CROWNS IN GENERAL DENTAL PRACTICE

Reasons for the Placement

and Replacement of Crowns
in General Dental Practice
Neil A Wilson, Shaun A Whitehead, Ivar A Mjr and Nairn HF Wilson

Aims: The purpose of the study was to

apply established methods to survey
reasons for the placement and replacement of crowns in general dental practice in the United Kingdom.
Materials and Methods: One hundred
and twenty-eight general dental practitioners were recruited. Participants
recorded t he pri nci pal reason f or
t he provision of each initial and replacement crown they provided over a
12-week period.
Results: Overall, data were collected

from 92 practitioners in respect of 1714

patients and 2164 crowns, of which
1452 (67%) were initial placements
and 712 (33%) replacements. The teeth
most frequently crowned were maxillary incisors (33%), with 72% of the
crowns surveyed being of the porcelain
bonded to metal variety. Overall 64% of
the initial placement crowns were provided because of restoration failure
(26%) or tooth fracture (38%). The most
common reason for crown replacement
was crown failure (27%).

KEY WORDS: PLACEMENT/REPLACEMENT OF CROWNS, GENERAL DENTAL PRACTICE

Introduction
The p lacement and rep lacement of crowns comp rises a
substantial p rop ortion of routine dental care p rovided
in general dental p ractice. By 1998 one-third of dentate
adults in the UK had at least one crown. 1 Farrell and
Dyer 2 looked at the p lacement of crowns within the
General Dental Services (GDS) between 1948 and 1988
and found a steady rise in the numbers p laced with the
31-40 year age group receiving the greatest number of
crowns. This was confirmed in the UK Adu lt Den tal
Health Su rvey in 19981 which identified p eop le aged

NA Wilson BDS, MSc, MFGDP(UK), MFDS.

General Dental Practitioner. Honorary Specialist Trainee
in Prosthodontics.1
SA Whitehead PhD, MSc, BDS, FDS, MRD, LDS.
Consultant in Restorative Dentistry, Central Clinic, Carlisle, UK.
Formerly Lecturer in Restorative Dentistry.1
IA Mjr MS, BDS, MSD, DrOdont.
Professor, Department of Operative Dentistry, College of Dentistry,
University of Florida, USA. Visiting Professor of Operative Dentistry.1
NHF Wilson PhD, MSc, BDS, FDS, DRD.
Professor of Restorative Dentistry, Guys, Kings and St Thomas Dental
Institute, Kings College, University of London. Formerly Professor of
Restorative Dentistry.1
1. University Dental Hospital of Manchester, UK.

Conclusion: It is concluded that surveys of the type reported may provide

new insights into the reasons for and
pattern of provision of initial placement
and repl acement crowns i n cl i ni cal
practice. In this study the most common
reason for the provision of initial placement crowns was tooth fracture. The
most common reason for the replacement of crowns, notably porcelain jacket
crowns, was crown fracture.

PRIMARY DENTAL CARE 2003;10(2):53-59

45-54 as having the most crowns with nearly half of

that age group having at least one crown. In 1988, 62%
of the crowns p rovided were p orcelain fused to metal
cro w n s (PFM). In 1997/ 98 1,331,143 cro w n s w e re
p rovided for adults in England and Wales in the GDS
at a cost of 120,503,000. This sum rep resented 15% of
the then total cost of dentistry within the GDS. 3 No
figures are available for the number of crowns p laced
outside the GDS; however, the total number is believed
to be very substantial.
De sp ite 50 ye ars o f re se arch o n th e re aso n s fo r
th e p lacement and rep lacement of direct, intracoronal
re sto ratio n s, 4 little is kn o w n o f th e re aso n s fo r th e
in itial p rovision and subsequent rep lacement of other
forms of restorations in everyday clinical p ractice. This
is an imp ortant deficiency in existing knowledge and
understanding, given that research on the p revention
o f o ral d ise ase an d m o re e ffe ctive o ral h e alth care
p rovision may, at least in p art, be based on information
relating to reasons for op erative intervention.
A re ce n t re vie w o f th e lite ratu re 5 co n firme d th e
view that dental restorations do not last forever. Over
60% of all restorative dentistry involves the rep lacement of restorations. For intracoronal, direct restorations reasons for p lacement and rep lacement include
p rimary carie s, se co n d ary carie s, u n acce p tab le margin al ad ap tatio n , b u lk fractu re , fractu re o f th e to o th ,
PRIM ARY DENTAL CARE A PRIL 2003

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PLA CEM ENT/REPLA CEM ENT

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CROW NS

Table 1: Reasons for placement of crow ns

Failed restorations

Includes all reasons for the failure of restorations

such as secondary (recurrent) caries, fractured
restorations (bulk and marginal) resulting in the
placement of crowns.

Tooth fracture

All forms of tooth fracture, including those

that extend into a restoration and fracture due
to trauma.

Aesthetics

Crowns placed to improve aesthetics for any

reason (tetracycline discoloured teeth, large
unsightly restorations).

Wear

Wear of tooth tissues by attrition, abrasion

and erosion.

Endodontic reasons

Endodontic reasons for crown provision,

including the need for post and core to obtain
adequate retention for a crown.

Occlusal problems

Occlusal reasons for crown placement.

Primary caries

Is caries on a surface not directly associated with

any existing restoration? If approximal caries is
unrelated to an existing sound restoration, primary
caries is recorded.

Other

Any other reasons for placement of a crown.

u n sigh tlin e ss, n o n -cario u s to o th su b stan ce lo ss an d

p ain / sen sitivity. 6 Primary caries h as b een rep eated ly
found to be the p rincip al reason for the p lacement of
initial restorations, and secondary caries (as diagnosed
clinically) the most common reason for the rep lacement of existing restorations. 4
An American three-year study on 406 p atients found
1320 units of crown and bridgework that were considered unserviceable. 7 In this study, the word unservice able was used because the authors felt it was wrong to
classify a crown or bridge as a failure if it had been in
service for 50 or more years and had simp ly worn out.
This study, in common with others 8,9 that considered
crowns and bridges collectively, concluded that secondary caries was the largest single reason for failure
(37%). O ral d ise ase in ge n e ral w as co n sid e re d to
account for 60% o f th e failu res. Oth er failu res were
mechanical in nature. The mean life of service of single
crowns was 9.4 years. Interestingly, aesthetics was not
found to be a reason for crown rep lacement.
Walton et a l 9 p ublished a similar study on crown
and bridge failures. This found caries to account for
22% o f failu re s. O ve rall, o ral d ise ase w as fo u n d to
acco u n t fo r 29% o f failu res an d mech an ical reaso n s
70%. Regarding the somewhat different findings from
th e p re vio u s stu d y, th e au th o rs fe lt th at th is migh t
h ave b e e n d u e to a re d u ctio n in th e carie s rate in
th e American p op ulation. The mean length of service
for crowns and bridges in their study was eight years.
Again ae sth e tics w as n o t fo u n d to b e a re aso n fo r
failure.
Cheung 10 looked at 132 p atients (out of 400 p eop le
54

PRIM ARY DENTAL CARE A PRIL 2003

contacted) who together had 152 crowns with a mean

length of service of 34 months. Of these crowns 14%
where deemed to have failed. Technical failure was the
mo st p re vale n t cau se (8%), w ith n o cro w n s h avin g
been found to have failed due to caries. Cheung felt
th at th e majo r cau se s o f failu re d iffe re d fro m o th e r
studies, giving the reason for this as the fluoridation of
water sup p lies in Hong Kong since 1961.
In a study by Fyffe 11 720 p atients had their dental
re co rd s mo n ito re d lo n gitu d in ally o ve r a te n -ye ar
p eriod. Of the p atients surveyed 600 had at least one
co u rse o f d en tal treatmen t d u rin g th e p erio d o f th e
study. A total of 213 crowns was p rovided for 116 of
the p atients. Of these crowns, 30 were rep lacements
p rovided p rior to commencing the study and 18 were
re p lace me n ts o f cro w n s p lace d d u rin g th e stu d y.
Overall, 23% of the crowns p laced were rep lacement
crowns. Of these crowns 7% were gold, 31% PFM and
62% all p orcelain, with 67% of all the crowns p laced
being on up p er anterior teeth.
In accep ting that dental restorations do not last forever, 5 with over 60% of all intracoronal restorative dentistry being the rep lacement of existing restorations at
any given time, there are comp elling reasons for studying the ways in which restorations fail. Work done to
date highlights the need for more information on reaso n s fo r th e p lace me n t an d re p lace me n t o f cro w n s,
esp ecially in general dental p ractice, the environment
in which most crown work continues to be undertaken.
Table 2: Reasons for replacement of crow ns
Secondary/
recurrent caries

Is caries detected at the margins of an existing

crown?

Unacceptable
marginal adaptation

Only those crowns with degraded or poor

margins but without secondary caries should be
recorded in this category of failure.

Lost crown

Cementation failure leading to the need for

crown replacement.

Crown fracture

Fracture of any part of the crown that is the

reason for replacement.

Tooth fracture

Any form of tooth fracture that does not involve

the crown but is the reason for crown replacement.

Aesthetics

Aesthetic reason for the crown to be replaced. This

may include gingival recession exposing the crown
margin.

Wear

Wear by attrition, abrasion or erosion that results

in the need for crown replacement.

Endodontic reasons

Endodontic reasons that lead to the need for

crown replacement.

Change of material

Is used to denote replacement of a serviceable

crown where the change of material was the
reason for the replacement rather than failure of
the crown.

Occlusal problems

Occlusal reasons for crown replacement.

Other

Includes any other reasons for the replacement of

a crown.

NA W ILSON

Table 3: Distribution of the practitioners according to region and

practice location
Region

Practice location Number (% )

Inner city

Suburbs

Rural

M idlands

8 (19)

29 (69)

5 (12)

Nort hw est

14 (29)

18 (37)

17 (34)

Tot al

22 (24)

47 (52)

22 (24)

Chi-square test chi value=10.28 df =2 p =0.006

No inf ormat ion w as collect ed in respect of one pract ice.

Th e a im s a n d o b je ctive s o f th e p re se n t stu d y
w e re to:
Investigate asp ects of the reasons for the p lacement
and rep lacement of crowns p rovided in a group of
selected general dental p ractices in the UK.
Pro vid e in fo rm atio n o n th e typ e o f in itial an d
re p lace d cro w n s p ro vid e d in a gro u p o f se le cte d
general dental p ractices in the UK.

Materials and Methods

Th e stu d y w as in th e fo rm o f a p ro sp e ctive su rve y
to co lle ct in fo rmatio n o n th e p rin cip al re aso n s fo r
th e p lacement and rep lacement of crowns in general
d e n tal p ractice . Th e me th o d o lo gy, d ata co lle ctio n
forms and associated documentation were develop ed
from the p rotocol by Mjr. 6
Th e p o p u latio n o f ge n e ral d e n tal p ractitio n e rs
identified for the study were the 700 dentists registered
with a dental care comp any (Denp lan, Winchester, UK)
in the Midlands and the north-west of England. A letter
was sent to these dentists inviting them to p articip ate
in the study.
The p ractitioners who agreed to p articip ate in the
stu d y w e re aske d to co lle ct d ata p e rtain in g to co nse cutive cases of crownwork over a 12-week p eriod
between March and July 1998.
Data w e re co lle cte d o n sp e cially d e sign e d d ata
sheets. One sheet was used for each crown p laced. The
data forms were bound together in the form of a book.
Th is b o o k co n tain e d in stru ctio n s, th e crite ria to b e
used (Tables 1 an d 2) and a questionnaire about the
p ractitioner and his/ her p ractice.
Th e d ata co lle ctio n fo rm w as re fin e d b y a statisticia n , to e n su re th e in fo rm a tio n o b ta in e d co u ld
readily be converted into usable data. The data were
co m p u te rise d u sin g SPSS 8.0 so ftw a re (SPSS In c
Ch icago , Illin o is, USA. 1997) an d an alyse d u sin g th e
ch i-squared test.

Results
Of the 700 dentists ap p roached regarding the p resent
study 128 (18%) accepted the invitation and of these 92
(72%) completed and returned data collection booklets.
Data were collected in respect of 2164 crowns, of which

ET A L

1452 (67%) were initial placements and

712 (33%) replacement crowns.

Demographics
The 92 p ractitioners who collected and
Total
re tu rn e d d ata in clu d e d in th e stu d y
42 (100)
co m p rise d 79 ( 86%) m a le s a n d 13
( 14%) fe m a le s . Th e ir ye a r o f g r a d 49 (100)
u a tio n ra n ge d fro m 1956 to 1992.
91 (100)
Mo st o f th e p articip an ts (60%) w e re
single-handed p ractitioners, with 28%
in some form of p artnership and 11%
working as associates.
Th e d istrib u tio n o f th e p ractitio n ers acco rd in g to
region and location of their p ractice is summarised in
Table 3, with similar numbers coming from the northwest of England and the Midlands. Fifty-two p er cent
o f th e p ractitio n e rs re gard e d th e ir p ractice s to b e
located in the suburbs, 24% in an inner city location
and 24% in a rural setting. The distribution of the sub urban, inner city and rural p ractices was statistically
similar for the north-west of England and the Midlands.
Distribution of crow ns
A to tal o f 1714 p atie n ts re ce ive d th e 2164 cro w n s
included in the survey. The number of crowns p laced
in the p atients ranged from one to a maximum of 12
(Ta ble 4). Mo st (73%) o f th e p atie n ts h ad o n ly o n e
crown p laced.
Table 4: Distribution of the initial placement and
replacement crow ns according to teeth
crow ned
Teeth

Placement

Replacement

Number (% )
Upper
Incisors

278(19)

441(62)

Canines

81 (6)

57 (8)

351 (24)

63 (9)

Premolars
M olars

193 (13)

46 (7)

Subtotals

903 (62)

607 (85)

42 (3)

13 (2)

Low er
Incisors
Canines

27 (2)

4 (1)

Premolars

164 (11)

28 (4)

M olars

316 (22)

60 (8)

Subtotals

549 (38)

105 (15)

Ant eriors

428 (30)

515 (72)

Post eriors

1024 (70)

197 (28)

Totals

1452 (100)

712 (100)

Chi-square test f or comparison of upper and low er t eet h.

Chi-square value=120.5 df =1 P<0.001
Chi-square test f or comparison of ant erior and post erior t eet h.
Chi-square value=356.8 df = 1 P<0.001
NB Relevant dat a w ere missing in respect of 16 crow ns.

PRIM ARY DENTAL CARE A PRIL 2003

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PLA CEM ENT/REPLA CEM ENT

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CROW NS

40
SS
Secondary Caries
UM A Unaccept able M arginal
Adapt at ion
RF
Rest orat ion
Failure/Crow n Fract ure

30

TF
LC
A
W
ER

Toot h Fract ure

Lost Crow n
Aest het ics
Wear
Endodont ic Reasons

CM
OP
PC
OR
FT

Change M at erial
Occlusal Problems
Primary Caries
Ot her
Food Trap

% 20

10

0
SC

UMA

RF

TF

LC

ER

CM

OP

PC

OR

FT

OP

PC

OR

FT

Figure 1 Reason f or t he init ial placement of crow ns

30

20

%
10

SC

UMA

RF

TF

LC

ER

CM

Figure 2 Reason f or t he replacement of crow ns

A similar p ercentage of males (45%) and females

(54%) received crowns. The mean age of the p atients
was 48 (+/ -14) years. There were no significant differences (P>0.05) between the male to female ratio or
th e me an age s o f th e p atie n ts w h o re ce ive d in itial
p lacement and rep lacement crowns.
O ve rall, th e mo st co mmo n ly cro w n e d to o th w as
the up p er left central incisor (10%). The up p er central
incisors as a group were crowned more frequently than
lateral incisors. Overall, the up p er incisors were the
mo st freq u en tly cro wn ed gro u p o f teeth (33%). Th e
teeth least commonly crowned were the lower canines
(1%) and the lower incisors (2.5%).
Wh e n lo o kin g at th e d istrib u tio n o f te e th th at
re ce ive d in itial cro w n p lace me n t an d th o se th at
re ce ive d re p la ce m e n t cro w n s, a h igh ly sign ifica n t
d ifference (P<0.001) was identified (Table 4). Overall,
up p er p remolars were found to be the teeth to have
received the most initial crown p lacements (24%), with
the up p er second p remolars accounting for more initial
p lacements than up p er first p remolars. The up p er p remolars were closely followed by the lower p ermanent
mo lars (22%) an d u p p er in ciso rs (19%). In co n trast,
62% of the rep lacement crowns were p laced on up p er
incisors, esp ecially up p er central incisors. The tooth
56

PRIM ARY DENTAL CARE A PRIL 2003

most commonly p rovided with a rep lacement crown

was the up p er right central incisor (18%) (Table 4).
Reasons for initial placement
of crow ns and the replacement of crow ns
Overall, tooth fracture (38%) was the most frequently
rep orted reason for the p rovision of a crown, closely
followed by restoration/ crown fracture (27%). When
looking at the reasons for initial crown p lacement and
the reasons for crown rep lacement, a highly significant
d ifferen ce (P<0.001) w as id e n tifie d . To o th fractu re
acco u n te d fo r 38% o f th e re a so n s fo r in itia l cro w n
Table 5: Details of porcelain fused to metal crow ns
and porcelain jacket crow ns considered to
have failed as a consequence of crow n
fracture
Crow n

Number (% ) failed
by fracture

Porcelain f used t o met al crow n

76 (19)

Porcelain jacket crow n

99 (47)

Chi-square test

Chi-square value=57.84

df =2

P<0.001

NA W ILSON

ET A L

p la ce m e n t, followed by restoraTable 6: Distribution of the type of crow n material used in the

tion failure (26%) and aesthetics
placement and the replacement of crow ns
(15%). Crown fracture accounted
Type of crow n
Placement
Replacement
Total
for 27% of the reasons for crown
rep lacement. Crown fracture was
Number (% )
followed by aesthetics (18%) and
Full gold crow n
180 (12)
44 (6)
224 (11)
secondary caries (15%) as diagnosed clinically. These differences
Three quart er gold crow n
23 (2)
2 (0)
25 (1)
are illustrated in Figu res 1 an d 2.
Non/semi-precious crow n
104 (7)
18 (3)
122 (6)
Although crown fracture was the
most frequent reason for crown
Porcelain f used t o met al crow n
1035 (71)
495 (72)
1530 (72)
replacement, it accounted for only
Porcelain jacket crow n
25 (2)
81 (12)
106 (5)
19% of the reasons for the failure
Dent ine bonded crow n/veneer
69 (5)
31 (5)
100 (5)
o f PFM cro w n s b u t 47% o f th e
reasons for porcelain jacket crown
Ot her
14 (1)
14 (2)
28 (1)
(PJC) failure (Table 5). This differTotal
1450 (100)
685 (100)
2135 (100)
ence was found to be statistically
significant (P<0.001).
Chi-square test f or t he purpose of st at ist ical analysis only t hree groups w ere f ormed: all met al crow ns,
porcelain f used t o met al crow ns and ot her (most ly all porcelain).
PFMs were the most common
Chi-square value=88.37 df =2 P<0.001
(72%) typ e o f cro w n p ro vid e d
No det ails in relat ion t o mat erial used w ere provided in respect of 45 crow ns.
( Ta b le 6 ) . Th is w a s t h e c a s e
fo r both initial and rep lacement
cro w n s. Th e p ractitio n e rs u se d
Table 7: Distribution of the material of the failed and replacement crow ns
the same material in 87% of cases
when rep lacing PFMs. However,
M aterial of failed crow n
M aterial of replacement crow n Number (% )
there was a significant difference
Porcelain
Porcelain
Other
(p <0.001) w h e n re p lacin g PJCs.
fused
to
metal
jacket
Th e p ractitio n e rs e mp lo ye d th e
same material for a rep lacement
Porcelain f used t o met al crow n
333 (87)
15 (4)
33 (9)
crown as the material of the failed
Porcelain jacket crow n
131 (62)
63 (30)
19 (9)
crown in only 30% of such cases
Ot her
32 (35)
4 (4)
56 (61)
(Ta ble 7). Sixty-tw o p er cen t o f
th e PJCs w e r e re p la c e d w ith
Kappa=0.37 (95% conf idence int erval 0.31, 0.73)
PFMs.
The crowns rep laced had been
th e m. So me o f th e p ro b le ms se e n in th e se stu d ie s
in clinical service for p eriods of between one month
and 30 years with a median time in service of ten years. relate to the p resent study.
Th e p ractitio n e rs in vo lve me n t w as b y in vitatio n
This information w as o b tain e d fro m th e p atie n t (46%)
to a se le cte d gro u p o f p ra ctitio n e rs. As su ch , th e
o r fro m th e clin ical records (54%).
p articip ants were not a random samp le of the selected
gro u p , le t a lo n e UK d e n tists. Th e re sp o n se ra te in
th e p resen t stu d y was relatively lo w, wh ich was to b e
The p urp ose of this study was to collect data on the
e xp e cte d fo llo w in g an o p e n in vitatio n to th e p racreasons for the p lacement and rep lacement of crowns
tisin g m e m b e rs o f De n p lan . It is co m p arab le w ith
in general dental p ractice in the UK. The p resent study op en invitations to other studies in the USA (21%), 14
is considered unique in terms of surveying reasons for Ge rman y (21.2%), 15 th e UK (10%) 16 an d in No rw ay
the p lacement and rep lacement of crowns. The p op u- (24%). 17
Future studies of the typ e rep orted could usefully
lation for the study was Denp lan-registered dentists in
the north-west of England and the Midlands. The mate - seek to recruit a more rep resentative samp le of p ractitioners. As in all p revious studies on the reasons for the
rials and methods used were based on those rep orted
p lacement and rep lacement of restorations, the greater
in recent studies into the reasons for the p lacement and
the number of p ractitioners and restorations involved
rep lacement of intracoronal restorations, as originally
the more meaningful the findings. 4 It is accep ted, howdescribed by Mjr. 6
It is w e ll d o cu me n te d th at stu d ie s o f th e typ e
ever, that the idea in such studies is a rep resentative
re p o rte d h ave man y b e n e fits in u n d e rstan d in g th e
samp le and the inclusion of data p ertaining to a large
work undertaken by p ractitioners in a general p ractice
number of restorations.
setting. 12 However, there are a number of disadvanTh e te e th mo st co mmo n ly cro w n e d fo r th e first
tages. Maryniuk 13 looked at 21 longevity studies and
time were up p er p remolar teeth (24%), lower molars
fo llo w e d me th o d o lo gical stan d ard s w h e n e valu atin g
(22%) and upper incisors (19%). In contrast, 62% of the

Discussion

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PLA CEM ENT/REPLA CEM ENT

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CROW NS

rep lacement crowns surveyed were on up p er incisor

teeth. It is conceivable that up p er anterior teeth were
those found most commonly to receive rep lacement
crowns because these teeth received initial crowns more
frequently than other teeth in p revious studies. 11 The
results do however suggest a change in pattern in crown
placement. The practice of previous years11 of principally
undertaking initial crown placements on upper anterior
teeth may be found to have changed. It could be that
many older people already have crowns on their upper
anterior teeth, and now their p remolars are receiving
cro w n th e rap y. Th is is n o t a co n vin cin g argu me n t,
h o w e ve r, as th e re w as n o sign ifican t d iffe re n ce in
crown location according to patient age (P>0.05). It may
be that the introduction of imp roved, more cosmetic
comp osite materials has encouraged less destructive
ways of improving aesthetics rather than having to place
a crown.18 Composite materials have been less successful on posterior than on anterior teeth 15 and practitioners
may therefore believe that the placement of crowns on
p osterior teeth remains a more p redictable ap p roach
than p lacing large tooth-coloured restorations. Further
work is needed to investigate such trends.
Sixty-four per cent of initial crown placements followed either restoration failure (26%) or tooth fracture
(38%). Aesthetic reasons accounted for only 15% of the
in itial cro w n p lacemen ts in d icatin g th at, co n trary to
certain perceptions, cosmetic considerations may not be
found to be a principal driver for resorting to the initial
p rovision of crowns among certain group s of p ractitioners in the UK. Smith 19 suggests indications for crowns
are badly broken-down teeth, including secondary
caries and tooth fracture. Other indications include primary trauma, toothwear, hypoplastic conditions, altering
the shape of the tooth, and to alter the occlusion.
Bader et al 20 investigated the p lacement of crowns
to p re ve n t to o th fractu re , an in cre asin g p ro b le m in
e ve ryd ay p ractice . 21 Th e y fe lt th at th e gu id e lin e s
available to dentists to assess the risk of tooth fracture
to b e p o o r. Th e stu d y fo u n d th at w h e n a p an e l o f
d e n tists e xamin e d vital te e th , o n ly a q u arte r co u ld
agree as to when a crown was needed to p revent tooth
fracture.
In light of this information, future studies may need
to identify in more detail the different factors involved
in restoration failure and tooth fracture to understand
b e tte r d e cisio n -m akin g in re latio n to in itial cro w n
p lacement in everyday clinical p ractice. Future editions
of textbooks and related teaching material may then
be able to be more sp ecific on the reasons for initial
p lacement of crowns.
The most common reasons for crown rep lacement
in th e p resen t stu d y w ere cro w n fractu re an d to o th
fracture, followed by aesthetics and secondary caries.
Walton et a l 9 found caries to be the most co m mo n
re aso n fo r cro w n failu re , w ith ae sth e tics accounting
fo r 11% an d p o rce lain failu re 16%. Sch w artz et a l 7
found 37% of failures were due to caries and p oor aesth etics. Bo th o f th ese stu d ies in clu d ed sin gle cro wn
58

PRIM ARY DENTAL CARE A PRIL 2003

units and bridges. Anusavice,22 summarising the p ap ers

delivered to an international symp osium on the criteria
for p lacement and rep lacement of dental restorations,
concluded that longevity data suggested that secondary
caries and excessive forces were the p rimary causes of
in traco ro n al re sto ratio n failu re . Th e fin d in gs o f th e
p r e s e n t s t u d y in d ic a t e t h a t t o o t h fr a c t u r e in t h e
p re sence or absence of excessive occlusal forces may
be the p rincip al reason for initial crown p lacement.
Th e re aso n s fo r cro w n failu re may b e d iffe re n t in
future studies, as PFMs are increasingly p laced in p reference to PJCs, which have a significantly higher failure
rate due to crown fracture. The rep lacement of crowns
fo r ae sth e tic re aso n s may b e fo u n d to in cre ase as
p atients exp ectations continue to rise; however, this
too needs further investigation. The design of p rep arations for crowns in clinical p ractice and the laboratory
te ch n iq u e s u se d in th e m a n u fa ctu re o f su ch re sto ratio n s n e e d to b e stu d ie d to d e te rmin e w h e th e r
imp rovements in these areas may reduce the failure of
crowns by fracture. Further studies of the typ e rep orted
co u ld u se fu lly a tte m p t to id e n tify cro w n fra ctu re s
arising from inadequate p rep aration, technical shortcomings, occlusal overload and trauma.
PFM crowns were the most common typ e of crown
p laced in the p resent study, with failed PJCs typ ically
being rep laced by PFM crowns. It was noted however
that PJCs were more likely to be chosen as rep lacement
crowns if the p revious crown was a PJC.
Th e tre n d to w ard s mo re u se o f PFMs is also
rep orted by Fyffe. 11 The author saw an increase in the
number of PFMs p laced over a ten-year p eriod. With
the main reason for the failure of crowns being the
fracture of PJCs, it seems logical that p ractitioners are
moving towards PFMs when they require an aesthetic
full-coverage restoration. PFM crowns require considerable tooth p rep aration, however, and the increased
risk o f p o st-o p e rative lo ss o f to o th vitality mu st b e
w e igh e d again st th e n e e d fo r mo re fre q u e n t cro w n
rep lacement as would ap p ear to be the case with PJCs.
Future studies of this typ e rep orted could usefully look
at differences, if any, between reasons for the failure of
traditional PJCs and resin-bonded, all-ceramic crowns.
Th e med ian age o f th e cro wn s rep laced was ten
years. This study p rovides information on failures and
cannot be comp ared with longitudinal studies because
data were not collected on the age of crowns still in
service. The data do, however, show similarities with
findings from other studies, 23 with the median age of
the crowns at the time of failure being slightly lower
than rep orted by Maryniuk. 24

Conclusion
It is concluded that surveys of the typ e rep orted may
p rovide new insights into the reasons for, and p attern
o f p ro visio n o f in itial p lace me n t an d re p lace me n t
cro w n s in e ve ryd ay clin ical p ractice . In th e p re se n t
stu d y, th e m o st co m m o n re aso n fo r th e p ro visio n o f

NA W ILSON

initial p lacement crowns was tooth fracture. The most

common reasons for the rep lacement of crowns were
also cro wn an d to o th fractu res, with cro wn fractu re
being most common in p orcelain jacket crowns.

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Correspondence: NA Wilson,
Department of Prosthodontics, University Dental Hospital of
Manchester, Higher Cambridge Street, Manchester M15 6FH.
E-mail: neilwilson73@tiscali.co.uk

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