RESEARCH AND EDUCATION

Clinical acceptance of single-unit crowns and its association

with impression and tissue displacement techniques: Findings
from the National Dental Practice-Based Research Network
Nathaniel C. Lawson, DMD, PhD,a Mark S. Litaker, PhD,b Ellen Sowell, BA,c Valeria V. Gordan, DDS, MS,d
Rahma Mungia, BDS, MSC,e Kenneth R. Ronzo, DDS, MS,f Ba T. Lam, DDS,g Gregg H. Gilbert, DDS, MBA,h
Michael S. McCracken, DDS, PhD, i and National Dental PBRN Collaborative Groupj

ABSTRACT
Statement of problem. The definitive impression for a single-unit crown involves many material and technique factors that may affect the
success of the crown.
Purpose. The purpose of this prospective cohort study was to determine whether impression technique (tray selection), impression material,
or tissue displacement technique are associated with the clinical acceptability of the crown (CAC).
Material and methods. Dentists in the National Dental Practice-Based Research Network documented details of the preparation, impression,
and delivery of 3730 consecutive single-unit crowns. Mixed-effects logistic regression analyses were performed to evaluate associations
between impression techniques and materials and the CAC and to assess associations between the presence of a subgingival margin
with the displacement technique and the outcome variables CAC and number of impressions required.
Results. Of the 3730 crowns, 3589 (96.2%) were deemed clinically acceptable. A significant difference in the CAC was found with different
impression techniques (P<.001) and different impression materials (P<.001). The percentage of the CAC for digital scans was 99.5%, 95.8% for
dual-arch trays, 95.2% for quadrant trays, and 94.0% for complete-arch impression trays. Although no statistically significant difference was
found in the CAC produced with dual-arch trays without both mesial and distal contacts, crowns fabricated under these conditions were less
likely to achieve excellent occlusion. The percentage of the CAC for digital scans was 99.5%, 97.0% for polyether impressions, 95.5% for
polyvinyl siloxane impressions, and 90.5% for other impression materials. Accounting for the location of the margin, the use of a dual-
cord displacement technique was significantly associated with lower rates of requiring more than 1 impression (P=.015, odds ratio=1.43).
Conclusions. Dual-arch trays produced clinically acceptable crowns; however, if the prepared tooth was unbounded, the occlusal fit was more likely
to have been compromised. Digital scans produced a slightly higher rate of CAC than conventional impression materials. The use of a dual-cord
technique was associated with a decreased need to remake impressions when the margins were subgingival. (J Prosthet Dent 2019;-:---)

Single-unit crowns have proven to be a reliable restor- (lithium disilicate and leucite).1 To achieve this successful
ative treatment, with estimated 5-year survival rates of outcome, many steps are required to produce a crown
95.7% (metal-ceramic), 93.8% (zirconia), and 96.6% that is deemed acceptable at the time of delivery. From
Supported by NIH grant U19-DE-22516 and U19-DE-28717.
An Internet site devoted to details about the nation’s network is located at http://NationalDentalPBRN.org.
a
Assistant Professor, Department of Clinical and Community Sciences, School of Dentistry, University of Alabama at Birmingham, Birmingham, Ala.
b
Associate Professor, Department of Clinical and Community Sciences, School of Dentistry, University of Alabama at Birmingham, Birmingham, Ala.
c
Regional Coordinator, Department of Clinical and Community Sciences, School of Dentistry, University of Alabama at Birmingham, Birmingham, Ala.
d
Professor, Department of Restorative Dental Sciences, College of Dentistry, University of Florida, Gainesville, Fla.
e
Assistant Professor, Department of Periodontics, School of Dentistry, University of Texas Health Science Center at San Antonio, San Antonio, Texas.
f
Private practice, Rochester, NY.
g
Private practice, Inver Grove Heights, Minn.
h
Distinguished Professor and Chair, Department of Clinical and Community Sciences, School of Dentistry, University of Alabama at Birmingham, Birmingham, Ala.
i
Professor, Department of Clinical and Community Sciences, School of Dentistry, University of Alabama at Birmingham, Birmingham, Ala.
j
The National Dental PBRN Collaborative Group includes practitioner, faculty, and staff investigators who contributed to this activity. A list is available at http://
nationaldentalpbrn.org/collaborative-group.php.

THE JOURNAL OF PROSTHETIC DENTISTRY 1

2 Volume
Clinical Implications
Dual-arch trays can be recommended for
single-tooth crowns; however, the tooth
preparation should be bounded anteriorly and
posteriorly. Digital scans show promise for
producing more acceptable crowns. Keeping crown
margins supragingival reduces the risk of requiring
an additional impression, but if a subgingival
margin is required, a double-cord tissue
displacement technique seems advisable.
the perspective of the clinician, proper tooth preparation
and accurate impressions are perhaps the most critical
steps. In a recent study of crown and fixed partial denture
impressions sent to 4 commercial laboratories, 86% of
impressions contained at least 1 detectable error, and
55% of impressions contained a critical error related to
the finish line.2 The errors created while making an
impression can be related to tray selection, material
choice, and tissue displacement.
Broadly, 2 different tray types can be used for single
crown impressions: single- and dual-arch trays. Com-
plete single-arch trays can record the complete dentition
in a rigid mold which aids the articulation of casts. As
these trays capture the teeth on the side of the mouth
contralateral to the crown preparation, occlusal in-
terferences may be avoided. Partial single-arch trays may
also be used, but this technique presents challenges in
mounting.3 Dual-arch trays (closed mouth technique) are
faster to use and more comfortable for the patient and
use less material than complete-arch trays.4 In addition, a
dual-arch tray may more accurately capture the rela-
tionship of the arches in maximum intercuspation
without the errors introduced by the external articulation
of opposing casts.5 However, the flexure of the dual-arch
tray that may occur during closing from inadvertent
contact with the alveolus can distort an impression.6 A
2009 survey of impressions of fixed restorations sent to a
commercial dental laboratory observed that over 70%
were made with a dual-arch impression tray. Of the
dual-arch trays, only 55.7% recorded a single unit
bounded by intact teeth that was opposing an intact
tooth.7 A 2013 survey of impressions of fixed restorations
sent to 4 different commercial laboratories discovered
that 62% of impressions were made with a dual-arch tray
and many violated the requirements for their use. Of
these dual-arch impressions, 26% did not record an
unprepared tooth anterior and posterior to the prepara-
tion, 14% did not register canine teeth, and 9% were not
made in maximum intercuspation.2 There is little clinical
evidence of the effects of violating the requirements for
the use of a dual-arch tray.
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- Issue -
Polyvinyl siloxane (PVS) impression materials are the
most commonly used type of material for obtaining a
definitive impression for fixed restorations.8 Polyether
impression materials have similar properties to those of
PVS materials, but they are differentiated by a higher
flow,9 inherent hydrophilicity,10 and lower tear
strength.11 In a clinical trial conducted with dental stu-
dents, impressions made with polyether and PVS mate-
rials resulted in similar success rates when used with
complete-arch trays, but PVS materials demonstrated a
higher success rate when used with dual-arch trays.12
The most common operator error for both types of im-
pressions was inadequate gingival displacement. Digital
scanning techniques have been reported for 12% of
definitive impressions.8 Recent reviews have reported
that digital scans produce similar13-15 or better16 marginal
fit than conventional impressions.
Several methods of displacing gingival tissue, including
displacement cord, injectable displacement pastes, and
soft tissue lasers, can be used alone or in combination
before making a definitive impression. A previous survey
reported that 92% of dentists used displacement cords and
20.2% used lasers as an adjunct.17 Another recent survey
reported that a dual-cord technique was used by 35% of
respondents, single-cord technique by 35%, and an
injectable displacement technique by 16%.7 One clinical
evaluation determined that an injectable displacement
paste created more horizontal displacement of the sulcus
(0.26 ±0.02 mm) than a displacement cord (0.21 ±0.01
mm),18 whereas another trial reported that cord produced
more displacement (0.74 mm) than 2 types of paste (0.48
and 0.41 mm).19 A clinical trial determined that impreg-
nated displacement cord, displacement paste, or both used
in combination produced perfect or acceptable impres-
sions. Nonimpregnated displacement cord produced a
lower quality of impressions.20 Displacement may be
particularly important in crown preparations with sub-
gingival margins. A clinical study reported that margins
located more than 2 mm below the gingival tissue led to
inferior impression quality.21 A possible disadvantage of
displacement cord is that a recent clinical trial reported
that the use of a double-cord technique led to a higher rate
(32%) of minor gingival recession (0.1 to 0.5 mm) than the
use of an injectable displacement paste (8%).22
A previous questionnaire study surveyed dentists in
the National Dental Practice-Based Research Network
regarding impression material and technique preference.8
In addition, previous studies have examined errors
detected in definitive impressions related to material and
technique choice.2,7 Ultimately, the clinician should be
informed which aspects of impression making affect the
outcome of the definitive crown. The purpose of this
study was to determine whether impression technique
(tray selection) is associated with clinical acceptability of
the crown (and more specifically whether the presence of
Lawson et al
- 2019
mesial and distal contacts is associated with crown
acceptability and occlusal fit with the use of dual-arch
trays); whether the choice of impression material is
significantly associated with the ultimate clinical accept-
ability; and whether the displacement technique is
associated with clinical acceptability or the number of
impressions required to obtain an acceptable impression,
while accounting for the presence of a subgingival
margin. The null hypotheses were that impression
technique (tray selection) would not be associated with
clinical acceptability of the crown (and more specifically
that the presence of mesial and distal contacts would not
be associated with crown acceptability and occlusal fit
with the use of dual-arch trays); whether the choice of
impression material would not be significantly associated
with the ultimate clinical acceptability of the crown; and
whether the displacement technique would not be
associated with clinical acceptability of the crown or the
number of impressions required to obtain an acceptable
impression, while accounting for the presence of a sub-
gingival margin.
MATERIAL AND METHODS
This study was conducted by dentists in the National
Dental Practice-Based Research Network (PBRN;
“network”). The network is a consortium of dental
practices and dental organizations focused on improving
the scientific basis for clinical decision-making.23 This
network study comprised a prospective cohort study
focused on the acceptability of crowns made in routine
clinical practice. Network regional coordinators (RCs)
were asked to recruit 200 dentists to participate in this
study from within the network. Data were collected
about each practitioner using the network’s Enrollment
Questionnaire. This questionnaire is publicly available
at http://nationaldentalpbrn.org/study-results/factors-
for-successful-crowns.php. Questionnaire items doc-
umenting test and retest reliability were taken from
previous practice-based studies of dental care.24,25 Den-
tists enrolled in the network were eligible for this study if
they met all of these criteria: completed an Enrollment
Questionnaire; were currently practicing and treating
patients in the United States; were in the network’s “full”
network participation category; completed the stage 1
questionnaire26; and reported doing at least 7 crowns in a
typical month. Practitioners were required to complete
human subjects training and secure the participation of at
least 1 dental laboratory for the technical evaluation of
the crown preparations done in the study.
The network’s applicable institutional review boards
approved the study, and all participants provided
informed consent. The study was launched on March 1,
2016; clinician training was completed by August 15,
2016; all patients had been enrolled by December 31,
Lawson et al
3
2016; and patient follow-up was closed on February 28,
2017. Once they had agreed to participate, dentists were
trained in the proper conduct of the study protocol by
RCs. Once a clinician began the study, he or she was
asked to complete patient enrollment within 3 months.
Each clinician’s goal for enrollment was 20 patients.
Dentists or their practices were remunerated $50 for
conducting informed consent, enrolling the patient,
completing the study’s data forms, and $25 for completing
the insertion visit data forms and communicating regularly
with the RC about any data monitoring issues. All data
forms are publicly available at http://nationaldentalpbrn.
org/study-results/factors-for-successful-crowns.php.
Clinicians recruited patients from among their current
patients needing a single-unit crown. Clinicians were
asked to recruit patients consecutively and to record the
number of patients recruited for the study, those who
declined, and, if they declined, why. To be eligible, pa-
tients had to meet the following criteria: 18 years or older;
able to provide informed consent; and in need of a
single-unit crown on a natural tooth. Abutments for fixed
partial dentures were not permitted in this study nor
were patients who needed multiple single-unit crowns
done in a single appointment. This was done to eliminate
the possibility that providing multiple units might affect
the impression or ultimate clinical acceptability of the
crown at cementation.
Once enrolled in the study, the clinicians prepared the
tooth for a crown and completed a crown preparation data
form regarding clinical aspects of the procedure, including
impression technique (quadrant tray, complete-arch tray,
dual-arch tray, or digital scan), impression material (PVS,
polyether, digital scan, or other), and tissue displacement
technique (none, single cord, dual cord, injectable tissue
displacement material, dual impression technique, gingival
troughing, tissue displacement cap, and/or other). Clini-
cians were asked if the tooth to be crowned had a mesial
contact and/or a distal contact or no proximal contact.
Clinicians were asked to estimate the deepest margin of
the preparation (above the crest of the gingival tissue, at
the crest of the gingival tissue, 1 mm below the gingival
tissue, 2 mm below the gingival tissue, or 3 mm or more
below the gingival tissue). Finally, clinicians were asked
the number of impressions required to obtain an accept-
able definitive impression. Clinicians were asked to place
the crown within 6 weeks of preparation.
At the time of insertion, clinicians were asked to eval-
uate the crown clinically and report this information on a
second insertion data form. The primary outcome for this
study was clinical acceptability of the crown as judged by
the treating clinician. A secondary outcome measured was
an assessment of the occlusion of the crown after adjust-
ments (excellent, good, or acceptable). Another secondary
outcome was the number of impressions required to obtain
acceptability (1 or more than 1).
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4 Volume - Issue -

Overall percentages were calculated as descriptive Table 1. Characteristics of participating dentists

statistics across all practitioners. To address the first aim Characteristics Numbera (n=205) Percent (%)
of this study, the association between impression tech- Sex

nique and clinical acceptability of the crown was evalu- Male 148 73
Female 54 27
ated using mixed-effects logistic regression analysis
(a=.05). A random-effect term was included to account Years since dental school graduation
<10 28 14
for correlation due to clustering of patients within prac-
10-19 54 26
titioners. Because crowns and patients were clustered
20-29 42 21
within practitioners, outcomes from patients treated by 30+ 80 39
the same practitioner are not independent. The crown Type of practice
preparations impressed with a dual-arch tray were Owner of private practice 153 76
categorized as having both a mesial and distal contact Associate in private practice 22 11
and not having both contacts (mesial contact only, distal Health partnersb 8 4
contact only, or no proximal contact). Clinical scenarios Permanenteb 8 4
with both mesial and distal contacts were compared with Other 9 5
those without both contacts for the outcomes clinical Network regionc
acceptability and occlusal assessment using mixed-effects Western 28 14
logistic regression analysis (a=.05). Occlusal assessment Midwest 34 17

was divided into 2 groups, excellent and not excellent Southwest 39 19

South Central 46 23
(good or acceptable).
South Atlantic 32 16
To address the second aim of this study, the associ-
Northeast 25 12
ation between impression material and clinical accept-
Time commitment
ability of the crown was evaluated using mixed-effects
Full time 179 89
logistic regression analysis (a=.05). A random effect term Part time (<32 h) 23 11
was included to account for correlation due to clustering Race
of patients within practitioners. White 165 81
To address the third aim of this study, mixed-effects Black/African-American 11 5
logistic regression analyses were performed to evaluate Asian 19 9
multivariable associations between the presence of a Other 8 4
subgingival margin and tissue displacement technique Ethnicity
and the outcome variables, clinically acceptable crown, Hispanic 7 4
and number of impressions. Models using subgingival Non-Hispanic 192 96
margin as the sole predictor variable were evaluated, Private insurance status

followed by models for each tissue displacement tech- <40% private insurance 3 2
40%-79% private insurance 87 44
nique, accounting for the effect of margin location. The
80%+ private insurance 107 54
comparison group for each tissue displacement technique
Practice location type
included all observations for which the tissue displace-
Urban/inner city 27 13
ment technique currently being evaluated was not
Urban (not inner city) 55 27
checked. In other words, these analyses compared ob- Suburban 96 47
servations in which a particular tissue displacement Rural 25 12
technique was checked versus all observations for which a
Owing to missing values, not all columns add to 100%. bEither HealthPartners Dental Group
that technique was not checked, including those for in greater Minneapolis, MN, or Permanente Dental Associates in greater Portland, OR.
c
Reported on Enrollment Questionnaire as state, subsequently categorized into 1 of 6
which no technique was checked. The presence of a regions of network.
subgingival margin was defined by categorizing margins
located 1 mm below the gingival tissue, 2 mm below the
gingival tissue, or 3 mm or more below the gingival tis- are presented in Table 1. Most were male (73%) and the
sue. Adjusted odds ratios (ORs) were calculated, ac- owner of a private practice (76%). These dentists repre-
counting for the effects of clustering and of margin sented each of the network’s 6 regions. A large majority
location, in the analysis of tissue displacement work full-time. Two dentists were prosthodontists; the
techniques. rest reported being general practitioners. The majority
(60%) had been in practice for over 20 years, and 28
(14%) clinicians reported practicing less than 10 years.
RESULTS
Of the 3883 patients who were approached to
A total of 205 dentists recruited at least 1 patient and participate in the trial, 3806 (98%) provided informed
crown into this study. The characteristics of these dentists consent. Of the 3730 patients who had crowns which

THE JOURNAL OF PROSTHETIC DENTISTRY Lawson et al

- 2019
Table 2. Percentage and number of crowns produced by the type of
impression technique used to produce crown, impression material used,
and tissue displacement technique used (N=3730)
Factor
Impression technique
Dual-arch tray
Quadrant tray
Digital scan
Complete-arch tray
Impression material
PVS
Digital scan
Polyether
Other
Tissue displacement technique
Single cord
Dual cord
Injectable tissue displacement material
None
Tissue displacement cap
Dual impression
Gingival troughing
Other
Note that multiple selections were possible for tissue displacement technique, so
percentages total over 100%.
were evaluated for clinical acceptability, slightly more
were females than males (56% versus 44%). Most of
these patients were white (87%), and the remainder of
the patients were African-American (7%), American In-
dian or Alaska Native (3%), Asian (1%), Pacific Islander
(<1%), or multiple races (1%). Most of the patients (83%)
had at least some college or associate degree education.
Most had some form of dental insurance, although 20%
reported no insurance. The mean (±SD) age of the pa-
tients was 55 ±15 years, with a range between 18 and 100
years.
A total of 3589 of the 3730 crowns in this study were
deemed clinically acceptable for cementation, a 96.2%
acceptance rate. Of the impressions made for these
crowns, 87.0% were deemed acceptable at the first
attempt. At the time of impression, 58.9% of the crown
preparations had subgingival margins, and 46.5% of the
preparations had some bleeding during the impression.
The percentage and number of overall crowns produced
with each type of impression technique, impression
material, and tissue displacement technique are pre-
sented in Table 2.
The number and percentage of clinically acceptable
crowns for each type of impression technique used are
presented in Table 3. A statistically significant difference
was found in the clinical acceptability of crowns produced
with different impression techniques (P<.001). The per-
centage of clinically acceptable crowns for digital scans
(99.5%) was significantly higher than the other
techniques.
Lawson et al
5
Table 3. Percentage and number of clinically unacceptable crowns by
the type of impression technique used (N=3730)
Impression Technique Clinically Acceptable Crowns, % (n/N)
Crowns, % (n) Digital scan 99.5 (603/606)a
Dual-arch tray 95.8 (2214/2311)b
62.0 (2311) Quadrant tray 95.2 (599/623)b
16.9 (629) Complete-arch tray 94.0 (173/184)b
16.3 (606) P<.001, mixed-model logistic regression accounting for clustering by clinician. Means
4.9 (184) with different superscript letters differ significantly, P<.05, by Tukey test.
71.9 (2681)
Table 4. Percentage and number of clinically acceptable crowns for each
16.2 (605)
type of impression material used (N= 3730)
10.8 (402)
Impression Material Clinically Acceptable Crowns, % (n/N)
1.1 (42)
Digital scan 99.5 (602/605)a
Polyether 97.0 (390/402)a,b
33.8 (1262)
PVS 95.5 (2559/2681)b
31.0 (1158)
Other 90.5 (38/42)c
18.7 (698)
11.6 (434) P<.001, mixed-model logistic regression accounting for clustering by clinician. Means
with different superscript letters differ significantly, P<.05, by Tukey test.
10.1 (378)
8.2 (304)
6.2 (231)
Among the 2311 crowns with a dual-arch tray, 1589
4.5 (167)
indicated that both mesial and distal contacts were pre-
sent. Of the records in which a dual-arch tray was used to
record a tooth without mesial and distal contacts, 96.5%
of the crowns were deemed clinically acceptable, and
95.5% of crowns were clinically acceptable in clinical
scenarios with mesial and distal contacts. Having both
contacts present was not significantly associated with the
clinical acceptability of the crown (P=.218). Of the records
in which a dual-arch tray was used to record a tooth
without mesial and distal contacts, 57.9% of the crowns
reported an excellent occlusal fit, which was significantly
lower than the 66.2% of crowns with mesial and distal
contacts with excellent occlusal fit (P=.001).
The number and percentage of clinically acceptable
crowns for each type of impression material used are
presented in Table 4. A statistically significant difference
was found in the percentages of clinical acceptability of
crowns produced with different impression materials
(P<.001). Digital scans produced 5% more clinically
acceptable crowns than PVS impressions and 9% more
clinically acceptable crowns than “other” impressions.
For 41 of the 42 crowns in which “other” was selected as
the impression material, a vinyl polyether silicone (VPES)
material was used.
The number and percentage of clinically acceptable
crowns for each type of tissue displacement technique are
presented in Table 5. Crowns impressed without the use
of a tissue displacement material or technique showed
higher rates of acceptable crowns, with unadjusted
acceptance rates of 98.4% versus 95.9% for crowns using
any material or technique (P=.012, OR=2.14). No other
tissue displacement technique was associated with a
higher rate of acceptable crowns. The results of the
mixed-effects logistic regression analyses found no
THE JOURNAL OF PROSTHETIC DENTISTRY
6 Volume - Issue -

Table 5. Percentage and number of clinically unacceptable crowns by Table 6. Percentage and number of clinical scenarios requiring 1
type of tissue displacement technique used impression for each type of tissue displacement technique
Clinically Acceptable Only One Impression
Tissue Displacement Technique Crown, % (n/N) P Tissue Displacement Technique Required, % (n/N) P
Injectable tissue displacement material 94.4 (656/695) .066 Injectable tissue displacement material 86.1 (600/697) .328
Dual impression 96.0 (291/303) .904 Dual impression 82.2 (250/304) .456
Single cord 95.8 (1200/1253) .469 Dual cord 83.4 (961/1153) .008
Dual cord 95.8 (1106/1154) .561 Tissue displacement cap 84.9 (321/378) .345
Tissue displacement cap 96.0 (362/377) .793 Gingival troughing 85.2 (196/230) .257
Other 97.6 (162/166) .311 Single cord 88.6 (1116/1259) .233
Gingival troughing 97.8 (226/231) .444 Other 89.8 (149/166) .471
None 98.4 (423/430) .010 None 93.8 (407/434) .012

Tissue displacement technique categories not mutually exclusive. N=number of crowns Tissue displacement technique categories not mutually exclusive. N=number of crowns
for which specific tissue displacement technique was reported. P values are for for which specific tissue displacement technique reported. P values for associations of
associations of each technique separately with clinically acceptable crown. each technique versus all others in prediction of use of only 1 impression.

association between the presence of subgingival margins

away from the finish line. Nonclinical factors were also
and the clinical acceptability of the crown, irrespective of
associated with accepting errors in an impression, such as
the tissue displacement technique used. Of clinically
how busy the practice was. Within a commercial dental
acceptable crowns, 58.9% (2111/3585) had subgingival
laboratory, independent evaluators determined 86% of
margins, and 41.1% (1474/3585) had supragingival
crown and fixed partial denture impressions contained at
margins.
least 1 detectable error and 55% contained a critical error
The number and percentage of clinical scenarios
related to the finish line.2 This high error rate seemingly
requiring one impression for each type of tissue
contradicts the high clinical acceptance rate of single-unit
displacement technique are presented in Table 6. Ac-
crowns reported in this study (96.2%). These observa-
counting for subgingival margins, the use of a dual-cord
tions suggest that errors viewed in an impression are not
tissue displacement technique was significantly associ-
critically important for achieving a well-fitting crown,
ated with lower rates of having more than 1 impression
that clinicians are not aware of these errors, or that cli-
made (P=.015, OR=1.43). No other tissue displacement
nicians are tolerant of these errors.
technique was associated with the rate of requiring more
The first aim of this study was to determine the as-
than 1 impression. Controlling for tissue displacement
sociation between crown acceptability and different
technique, the results of the mixed-effects logistic
impression techniques (tray selection). The results indi-
regression analyses showed the presence of subgingival
cate that digital scans produced a higher percentage of
margins to be significantly associated with the number of
acceptable crowns than complete-arch trays, dual-arch
impressions made (P<.001, OR=1.47). The odds ratio for
trays, and quadrant trays. Complete-arch, dual-arch,
the association indicates that patients with the deepest
and quadrant trays all produced similar rates of clinically
part of the margin below the gingival crest have higher
acceptable crowns. Previous studies have reported similar
rates of requiring more than one impression. Of the
accuracy with the use of dual-arch and complete-arch
crowns with a subgingival margin, 85.1% (1875/2203)
impression trays.28-30 Dual-arch trays were used for
required only one impression, whereas 89.9% (1378/
most impressions (62.0%), followed by quadrant trays
1533) of those without subgingival margins required only
(16.8%) and then complete-arch trays (4.9%). Of the
one impression. Note that the total sample size for this
dual-arch impressions, 31.3% did not fulfill the require-
comparison was 3736 of 3740 crowns that had no missing
ment to have both mesial and distal contacts for the
values for the number of impressions.
prepared tooth. This value is within the range of 26% to
44.3% of definitive impressions in violation of this rule
DISCUSSION
previously reported.2,7 The theory for requiring teeth
In this study, 87% of impressions were deemed accept- mesial and distal to the prepared tooth with a dual-arch
able after the first attempt even as most were made on tray is that these teeth help to create occlusal stability
subgingival preparations and many with bleeding pre- between the maxillary and mandibular casts during
sent. Many factors may prevent a dentist from remaking mounting. In addition, the occlusal stops from the adja-
an impression, such as time, cost, patient comfort, and cent teeth can help prevent flexure of the impression in a
soft tissue health. Therefore, dentists will accept some nonrigid dual-arch tray. Despite the violation of this
errors in their impression. A previous study reporting requirement, no difference was found in the clinical
thresholds of acceptability of definitive impressions27 acceptability of the crowns produced with dual-arch trays
demonstrated that few dentists (14%) will tolerate voids without either mesial or distal contacts; however, crowns
on the finish line, whereas many (47%) will accept voids fabricated under these conditions were less likely to

THE JOURNAL OF PROSTHETIC DENTISTRY Lawson et al

- 2019
achieve an excellent occlusion assessment (66.2% with
both contacts and 57.8% without). When faced with a
fully or partially unbounded tooth preparation, the
clinician must balance the time saving achieved with a
dual-arch tray with the slightly compromised outcome of
the crown. An absolute contraindication to the use of a
dual-arch tray is recording the most posterior tooth in the
arch.31 This information was not recorded in the current
study.
The second aim of this study was to determine the
association between crown acceptability and different
impression materials. PVS materials were used for most
of the definitive impressions (71.9%), followed by digital
scans (16.2%), polyether (10.8%), and others (1.1%). A
slight improvement was noted in crown acceptability for
polyether materials (97.0%) over PVS materials (95.5%).
With additional surfactants that have been added to PVS
materials to improve their hydrophilicity9 and the avail-
ability of extra light body PVS materials, the properties of
PVS and polyether materials have become relatively
similar. In addition, clinicians used the impression ma-
terial they were currently using in their office. As the
dentist was experienced with using this material, they
could be expected to know the techniques necessary to
obtain a satisfactory impression with that type of mate-
rial. This aspect of the study design also may have
contributed to the relatively similar performance of both
materials. In all but 1 of the clinical scenarios in which
“other” was selected as the impression material, a VPES
material was used. This is a relatively new material that is
claimed to be a hybrid of polyether and PVS. Laboratory
testing of this material showed acceptable dimensional
stability,32 hydrophilicity,33,34 and flow33 but less
consistent detail reproduction.32 There was a lower rate
of clinically acceptable crowns with VPES (90.5%);
however, only a small number of clinicians (1.1%) used
this material, and failures may have been related to other
factors in their technique.
Digital scans had a higher rate of crown acceptability
than conventional impression materials. There are several
possible explanations. Although some have claimed a
similar accuracy for digital and conventional impression
making,35 there is little evidence that digital scanning
technology is equally or more accurate than conventional
impression material for short dentate spans. More likely,
the use of digital impressions and digital crown production
eliminates some of the errors that can be introduced
during the conventional impression making and labora-
tory production processes, including improper tray selec-
tion, violation of working and/or setting time, errors in cast
or die, and improper application of die spacer. Systematic
reviews suggest a similar level of marginal and internal fit
of crowns fabricated from conventional impressions and
digital scans.13-15 Second, crown acceptability may have
been higher with digital scans as the majority of the
Lawson et al
7
resulting crowns were fabricated by in-office milling. As
these crowns were fabricated in the clinician’s office, the
dentist would have more control to locate the crown
margins and design the crown to the desired specifica-
tions. Furthermore, the clinician may have had a bias
toward accepting the crown, as errors in fabrication would
be the responsibility of the clinician rather than an external
laboratory.
The third aim of this study was to determine whether
tissue displacement technique is associated with the
clinical acceptability of a crown. To examine the effects of
tissue displacement technique, a regression analysis was
performed to account for the existence of subgingival
margins. In addition, the number of impressions required
to achieve an acceptable definitive impression was also
used as a secondary outcome. Irrespective of the tissue
displacement technique used, preparing a tooth with a
subgingival margin did not cause a higher incidence of
producing a clinically unacceptable crown. However,
crowns with subgingival margins had a higher incidence
of requiring more than 1 attempt to achieve an acceptable
definitive impression.
Regarding tissue displacement technique, the only
tissue displacement technique associated with higher
rates of acceptable crowns was the use of no tissue
displacement. Although this result seems counterintui-
tive, it is likely the result of clinicians choosing this
technique based on the clinical presentation of the tooth
preparation. While this regression analysis accounted for
the presence of subgingival margins, only 28.6% of the
impressions made without tissue displacement were
subgingival, whereas 58.6% to 88.4% of the impressions
made with gingival troughing or cord technique were
subgingival. In addition, only 32.0% of impressions made
without tissue displacement had some bleeding around
the preparation and 49.4% to 53.3% of impressions made
with gingival troughing or cord technique presented with
bleeding. The choice not to use tissue displacement could
also have been related to the gingival biotype or gingival
health of the patient, which was not recorded on the data
collection form. It is also possible that clinicians who
were less judicious with tissue displacement were also
less discriminating in determining crown acceptability.
The use of a dual-cord technique was the only tissue
displacement technique associated with lower rates of
requiring more than 1 impression. In this technique, 1
cord is removed immediately before making the impres-
sion, whereas the other cord is left in the sulcus. In the
single-cord technique, no cord is left in the sulcus. The
cord that remains in the sulcus in a double-cord technique
prevents recoil of the cuff of the gingival tissue and serves
as a sulcus liner to block fluid exudate and tearing of the
epithelium when the outer cord is removed.36 As errors at
the margin are the most common cause of inadequate
impressions,2,12 these benefits of the double cord likely
THE JOURNAL OF PROSTHETIC DENTISTRY
8 Volume
lead to lower rates of making supplemental definitive
impressions.
There were limitations of this study. The evaluation of
the crowns during insertion was subjective, as the eval-
uations were all performed by different clinicians who
may have held themselves to different standards when
deciding whether cementation was warranted given all
possible considerations on a given clinic day. This limi-
tation underscores the practicality of practice-based
research, in which straightforward indicators of clinical
performance are emphasized. Future research could
evaluate whether long-term clinical outcomes differ as a
result of different interclinician standards. Additional
limitations include the potential for bias toward finding
the crown clinically acceptable, as these crowns were all
evaluated by the clinician who prepared and made the
impression of the prepared teeth. Ideally, crowns would
be evaluated by independent clinicians; however, this is
not practical in a practice-based research study. Another
limitation is that clinicians could indicate the use of
multiple tissue displacement techniques. The option to
record multiple selections complicated the statistical
analysis. In addition, although network practitioners
have much in common with dentists at large,37,38 it may
be that their crown procedures are not representative of a
wider group of dentists. Network members were not
recruited randomly, so factors associated with network
participation (such as, an interest in clinical research)
may make network dentists unrepresentative of dentists
at large. While it cannot be asserted that network dentists
are entirely representative, it can be stated that they have
much in common with dentists at large, while also of-
fering substantial diversity in these characteristics. This
assertion is warranted because substantial percentages of
network dentists are represented in the various response
categories of the characteristics in the Enrollment
Questionnaire because findings from several network
studies document that network general dentists report
patterns of diagnosis and treatment similar to those
determined from nonnetwork general dentists39-42 and
because network dentists are similar to nonnetwork
dentists according to the 2010 ADA Survey of Dental
Practice.43
CONCLUSIONS
Within the limitations of this practice-based study, the
following conclusions were drawn:
1. Dual-arch trays produced clinically acceptable
crowns; however, if the prepared tooth was un-
bounded, the occlusal fit was more likely to have
been compromised.
2. Digital scanning produced a slightly higher rate of
clinically acceptable crowns than conventional
impression materials.
THE JOURNAL OF PROSTHETIC DENTISTRY
- Issue -
3. The use of a dual-cord technique was associated
with a decreased need to remake impressions when
the margins were subgingival.
REFERENCES
1. Sailer I, Makarov NA, Thoma DS, Zwahlen M, Pjetursson BE. All-ceramic or
metal-ceramic tooth-supported fixed dental prostheses (FDPs)? A systematic
review of the survival and complication rates. Part I: Single crowns (SCs).
Dent Mater 2015;31:603-23.
2. Rau CT, Olafsson VG, Delgado AJ, Ritter AV, Donovan TE. The quality of
fixed prosthodontic impressions: An assessment of crown and bridge im-
pressions received at commercial laboratories. J Am Dent Assoc 2017;148:
654-60.
3. Hammond BD, Myers ML, Haywood VB. A quadrant tray and bite regis-
tration as an alternative to dual-arch impressions for fixed prosthetics: a
clinical and dental laboratory technique. Gen Dent 2011;59:350-4.
4. Lane DA, Randall RC, Lane NS, Wilson NH. A clinical trial to compare
double-arch and complete-arch impression techniques in the provision of
indirect restorations. J Prosthet Dent 2003;89:141-5.
5. Parker MH, Cameron SM, Hughbanks JC, Reid DE. Comparison of occlusal
contacts in maximum intercuspation for two impression techniques.
J Prosthet Dent 1997;78:255-9.
6. Larson TD, Nielsen MA, Brackett WW. The accuracy of dual-arch impres-
sions: a pilot study. J Prosthet Dent 2002;87:625-7.
7. Mitchell ST, Ramp MH, Ramp LC, Liu PR. A preliminary survey of impres-
sion trays used in the fabrication of fixed indirect restorations. J Prosthodont
2009;18:582-8.
8. McCracken MS, Louis DR, Litaker MS, Minyé HM, Oates T, Gordan VV,
et al. Impression techniques used for single-unit crowns: Findings from the
National Dental Practice-Based Research Network. J Prosthodont 2018;27:
722-32.
9. Lawson NC, Cakir D, Ramp L, Burgess JO. Flow profile of regular and fast-
setting elastomeric impression materials using a shark fin testing device.
J Esthet Restor Dent 2011;23:171-6.
10. Menees TS, Radhakrishnan R, Ramp LC, Burgess JO, Lawson NC. Contact
angle of unset elastomeric impression materials. J Prosthet Dent 2015;114:
536-42.
11. Lawson NC, Burgess JO, Litaker M. Tear strength of five elastomeric
impression materials at two setting times and two tearing rates. J Esthet
Restor Dent 2008;20:186-93.
12. Johnson GH, Mancl LA, Schwedhelm ER, Verhoef DR, Lepe X. Clinical trial
investigating success rates for polyether and vinyl polysiloxane impressions
made with full-arch and dual-arch plastic trays. J Prosthet Dent 2010;103:
13-22.
13. Tsirogiannis P, Reissmann DR, Heydecke G. Evaluation of the marginal fit of
single-unit, complete-coverage ceramic restorations fabricated after digital
and conventional impressions: A systematic review and meta-analysis.
J Prosthet Dent 2016;116:328-35.
14. Ahlholm P, Sipilä K, Vallittu P, Jakonen M, Kotiranta U. Digital versus
conventional impressions in fixed prosthodontics: A review. J Prosthodont
2018;27:35-41.
15. Nagarkar SR, Perdigão J, Seong WJ, Theis-Mahon N. Digital versus con-
ventional impressions for full-coverage restorations: A systematic review and
meta-analysis. J Am Dent Assoc 2018;149:139-47.
16. Chochlidakis KM, Papaspyridakos P, Geminiani A, Chen CJ, Feng IJ, Ercoli C.
Digital versus conventional impressions for fixed prosthodontics: A system-
atic review and meta-analysis. J Prosthet Dent 2016;116:184-90.
17. Ahmed SN, Donovan TE. Gingival displacement: Survey results of dentists’
practice procedures. J Prosthet Dent 2015;114:81-5.
18. Prasanna GS, Reddy K, Kumar RK, Shivaprakash S. Evaluation of efficacy of
different gingival displacement materials on gingival sulcus width. J Contemp
Dent Pract 2013;14:217-21.
19. Shrivastava KJ, Bhoyar A, Agarwal S, Shrivastava S, Parlani S, Murthy V.
Comparative clinical efficacy evaluation of three gingival displacement sys-
tems. J Nat Sci Biol Med 2015;6:S53-7.
20. Acar Ö, Erkut S, Özçelik TB, Ozdemır E, Akçil M. A clinical comparison of
cordless and conventional displacement systems regarding clinical perfor-
mance and impression quality. J Prosthet Dent 2014;111:388-94.
21. Beier US, Kranewitter R, Dumfahrt H. Quality of impressions after use of the
Magic FoamCord gingival retraction system - a clinical study of 269 abutment
teeth. Int J Prosthodont 2009;22:143-7.
22. Einarsdottir ER, Lang NP, Aspelund T, Pjetursson BE. A multicenter ran-
domized, controlled clinical trial comparing the use of displacement cords, an
aluminum chloride paste, and a combination of paste and cords for tissue
displacement. J Prosthet Dent 2018;119:82-8.
23. Gilbert GH, Williams OD, Korelitz JJ, Fellows JL, Gordan VV, Makhija SK,
et al. Purpose, structure, and function of the United States National Dental
Practice-Based Research Network. J Dent 2013;41:1051-9.
Lawson et al
- 2019
24. Gilbert GH, Richman JS, Gordan VV, Rindal DB, Fellows JL, Benjamin PL,
et al. Lessons learned during the conduct of clinical studies in the dental
PBRN. J Dent Educ 2011;75:453-65.
25. Florida Dental Care Study. Available at: http://nersp.nerdc.ufl.edu/wgilbert/.
Accessed April 22, 2019.
26. McCracken MS, Louis DR, Litaker MS, Minyé HM, Mungia R, Gordan VV,
et al. Treatment recommendations for single-unit crowns: Findings from The
National Dental Practice-Based Research Network. J Am Dent Assoc
2016;147:882-90.
27. McCracken MS, Litaker MS, George AJ, Durand S, Malekpour S,
Marshall DG, et al. Impression evaluation and laboratory use for single-unit
crowns: Findings from The National Dental Practice-Based Research
Network. J Am Dent Assoc 2017;148:788-96.
28. Wöstmann B, Rehmann P, Balkenhol M. Accuracy of impressions obtained
with dual-arch trays. Int J Prosthodont 2009;22:158-60.
29. Arora M, Kohli S, Kalsi R. Influence of custom trays, dual-arch passive, flexed
trays and viscosities of elastomeric impression materials on working dies.
J Clin Diagn Res 2016;10:ZC112-6.
30. Ceyhan JA, Johnson GH, Lepe X, Phillips KM. A clinical study comparing the
three-dimensional accuracy of a working die generated from two dual-arch
trays and a complete-arch custom tray. J Prosthet Dent 2003;90:228-34.
31. Kaplowitz GJ. Trouble-shooting dual arch impressions. J Am Dent Assoc
1996;127:234-40.
32. Nassar U, Chow AK. Surface detail reproduction and effect of disinfectant
and long-term storage on the dimensional stability of a novel vinyl polyether
silicone impression material. J Prosthodont 2015;24:494-8.
33. Huettig F, Chekhani U, Klink A. A modified shark-fin test simulating the
single-step/double-mix technique: A comparison of three groups of elasto-
mers. Dent Mater J 2018;37:414-21.
34. Balkenhol M, Eichhorn M, Wostmann B. Contact angles of contemporary
type 3 impression materials. Int J Prosthodont 2009;22:396-8.
35. Aragón ML, Pontes LF, Bichara LM, Flores-Mir C, Normando D. Validity and
reliability of intraoral scanners compared to conventional gypsum models
measurements: a systematic review. Eur J Orthod 2016;38:429-34.
36. Thomas MS, Joseph RM, Parolia A. Nonsurgical gingival displacement in
restorative dentistry. Compend Contin Educ Dent 2011;32:26-34.
37. Makhija SK, Gilbert GH, Rindal DB, Benjamin P, Richman JS, Pihlstrom DJ,
et al. Practices participating in a dental PBRN have substantial and advan-
tageous diversity even though as a group they have much in common with
dentists at large. BMC Oral Health 2009;9:26.
38. Makhija SK, Gilbert GH, Rindal DB, Benjamin PL, Richman JS, Pihlstrom DJ;
DPBRN Collaborative Group. Dentists in practice-based research networks
Lawson et al
9
have much in common with dentists at large: evidence from the Dental
Practice-Based Research Network. Gen Dent 2009;57:270-5.
39. Gordan VV, Garvan CW, Heft MW, Fellows JL, Qvist V, Rindal DB, et al.
Restorative treatment thresholds for interproximal primary caries based on
radiographic images: findings from the Dental Practice-Based Research
Network. Gen Dent 2009;57:654-63.
40. Gordan VV, Garvan CW, Richman JS, Fellows JL, Rindal DB, Qvist V, et al.
How dentists diagnose and treat defective restorations: evidence from the
dental practice-based research network. Oper Dent 2009;34:664-73.
41. Norton WE, Funkhouser E, Makhija SK, Gordan VV, Bader JD, Rindal DB,
et al. Concordance between clinical practice and published evidence: findings
from The National Dental Practice-Based Research Network. J Am Dent
Assoc 2014;145:22-31.
42. Gilbert GH, Riley JL, Eleazer PD, Benjamin PL, Funkhouser E; National
Dental PBRN Collaborative Group. Discordance between presumed standard
of care and actual clinical practice: the example of rubber dam use during root
canal treatment in the National Dental Practice-Based Research Network.
BMJ Open 2015;5:e009779.
43. American Dental Association Survey Center. The 2010 survey of dental
practice. Chicago: American Dental Association; 2012. p. 1.
Corresponding author:
Dr Nathaniel C. Lawson
Department of Clinical & Community Sciences
UAB School of Dentistry
SDB Room 602
1530 Third Avenue South
Birmingham, AL 35294-0007
Email: nlawson@uab.edu
Acknowledgments
The authors thank the network’s regional coordinators who interacted with the
participating practitioners throughout the study (Midwest Region: Tracy Shea,
RDH, BSDH; Western Region: Stephanie Hodge, MA; Northeast Region: Chris-
tine O’Brien, RDH; South Atlantic Region: Hanna Knopf, BA, Deborah McEd-
ward, RDH, BS, CCRP; South Central Region: Claudia Carcelén, MPH,
Shermetria Massengale, MPH, CHES, Ellen Sowell, BA; Southwest Region: Ste-
phanie Reyes, BA, Meredith Bucherg, MPH, Colleen Dolan, MPH).
Copyright © 2019 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2019.05.016
THE JOURNAL OF PROSTHETIC DENTISTRY