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Periodontal dictates for esthetic

ceramometal crowns

R. Sheldon Stein, DMD

Periodontal health must be the crucial con

sideration in any restorative treatment plan.
The interaction between the crown and the
investing tissue contributes to the health of
the gingiva. The dentist must consider the
toothsposition, shape, function, andphysi
cal state as well as the means by which it is
restored, whenyieldingto thedemands ofthe
patientfor an improvedesthetic appearance.
eriodontal disease usually is attrib
uted to calcific deposits associated
with root surfaces o f teeth. H ow ever, the
c o m p lic a te d in te r a c tio n b e tw e e n th e
crow n and the investing tissu es1 (Fig 1)
also contributes to the pathological condi
tion.
Ideally, all margins of crow ns should be
supragingival. Crow ns conceived in the
presence o f periodontal disease and en
larged, edem atous, inflamed gingiva can
attain only lim ited esthetic appeal and will
exacerbate the periodontal disturbance. It
is true th at im properly fabricated crow ns
will contribute to periodontal disease, and
it is equally true that periodontal disease
may destroy otherw ise excellent crow ns.
A mutual protective com plex m ust exist
betw een restoration and periodontium .2
N o subgingival tooth preparation (crown)
should be placed w hen gingival disease is
present. F urtherm ore, to attain the most
predictable, consistent, and best esthetic
r e s to ra tio n , the cro w n sh o u ld n o t be
placed unless the tissue is in an absolute
state of health.
In view o f the dem ands o f the currently
cosm etically concerned dental p u b lic,3

many factors involved in tooth-tissue in

teraction are overlooked, resulting in a
violation of the factors essential to the
success of restorative procedures in clini
cal practice. O ne o f the m ost com m on er
rors concerns preoccupation with color.
Tooth form , size, and position often are
sacrificed in the attem pt to achieve w hat is
thought to be a cosm etically pleasing re
sult that, m ore often than not, represents
concessions to p atien ts dem ands (Fig 2).
W hen cosm etic appearance is the prim ary
factor, m ost restorative procedures will
fail. T he cosm etic appearance as repre
sented by color (shade m atching), is only
one of the esthetic considerations in the
developm ent o f a harm onious and effec
tive natural too th com position.
It is an inflexible dictum that there can
not be an esthetic or successful restoration
in the presence of periodontal disease.
E sthetic dentistry is the science th a t at
tem pts to deduce from nature the rules and
principles o f art. In th at nature will con
t r i b u t e to th e o b j e c t i v e , n a t u r a l
phenom ena m ust be studiously observed
with regard to teeth and their surrounding
tissues. This m eans the form , size, posi
tion, arrangem ent, com position, texture,
and, to be sure, color o f teeth m ust be
precisely evaluated in each case. Thus,
this discussion focuses on anterior crow ns
(although virtually the sam e principles
apply to other areas o f the m outh) and
considers those factors that have a signifi
cant role in w hat is generally accepted as
esthetic dentistry.

Tooth form
The com m on categories o f tooth form are
described by the fam iliar morphological

term s: square, tapered, and ovoid, with

m odifications and com binations of these.
H ow ever, the shape o f the p atien ts face
o r fram e o f lips m ay affect the perception
o f form . One com m on attrib u te is the m or
phological a rc h ite c tu re at th e gingival
third o f a crow n w hen the adjacent gingiva
is healthy. It is not only a question o f ap
pearance. T he m ost crucial link betw een
tooth form and gingival health is the design
o f the cervical third o f the crow n. T he
need for the proper em ergence profile
cannot be overem phasized (Fig 3).4-8 This
linkage betw een the em ergence profile and
transient planes affords a natural appear
ance to the basic to o th form s and, in addi
tion, supplies the properly deflective func
tional contours. This com plem entary rela
tionship betw een form and function is es
sential to m eet biologic dem ands for an
extended tim e (Fig 4).
Careful appraisal o f the facial aspect of
an an terio r tooth in relationship to the gin
giva show s a trigonal outline rath e r than
the sem ilunar image perceived by m ost
dentists and technicians (Fig 5). T he facial
surface o f the cervical third o f the crow n is
m ade up o f two rhom boids o f som ew hat
different dim ensions because o f the tri
gonal nature of the gingival outline (Fig 6).
O bedience to this rule, deduced from the
natural ap pearance, not only leads to a
m ore e sth e tic re su lt b u t also com p els
so u n d er p rep aratio n o f the to o th for a
biocom patible crow n th at would be dif
ficult, if not im possible, to achieve by any
oth er approach.
A s said before (but p erhaps not often
enough), restorations co n stru cted to ac
com m odate gingiva enlarged and distorted
by chronic or acu te inflam m atory changes
will be esth etically u n sa tisfac to ry , will
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Fig 1 Gingival inflammation and enlargement as

sociated with ceramometal crowns placed 6 months pre
viously. Clinical probing disclosed appreciable misfit of
crown margin and root surface.

Fig 2 Advanced periodontal problem concerning the

maxillary central incisor restored with a crown 2 years
earlier. The patient insisted on restorative treatment to
close midline diastema. Extension of form and contour
beyond physiological limits is apparent. Elongation and
migration led to superimposed traum a from occlusion.
Orthodontic movement of all anterior teeth or crowns on
both central incisors might have been a better solution.

place an undue burden on tissue m ainte

nance, and will lead to prem ature tooth
instability. The relationship of tooth form
to the periodontal com plex does not begin
and end at the gingival margin but extends
to the occlusal/incisal aspect. O bedience
to th e p ro p e r e m e rg e n c e pro file will
strongly influence the bulk of the ultimate
crow n and, accordingly, the depth and
shape of the preparation. T he tooth prepa
ration should be a prototype o f the antici
pated crow n form (Fig 7).
In th e s im p le s t c a s e o f in d iv id u a l
crow ns, the ideal crow n should look as if it
b elo n g s th e re , ap p e arin g harm o n io u s,
n atu ral, inconspicuous, and in con cert
w ith th e o th e r teeth (Fig 8). All these
p hrases and adjectives apply to the same
objective, but as these attributes cannot,
in and o f them selves, provide m ethodolog
64-E JADA (Special Issue) December 1987

ical advice, the param eters o f a crow n

should be exam ined in more detail. Invari
ably, attention to detail m akes for w orthy
achievem ents in both art and science.

Crown size
Size and form are intim ately related, as the
support of gingival health is of param ount
im port. The constraints that apply in co n
structing a crow n should not be viewed as
inhibition but rath er as a positive guide.
Height or length o f a crow n is influenced
by the distance betw een the incisal table
and the apex o f the cissoid angle of the
trigone (the highest point of the gingival
outline). T he natural design often is al
te re d by perio d o n tal d isease, the su b
sequent treatm ent of which exposes root
surfaces. At th at point the patient will seek

esthetic treatm ent, particularly w hen the

m axillary gingival architecture show s un
s ig h tly ro o t s u rfa c e s and e m b ra s u re
spaces (Fig 9).
If the incisal relationship is edge-toedge, there is little possibility for a d e
crease in vertical dim ension. Only slight
am elioration can be accom plished with o r
thodontic treatm ent, endodontic therapy,
and modification of root surfaces. Again,
it is w orth noting that the margin of an
ideal cro w n sh o u ld b e su p rag in g iv al.
(W h ere m any te e th are in v o lv e d , an
acrylic labial facade may be used.)
W hen the patient has a sufficient o ver
bite, the dentist has more options and can
shorten the crow n vertically (endodontic
therapy may be required) and rem odel the
exposed root to sim ulate an acceptable
crow n form.

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Fig 3 Top and middle, close examination shows either

a straight line or concave contour at the cervical third of
crown form . P ro p er em ergence profile provides
biocompatible contour with gingival tissue. Bottom,
overcontour at gingival aspect causes pressure atrophy
of gingival tissues, resulting in an inflammatory re
sponse.

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Fig 4 Top left, preoperative view of patient with periodontal involvement and 5- to
6-mm pocket on mandibular anterior teeth. Periodontal surgery was done to elimi
nate pockets. Top right, postoperative appearance 2 weeks after final insertion of
restorations. Vertical dimension is not increased but tooth height appears shortened
as gingival margin is located apically after periodontal therapy. Bottom left and
right, postoperative appearance of maxillary and mandibular teeth sextants 11 years
after treatment. Patient maintains meticulous oral hygiene.

As to the appropriate width of a crow n,

it should be realized that a crow n m ade to
fill a m esiodistal space that is too wide will
inevitably be overcontoured and provoke
periodontal disorders. If, how ever, the
space is too narrow , it is reasonable to
assu m e th e re is g en erally insu fficien t
i n t e r r o o t s p a c e to a c c o m m o d a te a
biocom patible crow n or pontic. In both
in stan ces, orthodontic treatm ent is the
preferred rem edy. Any com prom ise pre
dicts failure.
A nother dim ension of size th a t deserves
m ention is dep th . This term conn o tes
translucency, although perhaps opales
c e n c e m ore ac cu rately describ es the
phenom ena that give a crow n or tooth vib
rancy and vitality. O palescence can be
achieved only through m eticulous atten
tion to the art and science o f ceram ics (Fig
10).

66-E JADA (Special Issue) December 1987

Position
A nother esthetic problem is that of malposed teeth in lingual or labial version.
T he form er often presents an anatom ic
cu l-de-sac th a t h am pers effectiv e oral
hygiene, leading to inflammation o f su r
rounding gingiva. Efforts to align the tooth
by exaggerating its bulk invariably result
in overcontouring the body to incisal as
pect of the crow n. Inevitably, such distor
tion o f the coronal anatom y will co m
prom ise periodontal health. T he latter
problem of labial version is often accom
panied by scuffing, caused by toothbrush
abrasion of the adjacent gingiva. W here
the labial version is slight, minor o rth o
dontic treatm en t may help resolve the
situation, although orthodontic correction
could also produce a diminished interroot
space. If that is the case, m ajor orthodon

tic correction can be undertaken. If this is

not possible, it is best to weigh the advan
tages o f selective extraction, rem em bering
the maxim: A tooth would rath er have
good pontic than a poor tooth relationship
as its neighbor! 5
An exam ple is the dilemma posed by the
attem pts to modify a peg-shaped lateral
incisor. To achieve a size and form that
looks good, overcontouring seem s un
avoidable. This in turn will lead to a nega
tive periodontal response. In such a case
the intensity of the patients desire m ust be
weighed against the thoroughness o f his or
her com prehension of the liabilities. The
issue is a com plex anatom ical one and not
predictably rem edied by a crow n. N or can
it be any b etter resolved by lam inate ve
neers o r bonding. R ather, its ultim ate fail
ure is predicated on the distortion of the
em ergence profile and the interrelation-

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Fig 5 Top, various tooth forms with healthy tissue show trigonal gingival outline. Middle, diagram contrasts
semilunar gingival outline generally visualized by dentist and technician (top) with actual trigonal outline (bottom)
noted in natural dentitions. Middle depiction shows common invasive tissue error made during crown preparation
when outline is visualized as semilunar. Bottom, four maxillary incisor crowns display trigonal outline of gingival
outline when tissue is in absolutely healthy state as guide for clinical delineation of margin area during tooth
preparation.

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Fig 6 Top and middle, overlay analysis of anterior

incisors depicts rhomboidal forms in relationship to
emergence profile and transient planes whereby trigone
is formed.

Fig 7 Proper tooth preparation shows sufficient cer

vical reduction, vertical and lingual oblique axial
planes, and concave lingual reduction, all confirmed by
incisal table aligned to middle of proximal aspect. These
features enable a technician to fabricate a crown of ideal
proportions, form, position, and inclination.

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Fig 8 Top left, ceramometal crown with gold collar on mandibular right first
premolar shows ideal emergence profile 4 years after insertion. Top right and middle
left, buccal and lingual views of ceramometal crown with gold collar on mandibular left
first molar shows biocompatible tissue response and overall esthetic appearance as
result of proper emergence profile 5 years after insertion. Middle right and bottom left,
pre- and postoperative appearance of maxillary right lateral, central, and left central
incisors. Excellent gingival adaptation 5 years after highfusing (2,400 F) porcelain
veneer crowns were placed. Appearance is natural because of harmonious blend of
color and form in addition to healthy tissue response in concert with remaining teeth.
Bottom right, crown on lateral incisor was inserted 7 years earlier. Gold collar is
concealed subgingivally and margin ends at epithelial attachment.

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Fig 9 Top, after periodontal therapy, roots are ex

posed and interproximal spaces are exaggerated. Mid
dle, when overbite relationship permits, foregoing case
can be corrected by shortening of clinical crown and
raising of contact areas to create a more esthetic appear
ance. Bottom, edge-to-edge relationship is corrected by
redesigning and root coloration of clinical crowns. Re
sult is not as esthetically pleasing as in middle figure, but
is an acceptable compromise to some patients.

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Fig 10 a Maxillary and mandibular posterior quadrants restored with ceramometal

crowns show match with natural counterparts when ceramic art is meticulously
observed.

Fig 11 Top left, flaking of porcelain at margins occurs during try-on of six-unit
anterior bridge with multiple butt joint preparations. Top right, section of five-unit
anterior fixed partial denture with 1-mm gold collars. Bottom left, internal view of
crowns with adequate chamfer shoulder and bevel. Bottom right, 10-year postopera
tive appearance of fixed partial denture, extending from maxillary right lateral
incisor to left canine.

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Fig 12 Left, cross section of root at gingiva. Irregularities of outline must be

removed during preparation to ensure precise adaptation of crown margin (orig mag x
100). Right, microscopic analysis of beveling to remove root circumference ir
regularities with multifluted bur (Illustration, courtesy of Dr. Peter Scharer, Zurich,
Switzerland).

ship betw een gingiva and restorative m ar

gin. (M oreover, several new and popular
techniques have an additional difficulty:
subgingival finishing of m argins.)

Tooth preparation
M aterials and laboratory m ethods used to
attain a precise marginal fit have been im
proved. Although attention to the careful
delineation o f the crow n preparation itself
rem ains a constant requirem ent and de
spite the availability of various excellent
im pression m aterials, a good im pression
o f a poor preparation does not ensure a
good restoration.
Strategies o f crow n preparation are di
verse, b ut one com m on denom inator is
provision o f a marginal area in sufficient
dim ension so it will accom m odate resto ra
tive m aterials and be of proper form , fit,
and color. The debate on how to prepare a
to o th for a crow n is often reduced to a
choice betw een a bevel o r a butt joint.
Some clinicians advocate a shoulder bevel
on the proxim al and lingual aspects, and a
butt jo in t on the labial surface.
T he bevel provides a circum ferential
guide plane for the definitive seating o f
multiple units by perm itting minute tooth
m ovem ent in any direction. T he butt jo in t
does n ot lend itself to m ultiple-unit resto
rations because o f th e probability that a
tolerant yet accurate parallelism betw een
u n its d im in ish es e x p o n e n tia lly as th e
72-E JADA (Special Issue) December 1987

num ber of units increases. In such cases,

there is flaking or chipping o f porcelain at
the margins.
T h e a p p e a l o f th e b u tt j o i n t an d
avoidance o f a gold collar is, with rare
exceptions, overcom e by a properly de
signed cham fered shoulder w ith bevel.
This preparation provides a m ore precise
fit (F ig l l ) . 6 A n ad d e d b o n u s is th e
sm oothing o f irregularities of the root sur
face as the bevel (and only the bevel) is
placed in the sulcus (Fig 12).
A ccess to the sulcus is easily attained by
the p roper use o f retraction cord o r elec
trosurgery if tissues are healthy. The labial
cham fer-shouldercan be redefined so that
the labial bevel is reduced to half its size.
The argum ent th at subsequent recession
of the gingiva will expose the gold collar
can be effectively refuted because there is
a distinct dem arcation betw een porcelain
and root surface color w hen recession un
covers the butt joint.

Marginal finish
The finish of a crow n, both the porcelain
and the m etal, is crucial. The sm oothness
of the surfaces affects the deposition of
plaque.7 T he desirable finish of porcelain
is described as clam shell, as such a tex
ture diffracts light ideally and provides a
su rfa c e s m o o th n e ss th a t d isc o u ra g e s
plaque form ation. T he finely textured sur
face can be attained with use of disks and

survives self-glazing. Use o f liquid over

glaze is discouraged. The overglaze tech
nique produces a rougher surface because
m icroscopic bubbles are form ed during
the procedure and subsequently ru p tu re.8
A self-g lazin g p ro c e s s 9 p re se rv e s the
clam -shell surface achieved in the pre
glaze porcelain finishing.
As for the finishing o f m etal, a sm ooth,
clean surface is essential. It is not widely
appreciated th at some agents (rouge and
tripoli) used to achieve this goal leave a
residue, such as copper oxide, w hich is
toxic to soft tissues. W ater-soluble polish
ing agents are available.
R ecent investigations indicate that an
alarm ing num ber of the new form ula alloys
m ay be to x ic .10 " Locally, the toxicity is
seen as a black discoloration o f the gingiva
adjacent to the m etal (Fig 13). T he com
plete clinical significance of this reaction is
not know n, but its presence indicates th at
dentists and technicians should carefully
select alloys, and m anufacturers should
also be p recise regarding com position.
Gingival discoloration o f this nature de
fe a ts th e e s th e tic ac h ie v e m e n t o f the
crow n.

Cementation
T he final e sth etic resu lt m ay be co m
prom ised during cem entation. N ot only
m ust excess subgingival cem ent be com
pletely rem oved but the scratches and im-

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perfections induced by its removal must

also be elim inated to avoid consequent
plaque deposition and gingival inflam m a
tion. M oreover, care m ust be taken during
later prophylaxes as ultrasonic o r hand
scalers can m ar m etal surfaces at the m ar
gins. If this occurs, the defects can be
sm oothed with a fine flour o f pumice.
A lso, tem p o rary cem entation o f the
finished crow n is recom m ended because it
provides for esthetic rvaluation as well
as assessm ent o f gingival responses. Un
fortunately, such a procedure may be im
practical when all-ceramic crow ns are in
serted.

Conclusion
T he to o th s p osition, sh ap e, function,
physical state, and the m eans by which it is
restored help to determ ine, by their in
teraction, w hether periodontal injury will
o ccur in tooth and tissue if an esthetic
crow n is placed. Tissue dem ands m ust be
considered throughout all restorative pro
cedures to achieve a durable and esthetic
restoration. Gingival health is the ultimate
criterion of all restorations.
Dr. Stein is an assistant dean, clinical affairs, and
research professor o f prosthetic dentistry, Boston
University Goldman School of Graduate Dentistry,
and maintains a private practice, 50 Staniford St, Bos
ton, 02114. Address requests for reprints to the author.
1. Stein, R.S., and Glickman, I. Prosthetic consid
erations essential for gingival health. Dent Clin North
Am 177-188, 1960.
2. Stein, R.S. Mutual protective complex of dental

Fig 13 Black gingiva response to cytotoxic alloy occurred 3 months after insertion. Similar response occurred
with a fixed partial denture placed 6 months earlier. Removal of prostheses showed base metal alloy was used in both
cases.

restorations. In Laney, W .R., and Gibilisco, J.A.

Diagnosis and treatment in prosthodontics. Philadel
phia, Lea & Febiger, 1983.
3. Watson, J.F ., and Crispin, B.J. Margin place
ment of esthetic veneer crowns. Attitudes of patients
and dentists. J Prosthet Dent 455:499-501, 1981.
4. Stein, R.S. The emergence profile. Jap J Techn
15(1 ):30-39, 1987.
5. Stein, R.S. Pontic-residual ridge relationship: a
research report. J Prosthet Dent 16(2):251-285, 1966.
6. Panno, F.V., and others. Evaluation of the 45degree labial bevel with a shoulder preparation. J Pros
thet Dent 56(6):655-661, 1986.
7. Swartz, M ., and Phillips, R. Comparison of

bacterial accumulations on rough and smooth enamel

surfaces. J Periodontol 28(10):303-307, 1957.
8. Stein, R.S., and Kuwata, M. A dentist and a
dental technologist analyze current ceramo-metal pro
cedures. Dent Clinic North Am 21(4):729-749, 1977.
9. Stein, R.S., and Abdullah, B. Modified stain
technique for ceramo-metal restorations. Thesis, Bos
ton University, 1984.
10. Stein, R.S.; Hitti, F .R .,an d Duval, M. Possible
cytotoxicity of dental alloys. Thesis, Boston Univer
sity, 1984.
11. Bergman, M. Erosion in the oral cavity po
tential local and systemic effects. Int Dent J 36(1):4144, 1986.

Stein: PERIODONTAL DICTATES FOR CERAMOMETAL CROWNS 73-E