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Crowns Revisited
DAVID BARTLETT
prepare the tooth with greater tapers than this, and the combination of a rigid material and the luting cement is usually sufficient to retain the crown. For the most part, restoring teeth with crowns is relatively straightforward. But it is more difficult to be dogmatic about the indications, especially with the 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; l Repeatedly fracturing teeth; l Appearance especially replacement of extensively restored anterior teeth; l Treatment of short clinical crowns and toothwear; l Function. Restoring broken down teeth, possibly following endodontics, is a routine decision-making process. The appearance of some extensively restored anterior teeth can be improved by crowns, even though the translucency of

Abstract: This paper overviews recent changes to making crowns. For the most part it
presents clinically relevant information using examples where necessary. The paper will act as a useful reminder for the techniques involved with crown preparations and the choices of materials available. Dent Update 2003; 30: 516522

Clinical Relevance: This paper presents some useful hints and information for
practitioners making crowns.

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, Guys, Kings and St Thomas Dental Institute, Guys 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 prepared, not because they have an insufficient shoulder width, but because the contour of the preparation is not matched to that of the tooth. Teeth have curves! The burs we use do not. Burs can be tapered to provide the optimum tooth reduction for retention, but clinicians often fail to remove sufficient tooth tissue along the mid-buccal and incisal regions necessary for the best appearance (Figure 1). The result creates 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 length of the preparation and its taper. The ideal taper for a conventional crown is around 15o, although most practitioners

Figure 1. The preparation on the premolar has three buccal planes a cervical, mid-buccal and incisal. This creates sufficient space for the metal and ceramic need for the crown. Dental Update November 2003

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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
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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 modellers 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

the shape of the matrix. If, on the other hand, there are more comprehensive changes planned, then a diagnostic waxup 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 midline 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. 517

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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.

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.

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
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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, Coltne/ 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

THE TYPE OF CROWN

The most common type of crown is a combination of metal and ceramic. Whilst
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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.

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

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.

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 nonadhesive 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

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

e-mail to a laboratory where a computercontrolled 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 6. Procera crowns on the incisors have been used to replace the discoloured and extensively restored teeth. Note the translucency of the crowns.

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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 crowns 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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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.

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 subgingival 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.

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.

REFERENCES
1. 2. Wassell RW. Plastic trays and accurate impressions. Br Dent J 1998; 184: 266. 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. Giordano R. A comparison of all-ceramic restorative systems, Part 1. Gen Dent 1999; 47: 566. Bartlett DW. Adapting crown preparations to adhesive materials. Dent Update 2000; 27: 460 463.

3.

CEMENTATION
For the most part, provided the preparation fulfils optimum retention,

4.

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