When I graduated from dental school in 1988 most teeth that received indirect restorations also got a buildup. The buildup, in those days usually amalgam, replaced the parts of the tooth that had been lost to decay internally. This accomplished several goals, it allowed the indirect preparation to have retention form and resistance form. It also allowed for a uniform thickness of metal in the indirect restoration, which was important during the firing cycles of veneering porcelain on PFM’s. The buildup was retained in the tooth with traditional mechanical retention, facilitated by root canal therapy and posts if inadequate tooth structure remained.
Today many of us are using monolithic all ceramic restorations in the posterior. The all ceramic material means that we no longer have to be concerned about metal thickness and the ceramic firing cycles of PFM’s. The strength of the monolithic materials eliminate the concern of veneering porcelain chipping and needing to design cores for support. Lastly, the materials can be bonded directly to the tooth in addition to the inclusion of retention features so the need for specific prep features is no longer a concern. In actuality, since most of our modern materials are bonded to the tooth, we add the complexity of multiple interfaces with a buildup.
Thinking back over my practice what failed most often was the buildup, and I’d find most of them inside of crowns that came into the office in Ziploc bags. Since I moved to monolithic ceramic restorations bonded in with dual cure resin cements and no buildups I experience fewer structural failures. So, do we need a buildup or not? I’d love to see some long-term clinical studies comparing the two, but until then its up to our clinical judgement. If you are in the camp moving away from buildups take a moment and revisit your fees for all ceramic crowns and onlays.