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Dental Crowns and Bridges: Materials, Procedures, and Clinical OutcomesJul 20
Jul 20
Introduction
Dental crowns and bridges are among the most frequently performed fixed prosthodontic procedures worldwide. A crown (or cap) covers an individual tooth to restore its shape, size, strength, and appearance. A bridge replaces one or more missing teeth by anchoring artificial teeth (pontics) to adjacent natural teeth or implants. With advances in material science and digital dentistry, clinicians today have an unprecedented range of options for delivering durable, aesthetic restorations.
Dental Crowns: Indications and Material Selection
Clinical Indications
- Extensive caries or fracture: When tooth structure loss exceeds 50%, direct restorations (fillings) become inadequate. A crown provides circumferential protection against further fracture.
- Root canal treated teeth: Endodontically treated posterior teeth have increased fracture risk. Full-coverage crowns are recommended, particularly for molars and premolars.
- Severe attrition or erosion: Crowns restore vertical dimension and protect against further wear.
- Aesthetic improvement: Discolored, malformed, or severely misaligned teeth can be restored with all-ceramic crowns for optimal aesthetics.
- Implant restoration: Crowns are the final prosthetic component for single-tooth implants.
Crown Material Options
| Material | Advantages | Disadvantages | Best For |
|---|---|---|---|
| Full Metal (Gold, Base Alloys) | Exceptional durability, minimal tooth reduction, no ceramic fracture risk | Poor aesthetics, metal allergy risk | Posterior teeth, heavy bruxers |
| Porcelain-Fused-to-Metal (PFM) | Good strength, acceptable aesthetics, proven long-term track record | Metal margin display, gingival discoloration, ceramic chipping | Posterior and anterior, budget-conscious |
| Lithium Disilicate (e.max) | Excellent aesthetics, high flexural strength (360–400 MPa), adhesive bonding | Higher cost, technique-sensitive cementation | Anterior and posterior, aesthetic zone |
| Zirconia (Monolithic) | Extreme strength (1000+ MPa), tooth-colored, minimal antagonist wear (polished) | Opacity challenges for anterior, limited translucency in early generations | Posterior bridges, bruxers, full-arch |
| Zirconia (Layered / High-Translucency) | Improved aesthetics, strength 600–900 MPa | Potential for veneering ceramic chipping | Anterior and posterior, aesthetic bridges |
| Composite Resin | Lowest cost, easy repair, minimal antagonist wear | Lower strength, higher wear rate, staining | Temporary crowns, budget-limited cases |
Dental Bridges: Classification and Design Principles
Traditional Fixed Bridges
- Conventional bridge: Pontic suspended between two or more abutment crowns. Requires preparation of adjacent healthy teeth. The most common design.
- Cantilever bridge: Pontic supported by a single abutment crown on one side only. Suitable when only one adjacent tooth is available. Higher leverage forces limit its use to areas of low occlusal load.
- Maryland bridge (resin-bonded): Pontic with metal or ceramic wings bonded to the lingual surfaces of adjacent teeth. Minimally invasive, preserves enamel. Single-wing designs show better survival than two-wing. 5-year survival approximately 87% in anterior applications.
Implant-Supported Bridges
When multiple teeth are missing, implant-supported bridges provide a fixed solution without involving natural teeth. Two or more implants support a connected prosthesis. This approach preserves adjacent tooth structure and provides superior long-term survival (10-year survival >95%). Compared to traditional bridges, implant-supported restorations show lower annual failure rates and better patient satisfaction.
Pontic Design Considerations
- Sanitary (hygienic) pontic: Easy to clean but poor aesthetics. Used in non-aesthetic posterior regions.
- Modified ridge-lap pontic: Slight tissue contact on the buccal aspect only, T-shaped cross-section. Good compromise between aesthetics and hygiene.
- Ovate pontic: Concave tissue surface extending into a prepared socket. Best aesthetics for anterior regions. Requires excellent oral hygiene.
Clinical Procedure: From Preparation to Cementation
Step 1: Tooth Preparation
Tooth reduction follows material-specific guidelines. All-ceramic crowns require 1.5–2.0 mm occlusal reduction and 1.0–1.5 mm axial reduction. PFM requires 1.5–2.0 mm occlusal and facial reduction, 1.0–1.5 mm lingual. Full metal requires least reduction (0.5–1.0 mm). Chamfer or rounded shoulder finish lines are preferred. Sharp line angles and undercuts must be eliminated.
Step 2: Impression and Temporization
- Conventional impression: Polyvinyl siloxane (PVS) or polyether materials for accuracy.
- Digital impression: Intraoral scanners (IOS) capture preparation geometry with high accuracy. Benefits include patient comfort, faster workflow, and reduced remakes. Systems such as CEREC, 3Shape TRIOS, and iTero are widely used.
- Temporary restoration: Provisional crowns fabricated from bis-acryl composite or PMMA, cemented with temporary (eugenol-free) cement to prevent sensitivity and maintain occlusion.
Step 3: Laboratory or CAD/CAM Fabrication
Conventional fabrication involves wax pattern, investing, casting, and porcelain layering. Digital workflows use CAD software to design the restoration, followed by CAM milling from pre-sintered blocks (lithium disilicate, zirconia) or 3D printing of patterns for casting.
Step 4: Try-In and Cementation
- Try-in: Assess marginal fit (<50 μm ideal), proximal contacts, occlusion, and aesthetics.
- Cement selection: Resin-modified glass ionomer (RMGI) for conventional cementation. Adhesive resin cement for all-ceramic restorations (especially lithium disilicate). Zirconia can be conventionally cemented with RMGI when retention form is adequate, or adhesively bonded with MDP-containing primers.
- Occlusal adjustment: Verify centric and excursive contacts. Polished zirconia causes minimal antagonist wear; unpolished or adjusted surfaces should be repolished.
Longevity and Complications
Systematic reviews report 5-year survival rates: all-ceramic crowns 93–96%, PFM 94–97%, full metal 97%, conventional bridges 88–94%. Common complications include secondary caries, ceramic fracture, loss of retention, endodontic complications, and periodontal issues around abutments. Factors reducing longevity: poor oral hygiene, bruxism, inadequate tooth preparation, and suboptimal cementation technique.
Cost Considerations and Treatment Planning
Crown costs vary by material: composite resin ($300–600), PFM ($600–1000), lithium disilicate ($800–1200), zirconia ($900–1500). Bridge costs multiply per unit. Implant-supported restorations have higher initial costs but lower long-term maintenance. Treatment planning should consider biological cost (tooth structure sacrificed), financial cost, aesthetic demands, and patient preferences.
Conclusion
Dental crowns and bridges remain essential tools in restorative dentistry, offering predictable solutions for tooth restoration and replacement. Material selection should be individualized based on clinical requirements, aesthetic demands, and functional considerations. Digital workflows continue to improve efficiency and precision, while evidence-based cementation protocols enhance longevity.
References
- Pjetursson BE, Sailer I, Zwahlen M, Hämmerle CH. A systematic review of the survival and complication rates of all-ceramic and metal-ceramic reconstructions. Dent Mater. 2007;28(1):86–95.
- Sailer I, Makarov NA, Thoma DS, et al. All-ceramic or metal-ceramic tooth-supported fixed dental prostheses? A systematic review. Dent Mater. 2015;31(6):624–639.
- Raigrodski AJ, Hillstead MB, Meng GK, Chung KH. Survival and complications of zirconia-based fixed dental prostheses: a systematic review. J Prosthet Dent. 2012;107(3):170–177.
- Pjetursson BE, Thoma D, Jung R, et al. A systematic review of the survival and complication rates of implant-supported fixed dental prostheses. Clin Oral Implants Res. 2012;23(Suppl 6):22–38.
- Edelhoff D, Sorensen JA. Tooth structure removal associated with various preparation designs for anterior teeth. J Prosthet Dent. 2002;87(5):503–509.
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