R E DS ETNOTRI A

R E S TO R AT I V E S T RI Y
V E D E N T I S T R Y

Crowns Revisited
DAVID BARTLETT

prepare the tooth with greater tapers than

Abstract: This paper overviews recent changes to making crowns. For the most part it this, and the combination of a rigid
presents clinically relevant information using examples where necessary. The paper
material and the luting cement is usually
will act as a useful reminder for the techniques involved with crown preparations and
the choices of materials available. sufficient to retain the crown.
For the most part, restoring teeth with
Dent Update 2003; 30: 516–522 crowns is relatively straightforward. But
it is more difficult to be dogmatic about
Clinical Relevance: This paper presents some useful hints and information for the indications, especially with the
practitioners making crowns.
development of newer composites which
can match the appearance of some
porcelain crowns. However, there is still a
place for crowns to restore:

l Broken down teeth;

C rowns are an important part of

practice life and may contribute
significantly to the income of dental
practitioners. Therefore, getting it right is
fundamental. Should you use a metal
ceramic crown and cement it with zinc
phosphate, or use an adhesive cement
with an all-ceramic crown? Which
combination might achieve the optimum
appearance? Do the preparations need to
differ between products and what
changes to clinical techniques have
occurred to make the process simpler?
THE BASICS
Preparation
Probably the most important stage in
making crowns is not what material to use
David Bartlett, BDS, PhD, MRD, FDS
RCS(Rest. Dent.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry (GKT), Floor
26, Division of Conservative Dentistry, Guy’s,
King’s and St Thomas’ Dental Institute, Guy’s
Tower, London Bridge, London SE1 9RT.
but to create sufficient space in the right
place for the crown. Often preparations
sent to laboratories are inadequately
l Repeatedly fracturing teeth;
l Appearance – especially
replacement of extensively restored
prepared, not because they have an anterior teeth;
insufficient shoulder width, but because l Treatment of short clinical crowns
the contour of the preparation is not and toothwear;
matched to that of the tooth. Teeth have l Function.
curves! The burs we use do not. Burs can
be tapered to provide the optimum tooth Restoring broken down teeth, possibly
reduction for retention, but clinicians following endodontics, is a routine
often fail to remove sufficient tooth decision-making process. The
tissue along the mid-buccal and incisal appearance of some extensively restored
regions necessary for the best anterior teeth can be improved by
appearance (Figure 1). The result creates crowns, even though the translucency of
problems for the technician who faces the
difficult dilemma of whether to overbuild
the incisal and buccal porcelain to
maintain the translucent appearance of
the porcelain on the crown, or overbuild
the porcelain to preserve the appearance
but make the contour bulky. The ideal
solution is to remove sufficient tooth to
make the job of the technician more
straightforward.
Most crowns gain retention from the
Figure 1. The preparation on the premolar has
length of the preparation and its taper. three buccal planes – a cervical, mid-buccal and
The ideal taper for a conventional crown incisal. This creates sufficient space for the metal
is around 15o, although most practitioners and ceramic need for the crown.

516 Dental Update – November 2003


Figure 2. A wax sausage is taken of the pre-operative state of the tooth and used to form the
matrix.
the natural teeth can rarely be matched.
Restoring short clinical crowns is more
difficult and should only be considered
as part of an overall treatment plan.
Increasingly, the benefit of using
adhesive cements to supplement the
retention of crowns has helped
practitioners but, when they are the major
retentive feature, careful planning should
be undertaken and the occlusion should
be carefully assessed.
After teeth are extracted there is a
potential for the adjacent and opposing
teeth to drift into the edentulous space.
When this movement changes the
intercuspal position, or creates an
interference, the term unstable occlusion
is used. Crowns can be used to remove
the interference, possibly with occlusal
adjustment, and even out the occlusal
plane to produce a more stable occlusion.
Pre-preparation Matrix
This is an often under-appreciated part of
the process, because the provisional
crown will provide a lot of useful
diagnostic information. Probably most
important is the assessment of whether
sufficient tooth has been cut away during
the crown preparation. But other
information includes:
l Occlusal reduction;
l Buccal and palatal/lingual reduction;
l Shape of the crown – height and
width;
l Gingival contour.
Normally, a matrix is taken of the tooth
either with alginate, silicone or pink wax.
The pre-operative state of the tooth then
acts as a guide or matrix for the final
Dental Update – November 2003
R E S TO R AT I V E
crown. Some problems arise when the
pre-operative shape of the tooth is not
quite what is planned. For instance, on
mesially tilted lower molars, there is little
need to cut away tooth when there is no
opposing contact in that area. The
sensible thing is to leave the tooth
unprepared and only reduce the clinical
height in those areas that need it. But
when the provisional crown is made
using the original tooth shape there is
insufficient occlusal material. One way is
to add a small amount of composite,
without bonding, to the occlusal surface
to increase the height of the tooth. The
matrix then records this and the other
details and the provisional crown is
easier to make. Another way is to use
modeller’s wax (Figure 2). Take an
impression of the pre-operative state of
the tooth in wax, use sufficient wax to
form a bulky sausage shape and allow the
wax to cool in the mouth. Remove the wax
and then, with a sharp instrument, carve
away the fit surface of the wax. This is to
increase the thickness of the provisional
crown. The wax is rigid enough and,
when used in thick section, strong
enough to support making the
provisional restoration. It is particularly
useful for gold crowns when the tooth
reduction is minimal. The only
disadvantage of the wax or alginate
techniques is that they can only be used
once. Silicone impressions are better if
there is a concern that the provisional
crown may need replacing, as the material
is dimensionally stable.
The other main use of a provisional
restoration is a test of the design for the
planned restorations. If the plan is to
accept most aspects of the tooth shape,
then the existing tooth can be used for
D E N T I S T RY
the shape of the matrix. If, on the other
hand, there are more comprehensive
changes planned, then a diagnostic wax-
up is needed to inform the patient of the
planned change and also to provide a
form for the provisional restorations. The
diagnostic wax-up can be duplicated and
a 2 mm vacuum-formed splint made
around it, or a putty impression taken.
The advantage of the clear splint is that it
is possible to see the presence of
airblows in the splint whilst filling the
tooth spaces and so avoid them, whereas
with the putty matrix this is not possible.
A final use of a matrix is to check to see
if sufficient tooth has been removed
along the mid-line of the prepared tooth
(Figure 3). After the tooth has been
prepared, cut the matrix along the midline
of the silicone and replace the sectioned
matrix into the mouth. Then inspect the
gap between the tooth and the matrix to
see if it is even. Particular care should be
taken around the incisal and mid-buccal
regions as this is an area, for reasons
mentioned earlier, that is often under
prepared. You obviously do not need to
do it every time, but it is worthwhile
auditing your own preparation technique
every so often, in which case you would
need to take two matrix impressions – one
for the provisional and one for the
assessment.
Gingival Retraction Methods
The other important choice is how to
obtain adequate retraction of the gingival
tissues, the most commonly used method
being impression cord. There are a
number of makes on the market with a
Figure 3. The matrix is sectioned along the mid-
line of the tooth and re-inserted into the mouth.
The gap between the original outline of the tooth
and the preparation indicates where the tooth
has been reduced and, if so, by how much.
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range of sizes available to suit the clinical
need (Ultradent, Utah, USA), these being
more adaptable than the single-sized
varieties (Racestyptine, Septodont,
France). Retraction cord is often
unnecessary, especially if the preparation
is at or just below the gingival margin. It is
needed if the preparation is sub-gingival,
when the cord displaces the gingival
tissues so that the impression material
flows around and beneath the margin.
Some clinicians leave the cord in place,
others remove it just before the impression
is syringed into place, and some place two
layers of cord and remove one just before
taking the impression. Removing the cord
can create gingival bleeding, which will
hinder the flow of the impression, even
with the most hydrophilic materials. The
author prefers to leave the cord in place,
take the impression and then remove it
before placing the provisional restoration.
A recently introduced product, which
uses a paste that is squeezed along the
gingival margin with a specially made
applicator to control bleeding and retract
the tissues, is Expasyl (Kerr/Hawes,
Peterborough, UK). The material is
introduced at right angles into the gingival
crevice, allowing the material to flow and
gradually move along the margin, finally
leaving it in place for about two minutes.
After washing, the impression is taken
using a normal technique (Figure 4). The
advantage of this new product is that it
518
Figure 4. Expasyl (Kerr/Hawes,
Peterborough, UK) is a new retraction system
utilizing a haemostatic paste which is injected
along the gingival margin forcing the tissue
aside and creating space for the impression
material to flow.
chemically prevents bleeding and, at the
same time, provides gingival retraction.
The Impression
The choice of impression material is
usually personal. Silicones tend to be
quite hydrophobic, although some
recently introduced by the manufacturers
claim not to be (Take One, Kerr/Hawes,
Peterborough, UK; Affinis, Coltène/
Whaledent, Surrey, UK). In reality, all
impression materials need a clean, dry
surface to record the details accurately.
They are available in a number of
dispensing methods and formulations.
The low viscosity materials are generally
delivered with a mixing gun, whilst putty is
presented as a catalyst and base mixing
technique. The putty supports the wash
and effectively provides a special tray. If
you are using a putty/wash technique,
ensure that the low viscosity material
covers all the teeth, not just the
preparation, as this will ensure the
accuracy of the impression for the
occlusion.
Silicones or polyethers (Impregum, 3M
ESPE, Seefeld, Germany) are available as
single stage materials. 3M ESPE
developed an automixer (Pentamix: 3M
ESPE, Seefeld, Germany) to dispense
Impregum because some clinicians
criticized the difficulty of mixing; this new
system has significantly improved its
handling properties. The automixer
simplifies the process and provides an
evenly mixed material. It has recently been
adapted to be used with silicones from 3M
ESPE and other manufacturers’ materials.
Your impression must provide sufficient
information for the technician to construct
the crown:
l The margin should be clearly visible
around the periphery of the
preparation;
l There should be no drags or tears
anywhere on the impression,
especially around the impression of
the prepared tooth/teeth;
l Shiny, reflective surfaces around the
tooth preparation often represent
inaccuracies, possibly representing
moisture contamination;
l The occlusal morphology of adjacent
teeth should be clearly seen;
l Ensure that the impression is firmly
attached to the tray.
The choice of material may not be as
critical as the choice of impression tray.1,2
Rigid trays are essential for accurate
impressions; it should not distort when
the impression is seated and removed from
the mouth. A tray adhesive is used to
prevent partial displacement of the
impression from the tray and eventual
distortion of the impression. Some
operators prefer metal trays and, whilst
these can be re-usable, they appear to be
no more accurate than a rigid plastic one.1
One of the most demanding situations
is the most distal standing tooth. In less
rigid trays there is a tendency for flexure of
the tray to occur on seating, especially
with more viscous materials. Commonly,
pressure is applied on the anterior part of
the tray or over the premolar region and
consequently this may distort the most
posterior or distal aspect. This distortion
returns to its pre-elastic state after the
pressure is released. The end result is that
a preparation around the 2nd or 3rd molar
region is inaccurate and the fit of the
crown may not be achievable.
THE TYPE OF CROWN
The most common type of crown is a
combination of metal and ceramic. Whilst
Dental Update – November 2003
 R E S TO R AT I V E D E N T I S T RY
Figure 5. Inceram crowns. This patient wanted
extremely white teeth after she had bleaching.
The rather monochromatic colour of the tooth
represents the colour choice of the patient rather
than the material. Different surface
characteristics could have been added to the
outer surface with conventional porcelains to
achieve a better surface finish.
this produces an acceptable appearance
most of the time, occasionally the opacity
of the underlying metal becomes a
problem. The natural tooth is translucent
and, whilst the metal provides strength, it
stops light transmission. The technician
hides this by placing opaque porcelain
onto the metal surface but, in doing so,
makes the crown appear bright, increasing
the value. Adding more layers of dentine
and enamel porcelain reduces this but the
natural appearance of teeth is rarely
achieved. Therefore, providing sufficient
tooth reduction is imperative for the
technician to hide this opaque layer.
There is extensive choice available for
all-ceramic crowns and the more recent
types appear to perform well in most
mouths. Theoretically, porcelain crowns
are not as strong as metal ceramic ones,
but the optimum strength for a crown is
almost impossible to predict. The strength
reported by the manufacturers will
normally be based on laboratory studies
and, whilst these will give an indication of
Figure 6. Procera crowns on the incisors have been used to replace the discoloured and
extensively restored teeth. Note the translucency of the crowns.
520
its performance, it will never replace the
clinical test. The following is a list of some
of the new porcelain materials:
i. Ceramic cores
a. Inceram
b. Procera
ii. Castable ceramics
a. Empress I
b. Empress II
iii. CAD CAM
a. Cerec I, II, III
iv. Non-castable metal ceramic crowns
a. Captek
Ceramic Cores
Inceram (Vita Zahnfabrik, Bad
Sackingen, Germany)
The crown consists of two layers, an inner
core made from Inceram to provide
strength and an outer layer made from
conventional feldspathic porcelains to
improve the appearance (Figure 5). The
crown is made of an absorbent refractory
die over which molten glass is poured to
produce a strong and dense crystalline
core with a relatively poor appearance.
Conventional porcelains are needed to
create an aesthetically pleasing crown.
The high content of aluminia makes
adhesive bonding difficult as the surface
is resistant to most acids and so non-
adhesive cements are used to lute the
crowns.
Procera (Nobel Biocare, Goteborg, Sweden)
The concept is not unlike Inceram but, in
this case, computer-controlled technology
is used to make the crown. The working
die is scanned by sapphire probe and
converted into data which is sent by
Figure 7. Empress crowns on the two central
incisors – there is little distinction between this
and the Procera material and both provide a
very good result.
e-mail to a laboratory where a computer-
controlled milling machine makes the core
from an aluminium oxide powder. The
outer surface, like Inceram, is made from
conventional porcelains (Figure 6). The
material can be adhesively bonded to
teeth. In theory, because the Procera has
an opaque core, it can block out
discoloured areas such as mildly stained
teeth. But the potential disadvantage of
the technique, even with the thinner core
size of 0.4 mm, is that more tooth needs to
be cut away.
Castable Ceramics
Empress I and II (Ivoclar
Vivadent, Schaan, Liechtenstein)
The crown again has two layers, an inner
material made from Empress and an outer
layer made from conventional porcelains
(Figure 7). Unlike Inceram the outer layer
is much thinner and characterizes the
surface finish. The Empress core is made
using the lost wax technique. Porcelain is
forced under pressure into the shape left
after the wax is burnt away, eventually
cooling to form the crown. The fit surface
can be acid-etched with hydrofluoric acid
to allow adhesive bonding. The advantage
of the Empress system is that, since the
colour of the crown is consistent
throughout the restoration, in a case
where horizontal space is at a premium, the
Empress might be a better option to use
than, for example, a Procera which still
needs space for a core. However, with
thinner crowns and the need to use only
the intrinsic colour of the Empress, there
would be less space for characterization of
the tooth.
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Figure 8. The preparation for all-ceramic
crowns needs to be at least 1.3 mm plus for
sufficient space, and preferably more. The
internal line angles need to be rounded.
CAD-CAM
Cerec (Sirona, Bensheim, Germany)
This is a computer-controlled milling
machine but, unlike Procera, the whole
crown is milled from a block of standard
porcelain. The only area where there is
some difficulty is the characterization and
the occlusal form.
Non-castable Metal Ceramic
Crowns
Captek (Davis, Schottlander & Davis,
Letchworth, UK)
The crown’s basic structure is similar to
conventional metal ceramic crowns in that
the core is metal and the outer part is
porcelain. Unlike a metal ceramic crown,
there is no need for a casting machine. A
series of different wax strips containing
gold or platinum are sequentially applied
over an investment model and the wax is
burnt away leaving the metal to form a
core over which is layered porcelain. The
underlying gold is said to give the crowns
a warmer appearance than conventional
metal ceramic crowns. Until recently,
adhesively bonding gold to teeth was
unreliable but a new material has
overcome this problem.
Not only is the choice of porcelain
important, but the tooth preparation must
match the material used. Virtually all the
all-ceramic crowns need extensive tooth
reduction over the whole tooth, unlike
metal ceramic restorations where lingual
and, occasionally, occlusal preparations
can be reduced if a metal surface is
preferred. The sapphire scanner used for
making Procera crowns cannot read
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D E N T I S T RY
sharp edges on preparations and
therefore they must be avoided. The
manufacturer provides correctly shaped
burs and advises significant tooth
preparation to achieve the optimum
results – they are not conservative of
tooth tissue! The shoulder should be
rounded as should the core margins
(Figure 8). The all-porcelain crowns
appear more translucent and vital than
the metal ceramic ones, especially around
the gingival margin.
For most patients, this theoretical
reduction in strength of all-ceramic
crowns is probably unimportant but,
where a parafunctional habit is present,
the load transferred to the crown may be
excessive leading to cracks or fractures.
The porcelains are suitable for anterior
three-unit bridges but their use
posteriorly increases the risk and larger
spans are contraindicated.3 Procera
provide blanks onto which is added
conventional porcelain to produce a
necessary tooth shape and the resulting
tooth is glued to the adjacent crowns.
Inceram and Empress use similar
techniques for three-unit bridges. The
gold connector for Captec is soldered
onto the adjacent crowns to provide the
bridge.
WHICH CROWN MATERIAL
TO USE AND WHEN
Probably the most important factor in this
choice is the ability of the technician. A
really good technician will produce a
magnificent metal ceramic crown which
will match any all-ceramic. Conversely, the
choice of an all-ceramic crown does not
necessarily mean that the result is going
to be superior. Another important factor is
what system does your normal technician
supply? For instance, if you are content
with the standards of your normal
technician, then he/she may only supply
one particular type and therefore the
decision is personal. Finally, as mentioned
above, the different types of all-ceramic
crowns have individual advantages.
CEMENTATION
For the most part, provided the
preparation fulfils optimum retention,
non-adhesive cements can produce
clinically acceptable results. If the
preparation is unretentive, for a variety
of reasons, the cement lute may become
more important in securing the crown to
the tooth than the shape of the
preparation.4 In such cases, adhesive
cementation may be of value, using a
resin-based luting system in
conjunction with the treatment of the
prepared tooth with a dentine-bonding
agent. Such cement lutes are generally
dual-cured systems and all contain
priming agents, such as silanes, to
increase the wetting and bonding of the
lute to the rough fitting surface of the
crown or retainer.
Until recently it was difficult to bond
adhesive cements to Type III gold used
for crowns and bridges. Tin plating and
oxide layer formation were described to
provide a suitable surface for bonding,
but the technique introduced additional
technical stages and was not convenient.
Panavia F (Kuraray, Japan) is supplied
with a metal primer allowing direct
cementation of high gold content alloys
to the cement lute.
SUMMARY
l Ensure that the crown preparation
follows the shape of the natural
crown and follows the basic
principles of retention and resistance
form.
l Retraction cord can be helpful in sub-
gingival preparations but is not
necessary for supra preparations or
those to the gingival margin.
l Adhesive cements can supplement
unretentive crown preparations, as
can slots and grooves.
REFERENCES
1. Wassell RW. Plastic trays and accurate impressions. Br
Dent J 1998; 184: 266.
2. Abuasi HA, Wassell RW. Comparison of a range of
addition silicone putty wash impression materials
used in the one-stage technique. Eur J Prosthodont
Rest Dent 1994; 2: 117.
3. Giordano R. A comparison of all-ceramic restorative
systems, Part 1. Gen Dent 1999; 47: 566.
4. Bartlett DW. Adapting crown preparations to
adhesive materials. Dent Update 2000; 27: 460–
463.
Dental Update – November 2003