By: Keith Titley BDS, MScD, FRCD(C), David Farkouh BSc, DMD and Robe 2001-07-01

For many years stainless steel crowns have been a significant part of the restorative armamentarium in paediatric dentistry. By definition they are prefabricated crown forms that are adapted to individual teeth and cemented with a biocompatible luting agent.1 If some logical sequences of steps in tooth preparation and crown adaptation are followed it is a relatively simple restorative treatment modality to employ. The principal indications for their use is in those primary and permanent teeth that are either hypocalcified or that have multiple and extensive carious lesions and whose pulps have been removed. As a result stainless steel crowns continue to be the restoration of choice for compromised primary molar teeth although they are not aesthetically pleasing. The eventual exfoliation of primary teeth ensures that aesthetics will ultimately be restored while the integrity of the dentition is maintained through its mixed dentition stage of development. In the case of permanent molar teeth, stainless steel crowns are a useful semi-permanent restoration that can be used until the tooth fully erupts and more permanent and aesthetic coronal restorations can be selected. The full coronal coverage that stainless steel crowns supply virtually ensures that re-decay will not occur and, furthermore, their smooth surfaces renders the tooth easier to clean using routine oral hygiene procedures. TYPES OF STAINLESS STEEL CROWNS There are, currently, three types of stainless crowns that are available to the practitioner and these are: Crowns with straight sides with margins that follow the gingival contours of the tooth. The gingival margins can be trimmed where necessary but also need contouring and crimping to ensure gingival adaptation to the prepared tooth. Crowns that have been pre-formed and pre-crimped that, as a result, are more difficult to adapt since trimming will result in the removal of the manufacturers' gingival crimp. The ensuring of a proper fit usually requires modification of the prepared tooth rather than the crown. Aesthetic crowns have recently been introduced but they have been assessed to promote poor gingival health, they appear bulky, do not possess a natural appearance and are very expensive.2 INDICATIONS FOR USE Stainless steel crown restorations are indicated for the restoration of primary and permanent molar teeth with1,3 Extensive carious lesions which undermine cusps and expand beyond line angles Cervical decalcification

 Developmental defects such as hypoplasia and hypocalcification Failure of other available restorative materials is likely Following pulpotomy or pulpectomy For restoring a primary molar tooth to be used as an abutment for a space maintainer The intermediate restoration of fractured teeth CONTRA-INDICATIONS FOR USE Stainless steel crowns are contra-indicated when More than two thirds of the roots are resorbed There is clinical and/or radiographic evidence of radicular pathology The tooth exhibits excessive mobility AIMS, OBJECTIVES AND OUTCOME INDICATORS The stainless steel crown is a durable restoration and its clinical success is predicated upon the following.1,3 Its surface is smooth and polished and remains intact Crown margins are closely adapted to the tooth and do not cause gingival irritation All excess cement is removed from around the margins Contact with adjacent teeth is appropriately established Crown is in proper occlusion Where possible the vitality of the tooth is maintained The restoration should not interfere with the eruption of the succadaneous tooth The restoration enables the patient to adequately maintain oral hygiene TOOTH PREPARATION AND CROWN ADAPTATION

Since teeth that require stainless steel crown restorations invariably have large carious lesions and there is, as a result, the possibility of a pulp exposure it is recommended that once adequate local anaesthesia is achieved the initial stages of tooth preparation are performed under rubber dam isolation.4 The first step in tooth preparation is to reduce the occlusal surface by at least 2mm. This step may be carried out before rubber dam application to ensure that the tooth is out of occlusion. Since the cuspal anatomy of stainless steel crowns is shallow there is no need to follow the cuspal outlines so that the occlusal table may be flattened. Following occlusal reduction all caries should be removed. It is recommended that caries removal should start at the periphery and progress towards the pulp. This sequence ensures that if the pulp is exposed the operator is ensured that the tooth is not only caries free but a pulpotomy or pulpectomy can be performed in a clean uncontaminated field. In the absence of a pulp exposure the exposed dentin can be protected by calcium hydroxide or glass ionomer cement. Remembering that stainless steel crowns gain their retention from engaging the crown-root undercut smooth surface reduction can be achieved by using a tapered diamond fissure bur. With the bur angled at 10 to 15 the buccal and lingual surfaces are reduced to just below the free gingival margin of the tooth ensuring that the crown-root undercut is left intact. The mesial and distal surfaces are prepared in a similar manner making sure that a dental explorer may be freely passed between the adjacent teeth. Buccal and lingual reduction is recommended before proximal surface reduction because primary molar teeth have broad contact areas and this sequence minimizes the risk of damaging the adjacent tooth. The preparation should now be carefully examined and any sharply angled corners at the mesial and distal buccal and lingual aspects of the preparation should be rounded off (Figs. 1 & 2). The rubber dam can now be removed and a crown adapted. CROWN ADAPTATION A stainless steel crown of the correct mesial distal width is selected and tried on the tooth. The crown height should be checked to ensure proper occlusion. If a preformed and precrimped crown is being used it must be remembered that this crown can only tolerate a minimal amount of adjustment to ensure an adequate marginal fit. It is thus the authors' opinion that the uncrimped straight sided crown is more versatile, although more time consuming, since it can be cut and contoured to fit. The initial trying on of the crown may indicate that it is in supra occlusion and the reason for this may be that the occlusal reduction of the tooth was insufficient or that the crown is too long. In the case of the former further occlusal reduction can be carried out and in the latter the length of the crown can be reduced by using crown and bridge scissors at its gingival margin or by the use of abrasive stones. When reducing the height of the crown an even width band of stainless steel should be removed from its periphery. This ensures that the finished crown will follow the gingival contour of the tooth. All cut and abraded margins should be polished. The crown can then be adapted to fit the tooth by the selective use of pliers. Open contacts are eliminated by the use of a ball and socket plier at the mesial and distal (Fig. 3). If

necessary, the marginal circumference can be reduced by the use of a band contouring plier (Fig. 4). The final mandatory gingival crimp is achieved by the use of a gingival crimping plier (Fig. 5). The margins of the crown are engaged by the top two thirds of its beak and bent inwards. It is important to even out the crimp as one progresses round the periphery of the crown so the final margin is smooth with no kinks and unwanted projections. A contoured and crimped crown should be placed on the tooth by engaging the lingual surface and then wedged over to the buccal. A well adapted crown should audibly snap into place without the application of an excessive amount of force. The margins should be checked with an explorer to check the marginal adaptation and appropriate adjustments made in cases of deficiency (Fig. 6). Before final cementation the occlusion should also be checked again. A polycaboxylate or glass ionomer cement can be used for the crowns final cementation and the clinician must ensure that any excess cement is removed. Any deficiencies in the coronal hard tissues will be made up by the cement itself so that coronal build up is not necessary. FURTHER CONSIDERATIONS IN CASE SELECTION The stainless steel crown is an important restorative modality for the treatment of special needs children and children from remote areas who do not have ready access to regular dental care. Furthermore, many of these children also require the adjunctive use of general anaesthesia for their dental care. A general anaesthetic is indicated when the dental health of the patient has, or has the potential to, interfere with their general health particularly when they do not have the capability to tolerate treatment in a conscious state, or when distance from care precludes multiple appointments. The use of general anaesthesia in paediatric dentistry is generally indicated under the following conditions: Extreme non cooperation, anxiety and fearfulness Patients with medical conditions who are in need of significant dental treatment Mental and physical disabilities Patients with extensive dental needs from remote areas where access to regular dental care is not available Allergy to local anaesthetics Very young patients with extensive caries i.e. Nursing bottle caries. The availability of general anaesthetic facilities to dentists and their child patients is extremely limited and the waiting lists for these services are extensive. As a result, the majority of these children, particularly those living in remote areas, have irregular and infrequent access to dental treatment and their teeth often present with caries that affects multiple surfaces. Stainless steel crowns are indicated in these children in order to restore their dentitions to a healthy state not only because of their durability and reliability but also

because of their long-term effectiveness in preventing recurrent caries. Similarly in those patients who demonstrate an inability to maintain good oral hygiene because of either physical or mental disability the full coverage provided by the stainless steel crown significantly reduces the incidence of recurrent caries. Children who are on chronic doses of pharmaceutical agents for a multitude of medical conditions are also at risk for caries because many of these preparations contain large amounts of sucrose in order to make them more palatable. The findings of Randall et al5 in their analysis of ten studies showing that stainless steel crowns demonstrated superior clinical success rates over the long term when compared with Class II restorations adds further support for the use of stainless steel crowns in all of these children. In fact if it is determined that the patient is at high risk for developing new caries in the future the dentists' use of stainless steel crowns rather than more conservative Class II restorations may be justified. The authors believe that for children with high caries rates who match the criteria cited above, serious consideration should be given to full coronal coverage of primary molar teeth with stainless steel crowns particularly when restorative treatment under general anaesthetic is a necessity. This rationale applies even if teeth are only minimally affected by caries. The use of this crown and its effectiveness in preventing recurrent caries may further prevent or decrease the number of future treatments requiring general anaesthesia particularly since the availability of these services are limited. The risks of morbidity and mortality associated with the use of general anaesthesia are similarly reduced. It is the authors' opinion that there is a general under-use of the stainless steel crowns in paediatric dentistry and that this can largely be attributed the lack of familiarity with the indications for their use, the procedures involved in tooth preparation and their adaptation. The intent of this review is to assist the practitioner in gaining an insight of their effectiveness, ease of use and the multitude of indications for their use in the maintenance of the integrity of the developing dentition particularly in children who exhibit a high caries risk. Keith Titley is Professor, Department of Paediatric Dentistry, University of Toronto. David Farkouh is a MSc candidate, Department of Paediatric Dentistry, University of Toronto. Robert Chernecky is Senior Technician, Department of Biomaterials, University of Toronto. Oral Health welcomes this original article. REFERENCES 1. Academy of Pediatric Dentistry. Special issue. Reference Manual. 21(5): 105, 1900-00. 2. Fuks AB., Ram D., Eidelman E. Clinical performance of esthetic posterior crowns in Primary molars: a pilot study. Ped. Dent. 21:445-448, 1999.

3. Academy of Pediatric Dentistry. Pediatric Dentistry Handbook. AJ Nowak ed.: 86-87, 1999. 4. Paediatric Dentistry Manual. Faculty of Dentistry, Department of Paediatric Dentistry, University of Toronto. Sigal MJ ed.: Seventh Edition:168-177, 1998. 5. Randall RC., Vrijhoef MMA., Wilson NHF. Efficacy of preformed metal crowns vs amalgam restorations in primary molars: a systematic review. J.A.D.A. 131: 337-343, 2000. BAB II TINJAUAN PUSTAKA 2.1 Definisi Stainless Steel Crown Stainless-steel crown (SSC) adalah restorasi ekstrakoronal siap pakai yang sering juga disebut sebagai chrome steel crown (Matthewson, 1995). Pertama kali digunakan dalam kedokteran gigi anak oleh Humphrey pada tahun 1950 (Sharaf, 2005; Welburry, 2001). Sejak saat itu, SSC menjadi teknik restoratif pilihan untuk perawatan gigi sulung dengan kerusakan yang hebat (Sharaf, 2005). Bahan yang digunakan pada SSC adalah alloy yang mengandung 18% kromium dan 8% nikel (disebut juga 18-8 alloy) dengan kandungan karbon sebesar 0,8 % sampai 20%. Kandungan kromium yang tinggi ini mengurangi korosi (Matthewson, 1995). SSC biasanya dipertimbangkan bila gigi sulung posterior, terutama molar pertama memerlukan restorasi karena mahkota ini jauh lebih baik dari pada restorasi lainnya dan hampir tidak perlu diganti hingga gigi tersebut tanggal (Welburry, 1995). Keunggulan dan durabilitas SSC bila dibandingkan dengan amalgam dan restorasi lainnya telah banyak diteliti. Braff pada tahun 1974 membandingkan SSC dengan restorasi kelas II amalgam. Penelitian ini menyimpulkan keunggulan SSC. Penelitian Dawson pada tahun 1981, juga mendukung pendapat Braff (Matthewson, 1995). Keunggulan-keunggulan ini menyebabkan SSC banyak digunakan. Namun, disamping keunggulan, terdapat pula kekurangan SSC yang berkaitan dengan kesalahan prosedur klinik. Penempatan SSC yang tidak tepat dapat

menimbulkan beberapa gangguan antara lain pada kesehatan gusi dan tulang pendukung (Sharaf, 1995).

2.2 Indikasi Terdapat dua indikasi utama penggunaan SSC dalam kedokteran gigi anak, yaitu untuk molar sulung dengan kerusakan yang hebat dan molar pertama permanen dengan defek perkembangan yang parah (Raadal, 2001). Pada kasus pertama, SSC digunakan sebagai restorasi alternatif dibandingkan dengan restorasi yang diketahui memiliki prognosis buruk dan memerlukan perbaikan secara berkala. Jika digunakan dengan tepat, SSC memberikan resiko komplikasi yang rendah hingga molar sulung tersebut tanggal. Pada molar permanen dengan kerusakan pada seluruh permukaan mahkota karena defek perkembangan, SSC digunakan sebagai retorasi sementara hingga mahkota yang lebih permanent dapat dibuat (Raadal, 2001) Secara terperinci, indikasi penggunaan SSC adalah gigi sulung atau permanen dengan lesi karies yang luas atau gigi sulung dengan karies di tiga permukaan, molar sulung yang telah dirawat pulpa, gigi sulung atau permanen dengan defek pada email atau dentin (seperti hipoplasia email, amelogenesis imperfekta, atau dentinogenesis imperfekta), gigi-gigi pada anak dengan resiko tinggi karies atau rampan karies, gigi yang digunakan sebagai pejangkar space maintainer, serta pasien handicapped dengan kebersihan mulut yang buruk (Matthewson, 1995; Drummond, 2003; Sim,1991).

2.3 Prosedur Klinik Tanpa melihat apakah gigi yang akan direstorasi vital atau non vital, anestesi lokal harus digunakan ketika menempatkan SSC karena manipulasi pada jaringan lunak (Drummond, 2003). Adaptasi marginal merupakan bagian penting dari prosedur restoratif SSC. Ekstensi aksial dari SSC harus mereplikasi semirip mungkin dimensi dan kontur bentuk gigi asli. Margin SSC yang beradaptasi buruk dapat mempengaruhi kesehatan jaringan periodontal dan mengganggu erupsi gigi yang berdekatan (Croll , 2003).

2.3.1 Preparasi Gigi

Prosedur klinik diawali dengan penumpatan restorasi gigi dengan menggunakan semen ionomer kaca tipe restoratif sebelum preparasi untuk SSC (Gambar 1 A dan B). Setelah itu permukaan oklusal yang pertama dikurangi sekitar 1,5 mm dengan menggunakan bor diamond tapered. Reduksi oklusal yang merata akan mengurangi resiko prematur kontak pada saat penempatan SSC (Gambar 2). Dengan menggunakan bor diamond tapered yang panjang, permukaan interproksimal mesial dan distal dipotong. Pengurangan dilakukan hingga sonde dapat dilewatkan melalui daerah kontak (Gambar 2). Pengurangan daerah bukolingual hanya dilakukan seminimal mungkin karena daerah ini merupakan daerah retensi (Gambar 1 C) (Matthewson, 1995; Drummond, 2003). Gambar 1. A Gigi setelah pulpotomi. B. Sebelum preparasi untuk SSC, gigi dibentuk kembali dengan GIC. C. Gigi telah dipreparasi bagian interproksimal untuk menghilangkan daerah kontak dan ketinggian oklusal telah dikurang 1,5 mm. D. SSC yang telah selesai ditempatkan. (Drummond, 2003)

2.3.2 Pemilihan Mahkota Tiga pertimbangan utama dalam memilih SSC yang tepat adalah diameter mesiodistal yang tepat, ketinggian oklusal yang tepat, dan resistensi yang ringan saat penempatan mahkota (Matthewson, 1995). Ukuran SSC dipilih dengan mengukur lebar mesiodistal. Mahkota yang terlalu besar akan rotasi pada preparasi gigi dan akan memakan waktu lama pada saat adaptasi mahkota (Matthewson, 1995; Drummond, 2003). Gambar 2. Preparasi koronal dan proksimal yang diperlukan untuk penempatan SSC. (Drummond, 2003)

2.3.3 Adaptasi Mahkota Mahkota yang telah dipilih diuji coba pada gigi. Mahkota harus sedikit longgar dengan kelebihan 2 hingga 3 mm pada daerah gingival. Kemudian dengan scaler, dibuat goresan sekeliling margin gingival mahkota. Garis goresan ini menunjukkan garis gingival dan kontur gingival. Lepaskan mahkota dari gigi yang telah dipreparasi. Mahkota dipotong 1 mm di bawah garis goresan dengan menggunakan gunting crown and bridge. (Gambar 3 A). Mahkota diuji coba kembali sebelum sementasi. Penting untuk diperhatikan bahwa tepi mahkota harus berada tidak lebih dari 1 mm subgingival. Jika terdapat daerah pucat pada gingiva

akibat tekanan tepi mahkota, maka harus dilakukan pengurangan kembali (Matthewson, 1995; Drummond, 2003).

Dengan crimping plier tepi SSC dibengkokkan sedikit ke dalam sekeliling tepi mahkota. (Gambar 3B dan C). Mahkota dipasang kembali pada gigi. Adaptasi dapat diperiksa dengan menggunakan sonde pada semua tepi mahkota. Jika terdapat daerah tepi yang terbuka, maka daerah tersebut harus dibentuk kembali dengan plier (Gambar 3 D). Penyelesaian terakhir dilakukan dengan menghaluskan tepi SSC dengan batu putih dan dipoles dengan rubber wheel. Selanjutnya sementasi SSC dengan semen ionomer kaca, semen seng-fosfat, atau polikarboksilat (Matthewson, 1995; Drummond, 2003). Gambar 3. A. Pengurangan 1 mm di bawah garis goresan. B. Pembentukan kontur mahkota dengan plier no. 114. C. Pembentukan tepi mahkota dengan crown crimping plier. D. Pemeriksaan tepi mahkota untuk adaptasi. (Matthewson, 1995)

2.3.4 Sementasi Mahkota Sebelum sementasi mahkota daerah kontak diaplikasikan vaselin untuk memudahkan pembuangan kelebihan semen setelah sementasi. Kuadran gigi yang akan direstorasi diisolasi dengan cotton roll. Semen yang telah dimanipulasi sesuai dengan jenis yang digunakan, diaplikasikan pada mahkota (Gambar 4A). Pemasangan mahkota biasanya pertama dilakukan pada sisi lingual kemudian sisi bukal. Mahkota harus dipastikan masuk dengan tepat (Gambar 4B). Jika gigi diisolasi dengan cotton roll, tutupi mahkota dengan foil kering agar mahkota gigi tetap bebas kelembaban sampai semen mengeras (Gambar 4C). Setelah semen mengeras, kelebihan semen dibuang dengan scaler atau sonde (Gambar 4D) Gambar 4. A. Pengisian mahkota dengan semen. B. Penempatan mahkota dari sisi lingual ke sisi bukal. C. Mahkota dibiarkan dalam keadaan kering. D. Pembuangan kelebihan semen dengan scaler. (Matthewson, 1995)

2.4 Evaluasi Keberhasilan Keberhasilan penggunaan SSC ditentukan oleh pembuangan karies serta perawatan pulpa yang tepat bila diperlukan, reduksi optimal dari struktur gigi untuk mendapatkan retensi

mahkota yang adekuat, tidak adanya kerusakan pada gigi yang bersebelahan setelah pembebasan kontak interproksimal, pemilihan ukuran mahkota yang tepat untuk mempertahankan panjang lengkung rahang, adaptasi marginal dan kesehatan gingiva yang akurat, oklusi fungsional yang baik, dan prosedur sementasi yang optimal (Matthewson, 1995).