Crowns in pediatric

dentistry
Crown is a restoration that covers a tooth to restore it
to normal shape and size
 Should represent the normal tooth. Should restore
normal function , esthetics, arch length.
 Color should match adjacent teeth
 Should be biocompatable
 Should be economical
CLASSIFICATION

ACCORDING TO MATERIALS USED:

 STAINLESS STEEL CROWN
 NICKEL CHROMIUM CROWN
 POLYCARBONATE CROWNS
 PEDO STRIP CROWNS
ACCORDING TO LOCATION
CROWNS FOR ANTERIOR TEETH
CROWN FOR POSTERIOR TEETH

ACCORDING TO FORM AND CONTOUR

 UNTRIMMED , UNCONTOURED AND UNCRIMPED
 PRECONTOURED AND UNTRIMMED
 PRETRIMED , PRECONTOURED AND PRECRIMPED
FULL COVERAGE RESTORATION FOR
ANTERIOR TEETH
OBJECTIVE FOR ANTERIOR FULL
COVERAGE RESTORATIONS

 Restoring esthetics
 Preventing psychological trauma
 Restoring the function
 Maintaining occlusion
 Complete coverage of teeth , thereby preventing
fracture.
INDICATION

 Primary anterior teeth with severe dental caries

 Malformed teeth
 Fractured teeth
 Full coverage following pulpotomy or pulpectomy
 Discoloured anterior teeth
TYPES OF FULL COVERAGE
RESTORATIONS FOR ANTERIOR TEETH
Polycarbonate crowns
Acid etch composite crowns ( strip crown)
Stainless steel crowns
Open faced stainless steel crowns
Veneered stainless steel crowns
Post cowns in nonvital primary anterior teeth
POLYCARBONATE
CROWNS
POLYCARBONATE CROWNS

 ARE preformed acrylic resin crowns

 Widely used prior to introduction of composite resins

TECHNIQUE

 Caries Removal and application of pulp protecting agents

 Administration of L.A
 Selection of Crown Size
 According to mesiodistal width
 Placement of rubber dam
 Tooth Preparation
Can be performed in 2 ways
Tooth structure intact in cervical region- shoulderless jacket
preparation
Damaged- with shoulder
SHOULDERLESS PREPARATION
 Caries Removal, Pulp protection
 Reduce labial surface – 0.5 mm
 Reduce incisal edge- 1 mm
 Reduce lingual surface- 0.5 mm
 Create undercut around tooth

PREPARATION WITH SHOULDER

 After caries excavation , if ledge formed – modified to
shoulder
 Roughening of interior surface

 Cementation
 With zn phosphate or GIC
ADVANTAGE
 Improved esthetics
 Helps in phonation

DISADVANTAGE
 Difficult to place
 Poor retention
 Prone to wear
 Brittle
 No choice of shade
 Margins cannot be crimped
Anterior Strip Crowns
Anterior Restorations
 STRIP CROWNS (Direct resin crowns , Composite resin
crowns, Acid etch composite crowns, Celluloid crowns)

 Are cellulose acetate crown forms which are used to make

anterior aesthetic restorations with composite resins

 Disadvantage – tooth reduction required to provide space

for restorative material
RECOMMENDED MATERIALS
Cellolose strip crown
Curved crown scissors
Resin composite restorative material
Bonded Resin composite strip crown is perhaps the
most esthetic of all the restoration available to the
clinician for treatment of severely decayed primary
incisors.
However strip crowns are also most technique senstive
and may be difficult to place ,Dr . Kupietzky in 2002
STEPS IN PLACEMENT OF
STRIP CROWN
ADVANTAGES
More esthetic crowns
Improved retention
Better wear resistance

DISADVANTAGE
More technique sensitive
Fracture when traumatised
D.Ram & A. B.Fuks (2006)(BSPD)
Concluded high success rate of resin bonded
composite strip crowns with a 2 year follow up &
suggests this treatment modality is an aesthetic and
satisfactory means of restoring carious primary
incisors in young children.The retention rate is lower
in teeth with decay in three or more surfaces.
Stainless Steel Crowns
 INTRODUCTION
Objectives of restoration of primary molars:
mastication
maintaining of space

SSC introduced to pediatric dentistry by Humphery 1950

Its stainless steel metal made either trimmed or contoured as

necessary to fit individual teeth
The SSC is an extremely durable restoration in
children with extensive decay or multisurface
lesions in primary molar should be treated with
SSC.
Stainless steel crowns are full coverage restoration that
increased durability and longitivity

 Finally a strong argument for the use of SSC

restoration is its cost effectiveness based on its
durability and longitivity.
Advantage of Stainless Steel Crowns
Durable
Inexpensive and cost-effectiveness
Quick placed
Preventive aspect
No potential for long-term follow-up and parental
compliance in home care
Disadvantages of Stainless Steel Crowns

Appearance

occlusal surface may wear

Gingivitis is common around defective margins

HUMPHERY first published his article on the use of chrome
steel in children’s dentistry in 1950
Chrome steel restoration has been used for nearly 300 years
The initial crown preparation as suggested by Mink and
Bennett is still being used.
Types of stainless steel
crowns

Indications for use of

stainless steel crowns
COMPOSITION OF STAINLESS STEEL CROWNS

 STAINLESS STEEL CROWNS (18- 8 CROWNS)

 NICKEL – BASED CROWNS

STAINLESS STEEL CROWNS- (18-8 crowns)
 Martensitic type
Ferrite types
Austenitic types
The composition is
-Chromium – 17-19%
-Iron- 67%
-Minor elements- 4%
 -Nickel – 10-13%
NICKEL BASE CROWNS
Nickel – 76%
Chromium – 15%
Iron- 8%
Carbon- 0.08%
Manganese – 0.35%
Silicon – 0.2%
ACCORDING TO TRIMMING
Untrimmed Crown
Pretrimmed Crown
Precontoured Crown
ACCORDING TO COMPANY NAMES
Rocky mountain
Unitek
3M
Iconel
ACCORDING TO OCCLUSAL ANATOMY
Ion
Unitek
Rocky mountain
Ormco
Anterior Stainless Steel Crowns
Anterior SSC with
window
Preveneered stainless
steel crowns
Stainless Steel
Pre-fabricated
Full coverage restoration
Pre-crimped with 6 sizes
Adapted to tooth
Stainless Steel Indications
Pulpotomy

Fractured teeth
Restoration of primary or
young permanent teeth
with extensive carious
lesions.
Restoration of hypopastic primary or permanent
teeth
Restoration of teeth with hereditary anomalies
such as dentinogenesis imperfect or amelogenesis
imperfect
As an abutment for space maintainers
or prosthetic appliances.
Crown and loop
Placed on tooth that has
extensive decay with
space maintenance
needs
Space Maintainer
Distal Shoe / loop
High caries risk children
Single tooth crossbite
For replacing prematurely lost anterior teeth
 FACTORS TO BE CONSIDERED
IN PREOPERATIVE EVALUATION
DENTAL AGE OF THE PATIENT
COOPERATIPON OF THE PATIENT
MOTIVATION OF THE PARENTS
MEDICALLY COMPROMISED / DISABLED
CHILDREN
ARMAMENTARIUM
Crown Cutting burs
Pliers
Scaler
Crown and bridge scissors
Crown seater and remover
Stone and finishing burs
Cements
Stainless Steel Crown Placement

Copyright © 2006 Thomson Delmar Learning. ALL RIGHTS RESERVED. 16

EVALUATE THE PREOPERATIVE
OCCLUSION
 Take the alginate impression of U/L dental arch of
the patient
 Pour the cast in dental stone
 Note the dental midline and cusp fossa
relationship bilaterally
 Pick the crown with the help of sterile tweezers or
thumb foreceps.
 
CROWN SELECTION
The main considerations in selecting the proper
stainless steel crown are adequate mesiodistal
diameter , PROPER OCCLUSAL HEIGHT.
A crown should be somewhat larger than the tooth to
which it is being adapted
Determine the mesiodistal width of crown from either
pre – measured chart or measure it using boley gauge
or varnier calipers.
TOOTH PREPARATION

PRE – REDUCTION
OCCLUSAL REDUCTION
PROXIMAL REDUCTION
BUCCAL / LINGUAL
FINISHING
 TOOTH PREPARATION

 Administration of L.A

 Isolation
 Rubber dam
 Cotton rolls
PREREDUCTION
 Evaluate the occlusion by visual examination and
transfer this relation on the wax sheet by asking the
patient to bite on it.
OCCLUSION REDUCTION
169L tapered fissure bur
 Reduce the occlusion by about 1.0 – 1.5 mm
uniformly along the cuspal structure
OCCLUSION REDUCTION
PROXIMAL REDUCTION
169L tapered fissure or thin needle shaped bur.
 Break proximal contacts at appropriate
depth in single sweeping motion.
 Avoid bur damage on adjacent teeth

 Feather-edge finish line.

 Common error - ledge formation
PROXIMAL REDUCTION
BUCCAL LINGUAL REDUCTION
 Great diversity of opinions exists over this part of the
preparation
Mathewson et al(1974) and Savides(1979) believed
that retention depended more upon cement than
upon the remaining undercut
Savides showed that retention was higher with
greater buccal and lingual residual undercuts. So aim
should to remove as little as possible from buccal and
lingual aspect of the tooth crown
BUCCAL LINGUAL REDUCTION
 169L or diamond bur
 Round off all line
angles.
 Occasionally, an
exagerrated mesiobuccal
or cervical bulge
may warrant more
buccal and lingual
reduction.
FINISHING
Reduce and round off all line angles and sharp corners
of preparation with the help of finishing bur
The preparation is completed by beveling the external
line angles around the occlusal part and where the
proximal reduction meets the buccal and lingual
surfaces
There should be a gap of 1- 1.5 mm between the
prepared tooth and opposing tooth during occlusion.
This is verified by asking the patient to bite on the wax
block and no marking of prepared tooth should be
observed.
Tooth is now ready for trial fitting
CROWN SELECTION AND TRY IN
 SELECT smallest crown that completetly covers the
preparation.
 Occlusal dimensions of SSC should be same as
pre-op. tooth.
 Impingement upon the primate space by an oversized
crown may prevent early mesial migration of the
mandibular first permanent molar from a cusp to cusp
occlusion into an Angle Class I relationship (Baume
1950)
Most commonly used molar SSC is size 4.
CROWN SELECTION
Unitek or Ion stainless – steel crown is superior to the
others mentioned
 The correct size of preformed crown will seat into the
residual undercut with a degree of pressure from
finger or thumb .
Robert H.Spedding, 1984 formulated two principles to
improve the technique for crown adaptation
PRINCIPLE I- Stainless steel crown length
PRINCIPLE II- Shapes of stainless steel crown
margins
Based on tooth morphology and contours of
marginal gingiva.
STAINLESS STEEL LENGTH
Primary molar have characteristic convergence from
marginal gingival crest towards occlusal surface that
shows greatest diameter of tooth located adjacent to
these crests.
Margin of crown should be located at some point in
the gingival sulcus
As the metal crown is reduced in length, its margins
come closer to greatest diameter of tooth crown, & the
space between margins of crown and tooth surfaces is
lessened & metal margins can be adapted closely to
tooth.
SHAPE OF STAINLESS STEEL CROWN MARGIN
Should follows the contours of marginal gingiva
BUCCAL AND LINGUAL MARGINAL GINGIVA:-
 Second primary molars ,the greatest occlusogingival
height of the clinical tooth crown is found midway on
the buccal and lingual surfaces and decreases
gradually towards both mesial and distal surfaces.So
outline of these marginal gingiva resemble SMILES.
First primary molar:Greatest occlusogingival height on
the buccal surfaces located at mesiobuccal side.So
buccal marginal gingivae of these teeth resmble
Stretched – OUT- S
But the contours of lingual marginal gingiva resmble
SMILES.

PROXIMAL MARGINAL GINGIVA

All primary molars: The shortest occlusogingival height
located midway in a buccal lingual direction,opposite
that observed on buccal and lingual surfaces .So these
margins appear to FROWN.
CROWN ADAPTATION
 Remove the rubber dam
 Festooning on proximal surface should be performed
before try in as it will limit the blanching sign.
 Festooning is performed with help of stone burs
depending on shape of tooth
 Place crown on lingual side
 Crown should fit lossely with 2-3mm excess gingivally
 With a scaler scratch around the gingival margin
on the crown or mark with a glass marking pencil.
This scratch line indicates the the portion of crown
to be removed.
 With the help of crown bridge scissors , cut the
crown 1mm below the scratch line. Now smoothen
the edges with finishing burs. Retry the crown on
the tooth .
 Trim only in areas where blanching is visible.
CONTOURING OF THE CROWN
Contouring reciprocate the
original contour of the tooth
Most of the crowns provided
today are precontoured
Done with the help of no. 114
Johnson contouring pliers.
CRIMPING THE CROWN
 Crimping involves bending the gingival 1/3of the
crown’s margins inward to establish a tight marginal fit
and adaptation.
 Pliers - #114, 417
 ION crowns require
least adjustments
S S C- PRIMARY MOLAR
Linguo-buccal Seating of crown
Snap fit.
CROWN FINISHING
A slow speed handpiece is used to produce a sharp
featheredge at gingival margin . Crown is then
smoothened with finishing burs and polished with
rubber wheel
FINAL ADAPTATION
Fit the finished crown and check for occlusal harmony
Ask the patient to carry out the masticatory
movement
Check for any destabilization or rocking of crown
Evaluate for blanching
Take a pre cementation radiograph
CROWN CEMENTATION
Rinse and dry crown
Prepare glass ionomer
cement and fill crown to
2/3 with all inner
surfaces covered.
 Seat crown completely
 Remove excess cement
from margins
 Rinse and floss
interproximal
areas
 Check occlusion
CEMENTATION
Remove excess cement SSC
SSC IN PRIMARY MOLAR
 SPECIAL CONSIDERATIONS FOR
STAINLESS STEEL CROWNS
QUADRANT DENTISTRY
ACCORDING TO Nash 1981
Prepare the occlusion reduction of one tooth
completely before beginning the other as there is a
tendency to underreduce both when reduction on
them is done simultaneously
Reduce the adjacent proximal surface of the teeth
being restored more than when only one tooth is
restored.
Both crowns should be trimed , contoured and
prepared for cementation simultaneously to allow
adjustmant in interproximal spaces.
Seat the crown on the most distal tooth first and
proceed mesially
CROWN IN AREAS OF SPACE LOSS
Mc Evoy( 1977)
When there is extensive and long standing caries
Select larger crown which will fit over the greatest
convexity
Reduce the MD width by grasping the marginal
ridge of the crown with Howe utility pliers
Recontour the proximal buccal lingual walls of the
crown with the No. 137,114 pliers
Preparing SSC adjacent to class II Amalgam (Mc
Evoy 1985)
Crown reduction is completed and the crown is
adapted
Next a matrix band and wedge are placed.Amalgam
is inserted and carved
Crown is removed without fracturing amalgam
Remove the matrix band and final carving of
amalgam is done
Complete the crown adaptation and cement it
CONCERN ABOUT EXFOLIATION
Stainless steel crowns do not interfere in any way with
the normal exfoliation of primary molar, with stainless
steel crown the primary molar crown being exfoliated
together.
SUCCESS RATE OF SSC COMPARED WITH
OTHER RESTORATIONS IN PRIMARY MOLARS

Researches have shown that SSC restoration of

primary molars is superior to that achieved with
Amalgam , Composite resin , Glass Ionomer
Cement.
Once fitted the crowns seldom need replacement
STAINLESS STEEL CROWNS
Approximately 90% successful from
time of placemant regardless of age
Failures mainly due to pulp pathology Success rate is more when life
not due to restoration failure
More expensive
MUTI SURFACE SILVER
AMALGAM RESTORATIONS
Approximately 50% failure rate when
placed in children less than 4 years of
age
expectancy of the tooth is less than 3
years
Cheaper than crowns
COMPLICATIONS

INTERPROXIMAL LEDGE

 Produced if the angulation of tapered fissure bur is incorrect.

 Occurs commonly when adjacent tooth is partially erupted

and contact area is poorly established
POOR MARGINS

 Occurs when crown is poorly adapted.

 Recurrent caries may occur around poor margins

 Increased chances of plaque retention and subsequent

gingivitis.
INHALATION OR INGESTION OF CROWN

 Can occur due to sudden movement

Prevention
 Rubber Dam should remain in place till cementation –
prevents accidental swallowing or aspiration of the crown

Management
 Attempt by holding the child upside down
 If unsuccessful, medical referral for immediate chest x- ray
 If in bronchi or lung, bronchoscopy
CROWN TILT

 Occurs because of complete destruction of buccal or lingual

wall .

 Supraeruption of opposing tooth

OCCLUSION WEAR
 Children with tooth grinding habits may exhibit wear
through existing stainless steel crowns.
 Crown should be replaced
 If the wear is confined to a small area on the tip of the
cusp then a small amalgam restoration can be placed .
 MODIFICATIONS OF STAINLESS STEEL CROWN

 Oversized Crown

 Undersized Crown

 Open contact

 Open face Stainless Steel Crown

 Prefabricated Veneered Stainless Steel Crowns

Technique For Adapting oversized crown to tooth structure
UNDERSIZED CROWN
 A v shaped groove is made in the crown on the
buccal or lingual side
 Try the crown on the tooth for fit.
 Spot – weld a strip of orthodontic band material
over the V shaped groove
 Retry the crown on the tooth.
 Solder adapt contour and crimp the crown Polish
the soldered area and cement the crown.
Open contact

 By selection of larger crown or exaggerated interproximal

contour can be obtained with 112 plier to establish a close
contact.

 Interproximal contour can also be build by addition of a

solder
OPEN FACE STAINLESS STEEL CROWNS

 For grossly decayed anterior primary teeth

 A steel crown of appropriate size is selected , contoured at

the cervical margins, polished and cemented into place

 Most of the labial metal is cut away leaving a labial

window which is then restored with composite resin
(Croll 1998)
 PREFABRICATED VENEERED STAINLESS STEEL
CROWNS

 Available with a variety of facing materials – composite

resins, thermoplastic resins bonded to stainless steel
crowns either mechanically or chemically.
 Kinder crowns or Nusmile Primary Crowns

 Composite resin facing veneered directly to stainless steel

crowns
INDICATION
 When a full coverage restoration is needed for longevity
and for protection of remaining tooth structure.
ADVANTAGE
 Anatomically correct
 Color compatible tooth color
 Easy to place
 Less time consuming
 Durable
Purvi V Shah ,BS Jessica Y Lee (2004)(Pediatric
Dentistry)
 Conducted a study on clinical success and parental
satisfaction with anterior preveneered primary
stainless steel crowns
& concluded Kinder krown prefabricated resin faced
SSCs showed a low failure rate and the parental
satisfaction with treatment was positive.
 Cheng Crowns
 These are crowns with a pure resin facing which makes
them stain resistant
 These are pre crimped
 ADVANTAGES
 Less time consuming
 Less technique sensitive
 Require single patient visit
 Stain resistant
 Advantages
 Enhanced esthetics
 Retention similar to stainless steel crowns

 Disadvantages
 Contouring or crimping may lead to fracture
 More expensive
 Cannot be heat sterilized – cause veneer damage
 Whiter Biter Crowns
 Have flexible thermoplastic resin veneered by
welded metal meshwork for mechanical retention
Thank-you!