Inlay / Onlay Notes Template for UK Dentists
Nosht
Published by Nosht Limited
NHSBSA audits flag inlays and onlays without a documented clinical rationale for choosing indirect over direct. Below is a template for UK clinicians to paste into their PMS to make the rationale defensible from the start.
Why this inlay / onlay template wins
- Indirect vs direct rationale on its own line — NHSBSA-defensible for NHS cases, audit-defensible for private.
- Crack assessment with transillumination/wedge test — captures cracked tooth syndrome risk that drives the cusp-coverage decision.
- Cusp coverage map — which cusps and why — defends against later disputes about whether coverage was needed.
- Non-eugenol temporary cement when resin definitive planned — prevents bond failure at cementation.
- Pre-op photographs — cracked tooth syndrome cases need baseline visual evidence.
The template (paste into your PMS notes field)
Paste the inlay / onlay template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.
TOOTH / SURFACES: [FDI — surfaces / cusps covered] INDICATION: [Failed restoration / 2° caries / fracture / wear / cusp protection] RATIONALE FOR INDIRECT (vs DIRECT COMPOSITE): [Wide cavity >2/3 isthmus / cusp cracked or weakened / large prep where direct shrinkage = leakage / wear case needing increased OVD / patient preference for ceramic durability] PRE-OP ASSESSMENT: - Vitality: [Cold / EPT — response] Percussion: [+/-] - Existing restoration: [Type / extent] - Crack lines: [Transillumination — visible Y/N / wedge test result] - Pulp distance: [BW reviewed] - Photographs: [Pre-op taken Y/N] CONSENT (Montgomery): Risks discussed — post-op sensitivity, possibility of crack propagation requiring crown or extraction (if existing cracks), pulpal involvement requiring RCT, debonding, longevity (10-15yr ceramic, 20+yr gold). Benefit: cusp protection, more conservative than crown. Alternative: composite (risk of fracture/failure given prep size), crown (more reduction), extraction. Patient elects [option]. LA: [Agent — volume — technique]. Profound anaesthesia confirmed. PREPARATION: - Type: [Ceramic (e.max / leucite) / gold / composite] - Cusp coverage: [Mesial / distal / both — rationale: crack present / minimum 2mm cusp thickness] - Reduction: [Occlusal __ mm / axial __ mm] - Internal form: [Divergent walls 6-10°, rounded internal angles] - Margin: [Butt joint for ceramic / chamfer for gold] - Isthmus width: [Conservative] IMPRESSION / SCAN: [Method / bite registration] TEMPORARY: [Material / cement / occlusion checked] LAB PRESCRIPTION: [Lab — material — shade if ceramic — cusp coverage map]. MDR statement of conformity required on return. POST-OP ADVICE: LA wearing off in 2-3h. Sensitivity expected 1-2 weeks. Avoid hard chewing on temporary. Contact if temp debonds. FIT APPOINTMENT BOOKED: [Date]
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What good looks like — a worked example
The same inlay / onlay template, completed for a realistic case.
TOOTH / SURFACES: UR6 — MOD with mesio-buccal cusp coverage INDICATION: Failed MOD amalgam (>15yr) with mesio-buccal cusp crack visible on transillumination. Wedge test (Tooth Slooth) positive on release at mesio-buccal cusp. Asymptomatic but at risk of cusp fracture. RATIONALE FOR INDIRECT (vs DIRECT COMPOSITE): Cusp coverage required to protect cracked mesio-buccal cusp. Prep width >2/3 isthmus. Direct composite shrinkage in a cavity this size would risk margin leakage and crack propagation. Ceramic onlay provides cusp coverage with more conservative axial reduction than full crown. PRE-OP ASSESSMENT: - Vitality: Cold — brief response, resolves. EPT response at 18. Percussion: - - Existing restoration: MOD amalgam, ~50% of crown structure - Crack lines: Transillumination — mesio-buccal cusp crack visible, not extending to pulp - Pulp distance: BW reviewed — restoration 2mm clearance from pulp - Photographs: Pre-op taken (clinical + transillumination) CONSENT (Montgomery): Risks discussed — post-op sensitivity, possibility of crack propagation requiring crown or extraction (cracked tooth syndrome risk discussed), pulpal involvement requiring RCT (~5-10% in heavily restored teeth), debonding, longevity (10-15yr typical for e.max). Benefit: cusp protection, conservative compared to crown. Alternative: full crown (more reduction), direct composite (high failure risk given prep size). Patient elects e.max onlay. LA: Articaine 4% w/ adrenaline 1:100,000, 1.7ml buccal infiltration UR6. Profound anaesthesia. PREPARATION: - Type: e.max ceramic onlay - Cusp coverage: Mesio-buccal (cracked) — full coverage with 2mm functional reduction - Reduction: Occlusal 1.5mm (intercuspal), axial 1mm - Internal form: Divergent walls 8°, rounded internal angles - Margin: Butt joint, smooth, rounded line angles - Isthmus width: Conservative — 2mm IMPRESSION / SCAN: TRIOS 5 digital scan, including opposing arch + bite scan. STL files saved. TEMPORARY: Bis-acryl onlay (Protemp 4, shade A2). Temp-Bond NE (non-eugenol given resin cement planned). Occlusion checked — slight relief in ICP, no excursive interference. LAB PRESCRIPTION: Lab — Generic Dental Lab. e.max LT (low translucency), shade A2, butt joint margins. Cusp coverage mesio-buccal. Special instructions: maintain conservative isthmus, avoid over-bulking. MDR statement of conformity required. POST-OP ADVICE: LA wearing off in 2-3h — avoid hot food until sensation returns. Sensitivity expected 1-2 weeks (cold and biting). Avoid hard chewing on temporary. Contact if temp debonds or significant pain. FIT APPOINTMENT BOOKED: 2 weeks.
Compliance: the medico-legal angle
- CGDent Clinical Examination & Record-Keeping (3rd ed) — operative records and rationale for treatment choice.
- NHSBSA Inlay and Onlay Guidance (July 2019) — for NHS cases, the clinical indication for an indirect restoration must be documented.
- MDR 2017 — custom ceramic restorations are custom-made medical devices; statement of conformity required.
- Montgomery — cracked tooth syndrome carries a real risk of failure; this must be discussed and documented in consent.
Common documentation mistakes
- No rationale for indirect over direct — flags NHSBSA audit for NHS cases.
- No crack assessment documented — leaves the cracked-tooth-syndrome risk indefensible.
- Cusp coverage decision not justified per cusp — disputes about overtreatment.
- Eugenol-containing temp cement when resin definitive planned — debonding failure at fit.
- No pre-op photographs of cracked tooth — baseline evidence missing for any later complication.
Sources
- CGDent: Clinical Examination and Record-Keeping, Good Practice Guidelines (3rd edition) (accessed 18 October 2026)
- Montgomery v Lanarkshire Health Board (UK Supreme Court, 2015, UKSC 11) (accessed 18 October 2026)
Frequently asked questions
When should I choose an onlay over a crown?
When tooth structure can be conserved. Onlay covers only the cusps that need protection (cracked, weakened) while preserving sound axial walls. Crown sacrifices sound tooth structure circumferentially. For a tooth with one or two compromised cusps and otherwise sound axial walls, onlay is the more conservative choice — better long-term tooth survival.
How do I assess if a cusp needs coverage?
Three tests: (1) Transillumination — visible crack lines; (2) Wedge / Tooth Slooth test — positive on release indicates cracked tooth syndrome; (3) Cusp thickness assessment — if remaining cusp <2mm at base after caries removal, cover it. Document which test(s) and result.
Ceramic, gold, or composite for an inlay/onlay?
Ceramic (e.max, leucite): aesthetic, ~10-15yr survival, requires resin cementation. Gold: 20+yr survival, less aesthetic, lower cost, easier to adjust. Composite: cheaper, ~5-7yr survival, less wear-resistant. Patient preference, occlusal load, aesthetic demand all factor. Document the choice and rationale.
What's the difference between an inlay and an onlay?
Inlay — intracoronal restoration, no cusp coverage. Used for moderately wide cavities with sound cusps. Onlay — extends over one or more cusps for protection. Used for cracked or weakened cusps. The distinction matters for NHSBSA classification and for the prep design.
Why do NHS audits flag inlays?
NHSBSA Inlay/Onlay Guidance (2019) — under NHS contracts, indirect restorations should not be used where a direct composite would be equally effective. The audit looks for documented clinical rationale showing why indirect was clinically necessary. "Wide cavity, cracked cusp, cusp coverage required" is defensible; absent rationale flags the case for review.
How do I temporarily restore an onlay prep?
Same as crown — bis-acryl (Protemp, Luxatemp) or preformed shell. Use non-eugenol cement if resin cement is planned for the definitive. Check occlusion — temporary should NOT contact in heavy excursions or it'll fracture.
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Nosht
Published by Nosht Limited
Nosht Limited makes structured clinical note templates for UK dental professionals. Articles refer to guidance from the GDC, CGDent, BSP, SDCEP and NICE. Check the current version of a source before relying on it.