Escolar Documentos
Profissional Documentos
Cultura Documentos
PEDIATRIC DENTISTRY
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Editor
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Prashant Babaji MDS
Professor
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Department of Pedodontics and Preventive Dentistry
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Sharavathi Dental College and Hospital
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Shivamogga, Karnataka, India
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VV Subba Reddy
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Fax: +91-11-43574314
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2015, Jaypee Brothers Medical Publishers
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Almighty for giving me immense pleasure to write this book
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My little master Tanush for his continuous love, understanding and
support during preparation of the book.
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My parents and family members for their constant encouragement to go forward.
My teachers who shared their knowledge with me.
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Reader Principal and Professor
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Department of Pedodontics Department of Periodontics
Buddha Dental College Venkateswar Dental College
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Patna, Bihar, India Puducherry, India
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Jalarak C Patel Shashikiran ND
Senior Lecturer Dean and Head
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Department of Pedodontics Department of Pedodontics
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Goenka Research Institute of Dental Science Peoples College of Dental Sciences
Gandhinagar, Gujarat, India Bhopal, Madhya Pradesh, India
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Nitin Sharma Suresh BS
Reader Professor
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Department of Pedodontics Department of Pedodontics
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Rajasthan Dental College Sharavathi Dental College and Hospital
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Jaipur, Rajasthan, India Shivamogga, Karnataka, India
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Poonacha KS Vikram Shetty K
Reader Associate Professor and Head
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Department of Pedodontics Department of Conservative Dentistry
KM Shah Dental College and Hospital Faculty of Dentistry
Vadodara, Gujarat, India Melaka Manipal Medical College
Melaka, Malaysia
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Prashant Babaji
Professor Vinaykumar S Masamatti
Department of Pedodontics and Preventive Dentistry Senior Lecturer
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Sharavathi Dental College and Hospital Department of Conservative Dentistry and
Shivamogga, Karnataka, India Endodontics
Maratha Mandel Dental College
Raghavendra Shetty Belagavi, Karnataka, India
Professor
Department of Pedodontics Vishwajit Rampratap Chaurasia
Chhattisgarh Dental College and Research Institute Department of Conservative
Rajnandgaon, Chhattisgarh, India Dentistry and Endodontics
Mumbai, Maharashtra, India
Ranjithkumar Rampratap Chaurasia
Department of Prosthodontics
Mumbai, Maharashtra, India
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Foreword s .i
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It is an honor for me to write the foreword to my own students special book on, Crowns in Pediatric
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Dentistry. This informative book provides information on conventional and newer crowns as
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well as advanced techniques. It covers illustrations, principles and colorful images for better
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understanding. The book helps the readers to improve their current concepts and to upgrade
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their knowledge and techniques for crown placement and to solve the clinical problems.
I am confident that the book written by Dr Prashant Babaji will be very useful for clinicians,
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undergraduate and postgraduate dental students for successful dental practice.
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VV Subba Reddy
BDS MDS FICD (USA)
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Department of Pedodontics
Director and for Principal, College of Dental Sciences
Bapuji Educational Association
Davangere, Karnataka, India
Nowadays various pediatric crowns are available, but available information and long-term clinical
studies about it are very scarce. Pediatric crown development has moved from conventional
unesthetic stainless steel crown to strip crown, ceramic and preveneered crown with better
clinical success and patient and parent satisfaction. Hence, the present book aims to provide
information about conventional and newer pediatric anterior and posterior crowns.
Prashant Babaji
2. General Considerations 4
Prashant Babaji, Shashikiran ND
Importance of Restoring Primary Teeth4
Materials and Equipment8
Isolation Procedure: Rubber Dam Application10
Cementation/Cements Used for Cementation of Crowns16
PedoNatural Crown90
Anju Bansal
Pedo Jacket Crown93
Artglass Crowns/Glastech Crowns94
Preveneered Stainless Steel Crowns97
NuSmile Crowns100
Flex White Faced Pediatric Crown103
Pedo Pearls (Aluminum Crowns with Facing)104
Cheng Crown107
Whiter Biter Crown109
Pedo Compu Crown109
High Density Polyethylene Veneered Crowns For Children110
Dura Crowns110
All Ceramic/Porcelain/Zirconia Jacket Crown111
ZIRKIZ Crowns111
EZ-crown113
Kinder Krowns115
Cerec Crowns-All Ceramic CrownsCAD/CAM System119
Ceramo Base Metal Crown121
Biologic Crown122
Limitations122
Tooth Preparation122
Fabrication of Crown Portion122
Radiographic Evaluation123
Cementation of Biologic Crown123
Dentistry has undergone a significant evolution they should be retained in the oral cavity in
since beginning. Today, with the search for nonpathologic state until exfoliation.
beauty and natural color taking such a dominant Primary teeth often get destructed either
role in our society, modern dentistry should due to caries or traumatic injuries. Teeth need
make advances in these fields. Esthetics to be restoration due to loss of crown structure
by definition is the science of beauty: that following caries or traumatic injury. The pre
particular detail of an animate or inanimate valence of traumatic injuries is 8.1 in 1000.
object that makes it appealing to the eye. In the Anterior tooth trauma often results in functional,
modern civilized cosmetically conscious world, esthetic and psychological problems. Dental
well contoured and well aligned white teeth set caries is one of the most common infectious
the standard for beauty. Such teeth are not only diseases affecting the teeth of children. Caries in
considered attractive, but are also indicative very young children known as early childhood
of nutritional health, self esteem, hygienic and caries may be defined according to the American
shows economic status of a person. Academy of Pediatric Dentistry, as the presence
Primary maxillary anterior teeth dominate of one or more decayed, missing (due to caries),
the physical appearance and their structural or filled tooth surfaces in any primary tooth in
loss affects not only esthetics but also leads to a child 71 months of age or younger. Rampant
compromised mastication, poor phonetics, caries (Fig. 1.1) can occur in primary, mixed or
development of aberrant oral habits, neuro permanent dentition. It affects 1 to 12 percent of
muscular imbalance, and difficulty in social the pediatric population in developed countries,
and psychological adjustment of the child. and up to 70 percent in underdeveloped
Primary posterior teeth are important for countries. Kaste et al. (1996) reported caries
mastication, as natural space maintainer and incidence of 18 percent in 2 to 4-year-old and
to establish proper occlusion; loss of which 52 percent in 6 to 8-year-old children.
can result into space loss, malocclusion and Caries on primary molars can results
impaction of succedeneous teeth. Hence, into loss of arch circumference, pain, tooth
maintenance of primary teeth is mandatory. loss, disrupted occlusion. Hence, restoration
However, these issues are overlooked by most of of carious or pulpally treated tooth is must.
the parents resulting in to difficulties in eating, Selecting an ideal restorative material for resto
establishing social contacts and speaking. Even ration of grossly decayed teeth is challenging.
though primary teeth are temporary dentition, The most commonly used restorative materials
subgingival caries and solder joint for 1990 to 1995Hall technique was introduced
interdental spacing. SSC modification for by Dr Norna Hall for SSC adaptation on
deep subgingival caries. carious tooth without tooth preparation
1977McEvory advised modification of 1993Beemer et al. advised band adaptation
SSC technique for SSC with arch length or on SSC crown as space maintainer rather
space loss than crown and loop
1980 to 1990Various preveneered stainless 1997Pedo natural crowns were introduced
steel crowns (PVSSC) were introduced to market
1980Pedo Perls crowns were introduced 1997Zirlock (Incisalock) technology
1981Nash advocated modification of SSC was introduced for better retention of
for adjacent crowns placement preveneered crowns
1983Hartman advised veneered SSC 2002Kuietzky advised split technique
technique for esthetic anterior crown of rubber dam isolation technique for
restoration restoration of multiple primary anterior teeth
1987Cheng crowns were introduced by 2010EZ zirconia crowns were introduced
Peter Cheng by Hansen JP and Fisher JP as pediatric
1989Kinder crowns were introduced esthetic crowns.
FLOW CHART 2.1 Importance of primary teeth remaining piece. If the chipping is extensive, the
crown may need to be replaced.
Loose crown: Sometimes the cement washes
out from the crown. Not only does this allow the
crown to become loose, it allows bacteria to leak
in and cause decay to the tooth that remains. If a
crown feels loose, advise to visit dentist
Crown falls off: Sometimes crowns fall off.
Usually this is due to an improper fit, a lack
of cement, or a very small amount of tooth
structure remaining that the crown can hold on
Instructions to Child and Parents to. If this happens, instruct parents to report to
dentist with the crown
after Placement of Crown
Allergic reaction: Because the metals used to
Care for Crown make crowns are usually a mixture of metals, an
allergic reaction to the metals or porcelain used
Avoid sticky, chewy foods (for example, in crowns can occur, but this is extremely rare.
chewing gum, caramel), which have the Instruct patient to visit dentist if so.
potential of grabbing and pulling off the Dark line on crowned tooth next to the
crown. gum line: Instruct child that a dark line next
Minimize use of the side of your mouth with to the gum line of crowned tooth is normal,
the temporary crown. Shift the bulk of your particularly if a veneered SSC crown is used.
chewing to the other side of the mouth. This dark line is simply the metal of the crown
Minimize chewing hard foods (such as raw showing through.
vegetables), which could dislodge or break Tooth exfoliation: Crowned tooth exfoliates in
the crown. a similar manner as that of uncrowned tooth.
Slide flossing material out-rather than lifting
out-when cleaning your teeth. Lifting the General Considerations during
floss out, as you normally would, might pull
Crown Placement
off the temporary crown.
Aseptic Technique
Instructions after Crown Delivery
Prevention of disease transmission during and
Discomfort or sensitivity: Newly crowned after temporary restoration is required, as it is
tooth may be sensitive immediately after the necessary for all intra-oral procedures. Infection
procedure as the anesthesia begins to wear off. control guidelines for dental offices that have
If the tooth that has been crowned still has a been published by the Center for Disease
nerve in it, patient may experience some heat Control should be followed. Personal protection
and cold sensitivity. Advice to brush teeth with and barrier protection measures should be
toothpaste designed for sensitive teeth. Pain or followed (e.g. gloves, mask, protective eye wear
sensitivity that might occur on biting usually and lab coat). Cross-contamination should be
means that the crown is too high on the tooth. avoided. Do not touch instruments, areas which
Chipped crown: Crowns made up of all have not been sterilized or disinfected. Practice
porcelain or SSC with facing can sometimes proper hand washing techniques, properly
chip. If the chip is small, a composite resin clean, disinfect or sterilize all instruments and
can be used to repair the chip with the crown equipment.
Occlusion
If tooth left without crown after preparation for Differences between Primary and
many days then there is chance of tooth fracture. Permanent Tooth and Tooth
Hence cement the crown in the same visit. Preparation (Fig. 2.2)
Finish Lines Enamel and dentine are thinner in primary
than permanent teeth hence decay spreads
The finish line is a continuous edge that borders faster in primary compared to permanent.
the entire preparation commonly the location Since primary teeth have thinner enamel
where the bur stops. It is essential that you have and dentin (about 1 mm each) extensive
a mental image of the location and contour of occlusal reduction is not indicated during
a preparations finish line in order to contour a tooth preparation. Hence, semi permanent
temporary restoration for that tooth. crowns are used with minimal tooth
Contraindications
Advantages
Maintains esthetics of child
Avoids development of psychological and
functional problems due to loss of primary
teeth
Preserves arch length and space.
FIGURE 2.3 Diagnostic equipment
Crown Selection
Crown selection can be done by mainly three
methods.
1. Selection before tooth preparation by
measuring the mesiodistal dimension of
tooth to be restored and comparing it with
crown
2. Selection after tooth preparation
3. Trial error method
MATERIALS AND EQUIPMENT FIGURE 2.4 Different crowns and trimming burs
1. Contouring pliers (Fig. 2.8): Gordon gingival margin of SSC and temporary
pliers (No. 137) used for general crowns (Fig. 2.8).
contouring and shaping 3. Howe pliers (No. 110): Straight and
Johnsons Ball and socket contouring curved pliers used to adjust proximal
pliers (No. 800112): Used to improve contact and contours (Figs 2.8 and 3.10).
contour at interproximal contacts and Scissorsstraight, curved (Fig. 2.9)
gingival margins for stainless steel and Crown scissors (Fig. 2.9):
temporary crowns. A. Festooning-801203
2. Crimping pliers No. 800417, No. B and D. Curved scissor-801202
800421: Specially designed to crimp the C. Straight scissor-801201
E. All-purpose scissors 230-212.
FIGURE 2.6B Handpiece (arotor, straight), different tooth preparation burs (round, round end taper, thin taper,
flame-shaped), Crown finishing and polishing burs
ISOLATION PROCEDURE:
RUBBER DAM APPLICATION
Rubber dam isolation method in pediatric
restorative dentistry is strongly recommended
during tooth preparation and crown placement
for better access and visualization.
A B C D
F G
FIGURES 2.9A TO G Crown cutting scissors (Festooning, curved, starignt and all purpose scissors: (A) Festooning
scissor; (B) Straight crown cut scissor; (C) Curved scissor; (D) All purpose scissor; (E) Crown cutting scissor;
(F and G) Crown cutting scissors: (i) Curved festooning; (ii) Straight smooth; (iii) Curved
Ash range (Ash Instruments Dentsply, Patient with upper airway problems, which
Addlestone Surrey UK) restricts nasal breathing such as sinusitis
Hygenic and Hu Friedy Known allergy to latex
Coltene Whaledent Uncooperative patient.
Zirc
Roeko Rubber Dam Apparatus
Ivory by Heraeus Kulzer
(Figs 2.10A to F)
Ultradent
Rubber dam sheet
Other Dental Dams Rubber dam frame (metal or plastic)
Rubber dam template
Optidam by Kerr Rubber dam punch
Optradam by Ivoclar Vivadent Rubber dam forcep
Rubber dam clamps (winged or wingless)
Advantages of Rubber Dam Othersrubber dam napkin, lubricants,
dental floss (Fig 2.10G).
Better access and visualization of operating
area Rubber Dam Sheet
Moisture control
Protects soft tissue injuries by retraction One box contains 32 or 56 sheets. It is available
Prevents aspiration of foreign bodies such as as rectangular size (pre cut 150 mm squares) or
crown and smaller instruments roll type. It is available as different sizes (5 5
Increases child cooperation or 6 6 inch), thickness (thin, medium or thick,
Acts as barrier in preventing transmission of medium most commonly used for pediatric
cross infection and endodontic procedures) and colors (green,
Enhances the effectiveness of nitrous oxide, blue, purple, black, grey, pink, purple, white
when needed for behavior management, and yellow) (Fig. 2.10A). Most rubber dams are
by forcing the child to engage in nasal made of latex although non latex rubber dams
breathing (Silicone versions) are also available. A size
Provides clean and dry operatory area. 5 5 inch medium gauge rubber dam is best
suited for use in children. The darker the color,
Indications the better will be the contrast between the dam
and the tooth. It has dull and shiny surfaces;
For isolation dull surface should be towards operatory and
Prevents aspiration of dental equipments shiny surface towards tissue. Rubber dam
and materials sheets are available in flavored to mask the
Prevention of cross infection latex taste. Rubber dam is also available as
For clear visualization of operatory area. readymade disposable one as fast dam, quick
B C
D E
A F G
H I
FIGURES 2.10A TO I (A) Rubber dam sheet; (B) Rubber dam frame; (C) Template; (D) Punch; (E) Forcep;
(F) Clamps; (G) Rubber dam napkin, dental floss, lubricants; (H) Fast dam, quick dam; (I) Different rubber dam
frames (metal and plastic), forcep, punch
dam (Fig. 2.10H). The performance and quality Rubber Dam Template
of rubber dam is best where stock is not too old
and has been stored in a cool, dry environment, This is white sheet showing the landmark areas
preferably in refrigerator. Old stocks of rubber of primary and permanent teeth for punching
dam are more susceptible to tear. hole in rubber dam sheet (Fig. 2.10C).
A B
FIGURES 2.11A AND B (A) Rubber dam punch; (B) Method of punching the sheet
A B
FIGURES 2.13A AND B Wingless (A) and winged (B) clamps
A B
FIGURES 2.14A AND B Individual tooth isolation with rubber dam and securing with floss and clamp
plated steel (susceptible to corrosion). There the maxillary left second primary molar and
are even non metallic clamps made of plastic the mandibular right second primary molar.
(SoftClamp, KerrHawe, Bioggio, Switzerland). The 13A clamp (Ivory, Miles Inc., Dental
Clamps can also be classified as retentive or Products, South Bend, IN): It is for clamping
bland. Retentive clamps provide four point the maxillary right second primary molar
contact on the tooth. and the mandibular left primary second
Always while using rubber damp, it should molar.
be tied with dental floss to prevent from The 2A clamp (Ivory, Miles Inc., Dental Prod-
accidental swallowing. A 8 to 10 inch length ucts, South Bend, IN; Hygienic Corp, Akron,
of dental floss may be tied through one of the OH) for clamping the first primary molars.
clamp holes, wound around the bow of the The 14 clamp for clamping fully erupted
clamp and then passed through and tied to the permanent molars
opposite clamp hole. Some frequently used The 14A clamp for clamping partially
clamps used in pediatric dentistry are: erupted permanent molars
The 12A clamp (Ivory, Miles Inc., Dental After selecting the appropriate clamp place
Products, South Bend, IN): It is for clamping a 12 to 18 inch piece of dental floss on the bow
of the clamp to aid in retrieval of the clamp, if 3. Bow of clamp in the rubber dam: The bow of
it is dislodged from the tooth and falls into the the clamp is placed through the perforation.
posterior pharyngeal area. Then the rubber dam is gathered to one side
and held with the hand, while the clamp
Other Accessories (Fig 2.10G) is placed onto the tooth. Afterwards the
rubber dam is placed onto the frame. This
Rubber dam napkin: Rubber dam napkin can technique offers excellent view on the area
be placed between the dental dam and the where the clamp has to be placed.
patients face. This helps to absorb moisture and 4. All in one: This method involves pre-loading
increase comfort for the patient. of a winged clamp onto the rubber dam. The
Lubricants: Lubricant such as topical Ultradents perforated rubber dam is placed onto the
or KY jelly can be placed on the underside of the frame. Then a winged clamp is placed into
dental dam for easier placement over the teeth the opening engaging the wings of the clamp
and through the interproximal areas. into it. Rubber dam and clamp are applied
as a unit together. The unit is placed with
Rubber Dam Placement Techniques the rubber dam forceps. Then the dam is
slipped off the wings with a flat bladed
The rubber dam during application in children instrument to the subclamp position. This
should be introduced as any other routine technique can be accomplished without the
dental procedure. The euphemism terms are aid of an assistant.
used such as; rain coat for rubber dam sheet,
button for clamp and coat hanger for frame. For Anterior Teeth
Proper local anesthesia should be administered
to prevent uneasiness during rubber dam The two most popular techniques for isolating
placement. anterior teeth are individual tooth isolation and
There are four techniques in rubber dam the split dam/trough technique.
placement;
1. Clamp first, then rubber dam: First a well- Individual Tooth Isolation
fitted abutment tooth clamp is selected and
then seated in place. Rubber dam sheet The advantage of individual tooth isolation is
is placed after checking the stability of that it provides greater deflection of gingival
clamps place index fingers on the dam tissues and better moisture control. The disad
buccally and lingually to the abutment vantages are ligature ties may cause bleeding
hole, stretching the dam to an oval shape of gingival tissues, inhibit rapid removal of the
and passing it over the bow of the clamp rubber dam and interfere with the placement
and then over the wings. This method offers and finishing of crowns.
excellent visibility on tooth and clamp. The rubber dam is prepared by stretching
Clamp securing, e.g. with dental floss is very the dam material over the frame and punching
important. the appropriate number of holes in the dam
2. Rubber dam first, then clamp: The material, as described earlier. The holes are
abutment hole is stretched in buccal-oral stretched over the teeth so they poke through
direction and then placed over the teeth till the rubber dam. The dam may be stabilized
the gingival tissue is visible. The rubber dam by placing a wooden wedge or a small piece of
is held in this position and an assistant can rubber dam material interproximally between
place clamp. Then the rubber dam can be the two teeth distal to the treated teeth. The teeth
released. may be ligated by placing 12 to 18 inches of floss
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A B
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FIGURES 2.15A AND B Split dam method
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around the cervix of the tooth and have the dental rubber band may be placed bilaterally at
is a
assistant hold the floss gingivally on the lingual interproximally between the primary cuspids
with a blunt instrument (Fig. 2.14B). The floss is and first primary molars and stretched around
drawn interproximally to the facial surface, and the rubber dam frame and the patients head.
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tightened with a surgical knot below the cervical Upon completion of treatment the rubber dam
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budge. If the dam is not sufficiently stabilized, is removed by removing the wedges and clamps.
additional holes are added and rubber dam The clamp(s), dam and frame are removed as a
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clamps are placed on the molars. unit.
Upon completion of treatment the rubber
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dam is removed by cutting and removing CEMENTATION/CEMENTS USED
the ligatures and the wedges. The rubber is
FOR CEMENTATION OF CROWNS
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stretched so that the dams interproximal septa
may be cut with a pair of scissors. The clamp(s),
dam and frame are removed as a unit. All types of crowns used in pediatric dentistry
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such as stainless steel crowns and PVSSC
Split/Trough Dam Method are cemented with variety of luting cements.
Numbers of cements are available to accomplish
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The advantages of the split dam method are the this. Zinc phosphate and polycorboxylate
rapid application and removal of the dam and cement have been recommended for crown
non-interference with crown placement and cementation. However, adhesive cements
finishing of the restoration. The disadvantage such as glass ionomer and resin modified
is that it only provides moderate moisture control. glass ionomers provide excellent retention and
The rubber dam is prepared by stretching demonstrate less microleakage than the non
the dam material over the frame and punching adhesive zinc phosphate and polycarboxylate
the appropriate number of holes in the dam cements. Decreased microleakage has the
material. The interproximal rubber dam potential to reduce clinical failures caused
material is cut with scissors connecting the by recurrent caries, pulpal pathology and
holes (Figs 2.15A and B). The hole is stretched failure of root canal treatments due to coronal
around the teeth to be treated and stabilized microleakage.
with a wooden wedge or a small piece of rubber Temporary cement is used to hold the
dam material. Alternatively, a household restoration in place. It fills the space between
the crown and the preparation, thus supporting problems. Luting consistency of cement are
the occlusal contours, filling and sealing the used during crown cementation.
margin/finish line area. During cementation
it is imperative to remove all debris, to rinse Types of Cements Used for Crown
and dry (not to desiccate causing sensitivity to
Cementation (Fig. 2.16)
exposed dentinal tubules) the preparation, and
to isolate the area with cotton rolls to prevent Zinc phosphate
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contamination by saliva. Depending on the GIC
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consistency of the cement mix, cement creates Resin modified glass ionomer
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pressure as it dries, occasionally which forcing Zinc polycorboxylate cement
the crown in an occlusal direction. This can be Zinc oxide eugenol cement
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detected by a post-cementation occclusal check. Resin cementPanavia 21
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Minor occlusal prematurities (high contacts) The prevailing opinion on the retention
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can generally be adjusted with the crown of steel crowns appears to be that the cervical
in the patients mouth. Gross malocclusion adaptation of the crown to the tooth is the
is a
(deviation from acceptable contact) will also most important aspect. Noffsinger et al. tested
tend to lift the crown from the preparation retentive properties of three dental cements
finish line; adjustment necessitates removal using stainless steel crowns fitted to extracted
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and re-cementation of the crown. Holding the third molar teeth. No significant difference was
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teeth firmly together in centric occlusion during found between the overall mean retentive forces
cementation should prevent most of these of the polycarboxylate cement and the two
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FIGURE 2.16 Different cements for crown cementation (left to right, GIC, polycarboxylate, zinc phosphate,
zinc oxide eugenol, silicophosphate cement resin-Panavia 21 cements)
glass ionomer cements. Mechanical retention and buffered orthophosphoric acid as their
of the crowns was not a factor in the overall liquid; therefore all can be expected to produce
retentive value. In the study by Berg JH. Pettey certain degrees of pulp irritation due to their low
DE and Hutchins MO (1988) evaluated the pH. The powder for copper phosphate cement
microleakage through margins of stainless steel is cuprous (red) or cupric (black) oxide, for zinc
crowns when cemented with polycarboxylate, phosphate is zinc and magnesium oxide, and
zinc phosphate, or glass ionomer cement by for silicophosphate essentially aluminosilicate
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measuring the amount of leakage through the glass. The initial pH is lowest for the copper
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crown margins. It was concluded that the newer cements and highest for zinc phosphate. At
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glass ionomer cement provides comparable 28 days the same relative pH order exists, with
protection to that of the other two traditional copper about 6, silicophosphate about 6.7 and
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cements used with stainless steel crowns. zinc phosphate about 7.
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Zinc Phosphate Cement
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is a
Zinc oxide cement is prepared by mixing zinc Mixing zinc oxide with phosphoric acid forms
oxide powder and eugenol liquid on glass slab. zinc phosphate cement. It is used mainly for
Zinc oxide-eugenol cements have long been luting or mechanically locking a restoration by
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recognized for their kindness to the pulp; they filling in voids and defects. It is used primarily
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are the standard to which all newly developed with stainless steel bands for space maintainers.
cements are compared for pulp compatibility. Zinc phosphate cements are easily handled and
.p
The set cement is a composite of unreacted zinc manipulated and have many years of clinical
oxide particles and eugenol surrounded by and use.
iv p
held together with the reaction product zinc In the studies by Mathewson et al. (1974)
eugenolate. However, certain higher strength zinc phosphate cement was found to be the best
/: /
brands have been successfully used for steel choice of five different types of cements used
crown cementation. The occasional need for for final cementation of stainless steel crowns.
re-cementation is counter balanced by pulp To achieve maximum strength, low solubility,
tt p
acceptance. The strength of these unmodified proper film thickness and less free acid in the
cements has been considerably improved by final mix of cement, use a high powder/liquid
the addition of synthetic resins or quartz to ratio, by refrigerating cement mixing slabs
h
the powder and ethoxybenzoic acid to the have a longer working time, a shorter setting
liquid. Although the compressive strength is time in the mouth, and increased retention of
increased (from 2000 to 15,000 psi) solubility orthodontic bands could be achieved from the
as measured by water immersion increases as mixed zinc phosphate cement (Shepard, 1978).
much as fourfold. Nevertheless, these improved
cementsFynal, IRM (LD Caulk Co.) and Disadvantages of Zinc Phosphate
Opotow EBA Alumina (Teledyne Corp) are
preferred by some Pedodontists for steel crown Its low pH, which can cause pulp irritation.
cementation. When first mixed, zinc phosphate cement
has a very low pH that can remain below
Copper, Zinc and Silicophosphate 7.0 for as long as 48 hours (Norman, 1966).
Wilson (1974) found that the zinc phosphate
Cement
cements to be soluble in distilled water and
Copper, zinc and silicophosphate cements all organic acids.
have the common denominator of water-diluted Lack of antibacterial properties.
Solubility in oral fluids, and lack of adhesion. to the outer surface; this binding seems to occur
The phosphate cements usually require between carboxylate cements and stainless
two coats of application of varnish prior to steel. This is the reason why these cements are
cementation on a vital tooth. highly recommended for use with steel crowns.
Although the initial pH of polycarboxylate
Silicophosphate Cement cements is quite low (about 1.7), their overall
reaction on the pulp is comparable to that
Due to fluoride release, silicophosphate reduces of zinc oxide-eugenol, they therefore cause
caries activity. The powder is essentially zinc minimal irritation. The reason for this, tolerance
oxide and the liquid largely polyacrylic acid. is thought to be related to the molecular
Silicophosphate shows the highest 7-days size of the acid molecule and/or to protein
compressive strength (about 25,000 psi), complexing. One way or another, diffusion
whereas copper and zinc phosphate cements through the tubules to the pulp is limited.
have compressive strength about 22,000 psi. The primary objection to the carboxylate are
too rapid setting, which limits the number of
Polycarboxylate Cement units that can be cemented from one mix. The
compressive strength of zinc polycarboxylate is
It is developed to provide a chemical bond less than that of the zinc phosphate; however,
between tooth structure and cement. By virtue tensile tests (both diametric and simulated by
of its chemical structure the polyacrylic acid removing cements castings) show only small
chemically binds or chelates with certain differences. The solubility of these cements
cations. Thus tooth calcium or phosphorous is low and does not seem to be an important
chemically unites with the setting cement. It consideration. However, crown loosening does
consists of a mixture of zinc oxide powder with occur with over tapered preparations and is
a polyacrylic acid liquid. It was observed as thought to be due to creep or flow of the cement.
a direct bonding between the stainless steel,
carboxylate cement, and enamel (Mizrahi and Glass Ionomer Cement
Smith, 1968). Polycarboxylate cements have
minimal irritation effect on the pulp, same as Glass ionomer cements are quite new and very
zinc oxide-eugenol. Polycarboxylate cements, promising. Their powder is aluminosilicate glass
when compared with zinc phosphate and and liquid is a mixture of polyacrylic, itaconic,
improved zinc oxide eugenol cement, have a and tartaric acid. Just as silicophosphate
high level strength (Arfali and Asgar, 1978). is a hybrid of silicate and zinc phosphate,
However, the strength is not related to increased the glass ionomers are hybrid of silicate
physical properties such as tensile strength, and polycarboxylate. These cements have
compressive strength, or film thickness. comparable strengths with zinc phosphate,
The main advantage of polycarboxylate release of fluoride as do the silicophosphate,
cement is the low irritant factor to oral tissue. chelate or bond to tooth structure as the
There is adhesion to tooth substance and polycarboxylate, and are as pulpally compatible
stainless steel alloys. Other physical properties as the polycarboxylates. They could prove to
are similar to the phosphate cement. The be the best cement available for steel crown
disadvantages are the requirements for precise cementation. Silicate and polyacrylate systems
proportioning, optimum manipulation, and the are combined to form the glass ionomer
need for a clean, uncontaminated tooth surface. cements. The powder is fine ground calcium,
Zinc (from zinc oxide) causes entrancement aluminium, and fluorosilicate glass combined
binding whereas certain restorative metals bind with a solution of 50 percent polyacrylicitaconic
acid. The powder/liquid ration is 1.3:1, which Rinse and dry the crown inside and outside
is most important. Glass ionomer cements and prepare to cement it. Zinc phosphate
seemed to be soluble in saliva with slow setting cement, polycarboxylate or GIC cements are
time. These cements have the potential to preferred for crown cementation.
adhere to tooth structure but these surfaces If zinc phosphate cement is used, 2 coats
must be isolated. These cements leach fluoride of cavity varnish should be applied on vital
with subsequent uptake by adjacent enamel. tooth before cementation. Luting cement
Postoperative sensitivity in permanent teeth has should be of consistency so that it stings
been reported. The advantage of GIC is similar about 1 inches from mixing pad with the
to polycarboxylate cements. The disadvantages spatula cement. It is filled in approximately
include moisture sensitivity; occasionally pulp 2/3rd of crown, with all inner surface
irritation, initial low set and questionable covered. Avoid air bubbles in mixed cement.
adhesive properties, their radiolucency and Seat the crown completely on dried tooth
the lack of long term clinical efficacy. Smith surface preparation. Final placement should
(1983) in an excellent review of dental cement follow an established path of insertion of the
states that there is yet no ideal dental cement. crown. Cement should be expressed around
Each material must be used on its merits with all margins. To ensure complete seating of
knowledge of its limitations. the crown, handle of mirror or band pusher
may be used.
Resin CementPANAVIA 21 Before the cement sets, ask the patient to
close into centric occlusion by applying
(Fig. 2.16)
pressure through a cotton roll and confirm
Panavia 21 in a self etching advance resin that the occlusion has not been altered.
cement that bonds directly to metal and silinated Zinc phosphate cement can be easily
surface with no need for a bonding agent. The removed with an explorer or scaler. After
setting mechanism of Panavia 21 provides the polycarboxylate cement is partially set,
custom working time and trouble free clean it will reach a rubbery consistency. Excess
up. It is available in three different radiopaque cement should be removed at this stage
shades and translucencies. It is indicated for with explorer tip. Dental floss is passed
the cementation of metal crowns, bridges and interpriximally to remove excess cement
inlays/onlays. It is antibacterial, eliminates the from interproximal areas.
need to use additional disinfectants. Rinse the oral cavity before dismissing the
Two other categories of cements are acrylic patient, reexamine the occlusion and the
and composite resins. Problems encountered soft tissue.
have been proportioning and manipulation
difficulties, to create a film thickness, difficulty in BIBLIOGRAPHY
removing excess, and (especially) postoperative
sensitivity. Their strength is adequate to excel- 1. Anterior crowns used in children. Morenike
lent and their solubility is low, but these advan- Ukpong. Dep of Paediatric Dentistry, Obafemi
tages are far outweighed by their disadvantages. Awolowo University, Ile-Ife, Nigeria.
2. Schwartz s. Full coronal aesthetic restoration of
Steps for Cementation anterior primary teeth. Crest, Oral-accessible at
www.dentalcare.com, 2012, 21 pages.
Crowns should be cemented only on clean, dry 3. Guideline on Pediatric Restorative Dentistry.
tooth. Isolation of teeth with cotton rolls is also Reference Manual. Pediat Dent. 2013; 34(6):
recommended. Apply Vaseline to contact areas: 21421.
treatment for grossly decayed primary teeth alloys used by manufactures for steel crown
was extractions. Since then between 1950 and construction were stainless steel. Rocky
1968, several modifications were recommended Mountain and Unitek crowns still are stainless
for stainless steel crown techniques which has steel; but the Ion crown is Iconel, a nickel-
simplified the fitting procedure and improved chromium alloy. Nickel-chromium crowns are
the morphology of the crown to duplicate widely used.
the anatomy of primary molar teeth. The Stainless steel is composed of iron, carbon,
morphology of primary molar tooth differs chromium, nickel, manganese and other
significantly from its permanent successors, metals. The term stainless steel is used when
in having greatest convexity at the cervical the chromium content exceeds 11 percent and
third of the crown. Thin metal of preformed is generally in the range of 12 to 30 percent.
crown margin is flexible enough to spring into Chromium oxidizes and forms a thin surface
undercut area. Enamel and dentin thickness of film of chromium oxide (Cr2O3), known as
primary teeth are much thinner than permanent passivating film which protects against
teeth. The SSCs are designed for primary corrosion. Stainless steel is classified as ferritic
and permanent teeth closely resemble to the (the nonheat hardenable 400 series), martensitic
natural anatomy. It obtains retention mainly (the heat hardenable 400 series), and Austenitic
from cervical undercuts. SSCs are generally stainless steel (chromium-nickel-manganese
considered as superior to large multisurface 200 series and chromium nickel 300 series) is
amalgam restoration with longer clinical life used extensively for the fabrication of dental
span. Due to esthetic concern anterior SSC appliances and is composed of chromium
crowns are modified with open faced SSC. (11.527%), nickel (722%) and carbon (0.25%).
Preveneered SSC are available in the market Nash (1981) stated that nickel-chromium
with different brand names. crowns have the advantage over stainless steel
Stainless steel crowns are used as temporary crowns in that they are fully shaped and strain-
crowns in permanent teeth because the margins hardened during manufacture.
of the crowns cannot be made as accurate Austenitic types: The austenitic types are
as gold and other materials for marginal used by Rocky Mountain and Unitek for their
adaptation. They are not durable for a longer crowns referred to as 18-8 stainless steel since
period. Kowolik et al. (2007) from their study they contain about 18 percent chromium and
hypothesized that greater use of the stainless 8 percent nickel. In addition, they contain
steel crowns would be made by specialists small amounts of other alloying elements,
than by general dentists. Saraf and Farsi (2004) carbon (0.080.15%) and iron. The austenitic
from their study concluded that stainless steel types have high ductility, low yield strength
crowns are still a valuable procedure that has no and high ultimate strength, which make them
harmful effect on the gingiva and bone provided outstanding for deep drawing and forming
that good oral hygiene level was maintained. procedures. They are readily welded and can
Knowledge of the different stainless steel be work hardened to high levels, although not
crowns is necessary to determine how they as high as can be obtained by heat-treating the
can affect the adaptation of the various crowns appropriate types of the 400 series.
to the type of preparation recommended. The austenitic types provide the best
The characteristics of the Ion, Unitek, Rocky corrosion resistance of all the stainless steels,
Mountain and Ormco, crown forms and the particularly when they have been annealed to
variations in contouring, festooning and dissolve chromium carbides and then rapidly
occlusal anatomy can be noted. The original quenched to retain the carbon in solution.
Different Crowns Used in Pediatric Dentistry 25
A B
FIGURES 3.1A AND B Rampant caries affecting primary incisors and molars
Different Crowns Used in Pediatric Dentistry 27
Hypoplastic Defects
A B C
FIGURES 3.3A TO C Hypoplastic/developmental defects
28 Crowns in Pediatric Dentistry
As an Abutment/Space Maintainer
Restoring primary teeth used as abutment
for a space maintainer such as crown and
loop space maintainer (Fig. 3.4).
The placement of a stainless steel crown
and loop space maintainer following the FIGURE 3.4 Crown and loop space maintainer
extraction of first primary molar.
Bruxism
In severe cases of bruxism, teeth may be so
abraded and severely worn (Fig. 3.5) so that
stainless steel crowns are required to restore
the interarch vertical dimension and prevent
FIGURE 3.5 Occlusal wear due to bruxism
traumatic pulpal exposure. In the mixed
dentition phase, the stainless steel crown
adapted to the primary molars will assist in
preventing wear of the first permanent molars.
Cross-bite Correction
Correction of anterior cross-bite or to alter the
shape, size or inclination of teeth, a large sized
anterior SSC placed in reverse position on
maxillary anterior tooth (Fig. 3.6).
parations in Class II situations, weakening the quality of SSCs can be improved with use of
tooth and reducing support for an amalgam open faced SSC or preveneered crowns.
restoration.
A number of authors have cited that the Longevity of Crown Over
preformed metal crown is a preferred treatment
Amalgam Restoration
for multisurface caries on primary molars and
as the restoration of choice after endodontic Table 3.1 shows list of studies regarding longevity
therapy for primary molars. Unlike amalgam, of SSC over multisurface amalgum restoration.
which requires retention features to be incor- Randall (2002) in her review of literature
porated into the cavity design, the preformed with five studies mentioned the performance
crown obtains its retention from the flexibility of multisurface amalgam restorations over SSC.
of the thin, precontoured crown margins. This The five studies included a total of 1210 crowns
allows it to spring into the undercut area apical and 2201 amalgams, followed for 2 to 10 years.
to the cementoenamel juction (CEJ) in a primary From all five studies it was concluded that crown
molar. They are also more cost effective because restorations were superior to the multisurface
of comparatively simple procedure involved in amalgam restorations on primary molars.
restoring even severely affected primary molars. Braff (1975) compared success rate of SSC
Age, general health, condition of the teeth, (76) over amalgam restorations (150) in a 4-year-
oral hygiene and susceptibility of the patient old patient. He found that nearly 30.03 percent
to dental caries are presented as factors to be of amalgam restorations needed retreatment
considered in selecting restoration for childrens over 8.7 percent for SSC. Dawson et al. (1981)
teeth. and Einwang and Dunninger (1996) stated that
stainless steel crown has long life span compared
Studies Pertaining to to multisurface amalgam restorations. Dawson
also concluded that Preformed Metal Crown
Stainless Steel Crown Uses
are treatment of choice for primary molars with
Esthetic and Parental Satisfaction multisurface lesions in children less than 8 years.
Similarly, Eriksson et al. (1988) and Masser and
Several studies stated unacceptance of SSC by Levering (1988) observed that Preformed Metal
parents as concerned to esthetic aspect. Esthetic Crown are superior to multisurface amalgam
A B C
FIGURES 3.7A TO C Different metal crownsSSC (Uniteck), nickel-based (3M), tin-based (Iso-Form) crowns
32 Crowns in Pediatric Dentistry
A B C
FIGURES 3.9A TO C Untrimmed: (A) Untrimmed, uncontoured; (B) Pretrimmed, uncontoured;
(C) Pretrimmed and precontoured
Different Crowns Used in Pediatric Dentistry 33
stainless steel primary molar crown means TABLE 3.2 Stainless steel crown based on sizes
that minimal adjustment is necessary
to obtain good retention. There is good Crown shape Number of Width range
harmony with the patients occlusion and sizes available (mm)
the smooth stainless steel alloy surface helps Upper 1st primary 6 (27) 7.29.2
to maintain gingival health and patient molar
comfort. Upper 2nd 6 (27) 9.211.2
primary molar
Primary Molars
There are 80 crown sizes available in the 3M
ESPE Unitek stainless steel primary molar 3M ESPE Iso-Form Crowns
crown. (Tin-based Crown)
Kits 3M ESPE Iso-Form crowns are available in 80
908100: Primary anterior set-72 crowns. Set box crown sizes for molar and bicuspid forms (Table
only: PA-000 3.3).
902150: Primary molar set-112 crowns. Set box
only: PR-000 Kits
BC-64: Intro kit-64 bicuspid crowns
Availability for Permanent Molars MC-64: Intro kit-64 molar crowns
There are 24 crown sizes available in the 3M Set box only: BC-000 Bicuspid MC-000 Molar
ESPE stainless steel permanent molar crown
range. Nickel-chromium Crowns
Kits These are high nickel containing crowns
PO-96: Intro kit-96 crowns. Set box only: PO-000 Available as primary and permanent molar
crowns
Permanent Molars Sizes 1 to 7.
There are 82 crown sizes available in the 3M
ESPE Unitek stainless steel permanent molar CLINICAL PROCEDURES FOR SSC
crown range.
Steps in SSC Crown
Kits Adaptation/Placement
902600: Bicuspid set-84 crowns. Set box only:
SB-000 Preoperative evaluation for patient age,
902350: Molar set-84 crowns. Set box only: PM- cooperation and medical condition
000 Armamentarium used
Different Crowns Used in Pediatric Dentistry 35
FIGURE 3.10 List of pliers for crown adaptation (from left to rightReynold, Gordon, ball and socket, Jonson,
crimping, straight Howe, curved Howe pliers)
4 and 5 are most commonly used, while size 7 Crown selection: There are three methods of
is available for extra large teeth. Crown kit box crown selection (Flow chart 3.1).
consists of pair of crowns of all 6 sizes. Refill The SSC crowns are manufactured so that
crowns are available in set of 2 crowns. Refill length is proportional to the mesiodistal and
crowns available are referred with short form for circumferential measurement. The 3M crowns
identification as, upper (U), lower (L), Right (R), are pretrimmed and contoured which requires
left (L), primary first molar (D), primary second little adjustment, lesser adaptation time and
molar (E) as ULD, ULE, URD, requires minimal trimming and crimping
URE, LRD, LRE, LLD, LLE. The identification (Fig. 3.12). The SSC crowns are selected with
of each crown can be made by noting the thumb forcep from crown kit box. If the crown
marking on the buccal surface which indicates is not selected before the tooth reduction, after
type (D or E), size (2, 3, 4, 5, 6, 7), upper or lower the tooth reduction it can be selected as trial and
(upper right:, upper left: , lower left: , lower error procedure, which approximates the mesio-
right: ). Refill crowns can be ordered using distal widths of the crown. Many clinicians do
code words or order forms (Fig. 3.11). crown selection after tooth preparation or by
Different Crowns Used in Pediatric Dentistry 37
A B C
mesial and distal contours, as well as in the Check occlusion directly in the mouth or
contours of the occlusal surfaces (cusps, ridges, indirectly by using dental study casts for
pits, and grooves). incisor, canine and molar relationship on
both the side
Note: The correctly selected crown should cover
Note for dental midline and the cusp fossa
completely the prepared tooth crown and
provide resistance to removal. relationship bilaterally.
To better manage child behavior the initial step, making the diagnosis of very
To prevent ingestion of the stainless small pulp exposure, difficult. Thus, the best
steel crown during preparation. plan is to reduce the occlusal as the initial step,
One can alter the rubber dam by cutting removing any caries as part of that step. Then
the interproximal rubber to avoid cutting proceed with proximal surface reduction.
the dam with rotating instruments. Wedges The most common problem encountered
can also be used to protect the dam and in attempting to learn tooth preparation is
tissue. An alternate method is to punch a inadequate reduction. Mink and Bennett
large hole and slip it over the most posterior in 1968 recommended initial placement of
tooth receiving the stainless steel crown. 1 mm deep grooves in the occlusal surfaces,
Then stretch the dam forward to the canine which helps to establish the correct amount of
area. Split dam method is better for treating occlusal surface reduction. The cusp height of
multiple anterior teeth. the adjacent teeth and marginal ridges gives the
operator a good baseline to judge the amount of
Caries Removal occlusal reduction.
Caries can be removed either before or after tooth Use carbide fissure bur or flame-shaped bur
reduction. Remove the decay with large round (Figs 3.14C and 3.13C) to reduce the occlusal
bur in a slow speed hand piece. After removing surface by 1.5 to 2 mm, following the cuspal
caries perform pulp therapy if necessary. The outline and maintaining the original contour
previously carious area can be built up with. of the cusps (Figs 3.13A to L). Occlusal surface
GIC cement. Restore endodontically treated reduction can be judged by comparison with
tooth with GIC before tooth preparation. the marginal ridges of the adjacent teeth.
Though various views have been expressed
Wedging regarding the occlusal reduction it is found that
A wooden wedge may be placed tightly between about 1.5 to 2 mm of reduction has to be done to
the surface being reduced and the adjacent obtain occlusal clearance (Table 3.5). However,
surface to provide a slight separation between as much of tooth structure as possible must be
the teeth for better access and to reduce risk of left for retention. Excessive occlusal reduction
iatrogenic damage to adjacent teeth. It also helps can result into poor occlusal height, poor
to depress the gingival tissue and rubber dam. tooth structure for cementation of crown and
excessive gingival impingement, whereas under
reduction results into lack of proper occlusal
REDUCTION OF TOOTH clearance, heigh occlusal contact and open bite.
Occlusal Reduction
Note: Occlusal reduction should be based on
Occlusal reduction should be done to provide amount of clearance, attrition of teeth and supra-
space for SSC crown and should be done before eruption of teeth. Ideally there should be at least
proximal reduction to avoid invisibility of pre- 1 to 1.5 mm of clearance to receive stainless steel
paration areas due to blood contamination. crown.
Full et al. (1974) considered that occlusal
preparation should be done first to allow better Note: If much of the occlusal surface has already
access to the proximal areas of the tooth. While been lost due to caries, then reference can be
other authors suggest the proximal reduction made to the marginal ridges of neighboring teeth
before the occlusal surface. Gingival bleeding in regards to the amount of further reduction
will occur if the proximal reduction is done at needed to obtain space for the crown.
40 Crowns in Pediatric Dentistry
A B C D
E F G H
I J K L
FIGURES 3.13A TO L (Case-1) SSC adaptation procedure: (A) Preoperative occlusion; (B) Measurement of tooth
dimension; (C and D) Crown selection; (E) Occlusion reduction; (F) Proximal reduction; (G) Crown fitting linguo-
buccaly; (H) Marking gingival extension; (I) Contouring; (J) Crimping, (K) Radiographic evaluation; (L) Final fitting
of crown
To obtain retention, the crown must seat at It has been observed that many of the diffic-
the depth of 1 mm subgingivally and there ulties encountered in placing a stainless steel
should be no gingival blanching. crown are the result of attempting to fit a
Proximal surfaces are reduced using a round or oval crown form over a rectangular
No.69 L/tapered fissure bur at high speed. tooth preparation. Irregularities, projections,
Vertical slice is done that clears the contact or sharp angle on the circumference of the
area buccally, lingually and gingivally prepared tooth will prevent the crown form
(Figs 3.13F and 3.14A). The mesial and distal from being properly seated, will cause time-
slice should end slightly below the gingiva consuming repeated adjustments, and will
on enamel, leaving undercut area of intact prevent the crown from properly fitting the
enamel at the cervical circumference of tooth preparation.
tooth. The primary principle of the technique
Avoid damaging adjacent tooth surfaces for fitting stainless steel crowns is to make
while doing proximal reduction. Near vertical the tooth preparation to fit the crown form
reduction should be performed gingivally rather than attempt to make the crown
until the contact with adjacent tooth is fit the tooth preparation. By examining
broken and explorer can be freely passed the crown form, prior to preparation
between the adjacent teeth. The gingival of the tooth, one should see that the
margin of the preparation on proximal crowns of all manufactures are somewhat
surface should be smooth feathered edge oval and rhomboid. This conforms to
with no ledge or shoulder present. the rhomboid shape of the primary tooth. In
42 Crowns in Pediatric Dentistry
Proximal slices converge toward the occlusal placed in patient's mouth for trial and if not
and lingual, following the normal proximal cemented must be sterilized again.
contour. Uniteck nickel based crowns are pretrimmed
An explorer can be passed between the and contoured which require minimal
prepared tooth and the proximal tooth at adjustment during crown adaptation.
the gingival margin of preparation. Adaptation is important for retention and
Optional buccal and lingual surface are gingival health. Poorly adapted crown acts
reduced at least 0.5 mm with reduction as source of retention of plaque and bacterial
ending in a feather edge 0.5 to 1 mm into the accumulation leading to gingivitis and
gingival sulcus. recurrent cervical caries.
The buccal and lingual surfaces converge Spedding has advocated two principles for
slightly towards the occlusal. successful crown adaptation.
All the line angles in the preparation are 1. Establishment of correct occlusogingival
rounded and smoothened. crown length.
The occlusal third of buccal and lingual 2. Shaping crown margin circumferentially
surfaces are gently rounded. to follow the natural contours of the
Gingival finish line of preparation should be tooths marginal gingivae.
feather edge without ledge. Place the crown on prepared tooth
linguo-buccally by applying pressure in
CROWN ADAPTATION buccal direction so that crown slides over
the buccal surface into gingival sulcus
Using thumb forceps, select a crown from (Figs 3.13G and 3.15). Friction should be felt
the supply. Use of the forceps will keep as the crown slips over the buccal bulge.
contamination to a minimum. Size no. 4 Sometimes crown placement can be difficult
and 5 are the most frequently used. Crowns due to small crown size or excess buccal
After initial placement of crown, the shape in order to fit in a narrow mesiodistal
occlusion should be checked at this stage so space (Fig. 3.14C).
that crown is not opening the bite or causing With an explorer, check all the margins for
a shifting of the mandible into undesirable adaptation. Where the margins are open,
relationship with opposing teeth. re-crimp with the no. 800-417 pliers. At this
Croll and Riesenberger stated that majority stage, it is easy to over contour the crown so
of crowns do need adjustment to obtain that it no longer snaps into place/gently try
optimal adaptation to primary molars. to bend the margins over. If this results in a
distorted crown, it is best to start over with a
Note: Prepared crown should extend 1 mm new crown.
beneath the gingival margin without blanching. Brooke and King suggested to carry out
trimming procedures away from the
Contouring and crimping of the crown results patients face and to ensure proper eye pro-
in tight fitting crown. Contouring involves tection to patient.
inward bending of the gingival third of the
crown margin to restore anatomic features Crown contouring can be done with following
of the natural crown and to reduce marginal pliers:
circumference to achieve good fitting. Contouring pliers
Curved beak pliers used to redirect cut # 114 ball and socket pliers
edges cervically. Contouring and festooning # 137 Gordon pliers
# 800114 Johnson pliers
of crown can be done for proper adaptation.
Crown crimping
Crown can be replaced on prepared tooth
Crimping pliers No. 800417
to check final adaptation. There should
not be any blanching of gingival tissue.
Presence of gingival blanching indicates Note: A tight marginal fit aids in
need of additional trimming and marginal Mechanical retention of the crown
adaptation. Protection of cement exposure to oral fluids
Circumferential contouring can be achieved Maintenance of gingival health by preventing
with no. 137 Gordon pliers. Contouring pliers plaque accumulation.
with a ball and socket No. 114 design is used
at the cervical third of the buccal and lingual Sometimes solder may be added to the
surfaces for cervical crown adaptation. A proximal surfaces of the crown to improve
curved beak plier/No. 114 is further used contacts and contour. Trimming and con-
to improve the contour on buccal and touring are continued until the crown fits
lingual surfaces. Curved beak pliers may snugly and extends under free margin of the
also be used to contour the proximal areas gingival tissue.
of the crown to adapt desirable contact with The outline of crown margin should follow
adjacent teeth (Fig. 3.13I). Final adaptation the gingival margin of tooth. It should resemble
of the crown is achieved with crimping smile for primary second molar and stretched
pliers (no. 800-417 Unitek) by crimping the out S shape for primary first molar on buccal
cervical margin 1 mm circumferentially gingival margin. The buccal gingiva of primary
(Fig. 3.13J). first molar has different outline (stretched s)
If space loss has occurred, the crown can be because of cervical bulge, the gingival margin
squeezed with Howe pliers to a cylindrical dips down as it traced from distal to mesial
46 Crowns in Pediatric Dentistry
B C
FIGURES 3.16A TO C Smile and stretched out S shape at gingival margin
(Figs 3.16A to C). However contour of all first appear too long. Proximal contours of crowns
primary molars resembles smiles. The proximal are not well produced; this deficiency has little
contour of almost all primary teeth is frown effect on supporting periodontal tissue.
because of shortest occluso-cervical height. The The adaptation of the crown form to the
margins of finished crown consist of series of preparation will vary with the type of crown
curves or arcs as determined by marginal gingiva. used and the type of preparation. The Rocky
Mountain and Unitek crowns must be contou-
Gingival contour
red with the No. 114 or 115 pliers for the proper
Buccal gingival contour of second primary
buccolingual contours and to engage the bulge
molarsmile
Buccal gingival contour of first primary molar maintained for cervical retention. The Unitek
stretched-out S crown-crimping pliers may also be used to
Proximal gingival contour of primary molars improve retention. It tends to create a scalloped
frown margin and should be followed by the No. 114 or
Lingual gingival contour of all molarsSmile 115 pliers to obtain a smooth even margin. The
same type of contouring is recommended for
Final fit the Unitek crown, but usually less manipulation
Seat the crown in lingual to buccal direction
is necessary. The tapering thickness of the ion
It should snap/snagly fit into position under firm crown on the buccal, lingual, and proximal
figure pressure surfaces makes trimming and recontouring
If margins open: recrimp difficult and sometimes impractical. If the ion
If overextended: trim the crown crown is trimmed, it should be recontoured
with the No. 114 or 115 pliers and the margin
Final adaptation of crown should be carefully tapered, sharpened, and polished
confirmed by taking a radiograph, which prior to seating.
helps to check gingival contour and extension While finishing the margins of the crown
and to evaluate about full coverage of tooth. form, grind a bevel on the external surface of
More and Pink recommended a bite-wing the crown margin around the entire periphery
radiograph during try in stage to check for using a green stone held at 45 angle to the
any margin overextension in the proximal margin (Fig. 3.14B). A slow-speed hand piece
area. Radiographs are not must in all cases for will give better control and produce a sharp
evaluation. Radiographically crown margin feather edge margin that can be closely adapted
seems to be poorly adapted proximally or often to the prepared tooth at the gingival margin.
Different Crowns Used in Pediatric Dentistry 47
No study has been done on how the below the gingival crest and ending a feather
composition of steel crown affects the edge.
preparation, adaptation and cementation of the
restoration. Yates and Hembree (1978) reported Festooning and Adaptation
on the resistance to removal and on the hardness
of the Crown
of the steel used in the Rocky Mountain,
Unitek and ion crowns. They used a flame The flattened proximal surfaces should be
shaped diamond to round the line angles and somewhat oval rhomboidal in preparation. This
occlusal surface angles, with no buccolingual greatly aids in rapid crown adaptation because
reduction. The preparation was similar to that of the shape of the steel crown forms. It has
recommended by Mink and Bennett. They been stated that the retention of the stainless
festooned the three types of crowns as similarly steel crown restoration originates from contact
as possible to ensure a custom fit, contoured between the tooth and the margins of the
and adapted the crowns in essentially the same crown, which necessitating to reduce the buccal
manner. and lingual surfaces of the crown except on the
Yates and Hembree cut a sample of the buccal surface of the mandibular primary first
metal from the lingual surface of the three molar or where an abnormal bulge of enamel
brands after the crown had been crimped and may be present. The rationale for maintaining
contoured in the prescribed manner. They this bulging tooth structure is that it will
determined that the Unitek crowns were more contribute to the retention of the crown.
resistant to removal than the other two. There
was also wide variability in the Unitek sample. Crown Finishing
Initially, the ion crown was harder than the
other crowns before cold working. It was also It is safe to say that retention problems do not
resistant to work hardening by contouring and cause failure of the steel restoration; most
crimping. The Rocky Mountain crown was work failures result from poor and inadequate
hardened to a significantly greater degree and preparation, improper gingival adaptation, and
the Unitek crown showed wide variability with the inability to properly visualize and determine
decreased hardness when it was cold-worked. the relationship of the crown margin to the
Rocky Mountain crown requires more margin of the preparation. This being the case,
manipulation to work harden the metal prior to it is incumbent on each practitioner to pay more
cementation so it will snap over any remaining attention to this area of crown restoration so
bulge for proper retention. The Unitek crown that gingival irritation around the margin of the
seems to be soft enough to snap over type crowns will not occur.
of crown preparation recommended by Mink Large green stone is used to make knife edge
and Bennett and requires little manipulation finish at the cervical margin of crown
other than contouring of the buccal and lingual Bur is moved in counterclockwise direction
surfaces. The ion crown, on the other hand is at 45 degree angle
extremely hard and difficult to manipulate and Then rubber wheel is used to smoothen
requires much effort to fit over a large bulge. margins
It would seem to be more appropriate for Crown can be polished using Iron rouge
Troutmans preparation, in which the buccal The final step before cementation is to
and lingual surfaces are reduced approximately produce beveled gingival margin that may
0.5 mm with the preparation extending 0.5 mm be polished.
48 Crowns in Pediatric Dentistry
Polishing (Figs 2.6B and 3.14B) lingual surfaces converge occlusally from the
gingival crests, thus any point on the tooth
While polishing the crown, margins should occlusal to the greatest diameter is on the visible
be blunt since knife edge finish produces clinical crown, and any point on the tooth apical
sharp ends which act as areas of plaque is on an undercut surface of the tooth and is not
retention. A broad stone wheel should run visible in the mouth.
slowly, in light brushing strokes, across the The stainless steel crown that does not
margins, towards the center of the crown. adhere to the morphologic features of the
This will draw the metal closer to the tooth primary molar will be overextended and ill
without reducing the crown height and thus adapted. When the finished crown is correctly
improves the adaptation of the crown. seated on the prepared tooth with its occlusal
A wire brush can be used to polish the surface in the occlusal plane and its margin
margins to a high shine. placed just apical to the marginal gingival
To give a fine luster to crown, rough whiting crests, the crown is of correct length and its
or a fine polishing material can be used. margins can be adapted closely to the tooth. As
seen on the buccal and proximal surface when
Crown Fit the crown is shortened and is the proper length,
the crown is easily adapted to the crown.
Method to Determine Adequate Principle 2: If a dentist carefully examines the
Crown Fit contours of the buccal and lingual marginal
gingiva before a tooth is prepared for a stainless
Even though clinical adaptation and steel crown and produces steel crown margins
appearance of stainless steel crown is good but of similar shapes, when these margins are
radiographic extension of the crown extension adapted circumferentially against the tooth they
is variable with ragged margins (Fig. 3.13K). To will be located at the correct anatomic positions
avoid these discrepancies, Spedding, in 1984, at all points on the tooth.
proposed two principles based on morphology
of primary teeth and gingival contour. Before Final adapted crown should have:
cementation, a bite-wing is taken to verify Crown must snap into place, should not be
proximal marginal integrity. If the crown is removed with finger pressure.
too long, there is still an opportunity to reduce The crown should fit so tightly that there is
the length. If it is too short, then add weld and no rocking on the tooth.
solder an orthodontic band or adaptation of Moderate occlusal displacement forces at
another crown is indicated. If there is any doubt the margin should not displace the crown.
about the fit of the crown, a radiograph may be The properly seated crown will correspond
taken after cementation (Figs 3.13K and 3.14B); to the marginal height of the adjacent tooth
however routine radiographs of all patients to and is not rotated on the tooth.
determine the fit of all stainless steel crowns Crown is in proper occlusion and should not
are not justified. To amend these discrepancies, interfere with the eruption of teeth.
Henderson proposed two principles based on There should be no high points when
the morphology of primary teeth and gingival checked with an articulating paper.
contour. The following briefly outline his sugg- The crown margin extends about 1 mm
ested method: gingival to gingival crest.
Principle 1: When primary molars are viewed No opening exists between the crown and
from either proximal surface, the buccal and the tooth at the cervical margins.
Different Crowns Used in Pediatric Dentistry 49
Crown margins closely adapted to the tooth FLOW CHART 3.2 Guidelines for adaptation of crown
and should not cause gingival irritation
(Figs 3.13L and 3.14B).
Restoration enables the patient to maintain
oral hygiene.
The crown seats without cutting or blanching
the gingiva.
1. That recommended by Mink and Bennett, in placement of such boxes. There was a relatively
which only the occlusal third of both buccal high post-cementation retentive value in
and lingual surfaces is reduced. preparation with the buccal and lingual surfaces
2. That incorporating Class II preparations, in reduced subgingivally.
which the buccal and lingual walls of the The authors concluded that, although more
boxes converge toward the occlusal. tooth structure is lost in this preparation, it
3. That which reduces the buccal and lingual enables one to get excellent cervical adaptation
supragingivally to the crest. of the crown form to the tooth since the
4. That which removes the supragingival adaptation is easier to visualize. Because of its
bulge, extending 0.5 mm below the gingival better adaptation, it might be healthier for the
crest, as recommended by Troutman, with gingiva. This is indeed the best preparation
all undercuts on the buccal and lingual for steel crown restorations. It is especially
surfaces removed. significant when the ion crowns are used
5. That which removes all supragingival because of the hardness and difficulty of
tooth structure, permitting only part of the manipulating the nickel steel. Maintaining some
anatomic crown to remain (i.e. the tooth of the cervical bulge may be the preparation of
structure around which the crown would choice when the softer metal crowns (e.g. the
normally be adapted). Rocky Mountain) is used. The importance of
Crowns were adapted to these various types preparation in their study was to demonstrate
of preparation, and then proceeded to test the that even in a grossly destroyed tooth, relatively
forces required to remove the crown from the high retentive values could be obtained. Their
preparation before and after cementation. Very conclusion was that such teeth can indeed be
little difference was shown between preparations restored with steel crowns and need not be lost
to cementation. It was also observed that the to extraction. Finally, it has been determined
noncemented preparations demonstrated that preparations maintaining the greatest
only limited mechanical retention but that amount of buccal and lingual tooth structure are
following cementation the retentive values of the most retentive before cementation; however,
all preparations improved greatly and cementa- cement increases the retentive capacity of all
tion completely overshadowed the mechanical types of preparations and it would behave
retention demonstrated in the noncemented one to concentrate on making the steel crown
group. They concluded that mechanical re- restoration more physiologically acceptable
tention does not significantly contribute to to the oral cavity, particularly in the area of
separation resistance of the steel crown. the gingiva. Removal of the buccal and lingual
Mathewson et al. (1974) stated that retention bulges will greatly facilitate the achievement of
related more to the cement than to mechanical this goal.
adaptation. Rapp and Savide et al. pointed out One has to concentrate on making the
that a tight marginal fit of the crown below the stainless steel crown more physiologically
gingiva is more difficult to achieve and failure acceptable to the gingiva as it is seen in our
to do so might increase gingival inflammation. clinical practice; also that cement increases the
The second technique with the proximal boxes, retentive capacity of all types of preparations
which had similar retention, had the same reducing supragingival bulge with reduction
potential gingival problems as did in technique. extending 0.5 to 1 mm below the gingival crest
Although preparation had the highest helps to obtain an acceptable gingival response.
retention values, the difference was not It is especially significant when the ion crowns
sufficient to warrant endangering the pulp by are used because of hardness and difficulty of
Different Crowns Used in Pediatric Dentistry 51
manipulating the nickel steel when the softer Seat crown on the tooth, initially on lingual
metal crowns are used, (Rocky-mountain) side followed by buccally to engage buccal
maintaining the cervical bulge may be the undercut. The flat end of band seater may
preparation of choice. be used to ensure complete seating of
crown. The patient may be instructed to
Crown Cementation bite on tongue blade. Before cement sets
ask the patient to close the mouth in centric
(Figs 3.14B and C)
occlusion and make sure that occlusion is
Cementation of crown is depends upon the not changed.
pulpal status. Cavity varnish should be applied Remove excess cement with explorer.
first if the tooth is vital. GIC is most commonly The interproximal areas can be cleaned
used cement for cementing crown. Mathewson by tying a knot in a piece of dental floss
(1979) stated that retention of SSC crown is and passing dental floss interproximally.
due to cementing medium rather than due Croll has suggested removal of excess set
to mechanical adaptation. Saved et al. (1979) resin modified GIC cement by means of an
concluded from his study that, noncemented ultrasonic scaler.
preparations demonstrated only little mechani- Ask the patient to bite on wet cotton placed
cal retention and retentive values increased over crown for proper fit. Then ask the
following cementation in all the preperations. patient to bite to check for proper occlusion
Mechanical retention can be established using on left and right side. Apply vaseline over
buccal cervical bulge of tooth. Hence, proper gingival surface of crown to enhance setting
cementation should be done for success of of GIC cement.
crown.
Following cements can be used for crown
cementation:
RESPONSE OF GINGIVAL
Zinc oxide eugenol TISSUES TO STAINLESS STEEL
Zinc phosphate CROWN RESTORATION
Zinc silicophosphate
Polycarboxylate Goto (1970) reported incidence of gingivitis in
Glass ionomer primary teeth restored with nickel chromium
Resin modified glass ionomer crowns. He found higher percentage of gin-
Acrylic resin givitis in the posterior part of the mouth than
Composite resin. anterior and strongly associated with poor
fitting of crown. He observed clinically and
Crown Cementation Procedure radiographically that crowns classified as
failure showed 33 percent gingivitis, while those
Remove the rubber dam. classified as good showed 13 percent and those
Isolate the tooth; remove any blood clot rated fairly good showed 25 percent. Whereas
from tooth surface during cementation of Webber (1974) found no adverse effect on
crown. Before cementation clean and dry gingiva with PMC crowns.
both the crown and tooth. Meyers et al. Myers (1975) published a clinical study on
(1983) suggested application of varnish on the response of gingival tissues to steel crown
prepared vital teeth before cementation. restoration, concluding that the lower incidence
Mix the selected cement and fill the inner of gingivitis around crown without defects
portion of crown at least 2/3 with luting in the margins may be due to the fact that
cement (Figs 3.14B and C). these crowns are less likely to allow plaque to
52 Crowns in Pediatric Dentistry
/
the case, it may not necessarily be the fit of the
.i r
crown on the margin of the crown encroaching Common Problems during
on the gingival that causes the gingival
SSC Placement
s
problem but the fact that the stainless steel
crown surface enhances plaque accumulation, More and Pink (1973) described the causes of
s
thereby accounting for the association between stainless steel crown failure which include pulp
n
gingivitis and defective stainless steel crown. necrosis, ectopic eruption, improper contact
Whatever the cause, the effect is nevertheless which may cause space loss, gingivitis around
is a
the same; when the crown is improperly adapted the crown, insufficient retention leading to
or improperly polished in the gingival area, loss of a crown, and excessive occlusal wear.
the result will be a higher percent of gingivitis Following are some of the common problems
r
around steel crowns restorations. encountered during SSC crown placement.
e
Henderson reported that inflammation of
Improper Tooth Preparation
p
the gingiva may be due to irritation from the
.
surface of the material, over hanging margins,
rough surfaces, retained bacterial plaque, or Excessive reduction of the tooth in any area
iv p
a combination of these. He found that soft may cause the stainless steel crown to over-
tissue will adjust just as nicely to a rough and seat in that area. Maintain 1.5 to 2 mm uniform
/: /
unpolished surface as to a highly polished reduction following cuspal outline and
one but that bacterial plaque adheres and it adjacent marginal ridge as reference point.
retained by a rough surfaces is probably due Under tooth preparation results in high
tt p
to bacterial plaque accumulation rather than occlusion and open bite and traumatic
to mechanical irritation. Henderson noticed bite. Ledges prevent a crown from seating.
clinically and radiographically that no matter Ledge formation can be avoided by making
h
how accurately the crowns were trimmed, proper proximal slice and verifying it with
adapted and polished, some inflammation was radiograph.
always observed due to the differences in form Incorrect tooth reduction will lead to
and contour between the tooth and the crown. difficulty in seating the crown or the crown
Reduction of the cervical bulge will do a great may rotate as it is seated and there will be
deal to minimize this problem. lack of proper occlusal clearance.
tooth is over reduced or the stainless steel Avoid damage to adjacent teeth proximities
crown is over trimmed. Select appropriate sized crown to maintain
Crown may not fit on tooth if there is arch length
improper crown size selection or using Establish appropriate occlusal interaction
contralateral crown. Optimal cementation of crown.
Excessive crown reduction results into
open proximal space leading to plaque Instruction to Patient and Parents
/
accumulation and gingival inflammation.
after Crown Delivery
.i r
Failure to flatten/contour proximal portion
of crown when there is proximal space loss Child will feel numb for approximately
s
due to proximal adjacent caries. 3 hours after crown placement due to
Failure to adapt crown leads to loss of anesthetic effect from LA. Child will not
s
cement and dislodgement of crown, plaque have pain at this time. Be sure not to give
n
retention and gingival inflammation. any food to child at this time that has to be
Excessive gingival extension of crown chewed. Avoid him/her biting cheek/lip
is a
leading to blanching. while numb.
Lack of crown finishing and polishing at Some children will experience some mild
crown margin leading to rough margin sensitivity around new crown.
r
which results into plaque retention and Childs bite will become normal within
e
gingival inflammation. couple of days.
p
There may be mild bleeding when child
Failure to Sterilize Crown
.
brushes his/her teeth on the day of crown
placement.
iv p
Failure to sterilization of used contaminated Advise the child to maintain good oral
crown leads to cross infection. hygiene to allow healing of gums.
/: /
Parents should watch the childs diet so that
Causes for SSC Failure sticky foods like chewing gum, fruit, snacks,
taffy starburst, skittles and other sticky foods
p
Inadequate tooth reduction are rarely eaten.
t
Inadequate crown contouring and crimping Call dentist if the crown becomes loose
t
Inappropriately established occlusion or comes out. Save and carry the crown to
h
Inappropriate cementation methods (freq- dentist if crown comes out.
uent decementation)
Pulp treatment failure Modifications of Stainless Steel
Recurrent caries (improper contact).
Crown Placement
Steps for Successful Stainless Between 1950 and 1968, several modifications
were recommended for stainless steel crown
Steel Crown
techniques.
Remove caries followed by appropriate pulp With adjacent stainless steel crowns
therapy (Nash, 1981): When more than one crown
Optimum tooth structure reduction for needs to be placed in a quadrant, both the
adequate crown retention teeth should be prepared at the same visit
Begin tooth reduction from occlusal surface, (Figs 3.17A to C). When multiple crowns
proximal and very minimal buccal or lingual are to be placed in the same quadrant, the
surface adjacent proximal surfaces of the teeth being
54 Crowns in Pediatric Dentistry
A B
r/
s .i
C
n s
is a
e r
.p
D E
FIGURES 3.17A TO E Stainless steel crown on adjacent teeth
iv p
prepared should be reduced slightly more (Fig. 3.10), contoured simultaneously, but
/: /
than usual. This will make multiple crown posterior crown should be cemented first.
placements easier. Occlusal reduction of one Finally check for proper broad contact
tooth should be completed before reducing between crowns.
p
other. Simultaneous reduction of both SSC with adjacent (Class II amalgam/
t
the teeth results into improper reduction. GIC) restoration: When there is need of
t
Ensure for proper proximal reduction to placement of SSC and Class II amalgam
h
receive two crowns. restoration at the same appointment. Pulp
Pulp treatment can be done if required therapy followed by SSC crown should be
followed by, crown adaptation. There are done first, later Class II amalgam restoration
chances of mesiodistal space loss when should be done at the same time to allow for
there is proximal caries on adjacent teeth. proper contour of the SSC crowns marginal
To restore carious adjacent teeth with SSC ridge with indicated amalgam restoration.
both the preparations should be modified to The stainless steel crown is used as a guide in
allow the teeth to be fitted with smaller sized reproducing the anatomy and morphology
crowns than normal and further reduction of the amalgam restoration.
of the buccal and ligual tooth walls is carried Adjacent stainless steel crown with arch
out rather than more proximal reduction. length loss/space loss (Mc Evoy, 1977):
Howe No. 110 pliers can be used to flatten the Proximal space loss with shift of teeth
contact to adjust proximal contour of SSCs. occurs due to extensive and long standing
Both the adjacent crowns can be trimmed caries. This results in loss of mesiodistal
Different Crowns Used in Pediatric Dentistry 55
B
FIGURES 3.18A AND B (A) SSC adjacent to GIC
A restoration; (B) Space loss due to proximal caries
rubber wheel and fine abrasives before packing, increased plaque retention and
crown cementation. subsequently gingivitis. This problem
Under sized crown: If crown is can be solved by selection of a larger
undersized for tooth, then crown may be crown or exaggerated interproximal
cut on the buccal or lingual surface. After contour can be obtained with a 112 (ball
crown adaptation on prepared tooth, and socket) plier to establish a close
additional piece of 0.004 inch stainless contact. Interproximal contour can also
steel band material may be welded into be built by addition of solder proximally.
place (Fig. 3.20). Retry the crown on Multiple crowns in the same arch (Figs
tooth. Again scratch the band material 3.21A to D): Multiple crowns can be placed in
where it adapts to the crown. Then the the same arch at same visit. There is no need
crown may be contoured, crimped and of changes in procedure if crowns have to be
polished before cementation. placed in two sides of the same quadrant.
Open contact: If the closed contact Modification is required if crown has to be
area (except for the primate spaces) placed in adjacent tooth and opposing tooth
is not established, it will result in food on same side. When multiple posterior
crowns are to be seated, they should be
adapted and cemented simultaneously to
allow for adjustments in the interproximal
spaces and establish proper contact areas.
To get these adjustments, adapt and seat
the crown on the most distal tooth first and
proceed mesially.
Crown extension for deep subgingival
caries (Mink and Hill 1971)
Ideally crown margin should be extended
1 mm beneath the gingiva. In case of deep
proximal caries crown margin should be
FIGURE 3.20 Crown modification in size (small or
over extended to protect the proximal
large crown modification)
surface. For deep proximal/subgingival
A B C
A B C
FIGURES 3.22A TO C Crown modification in deep proximal caries
A B
FIGURES 3.23A AND B Management in bruxism/hypoplastic teeth
caries use metal piece to crown with Open faced stainless steel crown: It is a
an extension on the interproximal area chairside procedure to improve the esthetic
of the crown, which can be welded or of stainless steel crown. The stainless steel
soldered to crown (Figs 3.22A to C) crowns can be modified in anterior teeth
Trim the excess material with scissors by a open faced stainless steel crown with
and contour the crown with No. the labial surface trimmed away to leave a
114 pliers. Polish with wheel before crown perimeter, which is then restored with
cementation. a resin veneering with composite (Fig. 3.31).
Other approach is to complete the Modifications in extrusion of opposing
indirect pulp treatment and then tooth: In case of extrusion of the opposing
restore the cavity preparation with teeth, the extruded tooth may be
silver amalgam. The proximal areas are recontoured to re-establish the occlusal
sliced as in a routine crown preparation, plane and create interocclusal space for a
stainless steel crown is adapted stainless steel crown before beginning for
with amalgam substitutes for tooth crown adaptation.
structure at the interproximal finish Restoration of bruxism/hypoplastic teeth:
line of the subgingival caries occurs Bruxism/hypoplastic condition causes
interproximally, the unfestooned rocky greater occlusal wear (Figs 3.23A and B),
mountain crown can be used deep thus results into decreased vertical height. In
enough to cover the preparation. such condition occlusion can be increased
58 Crowns in Pediatric Dentistry
A B C
D E F
FIGURES 3.24A TO F Restoration of carious tooth by Hall technique (proximal space creation with orthodontic
separators followed by SSC crown placement)
60 Crowns in Pediatric Dentistry
there can be migration of the adjacent Final clearance of cement, check occlu-
molar into the cavitated area. This makes sion: Blanching disappears after removal of
difficulties in Hall technique of crown excess cement usually. Measure the degree
placement without making adjustments of bite opening, if excess then remove either
to the tooth or crown. In such cases occlusal part of the crown with high speed
rebuild the marginal ridge and allow the hand piece so that it is similar to orthodontic
separators to place. Adjust the crown band or remove entire crown. Check
with band forming pliers. Check for the buccal relationship of the crowned
occlusion in relation to anterior overbite, tooth. Advise parent and child that he will
check buccal relationship of the tooth to experience high in occlusion, this will not
be crowned with its opposing number. bother him by the following days. If there is
Protect the airway: It is important before any problem, then child should be recalled
the crown is placed, to ensure no danger for correction. At recall visit pulp condition
to child by inhalation or swallowing. This is should be monitored.
done by sitting the child upright. Otherwise
gauze swab square can be placed between Clinical Tips
tongue and tooth where crown to be fitted. It
should be extended to the palate and round Hall crown should not be fitted to opposing
the back of the mouth in front of the faces. teeth at the same appointment. Occlusion
Alternatively a piece of micropore tape can should be re-established with bilateral
be used to secure crown. contact before opposing crowns are fitted.
Sizing the crown: Select different sizes But crown on other side can be fitted at
of crowns until appropriate one selected same visit.
which covers all the cusps and approach the If there are difficulties in fitting adjacent
contact points. Select smallest crown size. crowns with Hall techniques, then it can be
Avoid fitting oversized crown to primary done at separate appointments.
second molar, where permanent first molar Crowns will try to follow the path of least
has still to erupt, which increases chances resistance and so may tilt towards the easier
of molar impaction. Avoid fully seating the of the contacts, making it almost impossible
crown through the contact points before to ease at tight contact.
cementation, since it is difficult to remove. If crown does not seat sufficiently, remove it
Loading the crown with cement: Dry the with excavator before cement sets.
inside part of crown using cotton roll. Load Patient and parents should be instructed
the crown with GIC luting cement and avoid that child will be used to it in 24 hours.
air blows and voids. Hall techniques is not fit and forget one, it
Fitting the crown and first stage seating: needs recall visit to check pulpal status.
Place the crown over the tooth using finger Occasionally a crown will wear through
pressure. Maintain firm finger pressure until occlusally, if it occurs it can be repaired with
cement sets. While removing finger make composite.
sure that crown is not falling off. Ask the
child to bite on crown before cement sets. Crown and Loop Space
Wipe the excess cement, check fit and
Maintainer (Myers, 1972)
second stage seating-after cementation
remove excess cement from crown margin Space maintainers may be fixed or remo-
using explorer. vable and constructed by direct or indirect
Different Crowns Used in Pediatric Dentistry 61
Poor margins: When the crown is poorly The 3M ESPE stainless steel crown allows for
adapted, its marginal integrity is reduced. a conservative preparation of the tooth to be
Recurrent caries may occur around open carried out. The preparation of a tooth for a
margins (Fig. 3.26C). permanent molar crown is essentially the same
Over extension of the crown: Over as that for a primary molar, but with slightly
extension of crown can be identified with less tooth tissue removal. The finishing line
gingival blanching, which can leads to loss placed just beneath the level of the free gingiva.
of periodontal attachment and periodontal The crown margin should subsequently fit just
problems due to food lodgment. This can apical to the finished line.
be corrected by identifying the adequate
(1 mm) gingival extension of the crown Indications
margin (Fig. 3.26B), scratching the line,
trimming the excess and crimping followed Extensive caries: The use of a preformed
by polishing. stainless steel crown restoration is indicated,
Ingestion/inhalation of crown: Accidental where the extensive carious destruction of
ingestion of crown can occur due to unco- a posterior tooth in which caries control is
operative behavior of child or negligence indicated, but retention of the temporary
from dentist. filling material is uncertain, where gross
carious destruction of a posterior tooth for
The Preformed Stainless Steel which alloy restoration is contraindicated
Crown for Restoration of because of pulpal considerations.
Permanent Posterior As temporary restoration: As a semi-
permanent restoration until a cast or
Teeth in Special Cases ceramic facing restoration is placed.
Here, this entity is considered separate as that of Teeth defects: For full coverage in young
stainless steel crown for primary teeth in regards posterior teeth that have enamel or dentinal
of indications, contraindications and tooth abnormalities.
preparations. According to Croll and Castaldi Endodontic aspect: For restoration of a
(1978) there are problems involving permanent tooth during endodontic treatment in which
posterior teeth for which the stainless steel access is made through the occlusal surface
crown may provide the most desirable short- of the steel crown.
term solution. The objectives sought in the use of the
For each permanent molar in the arch there stainless steel crown procedure are identical
are 6 sizes of crowns, ranging in mesiodistal to those of any restorative dental treatment.
dimension from 10.7 to 12.8 mm, increasing in Not only the occlusion be recreated ideally for
approximately 0.4 mm increments. The crowns the patient but, in addition, proximal contact,
gain their retention mainly from the cervical where indicated, must also be established. The
margin area. The crown margin should be overall tooth architecture must be restored to
placed just apically to the gingival margin and be physiologically acceptable and to preserve
carefully adjusted to give an accurate fit in this masticatory function and periodontal integrity.
region. Fitting a permanent molar stainless steel
crown requires significantly more chairside time Procedure
than is needed to fit a primary molar crown.
When preparing a permanent molar for a The procedure consists of radiological consid-
stainless steel crown, future preparation needs erations, administration of the anesthesia,
for a cast restoration must be considered. occlusal considerations before preparation of
Different Crowns Used in Pediatric Dentistry 63
A B
FIGURES 3.27A AND B The SSC adaptation on permanent molar
the operative field, preparation of the tooth and may be adversely affected and may require
protection of the pulp, selection and adaptation adjustments before preparing the tooth to
of the crown, establishing occlusal relationships, be restored. The opposing molar would have
radiographic confirmation of gingival fit, and over erupted into the mandibular first molar
cementation of the crown. space. It would be necessary first to correct
Radiological considerations: Along with a the over eruption by tooth reduction. The
preoperative diagnostic radiograph of the occlusal adjustment should be done at this
affected tooth and associated structures, stage to establish the correct occlusal plane
precementation radiographs are essential initially.
to assess precise marginal adaptation of Preparation of the operative field: Rubber
the crown by showing interproximal areas dam isolation for entire procedure should
where marginal coverage is difficult to be done until crown cementation. The
assess (Fig. 3.27A). major advantage of the rubber dam is that
Anesthesia: As a primary concern in the gingival marginal fit can be visualized
dental practitioner and complete comfort of around the entire circumference of the tooth
the patient during dental treatment, routine being restored with the possible exception
local administration of an anesthetic is of the center of the proximal surfaces, which
essential to eliminate pain from the cutting can be evaluated with a precementation
procedures and for the retraction and radiograph.
manipulation of the soft tissues associated In most cases, two types of rubber dam
with the treatment. clamps are used. The first is a retentive
Occlusal considerations before prepara- clamp to secure the dam in position; it is
tion of the tooth: Although the importance usually placed on a tooth distal to the tooth
of studying occlusal relationships before being restored. The second is a retracting
actual cutting procedures begin is em- clamp, which is designed to gently displace
phasized in restorative dentistry. These the free gingiva on the tooth that is being
occlusal relationships in the young patient restored.
are often ignored because of the dynamic Preparation of tooth and protection of
physiology of the mixed and early permanent pulp: There are various combinations of
dentitions, however, if the permanent tooth instruments that can be used effectively for
to be restored with a steel crown which has preparation of the tooth. Use barrel-shaped
grossly caries, then occlusal relationships diamond or flame-shaped bur for occlusal
64 Crowns in Pediatric Dentistry
reduction and then reduce proximal interference of the rubber dam and to avoid
surface with tapered fissure bur. Liberal laceration of the gingiva. The finish line
water spray is essential during preparation should be placed just beneath the level of
to eliminate unpleasant odor, reduce dust gingiva. In the next step, slightly reduce the
from tooth debris, and most importantly to convexity of the buccal and lingual surfaces
limit iatrogenic thermal injury to vital pulp of the tooth. It is important to reduce these
tissues. surface convexities in the gingival third of
There are anatomical variations and the tooth so the stainless steel crown may
practical considerations that alter the assume the original convexity and thus
rationale of the preparation for a permanent produce an over contoured, enlarged bucco-
tooth compared with that of a deciduous lingual dimension. A fine, feather-edged
tooth. There are no gross cervical bulges on gingival margin at the crest of the gingiva
permanent teeth that facilitate retention of should be produced, which will be covered
the crown. Cusp heights are much greater in by a thin smooth edge of the crown. When
permanent teeth. Also, conservation of tooth caries extends subgingivally, the margin
structure is more crucial for teeth of the must extend subgingivally also to furnish full
permanent dentition, as in all probability, a coverage of the preparation after complete
cast gold restoration will be indicated, which caries removal. The edge of the crown
must not have its retention compromised must be designed to embrace securely the
during a previous procedure. margin around the entire periphery of the
An essential step in preparation of the tooth. Caries removal is achieved in the
tooth is rounding of all angles. This includes conventional manner with spoon excavators
all axio-occlusal line angles as well as and slow-speed round burs. Pulpal
occlusobuccal, occlusolingual, and occluso- insulation procedures (bases and varnish
proximal. Crown seating and accurate applications) are now performed.
marginal adaptation are facilitated by this Selection and adaptation of crown:
operation. Initially, the tooth is reduced The selected crown for permanent teeth
occlusally in a similar manner to the should establish good contact area with
reduction for a cast gold crown. The general neighboring teeth and snap fit into place
anatomical form of the crown in reduced cervically. None of the available commercial
dimensions should be maintained while crowns are suitable for every situation. In
assuring between 1 and 2 mm occlusal fact, clinicians who are concerned about
clearance in the entire envelope excursive good occlusal relationships in restorative
movements. This is achieved readily with dentistry may be disappointed with the
the barrel shaped diamond bur. The occlusal types of crowns on the market. Occlusal
reduction is achieved first to facilitate better morphology, cusp height, buccolingual
control and vision for the next step, which is width, and occlusogingival length vary
the proximal reduction. widely.
The proximal slices eliminate all contact Selection of a specific brand of crown
with adjacent teeth and create the space may become easier by having a set of study
required to adapt the crown and to restore models as part of the patients permanent
contact if indicated. Proximal preparation record. Some prefestooned crowns are too
achieved with the 169 long carbide burs. It is short occlusogingivally in cases in which
helpful to place a wooden wedge or flattened there is deep proximal caries. Mink and
round toothpick between the teeth to prevent Hill (1971) described how this defect can be
Different Crowns Used in Pediatric Dentistry 65
overcome for the deciduous tooth by spot followed by refinement with a greenstone
welding an additional piece of crown or Castaldi has shown that a common error
band material. For permanent teeth, having in fabricating a preformed crown for
at least one of the nonfestooned crowns deciduous teeth is to make the crown too
available is recommended rather than short on proximal surfaces, predisposing
restoring to Minks add-on procedure. that surface to caries. This area is normally
The cusp heights of some types of crown covered by the gingival papilla, but is easily
tend to be steep and more like newly viewed with rubber dam retraction of the
erupted molars. The occlusal morphology tissue.
of other types resembles older, more worn In adapting the crown, the original length
teeth. Economic considerations in office of the clinical crown should be recreated. The
practice may preclude having a full selection orientation of the crown is important since
of all five available brands of crowns. it re-establishes the original long axis of the
Nevertheless, the wide variation in occlusal crown to the tooth, which will be helpful in
anatomy of teeth necessitates having at least eliminating interfering cusps, and associated
two brands available. mandibular shifts. After achieving proper
Once a suitable brand has been chosen orientation of the crown on the tooth, the
there are several ways to select a specific marginal areas are critically examined. Only
size crown for a tooth. Some practitioners the areas immediately below the proximal
advocate making measurements of the contacts cannot be easily seen. A pair of
prepared tooth, whereas others use the crown-crimping pliers is used to crimp the
trial and error method. Allen (1971) in his margin of the crown. These pliers scallop
observation stated that consideration of the the periphery, which is then smoothened
contralateral tooth, if possible, combined with a pair of contouring pliers. The crimped
with trial-and-error is the most expedient crown is again seated on the tooth and the
means of crown selection after experience margins are re-examined visually and with
is gained with the technique. The aim is to the explorer. Any open area disclosed by this
select a preformed crown that will permit examination can be marked with an indelible,
the marginal areas to be crimped and fine-pointed pencil or felt-tip marker to
contoured to assure a tight, ideal, marginal indicate where additional crimping and
adaptation. contouring may be necessary. When ideal
At this point in the procedure, the use adaptation has been achieved, the rubber
of the rubber dam is extremely important. dam is removed. The crown is reseated and
Visualization of every marginal area is occlusion is evaluated. The use of a wooden
important for ideal adaptation and proper tongue blade split lengthwise serves as an
use of the rubber dam; the clamp as a excellent bite stick for applying force in a
retractor can provide this visibility. A heavy particular area while seating the crown.
dam, with small hole size, aids in retracting Prematurities, coronal orientation, length of
the marginal gingival in conjunction with the crown, and stability of the restoration are
a retraction clamp. The interproximal part all verified and deficiencies are corrected.
of the rubber dam and suitable wedging Establishing occlusal relationships: The
retracts the interproximal gingiva. Proper patient should not be left with an open
length of the stainless steel crown has al- bite relationship from a high crown. To
ready been described and may be achieved assure that the crown is not high, it is
with curved crown and bridge scissors removed, and the patient is instructed
66 Crowns in Pediatric Dentistry
to close the mouth to full occlusion. The rubber dam is now removed; the
A pencil mark is made to record the interproximal rubber is snipped with a
overbite relationship in the canine pair of scissors. The previously established
area. The crown is then replaced and occlusal relationships and the crown
the correct relationship is confirmed orientation on the prepared tooth can now
(Fig. 3.27B). be verified. Deviations can be corrected
Radiographic confirmation of the gingi- before the cement hardens. Recreation of
val fit: Before cementation, a bitewing centric occlusion is confirmed with use of
radiograph is taken to verify proximal pencil line on the anterior teeth. The cement
marginal integrity. If the crown is too is allowed to set for several minutes while
long, there is still an opportunity to the patient bites gently on a 2-in square
reduce the length. If it is too short, the gauge.
add-on procedure or adaptation of Treatment of surrounding soft tissue
another crown is indicated. is important both during and after the
Final finishing and cementation: After procedure. An ideally adapted crown, with
all occlusal and gingival adjustments have smooth and polished margins, replicating
been accomplished, it may be necessary to the hard tissue architecture which once
re-crimp the crown as the metal may expand existed, is paramount for potentiating
minutely each time the crown is seated and optimal gingival health. Removal of excess
removed. The margins of the crown are then cement is important to prevent gingival
refined and smoothened with a greenstone irritation.
and a large rubber wheel that removes all
scratches. Final treatment of the margin can Longevity of Stainless Steel
be accomplished readily by buffing with
Crown for Permanent Teeth
a rag wheel and Tripoli abrasive and then
polishing with jewelers rouge. It is most The major factors concerning the longevity
important to thoroughly clean the interior of the crown are gingival recession, recurrent
to the crown with a wet cotton swab or small marginal caries, dissolution of the cement, and
brush before cementation. wearing through on the occlusal surface of the
Three types of cement widely used for crown. The only report of the long-term potential
cementation of the stainless steel crown of the stainless steel crown for permanent teeth
are zincoxyphosphate, polycarboxylate, is by Kimmelman and Riesner (1977). They
and zinc oxide and eugenol. After suitable reviewed 65 restorations of which 13 had been
pulp treatment, any of these cements are in the mouth from 49 to more than 120 months.
acceptable. The rubber dam is replaced and No description of clinical technique is included
the tooth is cleaned and dried with a liberal in their observations.
water spray and gentle application of warm One steel crown was observed in 1973 in
air. A creamy mixture of cement is prepared the mouth of a 42-year-old American soldier.
and the crown is then filled about three The restoration had been placed on a maxillary
quarters full, making sure that all margins molar in 1958, according to the military dental
are covered. It is then seated on the tooth record. No signs of gingival inflammation were
with gentle finger pressure or with a tongue evident, and although wear facets existed on
blade and mild biting force. Excess cement the occlusal surface, none of them was worn
is expressed around the margins. through the metal. A small area of recession
Different Crowns Used in Pediatric Dentistry 67
of the palatal gingiva was evident, exposing nickel-chromium crown. Whereas control
about 1 mm of root surface; however, the crown group with conventional stainless steel crown
margin was well adapted in that area. showed no statistically significant difference in
It was unfortunate that the contralateral patch test compared to a third control group
molar was absent, so that the tooth was unable to with no history of nickel containing dental
be viewed for palatal recession in an analogous appliances. Menek et al. (2012) in their study
area. The patient reported no symptoms during observed that nickel ion release was decreased
the entire 15-year history of the restoration. The with increasing pH. Furthermore nickel
preformed crown, when carefully done, can be releasing ratio was decreased in all time periods.
a respectable interim restoration until a more Yilmiaz et al. (2012) concluded from his case
desirable full cast crown is possible. report that cause of the perioral skin eruptions
was a delayed hypersensitivity reaction, which
Nickel Allergy was triggered by the nickel in the stainless steel
crown.
Nickel containing alloys have been used in
orthodontic appliances from past 35 years. ANTERIOR STAINLESS
Nickel ions released in sufficient quantities
STEEL CROWNS
from nickel-containing alloys may induce
nickel sensitization or elicit allergic contact Stainless steel crown for restoring anterior teeth
dermatitis. Nickel chromium crowns are (Figs 3.28A and B) is not used nowadays, rather
having significantly higher percentage of nickel SSC with facing are used for better esthetic
(70%) compared to stainless steel crowns, results. The tooth preparation is similar for
orthodontic bands and wires (912% nickel). incisor. Stainless steel crowns were for many
Nickel hypersensitivity is more prevalent in years the only quick and effective means of
females than males, which is in association with restoring fractured permanent incisor teeth on
ear piercing. Higher concentration of contact a semi permanent basis. These crowns were
allergen may be required to elicit response from criticized because of poor esthetics and have
oral mucosa compared to skin. It is difficult to now largely been replaced by acid-etch retained
evaluate nickel release into the oral cavity. composite resin restorations. One of the roles
Several studies had shown the nickel allergy of an anterior stainless steel crown, that of
with crown having higher percentage of nickel. retaining a temporary dressing on the fracture
Feasby et al. (1988) reported an increased site, can be achieved satisfactorily by using
nickel-positive patch test in children aged composite resin and the acid etch technique.
8 to 12 years, who had received old formulation However, the major attribute of the stainless
A B C
FIGURES 3.28A AND B Anterior primary stainless steel crowns. (A) Anerior and posterior SSC;
(B) Anterior SSC refill box; (C) Antertior SSC
68 Crowns in Pediatric Dentistry
steel crown is its ability to prevent space closure fit is achieved using the No. 417 crimping
and over eruption of the opposing tooth. When pliers or the smaller No. 421 pliers (Unitek
the fracture is horizontal and restoration is Corp.) Before cementing the crown, cover the
likely to be subjected to severe occlusal forces, a fractured surface of the dentin with a calcium
stainless steel crown will be more durable than hydroxide lining material. A composite resin
a composite resin. The stainless steel crown may then be used to replace the missing tooth
is only an interim method of treatment and substance. This crown can remain in place for
should eventually be replaced by a composite several months, during which time vitality
resin restoration or a porcelain crown. testing can be performed and any color changes
will be easily detected.
Manufacturers of Anterior
Indications
Stainless Steel Crowns
Following pulp therapy
3M Espe-Unitek Crowns, St Paul, MN and Acero Multisurface caries
Crowns, Seattle, WA., Rocky Mountain crown. Fractures incisor.
Stage 1 Advantages
Good retention
The first stage in the preparation of the fracture Long lasting.
incisor to receive a stainless steel crown is
the measurement of the tooths mesiodistal Disadvantages
dimension to facilitate selection of the crown of Unesthetic look.
the correct size. If there is no space between the
fractured teeth, a small proximal slice is required Availability
to allow the fitting of the crown. The stainless Anterior Crown Kit, 72 crownsthese crowns
steel crown is usually too long, and therefore, are identical to the Unitek.
marking the gingival margin and trimming it in Available for primary incisors and canines
the manner described for the posterior stainless and permanent incisors manufactures: Rocky
steel crown is necessary. This process must be Mountain and Unitek Corp.
repeated until the correct cervical contour has
been obtained. BIBLIOGRAPHY
Esthetics: Reasonable esthetics can be achieved
followed by cutting a labial window in the 1. Albers JH. Use of preformed stainless steel crowns
stainless steel crown. This can be done using in pedodontics. Quint. Int. 1979;10(6):35-40.
a diamond bur in an air turbine to cut away 2. American Academy of Pediatric Dentistry
the excess and finally a green stone to finish Reference manual, 1992-93. Guidelines for
the margins. Some material must be left to lap management of the developing dentition in
around on the labial surface of the tooth, or the pediatric dentistry, Chicago; 1992. pp. 46-9.
crown will be easily displaced. 3. Beemer RL, Ferracane JL, Howard HE.
Orthodontic band retention on primary molar
Stage 2 stainless steel crowns. Pediatr Dent. 1993;15:6.
4. Bigsby BG, DMD, Tunison M. Comprehensive
The next stage is to shape the cingulum with the Dental Care for Children, Adolescents and Chal-
No. 112 pilers to avoid creation of an occlusal lenged people. http://www.valleydentalpediat-
interference. Retention in the form of a snap rics.com/crowns.php.
Different Crowns Used in Pediatric Dentistry 69
5. Braff MH. A comparison between SSC and primary molars in general dental practice:
multisurface amalgams in primary molars. Jr acceptability of the technique and outcomes at
Dent Child. 1975;42(6):478-8. 23 months. BMC Oral Health. 2007;7(18):1-21.
6. Croll TP, Epstein DW, Castaldi CR. Marginal 19. Kennedy DB. The stainless steel crown. Pediatr.
adaptation of stainless steel crowns. Ped Dent. Oper. Dent. Bristol 1976, J Wright and Sons Ltd.
2003;25(3):249-52. 20. Kowolik J, Kozlowski D, Jones JE. Utilization of
7. Croll TP, Epstein DW, Castaldi CR. Marginal stainless steel crowns by general dentists and
adaptation of stainless steel crowns. Ped Dent. pediatric dental specialists in Indiana. J Indiana
2003;25:249-52. Dent Assoc. 2007;86(2):16-21.
8. Daydd Evans, Nicola Innes. The Hall technique 21. Mata AF, Bebermeyer RD. Stainless steel crowns
guide. The Hall Technique A minimal versus amalgams in the primary dentition and
intervention, child centred approach to managing decision-making in clinical practice. Gen Dent.
the carious primary molar. A user manual, 2006 ;54(5):34750;quiz 351, 367-8.
University of Dunde http://www.mendeley.com/ 22. Mathewson RJ, Lu KH, Falebi R. Dental cement
groups/1533433/reading-listcaries/ retentive force comparison on stainless steel
9. Duggal MS, Curzon ME, Fayle SA, Polar MA, crown. J Calif Dent Assoc. 1974;2:42.
Robertson AJ. Restorative techniques in pediatric 23. Mc Donald: Dentistry for child and adolescent,
dentistry: An illustrated guide to the restoration
5th edn. (1996);The C.V. Mosby Co.
of extensively carious primary teeth, London,
24. Menek N, Baaran S, Karaman Y, Ceylan G, en
Martin Dunitz. 1995;8:72.
Tun E. Investigation of Nickel Ion Release
10. Engel RJ. Chrome steel as used in childrens
from Stainless Steel Crowns by Square Wave
dentistry. Chron amaba Dist. Dent. Soc. 1950;13:
Voltammetry. Int. J. Electrochem. Sci. 2012;7:
255-8.
6465-71.
11. Fuks AB, Zadok S, Chosack A. Gingival health of
25. Mink JR, Bennett IC. The stainless steel crown. J
premolar successors to crown primary molars.
Dent Child. 1968;35:186-96.
Pediatr Dent. 1983;5(1):51-2.
26. Myers DR. A direct technique for the placement of
12. Goto, et al. Clinical evaluation of preformed
stainless steel crown-and loop space maintains.
crowns for deciduous teeth. Bull. Tokyo Dental.
Coll. 1970;11:169-75. J Dent Child; 1975. pp. 37-9.
13. http://www.mendeley.com/groups/486021/ 27. Nash DA. The nickel-chromium crown for
reading-list-restorative-dentistry/. restoring posterior primary teeth. J Am Dent
14. http://www.scottishdental.org/resources/ Assoc. 1981;102:44-9.
HallTechnique.htm. 28. Randall RC. Preformed metal crowns for primary
15. Humphrey WP. Use of chrome steel in childrens and permanent molar teeth: Review of literature.
dentistry. Dent. Surv. 1950;(26):945-53. Ped Dent. 2002;24: 489-500.
16. Hutcheson C, Seale NS, McWhorter A, Kerins C, 29. Randall RC. Preformed metal crowns for primary
Wright J. Multi-surface composite vs stainless and permanent molar teeth: review of the
steel crown restorations after mineral trioxide literature. Pediatr Dent. 2002;24(5): 489-500.
aggregate pulpotomy: a randomized controlled 30. Rapp R. A simplified, yet precise technique for the
trial. Pediatr Dent. 2012;34(7):460-7. placement of stainless steel crowns on primary
17. Innes N, Evans D, Hall N. The Hall Technique for teeth. J Dent Child. 1966;33:101-12.
managing carious primary molars. Dent Update. 31. Sahana S, Vasa KAA, Sekhar R. Esthetic crowns
2009;36(8):472-4, 477-8. for primary teeth. 2010;2 (2):87-93.
18. Innes NP, Dafydd JP Evans, David R Stirrups. The 32. Salama FS. Stainless steel crown in clinical
Hall Technique; a randomized controlled clinical Pedodontics: A review. The Saudi Dental Journal.
trial of a novel method of managing carious 1992;4(2):70-4.
70 Crowns in Pediatric Dentistry
33. Savide NL, Caputo AA, Luke LS. The effect of ALUMINUM CROWNS
tooth preparation on the retention of stainless
steel crowns. J Dent Child. 1979;46:25-33.
Aluminum crowns are temporary crowns used
34. Seale NS. The use of stainless steel crowns. Ped
for bicuspids (Figs 3.29A and B). These crowns
Dent. 2002;24:501-5.
have anatomical occlusal surfaces and tooth-
35. Sharaf AA, Farsi NM. A clinical and radiographic
evaluation of stainless steel crowns for primary
shaped cross-sections (not cylindrical). They are
molars. J Dent. 2004;32(1):27-33. much easy to adapt to the preparation without
36. University of Dundee. A minimally intervention, time-consuming in axial shaping. The larger
child centred approach to managing the carious sizes measures a full 11 mm, to cover and protect
primary molar. the tooth margin (Fig. 3.29C). A posterior tooth
37. Waggoner WF, Cohen H. Failure strength of four can be protected by an aluminum provisional
veneered primary stainless steel crown. Pediatric crown. Cementation of crown can be done with
Dent. 1995;17(1):36-40. IRM or zinc oxide eugenol (ZOE) cement (Figs
38. Waggoner WF. Restoring primary anterior teeth. 3.29D and E).
Ped Dent. 2002;24: 511-6.
39. Widenfeld KR, Draughn RA, Sheryl GE. Chairside
veneering of composite resin to anterior stainless
Availability of Crown
steel crowns: Another look. J Dent Child; 1995.
They come in nine sizes for molars and
pp. 270-3.
bicuspids, coded to the standard copper-
40. Wiedenfeld KR, Draughn RA, Welford JB.
An esthetic technique for veneering anterior
band numbering system. The introductory kit
stainless steel crown with composite resin. J Dent includes a compartmented tray makes selection
Child. 1994;61(56):321-6. easy (Fig. 3.29A). Each crown is stamped with
41. Yilmaz A, Ozdemir CE, Yilmaz Y. A delayed the size and quadrant to avoid confusion. Single
hypersensitivity reaction to a stainless steel aluminum crown costs $ 1.90 while 60 bicuspid
crown: a case report. J Clin Pediatr Dent. Spring crown kit costs $ 35. Available as BL, BU, ML,
2012;36(3):235-8. MU, sizes 4 to 12.
A B C
Manufacturer: Pearson dental supplies (since for a short time, unless it can again be re-
1945). lined with acrylic resin for added strength. 3M
ESPE Gold Anodized crowns are made from
Steps Using an Aluminum Shell a medium-hard aluminum for durability and
function. Gold anodization eliminates metallic
Table 3.6 shows steps for using an aluminum taste and galvanic shock for greater patient
shell. comfort.
Commercial product: 3M/Unitek Gold
Gold Anodized Crowns Anodized.
An Anodized aluminum crown is used most
commonly on premolars and molars because of Features
their resistance to wear, strength and unesthetic
appearance. These are medium-hard aluminum Medium-hard aluminum base that will not
for durability and function. The chief advantage easily deform and minimizes bite-through.
of this crown is its malleability, which allows for Pretrimmed gingival contour for minimal
good occlusal adjustment. These crowns are the trimming.
softest and most ductile crowns commercially Parallel wall design to save time by
available for the temporary coverage of posterior minimizing belling of the crown.
permanent teeth. The softness of the alloy Wide assortment of sizes including bicus-
eases marginal and occlusal adaptation, as the pids and molars.
material will stretch up to 50 percent. It can also 3M ESPE gold anodized crowns (Fig. 3.30)
be contoured and burnished without wrinkling. are available in 108 crown sizes for molar
Softness, however, is the chief disadvantage of and bicuspid forms. Crowns are available in
this crown. It can easily wear through during different sizes in mm. For refill crowns can be
normal mastication; hence, it is recommended ordered using crown order form (Fig. 6.6)
1. Select the crown before tooth preparation. Tooth preparation is similar as for SSC. After selecting
appropriate size crown, try it on the tooth to make sure the distance between contacts is correct.
2. See how much is necessary to trim at the gingiva. If the crown is 2 mm above the adjacent teeth, then
trim 2 mm all around at the gingiva using a crown scissors. It is important to trim in a smooth manner so
as not to leave sharp or uneven edges that can irritate the gingiva.
3. Use crimping pliers to crimp the margins of the crown inward (Contouring pliers Nos. 112, 114 and 115
are most common). Use the contouring pliers for adapting the crown to the finish line. It is possible
to omit the contouring and reline the shell with methylmethacrylate (self curing acrylic). This will give
a better internal fit and more exact margins and is probably preferable since it helps to avoid a metal
overhang.
4. Once the crown is seated on the prepared tooth, instruct the patient to bite down normally. This helps to
establish an initial occlusal anatomy onto the soft aluminum shell.
5. Further check the occlusion with articulating paper and make adjustments.
6. Check crown for rough metal margins. These can be smoothed using sandpaper, discs or a rubber wheel.
72 Crowns in Pediatric Dentistry
A B
FIGURES 3.30A AND B A. Gold anodized crown; B. Gold anodized refil box
A B C
D E F
FIGURES 3.31A TO F Open faced SSC procedure
Different Crowns Used in Pediatric Dentistry 75
Bond strength of all rebonding systems with 50 m aluminum oxide particles for
was greater than the original commercially 2 to 4 seconds, followed by the application
produced bond. of adhesive resin cement (Panavia) to the
The highest bond strength following sandblasted surfaces in a thin layer. A thin
rebonding was achieved with the Caulks coat of opaque light cured pit and fissure
Adhesive. sealant (Delton) was applied by rolling the
Ellman Adhesive System TM produced the panavia bonded surfaces in a drop of sealant
weakest bond. and was cured for 20 seconds, followed by the
No significant difference was found between application of light cured composite resin to the
mechanically prepared and unprepared sealant surface and was cured for 40 seconds.
groups. A study on 10 specimens was conducted in
Hartman (1983) evaluated new composite which beads of composite resins were bonded
resin that is bonded to stainless steel crowns. to the sandblasted stainless steel crown in the
One hundred patients were treated with a same manner. The bond strengths of the beads
stainless steel crown on a primary tooth, cover- to the crowns were measured by applying
up (parkell) was used to veneer the buccal or shear stresses at a crosshead speed of 1 mm
labial surfaces with a white shaded resin. All per minute. The bonding failed at the panavia
anterior surfaces of crowns were roughened cement and the metal interface. The results
by use of a diamond stone, bonding liner was included mean shear bond strength of 24.4
applied evenly, within three minutes a bonding MPa. It was concluded that, this technique
liner application, an opaque solution was yielded excellent esthetics and a very high bond
applied; then cover-up (4-meta) was placed strength of the veneered stainless steel crowns.
over opaquer. A thin layer of complus microfilm
followed and light cured for 20 seconds using an BIBLIOGRAPHY
optilux light. This veneering technique has too
many variables to hold forth any firm promises 1. AI-Shala TA, Till MJ, Feiga RJ. Composit bonding
of success. Within one year, only a third of the to stainless steel metal using different bonding
composite cases were totally intact. Shade agents. Ped Dent.1997;19(4):273-6.
stability decreased over a short period of time. 2. Waggoner WF. Restoring anterior teeth. Ped Dent.
Patient brushing habits profoundly affected 2002;24(5):511-6.
veneer surface removal. 3. Wiedenfeld KR, Draugh RA, Goltra SE. Chairside
Widenfeld et al. (1994) evaluated an esthetic veneering of composite resin to anterior stainless
technique for veneering anterior stainless steel steel crowns: another look. ASDC J Dent Child.
crowns with composite resin. The esthetic 1995;62(4):270-3.
surfaces of the crowns were sand blasted
crown is very esthetic when prepared correctly. depends on how much good tooth structure is
Anterior strip crowns are used to restore available to place the crowns onto. If the child
broken down front teeth or teeth with decay traumatizes the teeth/crowns (falls over), there
on multiple surfaces. Installing these crowns is a risk of the crown breaking or an abscess
demands skillful technique and often requires forming. Anterior crowns need good preventive
more time to perform. Because of the time care and regular monitoring by the dentist.
required, these crowns can be difficult to place Morgolis FS (2002) describes strip crown
on young, uncooperative children which need as a relatively easy technique that produces a
management under general anesthesia. With beautiful outcome in a comparatively short time
a cooperative patient, the time required for after using strip crown procedure on hundreds
placement is comparable to that of a stainless of children for more than 20 years. Ram and
steel crown or polycarbonate crown. Fuks (2006) observed high success rate of resin-
Composite strip crowns are composite filled bonded composite strip crowns with a 2-year
celluloid crowns forms. They have become a follow-up and suggests that this treatment
popular method of restoring primary anterior modality is an esthetic and satisfactory means
teeth because they provide superior esthetics of restoring carious primary incisors in young
as compared to other forms of anterior tooth children. The retention rate is lower in teeth with
coverage. Bonded composite strip crowns are decay in three or more surfaces, particularly
most esthetic restorative option for carious in children with a high caries risk. Kupietzky
primary incisors. This is the first choice of many (2002) stated that the bonded resin composite
clinicians due to the superior esthetics and the strip crown is perhaps the most esthetic of all
ease of repair if the crowns chips or fracture the restorations available to the clinician for the
frequently. However, it is most technique treatment of severely decayed primary incisors.
sensitive. Composite strip crowns rely on dentin Kupietzky et al. (2003) evaluated efficacy
and enamel adhesion for retention. Therefore, of strip crown performance in retrospective
the lack of tooth structure, the presence of clinical study utilizing photos, radiographs
moisture or hemorrhage contributes to com- and clinical examination on 112 strip crowns
promised retention. There is need of sufficient in 40 children. They observed no crowns loss
tooth structure after caries removal to ensure and 12 percent had some chipping, one tooth
sufficient surface area for bonding. demonstrated evidence of pulpal necrosis, color
They are less resistant to wear and fracture match with adjacent teeth was significantly
more readily than other anterior full coverage reduced when pulpectomy had been completed
restorations. Tate et al. (2002) found that prior to crown placement. They also found
composite strip crowns had a failure rate of 88 percent full retention rate for strip crowns at
51 percent, compared to an 8 percent failure rate 18 months retrospective study. They concluded
of stainless steel crowns. Resin crowns are much that strip crowns performed esthetically well.
weaker than stainless steel crowns and there is They found parental satisfaction with strip
an increased chance that a piece or corner of the crowns was excellent.
crown may fracture off. Kupietzky and Waggoner, (2004) assessed
The crowns help to seal the underlying parental satisfaction with 112 bonded resin
tooth from acid attacks and reduce the chance composite strip crowns for primary incisors
of developing further decay on the tooth. The compared with their clinical evaluation and
tooth surface is prepared to specific dimensions success. Parents were questioned as to their
and then the crown is carefully fitted over the satisfaction with the crowns. Overall parental
existing tooth. The success of these crowns satisfaction was very good regardless of poorer
Different Crowns Used in Pediatric Dentistry 77
B C D
FIGURES 3.32A TO D Crown selection, caries excavation, facial reduction
during crown placement the rubber dam may of resin composites, the dark color of the
be removed. excavated lesion will be seen through the
restoration.
Tooth Preparation
Strip crown case-1: Crown Placement
Administer appropriate anesthesia Trim the selected crown form to remove
Reduce the interproximal surfaces by excess crown form material cervically with
0.5 to 1 mm with a tapered diamond bur to crown and bridge scissors (Fig. 3.32J).
produce knife edge cervical margin identical Trial check for fitting of crown form on
to that of stainless steel crown preparation prepared tooth. Trimmed crown form
(Fig. 3.32E). The interproximal walls should should fit 1 mm below gingival margin with
be parallel. Proximal reduction should allow comparable height to adjacent teeth (Figs
a crown to slip over the tooth that is there 3.32K and L).
should be snap fit of crown. Consider the maxillary lateral incisors length
Reduce incisal edge approximately of 0.5 to 1 mm shorter than that of central
1 to 1.5 mm using fine tapered diamond incisors during crown form placement.
(169 L) bur (Fig. 3.32F). Punch a small hole with sharp explorer at
Reduce the facial surface by at least 1 mm incisal edge or at palatal surface of trimmed
and lingual surface by at least 0.5 mm (Figs crown form to create vent for flow of excess
3.32D and G). Create knife edge gingival composite material while placement
margin. Round all line angle. (Fig. 3.32I).
Create small cervical undercut with inverted Place an appropriate pulp liner to all exposed
cone bur (No. 35) or No. 330 bur on labial dentin under dry field before etching.
gingival margin (Fig. 3.32H) for retention Etch the prepared tooth with acid etchant
of composite restoration as it acts as for 15 to 20 seconds. Rinse and dry the tooth
mechanical lock to aid in retention. followed bonding agent application and
Further tooth reduction can be done to curing (Figs 3.32N and O).
allow placement of selected crown form Composite materials used to fill crown
over the tooth if the previous reduction was form are hybrid composite, compomers
inadequate. (sparingly), flowable composites, or
Minimal enamel reduction is desirable since combination of an anterior/posterior
retention of the restoration is based on the composite for strength perspective.
quality and quantity of enamel surface area Fill the crown forms with selected composite
exposed to acid etching procedure. shade material to approximately two-thirds
Remove existing carious lesions with a of length (Fig. 3.32M) and seat on to tooth
spoon excavator or round bur. Removal and check for correct position. Excess
of carious lesion will leave additional material should flow from gingival margin
undercuts which will aid in the retention and vent hole. Remove the excess composite
of the restoration. Removal of caries can material from gingival area with explorer
be done either before tooth preparation (Fig. 3.32Q).
(pikham) or after (Mathewson) (Fig. 3.32C). Light cure the celluloid crowns to polymerize
Do pulp therapy if required. the composite material. Curing should be
In cases of black colored arrested caries, done both labially and lingually (Fig. 3.32P).
a masking agent (Paint-On-Color, white After proper curing remove the celluloid
opaque, Coltene whaledent, NJ) may be crown form by using a composite finishing
used. Otherwise due to transference nature bur or curved scalpel blade to cut the
Different Crowns Used in Pediatric Dentistry 81
E F G
H I J
K L M
N O P
Q R S
FIGURES 3.32E TO S Strip crown placement procedure
82 Crowns in Pediatric Dentistry
material on the lingual surface and then Little finishing can be required on the facial
peel the form from the tooth or use explorer or gingival area. Abrasive disc are used for
to remove (Fig. 3.32R). Crown form removal final polishing of required areas.
should began from palatal side to avoid Strip crown for posterior teeth: Strip crown
scratches on labial surface. cases no. 2, 3 and 4 are shown in Figures 3.33
Remove the rubber dam and check for to 3.35. The tooth preparation is similar as that
occlusion (Fig. 3.32S). for stainless steel crown. Crown placement and
A B
FIGURES 3.33A AND B Strip crown case-2
A B
FIGURES 3.34A AND B Strip crown case-3
A B
FIGURES 3.35A AND B Strip crown case-4
Different Crowns Used in Pediatric Dentistry 83
A B C D
FIGURES 3.37A TO D Fabrication of composite shell crown
Source: Murthy et al. (2013 JAOR)
84 Crowns in Pediatric Dentistry
/
Shell crowns filled with dual cure luting resin 12 crowns (posterior) $ 169.50
.i r
and placed in silicone positioner and which is Individual crownAnterior-$ 9.95, Posterior-
transferred intraorally. Curing of luting agent $ 12.95
s
done from labially and lingually. After curing
positioner removed and check for occlusion Advantages
s
and teeth position (Fig. 3.37D). There is no
n
need of postcementation adjustment of Very esthetic crowns
crown since it has been done in laboratory Can be trimmed and reshaped with high
is a
stage. speed finishing burs.
r
NEW MILLENNIUM CROWN Disadvantages
e
These crowns are similar in form to Pedo Jacket Very expensive crowns compared to strip
p
and strip crown except that these crowns are crown and Pedo Jacket crowns
.
made up of lab enhanced composite resin Crowns are brittle
material and bonded to tooth. The crown form Needs adequate moisture control.
iv p
is filled with resin material and bonded to the
tooth. The crown forms are very brittle, can crack GLASS IONOMER CROWN
/: /
or fractured if forced down onto a preparation
that has not been adequately reduced. For These crowns are fabricated using GIC in
clinical success it requires adequate bonding conjunction with celluloid strips crown. This
p
area, excellent moisture control and absence of technique provides a distinct advantage of glass
t
hemorrhage. No long-term studies are available ionomer restorative material over composite
t
regarding these crowns (Fig. 3.38). in its ability to release fluoride for extended
h
period. The procedure of tooth preparation
and crown adaptation is similar to that for
strip crown except, crown forms are filled
with GIC (light cure or dual cured) instead of
composite.
Advantages
Antecariogenic property due to fluoride
release
Better adaptation to tooth structure due to
chemical adhesive nature of GIC
Restoration can be done in single visit
FIGURE 3.38 New millennium crown Advantages in primary teeth.
Different Crowns Used in Pediatric Dentistry 85
/
radiographic success of bonded resin composite Pedo jacket crowns
r
strip crowns for primary incisors. Ped Dent.
.i
PedoNatural crowns (Fig. 3.39).
2003;25(6):577-81.
2. Kupietzky A, Waggoner WF. Parental satisfaction
s
Manufacturers of Polycarbonate
with bonded resin composit strip crowns for
Crowns
s
primary incisors. Pediatr Dent. 2004;26(4):33-7.
n
3. Kupietzky A. Bonded resin composite strip crowns 3M ESPE
for primary incisors: clinical tips for a successful Direct dental products
is a
outcome. Pediatr Dent. 2002;24(2):145-8. Sweedish dental supplies Lab (SWE Den)
4. Kupietzy A, Waggoner WF, Galea J. Long-term PedoNatural crowns, Valencia CA
photographic and radiographic assessment of CrestOral-B.
r
bonded resin composite strip crowns for primary
e
incisors: Results after 3 years. Pediatr Dent.
3M ESPE Polycarbonate Crowns
2005;27(3):221-5.
.p
5. Margolis FS. The sandwich technique and There are 60 crown sizes available in the 3M
strip crowns: an esthetic restoration for ESPE polycarbonate molar crown range.
iv p
primary incisors. Compend Contin Educ Dent. Polycarbonate crowns are available in different
2002;23(12):1165-9;quiz 1170. sizes for incisors, cuspids and icuspids (Table
/: /
6. Murthy PS, Deshmukh S. Indirect composite 3.9 and Fig 3.39). Polycarbonate crowns can be
shell crown: An esthetic restorative option for ordered with crown order forms (Fig. 6.2).
mutilated primary anterior teeth. Journal of
Advanced Oral Research. 2013;4(1):1-4.
p
Kits
t
7. Ram D, Fuks AB. Clinical performance of resin- C-180: Intro kit-180 crowns
t
bonded composite strip crowns in primary Set box only: C-000
incisors: a retrospective study. Int J Paediatr
h
Polycarbonates are aromatic linear
Dent. 2006;16(1):49-54.
polyesters of carbonic acid. They exhibit high
8. Sahana S, Vasa AAK, Skhar R. Esthetic crowns for
impact strength and rigidity. Polycarbonate
primary teeth: a review. Annals and Essences of
Dentistry. 2010;2(2):87-93.
9. Steven Schwartz. Full Coverage Aesthetic
TABLE 3.9 Polycarbonate crowns
Restoration of Anterior Primary Teeth. http://
www.dentalcare.com/en-US/dental-education/ Crown type Sizes Available in
continuingeducation/ce379/ce379.aspx?Modul mm
eName=coursecontentandPartID=6andSection Upper central incisors 7 7.710.1
ID=-1 Upper lateral incisors 6 5.87.6
10. Tate AR, Ng MW, Needleman HL, Acs G. Failure
Lower incisors 10 4.96.3
rates of restorative procedures following dental
Cuspids 7 7.59.0
rehabilitation under general anesthesia. Pediatr
Bicuspids 10 6.27.5
Dent. 2002;24:69-71.
86 Crowns in Pediatric Dentistry
r/
s .i
n s
is a
e r FIGURE 3.39 Polycarbonate
crown kit and individual
p
crowns
.
iv p
crowns are heat-molded acrylic resin shells Polycarbonate crowns for posterior teeth
that are adapted to teeth with self cured acrylic are packaged separately. They are generally
/: /
resin. They were popular in the 1970s, they more difficult to use due to variations in
are more esthetic than stainless steel crowns. tooth size and shape.
Polycarbonate crowns are hollow, tooth-shaped Polycarbonate crown (a form of synthetic
p
with walls about 0.3 mm thick. Polycarbonate resin) is widely used for temporary crowns
t
crowns are usually available in two tooth- for several reasons:
t
colored shades (dark and light). These crowns It is strong yet flexible enough to contour
h
do not resists strong abrasive forces, leading to easily.
occlusal wear, fracture or dislodgement. With the It bonds chemically to a self-curing acrylic
advent of composite strip crowns they lost their resin material used to fill the shell. Although
popularity. In the 1990s new manufacturing plastic crowns do not bend and draw as
techniques made them thinner and more metal crowns do.
flexible resulting in stronger restoration. They have almost perfect bonding
properties.
Availability of Polycarbonate Crowns Any area of a plastic crown, including the
incisal edge, can be extended by adding
Available in a variety of shapes and sizes for layers of acrylic.
anterior and posterior teeth. Plastic crowns are commercially produced to
Available for maxillary and mandibular conform to standard surface contours of teeth
teeth, right and left sides, incisors through and are available in a range of sizes sufficient
premolars. to cover most preparations. Although the
Different Crowns Used in Pediatric Dentistry 87
Using an acrylic bur, greenstone or white says that, these crowns are easy to handle,
stone, adjust the gingival contours of the select and dispense with help of directa
crown. Remember that the axial walls mold guide. Polycarbonate crown is a hard
extend down toward the gingiva on the material that is resilient in the mouth and
buccal and lingual surfaces, and are allows adjustement of the crown without
shorter in the interproximal areas. risk of breakage. This company uses
It may be necessary to slightly adjust universally acclaimed coding system for
the internal surfaces of the crown as crown selection.
well in order for it to seat fully on the
preparation. Custom Resin Crowns
Reseat the crown periodically to check
the contouring of the margins. The custom resin crown is tooth colored and is
Trim until occlusal surface is close to completely fabricated by the operator. The fit
that of the adjacent teeth. If the proximal and external contours of the crown are superior
contacts are not closed, acrylic may to those of any other temporary crown, since it
be added to these areas later in the is made in an impression of the patients mouth.
procedure. Be sure that the margins This crown can be adapted to any tooth and
of the polycarbonate crown cover the is esthetically pleasing. The disadvantage to
finish line of the prepared tooth. this crown is that some operators feel it takes
While adjusting the crown, it is helpful longer to produce. The choice of an appropriate
to keep the handle attached to the temporary crown depends on which tooth is to
buccal cusp tip. This will aid in trying the be restored; the patients concern for esthetics,
crown on and off. Remove the handle and the length of time a temporary restoration
once adjustments are made. must serve. The commonly used resin is a
Crown cementation: An acrylic resin is then combination of a polymer (powder) and a
mixed and placed in the crown, which is monomer (a liquid). Five major categories for
subsequently seated on the preparation. temporary resin materials are:
The viscous resin fills the spaces between 1. Methyl methacrylates
the prepared tooth and the crown and as 2. Ethyl methacrylates
the acrylic resin hardens, the contours of 3. Vinyl ethyl methacrylates
the preprepared tooth are replicated. With 4. Epimines
the crown in place, occlusion is checked; 5. Composites.
then extra resin removed from the margin
of the crown. Finally, the crown is cemented KUDOS CROWNS
in place and a last occlusion check is made.
Success in placing this crown depends on Kudos crowns (temporary pediatric crowns) are
careful trimming and contouring of the newer generation polycarbonate crowns. It is
polycarbonate crown shell and the acrylic easy to use and handle along with considerably
resin. reducing the chairside working time and at the
Polycarbonate crown form direct dental same time overcomes the difficulties reported so
company produces crowns with various far pertaining to placement and retention. It is
opacities ranging fromtranslucent and more user friendly and esthetically acceptable.
opaque polycarbonate crowns available Figures 3.41A and B show commercial Kudos
for anteriors and molars. Several sizes are crowns. Figures 3.42A and B show Kudos crown
available for each quadrant. Company preparation and postoperative placement.
Different Crowns Used in Pediatric Dentistry 89
A B
FIGURES 3.41A AND B Kudos crowns for primary teeth
A B
FIGURES 3.42A AND B Kudos crown [Source: Karthik et al. (www.kudoscw.hk.in/images)]
After the final fit is done the crown is relined retentive force measured in pounds per square
using a cold cure acrylic material and placed inch (psi). 2. A polymethacrylate resin, when
it over the prepared tooth and removed till it used as a cement, also shows high values,
starts to set. This type of relining technique probably due to its ability to unite chemically
is done so that cold cure acrylic chemically with polycarbonated acrylic and to its low film
bonds to the polycarbonate crowns. thickness. 3. Composite resins of low viscosity,
After complete setting of the material, the low film thickness, and high compressive and
margins are trimmed and finished and the tensile strengths provide good retentive values
crown is cemented using a luting cement or and would contribute insolubility to a greater
composites. degree than the unfilled resin. 4. Polycarboxylate,
The firmness of the crown allows it to serve zinc phosphate, and reinforced zinc oxide-
as a provisional crown up to several months eugenol cements are not to be recommended as
Kopel et al. (1976) concluded from agents for cementing polycarbonate crowns. 5.
their investigation that 1. A composite resin It can be recommended on the basis of retention
processed directly against a roughened stainless only, composite crowns should be fabricated
steel dye, similar in shape to a primary anterior directly onto the tooth preparations of carious
tooth, which has been shaped to receive a primary anterior teeth.
polycarbonate crown, shows the highest
PEDONATURAL CROWN
Anju Bansal
The PedoNatural Crown is not a composite composite strip crown or composite veneered
restoration and is never used with composites. stainless steel crown. These crowns can be
All components of the PedoNatural Crown are easily used in crowded situations as well as
hydrophilic (moisture tolerant). The Pedo- Class III occlusions. Self-adhesive resin cements
Natural Crown is a polycarbonate crown unlike are available in several shades. For anterior
any other polycarbonate application previously PedoNatural Crowns the translucent shade
available in pediatric dentistry. These are ultra works best. For posterior crowns the translucent
thin crown form that is: anatomically correct, shade will also look great but in addition shade
flexible, easy to fit, extremely strong, durable A-1 gives an excellent result.
and automatically correctable polycarbonate Advantage of the PedoNatural Crown over
crown form.
the stainless steel crown and veneered crowns
The materials that are used in creating the
isthe ability to easily adapt it in situations
PedoNatural Crown form have been in clinical
where there has been loss of mesial-distal
use since 1997. Originally designed as a method
of providing long-term provisional splinting for dimension. Unlike stainless steel crowns, the
crown and bridge patients, the technique was flexibility of the PedoNatural Crown allows
adapted for use in the primary dentition and for easy application. Chances of breakage of
successfully endured 3 years of clinical studies PedoNatural Crown are less if occlusion is
as the PedoNatural Crown. properly checked. For anterior restorations the
PedoNatural Crowns provide the clinician patient must be in posterior occlusion with only
with a superior esthetic alternative to the minimal anterior contact.
Different Crowns Used in Pediatric Dentistry 91
C
FIGURES 3.43A TO C PedoNatural Crown placement (polycarbonate crown) (Courtesy: Steven Schwartz)
Different Crowns Used in Pediatric Dentistry 93
Later crimp all the gingival margin of the Fill the crown with self adhesive resin (e.g.,
crown using crimping pliers and check Rely X smartcem or G-Cem Automic). Seat
for final fit of crown. Check for snug fit of the crown in position over tooth and hold
crown. The fully seated crown should be it for few minutes, remove excess material
below the occlusal plane for posteriors. from gingival surface and light cure the
For anteriors finger pressure is sufficient to material (Fig. 3.43 C).
seat the crown. Crown Grabber instrument Procedure for PedoNatural Crown
should be used to remove crown from tooth Placement (Polycarbonate Crown) Figure 3.44
to avoid damage to crown margins. Take shows image of posterior pedo natural crown.
care to avoid any occlusal interference due
to crown. Procedure
The PedoNatural Crown can be prepared
chairside by filling the crown from with The PedoNatural Crown is fabricate chair-
specially formulated acrylic hybride mater- side by filling he crown form with a especially
ial that seamlessly units with the crown form formulated hybrid acrylic material
during curing. This Crown is cemented with
any commercially available self-adhesive That seamlessly unites with the crown form
resin cement, such as Relyx Unicem by 3M, during curing.
Smartcem by Dentsply, or GC Automix by
GC. These self-adhesive resin cements are The finished crown is cemented with a glass
moisture tolerant, fluoride releasing and ionomer cement
do not require etching and bonding. To
facilitate the adhesion and retention of the Resulting in a full crown restoration that is truly
cement to the crown, GC Coat Plus (made esthetic, strong, long lasting and durable
by GC) is applied to the inside of the crown
prior to loading the crown with cement. PEDO JACKET CROWN
PedoNatural Crown is used to restore
pulpally treated teeth. Pedo Jacket crown is like a strip crown. It is
Before cementation of crown clean and dry handled similar to a celluloid crown form. It is
the tooth surface and selected crown. Apply made up of tooth-colored polyester material
varnish adhesive agent to internal surface which can be filled with resin and left on the
of the crown using brush, followed by light tooth after polymerization. It comes only in a
curing. single shade which makes matching to adjacent
94 Crowns in Pediatric Dentistry
A B
FIGURES 3.45A AND B Pedo Jacket crown (anterior and posterior)
FLOW CHART 3.3 Properties of Art glass crowns forms, which is called polymer glass. The result
is a tough, elastic material. Most Artglass
parameters exceed those of conventional
composites significantly and with tough, elastic
properties, of porcelain as well. Flow chart 3.3
gives information about properties of Art glass
crowns. Figures 3.46A and B show art glass and
cases photos. Figures 3.47 and 3.48 show pre
operative and postoperative images with art
glass crowns.
Availability
Artglass crowns are available in a single shade
with six sizes for the each anterior teeth.
A B
FIGURES 3.46A and B Artglass crowns
96 Crowns in Pediatric Dentistry
6. Lee JK. Restoration of primary anterior 9. Pinkham JR, Casamassimo PS, McTigue DJ,
teeth: review of the literature. Pediatr Dent. Fields HW, Nowak AJ Pediatric Dentistry: Infancy
2002;24(5):506-10. through Adolescence. 4th edn. Philadelphia, PA.
7. MacLean JK, Champagne CE, Waggoner WB Saunders Company; 2005.
WF, Ditmyer MM, Casamassimo P. Clinical 10. Steven Schwartz. Full Coverage Aesthetic
outcomes for primary anterior teeth treated with Restoration of Anterior Primary Teeth. http://
preveneered stainless steel crowns. Pediatr Dent. www.dentalcare.com.
2007;29(5):377-81. 11. www.austinglastech.com.
8. McDonald RE, Avery DR, Dean JA. Dentistry for
the Child and Adolescent, 8th edn. Mosby. 2004.
Because of lack of esthetic function of stainless problem. Repair of the facing is possible but it
steel crown, an idea of white facing on stainless is suggested that the crown be replaced with the
steel crown has developed. In this technique facings fracture.
tooth colored materials are bonded to the Yucel et al. (2008) conducted a study to
labial surface of the stainless steel crowns. determine the shear bond strength (SBS) dye
These crowns come as preveneered stainless penetration (microleakage) and scanning
steel crowns. Preveneered stainless steel electron microscope (SEM) evaluation of
crowns (PVSSCs) are stainless steel/nickel preveneered posterior stainless steel crowns
chrome crowns that has an esthetic facing, (SSCs) that were repaired using 2 different
mechanically and/or chemically bonded. A materials. They concluded that posterior
resin or porcelain veneer restoration is a thin stainless steel crowns may be repaired using
layer of restorative material bonded over the either repair material types tested such as
facial or buccal surface of a tooth. Veneer Panavia opaque cement and Tetric Flow or
restorations are considered conservative in that Monoopaque and Tetric Flow. Ram et al. (2003)
minimal, if any, tooth preparation is required. evaluated long-term clinical performance of
PVSSC were introduced in the early 1990s. They esthetic primary molar crowns and compared
were initially developed for anterior teeth, but them to that of SSC. They concluded that
later developed for primary molars. Some of after 4 years all the esthetic crowns presented
the PVSSC for posterior primary molars on the chipping of the facing and consequently a very
market are Nusmile Primary Crowns (Houston poor esthetic appearance. Fracture resistance
TX), Kinder Krowns (St Louis Park, MN), and investigations showed that the crowns should be
Cheng Crowns (Exton PA). able to resist occlusal forces over short clinical
Preveneered stainless steel crown periods, however, long-term loading and fatigue
(PVSSC) come with inherent advantages and failures must be taken into account. The clinical
disadvantages. The most common concern outcomes for PVSSC are promising. Roberts et
of these veneered crowns is the retention of al. (2001) and Champagne et al. (2007) from
the esthetic facing. The facings can be prone their study found excellent parental satisfaction
to fracture and in some cases complete loss. If with prefabricated resin-faced stainless steel
these crowns are forced on to a preparation with crowns.
a lot of pressure, it may cause the white facing The PVSSC has the limited crimpability
to break, crack or chip. Over the years since of the crowns. They are relatively inflexible as
their introduction the facings have become the resin facing is brittle and tends to fracture
more resistant to fracture and loss is less of when subjected to heavy forces or crimping.
98 Crowns in Pediatric Dentistry
Hence, care must be taken to have as close fit Rona et al. (2011) evaluated the success of
as possible in order to eliminate the need for posterior NuSmile and Kinder Krown and
crimping. Because only the lingual portion determined the level of parental satisfaction
of the crown can be adjusted (crimped), with this treatment option. They concluded
significant removal of tooth structure must be that these crowns combine the durability
performed to fit the tooth to the crown rather of conventional stainless steel crowns with
than the crown to the tooth. There is limited improved esthetics and are proposed as a
shade choice in preveneered crowns. They are suitable alternative where esthetic demand is
more expensive to purchase than stainless steel increased. Wickersham et al. (1998) concluded
crowns, strip crown forms and polycarbonate that the two steam technique (121C (15 psi)
crowns (approximately 18 vs. 6 dollars). for 20 min and 132C (30 psi) for 8 minute)
Croll and Helpin (1996) described the tested can be used by clinicians to sterilize
technique for preformed resin veneer stainless either Kinder Krown or NuSmile preveneered
steel crowns for restoration of primary incisors. stainless-steel crowns without any change in
A study cast was poured in dental stone. A crown fracture resistance and color stability. Yumikom
form that fit the proposed preparation and had et al. (2002) measured colorimetric values of two
suitable mesiodistal and labiolingual dimension different kinds of esthetic stainless steel crowns
was selected. Preformed resin veneered and compared with the colorimetric values of
stainless steel crowns were cut to proper length primary anterior teeth in Japanese children.
with straight angle diamond wheel and crimped The colorimetric values of resin composite-
in the regions where there was no bonded resin faced stainless steel crowns (Kinder Krown) and
and the crowns were adapted successfully on epoxy-coated stainless steel crowns (White Steel
the incisors. Crown) were measured with a color difference
Fuks et al. (1999) conducted a study to meter. They concluded that the color difference
assess the clinical performance of esthetic between Pedo II crowns and Japanese primary
crowns and to compare these to conventional anterior teeth was relatively high, but the color
stainless steel crowns (SSC). The crowns were of Pedo II might be acceptable for clinical use.
evaluated clinically and radiographically after Studies suggests that extent of caries is the
6 months for following parameters; gingival main factor to use anterior veneered SSCs,
health, marginal extention, crown adequacy, where esthetics is a concern.
proper position or occlusion, proximal contact, These veneered crowns can be more difficult
chipping of the facing and cement removal. They to adapt (due to their limited crimping area)
concluded that the esthetic crowns assessed and are subject to fracture or loss of the facing.
had several inconveniences, as they resulted In some cases veneered SSCs possess a major
in poor gingival health, are very expensive and advantage over conventional SSCs due to their
although not measured are bulky and without superior esthetics and high parental satisfaction.
natural appearance. Waggoner and Cohen MacLean et al. observed for preveneerd
(1995) concluded that the Whiter Biter veneered SCC success as, 1 percent dislodgement and
crown is significantly better able to resist a 14 percent fracture rate. No matter which crown,
shearing force on the veneer than the other a certain percentage will fail (<15%). Some are
crowns tested (Cheng, Kinder and NuSmile spontaneous fractures and some are trauma
crown). Monika et al. (2008) concluded that the induced. Failure rate is probably similar to strip
veneer resistance to fracture for the crimped crowns, may be lower, however, is likely higher
crowns was comparable to noncrimped crowns. than open-faced SSCs. Ram et al. (2003) found
The crimped crowns, however, were associated that after 4 years esthetic primary molar crowns
with greater veneer surface area loss. presented chipping of the facing and a poor
Different Crowns Used in Pediatric Dentistry 99
The first step is to estimate the crown size 7. Rona L, Anne Oc. A clinical study evaluating
success of 2 commercially available preveneered
needed. This is best done prior to tooth
primary molar stainless steel crowns. Pediatric
preparation. Dentistry. 2011;33(4):300-67.
Next step is occlusal reduction. Minimum 8. Waggoner WF, Cohen H. Failure strength of four
of 2 mm of occlusal reduction must be veneered primary stainless steel crowns. Ped
accomplished. This can be done with a high Dent.1995;17(1):36-40.
speed tapered diamond, football diamond 9. Wickersham GT, Seale NS, Frysh H. Color change
and fracture resistance of two preveneered
or with simple straight fissure carbide.
stainless-steel crowns after sterilization. Ped
Circumferential reduction should be done Dent. 1998;50(5):336-40.
with tapered fissure bur. Care must be 10. Yucil Y, Taskin G, Ozge E, Nihal B. The repair of
taken to remove enough tooth structure to preveneered posterior stainless steel crowns. Ped
allow for the bulk of the crown. Preparation Dent. 2008;35(7):429-35.
should be a feather edge and extend slightly 11. Yumikom H, Koichi O, Michal SA. Colorimetric
values of esthetic stainless steel crowns.
subgingivally.
Quintessen ce International. 2002;33(7):537-41.
Upon try-in, the crown should fit passively
with no resistance to the fully seated
position. Snap fit of these crowns should NuSMILE CROWNS
not be achieved since forcing can produce
micro fractures of the veneer and ultimately These are stainless steel crowns with the most
loss of veneer. natural looking facing. These are anatomically
Prepare and adjust the tooth rather than correct stainless steel crowns, are less technique
adjusting the crown to fit the tooth. sensitive and offer excellent durability and color
Occlusion must be checked as a high stability. These crowns are having facing on
restoration would lead to premature fracture labial surface and metal portion on lingual side
of the facing. for crimping to achieve better seal. NuSmile
Cementation of crown can be done with a crowns available as anterior and posterior
glass ionomer cement. crowns. MacLean et al. (2007) and Jeanetterr
et al. (2007) concluded that NuSmile anterior
BIBLIOGRAPHY preveneered crowns (Figs 3.49 and 3.50) are
a clinically successful restoration for primary
1. Carla Cohen. Pre-Veneered Stainless Steel incisors with early childhood caries.
Crowns-An aesthetic alternative. 2012.pp.1-6.
www.dentaleconomics.com.
2. Fuks AB, Ram D, Eidelman E. Clinical performance Advantages
of esthetic posterior crowns in primary molars: a
pilot study. Ped Dent. 1999;21(7):445-8. Give most natural looking smile
3. Guideline on Pediatric Restorative Dentistry. Eliminates extra steps
REFERENCE MANUAL. Pediatric Dentistry.
Ensures successful results
2013;34(6):214-21.
4. Monica, Jung-Wei C, Joe OC. Veneer retention Autoclavable
of preveneered primary stainless steel crowns Designed for optimum zirconia-cement
after crimping. Journal of Dentistry for Children, retention
2008;4:44-7. Esthetically acceptable
5. Rama D, Fuks AB, Eidelman E. Long-term Long lasting
clinical performance of esthetic primary molar
Patientparents satisfaction
crowns. Ped Dent. 2003;25(6):582-4.
6. Robers C, Lee JY, Wright JT. Clinical evaluation Less chairside time
of and parental satisfaction with resin-faced Extremely compatible to natural tooth color
stainless steel crowns. Ped Dent. 2001;23(1):28-31. and translucency
Different Crowns Used in Pediatric Dentistry 101
Will not discolor with age coating. These are widely used, dependable,
Superior performance of composite bond- easy restorative option to traditional
ing to the stainless steel crown. stainless steel and composite strip crowns
(Fig. 3.49).
Disadvantages
NuSmile ZR Crowns
May resulted in poor gingival health
Very expensive Houston, TexasNuSmile pediatric crowns
Bulky has introduced NuSmile ZR. These are perfect
Lacks natural appearance balance of art and science. These are made from
Crimping may cause fracture. zirconia ceramic. Superior esthetic, durability,
easy to place compared to composite restoration
NuSmile Crown is and strip crown.
NuSmile ZR (Fig. 3.50) is a new zirconia
Available in Two Forms
crown that represents a balance of art and
1. NuSmile signature. science for pediatric dentistry. It is made from
2. NuSmile ZR. monolithic zirconia, NuSmile zirconia crowns
are said to be like ceramic steel while mimicking
NuSmile Signature Crowns the anatomical contours of natural primary
teeth to achieve a natural clinical outcome.
They are anatomically correct stainless steel NuSmile ZR launched in US as NuSmile
crowns with a natural looking, tooth color pediatric crowns. Using patent pending and
A B
FIGURES 3.49 A AND B (A) NuSmile anterior primary crowns; (B) labial and lingual view
A B
FIGURES 3.50A AND B NuSmile crownzirconia type
102 Crowns in Pediatric Dentistry
A B C
D E F
G H I
FIGURES 3.51A to I NuSmile crown placement procedure for incisor
Different Crowns Used in Pediatric Dentistry 103
A B
FIGURES 3.52A AND B Canine NuSmile crown
A B
FIGURES 3.53A and B Primary molar NuSmile crown. B. Nusmile posterior crown after cementation
(Courtesy: www.dentaleconomics.com)
A B
FIGURES 3.54A AND B Flex crowns (anterior and posterior)
stainless steel because the epoxy coating adapt kit, the posterior kit, and the complete arch
better to aluminum. This technology develops kit. Crowns are also sold in refill packages of
in 1980. Aluminum crown forms are frequently three crowns for all of sizes.
used as temporary crowns in the permanent Maintenance: Pedo pearl crowns, if
dentition. These aluminum crowns are relatively needed, can be touched-up or repaired
soft and this may create problem with long- easily. A self-cured or dual-cured composite
term durability. Additionally in areas of heavy is recommended.
occlusion, the white coating will wear off. Easy to cut and crimp, without chipping or
These crowns are constructed of heavy gauge peeling.
aluminum and coated with (FDA food grade Composite can be added.
powder) an organic enamel that is both flexible
and durable. The color coating will not chip or Disadvantages
peel. They are available as universal anatomical
types which can be used on either side, thus They are relatively soft thus creating a
reduce time and cost for selection. Any crown problem for long-term durability.
cement can be used for their cementation In areas of heavy occlusion, the white
but glass ionomer and self-curing composites coating will wear off.
enhance their performance and durability.These Less durability.
crowns are easy to cut and crimp which adjusts
to the perfect fit without chipping or peeling. Techniques to Make Pedo
Durable coating with excellent adhesion and high
Pearls Cost-effective
performance enamel coating bonds exceptionally
well with the heavy gauge aluminum crowns. If Cut, crimp, and fit to the tooth.
cosmetic touch-up is ever needed, a light cured Fill the crown with a self-curing composite
composite may be used. Natural primary tooth of same color as the crown and place on the
color-provides an attractive smile. tooth.
After composite sets, remove crown, and
Advantages trim off excess composite.
Coat the tooth with five air dried layers of
Cost: The price of a pedo pearl crown is much Copalite varnish.
less than the cost of any other esthetical metal Permanently cement the crown with Docs
crown on the market. They fit all economic best red or white copper cement. The
situations and have an infinite shelf life. antimicrobial properties in this clinically
Inventory: The anterior pedo pearl crowns proven cement will protect the tooth for
have universal anatomy. This drastically as long as it is in contact with the tooth
reduces inventory and therefore saves the structure.
dentist money and can be used on either side. Company Recommends or company has
Crown coating: The pedo pearl crown recommended few Suggestions for using Pedo
coating will not chip or peel. The dentist can Pearls to Maximize their Performance
cut and crimp the crown without damaging Recommend filling them with either self-
the coating. cure or dual-cure composite rather than
Natural look: Pedo pearl crowns are not using a regular crown cement, good results
bulky and fit easily to the tooth. This avoids observed with using Ketac-cem, RelyX
a chicklets in the mouth appearance. Unicem, and other composites that will
Flexible packaging: Pedo pearl crowns adhere to both tooth and crown. The crown
come in three kits for the dentist; the anterior should be completely filled with the material
106 Crowns in Pediatric Dentistry
A B C
FIGURES 3.56A TO C Pedo Pearls (anterior and posterior); A. Anteriro pedo pearl crown;
B. Posterior pedo pearls crowns
Posterior Kit
Item number: 2002PP
36 maxillary posterior crowns
1st molars (sizes 3 to 5)
2nd molars (sizes 3 to 5)
Both left and right anatomies.
BIBLIOGRAPHY
1. Anterior crowns used in children. Morenike
Ukpong. Dep of Paediatric Dentistry, Obafemi
AwolowoUniversity, Ile-Ife, Nigeria. B
2. http://pedopearls.net/products.htm FIGURES 3.57A AND B (A) Cheng crown;
3. Waggoner WF. Restoring primary anterior teeth. (B) Zirconia checng crown
Ped Dent. 2002;24(5):511-6.
Baker et al. (1996) conducted a study to
CHENG CROWN ascertain the amount of shering force necessary
to fracture, dislodge or deform the esthetic
Cheng Crowns from Peter Cheng Orthodontic veneer facing of four commercially available
Laboratories, Inc. made its public debut in 1987 veneered primary incisor SSCs,(Cheng crown,
to provide an esthetic alternative to stainless Whiter Biter crown, Kinder Krown and NuSmile
steel crown. The crowns are named after the crowns. A force was applied at the incisal edge
president of the company 'Mr Peter Cheng'. of the veneer at 148 degrees until the veneer
These are stainless steel pediatric anterior either fractured, dislodged or deformed.
crowns faced with a high quality composite, From the study it was concluded that Cheng
mesh-based with a light cured composite. There Crowns were better which was stastically
are no long-term clinical trials to assess the significant compared to Whiter Biter crowns.
durability of these crowns. Figure 3.57 shows anterior Chengs crowns, and
108 Crowns in Pediatric Dentistry
Posterior Crowns
Second primary molar crowns starter kit: 12
crowns, upper and lower, left and right, sizes
FIGURE 3.58 Cemented Cheng crown on primary 3 to 5 (one of each size) $400.00.
upper anteriors Primary molar crowns for left and right
upper and lower area available as sizes 2 to 7.
Figure 3.59 indicates Cheng crowns for primary
Figure 3.58 shows cemented primary maxillary anterior and posterior teeth.
anterior cheng crown.
Benefits/Advantages
Commercial Company
Single visit procedure
Peter Cheng Orthodontic Laboratories, Inc. Less technique sensitive procedure-having
pure resin facing on SSC
Availability Natural-looking
They can undergo heat sterilization without
It is available for the right and left central and significant effect on their bond strength and
lateral as well as cuspids with 6 sizes. color.
They are economic
Crown Sizes Stain resistant
Manufacturer claims it to be durable, color
Anterior Crowns stable, and matches pedoshades
Centrals laterals and cuspids: Sizes (1 to 6) left It does not cause wear of opposing teeth
and right Less patient discomfort.
Manufacturer
Whiter Biter Inc.
BIBLIOGRAPHY
1. Roberts C, Lee JY, awright JT. Clinical evaluation
of parental satisfaction with resin faced stainless
steel crowns. Pediatr Dent. 2001;23(1):28-31. FIGURE 3.60 Pedo anterior Compu-crown
110 Crowns in Pediatric Dentistry
A B
FIGURES 3.62A AND B Anterior and posterior dura crown
FLOW CHART 3.4 Zirconia pediatric crowns Tooth preparation: After clinical and
radiographic evaluations; caries should be
removed with stainless steel round burs
under local anesthesia. Reduce incisal
surface for 1 mm. Reduce 0.5 to 1.0 mm
on facial and lingual surface. The facial
and lingual preparation should meet
in a thin incisal edge corresponding
esthetics and natural appearance with short to the planned incisal edge of the final
chair time. Zirconia is a crystalline dioxide restoration. Occlusion should be checked
of zirconium. In particular, yttrium-oxide- for adequate clearance from opposing
partially-stabilized zirconia (3Y-TZP) has dentition. Interproximal reduction can be
mechanical properties very similar to those carried out and it involves creating parallel
of metals, yet it has a color similar to that of mesial and distal walls extending from
teeth. Its mechanical properties, which are 1 to 2 mm subgingivally to the incisal edge
similar to those of stainless steel, allow for of the preparation. After tooth preparation
a substantial reduction in core thickness. zirconia crown should fit passively.
Cyclical stresses are also well-tolerated by this Zirconia crowns are ceramic and cannot
extremely biocompatible material. Ready-made be trimmed with scissors like a traditional
primary zirconia crowns are now available for stainless steel crown (SSC). Glass ionomer
restoration of primary incisors including those cement should be used to fill the crown
that are directly bonded onto the tooth (Figs completely, to eliminate any internal
3.63A to C). voids. Light-cure resin cement is also
recommended for cementation of ZIRKIZ
Manufacturer crowns.
No clinical studies concerning anterior
ZIRKIZ, HASS Corp; Korea. crowns on primary teeth were identified
that met all or even a majority of criteria,
Clinical Technique in indicating that there was little scientific
support. Based on the limited number of
Crown Placement
short-term in vivo studies, zirconia appears
Crown selection: Select the appropriate to be suitable for the fabrication of single
crown size prior to tooth preparation crown. More recently, a new type of ceramic
Occlusal check material, based on zirconium dioxide,
Anesthetizing the tooth has been developed. Yttria-stabilized
Isolation with rubber dam tetragonal. Zirconia polycrystal, Y-TZP, has a
A B C
FIGURES 3.63A TO C ZIRKIZ crown
Different Crowns Used in Pediatric Dentistry 113
EZ-CROWN
EZ-pedos pioneering achievement is revolu-
tionizing the appearance of pediatric dental
FIGURE 3.65 EZ-crowns
crowns and renewing happy and healthy smile
on pediatric patients. EZ-pedo company first
developed monolithic zirconia pedo crowns as
anterior and posterior crowns (Figs 3.64 and
3.65). EZ-pedo is the first company worldwide
to offer fully white, prefabricated, ceramic
crowns especially designed for children.
These crowns are made of solid zirconia, a
biocompatible material. It is composed entirely
of one solid tooth-colored material; they look
extremely esthetic, both from the front view
and on the inside of the mouth. Each crown
is glazed with a hint of natural color, making
them very smooth, shiny and impermeable to
staining. They are exceptionally strong, and FIGURE 3.66 John P Hansen and Jeffrey P Fisher
their unsurpassed esthetics allows them to
blend in seamlessly with surrounding natural esthetically pleasing crowns like those typically
teeth. Tooth preparation for EZ-crown is similar custom-crafted for adults. Hansen said the
to that of SSC. crowns placed on his sons teeth were bulky,
did not match in color and presented a smile
Development of EZ-Crown that showed metal at the gumline. Then Hansen
thought of making esthetic crowns for children.
In 2004, Hansens 3-year-old son, John Paul, fell Local dentists Jeff Fisher and John Hansen did
in the bathtub and seriously injured four of his years of research with local dentists before
front teeth. Hansen sent his son to a pediatric founding all ceramic crown; EZ-Pedo Inc., in
dentist to have the boys smile reconstructed Loomis, California, in 2010. Jeffrey P Fisher
and was stunned to learn that there were no and John P Hansen (Fig. 3.66), of Sacramento,
114 Crowns in Pediatric Dentistry
Manufacturing of EZ-Crowns
The zirconia crowns are first milled in an exotic-
looking, custom-made machine (Fig. 3.67).
About 35 to 50 crowns placed in a disc can be
shaped simultaneously. From there, the crowns
will be smoothed, polished, put through a
FIGURE 3.67 Manufacturing of EZ-crown
staining solution, hardened in a 4,000-degree
chamber, microblasted and glazed. Every
crown gets a label, which can be scratched
off by a dentist before placement (Fig. 3.65).
There are 96 shapes and up to six sizes for each
specific tooth. Zirlock technology has been
implemented within the EZ-pedo crown to
improve retention (Fig. 3.68).
Advantages
Zirlock technology increases the internal
surface area for long lasting clinical success
Provides glazed facial surface for better
esthetic
Ultra low wear
Avoids chances of chipping, or fractured
facing
Biocompatible
FIGURE 3.68 Zirlock inside crown for retention
Provides better strength
Autoclavable.
Crown selection
Procedure for EZ-Crown Placement Tooth preparation-on lingual , incisal, facial,
proximal surfaces
for Primary Teeth
Checking for crown fit and crown cementa-
The tooth preparation and crown placement for tion.
anterior and posterior teeth are similar to that Figure 3.69 diagrammatically explains the
for SSC, i.e. procedure of EZ-crown placement.
Different Crowns Used in Pediatric Dentistry 115
FIGURE 3.71 Different Kinder Krowns for anterior FIGURE 3.73 IncisaLock for mechanical retention
and posterior teeth
to Kinder Krowns easier. These crowns are meet seating needs and preference, Kinder
consistent, easy to use, beautiful restorations Krowns are available in regular or 1 mm
every time. Kinder Krowns delivers a short length.
superior solution. The teeth in pedo bridges
are constructed completely out of composite, Benefits
making them more durable than acrylic teeth
and they are repairable at chairside. They match Autoclavable, easy to identify outer label
any bioform or vita shade for shade selection. Precisely manufactured to ensure proper fit
Custom pedo bridges are even made available Rough external surface for easy handling
from company. Kinder krowns can also be No contamination provides better retention.
used in fixed bridge farication for replacing
lost primary incisors (Fig. 3.74). Figures 3.75 to Available as (Fig. 3.71)
3.77 show clinical image of cemented Kinder
anterior Krown cases. Available for anterior and posterior primary
teeth (Tables 3.13 and 3.14)
Features Sizes D/E 1-6, in Pedo 1 or Pedo 2
Pedo 2 shade is the most natural shade,
Esthetics pedo 1 and 2 shade. while Pedo 1 shade is for those cases when
Durability: Crowns are faced with a special the bleached white shade is wanted.
bonding agent and a durable, high-flexural
strength dental composite. Anterior Crown (Fig. 3.70)
Ease of seating: Anterior crowns are a time- Anterior crowns are available as:
saving, less technique sensitive alternative Left and right
to other esthetic crowns, open-faced Universal and contoured types
window crowns and strip crowns. To better Lengthregular and short
Shade-Pedo 1 and Pedo 2.
TABLE 3.13 Kinder krown posterior kit TABLE 3.14 Anterior Kinder krown kit
r/
s.i
n s
is a
FIGURES 3.80A AND B A. Cerec crown-CAD CAM procedure; B. Computer generation cerec model
e r
.p
iv p
/: /
tt p
h
FIGURE 3.81 Computer generated tooth model
/
such as platinum and palladium. These
.i r
metals improve the strength and rigidity
of the prosthesis, making it better suited to
s
support the cosmetic layer of porcelain that
is applied to its outer surface.
s
FIGURE 3.83 Final prepared crown and after Noble alloys: Noble alloys have little
cementation
n
or no gold. The gold was replaced by
other precious metals such as silver and
is a
polishing it or glazing it in a furnace. Figure 3.83 palladium. This originally resulted in an
shows clinical photographs of final adapted alloy that was significantly cheaper than
primary crown. high noble alloys. Recently, the price of
r
palladium has escalated and the price
e
Advantages of CEREC Crown differential is no longer significant.
Base metal alloys: Base metal alloys contain
.p
Single visit appointment for crown pre- no noble metals. Consequently, they are
peration and placement significantly cheaper in price than high
iv p
Time saving noble and noble alloys. Over the years these
No need of temporary crown alloys have proven to function well as dental
/: /
Esthetically acceptable prostheses. They are generally an alloy of
Durable. nickel and chrome, which results in their
being very rigid. This can be a significant
p
Disadvantages advantage in the fabrication of long span
t
bridges. The microscopic surface roughness
t
They look greater on posterior teeth, but do of this alloy after it has been etched with acid
h
not have the esthetic quality of laboratary makes it the alloy of choice in the fabrication
made crowns. of Bonded (Maryland) Bridges.
Unique CEREC technology requires extra Since, these alloys usually contain nickel,
training on the part of the dentist. it is preferable to avoid using this alloy for
patients with a nickel allergy. Allergies are not
BIBLIOGRAPHY a problem with high noble and noble alloys.
Noble and base metal alloys evolved for dental
1. http://www.sirona.com/en/products/digital- use during the period after the regulation of
dentistry/cerec-chairside-solutions/?tab=241. gold prices was lifted and the price of gold
escalated dramatically. Recently the price
CERAMO BASE METAL CROWN of metals used in noble alloys has escalated;
consequently, there is only minimal difference
Ceramo-metal alloys are those used to create in price between high noble and noble alloys.
the substructure of a bridge or crown which Base metal alloys still remain substantially less
will have cosmetic porcelain fused to its visible expensive.
122 Crowns in Pediatric Dentistry
BIOLOGIC CROWN
In 1964 Chosak and Eildeman published the of severe loss of tooth structure, intra canal
first case report on reattachment of a fractured post of natural tooth can be done. Use of
incisor fragment, which was endodontically biologic restoration as a post and core has
treated by cast post and core. Fragment shown promising results. It is cost-effective
/
reattachment using natural teeth is a technique alternative.
.i r
known as biologic restoration. The biologic
restoration meets the esthetic and standard LIMITATIONS
s
of natural teeth. Biological restorations are an
alternative treatment for primary teeth. Biologic Lack of patient acceptance
s
restorations are made from tooth fragments Lack of availability of teeth with similar
n
selected from natural extracted teeth or from structure and color
a bank of tooth tissues and bonded with dual- Fabrication of post needs technically sound
is a
cure composite cement to prepared teeth. system
Biologic post and core are made from natural Adaptation of natural post to root canal may
extracted teeth radicular dentin. Presence of be less accuratedifficulties in getting crack
r
similar structure might enable to absorb and free structure
e
dissipate stress. Biologic restoration using Longevity affected by many factors like,
p
natural post and core can provide natural design, length, diameter of root, ferrule
.
esthetics. Biologic post and core, crown and effect cementation, quality and quantity of
veneer restoration are comparatively cheaper to remaining tooth structure.
iv p
other esthetic materials. These restorations are A biochemical property of biologic rest-
performed easily without need of sophisticated orations needs to be determined for long term
/: /
equipment. clinical use.
There are 2 methods of restoring tooth with
biologic restorations TOOTH PREPARATION
tt p
1. Autogenous biological restoration-done
when fractured fragment is available in Prepare the coronal portion of tooth to receive
satisfactory condition. Tooth fragment biologic crown (Fig. 3.84D).
h
obtained from the patient itself.
2. From donated extracted teeth. Tooth
fragment obtained from donor or tooth FABRICATION OF
bank. The biologic tooth can be obtained CROWN PORTION
from tooth bank where it is stored and
sterilized after thorough scaling and removal Select the biologic crown by measuring
of soft tissue, periodontal remnants, pupal mesiodistal dimension. Autoclave the se-
tissue from root canals. Teeth were kept at lected biologic tooth at 121 C for 15 minute.
40C in Hanks balanced salt solution with Coronal portion of selected sterilized tooth
donor identification like tooth parameters should be cut-off at CEJ and biologic crown
such as dimensions, color, shape, size and prepared by hollowing both internally
age. The combination of tooth fragment, as well on the cervical portion, leaving
adhesive and restorative material provides approximately 1 mm dentin with enamel
good functional and esthetic result. In case (Figs 3.84A and B).
Different Crowns Used in Pediatric Dentistry 123
A B C D
E F G H
FIGURES 3.84A to H Biologic restoration procedure. (A) Crown sectioning; (B) Biologic crown; (C) Tooth
preparation to receive biologic crown; (D and E) Trying biologic crown; (F) Radiographic evaluation of crown
adaptation; (G) Crown cementation; (H) Final radiographic evaluation of cemented biologic crown
[Source: Babaji P, et al. J Clin Diag Research. 2014;8(11):ZD11-13]
Place biological crown on prepared tooth cement and position the biologic crown
and adjust biologic crown to fit on the in place until polymerization completes.
prepared tooth (Figs 3.84C to E). Clinically, evaluate the crown after
cementation (Fig. 3.84G).
RADIOGRAPHIC EVALUATION Take radiograph after cementation again to
confirm proper adaptation and cementation
Confirm the fitting of biologic crown on (Fig. 3.84H).
prepared tooth with radiograph (Fig. 3.84F).
Benefits
CEMENTATION OF BIOLOGIC
Retention comfortable
CROWN Esthetic as natural tooth
Natural enamel has physiologic wear
The coronal portion of tooth to be fitted Superficial smoothness and cervical
and inner surface of biologic crown are adaptation compatible with those of the
conditioned with 37 percent phosphoric surrounding teeth.
acid, followed by application of adhesive Avoids long clinical appointments
and light curing. Later apply dual cure resin Avoids laborios technique
124 Crowns in Pediatric Dentistry
A B
FIGURES 4.1A AND B Early childhood caries (ECC)
A B C
FIGURES 4.2A TO C Post space shapes (Mushroom, tapered and onion shapes)
and Kevlar fibers, which interferes with the stress bearing areas and can bonded to any type
esthetics. of composites when compared to other posts
Use of a resin based composite reinforced these are invisible in resinous matrix. Hence,
with polyethylene fibers is preferred and they are most suitable for esthetic need.
the technique is referred to as the short post
technique, which requires root canal treatment Composite Posts (Figs 4.4A to C)
and a short composite post (Fig. 4.3).
Composite posts are fabricated directly in post
Glass Fiber Reinforced space. Composite resin posts provide satisfactory
esthetics but retention owing to polymerization
Composite Resin Posts (GFRP) (Fig. 4.7)
contraction could be a risk.
It is a new generation of fiber posts composed
of densely packed silanated E glass fibers in Metallic Post
a light curing gel matrix. The fibers are 710
micrometer in diameter. It is available in These posts are made up of stainless steel
different configurations, including braided, wire of 22 gauze/0.7 mm. It is very rigid, but
woven and longitudinal. Its flexural strength esthetic quality is compromised. The post
(1280 MPa) is closer to that of dentin and can part of wire can be smooth or retention can be
decrease in incidence of root fracture. It has increased with serration. Various designs are
greater ease of handling, can be used in high made on coronal part of wire to build core part
to receive crown. Even though conventional
prefabricated metal posts is a fast, low-cost
and simple technique, but is not accepted in
pediatric dentistry because of the potential
interference with physiologic root resorption.
Orthodontic wire designs such as omega, alpha
and half omega can be designed (Figs 4.5 and
4.6). The use of stainless steel orthodontic wire
as an intracanal post has also been a simple and
fast technique for reconstruction of primary
anterior teeth. However, in most cases, the wire
adaptation to the internal walls of the canal is
not adequate, leading to detachment of the wire
FIGURE 4.3 Polyethylene fiber post and restoration or radicular fracture, especially
(Source: Jain, et al. JISPPD. 2011;4(29):32732) in cases with excessive masticatory forces.
A B C
FIGURES 4.4A TO C Composite post
FIGURE 4.5 Different types of posts (from left to FIGURE 4.6 Different posts in primary anteriors
right, Fiber, threaded, half omega and omega-shaped) (Fiber, reverse screw, half omega posts)
Partially remove (34 mm) root canal filling priate celluloid strip crown forms, trim the
material 1 week after obturation. Root crown border to fit individual tooth and
canal preparation can be done followed by create small vent in crown form and fill it
irrigation and canal drying with selected shade composite material
Selected post (fiber or stainless steel wire and position it over selected tooth, remove
of # 22 gauze) tried into prepared canal and excess around margin and light cure the
post should be cut at the length 3 to 4 mm resin all around.
above the gingival margin of the tooth. Once composite sets remove the crown
The prepared canal should be etched with form with explorer and do light finishing or
37 percent phosphoric acid gel for 15 to 30 polishing of crown, if necessary.
second and rinsed with water spray and air Check for occlusion and correct, if necessary.
dried.
Apply thin layer of liquid bonding agent Modification in Post and
inside canal space and cure it with light cure
Core Fabrications (Figs 4.7 and 4.8)
unit.
Pack dual cure composite resin into Flowable composite material with fiber
prepared post chamber using incremental posts: If you use flowable composite resin,
layering technique (0.5 mm depth each insert it in canal space along with selected
layer). After first layer of composite was post and light cure. Then build up the
compressed into canal, the prepared coronal part (core) with flowable composite
stainless steel wire should be inserted in 3 to 4 mm above gingival margin to receive
the middle of canal space. The viscous mix crown
consistency of composite resin in the canal Reverse metal post-insertion technique
helps to stabilize stainless steel wire. Light (RMPT): In this technique prefabricated
cure the composite. Compress further layers metal screw post is inserted in root canal
of composite material with plugger and space in reverse position. Before insertion of
light cure it. Condense additional layer of post in the canal semi bevel the sharp angles
composite around the stainless steel wire of post to prevent stress concentration. Post
that penetrated above the root in order can be cemented in the canal with zinc
to fabricate the core portion. In this way, phosphate cement. At least 3 mm of metal
prepare core portion and polymerize resin post left coronally for core build up with
with light curing. flowable composite resin.
Confirm the post position and extent with Composite post: Composite posts are
radiograph fabricated directly by direct method in
Then proceed for core build, crown post space using composite in incremental
preparation and adaptation. Select appro layering technique (Figs 4.4A to C).
FIGURE 4.8 Post and core case-2 (Fiber, reverse metal and omega-shaped posts)
A B
FIGURES 4.9 A AND B Fiber reinforced composite crown with artificial tooth (pontic)
[Source: Jain, et al. JISPPD. 2011;4(29):32732)]
Artificial teeth bonded to adjacent natural be replaced using fiber reinforced strips (Figs
tooth: It involves bonding composite 4.9A and B).
artificial teeth directly to the adjacent
natural teeth reinforced with high density BIBLIOGRAPHY
fibers, without metal frameworks. It can be
done by passing a fiber splint from center 1. Eshghin A, Esfahan RK, Khoroushi M. A simple
of the strip crown and crown along with method for reconstruction of severely damaged
splint loaded with composite cured outside primary anterior teeth. Dental Research Journal.
the oral cavity then splinted to adjacent 2011;8(4):2215.
2. Jain M, Singla S, Bhushan BAK, Kumar S, Bhushan
teeth with composite. This technique has
A. Esthetic rehabilitation of anterior primary
advantage of little tissue removal and low
teeth using polyethylene fiber with two different
laboratory cost (Figs 4.9A and B).
approaches Journal of Indian Society of Pedodontics
Casellato et al. (2002) from their in vitro
and Preventive Dentistry. 2011;4(29):32732.
study reported that, threaded posts (FKG, FKG
3. Leena Verma, Sidhi Passi. Glass Fibre-Reinforced
Dentaire), Ni-Cr posts with macroretentions, Composite Post and Core Used in Decayed
alpha-shaped orthodontic wire, biologic posts Primary Anterior Teeth: A Case Report. Case
and root canal filled with resin composite Reports in Dentistry Volume 2011, Article ID
showed similar fracture resistance values when 864254, 4 pages, 2011.doi:10.1155/2011/864254.
submitted to shear bond strength tests. Parrela 4. Mendes FM, De Benedetto MS, Del Conte
et al. (1995) reported that threaded posts and Zardetto, CG, Wanderley MT, Correa MSN. Resin
alpha-shaped orthodontic wire showed an composite restoration in primary anterior teeth
average success rate of 76.47 percent after 10 using short-post technique and strip crowns:
months of clinical and radiographic follow-up A case report. Quintesence International.
in primary anteriors. Missing primary teeth can 2004;35(9):68992.
incorporated without any signs of gingivitis between gingivitis and stainless steel crowns.
and discomfort to the patient. According to Henderson, after examining children ages four
Henderson (1973), a patient with poor oral to thirteen years, concluded that no matter how
hygiene exhibits a high plaque and debris accurately the preformed stainless steel crown
index, accompanied by an increase in marginal was trimmed, adapted, and polished some
gingivitis. To minimize gingival problems, it is as inflammation was always observed because of
important to stress oral hygiene in a patient with the differences in form and contour between
preformed stainless steel crown. the tooth and crown.
Harrison indicates that the finish line of The results of the study by Durr et al.
the full veneer crown should be at the crest of (1982) indicated that the majority of stainless
the gingival tissue rather than beneath it, to steel crowns placed by undergraduate dental
prevent the constant irritation that results in students were clinically functional and
varying degrees of inflammation. Since primary acceptable. However, most of the crowns had
teeth are short occluso-cervically, the cervical one or more observable defects, ninety-five
border of the stainless steel crown must often crowns in forty-four patients were judged non-
be carried subgingivally to acquire sufficient ideal. Errors in crown crimping were the most
mechanical retention. Henderson reported that common, with defects in crown length, contour,
inflammation of the gingiva might be due to position, polish, contact, and cementation
irritation from the material per se, overhanging following in order of decreasing frequency.
margins, rough surfaces, retained bacterial Only six crowns in six patients were judged
plaque, or a combination of these factors. He ideal.
concluded that gingival inflammation adjacent In the retrospective study by Fuks et al.
to restorations is due to bacterial plaque rather (1983), the gingival health around the per
than to mechanical irritation. To minimize manent successors of crowned primary molars
mechanical irritation, it is suggested that the was not different from that of the rest of the
operator pay close attention to the criteria listed mouth. This would suggest that even, if gingivitis
under Evaluation of the crown. These criteria was present around the crown of primary
referred to the contour, the cervical adaptation, teeth it was resolved with the exfoliation and
the sulcular depth, and the length of the crown. subsequent eruption of the permanent teeth.
The patient should be taught about proper oral This conclusion should not be misinterpreted as
hygiene and the importance of continued oral a justification for ill-fitting and poorly contoured
health should be stressed. preformed crowns.
The studies of Goto (1970) and Henderson
(1973) indicated that there may be inflammation OVER EXTENSION
of the gingival tissues surrounding stainless
steel crowns. In children, ages two to nine years,
OF THE CROWN
gingivitis was associated with 23.6 percent of
all crowns with good marginal adaptation and Over extension of crown (Fig. 3.26B) can be
the most (33%) associated with those crowns identified with gingival blanching, which can
exhibiting poorly adapted margins. The authors leads to loss of periodontal attachment and
proposed that uncleanliness of the area, perhaps periodontal problems due to food lodgment.
due to the ill-fitting margins, accounted for the This can be corrected by identifying the
higher percentage of gingivitis in the latter group. adequate (1 mm) gingival extension of the
Myers (1975) stated that enhanced Plaque crown margin, scratching the line, trimming the
accumulation accounting for the association excess and crimping followed by polishing.
Management
Immediately after ingestion of crown check
for its location in mouth.
Attempt to removal of ingested crown can
be made by holding the child upside down
as soon as possible.
Advice posteroanterior (PA) radiograph of
chest to check the presence/location of crown
(Fig. 5.2). If crown is not found in radio
graph, then assume its passage through
A B
C D
E F
A B
A B
Contd...
Contd...
Contd...
Contd...
06.indd 144
TABLE 6.2 Comparison of full coverage restoration to primary anterior
Technique Strip crown SSC Open faced crowns Prefabricated Ceramic/ Polycarbonate Biologic
veneered SSC Zirconia crown crown crown
Esthetics Very good Poor Good but some metal Good Very good Average Very good
initially, may portion appears
discolor over a gingivally
period of time
Durability Retention Very good. Good like SSC but Good but facing good Poor Average
Crowns in Pediatric Dentistry
Contd...
30-01-2015 11:36:09
06.indd 145
Contd...
Technique Strip crown SSC Open faced Prefabricated Ceramic/ Polycarbonate Biologic crown
crowns veneered SSC Zirconia crown crown
Crimping, Trimmed with Can be crimped, Can be crimped Cannot be Not possible Can be trimmed, Crimping,
contouring, scissors trimmed and trimmed trimmed or crimped, contouring not
trimming crimped contoured possible,
trimming can be
done
Types Anterior and Untrimmed, All ceramic SSC Anterior and Anterior
posterior uncontoured with ceramic posterior
Pretrimmed facing
Recontoured
For anterior
and posterior
Manufacturers 3M ESPE 3M ESPE 3M ESPE
Disadvantages Technique Unesthetic Time Difficult to Can not Temporary Patient
sensitive consuming crimp, and trimmed or crown acceptance not
Needs trim crimped Strength no up there
moisture Difficult Needs to mark Availability
control to repair if more tooth No study
fractured reduction to check
Expensive durability and
strength
Advantages Esthetic Not technique Esthetic Easy to place ery good in
V Economical Economical
Repaired easily sensitive Not technique esthetic Easy to adapt Easy to
if fractured Can be done sensitive perform
minimal tooth
structure
Tables and Charts
145
30-01-2015 11:36:09
146 Crowns in Pediatric Dentistry
Form 2: Crown order form for iso-crown for (molar, bicuspid), Gold anodized (molar/bicuspid
crown), Polycarbonate crown, Strip crown.
grabber instrument 93 F
height of 38 Festooning scissor 10f
high density polyethylene 110 Fiber posts over metal posts 129
inhalation of 62 Finishing 48, 73
ion 25 Flex crowns 104f
loose 5
marginal adaptation of 49 G
morphology 59 Gingival contour 46
nickel-based 23, 31 Gingival finish lines 6f
nickel-chromium 25, 34 Gingival health 6
NuSmile 21, 99-101 Glass fiber reinforced composite resin posts 128
over amalgam restoration 30 Glass ionomer 51
over extension of 62, 134 cement 19, 29, 91, 126
pediatric 2, 7, 103 crown 21, 84
pedo jacket 21, 85, 93
PedoNatural 21, 85, 90 H
placement 7, 80 Head tilt-chin lift technique 139f
procedure of 78, 104 Heimlich maneuver 136, 137f
technique of 89 High density polyethylene crown 21, 110
polycarbonate 85, 85t Howe pliers 9
portion, fabrication of 122 Hybrid acrylic fill material 91
posterior 108, 117 Hypoplastic defects 27
pretrimmed 32
resin 75 I
retention 49 Incisors and molars 2f
scissors 9 Isolation procedure 10
selection 8, 35, 36, 78, 87, 112
and adaptation of 64 J
method of 37 Johnsons ball and socket contouring pliers 9
sizes 60, 108
stainless steel 67 K
sterilization of 52 Kinder krown kit 118t
strip 21, 77 Kudos crown 21, 85, 88, 89f
tilt 61, 133
tin-based 23, 34t
L
ZIRKIZ 21, 111 Laryngoscopy 140f
Curved scissor 10f
M
D Mandibular molar tooth 55
Metal crowns, anatomical 37
Deep proximal caries 57f Methyl methacrylates 88
Dental dams, traditional 11 Molars
Dental floss 12f permanent 34
primary 34
E Multiple crown placement 56f
Early childhood caries 125f Mushroom-shaped post space 127
N S
Natural tooth, adjacent 132 Sensitivity 6
Nusmile anterior primary crowns 101f Silicophosphate cement 19
Nusmile crown 101f Split dam method 16f, 79
placement procedure for incisor 102f Stainless steel crown 2, 21, 23, 26, 31, 33t, 41f, 43f,
54, 74, 97
O adjacent 54
classification of 31
Omega-shaped post 127, 129 for permanent teeth 66
placement, modifications of 53
P restoration 51
Pedo jacket crown 94f traditional 112
Pedo pearls 21, 104, 107f Stainless steel refill box 37f
kit box 106f Straight crown cut scissor 10f
Pedonatural crown placement 92f Strip crown 83f
Polishing 48, 73 order form 152f
Polycarbonate crown 21, 85, 86, 86f, 92f placement procedure 81f
Polycarboxylate cement 19
Polyethylene fiber post 128f T
Post and core fabrications, modification in 130 Threaded post 129
Post space design, type of 126 Tooth
Post, types of 126, 129f isolation, individual 15, 79
Primary molar NuSmile crown 103f preparation 73, 80, 91, 112, 122
Primary teeth, importance of 4, 5 reduction of 39
Proximal ledge formation 133f restoration, fractured 28
Pulp therapy 26 Troutmans preparation 47
Punching sheet, method of 13f
U
R Ultra-thin polycarbonate crown form 91
Resin cement 17, 20
Resin modified glass ionomer 17, 51
V
Restoration, temporary 62 Vinyl ethyl methacrylates 88
Restoring primary teeth, importance of 4
Reverse metal post-insertion technique 130 W
Rubber dam 11 Wedging 39
apparatus 11 Wipe excess cement 60
application 10
clamps 11, 13 Z
forceps 11, 13 Zinc oxide eugenol 17f, 51
frame 11, 12, 12f cement 17, 18, 70
isolation 129 Zinc phosphate 17, 17f, 18, 20, 51
napkin 12f, 15 cement 18
placement 15, 79 Zinc polycorboxylate cement 17
punch 11, 12, 13f Zinc silicophosphate 51
sheet 11, 12f Zirconia pediatric crowns 112
template 11, 12 ZIRKIZ crown 112f