Michel-Servet, CH-1211 Geneva, Switzerland. Email: irena.sailer@unige.ch

576 QUINTESSENCE INTERNATIONAL | volume 51 • number 7 • July / August 2020