Professional Documents
Culture Documents
IN BRIEF
● An introduction to the series on Crowns and other Extra-coronal Restorations
This series of articles is aimed at anybody who places crowns and other
extra-coronal restorations (ie veneers and adhesive onlays or ‘shims’) CONTENT OF THE SERIES
on individual teeth. We hope that everyone from experienced practi- A series of 13 Articles covering
tioners to undergraduate students may find something of value. The aim
the following:
of this series is to give guidance, based on available scientific evidence
where possible, towards the provision of high quality restorations. 1. Changing patterns and the
Treatment planning issues and materials choices feature at least as need for quality
strongly as technique description. 2. Materials considerations
We have concentrated on single tooth restorations, but all of the
3. Pre-operative assessment
principles described also apply to more complex multiple restorations,
including fixed bridges. However, we have not specifically covered 4. Endodontic considerations
replacement of missing teeth with bridges or implants. Replacement of 5. Jaw registration and
teeth involves consideration of a range of additional issues and treat- articulator selection
ment planning decisions, whilst an entirely different set of technical
rules are required for the consideration of implants. These will be left 6. Aesthetic control
for other authors to address. 7. Cores for teeth with vital
Where possible, we refer to published scientific evidence. Admitted- pulps
ly, randomly controlled clinical trials and systematic reviews are much 8. Preparations for full veneer
scarcer in dentistry than in medicine. Consequently, much evidence is
crowns
based on the experience of clinicians, or on laboratory or theoretical
considerations. This does not necessarily devalue existing practices, 9. Provisional restorations
but it does make it more difficult to make objective choices about treat- 10. Impression materials and
ment planning, materials or techniques. We have therefore tried to be technique
honest when our advice stems solely from experience or theory.
The series consists of 13 individual articles, each of which should be
11. Try-in and cementation of
able to stand alone. Each article will start with the specific learning crowns
objectives we hope to meet. In a series like this it is impossible to 12. Porcelain veneers
explore every technique or material ever described, this would make 13. Resin bonded metal
for very heavy reading and very dull writing. We hope though that restorations
these articles should enable the reader to evaluate his or her own prac-
tices against a set of fundamental principles.
Refereed Paper
© British Dental Journal 2002; 192: 143
1
IN BRIEF
● Crown provision has seen an enormous increase over the past three decades. In the UK
around 1 million teeth are fitted with crowns every year, many of these requiring complex
additional treatment prior to crown placement
● Around 15% of NHS dental spending annually is on crown provision and maintenance, so the
total cost is very large
● The pressures on dentists to produce high quality restorations is probably increasing and will
not diminish
● There are few data on the quality or longevity of restorations placed
● Technological advances have changed the way we are able to practice over recent decades,
and further developments will open up new possibilities
This series of articles is aimed at anybody who places crowns and other extra-coronal restorations (ie veneers and shims) on
individual teeth. We hope that everyone from experienced practitioners to undergraduate students may find something of
value. Whoever reads them, we would ask to do so with an open mind. We have tried not to be dogmatic, and the techniques
and materials described are not the only ones available, but are the ones which accord with the principles we describe.
Our aim in these articles is, by working from a possible, we have tried to support what we write
sound theoretical base, to try to give the reader the with appropriate previously published scientific
CROWNS AND EXTRA-CORONAL
RESTORATIONS: background to pick the best treatment options evidence, but good quality evidence is scarce
from the wide, and continuously changing, range and much of what has been written in the past is
1. Changing patterns and available. Technical issues are important and will based on the experience of clinicians, or on the-
the need for quality be addressed, but there is a need to recognise that oretical considerations. This does not necessarily
2. Materials considerations the provision of extra-coronal restorations is more devalue existing practices, but it does make it
3. Pre-operative than just cutting a shape which is free of under- more difficult to make objective choices about
assessment cuts, on to which something can be cemented. treatment planning, materials or techniques. We
Cutting a preparation and cementing a restoration have tried to identify where there is and where
4. Endodontic
are relatively easy. Cutting a preparation and
considerations
cementing a restoration which will last for many
5. Jaw registration and years without any further damage to the dental tis-
articulator selection sues is a different matter. Treatment planning
6. Aesthetic control issues and materials choices will occupy a greater
7. Cores for teeth with part of this series of articles than the technicalities
vital pulps of tooth preparation.
8. Preparations for full We have concentrated on single tooth
veneer crowns restorations, but all of the principles described
also apply to more complex multiple restora-
9. Provisional restorations
tions, including fixed bridges. However, we have
10. Impression materials and not specifically covered replacement of missing
technique teeth with bridges or implants. Replacement of
11. Try-in and cementation teeth involves consideration of a range of addi-
of crowns tional issues and treatment planning decisions,
12. Porcelain veneers whilst an entirely different set of technical rules
are required for the consideration of implants.
13. Resin bonded metal
These will be left for future authors to address.
restorations
In an ideal world we would have been able to
draw on the conclusions of full systematic
1*Senior Lecturer in Restorative Dentistry, reviews of the literature, based on randomised
2Senior Lecturer in Restorative Dentistry,
3Professor of Restorative Dentistry,
controlled clinical trials. Such an approach is
Department of Restorative Dentistry, widely used in many areas of medicine and
Fig. 1a and 1b. The provision of good quality crowns or
The Dental School, Framlington Place, allows objective assessment of the available
alternative adhesive restorations can result in a
Newcastle upon Tyne NE2 4BW techniques, drugs or materials. Few such reviews
*Correspondence to: J. G. Steele
tremendous improvement in oral health for the patient as
E-mail: jimmy.steele@ncl.ac.uk
are available in this area of dentistry though, well as being a fulfilling experience for the dentist.
probably because the raw material from which Despite being a relatively minor procedure, this patient’s
Refereed Paper they are derived, namely randomised controlled aesthetics and confidence were improved enormously by
© British Dental Journal 2002; 192: the provision of these anterior dentine bonded crowns
clinical trials, are themselves so sparse. Where
144–148
Fig. 2 A series of radiographs taken over a five year period showing how the provision of crowns can be detrimental to oral health where the treatment is ill
thought out and, in this case, poorly executed. This is a graphic illustration of ‘the need for quality’
Fig. 2d A decision is made to progress to overdentures Fig. 2e Periodontal attachment loss and periapical pathology
render overdenture abutments useless
Quality issues
Despite the vast number of crowns placed and
the need for high quality, we know very little
indeed about the performance of these restora-
tions. Even simple data on the longevity of
crowns, and the rate of loss or replacement are
limited. Research findings are often difficult to
interpret because of variability in the selection
criteria and treatment techniques used. Certainly,
the number of crowns which are dislodged and
require to be recemented is large in the UK; well
over half a million crowns are recemented every
year under the NHS. This figure rose rapidly in
the 1980s and 90s reflecting the increase in
overall crown provision(Fig. 4).1–5 But, crowns
which fall out are only one manifestation of fail-
ure. Others include those which become carious,
periodontally compromised or in which the
pulps become inflamed or necrotic as a result of
the treatment provided. Evidence for the long-
term effects of crown preparation on vital teeth
is very sparse indeed. There are estimates of the
damage to pulp vitality which occurs following
tooth reduction for crowns and bridges. This Fig. 6a and 6b Adhesive dentistry has much to commend it.
indicates that anything from 1–15% of teeth lose Contrast the destructive preparation for conventional
vitality after preparation, with two of the three porcelain fused to metal restoration (4a) with the much
studies cited here approaching the higher end of more conservative preparation for a porcelain veneer (4b)
2
IN BRIEF
● Familiarisation with the broad spectrum of contemporary materials allowing better-informed
decisions to be made
● Discovering the factors that influence choice of alloys for indirect metallic restorations
● Knowing the pitfalls of selecting a cheap alloy for cast post and core construction
● Familiarisation with the different types of all ceramic crown and which ones can be used
posteriorly
● An awareness of the many different types of metal copings for ceramo-metal restorations
● Consideration of the use of composite crowns for specific clinical situations
Materials selection is the second in the series on crowns and other extra-coronal restorations. Some of us are less than
inspired by dental materials science. Nevertheless, many of the things that concern us clinically with crowns and their
alternatives are based on material properties. We worry about the strength of the restoration, how well it fits and its
aesthetics. We also worry about wear, occlusal control and biocompatibility. Not least of our concerns are dental laboratory
charges, which inevitably have to be passed on to the patient.
lower kinetic energy during casting which in Itasca, USA). A worrying trend, however, is for
GOLD AND PALLADIUM turn reduces the penetration of molten metal some laboratories to substitute a precious metal
ALLOYS KEY POINTS: into the mould. Nevertheless, some authorities instead of nickel chromium without telling the
• Porous castings can argue that with ideal conditions almost all dentist. Clearly, this could reduce the expected
result from reused commercial alloys result in acceptable cast- bond strength.10
casting buttons ings,3 but experience indicates that technicians Leaving aside health concerns for a moment,
may find such conditions difficult to achieve. nickel chromium alloys are not without prob-
• Some alloys — especially
Tarnishing of some alloys is noticeable in lems. Casting conditions need to be carefully
those of low noble certain patients, particularly around the mar- controlled to obtain well fitting restorations
metal content — are gins of their restorations. This observation is and any technician will tell you that these
prone to corrosion born out by a five-year clinical study compar- alloys are hard to adjust and difficult to finish.
• The potential for ing two palladium silver alloys to a type III gold This in turn can be a nuisance clinically when
cheap alloys to cause alloy.4 In the UK the National Health Service fitting restorations.
lichenoid reactions is has encouraged the use of alloys containing Experience of use differs markedly from
currently not known only 30% gold. The potential for corrosion country to country. In the USA these alloys have
but needs to be kept in problems to result from this change is currently had a relatively good press12,13 and are used for
mind unknown. casting crowns and bridges by the majority of
Allergies to gold, palladium and platinum laboratories.9 In the UK these alloys account for
are extremely rare.5 In-vitro studies6 show that only 1% of the crowns provided on the National
high gold alloys have excellent corrosion Health Service. In Sweden, the National Board of
resistance, which implies that few metal ions Health and Welfare has warned against the use of
are eluted from restorations. Metal ions are alloys containing more than 1% nickel,9 effec-
eluted more easily from alloys of low noble tively precluding nickel-chromium alloys as they
metal content, including those of copper and all contain between 62 and 82% nickel.14
silver. Copper ions have been implicated in The health problems are worth exploring in
producing lichenoid reactions.7 However, more detail. Many laboratories use non-beryl-
lichenoid reactions to metal ions from crowns lium containing nickel chromium alloys, as
are not as well described as for amalgam where beryllium grindings and casting fumes are
many lichen planus series show up to a third of extremely hazardous unless controlled by an
patients to be sensitive to mercury salts.8 This adequate exhaust and filtration system. Acute
raises the possibility that some cases of lichen problems include conjunctivitis, dermatitis
planus adjacent to crowns may be linked to the and bronchitis. Chronic beryllium disease may
underlying amalgam core. Nevertheless, with not express itself for several years after expo-
current trends to use more easily corrodible sure.9 Similarly, nickel can cause technicians
casting alloys we should be alert to the possi- dermatological and lung problems with
BASE METAL ALLOYS bility of more lichen reactions in the future. high levels of nickel or nickel compounds
KEY POINTS: being carcinogenic. Tumours include rhab-
• Ni-Cr alloys are Base metal alloys domyosarcoma, nasopharyngeal and lung
popular in the USA but Base metal alloys used to make indirect restora- carcinomas. Again an effective exhaust sys-
tions include: tem is needed to keep concentrations below
are effectively banned
• Nickel-chromium recommended levels (Table 1). These levels
in Sweden vary from country to country, but if you are
• Nickel-chromium-beryllium
• A good bond strength fitting nickel chromium restorations you
• Titanium
can be achieved • ‘Progold’ should ensure adequate aspiration during
between certain adjustments.
Ni-Cr alloys and Nickel-chromium alloys Nickel is well known to cause contact der-
The most commonly used base alloys are nickel- matitis. Current estimates show that between
resin luting agents
chromium and nickel-chromium-beryllium. 10–20% of women and 1–2% of men are sensi-
• Ni-Cr alloys are stiffer Beryllium is added to improve the alloy’s physi- tised to the metal, possibly as a result of wearing
than most noble alloys cal properties; it is used as a hardener, grain nickel containing jewellery.15 Surprisingly, there
and can therefore be structure refiner and to reduce the alloy’s fusion have been few reports of patients reacting
used in slightly thinner temperature.9 As a result of health concerns (see adversely to nickel containing dental restora-
section below) some alloys contain molybdenum tions and little evidence that nickel adsorption
instead of beryllium.10 All of these alloys have a intra-orally exacerbates existing dermatitis.
• Technicians and higher modulus of elasticity than noble alloys. Nevertheless, there are authorities that counsel
dentists must avoid This means that they are more rigid which is dentists against using nickel in those patients
inhaling Ni-Cr helpful in preventing flexion of long span known to be sensitive to the metal.5,14
casting fumes or grind- bridges. Rigidity in thin section is necessary for
ing dust especially if adhesive bridge frameworks and for adhesively Table 1 Nickel and beryllium are toxic. In the UK
retained shims used to restore the palatal sur- maximum permitted air levels (in µg.m-3) of nickel for
the alloy contains
faces of worn incisors. It is also possible with an eight-hour shift have recently been reduced five
beryllium selected resin adhesives to obtain high bond fold78 but are still over six times higher than in the USA9
• In patients sensitive to strengths to the surface of the sandblasted alloy. UK USA
nickel it is best to avoid For instance Nery et al.11 reported a bond Beryllium 2 2
using Ni-Cr alloys strength of 22 Mpa for a nickel chromium alloy Nickel 100 15
bonded to dentine with All Bond 2 (Bisco Inc,
Methods of making indirect porcelain introduced in the UK, which also relies on hav-
ALL CERAMIC restorations ing a glass infused core. The core is built of small
‘splats’ of alumina sprayed from a plasma gun at
RESTORATIONS
Sintered porcelains a rotating refractory die. Again, after glass infu-
KEY POINTS: Sintered porcelains are built up from an aque- sion, the restoration is formed conventionally on
• Ceramics are ous slurry of porcelain particles condensed the core with a matched sintered porcelain. The
considered inert onto a platinum foil matrix or a refractory die. company claim a flexural strength as high as for
but can be attacked Sintering occurs at a temperature above the In-Ceram.
by APF gel softening point of porcelain whereby the glassy
• Ceramics are strength- matrix partially melts and the powder particles Cast glass ceramics
ened by the dispersion coalesce. There is volume shrinkage of Glass ceramics are polycrystalline solids pre-
of a crystalline phase 30–40%. Porosity can be reduced from 5.6 to pared by the controlled crystallisation of glasses.
through a glassy matrix 0.56% by vacuum firing.23 Sintering is the The best known of these systems, Dicor, is based
• Ceramics can be most commonly used technique of making on mica crystals although there is another, Cera-
PJCs and veneer restorations with a number of pearl, based on hydroxyapatite and experimen-
classified according to
different materials available: tal lithia-based materials.24 A Dicor restoration
fusion temperature and is made by investing a wax pattern and casting.
mode of manufacture • Aluminous porcelain eg Vitadur-N, Hi-Ceram
• Feldspathic porcelain reinforced with Zirconia Heating the reinvested crown for six hours at
• Ceramic systems 1070°C carries out controlled crystallisation,
fibres eg Mirage II
cannot be evaluated on • Feldspathic porcelain reinforced with leucite termed ‘ceraming’. This causes the Mica to form a
strength data alone eg Optec HSP strong ‘house of cards’ structure, which makes
• In-Ceram and Procera fracture propagation equally difficult in all
Allceram are suitable Glass infused ceramics directions. However, a reaction between the
for posterior crowns In-Ceram is a glass infused ceramic used for mica and the surrounding investment may result
based on long-term crowns (Fig. 2). It consists of a core containing in a weakened surface layer, which reduces sig-
clinical evaluation 90% alumina, which is built up on a refractory nificantly the overall strength of the material.25
die. During firing, at 1150°C for four hours, the Characterisation of the crown is achieved by sur-
• Resin bonding of
die shrinks so that it can be withdrawn from the face glaze. Prior to glazing the material has the
In-Ceram requires core. This process (which is also used to manu- appearance of frosted glass.
specific silanisation facture ceramic lavatory pans) is called ‘slip- To overcome the limitations of surface glaze,
techniques casting’. At this stage the core is a weak, porous which are considered in more detail later, a tech-
structure consisting of partially sintered alumi- nique of laminating a Dicor coping with felds-
na particles. Strength is conferred by painting a pathic porcelain has been developed with the
slurry of lanthanum containing glass onto the intriguing name ‘Willi’s Glass’.26 Providing the
outside of the core and refiring it. During refir- correct porcelain (Dicor Plus) is used for lamina-
ing the molten glass is drawn into the porous tion, the strength of the restoration should not
structure thus eliminating voids and creating a be adversely affected.27
glass-ceramic composite. The excess glass is
ground away and porcelain with a matched Hot pressed, injection moulded ceramics
coefficient of thermal expansion is built onto the IPS Empress is a leucite containing porcelain. As
surface. The manufacturers recommend that with cast glass ceramics the restoration is first
restorations be cemented with conventional acid waxed-up and invested, however the ingot,
base cements. which is made of sintered ceramic, is not molten
but softened before being pressed into a mould
under pressure at 1150°C (Fig. 3). The pressure is
maintained for 20 minutes during which time
the tetragonal leucite crystals are dispersed
throughout the restoration giving a 40% con-
centration by volume. The shade of the ingot
provides the basic shade, which can be modified
by either glazing or veneer porcelains. To ensure
compatibility with veneer porcelains the ingots
have a lower coefficient of thermal expansion
(14.9 x 10-6/°C) than those for the glazed materi-
al (18 x 10-6/°C). The application of veneer
Fig. 2 In-Ceram glass infused alumina cores prior to porcelains may require multiple firings that can
porcelain application (Courtesy of Vita) enhance the strength of the material.28
Another material, less well known in the UK
is Alceram, which is based on magnesium spin-
In-Ceram Spinnel is a similar type of material nel. It is important to emphasise that this is a
but uses the less hard magnesium spinnel quite different material to the much stronger
(MgAl2O4) instead of alumina. The material is Procera AllCeram which is mentioned later.
specifically designed for inlays and onlays. Most
recently introduced is In-Ceram Zirconia, which Machined glass ceramics
has a very high flexural strength. There are a number of milling systems available
A novel material called Techceram has been for milling ceramic blanks,29 which may be con-
Are all ceramic bridges possible? Some of the alloys already considered under
It is possible to make small anterior bridges with ‘all metal restorations’ can be used for metal- METAL-CERAMIC
most of these systems, but with the exception of ceramic copings. These include nickel chromi-
RESTORATIONS
Vita’s In-Ceram few manufacturers actively pro- um, nickel chromium beryllium, silver palladi-
mote this because of the risk of fracture, espe- um alloys and titanium. KEY POINTS:
cially at the connectors. The Procera AllCeram Control of the oxide layer thickness is impor- • High palladium low
specifies a minimum connector height of 3 mm tant to avoid problems of porcelain debonding. gold alloys have
and a maximum span of 11 mm. Clinical studies Some silver palladium alloys can cause a green- significant advantages
are underway but long-term results are not yet ish hue to appear due to diffusion of silver com- over high gold alloys
available. pounds into the porcelain. Titanium oxidises where rigidity is needed
easily and a thick nonadherent oxide layer can • Oxides of gallium,
Cost? form under regular feldspathic porcelains. Thus indium and tin are used
The cost of high strength ceramic restorations low fusing porcelains (eg Procera or Duceratin) to promote adhesion of
such as In-Ceram, AllCeram and Empress will are used to avoid problems of the oxide layer alloy to ceramic
take into account a laboratory’s investment in compromising strength.64 Porcelain bond
• Too thick an oxide layer
new equipment and training as well the time strengths to titanium are in any case not as high
taken to make a restoration. In the UK, high as with other alloys which may explain the high- can result in ceramic
strength ceramic crowns are up to £40 to £60 er risk of metal-ceramic failure seen in a 6-year debonding or
more expensive than an aluminous PJC. These clinical follow-up.65 discolouration
materials can be used on the National Health Low fusing ‘hydrothermal’ porcelains (Duc- • A metal occlusal
Service but not without prior approval. If eram, Duceragold) can also be fused to type IV surface can be incorpo-
approved, a discretionary fee is awarded which gold in what is known charmingly as the ‘Gold- rated in a cast coping
in most cases will not cover the laboratory bill. en Gate System’. Once again control of the but not in foil copings
oxide layer is crucial for achieving bonding • Foil copings are not
METAL-CERAMIC RESTORATIONS and good aesthetics.66 Aesthetics are improved strong enough for
Stress concentrations within PJCs often lead to by the underlying gold shining through the posterior restorations
cracks propagating outwards from the fit surface porcelain. The major perceived advantage of
• Metal composite
of the restoration. A comparatively tough metal this system is the potential to limit the number
coping effectively bonded to the ceramic will of different alloys used in a patient’s mouth. copings (Captek) are a
help stop cracks developing in this way. The first Cast copings are the most commonly used promising alternative
metal copings were cast but other methods of method of strengthening porcelain and have to cast copings where
coping construction, including foil and metal served us well, but consistently good aesthetics the occlusion is to be
composite copings, have since been developed. are difficult to achieve because the metal has to built in porcelain
be covered by an opaque layer which in turn • Electroformed copings
Cast copings limits the thickness of an adequate overlying are an interesting but
Porcelain fused to metal (metal-ceramic) tech- layer of porcelain. However, proper tooth reduc- unproven technology
nology was first described in 195662 and patent- tion and excellent technical support will largely • Surface treatment of
ed in 1962.63 Alloys were produced with melting overcome this problem. the ceramic by ion
points sufficiently high to resist the firing of One of the main advantages of cast copings is
exchange gives only
porcelain. The first alloys had a high noble metal that the coping can be waxed to create a metal
content of around 98% with iron, indium and tin occlusal surface — a facility that is either absent limited strengthening
used for hardening, and to create a superficial or more difficult to achieve in the following two
oxide layer to which the ceramic could be bond- systems.
ed. The ceramic had to be specially formulated to
have a high coefficient of thermal contraction to Foil copings
prevent unwanted stresses being built up In 1976 McClean 67 reported a technique of fus-
between it and the coping on cooling after fir- ing platinum foil to the fit surface of an alumi-
ing. This was achieved with a ceramic contain- nous PJC. The foil was made adhesive to the
ing 15–25 vol% leucite as its crystalline phase. porcelain by electroplating with tin and subse-
With such a high gold content the original quent oxidisation. The crown was made using
alloys were extremely expensive, resulting in two layers of foil with the first layer being
many laboratories preferring high palladium removed after firing.68 Any improvements in
low gold alloys – although paradoxically, palla- compressive strength are controversial with
dium prices have recently been so high that the some reports showing a positive effect and oth-
high gold alloys are sometimes the more afford- ers negative.69 Such differences are explained by
able alternative! High palladium alloys have the variations in test methodology. Other foils have
advantage of having a high modulus of elastici- been tried with aluminous porcelain including
ty and are therefore more rigid allowing slightly palladium70 and gold coated platinum.71,72 More
thinner copings to be made. This rigidity is par- recently a gold foil reinforced crown has been
ticularly useful in bridgework where flexion of introduced.73 The foil of this ‘Sunrise Crown’ is
the pontics under load can result in fracture of 50 µm thick and contains gold, platinum and an
the overlying porcelain. The alloy used by our oxidising element designed to facilitate porce-
dental hospital contains 78.5% Pa, 6.9% Cu, lain bonding. Unlike platinum foil, the gold
5.5% Ga, 4.5% In, 2% Sn, 2% Au. Other alloys alloy has too high a coefficient of thermal
also contain either gallium or indium or both to expansion to be used with aluminous porcelain.
promote chemical bonding to the porcelain.10 Standard metal-ceramic porcelains are used
a b
c d
Fig. 6 Schematic diagram showing how a Captek core is laid down as gold alloy impregnated wax
sheets: a) the granular appearance of Captek W after the first wax layer has been burnt off;
b) application of the second wax layer (Captek G); c) perfusion of the Captek W by the Captek G
during the second firing; and d) the resulting composite metal structure after firing (Courtesy of
Schottlander).
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36. Wagner W, Chu T. Biaxial flexural strength and indentation titanium and palladium-copper alloy. J Prosthet Dent 1995;
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1996; 76: 140-141. 65. Walter M, Reppel P D, Boning K, Freesmeyer W B. Six-year
37. Brunton P A, Smith P, McCord J F, Wilson N H F. Procera all- follow-up of titanium and high-gold porcelain-fused-to-
ceramic crowns: a new approach to an old problem. Br Dent J metal fixed partial dentures. J Oral Rehabil 1999; 26: 91-96.
1999; 186: 430-434. 66. Mattmuller A, Wassmann J, Biffar R. Hydrothermal ceramic
38. ISO. International standard 6872-1984. Dental Ceramic. 1st for porcelain-fused- to-metal crowns: an initial experience
ed.pp.1-14. Geneva, Switzerland: International Organisation report from clinical practice. Quintessence Int 1996; 27:
for Standardization, 1984. 521-526.
39. Ban S, Anusavice K J. Influence of test method on failure 67. McClean J, Sced I. The bonded alumina crown. 1. The bonding
stress of brittle dental materials. J Dent Res 1990; 69: of platinum to aluminous dental porcelain using tin oxide
1791-1799. coatings. Aust Dent J 1976; 21: 119-127.
40. McClean J, Jeansonne E, Chiche G, Pinault A. All ceramic 68. McClean J, Kedge M, Hubbard J. The bonded alumina crown.
crowns and foil crowns. In: Chiche G, Pinault A, editors. 2. Construction using the twin foil technique. Aust Dent J
Esthetics of anterior fixed prosthodontics. pp.97-113. 1976; 21: 262-263.
Chicago: Quintessence Publishing Co., Inc., 1994. 69. Philp G, Brukl C. Compressive strengths of conventional, twin
41. Brandson S J, King P A. The impact fracture resistance of foil, and all-ceramic crowns. J Prosthet Dent 1984; 52:
restored endodontically treated anterior teeth. J Dent Res 215-220.
1992; 72: 1141. 70. Piddock V, Marquis P, Wilson H. Comparison of the strengths
42. Madani M, Chu F C, McDonald A V, Smales R J. Effects of of aluminous porcelain fired onto platinum and palladium
surface treatments on shear bond strengths between a resin foils. J Oral Rehabil 1991; 13: 31-37.
cement and an alumina core. J Prosthet Dent 2000; 83: 71. Southan D. Defects in porcelain at the porcelain-to-metal
644-647. interface. In: Yamada H, Grenoble P, editors. Dental porcelain:
43. Blixt M, Adamczak E, Linden L A, Oden A, Arvidson K. Bonding the state of the art -1977. pp.48-49. Los Angeles: University
to densely sintered alumina surfaces: effect of sandblasting of Southern California, 1977.
and silica coating on shear bond strength of luting cements. 72. Hopkins K. A method of strengthening aluminous porcelain
Int J Prosthodont 2000; 13: 221-226. jacket crowns. Br Dent J 1981; 151: 225-227.
44. Karlsson S. The fit of Procera titanium crowns. Acta Odontol 73. Hummert T, Barghi N, Berry T. Effect of fitting adjustments on
Scand 1993; 51: 129-134. compressive strength of a new foil crown system. J Prosthet
45. McClean J W, von Fraunhofer J A. The estimation of cement Dent 1991; 66: 177-180.
film thickness by an in vivo technique. Br Dent J 1971; 131: 74. Hummert T, Barghi N, Berry T. Postcementation marginal fit
107-111. of a new ceramic foil crown system. J Prosthet Dent 1992;
46. Christensen G J. Marginal fit of gold inlay castings. J Prosthet 68: 766-770.
Dent 1966; 16: 297-305. 75. Shoher I, Whiteman A. Captek - A new capillary casting
47. White S N, Kipnis V. Influence of marginal opening on technology for ceramometal restorations. Quintessence Dent
microleakage of cemented artificial crowns. J Prosthet Dent Tech 1995; 18: 9-20.
1994; 71: 257-264. 76. Giordano R A, Campbell S, Pober R. Flexural strength of
48. Björn AL, Björn H, Grkovik B. Marginal fit of restorations and feldspathic porcelain treated with ion exchange, overglaze,
its relation to periodontal bone level. Odont Rev 1970; 21: and polishing. J Prosthet Dent 1994; 71: 468-472.
337-346. 77. Burke F, Watts D, Wilson N, Wilson M. Current status and
49. 147/242. PoCN, Morris H F. Department of Veterans Affairs rationale for composite inlays and onlays. Br Dent J 1991;
Cooperative Studies Project No. 242. Quantitative and 170: 269-273.
qualitative evaluation of cast ceramic, porcelain-shoulder, 78. EH40/97. Occupational exposure limits 1997 for use with The
and cast metal full crown margins. J Prosthet Dent 1992; 67: Control of Substances Hazardous to Health Regulations
198-203. 1994. pp.14-17. Sudbury: HSE Books, 1997.
50. Holmes R J, Sulik W D, Holland G A, Bayne S C. Marginal fit of 79. Seghi R, Daher T, Caputo A. Relative flexural strength of
castable ceramic crowns. J Prosthet Dent 1992; 67: 594-599. dental restorative ceramics. Dent Mater 1990; 6: 181-184.
51. Castellani D, Baccetti T, Clauser C, Bernadini U D. Thermal 80. Seghi R, Sorensen J. Relative flexural strength of six new
distortion of different materials in crown construction. J ceramic materials. Int J Prosthodont 1995; 8: 239-246.
Prosthet Dent 1994; 72: 360-366. 81. Wohlwend A, Strub J, Scharer P. Metal ceramic and all
52. Shearer B, Gough M B, Setchell D J. Influence of marginal porcelain restorations: current considerations. Int J
configuration and porcelain addition on the fit of In-Ceram Prosthodont 1989; 2: 13-26.
Considerations when planning treatment is the third in the series of crowns and other extra-coronal restorations. Articles or
chapters on treatment planning in restorative dentistry can make pretty dry reading, often built around a list of factors that
might influence your decision-making. In truth though, planning and placing crowns or other extra-coronal restorations
cannot be distilled into a series of lists. The decision-making involved requires experience, subtle understanding and a flexible
approach, none of which come easily.
CASE 1
In 1989 this patient had all of her
lower teeth crowned.
Two years later there was evidence
of caries around the margins of sev-
eral of them (Fig. 1).
A further decision was made to root
treat all of the teeth, initially with a Fig. 1
view to restoring them with crowns
and this treatment was started a short
time later, initially leaving the crowns
in place (Fig. 2).
The root treatments were under-
taken, but within a year they began
to fail because, among many other
reasons, it was proving very difficult to
ensure a coronal seal (Fig. 3), in fact it
is doubtful whether this biological
pre-requisite to successful endodontics
Fig. 2
had been considered at all.
As no progress was being made
(things were actually getting worse),
the decision was made to revert to an
overdenture (Fig. 4).
Within another year even the over-
denture abutments became mobile
and infected (Fig. 5) and in the end
they too were removed, leaving the
patient with a denture which she
could not wear. Fig. 3
The end result, a further 2 years
down the line, was the placement of
four implants and a very successful
lower implant retained fixed pros-
thesis (Fig. 6).
The whole case cost several thou-
sand pounds to manage, much of
which was used to provide treatment
which soon failed.
Fig. 4
Fig. 5
Fig. 6
CASE 2
This 18-year-old female patient
attended Newcastle Dental
Hospital requesting treatment to
improve the appearance of her
upper anterior teeth which were
chipped as a result of trauma with
UL1 (21) having been root filled
and discoloured (Fig. 8). She was
placed on a waiting list for con-
servative management involving
the provision of a labial porcelain
veneer to UL1 (21) and incisal
composite restorations to UR1 (11), Fig. 8
UR2 (12) and UL2 (22).
Inevitable delays with treatment
at the Dental Hospital led to the
patient seeking treatment else-
where. She did, however, return to
the Dental Hospital some 5 years
later with PJCs of poor quality on all
the upper anterior teeth and irre-
versible pulpitis in UR2 (12) and
UL2 (22) (Fig. 9). A further treat-
ment plan was formulated involving
endodontics to UR2 (12) and
UL2 (22) followed by replacement
crowns for the upper anterior teeth.
Once again, Dental Hospital waiting
lists resulted in the patient obtain- Fig. 9
ing treatment elsewhere. A further
8 years later, she was referred back
to the Dental Hospital by her latest
dentist who was suitably horrified
by what he found! The results of 13
years of treatment were six poor
crowns with carious margins,
unrootfilled or inadequately root-
filled teeth, short or perforating
posts and several teeth of very
doubtful prognosis (Fig. 10). In sum-
mary, an unnecessarily mutilated
dentition.
Fortunately, remedial treat-
ment from her own dentist was Fig. 10
possible in this case and the result
is much better than could have
been hoped for initially (Fig. 11).
This is also a very good illustration
of what can be achieved in the
General Dental Services under
ideal circumstances although it is
important to note that the treat-
ment required a further 17 visits
over a 9-month period, including
two surgical procedures, and the
longevity of the restorations
remains unpredictable.
Fig. 11
plan treatment and pick up a handpiece. Suc- are key elements in the treatment planning
cess with crowns and other extra-coronal process as is the importance of minimising fur-
restorations depends on many interacting fac- ther damage to the dentition and reducing the
tors; technical issues related to tooth prepara- risk of disease in the future. These essential fac-
tion, the relationship with the pulp and peri- tors could perhaps be summarised in one over-
odontal tissues and occlusion have been riding question before embarking on a course of
introduced and will be covered in greater detail treatment : ‘will this patient’s oral health be bet-
later in this series. However, the emphasis has ter off when I have finished?’. If there are any
been on planning for the future rather than pro- doubts about the answer to this question, the
viding a short-term fix for single teeth in isola- plan should be modified and an alternative
tion. The needs and expectations of the patient approach considered.
1. Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, 5. Steele J G, Sheiham A, Marcenes W, Fay N, Walls A W 9. Dummer P M H. The quality of root canal treatment
Nunn J, Pine C, Pitts N, Treasure E, White D. Adult G. Clinical behavioural risk indicators for root caries in provided by General dental Services working within the
Dental Health Survey: Oral Health in the United older people. Gerodontol 2001; 18: 95-101. general dental services of England and Wales. Part 2.
Kingdom in 1998. (2000) London: TSO. 6. Steele J G, Walls A W G, Murray J J. Partial dentures as Dent Profile 1998; 19: 8-10.
2. Saunders W P, Saunders E M. Prevalence of periapical an independent indicator of root caries risk in a group 10. Gough M B, Setchell D J. A retrospective study of 50
pathoses associated with crowned teeth in a Scottish of older adults. Gerodontol 1998; 14: 67-74. treatments using an appliance to produce localised
sub-population. Br Dent J 1998; 185: 137-140. 7. Locker D. Incidence of root caries in an older occlusal space by relative axial tooth movement.
3. Valderhaug A, Jokstad, Ambjornsen E, Norheim P W. Canadian Population. Comm Dent Oral Epidemiol Br Dent J 1999; 187: 134-139.
Assessment of the periapical and clinical status of 1996; 24: 403-407. 11. Dyer K, Ibbetson R, Grey N. A question of space:
crowned teeth over 25 years. J Dent 1997; 25: 97-105. 8. Dummer P M H. The quality of root canal treatment Options for the restorative management of worn
4. Bergenholtz G. Iatrogenic injury to the pulp in dental provided by General dental Services working within teeth. Dent Update 2001; 28: 118-123.
procedures: Aspects of pathogenesis, management the general dental services of England and Wales.
and preventive measures. Int Dent J 1991; 41: Part 1. Dent Profile 1997; 17: 1-5.
99-110.
Endodontic considerations is the fourth in the series on crowns and other extra-coronal restorations. This article focuses
strongly on contemporary biological principles, and is not intended to provide a comprehensive review of commercially
available materials and techniques. Principles are illustrated in a variety of clinical case scenarios.
CROWNS AND EXTRA-CORONAL Crowns should not be made without considera- opens a multitude of dentinal tubules that com-
RESTORATIONS: tion of the teeth which lay the foundations for municate directly with the pulp. The deeper the
1. Changing patterns and them. In this article, important principles are dentine is cut, the more permeable it is,3 and the
the need for quality outlined for the assessment of root-treated and more vulnerable the pulp becomes to chemical,
2. Materials considerations non root-treated teeth before crowning, avoid- physical and microbial irritants. The microbial
3. Pre-operative ing endodontic complications during crown fab- threat presented by the oral flora is by far the
assessment rication, and special considerations in the tem- most serious, and is capable of heralding intense
4. Endodontic porisation and restoration of root-treated teeth. inflammatory changes, with micro-abscess for-
considerations mation and progressive pulpal necrosis.4,5
5. Jaw registration and Pulp morbidity in crowned teeth Although the pulp shows considerable
articulator selection Dental pulp is the highly vascular, richly inner- resilience and is often capable of recovering
6. Aesthetic control vated soft tissue structure whose principal role is from irritation, the injuries induced can become
7. Cores for teeth with tooth formation. But even after teeth are erupted significant in the long term.5 Scarring as a
vital pulps into the mouth and fully formed, the dental pulp result of inflammation and repair interferes
is not a redundant organ. Pulp tissue retains the with the nervous and vascular supply to the
8. Preparations for full
important function of supporting its secretory tissue6 and jeopardises its resistance to further
veneer crowns
odontoblasts which lay down reparative dentine insult. It is important in this respect to recog-
9. Provisional restorations
in defensive response to dental injuries through- nise that crowns are rarely made for pristine,
10. Impression materials and out life. There is also some evidence that the pulp intact teeth. Rather, they are made to protect
technique may be involved in a pressure-receptive func- and restore teeth which have been damaged by
11. Try-in and cementation tion, limiting the possibility of damaging func- wear, trauma, or cycles of caries and repair.
of crowns tional overload on teeth.1 After a lifetime of cumulative insult, crown
12. Porcelain veneers If this were not sufficient justification to pre- preparation can be the final straw, bringing
13. Resin bonded metal serve healthy pulps, then the desire to do pulpal breakdown (Fig. 1a), and the need for
restorations patients no harm and to avoid the pain, swelling root canal treatment.7
and suffering which often accompanies the It is uncertain how many teeth lose vitality as
1Senior Lecturer,
2Professor,
injury and demise of a pulp surely must be. a direct consequence of crown preparation.
3Senior Lecturer in Restorative Dentistry, An insulating coverage of dentine and an Bergenholtz and Nyman’s8 much quoted study
Department of Restorative Dentistry, impervious layer of enamel protect the pulps of showed that 9% of crowned teeth, compared
The Dental School, Framlington Place, healthy, intact teeth from injury. Crown prepara- with only 2% of uncrowned controls lost vitality
Newcastle upon Tyne NE2 4BW
*Correspondence to: Dr J. M. Whitworth
tion places the pulp at risk in a number of ways. during long-term review. None of this was
E-mail: j.m.whitworth@ncl.ac.uk High speed stripping of hard tissue poses the attributable to caries or other obvious causes,
threat of pulpal overheating, with disturbance of but the crowned teeth in this study did have
Refereed Paper microcirculation, vascular stasis, thrombosis, advanced periodontal destruction, and were
© British Dental Journal 2002; 192:
315–327 reduced blood flow and internal bleeding.2 It also involved in extensive, cross-arch bridgework.
Buccal
Fig. 2a Overcut and misdirected access through a crown grossly weakens the
vertical walls of the preparation
Fig. 2b Disorientated by the presence of a crown which had modestly realigned the
tooth, the access cavity into this lower molar completely bypassed the pulp chamber to
the mesial and lingual. There were no less than five separate perforations
openings (Fig. 2a). Catastrophic errors such as involved teeth may be tender to biting pressure
perforation are also possible (Fig. 2b). or gentle percussion.
Of equal importance is the damage that can
be done to patient confidence and trust if a Special tests
recently crowned tooth becomes troublesome Characteristically, pulpal symptoms are diffi-
and has to be accessed or the restoration cult for patients to localise, and require sys-
removed for endodontic treatment.16 As the tematic provocation and reproduction to iden-
complexity of the crown and bridgework tify the offending tooth with certainty. If
increases, so the consequences become more sensitivity is reported to hot or cold, the teeth
serious. Replacing a single crown damaged should be challenged with that stimulus. Cold
during access is one matter; replacing a large can be applied with an ethyl chloride soaked
bridge which has suffered irreparable damage cotton pledget, though ice sticks or proprietary
to one of its abutments is quite another. refrigerants such as Endo-Frost (Reoko) can
It is certain that a small number of teeth will give a more profound cold challenge to stimu-
always develop unexpected endodontic prob- late the pulps of old or heavily restored teeth.
lems after crowning,11 but it is also certain that Heat can be applied with a stick of warm gutta
many such instances can be avoided by careful percha ‘temporary stopping’, taking care to
preoperative workup. coat the tooth first with petroleum jelly to pre-
vent the hot material from adhering. Electronic
PREVENTATIVE ENDONDONTICS — AVOIDING touch and heat instruments used in thermo-
THE AVOIDABLE plastic gutta percha filling techniques can also
All teeth scheduled to be crowned, whether they be used to deliver a known and reproducible
are presumed to have healthy pulps or previous- thermal challenge.
ly root-treated should be thoroughly assessed at As a general rule, thermal tests are more
the planning stage. In this way, potential discriminating of pulp condition than electri-
endodontic problems can be identified and cal.17 They should be repeated, and contra-
addressed and future embarrassment and trau- lateral and adjacent teeth tested for reference.
ma kept to a minimum. An exaggerated and lingering response may
indicate irreversible pulpal inflammation,
Teeth presumed to have healthy pulps whilst a consistent absence of response may
Pulps cannot be visualised directly to assess suggest pulp necrosis.
their health. Neither is there a single test which Pulp sensitivity tests are essential in
will reliably deliver this information in all cir- pre-operative assessment, but their results
cumstances. We rely therefore on a combina- should not be taken in isolation, and should
tion of fairly crude methods, including pain always be interpreted with caution.
history, clinical examination, special tests and
radiographs to build a picture of pulp
status. All teeth due to be crowned should be
tested systematically to give as clear a picture
as possible.
Pain history
A brief pain history reveals areas of the mouth
sensitive to hot, cold or sweet, and teeth sensi-
Fig. 3 A gutta percha point inserted
tive to chewing pressure, which require further into a discharging fistula locates its
examination. Review of the case notes may source at the apex of the premolar
identify teeth with a history of trauma, pulpal bridge abutment
exposure or pulpitic symptoms. But this is not
enough. Despite textbook accounts of classical Radiographs
toothaches, most injured pulps die quietly, and it Periapical radiographs should be of diagnostic
is also known that pulpal pain is poorly quality and taken by a paralleling technique. If
localised. The absence of reported symptoms is there is a discharging fistula, a gutta percha cone
therefore not proof of health, and further exami- size 25 or 30 should be inserted to source the
nation is needed to identify inflamed and infectious focus (Fig. 3). More than one film,
necrotic pulps in need of treatment. taken at different angles, may be needed to visu-
alise all roots and all root canals, and should be
Clinical examination examined for apical and lateral lesions of
Indications of pulp condition may come from endodontic origin. If root-treatment is indicated,
the identification of caries, large or leaking an assessment should be made of the degree of
restorations, non-carious tooth tissue loss and difficulty this presents, and whether a pre-
traumatic injury. Inspection and palpation of dictable, quality result is likely.
soft tissues overlying the apices of teeth to be The size of a healthy, vital pulp should also be
crowned may reveal signs of endodontic patho- noted, especially if the reason for the crown is to
sis, including swelling, redness and discharging realign the tooth. Heavy tooth reduction in such
fistulae. Non-vital teeth may appear slightly cases may result in embarrassing unexpected
darker than their neighbours, and periapically pulpal exposure.
(a) (b)
(e)
Ferrule (d)
Ferrule
(c)
(f)
Fig. 9 The development of protective ferrules for anterior teeth: a) Moderate loss of tooth tissue — the post and core provide no protection, a ferrule is provided by the
crown; b) Moderate loss of tooth tissue — bevelling of the residual tooth tissue allows the core as well as the crown to provide protective ferrules; c) Decoronated,
root-treated anterior tooth which is vulnerable to fracture and requires protection; d) No protective ferrule provided by the core, or by the crown; e) No protection
provided by the core, but the crown extends onto tooth and provides a protective ferrule; and f) Protective ferrule provided by a cast post and diaphragm
Post length
(b) There is little doubt that long posts are more
retentive than short posts. Endodontic posts
(a) should therefore be as long as possible, and it is
important to note that this is achieved not only
Fig. 12 a) Fractured and root- by extending the post apically, but also by pre-
treated incisor to be restored
with a post retained crown. serving tooth tissue coronally (Fig. 12). There is
b) Rooftop preparation no place for the decoronating ‘rooftop’ prepara-
damagingly removes all tion in the restoration of root-filled teeth. This is
remaining coronal tooth (c) Additional particularly so when evidence suggests that at
tissue, and may compromise post
the ability to create a
least 4–5 mm of gutta percha should remain api-
protective ferrule. length cally to ensure that the seal of the root filling is
c) Conservative preparation not compromised.11,33
preserves tooth tissue, Retaining coronal dentine also allows for
lengthens the post, and allows wrap-around coverage by the subsequent
the development of protective
ferrules crown, which provides the essential ‘ferrule
effect’ discussed earlier (Fig. 12c).
Post shape
All other factors being equal, parallel-sided
posts, such as the Parapost (Fig. 13) are more
retentive than tapered posts.34 However, the
preparation of a parallel-sided post channel, and Fig. 13 Parapost — parallel, serrated
subsequent cementation of a square-ended par- post
allel post may produce increased stress in the
narrow and tapering root-end35 (Fig. 14a) and
predispose to root fracture. Systems, which are (a) (b)
bevelled apically may therefore be preferred
(Fig. 14b). But once again, the preservation of
tooth tissue is important to the long-term
integrity of the tooth, and tissue should not be
sacrificed in order to create a parallel-sided post
channel if a well-adapted tapered post can be
placed with less sacrifice of dentine.
Tapered posts such as the PD system have a Fig. 14 a) Stress concentration at
good record of clinical success.36 Concerns have the base of a parallel post
often been raised over the generation of wedg- preparation. b) Reduced stress
concentration with a chamfered tip
ing stresses by tapered (including customised
cast) posts, and the tendency to promote root
fracture. However, such forces are not active in
the same way as those generated by self-tap-
ping screw systems, and it may be that many
cases of root fracture associated with tapered
posts reflect the type of cases in which such
posts are often used, ie the wide, thin-walled Fig. 15: Radix Anker — parallel,
tapered canal. Again, the importance of provid- self-tapping or pre-tapped post
ing a protective coronal ferrule cannot be over-
emphasised.
In their study of parallel versus tapered post
systems, Torbjornet et al.34 noted that in fact the
type of post may be of minimal importance to
the risk of root fracture if the tooth is covered by Fig. 16 Dentatus screw — tapered,
a complete crown with a good ferrule effect at self-tapping post
the crown margin area. Their comments were
not, however, directed to posts involving active
methods of retention.
Customised cast posts are especially versa-
tile and can often be fabricated with the mini- Fig. 17 Kurer Anchor — parallel,
threaded post for which the root
mum of additional canal preparation. Such
canal is pre-tapped
posts have a strong history of clinical suc-
cess28,37 especially once again when a coronal
ferrule is provided. Concerns have been expressed about all
In summary, parallel-sided posts are preferred threaded post systems, and it is notable that
to tapered posts, but each case should be carefully most manufacturers now recommend that the
considered on its merits, and dentine should post is used first to cut a thread, and is then
not be unnecessarily sacrificed to dogmatically removed and reinserted with cement, or is sim-
satisfy the desire to place a moderately more ply derotated a quarter turn to reduce stresses
retentive parallel post. which are generated during initial insertion. The
Kurer post system, in which the canal is first
Surface characteristics: threaded versus tapped before post insertion, is probably the
non-threaded posts least stressing of threaded post systems. Another
There is little doubt from the literature that method of limiting stress is seen in the Flexipost,
threaded post systems offer the maximum which incorporates a split-pin mechanism, the
mechanical retention. But the retention they split pin collapsing upon itself as the post is
provide is often by active engagement of elastic inserted to reduce pressure on the canal walls.39
dentine, producing stress concentration around Generally speaking, threaded posts are not
the threads, and increasing the risk of root frac- preferred and Meta analysis of the limited clinical
ture.38 This is especially so if posts are self- evidence available suggests that their perform-
tapping, and is amplified if the post also has a ance is inferior to that of customised cast posts.37
wedge-like, tapered design. If enhanced retention is required in a special situ-
Popular commercial threaded posts include: ation, then threaded posts are no longer the only
• Radix Anker (Fig. 15) option. Increasingly, resin-bonding agents may
• Dentatus (Fig. 16) be employed with serrated, and preferably sand-
• Kurer Anchor (Fig. 17) blasted metal or fibre posts, reducing the potential
for stress, and enhancing the possibility of devel- Minimal loss of coronal tissue
oping an hermetic coronal seal.28 Incisors and canines which have lost tissue dur-
ing access preparation, in addition to tissue loss
Minimising danger during post space caused by caries in one or both proximal sur-
preparation faces can often be restored to satisfactory
Ideally, post space preparation is completed at long-term function and aesthetics with dentine
the appointment when the root canal is filled. At and enamel-bonded composite resin. Gutta per-
this time, the practitioner is most familiar with cha should be cleared from the interior of the
the canal system and reference points. He is also crown with hot instruments or Gates Glidden
able to make post space with the rubber dam in drills. Powerful organic solvents such as chloro-
place to minimise microbial entry, and can fur- form or halothane are not recommended in post
ther condense the apical segment of the root fill- channel preparation, as it is impossible to
ing after the coronal gutta percha has been control their advance into the root canal where
removed. Gutta percha removal and post chan- they can rapidly dissolve gutta percha and sealer
nel preparation should not be undertaken in a at a deeper level than anticipated. All traces of
single act with the aggressive end-cutting twist sealer should be removed from the coronal
drills provided with proprietary post systems. To tissues to prevent later discolouration. Concerns
do so is to risk losing alignment and perforating have been expressed about zinc oxide-eugenol
the root for the sake of a few seconds of time. sealers in particular, traces of which may inter-
Gutta percha should first be removed to the pre- fere with the polymerisation of restorative resins.
determined length using burs with non-cutting Alcohol rapidly sequesters excess eugenol and is
tips (eg Gates Glidden) or with hot instruments not known to threaten the integrity of gutta per-
before the channel is shaped and enlarged pro- cha root fillings. It may be wise to rinse the pulp
gressively with measured twist drills. chamber with alcohol to remove traces of
eugenol before attempting to bond.41
Guarding against coronal microleakage Premolars and molars with only minimal
Coronal microleakage is a major cause of access cavities and no other coronal tissue loss
endodontic failure.40 Saliva and organisms from can be restored with amalgam or composite
the mouth migrate rapidly alongside poorly resin in combination with a resin bonding sys-
adapted restorations and even root fillings tem to enhance the marginal seal. The restora-
which appear well condensed.18 The periradicu- tive material should be extended 2–3 mm into
lar tissues will be inflamed by such reinfection canal entrances by carefully removing root fill-
and the reactivation of micro-organisms lying ing material with hot instruments or Gates Glid-
dormant after initial treatment. A well sealing den drills. However, large Gates should not be
coronal restoration is critical therefore to extended deeply into canals with the risk of
endodontic success, and it is again stressed that unnecessary dentine removal, and even strip
this applies as strongly to temporary restora- perforation. The first increments of core material
tions as it does to permanent ones. Posterior should be packed with a long, narrow plugger
teeth can be temporised with cuspal-coverage (eg Mortensen Condenser) to ensure good adap-
amalgam restorations, which will prove durable tation into these retentive features.
and well sealing for many months or years. But
the same cannot be said for anterior temporary Moderate loss of tooth tissue
post crowns, which should be in place for the Advances in bonding technology and improve-
minimum time possible. ments in the physical and aesthetic properties of
Restorations should be well adapted, and composite resins continue to increase the poten-
every use should be made of modern adhesive tial for simple, plastic restoration of anterior
systems in an effort to control salivary entry. teeth. Depending upon aesthetic and functional
demands, root-treated teeth with proximal and
TREATMENT GUIDELINES incisal tissue loss, in addition to the access cavi-
In summary, the guiding principles in restoring ty may often be restored without the need for a
root-treated teeth are: crown. Bonding composite resin soon after com-
1. Preserve as much tooth tissue as possible pletion of the root filling has the added advan-
2. If a post is needed make sure it is long tage of securing an early, hermetic seal against
enough to be retentive and sufficiently coronal microleakage.
strong to resist distortion It is impossible in this context to lay down
3. Avoid twist drills for the removal of gutta firm rules on the precise degree of tissue loss
percha that can be successfully restored in this non-
4. Avoid active restorations or restoration com- destructive way. But it should also be noted that
ponents which induce internal stresses teeth restored with simple plastic restorations
5. Provide the necessary coronal coverage for can always be revisited at a later stage for a
protection more advanced and destructive restoration if
6. Strive for the best possible fluid and bacteria- the need arises.
tight seal Anterior teeth, which have some coronal tis-
sue remaining, but where this is considered
These principles will now be illustrated for a insufficient for long-term restoration with com-
variety of restorative scenarios. posite resin, either on functional or aesthetic
grounds, require core build-up and a crown. The opment of a ferrule by extending crown margins
core may not always need a post for retention. well onto sound tooth tissue should minimise
Gutta percha and sealer are first cleared from the physical demands on the composite core.
the crown and coronal 2–3 mm of the root canal. Such extension may be subgingival or involve a
The remaining coronal tooth tissue is then pre- crown lengthening procedure or forced eruption
pared to receive a crown. Under no circum- to obtain supragingival margins.
stances should the tooth be decoronated to cre- Posterior teeth, which have lost one or both
ate a ‘rooftop’ preparation (Fig.12a, b). Weak, marginal ridges in addition to tooth loss for
undermined coronal tissue and spurs of tissue, endodontic access, require cuspal coverage.
which are taller than they are wide, should be Amalgam or composite cores can again often be
reduced and the remaining, well-supported tis- retained without the need for posts. If a post is
sue bevelled. Every effort should be made to pre- considered necessary, it should usually be placed
serve as much coronal tissue as possible. If there in the straightest and most bulky root, common-
is adequate retention and support available for ly the distal in lower molars, and the palatal in
the core material, then dentine-bonded compos- upper molars. Premolar roots should be judged
ite is cured into the chamber and extended to on their merits. Even if a post is placed, root-
complete the preparation coronally. filling materials should always be removed from
If tissue loss is more severe, then a post is the entrances of other canals to provide supple- Fig. 19 Cast post and core with
a diaphragm to cover and support
required (Fig. 12c). This may either be cast, or mentary retention for the core, and resistance to a damaged incisor root
prefabricated. Gutta percha is removed from the rotational torque.
canal, leaving 4–5 mm of filling material api- A cuspal coverage restoration can then be
cally. An initial path is made with hot instru- prepared which fits the functional and aesthetic
ments, or with Gates Glidden drills, numbers 2 demands of the situation. This may be as con-
and 3, which should be running at the maxi- servative as a cast metal onlay, or three-quarter
mum speed achievable with the slow speed crown, or as extensive as a full-coverage metal
handpiece to generate frictional heat which will or ceramo-metal crown (Fig. 18). Extracoronal
soften the gutta percha and ease its removal restorations should be extended at least
without disturbing the apical root filling.42 1–2 mm onto sound tooth tissue to provide all-
Having created a path, twist drills appropriate enveloping protection against fracture of the
to the post system selected are used to enlarge underlying tooth.
and shape the channel. Excessive dentine Adhesively retained plastic restorations can-
should not be removed to accommodate snugly not be relied upon as long-term internal
a preformed parallel post in a flared canal. In splints. If there is no plan to crown a weakened
this situation, a tapered or customised cast post posterior tooth, either because the root-treat-
or a fibre post is often preferred. ment is on probation, or for financial reasons,
Impressions may then be taken for the pro- then physical cuspal coverage and protection
duction of an indirectly constructed casting, or a must be provided by the core material. Cusps
direct pattern fabricated in the mouth. Metal adjacent to lost marginal ridges should be
castings have the advantage that features can be reduced in height by 3 mm and overlaid with
built in to provide a protective ferrule, and that dentine bonded amalgam or composite resin.
they can be customised to minimise the need for Such restorations can provide cost-effective,
dentine removal. The chief disadvantage of this durable service for many years.45
approach is that the tooth will need temporisa-
tion with a temporary post crown, which is Extensive loss of tooth tissue
unlikely to provide an hermetic coronal seal dur- Teeth with little or no coronal tissue remaining
ing the time required to fabricate the post.43 require special measures to provide a protective
For this reason, it may be preferable to restore ferrule. Again, surgical crown lengthening or
the tooth immediately with a prefabricated post, forced eruption may be needed to allow the place-
and composite core.43,44 An immediate, and per- ment of restoration margins on sound tissue.
manent coronal seal is then secured. This benefit Anterior teeth may be prepared to receive a
should be balanced in heavy loading situations cast metal post and diaphragm (Fig. 19), with
with consideration of the strength of the core extension of the metal casting over the bevelled
and the post-core interface. However the devel- or chamfered margins of the root-face to provide
Fig. 18 Cuspal protection and development of protective ferrules for posterior teeth with varying
amounts of tissue loss: a) Simple metal onlay, b) Three-quarter crown, c) Full coverage crown
term effects of crown preparation on pulp vitality. J Dent Res restorations: 2. Prefabricated post and core systems —
1989; 68 (special issue): 1009. (i) Non-threaded posts. Dent Update 1990; July/August:
10. Landolt A, Lang N P. Erfolg und misserfolg bei 244-249.
extensionsbrucken. Schweiz Monat Zahnmed 1988; 98: 31. Dummer P M H, Edmunds D H. Root canal retained
239-44. [German with English abstract] restorations: 2. Prefabricated post and core systems —
11. Reichen-Graden S, Lang N P. Periodontal and pulpal (ii) Threaded posts. Dent Update 1990; September: 286-289.
conditions of abutment teeth. Schweiz Monat Zahnmed 32. Edmunds D H, Dummer P M H. Root canal retained
1989; 99: 1381-1385. restorations revisited. Dent Update 1993; January/February:
12. Gonzalez G , Wier D J , Helm F , Marshall S J, Walker L, Stoffer 14-19.
W. et al. Incidence of endodontic treatment in teeth with full 33. de Cleen M J H. The relationship between the root canal
coverage restorations. J Dent Res 1991; 70 (special issue): 446. filling and post space preparation. Int Endod J 1993; 26:
13. Valderhaug J, Jokstad A, Ambjornsen E, Norheim P W. 53-58.
Assessment of the periapical and clinical status of crowned 34. Torbjorner A, Karlsson S, Odman P A. Survival rate and failure
teeth over 25 years. J Dent 1997; 25: 97-105. characteristics for two post designs. J Prosthet Dent 1995;
14. McLean J W. The Science and Art of Dental Materials. Vol. 1. 73: 439-444.
p 59. Chicago: Quintessence, 1979. 35. Standlee J P, Caputo A A, Collard E W, Pollack M H. Analysis of
15. Madison S, Jordan R D, Krell K V. The effect of rubber dam stress distribution by endodontic posts. Oral Surg 1972; 33:
retainers on porcelain fused-to-metal restorations. J Endod 952-960.
1986; 12: 183-186. 36. Weine F S, Wax A H, Wencus C S. Retrospective study of
16. Dental Protection. Annual Report of the Board 1996; 8: 22. tapered smooth post systems in place for 10 years or more.
17. Cohen S. In Cohen S, Burns R C. (eds). Pathways of the Pulp. J Endodont 1991; 17: 293-297.
6th edn. pp2-24. St Louis: Mosby, 1994. 37. Creugers N H J, Mentink A G B, Kayser A F. An analysis of
18. Khayat A, Lee S J, Torabinejad M. Human saliva penetration durability data on post and core restorations. J Dent 1993;
of coronally unsealed obturated root canals. J Endod 1993; 21: 281-284.
19: 458-461. 38. Deutsch A S, Cavallari J, Musikant B L, et al. Root fracture and
19. Walton R, Torabinejad M. Principles and Practice of the design of prefabricated posts. J Prosthet Dent 1985; 53:
Endodontics. 2nd edn. Baltimore: Saunders, 1996. 637-640.
20. Pitt-Ford T R. Harty’s Endodontics in Clinical Practice. 4th 39. Cohen B I, Musikant B L, Deutsch A S. A 10-year literature
edn. Oxford: Wright, 1997. review of a split-shanked threaded post. Compend Cont Educ
21. Clements R E, Gilboe D B. Labial endodontic access opening Dent 1995: 16: 630-631.
for mandibular incisors: Endodontic and restorative 40. Saunders W P, Saunders E M. Coronal leakage as a cause of
considerations. J Can Dent Assoc 1991; 57: 587-589. failure in root-canal therapy: a review. Endod Dent Traumatol
22. Langeland K, Langeland L K. Pulp reactions to cavity and 1994; 10: 105-108.
crown preparation. Aust Dent J 1970; 15: 261-276. 41. Tjan A H L, Nemetz H. Effect of eugenol-containing
23. Langeland K, Langeland L K. Cutting procedures with endodontic sealer on retention of prefabricated posts luted
minimized trauma. J Am Dent Assoc 1968; 76: 991-1005. with adhesive composite resin cement. Quintessence Int
24. Bergenholtz G, Cox C, Loesche W J, Syed S A. Bacterial 1992; 23: 839-844.
leakage around dental restorations: its effect on the dental 42. Haddix J E, Mattison G D, Shulmann C A et al. Post
pulp. J Oral Pathol 1982; 11: 439-450. preparation techniques and their effect on the apical seal.
25. Goldman M, Laosonthorn P, White R R. Microleakage: full J Prosth Dent 1990; 64: 515-519.
crowns and the dental pulp. J Endod 1992; 18: 473-475. 43. Fox K, Gutteridge D L. An in vitro study of coronal
26. Cox C F, Suzuki S. Re-evaluating pulp protection: Calcium microleakage in root-canal-treated teeth restored by the
hydroxide liners vs. cohesive hybridization. J Am Dent Assoc post and core technique. Int Endod J 1997; 30: 361-368.
1994; 125: 823-831. 44. Ferrari M, Vichi A, Mannocci F, Mason PN. Retrospective
27. Sorensen J A, Martinoff J T. Intracoronal reinforcement and study of the performance of fiber posts. Amer J Dent 2000;
coronal coverage: a study of endodontically treated teeth. 13 (special issue): 9B-13B.
J Prosthet Dent 1984; 51: 781-784. 45. Nayyar A, Walton R E, Leonard L A. An amalgam coronal-
28. Morgano S M. Restoration of pulpless teeth: an application radicular dowel and core technique for endodontically
of traditional principles in present and future contexts. J treated posterior teeth. J Pros Dent 1980; 43: 511-515.
Prosth Dent 1996; 75: 375-380. 46. Saupe W A, Gluskin A H, Radke R A. A comparative study of
29. Edmunds D H, Dummer P M H. Root canal retained fracture resistance between morphologic dowel and cores
restorations: 1. General considerations and custom-made and a resin-reinforced dowel system in the intraradicular
cast posts and cores. Dent Update 1990; June: 183-188. restoration of structurally compromised roots. Quintessence
30. Dummer P M H, Edmunds D H. Root canal retained Int 1996 ; 27: 483-491.
5
IN BRIEF
● Clarification of some of the terminology and concepts relating to occlusion as it is used in
everyday practice, making clear why these concepts matter
● Undertaking a simple pre-operative examination of the occlusion as a matter of routine
● Helping clinicians identify cases where articulated study casts will help plan treatment and
design restorations
● Advice is provided about selecting an appropriate articulator and taking appropriate records
at the treatment stage.
For many dentists, occlusion carries an air of mystique. It even seems sometimes that a perverse pleasure is derived in making
the whole subject more complicated than it really is. As a clinician, you need to be able to decide what you expect from your
proposed restoration, and to identify situations where you may need to alter the existing occlusal scheme. At a fundamental
level, you also need to provide the laboratory with appropriate clinical records to ensure that when you fit them, adjustments
to the expensively prepared restorations are minimal. This requires a sound understanding of the basics.
CROWNS AND EXTRA-CORONAL This fifth article in the series will try to present (ICP). Travel into this position is partly guided by
RESTORATIONS: important occlusal concepts in a way which the shape of teeth and partly by conditioned
1. Changing patterns and relates directly to the provision of successful neuromuscular co-ordination.1 ICP is the most
the need for quality crowns. It is not a comprehensive guide to occlu- ‘closed’ position of the jaws.
2. Materials considerations sion, or a manual of techniques for extensive
3. Pre-operative fixed prosthodontics. There are several useful Why does this matter?
assessment books and articles dedicated to the subject and ICP is usually the position in which vertical
some of these are specifically referenced (if a occlusal forces are most effectively borne by the
4. Endodontic
considerations technique is particularly well described) or are periodontium with teeth likely to be loaded axi-
listed in the further reading section. However, we ally, which helps to stabilise their position.
5. Jaw registration and
hope that this article should allow you to avoid Indeed it is the end point of the chewing cycle
articulator selection
most of the problems associated with the provi- where maximum force is exerted. In everyday
6. Aesthetic control sion of crowns. Occasionally some pre-operative practice this is the position of the jaws in which
7. Cores for teeth with occlusal adjustment is needed. Our experience is restorations are made.
vital pulps that this is best taught ‘hands on’ and we would
8. Preparations for full recommend attending an appropriate course Guidance (from the teeth)
veneer crowns before attempting more complex adjustments. What is it?
9. Provisional restorations When a patient moves their mandible from side
10. Impression materials and BASIC CONSIDERATIONS — WHAT MATTERS? to side so that the teeth in opposing jaws slide
technique One of the essential starting points with occlu- over each other, the path taken is determined
11. Try-in and cementation sion is to make sure that the terminology is clear. partly by the shapes of the teeth which make
of crowns There are any number of occlusal terms, many of contact, as well as by the anatomical constraints
12. Porcelain veneers which overlap. There are only a few that really of the temporomandibular joints (TMJs) and
13. Resin bonded metal matter and these need to be understood if what is masticatory neuromuscular function. Each has a
restorations to follow is to make any sense. bearing on the other, and, for want of a better
term, they should work in harmony. In these cir-
1*,3Senior Lecturer in Restorative Dentistry,
The intercuspal position (ICP or IP) cumstances the teeth provide guidance for the
Department of Restorative Dentistry,
The Dental School, Framlington Place, Synonyms: centric occlusion (CO), maximum movement of the mandible. The shape and form
Newcastle upon Tyne NE2 4BW intercuspation of the temporomandibular joints also guide the
2Consultant in Restorative Dentistry, The
movement of the mandible (sometimes called
Dental Hospital, Framlington Place,
Newcastle upon Tyne NE2 4AZ
What is it? posterior guidance). Guidance teeth can be any
*Correspondence to: J. G. Steele Most dentate patients, when asked simply to teeth, anterior or posterior.
E-mail: jimmy.steele@ncl.ac.uk ‘bite together on your back teeth’, close immedi- When the patient slides the mandible out to
ately into a comfortable, reproducible “closed” one side, the side they move the mandible
Refereed Paper
© British Dental Journal 2002; 192: position where the maximum number of tooth towards is called the working side (because it is
377–387 contacts occur. This is the intercuspal position usually the side on which they are about to
need to be made from good quality impres- Records for planning crowns: Articulated study
sions, which have been handled and poured casts
correctly. We will return to this important but Accurate casts of the dental arches mounted in a
underrated subject later (see below: ‘Opposing semi adjustable articulator are the most impor-
Casts’). tant tools of the trade when constructing artifi-
Hand-held study casts enable: cial crowns. The need for an articulator and the
• A judgement to be made regarding the ease of positions in which you mount the casts depend
obtaining a stable ICP. This helps to determine on what you need to do (see Box 3). Articulators
whether or not an interocclusal record is are surrounded by an aura of mystery, but at the
required for the working casts upon which the end of the day they are a tool to help give your
restoration(s) will be made. patient a successful restoration and to help you
• An unimpeded view of ICP. It is possible to to save time, money and hassle. The quality of
view aspects such as the lingual, which the final result is much less dependent on the
it would not be possible to see at the chair- articulator you use than it is on the care you
side. exercise to make and mount the casts that you
• Careful evaluation of clinical crown height put in it.
and the availability of inter-occlusal space for There is little merit in examining study casts
restorative material. These two factors can for planning purposes on a simple hinge or other
help make the decision on how to facilitate the ‘non-anatomical’ articulator because the ability
restoration of short teeth (see Part 3 ‘Pre-oper- to replicate physiological movements will be, at
ative assessment’ in this series). best, crude, and at worst, wholly misleading. A
non-anatomical articulator will allow casts to be
However tempting it may be to assume other- put into a reproducible ICP, which may be helpful
wise, hand-held casts provide no information if there are insufficient contacts to make hand-
about excursive tooth contacts or RCP, beyond held casts stable, but that is the limit of what a
the distribution of wear facets. simple hinge articulator can do.
The combination of a facebow record (which Records for planning crowns: the diagnostic
locates the approximate position of the condylar wax-up
hinge axis in relation to the upper arch) and a jaw In addition to its uses in planning changes in
relation record (which then locates the lower cast appearance (see Aesthetic Control — the sixth
to the upper), enables movements of casts articu- article in this series), a diagnostic wax-up can be
lated on a semi-adjustable articulator to be rea- an absolutely invaluable technique where you
sonably anatomical. You can simulate the move- are changing the occluding surfaces of several
ments of the teeth in lateral and protrusive teeth with crowns or resin bonded restorations
excursions, and around the hinge axis and be con- and allows you to plan the following:
fident that what you see is close to what is really • The new static occlusal contacts (in ICP) and
happening in the mouth. However, whilst the the shape of the guidance teeth
instrument is key, the quality of the casts and • The impact that the modified occlusion has on
the care with which they are mounted are just as appearance
critical. There is no room for carelessness at this • The best options for creating interocclusal
stage, wrongly articulated casts are probably space for restoration(s) or optimising crown
worse than no casts at all as they may result in height by periodontal surgery (see Part 3:
false assumptions about treatment. Similarly, inac- ‘Pre–operative Assessment’ in this series).
curacies with the original impressions can result in
profound errors and the use of an accurate and You can also use the completed wax-up as a
stable impression material (such as addition cured template to determine the form of temporary
silicone) may be appropriate in cases where a and final restorations.
detailed occlusal analysis is necessary. Details of
how to record a facebow record and a retruded PRACTICAL ASPECTS OF OCCLUSION:
hinge axis inter-occlusal record can be found in RECORDS FOR MAKING CROWNS
References 3 and 4. Some simple tips on accurate When the diagnosis stage has been completed,
impression recording can be found in Box 4. the crowns or restorations still need to be made,
Although you can see and reproduce move- and various records are essential at this stage
ments with carefully articulated casts, you may too. This section discusses the choice of articula-
often want to go on to the next stage and prepare tor and the need to obtain accurate occlusal
a diagnostic wax up. records, including the simplest things such as
opposing impressions, which are a frequent this is probably not economically realistic. Box 4
source of error. Finally, it introduces ways of describes the use of alginate for an opposing
controlling guidance on front teeth. impression. In cases involving multiple restora-
tions though, a very stable and accurate material
The articulator may be cost effective in the long term.
When manufacturing the final crowns, in the
interests of simplicity and cost it would seem Interocclusal records (IOR)
sensible to use the simplest cast relating device Once you have your working impression and
that will not compromise the final restoration.5 opposing impression you then need to decide
Small numbers of restorations, which are not whether you need to provide additional informa-
involved in excursive contacts, can very reason- tion to the lab to allow them to mount the casts;
ably be made on a non-adjustable articulator an inter-occlusal record (IOR). There is a common
and then any adjustments made in the mouth perception that providing an intercuspal record
before final cementation. However, crowns (such as a wax or silicone ‘bite’) will improve the
involved in excursions benefit from the use of accuracy of mounted casts. The truth is that in
an articulator with anatomical dimensions so many cases it does precisely the opposite.6
that the excursive movements can be made and For a patient with a stable intercuspal posi-
the shape of the crown adjusted in the lab with tion, the loss of interocclusal contact created by
reasonable accuracy, saving chairside time. This preparation of a tooth for a single unit restora-
becomes particularly important, and cost effec- tion, is unlikely to detract from the ease with
tive, when several restorations are being created which working and opposing casts can be locat-
at the same time. Highly sophisticated semi- ed in ICP. In this circumstance, placing a layer of
adjustable and fully adjustable articulators are wax or silicone between the casts to help to
available for this purpose, but the majority of locate them can often result in them failing to
cases can be managed quite satisfactorily using seat into ICP at all, and there is a very serious
a less sophisticated, fixed average value articu- risk of the record introducing inaccuracies,
lator in combination with a facebow. rather than acting as the ‘insurance policy’ you
It may not be possible to check occlusion on intended. It is worth taking the opportunity of
adhesive restorations prior to cementation, either examining the ease with which any study casts
because the act of checking may damage porce- can be located by hand before deciding whether
lain, which is delicate until cemented, or because an IOR is needed. Often (perhaps even usually)
they will not stay in place during excursions. In you are better with nothing at all.
these cases, controlling the role of the restorations Sometimes an IOR is required to stabilise
in guidance can be critical to their long-term sur- casts, particularly where the teeth that are pre-
vival. A semi-adjustable articulator can be pared are key support teeth in an arch. The
invaluable in situations such as these because it choice of materials is generally between hard
allows the technician to secure restorations onto wax alone, hard wax (as a carrier) used with zinc
the working cast and do the critical adjustments oxide/eugenol, silicone elastomers and acrylic
in the lab so that all you need to do is cement resins. The fundamental requirement is to obtain
them with little or no adjustment afterwards. enough detail in a dimensionally stable record-
ing material to enable casts to be confidently
Opposing casts located in the laboratory whilst not recording so
In any discussion about articulators, it is much detail that it stops the casts seating.
disturbingly easy to forget the importance of an Occlusal fissure patterns reproduced accurately
accurate cast to oppose the working cast. The in the IOR may well not be reproduced to the
opposing impression is often the last thing we do same extent in the cast, preventing full seating
and, after a long session preparing teeth, making of the casts in the record. Furthermore, an IOR
temporaries and taking impressions it tends to be which contacts soft tissues in the mouth and
a bit of an afterthought. However, a poor oppos- causes their displacement (which is obviously
ing impression is very easy indeed to achieve and not reproduced in the stone cast) will result in an
yet can cost a great deal of precious time subse- IOR which will not seat accurately (Figs 11 and
quently. A cast made with a distorted impression 12). In order to meet the requirements for suc-
or a porous impression resulting in plaster blebs cess, an IOR should:
on occlusal surfaces will not fit comfortably into
1. Record the tips of cusps or preparations
ICP. If such a cast is used in the lab it can result in
BUT
a crown which looks perfectly good on the cast
2. Avoid capturing fissure patterns as much as
but which may be very high in the ICP and which
possible
can take a great deal of time to get right prior to
AND
fit. It is easy to record bad opposing impressions,
3. Avoid any soft tissue contact
but good ones are just as easy. Attention to the
few steps listed in Box 4 takes, literally, no extra The key to a successful record is not so much
time but can save a lot of heartache. In an ideal the type of material used, but how it is used. The
world every opposing impression would be smaller the amount you use, the less it is likely to
recorded in a dimensionally accurate and stable cause a problem. A small, trimmed record,
material such as an addition cured silicone, but restricted to the area of the preps themselves,
6
IN BRIEF
● Identification and definition of the patient’s aesthetic problem
● Consideration of the balance between aesthetics and tooth destruction for conventional and
adhesive restorations
● An awareness of the aesthetic limitations of restorations and an attempt to ensure that the
patient’s expectations are realistic
● Incorporation of procedures leading to better aesthetics at each clinical stage
● Confidence in determining shade and communicating effectively with the laboratory
A pleasing dental appearance is the subjective appreciation of the shade, shape and arrangement of the teeth and their
relationship to the gingiva, lips and facial features. Achieving such a pleasing appearance in our patients is not always easy
but is critical, not least because our work is effectively on display and this has implications for patients’ perceptions of our
practice. To be successful, thorough assessment, careful planning and precise clinical execution is required. Every bit as
important though, is good communication, both with the dental laboratory and particularly with the patient. In few areas of
dentistry can effective communication be as critical as it is here.
CROWNS AND EXTRA-CORONAL Retention of natural teeth into old age is now reason for providing the restoration. The type of
RESTORATIONS: commonplace and whilst usually desirable, it materials used clearly have an important bearing
1. Changing patterns and has brought with it considerable additional on both the appearance and the amount of
the need for quality problems. Making well-aligned white teeth in a preparation and are an important part of the aes-
2. Materials considerations complete denture is usually straightforward, but thetic cost:benefit equation. Table 1 lists the aes-
3. Pre-operative matching a single crown or veneer to a group of thetic restorations commonly available. Whilst
assessment natural incisors is a different matter altogether. they are much less destructive of tooth tissue
4. Endodontic This problem is illustrated by data from the 1988 than traditional ceramo-metal crowns, adhesive
considerations survey of adult dental health in the United restorations such as the porcelain laminate
5. Jaw registration and Kingdom1 which showed that having just one or veneer and dentine bonded crown do have limi-
articulator selection two crowns was more likely to be associated tations: specifically the problem of masking the
6. Aesthetic control
with dissatisfaction with the appearance than colour of darkly stained teeth, problems of tem-
having none or many. porisation and the inability to cement restora-
7. Cores for teeth with
In each case, planning tooth preparation tions provisionally. Veneers are covered in detail
vital pulps
involves the dentist in a cost:benefit analysis, in a separate article in this series (Part 12).
8. Preparations for full where the cost of improved aesthetics is judged Furthermore whilst there have been significant
veneer crowns in terms of removal of tooth tissue and in the improvements in indirect composite technology
9. Provisional restorations potential for damage to the pulp and periodon-
10. Impression materials and tium. However the benefit of stunning porcelain
technique work is easiest to achieve where a thick layer of Table 1 Laboratory made aesthetic restorations
11. Try-in and cementation material can be used to develop the optimum • All porcelain
of crowns optical properties, but this usually requires more Conventional porcelain jacket crown
12. Porcelain veneers tooth tissue to be removed. This is a theme which
High strength porcelain jacket crown
13. Resin bonded metal runs right through all aesthetic considerations
Full coverage porcelain veneer (dentine
restorations and should underpin what follows. This concept
bonded crown)
does not sit comfortably with a dogmatic
Porcelain labial veneer
1Consultant in Restorative Dentistry, approach with hard and fast rules about the
Porcelain onlay
The Dental Hospital, Framlington Place, dimensions of a preparation. The clinician will
Newcastle upon Tyne NE2 4AZ choose to alter the cost:benefit balance in differ- • All composite
2,3Senior Lecturer in Restorative Dentistry,
Department of Restorative Dentistry, ent ways in different cases. The choice might be Crown
The Dental School, Framlington Place, made to sacrifice aesthetics for long-term health, Veneer
Newcastle upon Tyne NE2 4BW or to take a risk with long-term pulp health to Onlay
*Correspondence to: F. S. A. Nohl
E-mail: f.s.a.nohl@newcastle.ac.uk
maximise aesthetics; for example with a heavily • Ceramo-metal crown
prepared ceramo-metal restoration. • Composite bonded to metal crown
Refereed Paper Aesthetic improvements are most important • Partial coverage metal crown
© British Dental Journal 2002; 192: for anterior teeth and may often be the sole
443–450
Unrealistic expectations
Some patients may demand changes in
appearance which are objectively difficult to
appreciate and still more difficult to realise. In
most cases this is simply a problem of commu-
Fig. 3 Case requiring changes in nication, but unrealistic expectations and a
upper lateral incisor length and history of multiple previous treatments
levelling of lower incisal plane addressing appearance may be a warning of a
patient with Body Dysmorphic Disorder (BDD)
or Dysmorphophobia3: a preoccupation with a
defect in appearance which is either imagined
or excessive in relation to a minor defect and
which causes significant distress in social,
occupational and other areas of life. BDD is
probably rare but is an extraordinarily difficult
problem to deal with. It is unlikely that
demands to change appearance will be satis-
Fig. 4 Trial alterations to case in fied for this group of patients. A second opin-
figure 3: uncured composite added ion is a perfectly acceptable course of action if
to upper incisal edges and water- in doubt.
soluble ink to lower left incisors and
canine
FINAL PLANNING AND CLINICAL PROCEDURES
Having decided on the restoration type, it
remains to finalise margin features and carry out
the clinical stages, ultimately leading to cemen-
tation.
Shoulder or chamfer: what should the porcelain restorations go a long way to repro-
preparation finish line be like? ducing nature using a combination of skilful
There is a forceful argument that where possible, artistry and optical trickery. Before recording
ceramo-metal crowns should have metal mar- and prescribing shade it is useful to have a basic
gins because this produces the most predictable understanding of the science and dimensions of
marginal seal7 but as discussed earlier in this colour and texture so that shades can be inter-
series (Part 2 ‘Materials Considerations’), this is a preted and communicated precisely.
contentious issue. However by avoiding the
metal collar, a porcelain butt fit, created on a Dimensions of colour
shoulder finish line, will generally allow for Colour can be described in terms of three dimen-
better aesthetics in critical areas. A restoration sions:
whose margin is in porcelain may allow light to 1. Hue: The name of the colour eg blue, red etc.
pass into porcelain from the gingival aspect as it 2. Value: An achromatic measure of the light-
does into intact teeth contributing to a lifelike ness or darkness of a particular colour such
appearance.8 that high value refers to a shade which is
light and low value to one which is dark.
How much metal: where should the porcelain- Two completely different colours can have Fig. 6 Die with reduction to match
metal junction on ceramo-metal crowns be? exactly the same value. To help understand veneering material(s): the larger
There is no biological or technical benefit in this, imagine the effect of black and white buccal axial reduction is needed to
using porcelain at sites that are not visible. Con- accommodate metal and porcelain,
television on colours. the smaller palatal reduction is for
sideration given to the precise location of porce- 3. Chroma: The strength or saturation of a colour metal alone
lain-metal junctions for ceramo-metal crowns at of particular hue. Imagine increasing the
the planning stage gives the potential to opti- chroma of a small amount of colour pigment
mise conservation of tooth structure yet still diluted in water by adding more of the same
maintain satisfactory aesthetics. Volume to vol- pigment.
ume, the extent of reduction for metal alone is
substantially less than for metal and porcelain: Shade guides in common use (Figs 7 and 8)
different depths of tooth reduction can be used are not designed for a systematic assessment of
at different sites depending on the covering the dimensions of colour and have been criti-
material(s). Tooth preparation then becomes an cised for not including a broad enough range of
ordered technical exercise to satisfy the need for shades. Two commonly used guides (Vita Lumin
differential space attainment. It should be obvi- and Ivoclar Chromoscope) are composed of
ous to the technician examining the resulting groups based essentially on hue (Vita Lumin:
die where to locate porcelain-metal junctions A= reddish brown, B = reddish yellow, C = grey
(Fig. 6). There are laboratory cost implications to shades, D = reddish grey, Ivoclar Chromascop:
provision of ceramo-metal crowns of this sort. It 1 series = cream, 2 series = orange, 3 series =
is necessary to wax a full contour restoration on light brown, 4 series = grey, 5 series = dark
the die, mark the porcelain-metal junction and brown), with sub-classes of varying value and
then cut back space in the wax pattern for porce- chroma. The Vitapan 3D Master system uses a
lain rather than simply to create a thin metal simple but methodical approach to shade deter-
coping over the whole preparation which is cov- mination based on the three dimensions of
ered by porcelain. colour. In common with previous work,9 the
Shade matching
Shade matching is something many of us find
difficult and is often done last whereas in fact it
should be done first! It is not an exact science,
involving as it does a good deal of subjective
judgement. Although an accurate reproduction
of shade is an obvious goal, it cannot be
divorced from consideration of shape, surface
texture and special characteristics, which are Fig. 7 Vita Lumin shade
described later. Teeth possess a range of optical tabs with stained necks
features seemingly designed to make shade removed in order of
decreasing value
matching difficult! Teeth:
• Are non-uniform in colour
• May have complex visible internal and sur-
face features
• Are semi-translucent
• Exhibit a degree of fluorescence
• Change shade and shape with age
Special characteristics
These include fracture lines, white spots and
translucency. The best looking special character-
istics are incorporated during incremental
porcelain application. Surface stains can be used
to produce some of these effects but are prone to
wearing away with time.
Tooth preparation
Achieving optimum aesthetics depends heavily
on providing the technician with adequate space
for the incremental application of porcelain
(Fig. 9). The considerations have already been
discussed above, but when it comes to the prac-
Fig. 10 Putty mould sectioned and ticalities, the extent of tooth preparation is best
numbered on a diagnostic wax-up visualised intra-orally by reference to a prepara-
tion guide. A small putty mould, made over the
Clinical records
As well as the role of the facebow record in Fig. 12 Vacuum formed matrix
helping to make movements of casts on an in-situ
cements to facilitate the choice of colour. Manu- variations in shade and special characteristics J Prosthet Dent 1992; 67:
184-190.
factures’ instructions should be followed. to be understood. Where there are difficulties 6. Abdellatiff H M, Burt B A. An
in recording shade a wise dentist will involve epidemiological investigation into the
COMMUNICATION WITH THE LABORATORY the technician in the decision. Compliments as relative importance of age and oral
The dentist must accept ultimate responsibility well as constructive criticism will help techni- hygiene status as determinants of
periodontitis. J Dent Res 1987; 66: 13-
for all aspects of completed laboratory work. cians evaluate their work, and anyone who 18.
On the face of it this might suggest that a total- takes pride in their work will appreciate the 7. Bishop K, Briggs P, Kelleher M. Margin
ly prescriptive one-way communication is opportunity to see the final result of a job well design for porcelain fused to metal
restorations which extend onto the
required. Not surprisingly such an attitude can done. It is probably fair to say that quality root. Br Dent J 1996; 180: 177-184.
lead to feelings of frustration and dissatisfac- clinical work will be rewarded with higher 8. Lehner C R, Manchen R, Scharer P.
tion to all concerned. It does not have to be quality restorations. Variable reduced metal support for
like this! Trained technicians are highly skilled collarless metal ceramic crowns: a new
model for strength evaluation. Int J
in a unique blend of art, craftsmanship and CONCLUSION Prosthodont 1995; 8: 337-345.
science (as can be appreciated very rapidly by A complete understanding of a patient’s aes- 9. Sproull R C. Color matching in dentistry.
any dentist attempting to wield wax or porce- thetic problems is the key to treatment plan- Part II: Practical applications of the
organization of color. J Prosthet Dent
lain!). Better then to foster a team approach ning. Only then can an attempt be made to 1973; 29: 556-566.
and central to a conflict free relationship is the match expectations with realities and to pro- 10. Moser J B, Wozniak W T, Naleway C A.
establishment of dialogue and clearly defined vide appropriate restorations. This process Colour vision in dentistry: a survey.
J Am Dent Assoc 1985; 110: 509-510.
roles for dentist and technician. To this end depends heavily on an understanding of the 11. Culpepper W D. A Comparative study of
there is little to beat a personal visit to the lab- limitations of the techniques and materials shade-matching procedures. J Prosthet
oratory and subsequently it is helpful to be available. Dent 1970; 24: 166-173.
available to speak to technicians and to share 12. Sorensen J A, Torres T J. Improved color
Manufacturers’ details: matching of metal-ceramic
ideas. Certainly it is important at the very least restorations. Part I: A systematic
Ivoclar-Vivadent Ltd, Meridian South, Leicester LE3 2WY
to provide a clear written prescription which VITA Zahnfabrik, H Rauter GmbH & Co KG, Postfach, method for shade determination.
should include a diagram to enable regional D-79704, Bad Säckingen, Germany J Prosthet Dent 1987; 58: 133-139.
7
IN BRIEF
● Core placement nowadays demands more use of adhesives (coupled with retentive cavity
preparation) and less use of pins
● It is good practice to remove existing restorations of unknown provenance to facilitate cavity
inspection and ensure core retention
● Cores act either as a simple space filler or a structural build-up. The less tooth structure the
greater the mechanical demands on the core, the material for which must be chosen carefully
● Dentists placing pins need to be aware of how to prevent and manage pin placement problems
Cores for teeth with vital pulps is the seventh in the series of crowns and other extra-coronal restorations. A core is defined
as ‘that part of a preparation for an indirect restoration consisting of restorative material’. This article questions the need for
routine pin placement and addresses the following issues — removal of existing restorations, the need for a core, core
materials, core retention, and problem solving.
For almost half a century pinned amalgam preparation features, additional slots and boxes
CROWNS AND EXTRA-CORONAL
RESTORATIONS: restorations have been taught as the basis for and, most importantly, adhesion. Much of the
1. Changing patterns and cores in posterior vital teeth. Many schools, skill in placing a core involves the selection of
the need for quality including our own, continue this venerable tra- the most appropriate material and technique, but
dition in the knowledge that when skilfully car- whatever type of core is placed an important
2. Materials considerations
ried out in optimal circumstances it seems to principle is that existing restorations should first
3. Pre-operative work well. However, clinical research on pin be removed.
assessment
placement shows that the technique is not with-
4. Endodontic out problems.1 Of 429 pin placements by staff REMOVAL OF EXISTING RESTORATIONS
considerations and students at Leeds Dental School 19% Figure 2 shows a tooth that clearly is a potential
5. Jaw registration and showed complications — most frequently a loose candidate for a crown. Only one cusp remains
articulator selection pin or inadequate penetration of the pin into the plus the remnants of another. The tooth has been
6. Aesthetic control pin channel. However, 10% of complications repaired on a number of occasions and there is
7. Cores for teeth with were serious involving either perforation of the veritable jigsaw of amalgam ‘fillings’. There is
vital pulps pulp or periodontium, or tooth fracture. Inexpe- also a suggestion of mesial caries. No dentists in
8. Preparations for full rienced operators are especially prone to prob- their right mind would pick up a handpiece and
veneer crowns lems with almost half of the pins (41%) placed by start to prepare this tooth for a crown. The most
9. Provisional restorations second year students proving unsatisfactory. likely outcome would be a complete collapse of
10. Impression materials and Experienced operators are not immune to diffi- what is there with the potential for a rather diffi-
technique culty; a survey of 37 practitioners placing 1394 cult reassembly. Furthermore, if what is on dis-
11. Try-in and cementation pins over a 3-month period reported difficulties play is representative of previous treatment, the
of crowns in 1 in 20 placements.2 possibility exists of there being residual as well
A considerable amount of in-vitro evidence as recurrent caries and even perhaps latent
12. Porcelain veneers
(see Table 1) shows the potential pins have for involvement of the pulp chamber.
13. Resin bonded metal
causing crazing of the dentine (look at Fig. 1) Figure 3 shows a bitewing radiograph of the
restorations
and pulpal sensitivity. tooth. This adds to the diagnostic complexity of
1*Senior Lecturer, 2Lecturer, Department of In addition, an animal study12 showed the case. What is holding the amalgam in place?
Restorative Dentistry, The Dental School, severe pulpal inflammation where pins were There is no evidence of pins or other retentive
Newcastle upon Tyne NE2 4BW 3Specialist
Registrar in Restorative Dentistry, Eastman placed within 0.5 mm of the pulp. Some self- devices and there are signs that the pulp cham-
Dental Hospital, 256 Grays Inn Road, shearing pins cause stressing and crazing when ber has been visited in the past. The clear evi-
London WC1X 8LD they ‘bottom out’ in the pin channel,4 which dence of dentine bridges indicate a successful
*Correspondence to: Dr R.W. Wassell, Dept.
may explain the symptoms some patients pulpotomy and the question arises whether this
of Restorative Dentistry, The Dental
School, Newcastle upon Tyne NE2 4BW develop following pin placement. Of course, should be accepted or in view of the potential
E-mail: r.w.wassell@ncl.ac.uk symptoms may also arise from undetected risk of future pulp problems, should the tooth be
pulpal or periodontal perforations. root filled? (In this case the fillings were replaced
Refereed Paper
© British Dental Journal 2002; 192: Fortunately there are other methods of retain- with a more acceptable amalgam restoration and
499–509 ing a core including the use of existing cavity the tooth put on probation with a view to
Crazing of Dulling of twist drill during pin channel preparation caused by Newitter et al.,
dentine an adherence of smear debris behind the drill’s cutting edge. 19893
Stresses within dentine resulting from differences in Standlee et al.,
diameter between the drill and the pin. Potential for 19714
damage increases with the number of pins inserted and . Kera et al.,
the pin diameter 19785
Pin placement strain caused by pins which have a core Bione and Wilson,
diameter (ie at the inner aspect of the thread) greater 19866
than the drill diameter
Any fluid in the pin channel during pin insertion Hummert and
can contribute to cracking. Kaiser, 19927 Fig. 3 Bitewing radiograph of tooth in Fig. 2 revealing a
number of underlying problems
Pulpal Extensive cracks occurring with larger sized pins frequently Webb et al.,
inflammation communicate with the pulp chamber. 19898
• Pulpal exposure
following pin Heat generated during pin channel preparation, which is Cooley and
placement greater with larger diameter drills at higher speeds and Barkmeier, 1980 9
• Underlying caries
deeper penetration.
THE NEED FOR A CORE
Microleakage, which is worst with cemented pins and least Chan, 197410
with threaded pins. Cavity varnish does not reduce It is useful to think of a core as either a ‘build-
the problem up’, which contributes significantly to the
Some pins only partially penetrate the pin channel. Barkmeier and strength and retentiveness of the crown
This will reduce retention and leave a dead space prone Cooley, 197911 preparation, or ’filler’ that simply alters the
to bacterial invasion. shape of the preparation, usually with the pur-
pose of eliminating undercuts.13 Fillers are
often used on anterior teeth where class III
re-assessing the endodontic condition and and V restorations need to be replaced during
crowning it later.) tooth preparation.
Before a crown preparation is undertaken, Occasionally it may be necessary to elec-
look closely at the tooth and form a mental pic- tively devitalise a tooth and provide a post and
ture of what will be left after cutting. Consider core, often in combination with crown length-
the existing restorations; decide on whether they ening, to give adequate retention for the
are sound and whether they will remain in place restoration (eg where only a root face exists).
during the cutting procedure. A history of the However a resin bonded indirect restoration
restoration should be determined but if this is may provide a viable alternative to devitalisa-
not possible, especially if another operator has tion, especially where the intended crown is
done the previous treatment, then consideration short occluso-gingivally. In this situation the
should be given to replacing the restoration. adhesive would be subjected to less heavy peel
From personal experience, such restorations and sheer stresses during function than if the
have been found on removal to have caries, crown were long.
cracked cusps and in some cases, latent pulp It is worth emphasising that crown prepara-
exposure beneath them. It is better to remove tions do not always have to be built up with a
such fillings rather than be faced with an embar- core to an ‘ideal shape’. Instead, existing cavity
Fig. 1 Section of threaded pins rassing endodontic emergency after the crown features can be refined to give suitable grooves
placed into dentine. Notice the has been fabricated and cemented. It also gives and boxes. This approach is particularly useful
dentine crazing (A) and the failure you the chance to inspect (preferably under for crown preparations affected by short clinical
of a pin to fully penetrate the pin magnification) what remains of the tooth and crown height (Fig. 4).
channel (B)
decide whether this can be satisfactorily adapted Cores may be placed either at the time of
to retain the core. tooth preparation or beforehand. Where a
In summary, removal of existing restorations patient requires only a single restoration the
allows proper assessment of: core and preparation can be made simultaneous-
• The tooth’s structural integrity (bearing in ly in which case it is easiest to contour the core
mind the need for mechanical core retention to resemble the intended preparation (Fig. 5).
following tooth reduction during crown However, placing the core in advance gives a
preparation) better opportunity to assess the integrity of a
tooth and its pulp chamber and choose the most
appropriate indirect restoration for the amount
and configuration of remaining tooth tissue.
Cores placed in advance should be properly
contoured to provide occlusal stability, patient
comfort and freedom from food packing (Fig. 6).
This approach becomes more crucial where
patients require multiple cores. Once such cores
are placed, the patient can be reviewed to ensure
compliance with oral hygiene instruction,
Fig. 2 Would you use this amalgam dietary advice and disease control. If the
as a core? patient’s response is unsatisfactory the provision
Recommendations
• Excellent core build-up material for posterior
teeth
• Excellent interim restoration for posterior
teeth
• Adhesives and preparation features can often
substitute for pin retention
CORE MATERIALS
The material requirements of a core will differ
depending on whether it is to be used as a build-
up or filler. As a rule of thumb if sufficient tooth
remains to provide a strong and retentive prepa-
ration then the core acts simply as filler. Should
you be in any doubt it is better to choose a
strong build-up material than risk mechanical
failure of weak filler. Fig. 5 It is sometimes convenient to
build a core to resemble the
intended preparation. (Courtesy of
Amalgam Professor Ian Barnes)
Advantages
• Not especially technique sensitive
• Strong in bulk section
• Sealed by corrosion products
• Can be ‘glued’ into place with cements and
resins
Disadvantages
• Best left to set for 24 hours before tooth
preparation
• Weak in thin section
• Mercury content may be of concern to some
patients and dentists
• Potential electrolytic action between core and Fig. 6 Fully contoured cores are
metal crown essential when longer-term interim
restorations are needed
• Not intrinsically adhesive
build-up material (Fig. 8). In order to protect a lish occlusal stability. The authors were also at
GIC core the crown margin should, wherever pains to emphasise the need for ferruling the
possible, completely embrace 1–2 mm of sound crown preparation onto sound dentine in the
tooth structure cervically. Extension of the same way as for regular GICs. Also of some con-
crown margin in this way is termed the ‘ferrule cern, Vitremer prepared with a diamond bur had
effect’26 and should ideally be used for all cores. an inhibitory effect on the setting of a polyvinyl
siloxane impression material.30 This unset mate-
Resin modified glass ionomers rial may result in die inaccuracies.
Advantages At the present time we are not wildly enthusi-
• Command set astic about using these materials for cores other
• Stronger than regular GICs than as fillers.
• Either intrinsically adhesive or with simplified
bonding system CORE RETENTION
• Fluoride release In this section we consider techniques of secur-
Disadvantages ing the core, which may be used either singly or
• Most are weaker than amalgam and composite in combination. These include:
• Hydrophilic resins cause swelling and can
• Cavity modifications
crack overlying porcelain
• Resin bonding Fig. 8 GICs work best where the
• Some materials can inhibit surface setting of
• Cement bonding retention and resistance for the
addition silicone impressions definitive restoration is derived
• Pins
• Not reliable like amalgam and composite as an mainly from surrounding tooth
interim restoration There is little specific evidence of how well tissue. Here a silver cermet acts as
Recommendations these methods work to retain cores but much excellent space filler in a gold onlay
preparation
• Useful filler but confers few advantages over information can be derived from laboratory
regular GIC studies and clinical studies of large amalgam or
composite restorations.
These materials come in a number of presen-
tations, which can be used for a variety of pur- Cavity modifications
poses including fillings, cementation and core Anyone who has had a core detach within a
placement. They have been developed to provide crown (Fig. 9) will know that it is unwise to place
properties intermediate between regular GICs complete faith in either glues or pins. To gain
and light cured composites. There is a spectrum mechanical retention for the core it is always
of such materials. At one end are those that start worth capitalising on existing cavity features
to set in the same way as a GIC following mixing such as boxes or an isthmus. Where there is only
but are rapidly hardened by light curing the a small amount of tooth tissue remaining it is
incorporated resin (eg Fuji II LC, GC International also worth considering crown lengthening to
Corp, Leuven, Belgium). At the other end of the ensure the crown margin is ferruled onto sound
spectrum are the ‘compomers’, which have an tooth structure.
initial setting reaction similar to composites (eg Improved interlock between core and tooth
Dyract, Dentsply, Weybridge, UK). The GIC reac- can often be obtained by cutting new boxes or
tion does not occur until later when moisture grooves, or by reducing and onlaying weakened
from the mouth is absorbed into the set resin cusps with core material. Where cusps are
matrix where it activates incorporated poly- onlayed in this way the material must be suffi-
acids. The resins used in these materials are ciently thick so that the core is not catastrophi-
hydrophilic and swell slightly following water cally weakened during occlusal reduction of the
absorption. This expansion has the potential to crown preparation. As a rough guide cusps
fracture ceramic restorations overlying cores should be reduced in height where they are less
and cements made with resin modified glass than 1 mm thick or the wall thickness to height
ionomers or compomers.27 ratio is less than 1:1.31 Another useful tip is to
Dentists have received these materials with resolve sloping walls into vertical and horizontal
some enthusiasm not least because the adhesive components. This approach will improve the
systems are easier to use than for composite resistance for both cores and castings. When
resin and unlike GICs their rapid set does not cutting these auxiliary features one clearly
delay tooth preparation. As well as good han- wants to conserve tooth structure, but it is
dling properties there is also the advantage of worth sacrificing non-critical amounts to make
fluoride release. the work reliable. Problems with pulpal
Vitremer (3M, St Paul, USA) is an RMGI with involvement may occur if such features are cut
good strength properties,28 specifically advocated into the ‘heart’ of the tooth — a term used by
as a core material. In a short-term clinical trial it Shillingburg31 to describe the central volume of
behaved satisfactorily under gold crowns, with- dentine beneath which lies the pulp. The heart
out the need for pin placement.29 However, dur- may be avoided by not cutting any features
Fig. 9. A detached core still attached
ing the 3 months before crown preparation a more than 1.5 mm from the amelo-dentinal to its crown, despite a goodly
third of the cores developed significant surface junction (ADJ) in a transverse plane. number of pins. Notice that the
defects, which, although eliminated by crown Most dentists are familiar with the use of crown does not provide a ‘ferrule
preparation, suggest the material unsuitable for proximal grooves to retain Class II amalgam effect’ and the absence of cavity
retention features.
long-term interim restorations needed to estab- restorations. Not so many dentists know that
grooves can be used as an alternative to pins to strength34,37–39 and reduce microleakage.40 All
retain large amalgam and composite restora- Bond 2 has some of the highest bond
tions. Such grooves are cut into the base of strengths.38 However, some bonding agents are
cusps or into the gingival floor of boxes (Fig. ineffective, or relatively so, under conditions of
10). A small round bur (eg ½ or 1 depending on in-vitro testing. For instance, Panavia 21 had
tooth size) can be used. The depth of the groove such low bond strengths with one variety of
needs to be sufficient to offer resistance to with- amalgam it was considered ineffective for reten-
drawal of the head of the bur when it is used to tion.41 Worse still, all specimens made with
gauge the presence of undercut. This usually Amalgam Bond debonded prior to testing.38 But
means cutting to between two thirds and the it needs to be emphasised that better results have
complete depth of a round-headed bur. Grooves been obtained with Amalgam Bond Plus39,42 — a
need to be positioned to within 0.5 mm of the bonding agent, which provides a similar sheer
amelo dentinal junction. Newsome has written strength to pin retained amalgams.39,42 However
an excellent account of the practical mechanical retention, in the form of gooves or
procedure.32 boxes,43 should be provided where possible
The use of grooves (sometimes termed ‘slots’) rather than rely entirely on the adhesive.42
has been tested in–vitro and in-vivo. A circum- A clinical study has also compared the per-
ferential groove used to retain a full coronal formance of pinned amalgam restorations with
amalgam compared with four dentine pins those retained by resin adhesive. After 2 years
showed no significant difference in dislodging both types of restorations performed equally
force in one in-vitro study33 but was less resist- well with no deterioration or loss of retention in
ant in another.34 The majority of pinned cores in either group.44
these studies failed through amalgam slippage The disadvantage of most resin adhesives is
and pins bending. Where the slippage of amal- that they require a multi-stage placement tech-
gam had been slight this would have been diffi- nique involving etching, washing, and priming
cult to detect clinically. By contrast failure of the before the amalgam is condensed onto the wet
grooved cores was all or none. adhesive. Although some single-bottle primer/
Short-term clinical trials show that groove adhesive systems show promise for bonding
retained amalgams perform at least as well amalgam,45 extra time and effort is still needed
as pinned amalgams.35,36 However, grooves and contamination during critical stages will
are associated with less pulpal inflammation destroy the bond.
than pins.12
The above studies were carried out without Cement bonding (Baldwin technique)
adhesives or dentine bonding. A combination of Another way of getting amalgam to bond to
grooves and bonding should be even better. dentine is to pack it onto a thin, wet layer of
cement. This method, called the Baldwin Tech-
Resin bonding nique,46 was reported in 1897 — the very same
Resin adhesives were devised to bond composite year as grooves were described.47 Whilst this
restorations to enamel and dentine. These mate- approach may seem old fashioned it should be
rials have been developed into luting agents for remembered that screw pins for dentine also
adhesively retained bridges and also bonding originated from that time.48
agents for amalgam restorations. Examples of Baldwin used wet zinc phosphate cement to
amalgam bonding agents include: improve the seal of newly placed amalgam
restorations. The technique never really caught
Amalgam bonding agent Adhesive resin on, possibly because traditional teaching insists
Panavia EX and Panavia 21 Phosphate ester of Bis GMA that a cement base must be set to prevent its dis-
All Bond 2 NPG GMA placement by the condensed amalgam. Also, if
Amalgam Bond and 4 META/TBB-MMA, zinc phosphate were extruded to the cavity mar-
Amalgam Bond Plus HEMA gins in any thickness it would be vulnerable to
dissolution. Nevertheless, wet cement has been
In-vitro studies show that when properly recommended to assist with core retention by
placed these materials can enhance bond some highly reputable dentists.49
The evidence for using GICs as an amalgam
core adhesive is currently only laboratory based.
GICs form a good bond to dentine and an even
better one to amalgam.50,51 In bonding amalgam
to dentine GICs and resins give similar results.
Evaluations37,52,53 have included shear, tensile
and fracture strength tests for a variety of GICs
Fig. 10 Groove preparation in an (the luting agent, Ketac Cem; the base/lining
upper molar. A ½ round bur is being material, Vitremer, and the filling material Fuji II).
used to groove the cervical floor of
Unfortunately there are no comparative data,
the box. A: A number 1 round bur
has been used in the lingual cusp either laboratory or clinical, to guide us in the
B: Grooves should be sufficiently selection of the most suitable GIC. Therefore,
deep to offer some resistance to bur whilst the technique holds great promise we
withdrawal have to rely on empirical and derived informa-
Aggregate, Dentsply, Tulsa, USA), has the with water coolant and with aspiration to catch
potential to provide an excellent, biocompatible the fragment of cut pin.
seal.60 The occlusal portion of the pin channel
may need to be opened up sufficiently to allow Tooth fracture during pin placement
moisture control and the material to be con- Root treated or brittle teeth can chip and frac-
densed properly. If the pin is not retrievable it ture especially if the pin is placed too close to
may be left and the tooth put under probation the ADJ. It emphasises that dentine is deformed
with a view to later crown lengthening surgery by pin placement resulting in stresses which
should the tooth give symptoms. Certainly, it can crack the tooth. If the tooth can be saved,
would be unwise to place an expensive indirect the fractured area should be covered by the
restoration on such a tooth until its prognosis restoration.
was confirmed.
Pulpal perforations are usually easier to Matrix band placement
manage than periodontal perforations. Many The placement of a matrix band can often prove
teeth requiring large cores have a questionable a challenge to even the most experienced of
pulpal status, and, if perforated are best root dentists. However, ensuring the proximal con-
treated, especially if the tooth is crucial to the tacts are open and that there are no spicules of
treatment plan and the outcome of the root tooth at the gingival margin can facilitate place-
treatment can be assured. However, if there is ment. The choice of band is highly personal and
no rush to provide an indirect restoration the the best matrix system is ‘the one which works
tooth can be kept under probation and a pulp best for you.’ However occasions arise when a
capping technique used. Many materials seem more sophisticated matrix system is needed,
well tolerated by the pulp providing a bacterio- such as the Automatrix system (LD Caulk Co,
logical seal can be established and maintained. Milford, USA), which has the advantage of not
Some authorities suggest that even the pin being encumbered by a matrix retainer. In com-
itself can act as a ‘pulp cap’61,62 but few den- mon with other systems it does need to be
tists sterilise their pins before placement and wedged and where there are multiple cusps to be
the space between dentine and the inner diam- replaced it may sometimes need to be stabilised
eter of the thread will allow bacteria to spiral using greenstick, taking precautions not to scald
down into the pulp. At the very least the pin the patient with hot composition.
and surrounding dentine will need to be sur- Despite great advances in operative dentistry
face sealed with a dentine-bonding agent. the copper ring (PD Copper Bands, Vevey,
Alternatively, the pin may be removed ultra Switzerland) is sometimes the only way of fitting
sonically (if it has already been placed) and the a matrix to a tooth, especially where all the cusps
pulp capped with calcium hydroxide or MTA,60 have been lost. It is best to choose a band that is,
followed by sealing with composite and den- if anything, slightly too small, trim it to size with
tine bonding agent. Bee Bee scissors and squeeze it to the approxi-
Of course, groove preparation also has the mate outline of the tooth. It can then be adapted
potential to perforate either the pulp or peri- section by section around the tooth stretching
odontium, but this is likely to be a less frequent the band slightly with an amalgam plugger or
event than pin perforation and should it occur half Hollenback instrument. If the band is too
access for repair is very much easier. tight to fit it can be annealed and stretched fur-
ther. Annealing involves heating the copper to
Loose pin cherry red heat in a gas flame and quenching.
A pin may become loose immediately after Although many would consider leaving such a
placement, during pin length reduction or whilst band in place to allow the amalgam to be sup-
replacing an old pin retained restoration. If a ported whilst it sets there is a risk of unseen,
medium sized pin has been used it can be excess material being left and this could lead to
replaced with a large pin. Alternatively, the wis- gingival inflammation. It is usually an easy mat-
dom of replacing the pin can be reviewed, the ter to slit the band with a tapered diamond bur
pin channel converted into a groove and the and remove it at the time of placement. Ortho-
core bonded adhesively. dontic bands or aluminium temporary crown
A pin that is too tall will protrude through the shells with their occlusal surfaces removed can
occlusal surface of the core. Where the pin is act as a substitute for copper rings,63 but alu-
shortened with a bur it can very easily come minium reacts with mercury to form a flocculent
unscrewed, especially if the bur is kept in line airborne precipitate.
with the pin, which causes an anticlockwise fric-
tional force. The chatter from a tungsten carbide Early core fracture
bur is also effective in dislodging pins. We rec- We have all had the frustration of early core
ommend holding the tip of a long tapered dia- fracture occurring whilst the matrix band is
mond bur at right angles to the pin and cutting removed or when the patient bites onto a par-
from the side rather than grinding from above. tially set amalgam. If only a small portion of the
An airotor handpiece should be used with a light core breaks away it is often possible to shape the
touch. In this way the frictional forces generated remaining amalgam to provide a retentive cavi-
tend to act on the pin in a clockwise direction. ty and pack fresh amalgam — sometimes without
Needless to say this procedure should be done the need for the matrix being replaced. A more
catastrophic fracture will of course 13. Christensen G J. When to use fillers, Wilson M A. A short-term clinical 45. Cobb D S, Denehy G E, Vargas M A.
build-ups or posts and cores. J Am evaluation of a tricure glass-ionomer Amalgam shear bond strength to
necessitate the complete replacement Dent Assoc 1996; 127: 1397-1398. system as a transitional restoration dentin using single-bottle
of the core. 14. Gross M J, Harrison J A. Some and core buildup material. primer/adhesive systems. Am J
electrochemical features of the in Quintessence Int 1999; 30: 405-411. Dent 1999; 12: 222-226.
CONCLUSION vivo corrosion of dental amalgam. 30. Moon M G, Jarrett T A, Morlen R A, 46. Baldwin H. Cement and amalgam
J Appl Electrochem 1989; 19: Fallo G J. The effect of various fillings. Br J Dent Sci 1897; vol. XL:
A well-placed core is the foundation 301-310. base/core materials on the setting of 193-234.
for a successful restoration. Success 15. Cho G C, Kaneko L M, Donovan T E, a polyvinyl siloxane impression 47. Kirk E C. The American Textbook of
depends on selecting the most appro- White S N. Diametral and material. J Prosthet Dent 1996; 76: Operative Dentistry. Philadelphia:
compressive strength of dental core 608-612. Lea Brothers, 1897.
priate material and ensuring that it is materials. J Prosthet Dent 1999; 82: 31. Shillingburg H T, Jr., Jacobi R, Brackett 48. Ottolengui R. Methods of filling
properly retained. Pin retention is not 272-276. S E. Preparation modifications for teeth. 2nd ed.pp.112. London:
without problems and in most situa- 16. Hormati AA, Denehy GE. damaged vital posterior teeth. Dent Claudius Ash & Sons Limited, 1899.
tions can be avoided. Retention can be Microleakage of pin-retained Clin North Am 1985; 29: 305-326. 49. Vale W A. Everyday procedures in
amalgam and composite resin bases. 32. Newsome P R H. Slot Retention: An dentistry - abutment preparations
assured through cavity modifications, J Prosthet Dent 1980; 44: 526-530. alternative to pins in the large for fixed bridgework. Br Dent J
crown lengthening (to provide a fer- 17. Ziebert A J, Dhuru V B. The fracture amalgam restoration. Dent Update 1953; 94: 93-98.
rule effect on sound tooth structure) toughness of various core materials. 1988; 15: 202-207. 50. Aboush Y E, Jenkins C B. The
J Prosthodont 1995; 4: 33-37. 33. Outhwaite W C, Garman T A, Pashley bonding of glass-ionomer cements
and adhesives. 18. Burke F J T, Watts D C. Cermet — An D H. Pin vs. slot retention in extensive to dental amalgam. Br Dent J 1989;
ideal core material for posterior amalgam restorations. J Prosthet 166: 255-257.
1. Newsome P R, Youngson C C. teeth? Dent Update 1990; 17: Dent 1979; 41: 396-400. 51. Aboush Y E, Elderton R J. Bonding
Complications of pin placement. 364-369. 34. Pashley E L, Comer R W, Parry E E, of a light-curing glass-ionomer
A survey of 429 cases. Br Dent J 1987; 19. Beyls H M, Verbeeck R M, Martens L C, Pashley D H. Amalgam buildups: cement to dental amalgam. Dent
163: 375-378. Lemaitre L. Compressive strength of shear strength and dentin sealing Mater 1991; 7: 130-132.
2. Wilson N H. The pattern of usage of some polyalkenoates with or without properties. Oper Dent 1991; 16: 52. al-Moayad M, Aboush Y E, Elderton
dentine pins. Eur J Prosthodont Restor dental amalgam alloy incorporation. 82-89. R J. Bonded amalgam restorations:
Dent 1996; 4: 137-139. Dent Mater 1991; 7: 151-154. 35. Garman T A, Outhwaite W C, Hawkins a comparative study of glass-
3. Newitter D A, Gwinnett A J, Caputo L. 20. Walls A W, Adamson J, McCabe J F, I K, Smith C D. A clinical comparison ionomer and resin adhesives. Br
The dulling of twist drills during pin Murray J J. The properties of a glass of dentinal slot retention with Dent J 1993; 175: 363-367.
channel placement. Am J Dent 1989; polyalkenoate (ionomer) cement metallic pin retention. J Am Dent 53. Chen R S, Liu C C, Cheng M R, Lin C
2: 81-85. incorporating sintered metallic Assoc 1983; 107: 762-763. P. Bonded amalgam restorations:
4. Standlee J P, Caputo A A, Collard E W. particles. Dent Mater 1987; 3: 113- 36. Tewari S, Govila C P, Paharia Y N. using a glass-ionomer as an
Retentive pin installation stresses. 136. A clinical evaluation of dentinal slot, adhesive liner. Op Dent 2000; 25:
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5. Khera S C, Chan K C, Rittman B R. cermet for the restoration of primary 1990; 1: 14-17. trial of the glass-ionomer cement-
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distance. J Prosthet Dent 1978; 40: Br Dent J 1995; 179: 175-179. strength of dental amalgam bonded Quintessence Int 1990; 21: 507-
538-543. 22. Kovarik R E, Breeding L C, Caughman to dentin [published erratum appears 512.
6. Bione H M, Wilson P R. The effect of W F. Fatigue life of three core in Am J Dent 1991 Apr;4(2):94]. Am J 55. Butchart D G. A new self-threading
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7. Hummert T, Kaiser D. In vitro Parapulpal pins and their effects on dentin. J Esthet Dent 1991; 3: 117-20. 2-6.
evaluation of dynamic fluid the fracture resistance of pin- 39. Hadavi F, Hey J H, Strasdin R B, 57. Knibbs P J, Foreman P C, Smart E R.
displacement in dentinal tubules retained cores. J Oral Rehabil 1991; McMeekin G P. Bonding amalgam to The use of an analog type apex
activated on pin placement. J 18: 459-469. dentin by different methods. locator to assess the position of
Prosthet Dent 1992; 68: 248-255. 24. Combe E C, Shaglouf A M, Watts D C, J Prosthet Dent 1994; 72: 250-254. dentine pins. Clin Prev Dent 1989;
8. Webb E L, Straka W F, Phillips C L. Wilson N H. Mechanical properties of 40. Charlton D G, Moore B K, Swartz M L. 11: 22-25.
Tooth crazing associated with direct core build-up materials. Dent In vitro evaluation of the use of resin 58. Cooley R L, Lubow R M, Wayman B
threaded pins: a three-dimensional Mater 1999; 15: 158-165. liners to reduce microleakage and E. Treatment of pin perforations.
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9. Cooley R L, Barkmeier W W. under cast crowns. Dent Mater 1990; 112-119. removal of dentine pins. J Dent
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8
IN BRIEF
● The principles of crown preparation and crown selection
● Guidelines for tooth reduction and margin design
● Preparation of the taper
● Strategies for enhancing resistance and retention
● Tooth preparation
Preparations for full veneer crowns is the eighth in the series on crowns and other extra-coronal restorations. Whilst
handpiece skills are important, many other factors combine to ensure provision of a satisfactory full veneer crown (also
termed ‘full coverage crown’). Our aim in writing this article is to consider the principles which influence crown preparation,
seasoned with clinical advice our undergraduate and postgraduate students have found useful.
In the second article of this series we considered ed by making a thicker and perhaps very aes-
CROWNS AND EXTRA-CORONAL the broad range of materials from which crowns thetic crown, but the strength and pulpal vitality
RESTORATIONS:
are made. The four main categories of crown of the underlying tooth may be compromised. In
1. Changing patterns and
were metal, ceramic, metal-ceramic and com- reality, preparations should be planned accord-
the need for quality
posite. Tooth preparations need to reflect the dif- ing to each individual case and in each case the
2. Materials considerations ferent requirements of these materials in terms balance will be different. Clearly, patients need
3. Pre-operative of amount of space needed to accommodate the to be involved in deciding what is best for them.
assessment crown and its marginal configuration. Tooth This approach differs fundamentally from sim-
4. Endodontic preparations also need to be free from undercuts ply cutting ‘off the shelf’ preparations based
considerations whilst reliably retaining the crown. entirely on text-book diagrams.
5. Jaw registration and The principles of crown preparation described
articulator selection by Shillingburg1 (Table 1) determine the shape CROWN SELECTION
6. Aesthetic control and form of our preparations, but they cannot be The usual indications for full veneer crowns are:
7. Cores for teeth with considered in isolation as there has to be a bal-
• To protect weakened tooth structure
vital pulps ance between them. For example, minimal
• To restore the tooth to function
8. Preparations for full preparation can result in the production of a
• To improve or restore aesthetics
veneer crowns bulky, unaesthetic crown which can in turn
• For use as a retainer for fixed bridgework
9. Provisional restorations cause periodontal or occlusal problems (Fig. 1).
Conversely over preparation can be compensat- However, recent developments in dental
10. Impression materials and
technique
11. Try-in and cementation Table 1 Seven key principles of preparation (derived from Shillingberg1)
of crowns Seven key principles Function
12. Porcelain veneers
Conservation of To avoid weakening the tooth unnecessarily
13. Resin bonded metal tooth tissue To avoid compromising the pulp
restorations Resistance form To prevent dislodgement of a cemented restoration by apical or
1Consultant in Restorative Dentistry, obliquely-directed forces
Birmingham Dental Hospital, St Chad’s Retention form To prevent displacement of a cemented restoration along any of its
Queensway B4 6NN paths of insertion, including the long axis of the preparation
2*,3Senior Lecturer in Restorative Dentistry,
Structural durability To provide enough space for a crown which is sufficiently thick to
Department of Restorative Dentistry,
prevent fracture, distortion or perforation
The Dental School, Framlington Place,
Newcastle upon Tyne NE2 4BW Marginal integrity To prepare a finish line to accommodate a robust margin with close
*Correspondence to: R. W. Wassell adaptation to minimise microleakage
E-mail: R.W.Wassell@newcastle.ac.uk Preservation of the To shape the preparation such that the crown is not over
periodontium contoured and its margin is accessible for optimal oral hygiene
Refereed Paper
© British Dental Journal 2002; 192: Aesthetic considerations To create sufficient space for aesthetic veneers where indicated
561–571
materials mean that the use of less destructive cerns, real or imagined, over biocompatibility of
alternatives such as veneers, onlays, and suit- proposed materials.
ably designed plastic restorations are often an Full veneer metal crowns (VMC) have the
option. Where crowning is in the patient’s best advantage of requiring relatively little tooth
interests the type of crown provided will usually preparation. They are generally limited by aes-
depend on the functional requirements, the thetics to the back of the mouth, but bear in
strength and vitality of the remaining tooth and mind that some people may favour an anterior
the patient’s aesthetic demands. Occasionally, display of gold.
the choice may be limited by a patient’s con- Porcelain jacket crowns (PJC) are indicated in
areas of critical aesthetics, but problems of frac-
ture under occlusal load limit their use to anteri-
or teeth.
High strength porcelain crowns (HSPC), using
modern ceramics without the need for a metal
substructure, may be used on posterior teeth and
Fig. 1 Under preparation results in poor
in certain selected cases for anterior bridgework
aesthetics or an over built crown (dotted especially where the use of metal is an issue.
line) with periodontal and occlusal However, not all systems are suitable for these
consequences. Over preparation results purposes. The preparation design for a posterior
in pulp and tooth strength being HSPC is important2,3 and relatively destructive.
compromised
Enough tooth tissue needs to be removed to
permit an adequate thickness of porcelain while
the degree of taper should be greater than for a
conventionally cemented crown, and all corners
and line angles need to be rounded to allow
unhindered, passive seating of the crown. At
least one system (Procera AllCeram, Nobel Bio-
care, Göteburg, Sweden) provides burs designed
to cut a deep chamfer at the finish line to allow
the profile of the die to be scanned with a digital
profilometer for the production of a high
strength ceramic core.
Resin bonded porcelain crowns (RBPC) are
similar to porcelain veneers but provide cov-
erage on all surfaces and are very conservative
of tooth tissue. The strength of these restora-
tions is largely reliant on the resin bond as
there is no reinforcing ceramic core. Excellent
aesthetics are possible and a much less
Fig. 2 Preparation features for three different types of crown for an
upper central incisor: a) Porcelain fused to metal; b) Porcelain jacket; destructive preparation can be used than for
and c) Resin bonded porcelain crown (remaining enamel shown light either PJCs or porcelain fused to metal crowns
blue). Questions — which crown or crowns: Provide the best (look at Fig. 2). RBPCs may be particularly use-
aesthetics? Has the least destructive preparation? Is least destructive ful in younger patients who have large, vul-
to opposing teeth? Allows anterior guidance to be developed easily? Is
best suited to bruxists? (see text for answers)
nerable pulps. Long term follow-up is lacking
but a similar success rate to veneers might be
expected. In our experience this type of
restoration is not suited to areas of heavy
occlusal load (eg where tooth wear has been
caused principally by parafunction) as the
porcelain may fracture.
Porcelain fused to metal crowns (PFM), also
called metal-ceramic crowns, are undoubtedly
most versatile combining strength with aesthet-
ics. Tooth preparation to accommodate both
metal and porcelain can be very destructive
(Fig. 3) so the design, particularly the distribu-
tion of porcelain, needs to be carefully thought
through. Metal surfaces require less tooth
destruction, are easier to construct and adjust,
and do not chip like porcelain. Porcelain cover-
age should only be used where it is required for
aesthetics, or possibly when opposing other
Fig. 3 Sections (axial and transverse) through an upper first premolar showing how porcelain surfaces (as metal does not wear well
a logical use of metal lessens the amount of tooth reduction: a) Porcelain restricted against porcelain, especially the metal backs of
to buccal cusp; b) Porcelain covering proximal and occlusal surface; and c) Full anterior crowns).
porcelain coverage
If full porcelain coverage is required for a
worth, UK). This type of coping is 0.1–0.2 mm Occlusal reduction* Finish line depth and configuration
thinner than a cast coping made from a noble VMC 1 mm non-functional cusps 0–1.0 mm
metal alloy. 1.5 mm functional cusp Chamfer, knife-edge,
Composite crowns which use newly devel- shoulder or shoulder with bevel
oped laboratory materials have not been fully HSPC 2 mm non-functional cusps 0.8-1.0 mm
evaluated. Specific indications and limitations
2.5 mm functional cusps Shoulder or heavy chamfer
have yet to be defined. Manufacturers are cur-
PFM As for VMC if metal surface 1.2 mm labial shoulder† or chamfer
rently recommending that the tooth be prepared
2 mm non-functional cusps 0.5 mm lingual chamfer
in the same way as for a HSPC.
The major factor to be considered before 2.5 mm functional cusps
selecting the most suitable type of crown is the *Where tooth is tilted or where vertical dimension is to be increased, the amount of occlusal reduction
required will vary
amount of tooth destruction you are willing to †Too deep a reduction for diminutive teeth or for long clinical crowns where a metal collar is preferable
allow in order to give the aesthetics you want.
You may also want to consider the need for
the crown to incorporate special features,
Table 3 Suggested preparation features for anterior crowns
for example:
Crown type Anterior crowns — preparation features
• A metal anterior guidance surface Occlusal reduction* Finish line depth and configuration
• Rest seats and other features to retain a partial
denture PJC 2 mm incisally 0.8–1.0 mm shoulder
• Metal occlusal surfaces for a bruxist 1 mm lingual aspect
RBPC 2 mm incisally > 0.4 mm chamfer
0.5–1.0 mm lingual aspect
GUIDELINES FOR AMOUNT OF TOOTH
PFM 2 mm incisally 1.2 mm labial shoulder†
REDUCTION AND MARGIN DESIGN
0.5–1.0 mm lingual aspect or heavy chamfer
Tooth preparation represents a balance
(porcelain guidance requires 0.5 mm lingual chamfer
between, conserving tooth structure and pulp
greater clearance)
health on the one hand, whilst on the other,
*Where the vertical dimension is to be increased, the amount of occlusal reduction required will be less
achieving an aesthetic and strong crown. or non-existent
Guidelines for the amount of tooth reduction † Too deep a reduction for diminutive teeth eg lower incisors or for long clinical crowns where a metal
PREPARATION TAPER
The subject of taper is contentious. In the first
place it means different things to different
people. For our purpose it has the same meaning
as ‘convergence angle’ ie the angle between
opposing preparation walls. To avoid confusion
when reading different publications, it is impor-
tant to appreciate that ‘taper’ may also be
defined as ‘the angle between a single prepara-
tion wall and the long axis of the preparation’.
Taper defined by the first definition will be twice
the angle defined in the second.
As regards the question of ideal convergence
angle, text books have traditionally based their
Fig. 5. Finish lines with marginal configurations for PFMs: a) Shoulder with recommendations (variously between 3 and
porcelain butt fit; b) Deep chamfer with metal collar; c) Shoulder plus chamfer 14o)7–9 on the results of experimental studies10,11
(bevel) with metal collar; d) Knife edge with metal margin; and e) Chamfer with which show a decrease in retention of conven-
metal margin
tionally cemented crowns as taper is increased.
Experimental studies have also shown that
As a general rule when using porcelain or preparations with tapers greater than 20o display
PFMs, adequate clearance is required to achieve a significant fall in resistance to oblique displac-
good aesthetics. Traditionally, this is achieved ing forces12 and show increased stress concen-
with a shoulder or heavy chamfer of 0.8–1 mm tration within the cement13 which may rupture
width for PJCs and 1.2 mm width for PFMs. the cement lute.
However, shoulders of these depths may compro- On the other hand, clinical measurements
mise tooth strength and pulp health especially for of taper have been made indirectly on stone
diminutive teeth such as mandibular incisors. A casts. 14–18 These studies showed mean values of
similar problem occurs on teeth with long clini- about 20o with a considerable variability around
cal crowns because of the narrowing of their the mean. Furthermore, greater tapers were
diameter in the cervical region. In a long prepa- achieved on mandibular molars than on maxil-
ration extending onto or beyond the cemento- lary incisors19 possibly because of differences in
enamel junction, considerable tooth tissue must tooth shape and problems with access. These
be removed to eliminate undercuts. Solutions findings suggest that clinicians, even those who
include using a minimal shoulder, a metal collar are technically gifted, frequently cut a greater
on a chamfer (as illustrated in Fig. 6) or placing taper than text books recommend.
the margin at the cemento-enamel junction. The issue of taper may not be quite as critical
Under normal circumstances these options do for single crowns as was once thought, but as a
not compromise aesthetics, being hidden by the working rule operators should strive to produce
lip. Clearly, patients need to understand the ben- the least taper compatible with the elimination
efits of a less destructive preparation and, as stat- of undercut. It is helpful to know that many
ed previously, must be involved in the decision tapered burs have a 5–6o convergence angle
making process pre-operatively. which can be used to survey preparation taper
Some operators use what they describe as a by holding the handpiece in the same plane for
mini-shoulder, 0.5–0.7 mm wide, for both all axial surfaces.
Resin bonded crowns are the important
exception to the rule of minimizing taper, espe-
a b cially RBPCs which may benefit from having
tapers of about 20o to avoid generating high
seating hydrostatic pressures during luting
resulting in crown fracture.
Grooves Boxes
Grooves can be placed in one or more of the Boxes function similarly to grooves in providing
axial walls using a minimally tapered bur. The increased resistance and retention, but are less con-
bur chosen should be of sufficient diameter to servative so it is difficult to justify them being cut
provide a groove that will not be blocked out on into sound tooth structure unless there are other
the die with die-spacer (see flat-end tapered dia- reasons for their presence (eg provision of a crown
mond in Fig. 4). The groove should be placed with an intra-coronal attachment). Nevertheless, a
within a sound bulk of tooth tissue or core not tooth may have previously contained a restoration
leaving any weak surrounding areas which are with a box form. Instead of using the box to retain a
liable to fracture. The tooth may also be less vul- core the box can be incorporated into a crown
nerable to the effects of micro-leakage if the preparation. This is a useful approach where the
base of the groove is kept 0.5 mm clear of the core would otherwise be thin and weak. You may
need to take care to ensure the resulting crown is to allow the gingival tissues to recover fully to
not so bulky that casting porosity or thermal sensi- their final form.
tivity becomes a problem.
Boxes need not necessarily be sited solely on Pins and cross-pins
axial walls For example, it is sometimes very Pins and cross pins are rarely used as they are
useful to cut an intra-coronal box, resembling technically demanding and have become even
an occlusal inlay, into the occlusal aspect of a less popular since the introduction of resin
substantial core. Clearly, this approach would cements. Pins may be considered where there
be inappropriate if it weakened the core appre- is a good bulk of tooth tissue. They are incor-
ciably. porated during the construction of the
restoration and are sunk through the occlusal
Resin cements surface.
Resin cements (to be described in Part 13 of the Cross-pins are placed following cementation
series) provide a relatively simple option to over- and are screwed transversely through the axial
come the low tensile strength and poor adhesion surface of the crown into the underlying prepa-
of conventional cements. Resin cements have ration.
much higher tensile strength21 and when used in
combination with dentine bonding agents are less TOOTH PREPARATION
sensitive to repetitive dislodging forces.22,23 They To avoid any unwanted surprises, the struc-
are, however, technique sensitive and are not sup- tural, endodontic, periodontal, aesthetic and
ported by long term clinical data. Current clinical occlusal factors outlined in the previous parts
wisdom is, where possible, to combine sound of the series should be checked before bur is
retentive design with resin cementation. put to tooth.
There are a variety of burs which can be
Crown lengthening used for crown preparations and operators will
Exposure of a greater height of clinical crown have their own preferences. Some operators
may involve either gingivectomy (with a scalpel may prefer a flat ended bur for shoulder pro-
or electrosurgery) or flap surgery with osseous duction. However, the round ended bur has the
recontouring. It is an invaluable means of benefit of producing a rounded junction
enhancing retention, but can be a substantial between the finish line and axial walls which
undertaking and has to be balanced against the will help reduce stress concentration in this
disadvantage of patient discomfort. Details of vulnerable part of the preparation and is less
technique are described elsewhere.24 Crown likely to cut steps.
lengthening needs to be planned in advance of Most practitioners in the UK use air rotor
tooth preparation (Fig. 9). If the ultimate posi- handpieces, although in continental Europe
tion of the gingival margin is critical then good and elsewhere speed increasing handpieces
provisional restorations should be provided and are favoured. Whatever option is chosen a
worn for 2–3 months before the final impression water spray is absolutely essential to avoid
a b
c d
Fig. 9 When clinical crown height is short, plan ahead. a) Upper anterior teeth needing crowning with PFMs b) Crown
lengthening using apically repositioned flap and osseous recontouring c) Preparations made 3 months after surgery.
Note no incisal reduction needed as vertical dimension to be increased d) Preparations viewed occlusally (mirror view)
showing retention grooves in cingulum of UL2 (22)
Preparation sequence
There are definite advantages in following a set
order of tooth reduction and ensuring that each
element of reduction is complete before starting
the next. For instance, if the occlusal surface is
prepared first there will be better access for the
more difficult proximal preparation. Depth cuts
placed before embarking on larger areas of tooth
reduction help ensure controlled removal of
tooth tissue but where the proposed crown is to Fig. 10 Functional cusp bevel (FCB)
be shaped differently from the original tooth a of the holding cusps required for
preparation matrix, as described in Part 6 of the occlusal clearance
series, is more helpful. During axial preparation
it is best to complete the most difficult wall first space is available for good aesthetics. It is worth
so if any alignment modifications are required viewing the tooth from both occlusal and buccal
they can be made in more accessible areas. aspects to ensure the correct planes of adjust-
Each stage of reduction has its own special ment have been made.
considerations and these will now be discussed On molars the preparation may extend
in the sequence of preparation that we would towards the furcation region where a concavity
recommend. of the buccal surface can be found. To avoid cre-
ating a crown with an over-bulky buccal sur-
Posterior preparations face, the finish line should be cut to its full depth
Occlusal reduction in this area and the concavity should be extend-
Before any reduction is carried out it is important ed up the buccal axial wall to the occlusal sur-
to assess the occlusion and note any space already face. This approach, which may also need to be
available between opposing teeth. For example, used on other axial walls with cervical concavi-
a mesially tilted molar may require little or no ties, eg the mesial aspect of upper first premo-
reduction of its mesial occlusal surface so depth lars, results in a preparation having a kidney
cuts can be confined to the distal occlusal area. If shaped appearance when viewed occlusally.
the reduction follows the cuspal contours you will
get maximum axial wall height available for resist- Proximal reduction
ance and retention, but clearly this is not so critical During proximal reduction many adjacent teeth
where long axial walls are to be prepared. The are damaged.25 If a fine tapered bur is used for
functional cusp bevel, shown in Fig. 10, is a useful the preliminary cut it can be kept safe by ensur-
feature of the occlusal reduction and ensures space ing a fine sliver of tooth or core material remains
for adequate bulk of crown material in a site of between the preparation and the adjacent tooth.
heavy occlusal contact. The functional cusp (or This sliver can then be flicked away before refin-
holding cusp) must be identified and, after bevel- ing the reduction with a bur of larger diameter.
ling, adequate clearance should be confirmed in all To ensure clearance of the proximal contact, try
excursive movements. This small simple step helps to keep the tip of the bur at the level of the pro-
avoid the creation of an occlusal interference or posed finish line. There is no doubt that this is
perforation of a crown’s occlusal surface. the most difficult stage of the preparation.
Once the basic preparation is complete, check
Lingual reduction the path of insertion and taper. Again, if you
Lingual access may be difficult. However if the view the preparation from both occlusal and
lingual surface is the first axial surface to be buccal aspects you should ensure that no under-
prepared, it reduces the likelihood of produc- cut goes undetected. A surface reflecting mirror
ing an over tapered preparation especially if is especially useful for such inspection. When
the bur is held parallel to the long axis of the viewing occlusally do so with one eye closed
tooth. Subsequent alignments to the prepared because an undercut can be perceived as a near
lingual wall are then carried out on more parallel taper when seen with two eyes. Take
accessible surfaces. special care to check the junction between prox-
imal and buccal/lingual reductions which are a
Buccal reduction common site for undercuts.
Good retention relies on near parallelism cervi- On PFM preparations, where the deeper
cally of the buccal and lingual axial walls. How- reduction for porcelain and metal meets the shal-
ever, it is also important to ensure that the lower reduction for metal (this is shown from the
preparation is in harmony with the buccal con- occlusal aspect in Fig. 3a) there is often a distinct
tours of the adjacent teeth so that sufficient step in the axial wall. This feature is termed
Anterior preparations
With the exception of provision of a functional
cusp bevel, anterior preparations need similar
consideration to posterior preparations. However,
a few additional points need highlighting:
• Incisal reduction is best carried out first. This
will improve subsequent preparation access
Fig. 13 Full veneer crown preparation LL6 (36) and three quarter preparation at and helps to ensure correct proportioning of
LL5 (35): a) Occlusal reduction carried out on both teeth. In the same way each axial reduction planes
axial surface was completed sequentially. Note the depth grooves on the occluso- • The reduction of the labial surface should be
buccal aspect of LL6 (36); b) The completed preparations showing the mesial finish in two or more planes to achieve good aes-
line on a sound amalgam core
thetics and conserve tooth tissue. Long clini-
cal crowns will often need to undergo three occlusal seat of full crown preparations. J Prosthet Dent
1981; 45: 138-145.
plane reduction; Figure 11 illustrates this
7. Dykema R W, Goodacre C J, Phillips R W. Johnston’s Modern
• The palatal reduction needs to reproduce the Practice in Crown and Bridge Prosthodontics. pp.24.
natural concavity of maxillary teeth if space is Philadelphia: W.B. Saunders Co., 1986.
to be provided for the development of anterior 8. Shillingburg H T, Hobo S, Fisher D W. Preparations for Cast
Gold Restorations. pp.p16. Chicago: Quintessence Publishing
guidance; Figure 12 illustrates this. Unless Co., 1974.
clearance during lateral and protrusive move- 9. Tylman S D, Malone W F P. Tylman’s Theory and Practice of
ments has been checked, it is very easy to end Fixed Prosthodontics. pp.103. St. Louis: C. V. Mosby Co.,
1978.
up with a crown which occludes satisfactorily 10. Jorgensen K D. Relationship between retention and
in the intercuspal position, but which inter- convergence angle in cemented veneer restorations. Acta
feres during excursions. Odontol Scand 1955; 13: 35-40.
11. Kaufman E G, Coehlo D H, Colin L. Factors influencing the
rentention of cemented gold castings. J Prosthet Dent 1961;
Multiple preparations 11: 487-502.
Preparation of multiple teeth can be stressful for 12. Dodge W W, Weed R M, Baez R J, Buchanan R N. The effect of
both patient and dentist. Where possible try to convergence angle on retention and resistance form.
Quintessence 1985; 16: 191-194.
sequence treatment so that no more than four 13. El-Ebrashi M K, Craig R G, Peyton F A. Experimental stress
teeth are prepared at one sitting or perhaps six if analysis of dental restorations. Part III. The concept of the
dealing with the maxillary anteriors. geometry of proximal margins. J Prosthet Dent 1969; 22:
333-345.
If you are able to prepare multiple teeth with 14. Ohm E, Silness J. The convergence angle in teeth prepared for
a mutual path of insertion it will facilitate the artificial crowns. J Oral Rehabil 1978; 5: 371.
construction of provisional restorations and 15. Eames W B, O’Neal S J, Monteiro J, Roan J D, Cohen K S.
helps with cementation of definitive crowns. Techniques to improve the seating of castings. J Am Dent
Assoc 1978; 96: 432.
However, this must not be done at the expense of 16. Mack P J. A theoretical and clinical investigation into the
excessive tooth reduction. To ensure a mutual taper achieved on crown and inlay preparations. J Oral
path of insertion it is usually best to prepare Rehabil 1980; 7: 255.
17. Norlander J, Weir D, Stoffer W, Ochi S. The taper of clinical
each surface sequentially for all the teeth rather preparations for fixed prosthodontics. J Prosthet Dent 1988;
than fully complete each preparation before 60: 148-151.
moving onto the next (Fig. 13). 18. Noonan J E, Goldfogel M H. Convergence of the axial walls of
full veneer crown preparations in a dental school
environment. J Prosthet Dent 1991; 66: 706-708.
CONCLUSION 19. Kent W A, Shillingburg H T, Duncanson M G. Taper of clinical
Crown preparations are destructive to underly- preparations for cast restorations. Quintessence Int 1988;
ing tooth tissue and can affect the pulp. There- 19: 339-345.
20. Maxwell A W, Blank L W, Pelleu G B. Effect of crown
fore, the type of crown selected should have preparation height on the retention and resistance of gold
the least destructive preparation in keeping castings. Gen Dent 1990; May-June: 200-202.
with the patient’s functional and aesthetic 21. Michelini F S, Belser U C, Scherrer S S. Tensile bond strength
of gold and porcelain inlays to extracted teeth using three
requirements. Where appropriate the use of cements. Int J Prosthodont 1995; 8: 324-331.
less destructive, adhesively retained restora- 22. Wiskott H W, Nicholls J I, Belser U C. The relationship
tions should be considered. between abutment taper and resistance of cemented crowns
to dynamic loading. Int J Prosthodont 1996; 9: 117-139.
The authors would like to thank Mr Alan Waller, Audio- 23. Wiskott H W, Nicholls J I, Belser U C. The effect of tooth
Visual Department, for help with the diagrams. Thanks also preparation height and diameter on the resistance of
to Drs Eoin Smart and Ian Macgregor for their constructive complete crowns to fatigue loading. Int J Prosthodont 1997;
criticism and careful proof reading. 10: 207-215.
24. Smith D G. Toothwear: Crown lengthening procedures. In:
1. Shillingberg H T, Hobo S, Whitsett L, Jacobi R, Brackett S E. Barnes I E, Walls A W G, editors. Gerodontol pp.109-117.
Fundamentals of fixed prosthodontics. 3rd ed. Chicago: Oxford: Wright, 1994.
Quintessenence, 1997. 25. Moopnar M, Faulkner K D. Accidental damage to teeth
2. Burke F J T. Fracture resistance of teeth restored with dentin- adjacent to crown-prepared abutment teeth. Aust Dent J
bonded crowns: the effect of increased tooth preparation. 1991; 36: 136-140.
Quintessence Int 1996; 27: 115-121. 26. Silness J. Periodontal conditions in patients treated with
3. Broderson S P. Complete-crown and partial-coverage tooth dental bridges. II. The influence of full and partial crowns on
preparation designs for bonded cast ceramic restorations. plaque accumulation, development of gingivitis and pocket
Quintessence Int 1994; 25: 535-539. formation. J Perio Res 1970; 5: 219-224.
4. Rosner D. Function placement and reproduction of bevels for 27. Silness J. Periodontal conditions in patients treated with
gold castings. J Prosthet Dent 1963; 13: 1160-1166. dental bridges. III. The relationship between the location of
5. Ostlund L E. Cavity design and mathematics: Their effect on the crown margin and the periodontal condition. J Perio Res
gaps at the margins of cast restorations. Operative Dent 1970; 5: 225-229.
1985; 10: 122-137. 28. Hegdahl T, Silness J. Preparation areas resisting displacement
6. Gavilis J R, Morency J K, Riley E D, Sozio R B. The effect of of artificial crowns. J Oral Rehabil 1977; 4: 201-207.
various finish line preparations on the marginal seal and
9
IN BRIEF
● The functions of provisional (sometimes termed temporary) restorations
● Diagnostic uses of provisional restorations
● Provisional restorations for conventional preparations including: the concept of short,
medium, and long-term temporisation; materials; and direct and indirect provisional
restorations
● Provisional restorations for adhesive preparations
● Problem solving
The important role of provisional restorations is often overlooked. This may be because they are left until the end of an
appointment when time for construction is short or because they generally do not need to last for long. However, not only
can good provisional restorations help produce better final restorations, they can also save a lot of time and expense at
subsequent appointments. In fact time spent in their construction will be more than repaid in time saved doing additional
procedures, adjustments and remakes later on.
Provisional cements
Provisional restorations are usually cemented
with soft cement. Traditionally, a creamy mix of
zinc oxide eugenol was used, but nowadays
most dentists prefer proprietary materials such
as Temp Bond (Fig. 5). This material comes with
a modifier, which is used to soften the cement, as
described later in the article, to ease removal of
the provisional restoration from more retentive
preparations. Temp Bond NE is a non-eugenol
cement which may be used for patients with
eugenol allergy or where there is concern over
the possible plasticising effect of residual
eugenol on resin cements and dentine bonding
agents. Certainly, surface hardness11 and shear
Fig. 5 Temp Bond and Temp Bond NE: The modifier (central tube) can be mixed with Temp Bond bond strength of resin12 to resin can both be
Base and Catalyst to ease crown removal with retentive preparations. Regular Temp Bond contains affected by eugenol and it is worth noting that
eugenol, which can soften composite cores. Temp Bond NE (shown to right of photograph) does not eugenol cements can significantly reduce the
contain eugenol and will avoid this problem
bond of resin cements to composite cores.16
However, resin bond strengths to enamel13 and
dentine14 are not affected if the eugenol residue
a is removed with pumice and water before condi-
tioning. Microleakage15 is also unaffected by the
use of eugenol.
Occasionally, hard cement is needed to retain
a provisional on a short preparation. This is con-
sidered later in the ‘problem solving’ section.
a
Fig. 6 (a) A familiar polycarbonate
shell crown relined with Trim; and
(b) The provisional is carefully
trimmed to help maintain gingival
health
Cast metal
Alloys used include nickel chromium, silver and
scrap gold. Copings can be cast with external
retention beads for acrylic or composite. In less
aesthetically critical areas of the mouth, metal Fig 7 (a) Aluminium shell crowns are convenient, but
may be used on its own. Cast metals are very suitable only for short term use on posterior teeth; and
durable, but rarely used unless provisional (b) Crimping of the crown margins will improve
retention and fit
restorations have to last a long time.
Proprietary shells
Shells can be divided into proprietary and cus-
tom made. Proprietary shells made of plastic
(Fig. 6) or metal (Fig. 7) are used commonly in
practice when only one or perhaps two prepara- b
tions are involved.
Proprietary plastic shells: A crown with the
correct mesio-distal width is chosen and placed
on the tooth preparation. The cervical margins
are trimmed to give reasonable seating and adap-
tation. The preparation is then coated with petro- Fig. 8 (a) A commonly used matrix is
an alginate impression of the
leum jelly and the crown, containing a suitable unprepared tooth; and (b) The flash
resin eg Trim, is reseated. While the resin is still must be removed and the linked
incompletely set, the proximal excess is removed provisionals trimmed prior to
using a sharp bladed instrument such as a half cementation
Hollenback amalgam carver. The crown is then
removed and replaced several times to prevent Mill Crowns are formed by first cutting mini-
resin setting in undercuts. Finally, the crown is mal crown preparations on a stone cast. A pre-
adjusted and polished using steel or tungsten preparation matrix is then filled with poly-
carbide burs and Soflex discs. Diamond burs are methyl methacrylate and placed over the
best avoided, as they tend to melt the shell and preparations. The trimmed and adjusted provi-
resin because of the heat generated. sional crowns are again relined in the mouth.
Proprietary metal shells: Aluminium crowns
are really only suitable for short-term use as Matrices
they are soft resulting in wear and deformation. Many operators prefer matrices (Fig. 8) to shell
Furthermore, they can produce galvanic reac- crowns for making single or multiple provision-
tions in association with amalgam restorations. al crowns. This is because matrices closely dupli-
Their fit is usually poor unless considerable time cate the external form of satisfactory existing
is spent trimming and crimping the margins fol- teeth, or, if changes are required, a diagnostic
lowed by relining with a resin. Stainless steel or wax up. If the matrix is carefully seated minimal
nickel chromium crowns may occasionally be adjustments are generally needed other than
used on molar teeth opposed by flat cusps where trimming flash at the crown margin.
heavy occlusal loading would quickly wear or There are three main types of matrix:
break a resin crown.
• Impression (alginate or elastomer)
• Vacuum formed thermoplastic
Custom shells
• Proprietary celluloid
Some operators favour custom shells for multi-
ple tooth preparations. The shell is made in The simplest way of making a matrix is to
advance of tooth preparation so the desired record an impression of the tooth to be prepared
external contours are pre-formed, but relining either in alginate or silicone putty. Impression
and careful marginal trimming are necessary matrices are quick, easy and inexpensive, and
prior to fitting. Custom shells are of two types, can be formed while the local anaesthetic is
either beaded acrylic or ‘Mill Crowns’. Both offer allowed to take effect. When impression matri-
the advantage of being able to use the superior ces are used some judicious internal trimming
properties of polymethyl methacrylate, whilst may be helpful to improve seating and bulk out
avoiding pulpal damage by constructing the critical areas of the provisional restoration.
shell out of the mouth. These aspects are covered later when we deal
The beaded acrylic shell is formed within an with problem solving. Alginate matrices are
impression taken of the teeth prior to preparation best at absorbing the resin exotherm3 —
or of a diagnostic wax up. A thin shell of poly- although the temporary should have been
methyl methacrylate is constructed in the impres- removed before this stage of set. Elastomeric
sion by alternately placing small amounts of impression matrices have the advantage of
methyl methacrylate monomer followed by poly- being reusable, allowing them to be disinfected
mer, taking care not to make the shell too thick, and stored in case they are required again.
otherwise it will need time-consuming adjust- Polyvinylsiloxane putty impressions are fre-
ment later. Once set, it is trimmed and then relined quently used because of their ease of handling
in the mouth as with polycarbonate crowns. and long-term stability.
c d
provisional technique for onlay modifier should be added to the cement (Fig. CONCLUSION
preparations. J Esthetic Dent 1992; 4:
202-207.
5). Equal lengths of base and catalyst with a Quality restorative dentistry needs quality
9. Liebenberg W H. Improving third of a length of modifier will soften the provisional restorations for predictable
interproximal access in direct cement appreciably. Therefore, the proportion results. Dentists therefore need to be familiar
provisional acrylic resin restorations. of modifier needs to be gauged for each case. with the range of materials and techniques for
Quintessence Int 1994; 25: 697-703.
10. Shillingburg H T, Hobo S, Whitsett L D. Either finger pressure or instruments such as short term, medium-term and long-term tem-
Provisional Restorations. towel clips can then remove the restorations, porisation. Forethought and planning are also
Fundamentals of Fixed without risking damage to the preparation needed to ensure the most appropriate provi-
Prosthodontics. 4 ed pp.225-256.
Chicago: Quintessence international,
margin. sional is used, especially when multiple teeth
1998. are to be prepared or where occlusal or aes-
11. Civjan S, Huget E F, De Simon L B. Removal of excess cement thetic changes are envisaged. Such changes
Compatibility of resin composites Temporary cement removal is facilitated by are best tried out with provisionals so that
with varnishes, liners and bases. J
Dent Res (Special issue) 1973; 52: 65 pre-applying petroleum jelly to the outside of modifications can easily be made intra-orally
(Abstract no.27). the restorations and placing floss under each and when satisfactory copied into the defini-
12. Dilts W E, Miller R C, Miranda F J, connector of linked crowns before seating tive restorations. In this respect an initial
Duncanson M G J. Effect of zinc oxide
-eugenol on shear bond strength of (look at Fig. 13). Once set, the excess cement is diagnostic wax-up is invaluable to facilitate
selected core/cement combinations. easily removed with the strategically posi- the construction of laboratory formed provi-
J Prosthet Dent 1986; 55: 206-208. tioned floss. sionals or matrices.
13. Schwartz R S, Davis R D, Mayhew R
W. The effect of a ZOE temporary
cement on the bond strength of a
List of products mentioned in the text:
resin luting agent. Am J Dent 1990; 3:
28-31. Fermit Ivoclar-Vivadent UK Ltd, Leicester, UK
14. Schwartz R, Davis R, Hilton T J. Effect Protemp II (hand-mix) ESPE, Seefeld, Germany
of temporary cements on the bond
strength of a resin cement. Am J Dent Protemp Garant (syringe mix) ESPE, Seefeld, Germany
1992; 5: 147-150. Provipont DC Ivoclar-Vivadent UK Ltd, Leicester, UK
15. Woody T L, Davis R D. The effect of
Quicktemp Davis, Schottlander & Davis Ltd, Letchworth, UK
eugenol-containing and eugenol-
free temporary cements on Snap Parkell, Farmingdale, USA
microleakage in resin bonded Soflex Discs 3M Dental Products, St Paul, USA
restorations. Operative Dent 1992;
17: 175-180. Temp Bond Kerr UK Ltd, Peterborough, UK
16. Millstein P L, Nathanson D. Effects of Temp Bond NE Kerr UK Ltd, Peterborough, UK
temporary cementation on Trim II Harry J. Bosworth Co, Illinois, USA
permanent cement retention to
composite resin cores. Vita Autopolymerizing Panadent, London, UK
J Prosthet Dent 1992; 67: 856-859. K+B Acrylics
10
● An overview of impression materials
● A rationale is put forward for the choice of elastomeric materials
● Solutions are provided to common problems encountered by the clinician in producing good,
accurate impressions
● An emphasis on the need for feedback between the laboratory and the dentist
Well-fitting indirect restorations can only be made if there are accurate models of the oral tissues available, made from high
quality impressions. Waiting for an impression to set may be more stressful for the dentist than the patient. Should the
impression need to be repeated there is the embarrassment of having to explain this to the patient, the cost implications of
material and time wasted and the aggravation of running late for the next appointment. Yet, if a ‘Nelsonian’ eye is turned to a
defective impression we can only expect a substandard restoration in return.
Sometimes impression defects only come to light non-elastic and elastic materials as shown in
CROWNS AND EXTRA-CORONAL
RESTORATIONS: after the cast has been poured. Thus laboratory Figure 1. Non-elastic impression materials are
1. Changing patterns and
inspection is an important part of quality con- generally not used for obtaining impressions of
the need for quality trol, but many technicians find it difficult to feed crown preparations because of their inability to
back to their dentists for fear of the messenger accurately record undercuts. The elastic impres-
2. Materials considerations
being shot. Feedback between laboratory and sion materials can be divided into two groups:
3. Pre-operative dentist is critical to the establishment of an open the hydrocolloids and the synthetic elastomers.
assessment and honest relationship. Hopefully, an improved Table 1. details the physical properties of the
4. Endodontic understanding of impression materials coupled major groups of elastic impression materials
considerations with techniques to overcome problems will available.
5. Jaw registration and encourage higher standards and the confidence
articulator selection to accept appropriate advice. Hydrocolloid impression materials
6. Aesthetic control The first part of this article considers the The two types of hydrocolloids used in dental
7. Cores for teeth with factors influencing choice of impression materi- impressions are agar and alginate. Agar is a
vital pulps al. To have a practical understanding of impres- reversible hydrocolloid because it can pass
8. Preparations for full sion materials it is not necessary to have a PhD repeatedly between highly viscous gel and low
veneer crowns in dental materials science. Nevertheless, to viscosity sol simply through heating and cool-
9. Provisional restorations select an appropriate material it does help to ing. However, alginate once converted to the gel
10. Impression materials and have a feel for the classification of impression form cannot be converted back into the sol, and
technique materials as well as concepts such as working is therefore said to be irreversible hydrocolloid
11. Try-in and cementation time, setting time, permanent deformation and material.
of crowns dimensional stability. There are certainly other Agar and alginate may be used independently
important factors that will influence your deci- or in combination to record crown impressions.
12. Porcelain veneers
sion such as ease of manipulation, taste and Agar was first introduced into dentistry for
13. Resin bonded metal tackiness but these have so far eluded quantita- recording crown impressions in 1937 by Sears1
restorations
tive measurement. and was the first elastic impression material
The putty-wash technique has proven popu- available. It is not commonly used in dental
1Senior Lecturer in Restorative Dentistry, lar not least for its ease of handling, but there are practice today however, because of the need for
2Higher Specialist Trainee, 3Professor,
drawbacks that can have significant effects on expensive conditioning baths and water cooled
Department of Restorative Dentistry,
The Dental School, Newcastle upon Tyne its accuracy and these will be discussed. trays. Alginate, unlike agar, does not require any
NE2 4BW; The final part of the article will consider how special equipment. Being easy to use and inex-
*Correspondence to: Dr R. W. Wassell, to overcome the problems routinely encountered pensive it is popular for less critical applications
Department of Restorative Dentistry,
The Dental School, Newcastle upon Tyne
in recording impressions. eg opposing casts and study models.
NE2 4BW Alginate and agar produce impressions with
E-mail: R.W.Wassell@newcastle.ac.uk CLASSIFICATION OF IMPRESSION MATERIALS reasonable surface detail. They are both rela-
Impression materials are commonly classified tively hydrophilic and are not displaced from
Refereed Paper
© British Dental Journal 2002; 192: by considering their elastic properties once set. wet surfaces as easily as the elastomers.2 How-
679–690 Therefore, they can be broadly divided into ever, in respect of recording crown prepara-
Polysulphides
The polysulphide impression materials have the
longest history of use in dentistry of all the elas-
Non-elastic materials Synthetic elastomers Hydrocolloids tomers. Interestingly, they were first developed
as an industrial sealant for gaps between sec-
Impression plaster Reversible tional concrete structures.6 They are available in
Impression compound Irreversible a range of viscosities namely, light bodied (low
Impression waxes viscosity), medium or regular bodied and heavy
bodied (high viscosity).
These are now relatively unpopular materials.
Polysulphides The setting reaction of polysulphides tends to
be long with setting times often in excess of
Polyether 10 minutes (acceleration is possible by adding
a small drop of water to the mix). They are
Silicones also messy to handle and have an objection-
able odour.
Dies resulting from polysulphide impressions
Condensation Addition are generally wider and shorter than the tooth
preparation. This distortion, which worsens the
Fig. 1 Classification of impression materials longer the delay in pouring up, is the result of
impression shrinkage which is directed towards
tions these materials have two major disad- the impression tray — hence the wider die.
vantages. Firstly, very poor dimensional sta- Shrinkage occurs firstly as a result of a contin-
bility because of the ready loss or imbibition of ued setting reaction after the apparent setting
water on standing in dry or wet environments time, and secondly through the evaporation of
respectively. Secondly, low tear resistance water produced as a by-product of the setting
which can be a real problem when attempting reaction. A special tray, providing a 4 mm uni-
to record the gingival sulcus. form space, is needed to reduce distortion from
Some work supports the use of combined the shrinkage of a large bulk of material. The
reversible and irreversible hydrocolloid recommended maximum storage time of the set
impression systems.3,4 These systems are used impression is about 48 hours.6
in a way similar to the putty-wash technique A significant advantage of polysulphide,
for silicone rubbers described later in this arti- however, is its long working time. This is espe-
cle, with the agar injected around the prepara- cially useful when an impression of multiple
tion to capture surface detail and the more vis- preparations is required and some dental schools
cous alginate in the impression tray. The stock a few tubes to help students deal with this
advantages of this combination system com- difficult situation. Another advantage of these
pared with agar or alginate used individually is materials is that they possess excellent tear
the minimisation of equipment required to resistance, undergoing considerable tensile
record an agar impression (no water cooled strain before tearing. Unfortunately, their elastic
tray is needed) and the fact that agar is more properties are not ideal and some of this strain
compatible with gypsum model materials than may not be recovered (high value for stress
alginate. It is also relatively cheap in compari- relaxation 2 minutes after setting time — see
son to many synthetic elastomers. Lin et al.5 Table 1). To optimise the recovery of these vis-
demonstrated that the accuracy of this combi- coelastic materials, the impression should be
nation system is better than either the removed with a single, swift pull as the strain
reversible or irreversible materials used sepa- imparted on the material is a function of the
rately and is comparable to that of polysul- time for which the load is applied. This method
phide impression materials. However, the of removal of impressions should be adopted
problems of low tear resistance and poor when using any impression material, irrespec-
dimensional stability still apply resulting in tive of its elastic properties.
the need for impressions to be cast up immedi-
ately. For these reasons, most practitioners Polyethers
tend to reject the hydrocolloids in favour of A popular polyether impression material,
the synthetic elastomers to produce accurate Impregum (Espe GmbH, Germany), was the first
and stable impressions. elastomer to be developed specifically for use in
dentistry and introduced in the late 1970s. Ini-
The synthetic elastomers tially available only in a single ‘regular’ viscosi-
First introduced in the late 1950s, synthetic ty, slight modification of the viscosity is possible
elastomeric impression materials quickly with the use of a diluent. More recently a heavy
became popular as dental materials because light bodied system has been intoduced (Perma-
they significantly reduced the two main prob- dyne, Espe GMbH, Germany).
Polyether impression materials tend to have a The dimensional changes of condensation sili-
fast setting time of less than 5 minutes and, for cones are slightly greater than those of polysul-
this reason, have been popular for the recording phides, but the changes in both types of material
of single preparations in general practice. In are small in comparison to the changes which
contrast to polysulphides, they undergo an addi- occur with alginate. Nevertheless, to produce the
tion cured polymerisation reaction on setting most accurate models, regular and heavy body
which has no reaction by-product resulting in a impressions should be cast within 6 hours of
material with very good dimensional stability. being recorded.6 This may be a problem if the
The set material may however swell and distort laboratory is not close to the practice.
because of the absorption of water on storage in In contrast, addition cured silicone rubbers
conditions of high humidity. Impressions should are considered the most dimensionally stable
therefore be stored dry. They should also not be impression materials. Like polyethers, they set,
stored in direct sunlight. Ideally, impressions not unexpectedly, by an addition cured poly-
should be poured within 48 hours of them being merisation reaction. No by-product is produced
recorded.6 An advantage of their relative during cross-linkage resulting in an extremely
hydrophilicity is that polyether impression stable impression which has been shown to
materials are more forgiving of inadequate remain unchanged over a substantial period of
moisture control than the hydrophobic polysul- time, hence allowing impressions to be poured at
phides and silicone rubbers. leisure some days after they were recorded.
Polyether impression materials have ade- As with polysulphides, silicone rubbers are
quate tear resistance and very good elastic prop- very hydrophobic so unless the teeth are proper-
erties. However they do have a high elastic mod- ly dried ‘blowholes’ are likely to be produced in
ulus and consequently are relatively rigid when the set impression.
set, hence considerable force may be required to Both types of silicone rubber have the best
remove the impression from both the mouth and elastic properties of any impression material, the
the stone cast (Table 1, stress to give 10% com- recovery of strain being said to be almost instan-
pression). This may preclude their use in cases taneous (Table 1, stress relaxation at 2 minutes
where severe undercuts are present. after setting time). Like the other elastomers,
they have adequate tear resistance. They are
Silicones non-toxic and absolutely neutral in both colour
Silicone impression materials are classified and taste.
according to their method of polymerisation on A great deal of recent research has been cen-
setting, viz. condensation curing (or Type I) sili- tred around the production of hydrophilic sili-
cones and addition curing (or Type II) silicones. cone rubbers. Some commercial addition cured
Silicone rubbers are available in a similar products have recently been introduced (eg
range of viscosities to the polysulphides (ie Take 1 Kerr US, Misssouri USA). A study by
light, medium and heavy). However, the range is Pratten and Craig7 showed one of these
supplemented by a fourth viscosity; a very high ‘hydrophilic’ addition silicone materials to have
viscosity or ‘putty’ material. The high filler a wettability similar to that of polyethers. Other
loading of the putty was initially devised to studies have also shown that treatment of
reduce the effects of polymerisation shrinkage. impression materials with topical agents,
The putty is commonly combined with a low including surfactants, results in a decrease in
viscosity silicone when recording impressions, a the number of voids found in the final impres-
procedure known as the ‘putty-wash technique’ sion and the dies poured from them.8—11
which will be discussed in some detail later in
the article. THE PROBLEMS OF PUTTY-WASH
Condensation curing silicones were intro- The putty-wash technique is probably that most
duced to dentistry in the early 1960s. As with the commonly used in general dental practice. As
polysulphides, the setting reaction produces a with most techniques it has its problems, the
volatile by-product, but with type I silicones it is most common of which is invisible when the
ethyl alcohol, not water. Loss of the by-product impression is recorded only becoming apparent
leads to measurable weight loss accompanied by when the restoration is tried in and fails to seat
shrinkage of the impression material on storage. satisfactorily.
As has been mentioned already, putties were is to use the one stage technique with addition
developed initially to reduce the shrinkage of silicone putty in a rigid metal tray. There is no
condensation silicones, but the heavy filler load- doubt that plastic stock trays are convenient
ing is not needed for addition silicones since but whilst unreliable with putty-wash they can
their polymerisation contraction and dimen- produce accurate results with a combination of
sional stability are in any case excellent. Pre- heavy and light bodied addition silicones.12–14
sumably, addition silicone putty-wash impres- Special trays are only needed for heavy light
sions are preferred principally for their handling bodied addition silicone impressions where
characteristics. stock trays are a poor fit.
There are essentially three ways of recording
a putty-wash impression: DISINFECTION OF IMPRESSION MATERIALS
It has long been recognised that a potential
• One stage impression — putty and wash are
exists for cross-infection as a result of contami-
recorded simultaneously (also called twin mix
nated dental impressions.16–18 Consequently
or laminate technique)
such impressions pose a hazard to laboratory
• Two stage unspaced — putty is recorded first
personnel; it is therefore important that all
and after setting relined with a thin layer of
impressions are disinfected prior to being trans-
wash
ferred to a laboratory.
• Two stage spaced — as for two stage unspaced
A study by Blair and Wassell (1996)19 con-
except a space is created for the wash. This
sidered a number of solutions used for disin-
space may be made by:
fecting impression materials. It highlighted that
• Polythene spacer over the teeth prior to
there is no universally recognised impression
making the putty impression
disinfection protocol available but showed that
• Recording the putty impression before tooth
the use of a disinfectant of some description, at
preparation
least in dental hospitals, had increased from
• Gouging away the putty and providing
1988.20 The recommendations of the study are
escape channels for the wash.
supported by the British Dental Association;21
The problem that causes invisible, but some- namely that all impressions should at least
times gross distortions, is recoil. Recoil can undergo a disinfecting procedure by immersion
result in poorly fitting restorations and makes a in 1% sodium hypochlorite for a minimum of
mockery of using what should be accurate mate- ten minutes.
rials. Recoil works in the following way. Consid-
erable forces are needed to seat putty impres- PROBLEM SOLVING
sions, which can result either in outward flexion At Newcastle senior members of staff check all
of the tray wall or the incorporation of residual impressions for indirect restorations on removal
stresses within the material. On removing the from the mouth and again in the laboratory. It is
tray from the mouth the tray walls rebound surprising how often an impression, appearing
resulting in dies, which are undersized bucco- satisfactory to a cursory glance, is fatally flawed
lingually.12 This has been demonstrated clearly when viewed alongside the resulting cast. We
with plastic stock trays used with the one stage would encourage dentists to audit their own
technique. work in this way with peer review providing the
Although putties of lower viscosity are avail- best stimulus for improvement.
able they produce similar distortions with plastic Visible flaws related to impression technique
trays.13–15 Rigid metal trays however can min- which occur commonly include:
imise such distortions and are to be recommend-
• Finish line not visible
ed for putty-wash impressions.
• Air bubbles in critical places
The two stage technique is not immune to
• Voids or drags
distortion which may occur as follows:
• Unset impression material on surface of
1. Where it is used unspaced hydrostatic pres- impression and cast
sures can be generated during the seating of
Invisible impression flaws, resulting in an
the wash impression, which can cause defor-
apparently good fit of the restoration on the die
mation and subsequent putty recoil2 on
but a poor fit on the tooth, may also occur
removal. This problem can occur even with
because of:
rigid trays. It may be reduced but not neces-
sarily eliminated by spacing. • Tray and impression recoil (as described for
2. The putty impression may not be reseated the putty-wash technique)
properly causing a stepped occlusal surface • Detachment of impression from tray
of the cast and a restoration requiring exces- • Permanent deformation
sive occlusal adjustment. It is often difficult
Where multiple preparations are recorded the
to reseat an impression where the material
likelihood of an impression defect occurring is
has engaged undercuts especially interproxi-
increased and it is useful to have strategies to
mally. As such, unspaced or just locally
cope with this problem.
relieved impressions are most at risk.
Whilst we cannot cover every eventuality we
In summary, the most convenient and reli- hope that the advice given below will help in
able way of recording a putty-wash impression reducing problems. Specific techniques have
a b
c d
been summarised in the tables. For full accounts surgery and gingival retraction may be required
of potentially damaging — but useful tech- (see later). Leading up to the removal of the
niques, such as electrosurgery and rotary curet- defective restoration and during the time of tem-
tage, the reader is referred elsewhere.22 porisation, it may be helpful to prescribe an
antimicrobial rinse (eg Chlorhexidine gluconate
Visible flaws 0.12%) for 2 weeks.
Finish line not visible Subgingival finish line. The more subgingi-
If the technician cannot identify the finish line val a preparation the more difficult it is to
on the impression, the resulting crown will record the finish line adequately. Preparations
inevitably have a poor fit with a compromised finished at the gingival margin can occasional-
prognosis. It is therefore of some concern that ly be recorded without gingival retraction, but
recent studies report impression defects at the retraction cord will often give a more pre-
finish line in over a third of cases.23,24 These dictable result. Preparations finished within the
defects are usually the result of inadequate gin- gingival sulcus will certainly require gingival
gival management in the following circum- retraction. Any one or a combination of means
stances: can achieve retraction:
Gingival inflammation and bleeding. Every
• Retraction cord (plain or impregnated) with or
effort should be made to ensure that tooth
without accompanying solution
preparations are being carried out in a healthy
• Two-cord technique (described in Fig. 2)
mouth which means patients should have effec-
• Rotary curettage
tive periodontal treatment prior to recording
• Electrosurgery
impressions for definitive restorations. Bleeding
• Copper ring
from inflamed gingivae will displace impression
material resulting in an inaccurate cast. Further- The techniques (summarised in Table 2)
more, if inflammation has not been controlled become potentially more invasive towards the
and a sub gingival margin placed, there is a risk bottom of the list but may be essential to man-
of gingival recession leaving the margin as an age more difficult cases. We find the most con-
unsightly tide line. Where the potential for a sistently helpful approach for subgingival
successful outcome is low, it is often sensible to impressions to be the ‘two-cord’ technique25
delay taking the impression until the gingival used with ferric sulphate solution (Table 3)
condition is resolved. where necessary in combination with electro-
Certainly there are times when contours and surgery (Fig. 3). The principal advantage of the
ledges on pre-existing defective restorations technique is that the first cord remains in place
make it impossible for the patient alone to within the sulcus thus reducing the tendency of
resolve the inflammation. Prior to recording the the gingival cuff to recoil and displace partially
impression the defective part, or more usually set impression material. This approach not only
the whole restoration, should be removed and a helps to control gingival haemorrhage and exu-
well contoured provisional restoration placed. In date but also overcomes the problem of the sul-
order to obtain a satisfactory margin on the pro- cus impression tearing because of inadequate
visional restoration some localised electro- bulk — an especially important consideration
with the hydrocolloids, which have low tear Brägger et al.27 have shown that whilst in most
strength. The main disadvantage of the two-cord patients the gingival margin is stable following
technique is failing to remove the first cord crown lengthening, in 12% of sites 2–4 mm of
thereby inflicting a painful, florid gingival reac- recession occurred between 6 weeks and 6
tion. It is worth pointing out that where ferric months. These findings emphasise the need, in
sulphate solution is used, it must be applied aesthetically critical areas, to delay recording
firmly in order to stabilise the coagulum. This the impression until the stability of the gingival
approach differs to the gentle technique used margin is assured.
with other solutions. Localised gingival overgrowth. This annoying
Preparations that extend beyond the epithe- problem is often seen when replacing crowns
lial attachment may have finish lines adjacent to with open margins where an ingrowth of
the alveolar bone. In such cases the above tech- inflamed gingiva prevents access to the finish
niques are unsuitable and surgical crown line. It also occurs after a patient loses a crown
lengthening with osseous recontouring may be with subgingival margins or a poor quality tem-
indicated to ensure that the gingival attachment porary crown is cemented prior to the impression
has an adequate biological width (ie 2–4 mm of stage. In these circumstances packing with retrac-
gingival tissue above the alveolar crest).26 tion cord can be onerous and may be useless. A
a b
c d
Fig. 3 ‘Troughing’ with electrosurgery
prior to packing retraction cord (a, b).
The buccal tissues are relatively thin
and great care is needed to avoid
recession. Where subgingival finish
lines need to be uncovered (c,d)
electrosurgery is invaluable. Sufficient
haemostasis can usually be achieved
with ferric sulphate solution to allow
the impression to be recorded
the material to prevent it from flowing away knitted or woven cords, which should not be
from critical areas thus inducing impression twisted prior to insertion. Perhaps surprisingly,
drags that are commonly seen on the distal retraction solutions have not been shown to
aspects of teeth adjacent to edentulous spaces effect impression setting significantly.32
and in undercut regions. Preparations and
occlusal surfaces must be adequately dried with Invisible flaws
a three in one syringe or the relatively Impression and tray recoil
hydrophobic elastomers will be repelled and, A visible impression flaw may be made invisible
much like a skidding lorry on a wet motorway, by attempting a localised reline with a little light
aquaplane away from the tooth. We have found bodied material. It may be tempting but is not
the new generation of hydrophilic addition sili- good practice; seating pressures can result in
cones (eg Take 1, Kerr US, Misssouri USA) to impression recoil and significant distortion.33
offer much improved performance in overcom- Moreover, the addition may bond poorly and
ing these effects. subsequently peel away. If an impression is
All experienced dentists will recognise the unsatisfactory it should be retaken.
scenario of repeating an impression only to find As already discussed the use of putty-wash in
that the offending void or drag has reappeared non-rigid trays can result in tray wall recoil and
in the same place. The cause is often a poorly undersized dies.
adapted tray and the answer is to either adapt
the stock tray with a rigid material (eg com- Detachment of impression from tray
pound) to give more consistent spacing in the Detachment of the impression from the tray can
critical area or have a special tray made up. Spe- result in gross distortion of the cast. It may occur
cial trays are best avoided for putty-wash on removal from the mouth and may often go
impressions since there is a significant risk of the unnoticed. Prevention of detachment relies on
rigid, set impression locking into undercuts and the proper use of adhesive and having a tray
then having to be cut free from the patient’s with adequate perforations.34 It is a good idea to
mouth. select the tray and apply adhesive before the
Gingival control has already been considered tooth is prepared. Doing so will allow time for
but it is worth re-emphasising that crevicular the adhesive’s solvent to evaporate and for ade-
fluid and haemorrhage will displace impression quate bond strength to develop.35 Painting the
material and result in voids and rounded, indis- tray immediately before recording the impres-
tinct finish lines. sion is not a good idea. This advice applies to
Yet another cause of voids is premature elastomers and alginates. Alginates are more
syringing of impression material intra-orally easily debonded from the tray so it is good prac-
prior to seating the tray. The set of the syringed tice to use a scalpel to cut away excess alginate
material is accelerated by the warmth of the from the tray heels to facilitate inspection of this
mouth, resulting in a poor bond between vulnerable area. The excess needs to be removed
syringed and tray materials and the appearance before putting the impression down or the
of a fissure at the interface between them. This impression will distort.
type of void may be exacerbated by salivary Elastomeric impressions may require to be
contamination of the syringed material. The poured up more than once, especially if critical
skilful use of cotton wool rolls, flanged salivary air blows in the stone affect the resulting die.
ejector and high volume aspiration is critical to The repour will be grossly inaccurate if impres-
effective moisture control. sion material has lifted away from the tray
because of the lack of adhesive.36
Unset impression material Where a special tray is made it is important
This problem usually does not become appar- that the wax spacer does not come into contact
ent until the impression is cast-up and a tell- with the tray acrylic; contamination will
tale smear of unset impression material is seen reduce the strength of the adhesive bond. Tech-
on the surface of the die and the surrounding nicians may need to be instructed to place a
teeth; the affected stone cast often has a char- layer of aluminium foil over the surface of the
acteristic granular appearance. Alternatively, wax before forming the tray.35 Furthermore, a
the putty in a putty-wash impression may self cured acrylic tray should be made at least a
refuse to set. The most likely cause of both day in advance to allow for its polymerisation
these problems is contamination of the impres- contraction.
sion by ingredients of latex rubber gloves,
which poison the choroplatinic acid catalyst of Permanent deformation
addition silicones.29,30 Not all brands of latex Withdrawal from an undercut will test an
gloves are responsible31 and the simple expe- impression’s elastic recovery. As already men-
dients are to change brands or to use non-latex tioned the addition silicones have good resist-
gloves (eg polyethylene) for impression proce- ance to permanent deformation, however, there
dures. Where the string variety of retraction are situations where an impression can be
cord is used, twisting it tight. It in gloved hands deformed and the small but significant defor-
to make it more easily packable also has the mation is unlikely to be detected. In this respect
potential to contaminate and prevent impres- gingival embrasure spaces cause especial diffi-
sion setting.32 This is less of a problem with culty in two situations. Firstly, significant gin-
gival recession with the loss of the interproxi- acrylic so that stability of coping position is
mal papilla will lock set impression material ensured within the pick-up impression. Alter-
into the space. The impression will either be natively, excrescences of acrylic can be added
torn on removal from the mouth or deformed or to a coping to ensure it is retained within the
both. This problem is best dealt with by block- pick-up impression. After recording the pick-
ing out embrasure spaces with soft red wax or a up impression individual dies can be secured
proprietary blocking out material. Secondly, within their copings using sticky wax before
where there is a significant triangular inter- the master cast is poured. The technique can
proximal space below the preparation finish be used with stone dies, but there is a risk of
line it is best to extend the finish line gingival- the die being abraded by the construction of
ly. The space is thereby opened up to allow the the acrylic coping. This problem can be over-
impression to be withdrawn without tearing or come by double pouring each die. The coping
distortion. is made on one die, which is then discarded,
Special trays should be given sufficient spac- and the other die is used for the master cast.
ing (at least two layers of baseplate wax) to give
sufficient thickness of impression material to Where it is clearly going to be a problem to
resist undue stress and strain on removal from record many preparations on a single impression
undercut areas. this should be taken into account and planned
Finally, the elastic properties of materials are for. There are few cases that cannot be broken
not fully developed at manufacturers’ stated set- down into smaller more manageable stages even
ting times. So it is worth remembering that a sig- if this means using provisional restorations to
nificant improvement in resistance to perma- stabilise the occlusion while say four or six
nent deformation occurs if addition silicone definitive anterior crowns are constructed.
impressions are left a further minute or two When it is absolutely necessary to record simul-
before removal from the mouth.13 taneously more than six teeth in one arch it is
wise to use the transfer coping and pick-up
The problem of recording multiple preparations impression technique from the outset.
It is always distressing when in an attempt to
record multiple preparations one or two areas of CONCLUSION
the impression have a critical defect. There are The ability to record consistently good impres-
several strategies for dealing with the situation: sions is both a science and an art. We hope this
article has shed light on both aspects. It is worth
• Retake the whole impression bearing in mind that the impression influences
• Record a separate impression of the prepara- not only the quality of the subsequent restora-
tion (or preparations) having the impression tion but also the technician’s perception of the
defect. A copper ring may be used as described dentist’s skill. As none of us can achieve perfec-
previously in Table 2. The resulting die is then tion every time there is much to be said for
located in the defective region of the first encouraging technicians to feed back when they
impression before pouring up the master die. receive a substandard impression.
Not surprisingly, it can be difficult to locate
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27. Brägger U, Lauchenauer D, Lang NP. Surgical lengthening of A technique for tooth preparation and management of the
the clinical crown. J Clin Periodont 1992; 19: 58-63. gingival sulcus for impression taking. Int J Periodontol
28. Chong Y H, Soh G, Lim K C, Teo C S. Porosities in five Restorative Dent 1981; 1: 9-33.
automixed addition silicone elastomers. Operative Dent 46. Brady W F. Periodontal and restorative considerations in
1991; 16: 96-100. rotary curettage. J Am Dent Assoc 1982; 105: 231-236.
29. Noonan J E, Goldfogel M H, Lambert R L. Inhibited set of the 47. Kamansky F W, Tempel T R, Post A C. Gingival tissue response
surface of addition silicones in contact with rubber dam. to rotary gingival curretage. J Prosthet Dent 1984; 52:
Operative Dent 1985; 10: 46-48. 380-383.
30. Kahn R, Donovan T, Chee W. Interaction of latex gloves and
polyvinylsiloxane impression materials: a screening survey.
Int J Prosthodont 1989; 2: 342-346.
Having successfully negotiated the planning, preparation, impression and prescription of your crown, the cementation stage
represents the culmination of all your efforts. This stage is not difficult, but a successful outcome needs as much care as the
preceding stages. Once a restoration is cemented there is no scope for modification or repeat. You have to get it right first time.
Decemented crowns often have thick layers of residual cement suggesting problems with either initial seating or cement handling.
When the fate of restorations costing hundreds of pounds depends on correct proportioning of cements and the quality of
the mix, the value of a well-trained and experienced dental nurse is easy to see. Both dentist and nurse need a working
knowledge of the materials they are handling.
Crown seating relies on a satisfactory try-in and the patient’s tactile sense is not impaired which
CROWNS AND EXTRA-CORONAL
RESTORATIONS: this subject will be covered first. We will then is valuable in assessing the occlusion and tight-
1. Changing patterns and consider the topics of cements, their selection ness of proximal contacts.
the need for quality and usage. The crown should be tried in without forcing
it onto its preparation; if it fails to seat there are
2. Materials considerations
TRY-IN PROCEDURE FOR CROWNS a range of reasons why this may have happened.
3. Pre-operative
This involves three stages: firstly pre-operative It pays to use a systematic approach to localise
assessment
evaluation of crown on its die, secondly seating problems:
4. Endodontic on the tooth and finally evaluation of the seated
considerations 1. First, ensure there is no retained temporary
crown.
5. Jaw registration and cement or trapped gingival tissue
articulator selection 2. Then check and adjust tight proximal contacts
Checking the crown on the die
6. Aesthetic control (see following section) as these often prevent
It is always worth checking the fit of the crown
seating. Also check the original cast for dam-
7. Cores for teeth with on the cast before trying it in the patient. In this
vital pulps
age to the stone in these contact areas
way problems involving marginal fit, aesthetics
3. Then re-check the crown for the most obvious
8. Preparations for full and articulation can be anticipated prior to try
laboratory errors, including casting blebs,
veneer crowns in. Always check the fit surface of the crown for
damaged or chipped dies or grossly overex-
9. Provisional restorations defects and the die for damage, preferably with
tended margins. Casting blebs can be removed
10. Impression materials and a good light and under magnification (Table 1).
with a bur. Over-extended margins should be
technique Detecting these problems before try-in will
adjusted from the axial surface, not from
11. Try-in and cementation allow you either to address the problem your-
underneath (Soflex discs are useful for this
of crowns self or to negotiate with your laboratory from a
purpose — see Fig. 1). To avoid the abrasive
position of strength. It is surprising how often
12. Porcelain veneers dragging metal over the margin, run the disc
clear ledges or deficiencies can be detected at
13. Resin bonded metal so that the abrasive travels in the direction of
this stage. Subsequent stages then rely on the
restorations the occlusal surface, not towards the margin
crown being checked in the mouth and then
4. Where the crown still does not seat burnish
1,3Senior Lecturer in Restorative Dentistry, often back on the die again when there is a
marks on the internal walls of a sandblasted
2Higher Specialist Trainee, Department of problem with the fit.
metal crown may indicate where it is binding.
Restorative Dentistry, The Dental School,
Newcastle upon Tyne NE2 4BW; The identification of these points may be aided
Seating the crown
*Correspondence to: Dr R. W. Wassell, by the use of disclosing wax or aerosol sprays.
Department of Restorative Dentistry, Having checked the crown on the cast, any tem-
Any imperfections may be lightly ground with
The Dental School, Newcastle upon Tyne porary restoration is removed and the prepara-
NE2 4BW a bur or stone before retrying the crown.
tion is carefully cleaned of all residues of tempo-
E-mail: R.W.Wassell@newcastle.ac.uk
rary cement, especially in retention grooves. The With modern day addition silicones, impres-
Refereed Paper try-in procedure can normally (though not sion distortion is an unusual cause of ill-fitting
© British Dental Journal 2002; 192: always) be accomplished without the need for restorations but may be responsible where no
17–28 local anaesthetic. This is advantageous in that apparent fault can be detected on restoration or
Tight proximal Imprecise die location or abrasion of Check for displacement of the dies
contacts the adjacent stone contact points when the crown is seated on the
working cast. Identify tight contact by
interposing articulating paper, grind
and polish
Casting blebs on Air bubbles trapped during investment Identify under magnification and
fit surface remove with small round bur
Over-extended Poor impression, poor die trimming, Trim from axial surface (Fig. 1) and
crown margins surplus untrimmed wax or porcelain polish — consider returning crown to lab
Under-extended Poor impression, poor die trimming, If under-extension obvious and
crown margins difficulty identifying finish line impression satisfactory have crown
remade. Alternatively retake
impression
Damaged dies Finish line chipped because of careless Always try and determine why the die
handling or abraded when casting reseated is damaged. If the crown does not fit
with blebs or overextended margins after adjusting blebs or over-extended
margins return it to laboratory
No die spacer Technician not aware of technique or Lack of spacer results in a tightly
(Space needed to forgot to apply fitting crown which may not seat
accommodate during try in and may ‘lift’ further
cement lute) after cementation
die. Problems can occur where an impression is Once you have got to this stage, providing you
removed too soon or where unset impression and the laboratory have taken care with preced-
material results from glove contamination (look ing clinical and technical stages, minimal or no
out for the tell tale smear of unset impression adjustment should be necessary. Again it is
material on the surface of the cast). If you cannot important to adopt a systematic approach.
get the crown to seat easily and can find no
obvious reason, you may rightly suspect that Proximal contacts
there is an impression distortion. In that case, The tightness of proximal contacts can be test-
save time and just take a new one. ed with dental floss and should offer some
Finally, it is important to distinguish between resistance but not make its passage too diffi-
a crown that rocks on its preparation because of cult. If these are too tight they can be ground a
binding somewhere on the fit surface and one little at a time and polished. This requires the
that just has a loose fit resulting from the use of greatest care as it is easy to open the contact
die spacer. In fact, tightly fitting crowns confer accidentally, and it is very problematic trying
no additional retention after cementation1 and to rebuild it at this stage. Prior to adjustment it
may interfere with seating. may be helpful to mark the proximal contact
by sandwiching a small piece of articulating
Assessment of the seated crown paper between crown and tooth either on the
There is no point in making a detailed assess- cast or in the mouth.
ment of proximal contacts, marginal fit, aesthet- Open contact points occur less frequently
ics and occlusion until the crown is seated fully. and can only be modified by returning the
a) b) c)
crown to the laboratory for addition of porce- see the restoration and comment on it prior to
lain or gold solder. cementation. If the shape and shade are clearly
unacceptable it is better to acknowledge this
Assessment of marginal fit rather than risk a dissatisfied patient with the
Crowns really must have an accurate marginal possibility of having to cut off the restoration
fit if you intend them to survive in the long term. and repeat all the preceding stages.
There is a full spectrum of fit, from perfection
(which is probably rarely achieved) to open mar- Assessment of the occlusion
gins around the entire crown. It is up to you, The occlusion is the last assessment to make, but
your own clinical standards and perhaps your there is no point thinking about making any
patient at what point on that spectrum you adjustment to the occlusal surface until the
decide that the marginal fit becomes unaccept- crown is finally seated. It is then best to remove
able. A combination of clinical experience and it and identify a pair of adjacent occluding teeth,
empirical data suggest a marginal opening of termed index teeth, which, after re-seating, can
100 µm2 is at the borderline of acceptability, be used to assess visually, and with shim stock,
especially where the margin can only be how much adjustment is needed.
probed.3 Maintaining the highest possible clini- Visually checking the occlusion gives only a
cal standards at this stage has long-term bene- gross indication of the amount of adjustment
fits; ill-fitting margins will render the tooth needed; articulating foils and shim stock are
more susceptible to cement dissolution, plaque needed too. Figure 2 shows shim stock, which is
retention and recurrent caries. Defective subgin- a 10 µm thick Mylar film, held in mosquito for-
gival margins compromise gingival health by an ceps and used as a feeler gauge between occlud-
alteration in local bacteria.4 ing teeth. Shim stock can be bought from dental
Poor fit can present as a gap or an overhang- suppliers or can be made, very inexpensively, in
ing margin (positive ledge) or deficient margin the dental surgery by passing a ‘space blanket’
(negative ledge). Overextended margins and (the sort of thing marathon runners wrap around
positive ledges may be corrected by adjusting themselves after a race, available at camping
the crown from its axial surface until it is pos- shops) through an office shredder and then cut-
sible to pass a probe from tooth to crown with- ting it into 2 cm lengths.
out it catching. A larger problem, necessitating Miller’s forceps, used to support articulating
that the crown be remade if it is unacceptable,
occurs when a margin remains deficient or has
a
a negative ledge.
Gold restorations should have their accessible
margins burnished before cementation. The set
cement is likely to be cracked if the margin is
burnished afterwards. There is no evidence that
burnishing improves longevity but it can insure
that a discerning patient does not catch a finger-
nail at the margin! The procedure involves drag-
ging the gold from restoration to tooth using a
rotary instrument such as a green stone or steel d
finishing bur. Where only minimal burnishing is
needed a sharp hand instrument such as a pro- b
prietary gold knife or half Hollenback instru-
ment is useful. Once burnished the restoration
must be re-polished taking care to avoid the fine
edge of marginal gold.
Aesthetics
For porcelain crowns, some adjustment of
shape and shade is possible at this stage but it
is best to ensure minimal adjustment by fol-
lowing the advice given in Part 6 of the series.
Grinding with diamond burs can alter crown
contours and porcelain additions can be made to c
metal ceramic crowns if necessary. Shades that
are slightly too light may be darkened by the
addition of stain and re-firing while all ceramic
crowns with no cores may have their shade Fig. 2 Occlusal assessment. With the
restoration out select a pair of index
modified slightly by the luting composite in the
teeth, which hold shim stock (a).
same way as veneers. If you anticipate the need Mark with black articulating foil
for substantial adjustments, a try-in at biscuit and adjust ICP (b). Mark with red
bake can be specified so that the crown can be and adjust excursive interferences
glazed when you are happy with the final and deflections (c). Adjustment
complete (d)
appearance. Obviously the patient will need to
foils so that they do not crumple during intra- erupt back into occlusion. It may often be
oral placement, are also an advantage (again acceptable to monitor infra-occluding restora-
look at Fig. 2). Some articulating papers resem- tions and adjust interferences as necessary. In
ble blotting paper in consistency and thickness. more critical cases occlusal additions of porce-
They are prone to leave false marks and may lain or solder may be indicated or the restora-
alter the patient’s position of closure. These tion remade. The point is that it should not be
papers can be as thick as 200 µm, which is over necessary to do this at all because all of these
ten times as thick as the best thin foils such as problems can be avoided by taking care at the
GHM (GHM Occlusion Prüf Folie, Germany),5 preceding stages, especially with impressions
which are infinitely preferable. Despite their (including opposing impressions), jaw registra-
slightly higher cost, the accuracy and precision tion and temporary restorations.
with which they will mark a restoration can save
a great deal of time and effort provided the teeth Finishing and polishing
are dry. The final stage prior to cementation is polishing.
With posterior teeth, both restoration and A rough surface, especially in porcelain, will
adjacent teeth should hold shim stock firmly in rapidly wear the opposing tooth6 and so it is
the intercuspal position (ICP). With anteriors, if very important to use a sequence of abrasives
the other incisors hold shim stock lightly the designed for the material in question to achieve
restoration should be made to do so too. Failure a smooth surface. Details of the materials we use
to do so can result in the crowned tooth being are shown at the end of the article. Metal sur-
overloaded, which in turn can cause pain, faces can be finished with finishing burs fol-
mobility, fracture or displacement. As well as lowed by rubber abrasive points (Kenda: blue,
using shim stock and articulating foils, it is also brown and green). Abrasive discs (eg Soflex) are
worth listening to the occlusion with and with- useful for flat areas such as proximal contact
out the crown in place as small occlusal discrep- points and can be used on either metal or porce-
ancies can readily be heard with the teeth being lain. Porcelain can be also be finished with com-
tapped together. posite finishing diamonds (Premier: yellow and
Dentists will often have a favourite bur for white stripe), but a light touch and water spray is
occlusal adjustment. We prefer a large flame needed to avoid stripping off the diamond coat-
shaped diamond in an air rotor or speed ing. Further finishing is achieved with rubber
increasing handpiece. Occasionally, it may be abrasive points (Kenda: white) followed by a felt
necessary to adjust the tooth opposing a wheel or rubber cup charged with diamond pol-
restoration to avoid crown perforation or expo- ishing paste (Super Diglaze). Alternatively, a
sure of rough opaque porcelain. Such adjust- metal ceramic crown can be reglazed.
ments should be planned with the patient’s con-
sent and not sprung on them part way through CEMENTS
the procedure. A thickness gauge (eg Svensen When the fit of the crown is considered satisfac-
Gauge) is invaluable for predicting areas vul- tory and all adjustments have been made, the
nerable to perforation. crown can be cemented using one of the materi-
Once ICP has been re-established the excur- als described in this section.
sions can be checked, preferably with a different Cements may be classified as soft or hard.
ASSESSMENT OF THE coloured foil (eg red). ICP contacts are then re- Soft cements can be used for provisional cemen-
OCCLUSION marked with the original colour (eg black) allow- tation of definitive crowns when a trial assess-
ing the excursive contact to be differentiated ment period is needed, for example if the occlu-
It is important you have a
and refined. The decision about whether the sion or aesthetics is being significantly altered.
clear idea of the pattern restoration is to be involved in guiding jaw Hard cements are used for definitive cementa-
of occlusal contact you movement (which it often is with anterior teeth) tion. This article deals principally with hard
are trying to achieve or whether there should be disclusion (as often cements.
occurs posteriorly) should have been made well
before this stage and it is important you have a Hard cements
clear idea of the pattern of occlusal contact you Many types of hard cement have been devel-
are trying to achieve. Finally, it is worth guiding oped and continue to be available. This diversi-
back the mandible into the retruded path of clo- ty of choice suggests no one cement meets all
sure to ensure the restoration is not introducing of the requirements of an ‘ideal cement’ how-
a new deflective contact. ever some are more suitable than others for cer-
Occasionally, a restoration will be short of tain applications.
occlusion. This is used as a deliberate ploy in There are essentially three types of hard
some laboratories to eliminate the clinical need cement: conventional, resin or a hybrid of the
for occlusal adjustment. A thin card spacer two. Conventional cements (eg zinc phosphate,
placed over the cast of the opposing tooth cre- zinc polycarboxylate and glass ionomer) rely on
ates clearance. This may seem an innocuous, an acid-base reaction resulting in the formation
perhaps even a desirable practice, but can result of an insoluble salt (the cement) and water. Resin
in serious immediate problems presenting where cements set by polymerisation.
multiple restorations are fitted. The lack of con- The mechanisms by which cements secure
tacts can affect occlusal stability whilst restoration to prepared tooth include non-adhe-
destructive interferences may occur as teeth sive luting, micro-mechanical bonding and
molecular adhesion. The mechanisms of non- low tensile strength. It is this low tensile
adhesive luting and micro-mechanical retention strength, which dictates the importance of
are the main methods of action of conventional preparation geometry in reducing the develop-
cements. Molecular adhesion on the other hand ment of disruptive tensile stresses within the
is more significant in the case of resin cements cement lute resulting in loss of retention of the
and hybrid cements. Although some convention- restoration.
al cements have adhesive properties, such as zinc The retaining action of zinc phosphate
polycarboxylate and GIC, these are limited by the cement is one of micromechanical interlocking
cement’s tensile strength. Furthermore, adhesion between surface irregularities of the crown and
to noble metals is negligible but can be improved tooth. It does not bond to tooth substance or
in the case of GICs by the use of tin-plating. Tex- crown material.
turing the fitting surface of the crown, as after It is normally supplied as a powder (essential-
sandblasting, increases the resistance of the ly zinc oxide) and liquid (phosphoric acid
cement to dynamic lateral loading.7 buffered with zinc and aluminium ions), which
We will now go on to discuss the advantages are mixed together by hand. The proportions of
and disadvantages of each of the major groups powder and liquid are not normally measured
of cements and make recommendations for and therefore care must be taken to produce a
their use. ‘mix’, which provides a cement of low initial vis-
cosity to form a thin film, but with sufficient
Zinc phosphate cement powder incorporated to give adequate strength
Advantages once set.8 The powder should be incorporated in
• Long track record increments to prevent the cement setting too
• Good compressive strength (if correctly pro- quickly as a result of the exothermic reaction.
portioned) A slab cooled in the refrigerator can further
• Good film thickness extend working time. The consistency of zinc
• Reasonable working time phosphate may be checked by lifting the cement
• Resistant to water dissolution on the spatula and holding it over the slab. It
• No adverse effect on pulp although initially should string out slightly between the spatula
acidic and slab before running back onto the slab. If it
Disadvantages requires to be pushed off the spatula it is too
• Low tensile strength thick and conversely, if it runs off too quickly it
• No chemical bonding is not thick enough. Given how critical this is, it
• Not resistant to acid dissolution is worth making sure that you and your chair
Recommendations side assistant both understand fully what is
• Good default cement for conventional crowns required, and are prepared to stop and mix again
and posts with retentive preparations if a problem arises.
• Working time can be extended for cementa- All cements are to some extent soluble.
tion of multiple restorations by incremental Zinc phosphate has a low solubility in water
mixing and cooled slab but erosion leading to loss of the cement lute
and failure of the restoration is not normally
Zinc phosphate has the longest track record associated with this cement, crowns tending
and has remained popular for luting purposes to be lost more because of a poor retentive
due mainly to its high compressive strength, rel- design of the preparation. However, cement
atively long working time and ability to form a erosion is seen in patients with acid regurgita-
low film thickness between crown and tooth. tion (Fig. 3).
Look at Table 2 for the relative physical proper- Historically, zinc phosphate cements have
ties of cements and it is clear that in common been identified as having a potential irritant
with the other conventional cements, zinc phos- effect on the pulp.9 This has been attributed to
phate possesses high compressive strength but the low pH of the cement at the time of cementa-
Disadvantages
• Low tensile strength
• Can deform under loading
• Can be difficult to obtain low film thickness
• Not resistant to acid dissolution
Recommendations
• Traditionally used for vital or sensitive teeth,
but no evidence to support efficacy (dentine
bonding agents used to seal preparation prior
to cementation may be a better option)
• Occasionally useful to retain an unretentive
provisional crown
Fig. 3 Erosion of zinc phosphate
cement seen in a patient with acid Zinc polycarboxylate (or zinc polyacrylate)
reflux has a relatively long history as a luting cement.
Unlike zinc phosphate, polycarboxylate cement
tion, but preparation trauma, temporisation and does bond to tooth tissue, its bond strength to
bacterial contamination may also have been enamel being greater than that to dentine. It also
responsible. Although zinc phosphate is acidic bonds to stainless steel so dental instruments
on mixing (pH 2–3.5 depending on brand) this must be cleaned before the material sets to pre-
acidity reduces over the first 24 hours and sta- vent a tenacious bond forming.
bilises at a near neutral pH of 6.5. Despite this The tensile strength of polycarboxylate com-
acidity Brannstrom and Nyborg10,11 found no pares favourably to that of zinc phosphate
irritating effect on the pulp per se and, in prac- although its compressive strength tends to be
tice, this potential irritant effect does not seem to lower and it is difficult to achieve an equally low
be significant. film thickness.
At one time cavity varnish was advocated to Zinc polycarboxylate cement is not as acidic
coat a preparation prior to cementation to pro- on mixing (approx. 4.8) as zinc phosphate. There
tect it from cement but this adversely affected appears to be little irritation to the pulp18 possibly
retention.12,13 Nowadays a dentine-bonding because there is little penetration of the large
agent could be used and, anecdotally, this has polyacrylic acid molecules into the dentine
helped with some teeth, which have been sensi- tubules. The liquid for the cement is either a vis-
tive after preparation, but controlled studies are cous solution of polyacrylic acid or water. If water
needed to assess the long-term consequences. If is used the acid is contained in its anhydrous state
the dentine is to be etched it is essential that the within the zinc oxide powder. More recently
primer seals all the open tubules or sensitivity developed polycarboxylate cements contain fluo-
may worsen and bacterial invasion may jeopar- ride salts, which may aid caries prevention.
dise the pulp. Correctly mixed polycarboxylate cement has
a consistency similar to that of honey and the
Zinc oxide eugenol cements cement may appear too viscous to allow proper
Cements based on zinc oxide and eugenol are seating. However, this is normal and should not
classical soft cements. Attempts have been made be of concern since the cement undergoes ‘sheer
to create a more permanent cement by adding thinning’ which reduces the apparent viscosity
o-ethoxy-benzoic acid (EBA) to zinc oxide- during the seating of the crown.19
eugenol and by reinforcing it with aluminium
oxide and polymethylmethacrylate. Based on Glass ionomer cements
in vitro tests, this type of cement was reported to Advantages
have good strength and be less soluble than zinc • As for polycarboxylate cement but cement has
phosphate cement.14,15 Unfortunately, its per- similar acidity to zinc phosphate on mixing
formance was much poorer in vivo and studies • Fluoride release
have shown that it deteriorates much more rap- Disadvantages
idly in the mouth than other cements.16,17 It can- • Sensitive to early moisture contamination
not be recommended as a definitive lute for • Low tensile strength
restorations. • Not resistant to acid dissolution
• Has been accused of causing post-operative
Polycarboxylate cements sensitivity but a controlled trial reports it is no
Advantages worse than zinc phosphate
• Reasonable track record Recommendations
• Good compressive strength (if correctly pro- • Used empirically for conventional crowns
portioned) where patient has had a previously high caries
• Adequate working time rate
• Bonds to enamel and dentine • May be used as an alternative ‘default cement’
• Adequate resistance to water dissolution (but to zinc phosphate
less good than zinc phosphate)
• No adverse effect on pulp and less acidic than Conventional glass ionomer cements were
zinc phosphate on mixing first introduced into dentistry as a filling materi-
Resin cements are composites composed of a with subgingival margins. Indeed, proximal
resin matrix, eg bis-GMA or urethane extrusions of resin cement are often radiolucent
dimethacrylate, and a filler of fine inorganic and may remain undetected.35
particles. They have been available as direct fill-
ing materials since the early 1950s26 but it was CROWN CEMENTATION
not until the early 1970s that a composite resin When a crown has been successfully tried-in and
was introduced for crown and bridge cementa- the cement chosen, cementation may then take
tion.27 Resin luting cements differ from restora- place. This section will consider conventional
tive composites primarily in their lower filler cementation. Cementation with resin cements is
content and lower viscosity. Following on from covered more fully in Parts 12 and 13 of this
their successful use in the cementation of resin series on porcelain veneers and resin bonded
bonded bridges and veneers, their popularity has metal restorations respectively.
been increasing in recent years for crown
cementation because of their use in conjunction Trial cementation
RESIN CEMENTS with dentine bonding agents (DBA). However Most dentists are in the habit of fitting crowns
The tensile strength of even when DBAs are used, resin cements are not and then cementing them with hard cement.
resin cements is about without problems (see later). Whilst this approach is usually satisfactory there
ten times that of zinc Composite resin cements are available as self are times where it is difficult to predict a
phosphate cured, light cured and dual cured materials. The patient’s response to changes in aesthetics or
self cured materials are typically used as luting occlusion. If such a patient returns unhappy the
cements because of the inability, or at best diffi- offending crowns must be cut off — a distressing
culty, of light to pass through porcelain and experience for all concerned. In cases of doubt it
metal restorations. Examples include Panavia,21 is useful to have a period of trial cementation
All Bond 2 luting cement and Superbond. using soft cement, but you must ensure that the
Mechanical and physical properties of resin definitive restoration can be removed without
cements compare favourably with the other damage to it or the underlying preparation. To
cements discussed above (Table 2). In particular, make removal easier the cement should be
tensile strength is about ten times that of zinc applied in a ring around the inner aspect of the
phosphate, which in combination with the high crown margin. It is important that the manufac-
bond strength explains why preparation geome- turer’s modifier is added to the cement. Equal
try is of less importance to retention than with lengths of base and catalyst with a third of a
conventional cements. This makes resin cements length of modifier will soften cements such as
useful for bonding restorations on tooth prepa- Temp Bond. Alternatively, a ‘non-setting’ zinc
rations that would not be retentive enough to oxide eugenol material (eg Optow Trial Cement)
succeed with conventional cements. Moreover, a can be used for short periods of soft cementation
well-bonded composite lute will confer much where preparations are retentive. This material
greater strength to an overlying porcelain has the advantage that it is easily pealed out of
restoration than a weaker conventional cement. the crown like a membrane, but it cannot be
This feature has been demonstrated in vitro with relied upon for more than a few days retention.
porcelain veneers28 and in vivo with porcelain Restorations can be removed either by finger
inlays29 which were almost five times more like- pressure or by the application of a matrix band.
ly to fracture when cemented with conventional In cases of difficult removal a Richwil crown
glass ionomer. It should be noted that effective remover can be helpful. This crown remover is
resin bonding to some high strength porcelain simply a material, not unlike a sticky sweet,
cores (eg In-Ceram) could not be achieved by the which is softened in hot water, positioned over
usual etching with hydrofluoric acid because of the crown and the patient asked to bite. Once the
the lack of pores in the material.30 material has hardened the crown is removed by
Problems with the use of resin cements for asking the patient to snap open. Another way of
luting full crowns include excessive film thick- applying a dislodging force to a soft-cemented
ness with some materials,31,32 marginal leakage crown is to use an impact mallet. The problem
because of setting shrinkage, and severe pulpal with this technique is finding a point of applica-
reactions when applied to cut vital dentine. tion on the crown. One solution to this problem
RESIN CEMENTS However, this latter problem may be related is to incorporate small lugs resembling mush-
The Richwil crown more to bacterial infiltration than to any chemi- rooms on the lingual aspect of the crown’s metal
remover is not unlike a cal toxicity. The use of DBA under resin cement work.36 The lugs are removed, of course, prior to
sticky sweet is critical to its success unless the preparation hard cementation.
has been cut only into enamel. Pulpal response
is reduced by the use of DBAs, presumably by Controlling cement film thickness
sealing dentine tubules and reducing microleak- The interposition of a cement lute inevitably
age.33 Adhesive resin cement was found to pro- affects crown seating. Consequently, the art of
duce a better marginal seal than zinc phosphate cementation is to choose a cement with an
cement.34 However, even if the problems of inherently low film thickness and use techniques
microleakage and film thickness could be which allow it to escape whilst the crown is
solved, the problem of adequately removing being seated.
hardened excess resin from inaccessible margins Cement flow can be hindered by preparation
may preclude the use of resin cement for crowns features, which cause a build up of hydrostatic
pressure.37 Thus, retentive preparations, which • Coat the fit surface with cement - do not over-
are long, near parallel and have a large surface fill
area, are most at risk of not seating fully. This • Only apply cement to preparation if cement-
problem can be overcome by die spacing and ing a post
controlled cement application or by venting the The crown should be seated quickly with firm
crown. These techniques need to be used for all finger pressure until all excess cement has been
crowns not just apparently retentive ones. expressed from the margins. Seating force must
Die spacing is the most common method of be adequate to ensure complete seating of the
achieving space for the cement lute.38 It involves crown onto the preparation, but sudden exces-
TECHNIQUE
painting several layers of die relief agent over sive force may result in elastic strain of the den-
the whole of the die but avoiding the finish line. tine, creating a rebound effect, which results in Force must be adequate
The increased cement space results in more rapid the crown being partly dislodged when the force to ensure complete
seating with decreased deformation of the is removed.34 Karpidis and Pearson (1988)45 seating, but sudden
restoration.39–41 Die spacing results in a slightly revealed that crowns seated on preparations in excessive force may
loose fit of a crown on its preparation, but its bovine dentine with a force of 300 N/cm2 could result in elastic rebound
effect on retention is unclear with some studies be removed more easily than those cemented and the crown being
reporting an increase in retention37 while others with half the force. partly dislodged
report a decrease or no effect. A recent study Depending on the angulation of the tooth,
concluded that decreasing the width of the pressure may then continue to be exerted onto
cement layer increases the resistance to dynamic the crown by the dentist or by the patient biting
lateral loading.7 This variability may occur onto a cotton roll. Some operators prefer a
because of differences in cement film thickness. wooden orange stick or similar implement for
A very thin cement lute may have higher stress cementing posterior restorations as this can
concentrations than a slightly thicker one.42 reduce film thickness. However care must be
However, too thick a cement lute is also undesir- taken as these are rigid and may only contact
able as it is liable to fracture. part of the occlusal surface of the crown result-
Another factor which influences the vertical ing in tipping. Pressure should be maintained for
seating of crowns and hence marginal adapta- about one minute. Maintaining pressure beyond
tion is the amount of cement loaded into the this time has no appreciable additional effect.46
crown prior to cementation. A study on the It is worth checking the accuracy of the fit at this
effect of volume of zinc phosphate cement, stage using a sharp probe on the margin and if
reported that lesser amounts of cement placed necessary fine gold margins can be burnished
within a crown resulted in smaller marginal dis- before the cement sets.
crepancy and better occlusal accuracy.43 Indeed, Adequate moisture control should be main-
a crown treated in such a way seated almost 70% tained until the cement has set to prevent mois-
better than an identical crown completely filled ture contamination of the unset material at the
with cement. However, care must be taken in crown margin. In the case of conventional
applying cement in this way not to exceed the cements, excess cement should be left until after
working time or the cement may be too viscous the cement sets. For resin-based cements,
at the time of seating. removal of excess before setting is recommend-
Venting is an effective8 but less popular ed as it can be very difficult to remove following
method of reducing cement film thickness. Exter- setting but may still remain despite our best
nal venting involves creating a perforation in the efforts.47 Some operators apply a smear of petro-
occlusal surface of the crown, which is sealed with leum jelly to the outside of the crown which also
a separate restoration after cementation. With helps with removal of set cement, but if you do
internal venting an escape channel is created this take great care to prevent contamination of
either in the axial wall of the preparation or the fit the fit surface. A common failing is for excess
surface of the crown to help cement escape. cement to be left, especially interproximally.
The amount of force required to allow maxi- Your nurse can help by having a piece of floss
mum seating of cast crowns has been shown to ready. This can be made more effective by tying
be cement specific.44 Seating forces are discussed a knot in the middle of the floss and passing it
next in relation to cementation technique. through the interdental space. Following clean
up, a final evaluation of the cemented crown can
Technique be made including rechecking the occlusion.
Isolate the preparation and ensure good mois-
ture control. If the gingivae have overgrown the 1. Kaufman E G. The retention of crowns before and after
cementation. NY Univ J Dent 1967; 25: 6-7.
finish line use either retraction cord with 2. McClean J W, von Fraunhoffer J A. The estimation of cement
haemostatic agent or if more severe use electro- film thickness by an in vivo technique. Br Dent J 1971; 131:
surgery. A breakdown in technique at any of the 107-111.
3. Christensen G J. Marginal fit of gold inlay castings. J Prosthet
following stages will predispose to failure: Dent 1966; 16: 297-305.
4. Lang N P, Kiel R A, Anderhalden K. Clinical and
• Clean the preparation and crown with water microbiological effects of subgingival restorations with
spray overhanging or clinically perfect margins. J Clin Perio 1983;
10: 563-578.
• Air dry but do not desiccate preparation 5. Kelleher M G D, Setchell D J. An investigation of marking
• Mix cement according to manufacturer’s materials used in occlusal adjustment. Br Dent J 1984; 156:
instructions 96-102.
6. Monasky G E, Taylor D F. Studies on the wear of porcelain, 27. Lee H, Swartz M L. Evaluation of a composite resin crown and
enamel and gold. J Prosthet Dent 1971; 25: 299-306. bridge luting agent. J Rest Dent 1976; 51: 756.
7. Wiskott H W, Belser U C, Scherrer S S. The effect of film 28. Brandson S J, King P A. The compact fracture resistance of
thickness and surface texture on the resistance of cemented restored endodontically treated anterior teeth. J Rest Dent
extracoronal restorations to lateral fatigue. Int J Prosthodont 1992; 72: 1141.
1999; 12: 255-262. 29. Åberg C H, van Dijken J W V, Olofsson A-L. Three-year
8. Kaufman E G, Colin L C, Schlagel E, Coelho D H. Factors comparison of fired ceramic inlays cemented with composite
influencing the retention of cemented gold castings: the resin or glass-ionomer cement. Acta Odontol Scand 1994;
cementing medium. J Prosthet Dent 1966; 16: 731-739. 52: 140-149.
9. Langeland K, Langeland L K. Pulp reactions to crown 30. Awliya W, Oden A, Yaman P, Dennison J B, Razzoog M E.
preparation, impression, temporary crown fixation and Shear bond strength of a resin cement to densely sintered
permanent cementation. J Prosthet Dent 1965; 15: 129-143. high-purity alumina with various surface conditions. Acta
10. Brännström M, Nyborg H. Bacterial growth and pulpal Odontol Scand 1998; 56: 9-13.
changes under inlays cemented with zinc phosphate cement 31. White S N, Yu Z, Kipnis V. Effect of seating force on film
and Epoxylite CBA 9080. J Prosthet Dent 1974; 31: 556-565. thickness of new adhesive luting agents. J Prosthet Dent
11. Brännström M, Nyborg H. Pulpal reaction to polycarboxylate 1992; 68: 476-481.
and zinc phosphate cement used with inlays in deep cavity 32. White S N, Kipnis V. Effect of adhesive luting agents on the
preparations. J Am Dent Assoc 1977; 94: 308-310. marginal seating of cast restorations. J Prosthet Dent 1993;
12. Smith D C, Ruse N D. Acidity of glass ionomer cements 69: 28-31.
during setting and its relation to pulp sensitivity. J Am Dent 33. Qvist V, Stolze K, Qvist J. Human pulp reactions to resin
Assoc 1986; 112: 654-657. restorations performed with different acid-etch restorative
13. Chan K C, Svare C W, Horton D J. The effect of varnish on procedures. Acta Odontologica Scandinavia 1989; 47: 253-
dentinal bonding strength of five dental cements. J Prosthet 263.
Dent 1976; 35: 403-406 . 34. Tjan A H L, Dunn J R, Brant B E. Marginal leakage of cast gold
14. Brauer G M, McLaughlin R, Huget E F. Aluminium oxide as a crowns luted with an adhesive resin cement. J Prosthet Dent
reinforcing agent for zinc oxide-eugenol-o-ethoxy-benzoic 1992; 67: 11-15 .
acid cements. J Rest Dent 1968; 47: 622-628. 35. O’Rourke B, Walls A W, Wassell R W. Radiographic detection
15. Phillips R W, Swartz M L, Norman R D, Schnell R J, Niblack B F. of overhangs formed by resin composite luting agents.
Zinc oxide and eugenol cements for permanent cementation. J Dent 1995; 23: 353-357.
J Prosthet Dent 1968; 19: 144-150. 36. Pameijer J H N. Periodontal and occlusal factors in crown and
16. Osbourne J W, Swartz M L, Goodacre C J, Phillips R W, Gale bridge procedures. pp394. Amsterdam: Centre for Post
E N. A method for assessing the clinical solubility and graduate Courses, 1985.
disintegration of luting cements. J Prosthet Dent 1978; 40: 37. Carter S M, Wilson P R. The effect of die-spacing on crown
413-417. retention. Int J Prosthodont 1996; 9: 21-29.
17. Mesu F P, Reedijk T. Degradation of luting cements measured 38. Grajower R, Zuberi Y, Lewinstein I. Improving the fit of
in vitro and in vivo. J Rest Dent 1983; 62: 1236-1240. crowns with die spacers. J Prosthet Dent 1989; 61: 555-563.
18. Going R E, Mitchem J C. Cements for permanent luting: a 39. Wilson P R, Goodkind R J, Sakaguchi R. Deformation of
summarising review. J Am Dent Assoc 1975; 91: 129-137. crowns during cementation. J Prosthet Dent 1990; 64:
19. Lorton L, Moore M L, Swartz M L, Phillips R W. Rheology of 601-609.
luting cements. J Rest Dent 1980; 59: 1486-1492. 40. Wilson P R. The effect of die spacing on crown deformation
20. Wilson A D, Kent B E. A new translucent cement for dentistry. and seating time. Int J Prosthodont 1993; 6: 397-401.
Br Dent J 1972; 132: 133-135. 41. Wilson P R. Effect of increasing cement space on
21. Smith D C, Ruse N C. Acidity of glass ionomer cements cementation of artificial crowns. J Prosthet Dent 1994; 71:
during setting and its relation to pulp sensitivity. J Am Dent 560-564.
Assoc 1986; 112: 654-657. 42. Kamposiora P, Papavasilious G, Bayne S C, Felton D A. Finite
22. Kern M, Kleimeier B, Schaller H G, Strub J R. Clinical element analysis estimates of cement microfracture under
comparison of postoperative sensitivity for a glass ionomer complete veneer crowns. J Prosthet Dent 1994; 71: 435-441.
and a zinc phosphate luting cement. J Prosthet Dent 1996; 43. Tan K, Ibbetson R. The effect of cement volume on crown
75: 159-62. seating. Int J Prosthodont 1996; 9: 445-451.
23. Sidhu S K, Watson T F. Resin-modified glass ionomer 44. Wilson P R. Low force cementation. J Dent 1996; 24:
materials. A status report for the American Journal of 269-273.
Dentistry. Am J Dent 1995; 8: 59-67. 45. Karipidis A, Pearson G J. The effect of seating pressure and
24. Kanchanavista W, Arnstice H M, Pearson G J. Water sorption powder/liquid ratio of zinc phosphate cement on the
characteristics of resin-modified glass-ionomer cements. retention of crowns. J Oral Rehabil 1988; 15: 333-337.
Biomater 1997; 18: 343-349. 46. Jorgensen K D. Structure of the film thickness of zinc
25. Leevailoj C, Platt J A, Cochran M A, Moore B K. In vitro study of phosphate cements. Factors affecting the film thickness of
fracture incidence and compressive fracture load of all- zinc phosphate. Acta Odontol Scand 1960; 18: 479-501.
ceramic crowns cemented with resin-modified glass ionomer 47. Mitchell C A, Pintado M R, Geary L, Douglas W H. Retention
and other luting agents. J Prosthet Dent 1998; 80: 699-707. of adhesive cement on the tooth surface after crown
26. Schouboe P J, Paffenbarger G C, Sweeney W J. Resin cements cementation. J Prosthet Dent 1999; 81: 668-677.
and posterior type direct filling resins. J Am Dent Assoc 1956;
52: 584.
12
IN BRIEF
● The development of porcelain veneers
● Longevity and factors affecting it
● Tooth preparation, and management of existing restorations
● Impression recording and temporisation (in those few cases which require it)
● Try in, bonding and finishing
● Non-standard porcelain veneers
Porcelain veneers are resin-bonded to the underlying tooth and provide a conservative method of improving appearance or
modifying contour, without resorting to a full coverage crown. The porcelain laminate veneer is now a frequently prescribed
restoration for anterior teeth. The sums spent by the Dental Practice Board on this type of treatment increased from quarter
of a million pounds in 1988/89 to over seven million in 1994/95,1 representing some 113,582 treatments. Since that time the
number has stabilised at over 100,000 veneers prescribed each year.2 The objective of this paper is to give a practical guide
on providing these restorations.
appropriate to use short sections of retraction are required. These include directly placed com-
cord around the margins of the preparations to posite resin veneers and producing a transparent
facilitate the capture of both the finishing edge matrix from a thermoplastic material to allow
of the preparation and the adjacent area of multiple composite veneers to be made simulta-
unprepared tooth. Electro-surgery is best avoid- neously.30 Such provisional restorations need to
ed because of the risk of gingival recession be attached to the enamel surface and the only
revealing the veneer margin. practical way to do this is using the acid etch
An impression of the opposing arch is indis- technique. Obviously, only a very small area of
pensable if the incisal edges of the veneers are enamel in the centre of the preparation should
involved in guidance. be spot-etched to provide attachment for the
composite resin, which can then be removed
Laboratory prescription and manufacture easily during the next visit without damaging
Again, communication with your technician and the periphery of the preparation. It is best to
achieving maximum aesthetics is covered else- avoid the margins of the preparations when
where in this series. Of particular importance in doing this with spot etching at the centre only.
relation to veneers is careful shade selection, Provisional restorations should be made with
especially if you are planning to modify the care, avoiding gingival excess. Any such excess
colour of the tooth. If you intend to attempt to would cause gingival irritation whilst the
modify the shade of the veneer with the luting veneers are being made and may result in an
agent then it is sensible to ask the technician to alteration of the position of the gingival margin
provide space for the luting resin using a propri- or cause difficulty with bleeding during luting.
etary die-spacing system but bear in mind that Provisional restorations are useful when you
the porcelain should not be so thin that there is a plan to alter the position of the teeth using
risk of it being cracked by the thick composite veneers. The diagnostic wax-up can be used to
lute.21 In addition, if a diagnostic wax-up has prepare a thermoplastic matrix. This matrix is
been used to demonstrate a modification in then used to make composite resin veneers
anterior aesthetics then this should be sent to the directly in the mouth. This will allow the patient
laboratory as well. It can also be beneficial to to experience the planned changes to their teeth
send a study cast of the teeth prior to prepara- at first hand and to approve the change in their
tion if one is available should you want to pre- appearance before the definitive restorations are
serve the original tooth form. made, avoiding a potential cause for grievance.
There are a variety of methods for manufac- Trial placement. The veneers should be
ture of porcelain veneers using either a refracto- returned from the laboratory in a foam-lined
ry die material, a platinum matrix laid down on box rather than on the working model of the
a conventional working model or one of the patient. It is important that neither you nor the
castable ceramic materials prepared using the laboratory place the etched veneers back on the
lost wax technique. Sim and Ibbetson29 have stone dies. Any contact between the etched
shown that the best quality of marginal fit was porcelain surface and dental stone will result in
obtained with a platinum foil system, followed abrasion of the stone model and some stone dust
by a refractory die and that the worst fit was becoming trapped in the delicate veneer surface.
associated with cast glass restorations. Swift et al.31 have shown that such contamina-
It is best to ask your laboratory for the veneer tion results in a substantial fall in the bond
to be etched with hydrofluoric acid but not to strength between veneer and resin. They also
apply the silane-coupling agent. These agents found that it was very difficult to clean an
need to be applied just prior to luting the veneer etched porcelain surface that has been contami-
in place (whether or not the laboratory has nated with dental stone.
applied silane) and are provided in most com- Handling porcelain veneers can be difficult;
mercially available resin luting kits. Too early an they are small and delicate. There are commer-
application of a coupling agent, or contamina- cially available devices to help with this, either
tion of the coupling agent coated surface prior to in the form of a tiny suction cup or a small rod
bonding can reduce the strength of the attach- with a tacky resin at one end. Alternatively a lit-
ment between resin and veneer. Also, two com- tle piece of ribbon wax on the end of an amal-
ponent silane systems must not be kept after gam plugger makes a useful substitute.
mixing as the silane polymerises to an unreac- Check the quality of fit and gingival extension
tive polysiloxane, again with a reduction in of the veneer against the tooth, which should
bond strength.7 have been cleaned with pumice in water prior to
the trial. Once you are happy that the quality of fit
Provisional restorations is acceptable, the next stage is to assess the colour
It is difficult and time-consuming to provide match. The colour of a porcelain veneer cannot be
provisional restorations for teeth prepared for assessed if the veneer is simply placed on the sur-
porcelain veneers. It is often best simply to leave face of the tooth. Much of the overall colour for
the teeth in their prepared state providing the the final restoration comes from the tooth struc-
patient is aware that this is going to happen and ture, so a colour-coupling agent is needed
the teeth are not sensitive. between the tooth and the veneer (Fig. 6).
A variety of techniques have been described In its simplest form water will allow the
for placement of provisional restorations if they colour of the tooth to be expressed through the
NON-STANDARD VENEERS
Veneers are generally prescribed for the buccal Fig. 8 Finishing the gingival margin
aspects of maxillary anterior teeth, but there are of the veneer with a small particle
a number of ‘non-standard’ applications. These size diamond bur in a speed
accelerating handpiece. Once again,
include veneers for: a flat plastic instrument protects the
gingival tissues
• The palatal/lingual aspect of teeth which have
been worn or fractured
• Diastema elimination using slips restricted to
the proximal aspects of teeth
• Lower incisors
• Posterior occlusal onlays
All of these applications require some careful
thought to ensure a satisfactory result.
Palatal veneers
There are two main problems with palatal
Fig. 9 Final polishing of the gingival
veneers. margin of the veneer using a rubber
Firstly, it is not possible to adjust the occlusal cup and diamond polishing paste
contacts on the veneer until it is luted in place.
This will inevitably result in the need to adjust
porcelain in situ. When this is required it is
essential that the adjusted porcelain surface be
polished with graded abrasives, culminating in
diamond paste, to ensure that the opposing teeth
are not subject to excessive wear from rough-
ened unglazed porcelain.
Secondly, the finish line for such veneers often Fig. 10 Unsightly, porcelain-tooth
junctions at the incisal overlap of
extends onto the buccal surface of the tooth. It the palatal surface veneers at UL1,
can be very difficult to disguise that line as the UL2 and UL3 (21, 22 and 23). The
resin luting agent can prove highly visible at the junctions are clearly visible due to
junction between porcelain and tooth (Fig. 10). the abrupt change in optical
One option is to try to hide the finish line as much contrast and the straight finish line
as possible. There are three ways to improve this:
duce artificial overhangs that are not cleans-
• Never make the finish line a straight line. The able and are liable to act as plaque traps.
human eye is very good at identifying straight • The junction between porcelain and tooth
lines, but is less good at seeing wavy lines. If should be disguised. This is best hidden within
the finish line is made serpentinous, using the the natural anatomy of the tooth by placing
normal anatomy of the tooth to rise over the the finish line within the intermamelon
mamelons and dip between them, it becomes groove closest to the addition and by using the
more difficult to see (Fig. 11). same concepts as above to blend tooth and
• Extend the finish line over onto the buccal porcelain. In this circumstance it may be pos-
surface of the tooth significantly. Then ask sible to have a straight finish line, at worst it
your technician to gradually increase the mimics a crack on the crown surface.
quantity of translucent porcelain in the over-
lapping section so that more and more colour An alternative is simply to extend the veneer
from the restoration is drawn from the tooth over the whole buccal surface with an appropri-
and less and less from the veneer. This avoids ate extension into the proximal space.
sudden change in optical properties between
tooth and porcelain restoration. (Figs 10,11) Veneers for mandibular incisors
• Use a luting agent that is colour neutral with Mandibular incisors can be managed with
the tooth so that it blends as much as possible. porcelain veneers but the preparation usually
has to be extended over the incisal edge of the
Lateral porcelain slips tooth, particularly if the tooth is in functional
There are once again two problems with this sort contact. The incisal coverage of porcelain has to
of porcelain addition, commonly used to obliter- be sufficiently thick to be durable under contin-
ate a diastema between teeth. uing rubbing contact with the opposing tooth.
This would necessitate incisal edge reduction by
• Care must be taken to avoid a bulky gingival
between 0.75 and 1 mm. Obviously if the tooth is
emergence profile. It is not acceptable to pro-
not temporised there is a risk of over-eruption of
13
● The indications for the management of worn teeth, in occlusal management, and following
molar endodontics
● Design and tooth preparation for anterior and posterior teeth
● Clinical procedures, including management of existing restorations and bonding
● Problems with aesthetics and temporisation
● Maintenance and, where necessary, rebonding
Resin-bonded metal restorations is the final part of the series. Cast metal restorations which rely on adhesion for attachment
to teeth are attractive because of their potential to be much more conservative of tooth structure than conventional crowns
which rely on preparation features providing macromechanical resistance and retention.
As the adhesive minimal preparation bridge preparation has been carried out prior to place-
became commonplace, methods of modifying ment means that cumulative insults to the pulp
base metal alloys were developed to improve are likely to be less than when conventional
adhesion of the retainers to tooth substance via a restorations have been placed (assuming that the
resin-based cement. One technique was to incor- bonding process to dentine is not damaging to
porate irregularities into the fitting surface of the pulp!).
the retainers during pattern formation, which Central to the provision of RBMR are tech-
were subsequently reproduced in metal; these niques to create occlusal space for the restora-
took the form of voids left after the wash out of tion; suffice it to say that non-preparation tech-
salt crystals, spheres or meshwork, but had the niques, such as the Dahl approach,11 involving
disadvantage that castings were bulky and the controlled axial movement of teeth are attrac-
laboratory technique was exacting. Microscopic tive. In this approach teeth are built-up to cause
etch patterns in the fitting surface of bridge their intrusion and the supra-eruption of others
retainers greatly increase the surface area for taken out of occlusion. This topic is summarised
contact with luting agents and can be produced in Part 3 of this series. However, it is worth
by electrolytic corrosion in an acidic environ- emphasising that the build-up must result in
ment. Again this approach was technique sensi- axial loading. Non-axial loading, resulting from
tive but could produce reliable attachment a deflective contact or interference on the build-
between metals and resin.8 Base metal retainers up, can cause problems such as pain and tooth
can also be air abraded with alumina particles mobility.
that as well as increasing the surface area may
enhance the bond with some cements by chemi- In occlusal management
cal interactions.9 RBMRs are made in the laboratory using the lost
Lesser demands on rigidity with single unit wax casting technique. In conjunction with the
restorations enabled the use of precious metal dental technician, the dentist has good control
alloys (type III gold [ADA classification]) rather over form of occlusal surfaces of RBMRs, which
than the nickel based alloys used in adhesive can be used therefore to create occlusal stops
bridgework. This gives advantages in casting and guiding surfaces with a high degree of pre-
accuracy, ease of adjustment and finishing, the cision. RBMRs are particularly helpful when
potential for reduced wear of opposing teeth and such teeth are unrestored and where the alterna-
perhaps of appearance. Several precious metal tive of conventional crowns would be unaccept-
surface treatments have been documented. ably destructive.
These include tin plating,9 heat treatment of A drawback of the technique is that the new
high copper content gold alloys,10 air abrasion guidance surfaces cannot be tested using provi-
of the cast metal surface,2,10 and the Silicoater.11 sional restorations as with conventional crowns.
Air abraded base metal luted to etched enamel Guidance surfaces therefore need to be carefully
using two chemically active cements gave high- formed with the use of a semi-adjustable articu-
er bond strengths in-vitro than precious metal lator and the dentist must accept that some
alloy/surface treatment combinations.9 Howev- adjustment may be required after the RBMRs
er, tin plating or heat treating air abraded pre- have been cemented.
cious metal alloys gave enhanced bond
strengths in-vitro compared with this alloy air Following molar endodontics
abraded alone.10 Clinically, air abraded nickel- Many posterior teeth which have been root
chromium anterior RBMRs cemented with treated are at risk of fracture and will benefit
Panavia Ex gave a survival probability of 0.74 at from a protective cusp covering cast
56 months,1 and air-abraded gold RBMRs (ante- restoration.13 A RBMR with occlusal coverage
rior and posterior), also cemented with Panavia can provide a conservative restoration for a
Ex, were associated with a survival probability tooth already compromised by the need for
of 89% at 60 months.2 However it cannot be endodontic access.
assumed that because a metal surface treatment
works with one cement that it will necessarily be TECHNIQUES
effective with others.
Choice of metal
INDICATIONS If facilities do not exist to heat treat or tin plate
gold after try-in, it may be more sensible to use
In the management of worn teeth air abraded nickel-chromium, accepting that its
RBMR can protect worn and vulnerable tooth shade may look less harmonious in the oral
surfaces from the effects of further wear by environment than yellow gold.
forming a barrier against mechanical and chem-
ical insults. Design and tooth preparation: anterior teeth
Any technique, which could delay entry into Very thin portions of unsupported buccal enam-
a restorative spiral necessitating ever enlarging el remaining on some worn maxillary anterior
restorations with endodontic implications, is to teeth are highly vulnerable to damage on a stone
be welcomed. Although RBMR are susceptible to master cast resulting in a casting which will not
debonding, marginal recurrent caries and mar- fit the tooth. Such enamel should be removed
ginal lute wear, the fact that little if any tooth prior to making the impression and defects
waxed-up on the master cast before building up Table I Precautions for intra-oral air abrasion
patterns for RBMR (Fig. 3). After cementation,
composite resin can be packed against the RBMR Alumina particles are hazardous if inhaled, can scratch glass (eg spectacle lenses) and can leave patients
feeling like they have a mouthful of sand. To avoid these problems:
to replace lost buccal enamel. The latter tech-
1. Use rubber dam where possible.
nique can also be used to restore pre-existing
buccal tooth defects. No other tooth preparation 2. Pack-off area around tooth with wrung out wet paper towels (alumina will stick to towel — not
rebound).
is required for anterior palatal RBMR.
3. Cover patient’s whole face including spectacles, with wet paper towels. Fold to allow patient to
breathe from beneath towel.
4. Dentist and nurse must wear masks and eye protection.
5. Use high volume aspiration.
Appearance
Maxillary anterior teeth, which have been
thinned by wear on their palatal aspects, may
transmit light easily. RBMR luted to the palatal
aspects of these teeth may cause a grey coloura-
tion that can be unacceptable and is more likely
if non-opaque cement is used. On the other
hand, opaque cements may help disguise metal
but can also cause a lightening in shade. At the
initial assessment it is wise to assess possible
Fig. 9 Partially de-bonded adhesive
shade change caused by a RBMR and its cement.
metal splint
White modelling clay applied to the palatal
aspect of the thin tooth can mimic the effect of
opaque cement. Tin foil burnished onto the to declare itself by debonding than a conven-
palatal surfaces of teeth to be restored can indi- tionally retained crown which may stay in place
cate the effect of grey nickel chromium or dark long enough for the consequences of leakage to
oxidised gold in combination with non-opaque take effect. Analysis of the cause of failure for a
cement. RBMR may indicate that an attempt should be
Showing metal is aesthetically acceptable to made to re-attach it after appropriate cleansing
some patients but simply not for others! Yellow and surface treatments. All traces of old cement
gold can look more harmonious in the oral envi- should be removed from the RBMR, which
ronment than nickel-chromium. A useful tech- should then be handled and treated as new. An
nique is to use an air abrader to reduce the air abrasion device, abrasive discs and ultrasonic
reflectance of the polished RBMR. In our experi- scalers are useful in removing cement from the
ence the surface produced by air abrasion also tooth surface. A round diamond bur can be used
picks up ink of occlusal marking tape more easi- without water in a turbine or speed increasing
ly than metal left highly polished.17 A chairside handpiece. The powdery white surface of the
air abrader for intra-oral use is a ideal for this instrumented cement can easily be distinguished
purpose but needs to be used with care (Table 1). from the glossy appearance of instrumented
The advantages of RBMR should be fully enamel. Occasionally etching tooth surface can
explained to the patient: the informed patient help to establish whether or not cement remains:
may accept this compromise in appearance. areas not appearing frosty are either dentine or
residual cement. It is important to remove the
Temporisation of RBMR resin-infiltrated layer in both enamel and den-
In many cases temporary restorations are tine and hence facilitate bonding. Cement
unnecessary but as with porcelain labial veneers removal must be carried out carefully or changes
retention can be a problem. These aspects are in tooth shape or fit surface of the RBMR will
addressed in the ninth article in this series. result in an increase in lute thickness. Inevitably,
It is a significant disadvantage that RBMR repeated attempts at reattachment are increas-
cannot be reliably attached to teeth for a trial ingly likely to fail as the lute thickness rises.
period using temporary cement. Glass ionomer RBMRs linked rigidly together to act as a
cement (GIC) may afford easy retrieval (or post-orthodontic retainer or periodontal splint,
unplanned loss) in some situations but in others carry the risk that one or more retainers may
acts as a final cement! debond leaving the restoration as a whole
attached without causing any initial symptoms.
MAINTENANCE If this happens caries can progress unchecked
Erosion can cause loss of tooth tissue at the beneath decemented elements with disastrous
periphery of a RBMR (Fig. 8). This problem may results (Fig. 9). Adhesive splints need careful fol-
occur as a result of not identifying or not con- low-up: patients must be instructed to seek
trolling the aetiology of the patient’s presenting attention if they think a tooth has become
tooth wear. Repair with an adhesive filling mate- debonded. It is often necessary to remove the
rial may however be straightforward, although whole restoration and attempt to re-bond it. A
concern has been raised about the ability of the sharp tap to a straight chisel whose blade is posi-
repairing material to bond to the metal casting. tioned at the lute space is often sufficient to dis-
A RBMR whose lute has failed is more likely lodge the cemented portions of an adhesive
splint. Occasionally it is possible to accept the 7. Rochette A L. Attachment of a splint to enamel of lower
anterior teeth. J Prosthet Dent 1973; 30: 418-423.
compromise of removing a decemented retainer 8. Livaditis G J, Thompson V P, Etched castings: an improved
if this is at the end of the restoration. Linking mechanism for resin bonded retainers. J Prosthet Dent 1982;
RBMR should be avoided wherever possible. 47: 52-58.
9. Dixon D L, Breeding L C, Hughie M L, Brown J S. Comparison
of shear bond strengths of two resin luting systems for a
CONCLUSIONS base and a high noble metal alloy bonded to enamel.
RBMR rely for their attachment on chemically J Prosthet Dent 1994; 72: 457-461.
active cements. The choice is between precious 10. Eder A, Wickens J. Surface treatment of gold alloys for resin
adhesion. Quintessence Int 1996; 27: 35-40.
metal and base metal alloys with various surface 11. Hansson O. The Silicoater technique for resin-bonded
treatments to enhance adhesion with the prostheses: clinical and laboratory procedures. Quintessence
cement. RBMR have the potential to be very Int 1989; 20: 85-99.
conservative of tooth tissue but are technique 12. Dahl B L, Krogstad O, Karlsen K. An alternative treatment in
cases with advanced localised attrition. J Oral Rehabil 1975:
sensitive. To date few clinical studies exist 2: 209-214.
examining their success. 13. Sorensen J A, Martinoff J T. Intracoronal reinforcement and
coronal coverage: a study of endodontically treated teeth.
1. Nohl F S, King P A, Harley K E, Ibbetson R J. Retrospective J Prosthet Dent 1984; 51: 780-784.
survey of resin-retained cast-metal veneers for the 14. Shillingburg H T, Hobo S, Whitsett L D, Brackett S E.
treatment of anterior palatal tooth wear. Quintessence Int Fundamentals of fixed prosthodontics. 3rd ed. pp171-180.
1997; 28: 7-14. Chicago: Quintessence, 1997.
2. Chana H, Kelleher M, Briggs P, Hooper R.J. Clinical evaluation 15. Paul S J, Scharer P. Effect of provisional cements on the bond
of resin-bonded gold alloy veneers. J Prosthet Dent 2000; strength of various adhesive systems on dentine. J Oral
83: 294-300. Rehabilitation 1997; 24: 8-14.
3. Foreman P C. Resin-bonded acid-etched onlays in two cases 16. Jung M, Gnass C, Senger S. Effect of eugenol-containing
of gross attrition. Rest Dent 1988; 15: 150-153. temporary cements on bond strength of composite to
4. Harley K E, Ibbetson R J. Dental Anomalies- Are adhesive enamel. OperDent 1998; 23: 63-68.
castings the solution? Br Dent J 1993; 174: 15-22. 17. Kelleher M G, Setchell D J. An investigation of marking
5. Lyon H E. Resin-bonded etched-metal rest seats. J Prosthet materials used in occlusal adjustment. Br Dent J 1984; 156:
Dent 1985; 53: 366-368. 96-102.
6. Thayer K E, Doukoudakis A. Acid-etch canine riser occlusal
treatment. J Prosthet Dent 1981; 46: 149-152.