Dr.

Keyvan Moharamzadeh

Academic Unit of Restorative Dentistry
The University of Sheffield
Posterior Full-Coverage Crowns
Aims
The reasons for crowning a
compromised tooth
Design and biological considerations
Materials
Full coverage crowns: FGC, PFM,
All-ceramic
Tooth preparations
Clinical Stages
The reasons to restore a
compromised tooth
Restoring function (first) and
aesthetics (second)
Restoring structural integrity and
resisting fracture
Integrating with other prosthesis
The Compromised Tooth
Restoring function (first) and
aesthetics (second)
The Compromised Tooth
Restoring structural integrity and
resisting fracture
Endodontically treated
teeth
Weakened tooth due to access
cavity preparation
Loss of Structural integrity
associated with loss of roof of the
pulp chamber
Loss of dentine elasticity

Posterior Teeth
Cuspal protection is required if:
Loss of marginal ridges
Loss of substantial tooth structure
Heavily restored tooth
(Panitvisai P et al., J Endod 1995)

Posterior Teeth
Cuspal protection can be achieved by:
Adhesive restorations
Cusp-coverage cast restorations
Full-coverage restorations

The Compromised Tooth
Restoring function (first) and
aesthetics (second)
Restoring structural integrity and
resisting fracture
Integrating with other prosthesis
Posterior Crowns
Design Considerations
Is the tooth in function?
Appearance
Adjacent Teeth
Periodontal Tissues
Pulp
Retention of the crown to the tooth
Materials

Posterior Crowns
Periodontal Tissues
Plaque control
Periodontal attachment
Alveolar bone levels
Status of periodontal disease

Pulpal death following
crown preparations
Aggressive insult to the tooth,
dentine and odontoblasts
Thermal damage
Local anaesthesia
Dessication
Bacterial contamination

Pulpal death following
crown preparations
10% - Hammerle 2000
19% - Saunders 1999
10% - Valderhaug 1997
6% - Jackson 1992
10% - Kerschbaum 1979 and 1993

University of Graz

Austria
School of dentistry

Dep. of Prosthodontics

Gerwin Arnetzl
Minimum of 0,7 mm dentine thicknes
is recommended for pulpal protection

Gente 1995, Jde 1986, Robach 1982
0,7mm
Courtesy G. Unterbrink
A shoulder preparation of 1.2 mm
Results in a remaining dentine width of 0.7 mm
only in 50 % of maxillary molars












in all other premolars and molars the
remaining dentine width is less than
0.7mm

A 1.2mm shoulder crown preparation
on a posterior tooth leaves 0.7mm
remaining dentine thickness
Thermal
Chemical
Osmotic
Dessication
Thermal
Chemical
Osmotic
Dessication
Bacterial
Toxins
Posterior Crowns
Materials

Balancing Function
and Aesthetics

Posterior Crowns
Materials
Metal
Metal-Ceramic
Ceramic

Posterior Crowns
Materials
Metal (Full Gold Crown)
Minimal tooth reduction
Least aesthetic (? Not an issue)
Can be adjusted intra-orally (occlusion)



Gold alloy types:

Type I (Soft) was hard enough to stand up to biting forces
but soft enough to burnish against the margins of a cavity
preparation. It was used mostly for one-surface inlays.
Type II (Medium) was less burnishable but hard enough to
stand up in small, multiple surface inlays that did not include
buccal or lingual surfaces.
Type III (hard) The most commonly used type of gold for
all-metal crowns and bridges. A typical type III gold alloy
includes the following metals: Gold 75% Silver 10%
Copper 10% Palladium 3% Zinc 2%
Type IV (Extra hard) was used for partial denture
frameworks but was not used in fixed prosthetics.


Full Gold Crown
Donovan T, 2004: Retrospective clinical
evaluation of 1,314 cast gold restorations
in service from 1 to 52 years.
The survival rates at various time periods were
97% at 9 years, 90.3% at 20 years, 94.9% at
25 years, 98% at 29 years, 96.9% at 39 years,
and 94.1% for restorations in place > 40
years. It appears that properly fabricated cast
gold inlays, onlays, partial veneer crowns, and
full veneer crowns can provide extremely
predictable, long-term restorative service.

Posterior Crowns
Materials
Metal-Ceramic
Metal Core
Extensive buccal tooth reduction
Aesthetics at the cost of tooth tissue
Only the metal component can be
adjusted intra-orally


PFM alloy types:

High-noble alloys have a minimum of 60% noble metals (any
combination of gold, palladium, and silver) and a minimum of 40% by
weight of gold. They usually contain a small amount of tin, indium, or
iron which provides for oxide layer formation. These metals provide a
chemical bond for the porcelain.
Noble alloys (gold, palladium, or silver) contain at least 25% by weight
noble metal. They have relatively high strength, durability, hardness, and
ductility.
Base-metal alloys contain less than 25% noble metal. They are much
harder, stronger and have twice the elasticity of the high-noble and
noblemetal alloys. Castings can be made thinner and still retain the
rigidity needed to support porcelain. They appear to be the ideal metal
for cast-dental restorations and were heavily used for PFM frameworks
due to their low cost and high strength characteristics. Unfortunately,
nickel and beryllium, two of the most commonly used constituents of
base-metal alloys can cause allergic reactions when in intimate contact
with the gingiva.

Ceramic-Fused to metal Crown
PFM crown
Pjetursson et al., 2007. A systematic
review of the survival and complication
rates of all-ceramic and metal-ceramic
reconstructions after an observation
period of at least 3 years. Part I: Single
crowns.
In meta-analysis, the 5-year survival of all-
ceramic crowns was estimated at 93.3% and
95.6% for metal-ceramic crowns.



Posterior Crowns
Materials
All Ceramic
High strength ceramic core
Most aesthetic
Low edge strength
Requires extensive reduction
Intra-oral adjustment not possible

All ceramic Crowns
Wang X et al., 2012. A systematic review of all-
ceramic crowns: clinical fracture rates in
relation to restored tooth type.
All-ceramic crowns demonstrated an acceptable
overall 5-year fracture rate of 4.4%
irrespective of the materials used. Molar
crowns (8.1%) showed a significantly higher 5-
year fracture rate than premolar crowns
(3.0%), and the difference between anterior
(3.0%) and posterior crowns (5.4%) also
achieved significance.

Principles of Tooth
Preparation for crowns

Preservation of tooth structure
Retention
Resistance
Structural durability
Marginal integrity

Posterior Crowns
Retention of the crown
Retention Form: Prevents
dislodgement of the crown in an
axial direction.

Resistance Form: Prevents
dislodgement of the crown due to
rotation from a lateral load.
Tooth Preparation Design
Preparations should be well-defined
and well-finished


Tooth Preparation Design
Preparations should be well-defined and
well-finished
A clear finish line should be visible


Tooth Preparation Design
Preparations should be well-defined and
well-finished
A clear finish line should be visible
Ceramic margins should be a butt-
joint rounded shoulder


Contour to
gingiva
Shoulder
margin
- All Ceramic Crown -
Tooth Preparation Design
Preparations should be well-defined and
well-finished
A clear finish line should be visible
Ceramic margins should be a butt-joint
rounded shoulder
Metal margins should have chamfer
margins


Chamfer margins
Tooth Preparation Design
Preparations should be well-defined and
well-finished
A clear finish line should be visible
Ceramic margins should be a butt-joint
rounded shoulder
Metal margins should have chamfer
margins
All preparation line angles and point
angles are best rounded


Tooth Preparation for All
Ceramic Crown
Minimum occlusal reduction: 1.5mm
>2 mm in
areas of
stress
- All Ceramic Crown -
Occlusal reduction reflects the
morphology of the tooth and the
functional pathways of the occlusion
5 taper
Shoulder
margin
Occlusal
reduction:
>1.5mm
>2 mm in
areas of
stress
Zone of retention
Tooth Preparation for
PFM crown
PFM crown prep
PFM crown prep
Tooth Preparation for Full
Gold Crown
Full Gold Crown Prep
Posterior Crowns
Clinical Stages-Phase I
Pre-op clinical and radiographic
assessment
Further investigations, study models,
diagnostic wax-up
Treatment Planning
Informed consent



Posterior Crowns
Clinical Stages-Phase II

Tooth build up (if necessary) and
Preparation
Impression
Occlusal Record
Temporisation
Fabrication (Lab stage)


Posterior Crowns
Clinical Stages-Phase III
Removal of temporary crown
Try-in of definitive crown
Cementation of definitive crown
Occlusal check
Review