Journal of Oral Rehabilitation 2000 27; 93– 102
Pulp reactions to different preparation techniques on teeth
exhibiting periodontal disease
A. ZO8 LLNER* & P. GAENGLER† *Department of Prosthodontics, and the †Department of Conservative Dentistry, School
of Dental Medicine, University of Witten/Herdecke, Alfred Herrhausen Str. 50, 58448 Witten, Germany
SUMMARY To evaluate the histopathological out-
come of two preparation techniques (featheredge
preparation/shoulder preparation) on teeth ex-
hibiting pulp reactions due to age and periodontal
disease, 11 teeth were prepared for full veneer
crowns. Laboratory made resin crowns were fixed
with a zinc phosphate cement for a period of 90
days. After extraction, adjacent pulpal areas were
histo-
Introduction
Pulp reactions to preparation techniques are still a
major concern in restorative and prosthodontic den-
tistry. According to many longitudinal investigations
there is a high rate of primarily vital teeth exhibiting
typical signs of endodontal complications following
dental restorations. According to Bergenholtz and Ny-
man (1984), up to 15% of teeth showed negative
results to sensitivity testing, including periapical infl-
ammatory lesions, 4 – 13 years after crown preparation.
Different factors may accumulate and lead to these
dramatic changes of the endodontium, including age,
abrasion/attrition, periodontal disease, carious lesions
as natural occurring phenomena and pulp damage
caused by dental procedures and materials. Therefore,
it was the aim of the present investigation to compare
the influence of different preparation techniques, like
shoulder preparation and featheredge preparation, to
investigate further the reactions to bacterial invasion,
to characterize the reactions of the pulp in correlation
to the remaining dentin thickness, taking into account
the already predamaged pulp, and finally to conclude
clinical recommendations concerning pulp
degeneration.
© 2000 Blackwell Science Ltd
pathologically rated according to the BRD criteria
comprising the parameters (i) Bacterial invasion, (ii)
Regenerative parameters, (iii) Degenerative
parameters. Degenerative reactions were more cor-
related with tooth preparation than with advanced
periodontal disease. The severity of endondontal
reactions depends more on remaining dentin thick-
ness than on the type of preparation.
Material and methods
Eleven teeth with positive reactions to sensitivity test-
ing, no or minimal carious lesions, advanced periodon-
tal destruction, and therefore scheduled for extraction,
were prepared for full veneer crowns with the pa-
tient’s consent using two different preparation tech-
niques. The featheredge preparation, limited to the
enamel/dentin junction, was used in experimental
group 1, including 13 sites. The shoulder preparation,
extended deep into the dentin, was used in experi-
mental group 2, including nine sites. Either one or
both preparation techniques were applied. The control
group 3 with no experimental preparations consisted
of four teeth of the same patient with the same level
of periodontal destruction. Detailed information con-
cerning the results of the clinical investigation and the
type of preparation is summarized in Table 1. Labora-
tory made crowns (Visio Gem®*) were fixed with zinc
phosphate cement (Harvard®†). The frequent clinical
control included sensitivity testing, percussion testing
* Espe, Am Griesberg 2, 82229 Seefeld, Germany.
†
Richter & Hoffmann Harvard Dental, Johannisberger Str. 24,
14197 Berlin, Germany.
93
94 A . Z O8 L L N E R & P . G A E N G L E R

Table 1. Overview: clinical documentation of prepared teeth and control group

Age Probing depth Recession Attachment loss

Tooth Sex (years) Site Preparation technique (mm) (mm) (mm)

11 Female 50 Buccal Featheredge preparation 3 2 5

Oral Featheredge preparation 3 3 6
12 Female 50 — Control 4 1 5
12 Male 62 Buccal Featheredge preparation 4 1 5
Oral Featheredge preparation 4 1 5
13 Female 50 Mesial Featheredge preparation 4 2 6
Distal Featheredge preparation 4 2 6
17 Male 62 Buccal Shoulder preparation 4 3 7
Oral Shoulder preparation 4 3 7
21 Female 50 Buccal Shoulder preparation 3 3 6
Oral Featheredge preparation 3 2 5
21 Male 62 Buccal Shoulder preparation 3 2 5
Oral Shoulder preparation 3 2 5
22 Female 50 — Control 5 2 7
23 Female 50 Buccal Shoulder preparation 4 2 6
Oral Featheredge preparation 4 3 7
25 Female 50 — Control 6 0 6
25 Male 62 Buccal Shoulder preparation 3 2 5
Oral Featheredge preparation 3 2 5
32 Male 62 Buccal Featheredge preparation 3 4 7
Oral Shoulder preparation 3 4 7
34 Male 62 Buccal Featheredge preparation 3 1 4
Oral Featheredge preparation 3 1 4
37 Male 62 — Control 4 6 10
42 Male 62 Buccal Featheredge preparation 3 3 6
Oral Shoulder preparation 3 3 6

and pain history. The teeth were carefully extracted
after 90 days under local anesthesia and the roots
were cut off under permanent water cooling for rapid
penetration of 5% buffered, neutral formalin. The
specimens were then decalcified in HNO3, embedded
in paraffin, serially sectioned at 5 mm and stained with
haematoxilin – eosin, azan and according to J. Hopkins
for the detection of bacteria. Adjacent pulpal areas of
each section were histopathologically rated (micro-
scope: DMRM‡) according to the BRD criteria (Table 2)
comprising the parameters (i) Bacterial invasion, (ii)
Regenerative parameters, (iii) Degenerative parame-
ters. The endodontal reactions localized in the crown,
in the root or adjacent to the prepared margin were
separately rated. The quantitative measurement of
video-based pictures of each section (screen: KX-
14P1§; camera: CF11/1¶) included the width of the
‡
Leica, Lilienthalstr. 39–45, 64625 Bensheim, Germany.
§
Sony, 7-35 Kitashinagawa 6-chome, Shinagawa-ku, Tokyo 141,
Japan.
¶
Kappa, Kleines Feld, 37130 Gleichen, Germany.
shoulder (Fig. 1) and the thickness of the remaining
dentin (Fig. 2) at three different levels: D1—inner part
of the margin, shortest distance to the pulp; D2—in-
ner margin, following the direction of the dentin
tubules to the pulp and D3—end of the preparation,
following the direction of the dentin tubules to the
pulp.
Results
The mean extension of the shoulder preparation into
the dentin was 0.8 mm. Table 3 demonstrates the corre-
lation of bacteria in dentin tubules and the type of
preparation. Bacterial invasion occurs in both types:
featheredge preparation and shoulder preparation (Fig.
3). The correlation of grade of bacterial invasion to
irritation dentin (Table 4) as an example for the en-
dodontal reactions shows no significant results. The
histopathological changes of the endodontal areas adja-
cent to the rating points D1–D3 are summarized in

© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 93–102

 PULP REACTIONS TO CROWN PREPARATIONS 95

Table 2. BRD coding criteria

I Bacterial invasion
Grade 0: No signs of bacterial invasion
Grade 1: Moderate bacterial invasion along prepared margins
Grade 2: Moderate invasion in isolated dentin tubules
Grade 3: Severe invasion in most dentin tubules
Grade 4: Infection of necrotic pulp areas
II Regenerative paramenters of the endodontium
1. Regular irritation dentin
Grade 0: No signs of irritation dentin
Grade 1: Regular irritation dentin, localized in defined areas, no tendency to obliteration, well marked zone of uncalcified
dentin (predentin)
Grade 2: Regular irritation dentin, circumpulpal, no tendency to obliteration, well marked zone of uncalcified dentin (pre-
dentin)
Grade 3: Regular irritation dentin, tendency to obliteration, reduction or absence of uncalcified dentin (predentin)
2. Transient inflammation cells in pulpal tissue
Grade 0: No signs of inflammation cells
Grade 1: Isolated chronical and/or acute inflammation cells, fibroblast rich connective tissue (mesenchymal character)
Grade 2: Isolated chronical and/or acute inflammation cells, collagen rich connective tissue (loss of mesechymal character,
reduction of pulpoblasts and fibroblasts, isolated denticles)
III Degenerative parameters of the endodontium
1. Irregular irritation dentin
Grade 0: No signs of irregular irritation dentin
Grade 1: Irregular direction of dentin tubules, moderate numeric reduction of odontoblast processes, localized
Grade 2: Increase of irregular direction of dentin tubules, severe numeric reduction of odontoblast processes, localized
Grade 3: Severe irregularities in the direction of dentin tubules and/or loss of odontoblast processes, localized or circumpulpal
Grade 4: Mainly osteodentin, circumpulpal
Grade 5: Only osteodentin with inclusion of tissue, circumpulpal
Grade 6: Tendency to obliteration with areas of homogenous mineralisation, circumpulpal
2. Tissue necrosis
Grade 0: No signs of tissue necrosis
Grade 1: Isolated areas of tissue necrosis, localized and/or included by hard tissue
Grade 2: Extensive tissue necrosis (crown pulp)
Grade 3: Tissue necrosis reaching/including root pulp
3. Dentin resorption
Grade 0: No signs of dentin resorption
Grade 1: Isolated dentin resorption in crown dentin
Grade 2: Isolated dentin resorption in root dentin
Grade 3: Severe dentin resorption (internal granuloma)
4. Denticles
Grade 0: No signs of denticles
Grade 1: Fibrodenticles, isolated
Grade 2: Cellular fibrodenticles, isolated
Grade 3: Severe amount of denticles (free and/or attached), localised in crown pulp
Grade 4: Severe amount of denticles (free and/or attached), reaching the root pulp
5. Inflammation
Grade 0: No signs of inflammation cells
Grade 1: Isolated infiltration of chronical and/or acute inflammation cells
Grade 2: Infiltration of large areas of the pulp, tendency of demarcation
Grade 3: Severe infiltration without demarcation
Grade 4: Isolated abscesses
Grade 5: Large abcess (for example crown pulp)

© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 93 – 102

96 A . Z O8 L L N E R & P . G A E N G L E R
Fig. 1. Quantitative measurement: width of the shoulder (s).
Table 5. The most severe degenerative changes occur
in the area next to the rating point D2. The irregular
irritation dentin formation is characterized by grade 3
(out of 6): severe irregularities in the course of dentin
tubules and/or loss of odontoblastic processes. The
mean grade for the featheredge preparation is 1.6
(Fig. 4) and for the shoulder preparation 1.8 (Fig. 5).
More pronounced pathological changes like osteo-
dentin formation were not observed. Because of this
reaction pattern, Tables 6 – 9 refer only to this pulp
area adjacent to rating point D2. The correlation of
the two preparation techniques and the control group
(Table 6) clearly documents that regular irritation
dentin formation is less pronounced both in group 1
(featheredge preparation, mean BRD grading 0.5) and
in group 2 (shoulder preparation, mean BRD grading
0.4) compared with the control group 3 (mean BRD
grading 1.2). In contrast to this, the irregular irritation
© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 93–102
Fig. 2. Quantitative measurement: remaining dentin thickness at
rating point D1, D2, D3.
dentin is more pronounced in group 1 and group 2
compared with control group 3. A significant differen-
tiation between the two techniques was not possible.
Comparing pulp reactions and the remaining dentin
thickness (Table 7), three groups were formed: up to
2 mm, between 2.1 and 2.5 mm and more than
2.5 mm. Especially, the endodontal reactions to less
remaining dentin thickness are characterized by
severe irregular irritation dentin formation and total
absence of regular irritation dentin formation. This is
in sharp contrast to less pathological changes in cases
of thicker remaining dentin. The mean ratings of 0.6
and 1.1 demonstrate very normal regular irritation
dentin formation and only moderate irregular irrita-
tion dentin formation. Taking first the featheredge
preparation, Table 8 shows the rating of endodontal
reactions in different areas of the pulp: crown pulp,
 PULP REACTIONS TO CROWN PREPARATIONS 97

tion (crown pulp, area of the margin at point D2) 1.8

Table 3. Bacterial invasion into dentin tubules and type of
(Fig. 6)
preparation

BRD grading
Discussion
Mean Minimum Maximum
Earlier methodological prospective in vivo studies
Group 1 (featheredge 1.3 0 3
preparation) used graded classifications for the estimation of
Group 2 (shoulder prepa- 1.0 0 3 (pathological) pulpal changes, including the parame-
ration)
ters of inflammatory cell response, soft tissue organi-
zation, dentin bridge formation and bacterial staining,
as already suggested by Langeland et al. (1966),
slightly modified and confirmed for recent studies by
margin (D2) and root pulp. The most severe degener- Pameijer & Stanley (1995). Warfinge (1986) tried
ative reactions occurred in the crown pulp (irregular to introduce morphometric methods for the evalua-
irritation dentin, mean BRD grading 1.5) and in the tion of inflammatory responses. As a consequence,
area of the margin at point D2 (mean BRD grading pathological degenerative reactions are well defined
1.6). The results for the shoulder preparation (Table for teeth primarily exhibiting no pathological changes
9) document the same tendency with slightly different of the endodont, like in short-term biocompatibility
mean BRD gradings: irregular irritation dentin forma- testing for dental materials and methods defined in

Fig. 3. J. Hopkins stain (×320), isolated

bacteria in dentin tubules (BRD grade 2).

Table 4. Bacterial invasion

into dentin tubules and BRD grading
irritation dentin formation
Bacterial invasion Grade 0 Grade 1 Grade 2 Grade 3

Regular irritation dentin (mean/min/max) 0.0/0/0 0.7/0/1 0.0/0/0 0.0/0/0

Irregular irritation dentin (mean/min/max) 2.0/1/3 1.3/0/3 2.3/1/3 2.5/2/3

© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 93 – 102

98 A . Z O8 L L N E R & P . G A E N G L E R

(shoulder preparation)
Group 2

0.4/0/1

1.8/0/3
(featheredge preparation)
Group 1
Area D3

0.6/0/1

1.2/0/3
(shoulder preparation)
Group 2

0.4/0/1

1.8/0/3
(featheredge preparation)
Table 5. Irritation dentin formation at pulp areas adjacent to D1, D2, D3 (see Fig. 2)

Group 1
Area D2

0.5/0/1

1.6/0/3
Fig. 4. Azan stain ( × 1), featheredge preparation, overview. (shoulder preparation)

ISO/EN 7405 (1997). The suggested semi-quantitative

Group 2

classification proposes to consider the cumulative effect

0.3/0/1

1.3/0/3

caused by longstanding marginal periodontitis and dif-

ferent preparation techniques. It takes into account
(featheredge preparation)

that pulp changes are mainly localized and strongly

correlated to the place of origin of the causing irritant
in agreement with the design for human pulp studies
BRD grading

described by Stanley (1968). Therefore, the feath-

eredge preparation and the shoulder preparation were
Area D1

Group 1

0.5/0/1

1.3/0/3

investigated on one tooth, this experimental approach

enables the direct comparison of the histopathological
Irregular irritation dentin

outcome of these techniques on the predamaged pulp.

Regular irritation dentin

The criteria used for the evaluation of the sections are

(mean/min/max)

(mean/min/max)

based on well-defined terms in general pathology (Un-

derwood, 1982) concerning degeneration and regen-
eration, including especially, pulp tissue changes owing
to the physiological ageing process (Schroeder,
1993a,b).

© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 93–102


The regular irritation dentin formation is a
natural phenomenon and a typical feature in early
carious lesions (Gängler, 1996) and following mild
physiological abrasion and attrition (Schwarz & Gän-
gler, 1998). In contrast to regular irritation dentin,
the irregular irritation dentin formation represents
the numeric reduction or even loss of odondoblasts,
and therefore fewer cells and their processes are re-
sponsible for dentin formation (Langeland et al.,
1975). This is the first sign of degeneration followed
by the formation of fibrodenticles, osteodentin forma-
tion and/or dentin resorption by activation of odonto-
clasts. Finally, the tissue necrosis of smaller or larger
pulp areas is the degenerative result of crossing
the point of no return of cell reactivity. Without
doubt, isolated or confluenting abcesses (grade 4/5)
are signs of inflammation and they represent at least
a sublethal trauma of the pulp tissue. In contrast
to these undoubted degenerative features, isolated
infiltration of chronic and/or acute inflammation cells
does not characterize per se a degenerative pro-
cess. In general pathology, the reversibility of acute
and/or chronic inflammation is well described (Un-
derwood, 1982) and a prerequisite of a normal
healing process. However, this regenerative poten-
tial of connective tissue is limited in inflammatory
pulp responses. This is why the appearance of inflam-
matory cells to local irritants even in short-term
biocompatibility testing as defined in ISO/EN 7405
(1997) is classified as a potentially degenerative
process.
Concerning the interpretation of the BRD gradings,
the results of the control group are in agreement
with those of a previous investigation (Zoellner et
al., 1997) on incisors exhibiting periodontal disease
and occlusal attrition. Pulp reactions due to severe
marginal periodontitis are mainly characterized by
extensive regular irritation dentin formation with
some tendency to reduced numbers of odonto-
blasts. Therefore, pulp responses to different prepara-
tion techniques were clearly distinguished concerning
the area as well as the intensity of degenerative
changes.
These degenerative reactions my be caused by
bacterial infection due to microleakage occurring un-
der crowns fixed with zinc phosphate cement (Gold-
man et al., 1992). However, the influence of bacteria
as the main irritant is controversially disputed
© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 93 – 102
PULP REACTIONS TO CROWN PREPARATIONS 99
(Brännström & Nyborg, 1971; Mjör, 1974). Tron-
stad & Langeland (1971) proved that bacterial inva-
sion into opened dentin tubules in omnivorous
teeth via abrasion is a natural occurring phe-
nomenon. The results of both groups in this study
exploiting different preparation techniques con-
firm experimental studies in pigs, where pulp reac-
tions correlate better with the material toxicity and
the remaining dentin thickness of dentin than
with the microbial invasion into dentin tubules
(Schwarz & Gängler, 1998). Because of the non-
correlation of presence and absence of bacteria with
the pulp reactions in both groups, other factors
are responsible for the intensity of degenerative
changes.
The results document that the remaining dentin
thickness is strictly correlated to the severity of
degenerative parameters while different preparation
techniques do not demonstrate clearly different
endodontal reactions. According to the conclusions
of Smulson & Sieraski (1989), it is confirmed that
the amount of 2 mm and more remaining dentin
seems to be the critical factor in determining the
degree of pulp response. However, in contradiction to
their statement, that the shortest distance between
the prepared dentin margin and the pulp is decisive
for the severity of inflammatory reactions (Smulson
& Sieraski 1989), it is demonstrated in this study that
the critical remaining thickness of dentin follows the
direction of dentin tubules. From the experi-
mental and control results presented it is concluded
that pulp changes due to periodontal disease are
superimposed by typical mainly degenerative re-
sponses following crown preparation. Different pre-
paration techniques and various bacterial invasion
levels do not correlate with the severity of histo-
pathological changes. From a clinical point of view,
the remaining dentin thickness is the most important
factor of the cumulative effects including period-
ontal disease or type of preparation technique leading
to possible endodontal complications after crown
preparation. The application of different preparation
techniques on one tooth considering not only techni-
cal requirements for the crown fabrication but pri-
marily general and individual morphological tooth
characteristics like enamel and dentin thickness is
. recommended.
100 A. ZOELLNER & P. GAENGLER

Fig. 5. Azan stain ( ×64),

magnification from Fig. 4, irregular
irritation dentin formation (BRD grade
2) at rating point D2.

Table 6. Pulp reactions to different preparation techniques

BRD grading

Group 1 (featheredge preparation) Group 2 (shoulder preparation) Group 3 (control group)

(mean/min/max) (mean/min/max) (mean/min/max)

Regular irritation dentin 0.5/0/1 0.4/0/1 1.2/1/2

Irregular irritation dentin 1.6/0/3 1.8/0/3 0.8/0/1
Resorption 0.1/0/1 0.0/0/0 0.0/0/0
Denticles 0.1/0/1 0.1/0/1 0.5/0/3
Inflammation 0.1/0/1 0.0/0/0 0.0/0/0

Table 7. Pulp reactions and remaining dentin thickness

BRD grading

B2 mm 2–2.5 mm \2.5 mm Control group

(mean/min/max) (mean/min/max) (mean/min/max) (mean/min/max)

Regular irritation dentin 0.0/0/0 0.5/0/1 0.6/0/1 1.1/ 0/1

Irregular irritation dentin 2.8/2/3 1.2/0/3 1.4/0/3 0.8/0/1
Resorption 0.2/0/1 0.0/0/0 0.0/0/0 0.0/0/0
Denticles 0.0/0/0 0.1/0/1 0.1/0/1 0.5/0/3
Inflammation 0.0/0/0 0.0/0/0 0.1/0/1 0.0/0/0

Table 8. Pulp reactions in BRD grading

different areas: featheredge
preparation Crown Margin (D2) Root
(mean/min/max) (mean/min/max) (mean/min/max)

Regular irritation dentin 0.6/0/1 0.4/0/1 0.9/0/1

Irregular irritation dentin 1.5/0/3 1.6/0/3 0.7/0/2
Resorptions 0.0/0/0 0.1/0/1 0.0/0/0
Denticles 0.0/0/0 0.1/0/1 0.0/0/0
Inflammation 0.0/0/0 0.1/0/1 0.0/0/0

© 2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 93–102

 P U L P R E A C T I O N S T O C R O WN P R E P AR A T I O N S 101

BRD grading Table 9. Pulp reactions in

different areas: shoulder
Crown Margin (D2) Root preparation
(mean/min/max) (mean/min/max) (mean/min/max)

Regular irritation dentin 0.5/0/1 0.4/0/1 0.6/0/1

Irregular irritation dentin 1.8/0/3 1.8/0/3 1.0/0/2
Resorptions 0.0/0/0 0.0/0/0 0.0/0/0
Denticles 0.0/0/0 0.1/0/1 0.0/0/0
Inflammation 0.0/0/0 0.0/0/0 0.0/0/0

Fig. 6. Azan stain (× 6.25), shoulder

preparation, overview showing a mes-
enchymal pulp tissue with irregular
irritation dentin formation (BRD
grade 1) at rating point D2.

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Correspondence: Dr. Axel Zöllner, School of Dental Medicine,
University of Witten/Herdecke, Alfred Herrhausen Str. 50,
58448 Witten, Germany. E-mail: dagmark@uni-wh.de