[Downloaded free from http://www.jofs.in on Sunday, July 24, 2016, IP: 139.193.38.

37]

Case Report

Ceramic onlay for endodontically treated

mandibular molar
Roopadevi Garlapati, Bhuvan Shome Venigalla1, Shekhar Kamishetty1, Jayaprakash Thumu
Department of Conservative Dentistry and Endodontics, Sibar Institute of Dental Sciences, Guntur,
1
Department of Conservative Dentistry and Endodontics, Sri Sai College of Dental Surgery, Vikarabad,
Andhra Pradesh, India

ABSTRACT
Restoration of endodontically treated teeth is important for the success of endodontic
treatment. In full coverage restorations, maximum amount of tooth structure is compromised,
so as to conserve the amount of tooth structure partial coverage restorations, can be
preferred. This case report is on fabrication of a conservative tooth colored restoration for
an endodontically treated posterior tooth. A 22-year-old male patient presented with pain
in the mandibular left first molar. After endodontic treatment, composite material was used
as postendodontic restoration. The tooth was then prepared to receive a ceramic onlay and
bonded with self-adhesive universal resin cement. Ceramic onlay restoration was periodically
examined up to 2 years.

Key words: Ceramic onlay, endodontic treatment, post endodontic restoration

INTRODUCTION

Address for correspondence:

Dr. Roopadevi Garlapati,
Department of Conservative Dentistry
and Endodontics, Sibar Institute of
Dental Sciences, Takkellapadu,
Guntur - 522 509,
Andhra Pradesh, India.
E-mail: dr.rupagarlapati@gmail.com

Access this article online

Website:
www.jofs.in
DOI:
10.4103/0975-8844.132591
Quick Response Code:

Journal of Orofacial Sciences

Vol. 6 Issue 1 January 2014

Endodontic treatment is not considered

complete
until
an
appropriate
permanent coronal restoration is placed.
Endodontically treated teeth become
brittle and will fracture when subjected to
occlusal forces, so they require restorations
to provide protection from such injury.[1]
The complete coverage restorations will
provide the required protection to ensure
the clinical success of the treatment.
Some of the studies recommend complete
coverage restorations for endodontically
treated posterior teeth where much of
the tooth strength is lost,[2] whereas
some studies recommend use of complex
amalgam restorations and indirect cast
restorations to cover the weakened
cusps and to preserve the natural tooth
structure.[3]
With the advent of adhesively bonded
newer restorative materials with superior
esthetics, higher strength, and increased
mechanical reliability, the proportion of
restorative treatments in endodontically
treated posterior teeth using all-ceramics
is rapidly growing.[4]

In cases where the facial and lingual

surfaces of an endodontically treated
tooth are sound, to conserve the health of
the facial and lingual gingival tissues, a
partial coverage restoration like an onlay
can be designed with adequate resistance
form to prevent tooth fracture instead of a
full coverage restoration.[5] Ceramic onlays
are excellent esthetic restorations that
are often a better alternative than a full
coverage crown.
This case report presents the endodontic
treatment of a mandibular molar, followed
by postendodontic restoration with
ceramic onlay with complete cusp coverage
and pulp chamber extension and the case
was periodically examined.

CASE REPORT
A 22-year-old male patient presented to
the Department of Conservative Dentistry
and Endodontics, with a chief complaint
of continuous and radiating pain in the
left lower back tooth since 2 weeks. The
medical history was noncontributory.
Clinical examination revealed a deep
carious lesion in the mandibular left first
molar [Figure 1]. The patient complained
69

[Downloaded free from http://www.jofs.in on Sunday, July 24, 2016, IP: 139.193.38.37]
Garlapati, et al.: Ceramic onlay

of episodes of sensitivity to heat and cold in the

involved tooth. After detailed clinical and radiographic
examination, a treatment plan was suggested as
endodontic therapy followed by ceramic onlay with
pulp chamber extension and complete cusp coverage in
relation to mandibular left first molar. The patient was
informed about the procedure.
After administration of local anesthesia, tooth was
isolated with a rubber dam and a conservative access
opening was prepared. Working length of each canal
was confirmed by a radiograph, cleaning and shaping
of canals was performed, and the tooth was obturated.
Pulp chamber preparation was done by blocking
undercuts in the walls and floor of the pulp chamber
using hybrid resin composite (Filtek Z250) [Figure 2].
Before preparing the tooth a preliminary impression
was made and a B2 shade was selected using the Vita
shade guide.
Ceramic onlay tooth preparation was done as
conservatively as possible using crown and bridge
preparation kit (Shofu, Crown and Bridge Preparation
Kit). Cuspal reduction was done in the form of capping
rather than shoeing. Internal angles were made
rounded to enhance adaptation of restorative material.
Depth orientation grooves are placed on the cusps.
1.5-2.0 mm of occlusal clearance was done to prevent
fracture in all excursions. Hollow ground chamfer with
no conventional bevel confined to the marginal enamel
was placed which aided in developing an effective seal.
A distinct heavy chamfer was placed on the facial and
lingual surfaces with supragingival margins. Smooth,
distinct margins are essential for an accurately fitting
ceramic onlay restoration [Figure 3]. Preparation details
were recorded with a low viscosity material (Aquasil,
Dentsply). Temporary restoration was cemented with a
eugenol-free temporary cement. As esthetics is one of
the prime concern for the patient, IPS Empress II was
selected for the fabrication of the ceramic restoration.

Figure 1: Preoperative view of mandibular left first molar

Figure 2: Pulp chamber preparation with composite

The restoration was carefully positioned to check the

marginal adaptation, shape, and shade with complete
satisfactory results. The operating field was isolated
with a rubber dam.
Following etching, a dentin bonding system was used.
Self-adhesive universal resin cement is applied to the
restoration and inserted with slight pressure. Excess
of cement from the margins was removed with a
microbrush. Residual excess cement was removed using
explorer and dental floss. Final polishing was achieved
using diamond impregnated finishing points and
polishing gels [Figure 4]. The patient was periodically
reviewed after 6 months, 1 year, and 2 years.
70

Figure 3: Onlay tooth preparation

DISCUSSION
Compared to vital teeth chances of fracture of endodontically
treated teeth is higher because of loss of structural integrity
associated with dental caries, access cavity preparation,
and root canal preparation rather than changes in dentin.[6]
Journal of Orofacial Sciences
Vol. 6 Issue 1 January 2014

[Downloaded free from http://www.jofs.in on Sunday, July 24, 2016, IP: 139.193.38.37]
Garlapati, et al.: Ceramic onlay

ceramics against occlusal stresses.[9] Clinical studies

have proven the higher survival rates for anterior and
posterior IPS Empress II crowns.[10]
Tagtekin et al. evaluated 2-year clinical performance of 28
endodontically treated teeth restored with IPS Empress
II Ceramic Onlays and reported that all the restorations
performed well up to 2 years of their study.[11]
In Naeselius et al. 4-year retrospective study of clinical
evaluation of all-ceramic onlays, 93% of onlays were still
in function after 4 years and concluded that ceramic
onlay restorations are acceptable and can be alternative
over a 4-year period.[12]
Figure 4: Cemented ceramic onlay on mandibular left first molar

Endodontically treated teeth require coronal protection

to prevent fracture when masticatory forces are
delivered on them. Sorensen et al. reported that when
maxillary and mandibular premolars and molars were
restored with coronal coverage restorations, there was
increased success rate. This finding supports that when
endodontically treated teeth are restored with full
coverage restorations or partial coverage restorations
like onlays or complete metal crowns or complete metal
ceramic crowns or complete ceramic crowns there was
increased longevity of the treated teeth and improved
the success rate.[7]
Partial coverage restorations like gold onlays or ceramic
onlays or resin composite onlays and cusp-covering
silver amalgam restorations also provide the protection
for endodontically treated teeth against fracture.
Smales and Hawthorne in their study reported a good
survival rate of complex cusp covering silver amalgam
partial coverage restorations.[8]
Conservation, preservation, and reinforcement of tooth
structure of an endodontically treated tooth can also
be achieved by a partial coverage restoration rather
than a full coverage restoration. With the increased
demand of tooth colored restorations and improved
adhesive techniques, esthetic partial coverage crowns
like ceramic crowns can be restored to preserve the
maximum amount of sound tooth structure.[4]
In the present case, endodontically treated mandibular
left first molar was restored with a partial coverage
esthetic restoration, i.e., IPS Empress II Ceramic
Onlay and 2-year clinical performance was evaluated.
IPS Empress II all-ceramic material was selected
as it exhibits excellent esthetics, has superior wear
resistance, and has good bond strength to tooth structure.
IPS Empress II is a lithium disilicate ceramic which
is developed to increase the strength of the previous
Journal of Orofacial Sciences
Vol. 6 Issue 1 January 2014

During restorative procedures, health of the supporting

tissues must be carefully observed. In full coverage
restorations, margins placed near gingiva may result in
gingival overhangs, excessive axial contours, marginal
defects, and surface roughness of the restorative
material can cause localized gingival inflammation.
Unlike the full coverage restorations, the major
advantage of ceramic onlay preparation lies in placing
the margins of the restoration supragingivally, which
are least irritating to the periodontal tissues and finally
preserving the biological width. Biological width is
important for the preservation of periodontal health and
removal of irritants that might damage the periodontal
tissues.[13]
As the onlay preparations are more conservative, most
of the tooth structure is preserved during preparation
and the time needed for preparation is more less than
that needed for a full coverage restorations and placing
the supragingival margins causes less damage to the
periodontal tissues. But further long-term data are
necessary before this treatment to be considered for
general dental practice.

CONCLUSION
Ceramic onlays are partial coverage restorations which
are alternative for restoring endodontically treated
posterior teeth in certain clinical situations without
interfering with the adjacent periodontal tissues, and
not compromising much tooth structure, ceramic onlays
satisfy both functional and esthetic demands of patient.

REFERENCES
1.

2.
3.

Wagnild GW, Mueller KI. Restoration of the endodontically -treated

tooth. In: Cohen S, Burns RC, editors. Pathways of the Pulp. 8th ed.
St Louis, MO, USA: Mosby Inc; 2002. p. 765-95.
Goerig AC, Mueninghoff LA. Management of the endodontically
treated tooth. Part II: Technique. J Prosthet Dent 1983;49:491-7.
Reeh ES, Douglas WH, Messer HH. Stiffness of endodontically-treated
teeth related to restoration technique. J Dent Res 1989;68:1540-4.

71

[Downloaded free from http://www.jofs.in on Sunday, July 24, 2016, IP: 139.193.38.37]
Garlapati, et al.: Ceramic onlay
4.
5.
6.

7.

8.
9.

72

Griggs JA. Recent advances in materials for all-ceramic restorations.

Dent Clin North Am 2007;51:713-27, viii.
Roberson TM, Heymann HO, Swift EJ. Sturdevants Art and Science
of Operative Dentistry. 5th ed. St Louis: Mosby; 2006. p. 883.
Reeh ES, Messer HH, Douglas WH. Reduction in tooth stiffness
as a result of endodontic and restorative procedures. J Endod
1989;15:512-6.
Sorensen JA, Martinoff JT. Intracoronal reinforcement and coronal
coverage: A study of endodontically treated teeth. J Prosthet Dent
1984;51:780-4.
Smales RJ, Hawthorne WS. Long-term survival of extensive
amalgams and posterior crowns. J Dent 1997;25:225-7.
Holand W, Schweiger M, Frank M, Rheinberger V. A comparison of
the microstructure and properties of the IPS Empress 2 and the IPS
Empress glass-ceramics. J Biomed Mater Res 2000;53:297-303.

10. Valenti M, Valenti A. Retrospective survival analysis of 261 lithium

disilicate crowns in a private general practice. Quintessence Int
2009;40:573-9.
11. Tagtekin DA, Ozyney G, Yanikoglu F. Two-year clinical evaluation
of IPS Empress II ceramic onlays/inlays. Oper Dent 2009;34;369-78.
12. Naeselius K, Arnelund CF, Molin MK. Clinical evaluation of allceramic onlays: A 4-year retrospective study. Int J Prosthodont
2008;21:40-4.
13. Sharma A, Rahul GR, Gupta B, Hafeez M. Biological width: No
violation zone. Eur J Gen Dent 2012;1:137-41.
How to cite this article: Garlapati R, Venigalla BS, Kamishetty S,
Thumu J. Ceramic onlay for endodontically treated mandibular molar. J
Orofac Sci 2014;6:69-72.
Source of Support: Nil, Conflict of Interest: None declared

Journal of Orofacial Sciences

Vol. 6 Issue 1 January 2014