As featured on

2013

Crowns
Revision tool
An article designed to give dental students an overview
into the World of Crowns. Useful as a revision and
reference tool, this article is intended to be easy to
read for anyone unfamiliar with Crown provision, with
tips and guidance from an existing dental student.

-Chirag Patel-----5th Year Student

(Liverpool
University Dental
Hospital)

With Special thanks to:

Professor Callum Youngson (Head of Liverpool
University Dental School)
Dr Sophie Desmons (Clinical tutor at Liverpool
University Dental School)
Leona Yip (Editor)

Contents
Introduction ............................................................................................................................................ 4
Pre-operative assessment .................................................................................................................... 4
Types of Crown ii, , ................................................................................................................................... 8
Full Metal Crowns ............................................................................................................................... 8
Metal Ceramic Crowns ........................................................................................................................ 8
All Ceramic Crowns ............................................................................................................................. 9
Resin Bonded Porcelain Crown ........................................................................................................... 9
Composite Crowns ............................................................................................................................ 10
Post and Core Crowns ....................................................................................................................... 10
Three-quarter Crowns....................................................................................................................... 10
Occlusion , , ........................................................................................................................................... 11
Aesthetics , , , , ........................................................................................................................................ 14
Tooth Preparation iv, ii, , , ........................................................................................................................ 17
Full Metal Crown Preparation ........................................................................................................... 19
Metal Ceramic Crown aka Porcelain fused to Metal ........................................................................ 19
Anterior tooth preparation ........................................................................................................... 19
Posterior Tooth Preparation ......................................................................................................... 20
All Ceramic Crown ............................................................................................................................. 21
Resin Bonded Porcelain Crown ......................................................................................................... 22
High Strength Porcelain Crowns ....................................................................................................... 23
Posterior tooth preparation guideline: ......................................................................................... 23
Composite Crowns ............................................................................................................................ 23
Trouble shooting ............................................................................................................................... 23
Impressions , , ........................................................................................................................................ 25
Temporary restorations ii, iv, , ................................................................................................................. 27
Types of Temporary Crown ............................................................................................................... 27
1) Preformed Crowns: Plastic (Opaque: polycarbonate or acrylic) or Metal (aluminium,
stainless steel or nickel chromium)............................................................................................... 27
2) Matrices: Impression Matrix, Vacuum Formed Matrix, Odus Pella/Strip Crowns ................... 28
3) Direct Syringing ......................................................................................................................... 28
4) Lab made Temporary Crowns ................................................................................................... 29

Temporary restorations for Resin Bonded Crowns ...................................................................... 29

Try in and Cementation , ...................................................................................................................... 30
Try in procedure:............................................................................................................................... 30
Cementation of the Crown ............................................................................................................... 31
Choosing a cement........................................................................................................................ 31
Cementing Procedure ................................................................................................................... 33
References ............................................................................................................................................ 34

Introduction
A Crown is a type of dental restoration that covers a dental implant, or a tooth that has undergone
moderate to severe destruction by caries or wear. It is essentially a cap that covers a tapered
tooth preparation, to restore function and aesthetics. Crowns are fabricated outside of the mouth
(Indirect) and can be made from a number of materials, with choice depending on the clinical
situation and patient requirements. The indirect method of producing a Crown is more expensive
than direct methods of restoration because of the extra time and resources required in production
(often by a dental lab), however it allows for the production of an overall better restoration in terms
of both strength and form.
This revision article aims to give a basic overall understanding of the sequences involved in
producing a Crown, beginning with a pre-operative assessment, to final cementation.
All images, other than those explicitly stated, have been provided courtesy of Liverpool University
Dental Hospital.

Pre-operative assessment i ii iii

Crown preparations involve the removal of a large amount of coronal tooth structure and should
only be considered after less destructive alternatives have considered, but are too un-retentive, unaesthetic or lacking resistance. It is a given, that in Crown preparation, a small amount of sound
tooth structure is removed, however this is done with the intention of saving the tooth from
subsequent loss of larger quantities of tooth. A full coverage Crown can be indicated if all the axial
walls of a tooth have been affected by caries or wear, and a Three Quarter Crown is indicated if one
of the axial walls of the tooth remains sound.
The decision to restore a tooth with a Crown is further influenced by a number of factors, including
patient expectations, the patients oral hygiene and periodontal status, occlusion, and the dentists
ability to perform the procedure.
The following factors all need to be factored in before a decision can be made on whether a Crown is
suitable or not.
Patient expectations
-It is very important to gauge an individuals expectations from the Crown, and compare to ones
own clinical judgement on what can be achieved realistically. The response will also influence
selection of material, with often a compromise between function and aesthetics.
For example, for an anterior tooth, a Gold Shell Crown would be very retentive and require least
removal of tooth tissue compared with an All Ceramic Crown; however few patients would accept
this aesthetically.
Treatment tolerance and maintenance
-If the patient is unable to open their mouth sufficiently or for long periods of time, this would
impinge on a dentists ability to carry out the preparation and take impressions.
-If a patient suffers from parafunction such as bruxism, a Crown lifespan would be significantly
reduced.
-A patient must be able to maintain good oral hygiene, for the longevity of the Crown, and

periodontium.

Justification of tooth removal

-The inevitable removal of sound tooth in a Crown preparation, and therefore weakening of tooth
structure, must be justified by the provision of a Crown that will serve to protect the tooth from
further loss of tooth structure, and gain of function.
-Studies have shown that 1-15% of vital teeth become devitalized after Crown preparation, due to
exposure of thousands of dentinal tubules, and this needs to be kept in mind when considering
Crown preparation, as this can lead to periapical pathology later on.
Oral environment
-The oral environment in terms of plaque control, parafunction, caries risk and occlusion need to be
considered for the success of a Crown. Parafunction can be difficult to control, however the other
factors are manageable and once ideal, are key to the success of Crown work.
-Plaque is a primary cause of caries and periodontal disease, and it is important that a patients oral
hygiene is stabilized before the provision of any Crown work.
-High plaque levels in a patient with Crown restorations increase the risk of caries progression and
tooth loss, especially where there are marginal deficiencies between the tooth and Crown.
Periodontally, plaque can lead to loss of attachment, and gum recession, which would lead to
mobility and an unaesthetic appearance around the margins of the tooth.
-It is the dentists responsibility to communicate the importance of good oral hygiene and the direct
influence on the Crowns success. This information should be followed by oral hygiene instruction
including, tooth brushing advice, flossing techniques, mouthwash advice etc. A tell-show-do method
has proven to be successful in teaching patients how to brush and floss.
-Dietary advice is also important in reducing caries risk. The patient should be taught the link
between sugar attacks and acids with the risk of caries and to limit such exposures. The UK has an
aging population, and root caries within this cohort is likely to be an increasing threat. Root caries is
difficult to deal with, and will cause the failure of even the best Crown restoration.
Occlusion
-An accurate assessment of occlusion in ICP and the guiding teeth in both lateral and protrusive
movements is required in order to understand the stresses that the Crown will undergo. This can be
observed visually, using articulating paper and on study models.
-An ideal occlusion would be canine guided on lateral excursion, in the absence of non-working side
interferences
-Nearly all anterior teeth are involved in guidance on protrusion.
-Posterior teeth undergo the greatest amount of occlusal stress
-Decision of the material of the Crown is influenced directly by the occlusion
Periodontal health
-Teeth with attachment loss can be Crowned, and it is only in cases where the disease is
unstable/uncontrolled that a Crown be contraindicated.
-A Crown with poor margins can compromise the health of the periodontal tissues, especially if
meticulous oral hygiene isnt maintained.
-Ideally, all Crown margins should be placed supragingivally, to avoid the problems associated with
gingival recession, however, in cases where subgingival preparations are indicated, it is important
the margins are as smooth as possible.
-Subgingival preparations should lie within the depth of the gingival sulcus, and should never
encroach onto the biologic width of the periodontium. The biologic width is an approximately 2mm
of distance established by the supracrestal connective tissue and the junctional epithelium. If a

Crown margin encroaches on the biologic width, it causes inflammation, which may lead to
attachment loss, apical gingival migration and pocket formation.
Endodontic status
-In a vital tooth with no pulpal involvement, a Crown can be planned without endodontic treatment,
but a note kept in mind that there is a risk of devitalisation after tooth preparation.
-In a Non-vital tooth, or pulpally involved tooth, endodontic treatment should be carried, to remove
infection, prior to Crown placement.
-In a tooth that already contains a root filling, where there is still pathology, a decision needs to be
made on whether to re-endo or not. The success rate of re-endo treatment is low, however, there is
an increased chance of success if referred to a specialist.
Tooth structure
-Caries extent and existing restorations should be assessed, because the Crown needs to rest on a
sound margin of tooth and over a strong enough preparation or core.
-Frequently, the tooth to be Crowned has an existing restoration. All previously placed materials
should be removed, unless it has been recently placed and you are sure it is retained to sound tooth.
If >50% of coronal tooth structure remains after caries and restoration removal, and no more
increase in strength is required, then a bonded compomer or resin ionomer base may be used to
restore the tooth to the required preparation form. If <50% of coronal tooth structure remains, and
there is not a minimum of 2mm sound tooth circumferentially and gingivally to the preparation, a
high-strength core build-up is needed to increase tooth strength and provide retention and
resistance form. ii
Retention
-Adequate abutment height is critical for the
retention of Crowns.
-If insufficient abutment height remains, and gingival
tissue is appropriate, Crown lengthening surgery can
be undertaken.
-Retention can be increased by grooves.
-A minimum of 2mm of sound tooth structure is
required in order to create a ferrule, which is
essential to distribute lateral forces, and this does
not include the core build up material. ii
Ferrule- ...360 collar of the Crown surrounding the
parallel walls of the dentine extending coronal to
the margin of the preparation- Sorensen &
Engelman 1990

Image: D. N. J. Ricketts, C. M. E. Tait and

A. J. Higgins British Dental Journal (2005);
198, 463-471.

Space
-Sufficient occlusal space is required for the provision of a Crown, and this is deficient in cases of
moderate to severe toothwear. In such cases, a Dahl appliance or grinding of an opposed tooth may
be required to create such space, however neither are to be taken lightly and will require a full
occlusal assessment.
Own experience and skills
-It is important to evaluate your own skills against the complexity of a particular case, and refer

where treatment is beyond ones scope of experience, knowledge and skill.

Treatment planning
-Even after the above considerations, a degree of flexibility should be kept within ones mindset,
because of complications or other needs that may arise, for example, the need for endodontic
treatment, a lack of improvement in oral hygiene, caries that extends deeper than initially thought
etc. The patient should also be aware of such possibilities.

Types of Crown ii, iv, v

Full coverage Crowns
Full Metal Crowns
Metal Ceramic Crowns
All Ceramic Crowns
Composite Crowns
-Superior retention and resistance compared to Three Quarter Crowns and Veneers
-Good cosmetics achieved with MCCs, ACCs and Composite Crowns
-Should only be considered once less destructive alternatives have been considered
-Used where all axial surfaces have caries or have been previously restored
-Tie together tooth surfaces, for strength and support

Full Metal Crowns

-These are Crowns cast entirely in metal, and can be made from a number of
different alloys (mixtures of metal). They can be made in thin sections, whilst
still maintaining their properties in strength, and therefore tooth preparations
are less destructive than MCCs and ACCs.
-FMCs can have a hardness similar to enamel, and are used in situations where
occlusal loading is high, for example posterior teeth
-Occlusal and interproximal tooth contacts can be achieved easier with FMCs and so its use is
indicated in cases where this would be difficult to achieve with other materials
-Using dissimilar metals adjacent to each other can cause adverse reactions, and so if a patient has
existing successful metal FMCs then it could be wise to use the same again.
-Aesthetically, FMCs do not match the cosmetics of a normal tooth, and patient preference could be
a major factor in the decision to provide one or not.

Metal Ceramic Crowns

-These are Crowns consisting of a Metal coping/cap with a Ceramic layer
fused over it
-Combines the strength of a metal substructure, with the better aesthetic
properties of porcelain
-Greater strength than some ACCs due to the metal substructure
-Very destructive preparation, to accommodate for the thickness of the Metal
AND overlying Ceramic, however less so than an ACC.
-MCCs can be made with entire Porcelain coverage or partial coverage: Metal
occlusally and lingual/palatally. The advantage of the latter is that a less
destructive tooth preparation is required, with retention and resistance form
maximised. Metal occlusal contacts are also easier create and adjust, and
cause less opposing tooth damage compared to Porcelain.
-Used on posterior teeth where aesthetics are important, and FMCs are contraindicated for any
other reason
-If there is insufficient space anteriorly for an ACC, due to the thickness of the Ceramic, an MCC
could be indicated
-If a visible ACC repeatedly fails due to occlusal stress, an MCC could be indicated
Contraindications
-If there is a risk of excessive opposing tooth wear. In such cases, the opposing tooth could be

ground down and provided with a composite, or the patient could be provided with a night time
occlusal splint.
-In a young patient, where risk of pulpal damage during preparation is high. In such cases, a Dentine
Bonded Ceramic Crown may be a viable option.

All Ceramic Crowns

-An All Ceramic Crown is, as the name suggests, made entirely from ceramic, and can produce the
excellent aesthetic results compared to other Crowns.
-These Crowns are made via a number of different techniques, and are
classified under traditional Porcelain Jacket Crowns, Dentine Bonded Crowns
and those with strengthened cores.
-ACCs are relatively weak restorations, being brittle in thin sections,
so therefore are usually restricted to anterior restorations where
occlusal forces are usually lower and aesthetics are important.
-Apart from the Dentine Bonded kind, preparations for ACCs are the
most destructive compared to other Crown preparations, so
alternatives should be considered first.
-Due to the aesthetic nature of ACCs they can be used to mask
severely discoloured anterior teeth and existing post and core
substructures. In existing Post and Core restorations where there is a risk of trauma, an ACC is
preferred over an MCC, because stresses are more likely fracture the Porcelain, rather than being
transferred to the Post Core leading to root fracture.
Contraindications
-Edge to edge occlusion, due to risk of fracture under occlusal loading.
-Where opposing teeth occlude in the cervical fifth of the palatal surface.
-Where ideal preparation form cannot be achieved to support the porcelain.

Resin Bonded Porcelain Crown

-Although these can classified under the ACC group of
restorations, it is worth a separate entity, because of the
differences in properties and tooth preparation.
-RBPCs are a comparatively recent addition to a dentists
RBPC image from:
armamentarium, and have been described as a full-coverage
http://www.mkvasant.co.uk/
ceramic restoration, which is bonded to the underlying tooth
dental-publicationusing a resin composite based material. The bond interface lies
croydon.html
between a micromechanically retentive ceramic fitting surface
and a dentine bonding system.
-RBPC preparation is less destructive than other All Ceramic preparations, which causes less pulpal
irritation and adheres to the concept of being a conservative as possible. With this however, comes
the difficulty in production by the lab, and in fabricating a temporary restoration, which is important
for pulpal protection.
-As with other ACCs the manufactured RBPCs are weak until bonded to the underlying tooth,
especially because DBCs are thinner in section.
Other Advantages:
-Good fracture resistance vs other ACCs
-Excellent aesthetics
-Can facilitate for situations of large preparation taper, because retention lies to a larger extent in
the bond strength

-Luting material is insoluble in liquid

-No marginal gaps, as these are filled with the luting material
Disadvantages
-Fluid isolation is essential with the dentine bonding systems, and this can be difficult to achieve,
especially where margins are subgingival
-The luting procedure is more time consuming, and highly technique sensitive
-There is a lack of longitudinal data on effectiveness

Composite Crowns
-These are Crowns made from composite systems with reinforced fibres
-Currently, not widely used, however the potential for future use is considerable due to decreased
lab costs, good aesthetics and less wear to opposing teeth
-Do not chip as easily as Porcelains
-Greater wear rate and future staining due to abrasion removing protective surface

Post and Core Crowns

-These are Crowns placed on a core with an attached pre-fabricated or
custom Post that goes into the pulp chamber and root canal of an
endodontically filled tooth for the purposes of increased retention
where it cannot be achieved by other means.
-Previous thought, was that the inclusion of a post would strengthen a
root filled tooth, however studies have failed to prove this, and rather
there is a risk of root fracture as occlusal forces would be directed down
the long axis of the post.

Post and Core Image

from:
http://dentistatrajkot.co
m/Default.aspx?ql=1472

Three-quarter Crowns
-Three quarter Crowns are used where the one wall of a tooth
remains intact and healthy, hence
covering three of the axial walls and occlusal surface instead of full
coverage.
-A conservative option, however technically challenging.

Crown image from:

http://www.toothiq.com/denta
linformation/page.aspx?id=a13e
ea02-f12b-4ea0-a7d987607ac9ba91

10

Occlusion vi, vii, viii

-An understanding of occlusion is important to the success of Crown provision, and you should carry
out a pre-operative examination of a patients occlusion as a matter of routine.
-Before we carry on, it is important to get a grasp with some basic principles and terminology related
to occlusion:
ICP (aka Centric Occlusion and Maximum Intercuspation) The position of the mandible, when the
maxillary and mandibular teeth are at their most interdigitated.
-Generally this is the position in which restorations are made
RCP (aka Centric Relation) The reproducible position of the mandible independent of tooth-tooth
contact(s) when the mandible is closing in terminal hinge axis
-There are a few situations in which a Crown will need to be adjusted to conform in RCP too and
these include:
-When altering a patients OVD
-When ICP is not stable
-Where you need to habituate the mandible distally
-Where deflective contacts in RCP exist and need to be removed. A deflective contact is any contact
that diverts the mandible from the normal path of closure into ICP
-When restoring anterior teeth, and movement into RCP results in heavy anterior forces against
teeth to be prepared
-If RCP is a considerable factor, casts mounted in RCP and mounted on a semi-adjustable articulator
can be used to further assess occlusion and allow for trial adjusting
Terminal Hinge Axis (aka Retruded Axis)- The most retruded position of the mandible, determined
by the TMJ, not tooth contact. The mandible moves in a purely rotational movement in this
position.
Working Side (aka Rotating/ Functional side)- The side to which the mandible moves during a
functional movement, i.e. if the mandible moves to the right, the right side is the working side, and
the left is the non-working side.
Non- working Side (aka Balancing side)- The side opposite to the working side during lateral
excursion.
Functioning Cusps- These are the Palatal Cusps of the maxillary teeth and Buccal cusps of the
mandibular teeth which occlude with opposing fossae, marginal ridges and cusp slopes.
Non-functioning/Balancing Cusps- These are the Buccal Cusps of the maxillary teeth and Lingual
cusps of the mandibular teeth.
Guidance- The contacting teeth when a patient slides their mandible slides laterally or anteroposteriorly from ICP are guiding teeth. The path that the mandible takes is determined partly by the
teeth in contact, and hence they provide Guidance.
-When a patient slides their mandible to the side they are about to chew on, this side becomes the
working side and the opposite side becomes the non-working side
-Canine guidance is when only the upper and lower canines on the working side are in contact
during lateral excursion, causing all of the posterior teeth to disclude. For restorative purpose
canine guidance is the ideal.
-Group function is when several pairs of teeth are in contact on lateral movement to the working

11

side, usually being premolars or premolars and canines

-Incisors and canines usually provide guidance on protrusive movement
-Guidance teeth undergo non-axial (lateral or antero-posterior) forces on excursion and if a guiding
tooth is to be Crowned, there is an increased risk of fracture or decementation, particularly if the
loads are heavy. Considering the guiding teeth before preparation is essential, and will also
influence your choice of material. If the guiding teeth needing to be Crowned are strong enough,
then the same guidance pattern can be re-established, however if it is felt that occlusal stresses are
too high, then guidance can be moved onto other teeth. Changing guidance can be achieved by
altering the occlusion slightly, for example if Crowning a guiding canine tooth; the Crown can be
adjusted out of occlusion transferring the role to the premolars instead.
Interference- Interferences are any teeth that hinder smooth guidance of the mandible into ICP. A
Working side interference is an interfering tooth/teeth on the same side that the mandible is
moving to. A Non-Working side interference involves a tooth on the side that the mandible is
moving away from in this sense. Generally it is best to remove working and non-working side
interferences before a tooth is prepared.
Now that the terminology and basic principles have been outlined, we can further discuss and look
into the clinical applications

Occlusal Records
Initial Occlusal examination
-An initial examination with regards to ICP, RCP and tooth relation in guidance is essential before any
tooth preparation.
ICP- to assess reproduceability and contacts to be re-established
RCP- to assess if any deflective contacts are present
Guidance- if the Crowns to be prepared are guiding teeth, this will affect choice of material and
whether guidance needs to be altered. Mark teeth with different coloured articulating paper under
different excursions for an extra visual guide.
-TMJ dysfunction Palpate the muscles of mastication for tenderness
-Feel for any clicking or crepitus
-Assess mandibular movements, keeping an eye for any deviation
-Individual teeth assess mobility, wear, caries
-A more detailed initial examination may be needed if there are specific occlusal problems or a
history of Temporomandibular Dysfunction
-It is useful at this stage to take impressions for upper and low hand held study casts, for further
examination where there is an unimpeded view of occlusion. Study casts can also confirm whether
there is a stable ICP, and if there is not, the possibility of inter-occlusal records would need to be
considered. Study cast impressions can be done in Alginate with stock trays, with an emphasis on
impression quality in the occlusal areas rather than the peripheries and depths of the sulci. It is
important to note that simple Study Casts do not provide any information of excursion or RCP, and if
this is required, Articulate Study Casts are indicated.
Articulated Study Casts (Semi-adjustable articulator)
-Indications:
-Where you need to ensure correct guidance against your restoration, especially where multiple
Crowns are being prepared.
-If OVD is being increased
-Where occlusion is going to be reorganised because of removal of so many occlusal contacts, and

12

RCP will be the new reference

-Where Working and Non-Working Occlusal interferences are being removed
-Where jaw position is being stabilized by an
Occlusal splint
-Where an Occlusal splint is being prescribed to
protect the Crown/Crowns from bruxism

-To accurately position the casts to a patients

anatomy in terms of condylar hinge axis and jaw
relation, a Facebow record can be taken alongside an
Inter-Occlusal record. There are a number of systems
on the market to create a Facebow record and they
all work to allow the technician to mount Study Casts
and mimic excursions around to hinge axis as close
as possible. Inter-Occlusal records are achieved by
getting a patient to bite on silicone or wax, leaving a record of intercuspation. It has been shown
that Inter-Occlusal records, in many cases, reduce the accuracy of mounting of the casts. InterOcclusal records should not be used in single tooth restoration cases where a patient has stable ICP,
but rather where casts are unstable and teeth to be Crowned will be key for support. A good Interocclusal record captures the tooth cusp tips, and not fissures or soft tissue.

Replicating tooth guidance

-Where teeth to be prepared are involved in guidance, in both protrusive and lateral excursions, a
record of tooth guidance may be needed. This is so the technician can replicate the existing form of
the tooth/teeth, in order to re-establish occlusion after preparations.
-Making a record of these excursions is particularly important where the tooth or teeth to be
prepared are alone in guiding excursions.
-Where numerous teeth are to be Crowned, guidance can be lost altogether, if a record beforehand
is not taken.
-The two most effective methods to overcome this technical difficulties are:
-The Crown about method. Where alternate teeth are prepared, hence maintaining some tooth
surface for guidance
-The Custom Incisal Guidance Table Copies protrusion and lateral excursion by placing a mound of
putty on the Incisal Guidance Table of an Articulator, and moving the STUDY casts (and pin) in the
full range of protrusion and lateral excursions. Once the putty has set, a permanent record of
excursion is made, which is later used for guiding the WORKING casts.

13

Aesthetics ix, x, xi, xii, xiii

-Aesthetics is the branch of philosophy, which deals with the nature of art, beauty and taste, with
the creation and appreciation of such subjects. When dealing with shade, shape and form of
restorations, the decision on whether they are visually pleasing or not, is very subjective to a
patients own opinion. For this reason, it is important to gauge a patients demands before the
outset of any treatment. The ideals of patient then need to be weighed up against tooth removal
and potential damage to the pulp and periodontium, with consideration to a dentists scope of skills.
Where demands are unrealistic, it is important to communicate this with the patient beforehand,
making a decision based on existing knowledge and experience. Due to the subjective nature of
aesthetics, clinical experience will play a major role in being able to judge visual outcome, and it is
better to undervalue on the scale of realistic possibility, rather than promise over-realistic outcomes.
-Currently, the most aesthetically pleasing Crowns, which have been studied over an extensive
period of time, are those containing Porcelain. In most cases, this comes at the cost of tooth tissue,
because a thicker Crown shell needs to be made for strength, in particular Metal Ceramic Crowns,
which have the most destructive preparations. As stated previously, a more destructive preparation
is more likely to cause pulpal damage, and a decision needs to be made on whether to sacrifice longterm pulp health for aesthetics, or lose aesthetic quality for pulp health.
-Here is a table of what is generally accepted as aesthetically pleasing types of Crown:
All Porcelain
-Conventional Porcelain Jacket Crown
-High Strength PJC
-Dentine Bonded Crown/ Full Coverage
-Difficulty masking underlying staining due to
Porcelain Veneer
thickness
-Temporisation difficult
-Labial Porcelain Veneer
-Difficulty masking underlying staining due to
thickness
-Temporisation difficult
-Porcelain Onlay
All Composite (Crowns, Veneers, Onlay)
-little evidence on stability and longevity
Metal- Ceramic Crown/
-Most destructive
Ceramo-Metal Crown
Composite Bonded to metal Crown
Three Quarter Crown/
Partial Coverage Crown
-After a judgement has been made as to what is achievable in relation to patient demands, there are
ways to help a patient visualise what the restorations may
look like. Time spent showing the patient aesthetic
possibilities at this stage is invaluable in saving future
disappointment.
1. Diagnostic Wax Ups- Created by the lab, these are
study casts, with the potential restoration waxed
up to get an idea of form

14

2. Composite additions- Composite can be added to the patients teeth, without etching or
application of a bonding agent to show the patient form and shade
3. Black ink- Can be applied on teeth to mimic the effect of tooth reductions
4. Computer generated restorations- Software can be used to generate computer images for a
patient to see, and can be edited to patients preferences whilst in consultation
5. Photographs of previous restorations- Can show a patient the possibilities and limitation if
similar cases are used
6. Temporary restorations- Gives the patient a feel of the form and shape of the restoration in
relation to their other teeth and facial features before a final restoration is placed
Restoration Margins
-The margins of the restoration can supra or sub-gingival (up to 1mm).
-Where the tooth margin cannot be seen, there is good reason to place the margins supra-gingivally.
Finishing and maintenance is easier with supra-gingival preparations, and there is lower risk of
damaging periodontal health.
-Where Crown margins will cause an aesthetic problem, preparations can be placed up to 1mm subgingivally. However, caution must be taken where there are prominent roots or thin gingival
coverage, because there is a risk of recession.
-If preparations need to go further than 1mm subgingivally to because of insufficient preparation
height (and therefore retention), Crown lengthening is an option to avoid encroaching into the
biological width of the periodontium.
-In terms of metal or porcelain at the margins, there are arguments stating that metal produces the
most predictable marginal seal. However, in certain areas, where aesthetics are of utmost
importance, a porcelain margin on a shoulder finish line will produce the best results. It is also
worth noting that even a metal margin placed subgingivally can show through the gingival tissue,
affecting aesthetics, especially where tissue is thin.
Shade
-Shade matching is another aspect of aesthetics that is very subjective, and a good example where
patient involvement is important. Because of the subjective nature, there are a number of systems
on the market to help make a decision on the shade, with the most common being shade guides,
where a patients teeth are compared to common shades used in Crown manufacture.
-Difficulties arise in shade matching, because teeth are non-uniform in colour, have defects, unique
features, are semi-translucent and appear different shades in different lighting conditions.
-Colour can be described by Hue, Value and Chroma. Hue is the name of the colour, for example
red, blue, green. Value is the lightness or darkness of a colour, a high value indicating something is
light and a low value, dark. Chroma is the amount of saturation of a particular hue, for example red
with a high chroma would a deeper more intense red, than red with a low value chroma.
-Vita 3D Master and Ivoclar Chromoscope
are two examples of shade guides based on
Hue, with Value and Chroma subdivisions.
-Electronic devices have been created to
judge shades of teeth, however their
effectiveness has not been fully evaluated,
therefore it is useful to use these as
reference alongside your own judgement
-Devices with magnification and colour
corrected lighting are useful tools in

15

assessing surface detail as well as shade

-The following is a scheme for shade determination from the BDJ 2002; 192: 443-450 - Crowns and
other extra-coronal restorations: Aesthetic control:

A scheme for shade determination

1. Determine the shade at the start of an appointment, before eye fatigue and tooth
dehydration with resultant shade change occurs (especially after use of rubber dam)
2. Use natural light (not direct sunlight) or a colour-corrected artificial eye source
3. Drape the patient with a neutral coloured cover if clothing is bright, and have the patient
remove brightly coloured make-up
4. Assess the value by squinting. The reduced amount of light entering the eye may allow to
better distinguish degrees of lightness and darkness
5. Glance between shade tabs rapidly (no more than 5 seconds each viewing). Gazing at a soft
blue colour in between attempts is said to reduce blue fatigue- which can result in
accentuated yellow-orange sensitivity
6. Choose the dominant hue and chroma within the value range chosen. The canines have a
high chroma and may be useful to assess hue.
7. Compare the selected tabs under different condition e.g wet vs dry, different lip positions,
artificial and natural light from different angles etc
8. Select a shade which is higher in value (lighter) if in doubt. Surface stains can reduce these
dimensions, but not easily increase them
9. Assess for colour characterisation such as stained imbrication lines, white spots, neck
colouration, incisal edge translucency and halo effect (a thin opaque line sometimes seen
within a translucent incisal). Simple diagrams are invaluable.
10. Determine surface lustre

-The above scheme provides good guidance in a methodical approach to shade determination,
however, the results of the restoration will only be as good as your communication with the dental
laboratory. It is important that all the information obtained is communicated clearly, and clarity can
be emphasised by the use of diagrams, photos, two-way communication methods and even visits to
the dental lab if necessary.
-In cases where shade matching and detail has been a difficulty, trial placement of restorations can
be done, and this would be done, before the final surface glaze has been implemented.
Cementation during this trial period would involve the use of modified Zinc oxide and eugenol based
cements, because removal could be a great difficult otherwise. Pigmented luting cements to alter
porcelain shades slightly can also be used in such cases.

16

Tooth Preparation iv, ii, xiv, xv, xvi

-Tooth preparation considers a balance of all the factors mentioned in the pre-operative assessment,
with the ultimate goal of producing a preparation that has maximal height and minimum taper for
optimal resistance and retention form. Retention form is the preparations ability to resist vertical
displacement forces, and resistance form is the ability to resist rotation about the vertical axis.
-There are seven key principles of preparation, as outlined by Herbert Shillingberg that determine
the shape and form of preparations.

Seven Key Principles:

1. Conservation of tooth structure To maintain pulp health and tooth strength
2. Retention Form- To prevent the Crown dislodging
3. Resistance Form- To prevent rotational displacement along any of the Crowns path of
insertion, including long axis
4. Structural Durability- To provide sufficient space for the material of Crown, in order to
prevent fracture, distortion or perforation
5. Marginal Integrity- To implement a finish line that accommodates a robust margin, and
allowing close adaptation to prevent microleakage
6. Periodontium Preservation- To place the margin so that it is accessible for optimal oral
hygiene, and avoid recession
7. Aesthetics- To create sufficient space for an aesthetically pleasing restoration, in particular
where Veneers are indicated
-These principles should be adhered to, however, quite often; compromises need to be made
between them, because of a patients individual requirements. For example, conservation of tooth
structure; this is sacrificed where a Metal-Ceramic Crown is used, because an adequate thickness of
material needs to be made. In such cases, if preparations are too minimal, Crowns may end up
being excessively bulky and therefore unaesthetic.
Tooth preparations vary, with regards to-Amount of tooth removed- Most for Metal-Ceramic Crowns, Least in Resin Bonded Porcelain
Crowns
-Margin position- Supragingival is ideal; however aesthetic importance may depict the position of
the margin. Subgingival preparations are indicated where metal margins are visible such as: Anterior
teeth and MCC Crown preparations with a bevelled shoulder
-Accessory retention components- Grooves, Boxes
-Degree of Taper- 6 degrees of taper ideally, apart from in Resin Bonded Porcelain Crown
preparations, where around 20 degrees is preferable, and also in High Strength Porcelain Crowns.

17

-Margin FinishShoulder

Bevelled
Shoulder

Heavy Chamfer

Chamfer

Images from: http://www.excel-dental.com/dentallab/tooth_preparation.htm

Metal Ceramic Crown, Buccal of Metal
High Strength
Full Metal Crowns,
All Ceramic/ Porcelain Ceramic Crown
Porcelain Crowns,
Palatal/Lingual of
Jacket Crown
Buccal of Metal
MCCs, Resin Bonded
Ceramic Crowns
Crowns

Diamond Crown and

Bridge bur kit at LUDH
(from left to right): Long
Needle Diamond Bur,
Short Needle Diamond
Bur, Straight Shoulder Bur,
Straight Chamfer Bur,
Rugby Bur, Tapered
Chamfer Bur
TIPS to consider:
-Hold the bur parallel to the path of insertion at all times, to prevent undercut and create the correct
taper
-Assess for undercuts using one eye only whilst directing the mirror adjacent to the tooth
-Slightly under-prep, then smooth and refine the preparation, inevitably you will then get the
desired reduction amount
-Complete smoothing is not essential, as it poses a threat to pulp health due to overheating,
especially where a water coolant is not used. However, it is important to remove any irregularities,
sharp lines and corners
-It is helpful to know the exact diameters of the burs used during production of depth grooves,
because they can be used as a measurement tool

18

Full Metal Crown Preparation

-Generally restricted to the back of the mouth due to metal appearance, however some patients
may prefer a metal appearance anteriorly
-Relatively little removal of tooth structure compared to other Crown preparations
1. Take two initial Silicone putty indexes- one for the provision of a temporary Crown and the
second to use as a reference for how much tooth has been removed. If the existing tooth
contour is incorrect, an index can be made from diagnostic wax up
2. Using a Fissure Bur, carry out a 1.0mm occlusal reduction, using
depth grooves as a guide to reduction. Occlusal reduction is not
necessary if there is already a minimum of 1mm occlusal space in
ICP
3. Reduce the functional cusps of the tooth by an additional 0.5mm,
angled at approximately 45 degrees, producing the functional cusp
bevel. This is essential to prevent thin casting and fracture of the
functional cusp of the Crown.
4. Assess occlusogingival height, and decide on whether auxillary features such as grooves are
needed to aid retention.
5. At this stage you can check occlusal clearance using 2.0mm red wax strip, asking the patient
to bite, and then holding up the strip to the light
6. Reduce axial walls by up to 1.0mm using a Tapered chamfer
diamond; the tip creates a chamfer for Crown seating. Chamfer is
best for strength in this preparation.
7. Cut Interproximal areas with the Long needle diamond, which then
creates enough room for preparation with the Tapered Chamfer
diamond bur
8. A 0.5mm depth Seating groove can be placed, on the functional cusp side to prevent
rotation.
9. Smooth sharp lines, corners and irregularities with a Finishing Diamond Bur

Metal Ceramic Crown aka Porcelain fused to Metal

-Metal coping with a ceramic layer fused onto it
-Combines strength of metal substructure with aesthetics of porcelain
-Greater strength than some ACCs
-In most cases, Porcelain coverage is restricted to visible areas, and therefore facial surfaces have a
heavy shoulder preparation to accommodate the thickness of metal and porcelain, and
lingual/palatal surfaces have a lighter chamfer preparation for metal only
-Adequate prep needs to be done or else there will be: 1- poor contouring of tooth by lab, 2- the
shade wont match adjacent teeth due to incorrect thickness
Anterior tooth preparation
1. Take two initial Silicone putty indexes- one for the provision of a temporary Crown and the
second to use as a reference for how much tooth has been removed. If the existing tooth
contour is incorrect, an index can be made from diagnostic wax up

19

2. Using a Fissure Bur, carry out a 2.0mm occlusal reduction, using depth grooves as a guide to
reduction. Occlusal reduction is not necessary if there is already a minimum of 2mm occlusal
space in ICP
1. Now remove 1.2mm of tooth from the facial surface, using a
Shoulder bur via a 2 (or 3)
planar reduction to achieve adequate reduction and avoid
pulp. This involves creating two plane depth grooves- gingival
and incisally, followed by smoothing.
-Facial reduction is carried around and stopped 1.0mm away
from the proximal contacts
-If bevelled shoulder is chosen (0.3mm using flame shaped
diamond bur), a subgingival preparation would be needed to
hide the metal lining it
2. Remove 0.5mm from the lingual concavity using a Rugby
ball Diamond Bur.
3. Then remove 0.5mm from the lingual surface, creating a
chamfer, using a Tapered Chamfer bur
4. Reduce interproximal areas initially using a Long Needle
Diamond bur, then finish using a Tapered Chamfer diamond
bur
-This leaves a preparation with a winged appearance. The
primary reason for wings, is to preserve tooth structure, and
its secondary effect is that it provides resistance to rotation
-A winged preparation is not essential, and can be removed by blending
the chamfer margin with the shoulder margin using a Tapered Chamfer
Bur.
5. Smooth sharp lines, corners and irregularities with a Finishing Diamond
Bur

Posterior Tooth Preparation

-Usually involves Maxillary Premolars and First Molars, and mandibular Second Premolars as these
are often visible
-Other posterior teeth may require MCC for appearance if patient wishes so too
-Occlusal full ceramic coverage- involves extensive tooth removal and threatens opposing teeth as
dental porcelain is 40x more abrasive than gold to tooth enamel
1. Take two initial Silicone putty indexes- for the provision of a temporary Crown after
preparation, and to use as a reference for how much tooth has been removed. If the existing
tooth contour is incorrect, an index can be made from diagnostic wax up
2. Using a Fissure Bur, carry out a 1.0mm occlusal reduction (if occlusal metal) or 1.5mm
occlusal reduction (if occlusal porcelain), using depth grooves as a guide to reduction.
Reduce groove depth if the tooth is not in occlusion
3. Reduce the functional cusps of the tooth by an additional 0.5mm, angled at 45 degrees,
producing the functional cusp bevel. This is essential to prevent thin casting and fracture of
the functional cusp of the Crown

20

4. Now remove 1.2mm of tooth from the facial surface, using a

Shoulder bur via a 2 planar
reduction to achieve adequate reduction and avoid pulp. This
involves creating two facial plane depth grooves- gingival and
occlusal, followed by smoothing.
-Facial reduction is carried around and stopped 1.0mm away
from the proximal contacts
-If bevelled shoulder (0.3mm using flame shaped diamond bur) is
chosen, a subgingival preparation would be needed to hide the
metal lining it
5. Using a Tapered Chamfer bur remove 0.5mm lingually/palatally
with 2 planar reduction,
leaving a chamfer margin
-Finishing line initially just above gingival level, and then finished
off to at gingival level or slightly below
6. Reduce interproximal areas initially using a Long Needle Diamond
bur, then finish using a Tapered Chamfer diamond bur
-This leaves a preparation with a winged appearance. The primary reason for wings, is to
preserve tooth structure, and its secondary effect is that it provides resistance to rotation
-A winged preparation is not essential, and can be removed by blending the chamfer margin
with the shoulder margin using a Tapered Chamfer Bur-Winged prep or blend in
7. Smooth sharp lines, corners and irregularities with a Finishing Diamond Bur

All Ceramic Crown

-Capable of producing best aesthetics of all Crowns
-More susceptible to fracture due to brittleness
-Make as long preparations as possible to give maximum support for
porcelain
-Overshortened preparations- stress concentrates in labiogingival areas
producing half-moon fractures
-Best suited for incisors, due to risk of fracture posteriorly
-Avoid in edge-to-edge occlusion
-Should not be used where opposing teeth occlude in the cervical fifth of
the lingual surface
1. Take two initial Silicone putty indexes- for the provision of a
temporary Crown after preparation, and to use as a reference for
how much tooth has been removed. If the existing tooth contour
is incorrect, an index can be made from diagnostic wax up
2. Using a Fissure Bur, carry out a 2.0mm occlusal reduction, using
depth grooves as a guide to reduction. Occlusal reduction is not

21

3.

4.
5.
6.
7.

necessary if there is already a minimum of 2mm occlusal space in ICP

-The reduction should be inclined linguogingivally to prevent shearing
Now remove 1.2mm of tooth from the facial surface, using a Shoulder bur via a 2 (or 3)
planar reduction to achieve adequate reduction and avoid pulp. This involves creating two
plane depth grooves- gingival and incisally, followed by smoothing.
Remove 1.0mm from the lingual concavity using a Rugby ball Diamond Bur.
Then remove 1.0mm from the lingual surface, creating a shoulder, using a Shoulder bur
Reduce interproximal areas initially using a Long Needle Diamond bur, then
finish using a Shoulder bur, merging the labial and lingual finish lines
Smooth sharp lines, corners and irregularities with a Finishing Diamond Bur

Resin Bonded Porcelain Crown

-Excellent aesthetics
-Relatively conservative of tooth tissue
-Strength comes largely from the resin bond rather than an underlying core of material
-Ideal for younger patients with large pulps
-May not be suitable for areas of high occlusal load and where there is parafunction due to thin
porcelain, and therefore reserved for anterior teeth
1. Take two initial Silicone putty indexes- for the provision of a temporary Crown after
preparation, and to use as a reference for how much tooth
has been removed.
2. Using a Fissure Bur, carry out a 2.0mm occlusal reduction,
using depth grooves as a guide to reduction. Occlusal
reduction is not necessary if there is already a minimum of
2mm occlusal space in ICP
3. Now remove 0.5mm of tooth from the facial surface, using a
Tapered Chamfer bur via a 2 (or 3) planar reduction to
achieve adequate reduction and avoid pulp. This involves
creating two plane depth grooves- gingival and incisally,
followed by smoothing and production of a chamfer.
4. Remove 0.5mm from the lingual concavity using a Rugby
ball Diamond Bur.
5. Then remove 0.5mm from the lingual surface, creating a
chamfer, using a Chamfer bur
6. Reduce interproximal areas initially using a Long Needle
Diamond bur, then finish using a Chamfer bur, merging the
labial and lingual finish lines
7. Smooth sharp lines, corners and irregularities with a Finishing Diamond Bur

22

High Strength Porcelain Crowns

-Have no metal substructure, however utilize high strength ceramics for robustness
-Usually used on posterior teeth
-Relatively destructive preparation
-Degree of taper is greater than for a traditionally cemented Crown
Posterior tooth preparation guideline:
1. Take an initial Silicone putty index- for the provision of a temporary Crown after
preparation, and to use as a reference for how much tooth has been removed.
2. Using a Shoulder bur, carry out a 2.0mm occlusal reduction using depth grooves as a guide
to reduction (reduce groove depth if the tooth is not in occlusion)
3. Reduce the functional cusps of the tooth by an additional 0.5mm,
angled at 45 degrees, producing the functional cusp bevel.
4. Now remove 0.8-1.0mm of tooth from the facial surface, using a
Shoulder bur via a 2 planar reduction to achieve adequate
reduction and avoid pulp. This involves creating two facial plane
depth grooves- gingival and occlusal, followed by smoothing.
-In this case, create a greater taper than traditional Crown preps
5. Using a Shoulder bur remove 0.8-1.0mm lingually/palatally with 2
planar reduction, leaving a shoulder margin
-Finishing line initially just above gingival level, and then finished
off to at gingival level or slightly below
-Can use a heavy chamfer, depending on company to produce
HSPC
6. Reduce interproximal areas initially using a Long Needle Diamond
bur, then finish using a Shoulder bur, merging the labial and
lingual finish lines
7. Smooth sharp lines, corners and irregularities with a Finishing
Diamond Bur

Composite Crowns
-Indications have not yet been fully researched
-Preparation is the same as for High Strength Porcelain Crowns

Trouble shooting
My preparation has ended up too tapered, what should I do?
-You could straighten the axial walls up by further preparing from the base, however this risks pulpal
health and is destructive. Another option is to add accessory retention features such as grooves and
boxes, however once again this is further destructive.
-The best option here may be to use a resin cement to aid retention
My preparation has ended up too short, what should I do?
-3mm is the minimum preparation height, disregarding other factors such as cement used, occlusal
loads, type of Crown.
-If the preparation has become too short for the clinical situation, you may consider adding
retention features such as grooves and boxes; once again this is further destructive.

23

-Consider the use of a Composite Resin Cement

-Consider Crown lengthening surgery, to extend the margins further down the tooth and therefore
increasing preparation height

24

Impressions xvii, xviii, xix

- The impression stage of the appointment is just as crucial as the tooth preparation stage, and any
flaws in the impression sent to the lab, has a potential to produce an ill-fitting Crown. Therefore it is
important to be able to produce well defined impressions, and identify where impressions need to
be retaken. Retaking impressions, is both time consuming, costly, and can be unpleasant for the
patient, and therefore the ability to consistently produce good impressions is important.
-At Liverpool University Dental Hospital, the One Stage Heavy and light impression technique is
utilized, using addition silicones. These silicones have excellent dimensional stability and are
thought to have relatively good handling characteristics.
Technique guidelines:
1) Choose an appropriately sized stock tray by trying in the patients mouth
-If the tray is under-extended, it can be adapted by the addition of a stiff material (i.e impression
compound)
-If the stock tray cannot be adapted, a special tray would be indicated
-Metal trays are preferable, because they are rigid and reduce the risk of distortions. Recoil is a
problem that occurs more commonly in plastic stock trays, whereby the walls of the tray flex
outward during occlusal pressure, followed by an inward flexion, producing impressions that are
undersized bucco-lingually
2) Retract the gingiva around the Crown preparation, so that the finish line can be recorded
accurately. The most common method is the two cord
technique, where a thin cord is wrapped around the tooth
and placed into the sulcus followed by a thick cord, which
is removed just before the impression is taken.
Sometimes, the cords are impregnated with solutions to
prevent haemorrhage i.e. adrenaline and ferric sulphat.
Other methods include:

-Electrosurgery- controlled tissue removal using an electric current through a tip

-Rotary curettage- involves removal of epithelial tissue within the sulcus using a diamond chamfer
bur
3) Block out large embrasures using ribbon wax, to prevent the impression locking into the
patients mouth
4) Dry the tray and apply adhesive evenly. Blow dry the adhesive lightly to encourage
evaporation of the adhesives solvent.
-This stage can be done before tooth preparation to allow solvent evaporation and production of a
good bond strength
5) Syringe the wash material (i.e. light bodied silicone) into the sulcus, and over the tooth
preparation
-Remember to remove the thick retraction cord beforehand
-Ensure there are no air bubbles or voids by ensuring the nozzle is not removed from a continuous
stream of material
-Work from the most difficult aspect of the tooth to access and around to the easiest
6) Load the tray with a heavy bodied addition silicone material (i.e. Express 2 Penta) and take
the impression
-This should be done before the light bodied silicone sets in the One stage technique

25

7) Use excess of material to monitor setting, and remove

once set
-Bear in mind the warmth of the mouth will encourage setting
faster than externally

26

Temporary restorations ii, iv, xx, xxi

-Temporary Crowns are made for the period of time between tooth preparation and fitting the final
restoration. The only scenario in which a temporary restoration would not be essential, is when
making a Resin bonded Crown where space maintenance and aesthetics are important, because
there is no or minimal dentinal exposure.
-The functions of temporary restorations are summarized below:
-Tooth vitality protection: Traditional Crown preparations expose thousands of dentinal tubules,
which can lead to sensitivity and pulp death. Therefore it is important to provide a protective
covering over these tubules in the interim.
-Prevention of tooth movement: Without the provision of a temporary Crown, there is a risk of
drifting and over-eruption of the teeth in the long term, therefore disturbing the existing occlusion
-Maintenance of function: Allows the patient to masticate and speak normally
-Aesthetics: Especially important in anterior teeth, where it is important for the patient to have an
acceptable appearance. However, a diagnostic wax-up or computer imaging may be sufficient in
some cases to show the final appearance.
-Diagnostic purpose: For the patient to assess function and appearance of a Crown before a
permanent Crown is cemented in place. This is especially important where there are plans to
change the existing aesthetics or occlusion (i.e. increasing OVD or changing guidance surfaces). In
cases where Crown lengthening has been planned, you should provide a temporary restoration for a
minimum of 6 months before a definitive restoration, to allow stabilisation of the periodontium.

Types of Temporary Crown

-There are a number of different methods to temporise a Crown preparation, and a major factor
influencing the choice of material is the length of time between tooth preparation and cementation
of the final Crown. Generally, a laboratory made temporary Crown will last longer than a chair side
Crown, and can be tailored to the patients needs aesthetically, however the additional cost of
manufacture needs to be balanced against the pros of doing so.
1) Preformed Crowns: Plastic (Opaque: polycarbonate or acrylic) or Metal
(aluminium, stainless steel or nickel chromium)
-Non-Custom: These come in a variety of different sizes and the dentist needs to
pick according to the most appropriate marginal, proximal and occlusal fit.
-Plastic preformed Crowns are indicated for anterior teeth and metal Crowns for
the posterior
-Colour matching is needed when choosing an opaque plastic Crown (i.e. Direct-aCrown), as the outer shell is retained, differing from a Strip Crown matrix (mentioned later).
1) Once a preformed Crown of appropriate size has been selected, the margins are adjusted for a
closer fit and a small hole placed incisally on the lingual/palatal surface for excess flow, using a high
speed bur.
2) The tooth prepared is coated with petroleum jelly and the Crown is filled with a material such as
Trim plus (polymethyl methacrylate/PMMA) or Integrity (chemical cured composite), and placed
over the preparation.
3) Excess is trimmed away from the margins during the gel phase of the material using a sharp
bladed instrument such as a carver
4) Remove the Crown and adjust occlusal surfaces and any excess using steel or tungsten carbide
burs and soflex discs
5) Fill the preparation impression area with a small amount of temporary cement material, and

27

position back on the preparation. Remove excess from the margins.

6) Once set, further adjust the Crown margins using steel or tungsten carbide burs and soflex discs
7) Check occlusion using articulating paper
-As these Crowns are not custom-fitted, it is likely that considerable adjustments will need to be
made. For long term temporisation, or multiple Crown cases, lab made preformed Crowns can be
requested and these are usually made in acrylic, or poly-methyl methacrylate.
Temporary cement materials:
-Temp bond commonly used, however may soften preparations with a composite core. If a
preparation is very retentive, a small amount of modifier can be added so removal is possible.
-Temp bond NE (non-eugenol) used where there is a composite core or a patient has a eugenol
allergy
-Zinc Polycarboxylate (i.e. Poly-F) Where preparations may be unretentive and there is a risk of the
temporary Crown falling off

2) Matrices: Impression Matrix, Vacuum Formed Matrix, Odus Pella/Strip Crowns

-A matrix is a mould made in the shape of existing teeth or from a diagnostic wax up, and is used to
help fabricate a temporary Crown.
-Impression matrix: a quick and easy way of producing a matrix, frequently involving the use a
polyvinysiloxane to take an impression of the teeth before tooth preparation. The matrix duplicates
the existing tooth form back onto the Crown preparation, utilizing a self-curing composite such as
Integrity.
-Vacuum Formed Matrix: Made of a clear vinyl sheet that is pulled over a
stone cast or
diagnostic wax up, duplicating the form of the existing dentition. Due to the
flexibility of the vinyl sheet, distortions may occur on seating. A benefit of this
type of matrix is that a light cured resin may be used, and set through the clear
material.
-Odus Pella/Strip Crowns: These are clear, Crown shaped matrices, made of
cellulose acetate, and
come in a variety of different sizes. The procedure for creating a temporary
restoration using Strip Crowns is the same as for Preformed Crowns, except the
clear outer shell is removed before adjusting and light cured composite may be
used.
-Procedure for using Impression and Vacuum Formed Matrices:
1) The prepared tooth and adjacent teeth are coated with a thin layer of petroleum jelly and the
matrix is filled with a material such as Trim plus (polymethyl methacrylate), Integrity (chemical cured
composite) or Light cured composite (if clear matrix) and placed over the preparation. Care is taken
to avoid air blows, and over/under filling the impressed area
2) Allow the material to set, or command set with light as necessary, and remove the matrix
3) A mould of the temporary Crown should now be formed, and trimmed with stainless steel or
tungsten carbide burs and soflex discs
4) Cement the temporary Crown in place with the temporary cement materials mentioned before
3) Direct Syringing
-This is used in situations where a pre-formed Crown or matrix cannot be made for any reason. A
polyethyl methacrylate such as Trim or Trim II is indicated in such cases because of its handling
properties and low exothermic reaction.

28

-As the name suggests, the material is syringed all around the tooth preparation from base to tip,
and later trimmed down to the correct shape in occlusion.
4) Lab made Temporary Crowns
- These are indicated if:
- The plan is to change a patients teeth aesthetically, and the patient needs a trial
- Occlusal changes are to be made i.e. increase a patients OVD
- Crown lengthening is to be done, and periodontal stability is needed before final cementation of a
permanent Crown
- Multiple restorations are to be done, as the occlusion can be controlled on an articulator
- There is any other reason for long term temporisation
- Heat cured or Self-Cured acrylic is usually used to manufacture the temporary Crowns, and these
materials are more durable than other materials
- There is an increased cost associated with lab made temporary Crowns, and an extra appointment
is needed, unless there is an on-site technician. If an extra appointment is needed, which is the case
in most situations, other methods of temporisation will be needed in the interim.
- Usually lab made temporary Crowns will simply need cementing in place with little or no change to
occlusion.
Temporary restorations for Resin Bonded Crowns
- If required, the following methods can be used to temporise a Resin Bonded Crown:
1) Seal and Protect or Duraphat- If aesthetics are acceptable after tooth preparation, apply a thin
layer to protect exposed dentinal tubules
2) Composite resin can be applied, with a small spot etched, either freehand or with a matrix. If
the sole reason for application is to prevent over eruption, a composite stop can be placed on the
opposing tooth only, and removed when required.
3) Lab made temporary if a long term solution is required
4) Conventional temporary restorations as those mentioned above, except use a cement such as a
Zinc Polycarboxylate (i.e. Poly-F)
5) Zinc Phosphate Cement- applied in a thin layer in areas where aesthetics is not crucial, and
movement of teeth are unlikely. There is a risk of pulpal damage due to the drop in pH after mixing.

29

Try in and Cementation xxii, xxiii

-This is usually the final stage in Crown provision, during which the final Crown is assessed, and
material is chosen for final cementation in place. It is important to note that once a Crown has been
cemented, removal for modification is impossible without damaging the Crown and/or tooth
preparation.
-A systematic approach in Crown assessment is important, so as not to miss any defects or potential
future problems. Prior to the try-in procedure, the temporary Crown (if provided) must be removed
and the preparation cleaned thoroughly from any temporary cement for example, by using an
ultrasonic scaler.

Try in procedure:
1) Check the Crown on the die
-Look for obvious defects, such as casting
blebs, which can be removed with a bur
-Check occlusion
-Look for any fitting surface defects, marginal
fit, aesthetics and articulation. Keep in mind
any faults that will appear in the mouth too.
-If there are obvious faults in the Crown,
where it is not related to impression defect,
then it may be necessary to get a lab to
remake the Crown

2) Place gauze in the back of the patients mouth, to prevent the patient swallowing
the Crown
3) Attempt to seat the Crown on the tooth preparation. If the Crown does not seat:
-Ensure the preparation is completely clean of any temporary cement material
-Check proximal contacts: if too tight> grind and polish
-Check for over-extended margins > adjust from the axial surface and not the base, using
soflex discs
-Check the internal fitting surface for burnished areas where the preparation has come in
contact with the Crown. Disclosing wax, aerosol spray or light bodied silicone placed in the
fitting surface can help with identification of imperfections, which can then be ground down
with a white stone
-If the Crown still doesnt fit, and no obvious impression defect can be found, a remake may
be needed

4) Assess the fully seated Crown:

-Proximal contacts: check with floss, if too tight> grind and polish, if open contacts> return
to lab or build up adjacent teeth
-Marginal fit (the gap between the Crown margin and tooth preparation margin): A poor
marginal fit could render a tooth more susceptible to cement dissolution, plaque retention
and secondary caries. Data suggests that a marginal gap of 100m is at the borderline of
acceptability for long term success. If there is an overhanging margin > adjust from the axial
surface until a probe can pass without catching. If there is a deficient margin > the Crown
may need to be remade
-Aesthetics: Check the shade and contours. ACC shades can be altered slightly by using
coloured luting cements if necessary. MCC contours can be altered by grinding with
diamond burs, and colour adjusted by staining and refiring in the lab.
-Occlusion: Assess by eye, patient feedback, articulating paper and shimstock. Patient

30

feedback can only be relied upon if anaesthetic has not been

given. Initially, check the Crown visually in ICP, using
shimstock foils passed through the teeth in occlusion. In ICP
a firm grasp is needed between posterior teeth, and the
amount of grasp with anterior teeth is dependent on existing
anterior grasp, so compare with other anterior teeth. The
patient should then tap lightly on coloured articulating paper
with a thickness of around 40m, highlighting any areas for
adjustment.
Occlusal adjustment can be done using high speed
diamond burs, after which polishing may be necessary
again. Care must be taken not to perforate the tooth,
and a Svensen gauge is useful for checking Crown
thickness. Once the Crown has been checked in ICP,
occlusion needs to be checked using articulating
paper in lateral and protrusive excursion, with
adjustment as necessary.

5) Finish and polishing this is particularly important with porcelain, because unpolished
porcelain can rapidly wear away opposing teeth.
-Metal Surface, polishing sequence: Finishing diamonds > Rubber abrasive points > Soflex
discs (interproximally) > Felt wheel or rubber cup with diamond polishing paste or zinc oxide
-Porcelain Surface, polishing sequence: Finishing diamonds > Soflex discs (interproximally) >
Rubber abrasive points > Felt wheel or rubber cup with diamond polishing paste
-Composite Surface, polishing sequence: Composite finishing diamonds > White Stones >
Soflex discs > Silicone enhancer > Diamond polishing paste

Cementation of the Crown

Choosing a cement
-There are a variety of different cements available for use, and they are categorized into 1.Luting
Cements and 2.Adhesive cements.
-Luting Cements: Achieve retention by wetting and micro-mechanical interlocking, of the fitting
surface of the Crown, which is often sandblasted for further retention.
-Adhesive Cements: Achieve retention by molecular adhesion between the tooth preparation and
fitting surface of the Crown.
-Currently, the four major classes of luting cement include: Zinc Phosphate, Polycarboxylate,
Conventional Glass Ionomer Cement and Resin Modified Glass Ionomer Cement.
-There is only one type of Adhesive cement and that is Composite Resin Cements.
-There are a number of clinical factors that need to be considered in the choice of cement and these
include: occlusal forces, aesthetic demands, ability to achieve moisture control, preparation
retention and margin location.
-The following table considers the properties and indications of various cements:

31

Cement type

Brand Names

Main Strengths

Main Weaknesses

Recommendations

Zinc Phosphate

-DEHP Zinc Phosphate

Cement
-DeTrey Zinc Phosphate
Cement (Dentsply)

-Long clinical history

-Resistant to water dissolution
-Good compressive strength++
-Good film thickness

-Occasional initial sensitivity

-Low tensile strength
-No adhesion
-Not resistant to acid
dissolution

Polycarboxylate

-Poly-F Plus Zinc

Polycarboxylate Cement
-DEHP Polycarboxylate
Cement
-DeTrey Zinc
Polycarboxylate Cement
-Ketac Cem
-Fuji 1

-Fluoride ion release

-Low post-op sensitivity
-Bonds to tooth and metal
-Good compressive strength+

-Low adhesion
-Low tensile strength
-Not resistant to acid
dissolution
-Difficult to obtain low film
thickness
-Occasional initial sensitivity
-Low tensile strength
-Not resistant to acid
dissolution
-Moisture sensitivity

-Use in Metal supported

restorations with mechanically
retentive preparations
-Contraindicated with most
Composite and All Ceramic
Crowns, because of lack of
adhesion
-Use in Metal supported
restorations with mechanically
retentive preparations
-Can be used in mechanically
unretentive temporary Crowns

-RelyX Luting Cement

-RelyX Luting Plus
Cement
-Fuji PLUS
-FujiCEM

-Fluoride ion release

-Adhesion to tooth and metal
-Good compressive strength++
-Easy to use

Conventional GIC

Resin Modified GIC

-Fluoride ion release

-Adhesion to tooth and metal
-Easy to use

32

-Cement expansion
-Moisture sensitivity

-Use in Metal supported

restorations with mechanically
retentive preparations
-Use in Crowns with
strengthened cores, and
where mechanically retentive
-Use where moisture control is
adequate
-Use in Metal supported
restorations with mechanically
retentive preparations
-Use in Ceramic Crowns with
strengthened cores, and
where mechanically retentive

Composite Resins
-Total Etch System

-Self-Etching Primer
System

-Self-Adhesive
Cement System

-Variolink II
-Calibra
-C&B Metabond
-RelyX Veneer Cement
-RelyX Arc
-Panavia F

-High compressive strength+++

-High tensile strength
-Excellent adhesion to tooth
and metal
-Good aesthetics
-Resistant to water and acid
dissolution
-Enhances strength of ceramic
restorations
-Low post op sensitivity

-Limited clinical history

-Variable film thickness
-Potential marginal leakage
due to curing shrinkage
-Difficulty cleaning excess
-Moisture sensitivity with total
etch systems

-Use in Dentine Bonded

Crowns, and conventional
Crowns where preparations
are unretentive

-RelyX Unicem Cement

-As a summary, a strong Crown with good retention can be luted with any cement, whereas weak restorations and those with poor retention must be
bonded with strong cements such as composite resins.
Cementing Procedure
1) Isolate the tooth, using dental dam (where possible) or cotton wool rolls. If the gingivae inhibit seating, retract using gingival retraction cords
2) Clean the tooth preparation, and dry, but do not desiccate
3) Mix the cement according to manufacturers instructions
4) Coat the entire fitting surface with a small layer of cement
5) Seat the Crown quickly, applying finger pressure, and maintain
6) Excess conventional cement should be removed after complete setting. Composite resin based cements should be removed at the gel phase of set,
as it can be difficult to remove later on. Gold margins should be burnished before the cement sets, as doing this afterwards can crack underlying
cement

33

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