PERSPECTIVES OBSERVATIONS
The case for onlays versus tooth-colored
crowns
Gordon J. Christensen, DDS, MSD, PhD
bout 38 million indirect
A fixed restorations were
placed in the United
States in 2011, accord-
ing to estimates from the Na-
tional Association of Dental Lab-
oratories (B. Napier, executive
director, National Association of
Dental Laboratories, Talla-
hassee, Fla., written commu-
nication, July 1, 2012). And
about 5 percent of those indirect
restorations were onlays and
inlays, with the remainder being
full crowns (T. Limoli, president,
Limoli and Associates, Arling-
ton, Tenn., written communica-
tion, July 1, 2012).
WHY ARE MORE CROWNS
THAN ONLAYS USED AS
POSTERIOR TOOTH
RESTORATIONS?
When I ask practicing dentists
why more crowns than onlays
are used as posterior tooth res-
torations, they usually provide a
variety of answers.
Many dentists feel that
crowns are easier to place be-
cause of some debatable reasons
(on which I will provide my
Gordon J. Christensen, DDS, MSD, PhD
Copyright © 2012 American Dental Association. All rights reserved.
opinions). Many feel that tooth
preparations for full crowns are
accomplished more easily than
are onlays. The crown technique
essentially consists of reducing
the original tooth anatomy to a
smaller size with some well-
recognized, well-defined, rela-
tively simple tooth preparations.
I admit that it is easier to make
a typical full-crown tooth prepa-
ration. Most dentists are com-
fortable making full-crown
preparations because they have
made so many of them. Repeti-
tion of any task makes it easier
and more predictable. Dentists
apparently are not making
many onlay tooth preparations.
Is it not logical that if they did
more of those types of tooth
preparations, completing them
would become relatively easy as
well? In my opinion, tooth prepa-
rations for onlays are not diffi-
cult, whether they are for
laboratory-made indirect tooth-
colored restorations or for in-
direct onlays milled by in-office
milling machines. After per-
forming the onlay tooth prepara-
tion procedure for a short time,
JADA 143(10)
in my opinion and experience,
most dentists can become profi-
cient with the technique.
ARE THERE REASONS TO
INCREASE THE USE OF
TOOTH-COLORED ONLAYS?
The four tooth-colored crown
materials most used in the
United States in the past three
years are full zirconia, porcelain
fused to metal, lithium disilicate
and zirconia-based with ceramic
pressed or layered over the zir-
conia (J. Shuck, vice president
of sales and marketing,
Glidewell Laboratories, New-
port Beach, Calif., written com-
munication, July 3, 2012). Re-
gardless of the type of tooth-
colored crown material used,
when inevitable gingival tissue
recession occurs, the margins of
the crowns in the smile zone are
visible when the patient smiles.
The disagreeable esthetic result
varies according to the type of
material of which the crown is
made, but all of the materials
listed above show displeasing
color and opacity differences
between the crown, the cement
line between the crown and the
tooth and the tooth structure
http://jada.ada.org October 2012 1141
PERSPECTIVES OBSERVATIONS

BOX provide benefits for onlays that

cover one or more cusps of a
Technique for placing tooth-colored onlays. multicusp posterior tooth. How-
ever, most will not provide ben-
dAnesthetize the tooth if necessary efits for inlays that do not cover
dClean the tooth preparation with flour of pumice and water on a rubber cup any tooth cusps (T. Limoli, oral
dSelectively place phosphoric acid gel on just the enamel portions of the mar-
gins and perform a standard acid etch of the enamel; this is the so-called communication, July 5, 2012).
selective etching technique
dPlace whatever disinfecting or desensitizing material customarily used (for WHAT MATERIALS ARE
example, materials containing glutaraldehyde, such as Gluma [Heraeus SUGGESTED FOR ONLAYS?
Kulzer, South Bend, Ind.] or MicroPrime [Danville, San Ramon, Calif.])
dSeat the onlay with a self-etching resin cement such as Multilink Automix There is no question that cast
(Ivoclar Vivadent, Amherst, N.Y.) or Clearfil Esthetic Cement EX (Kuraray, New gold alloy onlays have served
York City), using the self-etching bonding agents supplied in the cement kit
by the manufacturer for many decades with success,
dMinimally cure the resin cement residue around the margins and remove it even when seated with the
before making the final light cure various cements of the past.
dFloss the contact areas before providing a full light cure of the restoration to However, practitioners know
avoid difficulty in clearing cement from the contact areas
well that most patients will not
dFinish and polish the margins and correct any high occlusal areas accept display of gold alloy in
their mouths. The question is
apical to the crown. In my expe- DO ONLAYS SERVE AS WELL whether the new varieties of
rience, this unfortunate situa- AS CROWNS DO? tooth-colored restorations simi-
tion occurs only a few years This is a difficult question to larly serve adequately. The suc-
after the crowns have been answer, because there are as cess of tooth-colored onlays
placed. many opinions as there are made by in-office milling
Tooth-colored onlays can be dentists. The results of re- machines has been well docu-
placed so that the juncture of search show that tooth-colored mented.10-14 According to my dis-
the restorative material and onlays have served well.1-8 cussions with manufacturers,
the tooth is near the occlusal When I am talking to dentists many dentists use lithium
surface of the tooth. These mar- in continuing education disilicate (IPS e.max, Ivoclar
gins can achieve excellent color courses, one question arises Vivadent, Amherst, N.Y.) and
blending of tooth structure and constantly: are onlays strong some use leucite-reinforced
restoration. Subsequently, enough to provide long-term glass (such as IPS Empress,
when the gingiva recede, the service? A recent in vitro study Ivoclar Vivadent) to create
natural tooth-structure color is showed the strength of onlays onlays. Both materials have
exposed at the gingival level of covering both facial and lingual had reported success,15-26
the tooth, which is a much more cusps of premolars to be greater whether made indirectly by lab-
desirable outcome than is an than that of the control uncut, oratories or milled by machines
exposed crown margin. virgin teeth.9 I conclude that in clinical offices. It is apparent
Onlays have another impor- there is enough in vitro re- that these two types of tooth-
tant positive characteristic in search supported by clinical colored onlays are serving in a
comparison with crowns. Many observation to tentatively con- satisfactory manner.
teeth being restored have clude that tooth-colored onlays Another material, full zir-
strong and beautiful remaining have adequate strength for conia, is gaining in popularity.
tooth structure on the facial long-term use. This material continues to show
and lingual surfaces and defec- significant success and promise
tive or lost tooth structure in WILL THIRD-PARTY in full-crown restorations.27 The
the intracoronal areas. Tooth PAYMENT COMPANIES success of zirconia in full
preparations for crowns require PROVIDE BENEFITS FOR crowns indicates its potential
ONLAYS?
removal of most of the as an onlay material.9
remaining tooth structure on Although third-party payment Another new material that
the facial and lingual surfaces for onlays has been a controver- appears to have significant
and placement of some type of sial issue in the past and, when promise is Lava Ultimate (3M
filler or build-up material in the lacking, has been an impedi- ESPE, St. Paul, Minn.). The
intracoronal areas. Onlay ment to use of onlays, the chal- American Dental Association
preparations eliminate or lenge of third-party payment amended the description of
greatly reduce this unfortunate has been overcome. Most third- porcelain/ceramic for the 2013
removal of tooth structure. party payment companies will Code on Dental Procedures and

1142 JADA 143(10) http://jada.ada.org October 2012

Copyright © 2012 American Dental Association. All rights reserved.

Nomenclature (CDT) to accom-
modate new types of dental
materials; this action was not
product specific, but allows for
Lava Ultimate to be coded as a
porcelain/ceramic. This action
was taken with the full support
of dentists and third-party
payer representatives involved
in code maintenance (D.M.
Preble, DDS, JD, director,
Council on Dental Benefit Pro-
grams, American Dental Asso-
ciation, Chicago, written com-
munication, Sept. 6, 2012). The
manufacturer has named Lava
Ultimate a resin-nanoceramic,
and it is the only material in
this classification. Practitioners
in the field have reported to me
that the material appears to be
a viable contender for the
crown and onlay market.
WHAT TECHNIQUE SHOULD
I USE TO PLACE ONLAYS?
Below I present the technique
I myself use to place onlay
restorations.
dPrepare the molar or pre-
molar for an onlay restoration.
Such tooth preparations are
similar to those for cast gold
alloy onlays, but without gin-
gival bevels and with more
divergence of all of the walls
and box forms than usually are
made for metal restorations.
Tooth preparations are some-
what different when they
involve the use of in-office
milling machines that require
the preparation to be designed
to meet the physical character-
istics of the burs used in the
milling machine.
dMake a conventional impres-
sion and send it to your labora-
tory, or make a digital impres-
sion if you are using that
technology.
dHave the onlay fabricated by
using one of the materials pre-
viously described, or if you are
using an in-office milling
machine, mill it yourself.
dReceive the onlay from the
Copyright © 2012 American Dental Association. All rights reserved.
PERSPECTIVES
laboratory or make it yourself if
using in-office milling.
dMany techniques are sug-
gested for seating these restora-
tions. After several decades
placing tooth-colored onlays
with success, I have developed
a preferred seating technique,
shown in the box.
I have observed that tooth-
colored onlays seated in the
manner described here provide
excellent service and do not
develop postoperative tooth
sensitivity.
SUMMARY
Dentists are placing far more
crowns than tooth-colored
onlays, although many teeth
have adequate tooth structure
remaining to support placement
of onlay restorations. I have
discussed some significant posi-
tive characteristics of onlays
when compared with full
crowns. Onlays are a more con-
servative restorative option
than are crowns. The results of
research are positive regarding
onlays’ service potential. Third-
party payment companies are
providing benefits for onlays.
Numerous well-proven, as well
as some new, materials make
the use of tooth-colored onlays a
viable procedure. More onlays
should be placed instead of
more radical, and potentially
less esthetic, full-crown
restorations. ■
Dr. Christensen is the director, Practical
Clinical Courses, and a cofounder and the
chief executive officer, CR Foundation, Provo,
Utah. He also is an adjunct professor,
Brigham Young University, Provo; and an
adjunct professor, University of Utah, Salt
Lake City. He is a diplomate of the American
Board of Prosthodontics. Address reprint
requests to Dr. Christensen at CR Founda-
tion, 3707 N. Canyon Road, Suite 3D, Provo,
Utah 84604.
The views expressed are those of the author
and do not necessarily reflect the opinions or
official policies of the American Dental
Association.
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