Photos provided by Gary Jackson.

Esthetic, Long-lasting Results from Contemporary Crowns

COLUMBUS, OHIO - Understanding the properties and indications for different restorative materials is the key to producing esthetic and long-lasting restorations, according to Daniel Ward, DDS, who spoke on the subject at the Updates in Contemporary Dentistry Meeting. There are advantages and disadvantages to all the alternatives on the market, according to Dr. Ward, who was Assistant Clinical Professor and Clinical Instructor at The Ohio State University College of Dentistry for 13 years and has been in private practice for more than 30 years. The advantages of indirect, tooth-colored inlay/onlay restorations are that they are esthetic, do not create polymerization shrinkage stresses during placement and allow for easy laboratory manipulation on the workbench. The challenges of these contemporary materials include the significantly greater marginal surface area, the need to bond the restorations, and technique sensitivity increasing the likelihood of errors. Yet these restorations are more conservative, Dr. Ward said, and dentistry begets dentistry, making the preservation of tooth structure a long-term benefit. Crowns are generally easy and predictable but sacrifice tooth structure. Onlay, Inlay Indications Discussing indications for inlays/onlays Dr. Ward said these include: That the isthmus width is greater than 50% of the buccal/lingual width That there is a wide interproximal gap between adjacent teeth That there is adequate tooth structure with no significant cracks present Dr. Ward said that the advantages of gold inlays are that the material lasts the longest of any product, and generally, they are a superior fit compared with tooth-colored alternatives. Also, he said, gold does not wear opposing tooth structure. The disadvantage of gold is the color. Composites Inlays/Onlays Discussing indirect composite resin systems, Dr. Ward said they generally are a good fit, and like gold, are not likely to wear the opposing tooth structure. One advantage to these systems is that they are able to be layered with different shades and translucent materials and blend better optically. Material can be added chairside if necessary and intraoral polishing in relatively simple. However, they typically wear more than porcelain. Dr. Ward recommends BISCOs Tescera system for fabricating and processing indirect composite restorations since they use the optimal material throughout the restoration. Strong hybrid composite bonds better to tooth structure and microfill composite on the outer surface is more translucent and wears less. He said he excavates the decay, using a low-speed handpiece, and then he uses a resin-modified glass ionomer as a base. Blocking out undercuts prior to performing the final preparation results in a more conservative preparation. He recommends Centrixs Access Crown bis-acryl composite temporary material, which he said can be removed from a patients mouth in about 60 seconds. It has an elastic behavior during polymerization. He said this crown allows users to pull it from undercuts or nonparallel tooth preparations, returning it to its original form. Dr. Ward then applies Heraeus Kulzers Gluma to decrease sensitivity and Telio CS dual-cured composite resin cement. Porcelain Inlays/Onlays The advantages of porcelain are that there is usually less wear and less porosity of material. The disadvantages are they are more difficult to re-polish if adjusted intraorally and these materials can wear the opposing tooth structure. Dr. Ward said that even though tooth colored inlay/onlays allow for a much more conservative restoration, they are more technique sensitive. Another disadvantage is that because of inconsistency of insurance reimbursements for these procedures, these types of restorations are often more expensive for the patient than a crown. Looks Versus Longevity Dr. Ward said it is important to consider looks versus longevity, when selecting crowns for patients. He noted that although cast gold crowns require the least preparation and do not wear the opposing tooth, they are not as esthetic as the other material choices. He cited a study in which dentists surveyed were more likely to select cast gold crowns in the most posterior areas of their own mouths but generally recommended porcelain surface crowns to their patients. Porcelain fused-to-metal (PFM) crowns are the workhorse of indirect systems, Dr. Ward said, in that they are esthetic, predictable, moderately strong, and the preparation is less critical. The disadvantages with PFM crowns are difficulty in providing ideal translucency involving color values and unaesthetic crown margins if the gum tissue recedes. The porcelain fused to thin high gold coping crowns are crowns he says should be considered in the anterior region when simplicity and improved aesthetics are required. The Metal-free Practice Shifting gears to all-ceramic restorations, Dr. Ward said there are certain challenges involved, not the least of which are more exacting and extensive preparations and somewhat higher postoperative sensitivity. He also noted somewhat higher laboratory bills with these types of restorations. However, he said, metal-free restorations provide increased translucency and vitality, and they provide the best esthetics. All-ceramic Crowns The most popular general-purpose all-ceramic crowns have cores made of lithium disilicate or zirconia. Material choices should be based on thickness of material, desired opacity and preference of cementation vs. bonding. The interface between the core and the layering porcelain is critical. Using an experienced laboratory is important to obtain the best long-term results. Etching, Bonding Considerations Dr. Ward said that the choice of an etch will influence how best to proceed when managing all of these indirect restorations. Total-etch adhesives require phosphoric acid etching and are applied in 1 or 2 layers; the self-etch adhesives have the acid built into the adhesive. The etchand-rinse category includes both 3-step and 2-step adhesives that remove the smear layer such as ALL BOND III (BISCO, Inc); the etch-and-dry category includes 2-step and 1step adhesives, such as ALL BOND SE (BISCO, Inc), that modify the smear layer without removal. When bonding restorations the optimal primers and materials should be used. BISCOs Z-Prime is an excellent metal and zirconia primer, he said. Duo Link resin cement works well as a dual cure cement even when light does not effectively expose the resin. Attention to Detail Summarizing his presentation, Dr. Ward stated that the most important factor for success was the skill and judgment of the clinician. He urged clinicians to communicate with their patients in determining their best treatment options. There is not one single ideal treatment so dentists should have many different materials in their clinical repertoire, he said. Colleen Platt

Daniel Ward, DDS earned his Doctor of

Dental Surgery (DDS) degree from The Ohio State University in 1979 and has practiced in Columbus since graduation. Dr. Ward was an Assistant Clinical Professor and instructor at The Ohio State University College of Dentistry for 13 years, and he continues to present to students. He lectures on smile design, esthetic dentistry, and digital dental photography and instructs students in the clinical setting.
Dr. Ward has received products for evaluation in his practice, written articles, and received honoraria from the following companies: Addent, Bisco, Dentsply Caulk, Centrix, Clinicians Choice, Coltene/Whaledent, GC America, Heraeus Kulzer, Ivoclar, Pulpdent, SDI, Shofu, SS White, Tokuyama, Triodent, and 3M ESPE.

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