Composite Onlay?! Why?!!

[OpenMargins]

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So, prosth wizards, what is the advantage of getting a lab to prepare for you a composite onlay? How is that any different from just injecting a whole bunch of composite into your prep/building up cusps yourself? 😕

 

[SuperC]

Hmm, that is a good question. I had to give my best guess, I would say that a lab tech, might have an advantage over the dentist simply in terms of aesthetics. Perhaps they have some materials that can produce better shading and translucies that would be better than some of the composite based material currently available for intraoral applications.

Also, this might also be an advantage in isolation issues. Direct resin veneers require some time, so a simple one step cure, might be a plus in some cases.

Lastly, as you know, a composite veneer is easily repaired as opposed to porcelain veneers. There also might be some wear issues here. Porcelain is much harder on enamel than composite, and some of the newer materials are approaching wear rates similar to enamel.

I am just thinking out loud. Feel free to trash these ideas!
-C

 

[DrJeff]

Hmm, that is a good question. I had to give my best guess, I would say that a lab tech, might have an advantage over the dentist simply in terms of aesthetics. Perhaps they have some materials that can produce better shading and translucies that would be better than some of the composite based material currently available for intraoral applications.

Also, this might also be an advantage in isolation issues. Direct resin veneers require some time, so a simple one step cure, might be a plus in some cases.

Lastly, as you know, a composite veneer is easily repaired as opposed to porcelain veneers. There also might be some wear issues here. Porcelain is much harder on enamel than composite, and some of the newer materials are approaching wear rates similar to enamel.

I am just thinking out loud. Feel free to trash these ideas!
-C

Lab processed heat cured composite resin is also slightly more wear resistant than direct light cured composite. Plus witht he added tiem the lab tech has, they'll tend to be able to build the depth of color from within a bit better than you can chairside.

 

[Soflex]

This is what I was told in my restorative class:

--Ceramic is a superior material but an indirect composite is a less expensive alternative.
--The composite is cured in a Triad oven is somewhat stronger and it does not have the same polymerization shrinkage as direct composite
--Bruxers do better with indirect composite- less wear on the opposing teeth than with porcelain.

 

[OceanDMD]

There are many different resin onlay materials. Several reasons why its advantageous to place them indirectly.

1- They can be quite esthetic, as much so as porcelain.
2- They are less brittle, and bend more than porcelain. This actually can result in better resistance to fracture, and as mentioned before , better for bruxers.
3- lab bill is on avererage 1/3 that of empress
4- Placing large direct resins requires layering them for successful curing. This does several things, creates more bonding interfaces, more shrinkage, more potential for voids which are sources of failure and/or sensitivity.
I use a material called Cristobal. I dont think Triad is a material you want to place/use for esthetics. To give you an idea about lab costs:
Empress porcelain is about $200/unit
Cristobal resin is about $80/unit
If you bill the same for the restoration(regardless of the material), and place a hundred a year, you realize the reduction in your lab overhead.

 

[OceanDMD]

Hmm, that is a good question. I had to give my best guess, I would say that a lab tech, might have an advantage over the dentist simply in terms of aesthetics. Perhaps they have some materials that can produce better shading and translucies that would be better than some of the composite based material currently available for intraoral applications.

Also, this might also be an advantage in isolation issues. Direct resin veneers require some time, so a simple one step cure, might be a plus in some cases.

Lastly, as you know, a composite veneer is easily repaired as opposed to porcelain veneers. There also might be some wear issues here. Porcelain is much harder on enamel than composite, and some of the newer materials are approaching wear rates similar to enamel.

I am just thinking out loud. Feel free to trash these ideas!
-C

I would never place an indirect composite veneer. The esthetics of composite, especially thin composites have no comparison to porcelain. The stain resistance over time is poor, and if someone is going to have anterior veneer preparations done, they would be crazy not to restore with empress. If veneer fracture or wear is a concern, than your occlusion is incorrect and there is no business restoring with veneers until that is adressed--unless of course you want to be miserably married to a patient that fractures a veneer every 6 months.

 

[Soflex]

I dont think Triad is a material you want to place/use for esthetics.

The Triad isn't a material, it's affectionately known as the "EZ-Bake oven" we cure the indirect composite in.

 

[SuperC]

I would never place an indirect composite veneer. The esthetics of composite, especially thin composites have no comparison to porcelain. The stain resistance over time is poor, and if someone is going to have anterior veneer preparations done, they would be crazy not to restore with empress. If veneer fracture or wear is a concern, than your occlusion is incorrect and there is no business restoring with veneers until that is adressed--unless of course you want to be miserably married to a patient that fractures a veneer every 6 months.

I am not arguing, that composite is better, I was simply stating some possible reasons as to why one might use them.
-C

 

[NileBDS]

Great discussion. I really don't know if I would ever use resins for Onlays. I don't see how a resin Onaly would brace the rest of the cusps. Bevels don't really count as shoeing cusps. (Relatively) esthetic, yes. Less wear than porcelain, sure. Cheaper, obviously.


Indirect resin for Inlays, maybe.

 

[NileBDS]

...
Empress porcelain is about $200/unit
Cristobal resin is about $80/unit
If you bill the same for the restoration(regardless of the material), and place a hundred a year, you realize the reduction in your lab overhead.

Ocean, are you saying you bill the patient the same fee, regardless of the restoration material you use ?

 

[DrJeff]

Ocean, are you saying you bill the patient the same fee, regardless of the restoration material you use ?

I'll chime in here, but in short, the answer for an indirect inlay/onlay is yes in my office reguardless of the material I use (composite, gold, porcelain), the only difference is how many surfaces it covers.

I also do the same thing for my crowns, doesn't matter the material the cost is the same.

I find that this way the patients don't factor cost into the materials as I'm discussing it with them and they're deciding what materials they want for their teeth.

While I'm aware of the general lab fee for each type of material(especially when I sign the check to the lab each month) I give the patient the same speach each time about material choices, and often it's not super detail specific, but more of a simple tooth colored vs. gold colored explanation. Most patients would simply get overwhelmed if you got into the differences in material hardnesses, flexural strengths, etc however a couple of times a year I will get that technical with a specific patient at their request😀

 

[OceanDMD]

I'll chime in here, but in short, the answer for an indirect inlay/onlay is yes in my office reguardless of the material I use (composite, gold, porcelain), the only difference is how many surfaces it covers.

I also do the same thing for my crowns, doesn't matter the material the cost is the same.

I find that this way the patients don't factor cost into the materials as I'm discussing it with them and they're deciding what materials they want for their teeth.

While I'm aware of the general lab fee for each type of material(especially when I sign the check to the lab each month) I give the patient the same speach each time about material choices, and often it's not super detail specific, but more of a simple tooth colored vs. gold colored explanation. Most patients would simply get overwhelmed if you got into the differences in material hardnesses, flexural strengths, etc however a couple of times a year I will get that technical with a specific patient at their request😀

Its the same amount of work/chairtime regardless of the material. Same preparation(unless you bevel your axial/proximal margins) so why cut yourself short? Patients dont usually understand nor want to understand materials. They want it painless, to look nice, and to last a reasonable amount of time.

 

[OceanDMD]

Great discussion. I really don't know if I would ever use resins for Onlays. I don't see how a resin Onaly would brace the rest of the cusps. Bevels don't really count as shoeing cusps. (Relatively) esthetic, yes. Less wear than porcelain, sure. Cheaper, obviously.


Indirect resin for Inlays, maybe.

I dont follow what you are saying here. The preparation for a resin onlay if you are replacing a cusp is essentially the same as porcelain. You need Occl. thinckness in both materials. "Bracing cusps" as you put it is dependent on the prep design with the mechanical feature incorporated and your BONDING MATERIAL AND TECHNIQUE. Both materials are bonded with resin bonded cements/or flowable composite(which is the same thing however you must use dual cure under onlays).


"I am not arguing, that composite is better, I was simply stating some possible reasons as to why one might use them' SUPER C


Let me restate in another way what I am trying to say. I have never heard of anyone doing an indirect composite veneer. Regardless of your reasons, I cant validate why you would restore a VENEER prep with indirect composite. I dont have a lab the offers composite as a restorative material for a veneer.

 

[DrJeff]

Its the same amount of work/chairtime regardless of the material. Same preparation(unless you bevel your axial/proximal margins) so why cut yourself short? Patients dont usually understand nor want to understand materials. They want it painless, to look nice, and to last a reasonable amount of time.

If find that when it comes to materials, once you get past the "what color will it be" question from some patients, about the only 2 other materials question you'll get with any regularity are: 1) Is there mercury in it?? 2) Patient specific allergy questions

Other than those, as Ocean said, pain and duration of the material. However every now and then you'll get the ultra inquisative 8 year old who will ask you about every last detail of evry material/instrument you use, but then again in those case the rubber dam and a bite block do wonders for limiting the amount of questions they can ask😉😀

 

[NileBDS]

I'll chime in here, but in short, the answer for an indirect inlay/onlay is yes in my office reguardless of the material I use (composite, gold, porcelain), the only difference is how many surfaces it covers.

I also do the same thing for my crowns, doesn't matter the material the cost is the same. ...

Jeff, I find that interesting. So you just tell them; "OK, you need a crown on this tooth: that will be $1000 (or whatever it may be). What color do you want your crown ?"
I am not trying to argue office policy here, but everything else being the same, why would patients choose anything other than Porcelain ? How difficult is it for you not to gravitate towards Gold (crowns) and/or Resin (inlays/onlays), since this obviously means more profit for you ?

Thanks.

 

[NileBDS]

Its the same amount of work/chairtime regardless of the material. Same preparation(unless you bevel your axial/proximal margins) so why cut yourself short?

Right, but you're not charging patients per hour (unless you actually are). Any fee usually includes doctor, lab and overhead.
Just curious, which is greater: your profit from using resin, or your loss from using porcelain.

Patients dont usually understand nor want to understand materials. They want it painless, to look nice, and to last a reasonable amount of time.

100%.

 

[OceanDMD]

Right, but you're not charging patients per hour (unless you actually are). Any fee usually includes doctor, lab and overhead.
Just curious, which is greater: your profit from using resin, or your loss from using porcelain.

100%.

Whats your point? I really don't think a indirect resin onlay is inferior to porcelain as a final restoration. I charge the same fee for an onlay as I do for full coverage. Besides, your average hourly production is one of the most important numbers to track. As a result I do take into consideration how long a procedure takes and what my fee is.

 

[DrJeff]

Jeff, I find that interesting. So you just tell them; "OK, you need a crown on this tooth: that will be $1000 (or whatever it may be). What color do you want your crown ?"
I am not trying to argue office policy here, but everything else being the same, why would patients choose anything other than Porcelain ? How difficult is it for you not to gravitate towards Gold (crowns) and/or Resin (inlays/onlays), since this obviously means more profit for you ?

Thanks.

That's pretty much what I say, basically the following is it "Mrs. Smith your need a crown on that tooth because of X or Y. It's cost before insurance is X, my financial coordinator will go over how it works with your insurance or the financing plans with you. For your crown, it can be made either tooth colored or Gold. The gold crown more closely mimics a natural tooth in how it wears than the tooth colored, but most folks will choose tooth colored. Either way, the cost is the same Mrs. Smith. Just let me know what type you'd like." That's just about all I end up saying to 98% of my indirect patients.

As for the cost differential to me, with what my lab charges me, it's maybe a 10 dollar difference between materials, so it's not a huge profit issue.

 

[OpenMargins]

Interesting thoughts... thanks for the responses.

Part of my confusion arises from the prices listed in my school's fee schedule:

D2663 Onlay-composite-3 Surfaces - $405
D2643 Onlay-porcelain-3 Surfaces - $425

😕

 

[OceanDMD]

Interesting thoughts... thanks for the responses.

Part of my confusion arises from the prices listed in my school's fee schedule:

D2663 Onlay-composite-3 Surfaces - $405
D2643 Onlay-porcelain-3 Surfaces - $425

😕

Dont pay any attention to your school's fee schedule. Its flawed. At my school, our fee for a PFM was 600, and the fee for a denture was 300. In private practice I charge 1000/PFM and 1500/denture. Unless insurance is dictating fees, you price them where you want. My denture fee is higher because more appointments are involved, more chair time, more adjustments, and I dont like doing dentures as much as I do cutting teeth. I have not had one patient not accept my denture fee (even though its probably on the high end).

 

[NVDental]

At USC we will fabricate what we call a semi-direct composite inlay/onlay. We will fabricate it chairside, or at least take the impressions and then fabricate the restoration ourselves then, deliver and bond it during the next pt visit. I have personally made three of these and I was able to complete 1 of them and bond it during one pt visit. The other two I had to complete later, then delivered them at the next visit.

There are a few advantages to this type of restoration vs lab fabricated restorations.

Cost: We charge the pt $225 per unit, vs $425 for a lab fabricated indirect restoration

Time: Our turn around is much quicker for the patient, than with lab fabricated restorations.

Here are the advantages vs. direct composites.

Esthetics: We have more control morphologically and use more sophisticated layering and staining techniques by curing and shaping extraorally.

Control: We have better occlusal control when multiple occlusal restorations are needed.

 

[OceanDMD]

At USC we will fabricate what we call a semi-direct composite inlay/onlay. We will fabricate it chairside, or at least take the impressions and then fabricate the restoration ourselves then, deliver and bond it during the next pt visit. I have personally made three of these and I was able to complete 1 of them and bond it during one pt visit. The other two I had to complete later, then delivered them at the next visit.

There are a few advantages to this type of restoration vs lab fabricated restorations.

Cost: We charge the pt $225 per unit, vs $425 for a lab fabricated indirect restoration

Time: Our turn around is much quicker for the patient, than with lab fabricated restorations.

Here are the advantages vs. direct composites.

Esthetics: We have more control morphologically and use more sophisticated layering and staining techniques by curing and shaping extraorally.

Control: We have better occlusal control when multiple occlusal restorations are needed.

When you graduate I would really be surprised if you "fabricate" any indirect restoration. Thats like setting your own denture teeth.

 

[NVDental]

If my practice was slow, and I was trying to save on some overhead, then I would probably do this until I could either more productively fill my chairs or afford a CEREC machine. 🙂