Crown Preparation Design: An Evidence-Based Review

Jason W. Soukup, DVM

scheme derived from a classification system proposed for use

Summary: in veterinary clinical nutrition (Table 1).6 This scheme has also
Evidence-based clinical guidelines for full metal crown been applied to oral homecare products.1 In this classification
preparation design are seldom encountered in the veterinary scheme, grade I represents the evidence with the highest quality
literature. The veterinary literature regarding prosthodontic and is comprised of randomized, controlled clinical studies in the
treatment in companion animals is sparse and consists primarily target species. Grade IV represents the evidence with the lowest
of case reports and expert opinion based primarily on clinical quality and is comprised of evidence from textbooks, editorials,
experience. The goal of this manuscript is to present concepts proceedings, etc. Most available veterinary literature on crown
of evidence-based practice, review common recommendations preparation design in dogs would fall into grade III or IV.
on crown preparation design from the veterinary literature,
and to provide an assessment of the evidence for or against Common Clinical Recommendations and
those recommendations. J Vet Dent 30(4); 214-219, 2013 Associated Evidence for Veterinary Crown
Preparation Design
Recommendation #1 - A Convergence angle of 5-14 degrees
Introduction should be utilized to achieve acceptable retention/resistance
The problem was best articulated by Roudebush, Logan and form (Table 2 and Fig. 2).2,3,9-12
Hale1: “The prevailing system of veterinary medical education A recommendation that is perpetuated in the veterinary
and the practice of continued learning are not based on rigorous literature is that axial wall reduction should be performed in
assessment of evidence for or against particular management order to achieve parallelism. This recommendation appears
options, including many aspects of veterinary dentistry”. One to be based on very early human studies. In an in vitro study
such aspect of veterinary dentistry that has traditionally not been performed in 1955, it was shown that if a tensile force were
firmly rooted in evidence-based practice is prosthodontics; in applied, the amount of force required to separate a restoration
particular preparation design for the application of full metal cemented to a die with zinc phosphate luting cement would drop
crowns in dogs. Evidence based medicine is the incorporation as the convergence angle (CA) increased.13 This relationship was
of best research evidence, clinical expertise and patient values found to be hyperbolic with a precipitous drop in retention as the
(in veterinary medicine this is more appropriately referred to CA increased from 5° to 20° and a plateau in retention between
as client values) into the clinical decision making process. The 20° and 90°. These findings were confirmed in subsequent in
best clinical decisions are made when all three aspects are fully vitro studies. However, if the inner surface of the cast restoration
considered. The clinician must successfully incorporate research was etched (sandblasted) there was a 2-3-fold increase in the
evidence with his/her own clinical expertise and experience. amount of force required to separate the restoration from the die.
The ultimate decision will also be guided by the preferences, This latter finding has essentially been forgotten and, thus, has
concerns, and expectations of the client and the veterinarian’s not been factored into present recommendations on acceptable
obligation to respect the interest of the patient (health status, CA. Sandblasting the inner surface of a metal crown is common
prognosis, benefits and risks of each treatment option). When practice today and should be factored into the equation when
making diagnostic and treatment decisions, veterinarians should determining an acceptable CA.
strive to seek and apply information derived from systematic, In an in vitro investigation into the effect of CA on resistance
controlled clinical studies, with appropriate statistical analysis. form, dies were prepared that had a length of 3.5-mm, a diameter
of 10-mm, and varying CA between 10-22°.14 The ability of the
crown to resist shear forces was tested and it was found that the
Evidence Levels amount of force required to displace the crown decreased as
In order for a clinician to use solid evidence in the the CA increased, consistent with previous findings.13 However,
decision making process, he/she must have an appreciation the mean force required to displace the crown at a CA of 22°
for what constitutes best research evidence. Several methods (consistent with what is achievable in dogs12) was 1386 N. It
for evaluating research evidence have been presented.1,6-8 An has been shown that the amount of force a dog generates during
evidence pyramid is one such method (Fig. 1). The top of encouraged chewing behavior, primarily representing occlusal
the pyramid represents sources of the strongest evidence and stress at the restoration-cement-tooth interface, is in the range
includes randomized controlled clinical studies and systematic of 20-937 N.15 It has also been shown that the range of biting-
reviews. These are followed by sources of weaker evidence, such pulling force generated on canine teeth, primarily representing
as epidemiologic studies, models of disease, case series, case shear stress at the restoration-cement-tooth interface, by military
reports and textbooks (non-peer reviewed ideas and opinions). dogs is 180-1120 N.16 The forces dogs have been shown to
As one progresses up the pyramid, the amount of available generate in the referenced studies are lower than the forces
literature decreases. required to displace a crown on a tooth that has unfavorable
An alternative method for assessment of evidence is a physical characteristics.

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 Figure 1 Figure 2
Evidence Pyramid. This representation presents the levels Comparison of con-
of evidence in a semi-quantitative manner. The apex of the vergence angle (CA)
pyramid represents the most desirable (and least available) and taper. Taper (T)
evidence and the base represents the least desirable (and is the angle between
most available) evidence. one axial wall of
the preparation and
the long axis of the
preparation. CA (CA)
is the angle between
two opposing axial
walls of a preparation
and equals the sum
of the taper of two
opposing axial walls.

(From: Soukup JW, Snyder CJ, et al. Achievable CA

and the effect of preparation design on the clinical
outcome of full veneer crowns in dogs. J Vet Dent
2011; 28:72-82. Reprinted with permission.)

Table 2
(From: Evidence-based practice in the health sciences: Evidence-based nursing tutorial.
Commonly recommended axial wall inclinations (taper/
Information Services Department of Library of the Health Sciences-Chicago, University of
Illinois at Chicago. Available at http://ebp.lib.uic.edu/nursing/node/12. Accessed on June convergence angle [CA]) in veterinary dentistry.
26, 2012. Reprinted with permission.)
Veterinary Recommendation Reference Evidence
Source Provided Grade

Table 1 Reference # 2

CA = 6° None Grade IV
Textbook/expert opinion

Evidence Grades. Grade I is the most desirable evidence Reference # 9 Taper = 5-7° Human textbook Grade IV
and grade IV is the least desirable evidence. chapter Textbook/expert opinion,
studies in other species

Evidence Grade Evidence Guidelines Reference # 10 CA = 5-10° None Grade IV

Textbook/expert opinion
I Evidence obtained from at least 1 properly
randomized controlled clinical study that used the Reference # 3 CA = 10° None Grade IV
Textbook/expert opinion
treatment in the target species with animals that had
developed the disease/condition naturally Reference # 11 Taper = 6° None Grade IV
Textbook/expert opinion

II Evidence obtained from randomized controlled Reference # 12 CA < 25-30°; but N/A - Grade III – Clinical study
clinical studies conducted in a laboratory setting that dependent on height and original study
diameter of preparation
used the treatment in the target species with animals
that had developed the disease/condition naturally

III Evidence obtained from 1 or more of the following*: Only one veterinary study exists assessing CA in dogs and
• At least 1 properly designed clinical study without it suggested that parallelism was not as important to success
randomization
• Cohort or case-controlled analytic studies
as previously reported.12 The mean CA of clinically successful
• Studies that used acceptable models of disease crowns was 25.7°. It also showed that the necessary CA for a
or simulations in the target species successful outcome was not dictated solely by CA. It was also
• Case series dependent on other physical parameters of the preparation (i.e.
• Dramatic results from uncontrolled studies height and diameter of the tooth). Near parallelism can rarely
be achieved clinically (0-13% of the time)12,17-19 and achievable
IV Evidence obtained from 1 or more of the following:
• Opinions based on clinical experience (textbooks,
angles range from 16-27° in humans17-21 and 8-70° in dogs12.
monographs, or proceedings) In addition, most CA studies have focused on the CA
• Descriptive studies between the opposing axial walls of a preparation. By
• Studies conducted in other species implementing internal grooves, the “effective” CA can be
• Pathophysiologic justification decreased and, thus, improve the resistance/retention form
• Reports of expert committees
(Fig. 3).22,23 Parallel, vertical, 1-mm deep proximal grooves
*Data published in peer-reviewed journals is preferred. placed into a cast/die in vitro were tested and evaluated.22 These
grooves provided complete resistance to dislodgement in dies
with unfavorable preparation design properties (height of 3 to
4-mm and taper of 10-15°), whereas, without the grooves, the
same design failed to provide dislodgement resistance. Similar

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 Figure 3 Table 3
Internal grooves placed in a crown preparation with poor Commonly recommended minimum clinical height (mm) for
resistance/retention features (low height/diameter ratio and support of crown in veterinary dentistry.
high convergence angle [CA]). Note the wall of the internal
groove intersects with the path of rotation (red arrow) Veterinary Recommendation Reference Evidence
Source Provided Grade
reducing the “effective” CA of the preparation and prevents
dislodgement of the crown when an oblique occlusal force Reference # 9 3 to 4-mm Human textbook Grade IV
(black arrow) is delivered. chapter Textbook/expert
opinion, studies in
other species

Reference # 10 6 to 8-mm None Grade IV Textbook

/expert opinion

Reference # 11 4 to 6-mm None Grade IV Textbook

/expert opinion

Reference # 25 1/3 of clinical crown None Grade IV

Descriptive/case
report

Reference # 26 1/3 of clinical crown None Grade IV

should be available Textbook/expert
opinion

Reference # 12 H/D should be > 1.6 N/A – original study Grade III
Clinical study
H = height; D = diameter; CA = convergence angle

up to 25-30° may be clinically acceptable in dogs. However,

the recommendation for CA is dependent upon other physical
dimensions (height, diameter, surface area) of the preparation
(see below). There is also grade III and IV evidence that when
using resin-based cements even larger CAs are often clinically
acceptable.

Recommendation #2 - A Minimum 3 to 8-mm (or 1/3)

(From Blair FM, Wassell RW, et al. Crowns and other extra-coronal restorations: Clinical Crown Must Exist to Support a Full Metal Crown
preparations for full veneer crowns. Br Dent J 2002; 192:561-571. Reprinted with (Table 3):9-12,25,26
permission.)
Most veterinary references have historically made
recommendations that fail to consider the interdependency
axial wall grooves improved resistance to dislodgement over a of CA, tooth diameter, tooth height, and tooth surface area.
control group in dies prepared with extremely unfavorable design However, the human literature emphasizes this point. It
properties (H/D ratio near 0.25 and CA of 20°).23 has been shown that, for a given base diameter and CA, an
It is also important to note that the comparison 1955 study increase in height resulted in increased retention.27 Others
used a luting cement of zinc phosphate.13 Zinc phosphate cements have elaborated on the roles of height, base diameter, and
are no longer utilized due to their poor bonding properties CA in preventing restoration dislodgement (Fig. 4).14 For a
compared to more modern cements. The effect of various given tooth diameter and CA, preparation height is directly
cements (zinc phosphate, glass ionomer-based, resin-based) was proportional to dislodgement resistance. Conversely, for a
compared on the retention of crowns cemented onto dies with given height and diameter, CA is inversely proportional to
varying physical properties (height, diameter, CA).24 The amount dislodgement resistance.
of force required to dislodge a crown cemented onto a die with a A tailored guideline that considers all 3 physical
CA of 24° and a height of 4-mm was increased 3.5 times when properties for crown preparation in dogs has been provided.12
a resin-based cement was utilized instead of zinc phosphate. Each preparation has a unique H/D ratio and preparations
Even when a 70° CA was used, the force required to dislodge the with H/D ratios < 1.6 may be more likely to fail compared to
crown was 600 N. In a recent study, it was found that the use of those with H/D ratios > 1.6. This study also showed that there
resin-based cements allowed the use of high (up to 70°) CAs.12 is no minimum height necessary, per se. However, for a given
Therefore, the use of more modern materials must be taken into diameter, as the height decreases, a smaller CA becomes more
consideration when determining an acceptable CA. critical for resistance/retention form.
Summary: There is only grade IV evidence for the use of A preparation with higher surface area allows for a greater
a CA of 5-12°. There is grade III evidence that achieving the surface area for the formation of an adhesive bond between the
commonly recommended CA of 5-12° is very difficult and tooth and the crown cement. A direct correlation has been shown
rarely achieved. There is grade III evidence that suggests CAs between surface area and dislodgement resistance in an in vitro

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 Figure 4 Table 4
Figures depicting the relationship between height (H), Commonly recommended maximum crown height (length) in
diameter (D) and convergence angle (CA). (A) If, for a given veterinary dentistry.
D (10-mm), CA (10°), and H (3-mm), line AB is equal to or
longer than line AC, casting will dislodge. (B) If height is Veterinary Recommendation Reference Evidence
Source Provided Grade
increased to 4.2-mm, casting will not dislodge because of
interference with side BC. (C) If diameter is decreased to Reference # 9 < 2/3 of the original None Grade IV
6-mm, casting will not dislodge because of interference with crown length Textbook/expert opinion
side BC. (D) If CA is reduced to 5°, casting will not dislodge Reference # 10 < 2/3 of the original None Grade IV
because of interference with side BC. crown length Textbook/expert opinion
Reference # 26 Slightly shorter than None Grade IV
the lost crown Descriptive/case report
Reference # 12 H/D ratio < 1.6 N/A
original study Grade III – Clinical study

(see recommendation #4 below). An alternative method to

maximize crown height without the negative consequences to the
periodontium from a sub-gingival margin is to perform a crown
lengthening procedure.9
Summary: There is grade IV evidence for the recommendation
of a minimum crown height as reported in an absolute unit
(mm). There is grade III evidence that suggests crown heights
of less than 1/3 of the original height may lead to higher rates
of crown failure of the canine tooth in dogs. There is also grade
III evidence that crown treated teeth with H/D ratios < 1.6 may
have higher failure rates. It is accurate to note that retention and
resistance improves with increasing height of the preparation.
However, given the broad range of clinical tooth presentations
(Modified with permission from Weed RM, Baez RJ. A method for determining (breed, size, fracture versus non-vital tooth) a veterinary dentist
adequate resistance form of complete cast crown preparations. J Prosthet Dent 1984;
52:330-334.) may encounter, and in light of the interdependencies described
here, making the statement that a minimum height of 3 to 8-mm
study.27 The dislodgement resistance was evaluated for a tensile of clinical crown is required for adequate resistance/retention
load applied to a cast crown cemented to a machined aluminum may be misleading.
alloy die with zinc phosphate cement. The force required to
dislodge the crown from the die was directly correlated with the Recommendation #3 - Final Cast Crown Height Should Not
surface area. It has been suggested that this relationship is also Exceed 2/3 the Original Crown Length (Table 4):9,10,12,25
true in dogs.a In an in vivo study, the surface area of clinically This recommendation has been made in order to take the
prepared dies for canine teeth in dogs was measured with a tooth out of occlusion and thus reduce the forces placed upon
3-D scanner. The surface area was recorded and compared to the restoration. It is argued that doing so would decrease the
the clinical outcome (dislodgement, no dislodgement, crown chance of clinical failure (crown dislodgement, crown fracture).
fracture) of the crown. It was shown that the lower the surface However, there does not appear to be an evidence-based origin
area, the more likely the crown was to be dislodged (poor for this recommendation. A literature search revealed only one
resistance/retention form). study that comments on any association between tooth height and
A preparation’s surface area is largely dictated by the the clinical outcome. Another study failed to show any positive
physical dimensions of the preparation (height, diameter, CA). association between increasing height and crown dislodgement.12
However, these physical dimensions do not necessarily restrict In fact, the opposite association was found to exist. A crown
the surface area available for cement contact. Internal features was more likely to be dislodged when the H/D ratio was < 1.6.
(grooves, boxes, etc.) may be placed into the preparation to However, the study also revealed that preparations with H/D
increase a preparation’s surface area.22,23 In addition to altering ratios > 1.8 may be more likely to fracture.
the effective CA, as described above, this technique also increases Considering height alone to evaluate possible future clinical
the available surface area for adhesive bonding of the cement. outcome has been shown to be oversimplified. All physical
Although not recommended by this author, another method parameters of a preparation play a role in the clinical outcome
of increasing height, and thus surface area, is to place the margin and the clinician must consider the interplay between those
subgingivally.28,29 The decision to place a margin subgingivally parameters when making preparation design decisions. a,12,14,30,31
must be considered carefully. The potential quantitative benefit Summary: There is grade IV evidence for the recommendation
of an increase in retention and resistance form must be weighed that a final cast crown height > 2/3 the original crown height
against the potential negative consequences to periodontal health may lead to clinical failure. On the contrary, there is grade

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 Table 5
Common recommendations regarding the placement of the crown margin in veterinary dentistry.

Veterinary Source Recommendation Reference Provided Evidence Grade

Reference #9 Studies…report increases in gingival inflammation Larato DC. Effect of cervical Grade IV – Textbook/expert opinion,
and periodontitis in areas of sub-gingival restorative materials margins on gingiva. studies in other species
J Calif Dent Assoc 1969; 45:19.
Sub-gingival margin should only be used in specific cases Loe H. Reactions of marginal periodontal
where good oral hygiene will be practiced tissues to restorative procedures.
Int Dent J 1968; 18:759.

Reference #11 Margin placement [should be] 1-2 mm coronal

to the free gingival margin None Grade IV – Textbook/expert opinion

Reference #26 [Margin] should be seated 1-2 mm above the gingival margin None Grade IV – Textbook/expert opinion

III and grade IV evidence that taller preparation heights aid patients with subgingival margins in that only slightly > 50 %
in resistance/retention form and generally improve clinical of the original subgingival margins remained subgingival at
success. However, there is grade III evidence that suggests the end of the study.33,34 In contrast, one human study showed
preparations with H/D ratios > 1.8 may have higher crown that a slightly subgingival margin did not have a significant
fracture rates. deleterious effect on the gingiva.44 However, an intensive
hygiene program directed by professionals was required to
Recommendation #4 – The crown margin should be placed achieve these results. The reality in veterinary patients is
supragingivally (Table 5):9,11,26 that hygiene is moderate at best and the same positive results
Most veterinary references recommend a supragingival should not be expected.
margin, except when otherwise dictated by esthetics or the Summary: There is grade III and IV evidence supporting
need for increased height for improved retention/resistance the recommendation that a crown preparation margin should
form. This recommendation appears to be firmly based on be placed supragingivally whenever possible in order to
clear evidence in both dogs and humans. Subgingival margins preserve the health of the periodontium.
are associated with increased plaque accumulation32, gingival
inflammation33-38, deep pocket formation33,34,37,39, attachment Conclusions
loss33,34, and gingival recession40. The best evidence available shows that retention and
The clinical and histologic consequences of both resistance form generally increases with a lower CA. Also,
subgingival and supragingival crown margins to normal the larger the H/D ratio, the better the retention and resistance
control teeth has been compared in adult dogs.28 The study form. However, CA, tooth height, tooth diameter, and tooth
reported increased clinical gingivitis and higher degrees of surface area are inherently interdependent. This intimate
histologic inflammatory changes associated with subgingival relationship, along with the morphology of the canine tooth
margins. There was a direct relationship between the depth in the dog and the use of axial grooves generally allows
of margin within the sulcus and the degree of inflammation. for larger CAs than have historically been considered ideal.
The deeper the margin within the sulcus, the more pronounced In addition, the best evidence shows that H/D ratio can be
the inflammation. In addition, gingival recession was seen used as a reliable method for a clinical assessment of future
with subgingival margins. Degree of gingivitis and histologic adhesive/cohesive failure and tooth fracture. Although minor
evidence of inflammation for supragingival finishes were increases in retention and resistance form may be gained with
minimal and consistent with the normal control teeth. subgingival preparations, the best evidence suggests that this
Placing the margin in the subgingival space increases practice is not usually necessary and the gains in retention and
the likelihood of compromising biologic width.41 Two studies resistance form are minimal when compared to the potential
in beagle dogs have demonstrated the negative periodontal deleterious effects on the periodontium.
consequences of compromising biologic width. Restorative Evidence-based recommendations regarding veterinary
margins at the alveolar crest were associated with 5-mm of crown therapy are limited. However, given the recent interest
alveolar bone resorption.42 Margins placed 4-mm coronal in the practice of evidence-based medicine, the paucity of
to the alveolar crest caused minimal resorption. In addition, prosthodontics research in veterinary dentistry will likely
significant gingival recession and bone loss compared to improve. In the meantime, this review should serve to guide
a control (3.16 and 1.17-mm versus 0.5 and 0.15-mm, veterinary dentists in designing a crown preparation with
respectively) occurred in class V restorations with the apical features that both increase resistance and retention form and
extent at the alveolar crest.43 avoid deleterious effects on periodontal health.
The human literature supporting this recommendation is ___________________________________________________
much more abundant. One important 10-year longitudinal a
Riehl JR, Soukup JW. (2012). The effect of surface area on the clinical
study revealed that gingival recession was common among outcome of full veneer crowns of the canine teeth in dogs. Unpublished data.

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