Same-Day Indirect Ceramic Polymer Inlays/Onlays

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INTRODUCTION
More and more people are demanding reliable, functional, and aesthetic alternatives to conventional crown and bridge dentistry. As the population is aging, people are seeking out treatment to improve their teeth and still conserve their natural, healthy tooth structure.1 According to Dr. Ross Nash, “Laboratory-processed composite resin may be a viable option for the patient who desires an aesthetic alternative to gold. While ceramics can provide many of the same benefits, composite resin has some advantages, including ease of adjustment and repair, resilience for comfort and shock absorption, less chance for differential wear at the luting agent-restoration interface, and no wear of opposing structures in functional contact.”2

Unfortunately, 2-appointment procedures for crowns are inconvenient, uncomfortable, and expensive. Furthermore, more preparation may be required for additional mechanical retention of temporary restorations, defeating the purpose of trying to save the most tooth structure. So, what are our options—direct resins, indirect resins, and porcelain crowns? Crowns, we all know, will require the removal of even more tooth structure, 2 appointments, and provisional crowns.

Let’s think like our patients. Our patients want to replace old, ugly, and failing restorations, but they want to do it consistently, efficiently, and predictably—and they would prefer to do it in one appointment. Direct fillings can be done in one appointment, but when wide, deep, and/or interproximal surfaces are involved, they can prove difficult, time-consuming, and inadequate.

Adhesive dentistry offers a more conservative restorative approach to patient care. Why take away healthy tooth structure? Why not attempt to save the good and just replace the bad? A laboratory-fabricated composite resin system is a valuable and worthwhile option to preserve both tooth structure and long-term dental health. After all, preserving natural tooth structure is always in the best interest of the patient, whenever possible. This article will demonstrate a conservative and biomimetic approach to restorative care.

        

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Inlay/Onlay Reimbursement

An inlay is an indirect restoration constructed of cast metal, porcelain/ceramic, or composite/resin that neither supports nor replaces a cusp (or cusps) of a tooth. The inlay restoration is nothing more than a centric stop in that it provides no protection for the cusp tip as concerns lateral and/or protrusive masticatory forces in excursions. The onlay component of an inlay/onlay restoration is another story. The onlay component replaces the cusp tip (or tips). The onlay entirely replaces the cusp tip so as to maintain and/or restore the vertical dimension in the preparation. When the cusp tips are sound (Figures 3, 6, and 8), the original vertical dimension is not altered. The coding sequence provides for a single code number to identify an inlay with an associated onlay component. As we all know, it is a technical impossibility to construct an onlay without first identifying the surfaces of the inlay. Hence, the descriptions are currently somewhat misleading. With regard to third-party reimbursement, few if any benefit plans consider an inlay in the absence of an onlay component to be a contractual benefit. Since an inlay is nothing more than a centric stop that adds little or no strength to the remaining natural tooth structure, it is traditionally reimbursed at the level of a traditional, direct restoration. Inlay restorations (Figures 6, 7, and 9) are optional benefits when the tooth can be restored adequately with a similar direct restoration. An allowance is generally made for that similar material, and the patient is responsible for the difference in cost. Table. 2010 Resin-Based Composite Inlays/Onlays Code Description Lower Low Medium High Higher Average RV   Inlay/Onlay Restorations               D2650 Inlay-resin based composite composite/resin-1 surface $205 $448 $450 $801 $1,115 $574.00 13.05 D2651 Inlay-resin based composite composite/resin-2 surfacea $250 $493 $495 $846 $1,200 $619.00 14.07 D2652 Inlay-resin based composite composite/resin-3 or more surfaces $350 $593 $595 $946 $1,300 $719.00 16.34 D2653 Onlay-resin based composite composite/resin-3 surfacea $500 $743 $745 $1,096 $1,450 $869.00 19.75 D2654 Onlay-resin based composite -4 ore more surfaces $554 $783 $795 $1,169 $1,475 $968.70 22.02 This data represents 100% of the 90th percentile. The relative value is based upon the national average and not the individual columns of broad-based data. The abbreviated code numbers and descriptors are not intended to be a comprehensive listing.

        

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Figure 3. Filling undercuts on the model.
Figure 6. Polished inlays on the model.

Figure 7. Inlay try-in. Voids will be filled in with a resin cement.	Figure 8. Etch and prime restorations using a split rubber dam and Fender Wedges.
Figure 9. Immediate post-op photo: the cemented inlays.

 

        

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