2. WHEN YOU ARE PRESENTING TO YOUR FELLOW COLLEAGUES ,
IT IS SIMILAR FEELING TO STAND IN THE FIRING SQUAD
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. 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
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. 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
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. 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. 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. 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. 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. 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. 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. 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. • 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. • 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. 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. 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
26. ???
When can Stainless Steel crowns be a suitable
management option for carious primary molars?
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
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. Step 1.
Assessing the tooth shape,contact points/
areas and the occlusion
Step 2.
Protecting the airway
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. 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. Before Preparation, what need to do:
• L.A. should be administrated
• Isolation by rubber dam or cotton rolls
• Remove the decay
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. 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. 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. 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. 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. 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. • 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.
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