CLINICAL
PRACTICE
A B S T R A C T
Dentin-bonded all-ceramic
crowns employ contemporary
techniques to lute the crown to
the tooth using a resin luting
material and dentin-bonding
system. The advantages of these
crowns are that they provide
good esthetics and fracture re-
sistance and can be used in
cases of substantial tooth loss.
Their principal disadvantages
are that the luting procedure is
more time-consuming and that
these crowns should not be used
where margins are subgingival.
Dentin-bonded all-ceramic
crowns may be a useful addition
to the dentist’s armamentarium,
but long-term clinical studies are
needed to fully assess their
performance.
DENTIN-BONDED ALL-CERAMIC
CROWNS: CURRENT STATUS
F.J. TREVOR BURKE, D.D.S., M.D.S., M.SC., F.D.S., M.G.D.S., R.C.S.
(EDIN); ALISON J.E. QUALTROUGH, B.CH.D., M.SC., PH.D., F.D.S.,
M.R.D., R.C.S. (EDIN); RICHARD W. HALE, B.D.S.
Dentin-bonded all-ceramic crowns have been defined as full-cov-
erage restorations in which an all-ceramic crown is bonded to the
underlying dentin and any available enamel using a composite
resin–based luting material; the bond is mediated using a dentin-
bonding system and a micromechanically retentive ceramic fitting
surface.1 The essential elements of this restorative technique are
da ceramic material, the fitting surface of which may be etched to
provide a micromechanically retentive fitting surface;
da dual-cure, composite resin luting material;
da dentin-bonding system in which the composite resin luting sys-
tem bonds to the dentin and any available enamel;
da silane bond-enhancing agent that treats the etched ceramic fit-
ting surface.
The dentin-bonded all-ceramic crown is considered an extension
of the porcelain veneer concept,2 except that it is bonded predomi-
nantly to the dentin rather than to the enamel. The tooth acts as a
core for the ceramic crown, as compared with alumina in the alumi-
nous porcelain-jacket crown and metal in the metal-ceramic crown.
The strength of the final restoration may be the result of a syner-
gism between the tooth and the luting material, and the luting ma-
terial and the etched ceramic.3 In this article, we discuss the ratio-
nale for and indications, advantages and disadvantages of using
dentin-bonded all-ceramic crowns.
APPROPRIATE CERAMIC MATERIALS
Ceramic materials that can be used in the dentin-bonded all-ceram-
ic crown technique are those that can be etched with hydrofluoric
acid to provide a micromechanically retentive fitting surface, which
can facilitate bonding to the composite resin luting material.
Low-fusing porcelains. Low-fusing feldspathic porcelains,
such as Mirage Porcelain (Chameleon Dental Products), may be
used. Low-fusing porcelain crowns are built up on a refractory die
and may be fired up to four times before the final glaze is applied.
The crown is refitted to the master die for final finishing of the
margins.
Reinforced porcelains. Alumina-reinforced porcelains, such as
JADA, Vol. 129, April 1998 455
CLINICAL PRACTICE

be one in which the resin layer

ADVANTAGES OF DENTIN-BONDED ALL-CERAMIC CROWNS.* is of minimal film thickness.
Systems derived from the work
dMinimal preparations can be used that may minimize of Bowen,6 such as All Bond 2
the potential for pulpal damage. (Bisco Inc.), Mirage and Tenure
dGood esthetics can be achieved as a result of lack of (Den-Mat Corporation), appear
metal substructure or opaque lute.
to fulfill this requirement.
dA good peripheral blend of shade from crown to tooth
potentially can be achieved. However, more recently intro-
dRetention is not wholly dependent on parallel or duced systems, such as
minimally divergent preparation. Scotchbond Multipurpose Plus
dThey can be used in cases of substantial tooth (3M Dental Products), also may
destruction.
be appropriate because the
dMargins can minimize periodontal irritation if finished
satisfactorily. manufacturer’s details suggest
dThey are fracture-resistant. that the film thickness is mini-
dLuting material is not soluble in oral fluids. mal.7 Given the importance of
the dentin-bonding procedure to
* Based on information from Burke and colleagues.2 the overall result, both in terms
of fracture resistance of the re-
stored unit and the microleak-
Hi-Ceram (Vident), may be ap- complete crown for a posterior age prevention, this potentially
propriate. An alumina core is tooth. The leucite-reinforced technique-sensitive bonding
built on a refractory die with glass ceramic is pneumatically procedure needs to be per-
subsequent buildups applied pressed in a specially designed formed according to the manu-
using standard feldspathic apparatus. Conventional feld- facturer’s instructions.
porcelain powders. spathic porcelains can be applied
APPROPRIATE LUTING
A leucite-reinforced porcelain to provide further anatomical SYSTEMS
(Fortress, Chameleon Dental and esthetic features.
Products) was recently intro- Castable-glass ceramics. Resin-composite luting systems
duced. In this system, the The Dicor system (Dentsply have a number of advantages
Fortress powder is made from a International, Trubyte over conventional systems.
glass that is transformed into a Division), which was first de- Among these advantages are
fine glass ceramic powder by a scribed in 1973,5 uses a lost wax their low solubility in oral flu-
special manufacturing process. process in which a silica-based ids; their good optical proper-
The ceramic is essentially a glass ingot is cast before under- ties, which preserve the trans-
two-phase glass ceramic with going ceramming—a process in lucency of the final restoration8;
leucite crystals in a glass ma- which the ceramic material is and the enhanced fracture re-
trix. It is strengthened by crys- converted into a mechanically sistance of the final restora-
tals that form within the glass stronger crystalline ceramic. tions.3,9 Light-cured, composite
matrix of the ceramic powder Shading is applied to the sur- resin luting materials are ap-
during the manufacturing pro- face of the completed restora- propriate for the majority of ve-
cedure. Leucite crystals with a tion through a complex reaction neer restorations. Using a dual-
high thermal expansion coeffi- between the porcelain and sur- cure cement, however, may be
cient imbedded in a glass ma- face stains. The surface shad- appropriate for dentin-bonded
trix with a low thermal expan- ing, however, may alter after all-ceramic crowns, as the
sion coefficient are reinforced in routine prophylaxis. A potential restoration’s thickness may be
the cooling process.4 Processing, disadvantage of this ceramic is greater than that of veneers
in general, is similar to that of that the surface stain may be and may reduce the potential
porcelain fused to metal. removed after occlusal adjust- transmission of light energy
Pressed-glass ceramics. ment. through the restoration. As
The Empress system (Ivoclar many dual-cure luting materi-
APPROPRIATE DENTIN-
North America) uses a modified BONDING SYSTEMS
als depend on light activation
lost wax process to produce a during the curing process,10,11 it
core for an anterior crown or a A dentin-bonding system should may be appropriate to light-

456 JADA, Vol. 129, April 1998

 CLINICAL PRACTICE

cure the luting material for

longer than is recommended,
especially if the crown is thicker
than required or if a dark shade
of porcelain is used. A variety of
luting material shades are ap-
propriate for anterior dentin-
bonded all-ceramic crowns, as
the luting material’s shade can
influence the restoration’s final
shade in a manner similar to
DISADVANTAGES OF DENTIN-BONDED ALL-CERAMIC CROWNS.*
dNo long-term clinical trial results are available.
dThe luting procedure is more technique-sensitive and
time-consuming than it is for conventional crowns.
dThey are not suitable for subgingival margins.
dOcclusal adjustment must be carried out after luting.
dMargins may cause gingival irritation if inadequately
finished.
* Based on information from Burke and colleagues.2

that described by Friedman12 for

veneers.
Chemically cured luting ma-
terials also can be used, despite
their less favorable working
times. The luting materials used
for dentin-bonded all-ceramic
crowns need to be available in a
wide range of shades, as dis-
cussed previously. Few chemi-
cally cured luting materials are
available in as wide a range of
shades as dual-cure and light-
cured luting materials.
PREPARATION
The preparation should be kept
to a minimum, with retention of
some enamel if possible.2
Minimal shoulder or chamfer
preparations are appropriate at
the gingival margins. These
marginal preparations may pro-
duce an optimal peripheral
blend from restoration to tooth.
However, a visible finishing line
is needed with which the tech-
nician can work, and a too-thin
marginal preparation will in-
crease the risk of the porcelain
fracturing at the restoration
margin during luting.
Cases in which the tooth to
be prepared is discolored con-
traindicate the use of minimal
marginal preparations, because
with minimal preparations
there may be insufficient space
to provide adequate porcelain
depth to mask the discoloration.
Margins should be supragingi-
val, because achieving isolation
for the bonding and luting pro-
cedure may be difficult in sub-
gingival areas. Furthermore,
margins ideally should be on
enamel, where marginal mi-
croleakage may be reduced com-
pared with dentinal margins.13
All preparation line angles
should be rounded off to reduce
the risk of stress concentration
areas in the ceramic. Undercuts
should be blocked out using a
glass ionomer material or
dentin-bonded composite. As
the retention of the restoration
is not wholly dependent on me-
chanical retention, the taper of
the preparation may need to be
greater than that of conven-
tional crowns. Similarly, crown
height also may not need to be
as great as that of conventional
crowns. Occlusal clearance
should be a minimum of 1 mil-
limeter in centric relation and
lateral or incisal excursions.
This clearance is less than what
is appropriate for conventional-
ly luted porcelain jacket crowns;
by bonding the ceramic to the
tooth, however, the ceramic ma-
terial is reinforced by the tooth
substance. Therefore, less oc-
clusal clearance may be appro-
priate.
IMPRESSIONS AND
TEMPORIZATION
The impression techniques and
temporary crown construction
used for dentin-bonded all-ce-
ramic crowns are similar to
those required for a convention-
al crown. Difficulties, however,
may be experienced when the
preparation is minimal, because
temporary crown materials may
be weak at the thin margins
and the temporary luting ce-
ment may shine through the
thin areas of the temporary
crown. Eugenol-free temporary
cements may be appropriate, al-
though not all researchers
agree that these cements influ-
ence the performance of resin
luting materials, especially if
the dentin or enamel surface is
cleaned with pumice before the
luting procedure.14
DENTIN-BONDED
ALL-CERAMIC CROWN
PLACEMENT
We believe that it is inadvisable
to check the occlusion on the
crown until it has been luted in
position and supported fully by
the underlying tooth structure.
This is because the crown may
become fractured if occlusal
forces are applied before cemen-
tation.
The marginal fit should be
checked, as the luting material
should not be expected to make
good any discrepancies of fit.
The shade match also should be
checked. If the shade of the
crown is satisfactory, a luting
material with a similar shade
as that selected for the crown

JADA, Vol. 129, April 1998 457

CLINICAL PRACTICE
Figure 1. A 40-year-old patient who requested
nonorthodontic treatment for his imbricated upper
anterior teeth.
should be chosen. If the shade
match is not satisfactory, a suit-
able luting material shade may
be chosen by using luting mate-
rial try-in pastes—if available—
until a satisfactory match is ob-
tained. A dual-cure luting
material of similar shade may
then be used. Dual-cure luting
materials are appropriate, but
adequate light-curing times are
required to ensure the initiation
of polymerization.10,11 It is, how-
ever, not possible to bring about
gross changes by varying the
shade of the luting material.
Friedman12 has shown that the
luting material accounts for
only 20 percent of the overall
veneer shade. This percentage
may be less for thicker dentin-
bonded all-ceramic crowns.
Before placement, apply 35
percent phosphoric acid to the
interior surface for 30 seconds
to clean it and remove any sali-
vary contaminants and try-in
paste remnants. Then, apply a
silane bond-enhancing solution
to the interior surface for one
minute; it has been shown that
applying silane to the interior
surface increases the bond
strength of composite resin to
etched ceramic.15
When treatment of the interi-
or surface of the crown has been
458 JADA, Vol. 129, April 1998
Figure 2. Patient in Figure 1 after dentin-bonded all-ce-
ramic crowns were placed at teeth nos. 6–11. We sug-
gested gingival contouring or crown lengthening to
the patient so the gingival level at teeth nos. 8 and 9
would be similar. The patient declined this treatment.
completed, the
operator may proceed with the al should be cured as indicated
treatment of the dentin surface previously, and when polymer-
as suggested by the manufac- ization is complete, the margins
turer of the system being used. should be finished using fine-
Any available enamel should be tipped, 15-micrometer grit dia-
etched with either 35 percent mond finishing burs or 12-blade
phosphoric acid for 30 seconds carbide burs. The occlusion
or the etchant supplied with the should be checked in centric re-
dentin-bonding system in a lation and lateral or protrusive
total-etch technique. excursions and adjusted if nec-
The dual-cure luting material essary. Adjusted surfaces
should be mixed and placed in- should be polished using white
side the crown, using gentle fin- stones, disks, rubber points,
ger pressure to minimize the aluminum oxide paste or dia-
risk of causing a marginal frac- mond polishing paste. If these
ture of the crown. Excess luting stages are carried out meticu-
material should be removed lously, the risk of damage
using a probe, sponge pellets or caused by a rough ceramic sur-
pads. Dental floss should be face’s abrading opposing teeth
passed interproximally between may be minimized.17
the teeth to remove excess lut-
DISCUSSION
ing material from the interprox-
imal gingival margins and then Dentin-bonded all-ceramic
passed between the contact crowns are a comparatively re-
area of the crown and the adja- cent addition to the dentist’s ar-
cent teeth. All excess luting ma- mamentarium,18 and they ap-
terial needs to be removed at pear to have a number of
this stage, because cured com- advantages compared with con-
posite resin luting material is ventional metal-ceramic crowns
difficult or impossible to re- (Box, “Advantages of Dentin-
move. The margins should be Bonded All-Ceramic Crowns”).
covered with an air-inhibition First, their esthetic properties
gel, as marginal adaptation may be good because the com-
may be improved when air inhi- posite resin luting material is
bition of the resin luting agent more translucent than conven-
is inhibited.16 The luting materi- tional cements, which improves

the transmission of light
through the restored unit,7 and
because a good peripheral blend
at the gingival margin provides
optimal esthetics in the restora-
tion area without a black-line
margin.19
Second, the gingival response
may be better, given that the
periodontal response to porce-
lain veneers is said to be excel-
lent20 and the dentin-bonded all-
ceramic crowns’ margins should
be similar to those associated
with veneers. The finishing pro-
cedures, however, need to be
carried out meticulously to re-
move any excess luting materi-
al. Also, given the insoluble na-
ture of the luting material, the
periodontal response associated
with dentin-bonded all-ceramic
crowns may be superior to that
associated with conventional
crowns in which the luting
agent at the margins could dis-
solve, resulting in possible
plaque accumulation.
Third, laboratory studies by
Jensen and colleagues21 and
Burke and Watts3 have shown
that dentin-bonded all-ceramic
crowns’ fracture resistance was
good, even though minimal
preparations were used. In the
study by Burke and Watts,3 no
statistical difference was noted
between the fracture resistance
in a group of 10 teeth prepared
to a standardized minimal
preparation with a 6-degree
taper and a group of 10 sound
teeth.3 Other related laboratory
studies have shown that achiev-
ing high fracture resistance de-
pends on the use of a dentin-
bonding system and, that, when
the dentin-bonding system is
not used, fracture resistance is
reduced by 25 percent.22 When
zinc oxyphosphate—a conven-
tional cement—was substituted
for the composite resin luting
CLINICAL PRACTICE
INDICATIONS AND CONTRAINDICATIONS FOR
DENTIN-BONDED ALL-CERAMIC CROWNS.*
INDICATIONS
dCoverage or preparation is greater than that
which is appropriate for veneers.
dMinimal preparation is appropriate.
dTooth substance is lost because of erosion.
dRealignment of moderately displaced teeth is
suggested.
dReplacement of conventional crowns is suggested.
CONTRAINDICATIONS
dSubgingival margin isolation is not possible and cannot
be finished.
dThere are extreme occlusal interferences.
dParafunctional habits, such as bruxism, are suspected.
dIt is not possible to maintain a dry operating field.
dThere is insufficient tooth substance available for
bonding.
dThe patient’s motivation, caries control or periodontal
condition is poor.
dThe patient is hesitant to accept a restorative tech-
nique of unknown longevity.
* Based on information from Burke and colleagues.2
system, the force needed to but long-term clinical trials are
cause a fracture was reduced by needed to completely assess the
50 percent.22 These results ap- performance of dentin-bonded
pear to demonstrate the syner- all-ceramic crowns in clinical
gism between the crown and service. In this respect, a recent
tooth substance when adhesive retrospective clinical evaluation
techniques are used, with the of 60 dentin-bonded all-ceramic
tooth effectively providing a crowns has shown a low rate of
core for the porcelain. failure over a mean 2.4 years
Further work has demon- and a high level of patient satis-
strated that minimal prepara- faction.23
tion and the subsequent mini- The disadvantages of dentin-
mal ceramic thickness do not bonded all-ceramic crowns (Box,
adversely affect fracture resis- “Disadvantages of Dentin-
tance.1 This finding was illus- Bonded All-Ceramic Crowns”)
trated in a study in which in- are related principally to the
creasing the occlusal technique-sensitive and time-
preparation from 2 mm to 3 mm consuming nature of the luting
and providing a 1-mm cervical procedure and the lack of data
shoulder rather than a minimal on their clinical performance.
cervical preparation did not Nevertheless, the use of dentin-
lead to increased fracture resis- bonded all-ceramic crowns is in-
tance.1 creasing,24 and there appears to
The results of these laborato- be a wide variety of clinical in-
ry studies may be promising, dications, particularly in situa-
JADA, Vol. 129, April 1998 459
CLINICAL PRACTICE
Dr. Burke is a profes- Dr. Qualtrough is a
sor of dental primary senior lecturer in en-
care, Unit of Adult dodontology, Unit of
Dental Care, Restorative
University of Dentistry, University
Glasgow Dental Dental Hospital of
School, 378 Manchester,
Sauchiehall Street, England.
Glasgow, G2 3JZ,
Scotland. Address
reprint requests totions in which
Dr. Burke.
a minimal
preparation is
indicated or in which there al-
ready has been tooth substance
loss (Figures 1 and 2). Milosevic25
reported the use of dentin-bond-
ed all-ceramic crowns to restore
teeth subjected to chemo-
mechanical erosion in a patient
suffering from bulimia.
The minimal preparation as-
sociated with dentin-bonded all-
ceramic crowns may be less
traumatic to pulpal tissue than
that associated with convention-
al crowns, thereby reducing po-
tential vitality loss after the
crown has been prepared and
placed. The indications and con-
traindications for dentin-bonded
all-ceramic crowns are summa-
rized in the box, “Indications and
Contraindications for Dentin-
Bonded All-Ceramic Crowns.”
Finally, recently introduced
highly filled polymer and fiber-
reinforced polymer materials
can be used for crowns and can
be bonded to tooth substances
in a manner similar to the pro-
cess used for dentin-bonded all-
460 JADA, Vol. 129, April 1998
ceramic
crowns. Early
reports are
positive about
their service,26
but further re-
Dr. Hale is a general search is re-
practitioner, Cottage
Dental Practice,
quired to ex-
amine their
Cheadle Hulme,
Cheshire, England. potential.
CONCLUSION
Dentin-bonded all-ceramic
crowns can be a useful addition
to the dentist’s armamentari-
um, as they reportedly have
good esthetics, tooth prepara-
tions are minimal and there is a
potential for good periodontal
response. Long-term clinical
studies are needed to more fully
assess their clinical perfor-
mance. ■
1. Burke FJT. Fracture resistance of teeth
restored with dentin-bonded crowns: the ef-
fect of increased tooth preparation.
Quintessence Int 1996;27:115-21.
2. Burke FJT, Qualtrough AJE, Hale RW.
The dentin-bonded ceramic crown: an ideal
restoration? Br Dent J 1995;179:58-63.
3. Burke FJT, Watts DC. Fracture resis-
tance of teeth restored with dentin-bonded
crowns. Quintessence Int 1994;25:335-40.
4. Chameleon Dental Products. Fortress
Information Leaflet. Kansas City, Kan.:
Chameleon Dental Products.
5. Grossman DG. Tetrasilicic mica glass-ce-
ramic method. U.S. patent no. 3,732,087, May
8, 1973. Washington, D.C.: U.S. Patent Office.
6. Bowen RL. Adhesive bonding of various
materials to hard tooth tissues. Part 2: bond-
ing to dentin promoted by a surface-active
comonomer. J Dent Res 1965;44:895-902.
7. 3M Dental Products. Scotchbond
Multipurpose Plus Technical Product Profile.
St Paul, Minn.: 3M Dental Products; 1994.
8. Crocker WP. The cementation of porce-
lain jacket crowns with adhesive resins. Br
Dent J 1992;172:64-7.
9. McCormick JT, Rowland W, Shillingburg
HT, Duncanson MG. Effect of luting media on
the compressive strengths of two types of all-ce-
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10. Hasegawa EA, Boyer DB, Chan DC.
Hardening of dual-cured cements under com-
posite resin inlays. J Prosthet Dent
1991;66:187-92.
11. El-Badrawy WA, El-Mowafy OM.
Chemical versus dual curing of resin inlay ce-
ments. J Prosthet Dent 1995;73:515-24.
12. Friedman M. Multiple potential of
etched porcelain laminate veneers. JADA
(Special Issue)1987;83E-7E.
13. Lacy AM, Wada C, Du W, Watanabe L.
In-vitro microleakage at the gingival margin
of porcelain and resin veneers. J Prosthet
Dent 1992;67:7-10.
14. Schwartz R, Davis R, Hilton TJ. Effect
of temporary cements on the bond strength of
a resin cement. Am J Dent 1992;5:147-50.
15. Calamia JR, Simonsen RJ. The effect of
coupling agents on bond strength of etched
procedure (Abstract no. 79). J Dent Res
1984;63:179.
16. Bergmann P, Noack MJ, Roulet J-F.
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Quintessence Int 1991;22:739-44.
17. Jagger DC, Harrison A. An in vitro in-
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18. Rezinkior H. The dentin bonded porce-
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19. Bertolotti RL. Removal of ‘black-line’
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