Pre-fabricated, direct, single-visit, ceramic inserts

Ceramic inserts have been designed as single-visit systems and an alternative to conventional ceramic restorations produced in two appointments by means of indirect technique. Luting ceramic inserts with a small amount of composite resin is expected to reduce the amount of polymerisation shrinkage by reducing the bulk of resin composite needed to restore the tooth. Another advantage is that the occlusal contacts can be placed on the ceramic surface, rather than on the composite, for longer-term stability.

One of the most studied systems is Cerana, which utilises pre-etched and silanated leucite inlays with matched diamond burs. After caries removal and the preparation of a usual adhesive-type preparation for bonded restorations (Figure 1), the cavity is refined using one of three conical burs (Figure 2). Enamel and dentine are etched if etch-and-rinse adhesive is used or self-etch systems are applied and cured. Composite is then applied to the cavity, filling it to or just above the enamel-dentin junction (Figure 3). A thin coat of composite can be applied to the ceramic insert which is then pressed into the cavity. Excess resin composite is removed and the restoration is cured for 20 s or 40 s depending on the light-curing unit (Figure 4). The occlusal contour of the inlay is shaped to match the surrounding enamel and the occlusion adjusted (Figure 5). The restoration is cured for a further 20 s or 40s and polished.

(Figures from manufacturer's recommendations for use. Nordiska Dental AB, Sweden)
A 3-year prospective clinical trial has shown that “The results indicate that Cerana is an alternative to composite resin restorations in Class I situations, but should be avoided in connection with Class II tunnel preparations.” (Odman 2002)

Another 8-year prospective clinical trial has shown that “Cerana is acceptable in terms of aesthetics, patient acceptance, occlusal wear and ease of use and is a good alternative for a single-visit, tooth coloured restoration in suitable cavity shapes.” (Millar & Robinson 2006)

In an in vitro study Cerana inserts luted with flowable composite in Class V cavities showed significantly less microleakage than those cemented with the high-viscous material only at the gingival margins. Microleakage was reduced around inserts compared to the bulk filling with flowable composites but no difference was observed between inserts and bulk filling with high-viscous composite material (Salim et al. 2005).

It was also shown that in vitro thermocycling 4000 times between 5 and 55 degree C does not increase microleakage around Cerana inserts (Santini et al. 2006). After thermocycling, Cerana inserts showed siginificantly less microleakage along both occlusal and gingival margins compared to Beta Quartz glass-ceramic inserts and Tetric Ceram resin-based composite. Both findings were attributed to the coefficient of thermal expansion of Cerana inserts which approximates that of enamel (Tan & Santini 2005; Santini et al. 2006).

References:

1. Odman P. A 3-year clinical evaluation of Cerana prefabricated ceramic inlays. Int J Prosthodont 2002; 15: 79-82.
2. Millar BJ, Robinson PB. Eight year results with direct ceramic restorations (Cerana). Br Dent J 2006; 201:515-520.
3. Salim S, Santini A, Safar KN. Microleakage around glass-ceramic insert restorations luted with a high-viscous or flowable composite. J Esthet Restor Dent 2005;17: 30-38.
4. Santini A, Ivanovic V, Tan CL, Ibbetson R. Effect of prolonged thermal cycling on microleakage around Class V cavities restored with glass-ceramic inserts with different coefficients of thermal expansion: an in vitro study. Prim Dent Care. 2006 Oct;13(4):147-53.
5. Tan CL, Santini A. Marginal microleakage around class V cavities restored with glass ceramic inserts of different coefficients of thermal expansion. J Clin Dent. 2005;16(1):26-31.