Full Crowns: Are They Still Necessary?

Full Crowns: Are They Still Necessary?

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A mouth full of crowns.

Indications for Full Non-Metal Crowns

Most of the time, the indication for a full non-metal crown will be replacing an existing full crown (Figure 11.1a–e). On rare occasions, caries literally envelopes every surface of the tooth, and a full coverage crown is indicated. Even in such cases, however, the additional removal of healthy tooth to create the axial wall and any other form of mechanical retention is unnecessary. Crowns may also be used as abutments for a fix prosthesis, although adhesive techniques and improved materials offer new options, such as bonded bridges (Figures 11.2a–e, 11.3a–d). Full crowns are used as a final restoration covering the abutments of an implant, and even in these cases supragingival margins are desirable and make it easier to remove cement on cemented crowns (Figures 11.4a–d, 11.5a,b). Regardless of the indication, thanks to better restorative materials, full crowns today should be very different from those used in the past. More translucent restorative materials for crowns allow for a more supragingival margin placement whenever possible. The choice of restorative material for a full crown is very important. The correct choice of restorative material for the specific needs of full crowns will dictate the amount of tooth reduction required, margin placement and choice of cement to be used.

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Figure 11.1 (a) While the clinical appearance is acceptable, the patient experienced bad odor and inflammation. (b) Radiographically, it is clear why subgingival margins can be so unhealthy. (c) After crowns were removed, it is evident that the proximal margins are very subgingival, which made good results difficult to achieve. (d) A separate posterior case, showing wide open subgingival margins. (e) It is clear how a short clinical crown was the reason that margins were placed so far subgingivally looking for mechanical retention, a facial groove was added for retention. Subgingival margins are usually very unpredictable.

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Figure 11.2 (a) Nice results on a bonded bridge case. The left lateral incisor is the pontic, and very little overbite gives the necessary space for lingual wings. (b) Zirconia Maryland bridge. (c) Bonding procedure, etching of enamel. (d) Facial view. (e) Large lingual wings are possible because, as (a) shows, there is minimal overbite and there is no occlusion on them.

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Figure 11.3 (a) A 3-year-old, chairside composite bonded bridge, with an unhygienic pontic and embrasures. (b) After an ovate pontic was developed. (c) Zirconia Maryland bridge. (d) A very esthetic and hygienic result.

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Figure 11.4 (a) Supragingival zirconia abutment, showing excellent esthetic results, with almost zero risk of subgingival leftover cement. (b) Supragingival crown on a titanium abutment. Some visible metal has no esthetic consequences in the lower posterior area. (c) Traditional deep subgingival pontic margins, which will compromise the cement cleanup. (d) An acceptable esthetic result.

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Figure 11.5 (a) Zirconia abutment in the esthetic zone with equigingival to supragingival margins. (b) Supragingival implant crown with excellent results.

The Options in Non-Metal Restorative Materials for Full Crowns

There are several choices for restorative materials specifically for full crowns, each with different characteristics, and it would be a mistake to use one for all cases. The choice of the restorative material depends on the condition of the tooth after the removal of the old crown, the margin location, the cement to be used, and where the tooth is located in the mouth (anterior or posterior area). Understanding that anterior and posterior teeth have very different thresholds for esthetic requirements, as well as occlusal loads and forces, means that material choices will vary based on those requirements.

The indications and space requirements for each material differ, with specific consideration for full crowns. This chapter considers the current most popular restorative materials for crowns, discussed from the weakest and most translucent to the strongest and least translucent [1]. An important additional consideration is that the thickness of the material alters its level of translucency [2], so its blending ability will contribute to its strength as well as the thickness of the material [3].

Leucite-reinforced feldspathic porcelain

Leucite-reinforced feldspathic porcelain, layered or pressed, is an option in the anterior region when margins are supra-gingival and there is a good amount of remaining enamel for adhesive luting, the adjacent teeth are being treated with feldspathic veneers and the esthetic demands are great (Figure 11.6a–d). Using leucite-reinforced feldspathic porcelain for full crowns in the posterior area is questionable, although it has been popular with computer-aided designed and manufactured (CAD-CAM) crowns. Because of its intrinsic weakness, this material depend on adhesion for its strength and a strong enamel substrate is very desirable. Subgingival margins are undesirable because they complicate adhesion. Generally speaking, this material is better used for bonded partial coverage veneers and, in rare situations, onlays [4,5]. The mode of failure of crowns made from this material is fracture of the restorative material, and for this reason they are not a primary choice (Figure 11.7a,b) [6,7].

Photographs show patient’s teeth with a: existing unesthetic porcelain-fused-to-metal crown; b: Leucite-reinforced feldspathic crown; c: close-up final feldspathic crown; and d: improved smile.

Figure 11.6 (a) Existing unesthetic porcelain-fused-to-metal crown on a right central incisor. (b) Leucite-reinforced feldspathic crown preparation (right central incisor) used along several feldspathic veneers. (c) Close-up of final feldspathic crown and veneers. (d) Improved smile; compare with (a).

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Figure 11.7 (a) Fractured feldspathic Empress crown. (b) Fractured feldspathic porcelain layered over a porcelain-fused-to-semi-precious metal.

Lithium disilicate

Lithium disilicate is unique because it can be used in two different modalities. First, bonded lithium disilicate may be used when margins are supragingival, to allow for predictable adhesive luting, because lithium disilicate is much stronger when bonded to the tooth, space requirements are less, 1 mm axial, 1.5–2 mm occlusal (Figures 11.8, 11.9). Lithium disilicate (e-Max, Ivoclar) is much stronger when bonded than when cemented. When it is bonded to mostly rigid tooth structures such as enamel, its strength can be close to that of zirconia, even when it is thinly applied, but when bonded to a less rigid structure like dentin, it is considerably less strong [3]. Lithium disilicate can be pressed or milled in a CAD-CAM machine. For many reasons, this material has quickly become the most ideal for bonded onlays [8,9]. The pressed version of e-Max appears to be a little stronger, with a better fit [10]. It comes in high-translucency and low-translucency versions. High translucency is preferable for most cases of partial coverage and supragingival margins where the cavosurface margin is considerably coronal to the gingival line and good blending is very important. Low translucency may be preferred if the color of the tooth needs to be hidden, but the disadvantage of opacious materials is that the margin line of the tooth and restoration will be very visible and will often need to be hidden, subgingivally. E-Max can also be layered, but its strength decreases considerably [11].

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Figure 11.8 Preparation of posterior cemented e-Max.

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Figure 11.9 Preparation ideal for lithium disilicate-bonded anterior crown.

Second, cemented (not-bonded) lithium disilicate can be used when margins are subgingival and isolation will be difficult, requiring the use of more contamination resistant traditional crown and bridge cement, such as RMGI Meron Plus AC (VOCO; Figures 11.10a,b, 11.11).

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Feb 19, 2019 | Posted by in Periodontics | Comments Off on Full Crowns: Are They Still Necessary?
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