![]()
The University of Western Australia logo at the top right, with a yellow and blue horizontal line beneath it. The slide title reads "Lecture 9: Clinical Steps" in large blue font, followed by "By Dr Cheryl Fu" and "Based on slides by Dr Matsubara" in smaller black font. A small speaker icon is visible in the bottom right corner.
# Learning Objectives
- The “big picture” of indirect restorations
- Clinical steps for treatment planning, preparation stage and insert
- Assessing the permanent crown
No reading for this lecture!
# **Learning Objectives**
- The “big picture” of indirect restorations
- Clinical steps for treatment planning, preparation stage and insert
- Assessing the permanent crown
> [!info]
> This lecture provides a comprehensive overview of the clinical steps involved in single-unit indirect restorations, with a particular focus on the **try-in procedure**. It revisits key concepts from the entire module, starting from initial treatment planning to the final insertion and review of a crown, aiming to present the 'big picture.'
No reading for this lecture!
```mermaid
flowchart LR
A[Clinical examination] --> B[Primary Impression]
B --> C[Tooth preparation + Temporisation]
C --> D[Definitive Impression]
D --> E[Intraoral scanning]
E --> F[CAD<br>All-ceramic]
F --> G[Milling]
G --> H[Try-in]
H --> I[Cementation]
I --> J[Review]
F --> K[Wax up<br>(gold crown, PFM)]
K --> L[Casting and veneering]
L --> H
```
```mermaid
flowchart LR
A[Clinical examination] --> B[Primary Impression]
B --> C[Tooth preparation + Temporisation]
C --> D[Definitive Impression]
D --> E[Intraoral scanning]
E --> F[CAD<br>All-ceramic]
F --> G[Milling]
G --> H[Try-in]
H --> I[Cementation]
I --> J[Review]
F --> K[Wax up<br>(gold crown, PFM)]
K --> L[Casting and veneering]
L --> H
> [!note] Overall Process
> 1. **Clinical Examination & Diagnostic Models:** Initial assessment of the patient and dentition.
> 2. **Treatment Plan:** Formulation of a plan, including the decision for a crown.
> 3. **Patient Consent:** Informing the patient of all risks, benefits, and alternatives.
> 4. **Tooth Preparation:** Preparing the tooth for the restoration.
> 5. **Impression:** Taking a physical or digital impression.
> 6. **Laboratory Fabrication:** The lab creates the permanent crown (approx. 2-3 weeks).
> 7. **Try-in:** Evaluating the crown's fit, function, and aesthetics.
> 8. **Cementation:** Permanently bonding the crown if all criteria are met.
> 9. **Review:** A follow-up appointment (1-2 weeks later) to check occlusion and patient comfort, as the patient is often numb during cementation.
```
**Treatment planning**
- Assessing the tooth (+assessing all the dentition and the patient)
# **Treatment planning**
# Treatment planning
- Assessing the tooth (+assessing all the dentition and the patient)
## Why Does a Tooth Need a Crown?
**Considerations for a crown:**
- Destruction of tooth structure
- Aesthetics
- Plaque Control/Moisture Control
- Retention
**Figure 3a.**
**Figure 3b.**
*Figure 3. Patients abusing methamphetamine often present with rampant caries.*
*(Photo courtesy of Dr. Jana Emsen)*
*Terry E. Donovan (2006) Longevity of the Tooth/Restoration Complex: A Review*
Lecture 1!
- Assessing the tooth (+assessing all the dentition and the patient)
- **Individual Tooth Assessment:**
- **Restorability:** Use periapical (PA) radiographs to assess the periapical status and remaining tooth structure. Any prerequisite treatments (e.g., endodontics, periodontal therapy) must be completed and stabilized first.
- **Long-term Prognosis:** Evaluate if saving the tooth is worthwhile in the long run. Factors like extensive subgingival loss of tooth structure can compromise the prognosis even with a perfect crown.
- **Dentition and Patient Assessment:**
- **Holistic Approach:** A tooth cannot be treated in isolation. Control phases (e.g., periodontal and caries control) must be completed before restorative work.
- **Complex Cases:** If a patient has generalized wear or requires complex oral rehabilitation (e.g., increasing the vertical dimension of occlusion - VDO), a single crown may need to be planned as part of a larger, comprehensive treatment plan. Placing a single crown first could lead to it being cut off and remade later.
- **Patient Management:** Assess the patient's ability to tolerate the procedure and their expectations. Unrealistic expectations (e.g., wanting a smile to look exactly as it did decades ago) can lead to dissatisfaction. It is crucial to manage these expectations or refer the patient if necessary.
## **Why Does a Tooth Need a Crown?**
**Considerations for a crown:**
- **Extensive Destruction of Tooth Structure:** To protect a tooth from uncontrolled fracture, especially when:
- A cusp is lost.
- A restoration covers three or more surfaces.
- Large amalgam restorations are present, which may hide developing cracks.
- > [!example] Anecdote
> A patient fractured a premolar (1-5) with a small MO composite down to the bone level, rendering it non-restorable. A crown could have potentially prevented this.
- **Failure of Direct Restorations:** When direct composite restorations repeatedly fail due to a patient's heavy occlusal forces or wear. Ceramic materials like zirconia offer much higher fracture toughness.
- **Enhanced Retention:** A full crown provides significantly more retention and resistance form compared to onlays or direct fillings.
- **Control of External Contour:** A crown allows for complete control over the tooth's shape, which is essential for creating a **survey crown** to act as an abutment for a removable partial denture clasp.
- Destruction of tooth structure
- Aesthetics
- Plaque Control/Moisture Control
- Retention
*Figure 3. Patients abusing methamphetamine often present with rampant caries.*
*(Photo courtesy of Dr. Jana Emsen)*
*Terry E. Donovan (2006) Longevity of the Tooth/Restoration Complex: A Review*
Lecture 1!
> [!tip] Patient Communication
> - Explain the steps of the procedure to the patient, including the long appointment time, the need to reduce the tooth, taking impressions, and the use of a temporary crown.
> - Inform them that the temporary crown is not strong and is cemented with temporary cement so it can be removed. This manages expectations if it comes loose.
# Treatment planning
- Assessing the tooth (+assessing all the dentition and the patient)
## Principles of Tooth Preparations
### ABUTMENT TOOTH
- Principles of tooth preparation
- Partial or complete preparation
### BIOLOGICAL
- Conservation of tooth structure
- **Avoidance of overcontouring**
- Supragingival margins
- Harmonious occlusion
- Protection against tooth fracture
### MECHANICAL
- Retention form
- Resistance form
- Deformation
### AESTHETIC
- Minimum display of metal
- Maximum thickness of porcelain
- Porcelain occlusal surfaces
- Subgingival margins
![]()
Diagram illustrating tooth preparation principles with cross-sections labeled A, B, and C showing flow of food, gingiva, injury, overcontoured crown, plaque retention, and a note stating "Patient can't clean this!"
## **Principles of Tooth Preparations**
### **ABUTMENT TOOTH**
- Principles of tooth preparation
- Partial or complete preparation
- A crown can be designed as a **survey crown** to provide ideal contours (guide planes, undercuts) for a removable partial denture (RPD) clasp, improving the stability and retention of the prosthesis.
- > [!warning] Clinical Scenario
> For an elderly patient with an existing RPD, crowning an abutment tooth is complex. It would require retrofitting the crown to the existing denture, which is difficult. It may be better to wait until the patient needs a new denture.
### **BIOLOGICAL**
- Conservation of tooth structure
- **Avoidance of overcontouring**
- Supragingival margins
- Harmonious occlusion
- Protection against tooth fracture
- **Pulp Health:** Crown preparation involves removing significant tooth structure, which poses a risk to the pulp. Patients must be informed that the tooth is already compromised and that there is a risk of needing root canal therapy in the future.
- **Periodontal Health:** The preparation and final crown margin must be designed to maintain gingival health.
### **MECHANICAL**
- Retention form
- Resistance form
- Deformation
- **Conservation of Tooth Structure:** While achieving mechanical goals, as much tooth structure as possible should be conserved to protect the pulp and maintain tooth strength.
- **Assessing Remaining Structure:** Before deciding to crown, it's vital to assess what will be left after removing old restorations and caries. Removing a large, pin-retained amalgam might leave insufficient structure for a crown, making the situation worse.
### **AESTHETIC**
- Minimum display of metal
- Maximum thickness of porcelain
- Porcelain occlusal surfaces
- Subgingival margins
- **Patient Expectations:** The aesthetic goals of the crown must align with the patient's expectations. It's crucial to identify and manage unrealistic expectations early on.
- **Material Selection:** The choice of material (e.g., aesthetic Emax vs. strong Zirconia) will be guided by aesthetic demands versus functional requirements.
# Treatment planning
- Assessing the tooth (+assessing all the dentition and the patient)
> "Between 3 and 25% of teeth prepared for full coverage crowns will lose vital pulp functions within 15–20 years, with previously compromised teeth faring worse than those that are more intact"
![]()
Clinical image showing a prepared lower premolar with multiple amalgam restorations and a buccal composite repair.
> "Between 3 and 25% of teeth prepared for full coverage crowns will lose vital pulp functions within 15–20 years, with previously compromised teeth faring worse than those that are more intact"
**Treatment planning**
![]()
Close-up clinical photograph of a posterior tooth with extensive dark restorative material and adjacent teeth, with the question "Would you crown this tooth?" below it.
# Treatment planning
Well, it depends on the exact clinical scenarios
**What if you took a PA and saw this?**
Would that change your treatment plan?
*This is obviously not a radiograph of the same tooth, I just found an image from Google*
**What if you removed the restoration and saw this?**
Would that change your treatment plan?
*This is obviously not photo of the same tooth, I just found an image from Google*
Well, it depends on the exact clinical scenarios
**What if you took a PA and saw this?**
Would that change your treatment plan?
*This is obviously not a radiograph of the same tooth, I just found an image from Google*
**What if you removed the restoration and saw this?**
Would that change your treatment plan?
*This is obviously not photo of the same tooth, I just found an image from Google*
# Treatment planning
Well, it depends on the exact clinical scenarios
**What if that tooth was acting as an abutment tooth for an elderly patient?**
**What if after restoration removal this was all that was left of the tooth?**
*This is obviously not a radiograph of the same tooth, I just found an image from Google*
**What if that tooth was acting as an abutment tooth for an elderly patient?**
**What if after restoration removal this was all that was left of the tooth?**
*This is obviously not a radiograph of the same tooth, I just found an image from Google*
**Treatment planning**
Some pearls of wisdom:
- Carry out all investigations that COULD potentially change your treatment plan
- Not every tooth NEEDS a crown even if it meets the indications (It depends on the combination of unique clinical factors)
- Think about if your treatment is really going to benefit the patient (weighing against the financial+time commitments of the patient)
Some pearls of wisdom:
- Carry out all investigations that COULD potentially change your treatment plan
- Not every tooth NEEDS a crown even if it meets the indications (It depends on the combination of unique clinical factors)
- Think about if your treatment is really going to benefit the patient (weighing against the financial+time commitments of the patient)
# Preparation stage
- **Before patient arrives:**
- Decide on material of choice. Why is that material the best?
- Approval of treatment plan (more on this later)
- Wax up of tooth if any modifications require for existing tooth + putty key
- **Day of preparation**
- Bring patient in, confirm treatment with them quickly, make sure they know what’s happening
- Administer LA. (If you don’t have up to date opposing model because you did other restorative work since the diagnostic model, then take new impression. If you don’t have putty key, do it now)
- Prep tooth according to guidelines for the correct materials. Check for undercuts and sufficient occlusal clearance
- Make provisional restoration
- Retraction cord + expasyl
- Impressions, remove retraction cord!
- Temporise
![]()
Figure 11-1: Recommended reduction for all-ceramic crowns. Figure 11-2: A sloping shoulder margin is not recommended for the all-ceramic crown. It does not support the porcelain. Incisal loading leads to tensile stresses near the margin if the forces are not reciprocated (arrows), which may cause brittle failure. F, Force.
# **Preparation stage**
- **Before patient arrives:**
- Decide on material of choice. Why is that material the best?
- Approval of treatment plan (more on this later)
- Wax up of tooth if any modifications require for existing tooth + putty key
- **Putty Key Fabrication:** Create a putty key on a dental cast for a more accurate and easier fabrication of the provisional restoration.
- **Day of preparation**
1. **Confirm Treatment & Anesthetize:** Confirm the plan with the patient and administer local anesthetic.
2. **Pre-operative Records:** Take a new opposing model or putty key if any changes have occurred since the initial records.
3. **Shade Selection:** Select the shade *before* preparing and dehydrating the tooth.
4. **Tooth Preparation:** Prepare the tooth according to the material guidelines.
5. **Check Preparation:** Ensure sufficient occlusal clearance and no undercuts.
6. **Provisional Restoration:** Fabricate the provisional crown *before* taking the final impression. This ensures the patient can leave with a temporary if the impression needs to be retaken.
7. **Impression:** Use retraction cord or a product like Exposil for soft tissue management, then take the final impression. **Remember to remove the retraction cord immediately after.**
8. **Temporization:** Cement the provisional restoration with temporary cement.
- Bring patient in, confirm treatment with them quickly, make sure they know what’s happening
- Administer LA. (If you don’t have up to date opposing model because you did other restorative work since the diagnostic model, then take new impression. If you don’t have putty key, do it now)
- Prep tooth according to guidelines for the correct materials. Check for undercuts and sufficient occlusal clearance
- Make provisional restoration
- Retraction cord + expasyl
- Impressions, remove retraction cord!
- Temporise
**Shade selection**
Several methods of shade selection:
- Shade tabs (different methodologies)
- Digital shade selection (may be built into intra-oral scanners)
- Send patient to lab
# **Clinical Sequence**
## **Shade Selection**
Several methods of shade selection:
- Shade tabs (different methodologies)
- Digital shade selection (may be built into intra-oral scanners)
- Send patient to lab
**Clinical Sequence**
**Shade Selection**
- Hue
- Chroma
- Value
**Hue**: the particular variety of a color.
e.g. Blue, red, green, yellow, etc.
**Chroma (saturation)**: the intensity of a hue.
- **Hue**: the particular variety of a color.
- e.g. Blue, red, green, yellow, etc.
- **Chroma (saturation)**: the intensity of a hue.
# Clinical Sequence
## Shade Selection
- **Hue**
- **Chroma**
- **Value**
**Hue**: the particular variety of a color.
e.g. Blue, red, green, yellow, etc.
**Chroma (saturation)**: the intensity of a hue.
**Value**: the relative lightness or darkness of a color
![]()
Color shade selection chart with axes labeled "Value" (vertical, from Black to White) and "Chroma" (horizontal, increasing saturation), showing a gradient of shades with numerical labels (e.g., 2/1, 3/2, 4/4, 5/6, 6/8, 7/10, 8/12, 9/8) and a hue label "5Y".
- **Value**: the relative lightness or darkness of a color
**Clinical Sequence**
**Shade Selection**
**Shade guides**
![]()
Image showing three different shade guide systems: VITAPAN classical, CHROMASCOP, and VITAPAN 3D-MASTER, with arrows indicating their relationship.
### **Shade guides**
**Clinical Sequence**
**Shade Selection**
**VITA**
Shade guides
Chroma and Value
1° Hue
2° Chroma and value
![]()
Shade guide with labeled tooth samples (A1–D4) showing progression from orangeish to yellow/grayish hues, with annotations for hue, chroma, and value.
**VITA**
Shade guides
Chroma and Value
- A simpler system with 16 shades, grouped by **hue** (A-reddish, B-yellowish, C-greyish, D-reddish-grey).
- The process is to first select the hue family (e.g., 'A') and then choose the specific chroma/value combination (e.g., A1, A2, A3).
- *Limitation:* Less precise as chroma and value are locked together.
1° Hue
2° Chroma and value
# Clinical Sequence
## Shade Selection
### Shade guides
**Vitapan 3D-Master**
- **Hue**
- **Chroma**
- **Value (Lightness value)**
![]()
Shade guide with labeled sections for Hue, Chroma, and Value, showing tooth samples arranged in a row with annotations.
**Vitapan 3D-Master**
- **Hue**
- **Chroma**
- **Value (Lightness value)**
- A more complex and accurate system.
- The recommended process is **Value -> Chroma -> Hue**.
1. **Value:** Select the correct value group (tabs are arranged from light to dark, 1-5).
2. **Chroma:** Within that group, determine the chroma (intensity).
3. **Hue:** Finally, select the hue (L-lighter/yellower, M-medium, R-redder).
# Clinical Sequence
## Shade Selection
Shade guides
### 1° Value
![]()
Shade guide samples arranged from light to dark, labeled with numbers and letters, showing value (lightness level) progression.
1° Value
**Clinical Sequence**
**Shade Selection**
**Shade guides**
**1° Value**
**2° Chroma**
![]()
Diagram showing shade guides with labeled value and chroma steps, including a close-up of shade selection process with hand holding a shade guide.
2° Chroma
**Clinical Sequence**
**Shade Selection**
Shade guides
1° Value
2° Chroma
3° Hue
Yellowish ←→ Reddish
![]()
Shade guide chart with labeled columns (L, M, R) and rows (1-5), indicating value, chroma, and hue variations.
3° Hue
Yellowish ←→ Reddish
**Clinical Sequence**
Shade Selection
Photographs with the shade guide
![]()
Close-up of a patient's mouth with two shade guide tabs (A1 and A2) being held against the teeth for color matching.
Photographs with the shade guide
> [!tip] Tips for Shade Taking
> - Perform before tooth preparation to avoid dehydration.
> - Use quick glances to avoid fatiguing the eye's cone cells.
> - Communicate with the lab for custom needs, such as in-between shades (e.g., A1.5) or different shades for different parts of the tooth (e.g., cervical vs. incisal).
**Clinical Sequence**
**Shade Selection**
Digital Systems
TRIOS intra-oral scanner (3Shape)
![]()
Image showing a dental intra-oral scanner connected to a laptop displaying a digital tooth model with shade indicators (A1, A2, B1) overlaid on teeth.
### **Digital Systems**
TRIOS intra-oral scanner (3Shape)
**Clinical Sequence**
**Shade Selection**
**Digital Systems**
In vivo tooth-color measurement with a new 3D intraoral scanning system in comparison to conventional digital and visual color determination methods.
- Dentists and Dental technicians – Vita 3D Master
- 3Shape Trios
- Vita Easyshade (2 models)
- SpectroShade (2 models)
Negligible clinical differences between conventional method and Trios
No significant difference between digital systems
Mehl et al. 2017
**In vivo tooth-color measurement with a new 3D intraoral scanning system in comparison to conventional digital and visual color determination methods.**
- **Key Findings (Mehl et al. 2017):**
- There are negligible clinical differences between conventional shade determination methods (Vita 3D Master) and the 3Shape Trios intra-oral scanner.
- No significant difference was found between various digital systems (Trios, Vita Easyshade, SpectroShade).
**TRY-IN PROCEDURE**
**Evaluation:**
Seating, fitting, contact points
**Systematic approach**
1. Evaluation of the crown on the die
2. Seating the crown on the prepared tooth
3. Assessment of the seated crown
# **TRY-IN PROCEDURE**
**Evaluation:**
- Seating, fitting, contact points
**Systematic approach**
1. Evaluation of the crown on the die
2. Seating the crown on the prepared tooth
3. Assessment of the seated crown
**Lab steps**
After the crown is returned from the lab we must check the crown.
**Lab steps**
After the crown is returned from the lab we must check the crown.
# TRY-IN PROCEDURE
## EVALUATION OF CROWN ON THE DIE
**Aims:**
- Detection of fabrication errors (laboratory related) prior to the clinical appointment
- Save critical chair time
- Anticipation of problems before clinical appointment
- Consider good lighting and magnification
- In case of problem, consult with the dental laboratory
![]()
Two images of a dental model showing a crown on a die, one with a green layer and one with a pink layer, illustrating the try-in procedure.
## **EVALUATION OF CROWN ON THE DIE**
**Aims:**
- Detection of fabrication errors (laboratory related) prior to the clinical appointment
- Save critical chair time
- Anticipation of problems before clinical appointment
- Consider good lighting and magnification
- In case of problem, consult with the dental laboratory
**TRY-IN PROCEDURE**
**EVALUATION OF CROWN ON THE DIE**
**Assess the die and opposing model**
- Poor pouring
- Overtrimming
- Fracture
- Scratches
- Wear
### **Assess the die and opposing model**
- Poor pouring
- Overtrimming
- Fracture
- Scratches
- Wear
- Ensure the lab has not over-trimmed the die around the margin, which could lead to an inaccurate (under-extended) crown margin.
**TRY-IN PROCEDURE**
**EVALUATION OF CROWN ON THE DIE**
**Internal surface:**
- Casting problems: air bubbles
- Casting nodules or blebs
- Ideally, the casting should touch the die at the margins only
Die spacer
### **Internal surface:**
- Casting problems: air bubbles
- Casting nodules or blebs
- Ideally, the casting should touch the die at the margins only
Die spacer
- Note the presence of **die spacer**, a layer painted on the die to create space for cement. Because of this, the crown should fit slightly loosely on the die, not with a tight, friction fit.
**TRY-IN PROCEDURE**
EVALUATION OF CROWN ON THE DIE
**Overall fit and resistance:**
- Looseness
- Excessive gap
- Proximal contact areas
**Marginal fit:**
- Open margins
- Overhangs or underextensions
### **Overall fit and resistance:**
- Looseness
- Excessive gap
- Proximal contact areas
### **Marginal fit:**
- Open margins
- Overhangs or underextensions
# TRY-IN PROCEDURE
## EVALUATION OF CROWN ON THE DIE
**External surface**
- Appearance (restoration design)
- Contour
- Shade
- Rough or smooth (polished)
**Occlusion (articulator)**
- Centric contacts
- Eccentric contacts
- Interferences
### **External surface**
- Appearance (restoration design)
- Contour
- Shade
- Rough or smooth (polished)
- Ensure the lab has delivered what was requested.
- > [!example] Anecdote
> Examples of lab errors caught at this stage include receiving a crown with a hole in it or an implant crown that wasn't cemented to its abutment.
### **Occlusion (articulator)**
- Centric contacts
- Eccentric contacts
- Interferences
**Insert Appointment:**
- Bring patient in, administer LA if required
- Remove temporary crown. Can sometimes wiggle it off. If not possible, carefully section temp crown and break the temporary.
- Clean off temporary cement with ultrasonic scaler
- Try-In
**Insert Appointment:**
- Bring patient in, administer LA if required
- Remove temporary crown. Can sometimes wiggle it off. If not possible, carefully section temp crown and break the temporary.
- Clean off temporary cement with ultrasonic scaler
- Try-In
**TRY-IN PROCEDURE**
**SEATING THE CROWN**
**Remove the provisional restoration**
- Excavator, sickle probe
- Hemostat, Backhaus forceps, pliers
- Crown remover:
- Back-action crown remover
- Automatic crown remover
- Richwill crown remover
![]()
Figure showing step-by-step removal of a provisional crown with labeled tools and clinical images.
## **SEATING THE CROWN**
### **Remove the provisional restoration**
- Excavator, sickle probe
- Hemostat, Backhaus forceps, pliers
- Crown remover:
- Back-action crown remover
- Automatic crown remover
- Richwill crown remover
- Gently use a plastic instrument or artery forceps with gauze.
- If it is firmly stuck, the crown may need to be **sectioned**: cut a groove through the buccal/occlusal/lingual surfaces and use an instrument to wedge the two halves apart.
- Thoroughly clean all temporary cement from the tooth preparation using an ultrasonic scaler.
**TRY-IN PROCEDURE**
IDEAL CROWN
- Easily seated
- Stable
- Accurate occlusal contact
- Adequate proximal contacts
- Accurate marginal fit
- Aesthetic
**IDEAL CROWN**
- Easily seated
- Stable
- Accurate occlusal contact
- Adequate proximal contacts
- Accurate marginal fit
- Aesthetic
**TRY-IN PROCEDURE**
**SEATING THE CROWN**
- The crown should seat on the prepared tooth without forcing
- If it is not seating, possible **causes** may involve:
- The crown should seat on the prepared tooth without forcing
- If it is not seating, possible **causes** may involve:
**TRY-IN PROCEDURE**
**SEATING THE CROWN**
- The crown should seat on the prepared tooth without forcing
- If it is not seating, possible **causes** may involve:
**Single crown**
Proximal contacts
Internal fit
Inaccurate margins/ over extensions
Retained temporary cements
Trapped gingival tissue
- **Single crown**
- Proximal contacts
- Internal fit
- Inaccurate margins/ over extensions
- Retained temporary cements
- Trapped gingival tissue
**Try-In**
Order to check:
a) Proximal contact
b) Internal fit
c) Marginal fit
**Try-In**
Order to check:
a) Proximal contact
b) Internal fit
c) Marginal fit
# TRY-IN PROCEDURE
## SEATING THE CROWN
### Proximal contacts
- Assess tightness with dental floss
- There should be some tightness but not too difficult
- Articulating paper (20 μm), marking liquid (Accufilm), sprays (occlude)
- The shim stock (8 μm) should just pass through the contact
- Minor adjustment at a time
- If the contacts are open, return to the laboratory for material addition
### **Proximal contacts**
- Assess tightness with dental floss
- There should be some tightness but not too difficult
- Articulating paper (20 μm), marking liquid (Accufilm), sprays (occlude)
- The shim stock (8 μm) should just pass through the contact
- Minor adjustment at a time
- If the contacts are open, return to the laboratory for material addition
- **Assessment:**
- Place the crown and hold it with finger pressure.
- Use **dental floss**; it should pass through with resistance and a 'click.'
- **Adjustment:**
- If contacts are too heavy, adjust the marked areas with a fine diamond bur. Make minor adjustments and re-check frequently.
- **Do not create an open contact.**
**TRY-IN PROCEDURE**
**SEATING THE CROWN**
**Proximal contacts**
![]()
Clinical images showing dental crown try-in with blue articulating paper and a dental clamp on a model.
**TRY-IN PROCEDURE**
**SEATING THE CROWN**
**Proximal contacts**
Should be at the same location to the natural proximal contacts
![]()
Two dental crown images showing proximal contact areas with red markings on a purple background.
Should be at the same location to the natural proximal contacts
**TRY-IN PROCEDURE**
**SEATING THE CROWN**
**Internal fit**
► The restoration should seat completely without interference of the occlusal or axial surfaces
► The fitting surface should be checked and adjusted accordingly
- Disclosing medium (Fit Checker, LB impression material)
- Spraying thin layer of aerosol indicator (Occlude)
► The relief can be achieved with a diamond bur
### **Internal fit**
- ► The restoration should seat completely without interference of the occlusal or axial surfaces
- ► The fitting surface should be checked and adjusted accordingly
- - Disclosing medium (Fit Checker, LB impression material)
- - Spraying thin layer of aerosol indicator (Occlude)
- ► The relief can be achieved with a diamond bur
- **Assessment:**
- If the crown rocks or doesn't seat fully, there may be an internal high spot.
- Use a disclosing medium like **Fit Checker** or an occlusal spray on the internal surface. Seat the crown, remove it, and inspect. Areas where the medium has been completely wiped away are high spots.
**TRY-IN PROCEDURE**
**SEATING THE CROWN**
**Internal fit**
Fit Checker application
- Penetrated areas of the medium indicate high spots
- Can be adjusted accordingly
![]()
Six clinical images showing crown try-in steps: Fit Checker application, crown placement, and adjustment with a pencil marker.
**Fit Checker application**
- Penetrated areas of the medium indicate high spots
- Can be adjusted accordingly
**TRY-IN PROCEDURE**
---
**SEATING THE CROWN**
**Internal fit**
If crown fits the model well but does not seat in the mouth, consider problems with impression
Caused by:
- Early impression removal
- Distortion of impression
- Latex contamination
↓
Take a new impression
If crown fits the model well but does not seat in the mouth, consider problems with impression
**Caused by:**
- Early impression removal
- Distortion of impression
- Latex contamination
↓
Take a new impression
**TRY-IN PROCEDURE**
**SEATING THE CROWN**
**Marginal fit**
- Should be as accurate as possible
- Poor marginal adaptation:
- Gap (100 micron is the borderline for acceptability)
- Overhang
- Under extension
- Ledge
### **Marginal fit**
- Should be as accurate as possible
- **Poor marginal adaptation:**
- Gap (100 micron is the borderline for acceptability)
- Overhang
- Under extension
- Ledge
**TRY-IN PROCEDURE**
**SEATING THE CROWN**
**Marginal fit**
| Ideal | Overextended | Underextended | Overhang | Open margin |
|-------|--------------|---------------|----------|-------------|
| | | | | |
![]()
Ideal marginal fit illustration
![]()
Overextended marginal fit illustration
![]()
Underextended marginal fit illustration
![]()
Overhang marginal fit illustration
![]()
Open margin marginal fit illustration
<table>
<thead>
<tr>
<th>Ideal</th>
<th>Overextended</th>
<th>Underextended</th>
<th>Overhang</th>
<th>Open margin</th>
</tr>
</thead>
<tbody>
<tr>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>
**TRY-IN PROCEDURE**
---
**SEATING THE CROWN**
**Marginal fit**
Effects of open margins:
- Sensitivity
- Dissolution of cement
- Plaque retention
- Caries
- Gingival inflammation
**Effects of open margins:**
- Sensitivity
- Dissolution of cement
- Plaque retention
- Caries
- Gingival inflammation
**TRY-IN PROCEDURE**
---
**SEATING THE CROWN**
**Marginal fit**
▶ Poor marginal fit can be due to inability to read the finish line by the technician
Overhangs/overextension: can be adjusted
Underextension: may require remake
Gap: require remake
▶ Poor marginal fit can be due to inability to read the finish line by the technician
- Overhangs/overextension: can be adjusted
- Underextension: may require remake
- Gap: require remake
- **Adjustment:**
- **Overhangs** can be carefully adjusted from the **external surface only**. Adjusting from the internal surface will create a gap.
- **Under-extensions or open margins** cannot be fixed chairside and require a remake.
**TRY-IN PROCEDURE**
**SEATING THE CROWN**
**Marginal fit**
- **Gingivo-occlusal direction**
- **Occluso-gingival direction**
- **Both**
- **New impression**
- **Gingivo-occlusal direction**
- **Occluso-gingival direction**
- **Both**
- **New impression**
**TRY-IN PROCEDURE**
**SEATING THE CROWN**
**Marginal fit**
Adjust overextended margins or overhangs from the external surface, not the fitting surface
![]()
Diagram illustrating correct and incorrect methods for adjusting crown margins during seating.
Adjust overextended margins or overhangs from the external surface, not the fitting surface
**TRY-IN PROCEDURE**
---
**ASSESSMENT OF THE SEATED CROWN**
**Aims**
► Check
- Stability
- Contour
- Occlusion
- Aesthetics
► Confirm the suitability for cementation
---
## **ASSESSMENT OF THE SEATED CROWN**
**Aims**
- ► Check
- Stability
- Contour
- Occlusion
- Aesthetics
- ► Confirm the suitability for cementation
**TRY-IN PROCEDURE**
**ASSESSMENT OF THE SEATED CROWN**
**Stability**
- Restoration should not rotate when the force is applied
- Instability causes failure in function (mainly in cementation)
internal surface misfit
caused by distortion in impression or fabrication process
### **Stability**
- Restoration should not rotate when the force is applied
- Instability causes failure in function (mainly in cementation)
internal surface misfit
caused by distortion in impression or fabrication process
**TRY-IN PROCEDURE**
**ASSESSMENT OF THE SEATED CROWN**
**Contour**
► Improper contour may impair gingival health and affect the natural appearance
► They must be adjusted before cementation
![]()
Diagram illustrating crown contour effects on gingiva, including adequate, undercontoured, and overcontoured crowns with labels for "Flow of food," "Gingiva," "Injury," and "Plaque retention."
### **Contour**
- ► Improper contour may impair gingival health and affect the natural appearance
- ► They must be adjusted before cementation
- The axial contours should mimic a natural tooth to protect the gingiva.
- Avoid over-contouring, which creates plaque traps.
**TRY-IN PROCEDURE**
**ASSESSMENT OF THE SEATED CROWN**
**Occlusion**
- The crown should be fully seated
- Major adjustments should be done prior to cementation
- Minor adjustments can be completed after cementation
- Inadequate occlusal contacts can be caused by
- Poor occlusal recording
- Poor articulation
### **Occlusion**
- The crown should be fully seated
- Major adjustments should be done prior to cementation
- Minor adjustments can be completed after cementation
- Inadequate occlusal contacts can be caused by
- Poor occlusal recording
- Poor articulation
- **Goal:** Achieve evenly distributed contacts that match the adjacent teeth. The adjacent teeth should still hold shim stock or mark with articulating paper.
# TRY-IN PROCEDURE
## ASSESSMENT OF THE SEATED CROWN
### Occlusion
**Shim stock assessment**
- The shim stock will determine if an occlusal contact is present
- Assess the occlusion on all teeth with and without the prosthesis
- Assess the occlusion on the crown
*8 μm thick*
#### **Shim stock assessment**
- The shim stock will determine if an occlusal contact is present
- Assess the occlusion on all teeth with and without the prosthesis
- Assess the occlusion on the crown
- **Posterior teeth:** The crown and adjacent teeth should all hold the shim stock firmly.
- **Anterior teeth:** The crown should lightly hold shim stock, consistent with the other anterior teeth.
*8 μm thick*
**TRY-IN PROCEDURE**
**Analysis of Active Oral Tactile Sensitivity in Individuals with Complete Natural Dentition**
Tiago HS Anastacio¹, Nathalia B de Moraes², Eduardo J de Moraes³, Valquiria Quinelato⁴, Jose A Calasans-Maia⁵, Cintia CP Martins⁶, Telma Aguiar⁷, Aldir N Machado⁸, Priscila L Casado⁹
**ABSTRACT**
**Aim:** To evaluate the active tactile sensitivity in individuals with complete natural dentition, determining the smallest thickness detected by the participants, and clarifying if there is a difference between the thicknesses analyzed.
**Materials and methods:** Active tactile sensitivity was evaluated in 40 research participants. Inclusion criteria included participants with complete natural dentition, without active or history of periodontal disease, absence of temporomandibular disorders, bruxism, and restorations in the evaluated area. Exclusion criteria included age below 18 years. The active tactile perception threshold was evaluated by using carbon sheets of different thicknesses (0, 12, 24, 40, 80, 100, and 200 μm), which were inserted in the participants’ premolars, bilaterally. The carbon sheet was inserted so as not to come into contact with the oral soft tissues. Subsequently, the participant occluded and was asked about the perception of the intraocclusal object 20 times in each occlusal contact. The collected data were tabulated considering the amount of positive and negative responses for each carbon thickness. Values of *p* < 0.05 were considered significant.
**Results:** The results showed that there was linearity in perception, on both sides, besides, the natural dentition was able to perceive difference in thickness from 12 μm.
**Conclusion:** We conclude that the 12 μm thickness is noticeable in occlusion and can be differentiated from other thicknesses in natural dentition and that there is no difference between the tactile sensitivity of the right and left sides.
**Clinical significance:** A better understanding of active oral tactile sensitivity will contribute to numerous clinical applications in dentistry, including occlusal adjustment in dental rehabilitation, dental implants prosthesis design, and survival of prosthetic rehabilitation.
**Keywords:** Active tactile sensitivity, Dental occlusion, Mechanoreceptors, Oral proprioception, Periodontal ligaments, Permanent dentition.
*The Journal of Contemporary Dental Practice (2021): 10.5005/jp-journals-10024-3069*
![]()
Close-up of teeth with a thin carbon sheet inserted between them, labeled "8 μm thick"
**Analysis of Active Oral Tactile Sensitivity in Individuals with Complete Natural Dentition**
- **Key Findings (Anastacio et al. 2021):**
- Natural dentition can perceive a thickness difference as small as 12 μm.
- There is no difference in tactile sensitivity between the right and left sides.
# TRY-IN PROCEDURE
## ASSESSMENT OF THE SEATED CROWN
### Occlusion
**Articulating paper assessment**
- Mark heavy contacts or interferences in centric and eccentric
- Articulating paper will locate the contact area
- Use different colors for different movements
#### **Articulating paper assessment**
- Mark heavy contacts or interferences in centric and eccentric
- Articulating paper will locate the contact area
- Use different colors for different movements
- Adjust until the marks on the crown are of similar intensity to those on adjacent teeth.
# TRY-IN PROCEDURE
## ASSESSMENT OF THE SEATED CROWN
### Occlusion
- **Dark articulating paper (blues)** for CR or maximal intercuspation position
- **Lighter articulating paper (red)** for eccentric position
![]()
Clinical image showing occlusal contacts marked with red and blue articulating paper, labeled for Protrusion, Lateroprotrusion, and MIC.
- **Dark articulating paper (blues)** for CR or maximal intercuspation position
- **Lighter articulating paper (red)** for eccentric position
**TRY-IN PROCEDURE**
**ASSESSMENT OF THE SEATED CROWN**
**Occlusion**
*Premature contact (centric)*
- Adjust grooves or cusp inclines
- Never the tip of cusp
*Interferences (eccentric)*
- Adjust cusp inclines
- Tip of cusps if necessary
- *Premature contact (centric)*
- Adjust grooves or cusp inclines
- Never the tip of cusp
- *Interferences (eccentric)*
- Adjust cusp inclines
- Tip of cusps if necessary
# TRY-IN PROCEDURE
## ASSESSMENT OF THE SEATED CROWN
### Occlusion
The prosthesis thickness should be measured
**Thickness Gauge (Svensen Gauge)**
In some cases the opposing tooth can be adjusted
The prosthesis thickness should be measured
**Thickness Gauge (Svensen Gauge)**
In some cases the opposing tooth can be adjusted
**TRY-IN PROCEDURE**
![]()
Dental procedure images showing tooth preparation with dental bur, highlighting areas of decay or restoration on molars.
**TRY-IN PROCEDURE**
![]()
Diagram showing four dental restorations with colored layers, illustrating the try-in procedure for dental prosthetics.
**TRY-IN PROCEDURE**
![]()
Diagram showing dental try-in procedure with tooth models and color-coded sections.
**TRY-IN PROCEDURE**
![]()
Diagram showing four dental restorations with color-coded layers, illustrating the try-in procedure for dental crowns or fillings.
**TRY-IN PROCEDURE**
![]()
Diagram showing dental try-in procedure with tooth preparations and a dental handpiece.
**TRY-IN PROCEDURE**
![]()
Diagram showing dental try-in procedure with two tooth models and a dental handpiece.
**TRY-IN PROCEDURE**
![]()
Diagram showing four dental restorations in cross-section, illustrating different stages or types of tooth preparation and restoration.
TRY-IN PROCEDURE
![]()
Diagram showing dental try-in procedure with tooth models and colored sections indicating different materials or areas.
**TRY-IN PROCEDURE**
![]()
Diagram showing dental try-in procedure with tooth models and a dental handpiece.
**TRY-IN PROCEDURE**
![]()
Diagram showing dental restorations with color-coded layers, illustrating the try-in procedure for dental prosthetics.
TRY-IN PROCEDURE
![]()
Diagram showing dental try-in procedure with four tooth illustrations: two showing cross-sections with pink and yellow layers, and two showing occlusal views with pink markings.
**TRY-IN PROCEDURE**
![]()
Diagram showing dental crown try-in procedure with colored illustrations of tooth and crown fitting.
**TRY-IN PROCEDURE**
![]()
Diagram showing four dental restorations with colored layers, illustrating the try-in procedure for dental crowns or inlays.
**TRY-IN PROCEDURE**
![]()
Illustration showing dental try-in procedure with tooth preparations and a dental handpiece in use.
**TRY-IN PROCEDURE**
![]()
Diagram illustrating the try-in procedure for dental restorations, showing tooth preparation, placement of restoration, and adjustment with a dental handpiece.
# TRY-IN PROCEDURE
## ASSESSMENT OF THE SEATED CROWN
### Occlusion
- **Completed adjustment**
- Well distributed occlusal contacts
- Posterior teeth: the prosthesis and the remaining dentition should have the same occlusal contact and hold shim stock
- Anterior teeth: the prosthesis should lightly hold shim stock if other anterior teeth do
- **Completed adjustment**
- Well distributed occlusal contacts
- Posterior teeth: the prosthesis and the remaining dentition should have the same occlusal contact and hold shim stock
- Anterior teeth: the prosthesis should lightly hold shim stock if other anterior teeth do
**TRY-IN PROCEDURE**
**ASSESSMENT OF THE SEATED CROWN**
**Aesthetics**
- Patient approval should be obtained prior to cementation
- Shade and morphology
- Lighter shade: can be stained and glazed
- Darker shade: should be cut back and followed by new ceramic application
- Modify the morphology with diamond burs and soflex discs
- Send back for glazing
- Consider temporary cementation
![]()
Before and After images of a seated crown showing aesthetic improvement.
### **Aesthetics**
- Patient approval should be obtained prior to cementation
- **Shade and morphology**
- Lighter shade: can be stained and glazed
- Darker shade: should be cut back and followed by new ceramic application
- **Modify the morphology with diamond burs and soflex discs**
- Send back for glazing
- Consider temporary cementation
- **Patient Approval:** Always show the patient the crown in a mirror and get their explicit approval before cementation.
- **Adjustments:**
- Minor contouring (e.g., shortening) can be done chairside.
- A shade that is too light can sometimes be stained and re-glazed.
- A shade that is too dark, or a tooth that is too short, requires a remake.
- **If the patient is uncertain,** especially for anterior teeth, consider cementing the crown with **temporary cement**. This allows them to 'test drive' the aesthetics for a week before final cementation, avoiding the difficult process of cutting off a permanently cemented crown.
**TRY-IN PROCEDURE**
**ASSESSMENT OF THE SEATED CROWN**
**Finishing and Polishing**
- **Metal**: rubber polishing wheels and points
- **Ceramic**: Rough ceramic will wear the opposing teeth
- Composite finishing rubber burs
- Rubber cup and diamond polishing paste
- Or send to laboratory for reglazing
### **Finishing and Polishing**
> [!warning] Important
> Any areas of the ceramic that have been adjusted with a bur must be thoroughly polished to restore a smooth surface. A rough surface will feel uncomfortable and can cause wear on the opposing teeth.
**TRY-IN PROCEDURE**
**ASSESSMENT OF THE SEATED CROWN**
**Finishing and Polishing**
- **Metal**: rubber polishing wheels and points
- **Ceramic**: Rough ceramic will wear the opposing teeth
- Composite finishing rubber burs
- Rubber cup and diamond polishing paste
- Or send to laboratory for reglazing
- **Metal**: rubber polishing wheels and points
- **Ceramic**: Rough ceramic will wear the opposing teeth
- Composite finishing rubber burs
- Rubber cup and diamond polishing paste
- Or send to laboratory for reglazing
**TRY-IN PROCEDURE**
**Systematic approach**
1. **Evaluation of the restoration on the die**
a) Die and opposing model
b) Internal surface of restoration
c) Restoration on the model (die)
2. **Seating the crown on the prepared tooth**
a) Proximal contact
b) Internal fit
c) Marginal fit
3. **Assessment of the seated crown**
a) Stability
b) Contour
c) Occlusion
d) Aesthetics
## **Systematic approach**
1. **Evaluation of the restoration on the die**
a) Die and opposing model
b) Internal surface of restoration
c) Restoration on the model (die)
2. **Seating the crown on the prepared tooth**
a) Proximal contact
b) Internal fit
c) Marginal fit
> [!info] Rationale
> This sequence must be followed in order to correctly diagnose any fitting issues. A crown cannot seat fully if the proximal contacts are too tight.
3. **Assessment of the seated crown**
a) Stability
b) Contour
c) Occlusion
d) Aesthetics
> [!success] Conclusion
> The lecture emphasizes that a successful crown delivery relies on a systematic, step-by-step evaluation. By following the prescribed order (proximal contacts -> internal fit -> marginal fit -> stability, occlusion, aesthetics), clinicians can efficiently diagnose and resolve issues without creating new problems. The foundation for a good-fitting crown is a high-quality preparation and an accurate impression.
**Questions?**
Send me an email if you have questions!
# **Questions?**
Send me an email if you have questions
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