RestorativeDentistry
Andrew MacInnes
Andrew F Hall
Indications for Cuspal Coverage
Abstract: Cuspal-coverage restorations are important to preserve the integrity of a weakened tooth against the forces of occlusion.
This article discusses the clinical indications for both direct and indirect cuspal-coverage restorations and the evidence supporting their
use. Factors that modify a tooth’s ability to dissipate normal occlusal forces and the effect cuspal-coverage restorations have on force
distribution are examined. Clinical criteria, choice of restorative material and methods for tooth preparation are also discussed.
CPD/Clinical Relevance: Re-enforcement of weakened teeth with cuspal-coverage restorations provides a minimally invasive alternative to
conventional crowns.
Dent Update 2016; 43: 150–158
A cuspal-coverage restoration may be
defined as one where the restorative material
covers all, or part of, one or more cusps of
a molar, premolar or canine tooth. In this
regard, conventional crowns may be classed
as cuspal-coverage restorations. Cuspal-
coverage restorations may be either direct or
indirect restorations.
For the purposes of this article,
the term ‘cuspal coverage’ will refer to a
technique used for either direct or indirect
restorations that covers only part of one or
more cusps of a molar or premolar tooth.
These restorations may also be called direct
or indirect onlays.
The main role of a cuspal-
coverage restoration is to reinforce a
weakened cusp, thus reducing the chance for
fracture and overall failure of the tooth. Other
roles include:
 Augmentation of cusp shape to facilitate
modifications to an existing occlusal
Andrew MacInnes, BDS(Hons), MFDS
RCPS, Specialty Registrar in Restorative
Dentistry, Glasgow Dental Hospital
and Andrew F Hall, BChD(Hons), FDS
RCPS, PhD, FDS RCPS(Rest Dent), Senior
Lecturer and Honorary Consultant in
Restorative Dentistry, University of
Dundee, Dundee, UK.
150 DentalUpdate
scheme;
 A means of securing additional resistance
form or bonding area for indirect or direct
restorations.
To understand the indications for
cuspal coverage it is necessary to discuss the
forces on teeth and factors that modify the
ability of the tooth to resist such forces.
Force distribution on teeth
In normal function, teeth have
the greatest forces applied to them as a
result of mastication of food. For individual
teeth, the ideal occlusal contact distributes
the force down the long axis of the tooth and
occurs at the same time as all the other teeth
in the arch.1 Molar and premolar teeth are
most often involved in crushing and grinding
of food to aid swallowing and subsequent
digestion. Normally, occlusal loading on
such teeth is between 350−700N and for an
average cumulative total of 17.5 minutes per
day.2 There are a number of factors that can
affect the ability of the tooth to withstand
these parameters including:
 The prevalence of dental caries and
restorative interventions;
 Previous endodontic treatment;
 Previous tooth loss; and
 Parafunction.
Dental caries and restorative interventions
Dental caries and subsequent
restorative interventions result in substantial
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loss of tooth structure, weakening the tooth
and increasing the likelihood of fracture
of remaining tooth tissue. The three-
dimensional extent of dental caries in a
tooth can affect the residual tooth strength.
For example, caries may undermine cusps
of teeth, resulting in a predisposition to
undergo excessive flexure with an increased
likelihood of subsequent cuspal fracture.3
Such undermining of cusps may also be
a feature of conventional amalgam cavity
preparation for the purposes of retention
of the restoration. However, advances in
the use of adhesive technology and a shift
towards minimally invasive dentistry have
encouraged an increase in the clinical use of
composite as a posterior restorative material
and a reduction in cavity size due to the
obsolescence of retention and resistance
form.4
Reeh et al demonstrated the
effect that restorative and endodontic
procedures have on the stiffness, and
therefore fracture resistance, of remaining
tooth tissue.5 Their results indicated that
occlusal and mesio-occlusal-distal (MOD)
cavity preparations reduced tooth stiffness
by 20% and 63%, respectively. The additional
reduction in tooth stiffness as a result of a
subsequent endodontic preparation was
approximately five percent. There is some
limited in vitro evidence that premolar teeth
after endodontic treatment and restoration
March 2016

are particularly prone to cuspal fractures
without a cuspal-coverage restoration,
possibly due to their overall shape.6
Mondelli et al prepared Class
I and Class II cavities in freshly extracted
premolar teeth. They demonstrated, in
vitro, the protective effect of preserving the
marginal ridges and recommended that Class
II cavities, where the occlusal isthmus was
half the intercuspal width, or more, should
receive indirect restorations with cuspal
coverage.7
The mechanism of failure results
from the application of a ‘wedging’ force
on the tooth, exerting buccal and lingually
directed lateral forces on the remaining tooth
walls.8 Fisher et al demonstrated areas of high
stress concentration in conventional inlay
restorations that increased the likelihood
of fracture of remaining tooth walls when
compared to the ‘protective’ force distribution
exhibited with onlay restorations.9
Traditionally, photoelastic
stress analysis has been used to analyse the
distribution of forces through restorations
and teeth.10 This involves the analysis of
colourful chromatic fringes, seen on cross-
sectional slices of teeth when viewed in
polarized light, and how these fringes
change when stresses are applied to teeth.11
Although this has been a valuable method of
stress analysis, in the current literature, finite
element analysis is more commonly used
due to its accuracy, ease and adaptability in
stress analysis. This involves the analysis of
complex structures using a computer-based
mathematical model. Structures are broken
down into simple blocks and equations of
how these behave individually are generated
and combined to assess the overall response
of a structure to stress. Finite element
analysis demonstrates greater sensitivity in
the analysis of structural response to stress,
although this is dependant on the accurate
description of several parameters, such as the
structure of the outer surface of the tooth.10
Care must be taken with the final
restoration contour. Simultaneous occlusal
contact with axial loading may not occur if
the occlusal surface is restored incorrectly. A
poorly contoured occlusal surface of an intra-
coronal restoration may result in a premature
contact which, if on the incline of a cusp, will
result in lateral forces to that cusp with the
possibility of subsequent fracture.1
March 2016
Previous endodontic treatment
Lack of pulp tissue in an
endodontically treated tooth will reduce
the opportunity for preventive biofeedback
under occlusal loading and could partly
explain the increased fracture rate in
posterior root-filled teeth when restored
with an intra-coronal restoration.12 A
retrospective cohort study, involving 220
endodontically treated teeth over an
11-year period, concluded that composite
restorations offered a degree of improved
fracture resistance, whereas amalgam
restorations provided little or no resistance
to cuspal movement. However, when
compared, conventional direct restorations
have been shown to be less successful
with regard to overall tooth survival than
restorations with cuspal coverage.13
A further factor that must be
considered with regard to endodontic
treatment is the fracture pattern and
subsequent tooth restorability. Fennis et al
demonstrated that endodontically treated
teeth are more often associated with a
subgingival fracture location, potentially
impacting on the subsequent restorability
of the tooth.14
Reports of improved survival
rates of endodontically treated teeth
restored with a crown are widely cited in
the dental literature.13,15,16 Although it must
be noted that a Cochrane systematic review
in 2012, appraising ‘the success rate of single
crowns versus conventional fillings for the
restoration of endodontically treated teeth’,
concluded that there is insufficient high
quality evidence to endorse the clinical
effectiveness of crown placement for the
long-term survival of endodontically treated
teeth.17
Cuspal-coverage restorations
facilitate the distribution of masticatory
forces down the long axis of the tooth,
providing an element of support
for residual cusps.18 This finding was
corroborated by Craig et al, who
demonstrated the protective dissipation of
forces evident when the restoration overlays
the cusps of a tooth. The authors analysed
the stress distribution, using photoelastic
two-dimensional stress analysis, when
teeth restored with MOD inlays and crown
preparations were loaded. They concluded
that cuspal-coverage restorations reduce
the compressive stresses elicited by MOD
restorations and redistributed them
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RestorativeDentistry
towards more protected areas of remaining
tooth tissue.19,20 It was also noted that a
rounded cuspal reduction prevents high
compressive stresses being focused on the
fitting surface of the restoration, possibly
leading to restoration failure.20 Farah
et al demonstrated substantially lower
compressive stresses were present when
cusps were overlaid with gold restorations.
Furthermore, the authors evidenced,
through an in vitro study, that when a cusp
was completely protected by a restoration,
the average compressive stress exerted on
residual tooth structure was significantly
lower and more uniformly distributed than
with restorations that did not overlay the
residual cusps of a tooth.21
Tooth loss
Tooth loss may result in
tilting, rotating or drifting of teeth and
a subsequent change in the occlusal
forces applied to them. In many cases,
the change in position of teeth may result
in the application of non-axial forces
during function.22 The application of this
force may result in excessive flexure and
fracture of cusps previously weakened by
caries or restorative intervention. Indeed,
there may be forward movement of the
mandible to achieve best occlusal contact
in cases where tipping or tilting has
resulted in an abnormal occlusal scheme,
further influencing the application of
non-axial forces to teeth.23 Craig et al also
demonstrated that stress concentration was
greater in tilted teeth than their non-tilted
counterparts and this may increase the
likelihood of fracture.19
Parafunctional activity
Increased occlusal loading on
all teeth may occur due to various types of
normal activity, for example, clenching the
teeth together when lifting heavy loads, or
due to abnormal activity such as clenching
or grinding habits, otherwise known as
parafunction or bruxism. Such forces on a
tooth that has already been compromised
by caries or extensive or poorly contoured
restorations may result in crack formation or
fracture. Additionally, bruxism may result in
the application of non-axial forces to teeth
and further increase the likelihood of tooth
fracture due to suboptimal distribution of
occlusal forces.22
DentalUpdate 151
 RestorativeDentistry
Clinical factors for cuspal
coverage
Through the use of cuspal-
coverage restorations, practitioners have
the opportunity to develop a greater degree
of control over the direction of occlusal
loading on a tooth. Therefore, care can be
taken to ensure an optimal occlusal scheme
aiming for direct loading down the long
axis of the tooth and preventing potentially
pathological interferences in excursion.
It can be seen that a variety of
factors can modify the intensity and direction
of forces upon teeth, as well as the ability
of the tooth to resist such forces. With this
information, clinicians have developed a
number of indications for cuspal coverage.
When cuspal coverage is
indicated for a tooth, a practitioner has
several restorative options for replacement of
lost tooth tissue. In the authors’ experience,
general dental practitioners more commonly
opt to restore teeth with full cuspal-coverage
restorations (crowns) as opposed to partial
cusp coverage restorations (onlays). There is
a lack of evidence available to support this.
However, much of the endodontic literature
discusses tooth survival of endodontically
treated teeth restored with crowns, rather
than onlay restorations, and so practitioners
may automatically make this choice. There
may be a variety of possible reasons for this
choice including; practitioner experience,
ease of preparation, laboratory costs and
remuneration fees.
Clearly, there is less tooth
destruction with partial coverage
preparations compared with full coverage
tooth preparations. Murphy et al
demonstrated that, when practitioners were
given the opportunity to assess the degree
of tooth tissue loss following preparation for
a full coverage restoration, they tended to
revise their choice of preparation to a less
destructive cuspal-coverage preparation,
such as an onlay.24
Essentially, the decision to
provide a cuspal-coverage restoration comes
down to:
1. The amount and distribution of remaining
coronal tooth tissue;
2. The type of restorative material to be
used;
3. The load to be applied to a tooth during
daily function; and, possibly,
4. The knowledge and experience of the
154 DentalUpdate
practitioner.
The first two of these factors will
now be discussed.
The amount and distribution of remaining
coronal tooth tissue (tooth restorability)
Any restorative procedure
requires an initial diagnosis to facilitate
the planning of treatment. A key stage in
this is the assessment of the restorability
of compromised teeth and planning for
appropriate reconstruction. In order to plan
the placement of restorations appropriately,
practitioners must be able to appraise the
value of remaining tooth tissue prior to
definitive restoration. Ideally, this should be
done before undertaking any endodontic
treatment for a tooth. However, this is not
always possible.
The evidence base for appraising
tooth restorability is not extensive. A
common method of assessing tooth
restorability involves the visualization of the
remaining tooth tissue following preparation
for a cast restoration.13,16
In an attempt to increase
objectivity, Bandlish et al formulated the
Tooth Restorability Index (TRI), an assessment
methodology to determine the strategic
value of remaining tooth tissue.25 This
technique divided the remaining tooth
structure into sextants and assigned a score
to each sextant based on the thickness,
height and distribution of coronal dentine
present. The scores allocated to each sextant
ranged from 0 to 3. Individual sextant scores
are added together to give a score from 0 to
18, indicating the restorability of the tooth.
Lower scores represent a more guarded
prognosis for restoration. This study also
highlights the utility of assessing teeth in this
way, as there was fair-to-good or substantial
agreement between assessors (Kappa =
0.63).26,27 Although this assessment criterion
is a useful objective tool in the appraisal of
tooth restorability, it is necessary to consider
that advances in adhesive dentistry have
also facilitated the restoration of many teeth
which may have low TRI scores.28
The type of restorative material to be used
Cuspal-coverage restorations
can be created using a variety of dental
materials. Most commonly, gold, composite,
amalgam, porcelain or porcelain-fused-to-
metal restorations are utilized. Other cast
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restorations, including nickel chromium,
may also be considered but have fallen
out of favour with practitioners, possibly
due to concerns regarding possible allergic
reactions.29
Gold
Gold onlay restorations
are commonly utilized as a suitable
alternative to full or partial coverage
crowns when maintaining residual tooth
tissue is a priority. These restorations
have the advantage that they are usually
less destructive to tooth tissue, as
less preparation is required, although
a significant laboratory cost may be
incurred to the practitioner. Nagasiri and
Chitmongkolsuk demonstrated that the
strength of teeth restored with gold onlay
restorations was significantly higher than
teeth restored with amalgam or composite
restorations15 (Figure 1).
Composite
Brunton et al carried out an in
vivo randomized controlled trial assessing
the fracture resistance of several tooth-
coloured onlay materials. They concluded
that indirect composite restorations
provided a greater degree of protection to
the residual tooth compared to ceramic or
fibre-reinforced composite restorations of a
similar design.28,30 Additional work by Burke
et al also concluded, through in vitro testing
of composite inlay and onlay restorations,
that a significant increase is seen in fracture
resistance of teeth restored with composite
onlay restorations when compared to
composite inlay restorations.31
Amalgam
Although amalgam is often
advocated in expert opinion articles as an
alternative material for cuspal-coverage
restorations, current literature is bereft
of high quality studies assessing the
long-term survival of complex amalgam
restorations overlaying the cusps of teeth.32
An in vitro study by Basir et al compared
the fracture resistance of cuspal-coverage
amalgam MOD restorations with that of
conventional amalgam MOD restoration,
concluding that cuspal overlay techniques
were more effective in the prevention of
tooth fracture.33 Additionally, amalgam
restorations may offer an economic
March 2016

advantage to other materials owing to its
relatively low cost.
Ceramic
Advances in milled and pressable
ceramics have encouraged an increase
in their use, although there is currently
insufficient evidence as to their long-term
success rates.34 Krämer et al demonstrated
a 7% and 8% failure rate of ceramic inlays
and onlays after four and eight years,
respectively.35,36 Additionally, Ozyoney et
al demonstrated a 92.5% success over a
four-year period with glass ceramic onlays
restoring endodontically treated teeth,
although it is evident that current literature
lacks high quality long-term studies.37 The
increasing use of CAD/CAM technology
within modern dentistry is encouraging
a growing number of practitioners to use
ceramic restorations. Although the evidence
base for their use is limited and lacking
a cuspal-coverage restoration it is important
b preparation and has a long track record of
Figure 1. (a, b) Cuspal coverage with gold for DO
onlay retainer for tooth LR5 as part of an all gold
conventional bridge.
March 2016
long-term follow-up, ceramic onlay materials
have been shown to achieve restoration
strengths suitable for use in cuspal overlay
restorations38 (Figure 2).
One concern regarding the use
of all-ceramic restorations is the potential
for abrasion of opposing tooth substance.
Although commonly referenced, a systematic
review carried out by Hmaidouch and
Weigl demonstrated that there is currently
insufficient evidence to conclude that all-
ceramic restorations are associated with
increased toothwear. This study concluded
that some ceramic restorations are as wear
friendly as metal ceramic restorations,
although all-ceramic restorations may
have an abrasive nature due to suboptimal
surface treatment, such as failure to polish
adequately or re-glaze following occlusal
adjustment.39
Methods of tooth preparation
When preparing a tooth for a
to consider the requirements for the
successful use of the restorative material
chosen. Preparation of the residual tooth/
core must facilitate an adequate thickness of
restorative material to prevent perforation
of the restoration or fracture of inadequately
supported sections of the restoration.22
A common clinical practice is
to ensure that there is adequate reduction
of supporting cusps. This is also known as a
functional cusp bevel. Supporting cusps are
defined as those cusps or incisal edges of
teeth that contact in and support maximum
intercuspation. These are usually buccal
cusps of the mandibular posterior teeth, the
maxillary palatal cusps, and the incisal edges
of the mandibular anterior teeth.40 Generally,
increased occlusal forces are applied to
supporting cusps. For gold restorations a
minimum of 1.5 mm thickness is commonly
required over a supporting cusp, whereas
metal-ceramic and all-ceramic restorations
require 1.5 mm and 1.5 mm to 2 mm occlusal
reduction, respectively.41
There is a degree of uncertainty
in the literature as to the absolute indications
for a shoulder, chamfer or deep chamfer
margin preparation for a cuspal overlay
restoration. In the authors’ opinion, the most
commonly utilized margin preparations
include: a chamfer preparation for a gold
restoration; a deep chamfer preparation
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RestorativeDentistry
for all-ceramic preparations and a shoulder
preparation for metal ceramic restorations.
There is also some evidence from standard
texts to suggest that a shoulder preparation
should be utilized when a restoration is
required to overlay a supporting cusp,
regardless of the material chosen, as this
promotes a bulk of onlay material to protect
the supporting cusp.18
Conclusions and
recommendations
Based on the previous
information, the following recommendations
for cuspal-coverage/onlay restorations could
be applied to molar and premolar teeth.
Restoration of teeth
Conventional cavity preparation,
where the marginal ridge is lost and where
the isthmus is more than half the occlusal
width, would benefit from cuspal protection
by either bonding the restoration within the
cavity or cuspal coverage.7
Endodontically treated molars
and premolars where cavity preparation has
resulted in the loss of one or more marginal
ridges would probably benefit from a final
restoration with cuspal protection.6,7
Cuspal coverage may be used to
increase the resistance form of an indirect
restoration thus reducing the stress on any
cementation agent.
Materials
Gold is still a popular choice of
material for cuspal coverage when aesthetics
are not a priority. It requires minimal tooth
success.15,18
Indirect composite restorations
may be used with some success.30,31
Ceramic is a popular choice for
cuspal-coverage onlays, but there are no
long-term data available for their survival or
the effect of the newer ceramic restorations
on the opposing tooth structure.39
With the increasing popularity of
tooth-coloured restorative materials and the
skill required for placement, amalgam is less
favoured than gold or restorative materials
with better aesthetic properties.
Method of preparation
 If cuspal coverage is to be undertaken
DentalUpdate 155
 RestorativeDentistry
this should ideally be thicker over the
supporting cusps.18
 Between 1 and 2 mm of occlusal tooth
reduction is required to overlay a cusp.
This will be greater on the supporting
cusp compared with the non-supporting
cusp.18
 The type of margin preparation is
generally not relevant, although
shoulder margins result in increased
strength of restorative material and
might be considered over a supporting
cusp.18
The current literature lacks clarity on:
 The specific criteria important when
Figure 2. All-ceramic onlay preparation for tooth LR6, previously restored with narrow but deep
amalgam that developed a mesial-distal fracture initially resolved with root canal therapy and a
bonded intra-coronal composite restoration. (a) Pre-operative, (b) shoulder preparation at supporting
cusp with 1.5 mm inter-occlusal clearance, (c) deep chamfer preparation on lingual aspect and (d)
fitting surface morphology of provisional restoration.
156 DentalUpdate
deciding to undertake cuspal coverage for
vital teeth;
 The choice of restorative material used for
cuspal coverage; and
 The method of tooth reduction when a
decision has been made to provide cuspal
coverage.
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Dental Update welcomes
Ken Hemmings
BDS, MSc, DRD RCS, MRD RCS, FDS RCS,
ILTM FHEA
It is my great pleasure to announce that
Ken Hemmings has agreed to join the
Editorial Board of Dental Update. Having
graduated with honours in Dental Surgery
from Bristol
University
in 1982, Ken
worked in
various hospital
posts before
gaining a
Registrar in Oral
Surgery position
at the Royal
London Hospital,
later entering the specialty of Restorative
Dentistry.
Whilst studying for a two year
MSc programme in Conservative Dentistry
at the Eastman Dental Hospital, he avoided
financial destitution by working part-
time as a Registrar and in general dental
practice. He completed Senior Registrar
training at the Eastman in 1993, taking
up a full-time consultant post there in the
departments of Conservative Dentistry
and Periodontology in August 1995. He
is recognized by the GDC as a specialist
in Restorative Dentistry, Prosthodontics,
Periodontology and Endodontics. He
was President of the British Society for
Restorative Dentistry 2014−15.
Ken’s research interests and
publications, including two books, have
covered the management of toothwear,
hypodontia, tooth replacement and
periodontal/restorative interactions. His
1997 publication in Dental Update on
the treatment of toothwear using resin
composite was among the first, worldwide,
to describe this technique, with this now
being a well-established form of treatment.
He now shares his time between hospital
and private practice. His wife and three
children make for a busy and fun home
life. Retirement from rugby coaching has
allowed some time for triathlon training and
competition.
Ken, I and the other members
of the Editorial Board are thrilled that you
are able to join us. We know that your
experience in the field of Restorative
Dentistry will be most valuable to us. You
are very welcome.
F J Trevor Burke
Editorial Director

158 DentalUpdate March 2016

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