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V O L U M E 47 N U M BE R 1

JU LY 1953

O F T ff

A M F J U C A iV

D E N T A I A S S O C IA N O #

M ethodical jacket crown preparation


Charles B. W alton, D .D .S., Pittsburgh

The preparation of a vital tooth for a


jacket crown is the most radical operation
that a tooth must undergo and yet re
main vital. At best it is a traumatic ex
perience for the tooth and for the patient.
The purpose of this paper is to suggest
some details that will reduce the physical
trauma to the tooth and the psychological
trauma to the patient. Its aim, also, is to
aid the dentist; to suggest ways to in
crease his skill and efficiency, to reduce
his operating time, and thus to minimize
his fatigue.
Preliminary treatment of the patient
is important. A clinical examination, with
accurate roentgenograms and study casts,
should precede any mouth rehabilitation.
Before reconstruction, if there is any evi
dence of gingival inflammation, a
thorough prophylaxis is necessary, and
particular care must be taken to remove
serumal calculus. It is imperative to pro
duce normal gingival tissue tone and to
promote the proper position of this tissue
for the margins of the completed jacket
crown.

Careful attention during this prophy


lactic treatment will help the operator to
appraise the patients emotional and pain
reactions.
Examination of the patients occlusion
and, if necessary, grinding in the occlu
sion in order to coordinate it to the hingeaxis relation of the mandible are essential
before any preparation of teeth is begun.1
The prophylactic treatment and occlusal
equilibration will establish the confidence
of the patient and convince him of the
dentists interest in his oral health. He
will then be better prepared emotionally
to accept more radical operations.
I f gross malalignment of anterior teeth
must be corrected, it will be useful to cut
preparations on a duplicate study cast of
the mouth and make wax patterns of

Presented before the Section on Partial Prosthodontics, ninety-third annual session, Am erican Dental A sso
ciation, St. Louis, September 9, 1952.
Associate professor, head of ceramics department,
Dental School, University of Pittsburgh.
I.
Lauritzen, A . G . Function, prime object of restora
tive dentistry. J.A.D.A. 42:523 M a y 1951.

2 T H E J O U R N A L O F T H E A M E R IC A N D E N T A L A S S O C IA T IO N

proposed crowns. The study cast enables


the operator to develop a method for the
preparatory work on the individual teeth
and he also can visualize how the mouth
may be expected to look when the work is
completed. In addition, this cast may be
shown to the patient so that he can better
understand the proposed treatment. Fig
ure 1 shows an example of a congenitally
missing upper lateral incisor and hypo
plastic enamel of the central incisors.
Slightly narrow jackets are made for the
central incisors so that a normal width
lateral incisor may be supplied. These
central incisors are cut for jackets on a
study cast so that three teeth may be posi
tioned normally.
M ETH O D IC A L T E C H N IC

It is most important to establish a well


organized method for jacket crown
preparation. Such a preparation should
be viewed as a surgical operation and be
patterned after the surgeons operating
routine as much as possible. The equip
ment and instruments should be prepared
and laid out beforehand and a step by
step plan should be followed. Each cut
on the tooth should be made in its
planned sequence and each instrument
should be used to complete a cut before
it is discarded. I f this idea is followed,
certain benefits will accrue:
1. Needless pain and discomfort will
be eliminated.
2. The pulp and gingiva will undergo
less trauma.

3. A better preparation will result.


4. Operating time will be saved.
I f the dentist follows an organized
plan, his habits of work will be benefited
and the patient will be impressed by the
sureness and confidence of the operator.
PR E PAR ATIO N OF T E E TH

The excellent treatise by H. Conod2 has


been used as a guide to the preparation of
teeth for jacket crowns. In his article
Conod clearly illustrates the mechanical
principles that are significant in the de
velopment of a proper tooth form so that
the porcelain crown may be well sup
ported by the preparation. H e illustrates
how the preparation can be made so that
the porcelain will be subjected to com
pressive forces rather than to destructive
tensile forces during mastication.
Enough time must be allotted to the
patient so that the preparation may be
completed, the impressions taken and the
temporary crown placed at one appoint
ment. Brecker3 suggests that all prepara
tory cutting be done on any one tooth at
the same appointment. This is sound
practice because it prevents repeated
irritation to the pulp and the periodontal
tissues, and it certainly is much less ob
jectionable to the patient. Usually one
and a half hours is sufficient for the

2. Conod, H. Etude sur la statique de la couronne


aquette. Actualit Odontostom atologique, no. 14, 1951.
3. Brecker, S. C. The porcelain jacket crown. St.
Louis, C. V. M osby Co., 1951, p. 22.

Fig. 1 Cast. L e ft: P reoperative labial view. C en ter: T eeth prepared. R ig h t: W ax patterns of
proposed restorations

W A L T O N . . . V O L U M E 47, JU LY 1953 3

completion of the afore-mentioned steps


on a single tooth. Much less time, propor
tionately, will be required for the two
adjoining teeth.
Routine presedation of the patient with
a barbiturate of short duration, such as
secobarbital sodium, ^4 grain or 1f i
grains, will reduce apprehension and
make the patient more cooperative. The
depth of local anesthesia also will be
enhanced.
The assistant should have the armamen
tarium and materials prepared before
hand so that they may be available
quickly and without confusion. Her co
operation is important here and is in
valuable during operating procedure.
Effective local anesthesia for so long
a procedure may be obtained by the use
of 4 per cent procaine hydrochloride with
phenylephrine 1:2,500, or by 2 per cent
lidocaine hydrochloride with epinephrine
1:100,000. Our experience has been satis
factory with these more potent anes
thetics.
IN S TR U M E N TA TIO N

The following method is- suggested for


the preparation of an upper incisor tooth
in normal alignment.
Diamond disks and wheels are used to
reduce the major bulk of the tooth. Tepid
water is kept running over the instrument.
1. The outline of mesial and distal
slices are pencilled. These are cut with
a true-running % inch or /g inch flat
diamond disk. Proximal shoulders are
established with this instrument and the
shoulders are carried through to the
lingual angles.
2. The incisal angle is reduced with
a /% inch narrow diamond wheel, one
half being reduced at a time. I f the in
cisor is thin, it is not cut to the full depth
until after the labial and lingual enamel
is removed.
3. The important cuts are those which
reduce the four proximal line angles and
those which establish the shoulders at the

proximolabial and proximolingual angles


of the tooth. When there are two ad
joining sound teeth, these cuts are made
by a % inch or % inch cup-shaped true
diamond or vulcarbo disk. Considerable
water is poured over it. The inner edge
of the disk is used, beginning at the in
cisal edge and gradually cutting to the
shoulder area, so that the proximal line
angle of enamel may be removed easily
without touching the approximating
tooth. When use of this disk is mastered,
these difficult line angles may be cut
easily and the cutting of the shoulders
at the angles begun. For use on these
angles, the cup-shaped disk is preferable
to the small diameter, cylinder cutter
which is inefficient and which creates
heat. Figure 2 illustrates the use of the
cup-shaped disk. The object is to reduce
the enamel with as large an abrasive in
strument as can be used safely and one
which can, at the same time, be used to
begin the shoulders in these difficult areas.
This means, naturally, that the finger
rests and guards for teeth, lips and tongue
must be especially good.
4. Next the shoulder is established
(but not finished) around the entire
tooth. A thin diamond wheel of about
2.5 mm. diameter cuts the labial shoulder
to the dentin from the mesial to distal
angles. Then it is used to make the lingual
shoulder.
5. This same wheel is used to cut a
median groove in the labial enamel to
the incisal edge in order to establish the
depth of labial enamel to be removed.
6. One half of the labial enamel is
removed at a time with
inch or %
inch diameter diamond wheel (Fig. 3,
left). The cutting edge is held parallel
to the axis of the tooth. This is followed
by a
inch diamond wheel held in
the opposite direction (Fig. 3, right) to
remove the remaining collar of enamel
incisal to the shoulder groove.
7. The lingual enamel is removed by
the 54 inch diamond wheel, following the
contour of the surface. This is finished

4 T H E J O U R N A L O F T H E A M E R IC A N D EN T A L A S S O C IA T IO N

with a small barrel-shaped carborundum


wheel to prevent the formation of sharp
angles.
8. A Bastian shoulder cutting wheel is
used ( right-angle style held in the straight
handpiece) to raise the shoulder beneath
the free gingiva on the labial side.
9. A thin tapered cylinder mounted
point with square end, preferably an ex
tremely fine grit, is now used to hone all
the axial walls, to reduce sharp axial
angles and to straighten the shoulder.
10. A no. 600 plain fissure bur is
then used to sharpen the shoulder after
which it is filed with end-cutting Bastian
files.
11. The preparation is polished with
lubricated fine-grit paper disks.
IM PR E S S IO N M ETH O D

On completion, the prepared tooth


should be isolated and scrubbed carefully
with some mild antiseptic and obtundent.
The formula may be the one preferred
by the University o f Michigan (phenol,
1 part; creosote, 2 parts; eugenol, 3
parts), or it may be Blacks 1-2-3 solu
tion. The dentin is dried with cotton and
two or three thin coats of copal varnish
are applied. Desiccating agents such as
alcohol or other volatile irritants should
not be used for drying.
It has been found that while the tooth
is free of saliva, the operator can fit the
copper bands for the tube impressions
most satisfactorily. Fairly tight, well an
nealed copper seamless bands are used.
The bands are not selected for size until
after the preparation because they are
always found to be too large if selected
before the shoulder cutting is complete.
I f the band is contoured to the gingival
section of the tooth and is carried under
the lingual shoulder first and gradually
rotated forward, it will conform to the
proximal surfaces easily. Scribing can be
done in order to trim it to fit uniformly
beneath the gingival tissue.

The festooned band is beveled on its


outer gingival edge. The tube impression
is taken in graphite-impregnated wax for
an electro-formed copper die. This wax
has a low fusing point and may be
softened thoroughly in the band. The
band is pressed to position with a mini
mum of pressure on the open end. Just
enough pressure is created while seating
the band so that it will hold the wax in
the band. After the band is placed in its
proper position, it may be held at that
level by the fingers, and as cool water is
dropped on it, heavier pressure is applied
against the open end. The object is not
to force the edges deeply into the perio
dontal attachment and to prevent excess
impression material from extruding at
the gingival edge. In this way, minimum
irritation occurs.
For the transfer, or master impression,
it is best to take a duplicate tube im
pression in low-fusing inlay wax and pinch
the band so that the contacts of the ad
joining teeth are established against the
band. Plaster is the material preferred
for the transfer impression so that the
duplicate tube impression may be exactly
positioned and the die may be pressed
into it without fear of forcing it out of
position.
TEM PO R AR Y PROTECTION
OF T H E T O O TH

After impressions are complete, the


tooth is again isolated and the sedative
solution applied. A moderately stiff mix
of zinc oxide and eugenol cement is
spatulated into a small string of cotton
fibers for a gingival pack. After the tooth
is lubricated with petroleum jelly, this
little rope is packed into the shoulder
area against the gingival third of the cut
dentin. Silicate that has been mixed on
a cold slab is then molded over this to
tooth form with plastic instruments. The
silicate must not impinge against the
gingival tissue and any existing impinge
ment must be removed. In this manner

W A L T O N . . . V O L U M E 47, JU L Y 1953 5

Fig. 2
R eduction
of
proxim al angles. L e ft: Labial
view of cup-shaped disk cut
ting labioproximal
angle.
R ight: Incisal view of disk

Fig. 3 R edu ction of labial


surface. Large w heel used to
reduce bulk. R ig h t: Smaller
w heel used to rem ove re
maining collar of enamel

the tooth is carefully protected and no


irritating edges are forced against the
gingiva to injure it.
It is usual to allow several days to
elapse before the jacket crown is
cemented. This will help the pulp to re
cover from operative shock and the
gingiva to be less irritated.
SUM M ARY

During diagnosis and prophylactic treat


ment it is possible to estimate the
temperament of the patient and to estab
lish his confidence.
When repositioning of teeth is required,
it is helpful to prepare the teeth on a
duplicate study cast and build a mockup in wax. This will clarify the method
of procedure. The dentist then may cut
the preparations with a definite and
methodical plan in mind, working pre
cisely and without confusion.
The larger abrasive instruments are
used for the major enamel cutting. Each
cut requiring a particular instrument

should be completed before the next cut


is begun. The use of concave disks to
reduce the proximal angles and to cut
the shoulders in these difficult angles will
expedite and simplify the whole prepara
tion. This also will eliminate the heat
and trauma that can be produced so
easily when cutting with small cylindrical
instruments. The reduction of the
shoulder subgingivally is done principally
with wheel-shaped instruments, and the
shoulder is merely sharpened and finished
with steel burs. Sharp .line angles and
corners should be eliminated from the
axial surfaces so that internal tensions
are reduced in the porcelain crown.
Proper care of the cut dentin with a
sedative cement pack and a temporary
crown that does not impinge on the
gingiva and is not in traumatic occlusion
will eliminate most postoperative pain
and sensitivity. The gingiva will be kept
as nearly normal as possible so that
cementation of the permanent jacket
crown will be accomplished without the
interference of serum or hemorrhage.