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Planning and Making
Crowns and
Bridges
Fourth Edition

Bernard GN Smith
Leslie C Howe
Planning and making
crowns and bridges
Planning and
making crowns
and bridges

Fourth Edition

Bernard G N Smith
BDS, PhD, MSc, MRD, FDSRCSEng, FDSRCSEdin

Professor Emeritus of Conservative Dentistry

Guy’s, Kings and St Thomas’ Dental Institute, London

Leslie C Howe
BDS FDSRCSEng

Consultant in Restorative Dentistry

Guy’s and St Thomas’ NHS Hospitals Trust
and Private Practitioner
© 1986, 1990, 1998 Bernard GN Smith, 2007 Bernard GN Smith and Leslie C Howe

Fourth edition published in the United Kingdom in 2007 by

Informa Healthcare
4 Park Square
Milton Park
Abingdon, Oxon OX14 4RN, UK

Informa Healthcare is a trading division of Informa UK Ltd.

Registered Office: 37/41 Mortimer Street, London W1T 3JH.
Registered in England and Wales number 1072954.

Tel: +44 (0)20 7017 6000

Fax: +44 (0)20 7017 6336
E-mail: [email protected]
Website: www.informahealthcare.com

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form
or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the publisher
or in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of any licence
permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 0LP.

The Authors have asserted their rights under the Copyright, Designs and Patents Act 1988 to be identified as the Authors of
this Work.

A CIP record for this book is available from the British Library.

Library of Congress Cataloging-in-Publication Data

Data available on application

ISBN-10: 0 415 39850 9

ISBN-13: 978 0 415 39850 3

Distributed in the United States and Canada by

Thieme New York
333 Seventh Avenue
New York, NY 10001, USA

Distributed in the rest of the world by

Thomson Publishing Services
Cheriton House
North Way
Andover, Hampshire SP10 5BE, UK

Composition by Scribe Design Ltd, Ashford, Kent, UK

Printed and bound in
Contents
Preface vii

Acknowledgements ix

Part 1 Crowns

1 Indications and contraindications for crowns 3

2 Types of crown 29

3 Designing crown preparations 53

4 Occlusal considerations 77

5 Planning and making crowns 105

6 Clinical techniques for making crowns 123

Part 2 Bridges

7 Indications for bridges compared with partial dentures

and implant-retained prostheses 177

8 Types of bridge 197

9 Components of bridges: retainers, pontics and

connectors 211

10 Designing and planning bridges 225

11 Clinical techniques for bridge construction 241

Part 3 Implants, splints and maintenance

12 Dental implants 261

13 Fixed splints 287

14 Crown and bridge failures and repairs 297

Index 319
 Preface
The aim of this book is to answer at least as many Undergraduate and postgraduate students need
of the questions beginning with ‘why’ as those also to take advantage of their own and others’
that begin with ‘how’. A textbook is not the ideal clinical experience and learn by thinking about
medium for teaching practical, clinical or techni- their clinical problems and talking about them
cal procedures. These are best learnt at the chair- with others. Making the right decision is as impor-
side and in the laboratory. However, the mass of tant as executing the treatment well.
material which must be learnt, usually in a There is no reference to ‘case selection’ or
restricted timetable, in the clinic and laboratory ‘patient selection’ for the techniques described.
means that there is often insufficient time to That is not the way things are in practice. There
answer the questions, ‘Why am I doing this?’ or, it is necessary to select the appropriate technique
‘When should I not do this?’ or even, ‘What on for the patient in front of you rather than select
earth can I do here?’. the patient for the technique. Things are different
The book is meant for clinicians, both under- in dental schools. It often happens that in order
graduate and postgraduate, and so although the to provide a balanced range of experience for
emphasis is on treatment planning, crown and undergraduate students in a limited period of
bridge design and the related theory, clinical time, patients are selected to go on to particular
techniques are also described in some detail. waiting lists to provide a flow of ‘clinical material’
Laboratory technique is, though, almost com- for the students’ needs. This may be necessary
pletely omitted, both to keep the book to but the attitudes it sometimes develops are
manageable proportions and because most clini- unfortunate. The essential feature of any profes-
cians no longer undertake this themselves. It is sion is that it attempts to solve the problems of
nevertheless abundantly clear that a good stan- its clients before concerning itself with its own
dard of laboratory work is as important as the welfare.
other phases in the construction of crowns, Because this is the approach, clinical photo-
bridges and implants. graphs or at least photographs of extracted teeth
The process may be divided into three stages: or casts, are used to illustrate the text in prefer-
ence to line drawings, except where a photograph
Initial decision making and mouth preparation is impractical. Photographs are used even when
Clinical procedures the work shown is not ‘perfect’. No apology is
Technical procedures. made for this. In reality, although we should strive
for perfection (if we know what perfection is in
The purpose of this book is to help quite a lot a given case, and we often do not), we will
with the first stage, rather less with the second frequently not achieve it. It is more realistic to
(a book cannot replace clinical experience) and talk about levels of acceptability. This is not to
hardly at all with the third. advocate unnecessary compromise, but to recog-
The intention is to help solve real clinical nise that in many situations a compromise (from
problems. The student sitting in a technique knowledge, not ignorance) is necessary. After all,
laboratory faced with an arch of intact perfectly the ideal would be to prevent caries, trauma and
formed natural or artificial teeth planning to congenital deformity so that crowns and bridges
undertake ‘ideal’ crown preparations will find were not necessary in the first place. Once they
little help here. It may be good initial teaching to are needed there is already a situation that is less
cut ‘classic’ preparations, but this is only part of than perfect.
the training towards solving the real problems of Some of the work photographed is the authors’,
real patients in the real world. The opinions some is undergraduate and postgraduate student
expressed in a textbook can only go a little way work with a greater or lesser amount of help by
further towards solving these problems. teachers, some of the technical work is carried out
viii Preface

by the clinicians themselves but most by techni- the new Chapter 12 on implants. Much more
cians or student technicians, and some illustrations attention is given to implants than in previous
have been kindly lent by colleagues. In view of the editions. Modern implants had only recently been
likelihood, and indeed the intention that readers introduced into the UK when the first edition was
will find fault with some of the illustrations and published. The purpose is to help dentists to
because some illustrate the work of a team rather advise patients in their choice of what to do when
than an individual, no acknowledgement is given teeth are missing. It is also to inform dentists
for individual illustrations. We are, however, about details of implant treatment so that they
extremely grateful to all those who have allowed can explain to patients what to expect and help
us to photograph their work and in particular to them to make informed choices.
those who have lent their own illustrations. Their Chapter 12 is not sufficient to guide dentists in
names appear in the Acknowledgements. starting to place implant-retained restorations
There are no text references. In a book of this themselves. Much more training is needed before
size, which is not intended to be a reference that can be done. A comparison can be made
book, it is not possible to be comprehensive, with referral for orthodontic treatment which,
while it is impolite to use phrases such as ‘there like implants, most dentists do not offer but they
is evidence that . . .’ without making proper refer- do need to know who and when to refer and to
ence to the source of the evidence. Isolated be able to answer patients’ questions.
references in these cases could well lead the Much of the material in earlier editions has
enthusiastic student into an unbalanced reading been omitted as being out-of-date; however,
programme. The further reading suggestions some restorations which are no longer made but
which were in previous editions have been which a significant number of patients continue to
omitted as they so quickly became out-of-date in wear satisfactorily are still included so that
this fast-developing field and because computer dentists can recognise them and know something
access to the literature is now very easy. about their maintenance and repair.
Leslie Howe has joined Bernard Smith as a joint Because of these deletions, many illustrations
author for the fourth edition. His influence can have been left out but even more have been
be seen throughout the book and particularly in added.

BGNS
LCH
 Acknowledgements
The following have lent photographs but for Evelyn Sheehy; Michael Thomas; Sachim Varma;
reasons explained in the preface, specific credit is John Walter; Katherine Warren; Tim Watson.
not given to each one. We are, however, Other help with illustrations has been given by:
extremely grateful to them for their generosity: Ruth Allen; Osama Atta; Dennis Bailey; Trevor
Chris Allen; David Bartlett; Nicholas Capp; John Brooker; Peter Chittenden; Cottrell and Co.,
Cardwell; Russell Greenwood; George London; Usha Desai; Andrew Dyer; Terence
Kantorowicz; Bernard Keiser; Frances Manochi; Freeman; Richard Hamill; June Hodgkin; Orodent
Orthomax Limited, Bradford; Richard Palmer; Limited, Windsor; Peter Pilecki; Peter Rhind; Bill
David Parr; Ian Potter; John Richards; David Sharpling; Nicholas Taylor; Leslie Wilcox;
Ricketts; Paul Robinson; Saridatum Abdul Samal; Geraldine Williams.
Part 1 Crowns
1 Indications and
contraindications
for crowns
Before the introduction of techniques to bond the enamel–dentine junction and balloons out in
restorative materials to teeth, crowns were the dentine towards the pulp. The growth of the
only way of restoring teeth that can now be carious lesion is much faster in dentine than it is
restored by these other techniques. At the same in enamel, so the enamel becomes undermined
time, more patients are keeping more of their teeth and then suddenly collapses into the cavity.
for longer and are expecting faulty teeth to be (Because of this, our forefathers thought that
repaired rather than extracted. Therefore, although caries started inside the tooth and worked its
there are fewer indications for crowning teeth than way to the surface.) Today, many carious lesions
there were, more teeth are actually being crowned are detected and treated at an early stage while
than ever before. About two million crowns per the enamel is still largely intact. Indeed, even
year are made in the UK National Health Service, more lesions are prevented from occurring at all.
representing two to three crowns per week per Since caries produces most of its damage inside
dentist. In the latest (1998) Adult Dental Health the tooth rather than on the surface, the common-
Survey in the UK, a third of all dentate adults had est types of restoration are fillings (intracoronal
at least one crown and nearly half the 45–54 age restorations). Often, sound enamel has to be cut
group had one or more crowns. Similar numbers away to give access to the caries. Only very rarely
of crowns are being made in many other countries. is the surface of a tooth extensively destroyed by
So, a lot of crowns are still being made. caries leaving a base of sound dentine, and it is
When the only choice for a tooth was a crown therefore most unusual in the treatment of primary
or extraction, the decision was relatively simple. caries for a crown (an extracoronal restoration) to
Now, with more options it is more difficult. This be made on a preparation consisting of intact
chapter discusses the current indications for dentine. When secondary caries develops around
crowns and their alternatives, and guides the reader existing fillings, intracoronal restorations are still
towards a decision. However, clinical decision more conservative and more closely relate to the
making is the very substance of the dentist’s work pattern of development of caries than crowns, and
and cannot be done by textbook instructions: do are therefore preferred whenever possible. Indeed,
not expect a set of clear rules to follow. Each set a high caries rate is a contraindication to crowns.
of clinical judgements and decisions must be unique, In these cases the caries should be removed, the
taken in the context of the patient’s circumstances. tooth stabilized and a preventive regime instituted
before crowns are made.
With larger lesions and particularly when cusps
General indications and are lost, the decision between filling and crowning
a tooth becomes more difficult (see pages 20–25).
contraindications for crowns

Crowns versus fillings in the General indications for crowns for

treatment of caries other reasons
Most dental restorations are provided as treat- Having established that primary caries is not a
ment for dental caries. Once the initial lesion has common reason for making crowns, more
penetrated the enamel, the caries spreads along common reasons are:
3
4 Indications and contraindications for crowns

Figure 1.1

General indications for crowns.

a This mouth has been well treated in the past but the
restorations are now failing. In particular the lateral
incisor has lost two fillings, the pulp has died and the
tooth is discoloured. It now needs a crown (Figure
2.1k).

b Trauma: the result of a blow from a hockey stick.

Two incisors have been lost and the upper right central
incisor is fractured, exposing the pulp, the fracture line
extending subgingivally on the palatal side. The lateral
incisor is fractured involving enamel and dentine only.
The pulp retained its vitality. Although it could be
restored in other ways, a crown would be the most
satisfactory solution since it would then match the
other anterior restorations. If the central incisor is to
be retained, it will need to be root-filled and crowned,
probably as a bridge abutment (see later).

c Gross tooth wear arising from a combination of

erosion and attrition. This has passed the point where
the patient can accept the appearance, and crowns are
necessary.

d Peg-shaped upper lateral incisors.

e A moderate degree of amelogenesis imperfecta

(defects in the formation of enamel) in a 16 year old.
The posterior teeth are affected more than the
anterior teeth but the upper incisors are slightly
discoloured and are chipping away at the incisal edge.
Crowns were made for all the teeth except the lower
incisors and these will be kept under review.
Indications and contraindications for crowns 5

f Dentinogenesis imperfecta (a defect in the formation

of dentine) in a teenage patient. The incisor teeth have
been protected with acid-etch-retained composite from
shortly after their eruption and the first molar teeth
have been protected with stainless-steel crowns. It is
now time to make permanent crowns for all the
remaining teeth.

g Typical distribution of enamel hypoplasia, in this case

due to typhoid in the patient’s early childhood. Crowns
were made rather than composite restorations or
veneers because the stain was too dark to be disguised
by these means.

• Badly broken-down teeth lost dentine will often need to be replaced by a

• Primary trauma suitable core of restorative material sometimes
• Tooth wear following endodontic treatment (Figure 1.1a).
• Hypoplastic conditions
• To alter the shape, size or inclination of teeth
• To alter the occlusion
Primary trauma
• As part of another restoration
• Combined indications An otherwise intact tooth may have a large
• Multiple crowns fragment broken off without damaging the pulp
• Appearance. and leaving sufficient dentine to support a crown:
see the upper right lateral incisor in Figure 1.1b.
If this was the only tooth damaged then a directly
Badly broken-down teeth placed composite restoration bonded to the
remaining tooth structure would usually be the
Extensive composite or amalgam fillings bonded initial treatment, progressing to a crown if the
to the remaining tooth structure or retained by direct restoration was inadequate or failed.
other means have the advantage of being directly
placed, are conservative of tooth structure and
do not involve laboratory procedures. However,
Tooth wear
when very large, involving most of the occlusal
surface, such restorations are rarely able to The processes of erosion (damage from acid
produce an acceptable occlusal and proximal other than that produced by bacteria), attrition
contour and have an unpredictable long-term (mechanical wear of one tooth against another)
durability and so a crown may be the treatment and abrasion (mechanical wear by extraneous
of choice. agents) occur in all patients. What is remarkable
Usually these teeth will have been restored is that teeth, which have little capacity for regen-
previously, and may have suffered secondary eration and which are in constant use, do not
caries or parts of the tooth or restoration may wear out long before the patient dies. Although
have broken off. Before crowns can be made the tooth wear is normal, if it is excessive or occurs
6 Indications and contraindications for crowns

Figure 1.2

Changing the shape and size of teeth.

a and b Increasing the size of incisors with composite:

a before, b after.

c A large midline diastema that the patient found

aesthetically unacceptable.

d The same patient after the central incisors have been

moved closer together orthodontically and all four
incisors crowned. The patient must be warned of any
compromise in the appearance that is anticipated – in
this case the triangular space that remains at the
midline. It is possible to increase the width of the incisal
edges to fill the space, but the width of the crowns at
the neck is determined by the width of the roots, so
that only minimal enlargement is possible without
creating uncleansable overhanging crown margins. It is
unlikely that a long-term acceptable result could have
been achieved with composite in view of the size of
the gap.

early in life, crowns or other restorations may be patient complains of the appearance, sensitivity
needed (Figure 1.1c). (which does not respond to other treatment),
The lifelong management of excessive tooth function is affected, or the wear reaches a
wear is a topic of increasing interest as patients point where restorations will become techni-
keep their teeth longer. In general the approach cally difficult.
should be: • At this point provide minimal restorations,
normally directly bonded composite restora-
• Early diagnosis and prevention. tions.
• Monitoring any further progression until the • If the problem continues, provide crowns.
Indications and contraindications for crowns 7

Figure 1.3

An attractive appearance spoiled by unsightly teeth.

Hypoplastic conditions is very destructive of tooth tissue and composite

or veneers should always be attempted first
These are divided into congenital and acquired
before irreversibly preparing the teeth for crowns.
defects. Examples of congenital defects are
hypodontia (small teeth – see the peg-shaped
lateral incisors in Figure 1.1d), amelogenesis
imperfecta (Figure 1.1e) and dentinogenesis To alter the occlusion
imperfecta (Figure 1.1f). Examples of acquired
defects are fluorosis, tetracycline stain and enamel Crowns may be used to alter the angulation or
hypoplasia resulting from a major metabolic occlusal relationships of anterior and posterior
disturbance (usually a childhood illness) at the age teeth as part of an occlusal reconstruction either
when the enamel was developing (Figure 1.1g). to solve an occlusal problem or to improve
function (see Chapter 4).

To alter the shape, size or inclination of

teeth As part of another restoration
Major changes in the position of teeth can be Crowns are made to support bridges and as
made only by orthodontic treatment, although components of fixed splints. They are also made
minor changes in appearance can be achieved by to alter the alignment of teeth to produce guide
building up the tooth with composite or by planes for partial dentures or to carry precision
composite or porcelain veneers (see pages attachments for precision attachment retained
13–20). For example, a diastema between teeth partial dentures (see Parts 2 and 3).
which the patient finds unattractive can be closed
or reduced by means of additions of composite or
veneers following orthodontic treatment (Figure
Combined indications
1.2a and b). However, when the space is large,
oversized crowns will produce a durable and More than one of these indications may be
attractive result (Figure 1.2c and d). This approach present, so that, for example, a broken-down
8 Indications and contraindications for crowns

Figure 1.4

The appearance of composite restorations.

a Following trauma the right central incisor tooth

requires root canal treatment.

b The appearance of the tooth has been restored by

internal bleaching and a composite repair to the mesial
corner.

c The central incisors were fractured in a riding

accident 8 years earlier. Composite restorations were
placed by the patient’s mother and then replaced by
another dentist and again at a dental school. These
restorations have been in place for 3 years and are
discolouring again. The patient was 21 and refused
further composites and crowns were made.

d Composite restorations at the necks of all the

incisor teeth. They have been present for 18 months
and are maintaining their appearance.

posterior tooth that is over-erupted and tilted Multiple crowns

may be crowned as a repair and at the same time
to alter its occlusal relationships and its inclina- With some of these indications, notably tooth
tion, providing a guide plane and rest seat for a wear and hypoplastic conditions, many or all of
partial denture. the teeth may need to be crowned.
Indications and contraindications for crowns 9

Figure 1.5

The central incisor has a necrotic pulp and is grossly

discoloured. This degree of discoloration could not be
resolved by bleaching or veneering the tooth. The
periodontal condition must be improved before a
crown can be made successfully.

Appearance relief and prevention of pain and infection it is

probably the next most important reason for
One of the principal reasons for patients seeking
providing dental treatment.
dental treatment is to maintain or improve their
appearance. Relative prosperity, changing social
attitudes and the success of modern dental
materials mean that expectations of good dental Function
appearance are rising. Fewer teeth are being It is possible to eat and speak without any teeth,
extracted, and when they are it is at a later age. or with complete dentures, but most patients
It is much less common now to see a mouth such (and probably all dentists) do not want to. As
as that shown in Figure 1.3) than it was in the with appearance, this is a question of the quality
mid-1960s, when this photograph was taken. As of life. An occluding set of natural, or second
standards of appearance and expectations rise, best, restored teeth is better at coping with a full
some dental defects or types of restoration, varied range of diet than dentures.
which at one time would have been tolerated, are
no longer acceptable to patients.
Much more can now be done to improve
Mechanical problems
appearance with the current range of composite
materials than was the case a few years ago. Sometimes, although it would be possible to
Composite has the advantage of being more restore a tooth by means of a filling, the pattern
adaptable than porcelain. It is applied, shaped and of damage to the tooth gives rise to anxieties
polished at the chair-side and later it can be about the retention of the restoration, the
repaired and resurfaced (Figure 1.4). This means strength of the remaining tooth tissue, or the
that crowns are now less often indicated to strength of the restorative material. The degree
improve appearance. to which a crown strengthens the remaining
Many patients simply wish to lighten the colour tooth structure compared to a bonded intra-
of their teeth, which may have darkened with age coronal restoration is not clear. Usually, however
or from smoking. If the teeth are substantially much damage there is, some sound tooth tissue
sound and their position and shape are accept- needs to be removed to prepare the tooth for a
able to the patient, a significant improvement can crown (see Figure 1.12).
be made by thorough cleaning and external Fillings fail because they fall out, because of
bleaching (see Figure 1.7). However, sometimes secondary caries, or because part of the tooth or
the discolouration is so intense that bleaching part of the restoration fractures. These failures
alone will not provide a satisfactory result (Figure are upsetting to the patient and embarrassing to
1.5). Initial bleaching to lighten the tooth as much the dentist, and it is therefore tempting to
as possible helps because the crown then does prescribe crowns when there is even a small
not have to disguise too dark a preparation. possibility that one of these problems will arise.
Appearance is important to the patient and is However, crowns can also fail. If a filling fails,
therefore important to the dentist. After the it is often possible to make a more extensive
10 Indications and contraindications for crowns

Figure 1.6

Tetracycline stain.

a Mild, uniform staining. It is unlikely that treatment

will be necessary other than to replace the missing
lateral incisors.

b Tetracycline staining with severe banding. The extent

of treatment depends on the lip line. In this case the
lower lip covered the gingival half of the lower incisors,
and therefore treatment for the lower teeth was not
necessary.

c Darker but more uniform tetracycline staining. In this

case a vital bleaching technique was used.

d Extreme tetracycline staining with banding.

e Darkly stained teeth with four teeth, the upper and

lower left premolars, prepared for crowns.
Indications and contraindications for crowns 11

restoration or a crown. If a crown fails, a further fying the cause and eliminating it as early as poss-
crown may not be possible and extraction may ible. Crowns should be made only when the cause
be all that is left. of the tooth wear cannot be identified or cannot
In deciding between a crown and a filling there be eliminated, and the damage is serious.
are two considerations to be weighed up. First, Sometimes the rate of tooth wear slows down or
how real is the risk of mechanical failure of the stops with no obvious explanation and the teeth
filling or surrounding tooth and what can be done remain stable for some years. Crowns are not a
to minimize this risk? Second, how much more good preventive measure except as a last resort.
destruction of sound tooth tissue is necessary to
make a crown?
In general, it is better to take the more conser-
vative approach first, even if this involves some Hypoplastic conditions
risk of the restoration failing. The alternative is to
provide far more crowns than are strictly neces- In many of the hypoplastic conditions the patient
sary and perhaps give rise to even greater (or parents) will seek treatment at an early age,
problems for the patient later on. often as soon as the permanent teeth erupt, and
treatment may be carried out in conjunction with
orthodontic treatment. In some of these cases
large numbers of teeth are affected, and so the
Indications for anterior crowns decision whether to crown them, offer some
alternative form of treatment, or simply leave the
Caries and trauma condition alone, is a fairly momentous one. Figure
1.6 shows several cases of tetracycline staining
All the general indications listed above may apply affecting many teeth. Differences in the lip
to anterior crowns. Before the days of acid-etch morphology, the depth of uniformity of the
retained composite restorations and composite colour, and the patient’s age and general attitude
and porcelain veneers, anterior crowns were will all influence the decision.
indicated much more frequently for the restora- Unfortunately tetracycline stain often does not
tion of carious or fractured incisors. Today many respond well to bleaching, particularly when the
of these teeth can be restored without crowns, staining is in bands. The success of veneers
which are often not needed until the pulp is depends on the quality of the remaining enamel
involved (Figure 1.1a and b). for bonding, but in suitable cases veneers are the
ideal treatment. The option of multiple crowns is
a considerable undertaking and should not be
Non-vital teeth embarked upon lightly by either patient or dentist.
In particular with young patients, the lifelong
When a pulp becomes necrotic the tooth often maintenance implications must be fully under-
discolours due to the haemoglobin breakdown stood. It should be explained that crowns are very
products. Internal bleaching (see Figure 1.7a and unlikely to last the whole of a natural lifetime and
b) is the initial treatment of choice and will often replacements will be costly if they are possible at
produce a good initial result, although sometimes all. If veneers are made first the teeth can still be
some of the discolouration returns. However, the crowned later but the opposite is not true.
discoloration may be such that it can only satis- However, if after proper consideration crowns
factorily be obscured by a crown following initial are made, they can dramatically improve the
bleaching to produce a lighter core for the crown patient’s appearance in a way that is difficult or
(Figure 1.5). impossible by any other form of treatment.
The decision often has to be made while the
patient is a teenager, when social development
Tooth wear can be seriously affected by appearance including
dental appearance. This is often an important
The ideal approach to problems of tooth wear is factor in making decisions on whether, how and
to prevent the condition getting worse by identi- when to treat.
12 Indications and contraindications for crowns

Figure 1.7

Alternatives to crowns – bleaching.

a A discoloured, non-vital lower central incisor.

b The tooth shown in a has been root-filled and inter-

nally bleached to produce a satisfactory appearance.

c This young patient was unhappy with the appearance

of their crowded discoloured teeth. The discoloration
is due to tetracycline given when the patient was a
child. Extensive and complex restorations could be
considered but the simplest approach would be to
undertake orthodontic treatment and then improve the
colour of the teeth with external home bleaching.

d The resulting appearance following external vital

bleaching – although not perfect the patient is happy
with the result and extensive restorations have been
avoided.
Indications and contraindications for crowns 13

As part of other restorations The home bleaching technique employs a 2%

carbamide peroxide gel applied to the teeth
Sometimes crowns are needed to support partial within a customized tray that the patient wears
dentures. Crowns as part of bridges and splints overnight. Chair-side bleaching utilizes a more
are dealt with in Parts 2 and 3. concentrated carbamide peroxide gel applied by
the dentist and activated by heat or light to act
in a short period of time. The colour changes
achieved by both techniques are not permanent
What are the alternatives to but can be repeated. Vital bleaching techniques
anterior crowns? applied over lengthy periods of time can treat
even very severe discolouration such as some
Internal and external bleaching types of tetracycline staining.

Bleaching agents can be used to lighten the colour

of teeth by internal or external application. Composite restorations
Controversy over the legality of some bleaching
materials and techniques in the UK has been The appearance of modern composite restora-
resolved after much debate. Dentists should be tions is excellent (Figure 1.4). With the rapid
aware of the regulations in their own countries development of anterior restorative materials, it
before using some of the bleaching materials and is better in many cases to replace and repair
techniques. restorations until such time as even more durable
The advantage of tooth bleaching is that it materials are available, rather than make crowns.
offers simple and conservative improvements for It is clear that no absolute rules can be given
patients who simply want whiter teeth or to on whether crowns or fillings are indicated other
reverse some of the effects of aging without than to say that in general the more conservative
damaging tooth structure. Tooth bleaching procedures are to be preferred.
techniques cannot do anything other than
improve colour and remove staining.
Composite and porcelain veneers

Internal bleaching There has been a debate in the dental profession

about the advantages and disadvantages of these
Discoloured non-vital teeth can be treated by two materials for veneers. Considerations in this
removing the contents of the pulp chamber and debate are discussed below.
sealing the root canal with a glass ionomer cement
at or just below the gingival level to prevent
leakage of the bleaching agent into the canal. Appearance
Hydrogen peroxide gel or a slurry of hydrogen
peroxide and sodium perborate is left sealed in the Both can have a very good appearance initially
tooth for 24 hours and repeated until the desired (Figure 1.8). Earlier composites tended to wear
shade is obtained (Figure 1.7a and b). The access and discolour, losing the quality of their appear-
cavity needs to be completely sealed to prevent ance. However, this is less of a problem with the
future relapse. Internal bleaching will not improve improving current materials. When veneers are
the colour of teeth made grey by the corrosion of being made to mask intense discoloration porce-
dental amalgam fillings in access cavities. lain veneers may be preferred because they can
have an initial layer of opaque porcelain which
helps to mask discoloration.

External bleaching
Reversibility
Vital teeth can be lightened by various techniques
with the external application of carbamide per- Composite veneers can be made very thin and so
oxide or other bleaching agents (Figure 1.7c and d). often do not need any tooth preparation. They
14 Indications and contraindications for crowns

Figure 1.8

Alternatives to crowns – veneers.

a Broken and eroded incisor teeth.

b The same patient as shown in a with composite

veneers 3 years after being placed.

c Eroded upper central incisors.

d The same patient as shown in c with two porcelain

veneers in place.
Indications and contraindications for crowns 15

e Polyacrylic veneers which have been in the mouth

for several years. The margins are staining and chipping.

f The same patient as e. The polyacrylic veneers have

been removed and the six anterior teeth prepared for
porcelain veneers.

g An incisal view of the prepared teeth.

h Porcelain veneers on the model for the patient

shown in e and f.
16 Indications and contraindications for crowns

i The etched fit surface of the porcelain veneers.

j The teeth have been isolated with acetate strip and

are about to be etched with phosphoric acid gel.

k An incisal view of the porcelain veneers in place. In

this case the porcelain was carried over the incisal
edges

l The completed porcelain veneers.

Indications and contraindications for crowns 17

Figure 1.9

a A sectioned upper central incisor b A view through the confocal c A porcelain veneer which has
tooth. Left the intact tooth, right the microscope of the margin of a been grit-blasted too much in its
tooth has been prepared for a porcelain veneer. From the left the construction, leaving the margin
porcelain veneer and the profile of veneer, the luting cement, enamel deficient.
the veneer is illustrated in wax. The and dentine. This is a good fit.
features of this preparation are that
the gingival margin is chamfered and
is in enamel and the incisal edge
preserves the bulk of the natural
tooth. Had the incisal edge been
more worn the veneer preparation
could have been taken over it as in
Figure 1.8k.

e A high magnification confocal microscope image with

a different contrast medium showing penetration of
d Porcelain surface etched with hydrofluoric acid. A composite luting cement into dentine tubules on the
grit-blasted surface looks similar. left and etched porcelain on the right.
18 Indications and contraindications for crowns

Figure 1.10

Failing veneers.

These porcelain veneers were made less than a year

ago and are now leaking.

can therefore be removed if the result is not Failures like this cannot be repaired and as the
ideal. Porcelain veneers almost always need some tooth has usually been prepared a new veneer or
tooth preparation because the margins cannot be crown is necessary. In an attempt to reduce the
made as thin as composite, which can be tapered effect of marginal staining some clinicians carry
down to nothing at the margin (Figure 1.9). This the preparations for veneers right through the
means that porcelain veneers are usually not mesial and distal contact points so that the margin
reversible. Because the indications for veneers is other lingual/palatal side. This is an even more
usually apply to young people the decision to destructive preparation. There have been no
prepare teeth for porcelain veneers must be good long-term studies of the success and failure
considered very carefully. Tooth preparation is of composite veneers, partly because clinicians
irreversible and it is often better to make, and know that the materials are changing all the time
when necessary refurbish, composite veneers, and starting a medium- or long-term survey of a
thus allowing the patient to keep their options particular material will become redundant in a
open for the long term. short time with the introduction of new, better
materials. However, clinical experience suggests
that composite veneers do have a good medium-
Cost term prognosis and also have the advantages that
they can be repaired and polished.
Porcelain veneers are more costly because two See Chapter 14 for a more detailed discussion
appointments are necessary and considerable of the success and failure of restorations.
chair-side time is necessary for the delicate
preparations and the bonding process. Laboratory
charges add considerably to the cost. Composite
Physical properties
veneers are placed at the chair side in one visit,
the total clinical time is usually less than porce- The modulus of elasticity of porcelain is quite
lain veneers and there is no laboratory cost. different to that of enamel. There is a view among
some dental material scientists that this difference
will inevitably lead to a breakdown of the bond
Surveys of success and failures of veneers at the margins of veneers in due course. Initially
the estimate was about 10 years and some of the
There have been a number of medium-term surveys confirm this approximate time. The
surveys that show that the life expectancy of coefficient of thermal expansion is also different
porcelain veneers is commonly less than had been between porcelain and enamel and this adds to
hoped. Fractures and debonding are not uncom- the likelihood that marginal breakdown will occur.
mon and a frequent type of failure is staining Composite is nearer to enamel in terms of
around the margins or even frank leakage (Figure these physical properties and because the
1.10). composite is bonded directly via a bonding resin
Indications and contraindications for crowns 19

Figure 1.11

Resin bonded ceramic crowns.

a Peg-shaped lateral incisors.

b The upper right lateral incisor prepared for a resin

bonded ceramic crown. The preparation is entirely
within enamel. The neck of the tooth has been
prepared all round with a chamfer finishing line, similar
to the preparation for a veneer, and a small amount
has been removed from the incisal edge. Nothing has
been removed from the labial or proximal surfaces
other than blending them into the gingival finishing line.

c Palatal view of the finished crowns.

d The labial appearance.

20 Indications and contraindications for crowns

Figure 1.12

Badly broken-down teeth, all of

which were vital when they
were extracted. Left: the tooth
on presentation. Right: after
removing old restorations,
caries and grossly overhanging
enamel. Only at this stage can a
final decision be made on the
most suitable restoration. These
teeth could be treated with:

a a bonded or pin-retained
amalgam restoration;

b a gold inlay with cuspal

protection or a glass ionomer/
composite layered restoration
to strengthen the cusps;

c a composite core or a bonded

or pin-retained amalgam core
and partial crown;

d a composite core or a bonded

or pin-retained amalgam core
and complete crown.
Indications and contraindications for crowns 21

Figure 1.13

Amalgam and gold restorations.

The amalgam in the first molar, which has just been

repolished, has been in place for 15 years. Less than
half the natural crown is present and so a crown could
have been considered when the treatment was first
planned. The decision to place an amalgam was justi-
fied. The amalgam restorations in the premolar teeth
are more recent, and less satisfactory. The inlay in the
second molar has been present for 20 years.

to the etched enamel, marginal breakdown is less Restoration of root-filled teeth

common. Porcelain veneers require two bonds,
one to enamel and the other to the porcelain. There is a strong clinical impression and some
Taking all these considerations together the scientific evidence that root-filled teeth are more
emphasis is now swinging towards composite likely to fracture than teeth with vital pulps. It
veneers rather than porcelain. However, porce- follows that some thin and undermined cusps of
lain veneers still have an important role to play root-filled teeth need to be protected or removed
in some cases. where similar cusps in vital teeth would be left.
Together with the original damage that necessitated
the root filling and the access cavity, this means that
many, but by no means all, root-filled posterior
An alternative to porcelain veneers – teeth are crowned. The fact that a posterior tooth
resin bonded ceramic crowns is root-filled is not in itself sufficient justification for
a crown. When a crown is indicated it is almost
These are, in effect, a porcelain veneer that goes always necessary to make a core.
right round the tooth and therefore does not
have the same problems with the differences in
physical properties between porcelain and enamel
as do porcelain veneers. They require the same As part of another restoration
amount of labial, incisal and approximal prepara-
tion as a porcelain veneer, usually entirely in In Parts 2 and 3 partial and complete crowns are
enamel, together with equivalent preparation of discussed as retainers for bridges and fixed
the palatal or lingual surface (Figure 1.11). splints. In addition, they may be indicated in
conjunction with conventional or precision-
attachment retained partial dentures.

Restoration of badly broken-down

teeth
What are the alternatives to
The most common indication for a posterior posterior crowns?
crown is a badly broken-down tooth usually
resulting from repeated restorations, each of Bonded or pin-retained amalgam
which fails in turn until finally a cusp or larger part restorations
of the tooth fractures off. In most cases it is
necessary to build up a core of amalgam or The success of bonding amalgam to large unreten-
composite before the crown is made. Two such tive cavities is improving. Some dentists now use
teeth are shown in Figure 1.12c and d. bonded amalgam routinely while others are less
22 Indications and contraindications for crowns

confident of the bond (and find the technique toxic hazard to patients, despite occasional
difficult) and use pins or a combination. flurries of media hype. It is also possible that the
Figure 1.13 shows an amalgam restoration which alternatives to amalgam may have equally low
has been present for 15 years. A crack is visible levels of toxic effect.
on the mesial palatal aspect of this tooth; this has Nevertheless there are some patients who
also been present for some years. The tooth is refuse to have amalgam restorations, and hence
symptomless and remains vital. It could be argued there has been a drive to develop satisfactory,
that all teeth with large lesions, such as this one, cost-effective alternatives for the restoration of
should be crowned in order to prevent such posterior teeth. Some patients also have concerns
cracks occurring. However, it is impossible to about the appearance of amalgam restorations,
predict which teeth will crack and what the effects even in areas of the mouth that show little, and
will be. It is therefore not justified to crown all request tooth-coloured restorations. The materi-
teeth with large cavities or restorations just as a als are improving year by year, but some dentists
preventive measure. To do so is overtreatment still feel that they are not yet comparable to
and is not cost-effective. It is better to apply a amalgam for the larger posterior restoration.
general policy of minimum intervention, with These dentists will therefore more commonly
prophylactic restorations only when there is a prescribe crowns than composite restorations in
clear risk of failure. When occasional failures, such teeth that would otherwise be treated with an
as broken cusps, do occur, these problems can amalgam restoration, for example the tooth
usually be solved without the need for extraction. shown in Figure 1.12a. The tooth shown in Figure
1.12b still has substantial buccal and palatal cusps
and a good ridge of dentine between them.
Tooth-coloured posterior restorations However, if the tooth is subject to occlusal stress
(and wear facets can be seen on the cusps) then
Composite materials suitable for posterior a restoration either protecting or reinforcing the
restorations have been developed intensively in cusps is indicated with this amount of tooth loss.
recent times. One reason for this is increasing There is good evidence that the layered
anxiety in some parts of the world and in some restoration (a core of glass ionomer cement
patients about the wisdom of continuing to use replacing the dentine, with an occlusal surface of
amalgam restorations in view of the possible risk composite replacing the enamel) is successful in
of mercury toxicity or allergy. The subject has binding weakened cusps together and producing
received much attention in the popular press and a stronger tooth than one restored with amalgam
in the rest of the media. The scientific evidence alone. It is used when there is a large MOD cavity
is that mercury allergy does exist in a very small where a crown preparation would simply remove
proportion of the population, although in some all or most of the remaining tooth tissue.
parts of the world, for example Japan, it appears In order to increase wear resistance and to
to be greater, probably due to patients being minimize the effects of polymerization contrac-
sensitized by eating fish contaminated with tions, which are complications of large directly
mercury that has got into the marine food chain. placed composite restorations, systems have been
Mercury toxicity is a proper concern of developed to process composite inlays outside
dentists, and over the last 30 years or so consid- the mouth by a combination of heat, pressure and
erable improvements have been made in mercury light. A non-undercut inlay cavity is prepared, an
hygiene. Most amalgam used now is capsulated, impression taken and the composite inlay (or
avoiding the need for liquid mercury to be avail- onlay) made in the laboratory (Figure 1.14).
able in bulk in the dental surgery, and other
precautions are also used to protect the staff in
the dental surgery. It is the staff, who are likely Gold inlays and onlays protecting
to be exposed over a long period to mercury weak cusps
vapour should mercury hygiene not be adequate,
who are at risk rather than individual patients. The gold inlay shown in Figure 1.13 is an intra-
There is no reliable scientific evidence that the coronal restoration and is not an alternative to a
mercury from amalgam restorations is a serious crown. Figure 1.15a shows a tooth similar to
Indications and contraindications for crowns 23

Figure 1.14

a The large MOD amalgam

restoration in the first molar tooth c Several extensive restorations in
requires replacement. composite only 2 years after place-
ment. They have worn badly with
marginal staining, loss of occlusal
contour and poor proximal
contacts.
b The restoration has been
replaced with a direct composite
restoration, significantly improving
its appearance.

d Well placed MOD composite restorations which are

5 years old and continue to function well with a good
appearance.
continued

Figure 1.12b. It has been prepared for a cuspal This restoration is very conservative of tooth
coverage MOD gold inlay and Figure 1.15b shows tissue and is retentive. Imagine on Figure 1.15
the sectioned tooth with a wax pattern for the how little of the buccal cusp would have remained
inlay. The metal overlying and protecting the had the tooth been restored with a core and then
cusps must be thick enough to prevent distortion prepared for a metal–ceramic crown (see
under occlusal forces. Chapter 2). The buccal cusp would have been
24 Indications and contraindications for crowns

Figure 1.14 continued

e A failed MOD amalgam restoration with secondary

caries beneath both the boxes. The mesial surface of
the amalgam was also unsightly.

f A laboratory-processed composite inlay shortly after

insertion.

g The same composite inlay after 8 years.

Indications and contraindications for crowns 25

Figure 1.15

MOD cuspal coverage inlay.

a The prepared tooth. Note the bevels on the occlusal

surface just down onto the buccal and lingual surfaces.

b Section of the prepared tooth with the wax pattern.

c Occlusal view of the completed wax-up.

26 Indications and contraindications for crowns

Figure 1.16

Ceramic inlays.

a A laboratory-made ceramic inlay. The inlay is

returned from the laboratory with a contoured
occlusal surface and occlusal staining. It should only
require cementation.

b A computer aided design/computer aided manufac-

ture (CAD/CAM) machine for producing ceramic inlays
at the chair side. This is an early version of the Cerec
machine but there are several other makes available.

c A failed composite restoration in the first premolar

tooth is to be replaced by a ceramic inlay.

d The completed ceramic inlay milled at the chair side

in the Cerec machine. The machine produces a good
fit and contact points that only require minor adjust-
ment and polishing. However, the occlusal surface is
not finished, and needs to be adjusted and polished in
the mouth after cementation. The main advantage of
the system is that the whole procedure is carried out
in one visit at the chair side and there are no labora-
tory stages.
Indications and contraindications for crowns 27

even more weakened. A disadvantage of this type • An amalgam or composite restoration

of restoration is that often with premolars and • A layered restoration of glass ionomer and
some molar teeth there is a visible display of gold, composite
which some patients do not like. • An amalgam with additional retention (for
example bonding or pins)
• A ceramic or composite inlay
• A gold inlay
Ceramic inlays and onlays • A gold inlay with occlusal protection (an onlay)
• A partial crown
Posterior ceramic inlays have many of the advan- • A complete crown
tages of posterior composite restorations in that, • A core of material to replace the missing
because they are bonded to the tooth, they dentine followed by a partial crown
strengthen weakened cusps, and they are tooth- • A core and complete crown.
coloured. In addition, the porcelain occlusal
surface is more wear-resistant than composite A further decision that must be made is whether,
and there is, of course, no polymerization if a complete crown is to be used, it should be an
contraction. all-metal or a metal–ceramic crown, or even in
There are two systems: one that includes a some cases an all-ceramic crown (see Chapter 2
laboratory stage and one that does not. With for a description of these different types of crown).
laboratory-made ceramic inlays, an impression of These decisions cannot be made without
the prepared tooth is sent to the laboratory and further information, and some of this will be
a porcelain inlay is made by one of a variety of gathered from the history, examination of the
techniques similar to the production of porcelain rest of the mouth, radiographs, and so on (again,
crowns using the die of the tooth (Figure 1.16a). these matters will be discussed in Chapter 3).
The chair-side system consists in milling a However, even with all this information it is
porcelain inlay from a design produced in a usually also necessary to remove the existing
computer from a three-dimensional video image restorations and caries before a final decision can
of the prepared tooth. This, of course, requires be made. Figure 1.12 shows the same teeth
a very complex, sophisticated and expensive piece before and after the caries and old restorations
of equipment (Figure 1.16b). It is too soon to say are removed.
whether this approach to dental restorations The decision depends upon three factors:
(CAD/CAM or computer-aided design/computer
aided manufacture) will be revolutionary or will • Appearance
stay on the fringes of dental treatment. • Problems of retention
• Problems of strength of the remaining tooth
tissue and the restorative material.
Choosing the right posterior As far as appearance is concerned, if the surface
restoration of the tooth to be restored is visible during
common movements of the mouth, and if the
In some of the teeth shown in Figure 1.12 the patient is concerned about appearance, a ceramic
failure is due to the restoration fracturing or inlay, composite restoration or crown will usually
becoming lost and in others it is the tooth itself be indicated for large restorations.
that has failed. In some the problem is secondary When the problem is simply one of retention,
caries. In all these cases decisions must be made an amalgam restoration with additional retentive
between restoring or extracting the tooth, and if features is usually chosen (Figure 1.12a).
it is to be restored, whether the pulp is healthy When the remaining tooth tissue is weak, a
or whether endodontic treatment is necessary. layered restoration, a ceramic inlay or a cuspal
Leaving these considerations to be discussed in coverage gold inlay will be the choice (Figure
Chapter 3, and assuming that all these teeth will 1.12a).
be restored, the next decision is whether the A core and partial crown is a very satisfactory
appropriate restoration is: restoration where a tooth previously restored
28 Indications and contraindications for crowns

with an MOD amalgam loses its lingual or palatal A core and complete crown is the last resort.
cusp. The partial crown protects the remaining Figure 1.12d shows a case where there is no
buccal cusp against occlusal forces, and this cusp choice but to provide a core and complete
can still provide valuable retention, often in crown.
conjunction with bonding and/or pins, for the These examples illustrate the importance of
core, as well as having an acceptable appearance. considering all the alternatives in each case. The
If a metal–ceramic crown is made, then the whole temptation to look rather casually at the tooth
or the majority of the buccal cusp will be cut off and immediately decide upon a crown without
in the preparation of the tooth, and the core will proper investigation and consideration must be
need much more substantial auxiliary retention avoided as it may lead to more destructive over-
(Figure 1.12c). treatment than necessary.
2 Types of crown

This chapter gives a general description of the • Reinforced crowns

various crown types together with their main • Ceramic resin bonded crowns.
advantages and disadvantages in relation to:

• Physical properties
Traditional porcelain jacket crowns (PJCs)
• Clinical considerations
• Appearance This is the oldest type of tooth-coloured crown
• Cost. and has been in use for more than a century. It
consists of a more or less even layer of porce-
Crowns are described under the following lain, usually between 1 and 2 mm thick, covering
headings: the entire tooth. Figure 2.1a, b, c and d shows a
selection of traditional feldspathic porcelain jacket
• Anterior complete crowns for vital teeth crowns in place.
• Anterior crowns for root-filled teeth The traditional feldspathic PJC is made by
• Posterior complete crowns adapting a very thin platinum foil to a die made
• Posterior partial crowns. from an impression of the prepared tooth.
Porcelain powder, mixed with water or a special
fluid, is built onto the platinum foil and fired in
the furnace. All PJCs made in this way are now
Anterior complete crowns for vital strengthened by having alumina incorporated into
teeth the porcelain powder. A core of high-alumina
porcelain is fired onto the platinum foil. This high-
In the anterior part of the mouth appearance is alumina core is opaque and needs to be covered
of overriding importance, and so the only types by more translucent porcelain that contains less
of crown to be considered are those with a alumina.
tooth-coloured labial or buccal surface. These fall Variations on fused ceramic crowns have been
into three groups: developed but most have now been replaced by
the systems described later. Examples of these
• Ceramic crowns strengthened ceramic systems were Hi-Ceram
• Metal–ceramic crowns (Figure 2.1e) and In-Ceram (Figure 2.1i).
• Other types of crowns. An alternative approach is to fire an extra-
strong core of ceramic material to a refractory
die and then add further layers of conventional
feldspathic porcelain. Once finished, the refrac-
Ceramic crowns tory die is grit-blasted away, leaving a fitting
surface that is slightly rough, aiding retention.
In recent years there have been several develop- Both these systems can also be used to make
ments in the ceramics used for crowns. These can porcelain veneers.
be classified as: Conventional dental porcelain is physically
more like glass than the porcelain used for
• Traditional fused porcelain jacket crowns domestic purposes. It is relatively brittle, and
(PJCs) before a PJC is cemented it can be broken fairly
• Pressed ceramic crowns easily. However, once it is cemented and
• Milled ceramic crowns supported by the dentine of the tooth, the force
• Cast crowns required to fracture it is of the same order of

29
30 Types of crown

Figure 2.1

Types of anterior crown.

a Traditional porcelain jacket crowns on all four upper

incisors. The preparations for the crowns are shown
in Figure 6.10.

b A single traditional PJC. The upper left central incisor

is the crown, the other teeth are natural.

c The same crown 25 years later. It has recently been

fractured traumatically and repaired with composite.
The appearance is not as good as the original crown
but the patient is happy to accept this and does not
want the crown, which has been so successful, replaced
yet.

d Both upper central incisors are traditional PJCs with

supragingival margins. Despite this, there is some gingi-
val inflammation. They had been present for about 5
years when this photograph was taken.
Types of crown 31

e Strengthened porcelain crowns (Hi-Ceram) on both

central incisor teeth.

f Pressed crowns on the upper and lower incisor teeth

in a patient with mild amelogenesis imperfecta. This can
be seen on the uncrowned teeth, particularly the lower
right first premolar. The system used was Empress.

g Six pressed crowns made by another system –

Metalor Stylepress – in which both the pressed and
applied layers are the same material.

h and i The upper left lateral incisor tooth has been

moved orthodontically into the position of the central
incisor and crowned with an infiltrated, reinforced
system (Inceram) to resemble the missing central
incisor.
32 Types of crown

j A cast ceramic crown (Dicor) on the upper right

central incisor.

k A metal–ceramic crown on the upper lateral incisor.

This is the patient shown in Figure 1.1a.

l A metal–ceramic crown with a buccal porcelain

margin so that no metal is visible on the labial surface.

m The cemented crown shown in l has an excellent

appearance and is indistinguishable from a porcelain
crown.
Types of crown 33

magnitude as the force required to fracture the Chair-side milled restorations

enamel of a natural tooth.
However, traditional PJCs do fracture and so Chair-side milling systems have been in develop-
the other systems have all been developed to ment for some years. Although these systems do
produce stronger all-ceramic crowns. not yet produce reliable crowns it is anticipated
that they will do so in the foreseeable future.

Pressed ceramic crowns Cast ceramic systems

There are a number of systems used to produce One of the earliest developments in the 1970s
a strong ceramic core by pressing a ceramic was of a system to produce strong ceramic
material at high temperature and pressure onto a crowns by the Dicor process in which a wax
die and then building up layers of traditional pattern of the crown was made on a conventional
porcelain to create the right contour and shade. die, invested and cast in a glass/ceramic material.
Examples of crowns made by this process are The casting was then placed in a ceramming oven
shown in Figure 2.1f and g and an example of the for several hours, during which it went through a
equipment used is shown in Figure 2.2a. crystallization conversion and became much
stronger. At this stage the casting had a cloudy-
clear appearance (similar to frosted glass). It was
Laboratory milled cores and crowns then stained and characterized using conventional
feldspathic porcelains in a porcelain furnace.
Several computer aided designs/computer aided Although the commercially available Dicor system
manufacture (CAD-CAM) have been developed was developed by the same company that devel-
and more are in the pipeline. One example is a oped domestic Pyrex glassware, the manufactur-
technique by which the die is scanned in a ers state that the material is not the same as
computer and the digital record is sent electron- Pyrex. A number of other castable ceramic or hot
ically to a central laboratory, often in another transfer-moulded glass ceramic systems have
country, where a core is produced in a strong been developed (Figure 2.1j).
ceramic material. This is then returned to the
original laboratory where additional porcelain is
added to complete the crown. The system can
Reinforced porcelains
also mill metal, in particular titanium (Procera).
The computer equipment is shown in Figure 2.2d One technique is to form an alumina substructure
and crowns made by this process are shown in on a special plaster die and following sintering in
Figure 2.2e and f. a furnace the porous substructure is coated with
glass fired powder and further fired for several
hours. This infiltrates the pores and eliminates
Zirconia cores them as a source of weakness. Filling the pores
also improves translucency and the final appear-
Porcelain crowns can also be manufactured using ance when additional porcelain is added. A typical
complex laboratory techniques with a zirconia system is In-Ceram and an example is illustrated
core onto which conventional porcelain is built. in Figure 2.1h and i.
Zirconia is an extremely strong material compar-
able to metal and is dense white in appearance.
The conventional porcelain therefore needs to be
Thin ceramic resin bonded crowns (see
relatively thick for the translucent porcelain to
also Chapter 1)
mask the opaque core underneath. Zirconia-
based crowns are proposed by the manufacturers All the previous crowns are usually cemented by
for use on posterior as well as anterior teeth due conventional means (see later). However, a
to their great potential strength, but there is not conservative technique is to prepare the tooth
yet sufficient evidence that they will survive for within enamel exposing the minimum amount of
the long term in high stress situations. dentine and then making thin ceramic crowns, no
34 Types of crown

Figure 2.2

Making pressed, milled and fibre re-inforced crowns.

a Equipment for construction of an Empress crown.

b and c Two Empress crowns restoring severely

damaged incisor teeth.
Types of crown 35

d The scanner used in the process of making a Procera

crown.

e A Procera core of dense aluminous porcelain ready.

The porcelain will be fired directly onto this.

f and g Procera crowns restoring three incisor teeth.

Note how the crowns disguise the gold post and cores
so the appearance is the same as the crown on the
natural tooth.

continued
36 Types of crown

Figure 2.2 continued

h, i and j A single molar crown made using a fibre

reinforced system.

thicker than a porcelain veneer (see later) but Choosing between ceramic crowns
covering the whole tooth. This is then bonded by
etching the enamel surface, grit-blasting the fit In this fast developing field, a list of current (at
surface of the crown and bonding with an the time of publication) materials and techniques
adhesive resin material (Figure 1.11). These would soon become out of date. Instead, when
restorations are becoming more popular with dentists look at an established or new system
some dentists, who believe that their prognosis they should recognise which type it is and assess
may be better than ceramic veneers because they the manufacturer’s descriptions and claims objec-
go right round the tooth, thereby reducing the tively. Not all dentists or technicians will use the
effects of the difference in thermal expansion full range. Most dentists gain experience in a
between porcelain and enamel, and also the risk limited range and choose the appropriate system
of marginal leakage and staining is reduced. for the patient’s particular clinical circumstances.
Types of crown 37

Advantages advantage in some situations, in most it is a disad-

vantage. In some patients where the crown
The advantages of ceramic crowns are: supports a partial denture or where the occlusal
forces are excessive, ceramic crowns are not
Appearance Because of their translucency and usually used.
the range of techniques and shades available, they
are better able to duplicate the appearance of a Removal of tooth tissue To overcome the
natural tooth than any other type of crown. problem of the brittleness of porcelain, and to
give the crown a natural appearance, there must
Stability Porcelain is dimensionally and colour be an adequate thickness of material, and so it is
stable and is insoluble in oral fluids. necessary to reduce the tooth fairly extensively,
weakening it and threatening the pulp. This is
Cost Some ceramic crowns are less expensive to especially true with small teeth, for example
produce in the laboratory than metal–ceramic lower incisors. This problem is much less with
crowns. resin bonded ceramic crowns.

Plaque Ceramic materials resist plaque accumu-

lation better than other crown materials.
Metal–ceramic crowns (Figure 2.1k
Brittleness The relative brittleness of a conven- and l)
tional PJC can be regarded as an advantage, partic-
ularly if the tooth being crowned was originally Dental porcelain can be bonded to a variety of
fractured in an accident. Should such an accident metal alloys. The process is similar to the glazing
recur (which is not at all uncommon among sports of domestic cast iron and steel baths and basins.
players, cyclists, children with Class II Division I The alloys used in dentistry fall into three groups:
incisor relationships, and others), the PJC is likely
to fracture rather than the root of the tooth. This • Precious metal alloys containing a high propor-
is still true, but to a lesser extent, with the newer tion of platinum and gold. These can be high
types of ceramic crown. With metal–ceramic or low gold content (75% down to 25% gold)
crowns, which are stronger than the remaining • Semi-precious alloys containing a high propor-
tooth tissue, more serious damage such as root tion of palladium, sometimes with silver as well
fracture is likely to result from a further accident. • Base metal alloys containing a high proportion
Where possible, the weakest link in the chain of nickel and chromium.
should be the one easiest to repair. The principle
is similar to the fuse in an electric circuit. Although this classification is still used, at the time
of writing palladium is more expensive than gold
and so the term ‘semi-precious’ is not really
accurate. Base metal alloys should only be used
Disadvantages in patients with a confirmed tolerance of nickel
as it is fairly common for patients to be sensitive
The disadvantages of ceramic crowns are: to cheap jewellery or coins containing nickel.
There is a difference in cost between these
Marginal fit Traditional porcelain jacket crowns alloys, but they all share the properties of a high
made on a platinum foil matrix that is removed melting temperature so that porcelain can be
prior to cementation often had a less satisfactory bonded to the surface. This is done by firing the
marginal fit than cast metal and other crowns. porcelain to the metal at a temperature which
However, the marginal fit of the newer types is does not melt or distort the metal.
comparable to cast-metal restorations; if shoulder The preparation for an anterior metal–ceramic
porcelain (see later) is used the fit is improved. crown differs from that for a posterior
metal–ceramic crown in two ways; first rather
Brittleness Although the brittleness of porcelain more tooth tissue needs to be removed from the
crowns was described earlier as a potential labial surface to allow for the thickness of the
38 Types of crown

metal as well as porcelain, and second rather less Figure 2.3

usually needs to be removed from the palatal or
lingual surface since only metal will usually cover Sections through three sets of casts of patients in inter-
at least part of this surface. cuspal position showing the profile of crown prepara-
tion.

a This is a Class I Division II incisor relationship with

Advantages deep overbite and minimal overjet. It often appears,
when looking at these patients from in front, that there
The main advantages of metal–ceramic anterior will be insufficient clearance for ceramic crown prep-
crowns are: arations. In fact, the bucco-lingual thickness of the teeth
is often normal and conventional preparations are
Strength The metal–ceramic crown is a very possible.
strong restoration, which resists occlusal and
other forces well. b Gross erosion of the palatal surfaces of the upper
incisor teeth due to recurrent vomiting. If crowns are
Minimum palatal reduction Some teeth, to be made, there will not be room to provide a palatal
particularly those severely worn by erosion and porcelain surface without the occlusal vertical dimen-
attrition that have then over-erupted back into sion being increased by techniques described later.
occlusion, may not be sufficiently bulky for a However a metal–ceramic crown preparation is poss-
porcelain jacket crown preparation with adequate ible. Because the diagnosis is erosion (chemical damage)
palatal reduction, whereas a metal–ceramic crown rather than attrition (physical damage), the additional
preparation may be possible. Figure 2.3 illustrates strength of the metal is not particularly important.
this problem in comparison with a normal incisor
tooth. c The lower incisors are worn to approximately one-
half their original length. A conventional crown prep-
Adaptability The metal–ceramic crown can be aration would not be possible but a one-piece
adapted to any shape of tooth preparation, metal–ceramic post-retained crown is. The dotted line
whereas the processes involved in making shows the metal–porcelain junction.
ceramic crowns require a smooth and uniform
preparation. Additional retention can be gained in
difficult preparations by the use of grooves or
pins, which is not possible with ceramic crowns.
Types of crown 39

Can be cast, soldered or laser welded For • Fibre-reinforced composite crowns.

bridges, metal–ceramic crowns can be attached to
other crowns or bridge pontics by casting them
together, soldering or laser welding. This cannot Cast metal acrylic or composite faced
be done with ceramic crowns. crowns
These are mostly used as long-term provisional
restorations. Laboratory-grade composite is
Disadvantages cured by an intense light in a special light box,
sometimes with the addition of heat or pressure.
The disadvantages of metal–ceramic crowns are: The cast metal framework needs to be mechani-
cally retentive for the facing.
Strength An accidental blow may result in the
tooth preparation or root fracturing because the
crown is stronger than the natural dental tissues.
Fibre-reinforced composite crowns
Appearance Because of the metal framework, it A range of techniques have been developed to
is sometimes more difficult to match the natural reinforce composite as a permanent crown
appearance of a tooth than with a ceramic crown, material. However, after a few years in use, the
particularly at the cervical margin (Figure 2.1k). results have been disappointing. Nevertheless,
However, with all-ceramic margins this can be they do make good long-term provisional crowns
largely overcome. and bridges. The techniques require a light box in
the laboratory but this is less expensive and the
Destruction of tooth tissue Metal–ceramic process is quicker than firing porcelain. Figure
crowns require more tooth reduction labially than 2.2h, i and j shows an example of this type of
ceramic crowns and so the tooth preparation is crown.
more likely to endanger the pulp. If this tooth
reduction is not sufficient – as is often the case –
the eventual crown either has a poor, opaque
appearance or is too bulky (see Chapter 3). Anterior crowns for root-filled
teeth
Cost Even if the relatively inexpensive base metal
alloys are used, the laboratory time taken to Often the endodontic access cavity together with
construct a metal–ceramic crown is more than the crown preparation will leave insufficient
for a PJC and therefore the overall cost is usually dentine to support a crown. In this case reten-
greater. However, when compared to the costs tion is gained by means of a post fitted into the
for most of the other types of ceramic crown enlarged root canal. These posts are used only
involving complex laboratory stages, the costs are for retention, and the idea that they add strength
similar. When precious metal alloys are used, the to the tooth has now been discounted. For this
cost is naturally greater. reason, if it is possible to obtain retention for the
crown without using a post, this is preferred.
Figure 2.4a shows examples of teeth that would
be restored by means of a simple composite
Other types of anterior complete restoration, a composite (or glass ionomer) core
crowns and crown or a post-retained crown. There are
four groups of crowns for root-filled anterior
Although the majority of anterior crowns fall into teeth:
one of the two previous groups, other alterna-
tives exist: • Composite (or glass ionomer) core and crown
• Post and core and separate crown
• Cast metal crowns with acrylic or composite • One-piece post crown
facings • Other types.
Other documents randomly have
different content
 THE BLACK HOLE.—II.

Some native officers went in search of a building where the

prisoners could be confined, but every room in the fort had already
been taken possession of by the nabob's soldiers and officers.
At eight o'clock they returned with the news that they could find
no place vacant, and the officer in command at once ordered the
prisoners into a small room, used as a guard-room, eighteen feet
square. In vain the Europeans protested that it was impossible the
room could contain them, in vain they implored the officer to allow
some of them to be confined in an adjoining cell.
The wretch was deaf to their entreaties. He ordered his soldiers
to charge the prisoners, and these, with blows of the butt-ends of
the muskets and prods of the bayonets, were driven into the narrow
cell.
Charlie's servant, Tim Kelly, kept close to his master. Mr. Haines'
native servant, Hossein, who would fain have shared his master's
fortunes, was forcibly torn from him when the English prisoners were
separated from the natives.
The day had been unusually hot. The night was close and sultry,
and the arched verandah outside further hindered the entrance of
air, and this, with the heavy fumes of powder, created an intolerable
thirst. Scarcely were the prisoners driven into their narrow cell,
where even standing wedged together there was barely room for
them, than cries for water were raised.
 "Tim, my boy," Charlie said, "we may say good-bye to each
other now, for I doubt if one will be alive when the door is opened in
the morning."
On entering, Charlie, always keeping Ada Haines by his side,
had taken his place against the wall farthest from the window, which
was closed with iron bars.
"I think, yer honour," Tim said, "that if we could get nearer to
the window we might breathe a little more easily."
"Ay, Tim; but there will be a fight for life round that window
before long. You and I might hold our own if we could get there,
though it would be no easy matter where all are struggling for life,
but this poor little girl would be crushed to death. Besides, I believe
that what chance there is, faint as it may be, is greater for us here
than there.
"The rush towards the window, which is beginning already as
you see, will grow greater and greater; and the more men struggle
and strive, the more air they require. Let us remain where we are.
Strip off your coat and waistcoat, and breathe as quietly and easily
as you can. Every hour the crowd will thin, and we may yet hold on
till morning."
This conversation had been held in a low voice. Charlie then
turned to the girl.
"How are you feeling, Ada?" he asked cheerfully. "It's hot, isn't
it?"
"It is dreadful," she panted, "and I seem choking from want of
air; and oh, Captain Marryat, I am so thirsty!"
"It is hot, my dear, terribly hot, but we must make the best of it;
and I hope in a few days you will join your mamma on board ship.
That will be pleasant, won't it?"
"Where is papa?" the girl wailed.
"I don't know where he is now, my child. At any rate we must
feel very glad that he's not shut up here with us. Now take your
bonnet off and your shawl. We must be as quiet and cheerful as
possible. I'm afraid, Ada, we have a bad time before us to-night. But
try to keep cheerful and quiet, and above all, dear, pray God to give
you strength to carry you through it, and to restore you safe to your
mamma in a few days."

THE BLACK HOLE.—III.

As time went on the scene in the dungeon became terrible. Shouts,

oaths, cries of all kinds, rose in the air. Round the window men
fought like wild beasts, tearing each other down, or clinging to the
bars for dear life, for a breath of the air without. Panting, struggling,
crying, men sank exhausted upon the floor, and the last remnants of
life were trodden out of them by those who surged forward to get
near the window.
In vain Mr. Holwell implored them to keep quiet for their own
sakes. His voice was lost in the terrible din. Men, a few hours ago
rich and respected merchants, fought now like maddened beasts for
a breath of fresh air. In vain those at the window screamed to the
guards without, imploring them to bring water. Their prayers and
entreaties were replied to only with brutal scoffs.
Several times Charlie and Tim, standing together against the
wall behind, where there was now room to move, lifted Ada between
them, and sat her on their shoulders in order that, raised above the
crowd, she might breathe more freely. Each time, after sitting there
for a while, the poor girl begged to come down again, the sight of
the terrible struggle ever going on at the window being too much for
her.
Hour passed after hour. There was more room now, for already
half the inmates of the place had succumbed. The noises, too, had
lessened, for no longer could the parched lips and throats utter
articulate sounds. Charlie and Tim, strong men as they were, leaned
utterly exhausted against the wall, bathed in perspiration, gasping
for air.
"Half the night must be gone, Tim," Charlie said, "and I think,
with God's help, we shall live through it. The numbers are lessening
fast, and every one who goes leaves more air for the rest of us.
Cheer up, Ada dear, 'twill not be very long till morning."
"I think I shall die soon," the girl gasped. "I shall never see
papa or mamma again. You have been very kind, Captain Marryat,
but it is no use."
"Oh, but it is of use," Charlie said cheerfully. "I don't mean to let
you die at all, but to hand you over to mamma safe and sound.
There, lay your head against me, dear, and say your prayers, and try
and go off to sleep."
Presently, however, Ada's figure drooped more and more, until
her whole weight leaned upon Charlie's arm.
"She has fainted, Tim," he said. "Help me to raise her well in my
arms, and lay her head on my shoulder. That's right. Now you'll find
her shawl somewhere under my feet; hold it up and make a fan of it.
Now try to send some air into her face."
 By this time not more than fifty out of the hundred and forty-six
who entered the cell were alive. Suddenly a scream of joy from
those near the window proclaimed that a native was approaching
with some water. The struggle at the window was fiercer than ever.
The bowl was too wide to pass through the bars, and the water was
being spilt in vain; each man who strove to get his face far enough
through to touch the bowl being torn back by his eager comrades
behind.

THE BLACK HOLE.—IV.

"Tim," Charlie said, "you are now much stronger than most of them.
They are faint from the struggles. Make a charge to the window.
Take that little shawl and dip it into the bowl or whatever they have
there, and then fight your way back with it."
"I will do it, yer honour," said Tim, and he rushed into the
struggling group. Weak as he was from exhaustion and thirst, he
was as a giant to most of the poor wretches who had been
struggling and crying all night, and, in spite of their cries and curses,
he broke through them and forced his way to the window.
The man with the bowl was on the point of turning away, the
water being spilt in the vain attempts of those within to obtain it. By
the light of the fire which the guard had lit outside, Tim saw his
face.
"Hossein," he exclaimed, "more water, for God's sake! The
master's alive yet."
 Hossein at once withdrew, but soon again approached with the
bowl. The officer in charge angrily ordered him to draw back.
"Let the infidel dogs howl," he said. "They shall have no more."
Regardless of the order, Hossein ran to the window, and Tim
thrust the shawl into the water at the moment when the officer,
rushing forward, struck Hossein to the ground: a cry of anguish
rising from the prisoners as they saw the water dashed from their
lips. Tim made his way back to the side of his master. Had those
who still remained alive been aware of the supply of water which he
carried in the shawl they would have torn it from him; but none save
those just at the window had noticed the act, and inside it was still
entirely dark.
"Thank God, yer honour, here it is," Tim said; "and who should
have brought it but Hossein. Shure, yer honour, we both owe our
lives to him this time, for I'm sure I should have been choked by
thirst before morning."
Ada was now lowered to the ground, and a corner of the folded
shawl was placed between her lips, and the water allowed to trickle
down. With a gasping sigh she presently recovered.
"That is delicious," she murmured. "That is delicious."
Raising her to her feet, Charlie and Tim both sucked the
dripping shawl, until the first agonies of thirst were relieved. Then
tearing off a portion in case Ada should again require it, Charlie
passed the shawl to Mr. Holwell, who, after sucking it for a moment,
again passed it on to several standing round. In this way many of
those who would otherwise have succumbed were enabled to hold
on until morning.
 Presently the first dawn of daylight appeared, giving fresh hopes
to the few survivors. There were now only some six or eight
standing by the window, and a few standing or leaning against the
walls around. The room itself was heaped high with the dead.
It was not until two hours later that the doors were opened and
the guard entered, and it was found that of the hundred and forty-
six English people inclosed there the night before, only twenty-three
still breathed. Of these very few retained strength to stagger out
through the door. The rest were carried out and laid in the verandah.
When the nabob came into the fort in the morning, he ordered
Mr. Holwell to be brought before him. He was unable to walk, but
was carried to his presence. The brutal nabob expressed no regret
for what had happened, but loaded him with abuse on account of
the paucity of the treasure, and ordered him and his friends to be
placed in confinement.

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