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BDJ Clinician’s Guides

Robert Wassell · Francis Nohl

Jimmy Steele · Angus Walls Editors

Extra-Coronal
Restorations
Concepts and Clinical Application
Second Edition
BDJ Clinician’s Guides
More information about this series at http://www.springer.com/series/15753
Robert Wassell • Francis Nohl
Jimmy Steele • Angus Walls
Editors

Extra-Coronal Restorations
Concepts and Clinical Application

Second Edition
Editors
Robert Wassell Francis Nohl
Department of Restorative Dentistry Department of Restorative Dentistry
Newcastle University School of Newcastle University School of
Dental Sciences Dental Sciences
Newcastle upon Tyne Newcastle upon Tyne
UK UK

Jimmy Steele Angus Walls

Newcastle University School of Edinburgh Dental Institute
Dental Sciences Edinburgh
Newcastle upon Tyne UK
UK

ISSN 2523-3327     ISSN 2523-3335 (electronic)

BDJ Clinician’s Guides
ISBN 978-3-319-79092-3    ISBN 978-3-319-79093-0 (eBook)
https://doi.org/10.1007/978-3-319-79093-0

Library of Congress Control Number: 2018947640

© Springer International Publishing AG, part of Springer Nature 2019

This book has been previously published in 2002 by BDJ Books with the following title: A Clinical
Guide to Crowns and Other Extra-coronal Restorations.
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recita-
tion, broadcasting, reproduction on microfilms or in any other physical way, and transmission or infor-
mation storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica-
tion does not imply, even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims
in published maps and institutional affiliations.

Printed on acid-free paper

This Springer imprint is published by the registered company Springer International Publishing AG part
of Springer Nature.
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
This book is dedicated to the memory of our
special friend and colleague, Professor
Jimmy Steele, CBE, who sadly died in
November 2017. A remarkable man whose
skill, knowledge, and influence extended
across a wide range of dentistry and far
beyond. We are privileged to have had his
important contribution to both the first and
second editions of this book.
Preface

In 2002 the British Dental Journal published “Crowns and Other Extra-coronal
Restorations”, a landmark series of articles. This became a clinical guide defining
contemporary materials and techniques for restoring individual teeth. A major
update is now timely because of important developments and changes, for example
the significant shift to adhesive dentistry. So, to de-emphasise the wholesale use of
crowns, the title has changed simply to Extra-coronal Restorations. This new edi-
tion must also reflect the major advances in materials, including developments in
digital dentistry and in high strength ceramics.
A new team of authors give fresh insight into this intriguing area of dentistry.
They come from five UK university dental schools with their affiliated dental
hospitals, and research centres/ institutes. Consequently, all have considerable
knowledge, expertise, and experience in their chosen clinical fields. The editors are
the same gang of four from 2002. Now older, and hopefully wiser, they have
witnessed dentistry change across four decades.
The book is divided into five parts:

Part I: Evidence Based Extra-coronal Restorations

Part II: A Healthy Start
Part III: Managing Future Risk
Part IV: Materials and Aesthetics
Part V: Planning and Provision of Extra-coronal Restorations

Parts I–IV provide an evidence base for providing extra-coronal restorations with
a reliable clinical performance while Part V is a practical guide to the relevant
procedures.
To ensure restorations are successful we emphasise “A Healthy Start” and
“Managing Future Risk”, subjects often covered superficially or not at all in other
operative texts. Within the parts there are new chapters covering periodontal aspects
of restoration, tooth surface loss, implant crowns, and methods of adapting crowns
to existing partial dentures. In line with modern dental education, each chapter starts

vii
viii Preface

with clinically relevant learning points. In addition, clinical tips make the book suit-
able for senior dental undergraduates, postgraduates, and practicing dentists. Given
the book’s tight focus, its scientific content should also be of interest to dental
academics.

Robert Wassell
Francis Nohl
Newcastle upon Tyne, UK Jimmy Steele
Edinburgh, UK Angus Walls
Acknowledgements

Thanks are due to the editors of the British Dental Journal and the former publica-
tion house, BDJ Books, for supporting the complete restructuring and rewriting of
this book.
Dr. Amar Naru, who is both a highly skilled dentist and renowned professional
artist, has drawn most of our diagrams. They elegantly and without fuss depict a
mine of information.
Distinguished clinicians have provided clinical cases: Matthew Brennand-Roper,
Edinburgh; Margret Corson, Newcastle; Marco Ferrari, Siena; Matthew Garnett,
Newcastle; Konrad Staines, Bristol; and the late Eoin Smart, Newcastle. These con-
tributions are acknowledged in the legends of individual figures. The authors have
also shared their images in unstinting support of the book.
Stuart Graham Scott and Mark Pickersgill from Newcastle Dental Hospital pro-
vided valuable laboratory material and images. Special thanks to Jan Howarth for
her patience, help, and photographic expertise. Thanks also to Krishna Bhatia,
Edinburgh Dental Institute, and to Smileline SA, Switzerland, for providing photo-
graphic images.
We are grateful to Elsevier for allowing us to publish under licence Fig. 2.5 in
Chap. 2.
The editors are indebted to all the authors for waiving royalty payments in favour
of the British Dental Association Benevolent Fund.

ix
Contents

Part I Evidence Based Extra-coronal Restorations

1 Introduction����������������������������������������������������������������������������������������������    3
Jimmy Steele and Robert Wassell
2 Clinical Performance ������������������������������������������������������������������������������   11
Claire Field, Heidi Bateman, Richard Holliday, and Robert Wassell

Part II A Healthy Start

3 Caries Management ��������������������������������������������������������������������������������   37
Heidi Bateman, Angus Walls, and Robert Wassell
4 Periodontal Considerations��������������������������������������������������������������������   43
Arindam Dutta, Louise O’Dowd, Angus Walls, and Robert Wassell
5 Endodontic Considerations ��������������������������������������������������������������������   59
Simon Stone, John Whitworth, and Robert Wassell
6 Recognising Tooth Surface Loss ������������������������������������������������������������   67
James Field, Angus Walls, Jimmy Steele, and Robert Wassell
7 Immunological Reactions to Materials��������������������������������������������������   75
Simon Stone, Jimmy Steele, and Robert Wassell
8 Temporomandibular Disorders and Occlusal Disease��������������������������   83
Pamela Yule, Jimmy Steele, and Robert Wassell

Part III Managing Future Risk

9 Preserving Pulp Vitality��������������������������������������������������������������������������   93
Simon Stone, John Whitworth, and Robert Wassell
10 Periodontal Considerations and Surgical Options������������������������������   99
Louise O’Dowd, Arindam Dutta, Angus Walls, and Robert Wassell

xi
xii Contents

11 Viability of Posts and Cores�������������������������������������������������������������������� 115

Simon Stone, John Whitworth, and Robert Wassell
12 Occlusal Control�������������������������������������������������������������������������������������� 135
Pamela Yule, Jimmy Steele, and Robert Wassell
13 Managing Tooth Surface Loss���������������������������������������������������������������� 147
James Field, Jimmy Steele, and Robert Wassell

Part IV Materials and Aesthetics

14 Material Choice���������������������������������������������������������������������������������������� 163
Touraj Nejatian, Richard Holliday, and Robert Wassell
15 Luting, Cements and Bonding���������������������������������������������������������������� 207
James Field, Michele Barbour, and Robert Wassell
16 Implant Abutments for Crowns�������������������������������������������������������������� 231
Richard Holliday, Francis Nohl, and Robert Wassell
17 Aesthetic Control������������������������������������������������������������������������������������� 247
James Field, Andrew Keeling, Robert Wassell, and Francis Nohl

Part V Planning and Provision of Extra-coronal Restorations

18 History and Examination: Why is it Important?���������������������������������� 277
Heidi Bateman and Robert Wassell
19 Core Build-Ups and Post Placement������������������������������������������������������ 295
Claire Field, Simon Stone, John Whitworth, and Robert Wassell
20 Fundamentals of Tooth Preparation������������������������������������������������������ 329
James Field, Jimmy Steele, and Robert Wassell
21 Gingival Management and Retraction�������������������������������������������������� 363
Jenna Trainor, Andrew Keeling, and Robert Wassell
22 Impression Materials and Techniques �������������������������������������������������� 375
Jenna Trainor, Andrew Keeling, and Robert Wassell
23 Provisional Restorations�������������������������������������������������������������������������� 395
James Field and Robert Wassell
24 Fitting and Cementation�������������������������������������������������������������������������� 421
Pamela Yule, Richard Holliday, James Field, Francis Nohl, and
Robert Wassell
25 Adapting Crowns to Existing Prostheses ���������������������������������������������� 445
James Field, Lesley Kilford, and Robert Wassell

Index������������������������������������������������������������������������������������������������������������������ 453
 Part I
Evidence Based Extra-coronal Restorations
Introduction
1
Jimmy Steele and Robert Wassell

1.1 Learning Points

This book provides learning points at the start of each chapter which relate to major
areas of clinical relevance. The introduction asks dentists to:

• Consider the consequences of providing extra-coronal restorations, particularly

where failure will result in damage to an already prepared and weakened tooth
• Recognise that patients may view dental restorations as normal consumer goods
causing disappointment unless expectations are managed
• Advise patients of the realities of having irreversible dental treatments, not only
in terms of improved dental and general health, but bad impacts too
• Use scientific evidence (where available) to inform choice of restoration
• Select, where suitable, minimally destructive, adhesively retained restorations
• Plan and perform work to a high standard employing sound biological and
mechanical principles.

In addition to the above learning points, the introduction outlines the content of
each of the Book’s five parts, mentioned previously in the preface.
The production and placement of some beautiful pieces of porcelain in the mouth
is a seductive process when it transforms a smile. All the authors of this book have
been there and done that. The day of final cementation, it is a fabulous feeling as you
replace the slightly dingy temporaries with true sparkle. So, in that moment, have

J. Steele
Newcastle University School of Dental Sciences, Newcastle upon Tyne, UK
R. Wassell (*)
Department of Restorative Dentistry, Newcastle University School of Dental Sciences,
Newcastle upon Tyne, UK
e-mail: Robert.wassell@ncl.ac.uk

© Springer International Publishing AG, part of Springer Nature 2019 3

R. Wassell et al. (eds.), Extra-Coronal Restorations, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-319-79093-0_1
4 J. Steele and R. Wassell

you ever paused to reflect on what you have really done? Alternatively, are you just
living in the moment, internally celebrating your own technical genius, because
these moments can become addictive? Covering teeth in a shell of ceramic (or
metal, or both) might be seductive, sometimes necessary, or at least advisable but
almost always biologically destructive.
Try and answer a simple pair of questions; how long will this restoration last and
what happens when it fails? Can you answer these? Two things are certain:

• Unless your patient is quite elderly it is unlikely that the beautiful crown will
outlive its owner
• Its failure will probably not just mean making a new crown and sticking it on.

Inevitably, the preparation weakens the tooth underneath and crown failure,
which is not inevitable in the remaining lifespan, but, likely, usually leads to further
tooth damage. That restorative cycle cannot usually be repeated too often without
terminal damage.

1.2 Excellence and Consumerism: A Patient’s Perspective

Our patients usually live in a world that is very different to ours where it can be dif-
ficult to distinguish dental restorations from normal consumer goods. No doubt,
some consumers would like to be able to choose their crown or veneer and perhaps
have it replaced repeatedly until they get one they like. If not perfectly satisfied, they
may also like to be able to take it back to the shop and have a full refund or choose
a replacement item. These are of course illusions but may be reinforced by the lan-
guage that we use to sell dentistry. This is a challenge for clinicians because clearly
there are fundamental differences between providing health care and selling con-
sumer goods. The changes we make are also fundamental and irreversible and can
have a bearing (good or bad) on long-term health.
We are lucky now that technologies have been developed over four decades,
particularly adhesive approaches, which allow us to use much less destructive tech-
niques. That means fewer dentine tubules are opened and less hydroxyapatite slurry
disappears up the aspirator, with huge benefits in terms of tooth health and long-­
term vitality. These technologies have transformed dentistry, and this book explores
them. The authors recognise that if dentists are going to employ them successfully,
they need to know what they are doing and why. You need to plan correctly, know
your options and your materials, and then finish the job with an attention to detail
that would leave a normal human being cold.

1.3 The Use of Evidence

Talking of leaving the normal human being cold, we need to think about evidence.
This understanding is not about taking what is written here as some sort of gospel
truth. You should question what we write and we have tried to do the same.
1 Introduction 5

Higher Systematic reviews & meta-analyses

quality of
evidence Randomized controlled trials

Cohort studies

Case control studies

Case reports and series

Ideas, editorials, opinion

Animal research Lower

quality of
In vitro / laboratory research evidence

Fig. 1.1 Hierarchy of evidence to support clinical decisions (adapted from Sacket et al. [4])

The concept of basing treatment on sound clinical evidence is now familiar, or

should now be familiar, to all dentists. As a clinician in this area of work, it can be
difficult to interpret or even find meaningful evidence about what approach is
“best” or, in response to the question above, how long your restorations should be
expected to last.
In this book, we have tried hard to find the best evidence we can, starting with
systematic reviews of which there have recently been an increasing number.
However, they do not cover every aspect, and we have often had to refer to lower, or
even much lower, levels of evidence (see Fig. 1.1). In many areas, we have had to
make judgements based on sound biological or mechanical principles with an
empirical rather than an experimental basis. We have tried to be clear about where
there is, and is not, a meaningful evidence base. We hope that the result is realistic,
balanced, and built around the needs of the patient.
This book consists of five parts which we outline below.

1.4 Part I: Evidence-Based Extra-Coronal Restorations

In some areas of dentistry, data and evidence are relatively plentiful, for example, we
have a pretty good understanding of the merits of various interventions related to
caries prevention and periodontal treatment, to give two examples. However, when it
comes to laboratory-made restorations, we are not nearly as well served. The reasons
for this relative lack of excellent clinical data are complex. In part, it is because we
have not been particularly good, as a profession, at setting up the trials that would
deliver this evidence, but let’s not beat ourselves up about this because the fact is that
there are valid reasons why the collection of such data (in conventional clinical trials)
is very challenging. We will look at these in Chap. 2, but one of the most important
reasons is that the time it takes to be able to record a meaningful outcome is not a
6 J. Steele and R. Wassell

matter of months or even a year or two; it could be a decade before we are able to
make judgments about the relative effectiveness of some of these treatments.
Consequently, the technology often moves faster than the evidence collection, so
some reports may relate to a redundant technology. That is nobody’s fault, but it is a
daily challenge to clinicians who seek to provide truly evidence-­ based care.
Nevertheless, there is clinical evidence to back some of our restorative treatment. It
must be interpreted meaningfully, and this will also be considered.
Where we are confident that our treatment can make a difference, a lack of trials
is not a viable reason to refuse treatment. But, as clinicians, we should never be too
confident (despite other rational reasons for choosing a treatment) that we are doing
the right thing; this is all a matter of balance.

1.5 Part II: A Healthy Start

Importantly, we need to avoid the temptation of diving in to tooth preparation before

existing dental disease, and the background risks are diagnosed and brought under
control. This includes not only caries and periodontal disease but also tooth surface
loss (tooth wear), mucosal disease, occlusal disease, and temporomandibular disor-
ders. Of course, the medical history (see Chap. 18) is an essential part of risk
assessment.
General dental practitioners (GDPs) in the UK will be familiar with the generic
preventative advice issued by Department of Health. This advice covers caries, peri-
odontal disease, and dental erosion [1]. It also advises on smoking cessation and the
carcinogenic risks of alcohol consumption. However, GDPs must use their knowl-
edge and clinical judgement to tailor specific advice and management for individual
patients [2].
Patient recalls are an important part of primary dental care because some disease-­
free patients may go on to develop caries and periodontal disease later [3]. A simple
and effective way is to identify patients who are not at risk from those who are at
risk. In this way, resources can be concentrated on those who need more targeted
action for the full range of dental diseases [2]. This approach is easier and more
reliable than assessing risk on a green, amber, red basis (see Fig. 1.2).

1.6 Part III: Managing Future Risk

To prevent extra-coronal restorations failing prematurely, all dentists need to know

what they can do during treatment and beyond to have a positive influence. As men-
tioned above they also need to recall patients at appropriate intervals. The five chapters
in Part III explore how future risk of failure can be managed in the following areas:

• Preserving pulp vitality

• Periodontal considerations (including surgical options)
1 Introduction 7

Fig. 1.2 The “red”, “amber”, “green”, system describes three levels of risk but is not always reli-
able. The preferred alternative is simply to distinguish patients at risk from those not at risk.
Patients at risk of caries show a change in clinically or radiographically detected caries status since
the last screening examination. Patients at risk of periodontal disease have a Basic Periodontal
Examination score of 3 or greater (see Chap. 4)

• Viability of posts and cores

• Occlusal control
• Tooth surface loss.

1.7 Part IV: Materials and Aesthetics

The development of dental materials in the past two decades has been phenomenal,
and this is reflected in the length of Chap. 14 for which we make no apology. This
chapter outlines the development of CAD/CAM, high-strength ceramics, and com-
posites but does not neglect metallic restorations which still have important clinical
uses, particularly in restoring bruxists. Read it over several sittings or dip in and out
as a reference.
8 J. Steele and R. Wassell

The materials used to lute (cement) restorations are equally important, and
Chap. 15 considers developments in adhesive bonding, including methods of pre-
conditioning the surface.
Dentists may be faced with having to recement an implant crown and need to
know about the various types of implant abutment available. Others may already be
attending a course on how to restore implants with crowns. Chapter 16 gives a good
overview.
A restored smile is a dentist’s shop window. Chapter 17 looks not only at the
technical aspects of achieving good results but also at the ethical implications of
providing irreversible and sometimes damaging treatment. Also addressed are
digital shade matching and issues of creating good aesthetics with implant
crowns.

1.8  art V: Planning and Provision of Extra-Coronal

P
Restorations

Part V provides a practical outline which will be of interest to dentists wanting to

improve their technique. Dentists must think about multiple factors and integrate
appropriate solutions when making a diagnosis and treatment plan. This is what
makes dentistry at once challenging and attractive. Of course, technical skills are
critical for successful extra-coronal restorations. So, detailed instructions plus hints
and tips are provided in the journey through:

• History and examination—why is it important?

• Core build-ups and post placement
• Fundamentals of tooth preparation
• Gingival management and retraction
• Impression materials and techniques
• Provisional restorations
• Fitting and cementation.

The final chapter reviews “Adapting crowns to existing prostheses”, allowing

dentists to offer extra-coronal restorations without having to replace an existing but
satisfactory partial denture.
We hope you find the book an intriguing and worthwhile read.

References
1. Delivering better oral health: an evidence-based toolkit for prevention. 2nd ed. Issued by: The
British Association for the Study of Community Dentistry and the Department of Health. 2009
[cited July 2017]. Available from: http://tinyurl.com/svc6ssr.
2. Brocklehurst PR, Ashley JR, Tickle M. Patient assessment in general dental practice—risk
assessment or clinical monitoring? Br Dent J. 2011;210:351–4.
1 Introduction 9

3. NICE dental checks: intervals between oral health reviews. Clinical guideline [CG19] [cited
February 2017]. Available from: https://www.nice.org.uk/Guidance/CG19.
4. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medi-
cine: what it is and what it isn’t—it’s about integrating individual clinical expertise and the best
external evidence. Br Med J. 1996;312:71–2.
Clinical Performance
2
Claire Field, Heidi Bateman, Richard Holliday,
and Robert Wassell

2.1 Learning Points

This chapter will emphasise the need to:

• Be alert to restorations which may be used as a more conservative alternative to

crowns
• Carefully evaluate clinical studies of restorations and be aware of the factors
which may bias outcomes
• Identify factors (including bruxism) which adversely affect veneer performance
• Be aware of the high clinical success rate of ceramic inlays and onlays
• Be cautious when using composite inlays and onlays in bruxists and in patients
with a previous high caries rate
• Manage expectations when prescribing implant crowns and arrange follow-up
for any mechanical issues and supportive peri-implant care, particularly in
patients susceptible to peri-implant disease.

How long will a restoration last? This is a simple question, but not so easy to
answer. Before discussing clinical performance, we need to consider the main types
of extra-coronal restoration and give an idea of numbers provided. There are now a
bewildering number of restorative systems and materials, many lacking the quality,

C. Field (*)
Department of Restorative Dentistry, Charles Clifford Dental Hospital, Sheffield, UK
e-mail: Claire.Field@sth.nhs.uk
H. Bateman · R. Holliday · R. Wassell
Department of Restorative Dentistry, Newcastle University School of Dental Sciences,
Newcastle upon Tyne, UK
e-mail: heidi.bateman@ncl.ac.uk; richard.holliday@ncl.ac.uk; Robert.wassell@ncl.ac.uk

© Springer International Publishing AG, part of Springer Nature 2019 11

R. Wassell et al. (eds.), Extra-Coronal Restorations, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-319-79093-0_2
12 C. Field et al.

long-term studies required to make an informed, evidence-based decision about what

best to use and when. Nevertheless, there is some useful information available on how
restorations perform, and the aim of this chapter is to guide the reader through it.

2.2 Types of Restoration

Extra-coronal restorations comprise crowns, partial coverage crowns, onlays (with

or without an inlay component) and veneers. As can be seen from Table 2.1, these
restorations can be made from a variety of materials (detailed in Chap. 14) and luted
(cemented) either conventionally or adhesively (Chap. 15).
Crowns are still the most commonly provided extra-coronal restoration, but
increasingly there is a trend to use adhesively retained restorations which benefit the
patient by having minimal tooth preparation. This trend is reflected in the British
Society of Restorative Dentistry’s rationale for crown provision (Box 2.1) [1].
Of course, crowns are not only used to restore individual teeth (Fig. 2.1) but also
dental implants (Chap. 16). We will consider performance of implant-retained
crowns at the end of the chapter.
So, the well-informed dentist needs to be aware of all types of extra-coronal
restoration, both conventional and adhesively retained.

Table 2.1 Indirect restorations can be classified in many ways

Type of restoration Description Examples
Conventional A restoration retained using conventional Crown, partial coverage
restoration dental cements in combination with tooth crown, onlaya (metal,
preparation features designed to prevent ceramic, ceramo-­metal
disruption of the cement and displacement of or composite)
the restoration
Adhesively retained A restoration retained using adhesive Veneers (ceramic or
restoration: technology, often resin based for strength and compositea)
 (a) Minimal chemical bonding. Minimal preparation Onlays (metal, ceramic,
preparation adhesive restorations do not rely to the same ceramo-­metal or
 (b) Conventional extent as conventionally cemented restorations compositea)
restoration on tooth preparation geometry to retain the Crown, partial coverage
cemented restoration crown, onlayb (metal,
adhesively Conventional restorations luted adhesively ceramic, ceramo-­metal
or composite)
Implant crown A restoration replacing a single tooth attached to Crown (ceramic or
a dental implant either via an abutment or directly ceramo-metal)
(implant head connection). The crown may be
retained either by a screw or a cement lute
a
Composite may be applied either directly or made as an indirect restoration luted adhesively
b
Onlays may have an inlay component but inlays per se are classed as intra-coronal restorations
2 Clinical Performance 13

Box 2.1: Rationale for Crown Provision

• To restore the form, function and appearance of teeth which are badly
broken down, worn or fractured to the extent that simpler forms of
­restorations are contraindicated or have been found to fail in clinical
service.
• To improve the form and appearance of unsightly teeth which cannot be
managed by more conservative cosmetic procedures.
• To reduce the risk of fractures occurring in extensively restored teeth
including endodontically treated posterior teeth.
• More rarely, to alter significantly the shape, size and inclination of teeth for
cosmetic and functional purposes.
• To restore a dental implant.

Highlighted in italics is the need to consider first more conservative proce-

dures [1].

a b

c d

Fig. 2.1 Crowns come in a variety of materials, e.g. ceramo-metal (a), all-metal (b), ceramic
(c). Crown preparation, particularly for some ceramic materials, can leave little remaining tooth
structure (d)
14 C. Field et al.

2.2.1 Conventional Restorations

A conventional restoration is distinguished by needing a tooth preparation so it can

be luted with conventional cement (e.g. zinc phosphate, zinc polycarboxylate and
glass ionomer). A properly designed tooth preparation (see Fig. 2.2) not only elimi-
nates undercuts so the restoration can be slipped onto the tooth; it also helps control
stresses within the cement lute which prevents the restoration being pulled or rotated
off by occlusal forces (see Chaps. 15 and 20). This is an important consideration
because conventional cements are inherently brittle and, like a piece of crisp bread,
will fail at relatively low tensile stress. Despite the adhesive properties of glass
ionomers and zinc polycarboxylates, they are still too brittle to be used with tooth
preparations which are short or too tapered (Chap. 15).
Preparations for conventional restorations require sufficient remaining tooth to
be effective, often in combination with a core build-up made of restorative material
to replace lost tooth structure. The core build-up may be retained by mechanical
undercuts or adhesively or both (see Chap. 19).
Tooth preparation may further weaken what remains of an already compromised
tooth predisposing to failure. To deal with this problem, several strategies can be con-
sidered including surgical crown lengthening (see Chap. 10) or using the root canal
prepared to accommodate a retentive cemented post (see Chaps. 11 and 19). The other
increasingly important approach is to use an adhesively retained restoration.

Fig. 2.2 A preparation for a conventionally cemented gold onlay. The preparation geometry
retains the cemented restoration effectively via the near parallel walls of the box forms and occlu-
sal isthmus
2 Clinical Performance 15

2.2.2 Adhesively Retained Restorations

Since their introduction in the 1970s, enamel and dentine bonding systems have
evolved considerably leading to the widespread use of restorations requiring little or
no retentive features in their preparation design. These developments started largely
in the 1980s with adhesively retained bridgework, but ceramic veneers and onlays
(metal or ceramic) soon followed. Indeed, tooth preparation may occasionally be
unnecessary with the retention of the veneer or onlay relying entirely on the strength
of the resin cement and its bond to tooth and restoration. These are most correctly
called “minimal preparation adhesively retained restorations” but colloquially they
are also called “adhesive restorations” (Figs. 2.3 and 2.4). Of course, the bond to
enamel is stronger and more reliable than the bond to dentine, so it is important to
have sufficient enamel for a reliable bond. It is also worth remembering that

Fig. 2.3 A preparation for an adhesively luted metal onlay. Without a strong adhesive lute, the
geometry of the preparation, with its short axial wall height, would be insufficiently retentive

Fig. 2.4 A preparation for an adhesively luted ceramic restoration (shown right). Again, retention
of the restoration relies on the adhesive lute. The orange wedges with stainless steel inserts protect
the adjacent proximal surfaces during tooth preparation. Courtesy of Marco Ferrari
16 C. Field et al.

different restorative materials need specific bonding procedures (e.g. etching of

some ceramics with hydrofluoric acid or impregnation of alloy surfaces with silica).
However, some materials (e.g. zirconia ceramics) are notoriously difficult to resin
bond (see Chaps. 15 and 24). So, bonding is particularly technique sensitive and
will have failure built in if the correct procedure is not followed.
Conventional restorations may also be luted adhesively, particularly if a tooth
preparation is short or tapered. Such restorations may also be considered “adhesive
restorations”. However, tooth preparation is usually not minimal resulting in con-
siderable underlying dentine being exposed. Therefore, temptation to use adhesives
for a simple solution to unretentive tooth preparation must be tempered by the need
for a meticulous bonding technique.
Nevertheless, when appropriately prescribed and skilfully placed, adhesively
retained restorations offer reliability and the benefit of preserving tooth tissue,
thereby safeguarding longevity of the tooth. These are extremely important consid-
erations when restoring worn, fractured or young vital teeth, where the chances of
further pulpal insult need to be minimised. In addition, adhesively retained restora-
tions are often the only viable conservative option where a tooth has already lost a
significant amount of tissue and where removal of further tissue to incorporate
retentive features (e.g. grooves and boxes) could render it unrestorable. Adhesive
technology may also be employed in the placement of posts in endodontically
treated teeth, which will be explored in Chap. 19.

2.3 Numbers of Restorations

A phenomenal number of teeth are restored with indirect restorations every year.
Information from the NHS Health and Social Care Information Centre reports
822,700 crowns, 28,600 veneers and 181,600 inlays (we assume some of these
inlays will have an onlay component) were prescribed within NHS primary care
dentistry in England in 2014/2015 alone. These figures are comparable with previ-
ous years [2, 3]. This of course does not include restorations provided in the private
sector, where levels of provision are not reported. However, the overall number of
crowns in the population across England, Wales and Northern Ireland can be derived
using data from the 2009 Adult Dental Health Survey: a staggering 37% of dentate
adults had artificial crowns with on average 3 per person giving an estimated 47.6
million crowns [4]. How many of these crowns have been cemented conventionally
or adhesively is unknown.
As already mentioned crowns by their very nature require destructive tooth
preparations, so a move to adhesively retained restorations with more conserva-
tive tooth preparation will spare more tooth tissue. Adhesive technology is also
likely to be used increasingly to repair and extend the lifespan of existing
restorations.
Nevertheless, using adhesive technology to retain indirect restorations can have
its disadvantages. Many dentists have already experienced the frustration of
2 Clinical Performance 17

removing a failed crown luted with adhesive cement. A conventionally cemented

crown simply requires the crown to be sectioned with a bur, and the brittle cement
is then easily fractured to allow the two fragments of crown to be removed. By com-
parison an adhesively retained crown with its tougher resin cement often needs to be
ground away entirely—unless the resin bond has failed. Crowns with high-strength
ceramic cores compound the problem of crown removal as they can take several
diamond burs to cut through. Techniques and technology to deal with failure are
advancing, and this is needed, given that most failures are likely to be encountered
in an increasingly ageing population with the additional requirements and chal-
lenges faced within gerodontology.

2.4 Clinical Performance of Restorations

As mentioned in Chap. 1, many restorations will eventually need to be replaced or

repaired, but sometimes failure is catastrophic leading to the loss of the restored
tooth. There are many modes of failure, and being aware of them should help us
prescribe and design restorations which perform well and should they fail cause
least damage. It is helpful to think about failure occurring at one or more “sites”
(Table 2.2). Whilst the site of failure of many restorations appears blindingly obvi-
ous, it can be notoriously difficult to be sure why a restoration has failed. For exam-
ple, the pulp of a restored tooth may eventually become nonvital, but how do we
know whether this resulted from thermal damage during tooth preparation or subse-
quent microleakage?
Despite these difficulties, it is worth being aware of the multiple factors working
singly or in combination which may predispose to failure (see Box 2.2). This com-
plexity means dentists must think about many things simultaneously, make sensible
choices and work skilfully to get a long-lasting restoration with which the patient is
happy.

Table 2.2 Types of failure according to site of failure with biological complications shown in
italics (NB “Restoration” also includes the lute and any core build-up)
Site of failure Types of failure
Tooth Caries
Periodontal disease/gingival disease/gingival recession
Pain/pulpal sensitivity
Loss of pulp vitality/apical periodontitis
Fracture of prepared tooth/core build-up
Wear of opposing tooth
Interface Bond failure of lute or core leading to microleakage or loss of retention
Restoration Physical disintegration (seen as roughness, wear, marginal deterioration)
Fracture (of ceramic or composite or of alloy posts)
Corrosion (of alloys)
Distortion (of alloys)
Aesthetics (deterioration of shade match, marginal staining)
18 C. Field et al.

Box 2.2: Factors Contributing to the Overall Outcome of an Indirect Restoration

Patient factors—Ability to care for the mouth as a whole-controlling oral
hygiene and diet, ability to tolerate treatment, ability to achieve moisture con-
trol, aesthetic desires, economic factors
Tooth factors—Condition and amount of the remaining tooth structure,
presence and type of core, vitality and endodontic status, ability to provide
retention and resistance form, location in the arch, absence of disease pro-
cesses, occlusal scheme, presence of parafunction/bruxism, previous
bleaching
Material factors—Type of bonding system employed, the material that is
being bonded to the tooth, preparation of the bonding surfaces, presence of
eugenol-containing temporary cement
Operator factors—Ability of the operator to perform technique-sensitive
procedures, clinician preferences

Patients often ask, “How long will this restoration last?”, but few dentists have
their own follow-up data to provide an accurate answer. Even if they did it is likely
that materials being used now will be different to those being used say 10 years ago.
The dental literature contains several studies which might provide a guide, but bear
in mind that compared with your practice, there may be differences in operator
skills, thus the patients’ disease susceptibility, in combination with operator skill,
material selection, parafunction, occlusion, prevention and maintenance regimen
will influence survival in an individual. So, if you are tempted to give the patient a
percentage survival rate based on the literature, it is worth mentioning the above
caveats. The same cautious advice would apply to advising government and com-
mercial agencies sponsoring dental care.
If you are being sold a new or different restorative product, it is worth having an
insight into the validity of the data, either clinical or laboratory, being presented.
Some reputable companies sponsor clinical studies of their products, but many
don’t. Instead they may present lab data (e.g. tensile strength, hardness, bond
strength, wear resistance and microleakage) which makes for impressive charts and
diagrams but cannot be relied upon to predict clinical performance [5]. The main
value of lab data is for screening new products to ensure they are not fatally flawed
before being launched. If there is only lab data, it is the dentists that carry out the
clinical trial—unofficially!
Before we consider clinical evidence supporting the use of extra-coronal restora-
tions, we need to discuss briefly how clinical performance is measured. This should
also provide a useful foundation when reading clinical studies.

2.5 Getting to Grips with Clinical Performance

This section provides a rough guide to clinical studies of restoration durability.

Readers needing more detailed information can find this elsewhere [6].
2 Clinical Performance 19

The strongest evidence of clinical efficacy is provided by systematic reviews or

meta-analyses of randomly controlled clinical trials (RCTs). The repository for
RCTs and meta-analyses is the Cochrane Collaboration which holds a huge amount
of data regarding drugs trials, but relatively little on clinical studies of restorations.
This reflects not only the financial and time constraints in carrying out these trials
but also the difficulties in designing RCTs free from bias. The Cochrane
Collaboration defines five main types of bias: selection bias, performance bias,
detection bias, attrition bias and reporting bias [7].
It’s relatively easy to eliminate bias with drugs trials but not so with trials of
extra-coronal restorations. For example, with drug trials both the prescribing doctor
and evaluator of clinical outcome are blind to which patients are taking the drug and
which the placebo. This effectively eliminates performance and detection bias. By
contrast, with trials of extra-coronal restorations, it is difficult if not impossible to
hide the type of restoration from the providing dentist and the follow-up evalua-
tor—either of whom may prefer a particular type of restoration. Furthermore, attri-
tion bias caused by patients failing to attend is less likely with drug trials where
follow-up is relatively short term compared with trials of restorations lasting many
years. Of course, dentists blessed with a loyal patient following may command bet-
ter long-term attendance. Nevertheless, their studies may be subject to selection
bias in choosing patients most likely to have a good outcome with the chosen treat-
ment. Reporting bias may manifest where trials are withheld from publication for
whatever reason so that the literature may not provide a full picture of restoration
performance.
In addition to possible issues of study bias, you need to be aware of the lack of
consensus over definitions of survival, success and failure [8]. However the follow-
ing advice may be useful:

• “Survival” is generally taken to mean a restoration is still in situ, but does not
take full account of its condition
• “Success” provides criteria in respect of the restoration’s condition (e.g. US
Public Health Service Corps (USPHS)) [9], but these may differ or be variously
modified between studies [8]
• “Failure” implies that the restored tooth needs further intervention, but not
always in relation to the restoration. The decision to intervene is often clinically
based and may lack adequate criteria. There are also differences between studies
as to what constitutes a failure (requiring a restoration to be replaced) and a par-
tial failure (where it is repaired or recemented).

This lack of agreed definitions prevents the results of clinical trials of extra-­
coronal restorations being easily combined in the form of a meta-analysis.
Nevertheless, there are clinical studies which provide at least an indication of
restoration performance. Bearing in mind that almost all trials of extra-coronal res-
toration will be at least mildly biased, what other factors should the reader be look-
ing for to ensure a study has some validity?
Firstly, find out what sort of study it is. There are basically two main types: effi-
cacy studies and effectiveness studies. Efficacy studies compare the performance of
20 C. Field et al.

the test restoration against a comparator with known characteristics. These are often
carried out in universities, and the best ones are randomly and prospectively con-
trolled and provide internal validity by controlling for variables affecting restoration
failure (Box 2.2). Effectiveness studies consider how well restorations perform in a
routine clinical setting—sometimes rather disparagingly described as “in the field”.
These often do not have a comparator group and are occasionally retrospective.
Retrospective studies can suffer from inconsistent data collection.
Secondly, check for details of the study design. If different types of restoration
are being compared in an efficacy study, the design may be parallel arm or split
mouth. Parallel arm involves two separate groups of patients, whilst split mouth has
only one group of patients. Each patient in a split mouth trial has at least one pair of
similar teeth restored: one tooth with the test restoration and the other with a com-
parator. Treatments should of course be randomised. Often, however, trials only
place test restorations and compare clinical performance with the results of other
studies which may well introduce multiple sources of bias.
Thirdly, look for adequate details of the clinical variables including:

• Restoration materials
• Case selection and patient demographics
• Placement conditions including cement type
• Operator: single or multiple, skills and experience
• Preparation design
• Calibrated examiners for follow-up.

Fourthly, check the number of patients who are lost to follow-up. Preferably, more
than 70% of patients should complete the trial, but less than 60% may indicate a weak
study. However, the longer the study, the greater the loss to follow-up, so at 10 years
a 60% return would not be unreasonable. Finally, consider the statistical analysis and
whether sufficient patients have been enrolled to give the analysis sufficient “power”.
Be aware that an underpowered study may show “no significant difference” where in
reality one exists (Type II error). Some dentists are excellent statisticians, but many
are not. As a rule of thumb, if the paper has been published in a reputable scientific
journal, this implies statistical methods have been scrutinised. Look also for a quali-
fied statistician as a named author or in the acknowledgements. A personal observa-
tion is that over the past 10 years or so scientific journals have become increasingly
rigorous statistically, but older papers may not always be so robust.
So far, we have considered prospective clinical trials of extra-coronal restorations
and have seen that in comparison with drugs trials, bias is difficult to avoid. Lower
down the hierarchy of clinical evidence is the cohort study. Despite its apparent lowly
position, this sort of effectiveness study has provided invaluable information in
respect of the large number of restorations placed by multiple dentists in the National
Health Service. Two major cohort studies of crowns [10] and veneers [11, 12] placed
in NHS primary dental care are described in the sections below. These studies give a
general idea of restoration performance in the real world—although sadly following
the UK’s new dental contract in 2006, this detailed data is no longer collected.
Another random document with
no related content on Scribd:
have me skin all the bull heads after that. I said I would rather milk
cows so the pirate gave me a milk pail and told me to go and milk
the freckled cow, and I went up to the cow as I had seen farmers do,
and sat down on a wooden camp stool and put the pail under the
cow, and began to squeeze the Summer Sausages she wore under
her stomach, four of ’em, and the more I squeezed the more there
didn’t any milk come, and the cow looked around at me in a pitying
sort of way, but the milk did not arrive on schedule time, and then I
thought of a farmer I once saw kick a cow in the slats, and I thought
maybe that was the best way to cause the milk to hurry and flow, so I
got up off the stool and hauled off my hind leg and gave that cow a
swift kick that sent her toes clear in to her liver and lights and
sausage covers.
Well I thought it was a car of dynamite running into an elevator and
exploding, but the boys that picked me up and poured milk on my
face to bring me to, said it was not an explosion, but that the cow
had reared up in front and kicked up behind, and struck me with all
four feet, and had hooked me with her horns, and switched me with
her tail, and pawed me with her forward feet, and licked my hair with
her tongue, and laid down and rolled on me. Well, I certainly looked
it. Gee, but I don’t want any more farmer’s life in mine.
I certainly thought that was the way to cause a cow to give milk.
Maybe I ought to have sworn at her the way the farmer did. I
remember now, that he used language not fit to print, but I have not
taken the swearing degree yet.
Well, they got me braced up so I could go to dinner, and it was surely
a sumptuous repast, fried bull heads and bread. I have eaten fish at
home and at hotels, where you had ketchup, and celery, and
vegetables, and gravy, and pie, and good things, but to sit down with
fifty boys and eat just bull heads, and stale bread, and try to look
pleasant like you were at a banquet, was one on your little Hennery
that made him feel that the pleasures of being an orphan had been
over drawn.
Gosh, but the boys tell me we have bull heads here six times a
week, because they don’t cost anything, and that the bones stick
through your skin so they hold your clothes on.
I am organizing a union among the boys and we are going to call a
strike, and if the pirate with one eye does not grant all we ask, we
are going to walk out in a body, and jump a freight train, and go out
in the wide world to make our fortunes. I shall go look for pa. There
can’t no man give me such a dirty shake. I feel like I had been left on
a door step, with a note on the basket asking the finder to take good
care of me “’cause I was raised a pet.”
 CHAPTER II.
No Encouragement for Inventive Genius in Orphan Home—The Boy
Uses His New Invention, a Patent Clothes Wringer, in Milking.

There is no encouragement for inventive genius in this orphans’

home that I am honoring with my patronage.
I always supposed that an orphanage was a place where they tried
to make an orphan feel that it wasn’t such a great loss not to have a
regular home, among your people as long as you could be lovingly
cared for in big bunches by charitable people, who would act like a
High School to you, and when you got a diploma from an orphans’
home you could go out into the world and hold up your head like a
college graduate, but I can see from my experience at this alleged
home that when we boys get out the police will have a tab on us, and
we will be pinched like tramps.
What encouragement is there to learn anything but being
chambermaid to cows? Gee, but I never want to look a cow in the
face again. When I failed to milk that cow and she galloped all over
the place, and kicked my liver around where my spleen ought to be,
the one-eyed warden of the place told me I must practice on that
cow till I got so that I could milk her with my eyes shut, and that I
wouldn’t get much to eat until I could show him that I was a he-
milkmaid of the thirty-third degree.
I told him I saw a machine last year at the State Fair that had a
suction pump that was put on to the cow’s works, and by touching a
button the milk and honey flowed into a pail, and if he would get such
a machine I could touch the button all right. He said the orphanage
couldn’t afford to buy such a machine, but if I wanted to invent any
device to milk cows I could go ahead, but it was up to me to produce
milk, one way or another.
Well, an idea struck me just like being hit with a base ball bat, and in
a short time I was ready.
I got a clothes wringer out of the laundry, and went to corral the cow.
I thought if a clothes wringer could squeeze the blue water out of a
wash tub of clothes, it would squeeze a pail of milk out of a cow, so I
took my clothes wringer and the milk pail and got under the cow and
gathered all her four weiners together in my hands and put the ends
of them between the rubber rollers, just easy, and the boys gathered
round to see where my inventive genius was going to get off at. Then
when my audience was all ready to cheer me, if the machine
worked, I took hold of the handle of the machine, which was across
my lap, and turned the crank with a yuck motion, until all the cow’s
weiners went through between the rollers, and I noticed the cow
flinched, and just there one of the sophomore boys threw a giant
firecracker under the cow’s basement near the milk pail, and when
the explosion came, just when I was cranking her up a second time
and turning on the high speed clutch, the cow bleated as though she
had lost her calf, and she went up into the air like the cow that
jumped over the moon, and she went across the country on a
cavalry charge, with me hanging on the handle of the wringer with
one hand, on her tail with the other, and the boys giving the orphan
school yell, and the cow bellowing like a whole drove of cattle that
have smelled blood around a slaughter house.
Gosh, but I never had such an excursion. The cow went around the
house and on to the porch where the manager and some women
were, and finally rushed into the kitchen, and everybody came and
tied me loose from the cow, and got the clothes wringer off her vital
parts, and shooed her back to the barn, and then they took me to the
manager’s office, and I fainted away.
 Gosh, But I Never Had Such an Excursion!

When I came to the one-eyed manager had a bandage over his nose
where the handle of the clothes wringer hit him when he tried to turn
the handle back to release the pressure on the cow’s bananas, and
he was so mad you could hear him “sis,” like when you drop water
on a hot griddle.
He got up and took me by the neck and wrung it just like I was a hen
having its neck wrung when there is company coming and he
dropped me “kerplunk” and said I had ruined the best cow on the
place by flattening out her private affairs so that nothing but skim
milk could ever get through the teats, and he asked me what in
thunder I was doing, milking a cow with a clothes wringer, when I
ought to have known that a clothes wringer would squeeze the milk
up into the second story of the cow.
I told him I had never been a dairy farmer, anyway, and a cow was a
new proposition to me, and he said I could go and live on bread and
water till doomsday, and that I was the worst orphan he ever saw,
and he pushed me out of the room.
The boys met me when I came out of the presence of the one-eyed
manager, and we went off into the woods and held an indignation
meeting, and passed resolutions condemning the management of
the orphanage, and I suggested that we form a union and strike for
shorter hours and more food, and if we did not get it, we could walk
out, and make the orphan school business close up.
We discussed what we would do and say to the boss, and just
before supper time we lined up in a body before the house and
called out the manager and made our demands, and gave him
fifteen minutes to accept, or out we would go, and I tell you we
looked saucy.
I never saw anything act as quick as that strike did. In five minutes
the manager came out and said he wouldn’t grant a thing, and
besides we were locked out, and couldn’t ever get back into the
place unless we crawled on our hands and knees and stood on our
hind feet like dogs, and barked and begged for food, and he shut the
door and the dining room was closed in our faces, and we were told
to get off the place or they would set the dogs on us.
For a few minutes not a word was said, then the boys pitched on to
me and another boy that had brought on the strike, and gave us a
good licking, and made us run to the woods, and when we got nearly
out of sight we turned and all the brave dubs that were going to
break up the orphanage were down on their seats on the grass,
begging like dogs to be taken back, because supper was ready, and
my chum and me were pulling for tall timber, wondering where the
next meal was coming from, and where we are going to sleep.
We were the only boys in that bunch of strikers that had sand
enough to stand up for union principles, and as is usually the case
the fellows who had the most gravel in their crops had little else, and
I was never so hungry in my life.
A diet of fried bull heads and skim milk, and sour bread for a few
days in the orphanage had left me with an appetite that ought to
have had a ten course banquet at once, but we walked on for hours,
and finally struck a railroad track and followed it to a town.
My chum stopped at a freight car on a side track and began to poke
around one of the oil boxes on a wheel, and when I asked him what
he was going to do, he said that to a hungry man the cotton waste
and the grease in a hot box of a freight car was just as good as a
shrimp salad, and he began to poke the stuff out of the hot box to eat
it. He said the lives of tramps were often saved by eating out of hot
boxes. I swore that I would never eat no hot box banquet, and I
pulled him away from the box car just as a brakeman came along
with a hook and a can of oil and a bucket of water to cool it off, and
we escaped.
I told him we would have a good supper all right, if he would stick by
me.
We went into the little town and it was getting dark, and all the
people were out doors looking up into the sky, and saying, “there it
is, I see it,” and I asked a man in front of a saloon what the
excitement was about, and he said that they were watching the
balloons from St. Louis, about two hundred miles away, which were
sailing to the east.
Did you ever have an idea strike you so sudden that it made you
dizzy? Well, I was struck with one so quick that it made me snicker,
and I pulled my new chum away and told him how we would get
supper and a place to sleep, and that was to go into the woods near
where the people were looking up into the air, and when a balloon
went over, after it got good and dark, we could set up a yell, as
though murder was being done, and when the crowd came to see
what was the matter, he could say we fell out of a balloon, and
landed in a tree and squirmed down to the ground.
Well, I didn’t want to lie, but my chum, who had once been in a
Reform School, did not care so much about lying, so he was to do
the talking and I was to be deaf and dumb, as though the fall from
the balloon had knocked me silly.
Well, when we saw a light in the sky over us and the people were
going wild over thinking they saw a balloon, we began to scream like
wild cats, and groan like lost souls, and yell for “help, help.” When
the people came on the run, and when they found us with our
clothes torn, and our hair standing on end, and our eyes bulging out,
and my chum, the old liar, said when we were leaning over the
basket of the balloon to see what town we were passing over, we fell
out in a tree, and we were so hungry.
 “Tossed him over the fence.”

Well, the way those good people swallowed that yarn was too
comical, and they picked us up and took us into a house. A pussy
woman got me under her arm and said “Poor dear, every bone in his
body is busted, but I saw him first, and I am going to have him
mended and keep him for a souvenir,” and I hung my legs and arms
down so I would be heavy, and she dragged me to the house. All I
said was, “pie, pie, pie,” and she said I was starving for pie, and
when they got us in bed, with nice night shirts on, they crowded
around us and began to feed us, and we took everything from soup
to mints, and went to sleep, and the last thing I heard was balloon
talk, and the woman who drew me in the shuffle said, “The ways of
Providence are past finding out,” and as I rolled over in bed I heard
my chum in another bed say “You can bet your sweet life,” and then
the people began to go away, talking about the narrow escape of
those dear boys, and my pussy fat lady held my hand and stroked
my aching stomach until long after midnight, and then she tip-toed
off to bed.
I spoke to my chum and said, “Did it work out all right?” and he
groaned and said, “Gee, but I et too much, I otter have saved some
of it for breakfast,” and then we went to sleep in nice feather beds
instead of those beds at the orphanage made of breakfast food.
 CHAPTER III.
The Boy Escapes from Orphan Asylum—The Boy and His Chum Had
Red Letter Days—The Boy Is Adopted by New Friends.

There is not much fun in being an orphan until you escape from the
orphan asylum, and I want to say that my chum and myself have had
two red letter days in the town where we seemed to drop out of a
balloon into the hearts of the country people.
They took up a subscription to buy clothes for us, and dressed us up,
and we looked as though we had been clothing dummies in front of a
clothing store, and then the people got into a quarrel as to who
should adopt us.
A farmer drew my chum and wanted him to get acquainted with
some mules and drive six mules to haul fertilizer on the farm. My
chum had to set on a saddle on one mule, and drive the other five
mules by using one line, which he pulled and hauled to make them
gee round grand right and left.
The fat woman adopted me because I was such a dear little thing.
She was one of those hay widows, whose husband got plenty of her
sauce, and took to the tall timber, and all she wanted to do was to
hug me, and tell me that if I had not dropped into her life, out of that
balloon, she would have kicked the bucket, and I thought of how any
bucket I ever saw would have collapsed, for she had a foot like a
fiddle box.
She made me tell her the story of my past life, and when she found I
was Peck’s Bad Boy, and I thought I had made my story so
sanguinary that she would want me to go away, so she could have a
quiet life, she just froze to me and said she could see that she had
been selected by Providence to take the badness out of me, and she
went to work hypnotizing me, and giving me absent treatment on my
meals, to take my strength for wickedness away, and then she got
me so weak I could not hug back when she squeezed me, and you
can imagine the condition a growing boy would be in who could not
do his share of the hugging.
The second day of my sentence to be her adopted son, with all my
crimes on my head, she let me go out on the farm to visit my chum,
and there is where my whole new life changed.
My chum was driving his mules around the farm, and I was riding
behind him on the wheel mule, when a balloon from St. Louis came
over, and the men in the balloon yelled to us to grab hold of the rope
as they wanted to land in the field. The mules began to act up and
my chum couldn’t control them, and I jumped off the mule and
grabbed the rope and gave it a hitch around the pole of the wagon,
and that settled it with the mules. They rolled their fawn like eyes
around at the great gas bag that was swaying over the wagon, with
the two men yelling, and the mules started to run, with the wagon
and the balloon, around that field, the balloon striking the fence
occasionally, and a tree once in a while, the men yelling for us to cut
the rope, and the mules braying and saying mule prayers, and me
chasing along to try and cut the rope, and my chum hanging on to
the ears of the wheel mule, and the farmers rushing into the field
from every direction to stop the mules, and the men in the balloons
using the worst language.
 Grabbed the Balloon Rope and Gave It a Hitch Around the
Pole.

The mules had run around the field several times, and the balloon
was doing its best to keep up, when I yelled to the men in the
balloon, “Why don’t you throw out your anchor?” and they then
seemed to recollect about the anchor, and they threw it out, and
when it caught fast in the ground the mules pulled loose from the
wagon and went through a fence, and started for Texas, and I guess
they are going yet. My chum got off all right, except he was so
scared he could not stand up. Well, we had a time straightening
things out, the farmers wanted to lynch the balloon men, and make
them pay for the mules, but in rolling up the balloon to take to the
station, to ship to St. Louis, I found a mail bag, and I told the farmers
these balloonists were carrying the U. S. mail, and any man that laid
hands on the government mail could be imprisoned for life for
treason, and I scared the farmers so they gave the balloonists their
dinner, and hauled the balloon to the station with the whole bunch of
us, and when the balloonists went away on the train they told my
chum and me that if we would come to St. Louis they would give us
jobs carrying off balloons, and they would teach us how to fly. Gee,
but that was nuts for us. To rise, at once, from being mule drivers
and adopted boys, to a place in balloon society, was what we
wanted, and my chum and I deserted our more or less happy homes
and began to plan to jump a freight train bound for St. Louis.
 “Any Man That Lays Hands on the Government Mail Can Be
Imprisoned for Life for Treason.”

We laid down on the platform of the station that night and went to
sleep and I dreamed that I sailed across the ocean in a balloon, and
landed in a park in Paris, and when the populace came to welcome
us to dear old France, Pa was one of the first to see me, and he fell
upon my neck, and when the people were going to give me a
reception, and a cross of the Legion of Honor, for being the first to
cross the ocean in a balloon, Pa told them I was his boy, and Pa
wanted to take all the credit for my grand achievement, and when I
woke up a watchman at the station kicked us off the platform like we
were tramps, and we walked down the tracks and were so mad we
wanted to throw stones at the switch lights, and my chum wanted to
put a tie on the track to wreck a train, but I persuaded him that it was
that kind of revenge that caused the enmity between tramps and the
richer class. Then he wanted to set fire to a tank car of kerosene,
because Rockafeller owned the railroad, and the watchman who
kicked us was an agent of the Standard Oil Company. If I hadn’t
been a pretty good citizen there would have been a bon-fire sure, but
I showed my chum that we were only temporary tramps, and that in
a few days we would achieve success, and own railroads, and that
we should show an example of patience, and strive to become
members of the four hundred. So we refrained from getting even,
and Rockafeller was not kept awake by hearing that another tank car
of oil had gone skyward.
We were pretty hungry, but tightened up our belts and pretty soon a
freight car stopped on a side track and a brakeman came along with
a lantern and I gave him the last half dollar I had and told him we
wanted to land in St. Louis, and he looked us over and pointed to a
car, and we hustled in and he locked the side door of the car, and we
were alone in the dark, hungry and thirsty.
We found a part of a bale of hay, and scattered some on the floor
and went to sleep, and I never slept better on a spring mattress, but I
dreamed of home, and all the fun I had ever had, making it hot for
other people, playing tricks on them, but now all was changed, and I
felt that I was on my own resources, making my own way in the
world, handicapped by always having an easy life.
Along towards daylight in the morning some horses began to paw
and whinner and a colly dog began to bark in the car, and some
sheep bleated in the car, and as morning came, and a little light
came in the car, which was hitting the high places, running at high
speed, so it shook us out of our hay bed, we looked around starved
and stiff, and sick at heart.
When the train stopped I walked through the car, over bags of oats,
and looked at the horses, and wished I was a horse. The dog was a
watch dog, and when I got near him he snarled and grabbed a
mouthful of my new pants and held on and shook me, and I yelled
and got away.
As it grew lighter I saw a box near the dog, and in it were some
square things that my practiced eye, as the son of an old hunter, told
me were dog biscuit, a sort of petrified dough and meat scraps made
for high class dogs that are not allowed to eat scraps from the table,
and I told my chum we would have breakfast. It took me half an hour
to steal a few dog biscuit away from that dog, and all the time he was
trying to make his breakfast off of me, but I finally poked out enough
for breakfast, and I called my chum to partake of the repast. He said
he always had to have some kind of breakfast food before he ate
meat, so I cut into a bag of oats, and gave him a handful, and there
we sat and chewed away, trying to imagine that we were happy, and
thinking of coffee and pancakes and sausage, and waffles, and
biscuit and honey.
It was probably the worst breakfast ever eaten by anybody. The dog
biscuits were so hard we had to pound them on the floor with a
currycomb, and that did not help the flavor much.
After breakfast we laid down on the hay with a horse blanket over us,
and slept till noon, when we heard water being poured into the tin
trough for the horses, and we quenched our thirst, and ate more dog
biscuit, and I hoped that other boys would hear of our distress, and
that no boys would ever run away from a happy home again.
My chum and I talked over the depression in the money market, and
the panic in Wall street, and tried to think we were better off than
millionaires who did not know where the next meal was coming from,
and with our stomachs full, and no care on our minds, we wished we
could give some of our dog biscuit to the hungry rich.
While we were thinking of the good one can do with a few dog
biscuit, there was a terrible crash, the car jumped on the ties and
reared up, and finally rolled over and down a bank and all was still as
death, except that the boiler of the engine was blowing off steam,
and the horses were groaning, and the confounded dog that chewed
me was dead.
Men run over the cars, and chopped with axes, and finally a fire
engine began to throw water on the burning cars, my chum and I
were wedged under bales of hay, one of my legs was asleep, and we
both yelled murder, and finally the fire was out, the side was
chopped out of the car, and they took us out and put us in an
ambulance and the brakeman who had let us into the car said,
“Tickets, please,” and the ambulance was driven to a hospital at East
St. Louis, and they wanted to amputate us, just for practice. One of
the hospital attendants asked me who I was, and when I told him I
was “Peck’s Bad Boy,” traveling for my health, he said, “Well, you are
certainly getting what is coming to you,” and I guess that is no lie.
 CHAPTER IV.
A Bad Railroad Wreck—The Boy Contrasts Their Ride to One in a
Parlor Car—The Lawyer Is the Greatest Man on Earth—The Boy
Settles His Claim for $20.

The accident by the wrecking of the freight train on which my chum

and myself were touring the country, viewing the scenery through an
auger hole in the side of a box car, was a darn sight worse than I
thought it was. What a come down it was for me, who have always
traveled with pa, in a parlor car, to have to ride in a box car, with live
stock, and feast on dog biscuit, instead of ordering from the menu in
a dining car.
No one likes the luxuries of foreign travel any better than I do, but
that freight car experience showed me that we do not know when we
are well off, but when a boy goes out into the world to make his
fortune, and cuts loose from home ties, and pie, and bath tubs, and a
warm bed, and victuals such as mother makes, and winds up in a
wreck, under a horse that he does not know the name of, he is going
some.
When we got to the hospital a lawyer, who had chased the
ambulance on a motorcycle, retained me as his client and offered to
sue the railway company for a million dollars damage, and he would
furnish all the evidence, and take half of what he got for his fee. I
thought it was a good proposition, and probably I can own a railroad
if I take stock for my damages, but I shall take nothing but money,
and let my lawyer have the railroad stock. Gee, but a lawyer is the
greatest man on earth. This one has been riding alongside the
railroad track on a motorcycle for years, waiting for an accident, and
when he selected me for a client he just cried for joy, and he has
drawn a complaint against the Railroad Company that is a work of
art.

Started on a stampede.

When he read it to me, and I saw how I had been broken up and
damaged by the soulless corporation, and how my promising career
had been ruined, I never was so overcome in my life. While I was not
hurt any, except where the horse laid on me and squeezed my dog
biscuits in my stomach so my backbone was poulticed by the
chewed biscuit, the lawyer had the doctors at the hospital put my
legs and arms in plaster of paris casts, and had my body done up in