460 Dental Update November 2000

RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
Flexible Removable Partial Dentures: Design and Clasp Concepts
Wri tten by P aul Kapl an , M Sci , D D S, M SD
Sunday, 30 N ovem ber 2008 l9:00
The us e of aes thet i c f l ex i bl e rem ov abl e part i al dentures (FRPD) has s ky
-rocketed ov er the l as t s ev eral y ears (Fi gure l). M ul t i pl e
adv ert i s em ents can be found i n ev ery j ournal wi th l aboratori es prom ot i ng l ower
cos t (com pared to conv ent i onal part i al dentures wi th
cas t fram eworks ), fas t s erv i ce, and bet ter aes thet i cs than conv ent i onal m etal
-bas ed rem ov abl e part i al dentures (RPD). ln s peaki ng
wi th pros thodont i s ts , l s t i l l get the feel i ng they bel i ev e that the us e of FRPDs
i s s om ehow s t i l l not qui te the ri ght thi ng to do.
A l though, s om e are now openl y adm i t t i ng that thes e pros thes es m ay , i n fact ,
hav e thei r pl ace, l thi nk that m any are s t i l l a bi t uns ure
about ex act l y what that pl ace i s . Thi s art i cl e wi l l des cri be techni ques needed to
prov i de aes thet i c FRPDs to y our pat i ents , and l wi l l
al s o s hare m y opi ni ons regardi ng thes e appl i ances and the need to em brace them
as a v i abl e treatm ent opt i on.
RlG lD ME TAL-BASE D RPDS VE RSUS F LE XlBLE RPDS
Part of the probl em for s om e to accept FRPDs i s that they don t j us t v i ol ate m
any of the "rul es " of RPDs they s im pl y i gnore them .
A nd y et , des pi te thi s , they are s t i l l s ucces s ful . There are no res t s eats trans m i
t t i ng the ax i al l oad down the l ong ax i s of the tooth.
There are no i nfra-bul ge cl as ps and s upra-bul ge cl as ps (i n the tradi t i onal s ens e),
and the t i s s ue does not s eem to care that thes e
dev i ces are non-ri gi d. A l l thes e thi ngs v i ol ate the tradi t i onal concepts of cl as s
i c m etal -bas ed (ri gi d) RPD des i gn. A nd y et , there are a
rapi dl y growi ng num ber of thes e appl i ances bei ng del i v ered to pat i ents ev ery y
ear, dem ons trat i ng that thei r popul ari ty i s s pri ngi ng
from pract i ci ng dent i s ts , and not from dental s chool s and/or l eadi ng pros thodont i s
ts .
There i s l i t t l e cl as s i c s ci ent i f i c res earch to s upport the us e of FPRDs , and the
cons tel l at i on of art i cl es and thought that s urround
tradi t i onal m etal -cl as ped (ri gi d) RPDs does not y et ex i s t for thes e dev i ces .
lnteres t i ngl y , i f one reads through enough art i cl es
begi nni ng wi th cl as p concepts ori gi nat i ng i n the "Dental Cos m os " of the earl y
l930s , i t becom es cl ear that cl as p des i gn for m etal -bas ed RPDs i s i n truth v ery
m uch a m at ter of opi ni on and conj ecture. Ev en hard core "s ci ent i f i c" art i cl es
l i ke thos e bas ed on s tres s s tudi es us i ng l i ght refract i on m odel s (Do thes e trul y
ref l ect what i s happeni ng i n bone and t i s s ue?); or
thos e bas ed on v ari ous l ab dev i ces that s how m ov em ent / f l ex ure of arm s /cl as ps
under deform at i on (They m ay be great m etal l urgi cal
s tudi es , but are they di rect l y and cl i ni cal l y ap-pl i cabl e?); and the m ul t i tude of
art i cl es wi th drawi ng af ter drawi ng s howi ng poi nts of
rotat i on, res t s eat ax i al l oad, and s o onare accepted as s tone-hard truth. l f hi s
tory s hows us one thi ng, i t i s that facts can be
m ani pul ated to s upport any num ber of concepts , and that the general cons ens us on
s om ethi ng m ay hav e s om e bui l t i n errors . ln
other words , i t can be qui te di f f i cul t to s eparate fact from f i ct i on.
OBSE RVATlONS AND lNDlCATlONS
From the pers pect i v e of m y pers onal cl i ni cal ex peri ence, the facts are s im pl e:
FRPDs (s uch as V al pl as t [V al pl as t lnternat i onal , lnc. ])
work ex trem el y wel l i n s om e s i tuat i ons , and reas onabl y wel l i n others . A l though
s om e peri odont i s ts hav e been qui ck to tel l of s om e
cas es or s i tuat i ons where t i s s ue s tri ppi ng has occurred wi th the us e of thes e appl
i ances , l hav e not obs erv ed thi s condi t i on i n
cas es that l hav e done, nor i n pat i ents that l hav e s een who were treated by other
dent i s ts . ln the s m al l num ber of pat i ents l hav e
obs erv ed who hav e worn FRPDs for an ex tended peri od of t im e, l hav e not s een
bone dam age or res orpt i on i n the tradi t i onal pat tern
of pos teri or ri dge res orpt i on (s addl e ri dge) that i s s o com m on under chrom e/acry l i
c s addl es us ed on m etal -bas ed RPDs . Tim e and
i ncreas ed pat i ent ut i l i z at i on m ay bri ng s om e of thes e i s s ues forward, but for
the m om ent they do not s eem to be a probl em . Pres ent
obs erv at i ons rev eal that pat i ent s at i s fact i on wi th FRPDs i s hi gh, the equi pm
ent cos ts and technol ogy to m ake them are l ow, and the
aes thet i cs can al s o be outs tandi ng when com pared to conv ent i onal m etal -bas ed
RPDs .
FRPDs are ex trem el y us eful as a prov i s i onal i n l i eu of res torat i v e tem porari es
or a s tandard acry l i c part i al . Whi l e the cos t i s a l i t t l e
m ore, the hi gher pat i ent s at i s fact i on us ual l y found wi th thes e, and the fact that
they wi l l not break, i s worth any ex tra ex pens e. No
repai rs are neces s ary , and no pat i ents are at the door wi th a broken acry l i c part i al i
n hand.
FRPDs hav e al s o been us ed s ucces s ful l y as obturators i n conj unct i on wi th m ax i l l
ectom y procedures . The wei ght of the appl i ance
(V al pl as t) i s us ual l y about one thi rd that of the conv ent i onal obturator. ln addi t i
on, the cl as pi ng and s tabi l i ty potent i al s can of ten far
ex ceed that of a m etal -bas ed RPD us ed i n the s am e fas hi on.
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When l f i rs t s tarted encouragi ng others to try a FRPD (s peci f i cal l y V al pl as t), l
found that s ev eral of m y fri ends had tri ed i t and had a
s om ewhat di s couragi ng ex peri ence. Rather then ex tol l i ng i ts v i rtues , l was curi
ous to know what probl em s they had ex peri enced.
Ques t i oni ng ex pos ed a bas i c f l aw i n thei r ex ecut i on and des i gn, i n that they
treated (whether i ntent i onal l y or not) V al pl as t as s om e
ki nd of di f ferent acry l i c. Our dental ex peri ences are s haped by acry l i c, s peci f i
cal l y form s of m ethy l m ethacry l ate. We of ten carry thi s
"acry l i c bi as " wi th us i nto other areas wi thout real i z i ng i t . FRPDs are not j us t s
om e other form of m ethy l m ethacry l ate, and at tem pt i ng
to treat i t as s uch wi l l res ul t i n a di s appoi nt i ng ex peri enceguaranteed!
Thi s i s not the f i rs t t im e when new techni ques and m ateri al s hav e arri v ed i n
the f i el d of dent i s try change i s i n the ai r (not j us t from
the fum es of a s pi l l ed m onom er) and thi s i s j us t one m ore that we hav e to face!
So, the f i rs t and m os t im portant thi ng i s to el im i nate
the "acry l i c habi t ." Thi s m eans that y ou wi l l hav e to el im i nate y our tradi t i onal
thoughts about how to gri nd and adj us t thi s f l ex i bl e
m ateri al . l t i s not eas i l y adj us ted, es peci al l y i f y ou at tem pt to do i t wi th i
ns trum ents and burs wi th whi ch y ou are us ed to adj us t i ng
acry l i c. The nex t thi ng y ou need to l et go of i s the "cl as p habi t ." Fl ex i bl e pol y ny
l on (V al pl as t) i s not wrought wi re or PGP wi re to be
s ol dered to a cas t fram ework. l t i s al s o not cas t round, cas t tapered, "back to
back," and i s not j us t l i ke any other m etal cl as p. M etal
cl as p rul es appl y to m etal cl as ps , not to V al pl as t . The qui ckes t way to end up wi
th bad res ul ts i s to confus e the 2, a m i s take that far
too m any com m erci al l aboratori es are s t i l l m aki ng.
Thi s trans l ates to the bas i c concept : care and at tent i on i s needed to s ucces s ful l y
des i gn and ut i l i z e thi s m ateri al for a rem ov abl e
pros thes i s .
MODE LS, SURVE Y lNG , AND TOOTH PRE PARATlON
F igure l. A es thet i c part i al s are
pos s i bl e wi th m odern m ateri al s and
thought ful des i gns .
F igure 2. Li ght enam el opl as ty to
create s urv ey z one.
A s i n m os t thi ngs i n dent i s try , the FRPD begi ns wi th an accurate di agnos t i c m
odel . A n accurate oppos i ng m odel i s al s o es s ent i al
s i nce the occl us i on wi l l di ctate the pl acem ent of com ponents ; and becaus e s ucces
s can onl y com e through careful cons i derat i on
and i ncorporat i on of the occl us i on i nto the f i nal des i gn.
Surv ey the teeth on the s tone m odel : l ev el the pl ane of occl us i on, s tabi l i z e the s
urv ey or tabl e, and run the carbon rod around the
teeth. That ' s the s urv ey l i ne. l t s ounds dangerous l y tradi t i onal , but i s now a
new concept . M etal cl as ps were al l about s urv ey l i nes ,
bei ng abov e them or bei ng bel ow them . Thi s concept , al though im portant , i s di f
ferent wi th f l ex i bl e part i al s . Pol y ny l on/V al pl as t l i kes a
"s urv ey z one," not a s urv ey l i ne. The s urv ey l i ne j us t i ndi cates to y ou where y
ou are goi ng to take a f i ne-tapered di am ond and do a
l i t t l e enam el opl as ty (Fi gure 2). Thi nk of i t as m aki ng a 2.0 m m gui depl ane that
goes around the tooth. That s urv ey z one, or
ci rcum ferent i al gui depl ane, i s the generator of the requi red s tabi l i ty and retent i on.
A LOOK AT CLASP DE SlG NS
F igure 3. Bul k i s not requi red for
s trength or retent i on.
F igure 4. A ci rcum ferent i al cl as p.
F igure 5. A 2-tooth cont i nuous cl as p. F igure 6. Ci rcum ferent i al cl as p for a
m es i al l y -t i pped di s tal m ol ar.
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F igure 7. A com bi nat i on cl as p. F igure 8. Preparat i on to al l ow for
cros s i ng the occl us al tabl e.
Let ' s f i rs t cons i der the des i gn of the "s tandard" or "m ai n" cl as p. l f y ou l ook at
any FRPD adv ert i s em ent y ou wi l l s ee the bas i c "m ai n
cl as p" (Fi gure 3). Thi s i s certai nl y a us eful cl as p, but i ts des i gn i s of ten far too
l arge and bul ky . Tooth preparat i on to im prov e the
contact z one i s es s ent i al for i ncreas ed retent i on and s tabi l i ty . Thes e do not need
to cov er l arge am ounts of tooth s tructure. A few
m i l l im eters of tooth contact and a few m i l l im eters of t i s s ue contact are al l that i
s neces s ary for retent i on and s tabi l i ty . M ore i s not
bet ter!
The ci rcum ferent i al cl as p (Fi gure 4) i s j us t that . l t goes total l y around a free-s
tandi ng tooth. l t can al s o engage al l av ai l abl e s urfaces
of m ul t i pl e teeth (Fi gure 5), i n whi ch cas e i t m ay be referred to as a "cont i nuous ci
rcum ferent i al cl as p." Thi s i s an i deal cl as p for a
free-s tandi ng, m es i al l y -t i pped di s tal abutm ent (Fi gure 6). What m akes thi s cl as
p s o unbel i ev abl y retent i v e i s the prepared s urv ey
z one.
The com bi nat i on cl as p (Fi gure 7) i s , i n fact , a com bi nat i on of the ci rcum ferent i al
cl as p and the conv ent i onal m ai n cl as p. l ts key
i ngredi ent i s a com ponent that cros s es the occl us al tabl e. Thi s com ponent al s o
acts as a "res t s eat" and al though i t m ay or m ay not
trans fer l oad to the ax i al root of the tooth, i t certai nl y does prov i de s tabi l i ty
and s trength to the FRPD by l i nki ng the pal atal (or l i ngual )
com ponents to the buccal . Thi s bas i c engi neeri ng concept of m utual rei nforcem ent
cannot be ov erl ooked or di s carded. Thi s can be
accom pl i s hed through a prepared s l ot (Fi gure 7), i f occl us i on or res -torat i ons do not
perm i t ; or through a wi de em bras ure s pace that
m ay be enl arged wi th a di am ond (Fi gure 8). V al pl as t does not hav e to be thi ck and
bul ky , howev er, i t does need a reas onabl e
am ount of m ateri al for s trength. Therefore, i t m us t be rei nforced by com ponents
that l i nk the pal atal / l i ngual wi th the buccal .
TROUBLE SHOOTlNG : CLASP DE SlG NS TO AVOlD
F igure 9. The "reach around"cl as p
des i gn s houl d be av oi ded.
F igure l0. Separated cl as ps that
l os e s trength and funct i on.
F igure ll. A hopel es s 2-tooth cl as p
that wi l l hi nge open, prov i di ng no
s trength or retent i on.
F igure l2. A wel l -des i gned f l ex i bl e
rem ov abl e part i al denture wi th 2
ci rcum ferent i al cl as ps and 2
com bi nat i on cl as ps .
The "reach-around cl as p" i s alm os t the s i ngl e wors t des i gn concept (Fi gure 9). l t
has to be wax ed thi ck for adequate s trength, and as
a res ul t , i t becom es bul ky and uncom fortabl e. l recent l y recei v ed s uch a cl as p
des i gn from a l aboratory where the pros thet i c
techni ci an di d not unders tand the concept of s urv ey area, the ci rcum ferent i al cl as p,
or com bi nat i on cl as p des i gn. The pat i ent was not
im pres s ed by the s i z e, l ook, or feel of what they prov i ded for us . Thi s ty pe of cl
as p i s us ual l y done by a dental techni ci an that s im pl y
does not unders tand the concept of cros s i ng the occl us al tabl e for s trength, ri gi di ty
, and retent i on.
The "s eparated" cl as ps (Fi gure l0) are al s o a was te of s trength and retent i on. Thes e
are cl as ps from a l aboratory i n whi ch the
pros thet i c techni ci an s t i l l thought cl as ps were m ade of m etal and had to be s
eparate. Thi s techni ci an s acri f i ced al l the s trength of the
ci rcum ferent i al cl as p and gai ned nothi ng i n ex change.
The pri z e for s im pl y the wors t des i gn and ex ecut i on i s the 2-tooth cl as p (Fi gure
ll). Cl i ni cal l y i t wi l l al way s be a fai l ure. Thi s i s
becaus e the phy s i cs wi l l force the uns upported end to hi nge away from the tooth s
urface when i t i s s eated. l t wi l l hav e abs ol utel y no
funct i on, no retent i on, and be of no us e. The onl y thi ng pos s i bl e here was to rem ov
e i t .
Dr. Virendra Vikram Singh
(25.03.20l2 (09:25:54))
Dr Annie Thomas
(22.02.20l3 (09:40:32))
RSS
Com m ent
A nt i s pam protect i on
Nam e
Em ai l
Subj ect
CONCLUSlON
The us e of FRPDs i s growi ng. Pat i ent s ucces s i s hi gh s i nce thes e appl i ances
can be ex trem el y aes thet i c. One m us t rem em ber that
careful at tent i on m us t be pai d to the bas i c concepts of di agnos i s and des i gn, and a
di f ferent approach to cl as p des i gn i s es s ent i al
(Fi gure l2).
l certai nl y do not bel i ev e that (FRPDs ) are the ans wer to ev ery thi ng. Howev er,
they repres ent a great s tri de forward as an ex cel l ent
pros thet i c choi ce av ai l abl e for our pat i ents . When appropri ate, thei r us e s houl d be
cons i dered by dental heal th profes s i onal s as a
v i abl e treatm ent opt i on.
Di scl osure: Dr. Kapl an has no rel at i onshi p wi th Val pl ast or any dental product com
pany.
Dr. Kaplan i s a graduate of lndi ana Uni v ers i ty School of Dent i s try . He recei v ed hi s
pos tgraduate pros thodont i c trai ni ng through the A i r
Force at Wi l ford Hal l M edi cal Center, and com pl eted hi s M ax i l l ofaci al Pros thodont i
c Fel l ows hi p at the Uni v ers i ty of Chi cago. He i s
current l y worki ng wi th the US A rm y i n Wi es baden, Germ any , and can be reached at
pgk.dent@gm ai l .com .
Hide comment form
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Masters in Prosthetics
Thi nki ng of pres ent i ng a j ournal Cl ub on Dr Kapl ans Fl ex i bl e Rem ov abl e Part i al
Dentures : Des i gn and Cl as p
Concepts .
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l 'm s o gl ad i read thi s art i cl e. Concepts that i i nev er knew when i m ade thes e
dentures for the pat i ents and was
nev er tol d that by the l ab ei ther. l was nev er tol d that i s houl d s urv ey the m
odel s . Thank y ou for the v al i d
i nform at i on.Current l y worki ng on a cas e. Wi l l i ncorporate what i l earnt i n thi s .
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Top M ORE_lNFO
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
Flexible Removable Partial Dentures: Design and Clasp Concepts
Wri tten by P aul Kapl an , M Sci , D D S, M SD
Sunday, 30 N ovem ber 2008 l9:00
The us e of aes thet i c f l ex i bl e rem ov abl e part i al dentures (FRPD) has s ky
-rocketed ov er the l as t s ev eral y ears (Fi gure l). M ul t i pl e
adv ert i s em ents can be found i n ev ery j ournal wi th l aboratori es prom ot i ng l ower
cos t (com pared to conv ent i onal part i al dentures wi th
cas t fram eworks ), fas t s erv i ce, and bet ter aes thet i cs than conv ent i onal m etal
-bas ed rem ov abl e part i al dentures (RPD). ln s peaki ng
wi th pros thodont i s ts , l s t i l l get the feel i ng they bel i ev e that the us e of FRPDs
i s s om ehow s t i l l not qui te the ri ght thi ng to do.
A l though, s om e are now openl y adm i t t i ng that thes e pros thes es m ay , i n fact ,
hav e thei r pl ace, l thi nk that m any are s t i l l a bi t uns ure
about ex act l y what that pl ace i s . Thi s art i cl e wi l l des cri be techni ques needed to
prov i de aes thet i c FRPDs to y our pat i ents , and l wi l l
al s o s hare m y opi ni ons regardi ng thes e appl i ances and the need to em brace them
as a v i abl e treatm ent opt i on.
RlG lD ME TAL-BASE D RPDS VE RSUS F LE XlBLE RPDS
Part of the probl em for s om e to accept FRPDs i s that they don t j us t v i ol ate m
any of the "rul es " of RPDs they s im pl y i gnore them .
A nd y et , des pi te thi s , they are s t i l l s ucces s ful . There are no res t s eats trans m i
t t i ng the ax i al l oad down the l ong ax i s of the tooth.
There are no i nfra-bul ge cl as ps and s upra-bul ge cl as ps (i n the tradi t i onal s ens e),
and the t i s s ue does not s eem to care that thes e
dev i ces are non-ri gi d. A l l thes e thi ngs v i ol ate the tradi t i onal concepts of cl as s
i c m etal -bas ed (ri gi d) RPD des i gn. A nd y et , there are a
rapi dl y growi ng num ber of thes e appl i ances bei ng del i v ered to pat i ents ev ery y
ear, dem ons trat i ng that thei r popul ari ty i s s pri ngi ng
from pract i ci ng dent i s ts , and not from dental s chool s and/or l eadi ng pros thodont i s
ts .
There i s l i t t l e cl as s i c s ci ent i f i c res earch to s upport the us e of FPRDs , and the
cons tel l at i on of art i cl es and thought that s urround
tradi t i onal m etal -cl as ped (ri gi d) RPDs does not y et ex i s t for thes e dev i ces .
lnteres t i ngl y , i f one reads through enough art i cl es
begi nni ng wi th cl as p concepts ori gi nat i ng i n the "Dental Cos m os " of the earl y
l930s , i t becom es cl ear that cl as p des i gn for m etal -bas ed RPDs i s i n truth v ery
m uch a m at ter of opi ni on and conj ecture. Ev en hard core "s ci ent i f i c" art i cl es
l i ke thos e bas ed on s tres s s tudi es us i ng l i ght refract i on m odel s (Do thes e trul y
ref l ect what i s happeni ng i n bone and t i s s ue?); or
thos e bas ed on v ari ous l ab dev i ces that s how m ov em ent / f l ex ure of arm s /cl as ps
under deform at i on (They m ay be great m etal l urgi cal
s tudi es , but are they di rect l y and cl i ni cal l y ap-pl i cabl e?); and the m ul t i tude of
art i cl es wi th drawi ng af ter drawi ng s howi ng poi nts of
rotat i on, res t s eat ax i al l oad, and s o onare accepted as s tone-hard truth. l f hi s
tory s hows us one thi ng, i t i s that facts can be
m ani pul ated to s upport any num ber of concepts , and that the general cons ens us on
s om ethi ng m ay hav e s om e bui l t i n errors . ln
other words , i t can be qui te di f f i cul t to s eparate fact from f i ct i on.
OBSE RVATlONS AND lNDlCATlONS
From the pers pect i v e of m y pers onal cl i ni cal ex peri ence, the facts are s im pl e:
FRPDs (s uch as V al pl as t [V al pl as t lnternat i onal , lnc. ])
work ex trem el y wel l i n s om e s i tuat i ons , and reas onabl y wel l i n others . A l though
s om e peri odont i s ts hav e been qui ck to tel l of s om e
cas es or s i tuat i ons where t i s s ue s tri ppi ng has occurred wi th the us e of thes e appl
i ances , l hav e not obs erv ed thi s condi t i on i n
cas es that l hav e done, nor i n pat i ents that l hav e s een who were treated by other
dent i s ts . ln the s m al l num ber of pat i ents l hav e
obs erv ed who hav e worn FRPDs for an ex tended peri od of t im e, l hav e not s een
bone dam age or res orpt i on i n the tradi t i onal pat tern
of pos teri or ri dge res orpt i on (s addl e ri dge) that i s s o com m on under chrom e/acry l i
c s addl es us ed on m etal -bas ed RPDs . Tim e and
i ncreas ed pat i ent ut i l i z at i on m ay bri ng s om e of thes e i s s ues forward, but for
the m om ent they do not s eem to be a probl em . Pres ent
obs erv at i ons rev eal that pat i ent s at i s fact i on wi th FRPDs i s hi gh, the equi pm
ent cos ts and technol ogy to m ake them are l ow, and the
aes thet i cs can al s o be outs tandi ng when com pared to conv ent i onal m etal -bas ed
RPDs .
FRPDs are ex trem el y us eful as a prov i s i onal i n l i eu of res torat i v e tem porari es
or a s tandard acry l i c part i al . Whi l e the cos t i s a l i t t l e
m ore, the hi gher pat i ent s at i s fact i on us ual l y found wi th thes e, and the fact that
they wi l l not break, i s worth any ex tra ex pens e. No
repai rs are neces s ary , and no pat i ents are at the door wi th a broken acry l i c part i al i
n hand.
FRPDs hav e al s o been us ed s ucces s ful l y as obturators i n conj unct i on wi th m ax i l l
ectom y procedures . The wei ght of the appl i ance
(V al pl as t) i s us ual l y about one thi rd that of the conv ent i onal obturator. ln addi t i
on, the cl as pi ng and s tabi l i ty potent i al s can of ten far
ex ceed that of a m etal -bas ed RPD us ed i n the s am e fas hi on.
MATE RlAL CONSlDE RATlONS AND DE SlG N CONCE PTS
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When l f i rs t s tarted encouragi ng others to try a FRPD (s peci f i cal l y V al pl as t), l
found that s ev eral of m y fri ends had tri ed i t and had a
s om ewhat di s couragi ng ex peri ence. Rather then ex tol l i ng i ts v i rtues , l was curi
ous to know what probl em s they had ex peri enced.
Ques t i oni ng ex pos ed a bas i c f l aw i n thei r ex ecut i on and des i gn, i n that they
treated (whether i ntent i onal l y or not) V al pl as t as s om e
ki nd of di f ferent acry l i c. Our dental ex peri ences are s haped by acry l i c, s peci f i
cal l y form s of m ethy l m ethacry l ate. We of ten carry thi s
"acry l i c bi as " wi th us i nto other areas wi thout real i z i ng i t . FRPDs are not j us t s
om e other form of m ethy l m ethacry l ate, and at tem pt i ng
to treat i t as s uch wi l l res ul t i n a di s appoi nt i ng ex peri enceguaranteed!
Thi s i s not the f i rs t t im e when new techni ques and m ateri al s hav e arri v ed i n
the f i el d of dent i s try change i s i n the ai r (not j us t from
the fum es of a s pi l l ed m onom er) and thi s i s j us t one m ore that we hav e to face!
So, the f i rs t and m os t im portant thi ng i s to el im i nate
the "acry l i c habi t ." Thi s m eans that y ou wi l l hav e to el im i nate y our tradi t i onal
thoughts about how to gri nd and adj us t thi s f l ex i bl e
m ateri al . l t i s not eas i l y adj us ted, es peci al l y i f y ou at tem pt to do i t wi th i
ns trum ents and burs wi th whi ch y ou are us ed to adj us t i ng
acry l i c. The nex t thi ng y ou need to l et go of i s the "cl as p habi t ." Fl ex i bl e pol y ny
l on (V al pl as t) i s not wrought wi re or PGP wi re to be
s ol dered to a cas t fram ework. l t i s al s o not cas t round, cas t tapered, "back to
back," and i s not j us t l i ke any other m etal cl as p. M etal
cl as p rul es appl y to m etal cl as ps , not to V al pl as t . The qui ckes t way to end up wi
th bad res ul ts i s to confus e the 2, a m i s take that far
too m any com m erci al l aboratori es are s t i l l m aki ng.
Thi s trans l ates to the bas i c concept : care and at tent i on i s needed to s ucces s ful l y
des i gn and ut i l i z e thi s m ateri al for a rem ov abl e
pros thes i s .
MODE LS, SURVE Y lNG , AND TOOTH PRE PARATlON
F igure l. A es thet i c part i al s are
pos s i bl e wi th m odern m ateri al s and
thought ful des i gns .
F igure 2. Li ght enam el opl as ty to
create s urv ey z one.
A s i n m os t thi ngs i n dent i s try , the FRPD begi ns wi th an accurate di agnos t i c m
odel . A n accurate oppos i ng m odel i s al s o es s ent i al
s i nce the occl us i on wi l l di ctate the pl acem ent of com ponents ; and becaus e s ucces
s can onl y com e through careful cons i derat i on
and i ncorporat i on of the occl us i on i nto the f i nal des i gn.
Surv ey the teeth on the s tone m odel : l ev el the pl ane of occl us i on, s tabi l i z e the s
urv ey or tabl e, and run the carbon rod around the
teeth. That ' s the s urv ey l i ne. l t s ounds dangerous l y tradi t i onal , but i s now a
new concept . M etal cl as ps were al l about s urv ey l i nes ,
bei ng abov e them or bei ng bel ow them . Thi s concept , al though im portant , i s di f
ferent wi th f l ex i bl e part i al s . Pol y ny l on/V al pl as t l i kes a
"s urv ey z one," not a s urv ey l i ne. The s urv ey l i ne j us t i ndi cates to y ou where y
ou are goi ng to take a f i ne-tapered di am ond and do a
l i t t l e enam el opl as ty (Fi gure 2). Thi nk of i t as m aki ng a 2.0 m m gui depl ane that
goes around the tooth. That s urv ey z one, or
ci rcum ferent i al gui depl ane, i s the generator of the requi red s tabi l i ty and retent i on.
A LOOK AT CLASP DE SlG NS
F igure 3. Bul k i s not requi red for
s trength or retent i on.
F igure 4. A ci rcum ferent i al cl as p.
F igure 5. A 2-tooth cont i nuous cl as p. F igure 6. Ci rcum ferent i al cl as p for a
m es i al l y -t i pped di s tal m ol ar.
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Viewpoint
F igure 7. A com bi nat i on cl as p. F igure 8. Preparat i on to al l ow for
cros s i ng the occl us al tabl e.
Let ' s f i rs t cons i der the des i gn of the "s tandard" or "m ai n" cl as p. l f y ou l ook at
any FRPD adv ert i s em ent y ou wi l l s ee the bas i c "m ai n
cl as p" (Fi gure 3). Thi s i s certai nl y a us eful cl as p, but i ts des i gn i s of ten far too
l arge and bul ky . Tooth preparat i on to im prov e the
contact z one i s es s ent i al for i ncreas ed retent i on and s tabi l i ty . Thes e do not need
to cov er l arge am ounts of tooth s tructure. A few
m i l l im eters of tooth contact and a few m i l l im eters of t i s s ue contact are al l that i
s neces s ary for retent i on and s tabi l i ty . M ore i s not
bet ter!
The ci rcum ferent i al cl as p (Fi gure 4) i s j us t that . l t goes total l y around a free-s
tandi ng tooth. l t can al s o engage al l av ai l abl e s urfaces
of m ul t i pl e teeth (Fi gure 5), i n whi ch cas e i t m ay be referred to as a "cont i nuous ci
rcum ferent i al cl as p." Thi s i s an i deal cl as p for a
free-s tandi ng, m es i al l y -t i pped di s tal abutm ent (Fi gure 6). What m akes thi s cl as
p s o unbel i ev abl y retent i v e i s the prepared s urv ey
z one.
The com bi nat i on cl as p (Fi gure 7) i s , i n fact , a com bi nat i on of the ci rcum ferent i al
cl as p and the conv ent i onal m ai n cl as p. l ts key
i ngredi ent i s a com ponent that cros s es the occl us al tabl e. Thi s com ponent al s o
acts as a "res t s eat" and al though i t m ay or m ay not
trans fer l oad to the ax i al root of the tooth, i t certai nl y does prov i de s tabi l i ty
and s trength to the FRPD by l i nki ng the pal atal (or l i ngual )
com ponents to the buccal . Thi s bas i c engi neeri ng concept of m utual rei nforcem ent
cannot be ov erl ooked or di s carded. Thi s can be
accom pl i s hed through a prepared s l ot (Fi gure 7), i f occl us i on or res -torat i ons do not
perm i t ; or through a wi de em bras ure s pace that
m ay be enl arged wi th a di am ond (Fi gure 8). V al pl as t does not hav e to be thi ck and
bul ky , howev er, i t does need a reas onabl e
am ount of m ateri al for s trength. Therefore, i t m us t be rei nforced by com ponents
that l i nk the pal atal / l i ngual wi th the buccal .
TROUBLE SHOOTlNG : CLASP DE SlG NS TO AVOlD
F igure 9. The "reach around"cl as p
des i gn s houl d be av oi ded.
F igure l0. Separated cl as ps that
l os e s trength and funct i on.
F igure ll. A hopel es s 2-tooth cl as p
that wi l l hi nge open, prov i di ng no
s trength or retent i on.
F igure l2. A wel l -des i gned f l ex i bl e
rem ov abl e part i al denture wi th 2
ci rcum ferent i al cl as ps and 2
com bi nat i on cl as ps .
The "reach-around cl as p" i s alm os t the s i ngl e wors t des i gn concept (Fi gure 9). l t
has to be wax ed thi ck for adequate s trength, and as
a res ul t , i t becom es bul ky and uncom fortabl e. l recent l y recei v ed s uch a cl as p
des i gn from a l aboratory where the pros thet i c
techni ci an di d not unders tand the concept of s urv ey area, the ci rcum ferent i al cl as p,
or com bi nat i on cl as p des i gn. The pat i ent was not
im pres s ed by the s i z e, l ook, or feel of what they prov i ded for us . Thi s ty pe of cl
as p i s us ual l y done by a dental techni ci an that s im pl y
does not unders tand the concept of cros s i ng the occl us al tabl e for s trength, ri gi di ty
, and retent i on.
The "s eparated" cl as ps (Fi gure l0) are al s o a was te of s trength and retent i on. Thes e
are cl as ps from a l aboratory i n whi ch the
pros thet i c techni ci an s t i l l thought cl as ps were m ade of m etal and had to be s
eparate. Thi s techni ci an s acri f i ced al l the s trength of the
ci rcum ferent i al cl as p and gai ned nothi ng i n ex change.
The pri z e for s im pl y the wors t des i gn and ex ecut i on i s the 2-tooth cl as p (Fi gure
ll). Cl i ni cal l y i t wi l l al way s be a fai l ure. Thi s i s
becaus e the phy s i cs wi l l force the uns upported end to hi nge away from the tooth s
urface when i t i s s eated. l t wi l l hav e abs ol utel y no
funct i on, no retent i on, and be of no us e. The onl y thi ng pos s i bl e here was to rem ov
e i t .
Dr. Virendra Vikram Singh
(25.03.20l2 (09:25:54))
Dr Annie Thomas
(22.02.20l3 (09:40:32))
RSS
Com m ent
A nt i s pam protect i on
Nam e
Em ai l
Subj ect
CONCLUSlON
The us e of FRPDs i s growi ng. Pat i ent s ucces s i s hi gh s i nce thes e appl i ances
can be ex trem el y aes thet i c. One m us t rem em ber that
careful at tent i on m us t be pai d to the bas i c concepts of di agnos i s and des i gn, and a
di f ferent approach to cl as p des i gn i s es s ent i al
(Fi gure l2).
l certai nl y do not bel i ev e that (FRPDs ) are the ans wer to ev ery thi ng. Howev er,
they repres ent a great s tri de forward as an ex cel l ent
pros thet i c choi ce av ai l abl e for our pat i ents . When appropri ate, thei r us e s houl d be
cons i dered by dental heal th profes s i onal s as a
v i abl e treatm ent opt i on.
Di scl osure: Dr. Kapl an has no rel at i onshi p wi th Val pl ast or any dental product com
pany.
Dr. Kaplan i s a graduate of lndi ana Uni v ers i ty School of Dent i s try . He recei v ed hi s
pos tgraduate pros thodont i c trai ni ng through the A i r
Force at Wi l ford Hal l M edi cal Center, and com pl eted hi s M ax i l l ofaci al Pros thodont i
c Fel l ows hi p at the Uni v ers i ty of Chi cago. He i s
current l y worki ng wi th the US A rm y i n Wi es baden, Germ any , and can be reached at
pgk.dent@gm ai l .com .
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Thi nki ng of pres ent i ng a j ournal Cl ub on Dr Kapl ans Fl ex i bl e Rem ov abl e Part i al
Dentures : Des i gn and Cl as p
Concepts .
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l 'm s o gl ad i read thi s art i cl e. Concepts that i i nev er knew when i m ade thes e
dentures for the pat i ents and was
nev er tol d that by the l ab ei ther. l was nev er tol d that i s houl d s urv ey the m
odel s . Thank y ou for the v al i d
i nform at i on.Current l y worki ng on a cas e. Wi l l i ncorporate what i l earnt i n thi s .
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Copy ri ght 20l4 Dent i s try Today . A l l Ri ghts Res erv ed.
Top M ORE_lNFO
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
Flexible Removable Partial Dentures: Design and Clasp Concepts
Wri tten by P aul Kapl an , M Sci , D D S, M SD
Sunday, 30 N ovem ber 2008 l9:00
The us e of aes thet i c f l ex i bl e rem ov abl e part i al dentures (FRPD) has s ky
-rocketed ov er the l as t s ev eral y ears (Fi gure l). M ul t i pl e
adv ert i s em ents can be found i n ev ery j ournal wi th l aboratori es prom ot i ng l ower
cos t (com pared to conv ent i onal part i al dentures wi th
cas t fram eworks ), fas t s erv i ce, and bet ter aes thet i cs than conv ent i onal m etal
-bas ed rem ov abl e part i al dentures (RPD). ln s peaki ng
wi th pros thodont i s ts , l s t i l l get the feel i ng they bel i ev e that the us e of FRPDs
i s s om ehow s t i l l not qui te the ri ght thi ng to do.
A l though, s om e are now openl y adm i t t i ng that thes e pros thes es m ay , i n fact ,
hav e thei r pl ace, l thi nk that m any are s t i l l a bi t uns ure
about ex act l y what that pl ace i s . Thi s art i cl e wi l l des cri be techni ques needed to
prov i de aes thet i c FRPDs to y our pat i ents , and l wi l l
al s o s hare m y opi ni ons regardi ng thes e appl i ances and the need to em brace them
as a v i abl e treatm ent opt i on.
RlG lD ME TAL-BASE D RPDS VE RSUS F LE XlBLE RPDS
Part of the probl em for s om e to accept FRPDs i s that they don t j us t v i ol ate m
any of the "rul es " of RPDs they s im pl y i gnore them .
A nd y et , des pi te thi s , they are s t i l l s ucces s ful . There are no res t s eats trans m i
t t i ng the ax i al l oad down the l ong ax i s of the tooth.
There are no i nfra-bul ge cl as ps and s upra-bul ge cl as ps (i n the tradi t i onal s ens e),
and the t i s s ue does not s eem to care that thes e
dev i ces are non-ri gi d. A l l thes e thi ngs v i ol ate the tradi t i onal concepts of cl as s
i c m etal -bas ed (ri gi d) RPD des i gn. A nd y et , there are a
rapi dl y growi ng num ber of thes e appl i ances bei ng del i v ered to pat i ents ev ery y
ear, dem ons trat i ng that thei r popul ari ty i s s pri ngi ng
from pract i ci ng dent i s ts , and not from dental s chool s and/or l eadi ng pros thodont i s
ts .
There i s l i t t l e cl as s i c s ci ent i f i c res earch to s upport the us e of FPRDs , and the
cons tel l at i on of art i cl es and thought that s urround
tradi t i onal m etal -cl as ped (ri gi d) RPDs does not y et ex i s t for thes e dev i ces .
lnteres t i ngl y , i f one reads through enough art i cl es
begi nni ng wi th cl as p concepts ori gi nat i ng i n the "Dental Cos m os " of the earl y
l930s , i t becom es cl ear that cl as p des i gn for m etal -bas ed RPDs i s i n truth v ery
m uch a m at ter of opi ni on and conj ecture. Ev en hard core "s ci ent i f i c" art i cl es
l i ke thos e bas ed on s tres s s tudi es us i ng l i ght refract i on m odel s (Do thes e trul y
ref l ect what i s happeni ng i n bone and t i s s ue?); or
thos e bas ed on v ari ous l ab dev i ces that s how m ov em ent / f l ex ure of arm s /cl as ps
under deform at i on (They m ay be great m etal l urgi cal
s tudi es , but are they di rect l y and cl i ni cal l y ap-pl i cabl e?); and the m ul t i tude of
art i cl es wi th drawi ng af ter drawi ng s howi ng poi nts of
rotat i on, res t s eat ax i al l oad, and s o onare accepted as s tone-hard truth. l f hi s
tory s hows us one thi ng, i t i s that facts can be
m ani pul ated to s upport any num ber of concepts , and that the general cons ens us on
s om ethi ng m ay hav e s om e bui l t i n errors . ln
other words , i t can be qui te di f f i cul t to s eparate fact from f i ct i on.
OBSE RVATlONS AND lNDlCATlONS
From the pers pect i v e of m y pers onal cl i ni cal ex peri ence, the facts are s im pl e:
FRPDs (s uch as V al pl as t [V al pl as t lnternat i onal , lnc. ])
work ex trem el y wel l i n s om e s i tuat i ons , and reas onabl y wel l i n others . A l though
s om e peri odont i s ts hav e been qui ck to tel l of s om e
cas es or s i tuat i ons where t i s s ue s tri ppi ng has occurred wi th the us e of thes e appl
i ances , l hav e not obs erv ed thi s condi t i on i n
cas es that l hav e done, nor i n pat i ents that l hav e s een who were treated by other
dent i s ts . ln the s m al l num ber of pat i ents l hav e
obs erv ed who hav e worn FRPDs for an ex tended peri od of t im e, l hav e not s een
bone dam age or res orpt i on i n the tradi t i onal pat tern
of pos teri or ri dge res orpt i on (s addl e ri dge) that i s s o com m on under chrom e/acry l i
c s addl es us ed on m etal -bas ed RPDs . Tim e and
i ncreas ed pat i ent ut i l i z at i on m ay bri ng s om e of thes e i s s ues forward, but for
the m om ent they do not s eem to be a probl em . Pres ent
obs erv at i ons rev eal that pat i ent s at i s fact i on wi th FRPDs i s hi gh, the equi pm
ent cos ts and technol ogy to m ake them are l ow, and the
aes thet i cs can al s o be outs tandi ng when com pared to conv ent i onal m etal -bas ed
RPDs .
FRPDs are ex trem el y us eful as a prov i s i onal i n l i eu of res torat i v e tem porari es
or a s tandard acry l i c part i al . Whi l e the cos t i s a l i t t l e
m ore, the hi gher pat i ent s at i s fact i on us ual l y found wi th thes e, and the fact that
they wi l l not break, i s worth any ex tra ex pens e. No
repai rs are neces s ary , and no pat i ents are at the door wi th a broken acry l i c part i al i
n hand.
FRPDs hav e al s o been us ed s ucces s ful l y as obturators i n conj unct i on wi th m ax i l l
ectom y procedures . The wei ght of the appl i ance
(V al pl as t) i s us ual l y about one thi rd that of the conv ent i onal obturator. ln addi t i
on, the cl as pi ng and s tabi l i ty potent i al s can of ten far
ex ceed that of a m etal -bas ed RPD us ed i n the s am e fas hi on.
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When l f i rs t s tarted encouragi ng others to try a FRPD (s peci f i cal l y V al pl as t), l
found that s ev eral of m y fri ends had tri ed i t and had a
s om ewhat di s couragi ng ex peri ence. Rather then ex tol l i ng i ts v i rtues , l was curi
ous to know what probl em s they had ex peri enced.
Ques t i oni ng ex pos ed a bas i c f l aw i n thei r ex ecut i on and des i gn, i n that they
treated (whether i ntent i onal l y or not) V al pl as t as s om e
ki nd of di f ferent acry l i c. Our dental ex peri ences are s haped by acry l i c, s peci f i
cal l y form s of m ethy l m ethacry l ate. We of ten carry thi s
"acry l i c bi as " wi th us i nto other areas wi thout real i z i ng i t . FRPDs are not j us t s
om e other form of m ethy l m ethacry l ate, and at tem pt i ng
to treat i t as s uch wi l l res ul t i n a di s appoi nt i ng ex peri enceguaranteed!
Thi s i s not the f i rs t t im e when new techni ques and m ateri al s hav e arri v ed i n
the f i el d of dent i s try change i s i n the ai r (not j us t from
the fum es of a s pi l l ed m onom er) and thi s i s j us t one m ore that we hav e to face!
So, the f i rs t and m os t im portant thi ng i s to el im i nate
the "acry l i c habi t ." Thi s m eans that y ou wi l l hav e to el im i nate y our tradi t i onal
thoughts about how to gri nd and adj us t thi s f l ex i bl e
m ateri al . l t i s not eas i l y adj us ted, es peci al l y i f y ou at tem pt to do i t wi th i
ns trum ents and burs wi th whi ch y ou are us ed to adj us t i ng
acry l i c. The nex t thi ng y ou need to l et go of i s the "cl as p habi t ." Fl ex i bl e pol y ny
l on (V al pl as t) i s not wrought wi re or PGP wi re to be
s ol dered to a cas t fram ework. l t i s al s o not cas t round, cas t tapered, "back to
back," and i s not j us t l i ke any other m etal cl as p. M etal
cl as p rul es appl y to m etal cl as ps , not to V al pl as t . The qui ckes t way to end up wi
th bad res ul ts i s to confus e the 2, a m i s take that far
too m any com m erci al l aboratori es are s t i l l m aki ng.
Thi s trans l ates to the bas i c concept : care and at tent i on i s needed to s ucces s ful l y
des i gn and ut i l i z e thi s m ateri al for a rem ov abl e
pros thes i s .
MODE LS, SURVE Y lNG , AND TOOTH PRE PARATlON
F igure l. A es thet i c part i al s are
pos s i bl e wi th m odern m ateri al s and
thought ful des i gns .
F igure 2. Li ght enam el opl as ty to
create s urv ey z one.
A s i n m os t thi ngs i n dent i s try , the FRPD begi ns wi th an accurate di agnos t i c m
odel . A n accurate oppos i ng m odel i s al s o es s ent i al
s i nce the occl us i on wi l l di ctate the pl acem ent of com ponents ; and becaus e s ucces
s can onl y com e through careful cons i derat i on
and i ncorporat i on of the occl us i on i nto the f i nal des i gn.
Surv ey the teeth on the s tone m odel : l ev el the pl ane of occl us i on, s tabi l i z e the s
urv ey or tabl e, and run the carbon rod around the
teeth. That ' s the s urv ey l i ne. l t s ounds dangerous l y tradi t i onal , but i s now a
new concept . M etal cl as ps were al l about s urv ey l i nes ,
bei ng abov e them or bei ng bel ow them . Thi s concept , al though im portant , i s di f
ferent wi th f l ex i bl e part i al s . Pol y ny l on/V al pl as t l i kes a
"s urv ey z one," not a s urv ey l i ne. The s urv ey l i ne j us t i ndi cates to y ou where y
ou are goi ng to take a f i ne-tapered di am ond and do a
l i t t l e enam el opl as ty (Fi gure 2). Thi nk of i t as m aki ng a 2.0 m m gui depl ane that
goes around the tooth. That s urv ey z one, or
ci rcum ferent i al gui depl ane, i s the generator of the requi red s tabi l i ty and retent i on.
A LOOK AT CLASP DE SlG NS
F igure 3. Bul k i s not requi red for
s trength or retent i on.
F igure 4. A ci rcum ferent i al cl as p.
F igure 5. A 2-tooth cont i nuous cl as p. F igure 6. Ci rcum ferent i al cl as p for a
m es i al l y -t i pped di s tal m ol ar.
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F igure 7. A com bi nat i on cl as p. F igure 8. Preparat i on to al l ow for
cros s i ng the occl us al tabl e.
Let ' s f i rs t cons i der the des i gn of the "s tandard" or "m ai n" cl as p. l f y ou l ook at
any FRPD adv ert i s em ent y ou wi l l s ee the bas i c "m ai n
cl as p" (Fi gure 3). Thi s i s certai nl y a us eful cl as p, but i ts des i gn i s of ten far too
l arge and bul ky . Tooth preparat i on to im prov e the
contact z one i s es s ent i al for i ncreas ed retent i on and s tabi l i ty . Thes e do not need
to cov er l arge am ounts of tooth s tructure. A few
m i l l im eters of tooth contact and a few m i l l im eters of t i s s ue contact are al l that i
s neces s ary for retent i on and s tabi l i ty . M ore i s not
bet ter!
The ci rcum ferent i al cl as p (Fi gure 4) i s j us t that . l t goes total l y around a free-s
tandi ng tooth. l t can al s o engage al l av ai l abl e s urfaces
of m ul t i pl e teeth (Fi gure 5), i n whi ch cas e i t m ay be referred to as a "cont i nuous ci
rcum ferent i al cl as p." Thi s i s an i deal cl as p for a
free-s tandi ng, m es i al l y -t i pped di s tal abutm ent (Fi gure 6). What m akes thi s cl as
p s o unbel i ev abl y retent i v e i s the prepared s urv ey
z one.
The com bi nat i on cl as p (Fi gure 7) i s , i n fact , a com bi nat i on of the ci rcum ferent i al
cl as p and the conv ent i onal m ai n cl as p. l ts key
i ngredi ent i s a com ponent that cros s es the occl us al tabl e. Thi s com ponent al s o
acts as a "res t s eat" and al though i t m ay or m ay not
trans fer l oad to the ax i al root of the tooth, i t certai nl y does prov i de s tabi l i ty
and s trength to the FRPD by l i nki ng the pal atal (or l i ngual )
com ponents to the buccal . Thi s bas i c engi neeri ng concept of m utual rei nforcem ent
cannot be ov erl ooked or di s carded. Thi s can be
accom pl i s hed through a prepared s l ot (Fi gure 7), i f occl us i on or res -torat i ons do not
perm i t ; or through a wi de em bras ure s pace that
m ay be enl arged wi th a di am ond (Fi gure 8). V al pl as t does not hav e to be thi ck and
bul ky , howev er, i t does need a reas onabl e
am ount of m ateri al for s trength. Therefore, i t m us t be rei nforced by com ponents
that l i nk the pal atal / l i ngual wi th the buccal .
TROUBLE SHOOTlNG : CLASP DE SlG NS TO AVOlD
F igure 9. The "reach around"cl as p
des i gn s houl d be av oi ded.
F igure l0. Separated cl as ps that
l os e s trength and funct i on.
F igure ll. A hopel es s 2-tooth cl as p
that wi l l hi nge open, prov i di ng no
s trength or retent i on.
F igure l2. A wel l -des i gned f l ex i bl e
rem ov abl e part i al denture wi th 2
ci rcum ferent i al cl as ps and 2
com bi nat i on cl as ps .
The "reach-around cl as p" i s alm os t the s i ngl e wors t des i gn concept (Fi gure 9). l t
has to be wax ed thi ck for adequate s trength, and as
a res ul t , i t becom es bul ky and uncom fortabl e. l recent l y recei v ed s uch a cl as p
des i gn from a l aboratory where the pros thet i c
techni ci an di d not unders tand the concept of s urv ey area, the ci rcum ferent i al cl as p,
or com bi nat i on cl as p des i gn. The pat i ent was not
im pres s ed by the s i z e, l ook, or feel of what they prov i ded for us . Thi s ty pe of cl
as p i s us ual l y done by a dental techni ci an that s im pl y
does not unders tand the concept of cros s i ng the occl us al tabl e for s trength, ri gi di ty
, and retent i on.
The "s eparated" cl as ps (Fi gure l0) are al s o a was te of s trength and retent i on. Thes e
are cl as ps from a l aboratory i n whi ch the
pros thet i c techni ci an s t i l l thought cl as ps were m ade of m etal and had to be s
eparate. Thi s techni ci an s acri f i ced al l the s trength of the
ci rcum ferent i al cl as p and gai ned nothi ng i n ex change.
The pri z e for s im pl y the wors t des i gn and ex ecut i on i s the 2-tooth cl as p (Fi gure
ll). Cl i ni cal l y i t wi l l al way s be a fai l ure. Thi s i s
becaus e the phy s i cs wi l l force the uns upported end to hi nge away from the tooth s
urface when i t i s s eated. l t wi l l hav e abs ol utel y no
funct i on, no retent i on, and be of no us e. The onl y thi ng pos s i bl e here was to rem ov
e i t .
Dr. Virendra Vikram Singh
(25.03.20l2 (09:25:54))
Dr Annie Thomas
(22.02.20l3 (09:40:32))
RSS
Com m ent
A nt i s pam protect i on
Nam e
Em ai l
Subj ect
CONCLUSlON
The us e of FRPDs i s growi ng. Pat i ent s ucces s i s hi gh s i nce thes e appl i ances
can be ex trem el y aes thet i c. One m us t rem em ber that
careful at tent i on m us t be pai d to the bas i c concepts of di agnos i s and des i gn, and a
di f ferent approach to cl as p des i gn i s es s ent i al
(Fi gure l2).
l certai nl y do not bel i ev e that (FRPDs ) are the ans wer to ev ery thi ng. Howev er,
they repres ent a great s tri de forward as an ex cel l ent
pros thet i c choi ce av ai l abl e for our pat i ents . When appropri ate, thei r us e s houl d be
cons i dered by dental heal th profes s i onal s as a
v i abl e treatm ent opt i on.
Di scl osure: Dr. Kapl an has no rel at i onshi p wi th Val pl ast or any dental product com
pany.
Dr. Kaplan i s a graduate of lndi ana Uni v ers i ty School of Dent i s try . He recei v ed hi s
pos tgraduate pros thodont i c trai ni ng through the A i r
Force at Wi l ford Hal l M edi cal Center, and com pl eted hi s M ax i l l ofaci al Pros thodont i
c Fel l ows hi p at the Uni v ers i ty of Chi cago. He i s
current l y worki ng wi th the US A rm y i n Wi es baden, Germ any , and can be reached at
pgk.dent@gm ai l .com .
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Thi nki ng of pres ent i ng a j ournal Cl ub on Dr Kapl ans Fl ex i bl e Rem ov abl e Part i al
Dentures : Des i gn and Cl as p
Concepts .
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Regarding this article
l 'm s o gl ad i read thi s art i cl e. Concepts that i i nev er knew when i m ade thes e
dentures for the pat i ents and was
nev er tol d that by the l ab ei ther. l was nev er tol d that i s houl d s urv ey the m
odel s . Thank y ou for the v al i d
i nform at i on.Current l y worki ng on a cas e. Wi l l i ncorporate what i l earnt i n thi s .
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Copy ri ght 20l4 Dent i s try Today . A l l Ri ghts Res erv ed.
Top M ORE_lNFO
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
Flexible Removable Partial Dentures: Design and Clasp Concepts
Wri tten by P aul Kapl an , M Sci , D D S, M SD
Sunday, 30 N ovem ber 2008 l9:00
The us e of aes thet i c f l ex i bl e rem ov abl e part i al dentures (FRPD) has s ky
-rocketed ov er the l as t s ev eral y ears (Fi gure l). M ul t i pl e
adv ert i s em ents can be found i n ev ery j ournal wi th l aboratori es prom ot i ng l ower
cos t (com pared to conv ent i onal part i al dentures wi th
cas t fram eworks ), fas t s erv i ce, and bet ter aes thet i cs than conv ent i onal m etal
-bas ed rem ov abl e part i al dentures (RPD). ln s peaki ng
wi th pros thodont i s ts , l s t i l l get the feel i ng they bel i ev e that the us e of FRPDs
i s s om ehow s t i l l not qui te the ri ght thi ng to do.
A l though, s om e are now openl y adm i t t i ng that thes e pros thes es m ay , i n fact ,
hav e thei r pl ace, l thi nk that m any are s t i l l a bi t uns ure
about ex act l y what that pl ace i s . Thi s art i cl e wi l l des cri be techni ques needed to
prov i de aes thet i c FRPDs to y our pat i ents , and l wi l l
al s o s hare m y opi ni ons regardi ng thes e appl i ances and the need to em brace them
as a v i abl e treatm ent opt i on.
RlG lD ME TAL-BASE D RPDS VE RSUS F LE XlBLE RPDS
Part of the probl em for s om e to accept FRPDs i s that they don t j us t v i ol ate m
any of the "rul es " of RPDs they s im pl y i gnore them .
A nd y et , des pi te thi s , they are s t i l l s ucces s ful . There are no res t s eats trans m i
t t i ng the ax i al l oad down the l ong ax i s of the tooth.
There are no i nfra-bul ge cl as ps and s upra-bul ge cl as ps (i n the tradi t i onal s ens e),
and the t i s s ue does not s eem to care that thes e
dev i ces are non-ri gi d. A l l thes e thi ngs v i ol ate the tradi t i onal concepts of cl as s
i c m etal -bas ed (ri gi d) RPD des i gn. A nd y et , there are a
rapi dl y growi ng num ber of thes e appl i ances bei ng del i v ered to pat i ents ev ery y
ear, dem ons trat i ng that thei r popul ari ty i s s pri ngi ng
from pract i ci ng dent i s ts , and not from dental s chool s and/or l eadi ng pros thodont i s
ts .
There i s l i t t l e cl as s i c s ci ent i f i c res earch to s upport the us e of FPRDs , and the
cons tel l at i on of art i cl es and thought that s urround
tradi t i onal m etal -cl as ped (ri gi d) RPDs does not y et ex i s t for thes e dev i ces .
lnteres t i ngl y , i f one reads through enough art i cl es
begi nni ng wi th cl as p concepts ori gi nat i ng i n the "Dental Cos m os " of the earl y
l930s , i t becom es cl ear that cl as p des i gn for m etal -bas ed RPDs i s i n truth v ery
m uch a m at ter of opi ni on and conj ecture. Ev en hard core "s ci ent i f i c" art i cl es
l i ke thos e bas ed on s tres s s tudi es us i ng l i ght refract i on m odel s (Do thes e trul y
ref l ect what i s happeni ng i n bone and t i s s ue?); or
thos e bas ed on v ari ous l ab dev i ces that s how m ov em ent / f l ex ure of arm s /cl as ps
under deform at i on (They m ay be great m etal l urgi cal
s tudi es , but are they di rect l y and cl i ni cal l y ap-pl i cabl e?); and the m ul t i tude of
art i cl es wi th drawi ng af ter drawi ng s howi ng poi nts of
rotat i on, res t s eat ax i al l oad, and s o onare accepted as s tone-hard truth. l f hi s
tory s hows us one thi ng, i t i s that facts can be
m ani pul ated to s upport any num ber of concepts , and that the general cons ens us on
s om ethi ng m ay hav e s om e bui l t i n errors . ln
other words , i t can be qui te di f f i cul t to s eparate fact from f i ct i on.
OBSE RVATlONS AND lNDlCATlONS
From the pers pect i v e of m y pers onal cl i ni cal ex peri ence, the facts are s im pl e:
FRPDs (s uch as V al pl as t [V al pl as t lnternat i onal , lnc. ])
work ex trem el y wel l i n s om e s i tuat i ons , and reas onabl y wel l i n others . A l though
s om e peri odont i s ts hav e been qui ck to tel l of s om e
cas es or s i tuat i ons where t i s s ue s tri ppi ng has occurred wi th the us e of thes e appl
i ances , l hav e not obs erv ed thi s condi t i on i n
cas es that l hav e done, nor i n pat i ents that l hav e s een who were treated by other
dent i s ts . ln the s m al l num ber of pat i ents l hav e
obs erv ed who hav e worn FRPDs for an ex tended peri od of t im e, l hav e not s een
bone dam age or res orpt i on i n the tradi t i onal pat tern
of pos teri or ri dge res orpt i on (s addl e ri dge) that i s s o com m on under chrom e/acry l i
c s addl es us ed on m etal -bas ed RPDs . Tim e and
i ncreas ed pat i ent ut i l i z at i on m ay bri ng s om e of thes e i s s ues forward, but for
the m om ent they do not s eem to be a probl em . Pres ent
obs erv at i ons rev eal that pat i ent s at i s fact i on wi th FRPDs i s hi gh, the equi pm
ent cos ts and technol ogy to m ake them are l ow, and the
aes thet i cs can al s o be outs tandi ng when com pared to conv ent i onal m etal -bas ed
RPDs .
FRPDs are ex trem el y us eful as a prov i s i onal i n l i eu of res torat i v e tem porari es
or a s tandard acry l i c part i al . Whi l e the cos t i s a l i t t l e
m ore, the hi gher pat i ent s at i s fact i on us ual l y found wi th thes e, and the fact that
they wi l l not break, i s worth any ex tra ex pens e. No
repai rs are neces s ary , and no pat i ents are at the door wi th a broken acry l i c part i al i
n hand.
FRPDs hav e al s o been us ed s ucces s ful l y as obturators i n conj unct i on wi th m ax i l l
ectom y procedures . The wei ght of the appl i ance
(V al pl as t) i s us ual l y about one thi rd that of the conv ent i onal obturator. ln addi t i
on, the cl as pi ng and s tabi l i ty potent i al s can of ten far
ex ceed that of a m etal -bas ed RPD us ed i n the s am e fas hi on.
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When l f i rs t s tarted encouragi ng others to try a FRPD (s peci f i cal l y V al pl as t), l
found that s ev eral of m y fri ends had tri ed i t and had a
s om ewhat di s couragi ng ex peri ence. Rather then ex tol l i ng i ts v i rtues , l was curi
ous to know what probl em s they had ex peri enced.
Ques t i oni ng ex pos ed a bas i c f l aw i n thei r ex ecut i on and des i gn, i n that they
treated (whether i ntent i onal l y or not) V al pl as t as s om e
ki nd of di f ferent acry l i c. Our dental ex peri ences are s haped by acry l i c, s peci f i
cal l y form s of m ethy l m ethacry l ate. We of ten carry thi s
"acry l i c bi as " wi th us i nto other areas wi thout real i z i ng i t . FRPDs are not j us t s
om e other form of m ethy l m ethacry l ate, and at tem pt i ng
to treat i t as s uch wi l l res ul t i n a di s appoi nt i ng ex peri enceguaranteed!
Thi s i s not the f i rs t t im e when new techni ques and m ateri al s hav e arri v ed i n
the f i el d of dent i s try change i s i n the ai r (not j us t from
the fum es of a s pi l l ed m onom er) and thi s i s j us t one m ore that we hav e to face!
So, the f i rs t and m os t im portant thi ng i s to el im i nate
the "acry l i c habi t ." Thi s m eans that y ou wi l l hav e to el im i nate y our tradi t i onal
thoughts about how to gri nd and adj us t thi s f l ex i bl e
m ateri al . l t i s not eas i l y adj us ted, es peci al l y i f y ou at tem pt to do i t wi th i
ns trum ents and burs wi th whi ch y ou are us ed to adj us t i ng
acry l i c. The nex t thi ng y ou need to l et go of i s the "cl as p habi t ." Fl ex i bl e pol y ny
l on (V al pl as t) i s not wrought wi re or PGP wi re to be
s ol dered to a cas t fram ework. l t i s al s o not cas t round, cas t tapered, "back to
back," and i s not j us t l i ke any other m etal cl as p. M etal
cl as p rul es appl y to m etal cl as ps , not to V al pl as t . The qui ckes t way to end up wi
th bad res ul ts i s to confus e the 2, a m i s take that far
too m any com m erci al l aboratori es are s t i l l m aki ng.
Thi s trans l ates to the bas i c concept : care and at tent i on i s needed to s ucces s ful l y
des i gn and ut i l i z e thi s m ateri al for a rem ov abl e
pros thes i s .
MODE LS, SURVE Y lNG , AND TOOTH PRE PARATlON
F igure l. A es thet i c part i al s are
pos s i bl e wi th m odern m ateri al s and
thought ful des i gns .
F igure 2. Li ght enam el opl as ty to
create s urv ey z one.
A s i n m os t thi ngs i n dent i s try , the FRPD begi ns wi th an accurate di agnos t i c m
odel . A n accurate oppos i ng m odel i s al s o es s ent i al
s i nce the occl us i on wi l l di ctate the pl acem ent of com ponents ; and becaus e s ucces
s can onl y com e through careful cons i derat i on
and i ncorporat i on of the occl us i on i nto the f i nal des i gn.
Surv ey the teeth on the s tone m odel : l ev el the pl ane of occl us i on, s tabi l i z e the s
urv ey or tabl e, and run the carbon rod around the
teeth. That ' s the s urv ey l i ne. l t s ounds dangerous l y tradi t i onal , but i s now a
new concept . M etal cl as ps were al l about s urv ey l i nes ,
bei ng abov e them or bei ng bel ow them . Thi s concept , al though im portant , i s di f
ferent wi th f l ex i bl e part i al s . Pol y ny l on/V al pl as t l i kes a
"s urv ey z one," not a s urv ey l i ne. The s urv ey l i ne j us t i ndi cates to y ou where y
ou are goi ng to take a f i ne-tapered di am ond and do a
l i t t l e enam el opl as ty (Fi gure 2). Thi nk of i t as m aki ng a 2.0 m m gui depl ane that
goes around the tooth. That s urv ey z one, or
ci rcum ferent i al gui depl ane, i s the generator of the requi red s tabi l i ty and retent i on.
A LOOK AT CLASP DE SlG NS
F igure 3. Bul k i s not requi red for
s trength or retent i on.
F igure 4. A ci rcum ferent i al cl as p.
F igure 5. A 2-tooth cont i nuous cl as p. F igure 6. Ci rcum ferent i al cl as p for a
m es i al l y -t i pped di s tal m ol ar.
Oral Medicine
Oral-Syst emic
connect ion
Ort hodont ics
Pediat ric Dent ist ry
Periodont ics
Pharmacology
Pain Management
Prev ent ion
Pros thodonti cs
R em ovabl e P rosthodonti cs
P rostheti cs
F i xed P rothodonti cs
Psychology
Radiography
Post -and-Core
T echnique
Regulat ory
Rest orat iv e
Sleep Disorders
Sport s Dent ist ry
T echno-Clinical
T echnology
T echnique of t he Week
T reatment Planning
Viewpoint
F igure 7. A com bi nat i on cl as p. F igure 8. Preparat i on to al l ow for
cros s i ng the occl us al tabl e.
Let ' s f i rs t cons i der the des i gn of the "s tandard" or "m ai n" cl as p. l f y ou l ook at
any FRPD adv ert i s em ent y ou wi l l s ee the bas i c "m ai n
cl as p" (Fi gure 3). Thi s i s certai nl y a us eful cl as p, but i ts des i gn i s of ten far too
l arge and bul ky . Tooth preparat i on to im prov e the
contact z one i s es s ent i al for i ncreas ed retent i on and s tabi l i ty . Thes e do not need
to cov er l arge am ounts of tooth s tructure. A few
m i l l im eters of tooth contact and a few m i l l im eters of t i s s ue contact are al l that i
s neces s ary for retent i on and s tabi l i ty . M ore i s not
bet ter!
The ci rcum ferent i al cl as p (Fi gure 4) i s j us t that . l t goes total l y around a free-s
tandi ng tooth. l t can al s o engage al l av ai l abl e s urfaces
of m ul t i pl e teeth (Fi gure 5), i n whi ch cas e i t m ay be referred to as a "cont i nuous ci
rcum ferent i al cl as p." Thi s i s an i deal cl as p for a
free-s tandi ng, m es i al l y -t i pped di s tal abutm ent (Fi gure 6). What m akes thi s cl as
p s o unbel i ev abl y retent i v e i s the prepared s urv ey
z one.
The com bi nat i on cl as p (Fi gure 7) i s , i n fact , a com bi nat i on of the ci rcum ferent i al
cl as p and the conv ent i onal m ai n cl as p. l ts key
i ngredi ent i s a com ponent that cros s es the occl us al tabl e. Thi s com ponent al s o
acts as a "res t s eat" and al though i t m ay or m ay not
trans fer l oad to the ax i al root of the tooth, i t certai nl y does prov i de s tabi l i ty
and s trength to the FRPD by l i nki ng the pal atal (or l i ngual )
com ponents to the buccal . Thi s bas i c engi neeri ng concept of m utual rei nforcem ent
cannot be ov erl ooked or di s carded. Thi s can be
accom pl i s hed through a prepared s l ot (Fi gure 7), i f occl us i on or res -torat i ons do not
perm i t ; or through a wi de em bras ure s pace that
m ay be enl arged wi th a di am ond (Fi gure 8). V al pl as t does not hav e to be thi ck and
bul ky , howev er, i t does need a reas onabl e
am ount of m ateri al for s trength. Therefore, i t m us t be rei nforced by com ponents
that l i nk the pal atal / l i ngual wi th the buccal .
TROUBLE SHOOTlNG : CLASP DE SlG NS TO AVOlD
F igure 9. The "reach around"cl as p
des i gn s houl d be av oi ded.
F igure l0. Separated cl as ps that
l os e s trength and funct i on.
F igure ll. A hopel es s 2-tooth cl as p
that wi l l hi nge open, prov i di ng no
s trength or retent i on.
F igure l2. A wel l -des i gned f l ex i bl e
rem ov abl e part i al denture wi th 2
ci rcum ferent i al cl as ps and 2
com bi nat i on cl as ps .
The "reach-around cl as p" i s alm os t the s i ngl e wors t des i gn concept (Fi gure 9). l t
has to be wax ed thi ck for adequate s trength, and as
a res ul t , i t becom es bul ky and uncom fortabl e. l recent l y recei v ed s uch a cl as p
des i gn from a l aboratory where the pros thet i c
techni ci an di d not unders tand the concept of s urv ey area, the ci rcum ferent i al cl as p,
or com bi nat i on cl as p des i gn. The pat i ent was not
im pres s ed by the s i z e, l ook, or feel of what they prov i ded for us . Thi s ty pe of cl
as p i s us ual l y done by a dental techni ci an that s im pl y
does not unders tand the concept of cros s i ng the occl us al tabl e for s trength, ri gi di ty
, and retent i on.
The "s eparated" cl as ps (Fi gure l0) are al s o a was te of s trength and retent i on. Thes e
are cl as ps from a l aboratory i n whi ch the
pros thet i c techni ci an s t i l l thought cl as ps were m ade of m etal and had to be s
eparate. Thi s techni ci an s acri f i ced al l the s trength of the
ci rcum ferent i al cl as p and gai ned nothi ng i n ex change.
The pri z e for s im pl y the wors t des i gn and ex ecut i on i s the 2-tooth cl as p (Fi gure
ll). Cl i ni cal l y i t wi l l al way s be a fai l ure. Thi s i s
becaus e the phy s i cs wi l l force the uns upported end to hi nge away from the tooth s
urface when i t i s s eated. l t wi l l hav e abs ol utel y no
funct i on, no retent i on, and be of no us e. The onl y thi ng pos s i bl e here was to rem ov
e i t .
Dr. Virendra Vikram Singh
(25.03.20l2 (09:25:54))
Dr Annie Thomas
(22.02.20l3 (09:40:32))
RSS
Com m ent
A nt i s pam protect i on
Nam e
Em ai l
Subj ect
CONCLUSlON
The us e of FRPDs i s growi ng. Pat i ent s ucces s i s hi gh s i nce thes e appl i ances
can be ex trem el y aes thet i c. One m us t rem em ber that
careful at tent i on m us t be pai d to the bas i c concepts of di agnos i s and des i gn, and a
di f ferent approach to cl as p des i gn i s es s ent i al
(Fi gure l2).
l certai nl y do not bel i ev e that (FRPDs ) are the ans wer to ev ery thi ng. Howev er,
they repres ent a great s tri de forward as an ex cel l ent
pros thet i c choi ce av ai l abl e for our pat i ents . When appropri ate, thei r us e s houl d be
cons i dered by dental heal th profes s i onal s as a
v i abl e treatm ent opt i on.
Di scl osure: Dr. Kapl an has no rel at i onshi p wi th Val pl ast or any dental product com
pany.
Dr. Kaplan i s a graduate of lndi ana Uni v ers i ty School of Dent i s try . He recei v ed hi s
pos tgraduate pros thodont i c trai ni ng through the A i r
Force at Wi l ford Hal l M edi cal Center, and com pl eted hi s M ax i l l ofaci al Pros thodont i
c Fel l ows hi p at the Uni v ers i ty of Chi cago. He i s
current l y worki ng wi th the US A rm y i n Wi es baden, Germ any , and can be reached at
pgk.dent@gm ai l .com .
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Thi nki ng of pres ent i ng a j ournal Cl ub on Dr Kapl ans Fl ex i bl e Rem ov abl e Part i al
Dentures : Des i gn and Cl as p
Concepts .
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l 'm s o gl ad i read thi s art i cl e. Concepts that i i nev er knew when i m ade thes e
dentures for the pat i ents and was
nev er tol d that by the l ab ei ther. l was nev er tol d that i s houl d s urv ey the m
odel s . Thank y ou for the v al i d
i nform at i on.Current l y worki ng on a cas e. Wi l l i ncorporate what i l earnt i n thi s .
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Top M ORE_lNFO
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
Flexible Removable Partial Dentures: Design and Clasp Concepts
Wri tten by P aul Kapl an , M Sci , D D S, M SD
Sunday, 30 N ovem ber 2008 l9:00
The us e of aes thet i c f l ex i bl e rem ov abl e part i al dentures (FRPD) has s ky
-rocketed ov er the l as t s ev eral y ears (Fi gure l). M ul t i pl e
adv ert i s em ents can be found i n ev ery j ournal wi th l aboratori es prom ot i ng l ower
cos t (com pared to conv ent i onal part i al dentures wi th
cas t fram eworks ), fas t s erv i ce, and bet ter aes thet i cs than conv ent i onal m etal
-bas ed rem ov abl e part i al dentures (RPD). ln s peaki ng
wi th pros thodont i s ts , l s t i l l get the feel i ng they bel i ev e that the us e of FRPDs
i s s om ehow s t i l l not qui te the ri ght thi ng to do.
A l though, s om e are now openl y adm i t t i ng that thes e pros thes es m ay , i n fact ,
hav e thei r pl ace, l thi nk that m any are s t i l l a bi t uns ure
about ex act l y what that pl ace i s . Thi s art i cl e wi l l des cri be techni ques needed to
prov i de aes thet i c FRPDs to y our pat i ents , and l wi l l
al s o s hare m y opi ni ons regardi ng thes e appl i ances and the need to em brace them
as a v i abl e treatm ent opt i on.
RlG lD ME TAL-BASE D RPDS VE RSUS F LE XlBLE RPDS
Part of the probl em for s om e to accept FRPDs i s that they don t j us t v i ol ate m
any of the "rul es " of RPDs they s im pl y i gnore them .
A nd y et , des pi te thi s , they are s t i l l s ucces s ful . There are no res t s eats trans m i
t t i ng the ax i al l oad down the l ong ax i s of the tooth.
There are no i nfra-bul ge cl as ps and s upra-bul ge cl as ps (i n the tradi t i onal s ens e),
and the t i s s ue does not s eem to care that thes e
dev i ces are non-ri gi d. A l l thes e thi ngs v i ol ate the tradi t i onal concepts of cl as s
i c m etal -bas ed (ri gi d) RPD des i gn. A nd y et , there are a
rapi dl y growi ng num ber of thes e appl i ances bei ng del i v ered to pat i ents ev ery y
ear, dem ons trat i ng that thei r popul ari ty i s s pri ngi ng
from pract i ci ng dent i s ts , and not from dental s chool s and/or l eadi ng pros thodont i s
ts .
There i s l i t t l e cl as s i c s ci ent i f i c res earch to s upport the us e of FPRDs , and the
cons tel l at i on of art i cl es and thought that s urround
tradi t i onal m etal -cl as ped (ri gi d) RPDs does not y et ex i s t for thes e dev i ces .
lnteres t i ngl y , i f one reads through enough art i cl es
begi nni ng wi th cl as p concepts ori gi nat i ng i n the "Dental Cos m os " of the earl y
l930s , i t becom es cl ear that cl as p des i gn for m etal -bas ed RPDs i s i n truth v ery
m uch a m at ter of opi ni on and conj ecture. Ev en hard core "s ci ent i f i c" art i cl es
l i ke thos e bas ed on s tres s s tudi es us i ng l i ght refract i on m odel s (Do thes e trul y
ref l ect what i s happeni ng i n bone and t i s s ue?); or
thos e bas ed on v ari ous l ab dev i ces that s how m ov em ent / f l ex ure of arm s /cl as ps
under deform at i on (They m ay be great m etal l urgi cal
s tudi es , but are they di rect l y and cl i ni cal l y ap-pl i cabl e?); and the m ul t i tude of
art i cl es wi th drawi ng af ter drawi ng s howi ng poi nts of
rotat i on, res t s eat ax i al l oad, and s o onare accepted as s tone-hard truth. l f hi s
tory s hows us one thi ng, i t i s that facts can be
m ani pul ated to s upport any num ber of concepts , and that the general cons ens us on
s om ethi ng m ay hav e s om e bui l t i n errors . ln
other words , i t can be qui te di f f i cul t to s eparate fact from f i ct i on.
OBSE RVATlONS AND lNDlCATlONS
From the pers pect i v e of m y pers onal cl i ni cal ex peri ence, the facts are s im pl e:
FRPDs (s uch as V al pl as t [V al pl as t lnternat i onal , lnc. ])
work ex trem el y wel l i n s om e s i tuat i ons , and reas onabl y wel l i n others . A l though
s om e peri odont i s ts hav e been qui ck to tel l of s om e
cas es or s i tuat i ons where t i s s ue s tri ppi ng has occurred wi th the us e of thes e appl
i ances , l hav e not obs erv ed thi s condi t i on i n
cas es that l hav e done, nor i n pat i ents that l hav e s een who were treated by other
dent i s ts . ln the s m al l num ber of pat i ents l hav e
obs erv ed who hav e worn FRPDs for an ex tended peri od of t im e, l hav e not s een
bone dam age or res orpt i on i n the tradi t i onal pat tern
of pos teri or ri dge res orpt i on (s addl e ri dge) that i s s o com m on under chrom e/acry l i
c s addl es us ed on m etal -bas ed RPDs . Tim e and
i ncreas ed pat i ent ut i l i z at i on m ay bri ng s om e of thes e i s s ues forward, but for
the m om ent they do not s eem to be a probl em . Pres ent
obs erv at i ons rev eal that pat i ent s at i s fact i on wi th FRPDs i s hi gh, the equi pm
ent cos ts and technol ogy to m ake them are l ow, and the
aes thet i cs can al s o be outs tandi ng when com pared to conv ent i onal m etal -bas ed
RPDs .
FRPDs are ex trem el y us eful as a prov i s i onal i n l i eu of res torat i v e tem porari es
or a s tandard acry l i c part i al . Whi l e the cos t i s a l i t t l e
m ore, the hi gher pat i ent s at i s fact i on us ual l y found wi th thes e, and the fact that
they wi l l not break, i s worth any ex tra ex pens e. No
repai rs are neces s ary , and no pat i ents are at the door wi th a broken acry l i c part i al i
n hand.
FRPDs hav e al s o been us ed s ucces s ful l y as obturators i n conj unct i on wi th m ax i l l
ectom y procedures . The wei ght of the appl i ance
(V al pl as t) i s us ual l y about one thi rd that of the conv ent i onal obturator. ln addi t i
on, the cl as pi ng and s tabi l i ty potent i al s can of ten far
ex ceed that of a m etal -bas ed RPD us ed i n the s am e fas hi on.
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When l f i rs t s tarted encouragi ng others to try a FRPD (s peci f i cal l y V al pl as t), l
found that s ev eral of m y fri ends had tri ed i t and had a
s om ewhat di s couragi ng ex peri ence. Rather then ex tol l i ng i ts v i rtues , l was curi
ous to know what probl em s they had ex peri enced.
Ques t i oni ng ex pos ed a bas i c f l aw i n thei r ex ecut i on and des i gn, i n that they
treated (whether i ntent i onal l y or not) V al pl as t as s om e
ki nd of di f ferent acry l i c. Our dental ex peri ences are s haped by acry l i c, s peci f i
cal l y form s of m ethy l m ethacry l ate. We of ten carry thi s
"acry l i c bi as " wi th us i nto other areas wi thout real i z i ng i t . FRPDs are not j us t s
om e other form of m ethy l m ethacry l ate, and at tem pt i ng
to treat i t as s uch wi l l res ul t i n a di s appoi nt i ng ex peri enceguaranteed!
Thi s i s not the f i rs t t im e when new techni ques and m ateri al s hav e arri v ed i n
the f i el d of dent i s try change i s i n the ai r (not j us t from
the fum es of a s pi l l ed m onom er) and thi s i s j us t one m ore that we hav e to face!
So, the f i rs t and m os t im portant thi ng i s to el im i nate
the "acry l i c habi t ." Thi s m eans that y ou wi l l hav e to el im i nate y our tradi t i onal
thoughts about how to gri nd and adj us t thi s f l ex i bl e
m ateri al . l t i s not eas i l y adj us ted, es peci al l y i f y ou at tem pt to do i t wi th i
ns trum ents and burs wi th whi ch y ou are us ed to adj us t i ng
acry l i c. The nex t thi ng y ou need to l et go of i s the "cl as p habi t ." Fl ex i bl e pol y ny
l on (V al pl as t) i s not wrought wi re or PGP wi re to be
s ol dered to a cas t fram ework. l t i s al s o not cas t round, cas t tapered, "back to
back," and i s not j us t l i ke any other m etal cl as p. M etal
cl as p rul es appl y to m etal cl as ps , not to V al pl as t . The qui ckes t way to end up wi
th bad res ul ts i s to confus e the 2, a m i s take that far
too m any com m erci al l aboratori es are s t i l l m aki ng.
Thi s trans l ates to the bas i c concept : care and at tent i on i s needed to s ucces s ful l y
des i gn and ut i l i z e thi s m ateri al for a rem ov abl e
pros thes i s .
MODE LS, SURVE Y lNG , AND TOOTH PRE PARATlON
F igure l. A es thet i c part i al s are
pos s i bl e wi th m odern m ateri al s and
thought ful des i gns .
F igure 2. Li ght enam el opl as ty to
create s urv ey z one.
A s i n m os t thi ngs i n dent i s try , the FRPD begi ns wi th an accurate di agnos t i c m
odel . A n accurate oppos i ng m odel i s al s o es s ent i al
s i nce the occl us i on wi l l di ctate the pl acem ent of com ponents ; and becaus e s ucces
s can onl y com e through careful cons i derat i on
and i ncorporat i on of the occl us i on i nto the f i nal des i gn.
Surv ey the teeth on the s tone m odel : l ev el the pl ane of occl us i on, s tabi l i z e the s
urv ey or tabl e, and run the carbon rod around the
teeth. That ' s the s urv ey l i ne. l t s ounds dangerous l y tradi t i onal , but i s now a
new concept . M etal cl as ps were al l about s urv ey l i nes ,
bei ng abov e them or bei ng bel ow them . Thi s concept , al though im portant , i s di f
ferent wi th f l ex i bl e part i al s . Pol y ny l on/V al pl as t l i kes a
"s urv ey z one," not a s urv ey l i ne. The s urv ey l i ne j us t i ndi cates to y ou where y
ou are goi ng to take a f i ne-tapered di am ond and do a
l i t t l e enam el opl as ty (Fi gure 2). Thi nk of i t as m aki ng a 2.0 m m gui depl ane that
goes around the tooth. That s urv ey z one, or
ci rcum ferent i al gui depl ane, i s the generator of the requi red s tabi l i ty and retent i on.
A LOOK AT CLASP DE SlG NS
F igure 3. Bul k i s not requi red for
s trength or retent i on.
F igure 4. A ci rcum ferent i al cl as p.
F igure 5. A 2-tooth cont i nuous cl as p. F igure 6. Ci rcum ferent i al cl as p for a
m es i al l y -t i pped di s tal m ol ar.
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F igure 7. A com bi nat i on cl as p. F igure 8. Preparat i on to al l ow for
cros s i ng the occl us al tabl e.
Let ' s f i rs t cons i der the des i gn of the "s tandard" or "m ai n" cl as p. l f y ou l ook at
any FRPD adv ert i s em ent y ou wi l l s ee the bas i c "m ai n
cl as p" (Fi gure 3). Thi s i s certai nl y a us eful cl as p, but i ts des i gn i s of ten far too
l arge and bul ky . Tooth preparat i on to im prov e the
contact z one i s es s ent i al for i ncreas ed retent i on and s tabi l i ty . Thes e do not need
to cov er l arge am ounts of tooth s tructure. A few
m i l l im eters of tooth contact and a few m i l l im eters of t i s s ue contact are al l that i
s neces s ary for retent i on and s tabi l i ty . M ore i s not
bet ter!
The ci rcum ferent i al cl as p (Fi gure 4) i s j us t that . l t goes total l y around a free-s
tandi ng tooth. l t can al s o engage al l av ai l abl e s urfaces
of m ul t i pl e teeth (Fi gure 5), i n whi ch cas e i t m ay be referred to as a "cont i nuous ci
rcum ferent i al cl as p." Thi s i s an i deal cl as p for a
free-s tandi ng, m es i al l y -t i pped di s tal abutm ent (Fi gure 6). What m akes thi s cl as
p s o unbel i ev abl y retent i v e i s the prepared s urv ey
z one.
The com bi nat i on cl as p (Fi gure 7) i s , i n fact , a com bi nat i on of the ci rcum ferent i al
cl as p and the conv ent i onal m ai n cl as p. l ts key
i ngredi ent i s a com ponent that cros s es the occl us al tabl e. Thi s com ponent al s o
acts as a "res t s eat" and al though i t m ay or m ay not
trans fer l oad to the ax i al root of the tooth, i t certai nl y does prov i de s tabi l i ty
and s trength to the FRPD by l i nki ng the pal atal (or l i ngual )
com ponents to the buccal . Thi s bas i c engi neeri ng concept of m utual rei nforcem ent
cannot be ov erl ooked or di s carded. Thi s can be
accom pl i s hed through a prepared s l ot (Fi gure 7), i f occl us i on or res -torat i ons do not
perm i t ; or through a wi de em bras ure s pace that
m ay be enl arged wi th a di am ond (Fi gure 8). V al pl as t does not hav e to be thi ck and
bul ky , howev er, i t does need a reas onabl e
am ount of m ateri al for s trength. Therefore, i t m us t be rei nforced by com ponents
that l i nk the pal atal / l i ngual wi th the buccal .
TROUBLE SHOOTlNG : CLASP DE SlG NS TO AVOlD
F igure 9. The "reach around"cl as p
des i gn s houl d be av oi ded.
F igure l0. Separated cl as ps that
l os e s trength and funct i on.
F igure ll. A hopel es s 2-tooth cl as p
that wi l l hi nge open, prov i di ng no
s trength or retent i on.
F igure l2. A wel l -des i gned f l ex i bl e
rem ov abl e part i al denture wi th 2
ci rcum ferent i al cl as ps and 2
com bi nat i on cl as ps .
The "reach-around cl as p" i s alm os t the s i ngl e wors t des i gn concept (Fi gure 9). l t
has to be wax ed thi ck for adequate s trength, and as
a res ul t , i t becom es bul ky and uncom fortabl e. l recent l y recei v ed s uch a cl as p
des i gn from a l aboratory where the pros thet i c
techni ci an di d not unders tand the concept of s urv ey area, the ci rcum ferent i al cl as p,
or com bi nat i on cl as p des i gn. The pat i ent was not
im pres s ed by the s i z e, l ook, or feel of what they prov i ded for us . Thi s ty pe of cl
as p i s us ual l y done by a dental techni ci an that s im pl y
does not unders tand the concept of cros s i ng the occl us al tabl e for s trength, ri gi di ty
, and retent i on.
The "s eparated" cl as ps (Fi gure l0) are al s o a was te of s trength and retent i on. Thes e
are cl as ps from a l aboratory i n whi ch the
pros thet i c techni ci an s t i l l thought cl as ps were m ade of m etal and had to be s
eparate. Thi s techni ci an s acri f i ced al l the s trength of the
ci rcum ferent i al cl as p and gai ned nothi ng i n ex change.
The pri z e for s im pl y the wors t des i gn and ex ecut i on i s the 2-tooth cl as p (Fi gure
ll). Cl i ni cal l y i t wi l l al way s be a fai l ure. Thi s i s
becaus e the phy s i cs wi l l force the uns upported end to hi nge away from the tooth s
urface when i t i s s eated. l t wi l l hav e abs ol utel y no
funct i on, no retent i on, and be of no us e. The onl y thi ng pos s i bl e here was to rem ov
e i t .
Dr. Virendra Vikram Singh
(25.03.20l2 (09:25:54))
Dr Annie Thomas
(22.02.20l3 (09:40:32))
RSS
Com m ent
A nt i s pam protect i on
Nam e
Em ai l
Subj ect
CONCLUSlON
The us e of FRPDs i s growi ng. Pat i ent s ucces s i s hi gh s i nce thes e appl i ances
can be ex trem el y aes thet i c. One m us t rem em ber that
careful at tent i on m us t be pai d to the bas i c concepts of di agnos i s and des i gn, and a
di f ferent approach to cl as p des i gn i s es s ent i al
(Fi gure l2).
l certai nl y do not bel i ev e that (FRPDs ) are the ans wer to ev ery thi ng. Howev er,
they repres ent a great s tri de forward as an ex cel l ent
pros thet i c choi ce av ai l abl e for our pat i ents . When appropri ate, thei r us e s houl d be
cons i dered by dental heal th profes s i onal s as a
v i abl e treatm ent opt i on.
Di scl osure: Dr. Kapl an has no rel at i onshi p wi th Val pl ast or any dental product com
pany.
Dr. Kaplan i s a graduate of lndi ana Uni v ers i ty School of Dent i s try . He recei v ed hi s
pos tgraduate pros thodont i c trai ni ng through the A i r
Force at Wi l ford Hal l M edi cal Center, and com pl eted hi s M ax i l l ofaci al Pros thodont i
c Fel l ows hi p at the Uni v ers i ty of Chi cago. He i s
current l y worki ng wi th the US A rm y i n Wi es baden, Germ any , and can be reached at
pgk.dent@gm ai l .com .
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Masters in Prosthetics
Thi nki ng of pres ent i ng a j ournal Cl ub on Dr Kapl ans Fl ex i bl e Rem ov abl e Part i al
Dentures : Des i gn and Cl as p
Concepts .
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l 'm s o gl ad i read thi s art i cl e. Concepts that i i nev er knew when i m ade thes e
dentures for the pat i ents and was
nev er tol d that by the l ab ei ther. l was nev er tol d that i s houl d s urv ey the m
odel s . Thank y ou for the v al i d
i nform at i on.Current l y worki ng on a cas e. Wi l l i ncorporate what i l earnt i n thi s .
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Top M ORE_lNFO
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
460 Dental Update November 2000
RESTORATlVE DENTlSTRY
Abstract: Traditional approaches to crown preparation for replacement crowns or teeth with
short clinical crowns are often overly destructive of tooth tissue. Adhesive cements or
composites combined with dentine bonding agents provide the clinician with some flexibility
in treatment planning and should be considered when more destructive techniques would
otherwise be necessary.
Dent Update 2000; 27: 460-463
Clinical Relevance: Adhesively bonded crowns or composites provide flexibility in
treating worn or broken down teeth.
RESTORATlVE DENTlSTRY
ver the past few decades the way
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
REFERENCES
l. Elderton RJ. The prevalence of failure of
restorations: a literature review. J Dentl976;4:
2072l0.
2. Elderton RJ. Restorative Dentistry: l. Current
thinking on cavity design. Dent Updatel986;4:
ll3l22.
3. Rochette AL. Attachment of a splint to enamel
of lower anterior teeth. J Prosthet Dentl973;30:
4l8.
4. Livaditis GJ, Thompson VP. Etch castings: An
improved retentive mechanism for resin-bonded
retainers. J Prosthet Dentl982;47: 5258.
5. Hussey DL, Pagni C, Linden GJ. Performance of
400 adhesive bridges fitted in a restorative
dentistry department. J Dentl99l;l9: 22l225.
6. Watson TF, Bartlett DW. Adhesive systems:
composites, dentine bonding agents and glass
ionomers. Br Dent Jl994;l76: 22723l.
7. McLean JW. The clinical development of glass
ionomer cements: l. Formulations and
properties. Aust Dent Jl977;22: l20l27.
8. Shillingburg HT, Hobo S, Witsett L, Jacobi R,
Brackett SE. Fundamentals of Fixed Prosthodontics.
Chicago: Quintessence, l997; pp. ll9l20.
9. Harley KE, lbbetson RJ. Dental anomalies - are
adhesive castings the solution? Br Dent Jl993;
l74: l522.
l0. Burke FJ, Qualtrough AJ, Hale RW. Dentin-bonded all-ceramic crowns: current status. J Am
Dent Assocl998;l29: 455-460.
ll. Bishop K, Bell M, Briggs P, Kelleher M.
Restoration of a worn dentition using a double
veneer technique. Br Dent Jl996;l80: 2629.
l2. Chana H, Kelleher M, Briggs P, Hooper R.
Clinical evaluation of resin bonded gold alloy
veneers. J Prosthet Dent2000;83: 294300.
l3. Smith BGN. Planning and Making Crowns and
Bridges. London: Martin Dunitz, l998; pp.l33
l35.
l4. Briggs P, Bishop K, Kelleher M. Case report: The
use of indirect composite for the management
of extensive erosion. Eur J Prosthodont Rest Dent
l994;3: 5l54.
l5. Briggs P, Djemal S, Chana H, Kelleher M. Young
adult patients with established dental er osion -what should be done? Dent Updatel998;25:
l66l70.
l6. Harley KE. Tooth wear in the child and the
youth. Br Dent Jl999;l86: 492496.
l7. Nohl FSA, King PA, Harley KE, lbbetson RJ.
Retrospective survey of resin retained cast
metal palatal veneers for the treatment of
anterior palatal tooth wear. Quint lntl997;28:
7l4.
l8. Burke FJT, Watts DC. Fracture resistance of
teeth restored with dentin-bonded crowns.
Quint lntl994;25: 335340.
l9. Burke FJT, Qualtrough AJ, Wilson NHF. A
retrospective evaluation of a series of dentin-bonded ceramic crowns. Quint lntl998;29:
l03l06.
20. Gates W, Diaz-Arnold A, Aquilino SRJ.
Comparison of the adhesive strengths of a Bis-GMA cement to tin-plated and non tin-plated
alloys. J Prosthet Dentl993;69: l2l6.
2l. Hemmings KW, Darbar UR, Vaughan S. Tooth
wear treated with direct composite restorations
at an increased vertical dimension: Results at 30
months. J Prosthet Dent2000;83: 293.
Flexible Removable Partial Dentures: Design and Clasp Concepts
Wri tten by P aul Kapl an , M Sci , D D S, M SD
Sunday, 30 N ovem ber 2008 l9:00
The us e of aes thet i c f l ex i bl e rem ov abl e part i al dentures (FRPD) has s ky
-rocketed ov er the l as t s ev eral y ears (Fi gure l). M ul t i pl e
adv ert i s em ents can be found i n ev ery j ournal wi th l aboratori es prom ot i ng l ower
cos t (com pared to conv ent i onal part i al dentures wi th
cas t fram eworks ), fas t s erv i ce, and bet ter aes thet i cs than conv ent i onal m etal
-bas ed rem ov abl e part i al dentures (RPD). ln s peaki ng
wi th pros thodont i s ts , l s t i l l get the feel i ng they bel i ev e that the us e of FRPDs
i s s om ehow s t i l l not qui te the ri ght thi ng to do.
A l though, s om e are now openl y adm i t t i ng that thes e pros thes es m ay , i n fact ,
hav e thei r pl ace, l thi nk that m any are s t i l l a bi t uns ure
about ex act l y what that pl ace i s . Thi s art i cl e wi l l des cri be techni ques needed to
prov i de aes thet i c FRPDs to y our pat i ents , and l wi l l
al s o s hare m y opi ni ons regardi ng thes e appl i ances and the need to em brace them
as a v i abl e treatm ent opt i on.
RlG lD ME TAL-BASE D RPDS VE RSUS F LE XlBLE RPDS
Part of the probl em for s om e to accept FRPDs i s that they don t j us t v i ol ate m
any of the "rul es " of RPDs they s im pl y i gnore them .
A nd y et , des pi te thi s , they are s t i l l s ucces s ful . There are no res t s eats trans m i
t t i ng the ax i al l oad down the l ong ax i s of the tooth.
There are no i nfra-bul ge cl as ps and s upra-bul ge cl as ps (i n the tradi t i onal s ens e),
and the t i s s ue does not s eem to care that thes e
dev i ces are non-ri gi d. A l l thes e thi ngs v i ol ate the tradi t i onal concepts of cl as s
i c m etal -bas ed (ri gi d) RPD des i gn. A nd y et , there are a
rapi dl y growi ng num ber of thes e appl i ances bei ng del i v ered to pat i ents ev ery y
ear, dem ons trat i ng that thei r popul ari ty i s s pri ngi ng
from pract i ci ng dent i s ts , and not from dental s chool s and/or l eadi ng pros thodont i s
ts .
There i s l i t t l e cl as s i c s ci ent i f i c res earch to s upport the us e of FPRDs , and the
cons tel l at i on of art i cl es and thought that s urround
tradi t i onal m etal -cl as ped (ri gi d) RPDs does not y et ex i s t for thes e dev i ces .
lnteres t i ngl y , i f one reads through enough art i cl es
begi nni ng wi th cl as p concepts ori gi nat i ng i n the "Dental Cos m os " of the earl y
l930s , i t becom es cl ear that cl as p des i gn for m etal -bas ed RPDs i s i n truth v ery
m uch a m at ter of opi ni on and conj ecture. Ev en hard core "s ci ent i f i c" art i cl es
l i ke thos e bas ed on s tres s s tudi es us i ng l i ght refract i on m odel s (Do thes e trul y
ref l ect what i s happeni ng i n bone and t i s s ue?); or
thos e bas ed on v ari ous l ab dev i ces that s how m ov em ent / f l ex ure of arm s /cl as ps
under deform at i on (They m ay be great m etal l urgi cal
s tudi es , but are they di rect l y and cl i ni cal l y ap-pl i cabl e?); and the m ul t i tude of
art i cl es wi th drawi ng af ter drawi ng s howi ng poi nts of
rotat i on, res t s eat ax i al l oad, and s o onare accepted as s tone-hard truth. l f hi s
tory s hows us one thi ng, i t i s that facts can be
m ani pul ated to s upport any num ber of concepts , and that the general cons ens us on
s om ethi ng m ay hav e s om e bui l t i n errors . ln
other words , i t can be qui te di f f i cul t to s eparate fact from f i ct i on.
OBSE RVATlONS AND lNDlCATlONS
From the pers pect i v e of m y pers onal cl i ni cal ex peri ence, the facts are s im pl e:
FRPDs (s uch as V al pl as t [V al pl as t lnternat i onal , lnc. ])
work ex trem el y wel l i n s om e s i tuat i ons , and reas onabl y wel l i n others . A l though
s om e peri odont i s ts hav e been qui ck to tel l of s om e
cas es or s i tuat i ons where t i s s ue s tri ppi ng has occurred wi th the us e of thes e appl
i ances , l hav e not obs erv ed thi s condi t i on i n
cas es that l hav e done, nor i n pat i ents that l hav e s een who were treated by other
dent i s ts . ln the s m al l num ber of pat i ents l hav e
obs erv ed who hav e worn FRPDs for an ex tended peri od of t im e, l hav e not s een
bone dam age or res orpt i on i n the tradi t i onal pat tern
of pos teri or ri dge res orpt i on (s addl e ri dge) that i s s o com m on under chrom e/acry l i
c s addl es us ed on m etal -bas ed RPDs . Tim e and
i ncreas ed pat i ent ut i l i z at i on m ay bri ng s om e of thes e i s s ues forward, but for
the m om ent they do not s eem to be a probl em . Pres ent
obs erv at i ons rev eal that pat i ent s at i s fact i on wi th FRPDs i s hi gh, the equi pm
ent cos ts and technol ogy to m ake them are l ow, and the
aes thet i cs can al s o be outs tandi ng when com pared to conv ent i onal m etal -bas ed
RPDs .
FRPDs are ex trem el y us eful as a prov i s i onal i n l i eu of res torat i v e tem porari es
or a s tandard acry l i c part i al . Whi l e the cos t i s a l i t t l e
m ore, the hi gher pat i ent s at i s fact i on us ual l y found wi th thes e, and the fact that
they wi l l not break, i s worth any ex tra ex pens e. No
repai rs are neces s ary , and no pat i ents are at the door wi th a broken acry l i c part i al i
n hand.
FRPDs hav e al s o been us ed s ucces s ful l y as obturators i n conj unct i on wi th m ax i l l
ectom y procedures . The wei ght of the appl i ance
(V al pl as t) i s us ual l y about one thi rd that of the conv ent i onal obturator. ln addi t i
on, the cl as pi ng and s tabi l i ty potent i al s can of ten far
ex ceed that of a m etal -bas ed RPD us ed i n the s am e fas hi on.
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When l f i rs t s tarted encouragi ng others to try a FRPD (s peci f i cal l y V al pl as t), l
found that s ev eral of m y fri ends had tri ed i t and had a
s om ewhat di s couragi ng ex peri ence. Rather then ex tol l i ng i ts v i rtues , l was curi
ous to know what probl em s they had ex peri enced.
Ques t i oni ng ex pos ed a bas i c f l aw i n thei r ex ecut i on and des i gn, i n that they
treated (whether i ntent i onal l y or not) V al pl as t as s om e
ki nd of di f ferent acry l i c. Our dental ex peri ences are s haped by acry l i c, s peci f i
cal l y form s of m ethy l m ethacry l ate. We of ten carry thi s
"acry l i c bi as " wi th us i nto other areas wi thout real i z i ng i t . FRPDs are not j us t s
om e other form of m ethy l m ethacry l ate, and at tem pt i ng
to treat i t as s uch wi l l res ul t i n a di s appoi nt i ng ex peri enceguaranteed!
Thi s i s not the f i rs t t im e when new techni ques and m ateri al s hav e arri v ed i n
the f i el d of dent i s try change i s i n the ai r (not j us t from
the fum es of a s pi l l ed m onom er) and thi s i s j us t one m ore that we hav e to face!
So, the f i rs t and m os t im portant thi ng i s to el im i nate
the "acry l i c habi t ." Thi s m eans that y ou wi l l hav e to el im i nate y our tradi t i onal
thoughts about how to gri nd and adj us t thi s f l ex i bl e
m ateri al . l t i s not eas i l y adj us ted, es peci al l y i f y ou at tem pt to do i t wi th i
ns trum ents and burs wi th whi ch y ou are us ed to adj us t i ng
acry l i c. The nex t thi ng y ou need to l et go of i s the "cl as p habi t ." Fl ex i bl e pol y ny
l on (V al pl as t) i s not wrought wi re or PGP wi re to be
s ol dered to a cas t fram ework. l t i s al s o not cas t round, cas t tapered, "back to
back," and i s not j us t l i ke any other m etal cl as p. M etal
cl as p rul es appl y to m etal cl as ps , not to V al pl as t . The qui ckes t way to end up wi
th bad res ul ts i s to confus e the 2, a m i s take that far
too m any com m erci al l aboratori es are s t i l l m aki ng.
Thi s trans l ates to the bas i c concept : care and at tent i on i s needed to s ucces s ful l y
des i gn and ut i l i z e thi s m ateri al for a rem ov abl e
pros thes i s .
MODE LS, SURVE Y lNG , AND TOOTH PRE PARATlON
F igure l. A es thet i c part i al s are
pos s i bl e wi th m odern m ateri al s and
thought ful des i gns .
F igure 2. Li ght enam el opl as ty to
create s urv ey z one.
A s i n m os t thi ngs i n dent i s try , the FRPD begi ns wi th an accurate di agnos t i c m
odel . A n accurate oppos i ng m odel i s al s o es s ent i al
s i nce the occl us i on wi l l di ctate the pl acem ent of com ponents ; and becaus e s ucces
s can onl y com e through careful cons i derat i on
and i ncorporat i on of the occl us i on i nto the f i nal des i gn.
Surv ey the teeth on the s tone m odel : l ev el the pl ane of occl us i on, s tabi l i z e the s
urv ey or tabl e, and run the carbon rod around the
teeth. That ' s the s urv ey l i ne. l t s ounds dangerous l y tradi t i onal , but i s now a
new concept . M etal cl as ps were al l about s urv ey l i nes ,
bei ng abov e them or bei ng bel ow them . Thi s concept , al though im portant , i s di f
ferent wi th f l ex i bl e part i al s . Pol y ny l on/V al pl as t l i kes a
"s urv ey z one," not a s urv ey l i ne. The s urv ey l i ne j us t i ndi cates to y ou where y
ou are goi ng to take a f i ne-tapered di am ond and do a
l i t t l e enam el opl as ty (Fi gure 2). Thi nk of i t as m aki ng a 2.0 m m gui depl ane that
goes around the tooth. That s urv ey z one, or
ci rcum ferent i al gui depl ane, i s the generator of the requi red s tabi l i ty and retent i on.
A LOOK AT CLASP DE SlG NS
F igure 3. Bul k i s not requi red for
s trength or retent i on.
F igure 4. A ci rcum ferent i al cl as p.
F igure 5. A 2-tooth cont i nuous cl as p. F igure 6. Ci rcum ferent i al cl as p for a
m es i al l y -t i pped di s tal m ol ar.
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F igure 7. A com bi nat i on cl as p. F igure 8. Preparat i on to al l ow for
cros s i ng the occl us al tabl e.
Let ' s f i rs t cons i der the des i gn of the "s tandard" or "m ai n" cl as p. l f y ou l ook at
any FRPD adv ert i s em ent y ou wi l l s ee the bas i c "m ai n
cl as p" (Fi gure 3). Thi s i s certai nl y a us eful cl as p, but i ts des i gn i s of ten far too
l arge and bul ky . Tooth preparat i on to im prov e the
contact z one i s es s ent i al for i ncreas ed retent i on and s tabi l i ty . Thes e do not need
to cov er l arge am ounts of tooth s tructure. A few
m i l l im eters of tooth contact and a few m i l l im eters of t i s s ue contact are al l that i
s neces s ary for retent i on and s tabi l i ty . M ore i s not
bet ter!
The ci rcum ferent i al cl as p (Fi gure 4) i s j us t that . l t goes total l y around a free-s
tandi ng tooth. l t can al s o engage al l av ai l abl e s urfaces
of m ul t i pl e teeth (Fi gure 5), i n whi ch cas e i t m ay be referred to as a "cont i nuous ci
rcum ferent i al cl as p." Thi s i s an i deal cl as p for a
free-s tandi ng, m es i al l y -t i pped di s tal abutm ent (Fi gure 6). What m akes thi s cl as
p s o unbel i ev abl y retent i v e i s the prepared s urv ey
z one.
The com bi nat i on cl as p (Fi gure 7) i s , i n fact , a com bi nat i on of the ci rcum ferent i al
cl as p and the conv ent i onal m ai n cl as p. l ts key
i ngredi ent i s a com ponent that cros s es the occl us al tabl e. Thi s com ponent al s o
acts as a "res t s eat" and al though i t m ay or m ay not
trans fer l oad to the ax i al root of the tooth, i t certai nl y does prov i de s tabi l i ty
and s trength to the FRPD by l i nki ng the pal atal (or l i ngual )
com ponents to the buccal . Thi s bas i c engi neeri ng concept of m utual rei nforcem ent
cannot be ov erl ooked or di s carded. Thi s can be
accom pl i s hed through a prepared s l ot (Fi gure 7), i f occl us i on or res -torat i ons do not
perm i t ; or through a wi de em bras ure s pace that
m ay be enl arged wi th a di am ond (Fi gure 8). V al pl as t does not hav e to be thi ck and
bul ky , howev er, i t does need a reas onabl e
am ount of m ateri al for s trength. Therefore, i t m us t be rei nforced by com ponents
that l i nk the pal atal / l i ngual wi th the buccal .
TROUBLE SHOOTlNG : CLASP DE SlG NS TO AVOlD
F igure 9. The "reach around"cl as p
des i gn s houl d be av oi ded.
F igure l0. Separated cl as ps that
l os e s trength and funct i on.
F igure ll. A hopel es s 2-tooth cl as p
that wi l l hi nge open, prov i di ng no
s trength or retent i on.
F igure l2. A wel l -des i gned f l ex i bl e
rem ov abl e part i al denture wi th 2
ci rcum ferent i al cl as ps and 2
com bi nat i on cl as ps .
The "reach-around cl as p" i s alm os t the s i ngl e wors t des i gn concept (Fi gure 9). l t
has to be wax ed thi ck for adequate s trength, and as
a res ul t , i t becom es bul ky and uncom fortabl e. l recent l y recei v ed s uch a cl as p
des i gn from a l aboratory where the pros thet i c
techni ci an di d not unders tand the concept of s urv ey area, the ci rcum ferent i al cl as p,
or com bi nat i on cl as p des i gn. The pat i ent was not
im pres s ed by the s i z e, l ook, or feel of what they prov i ded for us . Thi s ty pe of cl
as p i s us ual l y done by a dental techni ci an that s im pl y
does not unders tand the concept of cros s i ng the occl us al tabl e for s trength, ri gi di ty
, and retent i on.
The "s eparated" cl as ps (Fi gure l0) are al s o a was te of s trength and retent i on. Thes e
are cl as ps from a l aboratory i n whi ch the
pros thet i c techni ci an s t i l l thought cl as ps were m ade of m etal and had to be s
eparate. Thi s techni ci an s acri f i ced al l the s trength of the
ci rcum ferent i al cl as p and gai ned nothi ng i n ex change.
The pri z e for s im pl y the wors t des i gn and ex ecut i on i s the 2-tooth cl as p (Fi gure
ll). Cl i ni cal l y i t wi l l al way s be a fai l ure. Thi s i s
becaus e the phy s i cs wi l l force the uns upported end to hi nge away from the tooth s
urface when i t i s s eated. l t wi l l hav e abs ol utel y no
funct i on, no retent i on, and be of no us e. The onl y thi ng pos s i bl e here was to rem ov
e i t .
Dr. Virendra Vikram Singh
(25.03.20l2 (09:25:54))
Dr Annie Thomas
(22.02.20l3 (09:40:32))
RSS
Com m ent
A nt i s pam protect i on
Nam e
Em ai l
Subj ect
CONCLUSlON
The us e of FRPDs i s growi ng. Pat i ent s ucces s i s hi gh s i nce thes e appl i ances
can be ex trem el y aes thet i c. One m us t rem em ber that
careful at tent i on m us t be pai d to the bas i c concepts of di agnos i s and des i gn, and a
di f ferent approach to cl as p des i gn i s es s ent i al
(Fi gure l2).
l certai nl y do not bel i ev e that (FRPDs ) are the ans wer to ev ery thi ng. Howev er,
they repres ent a great s tri de forward as an ex cel l ent
pros thet i c choi ce av ai l abl e for our pat i ents . When appropri ate, thei r us e s houl d be
cons i dered by dental heal th profes s i onal s as a
v i abl e treatm ent opt i on.
Di scl osure: Dr. Kapl an has no rel at i onshi p wi th Val pl ast or any dental product com
pany.
Dr. Kaplan i s a graduate of lndi ana Uni v ers i ty School of Dent i s try . He recei v ed hi s
pos tgraduate pros thodont i c trai ni ng through the A i r
Force at Wi l ford Hal l M edi cal Center, and com pl eted hi s M ax i l l ofaci al Pros thodont i
c Fel l ows hi p at the Uni v ers i ty of Chi cago. He i s
current l y worki ng wi th the US A rm y i n Wi es baden, Germ any , and can be reached at
pgk.dent@gm ai l .com .
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Thi nki ng of pres ent i ng a j ournal Cl ub on Dr Kapl ans Fl ex i bl e Rem ov abl e Part i al
Dentures : Des i gn and Cl as p
Concepts .
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l 'm s o gl ad i read thi s art i cl e. Concepts that i i nev er knew when i m ade thes e
dentures for the pat i ents and was
nev er tol d that by the l ab ei ther. l was nev er tol d that i s houl d s urv ey the m
odel s . Thank y ou for the v al i d
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Copy ri ght 20l4 Dent i s try Today . A l l Ri ghts Res erv ed.
Top M ORE_lNFO
carious teeth are restored has
changed. The development of new
materials has altered the way we
prepare and restore teeth. Despite these
improvements in dental materials, little
has changed in the way we prepare
crowns. Generally, retention is still
based on the principles of friction, even
on occasions where newer techniques
would be more conservative. Perhaps it
is time to re-evaluate some of the
techniques in preparing crowns in the
light of the flexibility that these
materials present.
HOW ADHESlVES HAVE
CHANGED CLlNlCAL
PRACTlCE
ln the l970s, there was a realization
that lifetime restorations were
unattainable and this became an
important stimulus for the need to
conserve tooth tissue when preparing
teeth.
l
By the l980s Elderton
questioned the traditional cavity design
for intra-coronal amalgam
restorations.
2
Later, following the
development of composites, cavity
design changed again. The fundamental
principle became the need to remove
caries and not to retain a restoration.
Not surprisingly, this evolution in
materials produced changes in other
clinical techniques. Minimum
preparation bridges
3
and veneers
4
utilized the strength of composites
bonded to enamel to retain restorations
and the need to remove extensive
amounts of dentine became
unnecessary for these new
conservative techniques.
5
A clinically
acceptable bond to dentine
6
led
inevitably to changes in our concepts of
cavity design and the Sandwich
restoration became a method to
replace carious enamel with a
composite and dentine with a glass
ionomer.
7
Dentine bonding agents gain
most of their retention to dentine from
micro-mechanical retention.6The low
viscosity bonding agents infiltrate
dentine tubules and, after setting, form
minute resin tags and lock into the
tubules retaining the material.
Generally, in prosthodontics their use
has been limited to luting cements,
enhancing the bond rather than relying
on the material to retain a crown.
Perhaps it is time to reappraise how we
restore teeth for extra coronal
restorations in the light of the
developments in bonding to teeth that
have occurred in recent years.
CONVENTlONAL
PRlNClPLES FOR CROWN
PREPARATlONS
Conventionally designed crowns gain
retention from displacement by
frictional forces produced along the
length of a prepared tooth surface.
Figure l shows the ideal preparation
which is long and nears parallelism.
ldeally, the taper should approach 7
l5
o
,but in practice this rarely happens
and the taper of the preparation is often
much greater.8
lf non-adhesive luting
cements are used, the frictional force
Adapting Crown Preparations to
Adhesive Materials
DAVlDBARTLETT
D.W. BartlettBDS, PhD, MRD, FDS RCS(Rest.)
FDS RCS(Eng.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Floor 25,
Guy's Dental Hospital, London Bridge SEl 9RT.
Figure l. The conventional crown preparation
is long and approaches parallelism. Tooth
reduction occurs in three planes on the buccal
surface; gingival, mid-buccal and incisal to
represent the different contours of that surface.
The preparation should approach parallelism
with a 7-l5 taper. The retention is derived
from friction established along the length of the
preparation.
O
RESTORATlVE DENTlSTRY
Dental Update November 2000 46l
established between the preparation
and the cement is fundamental to the
retention of a crown. But this ideal
shape becomes increasingly difficult to
achieve after repeated crown
restorations. Glass ionomers can be
used to patch or make small additions
to cores, usually following the removal
of small amounts of caries, and allows
an ideal shape to be prepared, but their
use is limited. More extensive
modification often overwhelms the
bond strength of glass ionomers and
therefore more traditional techniques
are often used to retain cores. Pins or
posts can be used to gain additional
retention but all involve the loss of
further tooth tissue to retain a
restoration which is then subsequently
re-prepared to make a crown.
8
lncreased crown height can be created
by apically repositioning the gingival
margin, but this may lead to problems:
with appearance; it may be an
uncomfortable operation for the
patient; the result is not always reliable
and success often depends on the
clinical skill and experience of the
operator. Additional retention can often
be derived from slots or grooves,
prepared along a path parallel to the
path of withdrawal, but may not
provide sufficient retention. ln some
situations, elective devitalization has
been proposed to retain a post-retained
crown. All these conventional
techniques involve further tooth tissue
loss, often when it is at a premium,
such as in cases of tooth wear, and
where further tooth tissue loss may
result in exposure, weakened tooth
structure or the potential for root
fracture in root-filled teeth. Adhesive
materials can eliminate the need for
traditional forms of retention and are
worthy of consideration.
THE USE OF ADHESlVE
TECHNlQUES TO RESTORE
TEETH
Adhesive Luting Cements used
for Extra-coronal Restorations
Repeatedly failed crowns often produce
a core which is inherently unretentive.
The typical short and pyramidal shape
makes a replacement crown difficult to
retain if the sole retentive feature is the
taper of the preparation (Figure 2).
Despite the attempt to use slots and
grooves, the preparation remains
unretentive. ln these situations, some
clinicians might suggest elective root
treatment followed by a post-retained
crown or an overdenture preparation.
This is destructive and reduces the
longevity of the tooth. A different
approach could be to accept a less
than perfect preparation but allow the
retention of a crown to be provided by
an adhesive. This concept has been
proposed by a number of clinicians to
overcome the problem of broken down
teeth.
9-ll
Perhaps we need to approach
crown preparations with a different
philosophy? Should we maybe remove
carious dentine and then choose the
most appropriate material to restore the
tooth?
Figures 3, 4 and 5 show teeth from a
patient with dentinogenesis imperfecta
where an adhesive cement (Panavia 2l,
Kuraray, Osaka, Japan) has been used
to retain metal onlays without any
preparation. The root morphology of
teeth in patients with dentinogenesis
imperfecta usually means an absence of
a root canal, making post preparation
without prior root canal obturation
hazardous. ln this case, an impression
of the unprepared tooth surface was
taken and a non-precious metal alloy
crown made with the fit surface
sandblasted to produce a
microscopically rough surface and
cemented with a composite resin and a
dentine bonding agent. A more
traditional technique, using a pinned
retained amalgam core, had previously
Figure 2.These short clinical crowns have
been prepared using a combination of parallel
sides and slots but it still lacks effective
retention for conventional crowns. The eventual
crowns were cemented with an adhesive
cement.
Figures 3, 4, 5.The need to create a core to
retain a restoration is not always necessary as
the adhesive can provide most of the retention.
These illustrations are from a patient with
dentinogenesis imperfecta resulting in
obliteration of their root canals. The teeth were
worn to gingival level. Crowns were made
without the need for a core and conserved tooth
tissue and were cemented directly onto the
teeth. The crowns were made from a non
precious metal alloy and cemented with an
adhesive cement which had a dentine bond.
With the improvements in resin-based cements,
it is now possible to restore these surfaces with
a precious metal.
3 4
5
462 Dental Update November 2000
RESTORATlVE DENTlSTRY
failed leaving very little coronal tooth
tissue (Figure 3). Pinned retained
crowns have been described to restore
worn teeth, like these, but they are
usually luted with a non-adhesive
cement. Until recently, the bond to
dentine for cast precious metals relied
upon tin plating or forming a metal
oxide on the fit surface of the casting,
but Chana et al. recently presented
work which suggests this is not
necessary.
l2However, recently a new
adhesive (Panavia F, Kuraray, Osaka,
Japan) was introduced which forms a
bond between precious metals and
dentine. Porcelain is another alternative
but may cause unacceptable wear on
opposing natural teeth. Another method
would be to make a pinned crown but
use an adhesive cement as a luting
agent but this increases the potential
for perforation of the pulp or the
periodontal ligament.
l3
When cementing inherently
unretentive crowns or onlays, a
convenient way to adjust the occlusal
surface is after cementation. lf more
than one tooth is restored, crowns
should be made in the laboratory using
a semi-adjustable articulator and a face
bow recording.
THE USE OF COMPOSlTES
TO RESTORE SHORT
CLlNlCAL CROWNS
Ultimately, the need for a laboratory
made crown can be avoided if the tooth
is restored in composite. The
disadvantages of composites are that
they lack some of the translucency
found in porcelain and are a little
mono-chromatic. Careful handling of
the material, together with the use of
stains, produces very acceptable results
but it takes time. But from a general
practitioners perspective, direct
composite crowns have a major
advantage in that laboratory costs are
avoided and, if the procedure fails,
more traditional and conventional
techniques are still possible, as the
technique could be considered
reversible. Alternatively, indirect
composite crowns have been used to
restore worn teeth, with an
improvement in the appearance
compared to direct composites, but
these involve a laboratory cost.
l4
The principle of restoring worn or
broken down teeth with this technique
cannot be considered a panacea. When
planning restorations, the clinician
must first consider the occlusion and
the need for space for teeth with short
clinical crowns. With this in mind,
composites can provide a suitable
intermediate restoration for the worn
dentition.
l5
Composites, unlike
porcelain, can be repaired relatively
simply and repeatedly polished to
maintain a good surface finish. The
clinical time taken to produce the
desired result, which can take a number
of hours, must be considered as part of
their overall cost. Eventually, the
material may be replaced and, provided
it is intact and caries free, it can be used
as a core for a conventional crown.
Although direct composite restorations
used in this way may increasingly be
seen as a viable option, there has been
little research published on their
longevity. This is typical of adhesive
systems because their development is in
a continual state of flux; no sooner has a
new product been released than it has
been superseded.
Figure 6 shows a patient with severe
tooth wear caused by a combination of
erosion, attrition and abrasion. The
regurgitation of gastric juice was the
major cause of erosion, but there was a
contribution from a parafunctional habit
and abrasion on the lower incisors from
the porcelain crown on the upper
incisor. The upper left and right lateral
incisors were almost worn to the
gingival margin, leaving the dentine
exposed. The upper porcelain crown
made a convenient reference point for
the placement of the incisal edge of the
direct composite restorations. A
proprietary dentine bonding agent
(Optibond Solo, Kerr UK,
Peterborough) and composite (Herculite
XRV, Kerr UK, Peterborough) were
added to the teeth, which were left
unprepared and built into tooth shapes.
The restorations were eventually
polished and finished with a low
viscosity resin (Revolution, Kerr UK,
Peterborough) to produce the final result
as seen in Figure 7. An alternative to
shaping the crown freehand is to use a
stent made from a diagnostic wax up of
the worn teeth. The stent is filled with
composite and bonded to the teeth. The
technique is a practical solution to some
patients with tooth wear and could be
considered almost reversible. lt has the
ultimate advantage that, should the
technique fail, there has been no long-lasting damage to the tooth and could be
replaced by conventional indirect
restorations.
The Evidence Basis for using
Adhesive Techniques
The principle of sandblasted metal
surfaces linked to teeth with
Figures 6 and 7. The need for a crown made in the laboratory is not always necessary. A
combination of erosion, attrition and abrasion has resulted in severe tooth wear. The existing
porcelain fused to metal crown made a useful reference point when adding the direct
composite to the unprepared tooth surfaces. Only the dentine bonding agent provides the
retention for the restoration. lf the restorations deteriorate or partially fracture, more can be
added to 'render' the composite.
67
RESTORATlVE DENTlSTRY
Dental Update November 2000 463
composites has been used extensively
for minimal preparation bridges, with
clinically acceptable results
approaching those of conventionally
made bridges.5
The use of metal onlays
to restore worn teeth has been
described by Harley and lbbetson.
9,l6
The authors described a technique
usingsandblasted metal surfaces
cemented to teeth with a composite
resin. Chana et al.
l2
and Nohl et al.
l7
reported retrospective surveys on the
use of cast metal veneers to restore the
worn palatal surfaces of upper incisor
teeth. Both studies reported similar
success rates, although the method of
bonding to the tooth surface differed
slightly between them. Chanas study of
only 25 patients acknowledged that
operator experience was a significant
factor in the success of the technique.
Burke et aldescribed a slightly
different technique developed from
laminate veneers. The dentine bonded
crown requires less preparation than
conventional techniques but retains the
ideal shape of a crown preparation, and
uses a dentine bonding agent to link the
restoration to the tooth, producing a
unified and potentially stronger
structure.
l0
Burke reported that the
fracture resistance of dentine bonded
crowns was good in a small sample of
extracted teeth.
l8
The authors also
reported the results from 25 patients
who had received these restorations,
after two years. Fifty-seven of the
original 60 restorations remained intact
and the restorations were found to have
a low rate of failure and provided a
high level of patient satisfaction.
l9
More importantly, the concept resulted
in the preservation of tooth tissue.
Bishop et alintroduced yet another
concept, again using adhesive luting
cements to produce the necessary
retention to cement a double veneer
crown.
ll
Porcelain laminates were used
to restore the appearance of the buccal
surfaces of worn teeth whilst metal
veneers replaced the eroded palatal
surfaces. The authors claimed that the
bond between the tooth and the metal
was clinically acceptable and had the
added advantage that adhesive cements
appear to reduce the risk of
microleakage.20
More recently, Hemmings et al.
reported the results of restoring worn
teeth with direct composites at an
increased vertical dimension.
2l
The
authors described the results from a
small sample of l6 patients restored
with two different composites and
dentine bonding agents, giving a total
of l04 restorations which had a median
duration of 35 months (range l4-38
months). The authors considered the
technique clinically acceptable even
though over 50% of those restored with
Durafill(Kulzer, Wehrheim, Germany)
and Scotchbond Multipurpose(3M, St
Paul, Minn, USA) failed shortly after
placement. Those teeth restored with
Herculiteand Optibond(Kerr,
California, USA) performed better and
achieved clinically acceptable results.
All these minimalist techniques rely
less upon the taper of a preparation to
provide retention and more on the bond
between the composite and the tooth.
ln an increasingly conservative
approach to clinical dentistry, minimal
techniques can offer a better solution to
restore worn or broken down teeth and
should increase the longevity of a
tooth. What is fundamental to the
success of adhesive restorations is a
careful and meticulous handling of the
materials for, without this approach, the
restorations are more likely to fail as
most of the retention for restoration is
derived from the bond to dentine.
CONCLUSlONS
A more conservative approach can
often be adopted utilizing a dentine
bonding agent as the major retentive
feature rather than friction developed
between the preparation and the fit of
the crown.
The need to cut conventional shapes
for crown preparations becomes less
critical, especially with short clinical
crowns or replacement restorations.
Provided adhesive materials are used
carefully and manufacturers
instructions are followed, adhesive
resins or luting cements allow the
clinician greater flexibility to restore
teeth.
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