A 30-minute posterior crown for the economically-challenged patient

When your patient can’t afford a traditional core and crown, here’s a fast, reliable option that lets you restore function, comfort and a certain degree of esthetics at least for a few more years.

by Jason R. Tanoory, DMD
Canandaigua, NY

Before I begin, let me make several things clear:

• I do not pretend this a “permanent” crown.

• Unless I’m convinced the tooth is transitional, I never begin a case presentation with one of these direct/indirect crowns. I use it only as a fall-back option.

However, when definitive treatment must be postponed for personal or financial reasons or a maxed-out insurance plan, I feel very comfortable using a direct/indirect technique for restorations too large for direct composites.

I never suggest this treatment unless I have an immediate concern for the tooth. Most commonly it’s a huge MODLBXZY amalgam with one of three conditions: (1) large recurrent caries, (2) a cusp fracture, or (3) the tooth requires endo but the patient can’t afford both RCT and a crown at the same time.

And of course there are some patients who have the money for premium dentistry, but simply refuse to recognize its value. Who am I to refuse treatment to these individuals? If I can provide a service to these patients and I’m adequately compensated for it, let the games begin.

I try to make it absolutely clear to the patient that our goal in placing this restoration is to restore comfort and function and keep things from sliding downhill until something more permanent can be provided. We’re buying time.

However, based on my experience to date, I suspect that the need for further treatment may be more distant than I originally imagined.

Here’s the first direct/indirect crown I ever did!

About three years ago this patient presented with a lingual cusp fracture and caries on #15. The Precambrian alloy restoration was far beyond its useful life.

As usual, I recommended a build-up and full-coverage crown.

Unfortunately, for this patient the cost of a crown was prohibitive. She was going through a difficult stretch, and money was a real concern.

So what to do? A direct composite maybe? That would be really pushing the material to the limit.

So I tried a Hail-Mary



1) Using a double-arch tray, I took an impression.

2) Of course the impression recorded the fracture, so I carefully removed impression material in the lingual cusp area until the matrix approximated full crown contour. I was cautious to avoid removing impression material where the old restoration or surviving cusp remained.



3) After removing the old amalgam and eliminating caries, I prepped the tooth for a conventional 3/4 crown, taking care to avoid undercuts. This involved reducing the buccal wall approximately 1.5mm to allow more bonded surface and assure good draw.


4) I packed retraction cord and lubricated the preparation with KY jelly. (I suppose you could use Vaseline, but water-soluble KY jelly is much easier to remove.)

5) Going back to the impression, I inserted a nanohybrid composite (Simile® Incisal, Pentron) to a depth of about 1mm into the mould of #15. This would create an occlusal veneer of restorative composite that allowed polishability and wear-resistance. I light-cured the composite in the impression.
6) I immediately filled the balance of the recess with tooth-shade Absolute Dentin™ core material.

7) Going back to the mouth, I injected a little Absolute Dentin over the prep to assure good coverage.

8) Then I immediately reseated the impression, taking particular care to assure it was fully seated.

9) I allowed 4-minutes for the Absolute Dentin to self-cure, and then removed the impression. Because of the prelubrication and path-of-draw, removal was easy.



10) After carefully removing the 3/4 composite crown from its mould, I trimmed the flash and air-abraded the intaglio.

11) I washed and dried the tooth to remove the KY jelly plus any composite residue.



12) When I tried in the restoration, it fit like a dream. Both bite and contact were perfect ... no adjustments needed. The patient had a good centric stop without interferences, so I didn’t even consider taking the tooth out of occlusion.

13) After applying and curing my self-etch bonding agent (Brush&Bond®), I cemented the crown using a flowable dual-cure composite resin (Permaflo® - Ultradent).
Done! From beginning to end this particular restoration took just a little under an hour. But this was my first direct/indirect restoration, so that included some fumbling and hesitation. Today, I do similar cases comfortably in about 30 minutes.

Why these particular materials?

This technique is very close to the one many dentists use for their chairside temps. The primary difference between a temp and this “transitional resin crown” is the materials I use.

As already mentioned, I used Simile nanofilled composite for the exterior because of its excellent finishability and wear-resistance. In my hands it provides a nice smooth surface that resists staining and plaque accumulation. However, if you prefer another direct composite, I’m sure you could substitute it.

Absolute Dentin has been excellent for the body because -

1.) It’s a dual-cure, so it will polymerize under the impression.

2.) It bonds well to the overlying light-cure composite.

3.) When it’s first expressed through the mixing tip, Absolute Dentin provides a certain amount of flow, so it conforms well both to the tooth and to the impression. The margins have been almost perfect, and (so far at least) they’ve held up really well.

4.) My bonding agent (Brush&Bond) has been documented to bond well to Absolute Dentin.

CAUTION: If you decide to try this technique, be sure that whatever you use for a bonding agent is compatible with whatever you use for a dual-cure resin. Many are not.

So how long will it last?

I don’t know yet.

Over the past three years I’ve given my patients approximately 75 restorations using this technique.

Other than one restoration that debonded, all are currently performing admirably.

But if the treatment heads south or the patient decides to upgrade to a definitive crown, this direct/indirect approach leaves me a nice back door. All I have to do is prepare the resin-crown as if I were prepping a natural tooth, and I’ll be left with a bonded core ready for the definitive crown.

Selection, selection

This approach is appropriate primarily for posterior restorations where cosmetics aren’t a huge concern. A “tooth-shade” crown may be adequate distal to the first premolar, but most patients wouldn’t tolerate it in the anterior.

And remember, the whole idea of the impression is to quickly reproduce the pretreatment tooth anatomy in composite and minimize the need for post cementation adjustments. The unprepared tooth must retain sufficient structure to indicate the patient’s natural occlusion.

If the occlusal surface is totally bombed-out, there won’t be anything for the impression to capture. Depending on your freehand skill, you can rebuild missing anatomy using unbonded resin before impressing. I frequently do this while the patient is getting numb. If the addition comes out in the impression, simply remove it and proceed.

Of course, if the crown requires significant changes to existing anatomy, say closing an open bite, or alternatively opening a closed bite this technique won’t work.

And last but not least: Money matters

Because it’s so fast and easy, I can offer my economically challenged patients a serviceable restoration for roughly 1/3 the cost of a lab-fabricated crown. This frequently means the difference between treatment and no treatment. And even at that low price - I make money.

Three years later. This film shows the restoration at the 3-year recall. Since this restoration was cemented, the author has placed approximately 75 other restorations using this technique.

About the author: Dr. Jason R. Tanoory practices Family Dentistry in Canandaigua, NY. A graduate of the School of Dental Medicine at the University of Pennsylvania, he completed his advanced residency at the Eastman Dental Center, and continues to average 200 CE hours per year. He was recently awarded his Fellowship with the Academy of General Dentistry. Dr. Tanoory is an active member of Dental Town, where the technique described in this article was first presented. He can be reached at jrtmolar@yahoo.com.