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Stainless steel crown for Paeododontics

Stainless Steel Crowns for paedodontics. Victor Babes University, Timisoara, Romania.

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Stainless steel crown for Paeododontics

  3. 3. CONTENTS: • Guide of restorations in Paediatric dentistry • Classification of Paediatric crowns and types • Stainless steel crown (SSC) as restorative treatment option • Comparison with GIC, compomers resin modified GIC restoration • Alternative or Atraumatic Restorative Treatment (ART) and Aspects of SSC • History of SSC • Case control studies about Hall Technique • How SSC works in Hall Technique • Indications and contraindications in pictures • To be or Not to be: Case discussion • Restoration Protocol- Hall Technique • Restoration protocol with Tooth preparation
  4. 4. Age: Year 2-14 Restorative and preventive Dental treatment is very important. 1. developmental status of the dentition 2. caries-risk assessment 3. patient’s oral hygiene 4. anticipated parental compliance and likelihood of recall 5. patient’s ability to cooperate for treatment IMPORTANT ASPECTS IN PAEDODONTICS
  5. 5. Recommendations for Pediatric Oral Health Assessment, Preventive Services, and Anticipatory Guidance/Counseling
  6. 6. 1. Dentin/enamel adhesives 2. Bisphenol A and dental materials 3. Pit and fissure sealants ( for healthy permanent teeth) 4. Glass ionomer cements 5. Resin-based composites 6. Amalgam restorations 7. Resin Infiltration ( Example: ICON technique for white lesions) 8. Fixed prosthetic full coverage crown restorations ( stainless steel and others) 9. Removable prosthetic appliances •Removable prosthetic appliances may be indicated in the primary, mixed, or permanent dentition when teeth are missing. Removable prosthetic appliances may be utilized to: •1. maintain space using space maintainers •2. obturate congenital or acquired defects •3. establish esthetics or occlusal function; or •4. facilitate infant speech development or feeding JOHN HAS DECAYS IN PRIMARY TEETH. WHAT TREATMENT OPTIONS WE CAN DO after or before classic caries removal process?
  7. 7. The types of full coverage for primary teeth currently available are: • Stainless steel crowns • Open faced steel crowns • Polycarbonate crowns • Resin (composite) strip crowns • Pre-veneered steel crowns • Zirconia Crown The crowns that are available for restoring primary teeth can be placed into 2 categories: • those that are preformed and held onto the tooth by a luting cement. Example: Stainless steel crowns. • those that are bonded to the tooth. Example: Open faced or pre veneered CLASSIFICATION: BASED ON COMPOSITION 1. Stainless steel crowns 2. Nickel-Base Crowns 3. Tin-Base Crowns 4. Aluminium base crown
  8. 8. Stainless steel crowns Open faced steel crowns Polycarbonate crowns
  9. 9. Resin (composite) strip crownsResin (composite) strip crowns Pre-veneered steel crownsZirconia crowns
  10. 10. Restoration and Placement Area Aesthetics Durability Time and how easy for placement Cost Selection Criteria Stainless Steel crowns(Posterior Teeth) Poor Very good. Very retentive. Wears well. Fast. Easy to fit. Aesthetic not a concern. Moderate cost. Aesthetics not involved. Severely decayed teeth. Use when unable to control gingival haemorrhage or moisture and less than ideal patient cooperation. Open faced Stainless Steel crowns (Posterior and anterior Teeth) Fair. Metal shows through facing Good. Crown retentive. But facing may dislodge. Long two steps process. 1. Crown cementation 2. Composite replacement Moderate cost and including composite it is higher than SSC. Severely decayed teeth. Good durability and retention needed ( Bruxism, trauma prone child). Parents are concerned about aesthetics. Pre-veneered stainless steel crowns (Posterior and anterior Teeth) Good. Limited shades Good. Crown retentive. But facing may break. Moderate. Longer than SSC due tooth reduction and adaptation Higher than only Stainless steel crown. Severely decayed teeth. Good durability and retention needed. Child is trauma prone and bruxes. Parents are concerned about the aesthetics. Posterior and anterior colour match for restoration. Resin Composite strip Crowns (Anterior teeth) Very good Required adequate tooth structure for retention. Easily fractured with trauma or traumatic occlusion. Will vary with ability to isolate teeth and control moisture. Most technique sensitive. Very little finishing of the restoration is required when the celluloid crown has been properly fitted. Depending on the resin composite it is higher than pre- veneered SSC. Aesthetics are of great concern. Adequate tooth structure. Patient is not prone to trauma. Patient is cooperative. Polycarbonate Crowns (Posterior and anterior teeth) Very good Required adequate tooth structure for retention. Less prone to fracture than resin composite strip crowns. Not as technique sensitive as resin composite crown. The cheapest option of full coverage crown. Aesthetics is a great concern. Patient is cooperative and require adequate tooth structure. Zirconia Crown Very good Very good retentive. High strength. For anterior and posterior. No impression: only 1 visit. Saliva an haemorrhage control is very important compare to other crowns. Try-in crowns are effective and time saving. Very high cost. Aesthetics is a high priority for parents. Strength and biocompatibility is concerned. Patient is not suffering bruxism. Patient is cooperative. Poor Fair Good Very Good
  12. 12. Guide to the use of restorative materials in Paediatric Dentistry PRIMARY DENTITION Occlusal ( Class I) Glass Ionomer cement (GIC) Composite Resin Compomer Proximal (Class II) GIC Compomer Amalgam Composite resin/GIC sandwich Stainless Steel Crown Gross Carious breakdown or restoration after pulp therapy Stainless Steel Crown PERMANENT DENTITION Occlusal table Fissure sealant Occlusal enamel caries Fissure sealant Occlusal caries with minimal involvement of dentine Preventive resin restoration Occlusal caries with extension into dentine Composite resin Interproximal Amalgam Incisal edge Composite resin Cervical GIC Composite resin
  13. 13. Posterior Primary Teeth GICs, resin-modified GICs and compomers Indications • Small occlusal and interproximal cavities. Because of their lack of strength, GICs should not be used in large restorations, particularly in teeth that need to be retained for 3 years or more. • The use of polyacid-modified composite resins/compomers show considerable potential, particularly in terms of handling characteristics and radio-opacity. • However, they have limited fluoride-leaching ability. SUCCESS The median survival time for conventional GICs is around 33 months. The failure rate of GICs is 33% over 5 years. High viscosity GICs demonstrate greater durability. Stainless steel crowns for Posterior Teeth Indications Stainless steel crowns are preformed extra-coronal restorations that are particularly useful in the restoration of: • Grossly broken down teeth. • Primary molars that have undergone pulp therapy. • Hypoplastic or hypomineralized primary or permanent teeth. • Dentitions of children at high risk of caries, particularly children having treatment under general anaesthesia. SUCCESS Stainless steel crowns undoubtedly provide the most durable restoration for the primary dentition with survival times in excess of 40 months. Relatively expensive in relation to both time and money in the short term. However, the rate of replacement of these restorations is low (3% compared with 15% for class II amalgam restorations). This makes them economic.
  14. 14. The technique is named after Dr Norna Hall, a general dental practitioner from Scotland, who developed and used the technique for over 15 years until she retired in 2006. A retrospective analysis of the outcomes for the teeth she treated in this way was published in the British Dental Journal in 2006. 1990 : HALL TECHNIQUE 1950: Humphrey and Engel recommended stainless steel crowns 1968: Mink and Bennett encourages familiar treatment modalities HISTORY OF STAINLESS STEEL CROWN STAINLESS STEEL CROWN IS KNOWS AS: 1. Untrimmed crowns: e.g. Rocky mountain 2. Pre-trimmed crown: straight, non contoured sides but are festooned to follow a line parallel to the gingival crest, e.g. (Unitek stainless steel crowns, 3M Co., and Denvo crowns, Denvo Co. Arcadia, CA). Pre-contoured crown : festooned and precontoured, (e.g. Ni-Chro Ion crowns and Unitek stainless steel crowns and 3M Co.).
  15. 15. Stainless Steel Crowns Composition: • 17-19% chromium • 10-13% nickel • 67% iron • 4% minor element • These crowns are available in various sizes. • Mostly these crowns are used in posterior teeth which undergone pulp therapy. Other compositions: Nickel – base Crowns 72% nickel , 14%chromium, 6-10% Iron, 0.04% carbon 0.35% manganese, 0.2% silicon • The alloys have good formability and ductility necessary for clinical adaptation of crowns and wear resistance to resist opposing occlusal forces.
  16. 16. 2 year results for 124 teeth treated with the Hall Technique compared to 124 conventional restorations in a split mouth study with matched caries lesions prior to treatment Patient, carer and dentist preferences for Hall Technique or conventional restorations in a split mouth study for 132 children (264 teeth). Data from same study discussed above. A clinical trial set in nine general dental practices in Tayside, Scotland looked at outcomes at two years for teeth where a Hall crown was fitted, compared to teeth which had undergone conventional restorative treatment.
  17. 17. Alternative or Atraumatic Restorative Treatment (ART) AND STAINLESS STEEL CROWN Atraumatic Restorative Treatment compared to the Hall Technique for occluso-proximal cavities in primary molars: study protocol for a randomized controlled trial. Department of Cariology, Endodontics and Pedodontology, Academic Centre for Dentistry Amsterdam Hesse et al. Trials (2016) 17:169 ART was developed approximately 30 years ago and involves the use of manual instruments to prepare cavities, followed by placement of a high-viscosity GIC “A recent systematic review of the literature has shown the longevity of occluso-proximal ART restorations in primary teeth to be similar that of conventional restorations using amalgam, composite resin and compomer, suggesting that the real problem might be related to the type/extent of cavity and not the restorative material.” “However, preformed metal crowns offer physical protection to teeth affected by caries, through complete tooth coverage, as well as arresting caries progression. “
  18. 18. HOW STAINLESS STEEL CROWN CAN ARREST CARIES PROGRESSION? For decades, conventional teaching has been that all carious tooth tissue should be removed before restoring the tooth; how can leaving caries in the tooth be acceptable? However , except in extreme cases, the majority of tooth surfaces are relatively immune from caries. base of fissures contact point of proximal surfaces. 99% of dental caries begins on these two sites, which is Total 1% of the teeth Lack of supply of carbohydrates, oxygen, or pH for cariogenic potential of plaque Plaque and sugar would inevitably, after time, result in dental caries.
  19. 19. • Most plaque is not actively cariogenic. • Plaque which has matured in a sheltered environment to achieve cariogenic potential can lose that potential if its environment is altered. • The bacteria within the community respond to the environment and in an unfavourable environment, cariogenic bacteria will not continue to flourish. • Effective sealing from the oral environment can cause the necessary environmental change, resulting in plaque losing its cariogenic potential for as long as the seal is maintained. • The Hall Technique or Stainless Steel Crown is one method of achieving that seal for primary molar teeth. What about the soft dentinal lesion? How does the pulp react to caries? • dentine/ pulp complex is far from passive when exposed to dental caries. • tissues mount an active defence response from the earliest stages of carious lesion formation in the enamel. The dental pulp of a primary molar responding to dentinal caries by the deposition of reactionary dentine • This lesion is generally soft and active • the caries of soft dentinal lesion can be arrested, with the colour changing to dark brown or black.
  20. 20. • Stainless steel crown restorations are indicated for the restoration of primary and permanent molar teeth with1,3 • Extensive carious lesions which undermine cusps and expand beyond line angles • Cervical decalcification • Developmental defects such as hypoplasia and hypocalcification • Following pulpotomy or pulpectomy • For restoring a primary molar tooth to be used as an abutment for a space maintainer • The intermediate restoration of fractured teeth CONTRA-INDICATIONS FOR USE Stainless steel crowns are contra- indicated when: • More than two thirds of the roots are resorbed • There is clinical and/or radiographic evidence of radicular pathology • The tooth exhibits excessive mobility • Patient is non-cooperative where the clinician cannot be confident that the crown can be fitted without endangering the patient’s airway. • Parent or child unhappy with aesthetics. INDICATIONS FOR USE
  21. 21. irreversible pulpal involvement, and would contraindicate the placement of a Hall Crown/Stainless Steel Crown without pulp therapy There is a buccal sinus associated with this maxillary first primary molar (64). This mandibular first primary molar (84) has inter-radicular pathology, indicative of a dental abscess. This maxillary second primary molar (55) has an extensive mesioocclusal cavity, that has been painful, keeping the child awake at night. This is indicative of an irreversible pulpitis, or even an abscess developing. a mandibular first primary molar (84) which has given occasional pain, but is currently symptomless, is found to have non-physiological mobility. This, with the DO cavity and history, indicates a dental abscess This mandibular first primary molar ( 84) has a large disto-occusal cavity. Although symptomless, and with no inter-radicular pathology visible, there is no clear band of normal dentine between the caries and the pulp chamber. The pulp is almost certainly non-viable, and the tooth should have pulp therapy if a crown is to be placed.
  22. 22. This maxillary first primary molar (54) has a large multisurface cavity, with clinical exposure of a non-vital pulp chamber. Even in the absence of symptoms, this tooth should be extracted. This mandibular second primary molar (75) has a large occluso-lingual cavity which clearly involves the pulp chamber. Even in the absence of symptoms, the tooth should either be managed with pulp therapy or extraction. This maxillary first primary molar (64) has a pulp polyp. The pulp, although exposed, is vital. In the absence of symptoms, and clinical and radiographic signs, of sepsis, it would not be unreasonable to simply monitor the tooth This mandibular second primary molar (75) has a similar pulp polyp associated with the mesial root
  23. 23. TO BE OR NOT TO BE……
  24. 24. Primary molars with extensive caries lesions of a 6 year old child at 7.5. Stainless steel crown ?
  25. 25. 6 years old boy with caries in 6.2, 6.4
  26. 26. ??? When can Stainless Steel crowns be a suitable management option for carious primary molars?
  27. 27. When is there no need to fit stainless steel crowns? Insufficient tooth tissue Prevention needed. Caries arrested.Primary tooth already resorped Small Occlusal caries
  28. 28. The practical aspects of fitting a Stainless Steel Crown in Hall Technique
  29. 29. Instruments Needed Essential: • Mirror • Straight probe – to remove separators, if used • Excavator – to remove crown if necessary, and – useful for cement removal • Flat plastic – to load crown with cement • Cotton wool rolls – for child to bite down on and push crown over tooth, and – to wipe away cement • Band forming pliers – can be useful for adjusting crowns, particularly where the primary molar has lost length mesio-distally due to caries • Gauze to protect the airway and wipe off excess cement • Elastoplast to secure the crown for airway protection
  30. 30. Step 1. Assessing the tooth shape,contact points/ areas and the occlusion Step 2. Protecting the airway
  31. 31. Step 3. Sizing a crown Step 4. Loading the crown with cement
  32. 32. Step 5. Fitting the crown, and first stage seating Step 6. Wipe the excess cement away, check fit, and second stage seating Step 7. Final clearance of cement, check occlusion (adjusting crown if necessary) and discharge
  33. 33. Evaluate the preoperative occlusion • Take the alginate impression of U/L jaws. • Pour the cast with dental stone • Note the dental midline and the cusp fossa relationship bilaterally Selection of crown • The correct size crown is selected by the M-D dimensions of the tooth to be restored using Boley gauge. • To produce steel crown margins of similar shape examine the contour of gingiva of the buccal & lingual marginal gingiva. STAINLESS STEEL CROWN AFTER CROWN PREPARATION
  34. 34. Before Preparation, what need to do: • L.A. should be administrated • Isolation by rubber dam or cotton rolls • Remove the decay
  35. 35. • Occlusal reduction A 69L or 169L bur is used to reduce the occlusal surface by 1.5-2.0mm. • Proximal slices place the wooden wedges in the interproximal embrasures, the 69L bur is moved B-L across the proximal surface. • Buccolingual reduction • Round off all the line angles: It is done by using side of bur.
  36. 36. INITIAN ADAPTATION:  Two principles related to SSC length and margin shape that are based on an understanding of the tooth morphology and gingival tissue contours were presented by Spedding 1984. • The crown should be of a correct length and its margins should be adapted closely to the tooth. • For shaping the crown margins mark 3 light points on the metal at the (mesiolingual, lingual and distolingual)and at (mesiobuccal, buccal, distobuccal) surfaces at the crest of respective marginal gingiva without compressing the marginal gingiva.  Final finished margins are placed approximately 1mm below these marks. SEATING THE CROWN  Now the crown is tried on the preparation by seating the lingual first and applying pressure in a buccal direction so that the crown slides over the buccal surface into the gingival sulcus.  Resistance should be felt as the crown slips over the buccal bulge.
  37. 37. CROWN CONTOURING Initial crown contouring is performed with a 114 plier in the middle 1/3rd of the crown to produce a belling effect. This will give the crown a more even curvature. CROWN CRIMPING  The tight marginal fit aids in: 1. Mechanical retention of the crown. 2. Maintenance of gingival health. 3. Protect of cement from exposure to oral fluids. CROWN CONTOURING CROWN CRIMPING
  38. 38. CHECKING THE FINAL ADAPTATION OF THE CROWN • The crown should be replaced on the preparation after the contouring procedure to see that it snaps securely into place. • The occlusion should be checked at this stage to make sure that the crown is not opening the bite or causing a shifting of mandible into an undesirable relationship with opposing teeth. FINISHING AND POLISHING • Accumulation of plaque and inflammation of gingiva is commonly seen in practice of restorative dentistry due to rough and unpolished restoration. • To avoid these complications crown should be polished prior t o cementation with rubber wheel to remove all scratches. RADIOGRAPHIC CONFIRMATION OF GINIGIVAL FIT: Before cementation a bitewing is taken to verify proximal marginal integrity
  39. 39. CEMENTATION: • SSC should be cemented only on clean dry mouth, isolation of teeth with cotton roll is recommended. • Rinse and dry the crown inside & out side and prepare to cement it. • A zinc phosphate, polycarboxylate or GIC is preferred. • Before the cements set ask the patient to close into centric occlusion by applying pressure through a cotton roll and confirm that the occlusion has not been altered. • Remove the excess cement by an explorer or scaler & for interproximal area can be cleaned by passing dental floss through them. • Interproximal ledge. • Crown tilt. • Poor margins. • Inhalation or ingestion of crown. POSSIBLE COMPLICATIONS:
  40. 40. SPECIAL CONSIDERATION FOR SSC  Quadrant dentistry ( Nash, 1981) -Prepare the occlusal reduction of one tooth completely before beginning the other as there is tendency to under reduce both when reduction on them is done at the same time. -Reduce the adjacent proximal surface of the teeth being restored more than when only one tooth is restored. -Both crown should be trimmed, contoured and prepared before cementation simultaneously to allow for adjustment in inter proximal space and establish proper contact area.  Crown in area of space loss(Mc - Evoy 1977)  Preparing a SSC adjacent to a class II amalgam (Mc - Evoy 1985)
  42. 42. • AJ Nowak. Clinical performance of esthetic posterior crowns in Primary molars: a pilot study. Ped. Dent. 21:445-448, 1999.. Academy of Pediatric Dentistry. Pediatric Dentistry Handbook. ed.: 86-87, 1999. • American Association of Paediatric Dentistry. Guideline on Pediatric Restorative Dentistry. Clinical Affairs Committee – Restorative Dentistry Subcommittee. 2008 • Dafydd Evans & Nicola Innes. The Hall Technique minimal intervention, child centred approach to managing the carious primary molar:. University of Dundee 2011 • Daniela Hesse1*, Mariana Pinheiro de Araujo2, Isabel Cristina Olegário2, Nicola Innes3, Daniela Prócida Raggio2 and Clarissa Calil Bonifácio1. Atraumatic Restorative Treatment compared to the Hall Technique for occluso-proximal cavities in primary molars: study protocol for a randomized controlled trial.. 1Department of Cariology, Endodontics and Pedodontology, Academic centre for Dentistry Amsterdam (ACTA), Gustav ahlerlaan 3004, 1081LA, Amsterdam, The Netherlands. Hesse et al. Trials (2016) 17:169 • Fuks AB., Ram D., Eidelman E. Academy of Pediatric Dentistry. Special issue. Reference Manual. 21(5): 105, 1900-00. • Mcdonalds. Dentistry for Child and Adolescent,; 9th edition, chapter 16,17 and 18. • Paul S.Casamassimo , Henry W., Jr. Fields , Dennis J. McTigue , Arthur Nowak Pediatric Dentistry: Infancy through Adolescence,; 5th edition. • Randall RC., Vrijhoef MMA., Wilson NHF. Efficacy of preformed metal crowns vs amalgam restorations in primary molars: a systematic review. J.A.D.A. 131: 337-343, 2000 • Roger J Smales & Hak-Kong Yip. The atraumatic restorative treatment (ART) approach for primary teeth: review of literature.. American Academy of Pediatric Dentistry. Pediatric Dentistry – 22:4, 2000 • Sigal MJ. Paediatric Dentistry Manual. Faculty of Dentistry, Department of Paediatric Dentistry, University of Toronto. ed.: Seventh Edition:168-177, 1998. BIBLIOGRAPHY