Crowns in Pediatric Dentistry

1. CROWNS IN PEDIATRIC DENTISTRY
PRESENTED BY: ROSHNI
MAURYA(18.2.2015)
DEPT. OF PEDODONTICS &
PREVENTIVE DENTISTRY

2. Introduction
• Although advances in the application of preventive dentistry
techniques, widespread acceptance of community fluoridated
water, and increased dental education in parents have reduced
the incidence of caries in children, there is still a high
prevalence of early childhood caries especially in the lower
socioeconomic population.
• Aesthetic treatment of severely decayed primary teeth is one
of the greatest challenges to pediatric dentists. In the last half
century the emphasis on treatment of extensively decayed
primary teeth shifted from extraction to restoration.

3. • Early restorations consisted of placement of stainless steel
bands or crowns on severely decayed teeth. While functional,
they were unaesthetic and their use was limited to posterior
teeth.
• Similarly, a higher esthetic standard is expected by parents for
restoration of their children’s carious teeth. Thus the choice of
full coverage restorations for primary teeth must provide an
aesthetic appearance in addition to restoring function and
durability.

5. Indications for Full Coverage
• Tooth with large interproximal lesions
• Tooth with hypoplastic defects
• Unaesthetic tooth due to discoloration
• Tooth that have undergone pulp therapy with significant loss
of tooth structure
• Tooth with significant tooth structure loss due to trauma or
caries
• Tooth with small carious lesions and with large areas of
cervical discoloration

6. • 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
• Recent development s for anterior crowns.

7. • The crowns that are available for restoring primary
teeth (Table 1) can be placed into 2 categories:
 those that are preformed and held onto
the tooth by a luting cement, and
 those that are bonded to the tooth.

8. Waggoner ;Restoring primary anterior teeth Pediatric Dentistry – 24:5, 2002

9. Open Faced Stainless Steel Crowns
• With aesthetics of child’s smile of
extreme importance to parents, many
opted for extraction and prosthetic
replacement of severely decayed teeth
rather than placement of stainless steel
crowns.
• Although, more durable and retentive
than amalgam or composite stainless
steel crowns are unaesthetic, especially
on the anterior teeth.
• The advent of composite bonding,
allowed for a composite facing to be
placed on the facial surface of the tooth,
thus improving aesthetics.

10. • Open faced stainless steel crowns combine strength,
durability and improved aesthetics.
• However, they are time consuming to place as the composite
facing cannot be placed until the stainless steel crown cement
sets.
• Although this technique is a dramatic improvement over the
plain metallic appearance of stainless steel, the procedure is
time consuming and metal margins can still be seen.

11. Advantages
• The aesthetics are fair. (The metal shows through the
composite facing).
• They are very durable, wear well and retentive.
• The materials are fairly inexpensive.
Disadvantages
• The time for placement is long as it involves a two-step
process (crown cementation / composite facing placement.)
• Placement of the composite facing may be compromised
when gingival hemorrhage or moisture is present or when the
patient exhibits less than ideal cooperation.

12. Open Faced Stainless Steel Crown Technique
• Once the cement is set, cut a labial window in the cemented
crown using a no. 330 or no. 35 bur.

13. Extend the window:
• Just short of the incisal edge
• Gingivally to the height of the
gingival crest
• Mesio-distally to the line angles
• Using a no. 35 bur remove the
cement to a depth of 1mm.
• Place undercuts at each margin
with a no. 35 bur or with a
no. ½ round bur
• Smooth the cut margins of the crown
with a fine green stone or white
finishing stone.

14. • After using a glass ionomer liner to
mask differences in color between
remaining tooth structure and
cement place a layer of bonding
agent.
• Place resin based composite into
the cut window forcing the material
into the undercuts and polymerize.
• Add additional material in 1mm
increments and polymerize.

15. • Finish the restoration with abrasive disks.
• Run the disks from the resin to the metal at the margins so as
not to discolor the resin with metal particles
• Repeat the procedure for the remaining teeth.

16. Polycarbonate Crowns
• Polycarbonate crowns are heat-
molded acrylic resin shells that are
adapted to teeth with self cured
acrylic resin.
• They were popular in the 1970’s,
however, although they were more
aesthetic than stainless steel crowns
the polycarbonate material was:
i. brittle and
ii. did not resist strong abrasive forces,
exhibiting frequent fracture and
dislodgement.

17. Advantages
• They are very aesthetic, with greater durability than composite
strip crowns and pre-veneered crowns.
• They are not as technique sensitive as composite strip crowns
as the fabricated crown is cemented with self adhesive resin
cement rather than bonding.
• They take about the same amount of time to place as stainless
steel crowns, composite strip crowns and preveneered crowns,
and less than open faced stainless steel crowns.
Disadvantages
• They are not recommended in patients that are heavy bruxers.
• Greater tooth reduction is required.

18. Polycarbonate Crowns Technique
• Reduce the incisal edge a minimum of
2mm.
• Reduce the labial surface & lingual surface a minimum of
2mm, finishing the preparation subgingivally.

19. • For the interproximal reduction all
contact must be broken.
• Remove all remaining decay and
perform any necessary pulp tissue
treatment.
• Completed tooth preparation.
• Select a crown that fits easily over
the prepared tooth and has the
appropriate mesiodistal
dimension.
• If the crown does not seat without
incisal interference additional
tooth reduction is necessary.

20. • Remove the ID Tab and tab connector with a scissor and
sandpaper disc from the crown form.

21. • Reseat the crown form onto the
prepared tooth.
• All margins are subgingival.
• Check or estimate the occlusion.
• Adjust the margins and
occlusion.
• Remove the crown from the
tooth.
• Crimp all the gingival margins of
the crown using a bull nosed
crimping pliers.

22. • Simply grab the margin with the pliers and bend the margin
in. Continue around the circumference of the crown.

23. Cementation
• Immediately prior to cementation, thoroughly rinse the
tooth with a high speed water spray.
• Once the tooth is clean place a gauze over the tooth
with firm pressure on the gingival tissues to control any
bleeding, as necessary while the crown is being loaded
with self-adhesive resin cement.
• Apply GC Coat Plus (GC) to the internal surface of the
crown using a brush or pledget.
• Dry the GC Coat Plus with a gentle air flow until bone
dry and then light cure for 10 seconds.
• Fill the crown will self adhesive resin (e.g. RelyX (3M
ESPE, St. Paul, MN), SmartCem (Dentsply, York, PA) or
G-Cem Automix (GC America, Alsip, IL). Use a shade
labeled Translucent or Light
• Seat the crown fully and completely. Maintain finger
pressure on the crown and light cure the buccal and
lingual margins for 2-3 seconds.
• Remove excess cement with an explorer and floss
interproximately taking great care to stabilize the
crown so that the position of the crown is not
disturbed while the cement is setting.
• Light cure the crown for 20 seconds

24. • Once the cement is set the occlusion is checked and adjusted.

25. Composite Strip Crowns
• Composite strip crowns are
composite filled celluloid crowns
forms.
• Composite strip crowns rely on
dentin and enamel adhesion for
retention. Therefore the lack of
tooth structure, the presence of
moisture or hemorrhage contributes
to compromised retention.
• A 2002 study by Tate, et al. found
that composite strip crowns had a
failure rate of 51%, compared to an
8% failure rate of stainless steel
crowns.

26. Advantages
• It provides superior aesthetics. The cost of materials are
reasonable (approximately $6/crown).
• The time for placement is reasonable.
Disadvantages
• It is extremely technique sensitive.
• It is not as durable or retentive as stainless steel/open faced
crowns, pre-veneered crown or polycarbonate crown and is not
recommended on patients with a bruxism habit or a deep bite.
• Adequate moisture control might be difficult on an
uncooperative patient.

27. Composite Strip Crowns Technique
• Select a primary celluloid
crown form with a mesio-distal
incisal width equal to the tooth
to be restored by placing the
incisal edge of the crown
against the incisal edge of the
tooth.
• Remove decay with a medium
to large round bur on a slow
speed handpiece.
• If pulp therapy is required do it
at this time.

28. • Reduce the interproximal surfaces by 0.5
to 1.0 mm.
• The interproximal walls should be parallel
and the gingival margin should have a
feather edge.
• Reduce the facial surface by 1mm and
the lingual surface by 0.5mm.
• Create a feather-edge gingival margin.
• Round all line angles.
• Trim the selected crown by removing the
collar and the gingival excess material
with crown and bridge scissors.
• Place a small vent hole on the mesial
distal edge surface with a bur or explorer
to allow escape of trapped air when the
composite filled crown is seated.

29. Fit the crown on the prepared tooth.
• The crown should extend 1mm below
the gingival margin.
• Maxillary lateral incisors are usually
0.5 to 1.0 mm shorter than central
incisors.
• Select the appropriate shade of
composite (extra light).
• Fill the crown with resin material
approximately two thirds full.

30. • Etch the tooth with acid gel for 15
seconds, wash and dry the tooth, and
apply bonding agent . OR
• Use a self-etching bonding agent
Polymerize
• Seat the filled crown form on the
tooth.
• Remove the excess material from the
vent hole and the gingiva.
• Repeat the procedure with the
adjacent teeth.
• Polymerize the material from both
the facial and lingual directions.

31. • Repeat the procedure for adjacent teeth.

32. • Remove the celluloid form by cutting
the material on the lingual with
either a composite finishing bur or
scalpel.
• Pry the celluloid form off the tooth.
• Very little finishing is required except
for adjusting the occlusion and
smoothing gingival margins.
• Use flame shaped and rounded
composite finishing burs for
finishing.

33. • Although the technique has been well described, surprisingly, very
little clinical data exists on the longevity of these crowns.
[Webber DL, Epstein NB, Wong JW, Tsamtsouris A. A method of restoring primary anterior teeth
with the aid of a celluloid crown form and composite resins. Pediatr Dent. 1979;1:244-246.
Grosso FC. Primary anterior strip crowns J Pedodont. 1987;11:182-187. Croll TP. Bonded
composite resin crowns for primary incisors: technique update. Quintessence Int. 1990;21:153-
157.]
• The procedure is very technique sensitive, and any lapses in patient
selection, moisture and hemorrhage control, tooth preparation,
adhesive application and resin composite placement can lead to
failure.
• The difficulty in application is reflected in a study that only 21% of
general dentists surveyed perform strip crowns compared to 73% of
pediatric dentists. [McKnight-Hanes C, Myers DR, Davis HC. Dentists’ perception of
the variety of dental services provided for children. ASDC J Dent Child. 1994;61:282-284.]

34. Pre-veneered Stainless Steel Crowns
• They were introduced in the mid
1990’s.
• They are aesthetic, placement
and cementation are not
significantly affected by
hemorrhage and saliva and can
be placed in a single
appointment.
• The stainless steel crown is
covered on its buccal or facial
surface with a tooth colored
coating of polyester/epoxy hybrid
composition.

35. • A clinical disadvantage is they are relatively inflexible as the
resin facing is brittle and tends to fracture when subjected to
heavy forces or crimping.
• Because only the lingual portion of the crown can be adjusted
(crimped), significant removal of tooth structure must be
performed to fit the tooth to the crown rather than the crown
to the tooth.
• There is limited shade choice.
• They are more expensive to purchase than stainless steel
crowns, strip crown forms and polycarbonate crowns
(approximately 18 vs. 6 dollars).

36. Advantages
• They are aesthetically pleasing.
• They require relatively short operating time.
• They have the durability of a steel crown.
• They are less moisture sensitive during placement than composite strip
crowns.
Disadvantages
• They are 3 times more expensive than stainless steel, strip and polycarbonate
crowns
• The technique does not allow for major recontouring and reshaping of the
crown.
• The tooth is adjusted to fit the crown, rather than adjusting the crown to fit
the tooth.
• As crimping is limited to lingual surfaces there is not close adaptation of
crown to tooth.
• There are reports of the veneer facing fracturing, however it can be easily
repaired using the open faced stainless steel crown technique.

37. Pre-veneered Stainless Steel Crown Technique
• Size the crown to the tooth by
placing the incisal edge of the
crown against the incisal edge of
the tooth.
• Prepare the tooth as for a
standard stainless steel crown,
however more circumferential
tooth reduction required.

38. • Refine the prep to fit the crown.
• Do not force the crown on the
tooth.
• A properly fitted crown has a
passive fit.
• The crown should extend 1mm
past the gingival margin.
• The length of the crown is altered
by trimming the gingival margin
with a diamond bur and water
spray.

39. • The lingual aspect of the crown
may be crimped slightly with a no.
137 Gordon plier.
• Too much crimping of the metal
substructure may cause fractures
in the veneer material.
• The crown is cemented with glass
ionomer cement.

40. • The excess cement is
removed and the remainder
is allowed to set.
• After cementation the incisal
edges may be contoured with
a finishing disk or point.
• If the veneer fractures a
similar technique to the
open-faced crown may be
used for repair.

41. NUSMILE CROWNS
• Specially Formulated Hybrid Composite Substructure
• 2 Shades for Anterior Crowns(XL and NL); Posterior
Crowns(XL only)
• Centrals and Laterals sizes 1-6, Cuspids Sizes 0-6, 1st & 2nd
Primary Molars Sizes 1-7
• Waggoner and Cohen [1995] reported Cheng Crowns ,Kinder
Crowns ,NuSmile Primary Crowns have resin composite
facings whereas Whiter Biter Crown II has a flexible
thermoplastic veneer( exhibiting greatest shear force and
retention compared to other brands).

42. Advantages:
• Single appointment
• Easy placement technique
• Reduces operatory time
• Less technique sensitive
Disadvantages:
• More tooth preparation due to their greater bulk.
• Avoid crimping - facing susceptible to fracture, so
the tooth is prepared to fit the most appropriate
crown.
• Single-use only-sterilization is recommended

43. Selecting a Crown
• Very short clinical crowns and crowded dentitions may not
be ideal for beginning case selections.
Preparation of the Tooth
• crown fits the tooth passively: flexing of metal
substructure from pressure during fitting or seating can
cause micro-fractures

44. NUSMILE CROWNS Anterior teeth
• Reduce the incisal length of the tooth by approximately 2mm
and open the interproximal contacts.
• feather-edge margin
• tapered diamond burs : proceed from coarse to fine as the
preparation is completed.
NUSMILE CROWNS Posterior teeth
• The tooth should be reduced by approx 30%
• More preparation : buccal and occlusal aspects (at least
2mm)
• Crimping not necessary
• Do not crimp excessively or near the facing
• Minimally on lingual aspect of crown

45. CHENG CROWNS
• Peter Cheng Orthodontic Laboratory-1987 anterior
crowns faced with a high quality composite (mesh-based
with a light cured composite.)
Advantages:
• completed in one patient visit (and with less patient
discomfort)
• natural looking stain resistant
• doesn’t cause wear of opposing teeth
Disadvantages:
• fracture of veneers during crimping
• expensive.

46. Anterior Crowns
• Centrals : left & right sizes (1-6)
• Laterals : left & right sizes (1-6)
• Cuspids: upper& lower sizes (1-6)
Posterior Crowns
First primary molar: upper and lower - left and right sizes (2-7)
Second primary molar :upper and lower - left and right sizes (2-7)

48. PEDO PEARLS
• Heavy gauge aluminum crowns
coated with FDA food grade
powder coating and epoxy-resin.
ADVANTAGES:
• Universal anatomy-use on either
side
• Easy to cut and crimp, without
chipping or peeling.
• Non bulky & fits easily
DISADVANTAGES:
• less durability and the crowns are
relatively soft
• self-cured or dual-cured
composite is recommended for
repairing

49. DURA CROWNS
• White-Faced Crowns
• Crowns can be crimped labially and lingually, can be easily
trimmed with crown scissors, easily festooned and has got a
full-knife edge.
• Starter Kit includes:
• 24 Crowns.
• Centrals, left and right sizes 2,3,4 two of each.
• Laterals, left and right sizes 3,4,5 two of each

50. KINDER KROWNS
• 1988 by pediatric dentists
• natural shades and contour available
• Great depth and vitality from the lifelike composite
• Available in 2 shades; PEDO 1 & PRDO 2

51. PEDO CHEMPU CROWNS
• Sizes 2-4
• Color : White Color stable, plaque resistant, match natural
pediatric shades.
• Available for the right and left central and lateral as well as
cuspids.
• Kit includes -centrals, left and right sizes 2,3,4 (2 of each) –
• laterals, left and right sizes 2,3,4 (2 of each)

52. PEDO JACKET
• It is a tooth colored copolyester material which is filled with
resin and left on tooth after polymerization instead of being
removed.
ADVANTAGES:
• It does not split, stain or crack.
• Crowns can be easily trimmed with scissors.
• Thin yet strong interproximal wall allows multiple adjacent
restorations with a minimum amount of tooth reduction.
• Using a plastic primer, they can either be bonded into place
with composite resin or cemented with a glass ionomer
cement.
DISADVANTAGES:
• Only one size is available

53. NEW MILLENIUM CROWNS
• This is similar in form to the pedo jacket and strip crown,
except that it is lab enhanced composite resin material.
• Like others, this is also filled with resin material and bonded
to the tooth

54. ARTGLASS CROWNS
• Multi-functional methacrylate matrix – 3 D
molecular networks with a highly cross-linked
structure.
• 75% filler (55% microglass and 20% silicafiller)
• Available in 6 sizes for every primary tooth and
every Vita shade

55. Advantages
• One appointment placement
• Provide greater durability and esthetics than strip
crowns.
• Easily adjusted or repaired intraorally
• Color stable
• Wear of polymer glass similar to enamel, kind to
opposing dentition- feels natural to the patient.

56. Seating instructions :
• Preparation similar to S.S.C with more reduction Fits
passively
• Place artglass liquid for 1 min inside crown
• Then place flowable composite in crown and then place on
tooth
• Finish with carbide bur.

57. • Updyke studied 95 Artglass crowns that he placed in a 2-year period.
Of 95 crowns,
79 received Alfa (representing clinically ideal),
11 received Bravo (representing clinically acceptable), and
5 received Charlie (representing clinically unacceptable) ratings.
• The vast majority of the failures were due to bond failures. The
difficulty in interpreting this data is the absence of an independent
observer and the fact that the dentin adhesive was changed to a
different product during the study.
• Nevertheless, this study format illustrates how a clinician can initiate
a pilot study in evaluating his or her own procedures to establish a
more substantive investigation.
[Updyke JR. Esthetics and longevity of anterior artglass crowns. J Southeastern
Soc Pediatr Dent. 2000;6:25-26].

58. Conclusion
• Many options exist to repair carious primary teeth, but there is
insufficient controlled, clinical data to suggest that one type of
restoration is superior to another.
• This does not discount the fact that dentists have been using
many of these crowns for years with much success.
• Operator preferences, esthetic demands by parents, the child’s
behavior, and moisture and hemorrhage control are all
variables which affect the decision and ultimate outcome of
whatever restorative treatment is chosen.
(Pediatr Dent. 2002;24:511-516)

59. • Crowns remain the best restoration in many cases, and
esthetic crowns will have a larger role in pediatric dentistry if
improvements are made to reduce the bulk, lessen the
thickness of the veneer, improve the bonding between the
metal and the esthetic facing, and reduce the cost.
• These techniques are relatively new and need to pass the test
of long-term clinical use.
• With all full coverage restorations parents must be advised to
institute appropriate preventive health practices (elimination
of sugar containing drinks, regular tooth brushing and topical
fluoride application) to maximize gingival health and minimize
the recurrence of caries under the restorations.

60. Table1:Summarizes the properties and selection criteria of various full coverage
techniques currently available to practitioners.