Retrospective clinical study of 656 cast gold
inlays/onlays in posterior teeth, in a 5 to 44-year
period: Analysis of results
Ernesto Borgia, DDS1, Rosario Barón, DDS2, José Luis Borgia, DDS3

DOI: 10.22592/ode2018n31a6

Abstract
Objective. 1) To assess the clinical performance of 656 cast gold inlay/onlays in a 44‑year
period; 2) To analyze their indications and distribution regarding the evolution of scientificevidence. Materials and Methods. A total of 656 cast gold inlays/onlays had been placed in
100 patients. Out of 2552 registered patients, 210 fulfilled the inclusion criteria. The statisticalrepresentative sample was 136 patients; 140 were randomly selected and 138 were the patients
studied. Twelve variables were analyzed. Data processing was done using Epidat 3.1 and SPPS
software 13.0. Results. At the clinical examination, 536 (81.7%) were still in function and
120 (18.3%) had failed. According to Kaplan-Meier’s method, the estimated mean survival for
the whole sample was 77.4% at 39 years and 10 months. Conclusions. Knowledge updating
is an ethical responsibility of professionals, which will allow them to introduce conceptual andclinical changes that consider new scientific evidence.
Keywords: inlays/onlays, molar, premolar, dental bonding restorations, scientific evidence-based,
minimally invasive dentistry.

Disclosure
The authors declare no conflicts of interest related with this study.
Acknowledgements
To Lic. Mr. Eduardo Cuitiño, for his responsible and efficient statistical analysis of the data collected by the authors.

1

2
3

16

Professor, Postgraduate Degree in Comprehensive Restorative Dentistry, Postgraduate School, School of Dentistry, Universidad dela República, Montevideo, Uruguay. ORCID: 0000-0002-9888-4128.
Federico Abadie 2918, apt. 302, Montevideo, 11300, Uruguay. Phone: +59827113781 Fax: +59824872719. E-mail: eborgiabotto@
gmail.com
Associate Professor, Operative Dentistry Clinical Department, School of Dentistry, Universidad de la República, Montevideo, Uruguay. ORCID: 0000-0001-9264-6391
Assistant Professor, Prosthodontics Clinic, School of Dentistry, Universidad de la República, Montevideo, Uruguay. ORCID: 00000002-0206-9285
Odontoestomatología. Vol. XX - Nº 31 - Junio 2018

Introduction
Restorations in posterior teeth, mainly molars,
withstand the greatest occlusal forces. Moreover, 40% greater forces could be observed inpatients with bruxism, increasing their risk offailure(1). Additionally, restorations covering
more surfaces have had greater risk of failure(2).
For over 100 years, cast gold restorations havebeen widely used, mainly in posterior teeth.
Several clinical studies show excellent quality,
longevity and functional performance(3-6).
Since the beginning of the nineties there has
been a permanent scientific and technologicaldevelopment of adhesive ceramic materials forposterior inlays/onlays. Clinical studies andsystematic reviews have shown very good results(7-12). Moreover, improving biomechanicaland optical properties in direct light-activatedcomposite resins(13-18), as well as in the adhesive
systems(19-22) has increased their use(23-24), showing high long-term clinical success, performing
extended and large restorations in posterior
teeth(25-32). This scientific evidence has provided
the basis for using these materials as substitutesof cast gold restorations.
At the same time, cultural, sociological and psychological factors related to self‑esteem(33) andnew aesthetic parameters(34-36) have increased
patients’ demand for tooth-colored restorations.
All the above can change concepts and clinical procedures, leading to a reduction in theindication and placement of cast gold inlays/
onlays. These changes were observed in productivity studies conducted by the operator in his
private office in over 25 years. In fact, between
1995 and 2000 there was a 19.8% decrease in
the use of gold inlays/onlays (GIOs) (Fig. 1), an
increase of 107.6% in the placement of bonded
ceramic inlays/onlays (BCIOs) (Fig. 2) as well
as a 44.7% increase in posterior direct light-activated composite resins (PCRs) (Fig. 3).

80
70

51

60

68

56 59 56 56

49

50

37 38

40

GOLD INLAYS/ONLAYS
1990 - 2000
19.8%

30
20

31

10
0

1

2

3

4

5

6

7

8

9

10

Fig. 1. The chart shows a decrease in the use of GIOs
since 1995 (blue dot).
45 BONDED CERAMIC INLAY/ONLAYS 41
1900 - 2000
40
35
30
25

19

20

9

0

15

17

9

5
1

2

28

15

15
10

33

30

107.6%

27

3

4

5

6

7

8

9

10

11

Fig. 2. The chart shows an increase in the use of
BCIOs since 1995 (blue dot).

139 143

119

139

124

100

138
COMPOSITE RESINS
1990 - 2000
44.7%

50
0

191

181

200
150

238

223

250

1

2

3

4

5

6

7

8

9

10

Fig. 3. The chart shows an increase in the use of
PCRs since 1995 (yellow dot).

The right selection and the proper handling of
the new materials are possible if the professional’s knowledge is scientific and evidence-based.
In fact, it is an ethical responsibility.
Therefore the aims of this article were: 1) to assess the clinical performance of 656 cast gold
inlay/onlays in a 44-year period, and 2) to analyze their indications and distribution in relation to the evolution of scientific evidence.

Materials y Methods
This work was approved by the Ethical Boardof the School of Dentistry, Universidad de la
República.

Retrospective clinical study of 656 cast gold inlays/onlays in posterior teeth, in a 5 to 44-year period: Analysis of results

17

From April 2013, a retrospective clinical longitudinal study on six restorative procedures, performed by the first author in his private practice,
has been conducted covering a 44‑year period.
Four articles have been published(12,32,37,38). This
paper presents the results of a new study in theseries.
To be included in the study, the patients musthave been treated and evaluated in the first author’s office for at least seven years and be stillin the practice by 2013, with complete dental
arches (healthy or restored teeth). The patientswith removable dental prosthesis, disabilities,
that had moved or passed away were excluded.
The GIOs must have been in function for atleast five years to be included in the study. The
failure criteria were: loosening, removal of therestoration or tooth lost.
Out of 2552 registered patients, 210 fulfilled
the inclusion criteria and 136 patients were astatistically representative sample (at the lowest
range, a 95% CI for a proportion, with a lengthof ± 5%). Of these 210 patients, 140 were selected at random by a dental assistant, who was
blinded to the aim of the selection. They wereinvited to participate in clinical examinations
between November 2013 and April 2014: 138
agreed to participate.
Considering the period of the clinical examination (11/2013 - 04/2014), the inclusion criteria
for the GIO (> 5 years in function), and thesecond aim of this research, the restorations tobe analyzed were divided into two groups, according to the date of placement: A - between
April 1969 and April 1991, and B – between
April 1991 and October 2008.
According to the Glossary of Prosthodontics
Terms(39), the meaning of inlay and onlay terms
were slighty modified in this work for practical18

reasons: “inlay” is when the GIO covers partially the occlusal surface, including one or morecusps; “onlay” when the GIO covers the wholeocclusal surface.
Patient-based data were collected from the clinical personal charts and clinical examinations
for each patient, and then recorded on speciallydesigned sheet forms.
All restorations were made by the first author.
The co-authors participated as independent
evaluators. The calibration between the authors
was undertaken previously on 120 restorative
procedures from outside the sample. Cohen’s
Kappa Coefficient on the quality of restorations
ranged from 0.78 to 1 (excellent according toFleiss’s guidelines).
To establish the quality of the restorations, marginal adaptation (MA), marginal discoloration(MD), and occlusal surfaces (S) were the variables evaluated according to Ryge’s criteria(40) ;however, these variables were modified by theauthors (Table 1).
As was previously published(32), four success criteria (SC) were established on the quality of the
GIOs:- Excellent (Ex): When MA, MD, and S wererated “Alpha” in the same GIO. This group represents the best quality restorations.
- Good (G): When at least one variable (MA,MD, S) was rated “Bravo” in the same GIO.
This group was considered of satisfactory clinical acceptance.
- Functional survival (FS): When at least one
variable (MA, MD, S) was rated “Charlie” inthe same GIO. These restorations must be controlled, repaired or retreated.
- Clinically successful (CS): To establish clinical success, the GIOs in function rated “Excellent” and “Good”, were considered jointly.

Ernesto Borgia, DDS, Rosario Barón, DDS, José Luis Borgia, DDSMARGINAL ADAPTATIONALPHA: No lack of continuity along the margin observed with the explorer.
BRAVO: Evidence of a crevice along the margin, but the explorer cannot penetrate.
CHARLIE: Evidence of a crevice along the margin, which an explorer can penetrate. Requires control, repair or retreatment.
MARGINAL DISCOLORATIONALPHA: No pigmentation anywhere on the margin.
BRAVO: Pigmentation present but does not penetrate the margin toward the pulp.
CHARLIE: Severe pigmentation. The restoration must be removed.
SURFACE
ALPHA: The surface of the restoration is unaltered.
BRAVO: The surface of the restoration shows wear and must be controlled.
CHARLIE: The surface of the restoration shows perforations, fractures or significant tear. It must be polished, repaired or retreated.
Table 1. Ryge’s criteria(40), modified by the authors, to establish the quality of GIOs.

Patients signed an informed consent before theclinical examination. The clinical exams wereblinded among the authors and performed
with a mirror and a sharp explorer (Maillefer
6: Maillefer, Ballalgues, Switzerland). In casesof disagreement regarding the assessment of thequality of the restorations, the lowest rating wasrecorded.
The operator always conducted a clinical andfunctional study of the Stomatognathic System(SE). These data, as well as the clinical procedures performed, the materials applied and thepatient’s biological response were thoroughlyrecorded.
Since its availability in the market, a panoramic
radiograph was always indicated. When restorations, carious lesions and/or periodontal disease were present, standard X-rays were requested.
All the patients were enrolled in a comprehensive prevention plan and advised to undergo
periodical maintenance therapy. Since the lateeighties, if caries disease was present, biochemical and microbiological saliva tests were indi-cated and a dietary form filled. The aim was toestablish the individual caries risk and to implement the specific etiological treatments(41-44).
Furthermore, non‑cavitated carious lesions
were treated with topical fluorides.
Tooth preparation is considered by the operator as the most important factor in the clinicalsuccess of the restorative treatment. It must be
based on a conservative approach, according
to the extension of the carious lesion, remnant
tooth structure, location of occlusal contacts,
crown height, occlusal plane, habits of the patient, biomechanical properties of the restorative materials and aesthetic considerations. In
deep cavities, a thin layer of self-cured calcium
hydroxide was applied in the pulpal wall andcovered with glass-ionomer cement.
The variables analyzed were age, gender, type of
restoration, number, location, extension, quality and longevity of the restorations, type of
cement, secondary caries, parafunctional habits
and maintenance therapy.
Data processing was performed using Epidat
software (Conselleria de Sanidade de la Xunta

Retrospective clinical study of 656 cast gold inlays/onlays in posterior teeth, in a 5 to 44-year period: Analysis of results

19

de Galicia, Santiago de Compostela, Spain) v
3.1 developed by the Consellería de Sanidadede la Xunta de Galicia with the support of PAHO-WHO and SPSS software v13.0 (SPSS
Inc., Chicago, IL). In all cases, the variablesconsidered corresponded to an identically distributed independent random variable that was
generated from a probability sample. A result
was considered statistically relevant when, upon
the rejection of a null hypothesis, the probability of error was less than 5%. Statistical significance was set at P < 0.05. When analyzing thecomplete and censored values, the mean andmedian values were used to describe the central
tendency. If the number of complete values was
too small, a Kaplan-Meier’s curve could not be
used. Therefore, a Fisher’s exact test, Chi-square
test, Kruskal-Wallis test, and Mann‑Whitney
non-parametric test could be indicated to analyze significant differences.

Group A- and 1 in Group B-. The OMS for
failures was 18 years and 4 months. No statistically significant differences between the IOOs
in function (Student T Test, p = 0.65), nor in
the failures (Student T Test, p = 0.99) were observed in both sexes.
The annual failure rate was 0.08%. The estimated mean survival time (EMS), according to the
Kaplan-Meier’s method, was 85% at 25 years
and 77.4% at 39 years and 10 months (Fig.4).

Results
Six hundred and fifty-six GIOs had been placedin 100 patients. The observed mean age was 63
years and 9 months for both sexes. The observed mean time of attendance per patient was
30 years and 5 months.
Carious lesions [557], endodontic treatment[85], functional requirements [7], trauma [4]and periodontal disease [3] were the reasons toperform the GIOs.
The number of GIOs per patient varied from 1
to 20. The average was 6.56 GIOs per patient:6.22 in women and 7.07 in men. No statisticalsignificant difference was found regarding sex(Mann-Whitney Test, p = 0.92).
GIOs in function and failed
At clinical examination, 536 GIOs (81.7%)
were in function. The observed mean survival(OMS) was 27 years and 1 month. According
to the date of placement, 343 were in group Aand 193 in Group B-.
One hundred and twenty GIOs failed (18.3%),
61 in 16 men and 59 in 17 women; 119 in
20

Fig. 4. Overall estimated mean survival according
to Kaplan‑Meier’s curves.

Considering location, 331 GIOs in function
were in molars and 205 in premolars. There
was a statistically significant difference in thenumber of GIOs in function, restoring molars
and premolars, between the two groups (OR =0.42, p < 0.001) (Fig. 5).
50PRE. GR. B-

MOLARS & PREMOLARSIN FUNCTION

155

PRE. GR A-

143

MO. GR. B-

188

MO. GR. A0

50

100

150

200

Fig. 5. Distribution and number of GIOs infunction in molars and premolars in bothgroups (MO. =molars; PRE. = premolars; GR.
= group).
Ernesto Borgia, DDS, Rosario Barón, DDS, José Luis Borgia, DDSOut of 120 failures, 89 were in molars and 31
in premolars. Premolar survival was significantly higher (Log Rank Test, p < 0.0001). According to Kaplan‑Meier’s method, EMS was 479.8
months (39 years and 11 months) for premolars and 437.4 months (35 years and 5 months)
for molars (Fig. 6).

Fig. 7. Survival Kaplan‑Meier’s curves between onlays and inlays

Fig. 6. Survival Kaplan – Meier’s curves between
premolars and molars.

Regarding type of restoration, 424 GIOs were
onlays and 112 inlays. A statistically significant
difference was observed in the number of onlays
and inlays in function between the two groups(OR = 13.9, p < 0.0001). Thirty-eight onlays
and 82 inlays failed. Onlays presented a higher statistical survival rate (Log Rank Test, p <0.0001). The Kaplan‑Meier’s curves showed an
EMS of 498.4 months (41 years and 6 months)
for onlays and 402.2 months (33 years and 6
months) for inlays (Fig.7).

Considering extension, 95% of the all GIOs,
covered 3 surfaces: 507 in function and 116
failures; 20 covered 2 surfaces (4 failures) and13 more than 3 surfaces.
Regarding pulp state at the moment of placement, 86.6% of the GIOs, restored vital teeth(VT): 457 in function and 111 failed. Outof 88 (13.4%) endodontically treated teeth(ETT), 79 remained in function and 9 restoredwith casts posts failed, but only one was fractured. Furthermore, 9 GIOs in VT had to be
removed for endodontic treatment (1.4%).
Three GIOs were fixed with resin cement(Panavia, Kuraray, Japan) and 653 with zinc
phosphate cement. One GIO fixed with zinc
phosphate cement loosened after 32 years infunction.
Secondary caries was the major reason for failures (14.9%): 89 in occlusal surfaces and 9 ingingival location. Of the 120 failures, 15 teeth(14 in group A and 1 in group B) were lost.
Table 2 summarizes the information on failures
presented above.
In addition, 105 teeth in group A-, that had
lost their GIOs could be retreated: 90 with new
GIOs, that were included in this study, and 15
with other restorative procedures. Out of 90
GIOs (89 onlays and 1 inlay), 39 were retreated
before April 1991, remaining in group A. Fifty

Retrospective clinical study of 656 cast gold inlays/onlays in posterior teeth, in a 5 to 44-year period: Analysis of results

21

one performed after April 1991 were included criteria(32), the CS of the GIOs in function
in group B- .
was 93.6%. The CS for the whole sample was
76.1%.
PERIOD< 10 y10 - 20 y
20 - 30 y
30 - 40 y> 40 yTOTAL%O/C G/C End. Perio. Fra. Loos. R.R. TOTAL
24 3
2
1
1
0
1
32
34 1
3
4
0
0
1
43
21 0
4
1
0
0
0
26
10 3
0
3
0
1
0
17
0
2
0
0
0
0
0
2
89 9
9
9
1
1
2 120
74.2 7.5 7.5 7.5 0.8 0.8 1.7 100

Table 2. Failures of GIOs: causes, number, distribution in decades and percentages (O/C = occlusal caries; G/C = gingival caries; End.= endodontic
treatement; Perio.= periodontal disease; Fra.= root
fracture; Loos. = loosened; R.R.= rooth resorption;y = year).

ALPHA
BRAVO
CHARLIEMARGINAL
ADAPTATION
390
129
17

MARGINALDISCOLORATION
533
2
1

OCCLUSAL
SURFACE465
50
21

Table 4. Number, distribution and quality of thevariables analyzed, according to Ryge’s criteria(40)modified by the authors.

Three GIOs in Figure 8 were qualified Ex, and2 in Figure 9 were qualified B. The GIOs repaired in Figure 10 were qualified as FS.

Meanwhile, group B- included 194 GIOs
placed after April 1991 (193 in function, 1
failure). The distribution of the 193 GIOs infunction was: 48 in 22 patients that had notbeen in group A-; the above mentioned 51
GIOs retreated, and the 94 new GIOs placedin 62 patients in group A- (Table 3).
PERÍOD
04/91 - 04/95
04/95 - 04/99
04/99 - 04/04
04/04 - 10/08
TOTAL

Gr. B
9
15
12
12
48

Gr. A/B
35
29
18
12
94

RETR.
19
18
8
6
51

TOTAL
63
62
38
30
193

Table 3 . Distribution of GIOs in function in groupB-, placed after April 1991, according to the periodof placement and their origin (Gr. B- = GIOs installed in new patients; Gr. A/B = new GIOs placedin patients of group A-; RETR. = GIOs retreated inpatients of group A-).

Success criteria
According to Ryge’s criteria(40) modified by theauthors, the results on the quality of the variables analyzed are presented in Table 4. Considering these results, and the previous established22

Fig. 8. GIOs qualified Excellent (a= year, m= months).

Fig. 9. GIOs in premolars (44 years) qualified Bravo (a = year, m = months).

Occlusal function and maintenance.
Twenty-four patients (24%) had had history ofparafunction, and 33 (33%) were using stabilization occlusal splints due to bruxism. ThirErnesto Borgia, DDS, Rosario Barón, DDS, José Luis Borgia, DDS

ty-seven patients (37%), 21 women and 16 to the minimal invasive criteria, preferred tomen, attended at least once a year for mainte- repair before retreating. This agrees with Fishnance therapy.
er and Morgan WW(45). The fact that 63% of
the patients did not attend at least once a year
Repairs
for maintenance therapy could be considered
Meanwhile, in 21 patients, 27 repairs were per- a biological and biomechanical risk factor forformed (23 in occlusal and 4 in gingival areas). failure. Furthermore, parafunction might be a
The materials applied were Direct Light-acti- biomechanical risk factor of failure.
vated Composite Resin [20], Glass‑Ionomer Only one GIO loosened (0.15%). This result[1] and Amalgam [6]. These GIOs were con- was very low compared to other clinical studies:sidered in function and qualified as functional 32.7%(3) and 31%(4). This could be due to thesurvival. The OMS of the repairs was 12 years design of the tooth preparation, the quality ofand 8 months (range: 3 years to 22 years and the restoration and a thorough fixation proto9 months). Two GIOs repaired are shown in col by the operator.
The higher survival of premolars is in line with
Figure 10.
other studies(1,2). Meanwhile, the higher survival of onlays could be explained because onlays transmit mainly compressive forces, giving
better protection to the remnant tooth structure(46,47). Besides, due to the extension, their
margins could be less affected by the greater
forces exerted in patients with bruxism. In addition, Studer et al.(4) did not find differences
between inlays and onlays. The CS of the GIOs
in function was 93.6%, in line with Donovan
and Chee(5) and Donovan T et al.(6). The deFig. 10. Repairs with direct light-activatedcomposite resin, in buccal margins of 46
velopment above supports the first objective of(19 y) and 45 (8y). Both GIOs have been inthis work.
function for 44 years (y = year).
The second aim of this study was to analyze theindication and distribution of GIOs, related
to the new scientific evidence. Therefore, both
Discussion
groups must be compared to analyze the conThe high percentage of GIOs in function stitution of Group B- and to assess the possible(81.7%) and their EMS were in line with other coexistence of restorations as substitutes of theclinical studies(3,4,6). Regarding statistical data GIOs.
previously presented in this paper, the variables In fact, the number of GIOs in function inage and gender did not influence the results. Group B- (193) was 43.7% less than in Group
Secondary caries were 81.7% of the all fail- A-. These patients had been using GIOs forures, higher than in other studies: 33.7%(3) and a long time, they knew their results and did
40%(4).
not refuse to use gold restorations. NevertheOcclusal carious lesions could be related to less, when analyzing Table 3, 32.1% of GIOs
biomechanical factors associated with bruxism were placed in the “transitional period” (1995(marginal and/or surface wear of GIO, cement 1999), 19.7% and 15.6% in the two following
dissolution), biological factor (bacterial mi- periods, respectively. This gradual and constantcrofiltration) and the lack of periodic mainte- reduction in the use of GIOs might be due tonance control. Besides, the operator, according
Retrospective clinical study of 656 cast gold inlays/onlays in posterior teeth, in a 5 to 44-year period: Analysis of results

23alternative restorative procedures proposed by
the operator.
Using the same global sample, similar inclusion
end exclusion criteria than in this work, andrelative similar period of placement than restorations in Group B-, in two articles publishedby the authors(12,32) the following was studied:- 93 IOCAs in 47 patients, placed between
10/1995 - 10/2008 and assessed in a 5 to 18- year period. Eighty‑seven onlays (93.5%) remained in function(12).
- 105 RCDPs in 61 patients were installed between 10/1993 - 10/2008 and assessed in a 5
to 20-year period; 103 (98%) were in function
and 41% were large or extended restorations(32).
Therefore, in the 04/1991 - 10/2008 period, inthe same global sample, 50.4% of the partial
posterior restorations performed were GIOs
and 49.6% RCDPs or IOCAs. Meanwhile,
comparing the two groups, in Group B- we observed a reduction of 94.3% and 67.7% in thenumber of inlays and premolars restored with
GIOs, respectively. This could be due to theapplication of more conservative, aesthetic andefficient restorative materials such as RCDPs.
Besides, the reduction of onlays (21.1%) in
Group B-, might be linked to greater use of
IOCAs. Whereas in Group B-, only one GIO
failed due to periodontal problems. This result could be due to the scientific and clinicalchanges related to the new preventive actions
taken by the operator(41-44).
Considering all the above, besides the very
good clinical results, this work also showed aclose connection between the clinical and conceptual changes applied by the operator and the
updated scientific evidence.
Only one operator can reduce bias in the analytical comparison, but might improve the clinical success(48). The results could not be reproducible, but the operator believes this could bea relative limitation(49).

24

Conclusions
In this study, a high clinical performance of
GIOs was observed. However, as there are moreaesthetic restorative materials, with good longevity and requiring simpler and less invasive
teeth preparations, GIOs are less indicated bydentists and less accepted by patients.
Updated knowledge is an ethical responsibility of the professional. It will allow dentists tointroduce the clinical and conceptual changes,
taking into consideration the new scientific evidence, as was observed in this paper.

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Ernesto Borgia: eborgiabotto@gmail.com
Received on: 06.02.2018 – Accepted on: 13.04.2018

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Ernesto Borgia, DDS, Rosario Barón, DDS, José Luis Borgia, DDS