WHY do we do full crowns?

Think hard before you send the tooth up the suction

When you are missing a bunch
of tooth structure
Direct Resin

$350
Amalgam Core/Crown Ceramic Onlay

$280 $1500 $800

Amalgam

$280
A giant amalgam is better than a
giant composite
“…composite restorations required seven
times as many repairs as did amalgam
restorations. CLINICAL IMPLICATIONS:
Composite restorations on posterior tooth
surfaces in children may require
replacement or repair at higher rates than
amalgam restorations, even within five years
of placement.”

Soncini Ja, et al
J Am Dent Assoc. 2007 Jun;138(6):763-72
The Forsyth Institute, Boston, MA, USA
Direct Resin

$350
“Risk of secondary caries was 3.5 times greater in the composite group.
CONCLUSION: Amalgam restorations performed better than did composite
restorations. The difference in performance was accentuated in large restorations
and in those with more than three surfaces involved.”
Bernardo M, et. Al.
J Evid Based Dent Pract, 2008 Dec;8(4)225-6
 5 Billion

11. Jokstad A, Bayne S, Blunck U, Tyas M, Wilson N. Quality of dental restorations. FDI
Commission Project 2-95. International dental journal 2001;51(3):117-58.
Smales and Hawthorne, however, reported 15-year survival rates (48%) for complex
cusp covering silver amalgam restorations compared to higher success rate of crowns
(89%). Martin and Barder also compared the survival of large four- and five-surface silver
amalgam restorations to crowns and reported that crowns had both a higher success
rate and lower chance of catastrophic failure.

Smales RJ, Hawthorne WS. Long-term survival of extensive amalgams and posterior crowns. J Dent. 1997;25:225–7. [PubMed]
Martin JA, Barder JD. Five-year treatment outcomes for teeth with large amalgams and crowns. Oper Dent. 1997;22:77–8. [PubMed]
ADA Endorsed Indications
for resin
• Small and moderately sized restorations
• conservative tooth preparations
• Areas where esthetics is important
Includes class I and II
Replacement of failed restorations
Primary caries
Core/Crown

$1500
Endodontically treated teeth

Carter et al. indicated that dentin from

endodontically treated teeth shows significantly
lower shear strength and toughness than dentin
from vital teeth.

Carter JM, Sorenson SE, Johnson RR. Punch shear testing of extracted vital and endodontically treated teeth. J Biomech. 1983;16:841–8.
 Endodontically treated teeth

32. Aquilino SA, Caplan DJ. Relationship between crown placement and the survival of endodontically treated teeth. J Prosthet Dent. 2002;87:256–63. [PubMed]
Amalgam Core/Crown Ceramic Onlay

$280 $1500 $800

Vital Core
 Step 1

• take all the old junk out….all of it

 step 2

• Remove the decay

 step 3

• To
core or not to core, that is the
question.
 Ferrule Effect
•  Provides some reten3on
–  Especially with ver3cal wall
prepara3on
•  Great deal of resistance
–  Mezzomo et al, 2003
–  Stankiewicz & Wilson,
2002
–  Sorensen & Engelman,
1990
•  Increase longevity
–  Cheung & Chan, 2003
Ferrule Effect
Add Crown Length
No ferrule
 Ferrule effect
•  Sorensen & Engelman, 1990
–  1 mm ferrule doubles the resistance to fracture, compared to
non-ferrule approach
–  maximum benefit = 1.5-2 mm ferrule
•  Isador et al, 1999
•  Libman & Nicholls, 1995
•  Stankiewicz & Wilson, 2002
•  Zhi-Yue & Yu-Xing, 2003
•  Freeman et al, 1998
•  Al-Hazaimeh & GuSeridge (2001)
No difference in fracture resistance ± 2 mm ferrule
(prefabricated posts + resin cement), but the majority of
fractures without ferrule = unrestorable
–  Similar findings – Saupe et al (1996)
 Off access forces
•  2mm of ferrule is
adequate
–  Prevents root fracture
–  Prevents post fracture
–  Prevents post
dislodgement
•  Sites of Failure
–  Direct P&C at restora=on
–  Cast P&C root fracture
 Non Vital Core

Chamber retained or post retained

The only function of a post is to retain the core
 Treatment Planning
Before subsequent restora4on, exis4ng endodon4cally
treated teeth need to be assessed carefully for the
following:

1)  Good apical seal.
2)  No sensi4vity to pressure.
3)  No exudate.
4)  No fistula.
5)  No apical sensi4vity.
6)  No ac4ve inflamma4on.
If any of these occur consider endodon1c retreatment
and restorability.
Rosen4el S. Contemporary Fixed Prosthoson4cs, 2001

 Posts in molars
•  Sufficient tooth structure
–  reten2on for core
build-up can u2lize pulp
space
•  Especially for Amalgam cores
–  Kane &Burgess, 1991
•  If lack of reten2on
–  1 post in the largest canal
•  Palatal cusp Max molars
•  Distal cusps of Mand molars
2mm
2mm

3mm
 Pascal Magne: 'It should not be about
aesthetics but tooth-conserving dentistry
“The physiological performance of
intact teeth is the result of intimate and
balanced relationships between
biological, mechanical, functional and
esthetic parameters. Natural teeth,
through the optimal combination of
enamel and dentin, constitute the
perfect and unmatched compromise
between rigidity, strength and
resilience”
(Magne, 2002).
 Brittle , Stiff, Wear resistant, High
compressive strength

Plastic, Resilient, Tough , Not

wear Resistant , Flexes, Shock
absorbent
 hard,stiff
wear resistant

bonded together

tuff
flexible
resilient
Fibril Reinforced Bond
Fibril Reinforced Bond
 71
dental materials 2 7 ( 2 0 1 1 ) 1–16
72
73
 th
Smear Layer
Hydroxyapetite

Collagen

MMP
5 microns
tooth-conserving dentistry
The Inlay
The Onlay
The Crownlay
 crown
Crown inlay/onlay
Onlay/Inlay

4%

96%
ENAMEL
 ENAMEL
PRECIOUS
Restorations with cervical outline in dentin
showed a 78% higher risk for failure
compared to restorations with margins in
enamel
Longevity
 Class II Longevity
11years Amalgam
6-8 years Composite
1372Mjor, I. A., J. E. Dahl, and J. E. Moorhead. Age of restorations
at replacement in permanent teeth in general
dental practice. Acta Odontol. Scand. 58:97–101, 2000.

3. Christenson J G. Should resin-based composite dominate

restorative dentistry today?JADA 141(12) December 2010 page 1490-93
 1,748 restorations 7 years

J Am Dent Assoc 2007;138;775-783

and Timothy A. DeRouen
Martin, Brian G. Leroux, Tessa Rue, Jorge Leitão
Mario Bernardo, Henrique Luis, Michael D.
Survival and reasons for failure of amalgam
 =
7 year longevity
80% Amalgam
50% Composite
J Am Dent Assoc 2007;138;775-783
and Timothy A. DeRouen
Martin, Brian G. Leroux, Tessa Rue, Jorge Leitão
Mario Bernardo, Henrique Luis, Michael D.
Survival and reasons for failure of amalgam
versus composite posterior restorations
Placed in a randomized clinical trial
 6
Years
1. Beazoglou T, Eklund S, Heffley D, Meiers J, Brown LJ, Bailit H. Economic impact of regulating the use of amalgam restorations. Public Health Rep. 2007;122(5):657-663.
2. Bernardo M, Luis H, Martin MD, et al. Survival and reasons for failure of amalgam versus composite posterior restorations placed in a randomized clinical trial. J Am Dent Assoc.
2007;138(6):775-783.
3. Christensen GJ. Should Resin-Based Composite Dominate Restorative Dentistry Today? The Journal of the American Dental Association. 2010;141(12):1490-1493.
4. DeRouen TA, Martin MD, Leroux BG, et al. Neurobehavioral effects of dental amalgam in children: a randomized clinical trial. JAMA : the journal of the American Medical
Association. 2006;295(15):1784-1792.
5. Garcia-Godoy F, Krämer N, Feilzer AJ, Frankenberger R. Long-term degradation of enamel and dentin bonds: 6-year results in vitro vs. in vivo. Dental Materials. 2010;26(11):
1113-1118.
6. Khalichi P, Cvitkovitch DG, Santerre JP. Effect of composite resin biodegradation products on oral streptococcal growth. Biomaterials. 2004;25(24):5467-5472.
7. Kramer N, Garcia-Godoy F, Frankenberger R. Evaluation of resin composite materials. Part II: in vivo investigations. American journal of dentistry. 2005;18(2):75-81.
8. Levin L, Coval M, Geiger SB. Cross-sectional radiographic survey of amalgam and resin-based composite posterior restorations. Quintessence Int. 2007;38(6):511-514.
9. Manhart J, Chen H, Hamm G, Hickel R. Buonocore Memorial Lecture. Review of the clinical survival of direct and indirect restorations in posterior teeth of the permanent
dentition. Operative dentistry. 2004;29(5):481-508.
10. Murray PE, Windsor LJ, Smyth TW, Hafez AA, Cox CF. Analysis of pulpal reactions to restorative procedures, materials, pulp capping, and future therapies. Critical reviews in
oral biology and medicine : an official publication of the American Association of Oral Biologists. 2002;13(6):509-520.
11. Simecek JW, Diefenderfer KE, Cohen ME. An evaluation of replacement rates for posterior resin-based composite and amalgam restorations in U.S. Navy and marine corps
recruits. J Am Dent Assoc. 2009;140(2):200-209; quiz 249.
12. Soncini JA, Maserejian NN, Trachtenberg F, Tavares M, Hayes C. The longevity of amalgam versus compomer/composite restorations in posterior primary and permanent teeth:
findings From the New England Children's Amalgam Trial. J Am Dent Assoc. 2007;138(6):763-772.
13. Mjor IA, Dahl JE, Moorhead JE. Age of restorations at replacement in permanent teeth in general dental practice. Acta odontologica Scandinavica. 2000;58(3):97-101.
14. Collins CJ, Bryant RW, Hodge KL. A clinical evaluation of posterior composite resin restorations: 8-year findings. Journal of dentistry. 1998;26(4):311-317.
 “ I suggest in office milled ceramic
restorations properly prepped, milled
and seated can be the gold restoration
of today”
 Bonded Onlay Longevity

90 10
Otto, T. & De Nisco, S. (2002) Computer-aided El-Mowafy, O. & Brochu, J.F. (2002) Longevity and
Years

direct ceramic restorations: a 10-year prospective Martin, N. & Jedynakiewicz, N.M. (1999) Clinical Fuzzi, M. & Rappelli, G. (1999) Ceramic inlays:
clinical performance of IPS-Empress ceramic restorations:
clinical study of CEREC CAD/CAM inlays and performance of CEREC ceramic inlays: a systematic clinical assessment and survival rate. Journal of
a literature review. Journal of the
onlays. International Journal of Prosthodontics review. Dental Materials 15: 54–61. Adhesive Dentistry 1: 71–79.
Canadian Dental Association 68: 233–237.
15: 122–128.
Stoll R, Cappel I, Jablonski-Momeni A, Pieper K,
Beier US, Kapferer I, Bustscher D, Giesinger Stashniss V. Survival of inlays and partial crowns
05. Sjögren G, Molin M, van Dijken J. A 10 year prospective
JM, Dumfahrt H. Clinical performance of Hayashi M, Tsuchitani Y, Kawamura Y, Miura M, made of IPS empress after a 10-year observation
evaluation of CAD/CAM-manufactured (CEREC) ceramic inlays
all-ceramic inlay and onlay restorations in Takeshige F, Ebisu S. Eight-year clinical evaluation of period and in relation to various treatment
cemented with a chemically cured or dual cured resin composite.
posterior teeth. Int J Prosthodont. fired ceramic inlays. Oper Dent. 2000;25(6):473–481. parameters. Oper Dent. 2007;32(6):556–563
Int J Prosthodont. 2004;17(2):241–246.
2012;25(4):395–402
The Inlay
91% 10
Years
d e n t a l m a t e r i a l s 3 1 ( 2 0 1 5 ) e77–e87
d e n t a l m a t e r i a l s 3 1 ( 2 0 1 5 ) e77–e87
d e n t a l m a t e r i a l s 3 1 ( 2 0 1 5 ) e77–e87
In dentin and enamel the stress values are
13 times higher in the direct restoration
than in the inlay. Likewise, contact
stresses in the adhesive bond around the
direct restoration are 7 times higher.
Margins should have sharp edges for easy
identification

Occlusal reduction (1.5-2.0 mm)

Marg in s sh ou ld have sh a rp ed ge s fo r ea sy
1.5
identific
Isthmus depth mnm
atio
Rounded internal line angles
Occlusal reduction (1.5-2.0 mm)
Internal axial walls 6-10º
Isthmus depth 1.5 mm
Rounded internal line angles

Internal axial walls 6-10º

sharp
PREPARATION ASPECTS TO
AVOID
PREPARATION ASPECTS TO
AVOID
The Onlay
The Onlay
"Based on my findings,
the only other
restoration possible was
that of a full coverage
crown.  Please pay
benefits accordingly."
 Bonded Onlay Longevity

90 10
Otto, T. & De Nisco, S. (2002) Computer-aided El-Mowafy, O. & Brochu, J.F. (2002) Longevity and
Years

direct ceramic restorations: a 10-year prospective Martin, N. & Jedynakiewicz, N.M. (1999) Clinical Fuzzi, M. & Rappelli, G. (1999) Ceramic inlays:
clinical performance of IPS-Empress ceramic restorations:
clinical study of CEREC CAD/CAM inlays and performance of CEREC ceramic inlays: a systematic clinical assessment and survival rate. Journal of
a literature review. Journal of the
onlays. International Journal of Prosthodontics review. Dental Materials 15: 54–61. Adhesive Dentistry 1: 71–79.
Canadian Dental Association 68: 233–237.
15: 122–128.
Stoll R, Cappel I, Jablonski-Momeni A, Pieper K,
Beier US, Kapferer I, Bustscher D, Giesinger Stashniss V. Survival of inlays and partial crowns
05. Sjögren G, Molin M, van Dijken J. A 10 year prospective
JM, Dumfahrt H. Clinical performance of Hayashi M, Tsuchitani Y, Kawamura Y, Miura M, made of IPS empress after a 10-year observation
evaluation of CAD/CAM-manufactured (CEREC) ceramic inlays
all-ceramic inlay and onlay restorations in Takeshige F, Ebisu S. Eight-year clinical evaluation of period and in relation to various treatment
cemented with a chemically cured or dual cured resin composite.
posterior teeth. Int J Prosthodont. fired ceramic inlays. Oper Dent. 2000;25(6):473–481. parameters. Oper Dent. 2007;32(6):556–563
Int J Prosthodont. 2004;17(2):241–246.
2012;25(4):395–402
 Palatal Onlay

Occlusal Onlay

Full Venner coverage

J Prosthet Dent. 2013 Oct; 110(4): 264–273.

Palatal Onlay Occlusal Onlay Full Venner coverage

J Prosthet Dent. 2013 Oct; 110(4): 264–273.

1.5mm
1.0mm
0.5mm

J Prosthet Dent. 2013 Oct; 110(4): 264–273.

The Crownlay