Received Date : 26-May-2016

Accepted Date : 21-Jun-2016

Accepted Article
Article type : Original Article

Title:
All-ceramic crown preparations – an alternative technique

Short Running Title:

All-ceramic crown preparations

Authors:
John Anh Quan Tran, James Dudley, Lindsay Richards

Affiliations:
School of Dentistry, Faculty of Health Sciences
The University of Adelaide, Australia

Address for correspondence:

John Anh Quan Tran
68 Denison St
Villawood
Sydney, Australia 2163
Phone: +61 426 827 289
Email: jaqt667@hotmail.com

Acknowledgements
The authors would like to thank Columbia Dentoform and Henry Schein Halas for supplying
the model teeth and Komet burs used in this study.

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/adj.12433
This article is protected by copyright. All rights reserved.
 ABSTRACT
Background: The aim of this study was to compare the crown preparations dimensions
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produced from two different techniques of preparation for posterior all-ceramic crowns.

Methods: Twenty-four fourth year dental students undertook a course of advanced

simulation training involving education in an alternative technique of preparation for a 36 all-
ceramic crown. Crown preparations performed using the traditional technique were
compared to an alternative technique for total occlusal convergence (TOC) and reduction
difference (RD) using digital scanning and comparative software.

Results: Groups that spent the most time performing the alternative technique produced
crown preparations with significantly lower bucco-lingual (BL) TOC. The training resulted in
crown preparations that were closer to ideal TOC and RD measurements.

Conclusions: The alternative technique of crown preparation for a posterior all-ceramic

crown showed initial promise in creating a less bucco-lingually tapered and more ideally
occlusally reduced crown preparation.

KEYWORDS:
Crown preparation, dental education, digital scanning, reduction difference, total occlusal
convergence.

ABBREVIATIONS AND ACRONYMS:

TOC = total occlusal convergence; RD = reduction difference; BL = bucco-lingual; MD =
mesio-distal

INTRODUCTION
Traditional fixed prosthodontics literature has proposed tooth preparations should adhere to
five governing principles: preservation of tooth structure, retention and resistance form,
marginal integrity, structural durability and preservation of the periodontium.1 In
undergraduate curricula, students commonly proceed through a course of pre-clinical
simulation teaching involving crown preparations that are visually assessed by experienced

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 clinicians. Naturally, such a system harbours limitations such as the potential for inter-
assessor inconsistency and the subsequent variations in interpretation by students.2
Scanning technology has recently been used in dental schools as a means of providing
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standardised, less subjective, numerical evaluation of crown preparations. Specifically, E4D
Compare (D4D Technologies, Richardson, TX, USA) has gained interest as a tool for the
evaluation of dimensions of crown preparations. E4D Compare allows assessment of two
important parameters: total occlusal convergence (TOC), the angle of convergence between
two opposing prepared axial surfaces1, and reduction difference (RD), the amount of
reduction of tooth structure between a preparation and the ideal preparation.
The generally accepted traditional sequence for posterior crown preparations involves
reduction of the occlusal surface first followed by the axial reduction.1, 3, 4 By reducing the
occlusal surface first, the height of the remaining tooth can be assessed for the need to add
any additional retentive features.1 In addition, access for the more difficult proximal
reduction may be improved.5 Alternatively, axial reduction may be completed first and may
improve the maintenance and visualisation of the long axis of the tooth which could in turn
help achieve the appropriate TOC for optimal retention and resistance. There are no known
studies that have investigated the dimensions of the crown preparations achieved when axial
reduction is carried out first in preference to the more traditional occlusal reduction first.
There are many adjunctive tools that have been proposed to assist in the appropriate
reduction of tooth structure for crowns such as depth reduction guides, burs of limiting depth
cutting (such as those used in veneer preparations), and marked burs for depth gauging.6, 7, 8
However, there are currently no studies that have evaluated the effectiveness of such burs in
producing appropriate depths.
The fine motor skills required for accurate crown preparations can be challenging for
dental students as they embark on the process of performing crown preparations for the first
time. Interestingly, it has been found that basic manual dexterity is not essential, rather with
repetition of clinical procedures, students who demonstrated an ability to follow the basic
steps of training improved significantly over time 9-11
The aim of this study was to assess the effect of an alternative method of crown
preparation on the dimensions of all-ceramic crown preparations performed by undergraduate
dental students from The University of Adelaide. The null hypothesis was that the alternative
method of crown preparation and the volume and timing of training had no effect on the
dimensions of the crown preparations.

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 MATERIAL AND METHODS
Recruitment and Standard Preparation
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The study was conducted at The University of Adelaide Dental Simulation Clinic and was
approved by the University of Adelaide Human Research Ethics Committee (H-2015-091).
Fourth year undergraduate dental students from The University of Adelaide were invited to
participate.
An ideal crown preparation was created on a Columbia model (Columbia Dentoform
Corporation, Long Island City, NY, USA) tooth 36 in reference to the suggested preparation
parameters for an IPS e.max crown (Ivoclar Vivadent AG, Schaan, Liechtenstein).12

Study Design
Participants were randomly assigned to one of four groups (Groups 1 to 4) for the five week
program. During the first week, all participants were instructed to prepare tooth 36 on a
Columbia model (Columbia Dentoform Corporation, Long Island City, NY, USA) for an IPS
e.max crown using the traditional occlusal reduction first technique which all participants
were intimately familiar with from their previously completed pre-clinical program. Each
student constructed two laboratory putty key impressions that were sectioned bucco-lingually
and mesio-distally and used to check reductions.
Group 1 undertook the advanced simulation training in week 2, followed by Group 2
in week 3, Group 3 in week 4 and Group 4 in week 5. Once a group had completed the
training, the new technique was repeated in each subsequent week for the remainder of the
study. Each group undertook individualised programs in different sections of the simulation
clinic.

The advanced simulation training involved a seminar presentation of the specific stages and
guidelines required to achieve the ideal crown preparation dimensions using the axial
reductions first technique and a depth-marked bur.

The bur used was the Komet 6847KRD.314.015 bur (Komet Dental, Lemgo, Germany)
which has been specifically developed for IPS e.max crown preparations. The bur features
two depth marks at 1.5mm and 3.5mm from the tip a rounded tip that can be used to create a
chamfer or heavy chamfer, a 4 degrees taper and a 1.0mm diameter at the tip (Fig. 1).
.

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 Assessment of Crown Preparation Dimensions
For all crown preparations, the prepared Columbia model (Columbia Dentoform Corporation,
Long Island City, NY, USA) tooth and the two adjacent teeth were scanned using the E4D
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Design Centre and its associated system (D4D Technologies, Richardson, TX, USA). The
‘master model’ and each crown preparation was then imported into E4D Compare (version
1.0) and aligned using common landmarks in accordance with the E4D Compare user
manual.13 The margins of the preparations were outlined and the dimensions of the
preparations were assessed using two criteria: TOC and RD.

TOC

TOC was measured in both the bucco-lingual (BL) and mesio-distal (MD) planes (Fig 2).

Reduction Difference
The E4D Compare software was used to compare the two crown preparations to a specific
tolerance using a colour map shown as green (Good), over-reduced as red (Excess) and
under-reduced as blue (Insufficient). An overall percentage of surface area for each colour
was calculated (Fig 2). The tolerance value was set at 0.30 mm in reference to a previous
study2 and the percentage of Excessive, Insufficient and Good areas was measured for each
preparation. In addition the percentage of inaccurate areas (i.e. excessive and insufficient
percentages combined) was calculated.

Statistical Analysis
The data was collected and statistically analysed using the SPSS software (SPSS Inc,
Chicago, IL, USA). The differences in mean measurements (MD and BL TOC; Excessive,
Good and Insufficient RD) between the four groups were analysed using one-way ANOVA.
The relationship between each measurement (MD and BL TOC; Excessive, Good and
Insufficient RD) and group were analysed with correlation analyses. Paired-samples t-tests
were performed to evaluate the effect of training on each measurement (MD and BL TOC;
Excessive, Good and Insufficient RD). Statistical significance was set at the 0.05 probability
level.

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 RESULTS
One of the 24 participants withdrew from the study prior to the final session (week 5)
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resulting in a total of 119 crown preparations. Comparisons of mean TOC and RD before and
after training are shown in Fig 3 and Fig 4 respectively. The mean, standard deviation and
range of TOC and RD values for each groups are shown in Table 1 and Table 2.

There was a statistically significant correlation of greater numbers of training sessions with a
reduced BL TOC (p=0.037) but not a reduced MD TOC (p=0.514). The number of training
sessions did not influence Excessive (p=0.83), Good (p=0.867), Insufficient (p=0.968) RD.

One way ANOVA analysis failed to demonstrate a statistically significant difference between
mean measurements for BL (p=0.157) and MD (p=0.133) TOC or mean measurements for
Excessive (p=0.654), Good (p=0.778) and Insufficient (p=0.724) RD between the four
groups.

The training resulted in a statistically significant decrease in mean BL (p=0.019) and MD

(p=0.00) TOC, a significant increase in mean Good RD (p=0.005) and a significant decrease
in mean Inaccurate RD (p=0.036) after training. There was no statistically significant
difference between mean Insufficient RD measurements (p=0.054) or mean Excessive RD
measurements (p=0.580) when comparing the two methods of crown preparation.

A questionnaire administered on completion of the final session established a clear majority

of participants preferred the axial reduction first technique and the depth-marked bur.

DISCUSSION
The students in the groups that completed the largest amount of sessions practicing the new
technique produced crown preparations with an overall lower BL TOC. In preparing the axial
surfaces first and leaving the occlusal surface intact landmarks may be more easily
maintained resulting in orientation of the bur more consistently along the long axis of the
tooth. The trend observed in this study of each additional practice opportunity increasing the
quality of preparations, but at a gradually declining rate until there is no further improvement
has also been observed in other studies investigating the learning curves of students.14 As this

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 was the only significant correlation observed between all of the measurements and group,
further studies with greater repetition and sample sizes are required to validate this.
The statistically significant decrease in mean BL and MD TOC achieved with the
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alternative technique approached 20 degrees which is a taper proposed as a more realistic,
practical and clinically achievable ideal.15 The awareness and emphasis of the four degree
tapered bur used in the training may have contributed to the improvement in TOC. In general,
the mean TOC values produced in this study (Table 1) were greater than 4-14 degrees as
quoted in traditional textbooks3, 16, 17 and the 14-20 degrees reported in other studies of crown
preparations created by dental students.18-22
The significant increase in mean Good RD preparations and a significant decrease in
mean Inaccurate RD measurements after training can be attributed to the decrease in mean
Insufficient RD measurements as there was no significant change in Excessive RD
measurements. There was an initial trend for students to under-reduce the preparations which
is consistent with the observations from other studies of the conservative tendency of
practitioners.7, 23 Insufficient reductions could result in a restoration that is occlusally too high
or cervically over-contoured. However after undergoing the training, students were able to
achieve adequate occlusal reductions as many found the depth-marks on the new bur aided in
gauging the extent of tooth reduction.

The study was subject to some potential sources of bias. The process of learning a new
procedure or being observed, known as the ‘Hawthorne Effect’, may have influenced the
results of the study. It is therefore difficult to precisely reason the observed differences in this
study.
The study was conducted on Columbia model (Columbia Dentoform Corporation,
Long Island City, NY, USA) teeth of uniform and ideal anatomy and it is expressly
acknowledged there will be multiple differences in applying the concepts and results in vivo.
The study was limited to the measurement of TOC and RD due to the selected technique and
software available, but it is acknowledged that margin configuration, surface smoothness,
rounded internal line angles and damage to adjacent teeth contribute to the overall quality of
crown preparations.
The alignment of the models using the E4D Compare software was standardised as
much as possible but the method proposed by Callan et al.24 using small dots placed
diagonally on the buccal and lingual gingiva below the teeth in front of and behind the tooth
preparation was not achievable due to anatomical variations in the models. A different

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 tolerance value would have produced different percentages of Excessive, Insufficient and
Good areas, however the 0.3mm tolerance value used in this study was set in reference to a
previous study2 and was thought to be reasonable.
Accepted Article
This study used version 1.0 of the E4D Compare software that, like many things in
technology, has been superseded with a video camera-based scanning system that creates the
image as it actively scans the model.25 The newer version also has an auto-align feature that
eliminates the need for various methods of alignment and has been established to greatly
increase the inter-rater and intra-rater agreement of crown preparations.25

CONCLUSION
The alternative crown preparation technique for a posterior all-ceramic crown showed initial
promise in creating less bucco-lingually tapered and more ideally occlusally reduced crown
preparations. It would be beneficial to conduct further studies using larger sample sizes and
perform more in depth analysis using purpose-built software to establish the complete range
of benefits of the alternative method of crown preparation. This study ratified the use of
digital scanning technology and comparative software as an effective, visually engaging and
repeatable method of crown preparation evaluation.

REFERENCES

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prosthodontics. 3rd edn. Carol Stream: Quintessence, 1997:119-135.
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faculty grading in dental education. J Dent Educ 2013;77:168-175.
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clinical techniques. Br Dent J 2002;192:401-404.

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 7. Poon BK, Smales RJ. Assessment of clinical preparations for single gold and
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 22. Aleisa K, Al-Dwairi ZN, Alwazzan K, Al-Moither M, Al-Shammari M, Lynch E.
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TABLES

Table 1. Mean, standard deviations (SD) and range for TOC values (degrees) by group
Group
1 2 3 4
BL Mean 28.04 27.36 32.01 33.25
SD 0.745 4.32 5.03 7.20
Range 1.74 12.03 14.15 16.49

MD Mean 27.60 21.58 28.39 27.30

SD 3.30 5.38 5.17 6.33
Range 8.44 14.66 13.27 16.77

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 Table 2. Mean, standard deviations (SD) and range for RD values (%) by group
Group
1 2 3 4
Excessive Mean 5.18 7.62 6.73 6.76
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SD 2.26 3.28 3.73 4.55
Range 7.66 9.04 8.80 11.54

Good Mean 44.57 47.11 49.66 44.74

SD 10.06 7.09 9.78 8.58
Range 21.14 20.54 26.44 21.16

Insufficient Mean 50.25 45.27 43.60 48.51

SD 12.71 9.56 13.07 8.30
Range 28.14 28.30 33.90 18.66

Inaccurate Mean 27.71 26.44 25.97 27.85

SD 5.03 3.54 4.80 3.88
Range 10.56 10.27 13.22 10.58

FIGURE LEGENDS

Fig 1. Komet 6847KRD.314.015 bur introduced as part of the advanced simulation training.

Fig 2. E4D Compare Software (a) TOC measured in the mesio-distal slice-plane; (b) Colour
map showing reduction differences between student preparation and master model. Green =
good, blue = insufficient, red = excessive.

Fig 3. Mean TOC before versus after training.

Fig 4. Mean RD before versus after training.

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Accepted Article

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Accepted Article

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