Dental crown alternatives. -

Is a crown always needed?   What other options exist? - Onlays, 3/4 crowns, tooth build ups (fillings), phasing your treatment, tooth extraction. | What are the advantages, disadvantages and risks associated with alternative approaches?

If your dentist recommends a dental crown, do you have any other options?

You may find yourself in the position where your dentist has recommended placing a crown for a tooth but there are reasons why you are hesitant to commit to that treatment. If so, you'll need information about what possible alternatives you have.

That's what this page explains. It outlines what other treatment approaches might be possible in lieu of crown placement. And the various advantages, disadvantages and outcome that each of them might be expected to have.

Potential treatment options typically include:


Are there any exact or near equivalents to a crown?

Yes and no.

No other type of dental restoration cups over and encases its tooth as extensively as a full dental crown. And for that reason, there is no perfectly equivalent substitute.

But other types of restorations do exist that can either help to reinforce/strengthen your tooth or improve its appearance. And in some cases, the advantages associated with them may actually tend to make them a better choice.

Their suitability as a crown alternative simply depends on what needs to be accomplished for your tooth, and possibly what your objections are to it (usually in terms of how the restoration looks).

Here are some of the options that exist ...

a) Onlays and 3/4 crowns.

These restorations are very similar to full crowns. They cup over and encase the tooth they are placed on, just less fully.

Possible full crown alternatives.

Animation showing: complete onlay, partial onlay, 3/4 crown, full crown.
Definitions.
  • Onlays just cover one or more of a tooth's cusps. - A complete onlay covers its tooth's entire chewing surface (all cusps, just like a full crown does), while a partial onlay only encases some of them.
  • 3/4 crowns - These restorations encase all of a tooth's cusps (just like a full crown), and all but one of the tooth's sides (usually the side that shows).

Despite these definitions, a lot of variability can exist. And that means exactly what constitutes an onlay vs. some type of crown can sometimes be fairly abitrary. For example:

  • If the amount of damage that a tooth has sustained is substantial but not so extensive that a full crown is necessarily required, a complete onlay might be designed so it encompasses a greater extent of the tooth than is usual (like extending substantially onto one side of the tooth), so an adequate repair is accomplished.
  • But if this same type of extension is needed on most or all sides of the tooth (once again however, not to the same extent as is common with a full crown), whether the restoration should be classified as an onlay, 3/4 crown or full crown could be debatable.
Onlays vs. Inlays.

Possibly the greatest concern related to restoration definitions is what exactly constitutes an onlay versus an inlay. And insuring that what you are sold as an onlay really is, thus insuring the level of tooth protection that's expected.

A position paper published by the American Association of Dental Consultants (AADC) points out that the definition currently used by some practitioners is one where inlays that extend substantially onto one or more of the inclines of a tooth's cusp(s) is miscategorized as an onlay, a restoration that instead would fully cover over and encase the involved cusp(s).

The paper suggests that this stretch of the definition of inlays primarily has to do with bypassing dental insurance code limitations and helping to increase the utilization of expensive in-office equipment that can fabricate (mill) all-ceramic dental restorations.

Our only point here is this. An inlay can't be considered equivalent to a crown in the level of tooth protection it provides. So if an all-ceramic (milled) onlay is suggested as a crown alternative, ask questions to insure that the restoration you're being offered really is an onlay and not just an inlay.

Simply ask: Does the restoration fully overlay (cover over, encase) the tooth cusps involved (which a complete or partial onlay would and an inlay doesn't).

How equivalent are onlays and 3/4 crowns to full crowns?

As compared to crowns (generally meaning restorations that fully encase that part of a tooth that lies at and above the gum line), onlays (especially complete ones, partial ones less so) and 3/4 crowns can also help to reinforce the teeth they are placed on. So from that standpoint, they may serve as very suitable equivalents.

  • The external forces most likely to cause tooth fracture/damage are typically those associated with the act of closing your teeth together (chewing, teeth clenching, biting down on something hard, etc...).
  • Since full crowns, 3/4 crowns and complete onlays fully encase the chewing surface of the teeth on which they're placed, each is considered fairly equivalent in the level of protection/strengthening effect it can provide. (This of course assumes that the material from which the restoration has been made can adequately withstand these forces).
Advantages of onlays and 3/4 crowns over full crowns.

The primary advantage of placing one of these alternatives instead of a full crown is that less tooth structure must be sacrificed (trimmed away) when they are placed.

  • In terms of dental philosophy, it should be the goal of every dentist to preserve as much natural tooth structure as is possible when repairing a tooth.
  • Also, more aggressive tooth reduction (trimming) generally increases the potential for treatment complications.
  • Since plaque may be more difficult to remove from around dental restoration margins (edges), trimming away less of the tooth and having them higher on its sides (like when an onlay is placed) tends to make it easier for a person to maintain the health of their gums.
Disadvantages.
  • Generally speaking, the greater the degree to which a restoration covers over its tooth, the easier it is for a dentist to accomplish good restoration retention (how well it stays in place). So in some cases, a full crown might provide and advantage in this regard over an onlay (especially a partial one) or possibly even a 3/4 crown.

    However, in an era where "adhesive" cementation of restorations is possible, this is ever becoming less of a concern.

  • The material characteristics of a restoration must be considered. For example, will it be strong enough to provide a strengthening effect (not fracture)? Or if it shows, how will it look (will it be tooth-colored)?

    The construction of crowns (full or 3/4's) can be all-metal, all-ceramic or porcelain-fused-to-metal. Only all-metal or all-ceramic fabrication is common for onlays.

    Each type of construction varies in its characteristics and these must be considered. Onlays probably offer the greatest challenge in choice where the strongest type of fabrication (all-metal, gold) is not the most aesthetic. And the strongest all-ceramic options don't yet have a long, well-established track record.

In regard to cost, each of these alternatives (complete onlays, 3/4 crowns and full crowns) typically has a similar fee.

b) Preformed/shell crowns.

To the uninitiated, this type of restoration looks similar to a custom-made crown. But in reality, it has very few similarities to one at all (at least in terms of possessing favorable characteristics).

These crowns are prefabricated shells (metal, plastic or ceramic) that come in a range of sizes. The size best suited for your tooth is chosen. The tooth is then trimmed modestly, and the crown adjusted and adapted, until their fit with each other is acceptable.

This type of restoration can make a suitable choice for temporizing a tooth until its permanent crown can be made (an issue we discuss below). But generally, placing one makes a poor choice for any type of permanent application and therefore is not considered a reasonable alternative or substitute for a conventional crown. (We explain why in greater detail here: Preformed/shell dental crowns.)

c) Veneers.

A veneer is a type of restoration that's used to cover over the visible surface of front teeth so to give them a renewed appearance. Because less tooth structure is trimmed away when placing one, a dentist should always recommend this procedure instead of a crown whenever appropriate.

Primarily due to their differing strength characteristics, if your dentist has recommended a crown for your tooth it's unlikely that placing a veneer would provide a suitable alternative. (We explain more about crowns vs. veneers on this page.)


Other options and alternatives to the placement of a dental crown.

  1. Have a filling (tooth build up) placed instead.
  2. Delay having the crown placed.
  3. Temporize the tooth, so the placement of the crown can be postponed.
  4. Ask about financial arrangements that make immediate treatment possible.
  5. Confirm the need for the crown with a second opinion.
  6. Have the tooth extracted.

a) Have a filling placed instead of a crown.

Having your dentist place a dental filling instead of a crown can sometimes be a workable alternative. However, there are a number of factors that must be taken into consideration before selecting this option.

Big fillings don't strengthen teeth like crowns do, therefore possibly leading to cusp fracture.

Animation showing that large filling placement may lead to cusp fracture.
Fillings vs. Crowns.

Using a filling as an alternative, especially one that will need to be quite large, isn't usually considered ideal treatment. That's because:

Having said that, it's certainly not unheard of that a person's choice for filling placement has worked out just fine for them.

Bottom line, based on their knowledge and experience its your dentist's obligation to warn you of what may happen if a filling is placed instead of a crown, and the risks can be substantial. But no one can absolutely see the future outcome for any one person's situation and at times a filling may work out to be an adequate alternative.

A crown can still be placed at a later date.

Having a filling placed now doesn't mean that you can't have a crown placed later. In fact, that's a great thing to do.

  • In some cases, so much tooth structure has been lost (from fracture, tooth decay, etc...) that a dentist will place a "dental core" as a replacement for it before the tooth's crown is made. (This is often referred to as a "tooth build up.")

    Doing so can help to improve the crown's retention and stability. So the filling (build up) you have placed now, might be used to serve that benefit later on.

  • If you have opted for a filling instead of a crown, going ahead and having one placed whenever circumstances (financial, time, etc...) finally permit makes the safest and most predictable plan.

    This type of filling-first approach is common when a person's treatment needs to be phased. (As in, phase 1 involves placing a filling in your tooth and also fixing up your other teeth that have immediate needs. Then, once all active issues have been stabilized, phase 2 involves placing more definitive restorations, like a crown for your tooth).

Advantages of this alternative.

There are some general advantages that placing a filling instead of a crown offers. They include:

  1. Less cost, possibly significantly so. (Fees for: fillings, crowns.)
  2. A crown usually takes two appointments to place, whereas a filling just requires one trip to your dentist's office.
  3. Less tooth structure is trimmed away when placing a filling vs. a crown.

Of course none of these advantages really exist if choosing a filling leads to an event that causes further, possibly irreparable, damage to the tooth.

b) Delay having the crown placed.

Delaying placement of a crown can provide an appropriate alternative in some situations. With others however, doing so might make the absolute worst choice. For this reason, you should never choose this option without the advice and concurring opinion of your dentist.

  • Many times a tooth's need for a crown is diagnosed during a routine dental exam when the dentist first notices that a filling has begun to deteriorate.

    In the case where it is "serviceable although less than ideal," postponing the placement of a crown may make a reasonable choice.

  • But in cases where decay is already present or the tooth has broken, delaying your treatment could very well lead to more serious complications or even tooth loss.
Advantages of this alternative.

Delaying treatment really doesn't offer any advantages for your tooth. Your finances or schedule may make postponing your procedure a necessity. But keep in mind that in the mean time your tooth remains at some level of risk.

c) Temporize the tooth so its crown placement can be delayed.

Some teeth that require a crown have some type of immediate issue that needs to be addressed. This might be tooth decay, missing portions or a fragile state.

In some cases it might be possible for the dentist to temporize the tooth (phase 1), thus providing a somewhat extended time frame before its permanent restoration (phase 2) must be placed.

Examples:

1) Temporary fillings.

If a tooth has an area of decay, it might be possible for the dentist to stabilize it by removing the cavity and then placing some type of temporary filling.

  • Some temporary restoratives have a very short effective lifespan (in terms of the seal they create, resistance to wear, or the protection they provide such as resistance to fracture), and therefore only offer a short-term solution.
  • Others, including dental amalgam (a "silver" filling) or dental composite (a "white" filling), might be used to create a "semi permanent" temporary restoration that the dentist feels is durable enough to provide interim service for several months or even longer.
2) Temporary crowns.

If a substantial portion of the tooth is missing, a dentist might go ahead and place a temporary crown so it receives some protection. The crowning process could then be resumed at a later date.

A literature review by Schwass (2013) [page references] reported that:

  • The typical "chairside" temporary (one made by a dentist during the patient's appointment) can be expected to provide service for up to 3 months.
  • Laboratory fabricated ones (made from heat-cured plastics) can last as long as 1 year.
Advantages of these alternatives.

While either of these approaches may provide an adequate solution, neither would be considered "ideal" treatment. The temporary nature of these kinds of restorations places your tooth at some level of risk.

If this alternative is chosen, you should ask over what time frame it would be expected that your tooth's temporization should remain stable. You'll also need to ask what precautions you should take during this period.

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d) Ask if financial arrangements can be made.

For many people, it's the cost of the crown that creates the barrier to having their work performed.

Since this is such a common obstacle, it's likely that your dentist will have some type of financial arrangements or credit plan available so your crown can be placed now and paid for over time.

Advantages of this alternative.

Arranging so your dental work can be performed now offers a great solution for your tooth but may be hard on your pocketbook. Financing dental work is a type of "unsecured" consumer debt. As such, it's usually a comparatively expensive source of funds.

e) Confirm the need for the crown with a second opinion.

Different dentists have different training and clinical experiences, as well as different skills and abilities. Conferring with a second dentist may offer varying views or insights as to what might be considered usual and appropriate treatment for your tooth.

There isn't always just one right solution to every problem. Hear each dentist out and see whose approach makes the most sense to you.

Animation showing how loosing a tooth allows the neighboring teeth to shift.

Loosing a single tooth can trigger widespread changes with your bite.

f) Have the tooth extracted.

Tooth extraction vs. crown placement.

This seemingly cheapest and simplest alternative can easily make the worst and most expensive choice in the long run.

Potential problems and complications.

When a tooth is extracted, its neighboring teeth will tend to shift position, possibly significantly so. And the misalignment that results may have a major impact on a person's dental health in a number of ways.

The removal of even just one tooth can ultimately result in problems with chewing ability or jaw joint function. Or create a configuration that makes it harder to keep your remaining teeth plaque free (thus placing them at greater risk for tooth decay or gum disease).

Additional dental work will be needed.

So to avoid these types of complications, your dentist will probably recommend to you that you replace any tooth that has been extracted with an artificial one. The bill for replacing a missing tooth (via a dental implant, bridge or removable partial denture) can easily cost more than simply having a crown made for your tooth in the first place.

Advantages of this alternative.

As opposed to the routine placement of a crown as a way of salvaging a compromised tooth, from a dental-health standpoint extracting the tooth instead offers no advantages.

There may be issues in your life that necessitate the need to choose this alternative (such as time or financial constraints). But if a way can be found around these obstacles, your oral health will benefit.

 

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Comments

Crown versus onlay for damaged molar.

Lots of helpful information, but please include something about onlays versus crowns for damaged teeth, as one dentist recommends an Emax onlay (made in-house) and the other a PFM crown (outsourced locally) for a #15 molar that just lost a chunk of old amalgam and a bit of tooth. Thank you.

Editor's note: This question applies to information on this page, so we have reproduced it here and removed it from its original post location.

Jacquelin S.

The advantage of the onlay is that less sound tooth structure is trimmed away. (As compared when a crown is placed, a greater portion of your original tooth still exists.)

That's an advantage (the usual goal of dentistry is to preserve natural tooth structure to the greatest extent possible), the trade-off however is that retention (keeping the restoration in place) may be a problem. (Fully covering over a tooth [like a crown does] usually aids restoration retention.)

In your case, an eMax restoration can be cemented adhesively (bonded) or conventionally (like your PFM probably would be). Either way there's no real reason to expect that retention will be a problem. It's just that as compared to a crown there is more potential for it. The possibility of adhesive cementation makes the point of retention less of an issue for the onlay.

There could be strength concerns (fracture) with an all ceramic onlay (with a gold onlay there wouldn't be). Once again, there doesn't have to be, but as compared to a PFM crown there is more potential for it. (The link above is for all-ceramic crowns but applies to onlays too. Read points #2, #3 and #4. Note, monolithic ceramic construction is the strongest. Also notice that Zirconia is the strongest type of synthetic ceramic.)

Philosophically, assuming that conditions are correct for the onlay (no exceptionally heavy chewing forces, no teeth grinding habit, preferably monolithic construction), the onlay is probably more in line with what will be practiced as dentistry 10 years from now.

onlay or crown: % of molar visible for successful onlay?

Thank you for your reply; and fyi, the link above doesn't work but the information is available elsewhere. What is still unclear to me is how much damage a tooth can sustain before a crown is a better solution than an onlay, and I cannot find details about this on your site? With one dentist recommending an onlay (Lithium delicate), which I'd prefer because less tooth is removed, and the other a crown (PFM w/ high noble metal) and possible root canal (outsourced), depending on what lies beneath the remaining amalgam and decay once removed, it's hard to know if dentist 1 is optimistic (onlay) and dentist 2 greedy (crown), or if both proposal would work well and for as long? FYI, a cusp is gone and the amalgam filling was big and well over 10 years old before the 2 pieces broke off separately last month (a small piece of amalgam with tooth chip first, a big chunk of amalgam w/ no tooth weeks later). This was a first visit to new dentists (acquaintance recommendations), and dentist 1 (onlay) offered his proposal after bite-wings and a visual, and dentist 2 after an intraoral-periapical x-ray and visual (plus a glance at the bite-wings I brought on a digital key); the hole is large and the bite-chewing molar (#15) is missing a cusp. Again, thanks for any illumination to help decide which dentist to make an appointment with (!).

Editor's note: This question applies to information on this page, so we have reproduced it here and removed it from its original post location.

Jacquelin S.

>>What is still unclear to me is how much damage a tooth can sustain before a crown is a better solution than an onlay ...

The questions you ask are essentially the value of going to dental school and then "practicing" dentistry (as in gaining experience by treating patients). And overall, you're simply not going to find an adequate answer via the web because treating teeth is a clinical science, and as such involves multiple variables that require direct inspection.

We understand your dilemma but there's little of value that we can add. What contributes to our difficulty is knowing the exact extent of the "onlay" that has been suggested. (See inlay vs. onlay definition discussion above. Note, you have described it as an in-house, all-ceramic restoration).

Generally speaking, the direction dentistry is headed in is one of adhesive dentistry and minimizing the extent of restorations. But whether this makes the best solution for your current situation would be impossible for us provide valid input about. You'll either need to query your dentists, or other dentists, further, or defer to the judgment of the one you have the most confidence in.

onlay versus crown conundrum

Thank you. FYI, I have already paid for 2 opinions (dentist 2 because I disliked dentist 1, not his onlay proposal), and can ill afford a 3rd. As to the conundrum, an analogy might be whether to scarf in or replace a rotten stringer on a wooden boat (!).

Lower crown with a small spot worn through the gold crown

What are my options? I have no pain and the crown is 40+ Year’s old.

Gail

From the standpoint of crown strength or appearance, the perforation is probably a non-issue.

What your crown no longer does is predictably provide a seal over the tooth.

In theory, bacteria could leak through the opening and cause decay. And for that reason making a new crown, in theory, offers the best solution.

From a practical standpoint, your dentist may decide that they can adequately monitor the perforation for developing problems without any immediate treatment.

Or they may feel that placing a filling in the opening seals the tooth predictably enough.

Crown needed?

I am told I need a crown for the last bottom tooth that has a large filling. I do not have a tooth above it that bites down on it. Is the crown necessary?

Cheryl M.

It may be that with certain jaw movements that that tooth does come into contact with other teeth and therefore receives biting pressure, and thus could benefit from the protection (strengthening effect) of a crown.

With a little testing, you should be able to determine this, and possibly you already have.

If the filling and tooth are in good repair, and it receives zero chewing forces, we tend to agree with you that we're unclear of the benefit that the crown will provide.

If the there is an obvious defect with the tooth or filling, possibly the dentist feels that the needed restoration is so large that creating one "in the mouth" (as fillings are) would be difficult if not impossible, or would produce less ideal results.

Beyond that, if the tooth has had root canal treatment your dentist may feel that a crown creates a better seal over the tooth, thus better protecting that work.


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