Stainless-steel crowns

Stainless-steel crowns should be considered whenever posterior primary teeth (especially frst
molars) require restoraton

Preparation :

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The bur should be angled away from the vertcal so that a shoulder is not created at the gingival
margin.

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A cast crown is retained by fricton between the walls of the prepared tooth and the internal surface
of the crown. It is, therefore, important to have near parallel walls of adequate height. A stainless-

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steel metal crown is retained by contact between the margins of the crown and the undercut
porton of the tooth below the gingiva. The shape of the preparaton above the gingiva is relatvely
unimportant

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advantages

1. Single visit for placement.

2. Relatvely quick and simple procedure.

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3. Usually reduce sensitvity totally, because they cover the whole tooth.
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4. Inexpensive compared with cast restoratons.

5. Good retenton rate.

disadvantages:
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1. Require more tooth preparaton than cast preparatons.

2. Once a tooth has been prepared for a stainless-steel crown, it will need a full coverage
restoraton eventually. It has been suggested that placing orthodontc separators 1 or 2 weeks prior
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to preparaton reduces the amount of tssue requiring removal. However, some reducton is usually
necessary.

3. Gingival margins are sub-gingival.

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Operative techniuee

1. Obtain adequate anaesthesia.

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2. Isolate the tooth to be crowned.

3. Select the crown size.

4. Remove any carious dentne and enamel.

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5. Replace tooth bulk with glass ionomer.

6. Reduce the occlusion minimally.

 7. Reduce the mesial and distal surfaces, slicing with a fne tapered bur.  break the contacts
Depending on the natural anatomy of the tooth it may be necessary to create a peripheral chamfer
on the buccal and lingual surfaces.

8. Try the selected crown; adjust the shape cervically, such that the margins extend ~1 mm below
the gingival crest evenly around the whole of the perimeter of the crown. Sharp Bee Bee scissors
usually achieve this most easily, followed by crimping pliers to contour the edge to give spring and
grip. Permanent molar preformed metal crowns need this because they are not shaped accurately

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cervically. This is because there is such a variaton in crown length of the frst permanent molars.

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9. Afer the contouring, smooth and polish the crown to ensure that it does not atract excessive
amounts of plaque.

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10. Afer test fitng of the crown remove the rubber dam to check the occlusion then re-apply for
cementaton.

11. Cement the crown usually with a glass ionomer based cement.

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12. Remove excess cement carefully with an explorer and knoted oss. .inally recheck the
occlusion.

Anterior teeth
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'strip crown technique'. This utlizes celluloid crown forms and a light-cured composite resin
to restore crown morphology
Strip Crowns (3M ESPEE) are a useful aid in the restoraton of primary incisors.
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In the authors opinion, these crowns are excellent for building primary incisors where
extensive tooth tssue has been lost due to either caries or trauma. The technique for their
use is similar to that of such crowns used in permanent teeth;
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Steps :
1. the crowns are easily trimmed with sharp scissors ( 1mm beyond cavity margins )
2. flled with composite, and
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3. seated on a prepared and conditoned tooth.

4. The celluloid crown form can be stripped of afer the composite has been cured.
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Early childhood caries

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Early childhood caries (ECC) is a term used to describe dental caries presentng in the
primary dentton of young children. Terms such as 'nursing botle mouth', 'botle mouth
caries', or 'nursing caries' are used to describe a partcular patern of dental caries in which
 the upper primary incisors and upper frst primary molars are usually most severely
afected. The lower frst primary molars are also ofen carious, but the lower incisors are
usually spared⎯being either entrely caries-free or only mildly afected.. Such children ofen
have multple carious teeth and may be slightly older (3 or 4 years o age) at inital
presentaton This presentaton of caries is sometmes called 'rampant caries'. There is,
however, no clear distncton between rampant caries and nursing caries, and the term
'early childhood caries' has been suggested as a suitable, all-encompassing term.

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ETIOLOGY 

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1. frequent consumpton of a drink containing sugars from a botle or 'dinky' type
comforters
2. .ruit-based drinks are most commonly associated with nursing caries. The sparing of
the lower incisors seen in nursing caries is thought to result from the shielding of the

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lower incisors by the tongue during suckling, whilst at the same tme they are being
bathed in saliva from the sublingual and submandibular ducts. The upper incisors, on
the other hand, are bathed in uid from the botleefeeder
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3. children who tend to fall asleep with the botle in their mouths are most likely to get
ECC, and this is probably a re ecton of the dramatc reducton in salivary ow that
occurs as a child falls asleep.
4. linear enamel defects and malnutriton, may play an important role in the aetology
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of this conditon.
5. ECC may be associated with prolonged, on-demand breast-feeding. Breast milk
contains 7% lactose and, again, frequent, prolonged, on-demand consumpton
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appears to be an important aetological factor.

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Temporization of open cavities

As an inital step in the management of caries, open cavites should be handexcavated and
temporized with a suitable material such as a reinforced zinc oxide and eugenol cement, or,
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beter stll, a packable glass ionomer cement . Carious exposures of vital or non-vital teeth
can be dressed with a small amount of a polyantbiotc steroid paste (Ledermix) on coton
wool covered by a suitable dressing material.
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Temporizaton of teeth:
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• helps to reduce dental sensitvity and prevent toothache occurring before defnitve care is
complete;
• reduces the oral mutans streptococci load;
• serves as an introducton to dental treatment; and
 • provides a source for uoride release if a glass ionomer-based material is used.

Indirect pelp capping

All caries is frst cleared from the cavity margins with a steel round bur running at slow

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speed. Gentle excavaton then follows on the pulpal oor, removing as much of the

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sofened dentne as possible without exposing the pulp. Precisely how much dentne should
be removed becomes a mater of experience and clinical judgement, although some have
advocated the use of indicator dyes (e.g. 0.5% basic fuchsin) to show when all infected

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dentne has been eliminated.
A thin layer of seitng calcium hydroxide cement is then placed on the cavity oor to
destroy any remaining microorganisms and to promote the depositon of reparatve

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secondary dentne. In its classical applicaton, the indirect pulp cap was covered with zinc
oxide-eugenol cement, and following several weeks' observaton, the cavity was re-entered
to remove all remaining sofened dentne. More commonly, the calcium hydroxide pulp cap
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is simply covered with a layer of hard seitng cement and the tooth permanently restored at
the same visit. If, as has been discussed in the previous sectons, the pulp is deemed to be
in amed, pulp therapy should be considered even in the absence of a clinical exposure.
Direct pulp capping should not be carried out if an exposure is found on removal of caries,
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as placing a medicament, such as calcium hydroxide on an in amed pulp will lead to failure.
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PULPOTOMY in primary ( see below chart )

Direct pulp capping has a poor prognosis in carious primary molars.

• Pulpotomy has a beter prognosis than pulp capping.

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• A pulpotomy should only be performed when the pulp in ammaton is thought to be limited to
the coronal pulp.

• .erric sulfate (15.5%), available as Astringident is emerging as a good alternatve to formocresol for
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use as a pulp medicament.

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FISSURE SEALING
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Introduction
.issure sealants cannot be discussed in isolaton from caries diagnosis or treatment of pit
and fssure caries. The authors discuss use of these materials both preventvely and
therapeutcally. Toothbrush bristles cannot access the pit and fssure system because the
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dimensions of the fssures are too small. As a result micro-organisms remain undisturbed
within the fssure system. The tooth is most susceptble to plaque stagnaton during
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erupton, that is, a period of between 12 and 18 months. During this tme, children need
extra parental help in maintaining their oral hygiene.
The main benefciaries are:
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1. Children and young people with medical, intellectual, physical, and sensory
impairments, such that their general health would be jeopardized by either the
development of oral disease or the need for dental treatment
2. All susceptble sites on permanent teeth should be sealed in children and young people
with caries in their primary teeth (dmfs = 2 or more).
 3. Where occlusal caries afects one permanent molar, the operator should seal the
occlusal surfaces of all the other molars.
4. If the anatomy of the tooth is such that surfaces are deeply fssured, then these should
be sealed.
5. Where potental risk factors, such as dietary factors or oral hygiene factors, indicate a
high risk of caries, then all sites at risk should be sealed.
6. Where there is a doubt about the caries status of a fssure or it is known to have caries

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confned to the enamel, fssure sealants may be used therapeutcally.

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Clinical techniuee

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(a) Pretreatment prior to sealant application
Tooth preparaton with pumice and a rotary brush results in a good clinical
retenton rate. Dry brushing achieves similar results. Air polishing, using a 'Prophy-

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Jet', an early air abrasion system that uses sodium bicarbonate partcles as the
abrasive medium, provides good bond strength and sealant penetraton but has not
received general acceptance, probably, because most dental surgeries do not
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possess this equipment. Some researchers have advocated the use of
'Enameloplasty', a more aggressive interventon into the tooth, that is, mechanical
enlargement of the fssures with a bur or with air abrasion, to improve sealant
penetraton and reduce micro-leakage.
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(b) Etching
Etching for just 20 s with a range of concentratons of acid but most ofen, 35-37.5%
phosphoric acid is the tried and tested method. Its one drawback is the susceptbility of
the etched surface to saliva or moisture contaminaton, which reduces the bond
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strength. Salivary contaminaton results in signifcantly reduced bond.

(c) Bonding agents
Bonding agents used as an additonal layer under a resin sealant yield bond strengths
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signifcantly greater than the bond strength obtained when using sealant alone. The
use of a bonding agent under a sealant on wet contaminated surfaces yields bond
strengths equivalent to the bond strength obtained when sealant is bonded directly to
clean etched enamel without contaminaton.
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Retreatment
If the clinician places fssure sealant in newly erupted teeth it is more likely to fail, but
should stll be placed as early as possible, because the teeth are more vulnerable to
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caries at this tme. Even with the very poor retenton rates, sealing with glass ionomer
does seem to infer some caries protectve efect. This may be due to both the uoride
released by the glass ionomer and residual material retained in the botom of the
fssure, invisible to the naked eye. Hence, glass ionomers, used as sealants can be
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classed as a fssure sealant but more realistcally as a uoride depot material. They can
be usefully employed to seal partally erupted molars in high risk children since
erupton of the molars takes 12-18 months and during this tme they are ofen very
difficult to clean
 Filled or unflled resins? Retenton is beter for unflled resins probably because it
penetrates into the fssures more completely. It also does not need occlusal
adjustment as it abrades very rapidly. If a flled resin is not adjusted there is a
perceptble occlusal change, possible discomfort, and wear of the opposing antagonist
tooth.
Coloured or clear material? Opaque sealants have the advantage of high visibility at
recall. It has been found that identfcaton error for opaque resin was only 1% while

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for clear resin the corresponding fgure was 23% with the most common error being

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false identfcaton of the presence of clear resin on an untreated tooth. The
disadvantage of opaque sealant is that the dentst cannot examine the fssure visually
at future recalls

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Factors efecting Pit and fssure sealants 

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Patient factors
(a) Caries in primary teeth l&
(b) Caries in permanent teeth
(c) Pt with medical, mantal problems
(d) Risk factors
Tororth factors
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(a) Deep fssures

(b) Hypominerlizaton
(c) Hypoplasia
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(d) Difficult to clean  narrow fssures or erupton period

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