About 100 years ago, the cast gold restoration was introduced into dentistry. Cast gold restorations soon became a subject of great interest to both dentists and dental patients, and gold alloy soon proved itself to be a viable material for tooth restoration. Gold alloy’s most attractive characteristics were its malleability, when properly cast and clinically placed, and its wear similarity to that of tooth structure. The color of gold alloy was a negative feature to some people, but after a few years, gold restorations actually became a status symbol for some people. The longevity of cast gold alloy restorations became well known to patients, and when they could afford such restorations, educated patients preferred them over others available at that time.
Cast gold restorations were most popular from the 1930s to the 1970s. Among dental patients, this popularity stemmed from gold alloy’s acceptable function and restorative longevity. Restorative materials providing only esthetic acceptability were not well-received by the profession at that time.
In the early 1960s, the porcelain-fused-to-metal, or PFM, restoration was reintroduced to the profession after an unsuccessful start several years earlier. Many excellent restorative dentists rejected the PFM restoration; they claimed that it would never succeed. Its acceptance started slowly, but soon accelerated, and the profession’s esthetic revolution began. By the early 1970s, many dentists were using tooth-colored crowns, almost to the exclusion of cast gold restorations. That trend has continued through today.
In this article, I re-examine the viability of the cast gold restoration, and I propose a renewed observation of the desirability of restoration longevity vs. an obsession with esthetics.
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STATE OF THE ART IN FULL CROWNS
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It is instructive to look at the statistics on the types of crowns produced by a large U.S. laboratory in 2001 (J. Shuck, vice president, Glidewell Laboratories, April 27, 2001):
- – PFM crowns: 71 percent;
- – all-ceramic crowns: 15 percent;
- – gold alloy crowns: 8 percent;
- – polymer crowns: 6 percent.
This report shows the current trend toward tooth-colored crowns (92 percent, in this example). During my various speaking engagements around the country, laboratory personnel have reported to me that use of tooth-colored crowns, including all-ceramic crowns, is continuing to increase. This trend probably relates both to the introduction of several new tooth-colored crown types and to the high cost of palladium.
Every month, members of the profession receive many magazines showing various tooth-colored intracoronal and extracoronal restorations. Some of these restoration types have undergone very little basic research or clinical observation before being promoted by manufacturers or by speakers, many of whom work for manufacturers.
It is obvious that the public wants tooth-colored crowns. I agree—I want tooth-colored crowns also—but do the promoters of these types of restorations offer their patients adequate information about the crowns they are receiving? Do they inform patients that the treatment they are receiving is new and relatively unproven? Do they offer them the alternative of a better-proven, potentially longer-lasting treatment? Would patients choose to have the longer-lasting restorative therapy if they knew about it? It is my observation that many patients actually prefer longer-lasting restorations when given the opportunity to receive them.
I am a charter member and past president of the American Academy of Esthetic Dentistry, and I have been a longtime supporter of the esthetic dentistry concept. However, I am convinced that the time has come to re-examine our acceptance of many of the esthetic treatments that are being presented to the public without proper patient education and, therefore, are being administered without patients’ informed consent.
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A WELL-PROVEN RESTORATIVE CONCEPT PATIENTS SHOULD KNOW ABOUT
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Cast gold alloy restorations, properly placed, remain the only tooth structure replacement that wears in a similar manner to tooth enamel and does not wear opposing enamel aggressively. Properly quenched and finished type 2 cast gold restorations wear almost exactly as does tooth enamel. How many patients would accept cast gold restorations for their posterior teeth if they knew that these restorations would serve for a major portion of their lives?
My research among groups of practicing dentists has shown that most dentists prefer to have gold alloy restorations for their own posterior teeth.
I contend that cast gold restorations placed on maxillary second and third molars and all mandibular molars are seldom displayed in even a full smile. I fully accept that most dentists will not place inlays and onlays because they require more effort than crowns, and that third-party payment organizations will not pay well for them. However, the full cast gold alloy crown technique is no more difficult than the technique for PFM crowns.
There appears to me to be no reason why clinicians are not placing more full crowns made of cast gold. I have them in my own mouth. Also, my research among groups of practicing dentists has shown that most dentists prefer to have gold alloy restorations for their own posterior teeth. Even though you may disagree with me, your patients deserve to be educated about the availability of the cast gold restoration and the relative longevity of all the various crowns that you offer in your practice.
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ESTHETIC ACCEPTABILITY AND RESTORATION LONGEVITY: A RATIONAL TREATMENT APPROACH
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All patients considering crowns for their teeth should be educated about the treatment alternatives available for their mouths so that they can give informed consent to the treatment of their choice.
Molars.
Patients who desire both a good esthetic result and optimum longevity of the restorations should be offered cast gold restorations on their mandibular molars, as well as on their second and third maxillary molars.
Premolars.
Crowns on premolars can be made of gold alloy on the lingual cusps (to stabilize occlusion) and of ceramic on the facial cusps.
Anterior teeth.
Patients who have acceptable remaining lower anterior teeth but who need crowns on maxillary anterior teeth can be given PFM crowns with gold alloy lingual surfaces. This reduces the extreme wear on mandibular anterior teeth often associated with porcelain that comes in contact with the lingual chewing surfaces of maxillary anterior crowns.
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SUMMARY AND CONCLUSIONS
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Because of the introduction of numerous tooth-colored crown types, there is a tendency for dentists to place more tooth-colored crowns and for patients to demand such restorations. Some of the new tooth-colored crown types have been introduced on the market after very little research. Dentists placing tooth-colored crowns should evaluate research on the products.
PFM remains the most used and predictable type of tooth-colored crown. However, some of the newer all-ceramic crowns—such as Procera (Nobel Biocare), In-Ceram (Vident) and IPS Empress (Ivoclar North America)—are providing relatively predictable service for single-tooth and selected three-unit fixed partial dentures. When posterior tooth crowns are to be used in locations that do not require esthetic tooth color, the clinician should offer cast gold restorations.
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STATE OF THE ART...
A WELL-PROVEN RESTORATIVE...
