Crown-to-root ratio: Its significance in restorative

dentistry
Robert E. Penny, D.M.D., and Jan H. Kraal, D.D.S., M.S.*
Rock Hill, S. C., and Lexington, Ky.

P
dental
oar crown-to-root
treatment
ratio can result from improper
as well as from traumatic or
lated with oral hygiene levels, but with fermentable
carbohydrate intake.” These data suggest that the
pathologic changes that either increase the length of incidence of root surface caries may be a function of
the clinical crown or decrease the length of the diet rather than an inevitable sequelae of root
clinical root. However, the most common cause of exposure. The root surface concavities and increased
poor (increased) crown-to-root ratio is periodontitis. surface area associated with exposed roots also
Its predominant role in the crown-to-root ratio complicate oral hygiene efforts, thus favoring an
problem can be extrapolated from epidemiologic increased incidence of caries. Sensitivity from ex-
data on periodontal disease. In 1955, Marshall-Day posed root surfaces is also a common problem. A
and associates’ found crestal loss of alveolar bone in variety of techniques and substances are available
98% or more of a sample of individuals 35 years of for desensitization.” Unfortunately, no one approach
age or older. In 1962, examination of a random is uniformly successful.
sample of Americans revealed the increased preva- The early guidelines on crown-to-root ratio for
lence of periodontitis and advanced tissue destruc- abutment teeth were conservative, but they still serve
tion associated with older age groups.’ Since the as a standard in many texts7-ld Ante’s Law; states
prevalence and severity of periodontitis increases that “The combined pericemental area of the abut-
with age, problems in crown-to-root ratio are usually ment teeth should be equal to or greater in perice-
associated with an adult population. mental area than the teeth to be replaced.” Removal
This article considers the problems associated with of all teeth or roots that are “unfit” for further
poor crown-to-root ratio and reviews treatment service was also recommended. This conservative
modalities for teeth with poor crown-to-root ratio. approach assured successful results if sound opera-
Mobility, as related to crown-to-root ratio, occurs tive and prosthodontic principles were applied.
when alveolar support is no longer adequate to However, this approach provided limited treatment
withstand the forces encountered in the oral cavity. alternatives.
Tooth mobility becomes significant when the re- A better understanding of the etiology of dental
quirements of comfort and masticator-y function are caries and periodontal disease and improved treat-
compromised.’ ment capability allow for a more sophisticated
Development of dental caries on exposed root consideration of crown-to-root ratio.
surfaces is a potential problem. A recent study
revealed increased amount of caries on exposed root DEFINITIONS AND MEASUREMENT
surfaces in the mandibular arch, most frequently in TECHNIQUES
premolars.’ In these patients the prevalence of root Crown-to-root ratio is the ratio of the respective
surface caries did not correlate with the degree of tooth parts. It is important to differentiate between
oral hygiene or with evidence of previous coronal anatomic and clinical aspects of this relationship.
caries. The prevalence of root surface caries in The anatomic portions are defined by the location of
patients with or without periodontitis was not corre- the cementoenamel junction. This demarcation gives
no information on the amount of alveolar support.
*Associate Professor, Department of Periodontics, University of The clinical portions, however, are defined by the
Kentucky, College of Dentistry. level of supporting alveolar bone as determined

34 JULY 1979 VOLUME 42 NUMBER 1 0022-3913/79/070034 + 05$00.50/O 0 1979 The C. V. Mosby Co.
CROWN-ROOT RATIO

radiographically. The level of supporting bone is CROWN-TO- ROOT RATIO

rarely coincident with the cementoenamel junction
or dentogingival junction (Fig. 1). Evaluation is best
performed using the clinical crown-to-root ratio.
Further use of the term crown-to-root ratio will refer
to the clinical ratio unless otherwise specified.
Jepsen”’ compared root surface areas and radio-
graphic root areas and established that they could be CLINICAL 1
correlated within a 10% to 15% margin of error, CROWN
cT:ikm
thereby demonstrating the validity of radiographic I k
evaluation. One textbook recommends the use of
Ante’s Law when allowances for a 15% to 20%
variation in computations of the pericemental area
are made.” Other textbooks proposed the use of
actual crown-to-root ratio in determining prognosis.
Presumably these are based on linear measurements
from radiographs. A ratio of 1:2 was considered
ideal, 1: 1.5 was acceptable, and a crown-to-root ratio
of 1: 1 was considered minimal or doubtful.+”
Crown-to-root ratio was also discussed in terms of
the linear amount of bone loss although the impor- CLINICAL RATtO 2: I ANATOMK RATIO I:2
tance of this approach varies with root form and Fig. 1. Mandibular second premolar with severe bone
length.“-‘” Teeth exhibiting extensive bone loss, with loss demonstrating the contrast between anatomic and
pocket depth greater than 6 to 7 mm from the clinical crown-to-root ratio.
cementoenamel junction, are sometimes considered
hopeless because of the compromises encountered in hygiene efforts more difficult. Examples are the
periodontal surgery. Accurate and thorough probing addition of margins and solder joints and the expo-
of each tooth is required to determine the bony sure of less accessible, concave crown and root
topography around the tooth. surfaces.”
Bone loss accompanying a poor crown-to-root Periodontal surgery. Periodontal surgery can
ratio has also been expressed as the fraction of affect the crown-to-root ratio. Complete osseous
alveolar support remaining. Tylman” recommended resection of periodontal bony defects to create phys-
that teeth with a normal amount of bone be used for iologic contours may result in loss of surrounding
abutments. However, he stated that teeth lacking bone. This applies to the teeth involved with the
one third to one half of their normal periodontal defect and adjacent teeth if ideal hard and soft tissue
attachment, when judiciously selected, could render architecture is to be established. The significance of
satisfactory service. Beube,” discussing the retention the increase in clinical crown length may only apply
or extraction of teeth, assigned a poor prognosis to in severe osseous defects. Selipsky’” noted that the
teeth with only one third of the apical bone remain- decreased mobility obtained in initial therapy was
ing, advanced mobility, and poor root morphology. not compromised in the long-term (1 year) by
Goldman and Cohen” advocated the retention of definitive surgery within “clinically operable lim-
teeth based on their ability to return to health and its.“ls
maintain themselves in function. Periodontal support regeneration. Regeneration
of lost periodontal support is the most logical
TREATMENT CONSIDERATIONS FOR TEETH approach to improve poor crown-to-root ratio, and
WITH POOR CROWN-TO-ROOT RATIO bone grafting is the most reliable method. ‘IJnfortu-
Plaque. Plaque control and adequate oral hygiene nately, contradictory findings in published reports of
are of primary concern in teeth having poor crown- this approach obviate strict comparison of the differ-
to-root ratio. Continued progression of periodontitis ent techniques.‘” Ingber”’ presented the rationale
due to inadequate plaque control invites treatment and technique of forced eruption as a method of
failure.’ !, Ii Structural changes resulting from restor- treating one- and two-wall infrabony defects.
ative and periodontal treatment make successful oral Improved crown-to-root ratio and osseous architec-

THE JOURNAL OF PROSTHETIC DENTISTRY 35

 PENNY AND KRAAL

ture result from occlusal reduction (crown short- models have been used to analyze the stresses placed
ening) and ensuing eruption. Such changes in crown- on the dentition in splinted and nonsplinted
to-root ratio and osseous contours also have been teeth.‘“, Z’ A better distribution of forces is achieved
reported in the treatment of osseous defects of with splinted teeth than with free-standing teeth
periodontosis.” surrounded by edentulous spaces. The applicability
Occlusal reduction. Reducing clinical crown of these studies to living systems is not conclusive,
length by occlusal reduction of extruded teeth is a although these observations do coincide with those
valid approach to improving the crown-to-root ratio. obtained by Glickman and associates’” in their
Bohannan and Abram? discussed crown shortening histologic study of splinted and nonsplinted teeth.
in conjunction with intentional pulp extirpation.
RESTORATIVE CONSIDERATIONS
They noted an improved crown-to-root ratio but
encountered complications. For each millimeter of Cast restorations for teeth with poor crown-to-root
posterior tooth reduction and resultant decrease in ratios place greater demands on the dentist. Ideal
the vertical dimension of occlusion, an increase of 3 margins of restorations are essential, since inflamma-
mm of anterior vertical overlap (overbite) will occur. tion has been associated with restorations having
Overdentures represent an extreme approach to excellent margins.17 However, margins may be kept
crown shortening and crown-to-root ratio improve- away from the gingiva.
ment, providing a new treatment alternative. Design of the preparations for cast restorations are
Increasing stability. The mobility seen in teeth dictated by the anatomy of the root surfaces, which
with poor crown-to-root ratio can be reduced by may necessitate endodontic therapy. Root anatomy
selectively grinding occlusal surfaces and minimizing exerts further influence in making castings. Contours
horizontal forces in the existing dentition.” In a must be consistent with existing root contours and
theoretical computer model that related applied clinical crown form to permit essential hygiene.
occlusal forces to measured root surface areas, Obtaining laboratory services that include proper
Hillam”” found that in teeth subject to horizontal contours, margins, and prescribed occlusion also
forces, pressures on the periodontal ligament were may be difficult.”
rapidly increased when bone loss exceeded 55% of
EXTRACT’ION
the alveolar bone height. In teeth that were loaded
axially, the rapid increase of pressure on the perio- Extraction must be considered as a treatment
dontal ligament did not occur until 80% of the alternative. Removal or retention of molar teeth
supporting bone had been lost. Although this was a related to furcation. involvement was reviewed by
theoretical model, the results coincide with clinical Saxe and Carmen.“’ These considerations also apply
observations of teeth with poor crown-to-root ratio. to teeth with poor crown-to-root ratio. These authors
Teeth which have poor crown-to-root ratio and suggested that the indications for removal of prob-
exhibit mobility can be retained through splinting. lem teeth are (1) an unopposed terminal tooth in an
Initially, teeth may be temporarily or provisionally arch, (2) a periodontally involved tooth with sound
splinted as a diagnostic test of their ability to adjacent teeth providing other treatment alterna-
function in mastication and return to health.” tives, and/or (3) a solitary distal abutment that
However, mobile teeth that do not respond exhibits mobility. Generally, any noncritical tooth
(decreased mobility) to removal of local irritants and with serious periodontal liability should be removed.
selective grinding should be carefully evaluated as to Some seriously involved teeth may be retained if (1)
the cause of this mobility. Also, care must be taken to an involved terminal tooth in an arch is the antago-
determine the patient’s commitment to the final nist for a sound tooth and (2) a solitary tooth will
restorative therapy prior to permanent changes in serve as an abutment.
tooth structure. Some dentists feel that splinting is
indicated in periodontal therapy only when individ- RETENTION OF TEETH WITH POOR
ual teeth no longer withstand functional stresses.‘“’ Ifi CROWN-TO-ROOT RATIO
Dawson” emphasized the difficulty in maintaining The problem of crown-to-root ratio should be
good oral hygiene in splinted areas and suggested approached from the standpoint of the health of
splinting only when it is needed. each individual tooth. The primary consideration is
Many authors recommend multiple abutments for maintaining a noninflammed periodontium through
favorable force distribution when treating teeth with meticulous patient oral hygiene. This provides
poor crown-to-root ratio.‘“-19. lj. 16. “w% Photoelastic opportunity for the use and retention of teeth with

36 JULY 1979 VOLUME 42 NUMBER 1

CROWN-ROOT RATIO

reduced periodontal support even in the presence of lems were reviewed. Treatment possibilities were
mobility.‘” Mobility, in the absence of gingival discussed in terms of plaque control. periodontal
inflammation, has been demonstrated to be a revers- surgery, occlusal adjustment by selective grinding,
ible process that does not result in the loss of splinting, restorative considerations. and extrac-
connective tissue attachment or the formation of tion.
periodontal pockets?” The widened periodontal The original guidelines for crown-to-root ratio in
ligament space that is observed is regarded as a the selection of abutments were found tcj be excep-
physiologic adaptation..“- ‘!’ tionally conservative and treatment limiting.
Obviously, mobility is the second major clinical New treatment modalities were considered in light
problem associated with poor crown-to-root ratio. of increased understanding of periodontal inflamma-
Considering the previous data relative to mobility, tion and its control. With inflammation controlled
trauma from occlusion, and control of inflammation, and with a carefully designed occlusion, some degree
the problem of mobility is narrowed. If a tooth can of mobility may be tolerated, thereby permitting the
function in mastication and not be a source of retention of teeth with minimal alveolar support.
discomfort or distraction for the patient, then mobil-
ity can be acceptable, since the prognosis of the tooth REFERENCES
is not certain. I. Marshall-Day, C. D., Stephens, R. G., and (.&igley, I,. I;.,
Nyman and associates,,’ evaluating the role of Jr.: Periodontal disease: Prevalence and incidewr. ,J. Perio-
occlusion for the stability of fixed partial dentures, dontol 26:185, 1955.
2. Johnson, E. S., Kelly, J. E., and Van Kirk. I,, E.: Srlected
demonstrated the functional demands that can be
dental findings for adults. National Centrr for Health
placed on the severely reduced, noninflammed peri- Statistics. Series 11, No. 7, Washington. I).(‘.. 1965, U.S.
odontium. Patients were selected for their ability to Public Health Service.
maintain meticulous oral hygiene, rehabilitated with 3. Nyman, S., Lindhe, J., and Lundgren. D.: The rolr of
fixed restorations and periodontal surgery, and eval- occlusion for the stability of fixed bridges in patients with
reduced periodontal tissue support. J Clin Periotfontol 2:53,
uated yearly for 2 to 6 years. None of the patients
1975.
exhibited further bone loss. Mobility was present 4. Sumney, D. L., Jordan, H. V., and Englandcr H. V.: The
when the restorations were inserted but was consid- prevalence of root surface caries in selected populations. ,J
ered acceptable, since it did not increase. Bone Periodontal 44:500, 1973.
height on the abutments was unaltered, and the 5. Hix, J. 0.. and O’Leary, T. J.: The relationship between
cemental caries, oral hygiene and fermentable carhohydrare
radiographic width of the periodontal ligament
intake. ,J Periodontol 47:398, 1976.
space did not widen and was narrowed in some 6. Goldman, H. M., and Cohen, D. W.: Periodontal Therapy,
patients. cd 5. St. Louis, 19’73, The C. V. Mosby Co.
This study demonstrated that secondary occlusal 7. Ante, I. I-I.: The fundamental principles of abutmenrs. Mich
trauma in the noninflamed peridontium is not Dent Sot Bull 8~14, 1926.
8. Smith, G. P.: Objectives of a fixed partsal denture. .J
harmful. Additionally, it demonstrated a continuing
PROSTHE?. DENT 11:463, 1961.
stability that can be obtained with fixed restorations 9 Johnston, J. E., Phillips, R. W.. and Dykema, K. W..
in patients where there is a minimum of remaining Modern Practice in Crown and Bridge Prosthodontics. t:d 3.
periodontal tissue support, even in combination with Philadelphia, 1971, W. B. Saunders Co.
marked mobility of individual abutment teeth. 10 Reynolds, J. M.: Abutment selection for fixed prosthodon-
tics. J PROSTHET DENT 19~483, 1968.
It should be evident at this point that there must
11 Dykema, R. W.: Fixed partial prosthodontics .J ‘fenn Dent
be more than one guideline for evaluating teeth with Assoc 43:309, 1962.
bone loss and poor crown-to-root ratio. Crown- 12 Tylman, S. D.: Theory and Practice of Crown and Fixed
to-root ratio alone is not a realistic criterion. Assess- Partial Prosthodontics. ed 6. St. I.ouis, I9iO. The C. 17.
ment of the teeth is predicated on the elimination of Mosby Co.
13. Jepsen, A.: Root surface measurement and a method for
inflammation by plaque control and the removal of
x-ray determination of root surface area. Acra Odontol
all other etiologic agents and contributing factors. Stand 21:35. 1963.
With this, one can proceed more confidently in 14 Beube, F. E.: Correlation of the degree of alwolar bone loss
making a definitive treatment plan and predicting with other factors for determining the removal or retention
the prognosis of the treatment. of teeth. Dent Clin North Am 13:801, 1969.
15 Amsterdam, M.: Periodontal prosthesis: L5 years in retro-
SUMMARY spect. Alpha Omegan 67:8, 1974.
16 Prichard, ,J, F.: .4dvanced Periodontal Disease: Surgical and
The definition of the crown-to-root ratio, its mani- Prosthetic Management, ed 2. Philadelphia. 1972. W. B.
festation as a clinical problem, and associated prob- Saunders Co.

THE JOURNAL OF PROSTHETIC DENTISTRY 37

 PENNY AND KRAAL

17. Silttess, J.: Periodontal considerations in patients treated stresses in alveolar bone induced by a tilted molar. J
with dental bridges. J Pcriodontol Rcs 9:50, 1974. PROSTHET DENT 34:415, 1975.
18. Selipsky, H.: Osseous surgery-How much need we 29. Glickman, I., Roebcr, F. W., Brion, M., and Pameijer, J. H.
compromise. Dent Clin North Am 20:79, 1976. N.: Photoelastic analysis of internal stress in periodontium
19. Ellegaard, B.: Bone grafts in periodontal reattachment created by occlusal forces. J Pcriodontol 41:30, 1970.
procedures. J Clin Periodontol 3: I, 1976. 30. Glickman, I., Stein, S., and Smulow, J. B.: The effect of
20. Ingber, J. .S.: Forced eruption I: A method of treating increased functional forces upon the periodontium of
isolated one and two wall infrabony osseous defects-Ratio- splinted versus non-splinted teeth. J Pcriodontol 32:290,
nale and case sport. J Periodontol 45:199, 1974. 1961.
21. Everett, F. G., and Baer, P. N.: A preliminary report on the 31. Saxe, S. R., and Carmen, D. K.: Removal or retention of
treatment of the osseous defects in periodontosis. J Periodon- molar teeth: the problem of the furcation. Dent Clin North
tol 35:429, 1964. Am 13:783, 1969.
22. Bohannan, H. M., and Abrams, L.: Intentional vital pulp 32. Svanberg, G., and Lindhc, J.: Vascular reactions in the
cxtripation in periodontal prosthesis. J PROSTHET DENT periodontal ligament incident to trauma from occlusion. J
11:781, 1961. Clin Periodontol 1:58, 1974.
23. Hillam, D. G.: Stresses in the periodontal ligament. J 33. Poison, A. M.: Trauma and progression of marginal perio-
Periodontol Res 8:51, 1973. dontitis in squirrel monkeys. II. Co-destructive factors of
24. Lemmerman, K.: Rationale for stabilization. J Periodontol pcriodontitis and mechanically produced injury. J Periodon-
47:405, 1976. tol Res 9:103, 1974.
25. Dawson, P. E.: Evaluation, Diagnosis and Treatment of 34. Waerhung, J.: Pathogenesis of pocket information in trau-
Occlusal Problems. St. Louis, 1974, The C. V. Mosby Co. matic occlusion. J Periodontol 26:107, 1955.
26. Kronfeld, M.: Mouth Rehabilitation: Clinical and Labora- 35. Wcntz, F. M., Jaraback, J., and Orban, B.: Experimental
tory Procedures, cd 2. St. Louis, 1974, The C. V. Mosby occlusion trauma imitating cuspal interferences. J Periodon-
co. to1 29:117. 1958.
27. Clickman, I., Stein, S., and Smulow, J. B.: The effect of
increased functional forces upon the pcriodontium of Reprint requests to:
splinted and non-splinted teeth. J Periodontol 32:290, DR. ROBERT E. PENNY
1961. 1144 INDIA Hook RD., STE. D
28. Hood, J. A., Farah, J. W., and Craig, R. G.: Modification of ROCKHILL, S. C. 29730

ARTICLES TO APPEAR IN FUTURE ISSUES

Fabricating a post and core to fit an existing crown

N. Beheshti, D.M.D.

The significance of articulator capability. Part II: The prevalence of

immediate side shift
Neal D. Bellanti, D.D.S., MS., and Kenneth R. Martin, D.M.D.

Tissue response to posterior denture base-type pontics

Bruce J. Crispin, D.D.S., MS.

The Micro-Ring for full subperiosteal implant and prosthesis construction

David D. Dalise, D.D.S.

A measuring procedure for the determination of the three-dimensional

shape of dentures
Anton J. de Gee, Ph.D., Emmy C. ten Harkel, and Care1 L. Davidson, Ph.D.

Stress analysis of disjunct removable partial dentures

J. W. Farah, D.D.S., Ph.D., A. R. MacGregor, Ph.D., F.D.S.R.C.S., and T. P. G. Miller

Root retention and removable partial denture design

David N. Firtell, D.D.S., M.A., Thomas W. Her&erg, D.D.S., and Jeremiah F. Walsh

38 JULY 1979 VOLUME 42 NUMBER 1