CROWNS IN

PEDIATRIC DENTISTRY

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 CROWNS IN
PEDIATRIC DENTISTRY

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Editor

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Prashant Babaji MDS

Professor

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Department of Pedodontics and Preventive Dentistry

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Sharavathi Dental College and Hospital

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Shivamogga, Karnataka, India

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iv Foreword

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VV Subba Reddy

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The Health Sciences Publisher

New Delhi I London I Philadelphia I Panama






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Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information
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Crowns in Pediatric Dentistry

First Edition: 2015
ISBN: 978-93-5152-439-7

Printed at:

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 r/
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Dedicated to

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Almighty for giving me immense pleasure to write this book

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My little master Tanush for his continuous love, understanding and
support during preparation of the book.

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My parents and family members for their constant encouragement to go forward.
My teachers who shared their knowledge with me.

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 Contributors

Anju Bansal Senthilnathan S

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Reader Principal and Professor

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Department of Pedodontics Department of Periodontics
Buddha Dental College Venkateswar Dental College

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Patna, Bihar, India Puducherry, India

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Jalarak C Patel Shashikiran ND
Senior Lecturer Dean and Head

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Department of Pedodontics Department of Pedodontics

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Goenka Research Institute of Dental Science Peoples College of Dental Sciences
Gandhinagar, Gujarat, India Bhopal, Madhya Pradesh, India

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Nitin Sharma Suresh BS
Reader Professor

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Department of Pedodontics Department of Pedodontics

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Rajasthan Dental College Sharavathi Dental College and Hospital

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Jaipur, Rajasthan, India Shivamogga, Karnataka, India

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Poonacha KS Vikram Shetty K
Reader Associate Professor and Head

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Department of Pedodontics Department of Conservative Dentistry
KM Shah Dental College and Hospital Faculty of Dentistry
Vadodara, Gujarat, India Melaka Manipal Medical College
Melaka, Malaysia

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Prashant Babaji
Professor Vinaykumar S Masamatti
Department of Pedodontics and Preventive Dentistry Senior Lecturer

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Sharavathi Dental College and Hospital Department of Conservative Dentistry and
Shivamogga, Karnataka, India Endodontics
Maratha Mandel Dental College
Raghavendra Shetty Belagavi, Karnataka, India
Professor
Department of Pedodontics Vishwajit Rampratap Chaurasia
Chhattisgarh Dental College and Research Institute Department of Conservative
Rajnandgaon, Chhattisgarh, India Dentistry and Endodontics
Mumbai, Maharashtra, India
Ranjithkumar Rampratap Chaurasia
Department of Prosthodontics
Mumbai, Maharashtra, India

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 DR. V. V. SUBBA REDDY College of Dental Sciences
BDS, MDS, FICD (USA) DAVANGERE-577 004.
DIRECTOR Resi. :262684, College: 230432
Ex. Member, NBE (Government of India) Fax : 2M070
Ex. Member Dental Council of India E-mail : director@gmail.com
Ex. Member ICMR Cor.com
Ex. Senate Member RGUHS
Executive Council Member (Comed. K)

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Foreword s .i
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It is an honor for me to write the foreword to my own students special book on, Crowns in Pediatric

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Dentistry. This informative book provides information on conventional and newer crowns as

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well as advanced techniques. It covers illustrations, principles and colorful images for better

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understanding. The book helps the readers to improve their current concepts and to upgrade

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their knowledge and techniques for crown placement and to solve the clinical problems.
I am confident that the book written by Dr Prashant Babaji will be very useful for clinicians,

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undergraduate and postgraduate dental students for successful dental practice.

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VV Subba Reddy
BDS MDS FICD (USA)

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Department of Pedodontics
Director and for Principal, College of Dental Sciences
Bapuji Educational Association
Davangere, Karnataka, India

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 Preface

Nowadays various pediatric crowns are available, but available information and long-term clinical
studies about it are very scarce. Pediatric crown development has moved from conventional
unesthetic stainless steel crown to strip crown, ceramic and preveneered crown with better
clinical success and patient and parent satisfaction. Hence, the present book aims to provide
information about conventional and newer pediatric anterior and posterior crowns.

Prashant Babaji

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 Contents

1. Introduction and Historical Developments 1

Prashant Babaji
Historical developments in Pediatric crowns2

2. General Considerations 4
Prashant Babaji, Shashikiran ND
Importance of Restoring Primary Teeth4
Materials and Equipment8
Isolation Procedure: Rubber Dam Application10
Cementation/Cements Used for Cementation of Crowns16

3. Different Crowns Used in Pediatric Dentistry 21

Prashant Babaji, Jalarak C Patel, Poonacha KS, Anju Bansal, Raghavendra Shetty
Classifications of Crowns21
Restoration of Severely Decayed Tooth with Post and Core21
Full Coronal Restorations in Children22
All Metal Crowns23
Jalarak C Patel, Poonacha KS, Raghavendra Shetty
Composition of Crowns23
Stainless Steel Crowns23
Ion Crowns/Nickel-Chromium Crowns25
Clinical Procedures for SSC34
Reduction of Tooth39
Crown Adaptation43
Response of Gingival Tissues to Stainless Steel Crown Restoration51
Anterior Stainless Steel Crowns67
Aluminum Crowns70
SSC With Facing/Open Faced Stainless Steel Crown/Chairside Veneered SSC72
Veneering Technique for Anterior Stainless Steel Crown73
Composite Veneering of Primary Molar SSC74
Resin Crowns/Composite Crowns75
Composite Strip Crown for Anterior and Posterior Teeth75
Composite Shell Crowns83
New Millennium Crown84
Glass Ionomer Crown84
Polycarbonate Crown85
Kudos Crowns88

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 xiv Crowns in Pediatric Dentistry

PedoNatural Crown90
Anju Bansal
Pedo Jacket Crown93
Artglass Crowns/Glastech Crowns94
Preveneered Stainless Steel Crowns97
NuSmile Crowns100
Flex White Faced Pediatric Crown103
Pedo Pearls (Aluminum Crowns with Facing)104
Cheng Crown107
Whiter Biter Crown109
Pedo Compu Crown109
High Density Polyethylene Veneered Crowns For Children110
Dura Crowns110
All Ceramic/Porcelain/Zirconia Jacket Crown111
ZIRKIZ Crowns111
EZ-crown113
Kinder Krowns115
Cerec Crowns-All Ceramic CrownsCAD/CAM System119
Ceramo Base Metal Crown121
Biologic Crown122
Limitations122
Tooth Preparation122
Fabrication of Crown Portion122
Radiographic Evaluation123
Cementation of Biologic Crown123

4. Restoration of Destructed Primary Teeth with Post and Core 125

Prashant Babaji, Vishwajit Rampratap Chaurasia, Ranjithkumar Rampratap Chaurasia,
Vinaykumar S Masamatti, Vikram Shetty K
Management of Severely Damaged Teeth125
Post Space Designs127
Different Types of Posts127

5. Management of Complications 133

Prashant Babaji, Senthilnathan S, Nitin Sharma, Suresh BS
Crown Tilt133
Interproximal Ledge133
Poor Margins133
Over Extension of the Crown134
Ingestion/Inhalation of Crown135
Obstructed Airway in Children136

6. Tables and Charts 141

Prashant Babaji
Crown Order Forms146
Index 153

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 C hapter 1
Dentistry has undergone a significant evolution
since beginning. Today, with the search for
beauty and natural color taking such a dominant
role in our society, modern dentistry should
make advances in these fields. Esthetics
by definition is the science of beauty: that
particular detail of an animate or inanimate
object that makes it appealing to the eye. In the
modern civilized cosmetically conscious world,
well contoured and well aligned white teeth set
the standard for beauty. Such teeth are not only
considered attractive, but are also indicative
of nutritional health, self esteem, hygienic and
shows economic status of a person.
Primary maxillary anterior teeth dominate
the physical appearance and their structural
loss affects not only esthetics but also leads to
compromised mastication, poor phonetics,
development of aberrant oral habits, neuro
muscular imbalance, and difficulty in social
and psychological adjustment of the child.
Primary posterior teeth are important for
mastication, as natural space maintainer and
to establish proper occlusion; loss of which
can result into space loss, malocclusion and
impaction of succedeneous teeth. Hence,
maintenance of primary teeth is mandatory.
However, these issues are overlooked by most of
the parents resulting in to difficulties in eating,
establishing social contacts and speaking. Even
though primary teeth are temporary dentition,
01.indd 1
Introduction and
Historical Developments
Prashant Babaji
they should be retained in the oral cavity in
nonpathologic state until exfoliation.
Primary teeth often get destructed either
due to caries or traumatic injuries. Teeth need
to be restoration due to loss of crown structure
following caries or traumatic injury. The pre
valence of traumatic injuries is 8.1 in 1000.
Anterior tooth trauma often results in functional,
esthetic and psychological problems. Dental
caries is one of the most common infectious
diseases affecting the teeth of children. Caries in
very young children known as early childhood
caries may be defined according to the American
Academy of Pediatric Dentistry, as the presence
of one or more decayed, missing (due to caries),
or filled tooth surfaces in any primary tooth in
a child 71 months of age or younger. Rampant
caries (Fig. 1.1) can occur in primary, mixed or
permanent dentition. It affects 1 to 12 percent of
the pediatric population in developed countries,
and up to 70 percent in underdeveloped
countries. Kaste et al. (1996) reported caries
incidence of 18 percent in 2 to 4-year-old and
52 percent in 6 to 8-year-old children.
Caries on primary molars can results
into loss of arch circumference, pain, tooth
loss, disrupted occlusion. Hence, restoration
of carious or pulpally treated tooth is must.
Selecting an ideal restorative material for resto
ration of grossly decayed teeth is challenging.
The most commonly used restorative materials
30-01-2015 11:09:01
 2 Crowns in Pediatric Dentistry
FIGURE 1.1 Rampant caries affecting primary
incisors and molars
for primary teeth are amalgam, GIC and
composite. Silver amalgam restoration is not
suitable for multisurface caries. Cast crown
restoration is not adequate for primary and
young permanent teeth as there is chances of
more tooth reduction and possibility of pulp
exposure. Hence, prefabricated crowns such
as SSC and veneered crowns are advocated,
which requires lesser tooth preparation.
Preformed metal crowns (PMCs) for primary
molar teeth were first described in 1950 by
Engel and popularized by Humphery. Since
then design modifications have simplified
the fitting procedure and improved the
morphology of the crown to duplicate the
anatomy of primary molar teeth. Such crowns
should maintain esthetic function of infants,
children and adolescents throughout the
period of use. Faced with increasingly pressing
demands from patients not only in terms of
esthetics but also the mechanical and biological
(toxicity, allergy, corrosion, etc.) point of view,
materials specifications have expanded to the
limit. The main problem in performing esthetic
restorations on primary teeth is the small size
of teeth, close proximity of the pulp to the tooth
surface, relatively thin enamel and surface area
for bonding and the behavior of the child. Due
to unesthetic look of SSCs, this makes search for
01.indd 2
esthetically acceptable crowns for anterior and
posterior primary teeth.
Esthetic restorations in primary anterior
teeth have been a great concern and challenging
task for most of the clinicians. The restoration
of carious, fractured, or discolored primary
incisors is rewarding to dentists because it
gives them the satisfaction of knowing they
have restored the smile and self-confidence of a
growing child. However, restoring primary teeth
can be a strenuous task because of the difficulty
in keeping these patients teeth dry and the
uncooperative behavior of the child.
The demand for esthetics concern in
primary teeth by parents is increasing which
makes the development of crowns without
compromising strength and requirement for full
coverage, preveneered stainless steel crowns as
a most viable esthetic option. The simple truth
is if you do not offer an esthetic alternative for
full coverage you are missing an integral part
of your armamentarium. We must be able to
hear and react to the wants and needs of our
patients.
HISTORICAL DEVELOPMENTS
IN PEDIATRIC CROWNS
1947Preformed crowns (PMC) were
introduced by Rocky Mountain company
1950Stainless steel crown (SSC) was
described by Engel and popularized by
Willium Humphrey to Pediatric dentistry
1950 to 1968Various modifications in
preformed crowns occurred
1964Biologic restoration were advocated
by Chosak and Eildeman
1970Polycarbonate crowns were
introduced
1971Mink and Hill advised SSC
modification for over and undersized
crowns. SSC medications for deep
30-01-2015 11:09:01

subgingival caries and solder joint for
interdental spacing. SSC modification for
deep subgingival caries.
1977McEvory advised modification of
SSC technique for SSC with arch length or
space loss
1980 to 1990Various preveneered stainless
steel crowns (PVSSC) were introduced
1980Pedo Perls crowns were introduced
1981Nash advocated modification of SSC
for adjacent crowns placement
1983Hartman advised veneered SSC
technique for esthetic anterior crown
restoration
1987Cheng crowns were introduced by
Peter Cheng
1989Kinder crowns were introduced
01.indd 3
Introduction and Historical Developments 3
1990 to 1995Hall technique was introduced
by Dr Norna Hall for SSC adaptation on
carious tooth without tooth preparation
1993Beemer et al. advised band adaptation
on SSC crown as space maintainer rather
than crown and loop
1997Pedo natural crowns were introduced
to market
1997Zirlock (Incisalock) technology
was introduced for better retention of
preveneered crowns
2002Kuietzky advised split technique
of rubber dam isolation technique for
restoration of multiple primary anterior teeth
2010EZ zirconia crowns were introduced
by Hansen JP and Fisher JP as pediatric
esthetic crowns.
30-01-2015 11:09:01
 C hapter 2
IMPORTANCE OF RESTORING
PRIMARY TEETH
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. Clinically early childhood caries
proceeds from early involvement of maxillary
incisors to other teeth leading to rapid spread
and destruction of other teeth if neglected.
Esthetic treatment of severely decayed
anterior primary teeth is one of the greatest
challenges to pediatric dentists. In the last
half of century the emphasis on treatment of
extensively decayed primary teeth shifted from
extraction to restoration. Early restorations
consisted of placement of stainless steel bands
or crowns on severely decayed teeth. While
functional, they were unesthetic and their
use was limited to posterior teeth. Over the
last two decades there has been an explosive
interest by adults in esthetic restoration of their
compromised dentition. Similarly, a higher
esthetic standard is expected by parents for
restoration of their childrens carious teeth.
Esthetic full coverage restorations are available
02.indd 4
General Considerations
Prashant Babaji, Shashikiran ND
for anterior and posterior primary teeth, which
preserve the functions of primary teeth until
their exfoliation in healthy state.
Maintenance of primary dentition in a
healthy condition is important for the well-
being of the child as far as proper masticatory,
esthetics; phonetics, space maintenance
(Flow chart 2.1) and prevention of aberrant
habits are concerned. The major issues of
these problems are the development of
abnormal oral habits, psychological problems,
reduced masticatory efficiency and loss of
vertical dimension of occlusion. Owing to
these problems, it becomes more important
to restore the destroyed crowns to preserve
the integrity of the primary dentition until its
exfoliation and eruption of permanent teeth.
Numerous treatment approaches have been
proposed to address the esthetics and retention
of restorations in primary teeth such as stainless
steel crown, open-faced SSCs, strip crown,
PVSSCs, polycarbonate crowns.
Importance of Primary Teeth
(Flow Chart 2.1)
Crown may be used on primary teeth in order to:
Preserve the primary teeth until exfoliation
Maintain masticatory function
Maintain esthetic function.
30-01-2015 11:09:28

FLOW CHART 2.1 Importance of primary teeth
Instructions to Child and Parents
after Placement of Crown
Care for Crown
Avoid sticky, chewy foods (for example,
chewing gum, caramel), which have the
potential of grabbing and pulling off the
crown.
Minimize use of the side of your mouth with
the temporary crown. Shift the bulk of your
chewing to the other side of the mouth.
Minimize chewing hard foods (such as raw
vegetables), which could dislodge or break
the crown.
Slide flossing material out-rather than lifting
out-when cleaning your teeth. Lifting the
floss out, as you normally would, might pull
off the temporary crown.
Instructions after Crown Delivery
Discomfort or sensitivity: Newly crowned
tooth may be sensitive immediately after the
procedure as the anesthesia begins to wear off.
If the tooth that has been crowned still has a
nerve in it, patient may experience some heat
and cold sensitivity. Advice to brush teeth with
toothpaste designed for sensitive teeth. Pain or
sensitivity that might occur on biting usually
means that the crown is too high on the tooth.
Chipped crown: Crowns made up of all
porcelain or SSC with facing can sometimes
chip. If the chip is small, a composite resin
can be used to repair the chip with the crown
02.indd 5
General Considerations 5
remaining piece. If the chipping is extensive, the
crown may need to be replaced.
Loose crown: Sometimes the cement washes
out from the crown. Not only does this allow the
crown to become loose, it allows bacteria to leak
in and cause decay to the tooth that remains. If a
crown feels loose, advise to visit dentist
Crown falls off: Sometimes crowns fall off.
Usually this is due to an improper fit, a lack
of cement, or a very small amount of tooth
structure remaining that the crown can hold on
to. If this happens, instruct parents to report to
dentist with the crown
Allergic reaction: Because the metals used to
make crowns are usually a mixture of metals, an
allergic reaction to the metals or porcelain used
in crowns can occur, but this is extremely rare.
Instruct patient to visit dentist if so.
Dark line on crowned tooth next to the
gum line: Instruct child that a dark line next
to the gum line of crowned tooth is normal,
particularly if a veneered SSC crown is used.
This dark line is simply the metal of the crown
showing through.
Tooth exfoliation: Crowned tooth exfoliates in
a similar manner as that of uncrowned tooth.
General Considerations during
Crown Placement
Aseptic Technique
Prevention of disease transmission during and
after temporary restoration is required, as it is
necessary for all intra-oral procedures. Infection
control guidelines for dental offices that have
been published by the Center for Disease
Control should be followed. Personal protection
and barrier protection measures should be
followed (e.g. gloves, mask, protective eye wear
and lab coat). Cross-contamination should be
avoided. Do not touch instruments, areas which
have not been sterilized or disinfected. Practice
proper hand washing techniques, properly
clean, disinfect or sterilize all instruments and
equipment.
30-01-2015 11:09:28
 6 Crowns in Pediatric Dentistry
Occlusion
Before tooth preparation and crown adaptation
check for occlusion. Occlusion is the contact
of the mandibular teeth against the opposing
maxillary teeth during functional and non
functional movement of the mandible. The
static position of the bite is called centric
occlusion. Check for incisor, canine and molar
relationships.
Sensitivity
Following vital tooth preparation, dentine will
be exposed resulting into sensitivity of tooth
hence prepared tooth should be covered with
varnish before crown cementation.
Gingival Health
There are chances of gingival laceration during
tooth preperation which will heal in due time.
Gingival inflammation and recession occurs
if crown is not properly adapted or irritating
cement left after cementing crown. Food
impaction occurs if contact areas left open.
Hence care should be taken to remove excess
cement, crimp the crown for close adaptation,
and maintain proximal contact by proximal
contouring the crown or by adding solder.
Fracture of Prepared Tooth
If tooth left without crown after preparation for
many days then there is chance of tooth fracture.
Hence cement the crown in the same visit.
Finish Lines
The finish line is a continuous edge that borders
the entire preparation commonly the location
where the bur stops. It is essential that you have
a mental image of the location and contour of
a preparations finish line in order to contour a
temporary restoration for that tooth.
02.indd 6
FIGURE 2.1 Gingival finish lines (bevel, Chamfer,
feather/knife edge and ledge formation)
Four common forms of finish lines are (Fig. 2.1):
1. Bevel or slant
2. Chamfer or slope
3. Feather or knife edge (a shallower slope)
4. Shoulder or ledge.
When a preparation is cut, the circumference
of the tooth either increases or remains the
same with the finish line always at the greatest
circumference. This shape permits easy
placement and removal of a restoration. Knife
edge/feather finish line is used for primary
tooth preparation for crown while shoulder and
chamfer finish line for permanent since there
is increased cervical constriction in primary
teeth. The crown when well adapted, protects
the finish line from chipping, and prevents
marginal leakage of mouth fluids and bacteria,
which could cause sensitivity and decay of the
exposed dentin.
Differences between Primary and
Permanent Tooth and Tooth
Preparation (Fig. 2.2)
Enamel and dentine are thinner in primary
than permanent teeth hence decay spreads
faster in primary compared to permanent.
Since primary teeth have thinner enamel
and dentin (about 1 mm each) extensive
occlusal reduction is not indicated during
tooth preparation. Hence, semi permanent
crowns are used with minimal tooth
30-01-2015 11:09:28

FIGURE 2.2 Differences between primary and
permanent teeth [A: Enamel, C: Pulp, F: Dentin]
reduction such as stainless steel crowns,
which has thickness of around 0.2 to 0.3 mm
only.
Primary tooth has prominent cervical
convergence. Cervical bulge is used for
crown retention. Since there is prominent
cervical constriction, gingival seat of tooth
preparation should be knife/feather edge as
compared to shoulder for permanent.
Root bifurcation starts immediately below
cervical area.
Narrow occlusal table compared to
permanent.
Enamel rods run downwards in permanent
(needs beveling due to unsupported rods)
and occlusally in primary (which does not
leave unsupported rods).
Pulp horns are more prominent in primary,
hence excessive occlusal reduction is not
indicated in vital tooth due to chances of
pulpal exposure.
Ideal Requirements for
Pediatric Crown
Should be esthetically acceptable/should
have natural color
Should last until exfoliation of primary teeth
(durable)
02.indd 7
General Considerations 7
Should be biocompatible and not irritant to
gingiva
Easily and rapidly placed
Cost effective
Should require one visit treatment
Esthetic covering should not chip off while
clinical manipulation or during use in oral
cavity
Should maintain tooth integrity
Should maintain mesiodistal space until
eruption of permanent teeth
Should retain masticatory function
Should not abrade opposing teeth.
Objectives of Crown Placement
To repair or limit the damage from caries
To protect and preserve tooth structure
Reestablish adequate function
Restore esthetics.
Indications
(According to the clinical guidelines for the
American Academy of Pediatric Dentistry)
Children at high risk with anterior and/or
posterior decay
Children with extensive decay
Large lesions or multiple surface lesions
Pulpally treated teeth
Involved inscisal edge
Extensive cervical caries
Minimal caries but poor oral hygiene
Difficult to control moisture due to child
behavior management problems.
Other Indications
Hypoplastic defects
Significant tooth loss/fracture due to trauma
Phychologic benefit
Posterior crown for masticatory function
and to maintain arch length
Unesthetic incisors due to discoloration/
intrinsic stain.
30-01-2015 11:09:29
 8 Crowns in Pediatric Dentistry

Contraindications

Non restorable teeth

Teeth which can be restored by conventional
means.

Advantages
Maintains esthetics of child
Avoids development of psychological and
functional problems due to loss of primary
teeth
Preserves arch length and space.
FIGURE 2.3 Diagnostic equipment
Crown Selection
Crown selection can be done by mainly three
methods.
1. Selection before tooth preparation by
measuring the mesiodistal dimension of
tooth to be restored and comparing it with
crown
2. Selection after tooth preparation
3. Trial error method

MATERIALS AND EQUIPMENT FIGURE 2.4 Different crowns and trimming burs

Instruments and Others

Diagnostic equipmentmouth mirror,

explorer, probe, tweezer (Fig. 2.3)
Crowns (Fig. 2.4)
Cementing equipmentspatula (metal
or agate), glass slab, cement mixing pad,
cements, composite set (Figs 2.5 and 2.6A)
Restorative instrumentsplastic carrying
Otherssaliva ejector, retraction cord,
gauze piece, cotton, vaseline, dental floss
For tooth preparationaerator handpiece, FIGURE 2.5 Different cements and other aids
straight handpiece bursround end taper,
thin taper, flame-shaped burs (Figs 2.6B and
2.7) Pliers (Fig. 2.8)crimping, contouring (ball
Finishing and polishing burs and wheels and socket, Gordon pliers) crimping plier,
(Fig. 2.4) Howe pliers (Fig. 3.10)

02.indd 8 30-01-2015 11:09:29

 General Considerations 9

1. Contouring pliers (Fig. 2.8): Gordon
pliers (No. 137) used for general
contouring and shaping
Johnsons Ball and socket contouring
pliers (No. 800112): Used to improve
contour at interproximal contacts and
gingival margins for stainless steel and
temporary crowns.
2. Crimping pliers No. 800417, No.
800421: Specially designed to crimp the
gingival margin of SSC and temporary
crowns (Fig. 2.8).
3. Howe pliers (No. 110): Straight and
curved pliers used to adjust proximal
contact and contours (Figs 2.8 and 3.10).
Scissorsstraight, curved (Fig. 2.9)
Crown scissors (Fig. 2.9):
A. Festooning-801203
B and D. Curved scissor-801202
C. Straight scissor-801201
E. All-purpose scissors 230-212.

FIGURE 2.6A Composite kit FIGURE 2.7 Various burs

FIGURE 2.6B Handpiece (arotor, straight), different tooth preparation burs (round, round end taper, thin taper,
flame-shaped), Crown finishing and polishing burs

02.indd 9 30-01-2015 11:09:29

 10 Crowns in Pediatric Dentistry

ISOLATION PROCEDURE:
RUBBER DAM APPLICATION
Rubber dam isolation method in pediatric
restorative dentistry is strongly recommended
during tooth preparation and crown placement
for better access and visualization.

FIGURE 2.8 Crown adaptation pliers

A B C D

F G
FIGURES 2.9A TO G Crown cutting scissors (Festooning, curved, starignt and all purpose scissors: (A) Festooning
scissor; (B) Straight crown cut scissor; (C) Curved scissor; (D) All purpose scissor; (E) Crown cutting scissor;
(F and G) Crown cutting scissors: (i) Curved festooning; (ii) Straight smooth; (iii) Curved

02.indd 10 30-01-2015 11:09:30

 General Considerations 11

Traditional Dental Dams Contraindications

Ash range (Ash Instruments Dentsply, Patient with upper airway problems, which
Addlestone Surrey UK) restricts nasal breathing such as sinusitis
Hygenic and Hu Friedy Known allergy to latex
Coltene Whaledent Uncooperative patient.
Zirc
Roeko Rubber Dam Apparatus
Ivory by Heraeus Kulzer
(Figs 2.10A to F)
Ultradent
Rubber dam sheet
Other Dental Dams Rubber dam frame (metal or plastic)
Rubber dam template
Optidam by Kerr Rubber dam punch
Optradam by Ivoclar Vivadent Rubber dam forcep
Rubber dam clamps (winged or wingless)
Advantages of Rubber Dam Othersrubber dam napkin, lubricants,
dental floss (Fig 2.10G).
Better access and visualization of operating
area Rubber Dam Sheet
Moisture control
Protects soft tissue injuries by retraction One box contains 32 or 56 sheets. It is available
Prevents aspiration of foreign bodies such as as rectangular size (pre cut 150 mm squares) or
crown and smaller instruments roll type. It is available as different sizes (5 5
Increases child cooperation or 6 6 inch), thickness (thin, medium or thick,
Acts as barrier in preventing transmission of medium most commonly used for pediatric
cross infection and endodontic procedures) and colors (green,
Enhances the effectiveness of nitrous oxide, blue, purple, black, grey, pink, purple, white
when needed for behavior management, and yellow) (Fig. 2.10A). Most rubber dams are
by forcing the child to engage in nasal made of latex although non latex rubber dams
breathing (Silicone versions) are also available. A size
Provides clean and dry operatory area. 5 5 inch medium gauge rubber dam is best
suited for use in children. The darker the color,
Indications the better will be the contrast between the dam
and the tooth. It has dull and shiny surfaces;
For isolation dull surface should be towards operatory and
Prevents aspiration of dental equipments shiny surface towards tissue. Rubber dam
and materials sheets are available in flavored to mask the
Prevention of cross infection latex taste. Rubber dam is also available as
For clear visualization of operatory area. readymade disposable one as fast dam, quick

02.indd 11 30-01-2015 11:09:30

 12 Crowns in Pediatric Dentistry

B C

D E

A F G

H I
FIGURES 2.10A TO I (A) Rubber dam sheet; (B) Rubber dam frame; (C) Template; (D) Punch; (E) Forcep;
(F) Clamps; (G) Rubber dam napkin, dental floss, lubricants; (H) Fast dam, quick dam; (I) Different rubber dam
frames (metal and plastic), forcep, punch

dam (Fig. 2.10H). The performance and quality
of rubber dam is best where stock is not too old
and has been stored in a cool, dry environment,
preferably in refrigerator. Old stocks of rubber
dam are more susceptible to tear.
Rubber Dam Template
This is white sheet showing the landmark areas
of primary and permanent teeth for punching
hole in rubber dam sheet (Fig. 2.10C).

Rubber Dam Frame Rubber Dam Punch (Figs 2.11A and B)

Rubber dam frames are available in plastic and
metal and various sizes corresponding to the size
of the dam (Figs 2.10E and I). It can be available
as Youngs type or Svenska N-O (oval shape)
design. The frame is positioned on top of the
dam so that the top edge of the dame coincides
with the top of the frame arms. Plastic frame is
helpful in taking radiographs, which does not
interfere the radiographic interpretation.
The holes for the teeth are punched on sheet
with rubber dam punch so that the rubber dam
sheet is centered horizontally on the face and
the upper lip is covered by the upper border of
the dam without blocking the nostrils. Punching
the hole is depends upon the type and number
of teeth to be isolated. The size 1 hole punch
is used for the mandibular incisors, the size 2
hole punch is used for the maxillary incisors,

02.indd 12 30-01-2015 11:09:30

 General Considerations 13

A B
FIGURES 2.11A AND B (A) Rubber dam punch; (B) Method of punching the sheet

size 3 hole for canines and premolars, size 4 for

molars (Fig. 2.10I).
Punch the minimum number of holes
necessary to adequately isolate the tooth
(Fig. 2.11B). While treating interproximal
lesions adjacent teeth are also isolated. When
isolating several teeth, cutting the interproximal
dam material is advised to create a split (Fig.
2.14A).

Rubber Dam Forceps

It is used to hold, carry and remove clamps form
tooth surface (Figs 2.10E and I). The rubber
dam clamp forceps come in variety of designs.
Most forceps designs include the University of
Washingston/Stoke, Brewer (Ash, Dentsply,
Wey-bridge, Surrey, UK) and Ivory (Heraeus
Kulzer, South Bend, IN, USA) patters.
Rubber Dam Clamps (Fig. 2.12)
Rubber dam clamp selection is important
for stabilizing the rubber dam. Clamps are
classified as winged and wingless one. There are
over 50 different designs of rubber dam clamps
available. Clamps are available as labeled
numerically, alphabetically or color coded.
Each clamp consists of set of jaws connected by
FIGURE 2.12 Rubber dam clamps for primary
molars and incisors
a bow (Figs 2.13A and B). There are clamps with
asymmetric and serrated jaws to provide better
anchorage to the tooth. The selected rubber
dam clamp should achieve four-point jaw
contact at the cervical region of the tooth. The
clamp that is chosen will be dependent on the
tooth to be isolated, the application technique
and operators preference. Winged clamp allow
more tissue retraction and one step application,
whereas wingless clamps are used with the two
step technique. Most rubber dam clamps are
made of stainless steel but some are made from

02.indd 13 30-01-2015 11:09:31

 14 Crowns in Pediatric Dentistry

A B
FIGURES 2.13A AND B Wingless (A) and winged (B) clamps

A B
FIGURES 2.14A AND B Individual tooth isolation with rubber dam and securing with floss and clamp

plated steel (susceptible to corrosion). There
are even non metallic clamps made of plastic
(SoftClamp, KerrHawe, Bioggio, Switzerland).
Clamps can also be classified as retentive or
bland. Retentive clamps provide four point
contact on the tooth.
Always while using rubber damp, it should
be tied with dental floss to prevent from
accidental swallowing. A 8 to 10 inch length
of dental floss may be tied through one of the
clamp holes, wound around the bow of the
clamp and then passed through and tied to the
opposite clamp hole. Some frequently used
clamps used in pediatric dentistry are:
The 12A clamp (Ivory, Miles Inc., Dental
Products, South Bend, IN): It is for clamping
the maxillary left second primary molar and
the mandibular right second primary molar.
The 13A clamp (Ivory, Miles Inc., Dental
Products, South Bend, IN): It is for clamping
the maxillary right second primary molar
and the mandibular left primary second
molar.
The 2A clamp (Ivory, Miles Inc., Dental Prod-
ucts, South Bend, IN; Hygienic Corp, Akron,
OH) for clamping the first primary molars.
The 14 clamp for clamping fully erupted
permanent molars
The 14A clamp for clamping partially
erupted permanent molars
After selecting the appropriate clamp place
a 12 to 18 inch piece of dental floss on the bow

02.indd 14 30-01-2015 11:09:32


of the clamp to aid in retrieval of the clamp, if
it is dislodged from the tooth and falls into the
posterior pharyngeal area.
Other Accessories (Fig 2.10G)
Rubber dam napkin: Rubber dam napkin can
be placed between the dental dam and the
patients face. This helps to absorb moisture and
increase comfort for the patient.
Lubricants: Lubricant such as topical Ultradents
or KY jelly can be placed on the underside of the
dental dam for easier placement over the teeth
and through the interproximal areas.
Rubber Dam Placement Techniques
The rubber dam during application in children
should be introduced as any other routine
dental procedure. The euphemism terms are
used such as; rain coat for rubber dam sheet,
button for clamp and coat hanger for frame. For Anterior Teeth
Proper local anesthesia should be administered
to prevent uneasiness during rubber dam
placement.
There are four techniques in rubber dam
placement;
1. Clamp first, then rubber dam: First a well-
fitted abutment tooth clamp is selected and
then seated in place. Rubber dam sheet
is placed after checking the stability of
clamps place index fingers on the dam
buccally and lingually to the abutment
hole, stretching the dam to an oval shape
and passing it over the bow of the clamp
and then over the wings. This method offers
excellent visibility on tooth and clamp.
Clamp securing, e.g. with dental floss is very
important.
2. Rubber dam first, then clamp: The
abutment hole is stretched in buccal-oral
direction and then placed over the teeth till
the gingival tissue is visible. The rubber dam
is held in this position and an assistant can
place clamp. Then the rubber dam can be
released.
02.indd 15
General Considerations 15
3. Bow of clamp in the rubber dam: The bow of
the clamp is placed through the perforation.
Then the rubber dam is gathered to one side
and held with the hand, while the clamp
is placed onto the tooth. Afterwards the
rubber dam is placed onto the frame. This
technique offers excellent view on the area
where the clamp has to be placed.
4. All in one: This method involves pre-loading
of a winged clamp onto the rubber dam. The
perforated rubber dam is placed onto the
frame. Then a winged clamp is placed into
the opening engaging the wings of the clamp
into it. Rubber dam and clamp are applied
as a unit together. The unit is placed with
the rubber dam forceps. Then the dam is
slipped off the wings with a flat bladed
instrument to the subclamp position. This
technique can be accomplished without the
aid of an assistant.
The two most popular techniques for isolating
anterior teeth are individual tooth isolation and
the split dam/trough technique.
Individual Tooth Isolation
The advantage of individual tooth isolation is
that it provides greater deflection of gingival
tissues and better moisture control. The disad
vantages are ligature ties may cause bleeding
of gingival tissues, inhibit rapid removal of the
rubber dam and interfere with the placement
and finishing of crowns.
The rubber dam is prepared by stretching
the dam material over the frame and punching
the appropriate number of holes in the dam
material, as described earlier. The holes are
stretched over the teeth so they poke through
the rubber dam. The dam may be stabilized
by placing a wooden wedge or a small piece of
rubber dam material interproximally between
the two teeth distal to the treated teeth. The teeth
may be ligated by placing 12 to 18 inches of floss
30-01-2015 11:09:32
 16 Crowns in Pediatric Dentistry
A B
FIGURES 2.15A AND B Split dam method
around the cervix of the tooth and have the dental
assistant hold the floss gingivally on the lingual
with a blunt instrument (Fig. 2.14B). The floss is
drawn interproximally to the facial surface, and
r
tightened with a surgical knot below the cervical
e
budge. If the dam is not sufficiently stabilized,
additional holes are added and rubber dam
.p
clamps are placed on the molars.
Upon completion of treatment the rubber
p
iv
dam is removed by cutting and removing
the ligatures and the wedges. The rubber is
/: /
stretched so that the dams interproximal septa
may be cut with a pair of scissors. The clamp(s),
dam and frame are removed as a unit.
tt p
Split/Trough Dam Method
h
The advantages of the split dam method are the
rapid application and removal of the dam and
non-interference with crown placement and
finishing of the restoration. The disadvantage
is that it only provides moderate moisture control.
The rubber dam is prepared by stretching
the dam material over the frame and punching
the appropriate number of holes in the dam
material. The interproximal rubber dam
material is cut with scissors connecting the
holes (Figs 2.15A and B). The hole is stretched
around the teeth to be treated and stabilized
with a wooden wedge or a small piece of rubber
dam material. Alternatively, a household
02.indd 16
r/
s .i
s
n
rubber band may be placed bilaterally at
is a
interproximally between the primary cuspids
and first primary molars and stretched around
the rubber dam frame and the patients head.
Upon completion of treatment the rubber dam
is removed by removing the wedges and clamps.
The clamp(s), dam and frame are removed as a
unit.
CEMENTATION/CEMENTS USED
FOR CEMENTATION OF CROWNS
All types of crowns used in pediatric dentistry
such as stainless steel crowns and PVSSC
are cemented with variety of luting cements.
Numbers of cements are available to accomplish
this. Zinc phosphate and polycorboxylate
cement have been recommended for crown
cementation. However, adhesive cements
such as glass ionomer and resin modified
glass ionomers provide excellent retention and
demonstrate less microleakage than the non
adhesive zinc phosphate and polycarboxylate
cements. Decreased microleakage has the
potential to reduce clinical failures caused
by recurrent caries, pulpal pathology and
failure of root canal treatments due to coronal
microleakage.
Temporary cement is used to hold the
restoration in place. It fills the space between
30-01-2015 11:09:32
 General Considerations 17

the crown and the preparation, thus supporting
the occlusal contours, filling and sealing the
margin/finish line area. During cementation
it is imperative to remove all debris, to rinse
and dry (not to desiccate causing sensitivity to
exposed dentinal tubules) the preparation, and
to isolate the area with cotton rolls to prevent
problems. Luting consistency of cement are
used during crown cementation.
Types of Cements Used for Crown
Cementation (Fig. 2.16)
Zinc phosphate

/
contamination by saliva. Depending on the GIC

r
consistency of the cement mix, cement creates Resin modified glass ionomer

.i
pressure as it dries, occasionally which forcing Zinc polycorboxylate cement
the crown in an occlusal direction. This can be Zinc oxide eugenol cement

s
detected by a post-cementation occclusal check. Resin cementPanavia 21

s
Minor occlusal prematurities (high contacts) The prevailing opinion on the retention

n
can generally be adjusted with the crown of steel crowns appears to be that the cervical
in the patients mouth. Gross malocclusion adaptation of the crown to the tooth is the

is a
(deviation from acceptable contact) will also most important aspect. Noffsinger et al. tested
tend to lift the crown from the preparation retentive properties of three dental cements
finish line; adjustment necessitates removal using stainless steel crowns fitted to extracted

r
and re-cementation of the crown. Holding the third molar teeth. No significant difference was

e
teeth firmly together in centric occlusion during found between the overall mean retentive forces
cementation should prevent most of these of the polycarboxylate cement and the two

.p
iv p
/: /
tt p
h

FIGURE 2.16 Different cements for crown cementation (left to right, GIC, polycarboxylate, zinc phosphate,

zinc oxide eugenol, silicophosphate cement resin-Panavia 21 cements)

02.indd 17 30-01-2015 11:09:32

 18 Crowns in Pediatric Dentistry
glass ionomer cements. Mechanical retention
of the crowns was not a factor in the overall
retentive value. In the study by Berg JH. Pettey
DE and Hutchins MO (1988) evaluated the
microleakage through margins of stainless steel
crowns when cemented with polycarboxylate,
zinc phosphate, or glass ionomer cement by
measuring the amount of leakage through the
crown margins. It was concluded that the newer
glass ionomer cement provides comparable
protection to that of the other two traditional
cements used with stainless steel crowns.
Zinc Oxide-Eugenol Cement
Zinc oxide cement is prepared by mixing zinc
oxide powder and eugenol liquid on glass slab.
Zinc oxide-eugenol cements have long been
recognized for their kindness to the pulp; they
are the standard to which all newly developed
cements are compared for pulp compatibility.
.p
The set cement is a composite of unreacted zinc
oxide particles and eugenol surrounded by and
iv p
held together with the reaction product zinc
eugenolate. However, certain higher strength
/: /
brands have been successfully used for steel
crown cementation. The occasional need for
re-cementation is counter balanced by pulp
tt p
acceptance. The strength of these unmodified
cements has been considerably improved by
the addition of synthetic resins or quartz to
h
the powder and ethoxybenzoic acid to the
liquid. Although the compressive strength is
increased (from 2000 to 15,000 psi) solubility
as measured by water immersion increases as
much as fourfold. Nevertheless, these improved
cementsFynal, IRM (LD Caulk Co.) and
Opotow EBA Alumina (Teledyne Corp) are
preferred by some Pedodontists for steel crown
cementation.
Copper, Zinc and Silicophosphate
Cement
Copper, zinc and silicophosphate cements all
have the common denominator of water-diluted
02.indd 18
and buffered orthophosphoric acid as their
liquid; therefore all can be expected to produce
certain degrees of pulp irritation due to their low
pH. The powder for copper phosphate cement
is cuprous (red) or cupric (black) oxide, for zinc
phosphate is zinc and magnesium oxide, and
for silicophosphate essentially aluminosilicate
/
glass. The initial pH is lowest for the copper
r
cements and highest for zinc phosphate. At
.i
28 days the same relative pH order exists, with
copper about 6, silicophosphate about 6.7 and
s
zinc phosphate about 7.
n
Zinc Phosphate Cement
s
is a
Mixing zinc oxide with phosphoric acid forms
zinc phosphate cement. It is used mainly for
luting or mechanically locking a restoration by
r
filling in voids and defects. It is used primarily
e
with stainless steel bands for space maintainers.
Zinc phosphate cements are easily handled and
manipulated and have many years of clinical
use.
In the studies by Mathewson et al. (1974)
zinc phosphate cement was found to be the best
choice of five different types of cements used
for final cementation of stainless steel crowns.
To achieve maximum strength, low solubility,
proper film thickness and less free acid in the
final mix of cement, use a high powder/liquid
ratio, by refrigerating cement mixing slabs
have a longer working time, a shorter setting
time in the mouth, and increased retention of
orthodontic bands could be achieved from the
mixed zinc phosphate cement (Shepard, 1978).
Disadvantages of Zinc Phosphate
Its low pH, which can cause pulp irritation.
When first mixed, zinc phosphate cement
has a very low pH that can remain below
7.0 for as long as 48 hours (Norman, 1966).
Wilson (1974) found that the zinc phosphate
cements to be soluble in distilled water and
organic acids.
Lack of antibacterial properties.
30-01-2015 11:09:33

Solubility in oral fluids, and lack of adhesion.
The phosphate cements usually require
two coats of application of varnish prior to
cementation on a vital tooth.
Silicophosphate Cement
Due to fluoride release, silicophosphate reduces
caries activity. The powder is essentially zinc
oxide and the liquid largely polyacrylic acid.
Silicophosphate shows the highest 7-days
compressive strength (about 25,000 psi),
whereas copper and zinc phosphate cements
have compressive strength about 22,000 psi.
Polycarboxylate Cement
It is developed to provide a chemical bond
between tooth structure and cement. By virtue
of its chemical structure the polyacrylic acid
chemically binds or chelates with certain
cations. Thus tooth calcium or phosphorous
chemically unites with the setting cement. It
consists of a mixture of zinc oxide powder with
a polyacrylic acid liquid. It was observed as
a direct bonding between the stainless steel,
carboxylate cement, and enamel (Mizrahi and
Smith, 1968). Polycarboxylate cements have
minimal irritation effect on the pulp, same as
zinc oxide-eugenol. Polycarboxylate cements,
when compared with zinc phosphate and
improved zinc oxide eugenol cement, have a
high level strength (Arfali and Asgar, 1978).
However, the strength is not related to increased
physical properties such as tensile strength,
compressive strength, or film thickness.
The main advantage of polycarboxylate
cement is the low irritant factor to oral tissue.
There is adhesion to tooth substance and
stainless steel alloys. Other physical properties
are similar to the phosphate cement. The
disadvantages are the requirements for precise
proportioning, optimum manipulation, and the
need for a clean, uncontaminated tooth surface.
Zinc (from zinc oxide) causes entrancement
binding whereas certain restorative metals bind
02.indd 19
General Considerations 19
to the outer surface; this binding seems to occur
between carboxylate cements and stainless
steel. This is the reason why these cements are
highly recommended for use with steel crowns.
Although the initial pH of polycarboxylate
cements is quite low (about 1.7), their overall
reaction on the pulp is comparable to that
of zinc oxide-eugenol, they therefore cause
minimal irritation. The reason for this, tolerance
is thought to be related to the molecular
size of the acid molecule and/or to protein
complexing. One way or another, diffusion
through the tubules to the pulp is limited.
The primary objection to the carboxylate are
too rapid setting, which limits the number of
units that can be cemented from one mix. The
compressive strength of zinc polycarboxylate is
less than that of the zinc phosphate; however,
tensile tests (both diametric and simulated by
removing cements castings) show only small
differences. The solubility of these cements
is low and does not seem to be an important
consideration. However, crown loosening does
occur with over tapered preparations and is
thought to be due to creep or flow of the cement.
Glass Ionomer Cement
Glass ionomer cements are quite new and very
promising. Their powder is aluminosilicate glass
and liquid is a mixture of polyacrylic, itaconic,
and tartaric acid. Just as silicophosphate
is a hybrid of silicate and zinc phosphate,
the glass ionomers are hybrid of silicate
and polycarboxylate. These cements have
comparable strengths with zinc phosphate,
release of fluoride as do the silicophosphate,
chelate or bond to tooth structure as the
polycarboxylate, and are as pulpally compatible
as the polycarboxylates. They could prove to
be the best cement available for steel crown
cementation. Silicate and polyacrylate systems
are combined to form the glass ionomer
cements. The powder is fine ground calcium,
aluminium, and fluorosilicate glass combined
with a solution of 50 percent polyacrylicitaconic
30-01-2015 11:09:33
 20 Crowns in Pediatric Dentistry
acid. The powder/liquid ration is 1.3:1, which
is most important. Glass ionomer cements
seemed to be soluble in saliva with slow setting
time. These cements have the potential to
adhere to tooth structure but these surfaces
must be isolated. These cements leach fluoride
with subsequent uptake by adjacent enamel.
Postoperative sensitivity in permanent teeth has
been reported. The advantage of GIC is similar
to polycarboxylate cements. The disadvantages
include moisture sensitivity; occasionally pulp
irritation, initial low set and questionable
adhesive properties, their radiolucency and
the lack of long term clinical efficacy. Smith
(1983) in an excellent review of dental cement
states that there is yet no ideal dental cement.
Each material must be used on its merits with
knowledge of its limitations.
Resin CementPANAVIA 21
(Fig. 2.16)
Panavia 21 in a self etching advance resin
cement that bonds directly to metal and silinated
surface with no need for a bonding agent. The
setting mechanism of Panavia 21 provides
custom working time and trouble free clean
up. It is available in three different radiopaque
shades and translucencies. It is indicated for
the cementation of metal crowns, bridges and
inlays/onlays. It is antibacterial, eliminates the
need to use additional disinfectants.
Two other categories of cements are acrylic
and composite resins. Problems encountered
have been proportioning and manipulation
difficulties, to create a film thickness, difficulty in
removing excess, and (especially) postoperative
sensitivity. Their strength is adequate to excel-
lent and their solubility is low, but these advan-
tages are far outweighed by their disadvantages.
Steps for Cementation
Crowns should be cemented only on clean, dry
tooth. Isolation of teeth with cotton rolls is also
recommended. Apply Vaseline to contact areas:
02.indd 20
Rinse and dry the crown inside and outside
and prepare to cement it. Zinc phosphate
cement, polycarboxylate or GIC cements are
preferred for crown cementation.
If zinc phosphate cement is used, 2 coats
of cavity varnish should be applied on vital
tooth before cementation. Luting cement
should be of consistency so that it stings
about 1 inches from mixing pad with the
spatula cement. It is filled in approximately
2/3rd of crown, with all inner surface
covered. Avoid air bubbles in mixed cement.
Seat the crown completely on dried tooth
surface preparation. Final placement should
follow an established path of insertion of the
crown. Cement should be expressed around
all margins. To ensure complete seating of
the crown, handle of mirror or band pusher
may be used.
Before the cement sets, ask the patient to
close into centric occlusion by applying
pressure through a cotton roll and confirm
that the occlusion has not been altered.
Zinc phosphate cement can be easily
removed with an explorer or scaler. After
the polycarboxylate cement is partially set,
it will reach a rubbery consistency. Excess
cement should be removed at this stage
with explorer tip. Dental floss is passed
interpriximally to remove excess cement
from interproximal areas.
Rinse the oral cavity before dismissing the
patient, reexamine the occlusion and the
soft tissue.
BIBLIOGRAPHY
1. Anterior crowns used in children. Morenike
Ukpong. Dep of Paediatric Dentistry, Obafemi
Awolowo University, Ile-Ife, Nigeria.
2. Schwartz s. Full coronal aesthetic restoration of
anterior primary teeth. Crest, Oral-accessible at
www.dentalcare.com, 2012, 21 pages.
3. Guideline on Pediatric Restorative Dentistry.
Reference Manual. Pediat Dent. 2013; 34(6):
21421.
30-01-2015 11:09:33
C HAPTER 3
Different Crowns Used in
Pediatric Dentistry
Prashant Babaji, Jalarak C Patel, Poonacha KS, Anju Bansal, Raghavendra Shetty

CLASSIFICATIONS OF CROWNS Ceramic (Zirconia) crown

ZIRKIZ crown
Based on Material Used (We EZ-crown
Proposed Following Classification) Kinder Krown
CEREC crown
All metallic crown Ceramo basemetal crown.
Stainless steel crown (SSC/PMC) Biologic crowns
Aluminum crown
Stainless steel crowns (SSC) with facing Classification of Crowns According
Resinous/composite crown to Bonding or Luting of Full Coronal
Strip crown Restoration
Composite shell crown
New millennium crown Luted
Glass ionomer crown Stainless steel crown
Polycarbonate crown SSC with facing
Kudo crown Ceramic crowns.
PedoNatural crown Bonded
Pedo jacket crown Resin based
Artglass crown. Composite based
Preveneered stainless steel crown Natural tooth.
(PVSSC): SSC with composite, resinous,
HDP, polyethylene or epoxy facing
NuSmile crown
RESTORATION OF SEVERELY
Flex crown DECAYED TOOTH WITH POST
Pedo pearls AND CORE
Cheng crown
Whiter Biter crown Metal post-threaded, nonthreaded
Pedo compu-crown Fiber post
High density polyethylene (HDPE) crown Composite post
Dura crown. Natural post
22 Crowns in Pediatric Dentistry
FULL CORONAL
RESTORATIONS IN CHILDREN
Crowns can be made from:
All metal
Metal crown with facing
All ceramic
All resin preformed plastic crowns
Composite based crowns.
All Metal Crowns
Metals used in crowns include gold alloy,
other alloys (e.g. palladium), or a base-
metal alloy (e.g. nickel or chromium).
Less tooth structure needs to be removed
with metal crowns.
Metal crowns withstand biting and chewing
forces well and probably last the longest in
terms of wear down.
The metallic color is the main drawback.
Metal crowns are a good choice for out-of-
sight molars, e.g. stainless steel crown, cast
base metal crowns, aluminum crown.
Metal Crown with Facing
Can be color matched to the adjacent teeth
(unlike the metallic crowns).
More wearing to the opposing teeth occurs
if ceramic facing is used.
These crowns can be a good choice for
anterior or posterior teeth.
Metal appearance of SSC are masked with
composite, resin or ceramic veneers.
All Ceramic (Zirconia) Crowns
Provide the best natural color.
May be more suitable for people with metal
allergies.
All ceramic crowns are a good choice for
anterior teeth.
It has limited use in children because
it is expensive. Can fracture easily and
preparation requires extensive tooth tissue
reduction.
Its use is limited to the permanent dentition.
Examples of zirconia crowns for primary
teeth are EZ-crown, Kinder Krown.
A Porcelain Jacket Crown would only be
used as an anterior crown in children age
15 years and above for a number of reasons.
By age 15 years, there is reduction in the width
of the pulp chamber reducing the tendency
for pulpal exposure during tooth preparation;
active eruption of the anterior teeth should
be completed, this reduces the risk for pulp
exposure during crown preparation; the
tendency for crown fracture resulting from fall
or contact is reduced.
All Resin Crowns
(Acrylic Jacket Crown)
They are less expensive.
However, they wear down over time.
Are more prone to fractures than porcelain-
fused-to-metal crowns.
Acrylic jacket crowns are the most appro-
priate material before the age of 15 years
for anterior jacket crown because they are
inexpensive, tissue removal is minimal and
appropriate as a temporary material. This is
used as a temporary crown restoration material
because of two reasons:
1. The color changes very quickly especially in
children who eat color staining foods like
soup, tea (color stability is poor).
2. It can fracture very easily.
Acrylics, just like porcelain, are not used as
anterior jacket crown materials in the deciduous
dentitions for a number of reasons.
Acrylic has a tendency to release polymers
that are toxic to the pulp. Tendency for pulp
toxicity in the primary teeth is high since
the dentin is more porous and thin when
compared to the permanent teeth.
Acrylic also acts as gum strippers leading to
an increased tendency for gingival recession.
 Different Crowns Used in Pediatric Dentistry 23

Gingival recession could also occur due to Composite-based Crowns

gingival reactions to the leached materials
at the gum margins.
The amount to tooth material that needs to
be removed for both acrylic and porcelain
crowns during tooth preparation will lead to
pulpal exposure.
They have very good color matching to
adjacent natural teeth
Shade selection is possible
Does not wear opposing teeth
They have compatible strength
Require adequate moisture control during
cementation, e.g. strip crown, PedoNatural
crown.

ALL METAL CROWNS

Jalarak C Patel, Poonacha KS, Raghavendra Shetty

COMPOSITION OF CROWNS crowns are most durable restoration for severely

decayed primary teeth. It can be placed quickly
Stainless steel crowns and successfully onto very little tooth structure,
Chromium 1720 percent even in the presence of blood and saliva, and
Nickel 812 percent can be easily crimped. However, they are very
Carbon 0.15 unesthetic and unacceptable and rejected by
Iron 0.080.12 percent majority of parents as a viable restorative option
Nickel-based crowns to their childs teeth. On rare occasions, they
Nickel 7080 percent can cause localized tissue irritation and have
Chromium 1025 percent been known to be a contributing factor in metal
Molybdenum 24 percent allergies.
Aluminum 2 percent Stainless steel crowns are full coronal
Berylium 0.5 percent restorations. They are prefabricated crown
Tin-based crowns forms (preformed metal crownsPMC) that are
Tin 96 percent adapted to individual teeth and cemented with a
Silver 4 percent biocompatible luting agent. Preformed stainless
steel/nickel chrome crowns are reliable and
STAINLESS STEEL CROWNS durable. Except esthetic quality stainless steel
crowns are most certainly the gold standard of
Stainless steel crowns are the most common treatment in many aspects. Seale concluded that
type of crowns used in pediatric dentistry. SSC is an extremely durable and cost-effective
Stainless steel crowns were often referred as restoration. He also concluded that SSC should
chrome steel crowns. These are what many be used to protect future decay by full coverage.
people call silver crowns. These shiny silver Stainless steel crowns (preformed metal
crowns are very strong, economical and durable crowns) were introduced in 1947 by the Rocky
and are a great option if esthetics is not prime Mountain Company. Stainless steel (PMCs)
concern. Croll (2013) described that SSC are crowns for primary molar teeth were first desc-
easy to place, fracture proof, wear resistant and ribed by Engel in 1950 and popularized by Dr
attached firmly to tooth until exfoliation. The SSC Willium Humphery in 1950. Until then the
24 Crowns in Pediatric Dentistry
treatment for grossly decayed primary teeth
was extractions. Since then between 1950 and
1968, several modifications were recommended
for stainless steel crown techniques which has
simplified the fitting procedure and improved
the morphology of the crown to duplicate
the anatomy of primary molar teeth. The
morphology of primary molar tooth differs
significantly from its permanent successors,
in having greatest convexity at the cervical
third of the crown. Thin metal of preformed
crown margin is flexible enough to spring into
undercut area. Enamel and dentin thickness of
primary teeth are much thinner than permanent
teeth. The SSCs are designed for primary
and permanent teeth closely resemble to the
natural anatomy. It obtains retention mainly
from cervical undercuts. SSCs are generally
considered as superior to large multisurface
amalgam restoration with longer clinical life
span. Due to esthetic concern anterior SSC
crowns are modified with open faced SSC.
Preveneered SSC are available in the market
with different brand names.
Stainless steel crowns are used as temporary
crowns in permanent teeth because the margins
of the crowns cannot be made as accurate
as gold and other materials for marginal
adaptation. They are not durable for a longer
period. Kowolik et al. (2007) from their study
hypothesized that greater use of the stainless
steel crowns would be made by specialists
than by general dentists. Saraf and Farsi (2004)
from their study concluded that stainless steel
crowns are still a valuable procedure that has no
harmful effect on the gingiva and bone provided
that good oral hygiene level was maintained.
Knowledge of the different stainless steel
crowns is necessary to determine how they
can affect the adaptation of the various crowns
to the type of preparation recommended.
The characteristics of the Ion, Unitek, Rocky
Mountain and Ormco, crown forms and the
variations in contouring, festooning and
occlusal anatomy can be noted. The original
alloys used by manufactures for steel crown
construction were stainless steel. Rocky
Mountain and Unitek crowns still are stainless
steel; but the Ion crown is Iconel, a nickel-
chromium alloy. Nickel-chromium crowns are
widely used.
Stainless steel is composed of iron, carbon,
chromium, nickel, manganese and other
metals. The term stainless steel is used when
the chromium content exceeds 11 percent and
is generally in the range of 12 to 30 percent.
Chromium oxidizes and forms a thin surface
film of chromium oxide (Cr2O3), known as
passivating film which protects against
corrosion. Stainless steel is classified as ferritic
(the nonheat hardenable 400 series), martensitic
(the heat hardenable 400 series), and Austenitic
stainless steel (chromium-nickel-manganese
200 series and chromium nickel 300 series) is
used extensively for the fabrication of dental
appliances and is composed of chromium
(11.527%), nickel (722%) and carbon (0.25%).
Nash (1981) stated that nickel-chromium
crowns have the advantage over stainless steel
crowns in that they are fully shaped and strain-
hardened during manufacture.
Austenitic types: The austenitic types are
used by Rocky Mountain and Unitek for their
crowns referred to as 18-8 stainless steel since
they contain about 18 percent chromium and
8 percent nickel. In addition, they contain
small amounts of other alloying elements,
carbon (0.080.15%) and iron. The austenitic
types have high ductility, low yield strength
and high ultimate strength, which make them
outstanding for deep drawing and forming
procedures. They are readily welded and can
be work hardened to high levels, although not
as high as can be obtained by heat-treating the
appropriate types of the 400 series.
The austenitic types provide the best
corrosion resistance of all the stainless steels,
particularly when they have been annealed to
dissolve chromium carbides and then rapidly
quenched to retain the carbon in solution.

Annealing is especially important if previous
fabrication involved exposure in the range
900 to 1550F (sensitization range). Exposure
in this range results in carbide formation and
consequent chromium depletion primarily at
grain boundaries, where the majority of carbides
form. This will also happen if overheating occurs
during dental soldering procedures and will be
manifested intraorally by loss of the crowns
stainless properties.
Compared to ferretic, austenitic types are
preferred since austenitic types have following
properties:
Increased ductility
Ability to be cold worked with fracture
resistance and increased strength during
cold working
Greater ease of welding
Ability to overcome sensitization (>650C)
During annealing less critical grain growth
occurs.
Tables 6.1 and 6.2 provide comparative
chart of different pediatric crowns.
ION CROWNS/NICKEL-
CHROMIUM CROWNS
The ion crown is constructed of Iconel 600,
a relatively new addition to the category of
preformed crowns and is primarily nickel-
chromium. The typical constitution is 76 percent
nickel, 15 percent chromium, 8 percent iron,
0.08 percent carbon, and traces of other
elements. The metallurgic characteristics of the
nickel-chromium alloy permit these crowns to
be strain hardened during manufacture. The
higher hardness renders the ion crown more
difficult to contour and adapt to the prepared
tooth.
The nickel-chromium preformed crown has
been criticized in comparison with available
varieties of stainless steel crowns. First, the
nickel-chromium crown is said to have deep
occlusal anatomy in contrasts with other
crowns and with the natural primary tooth,
Different Crowns Used in Pediatric Dentistry 25
which require unnecessary occlusal reduction
and may interfere with lateral excursions of the
dentition. The sample measurements of occlusal
depths of two popular types of crowns indicated
considerable variation, in some instances;
the occlusal depth was greater on the nickel-
chromium crown and in others on the stainless
steel crown. However, the differences were
no greater than 0.001 inch and cannot be
considered clinically significant. It is possible
that an optical illusion, created by supplemental
grooves intended to replicate the morphology
of natural tooth, causes the nickel-chromium
crown to be perceived as having deeper occlusal
anatomy.
The nickel-chromium crown is thinner than
other crowns, resulting in more occlusal wear.
Thicknesses were fairly uniform throughout
the crown, with no indication of thinning of the
nickel-chromium crowns at the cervical as had
been suggested. The clinical significance of this
difference is unknown. The vickers micro hard-
ness tests indicate the nickel-chromium crown
to have a hardness of the magnitude of 325 to
350 compare with 250 to 306 for the stainless
steel crown and there is no clinical evidence of
increased occlusal wear of nickel-chromium
crown compared with stainless steel crown.
When indicated the nickel-chromium crown
offers the clinician significant advantages over
previously available crowns for the restoration
of primary molars, because of its flexibility and
simplicity of application
The highly contoured walls of the nickel-
chromium crown require greater tooth re-
duction. Both stainless steel and nickel
based crowns must ultimately be adapted
into the cervical infrabulge area; the ability
to accomplish the feature of the flexibility of
the crown, not the degree of tooth reduction.
The advocated technique of tooth preparation
does not specify reduction of either the buccal
or lingual surfaces. An exception to this is the
existence of an especially prominent buccal
bulge on the mandibular first primary molar,
26 Crowns in Pediatric Dentistry
the crown springs over the height of contour
because of its flexibility. It has been suggested
that the nickel-chromium crowns are too short
and leave enamel exposed and susceptible to
caries. If in rare instances, a nickel-chromium
crown was too short and other types of crowns
were of adequate length, it would be preferable,
nevertheless, to perform the crown lengthening
procedure than to use the crown that routinely
requires trimming and polishing.
Objectives
To achieve biologically compatible mastica-
tory component and clinically acceptable
restoration.
To maintain the form and function of tooth
and where possible, the vitality of the tooth
should be maintained.
Characteristics of
Stainless Steel Crown
Heating does not increase their strength
They are work harden
Strength increases from manipulation with
pliers
High chromium content reduces corrosion
Soldering with flux reduces their corrosion
resistance
A B
FIGURES 3.1A AND B Rampant caries affecting primary incisors and molars
Indications
Caries (Figs 3.1A and B)
Extensive decay in primary and young
permanent teeth with caries on three or
more surface or where caries extends
beyond the anatomic line angles, e.g.
caries on mesial surface of maxillary and
mandibular first molar.
The proximity of the pulp on mesial side
make placement of an acceptable amalgam
restoration difficult.
Primary incisors with Class V lesion.
Cervical decalcification
Extensive interproximal caries
In high caries-risk children
In patients with increased caries risk whose
cooperation is affected by age, behavior or
medical history
Child with rampant and nursing bottle caries.
Following the Pulp Therapy
In both the primary and permanent teeth as
pulp therapy (Fig. 3.2) leaves the treated tooth
brittle because of fluid loss, leading to chances
of crown fracture.

FIGURE 3.2 Radiograph showing SSC crown
following pulp therapy
As a Preventive Restoration
Where amalgam is likely to fail.
For patients who have developmental or
medical problems which will not improve
with age.
Restoration in disabled child or others with
extremely poor oral hygiene with likely
chances of restorative material failure.
If the patient has high susceptibility to caries
manifestation, either by numerous gross
carious lesions or by rampant caries and
in a handicapped child whose lack of oral
hygiene may encourage further decay.
For instance, developing Class V lesion is a
sign of poor oral hygiene and cariogenic diet.
When this occurs in the preschool children,
who also has Class II lesion in the same
tooth, the stainless steel crown is indicated
particularly in the first primary molar.
A B
FIGURES 3.3A TO C Hypoplastic/developmental defects
Different Crowns Used in Pediatric Dentistry 27
Hypoplastic Defects
Teeth with hypoplastic defects are more susce-
ptible to caries, because retention of the plaque
occurs in hypoplastic defects (Figs 3.3A to C).
The placement of stainless steel crowns in
hypoplastic teeth, treatment may involve the
crowning of the teeth in all 4 quadrants (often all
posterior teeth). Thus there is danger of altering
the vertical dimensions by impinging on the
freeway space. In such cases the crown should
be fitted quadrant wise.
Extensive Abrasion
If extensive abrasions have already resulted in
a loss of vertical dimension, then a slight (less
than 2 mm) opening of the bite is acceptable. If
the bite is opened more than 2 mm, it will result
in tenderness of the treated tooth and possible
adverse pulp response.
Developmental Defects
Primary or permanent teeth with enamel
or dentin defects such as, amelogenesis
imperfecta, dentinogenesis imperfecta and
hypoplastic teeth. In these developmental
defects, enamel is chipped or worn off
exposing the underlying dentin, which leads to
reduction in vertical height of the crown hence
SSC is advised to restore occlusal height and
strengthen the tooth. In these cases, crowns
C
28 Crowns in Pediatric Dentistry

should be placed in pairs one on each side of the

mouth, either in the same arch or the opposite
arch (Figs 3.3A to C).

As an Abutment/Space Maintainer
Restoring primary teeth used as abutment
for a space maintainer such as crown and
loop space maintainer (Fig. 3.4).
The placement of a stainless steel crown
and loop space maintainer following the FIGURE 3.4 Crown and loop space maintainer
extraction of first primary molar.

Fractured Tooth Restoration

Temporary restoration of fractured tooth.

Bruxism
In severe cases of bruxism, teeth may be so
abraded and severely worn (Fig. 3.5) so that
stainless steel crowns are required to restore
the interarch vertical dimension and prevent
FIGURE 3.5 Occlusal wear due to bruxism
traumatic pulpal exposure. In the mixed
dentition phase, the stainless steel crown
adapted to the primary molars will assist in
preventing wear of the first permanent molars.

Cross-bite Correction
Correction of anterior cross-bite or to alter the
shape, size or inclination of teeth, a large sized
anterior SSC placed in reverse position on
maxillary anterior tooth (Fig. 3.6).

Indications for Use in

Permanent Molar Teeth
FIGURE 3.6 Cross-bite correction with reverse SSC
Interim restoration of a broken down or
traumatized tooth until construction of a
permanent restoration. Contraindications
When financial considerations are uncertain
Teeth with developmental defects. Even though preformed crowns have been ad-
Full coverage restoration of partially erupted vocated for use in other circumstances, they are
permanent tooth. not the preferred restoration for:

Nonrestorable and severely broken down
teeth.
As a permanent restoration in a permanent
teeth.
Primary teeth exhibiting more than half of
root resorption.
The tooth exhibits excessive mobility.
Primary tooth is approaching exfoliation.
Teeth to be exfoliated within a brief period
of 6 to 12 months. The cost effectiveness
of any restoration should be considered
in treatment planning in many instances,
a temporary restoration can be placed in
molars approaching exfoliation.
Patients with nickel allergies.
Restorable tooth by conventional measure
with GIC (Glass ionomer cement) or
amalgam.
Inability to fit SSC crown due to lack of
patient cooperation (Duggal, 1989).
As an abutment for space maintainer:
Nash (1981) has stated that the preformed
crowns should be considered as a means
of restoring a primary tooth, not as a
method of fabricating a space management
appliance. Bands can be placed on primary
teeth to fabricate appliance to preserve
arch circumference, a more conservative
measure than reducing the tooth for crown
placement. Even when the adjacent tooth
requires crown placement, it is advisable to
maintain separate functions. A well-placed
crown can have a band and loop device
cemented to it rather than have the loop
directly appended to the crown. When the
space management device has served its
purpose it can be removed readily, leaving
the crown intact and undamaged. The use of
crowns on abutments for space maintainers
can result in poor adaptation of crown to
the tooth to accommodate the demands of
the space maintainer. In addition, cutting
the space maintainer from the crown
leaves a rougher surface, a nidus for plaque
development.
Different Crowns Used in Pediatric Dentistry 29
Advantages
Unbreakable
Crown completely covers the tooth and no
enamel is left exposed to decay/full coronal
restoration
Durable
Inexpensive
Minimal technique sensitivity
Pretrimmed, contoured and crimped
crowns needs minimal adjustment
Accurately duplicates tooth anatomy
Faster placement
Can be placed in presence of gingival
hemorrhage or moisture
Superior longevity compared to multi-
surface amalgam fillings.
Advantage of SSC Over
Multisurface Amalgam Restoration
Compared with silver amalgam restorations,
the stainless steel crowns are considered to
have several advantages. These include low
cost, less chair time, protection of tooth from
further decay, availability of many sizes,
durability, resistance to tarnish, absence
of mercury, the ability to regain vertical
dimension and retain occlusion, main-
tenance of morphologic form to preserve
the health of gingival tissues, and the ability
to preserve arch length.
These crowns are far superior to multi
surface amalgam restorations with respect
to both life span and replacement rate and
a most advantageous system of restoration
because of its retention and resistance.
The challenges involved in using amalgam to
restore multisurface caries in primary molars are
well documented. The close proximity of the pulp
to the outer mesial surface of the first primary
molars makes it difficult to obtain adequate
retention for an amalgam restoration.
The broad contact area between primary
molars can lead to flared proximal box pre-
30 Crowns in Pediatric Dentistry

parations in Class II situations, weakening the
tooth and reducing support for an amalgam
restoration.
A number of authors have cited that the
preformed metal crown is a preferred treatment
for multisurface caries on primary molars and
as the restoration of choice after endodontic
therapy for primary molars. Unlike amalgam,
which requires retention features to be incor-
porated into the cavity design, the preformed
crown obtains its retention from the flexibility
of the thin, precontoured crown margins. This
allows it to spring into the undercut area apical
to the cementoenamel juction (CEJ) in a primary
molar. They are also more cost effective because
of comparatively simple procedure involved in
restoring even severely affected primary molars.
Age, general health, condition of the teeth,
oral hygiene and susceptibility of the patient
to dental caries are presented as factors to be
considered in selecting restoration for childrens
teeth.
Studies Pertaining to
Stainless Steel Crown Uses
Esthetic and Parental Satisfaction
Several studies stated unacceptance of SSC by
parents as concerned to esthetic aspect. Esthetic
quality of SSCs can be improved with use of
open faced SSC or preveneered crowns.
Longevity of Crown Over
Amalgam Restoration
Table 3.1 shows list of studies regarding longevity
of SSC over multisurface amalgum restoration.
Randall (2002) in her review of literature
with five studies mentioned the performance
of multisurface amalgam restorations over SSC.
The five studies included a total of 1210 crowns
and 2201 amalgams, followed for 2 to 10 years.
From all five studies it was concluded that crown
restorations were superior to the multisurface
amalgam restorations on primary molars.
Braff (1975) compared success rate of SSC
(76) over amalgam restorations (150) in a 4-year-
old patient. He found that nearly 30.03 percent
of amalgam restorations needed retreatment
over 8.7 percent for SSC. Dawson et al. (1981)
and Einwang and Dunninger (1996) stated that
stainless steel crown has long life span compared
to multisurface amalgam restorations. Dawson
also concluded that Preformed Metal Crown
are treatment of choice for primary molars with
multisurface lesions in children less than 8 years.
Similarly, Eriksson et al. (1988) and Masser and
Levering (1988) observed that Preformed Metal
Crown are superior to multisurface amalgam

TABLE 3.1 Studies on SSC over multisurface amalgam restoration

Study Multisurface amalgam PMC crown Study duration

Number placed Failures % Number placed Failures % Years
Braff, 1975 150 87% 76 25% 2.5
Dwason et al. 1981 102 71% 64 13% 2
Masser/Levering, 1988 1177 22% 331 12% 5
Robert and Sherriff, 1990 706 12% 673 2% 10
Einwag and Dunninger,1996 66 58% 66 6% 8
Raw 2201 26% 1210 7% 5
Randall, 2002 2201 1210 210
Papathanasio, 1994 30% 20%

restoration. Papathanasiou et al. (1994)
concluded from retrospective study that, GIC
restoration had 73 percent failure, 43 percent for
composite, 30 percent for amalgam and lowest
failure rate for PMCs (20%) (Table 3.1).
Mata et al. (2006) provided evidence that
SSCs demonstrate greater longevity and reduced
need for retreatment, compared to multisurface
amalgam restorations. There is high-level evi-
dence for the use of SSCs because of their cost-
effectiveness, ease of placement, and longevity.
Hutcheson et al. (2012) concluded that white
MTA pulpotomies succeeded over 12 months
regardless of the restoration; however the
teeth restored with composite were not as
durable as considered an esthetic alternative to
the SSC.
Cost-effectiveness Over Amalgam
Multisurface amalgam restorations are either
fractured or dislodged frequently and require
re-restorations, hence they are costlier on long-
term compared to preformed metal crown.
Baff (1982) concluded that preformed metal
crown were more cost-effective than multi-
surface amalgam restorations. Eriksson et al.
(1988) stated that total cost of treatment for
the amalgam restored teeth was 35 percent
higher than for preformed metal crown.
Masser and Levering (1988) showed that
amalgam restorations are more costly than SSC
restoration; similar results were observed by Full
et al. in 1974.
A B
FIGURES 3.7A TO C Different metal crownsSSC (Uniteck), nickel-based (3M), tin-based (Iso-Form) crowns
Different Crowns Used in Pediatric Dentistry 31
Disadvantages
Metallic appearance gives rise to unesthetic
look
They are temporary crowns
Chances of nickel allergy.
Classification of Stainless Steel
Crowns
Based on Composition
Stainless steel crown: These are made up
of austenitic alloy (18-8). These types have
good formability and ductility. They also
have adequate hardness and wear resistance
to resist occlusal force. The austenitic types
provide the best corrosion resistance of
all the stainless steel (Fig. 3.7A), e.g. Rocky
Mountain, Denovo crown and Unitek 3M.
Nickel based crowns (Ion Ni-Ch crown-3M):
These crowns are widely used and are strain
hardened during manufacturing. Nickel-
base crowns are iconel 600 types of alloys.
The alloys have good formability and ductility
necessary for clinical adaptation of crowns
and wear resistance to resist opposing occ-
lusal forces. The metallurgical characteristics
of Ni-Chrome crown allows the crowns to be
fully shaped and strain hardened without a
defect during manufacture (Fig. 3.7B), e.g.
3M crowns.
Tin based crown/Tin-silver alloy crowns:
These crowns are readily adaptable but are
C
32 Crowns in Pediatric Dentistry
not permanent as stainless steel or nickel
based crowns. These crowns are made
from high purity tin-silver alloy that is soft
and ductile. Used for permanent molars
and premolars. They provide a positive
contact point with either natural or artificial
neighboring teeth. The crown margin is easy
to burnish.
Prefinished, belled and contoured
Ductile can be stretched and burnished
to fit prep margins
Faster placement than acrylics or
chemical resins for single units.
For example, 3M Iso-Form crown (Fig. 3.7C)
Aluminium based crowns: These are made
up of aluminum alloys containing 1.2
percent manganese, 10 percent magnesium,
0.7 percent iron, 0.3 percent silicon and 0.25
percent copper. They are readily adaptable
with lesser clinical durability (Fig. 3.8).
FIGURE 3.8 Aluminium based crowns
A B
FIGURES 3.9A TO C Untrimmed: (A) Untrimmed, uncontoured; (B) Pretrimmed, uncontoured;
(C) Pretrimmed and precontoured
Based on Morphology/Shape
(Figs 3.9 A to C)
Uncontoured and untrimmed crowns
(Unitek) (Fig. 3.9A): These crowns are
untrimmed and uncontoured requires
extensive trimming and contouring. These
types are special indicated for deep proximal
caries. They requires more chairside time for
adaptation
Pretrimmed crown (Unitek-3M, Denovo
crown) (Fig. 3.9B): These are straight,
noncontoured and pretrimmed crowns.
Festooning is done to follow a line parallel
to the gingival crest. They require additional
contouring and trimming.
Precontoured and pretrimmed crowns (Ni-
Chromium Ion crowns, Unitek-3M crowns)
(Fig. 3.9C): These crowns are prefestooned
and precontoured types. They stimulate
the normal appearance of the tooth. They
require minimal trimming and contouring.
Precontoured and pretrimmed crowns are
most widely used.
3M ESPE stainless steel crowns have
been designed to accurately duplicate the
anatomy of primary and first permanent
molars in a selection of sizes. The crowns
are manufactured with equivalent to natural
tooth height, contour and occlusal surface.
They are precrimped at the cervical margin
to give good retention and a snap fit. The
realistic anatomical shape of a 3M ESPE
C
 Different Crowns Used in Pediatric Dentistry 33

stainless steel primary molar crown means TABLE 3.2 Stainless steel crown based on sizes
that minimal adjustment is necessary
to obtain good retention. There is good Crown shape Number of Width range
harmony with the patients occlusion and sizes available (mm)
the smooth stainless steel alloy surface helps Upper 1st primary 6 (27) 7.29.2
to maintain gingival health and patient molar
comfort. Upper 2nd 6 (27) 9.211.2
primary molar

Based on Commercial Availability Lower 1st primary 6 (27) 7.49.4

molar
Rocky mountain: It is made up of 18-8 steel. It Lower 2nd 6 (27) 9.411.4
is not prefestooned and requires trimming. primary molar
Occlusal table is narrower buccolingually. It Upper 1st 6 (27) 10.712.8
is easily dislodge with occlusal interference. permanent molar
Ormco company: It is prefestooned crown Lower 1st 6 (27) 10.812.8
with broader occlusal table and long permanent molar
gingivo-occlusal height. Require gingival Upper 1st primary 7 6.69.0
trimming. It has prominent marginal ridge molar
and can dislodge with occlusal interference. Upper 2nd 7 8.511.0
It can provide excellent restoration after primary molar
proper beveling and trimming. Lower 1st primary 7 6.99.3
Unitek: It is variant of rocky mountain and molar
Ormco company. It is prefestooned with Lower 2nd 7 8.511.5
rounded cusps, shallow cuspal angles, pre- primary molar
venting lateral excursion. It has broader
occlusal table buccolingually, thus requires
less tooth reduction. It causes minimum Commercial Products
occlusal interference. It is made up of
18-8 steel. Various commercial SSC refill crowns can be
3M company: It is nickel based crown. These ordered using various order forms (Figs 6.1 to
are pretrimmed and precontoured crowns. 6.5).
It is easy to fit and require least amount
of additional crimping, trimming and 3M ESPE Unitek Stainless Steel
contouring.
Crowns (18-8 SSC Crown)
Denovo crown: These are pretrimmed
crowns, requires additional contouring. 3M ESPE Unitek stainless steel crowns offer
3M Iso-form crowns: These are tin-based over 20 years of proven successful clinical
crowns. use. The 3M ESPE Unitek crown line includes
primary anterior, first and second primary
Based on Sizes molars, bicuspid and permanent molar crowns.
Table 3.2 indicates primary and permanent
Classification of stainless steel crowns based on molar crowns with various crown sizes and
sizes is shown in Table 3.2. measurements.
34 Crowns in Pediatric Dentistry

Features TABLE 3.3 Tin-based crowns

Shallow occlusal anatomy requiring less
occlusal reduction. Crown shape Number Width range
Pretrimming to optimum length and of sizes available (mm)
contour. Upper 1st bicuspid 5 6.48.5
Parallel walls to provide broad, flat contact Upper 2nd bicuspid 5 6.08.0
points for easy fitting.
Lower 1st bicuspid 5 6.68.5
Availability for Primary Molars Lower 2nd bicuspid 5 6.89.0
There are 48 crown sizes available in the 3M
Upper 1st molar 5 10.312.0
ESPE stainless steel primary molar crown range.
Upper 2nd molar 5 9.010.5
Kits Lower 1st molar 5 11.112.4
ND-96: Intro kit-96 crowns. Set box only: ND-000
Lower 2nd molar 5 9.811.6

Primary Molars
There are 80 crown sizes available in the 3M
ESPE Unitek stainless steel primary molar 3M ESPE Iso-Form Crowns
crown. (Tin-based Crown)
Kits 3M ESPE Iso-Form crowns are available in 80
908100: Primary anterior set-72 crowns. Set box crown sizes for molar and bicuspid forms (Table
only: PA-000 3.3).
902150: Primary molar set-112 crowns. Set box
only: PR-000 Kits
BC-64: Intro kit-64 bicuspid crowns
Availability for Permanent Molars MC-64: Intro kit-64 molar crowns
There are 24 crown sizes available in the 3M Set box only: BC-000 Bicuspid MC-000 Molar
ESPE stainless steel permanent molar crown
range. Nickel-chromium Crowns
Kits These are high nickel containing crowns
PO-96: Intro kit-96 crowns. Set box only: PO-000 Available as primary and permanent molar
crowns
Permanent Molars Sizes 1 to 7.
There are 82 crown sizes available in the 3M
ESPE Unitek stainless steel permanent molar CLINICAL PROCEDURES FOR SSC
crown range.
Steps in SSC Crown
Kits Adaptation/Placement
902600: Bicuspid set-84 crowns. Set box only:
SB-000 Preoperative evaluation for patient age,
902350: Molar set-84 crowns. Set box only: PM- cooperation and medical condition
000 Armamentarium used

Selection of crown
Procedure of tooth preparation and crown
adaptation
Occlusal evaluation
Local anesthesia
Rubber dam isolation
Wedging
Removal of caries
Tooth preparationocclusal, proximal
and buccal/lingual surface reduction,
final finishing
Crown adaptationtrimming, crimping,
contouring, finishing and polishing
Cementation and final evaluation of
occlusion.
Preoperative Procedures
Dental age of the patient: This is recorded by
the root development of the underlying tooth
when a primary tooth can be expected to
exfoliate within 2 years of restoration following
crown placement. However, failure of extensive
amalgam restoration in the primary teeth can
be frustrating. This can be overcome by an initial
placement of stainless steel crown.
Cooperation of the patient: If the patient is
uncooperative, whether it is due to age (i.e. < 3
years) or due to negative behavior, if the child is
stubborn and does not want to cooperate, firstly
by a positive behavior has to be installed. If child
is unable to cooperate, then treatment under
conscious sedation and general anesthesia may
have to be considered. It is difficult to check
the correct occlusion so it is always better to
keep stainless steel crown at the level or slightly
below the level of the adjacent tooth, so that the
child does not have disturbed occlusion due to
premature contact.
Medically compromised/disabled children:
Children especially suffering from heart
problems should have prophylactic antibiotic
cover to safeguard against any subgingival injury
during tooth preparation. In case of medically
Different Crowns Used in Pediatric Dentistry 35
compromised child, it is advised to carry out the
procedure under general anesthesia.
Armamentarium
Burs and stones
No. 169L or No. 69L F.G.
No. 6 or No. 8 R.A.
No. 330 F.G.
Tapered diamond F.G.
Round bur for caries removal
Flame shaped diamond bur or round end
tapered bur for occlusal reduction
Long thin tapered bur for proximal, buccal
or lingual reduction
Others
Rough or whitening polish wheels.
Sharp scalars or instruments, America No.7.
Green stone or heatless stone/rubber wheel
stone for finishing and polishing rough
polishing wheel
Wire wheel for finishing crown
Cement medium
Glass slab, cement mixing pad
Spatula/Agate spatula
Zinc phosphate, zinc oxide eugenol, GIC
or zinc polycarboxylate cements
Dental floss
Rubber dam armamentarium
Sharp explorer for marking gingival exten-
sion of crown margin.
Pliers and instruments (Table 3.4, Fig. 2.8
and 3.10)
Selection of Crown
Manufacturers: 3M ESPE, Denovo Baldwin,
Park,Calif , Hu-Friedy Pedo crown, Kids crown
SSC crown availability: Various commercial
SSC products are available in the market
(Fig. 3.11). Stainless steel crowns are available
in 6 sizes for each primary tooth separately
for individual teeth size 2 to 6 (Fig. 3.12). Sizes
36 Crowns in Pediatric Dentistry

TABLE 3.4 Different crown adapting equipment

Pliers name Nomenclature of pliers Use of pliers

Johnson contouring plier
Gordon plier
Crimping plier (Unitec corp)
Ball and socket plier
Howe plier
Crown and bridge scissor
Reynold plier
Curved Howe
no 114 Contouring occlusal and middle third of crown
no 137 Contouring gingival third of crown
no 800-417 Marked gingival crimping
no 112 Exaggerating interproximal contour in open
contacts , for bell-shaped contouring
no 110 Flattening interproximal contour of crown
Cutting excess material at gingival third of crown
Contouring
no. 111 Proximal contouring of crown

FIGURE 3.10 List of pliers for crown adaptation (from left to rightReynold, Gordon, ball and socket, Jonson,
crimping, straight Howe, curved Howe pliers)

4 and 5 are most commonly used, while size 7
is available for extra large teeth. Crown kit box
consists of pair of crowns of all 6 sizes. Refill
crowns are available in set of 2 crowns. Refill
crowns available are referred with short form for
identification as, upper (U), lower (L), Right (R),
left (L), primary first molar (D), primary second
molar (E) as ULD, ULE, URD,
URE, LRD, LRE, LLD, LLE. The identification
of each crown can be made by noting the
marking on the buccal surface which indicates
type (D or E), size (2, 3, 4, 5, 6, 7), upper or lower
(upper right:, upper left: , lower left: , lower
right: ). Refill crowns can be ordered using
code words or order forms (Fig. 3.11).
Crown selection: There are three methods of
crown selection (Flow chart 3.1).
The SSC crowns are manufactured so that
length is proportional to the mesiodistal and
circumferential measurement. The 3M crowns
are pretrimmed and contoured which requires
little adjustment, lesser adaptation time and
requires minimal trimming and crimping
(Fig. 3.12). The SSC crowns are selected with
thumb forcep from crown kit box. If the crown
is not selected before the tooth reduction, after
the tooth reduction it can be selected as trial and
error procedure, which approximates the mesio-
distal widths of the crown. Many clinicians do
crown selection after tooth preparation or by
 Different Crowns Used in Pediatric Dentistry 37

A B C

FIGURES 3.11A TO D Commercial SSC products with labeling: (A) Denovo

D crown; (B) Hu Friedy pedo crown; (C) Omini pedo crown, and (D) Kids crown

FLOW CHART 3.1 Methods of crown selection

it with selected crown. If the crown is tried on

FIGURE 3.12 Stainless steel refill box
trial method from three different sizes. The
ideal method of crown selection is measuring
the mesiodistal dimension of unprepared tooth
using Boleys gauge or dividers and comparing
the patient mouth and used should be cleaned
and sterilized before replacing it to kit to prevent
contamination.
It should be kept in mind while crown
selection that over contoured or over sized
crowns on 2nd primary molar can prevent
normal eruption of 1st permanent molars.
Select smallest crown that completely covers the
prepared tooth. A crown should be somewhat
larger than the prepared tooth for crown,
especially when the gingival part of the crown
is trimmed and crimped. Too large crown will
rotate on the tooth preparation and too short
crown will not fit and create proximal spacing.
This thing should be kept in mind while crown
size selection.
Anatomical metal crowns: The term anatomi-
cal refers to crown forms whose exteriors
approximate natural teeth in facial, lingual,
38 Crowns in Pediatric Dentistry
mesial and distal contours, as well as in the
contours of the occlusal surfaces (cusps, ridges,
pits, and grooves).
Note: The correctly selected crown should cover
completely the prepared tooth crown and
provide resistance to removal.
Following factors should be considered during
crown selection:
Adequate mesiodistal diameter
Occlusal anatomy: Excessive occlusal anat-
omy may present with problems. Deep
occlusal fissures and high cusps require
greater occlusal reduction.
Height of the crown: The height of the crown
should be same as that of the uncut tooth
with cervical margin not more than 1 mm
beneath the gingival margin.
Primate space: Preoperative assessment
should be made for the presence of primate
or physiologic spaces.
Light resistance to seating/snap fit.
Procedure for Tooth Preparation and
Crown Placement
Aims of Tooth Preparation
To prepare tooth to provide sufficient space
for the steel crown
To remove all gross caries and irregularities
To keep sufficient tooth structure to support
and to retain steel crown.
A number of procedures must be performed
before starting the tooth preparation
Evaluation of preoperative occlusion: Before
placing a rubber dam and before beginning for
tooth preparation, observe for the following:
Whether the opposing tooth has extruded
due to longstanding carious lesions
Whether there is mesial drift due to carious
lesions leading to proximal space loss
Need for tooth reduction so that the restored
tooth can be returned to normal function.
Presence of spacing or crowding
Check occlusion directly in the mouth or
indirectly by using dental study casts for
incisor, canine and molar relationship on
both the side
Note for dental midline and the cusp fossa
relationship bilaterally.
Anesthesia
To eliminate the discomfort caused by cutting
the tooth and possible trauma to the soft tissues
during the trial fitting of stainless steel crown,
there must be adequate anesthesia of the tooth
and the adjacent soft tissues.
Anesthetize the tooth to be treated to
prevent pain and to avoid discomfort to child
since gingival tissues all around the tooth may
be manipulated during crown placement. It
is necessary to obtain adequate anesthesia of
buccal, lingual or palatal surfaces. In the lower
arch, use an inferior alveolar nerve block,
supplemented by an infiltration of the long
buccal nerve. In the maxilla, an infiltration
on the buccal and occasionally on the palatal
side of the tooth are required if pulp therapy
is planned. It is not necessary to place the
anesthetic solution on the palatal side over
the apex of the tooth. It can be placed in the
loose soft tissues adjacent to the tooth from the
buccal side after anesthetic solution has begun
to produce anesthesia (Wei SHY, 1988).
Isolation
Use of rubber dam is indicated wherever
possible for isolation is mandatory. When it
is not possible to use rubber dam, as in case
of terminal teeth in arch, cotton rolls, which
are held in position by cotton roll retainer or a
gauze oral screen should be used to prevent the
possible aspiration of a crown.
Use a rubber dam in preparing a tooth for
a stainless steel crown for the following
reasons:
To protect surrounding tissue
To improve visibility and efficiency

To better manage child behavior
To prevent ingestion of the stainless
steel crown during preparation.
One can alter the rubber dam by cutting
the interproximal rubber to avoid cutting
the dam with rotating instruments. Wedges
can also be used to protect the dam and
tissue. An alternate method is to punch a
large hole and slip it over the most posterior
tooth receiving the stainless steel crown.
Then stretch the dam forward to the canine
area. Split dam method is better for treating
multiple anterior teeth.
Caries Removal
Caries can be removed either before or after tooth
reduction. Remove the decay with large round
bur in a slow speed hand piece. After removing
caries perform pulp therapy if necessary. The
previously carious area can be built up with.
GIC cement. Restore endodontically treated
tooth with GIC before tooth preparation.
Wedging
A wooden wedge may be placed tightly between
the surface being reduced and the adjacent
surface to provide a slight separation between
the teeth for better access and to reduce risk of
iatrogenic damage to adjacent teeth. It also helps
to depress the gingival tissue and rubber dam.
REDUCTION OF TOOTH
Occlusal Reduction
Occlusal reduction should be done to provide
space for SSC crown and should be done before
proximal reduction to avoid invisibility of pre-
paration areas due to blood contamination.
Full et al. (1974) considered that occlusal
preparation should be done first to allow better
access to the proximal areas of the tooth. While
other authors suggest the proximal reduction
before the occlusal surface. Gingival bleeding
will occur if the proximal reduction is done at
Different Crowns Used in Pediatric Dentistry 39
the initial step, making the diagnosis of very
small pulp exposure, difficult. Thus, the best
plan is to reduce the occlusal as the initial step,
removing any caries as part of that step. Then
proceed with proximal surface reduction.
The most common problem encountered
in attempting to learn tooth preparation is
inadequate reduction. Mink and Bennett
in 1968 recommended initial placement of
1 mm deep grooves in the occlusal surfaces,
which helps to establish the correct amount of
occlusal surface reduction. The cusp height of
the adjacent teeth and marginal ridges gives the
operator a good baseline to judge the amount of
occlusal reduction.
Use carbide fissure bur or flame-shaped bur
(Figs 3.14C and 3.13C) to reduce the occlusal
surface by 1.5 to 2 mm, following the cuspal
outline and maintaining the original contour
of the cusps (Figs 3.13A to L). Occlusal surface
reduction can be judged by comparison with
the marginal ridges of the adjacent teeth.
Though various views have been expressed
regarding the occlusal reduction it is found that
about 1.5 to 2 mm of reduction has to be done to
obtain occlusal clearance (Table 3.5). However,
as much of tooth structure as possible must be
left for retention. Excessive occlusal reduction
can result into poor occlusal height, poor
tooth structure for cementation of crown and
excessive gingival impingement, whereas under
reduction results into lack of proper occlusal
clearance, heigh occlusal contact and open bite.
Note: Occlusal reduction should be based on
amount of clearance, attrition of teeth and supra-
eruption of teeth. Ideally there should be at least
1 to 1.5 mm of clearance to receive stainless steel
crown.
Note: If much of the occlusal surface has already
been lost due to caries, then reference can be
made to the marginal ridges of neighboring teeth
in regards to the amount of further reduction
needed to obtain space for the crown.
40 Crowns in Pediatric Dentistry

A B C D

E F G H

I J K L
FIGURES 3.13A TO L (Case-1) SSC adaptation procedure: (A) Preoperative occlusion; (B) Measurement of tooth
dimension; (C and D) Crown selection; (E) Occlusion reduction; (F) Proximal reduction; (G) Crown fitting linguo-
buccaly; (H) Marking gingival extension; (I) Contouring; (J) Crimping, (K) Radiographic evaluation; (L) Final fitting
of crown

2. If there is no clearance then the metal is

TABLE 3.5 Occlusal reduction for primary molars
unable to slide past the contact area and
suggested by various authors
into residual undercut.
SL Researchers Year Occlusal reduction The second step in the process of
No in mm preparing the tooth for a steel crown should
1 Humphrey 1950 Cups should be be the interproximal reduction. Myers (1976)
reduced if necessary described the chances of errors as excessive
2 Mink and 1968 11.5 mm uniform proximal reduction. Excessive reduction of the
Bennet reduction tooth in any area may cause the stainless steel
3 Mathewson 1974 11.5 mm crown to overseat in that area.
et al.
Note: Proximally, tooth reduction is made through
4 Troutman 1976 1.52 mm
and Kennedy the mesial and distal contact areas. The plane
of preparation being cut at a sufficient angle
5 Rapp 1966 Preparation height
to avoid the creation of ledges or steps at the
4 mm from gingival
gingival finishing line and care should be taken to
margin
avoid damage to neighboring teeth.

Proximal Reduction Note: Proximal slice must be extended below

gingival crest to avoid leaving a ledge. The
The proximal contact needs to be cleared for proximal slice should be done to create space
two reasons: for crown and to create knife/feather finish line
1. Caries starts at or beneath the contact area gingivally.

FIGURE 3.14A Stainless steel crown on second primary molar (case-2)
To obtain retention, the crown must seat at
the depth of 1 mm subgingivally and there
should be no gingival blanching.
Proximal surfaces are reduced using a
No.69 L/tapered fissure bur at high speed.
Vertical slice is done that clears the contact
area buccally, lingually and gingivally
(Figs 3.13F and 3.14A). The mesial and distal
slice should end slightly below the gingiva
on enamel, leaving undercut area of intact
enamel at the cervical circumference of
tooth.
Avoid damaging adjacent tooth surfaces
while doing proximal reduction. Near vertical
reduction should be performed gingivally
until the contact with adjacent tooth is
broken and explorer can be freely passed
between the adjacent teeth. The gingival
margin of the preparation on proximal
surface should be smooth feathered edge
with no ledge or shoulder present.
Different Crowns Used in Pediatric Dentistry 41
It has been observed that many of the diffic-
ulties encountered in placing a stainless steel
crown are the result of attempting to fit a
round or oval crown form over a rectangular
tooth preparation. Irregularities, projections,
or sharp angle on the circumference of the
prepared tooth will prevent the crown form
from being properly seated, will cause time-
consuming repeated adjustments, and will
prevent the crown from properly fitting the
tooth preparation.
The primary principle of the technique
for fitting stainless steel crowns is to make
the tooth preparation to fit the crown form
rather than attempt to make the crown
fit the tooth preparation. By examining
the crown form, prior to preparation
of the tooth, one should see that the
crowns of all manufactures are somewhat
oval and rhomboid. This conforms to
the rhomboid shape of the primary tooth. In
42 Crowns in Pediatric Dentistry
accomplishing the interproximal reduction
therefore, be careful to maintain that form in
the preparation. By beginning on the lingual
and following the contour of the proximal
surface of the tooth, one can more easily
accomplish an even and uniform reduction
of the surface, thereby maintaining this
rhomboid shape.
Making a slice also helps to eliminate the
interproximal ledge, which seems to be the
most frustrating problem in the restoration
of a tooth with a steel crown. Beginning
the slice at the marginal ridge with the no.
69 L or 169 L bur not only will result in the
frequent formation of a ledge but also will
rapidly dull and wear out the tip of the bur.
Note: It is suggested to carry out all necessary
tooth preparation except for the distal reduction
under rubber dam. The distal slice and crown
fitting are then completed after removal of
rubber dam.
Buccal and Lingual Reduction
Note: Minimal or no reduction requires for buccal
or lingual surfaces as it aid in retention because
of undercuts. Buccal reduction requires especially
for buccal bulge of the first primary molar.
The third step in the preparation concerns
the reduction of the buccal and lingual
surfaces. Buccal and ligual reduction is
optional.
Duggal and Curzon suggested trying select-
ed crown for size before carrying out lingual
or buccal reduction.
This area seems to be the most controversial.
The questions is whether to (1) reduce the
entire bulge, at least a significant portion
of it or (2) permit the buccal and lingual
cervical bulges to remain and reduce only
the occlusal third of the preparation.
Mink and Bennet (1968) suggested that
buccolingual reduction is not done for
retention, which is undertaken only if the
buccal or lingual bulges obstruct crown
placement such as for primary mandibular
first molar tooth which has bulky buccal
surface (Mathewson et al. 1974, Andlaw and
Rock, 1984).
No more than 0.5 to 1 mm tooth structure
should be removed buccolingually.
Knife edge finish line should be achieved
0.5 to 1 mm below gingival sulcus.
Avoid any ledge or step at the mesial or
distal finishing line presence of which will
create difficulties in crown seating.
Finishing
Remove all sharp line and point angles with
No. 69 L bur. Roundening of line angles is
done to prevent stress concentration.
Beveling
Line angles beveled at an angle of 30 to 45
degrees (Fig. 3.14A)
Round occlusobuccal and lingual surfaces
Remove sharp cusp tips
There should be unobstructed crown
placement.
Roundening all Line Angles
The buccal and lingual proximal line angles
are rounded
Bur is held parallel to the tooths long axis
and blend surfaces together.
Removal of Remaining Caries
Remove any remaining carious dentin if present
after crown preparation steps. Perform pulp
therapy if there is pulp exposure.
Evaluation Criteria for Correct
Tooth Preparation
The occlusal clearance should be 1.5 to 2 mm.

Proximal slices converge toward the occlusal
and lingual, following the normal proximal
contour.
An explorer can be passed between the
prepared tooth and the proximal tooth at
the gingival margin of preparation.
Optional buccal and lingual surface are
reduced at least 0.5 mm with reduction
ending in a feather edge 0.5 to 1 mm into the
gingival sulcus.
The buccal and lingual surfaces converge
slightly towards the occlusal.
All the line angles in the preparation are
rounded and smoothened.
The occlusal third of buccal and lingual
surfaces are gently rounded.
Gingival finish line of preparation should be
feather edge without ledge.
CROWN ADAPTATION
Using thumb forceps, select a crown from
the supply. Use of the forceps will keep
contamination to a minimum. Size no. 4
and 5 are the most frequently used. Crowns
FIGURE 3.14B Stainless steel crown (case-2)
Different Crowns Used in Pediatric Dentistry 43
placed in patient's mouth for trial and if not
cemented must be sterilized again.
Uniteck nickel based crowns are pretrimmed
and contoured which require minimal
adjustment during crown adaptation.
Adaptation is important for retention and
gingival health. Poorly adapted crown acts
as source of retention of plaque and bacterial
accumulation leading to gingivitis and
recurrent cervical caries.
Spedding has advocated two principles for
successful crown adaptation.
1. Establishment of correct occlusogingival
crown length.
2. Shaping crown margin circumferentially
to follow the natural contours of the
tooths marginal gingivae.
Place the crown on prepared tooth
linguo-buccally by applying pressure in
buccal direction so that crown slides over
the buccal surface into gingival sulcus
(Figs 3.13G and 3.15). Friction should be felt
as the crown slips over the buccal bulge.
Sometimes crown placement can be difficult
due to small crown size or excess buccal
44 Crowns in Pediatric Dentistry
FIGURE 3.14C Occusal reduction, proximal adaptaion, cement consistency
FIGURE 3.15 Crown adaptation
bulge. In such situation select larger crown
or reduce the buccal bulge of tooth.
After placing the selected crown over
prepared tooth, ask the patient to bite over
it. Check for preliminary occlusal and
marginal ridge relation. Then scratch mark
on the crown at the level of the free margin
of the gingival tissue (Fig. 3.13H). Other than
scratching 2 to 3 points can be marked with
thin taper bur at gingival margin of crown to
estimate gingival extension on both buccally
and ligually. This scratch or dotted lines
indicates the gingival contour, as well as the
portion of the crown to be removed. If the
crown is not trimmed, there will be excessive
trauma to the gingival tissue. Remove the
crown and trim or cut away the additional
crown portion gingivally 1 mm below scratch
line with a No. 11B curved scissors. Replace
the crown over tooth and check for gingival
extension of crown and if blanching present,
repeat marking and trimming until adequate
extension (1 mm beneath the gingival
margin) occurs without blanching.

After initial placement of crown, the
occlusion should be checked at this stage so
that crown is not opening the bite or causing
a shifting of the mandible into undesirable
relationship with opposing teeth.
Croll and Riesenberger stated that majority
of crowns do need adjustment to obtain
optimal adaptation to primary molars.
Note: Prepared crown should extend 1 mm
beneath the gingival margin without blanching.
Contouring and crimping of the crown results
in tight fitting crown. Contouring involves
inward bending of the gingival third of the
crown margin to restore anatomic features
of the natural crown and to reduce marginal
circumference to achieve good fitting.
Curved beak pliers used to redirect cut
edges cervically. Contouring and festooning
of crown can be done for proper adaptation.
Crown can be replaced on prepared tooth
to check final adaptation. There should
not be any blanching of gingival tissue.
Presence of gingival blanching indicates
need of additional trimming and marginal
adaptation.
Circumferential contouring can be achieved
with no. 137 Gordon pliers. Contouring pliers
with a ball and socket No. 114 design is used
at the cervical third of the buccal and lingual
surfaces for cervical crown adaptation. A
curved beak plier/No. 114 is further used
to improve the contour on buccal and
lingual surfaces. Curved beak pliers may
also be used to contour the proximal areas
of the crown to adapt desirable contact with
adjacent teeth (Fig. 3.13I). Final adaptation
of the crown is achieved with crimping
pliers (no. 800-417 Unitek) by crimping the
cervical margin 1 mm circumferentially
(Fig. 3.13J).
If space loss has occurred, the crown can be
squeezed with Howe pliers to a cylindrical
Different Crowns Used in Pediatric Dentistry 45
shape in order to fit in a narrow mesiodistal
space (Fig. 3.14C).
With an explorer, check all the margins for
adaptation. Where the margins are open,
re-crimp with the no. 800-417 pliers. At this
stage, it is easy to over contour the crown so
that it no longer snaps into place/gently try
to bend the margins over. If this results in a
distorted crown, it is best to start over with a
new crown.
Brooke and King suggested to carry out
trimming procedures away from the
patients face and to ensure proper eye pro-
tection to patient.
Crown contouring can be done with following
pliers:
Contouring pliers
# 114 ball and socket pliers
# 137 Gordon pliers
# 800114 Johnson pliers
Crown crimping
Crimping pliers No. 800417
Note: A tight marginal fit aids in
Mechanical retention of the crown
Protection of cement exposure to oral fluids
Maintenance of gingival health by preventing
plaque accumulation.
Sometimes solder may be added to the
proximal surfaces of the crown to improve
contacts and contour. Trimming and con-
touring are continued until the crown fits
snugly and extends under free margin of the
gingival tissue.
The outline of crown margin should follow
the gingival margin of tooth. It should resemble
smile for primary second molar and stretched
out S shape for primary first molar on buccal
gingival margin. The buccal gingiva of primary
first molar has different outline (stretched s)
because of cervical bulge, the gingival margin
dips down as it traced from distal to mesial
46 Crowns in Pediatric Dentistry
B C
FIGURES 3.16A TO C Smile and stretched out S shape at gingival margin
(Figs 3.16A to C). However contour of all first
primary molars resembles smiles. The proximal
contour of almost all primary teeth is frown
because of shortest occluso-cervical height. The
margins of finished crown consist of series of
curves or arcs as determined by marginal gingiva.
Gingival contour
Buccal gingival contour of second primary
molarsmile
Buccal gingival contour of first primary molar
stretched-out S
Proximal gingival contour of primary molars
frown
Lingual gingival contour of all molarsSmile
Final fit
Seat the crown in lingual to buccal direction
It should snap/snagly fit into position under firm
figure pressure
If margins open: recrimp
If overextended: trim the crown
Final adaptation of crown should be
confirmed by taking a radiograph, which
helps to check gingival contour and extension
and to evaluate about full coverage of tooth.
More and Pink recommended a bite-wing
radiograph during try in stage to check for
any margin overextension in the proximal
area. Radiographs are not must in all cases for
evaluation. Radiographically crown margin
seems to be poorly adapted proximally or often
appear too long. Proximal contours of crowns
are not well produced; this deficiency has little
effect on supporting periodontal tissue.
The adaptation of the crown form to the
preparation will vary with the type of crown
used and the type of preparation. The Rocky
Mountain and Unitek crowns must be contou-
red with the No. 114 or 115 pliers for the proper
buccolingual contours and to engage the bulge
maintained for cervical retention. The Unitek
crown-crimping pliers may also be used to
improve retention. It tends to create a scalloped
margin and should be followed by the No. 114 or
115 pliers to obtain a smooth even margin. The
same type of contouring is recommended for
the Unitek crown, but usually less manipulation
is necessary. The tapering thickness of the ion
crown on the buccal, lingual, and proximal
surfaces makes trimming and recontouring
difficult and sometimes impractical. If the ion
crown is trimmed, it should be recontoured
with the No. 114 or 115 pliers and the margin
carefully tapered, sharpened, and polished
prior to seating.
While finishing the margins of the crown
form, grind a bevel on the external surface of
the crown margin around the entire periphery
using a green stone held at 45 angle to the
margin (Fig. 3.14B). A slow-speed hand piece
will give better control and produce a sharp
feather edge margin that can be closely adapted
to the prepared tooth at the gingival margin.

No study has been done on how the
composition of steel crown affects the
preparation, adaptation and cementation of the
restoration. Yates and Hembree (1978) reported
on the resistance to removal and on the hardness
of the steel used in the Rocky Mountain,
Unitek and ion crowns. They used a flame
shaped diamond to round the line angles and
occlusal surface angles, with no buccolingual
reduction. The preparation was similar to that
recommended by Mink and Bennett. They
festooned the three types of crowns as similarly
as possible to ensure a custom fit, contoured
and adapted the crowns in essentially the same
manner.
Yates and Hembree cut a sample of the
metal from the lingual surface of the three
brands after the crown had been crimped and
contoured in the prescribed manner. They
determined that the Unitek crowns were more
resistant to removal than the other two. There
was also wide variability in the Unitek sample.
Initially, the ion crown was harder than the
other crowns before cold working. It was also
resistant to work hardening by contouring and
crimping. The Rocky Mountain crown was work
hardened to a significantly greater degree and
the Unitek crown showed wide variability with
decreased hardness when it was cold-worked.
Rocky Mountain crown requires more
manipulation to work harden the metal prior to
cementation so it will snap over any remaining
bulge for proper retention. The Unitek crown
seems to be soft enough to snap over type
of crown preparation recommended by Mink
and Bennett and requires little manipulation
other than contouring of the buccal and lingual
surfaces. The ion crown, on the other hand is
extremely hard and difficult to manipulate and
requires much effort to fit over a large bulge.
It would seem to be more appropriate for
Troutmans preparation, in which the buccal
and lingual surfaces are reduced approximately
0.5 mm with the preparation extending 0.5 mm
Different Crowns Used in Pediatric Dentistry 47
below the gingival crest and ending a feather
edge.
Festooning and Adaptation
of the Crown
The flattened proximal surfaces should be
somewhat oval rhomboidal in preparation. This
greatly aids in rapid crown adaptation because
of the shape of the steel crown forms. It has
been stated that the retention of the stainless
steel crown restoration originates from contact
between the tooth and the margins of the
crown, which necessitating to reduce the buccal
and lingual surfaces of the crown except on the
buccal surface of the mandibular primary first
molar or where an abnormal bulge of enamel
may be present. The rationale for maintaining
this bulging tooth structure is that it will
contribute to the retention of the crown.
Crown Finishing
It is safe to say that retention problems do not
cause failure of the steel restoration; most
failures result from poor and inadequate
preparation, improper gingival adaptation, and
the inability to properly visualize and determine
the relationship of the crown margin to the
margin of the preparation. This being the case,
it is incumbent on each practitioner to pay more
attention to this area of crown restoration so
that gingival irritation around the margin of the
crowns will not occur.
Large green stone is used to make knife edge
finish at the cervical margin of crown
Bur is moved in counterclockwise direction
at 45 degree angle
Then rubber wheel is used to smoothen
margins
Crown can be polished using Iron rouge
The final step before cementation is to
produce beveled gingival margin that may
be polished.
48 Crowns in Pediatric Dentistry
Polishing (Figs 2.6B and 3.14B)
While polishing the crown, margins should
be blunt since knife edge finish produces
sharp ends which act as areas of plaque
retention. A broad stone wheel should run
slowly, in light brushing strokes, across the
margins, towards the center of the crown.
This will draw the metal closer to the tooth
without reducing the crown height and thus
improves the adaptation of the crown.
A wire brush can be used to polish the
margins to a high shine.
To give a fine luster to crown, rough whiting
or a fine polishing material can be used.
Crown Fit
Method to Determine Adequate
Crown Fit
Even though clinical adaptation and
appearance of stainless steel crown is good but
radiographic extension of the crown extension
is variable with ragged margins (Fig. 3.13K). To
avoid these discrepancies, Spedding, in 1984,
proposed two principles based on morphology
of primary teeth and gingival contour. Before
cementation, a bite-wing is taken to verify
proximal marginal integrity. If the crown is
too long, there is still an opportunity to reduce
the length. If it is too short, then add weld and
solder an orthodontic band or adaptation of
another crown is indicated. If there is any doubt
about the fit of the crown, a radiograph may be
taken after cementation (Figs 3.13K and 3.14B);
however routine radiographs of all patients to
determine the fit of all stainless steel crowns
are not justified. To amend these discrepancies,
Henderson proposed two principles based on
the morphology of primary teeth and gingival
contour. The following briefly outline his sugg-
ested method:
Principle 1: When primary molars are viewed
from either proximal surface, the buccal and
lingual surfaces converge occlusally from the
gingival crests, thus any point on the tooth
occlusal to the greatest diameter is on the visible
clinical crown, and any point on the tooth apical
is on an undercut surface of the tooth and is not
visible in the mouth.
The stainless steel crown that does not
adhere to the morphologic features of the
primary molar will be overextended and ill
adapted. When the finished crown is correctly
seated on the prepared tooth with its occlusal
surface in the occlusal plane and its margin
placed just apical to the marginal gingival
crests, the crown is of correct length and its
margins can be adapted closely to the tooth. As
seen on the buccal and proximal surface when
the crown is shortened and is the proper length,
the crown is easily adapted to the crown.
Principle 2: If a dentist carefully examines the
contours of the buccal and lingual marginal
gingiva before a tooth is prepared for a stainless
steel crown and produces steel crown margins
of similar shapes, when these margins are
adapted circumferentially against the tooth they
will be located at the correct anatomic positions
at all points on the tooth.
Final adapted crown should have:
Crown must snap into place, should not be
removed with finger pressure.
The crown should fit so tightly that there is
no rocking on the tooth.
Moderate occlusal displacement forces at
the margin should not displace the crown.
The properly seated crown will correspond
to the marginal height of the adjacent tooth
and is not rotated on the tooth.
Crown is in proper occlusion and should not
interfere with the eruption of teeth.
There should be no high points when
checked with an articulating paper.
The crown margin extends about 1 mm
gingival to gingival crest.
No opening exists between the crown and
the tooth at the cervical margins.
 Different Crowns Used in Pediatric Dentistry 49

Crown margins closely adapted to the tooth FLOW CHART 3.2 Guidelines for adaptation of crown
and should not cause gingival irritation
(Figs 3.13L and 3.14B).
Restoration enables the patient to maintain
oral hygiene.
The crown seats without cutting or blanching
the gingiva.

Guidelines for Adaptation

of Crown (Flow Chart 3.2)
Marginal Adaptation of Crown
Marginal adaptation is an important part of
the stainless steel crown restorative procedure.
Marginal adaptation of SSC crowns involves
appropriate crown size selection, trimming the
crown form to achieve proper length, crimping
crown to edges to proximate the prepared tooth,
and finish and polish the crown. Poorly adapted
SSC margins affect associate periodontal
tissue and hinder eruption of adjacent teeth,
for example when over extended distal margin
on a second primary molar, SSC engages the
mesial marginal ridge of the 1st permanent
molar in its eruption.
Some SSCs such as 3M Uniteck, Denovo Edge of the of crown form (0.51 mm) to
crowns have flat axial surfaces and require bend slightly inward around the crown.
marginal adaptation and axial contouring to Abrasive wheel is then applied to the edges
replicate natural crown configuration. 3M crown of the crown to make thin crown margin
(formerly ION) are manufactured with a curved followed by finishing and polishing.
axial design and anatomically well-defined
occlusal surfaces resembling natural tooth. Crown Retention
Precontoured SSCs requires less manipulation.
Tooth preparation should be designed so Humphrey (1950) and Full et al. (1974) sugg-
that anatomical form of the adapted SSC will ested that retention of stainless steel crowns is
replicate natural tooth closely. related to minimal tooth reduction and contact
between the margins of the crown and the tooth.
Marginal adaptation can be achieved by: Elastic deformation of the stainless steel crown
Use large diameter rotating abrasive stone as it seats into undercut areas of the primary
for precise reduction of crown. For primary teeth further enhances the retention. Although
teeth crown margin can approximate laboratory research has determined that cement
the anatomical location of CEJ and for is a very important factor in crown retention.
permanent teeth, the contoured crown Savide et al. (1979) compared five different
margins should be more coronal. types of preparations for retention capabilities:
50 Crowns in Pediatric Dentistry
1. That recommended by Mink and Bennett, in
which only the occlusal third of both buccal
and lingual surfaces is reduced.
2. That incorporating Class II preparations, in
which the buccal and lingual walls of the
boxes converge toward the occlusal.
3. That which reduces the buccal and lingual
supragingivally to the crest.
4. That which removes the supragingival
bulge, extending 0.5 mm below the gingival
crest, as recommended by Troutman, with
all undercuts on the buccal and lingual
surfaces removed.
5. That which removes all supragingival
tooth structure, permitting only part of the
anatomic crown to remain (i.e. the tooth
structure around which the crown would
normally be adapted).
Crowns were adapted to these various types
of preparation, and then proceeded to test the
forces required to remove the crown from the
preparation before and after cementation. Very
little difference was shown between preparations
to cementation. It was also observed that the
noncemented preparations demonstrated
only limited mechanical retention but that
following cementation the retentive values of
all preparations improved greatly and cementa-
tion completely overshadowed the mechanical
retention demonstrated in the noncemented
group. They concluded that mechanical re-
tention does not significantly contribute to
separation resistance of the steel crown.
Mathewson et al. (1974) stated that retention
related more to the cement than to mechanical
adaptation. Rapp and Savide et al. pointed out
that a tight marginal fit of the crown below the
gingiva is more difficult to achieve and failure
to do so might increase gingival inflammation.
The second technique with the proximal boxes,
which had similar retention, had the same
potential gingival problems as did in technique.
Although preparation had the highest
retention values, the difference was not
sufficient to warrant endangering the pulp by
placement of such boxes. There was a relatively
high post-cementation retentive value in
preparation with the buccal and lingual surfaces
reduced subgingivally.
The authors concluded that, although more
tooth structure is lost in this preparation, it
enables one to get excellent cervical adaptation
of the crown form to the tooth since the
adaptation is easier to visualize. Because of its
better adaptation, it might be healthier for the
gingiva. This is indeed the best preparation
for steel crown restorations. It is especially
significant when the ion crowns are used
because of the hardness and difficulty of
manipulating the nickel steel. Maintaining some
of the cervical bulge may be the preparation of
choice when the softer metal crowns (e.g. the
Rocky Mountain) is used. The importance of
preparation in their study was to demonstrate
that even in a grossly destroyed tooth, relatively
high retentive values could be obtained. Their
conclusion was that such teeth can indeed be
restored with steel crowns and need not be lost
to extraction. Finally, it has been determined
that preparations maintaining the greatest
amount of buccal and lingual tooth structure are
the most retentive before cementation; however,
cement increases the retentive capacity of all
types of preparations and it would behave
one to concentrate on making the steel crown
restoration more physiologically acceptable
to the oral cavity, particularly in the area of
the gingiva. Removal of the buccal and lingual
bulges will greatly facilitate the achievement of
this goal.
One has to concentrate on making the
stainless steel crown more physiologically
acceptable to the gingiva as it is seen in our
clinical practice; also that cement increases the
retentive capacity of all types of preparations
reducing supragingival bulge with reduction
extending 0.5 to 1 mm below the gingival crest
helps to obtain an acceptable gingival response.
It is especially significant when the ion crowns
are used because of hardness and difficulty of

manipulating the nickel steel when the softer
metal crowns are used, (Rocky-mountain)
maintaining the cervical bulge may be the
preparation of choice.
Crown Cementation
(Figs 3.14B and C)
Cementation of crown is depends upon the
pulpal status. Cavity varnish should be applied
first if the tooth is vital. GIC is most commonly
used cement for cementing crown. Mathewson
(1979) stated that retention of SSC crown is
due to cementing medium rather than due
to mechanical adaptation. Saved et al. (1979)
concluded from his study that, noncemented
preparations demonstrated only little mechani-
cal retention and retentive values increased
following cementation in all the preperations.
Mechanical retention can be established using
buccal cervical bulge of tooth. Hence, proper
cementation should be done for success of
crown.
Following cements can be used for crown
cementation:
Zinc oxide eugenol
Zinc phosphate
Zinc silicophosphate
Polycarboxylate
Glass ionomer
Resin modified glass ionomer
Acrylic resin
Composite resin.
Crown Cementation Procedure
Remove the rubber dam.
Isolate the tooth; remove any blood clot
from tooth surface during cementation of
crown. Before cementation clean and dry
both the crown and tooth. Meyers et al.
(1983) suggested application of varnish on
prepared vital teeth before cementation.
Mix the selected cement and fill the inner
portion of crown at least 2/3 with luting
cement (Figs 3.14B and C).
Different Crowns Used in Pediatric Dentistry 51
Seat crown on the tooth, initially on lingual
side followed by buccally to engage buccal
undercut. The flat end of band seater may
be used to ensure complete seating of
crown. The patient may be instructed to
bite on tongue blade. Before cement sets
ask the patient to close the mouth in centric
occlusion and make sure that occlusion is
not changed.
Remove excess cement with explorer.
The interproximal areas can be cleaned
by tying a knot in a piece of dental floss
and passing dental floss interproximally.
Croll has suggested removal of excess set
resin modified GIC cement by means of an
ultrasonic scaler.
Ask the patient to bite on wet cotton placed
over crown for proper fit. Then ask the
patient to bite to check for proper occlusion
on left and right side. Apply vaseline over
gingival surface of crown to enhance setting
of GIC cement.
RESPONSE OF GINGIVAL
TISSUES TO STAINLESS STEEL
CROWN RESTORATION
Goto (1970) reported incidence of gingivitis in
primary teeth restored with nickel chromium
crowns. He found higher percentage of gin-
givitis in the posterior part of the mouth than
anterior and strongly associated with poor
fitting of crown. He observed clinically and
radiographically that crowns classified as
failure showed 33 percent gingivitis, while those
classified as good showed 13 percent and those
rated fairly good showed 25 percent. Whereas
Webber (1974) found no adverse effect on
gingiva with PMC crowns.
Myers (1975) published a clinical study on
the response of gingival tissues to steel crown
restoration, concluding that the lower incidence
of gingivitis around crown without defects
in the margins may be due to the fact that
these crowns are less likely to allow plaque to
52 Crowns in Pediatric Dentistry
accumulation. Myer's also reported a clinically
significant association between crown defects
and gingivitis.
It was suggested by Warhaug that gingival
inflammation is due to bacterial plaque accu-
mulation rather than to mechanical defects
produced by a poorly fitted crown. This being
the case, it may not necessarily be the fit of the
crown on the margin of the crown encroaching
on the gingival that causes the gingival
problem but the fact that the stainless steel
crown surface enhances plaque accumulation,
thereby accounting for the association between
gingivitis and defective stainless steel crown.
Whatever the cause, the effect is nevertheless
the same; when the crown is improperly adapted
or improperly polished in the gingival area,
the result will be a higher percent of gingivitis
around steel crowns restorations.
Henderson reported that inflammation of
p
the gingiva may be due to irritation from the
.
surface of the material, over hanging margins,
rough surfaces, retained bacterial plaque, or
iv p
a combination of these. He found that soft
tissue will adjust just as nicely to a rough and
/: /
unpolished surface as to a highly polished
one but that bacterial plaque adheres and it
retained by a rough surfaces is probably due
tt p
to bacterial plaque accumulation rather than
to mechanical irritation. Henderson noticed
clinically and radiographically that no matter
h
how accurately the crowns were trimmed,
adapted and polished, some inflammation was
always observed due to the differences in form
and contour between the tooth and the crown.
Reduction of the cervical bulge will do a great
deal to minimize this problem.
Sterilization of Crown
Clean the used SSC with detergent to remove
blood and salivary contamination and sterilize
it by autoclaving before transferring to crown kit
or before using on other patient.
Precautions
There are chances of aspiration of crown in small
child or crown may be slipped while trimming
and polishing, hence care should be taken. To
prevent aspiration of crown use rubber dam or
throat pack with 4 4 size gauze.
/
.i r
Common Problems during
SSC Placement
s
More and Pink (1973) described the causes of
s
stainless steel crown failure which include pulp
n
necrosis, ectopic eruption, improper contact
which may cause space loss, gingivitis around
is a
the crown, insufficient retention leading to
loss of a crown, and excessive occlusal wear.
Following are some of the common problems
r
encountered during SSC crown placement.
e
Improper Tooth Preparation
Excessive reduction of the tooth in any area
may cause the stainless steel crown to over-
seat in that area. Maintain 1.5 to 2 mm uniform
reduction following cuspal outline and
adjacent marginal ridge as reference point.
Under tooth preparation results in high
occlusion and open bite and traumatic
bite. Ledges prevent a crown from seating.
Ledge formation can be avoided by making
proper proximal slice and verifying it with
radiograph.
Incorrect tooth reduction will lead to
difficulty in seating the crown or the crown
may rotate as it is seated and there will be
lack of proper occlusal clearance.
Improper Crown Selection
Large or small crown size selection. The
crown may tend to rotate when the wrong
size crown is selected, in addition, the
stainless steel crown appears to tip when the

tooth is over reduced or the stainless steel
crown is over trimmed.
Crown may not fit on tooth if there is
improper crown size selection or using
contralateral crown.
Excessive crown reduction results into
open proximal space leading to plaque
accumulation and gingival inflammation.
Failure to flatten/contour proximal portion
of crown when there is proximal space loss
due to proximal adjacent caries.
Failure to adapt crown leads to loss of
cement and dislodgement of crown, plaque
retention and gingival inflammation.
Excessive gingival extension of crown
leading to blanching.
Lack of crown finishing and polishing at
crown margin leading to rough margin
which results into plaque retention and
gingival inflammation.
p
Failure to Sterilize Crown
.
iv p
Failure to sterilization of used contaminated
crown leads to cross infection.
/: /
Causes for SSC Failure
p
Inadequate tooth reduction
t
Inadequate crown contouring and crimping
t
Inappropriately established occlusion
h
Inappropriate cementation methods (freq-
uent decementation)
Pulp treatment failure
Recurrent caries (improper contact).
Steps for Successful Stainless
Steel Crown
Remove caries followed by appropriate pulp
therapy
Optimum tooth structure reduction for
adequate crown retention
Begin tooth reduction from occlusal surface,
proximal and very minimal buccal or lingual
surface
Different Crowns Used in Pediatric Dentistry 53
Avoid damage to adjacent teeth proximities
Select appropriate sized crown to maintain
arch length
Establish appropriate occlusal interaction
Optimal cementation of crown.
Instruction to Patient and Parents
/
after Crown Delivery
.i r
Child will feel numb for approximately
s
3 hours after crown placement due to
anesthetic effect from LA. Child will not
s
have pain at this time. Be sure not to give
n
any food to child at this time that has to be
chewed. Avoid him/her biting cheek/lip
is a
while numb.
Some children will experience some mild
sensitivity around new crown.
r
Childs bite will become normal within
e
couple of days.
There may be mild bleeding when child
brushes his/her teeth on the day of crown
placement.
Advise the child to maintain good oral
hygiene to allow healing of gums.
Parents should watch the childs diet so that
sticky foods like chewing gum, fruit, snacks,
taffy starburst, skittles and other sticky foods
are rarely eaten.
Call dentist if the crown becomes loose
or comes out. Save and carry the crown to
dentist if crown comes out.
Modifications of Stainless Steel
Crown Placement
Between 1950 and 1968, several modifications
were recommended for stainless steel crown
techniques.
With adjacent stainless steel crowns
(Nash, 1981): When more than one crown
needs to be placed in a quadrant, both the
teeth should be prepared at the same visit
(Figs 3.17A to C). When multiple crowns
are to be placed in the same quadrant, the
adjacent proximal surfaces of the teeth being
54 Crowns in Pediatric Dentistry
A B
C
e r
.p
D E
FIGURES 3.17A TO E Stainless steel crown on adjacent teeth
iv p
prepared should be reduced slightly more
/: /
than usual. This will make multiple crown
placements easier. Occlusal reduction of one
tooth should be completed before reducing
p
other. Simultaneous reduction of both
t
the teeth results into improper reduction.
t
Ensure for proper proximal reduction to
h
receive two crowns.
Pulp treatment can be done if required
followed by, crown adaptation. There are
chances of mesiodistal space loss when
there is proximal caries on adjacent teeth.
To restore carious adjacent teeth with SSC
both the preparations should be modified to
allow the teeth to be fitted with smaller sized
crowns than normal and further reduction
of the buccal and ligual tooth walls is carried
out rather than more proximal reduction.
Howe No. 110 pliers can be used to flatten the
contact to adjust proximal contour of SSCs.
Both the adjacent crowns can be trimmed
r/
s .i
n s
is a
(Fig. 3.10), contoured simultaneously, but
posterior crown should be cemented first.
Finally check for proper broad contact
between crowns.
SSC with adjacent (Class II amalgam/
GIC) restoration: When there is need of
placement of SSC and Class II amalgam
restoration at the same appointment. Pulp
therapy followed by SSC crown should be
done first, later Class II amalgam restoration
should be done at the same time to allow for
proper contour of the SSC crowns marginal
ridge with indicated amalgam restoration.
The stainless steel crown is used as a guide in
reproducing the anatomy and morphology
of the amalgam restoration.
Adjacent stainless steel crown with arch
length loss/space loss (Mc Evoy, 1977):
Proximal space loss with shift of teeth
occurs due to extensive and long standing
caries. This results in loss of mesiodistal

B
A restoration; (B) Space loss due to proximal caries
dimension, which is very difficult to restore
due to loss of arch length. More tooth
reduction is required if there is space or
arch length loss due to proximal caries. Pulp
therapy is performed if it is required. The
marginal ridge should be aligned before
crown cementation (Fig. 3.18A).
Smaller crowns are preferred to fit small
crown size mesiodistally. Usually crown
has to be adjusted according to the tooth
preparation due to drift of adjacent teeth.
For proximal space loss flattening of contacts
of SSC crown with straight Howe pliers
is advised. With properly aligned crown,
ask the patient to bite on tongue blade
until the cement is completely set. Nash
(1981) recommended additional reduction
of adjacent proximal surfaces of the
teeth when adjacent teeth are being restored
(Fig. 3.18B).
Before eruption of mandibular first
molar: When fitting a crown for a second
primary molar, where the first permanent
molar has not yet erupted, care must be
taken when measuring the available mesio-
distal dimension for the crown (Fig. 3.19). If
the stainless steel crown encroaches on the
space needed for eruption of the permanent
molar, its eruption path may be distorted.
Modification of stainless steel crown sizes:
In 1971, Mink and Hill reported several
Different Crowns Used in Pediatric Dentistry 55
FIGURES 3.18A AND B (A) SSC adjacent to GIC
FIGURE 3.19 Crown on second primary mandibular
molar tooth
ways of modification of stainless steel crown
when the crowns are either too large (over
sized) or too short (under sized).
Oversized crown or undersized tooth:
The undersized tooth or the oversized
crown commonly occurs due to a long-
standing interproximal caries, with
space loss has occurred. To reduce
the crown circumference, a V cut is
made on the buccal surface of crown.
The cut edges are re-approximated to
overlap one another making the crown
circumference smaller (Fig. 3.20). The
crown is tried on the tooth and amount
of overlapping is marked on the crown.
The overlapped edges are then spot-
welded. The crown is polished with a
56 Crowns in Pediatric Dentistry
rubber wheel and fine abrasives before
crown cementation.
Under sized crown: If crown is
undersized for tooth, then crown may be
cut on the buccal or lingual surface. After
crown adaptation on prepared tooth,
additional piece of 0.004 inch stainless
steel band material may be welded into
place (Fig. 3.20). Retry the crown on
tooth. Again scratch the band material
where it adapts to the crown. Then the
crown may be contoured, crimped and
polished before cementation.
Open contact: If the closed contact
area (except for the primate spaces)
is not established, it will result in food
FIGURE 3.20 Crown modification in size (small or
large crown modification)
A B
D FIGURES 3.21A TO D Multiple crown placement
packing, increased plaque retention and
subsequently gingivitis. This problem
can be solved by selection of a larger
crown or exaggerated interproximal
contour can be obtained with a 112 (ball
and socket) plier to establish a close
contact. Interproximal contour can also
be built by addition of solder proximally.
Multiple crowns in the same arch (Figs
3.21A to D): Multiple crowns can be placed in
the same arch at same visit. There is no need
of changes in procedure if crowns have to be
placed in two sides of the same quadrant.
Modification is required if crown has to be
placed in adjacent tooth and opposing tooth
on same side. When multiple posterior
crowns are to be seated, they should be
adapted and cemented simultaneously to
allow for adjustments in the interproximal
spaces and establish proper contact areas.
To get these adjustments, adapt and seat
the crown on the most distal tooth first and
proceed mesially.
Crown extension for deep subgingival
caries (Mink and Hill 1971)
Ideally crown margin should be extended
1 mm beneath the gingiva. In case of deep
proximal caries crown margin should be
over extended to protect the proximal
surface. For deep proximal/subgingival
C

A B
FIGURES 3.22A TO C Crown modification in deep proximal caries
A B
FIGURES 3.23A AND B Management in bruxism/hypoplastic teeth
caries use metal piece to crown with
an extension on the interproximal area
of the crown, which can be welded or
soldered to crown (Figs 3.22A to C)
Trim the excess material with scissors
and contour the crown with No.
114 pliers. Polish with wheel before
cementation.
Other approach is to complete the
indirect pulp treatment and then
restore the cavity preparation with
silver amalgam. The proximal areas are
sliced as in a routine crown preparation,
stainless steel crown is adapted
with amalgam substitutes for tooth
structure at the interproximal finish
line of the subgingival caries occurs
interproximally, the unfestooned rocky
mountain crown can be used deep
enough to cover the preparation.
Different Crowns Used in Pediatric Dentistry 57
C
Open faced stainless steel crown: It is a
chairside procedure to improve the esthetic
of stainless steel crown. The stainless steel
crowns can be modified in anterior teeth
by a open faced stainless steel crown with
the labial surface trimmed away to leave a
crown perimeter, which is then restored with
a resin veneering with composite (Fig. 3.31).
Modifications in extrusion of opposing
tooth: In case of extrusion of the opposing
teeth, the extruded tooth may be
recontoured to re-establish the occlusal
plane and create interocclusal space for a
stainless steel crown before beginning for
crown adaptation.
Restoration of bruxism/hypoplastic teeth:
Bruxism/hypoplastic condition causes
greater occlusal wear (Figs 3.23A and B),
thus results into decreased vertical height. In
such condition occlusion can be increased
58 Crowns in Pediatric Dentistry
by the addition of a layer of solder from
the impression surface of crown (Crolls
technique). In other way avoid or minimize
the occlusal reduction. Rest part of the tooth
preparation and crown adaptation is similar
to normal other than occlusal reduction.
Preveneered SSC: These are SSC crowns for
anterior and posterior teeth, where crowns
are preveneered with composite or resin
material to improve esthetic quality.
Hall technique in SSC placementthe
biological approach: Hall technique is
a method for managing carious primary
molars where decay is sealed under
preformed metal crowns (PMC) without
local anesthesia, tooth preparation or any
caries removal.
This technique named after Dr Norna Hall
from Scotland, who developed the technique
for over 15 years. Hall technique manipulates
plaque environment by sealing it into the
tooth, separating it from the substrate it would
normally receive from oral environment.
When the caries is effectively sealed from
oral environment, the bacterial profile and
carcinogenicity decreases. The remaining
soft caries get arrested and becomes hard.
Following crown sealing as an oral defense
mechanism, odontoblasts get stimulated
to lay down a layer of reactive dentin, thus
pulpal response to caries get prevented.
A study conducted in Scotland on Hall
technique on 132 children for 2 years follow-
up showed major failures with irreversible
pulpitis, inter-radicular radiolucency and
abscess development requiring pulpotomy
or extractions. However, the study showed
Hall technique was more effective than
other restorations and it is preferred over
conventional restoration. Clinical trial has
shown that Hall technique to be effective and
acceptable in majority of cases. It requires
careful and appropriate case selection. But
it is not a solution for all carious problems.
Innes et al. (2009) indicated that the Hall
technique is effective in managing dental
caries in primary molar teeth when used
by general dental practitioners (GDP), and
is preferred by them, their child patients
and the childrens parents to conventional
restorative methods for these teeth Nicola
et al. (2007) concluded from their study
that the Hall technique was preferred to
conventional restorations by the majority
of children, careers and GDPs. After two
years, Hall PMCs showed more favorable
outcomes for pulpal health and restoration
longevity than conventional restorations.
The Hall technique appears to offer an
effective treatment option for carious
primary molar teeth.
Advantages
Faster fitting of crown
Noninvasive procedure compared to
conventional SSC procedure
No need to remove caries and no need of
tooth preparation
SSC pushed onto primary molar crown
Less demanding for patients
Less demanding for dentists
No need of LA
No need for rubber dam.
Disadvantages
Esthetically not acceptable
Temporary bite opening
Caries progression cannot be assessed by
radiographically or clinically.
Indications
Moderatively advanced Class I lesion
where the extent of the cavity would make it
difficult to obtain a good seal with adhesive
material following partial caries removal.
Proximal Class II lesions, cavitated or non-
cavitated.

Occlusal Class I lesions, noncavitated if
the patient is unsuitable to accept a fissure
sealant or conventional restoration.
Occlusal Class I lesion cavitated, if the
patient is unable to accept partial caries
removal technique.
Contraindication to Hall Technique
Signs of irreversible pulpitis
Clinical or radiographic signs of pulpal
involvement or periradicular pathology,
periapical pathology, interradicular radio-
lucency
Buccal sinus
Crowns that are so broken down that they
would be considered unrestorable with
conventional technique
Extensive mesio-occlusal caries
Occasional pain
Pulp polyp
Insufficient sound tissue left to retain crown
Patient co-operation where the clinician
cannot be confident that the crown can be
fitted without endangering the patients
airway.
Risk of bacterial endocarditis
Patient unhappy with esthetics.
A B
D E
FIGURES 3.24A TO F Restoration of carious tooth by Hall technique (proximal space creation with orthodontic
separators followed by SSC crown placement)
Different Crowns Used in Pediatric Dentistry 59
Clinical Technique of Crown Placement
(Hall Technique) (Figs 3.24A to F)
Instruments required
Mirror
Straight probeto remove separators
Excavatorsto remove crown if necessary,
to remove cement
Flat plasticto load crown with cement
Cotton wool rollsfor child to bite down on
and push crown over tooth and to wipe away
cement
Band forming pliersfor adapting crown
Gauzeto protect the airway and wipe off
excess cement
Elastoplaststo secure the crown for airway
protection.
Procedural steps
Access the tooth shape, contact points
areas and the occlusion.
Tight contacts: If there is tight contact,
separate the teeth with orthodontic elas-
tic separators through mesial and distal
contacts. Recall the patient 35 days
later for crown placement after gaining
space.
Crown morphology: Often there is
marginal ridge breakdown in one molar,
C
F
60 Crowns in Pediatric Dentistry
there can be migration of the adjacent
molar into the cavitated area. This makes
difficulties in Hall technique of crown
placement without making adjustments
to the tooth or crown. In such cases
rebuild the marginal ridge and allow the
separators to place. Adjust the crown
with band forming pliers. Check for
occlusion in relation to anterior overbite,
check buccal relationship of the tooth to
be crowned with its opposing number.
Protect the airway: It is important before
the crown is placed, to ensure no danger
to child by inhalation or swallowing. This is
done by sitting the child upright. Otherwise
gauze swab square can be placed between
tongue and tooth where crown to be fitted. It
should be extended to the palate and round
the back of the mouth in front of the faces.
Alternatively a piece of micropore tape can
be used to secure crown.
Sizing the crown: Select different sizes
of crowns until appropriate one selected
which covers all the cusps and approach the
contact points. Select smallest crown size.
Avoid fitting oversized crown to primary
second molar, where permanent first molar
has still to erupt, which increases chances
of molar impaction. Avoid fully seating the
crown through the contact points before
cementation, since it is difficult to remove.
Loading the crown with cement: Dry the
inside part of crown using cotton roll. Load
the crown with GIC luting cement and avoid
air blows and voids.
Fitting the crown and first stage seating:
Place the crown over the tooth using finger
pressure. Maintain firm finger pressure until
cement sets. While removing finger make
sure that crown is not falling off. Ask the
child to bite on crown before cement sets.
Wipe the excess cement, check fit and
second stage seating-after cementation
remove excess cement from crown margin
using explorer.
Final clearance of cement, check occlu-
sion: Blanching disappears after removal of
excess cement usually. Measure the degree
of bite opening, if excess then remove either
occlusal part of the crown with high speed
hand piece so that it is similar to orthodontic
band or remove entire crown. Check
the buccal relationship of the crowned
tooth. Advise parent and child that he will
experience high in occlusion, this will not
bother him by the following days. If there is
any problem, then child should be recalled
for correction. At recall visit pulp condition
should be monitored.
Clinical Tips
Hall crown should not be fitted to opposing
teeth at the same appointment. Occlusion
should be re-established with bilateral
contact before opposing crowns are fitted.
But crown on other side can be fitted at
same visit.
If there are difficulties in fitting adjacent
crowns with Hall techniques, then it can be
done at separate appointments.
Crowns will try to follow the path of least
resistance and so may tilt towards the easier
of the contacts, making it almost impossible
to ease at tight contact.
If crown does not seat sufficiently, remove it
with excavator before cement sets.
Patient and parents should be instructed
that child will be used to it in 24 hours.
Hall techniques is not fit and forget one, it
needs recall visit to check pulpal status.
Occasionally a crown will wear through
occlusally, if it occurs it can be repaired with
composite.
Crown and Loop Space
Maintainer (Myers, 1972)
Space maintainers may be fixed or remo-
vable and constructed by direct or indirect
 Different Crowns Used in Pediatric Dentistry 61

technique. Removable space maintainers technique. Fields (1993) states that it is no

require the cooperation of the parent and longer advisable to use the crown-and-
child with the dentist for a prolonged period loop appliance because it precludes simple
of time. This is often difficult to achieve. appliance removal and replacement. He
Indirect techniques require laboratory recommends that teeth with stainless
time and multiple appointments. Space steel crown should be banded like natural
maintainers placed with cemented bands teeth. Mc Donald et al. state that a primary
require frequent recementation to prevent first molar stainless steel crown provides
decalcification under the band or loss of the a desirable retentive contour for placing a
appliance. stainless steel band.
Beemer et al. (1993) suggested a technique
for orthodontic band adaptation on primary Complications
molar stainless steel crowns. The rationale
for use of design of the fixed unilateral Crown tilt: Improper tooth preparation can
space maintainers is well-established in result into crown tilt (Fig.3.26A).
the practice of pediatric dentistry when a Interproximal ledge: A ledge will be pro-
primary molar is prematurely lost. A space duced instead of a shoulder free inter-
maintainer prevents migration of adjacent proximal slice (Fig. 3.25), if the angulation of
teeth, thus holding space in the dental arch the tapered fissure bur is incorrect. Failure
for the succedaneous teeth to erupt. Fixed to remove this ledge will result in difficulty
unilateral space maintainers may be of in seating the crown.
two types according to the current clinical
guidelines of the American Academy of
Pediatric Dentistry: band and loop and
crown and loop. The crown and loop
inherently has the advantage of superior
retention, but it takes two appointments
to fabricate and is difficult to adjust intra-
orally if deformed or rotated. If broken or
replacement is required, the crown must
be removed and a new crown and loop
appliance should be fabricated. Placing a
band and loop on a primary molar stainless
steel crown is a simpler and less time
consuming procedure. Only one crown
need be placed at the initial appointment FIGURE 3.25 Ledge formation
and administration of local anesthetic is not
usually required for the band cementation
appointment. If the need arises, the band and
loop can be removed, adjustments made or
a new appliance fabricated, and recemented
without removal of the abutment stainless A B C
steel crown. FIGURES 3.26A TO C Improper crown adaptation
Christensen and Fields (1988) advice that with poor margin (left to rightcrown tilt) (A); Over
the crown and loop are not a recommended extent of crown (B); Under extent of crown (C).
62 Crowns in Pediatric Dentistry
Poor margins: When the crown is poorly
adapted, its marginal integrity is reduced.
Recurrent caries may occur around open
margins (Fig. 3.26C).
Over extension of the crown: Over
extension of crown can be identified with
gingival blanching, which can leads to loss
of periodontal attachment and periodontal
problems due to food lodgment. This can
be corrected by identifying the adequate
(1 mm) gingival extension of the crown
margin (Fig. 3.26B), scratching the line,
trimming the excess and crimping followed
by polishing.
Ingestion/inhalation of crown: Accidental
ingestion of crown can occur due to unco-
operative behavior of child or negligence
from dentist.
The Preformed Stainless Steel
Crown for Restoration of
Permanent Posterior
Teeth in Special Cases
Here, this entity is considered separate as that of
stainless steel crown for primary teeth in regards
of indications, contraindications and tooth
preparations. According to Croll and Castaldi
(1978) there are problems involving permanent
posterior teeth for which the stainless steel
crown may provide the most desirable short-
term solution.
For each permanent molar in the arch there
are 6 sizes of crowns, ranging in mesiodistal
dimension from 10.7 to 12.8 mm, increasing in
approximately 0.4 mm increments. The crowns
gain their retention mainly from the cervical
margin area. The crown margin should be
placed just apically to the gingival margin and
carefully adjusted to give an accurate fit in this
region. Fitting a permanent molar stainless steel
crown requires significantly more chairside time
than is needed to fit a primary molar crown.
When preparing a permanent molar for a
stainless steel crown, future preparation needs
for a cast restoration must be considered.
The 3M ESPE stainless steel crown allows for
a conservative preparation of the tooth to be
carried out. The preparation of a tooth for a
permanent molar crown is essentially the same
as that for a primary molar, but with slightly
less tooth tissue removal. The finishing line
placed just beneath the level of the free gingiva.
The crown margin should subsequently fit just
apical to the finished line.
Indications
Extensive caries: The use of a preformed
stainless steel crown restoration is indicated,
where the extensive carious destruction of
a posterior tooth in which caries control is
indicated, but retention of the temporary
filling material is uncertain, where gross
carious destruction of a posterior tooth for
which alloy restoration is contraindicated
because of pulpal considerations.
As temporary restoration: As a semi-
permanent restoration until a cast or
ceramic facing restoration is placed.
Teeth defects: For full coverage in young
posterior teeth that have enamel or dentinal
abnormalities.
Endodontic aspect: For restoration of a
tooth during endodontic treatment in which
access is made through the occlusal surface
of the steel crown.
The objectives sought in the use of the
stainless steel crown procedure are identical
to those of any restorative dental treatment.
Not only the occlusion be recreated ideally for
the patient but, in addition, proximal contact,
where indicated, must also be established. The
overall tooth architecture must be restored to
be physiologically acceptable and to preserve
masticatory function and periodontal integrity.
Procedure
The procedure consists of radiological consid-
erations, administration of the anesthesia,
occlusal considerations before preparation of

A B
FIGURES 3.27A AND B The SSC adaptation on permanent molar
the operative field, preparation of the tooth and
protection of the pulp, selection and adaptation
of the crown, establishing occlusal relationships,
radiographic confirmation of gingival fit, and
cementation of the crown.
Radiological considerations: Along with a
preoperative diagnostic radiograph of the
affected tooth and associated structures,
precementation radiographs are essential
to assess precise marginal adaptation of
the crown by showing interproximal areas
where marginal coverage is difficult to
assess (Fig. 3.27A).
Anesthesia: As a primary concern in the
dental practitioner and complete comfort of
the patient during dental treatment, routine
local administration of an anesthetic is
essential to eliminate pain from the cutting
procedures and for the retraction and
manipulation of the soft tissues associated
with the treatment.
Occlusal considerations before prepara-
tion of the tooth: Although the importance
of studying occlusal relationships before
actual cutting procedures begin is em-
phasized in restorative dentistry. These
occlusal relationships in the young patient
are often ignored because of the dynamic
physiology of the mixed and early permanent
dentitions, however, if the permanent tooth
to be restored with a steel crown which has
grossly caries, then occlusal relationships
Different Crowns Used in Pediatric Dentistry 63
may be adversely affected and may require
adjustments before preparing the tooth to
be restored. The opposing molar would have
over erupted into the mandibular first molar
space. It would be necessary first to correct
the over eruption by tooth reduction. The
occlusal adjustment should be done at this
stage to establish the correct occlusal plane
initially.
Preparation of the operative field: Rubber
dam isolation for entire procedure should
be done until crown cementation. The
major advantage of the rubber dam is that
gingival marginal fit can be visualized
around the entire circumference of the tooth
being restored with the possible exception
of the center of the proximal surfaces, which
can be evaluated with a precementation
radiograph.
In most cases, two types of rubber dam
clamps are used. The first is a retentive
clamp to secure the dam in position; it is
usually placed on a tooth distal to the tooth
being restored. The second is a retracting
clamp, which is designed to gently displace
the free gingiva on the tooth that is being
restored.
Preparation of tooth and protection of
pulp: There are various combinations of
instruments that can be used effectively for
preparation of the tooth. Use barrel-shaped
diamond or flame-shaped bur for occlusal
64 Crowns in Pediatric Dentistry
reduction and then reduce proximal
surface with tapered fissure bur. Liberal
water spray is essential during preparation
to eliminate unpleasant odor, reduce dust
from tooth debris, and most importantly to
limit iatrogenic thermal injury to vital pulp
tissues.
There are anatomical variations and
practical considerations that alter the
rationale of the preparation for a permanent
tooth compared with that of a deciduous
tooth. There are no gross cervical bulges on
permanent teeth that facilitate retention of
the crown. Cusp heights are much greater in
permanent teeth. Also, conservation of tooth
structure is more crucial for teeth of the
permanent dentition, as in all probability, a
cast gold restoration will be indicated, which
must not have its retention compromised
during a previous procedure.
An essential step in preparation of the
tooth is rounding of all angles. This includes
all axio-occlusal line angles as well as
occlusobuccal, occlusolingual, and occluso-
proximal. Crown seating and accurate
marginal adaptation are facilitated by this
operation. Initially, the tooth is reduced
occlusally in a similar manner to the
reduction for a cast gold crown. The general
anatomical form of the crown in reduced
dimensions should be maintained while
assuring between 1 and 2 mm occlusal
clearance in the entire envelope excursive
movements. This is achieved readily with
the barrel shaped diamond bur. The occlusal
reduction is achieved first to facilitate better
control and vision for the next step, which is
the proximal reduction.
The proximal slices eliminate all contact
with adjacent teeth and create the space
required to adapt the crown and to restore
contact if indicated. Proximal preparation
achieved with the 169 long carbide burs. It is
helpful to place a wooden wedge or flattened
round toothpick between the teeth to prevent
interference of the rubber dam and to avoid
laceration of the gingiva. The finish line
should be placed just beneath the level of
gingiva. In the next step, slightly reduce the
convexity of the buccal and lingual surfaces
of the tooth. It is important to reduce these
surface convexities in the gingival third of
the tooth so the stainless steel crown may
assume the original convexity and thus
produce an over contoured, enlarged bucco-
lingual dimension. A fine, feather-edged
gingival margin at the crest of the gingiva
should be produced, which will be covered
by a thin smooth edge of the crown. When
caries extends subgingivally, the margin
must extend subgingivally also to furnish full
coverage of the preparation after complete
caries removal. The edge of the crown
must be designed to embrace securely the
margin around the entire periphery of the
tooth. Caries removal is achieved in the
conventional manner with spoon excavators
and slow-speed round burs. Pulpal
insulation procedures (bases and varnish
applications) are now performed.
Selection and adaptation of crown:
The selected crown for permanent teeth
should establish good contact area with
neighboring teeth and snap fit into place
cervically. None of the available commercial
crowns are suitable for every situation. In
fact, clinicians who are concerned about
good occlusal relationships in restorative
dentistry may be disappointed with the
types of crowns on the market. Occlusal
morphology, cusp height, buccolingual
width, and occlusogingival length vary
widely.
Selection of a specific brand of crown
may become easier by having a set of study
models as part of the patients permanent
record. Some prefestooned crowns are too
short occlusogingivally in cases in which
there is deep proximal caries. Mink and
Hill (1971) described how this defect can be

overcome for the deciduous tooth by spot
welding an additional piece of crown or
band material. For permanent teeth, having
at least one of the nonfestooned crowns
available is recommended rather than
restoring to Minks add-on procedure.
The cusp heights of some types of crown
tend to be steep and more like newly
erupted molars. The occlusal morphology
of other types resembles older, more worn
teeth. Economic considerations in office
practice may preclude having a full selection
of all five available brands of crowns.
Nevertheless, the wide variation in occlusal
anatomy of teeth necessitates having at least
two brands available.
Once a suitable brand has been chosen
there are several ways to select a specific
size crown for a tooth. Some practitioners
advocate making measurements of the
prepared tooth, whereas others use the
trial and error method. Allen (1971) in his
observation stated that consideration of the
contralateral tooth, if possible, combined
with trial-and-error is the most expedient
means of crown selection after experience
is gained with the technique. The aim is to
select a preformed crown that will permit
the marginal areas to be crimped and
contoured to assure a tight, ideal, marginal
adaptation.
At this point in the procedure, the use
of the rubber dam is extremely important.
Visualization of every marginal area is
important for ideal adaptation and proper
use of the rubber dam; the clamp as a
retractor can provide this visibility. A heavy
dam, with small hole size, aids in retracting
the marginal gingival in conjunction with
a retraction clamp. The interproximal part
of the rubber dam and suitable wedging
retracts the interproximal gingiva. Proper
length of the stainless steel crown has al-
ready been described and may be achieved
with curved crown and bridge scissors
Different Crowns Used in Pediatric Dentistry 65
followed by refinement with a greenstone
Castaldi has shown that a common error
in fabricating a preformed crown for
deciduous teeth is to make the crown too
short on proximal surfaces, predisposing
that surface to caries. This area is normally
covered by the gingival papilla, but is easily
viewed with rubber dam retraction of the
tissue.
In adapting the crown, the original length
of the clinical crown should be recreated. The
orientation of the crown is important since
it re-establishes the original long axis of the
crown to the tooth, which will be helpful in
eliminating interfering cusps, and associated
mandibular shifts. After achieving proper
orientation of the crown on the tooth, the
marginal areas are critically examined. Only
the areas immediately below the proximal
contacts cannot be easily seen. A pair of
crown-crimping pliers is used to crimp the
margin of the crown. These pliers scallop
the periphery, which is then smoothened
with a pair of contouring pliers. The crimped
crown is again seated on the tooth and the
margins are re-examined visually and with
the explorer. Any open area disclosed by this
examination can be marked with an indelible,
fine-pointed pencil or felt-tip marker to
indicate where additional crimping and
contouring may be necessary. When ideal
adaptation has been achieved, the rubber
dam is removed. The crown is reseated and
occlusion is evaluated. The use of a wooden
tongue blade split lengthwise serves as an
excellent bite stick for applying force in a
particular area while seating the crown.
Prematurities, coronal orientation, length of
the crown, and stability of the restoration are
all verified and deficiencies are corrected.
Establishing occlusal relationships: The
patient should not be left with an open
bite relationship from a high crown. To
assure that the crown is not high, it is
removed, and the patient is instructed
66 Crowns in Pediatric Dentistry
to close the mouth to full occlusion.
A pencil mark is made to record the
overbite relationship in the canine
area. The crown is then replaced and
the correct relationship is confirmed
(Fig. 3.27B).
Radiographic confirmation of the gingi-
val fit: Before cementation, a bitewing
radiograph is taken to verify proximal
marginal integrity. If the crown is too
long, there is still an opportunity to
reduce the length. If it is too short, the
add-on procedure or adaptation of
another crown is indicated.
Final finishing and cementation: After
all occlusal and gingival adjustments have
been accomplished, it may be necessary to
re-crimp the crown as the metal may expand
minutely each time the crown is seated and
removed. The margins of the crown are then
refined and smoothened with a greenstone
and a large rubber wheel that removes all
scratches. Final treatment of the margin can
be accomplished readily by buffing with
a rag wheel and Tripoli abrasive and then
polishing with jewelers rouge. It is most
important to thoroughly clean the interior
to the crown with a wet cotton swab or small
brush before cementation.
Three types of cement widely used for
cementation of the stainless steel crown
are zincoxyphosphate, polycarboxylate,
and zinc oxide and eugenol. After suitable
pulp treatment, any of these cements are
acceptable. The rubber dam is replaced and
the tooth is cleaned and dried with a liberal
water spray and gentle application of warm
air. A creamy mixture of cement is prepared
and the crown is then filled about three
quarters full, making sure that all margins
are covered. It is then seated on the tooth
with gentle finger pressure or with a tongue
blade and mild biting force. Excess cement
is expressed around the margins.
The rubber dam is now removed; the
interproximal rubber is snipped with a
pair of scissors. The previously established
occlusal relationships and the crown
orientation on the prepared tooth can now
be verified. Deviations can be corrected
before the cement hardens. Recreation of
centric occlusion is confirmed with use of
pencil line on the anterior teeth. The cement
is allowed to set for several minutes while
the patient bites gently on a 2-in square
gauge.
Treatment of surrounding soft tissue
is important both during and after the
procedure. An ideally adapted crown, with
smooth and polished margins, replicating
the hard tissue architecture which once
existed, is paramount for potentiating
optimal gingival health. Removal of excess
cement is important to prevent gingival
irritation.
Longevity of Stainless Steel
Crown for Permanent Teeth
The major factors concerning the longevity
of the crown are gingival recession, recurrent
marginal caries, dissolution of the cement, and
wearing through on the occlusal surface of the
crown. The only report of the long-term potential
of the stainless steel crown for permanent teeth
is by Kimmelman and Riesner (1977). They
reviewed 65 restorations of which 13 had been
in the mouth from 49 to more than 120 months.
No description of clinical technique is included
in their observations.
One steel crown was observed in 1973 in
the mouth of a 42-year-old American soldier.
The restoration had been placed on a maxillary
molar in 1958, according to the military dental
record. No signs of gingival inflammation were
evident, and although wear facets existed on
the occlusal surface, none of them was worn
through the metal. A small area of recession

of the palatal gingiva was evident, exposing
about 1 mm of root surface; however, the crown
margin was well adapted in that area.
It was unfortunate that the contralateral
molar was absent, so that the tooth was unable to
be viewed for palatal recession in an analogous
area. The patient reported no symptoms during
the entire 15-year history of the restoration. The
preformed crown, when carefully done, can be
a respectable interim restoration until a more
desirable full cast crown is possible.
Nickel Allergy
Nickel containing alloys have been used in
orthodontic appliances from past 35 years.
Nickel ions released in sufficient quantities
from nickel-containing alloys may induce
nickel sensitization or elicit allergic contact
dermatitis. Nickel chromium crowns are
having significantly higher percentage of nickel
(70%) compared to stainless steel crowns,
orthodontic bands and wires (912% nickel).
Nickel hypersensitivity is more prevalent in
females than males, which is in association with
ear piercing. Higher concentration of contact
allergen may be required to elicit response from
oral mucosa compared to skin. It is difficult to
evaluate nickel release into the oral cavity.
Several studies had shown the nickel allergy
with crown having higher percentage of nickel.
Feasby et al. (1988) reported an increased
nickel-positive patch test in children aged
8 to 12 years, who had received old formulation
A B
FIGURES 3.28A AND B Anterior primary stainless steel crowns. (A) Anerior and posterior SSC;
(B) Anterior SSC refill box; (C) Antertior SSC
Different Crowns Used in Pediatric Dentistry 67
nickel-chromium crown. Whereas control
group with conventional stainless steel crown
showed no statistically significant difference in
patch test compared to a third control group
with no history of nickel containing dental
appliances. Menek et al. (2012) in their study
observed that nickel ion release was decreased
with increasing pH. Furthermore nickel
releasing ratio was decreased in all time periods.
Yilmiaz et al. (2012) concluded from his case
report that cause of the perioral skin eruptions
was a delayed hypersensitivity reaction, which
was triggered by the nickel in the stainless steel
crown.
ANTERIOR STAINLESS
STEEL CROWNS
Stainless steel crown for restoring anterior teeth
(Figs 3.28A and B) is not used nowadays, rather
SSC with facing are used for better esthetic
results. The tooth preparation is similar for
incisor. Stainless steel crowns were for many
years the only quick and effective means of
restoring fractured permanent incisor teeth on
a semi permanent basis. These crowns were
criticized because of poor esthetics and have
now largely been replaced by acid-etch retained
composite resin restorations. One of the roles
of an anterior stainless steel crown, that of
retaining a temporary dressing on the fracture
site, can be achieved satisfactorily by using
composite resin and the acid etch technique.
However, the major attribute of the stainless
C
68 Crowns in Pediatric Dentistry
steel crown is its ability to prevent space closure
and over eruption of the opposing tooth. When
the fracture is horizontal and restoration is
likely to be subjected to severe occlusal forces, a
stainless steel crown will be more durable than
a composite resin. The stainless steel crown
is only an interim method of treatment and
should eventually be replaced by a composite
resin restoration or a porcelain crown.
Manufacturers of Anterior
Stainless Steel Crowns
3M Espe-Unitek Crowns, St Paul, MN and Acero
Crowns, Seattle, WA., Rocky Mountain crown.
Stage 1
The first stage in the preparation of the fracture
incisor to receive a stainless steel crown is
the measurement of the tooths mesiodistal
dimension to facilitate selection of the crown of
the correct size. If there is no space between the
fractured teeth, a small proximal slice is required
to allow the fitting of the crown. The stainless
steel crown is usually too long, and therefore,
marking the gingival margin and trimming it in
the manner described for the posterior stainless
steel crown is necessary. This process must be
repeated until the correct cervical contour has
been obtained.
Esthetics: Reasonable esthetics can be achieved
followed by cutting a labial window in the
stainless steel crown. This can be done using
a diamond bur in an air turbine to cut away
the excess and finally a green stone to finish
the margins. Some material must be left to lap
around on the labial surface of the tooth, or the
crown will be easily displaced.
Stage 2
The next stage is to shape the cingulum with the
No. 112 pilers to avoid creation of an occlusal
interference. Retention in the form of a snap
fit is achieved using the No. 417 crimping
pliers or the smaller No. 421 pliers (Unitek
Corp.) Before cementing the crown, cover the
fractured surface of the dentin with a calcium
hydroxide lining material. A composite resin
may then be used to replace the missing tooth
substance. This crown can remain in place for
several months, during which time vitality
testing can be performed and any color changes
will be easily detected.
Indications
Following pulp therapy
Multisurface caries
Fractures incisor.
Advantages
Good retention
Long lasting.
Disadvantages
Unesthetic look.
Availability
Anterior Crown Kit, 72 crownsthese crowns
are identical to the Unitek.
Available for primary incisors and canines
and permanent incisors manufactures: Rocky
Mountain and Unitek Corp.
BIBLIOGRAPHY
1. Albers JH. Use of preformed stainless steel crowns
in pedodontics. Quint. Int. 1979;10(6):35-40.
2. American Academy of Pediatric Dentistry
Reference manual, 1992-93. Guidelines for
management of the developing dentition in
pediatric dentistry, Chicago; 1992. pp. 46-9.
3. Beemer RL, Ferracane JL, Howard HE.
Orthodontic band retention on primary molar
stainless steel crowns. Pediatr Dent. 1993;15:6.
4. Bigsby BG, DMD, Tunison M. Comprehensive
Dental Care for Children, Adolescents and Chal-
lenged people. http://www.valleydentalpediat-
rics.com/crowns.php.

5. Braff MH. A comparison between SSC and
multisurface amalgams in primary molars. Jr
Dent Child. 1975;42(6):478-8.
6. Croll TP, Epstein DW, Castaldi CR. Marginal
adaptation of stainless steel crowns. Ped Dent.
2003;25(3):249-52.
7. Croll TP, Epstein DW, Castaldi CR. Marginal
adaptation of stainless steel crowns. Ped Dent.
2003;25:249-52.
8. Daydd Evans, Nicola Innes. The Hall technique
guide. The Hall Technique A minimal
intervention, child centred approach to managing
the carious primary molar. A user manual,
University of Dunde http://www.mendeley.com/
groups/1533433/reading-listcaries/
9. Duggal MS, Curzon ME, Fayle SA, Polar MA,
Robertson AJ. Restorative techniques in pediatric
dentistry: An illustrated guide to the restoration
of extensively carious primary teeth, London,
Martin Dunitz. 1995;8:72.
10. Engel RJ. Chrome steel as used in childrens
dentistry. Chron amaba Dist. Dent. Soc. 1950;13:
255-8.
11. Fuks AB, Zadok S, Chosack A. Gingival health of
premolar successors to crown primary molars.
Pediatr Dent. 1983;5(1):51-2.
12. Goto, et al. Clinical evaluation of preformed
crowns for deciduous teeth. Bull. Tokyo Dental.
Coll. 1970;11:169-75.
13. http://www.mendeley.com/groups/486021/
reading-list-restorative-dentistry/.
14. http://www.scottishdental.org/resources/
HallTechnique.htm.
15. Humphrey WP. Use of chrome steel in childrens
dentistry. Dent. Surv. 1950;(26):945-53.
16. Hutcheson C, Seale NS, McWhorter A, Kerins C,
Wright J. Multi-surface composite vs stainless
steel crown restorations after mineral trioxide
aggregate pulpotomy: a randomized controlled
trial. Pediatr Dent. 2012;34(7):460-7.
17. Innes N, Evans D, Hall N. The Hall Technique for
managing carious primary molars. Dent Update.
2009;36(8):472-4, 477-8.
18. Innes NP, Dafydd JP Evans, David R Stirrups. The
Hall Technique; a randomized controlled clinical
trial of a novel method of managing carious
Different Crowns Used in Pediatric Dentistry 69
primary molars in general dental practice:
acceptability of the technique and outcomes at
23 months. BMC Oral Health. 2007;7(18):1-21.
19. Kennedy DB. The stainless steel crown. Pediatr.
Oper. Dent. Bristol 1976, J Wright and Sons Ltd.
20. Kowolik J, Kozlowski D, Jones JE. Utilization of
stainless steel crowns by general dentists and
pediatric dental specialists in Indiana. J Indiana
Dent Assoc. 2007;86(2):16-21.
21. Mata AF, Bebermeyer RD. Stainless steel crowns
versus amalgams in the primary dentition and
decision-making in clinical practice. Gen Dent.
2006 ;54(5):34750;quiz 351, 367-8.
22. Mathewson RJ, Lu KH, Falebi R. Dental cement
retentive force comparison on stainless steel
crown. J Calif Dent Assoc. 1974;2:42.
23. Mc Donald: Dentistry for child and adolescent,
5th edn. (1996);The C.V. Mosby Co.
24. Menek N, Baaran S, Karaman Y, Ceylan G, en
Tun E. Investigation of Nickel Ion Release
from Stainless Steel Crowns by Square Wave
Voltammetry. Int. J. Electrochem. Sci. 2012;7:
6465-71.
25. Mink JR, Bennett IC. The stainless steel crown. J
Dent Child. 1968;35:186-96.
26. Myers DR. A direct technique for the placement of
stainless steel crown-and loop space maintains.
J Dent Child; 1975. pp. 37-9.
27. Nash DA. The nickel-chromium crown for
restoring posterior primary teeth. J Am Dent
Assoc. 1981;102:44-9.
28. Randall RC. Preformed metal crowns for primary
and permanent molar teeth: Review of literature.
Ped Dent. 2002;24: 489-500.
29. Randall RC. Preformed metal crowns for primary
and permanent molar teeth: review of the
literature. Pediatr Dent. 2002;24(5): 489-500.
30. Rapp R. A simplified, yet precise technique for the
placement of stainless steel crowns on primary
teeth. J Dent Child. 1966;33:101-12.
31. Sahana S, Vasa KAA, Sekhar R. Esthetic crowns
for primary teeth. 2010;2 (2):87-93.
32. Salama FS. Stainless steel crown in clinical
Pedodontics: A review. The Saudi Dental Journal.
1992;4(2):70-4.
70 Crowns in Pediatric Dentistry
33. Savide NL, Caputo AA, Luke LS. The effect of
tooth preparation on the retention of stainless
steel crowns. J Dent Child. 1979;46:25-33.
34. Seale NS. The use of stainless steel crowns. Ped
Dent. 2002;24:501-5.
35. Sharaf AA, Farsi NM. A clinical and radiographic
evaluation of stainless steel crowns for primary
molars. J Dent. 2004;32(1):27-33.
36. University of Dundee. A minimally intervention,
child centred approach to managing the carious
primary molar.
37. Waggoner WF, Cohen H. Failure strength of four
veneered primary stainless steel crown. Pediatric
Dent. 1995;17(1):36-40.
38. Waggoner WF. Restoring primary anterior teeth.
Ped Dent. 2002;24: 511-6.
39. Widenfeld KR, Draughn RA, Sheryl GE. Chairside
veneering of composite resin to anterior stainless
steel crowns: Another look. J Dent Child; 1995.
pp. 270-3.
40. Wiedenfeld KR, Draughn RA, Welford JB.
An esthetic technique for veneering anterior
stainless steel crown with composite resin. J Dent
Child. 1994;61(56):321-6.
41. Yilmaz A, Ozdemir CE, Yilmaz Y. A delayed
hypersensitivity reaction to a stainless steel
crown: a case report. J Clin Pediatr Dent. Spring
2012;36(3):235-8.
A B
D E
ALUMINUM CROWNS
Aluminum crowns are temporary crowns used
for bicuspids (Figs 3.29A and B). These crowns
have anatomical occlusal surfaces and tooth-
shaped cross-sections (not cylindrical). They are
much easy to adapt to the preparation without
time-consuming in axial shaping. The larger
sizes measures a full 11 mm, to cover and protect
the tooth margin (Fig. 3.29C). A posterior tooth
can be protected by an aluminum provisional
crown. Cementation of crown can be done with
IRM or zinc oxide eugenol (ZOE) cement (Figs
3.29D and E).
Availability of Crown
They come in nine sizes for molars and
bicuspids, coded to the standard copper-
band numbering system. The introductory kit
includes a compartmented tray makes selection
easy (Fig. 3.29A). Each crown is stamped with
the size and quadrant to avoid confusion. Single
aluminum crown costs $ 1.90 while 60 bicuspid
crown kit costs $ 35. Available as BL, BU, ML,
MU, sizes 4 to 12.
C
FIGURES 3.29A TO E (A to C) Aluminum
crowns; (D and E) Aluminum crown forms
and supply in box
 Different Crowns Used in Pediatric Dentistry 71

Manufacturer: Pearson dental supplies (since
1945).
Steps Using an Aluminum Shell
Table 3.6 shows steps for using an aluminum
shell.
Gold Anodized Crowns
An Anodized aluminum crown is used most
commonly on premolars and molars because of
their resistance to wear, strength and unesthetic
appearance. These are medium-hard aluminum
for durability and function. The chief advantage
of this crown is its malleability, which allows for
good occlusal adjustment. These crowns are the
softest and most ductile crowns commercially
available for the temporary coverage of posterior
permanent teeth. The softness of the alloy
eases marginal and occlusal adaptation, as the
material will stretch up to 50 percent. It can also
be contoured and burnished without wrinkling.
Softness, however, is the chief disadvantage of
this crown. It can easily wear through during
normal mastication; hence, it is recommended
for a short time, unless it can again be re-
lined with acrylic resin for added strength. 3M
ESPE Gold Anodized crowns are made from
a medium-hard aluminum for durability and
function. Gold anodization eliminates metallic
taste and galvanic shock for greater patient
comfort.
Commercial product: 3M/Unitek Gold
Anodized.
Features
Medium-hard aluminum base that will not
easily deform and minimizes bite-through.
Pretrimmed gingival contour for minimal
trimming.
Parallel wall design to save time by
minimizing belling of the crown.
Wide assortment of sizes including bicus-
pids and molars.
3M ESPE gold anodized crowns (Fig. 3.30)
are available in 108 crown sizes for molar
and bicuspid forms. Crowns are available in
different sizes in mm. For refill crowns can be
ordered using crown order form (Fig. 6.6)

TABLE 3.6 Steps in aluminum crown adaptation

Steps for using an aluminum shell

1. Select the crown before tooth preparation. Tooth preparation is similar as for SSC. After selecting
appropriate size crown, try it on the tooth to make sure the distance between contacts is correct.
2. See how much is necessary to trim at the gingiva. If the crown is 2 mm above the adjacent teeth, then
trim 2 mm all around at the gingiva using a crown scissors. It is important to trim in a smooth manner so
as not to leave sharp or uneven edges that can irritate the gingiva.
3. Use crimping pliers to crimp the margins of the crown inward (Contouring pliers Nos. 112, 114 and 115
are most common). Use the contouring pliers for adapting the crown to the finish line. It is possible
to omit the contouring and reline the shell with methylmethacrylate (self curing acrylic). This will give
a better internal fit and more exact margins and is probably preferable since it helps to avoid a metal
overhang.
4. Once the crown is seated on the prepared tooth, instruct the patient to bite down normally. This helps to
establish an initial occlusal anatomy onto the soft aluminum shell.
5. Further check the occlusion with articulating paper and make adjustments.
6. Check crown for rough metal margins. These can be smoothed using sandpaper, discs or a rubber wheel.
72 Crowns in Pediatric Dentistry

A B
FIGURES 3.30A AND B A. Gold anodized crown; B. Gold anodized refil box

Upper 1st bicuspid 8 5.69.1

Kits
942501: Bicuspid set-84 crowns
Upper 2nd bicuspid 8 5.69.1 942301: Molar set-84 crowns
Lower 1st bicuspid 7 5.78.6 Set box only: GB-000-BicuspidGB-000Molar
Lower 2nd bicuspid 7 6.29.1
BIBLIOGRAPHY
Upper 1st molar 6 9.411.9
1. h t t p : / / w w w . p a r k e l l . c o m / p ro d u c t s / 4 0 2 /
Upper 2nd molar 6 9.411.9
Aluminum-Crowns
Lower 1st molar 6 9.912.4
Lower 2nd molar 6 9.612.2

SSC WITH FACING/OPEN FACED STAINLESS STEEL CROWN/

CHAIRSIDE VENEERED SSC
Children too are becoming much aware of their
appearance because they live very much in an
era of peer influence. The esthetic implications
of dental treatment would be of a major concern
to the parents and young patients in 21st
century. Adhesive dentistry has developed at an
accelerated rate in the recent years; continuous
processes since the introduction of acid etch
technique for decades ago. With the advent of
the etched cast restorations, research has been
devoted to resin to metal bond, using different
techniques. Bonding a white resin to stainless
steel crown (ssc) offers the potential of wider
acceptance of this restoration and an entire new
standard in pediatric dentistry.
The stainless steel crowns can be modified
in anterior teeth by a open faced stainless
steel crown with the labial surface trimmed
away to leave a crown perimeter, which is then
restored with a resin veneering/tooth colored
plastic materials (Croll, 1996). But metals may
appear at the edge and back of the crown. They
take advantage of the strengths of preformed
stainless steel crowns. Veneering over the
labial/buccal surface of the stainless steel crown
with composite resin is an option to improve the
esthetics of posterior teeth.

VENEERING TECHNIQUE FOR
ANTERIOR STAINLESS STEEL
CROWN (HARTMANN, 1983)
Tooth Preparation
Anesthetize the tooth before the operative
procedure. Once proper anesthesia is
established, the mesial, distal and facial surfaces
are reduced with a No. 699 bur, in a high-speed
handpiece, maintaining the walls parallel to
the long axis of the tooth. The reduction is
extended 0.5 mm into the gingival sulcus, in
order to remove enough of the bulbous portion
of the tooth to insure a well-fitted stainless steel
crown. The incisal edge is then reduced 1.5 mm.
Finally, any remaining caries is removed with a
No. 4 round bur in a slow-speed handpiece, and
any pulp treatment indicated is performed.
Adaptation of the Crowns
A stainless steel crown is selected and fitted in
the customary fashion. The gingival margin on
the facial surfaces is extended as deep as the
sulcus will allow. Trim the excess crown margin
so that gingival extension of crown should
be 1 mm beneath gingiva without blanching.
After final crimping and polishing, the crown is
cemented with carboxylate cement. Any excess
cement is removed after setting.
Window Preparation
A window is now placed in the facial surface of
the crown. A No. 330 or No. 245 bur is used to
cut the rough window. The window is refined
incisally with a No. 35 diamond disk in a slow-
speed handpiece. The incisal portion of the
window is reduced in order to allow a 0.5 mm
undercut, while keeping the margin as straight
as possible. The esthetics of the finished crown
is improved with a straight incisal surface,
which is parallel to the incisal surfaces of the
adjoining teeth.
Different Crowns Used in Pediatric Dentistry 73
The window is opened mesiodistally with a
No. 330 or No. 245 bur so that very little stainless
steel is showing. Little retention is expected to
be gained proximally. The same bur is used to
shape the gingival margin of the window to the
level of the gingival crest. A No. 699 bur is then
used to prepare a retention channel 1 mm in
depth, gingivally. With this accomplished, all
remaining cement is removed from the incisal
undercut and proximally to within 1 mm of the
margins of the window. The depth of the window
should be sufficient so that no tooth structure
or remaining cement will be seen through the
finished resin.
Insertion of Composite
After etching, cleaning and drying the prepared
window, apply bonding agent, cure it. Then
selected composite resin is inserted with a
syringe. The injection begins by filling the
gingival channel and continues up to proximal
surface. The incisal undercut is then filled,
followed by the other proximal surface. This
method will ensure that the entire retention
area has been filled with composite. Filling the
central portion of the window completes the
resin injection. A premier cervical matrix form
No. 722 G is then used because it contours well
to the margins of the window and establishes
a good facial contour. The matrix is slipped 1
mm beneath the tissue with a cotton forceps
and then gently passed toward the crown with
finger pressure until all margins are contacted.
It is then held in place until the composite
is set.
Polishing and Finishing
After the composite is polymerized, the matrix is
removed and the excess composite is trimmed
from the margins using a No. 699 bur. No other
polishing or finishing is necessary.
74 Crowns in Pediatric Dentistry
COMPOSITE VENEERING OF
PRIMARY MOLAR SSC
Tooth preparation and crown placement is
similar to that of SSC as mentioned above.
Only difference is that, after crown
cementation, window is prepared on buccal
side of crown to provide place for placement of
composite facing. Leave thin margin of stainless
steel crown at gingival part on buccal surface.
After composite shade selection, etch the
tooth surface, wash it then apply bonding agent
followed by composite material application
in layer, curing and finishing to form SSC with
facing (Figs 3.31A to F).
Advantages
Inexpensive
Durable
Easy to do
Well adapted to tooth
Esthetically pleasing.
A B
D E
FIGURES 3.31A TO F Open faced SSC procedure
Disadvantages
Isolation and hemorrhage control is difficult
Difficulty to avoid blood and saliva contami-
nation since composite facing is done
Requires extra chairside time
Less than optimal esthetic
Metals may appear at the gingival edge of
the crown.
Weidenfeld et al. (1995) from their clinical
study concluded that chairside veneering
technique is successful for restoring severely
damaged primary anteriors and the resulting
veneer maintain the adaptability, strength and
gingival contour with cosmetic effect. AI-Shala
et al. (1997) conducted a study to determine the
in vitro bond strengths of composite rebonded
to stainless steel crown metal (SS) using five
different bonding agents (Scotchbond All-Bond
TM, Caulk TM, Ellman TM). Later composite to
SS bond failure had been produced. The main
conclusions of this study were:
Composite can be bonded effectively to SS
metal using a bonding agent.
C
F

Bond strength of all rebonding systems
was greater than the original commercially
produced bond.
The highest bond strength following
rebonding was achieved with the Caulks
Adhesive.
Ellman Adhesive System TM produced the
weakest bond.
No significant difference was found between
mechanically prepared and unprepared
groups.
Hartman (1983) evaluated new composite
resin that is bonded to stainless steel crowns.
One hundred patients were treated with a
stainless steel crown on a primary tooth, cover-
up (parkell) was used to veneer the buccal or
labial surfaces with a white shaded resin. All
anterior surfaces of crowns were roughened
by use of a diamond stone, bonding liner was
applied evenly, within three minutes a bonding
liner application, an opaque solution was
applied; then cover-up (4-meta) was placed
over opaquer. A thin layer of complus microfilm
followed and light cured for 20 seconds using an
optilux light. This veneering technique has too
many variables to hold forth any firm promises
of success. Within one year, only a third of the
composite cases were totally intact. Shade
stability decreased over a short period of time.
Patient brushing habits profoundly affected
veneer surface removal.
Widenfeld et al. (1994) evaluated an esthetic
technique for veneering anterior stainless steel
crowns with composite resin. The esthetic
surfaces of the crowns were sand blasted
RESIN CROWNS/COMPOSITE CROWNS
COMPOSITE STRIP CROWN
FOR ANTERIOR AND
POSTERIOR TEETH
Introduction
The maintenance of primary anterior teeth
is very important in children for mastication,
Different Crowns Used in Pediatric Dentistry 75
with 50 m aluminum oxide particles for
2 to 4 seconds, followed by the application
of adhesive resin cement (Panavia) to the
sandblasted surfaces in a thin layer. A thin
coat of opaque light cured pit and fissure
sealant (Delton) was applied by rolling the
panavia bonded surfaces in a drop of sealant
and was cured for 20 seconds, followed by the
application of light cured composite resin to the
sealant surface and was cured for 40 seconds.
A study on 10 specimens was conducted in
which beads of composite resins were bonded
to the sandblasted stainless steel crown in the
same manner. The bond strengths of the beads
to the crowns were measured by applying
shear stresses at a crosshead speed of 1 mm
per minute. The bonding failed at the panavia
cement and the metal interface. The results
included mean shear bond strength of 24.4
MPa. It was concluded that, this technique
yielded excellent esthetics and a very high bond
strength of the veneered stainless steel crowns.
BIBLIOGRAPHY
1. AI-Shala TA, Till MJ, Feiga RJ. Composit bonding
to stainless steel metal using different bonding
agents. Ped Dent.1997;19(4):273-6.
2. Waggoner WF. Restoring anterior teeth. Ped Dent.
2002;24(5):511-6.
3. Wiedenfeld KR, Draugh RA, Goltra SE. Chairside
veneering of composite resin to anterior stainless
steel crowns: another look. ASDC J Dent Child.
1995;62(4):270-3.
pronunciation, to avoid abnormal swallowing
and for esthetics. Restoration of extensively
destroyed anterior teeth with durable, esthetic
and retentive material is challenging. Several
methods are advised for full coronal restoration
such as, composite strip crowns, SSC or open
faced SSCs. Esthetic results of open faced
crowns are somewhat compromised. Strip
76 Crowns in Pediatric Dentistry
crown is very esthetic when prepared correctly.
Anterior strip crowns are used to restore
broken down front teeth or teeth with decay
on multiple surfaces. Installing these crowns
demands skillful technique and often requires
more time to perform. Because of the time
required, these crowns can be difficult to place
on young, uncooperative children which need
management under general anesthesia. With
a cooperative patient, the time required for
placement is comparable to that of a stainless
steel crown or polycarbonate crown.
Composite strip crowns are composite filled
celluloid crowns forms. They have become a
popular method of restoring primary anterior
teeth because they provide superior esthetics
as compared to other forms of anterior tooth
coverage. Bonded composite strip crowns are
most esthetic restorative option for carious
primary incisors. This is the first choice of many
clinicians due to the superior esthetics and the
ease of repair if the crowns chips or fracture
frequently. However, it is most technique
sensitive. 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 com-
promised retention. There is need of sufficient
tooth structure after caries removal to ensure
sufficient surface area for bonding.
They are less resistant to wear and fracture
more readily than other anterior full coverage
restorations. Tate et al. (2002) found that
composite strip crowns had a failure rate of
51 percent, compared to an 8 percent failure rate
of stainless steel crowns. Resin crowns are much
weaker than stainless steel crowns and there is
an increased chance that a piece or corner of the
crown may fracture off.
The crowns help to seal the underlying
tooth from acid attacks and reduce the chance
of developing further decay on the tooth. The
tooth surface is prepared to specific dimensions
and then the crown is carefully fitted over the
existing tooth. The success of these crowns
depends on how much good tooth structure is
available to place the crowns onto. If the child
traumatizes the teeth/crowns (falls over), there
is a risk of the crown breaking or an abscess
forming. Anterior crowns need good preventive
care and regular monitoring by the dentist.
Morgolis FS (2002) describes strip crown
as a relatively easy technique that produces a
beautiful outcome in a comparatively short time
after using strip crown procedure on hundreds
of children for more than 20 years. Ram and
Fuks (2006) observed high success rate of resin-
bonded composite strip crowns with a 2-year
follow-up and suggests that this treatment
modality is an esthetic 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, particularly
in children with a high caries risk. Kupietzky
(2002) stated that the bonded resin composite
strip crown is perhaps the most esthetic of all
the restorations available to the clinician for the
treatment of severely decayed primary incisors.
Kupietzky et al. (2003) evaluated efficacy
of strip crown performance in retrospective
clinical study utilizing photos, radiographs
and clinical examination on 112 strip crowns
in 40 children. They observed no crowns loss
and 12 percent had some chipping, one tooth
demonstrated evidence of pulpal necrosis, color
match with adjacent teeth was significantly
reduced when pulpectomy had been completed
prior to crown placement. They also found
88 percent full retention rate for strip crowns at
18 months retrospective study. They concluded
that strip crowns performed esthetically well.
They found parental satisfaction with strip
crowns was excellent.
Kupietzky and Waggoner, (2004) assessed
parental satisfaction with 112 bonded resin
composite strip crowns for primary incisors
compared with their clinical evaluation and
success. Parents were questioned as to their
satisfaction with the crowns. Overall parental
satisfaction was very good regardless of poorer
 Different Crowns Used in Pediatric Dentistry 77

ratings of color, size or overall appearance. Availability

When parents gave low marks for durability
their overall satisfaction was reduced. They There are 16 crown sizes available in the 3M
concluded that parental satisfaction is most ESPE pediatric strip crown range. Tables 3.7
affected by durability, even more so than and 3.8 show the features of commercial strip
appearance or color match. Kupietzky et al. crowns and sizes. Strip crowns can be ordered
(2005) found that 80 percent of strip crowns using crown order forms (Figs 6.2 and 6.7).
were totally retained after 3 years, and
20 percent were partially retained, with none Kits
being completely lost. Similar retention rate 915100: Intro kit-60 upper centrals 60 upper
was observed by King (2004), i.e. 80 percent laterals
retention after 18 months of strip crown with Set box only: PS-000
omega shaped stainless steel wire reinforced
and embedded in the root canal. Ram and Indications
Fuks (2006) reported 80 percent retention of Interproximal caries, excess or multisurface
strip crowns at 24 to 74 months retrospective caries on primary anterior teeth.
follow-up. Similarly, various researchers founds Following pulp therapy to primary anterior
retention rate of strip crown ranging from teeth.
50 to 100 percent. Tate et al. (2002) reported Restoration of fractured anterior teeth.
from their study that, children who were treated Incisors with hypoplastic defects, amelog-
under general anesthesia had a very high failure enesis imperfecta.
rate of composite resins (30%) and composite Discolored incisors.
strip crowns (51%), in comparison to stainless Congenitally malformed primary incisor.
steel crowns (8%).
Contraindications
Commercial Products Insufficient tooth structure for retention.
Deep overbite
3M ESPE Pediatric Strip Crowns
TABLE 3.7 Strip crowns
Strip crown forms simplify composite work
for pediatric anterior restorations. Trimmed Anterior and posterior pediatric strip crowns
and filled with restorative materials, they Color/Shades Clear
automatically contour the restorative material Anterior/Posterior Anterior and posterior
to match natural dentition. They strip off easily, Quantity 120
leaving a smooth surface. They are ideal for both Product brief Crowns
chemical and photo curing composites. Special features Ideal for ankylosed tooth build-
ups, crystal clear and very thin
Features of Strip Crown
Thin interproximal walls. TABLE 3.8 Anterior strip crown sizes
Anatomically shaped construction to match
Crown shape Number Width range
natural contours.
of sizes available in mm
Palmar notation on each crown tab for easy
identification. Upper central incisors 8 6.08.1
Sufficient strength for easy handling. Upper lateral incisors 8 4.36.7
78 Crowns in Pediatric Dentistry
Bruxism
Periodontal diseases.
Benefits
Parent/patient pleasing
Ideal for ankylosed tooth buildups
Simple to fit and trim
Removal is fast and easy
Easily matches natural dentition
Leaves smooth shiny surface
Easy shade control with composite
Superior esthetic quality
Ideal for photo cure
Crystal clear and thin celluloid crowns
Large selection of size
Easy to repair
Crowns are cost-effective (approximately $6/
crown)
Esthetic but more fragile than SSC
Better retention than poly carbonate crown
Functionally, allows occlusal wear
Require removal of small amount of tooth
structure
Automatically contours restorative material
to match natural dentition
Strips off easily leaving a smooth surface
Thin interproximal walls
Sufficient strength for easy handling
Ideal for chemical or light-cured composites.
Disadvantages
Moisture or blood contamination affects
resin bonding.
Time consuming procedure in young and
uncooperative childadequate tooth
structure required.
It is extremely technique sensitive.
It is not as durable or retentive as stainless
steel/open faced crowns, pre-veneered
crown or polycarbonate crown
It is not recommended on patients with a
bruxism habit or a deep bite.
Adequate moisture control might be difficult
on an uncooperative patient.
Chances of fracture or debond of crown.
It is a direct restorative method with
bulk pack technique which can lead to
postoperative sensitivity.
The bulk packing of the material may lead
to incomplete polymerization as the depth
of light curing is restricted to 2 mm from the
surface.
Occlusion cannot be checked until the strip
crowns have been removed which is only
after completion of restoration.
Strip crowns procedure requires longer
chairside time.
Armamentarium
Burs-taper fissure, inverted cone shaped bur
Curved crown and bridge scissor
Explorer
Dental floss
Rubber dam kit
Composite kit.
Preoperative Assessment
Check for incisor relation
Presence of remaining tooth structure
If remaining tooth structure is less then
consider for post and core followed by strip
crown
Cooperativeness of childif child is unco-
operative then crown placement shold be
performed under conscious sedation or GA.
Procedure of Crown Placement
Selection of Crown Form
Strip crowns are available in 6 sizes 1 to 6
number (Fig. 3.32A).
Select a primary celluloid crown form
(Unitek Strip Crown, 3M, St Paul, MN
Nowak Crowns, Nowak Dental Supplies Inc.,
Carrier, MS) with a mesiodistal incisal width
equal to the tooth to be restored by placing
the incisal edge of the crown against the
incisal edge of the tooth or by measuring the

B C
FIGURES 3.32A TO D Crown selection, caries excavation, facial reduction
MD dimension of the tooth to be restored
with caliper and matching it with required
crown form.
Shade Selection
Select the composite shade using shade guide
under natural light. Pedo shade can be selected
for better esthetic.
Rubber Dam Placement
Place and ligate the rubber dam. The two most
popular techniques for isolating anterior teeth
are individual tooth isolation and the split dam
technique.
Individual Tooth Isolation
The advantage of individual tooth isolation is
that it provides greater deflection of gingival
tissues and better moisture control. The rubber
dam is prepared by stretching the dam material
over the frame and punching the appropriate
number of holes in the dam material. The
holes are stretched over the teeth so they poke
through the rubber dam.
Different Crowns Used in Pediatric Dentistry 79
D
Split Dam Method (Kuietzky, 2002)
Routine use of ligature ties to deflect gingival
tissue and retain the rubber dam in place is
not suggested. Many times ligature ties may be
the cause of bleeding and discomfort to child.
Their use may inhibit rapid removal of rubber
dam. After curing the composite removal
ligature which are situated under the hardened
restoration is difficult to remove, hence split
dam method is advised.
The advantages of the split dam method are
the rapid application and removal of the dam
and noninterference with crown placement and
finishing of the restoration. The disadvantage
is that it gives moderate moisture control. The
rubber dam is prepared by stretching the dam
material over the frame and punching two
large holes at 1 to 2 cm apart and it is joined by
a scissors cut. The hole is stretched around the
teeth to be treated and stabilized with a wooden
wedge or a small piece of rubber dam material.
This method is used commonly for strip crown
placement for multiple teeth. Rubber dam is
advised to place only during caries removal and
80 Crowns in Pediatric Dentistry
during crown placement the rubber dam may
be removed.
Tooth Preparation
Strip crown case-1:
Administer appropriate anesthesia
Reduce the interproximal surfaces by
0.5 to 1 mm with a tapered diamond bur to
produce knife edge cervical margin identical
to that of stainless steel crown preparation
(Fig. 3.32E). The interproximal walls should
be parallel. Proximal reduction should allow
a crown to slip over the tooth that is there
should be snap fit of crown.
Reduce incisal edge approximately
1 to 1.5 mm using fine tapered diamond
(169 L) bur (Fig. 3.32F).
Reduce the facial surface by at least 1 mm
and lingual surface by at least 0.5 mm (Figs
3.32D and G). Create knife edge gingival
margin. Round all line angle.
Create small cervical undercut with inverted
cone bur (No. 35) or No. 330 bur on labial
gingival margin (Fig. 3.32H) for retention
of composite restoration as it acts as
mechanical lock to aid in retention.
Further tooth reduction can be done to
allow placement of selected crown form
over the tooth if the previous reduction was
inadequate.
Minimal enamel reduction is desirable since
retention of the restoration is based on the
quality and quantity of enamel surface area
exposed to acid etching procedure.
Remove existing carious lesions with a
spoon excavator or round bur. Removal
of carious lesion will leave additional
undercuts which will aid in the retention
of the restoration. Removal of caries can
be done either before tooth preparation
(pikham) or after (Mathewson) (Fig. 3.32C).
Do pulp therapy if required.
In cases of black colored arrested caries,
a masking agent (Paint-On-Color, white
opaque, Coltene whaledent, NJ) may be
used. Otherwise due to transference nature
of resin composites, the dark color of the
excavated lesion will be seen through the
restoration.
Crown Placement
Trim the selected crown form to remove
excess crown form material cervically with
crown and bridge scissors (Fig. 3.32J).
Trial check for fitting of crown form on
prepared tooth. Trimmed crown form
should fit 1 mm below gingival margin with
comparable height to adjacent teeth (Figs
3.32K and L).
Consider the maxillary lateral incisors length
of 0.5 to 1 mm shorter than that of central
incisors during crown form placement.
Punch a small hole with sharp explorer at
incisal edge or at palatal surface of trimmed
crown form to create vent for flow of excess
composite material while placement
(Fig. 3.32I).
Place an appropriate pulp liner to all exposed
dentin under dry field before etching.
Etch the prepared tooth with acid etchant
for 15 to 20 seconds. Rinse and dry the tooth
followed bonding agent application and
curing (Figs 3.32N and O).
Composite materials used to fill crown
form are hybrid composite, compomers
(sparingly), flowable composites, or
combination of an anterior/posterior
composite for strength perspective.
Fill the crown forms with selected composite
shade material to approximately two-thirds
of length (Fig. 3.32M) and seat on to tooth
and check for correct position. Excess
material should flow from gingival margin
and vent hole. Remove the excess composite
material from gingival area with explorer
(Fig. 3.32Q).
Light cure the celluloid crowns to polymerize
the composite material. Curing should be
done both labially and lingually (Fig. 3.32P).
After proper curing remove the celluloid
crown form by using a composite finishing
bur or curved scalpel blade to cut the
 Different Crowns Used in Pediatric Dentistry 81

E F G

H I J

K L M

N O P

Q R S
FIGURES 3.32E TO S Strip crown placement procedure
82 Crowns in Pediatric Dentistry

material on the lingual surface and then
peel the form from the tooth or use explorer
to remove (Fig. 3.32R). Crown form removal
should began from palatal side to avoid
scratches on labial surface.
Remove the rubber dam and check for
occlusion (Fig. 3.32S).
Little finishing can be required on the facial
or gingival area. Abrasive disc are used for
final polishing of required areas.
Strip crown for posterior teeth: Strip crown
cases no. 2, 3 and 4 are shown in Figures 3.33
to 3.35. The tooth preparation is similar as that
for stainless steel crown. Crown placement and

A B
FIGURES 3.33A AND B Strip crown case-2

A B
FIGURES 3.34A AND B Strip crown case-3

A B
FIGURES 3.35A AND B Strip crown case-4

preparation is similar to anterior strip crown.
Figure 3.36 shows commercial anterior and
posterior strip crown forms.
COMPOSITE SHELL CROWNS
Composite shell crowns are crowns prepared
with composite material by indirect method.
Advantages
Requires less chairside time
No need of trimming or crimping during
clinical procedure
No need of postoperative adjustment of
crowns since adjustments are made in lab
Less technique/moisture sensitive as com-
pared to strip crowns
Less postoperative sensitivity.
FIGURE 3.36 Strip crownanterior and posterior
A B
FIGURES 3.37A TO D Fabrication of composite shell crown
Source: Murthy et al. (2013 JAOR)
Different Crowns Used in Pediatric Dentistry 83
Disadvantages
Two visit procedure.
Needs lab procedures.
Procedure of Composite Shell
Crown Preparation and Placement
Remove all caries with spoon excavator (Fig.
3.37A).
Select composite shade for preparation of
shell crown with the help of vita shade guide
under natural light.
Take full arch impression of maxilla and
mandible and pore the cast. After cast sets,
apply double coating of the separating
media, which acts as spacer for luting agent
during crown cementation.
Composite buildup done on the maxillary
cast in harmonious with mandibular
anteriors to form composite shell crown
followed by light curing.
After completion of shell crowns check the
occlusion with mandibular cast and crown
should be finished and polished.
Before separation of shell crowns, a silicone
based positioner is fabricated which helps
in holding the crowns in the mouth during
cementation.
Silicone positioner is prepared by extending
the positioner bilaterally to cover at least one
tooth distal to the last tooth being restored,
palatally it should cover rugae area and half
of the palatal slope, labially covers only the
incisal third of labial surface (Fig. 3.37B).
C D
84 Crowns in Pediatric Dentistry

Once positioner is prepared, shell crown are Manufacturers

carefully detached from cast. The silicone
positioner checked intraorally for proper fit Success, essentials, space maintainers laboratory.
without crowns (Fig. 3.37C).
Then teeth are cleaned and dried, etched Availability
followed by application of bonding agent
and light curing. Starter kit-24 crowns (anterior)$ 290.00,

/
Shell crowns filled with dual cure luting resin 12 crowns (posterior) $ 169.50

.i r
and placed in silicone positioner and which is Individual crownAnterior-$ 9.95, Posterior-
transferred intraorally. Curing of luting agent $ 12.95

s
done from labially and lingually. After curing
positioner removed and check for occlusion Advantages

s
and teeth position (Fig. 3.37D). There is no

n
need of postcementation adjustment of Very esthetic crowns
crown since it has been done in laboratory Can be trimmed and reshaped with high

is a
stage. speed finishing burs.

r
NEW MILLENNIUM CROWN Disadvantages

e
These crowns are similar in form to Pedo Jacket Very expensive crowns compared to strip

p
and strip crown except that these crowns are crown and Pedo Jacket crowns

.
made up of lab enhanced composite resin Crowns are brittle
material and bonded to tooth. The crown form Needs adequate moisture control.

iv p
is filled with resin material and bonded to the
tooth. The crown forms are very brittle, can crack GLASS IONOMER CROWN

/: /
or fractured if forced down onto a preparation
that has not been adequately reduced. For These crowns are fabricated using GIC in
clinical success it requires adequate bonding conjunction with celluloid strips crown. This

p
area, excellent moisture control and absence of technique provides a distinct advantage of glass

t
hemorrhage. No long-term studies are available ionomer restorative material over composite

t
regarding these crowns (Fig. 3.38). in its ability to release fluoride for extended

h
period. The procedure of tooth preparation
and crown adaptation is similar to that for
strip crown except, crown forms are filled
with GIC (light cure or dual cured) instead of
composite.

Advantages
Antecariogenic property due to fluoride
release
Better adaptation to tooth structure due to
chemical adhesive nature of GIC
Restoration can be done in single visit
FIGURE 3.38 New millennium crown Advantages in primary teeth.
 Different Crowns Used in Pediatric Dentistry 85

Disadvantage 11. Waggoner WF. Restoring primary anterior teeth.

Ped Dent. 2002;24(5):511-6.
Lack of strength.
POLYCARBONATE CROWN
BIBLIOGRAPHY
Kudo crowns
1. Kupietzky, Waggoner WF, Galea J. The clinical and Art glass crowns

/
radiographic success of bonded resin composite Pedo jacket crowns

r
strip crowns for primary incisors. Ped Dent.

.i
PedoNatural crowns (Fig. 3.39).
2003;25(6):577-81.
2. Kupietzky A, Waggoner WF. Parental satisfaction

s
Manufacturers of Polycarbonate
with bonded resin composit strip crowns for
Crowns

s
primary incisors. Pediatr Dent. 2004;26(4):33-7.

n
3. Kupietzky A. Bonded resin composite strip crowns 3M ESPE
for primary incisors: clinical tips for a successful Direct dental products

is a
outcome. Pediatr Dent. 2002;24(2):145-8. Sweedish dental supplies Lab (SWE Den)
4. Kupietzy A, Waggoner WF, Galea J. Long-term PedoNatural crowns, Valencia CA
photographic and radiographic assessment of CrestOral-B.

r
bonded resin composite strip crowns for primary

e
incisors: Results after 3 years. Pediatr Dent.
3M ESPE Polycarbonate Crowns
2005;27(3):221-5.

.p
5. Margolis FS. The sandwich technique and There are 60 crown sizes available in the 3M
strip crowns: an esthetic restoration for ESPE polycarbonate molar crown range.

iv p
primary incisors. Compend Contin Educ Dent. Polycarbonate crowns are available in different
2002;23(12):1165-9;quiz 1170. sizes for incisors, cuspids and icuspids (Table

/: /
6. Murthy PS, Deshmukh S. Indirect composite 3.9 and Fig 3.39). Polycarbonate crowns can be
shell crown: An esthetic restorative option for ordered with crown order forms (Fig. 6.2).
mutilated primary anterior teeth. Journal of
Advanced Oral Research. 2013;4(1):1-4.

p
Kits

t
7. Ram D, Fuks AB. Clinical performance of resin- C-180: Intro kit-180 crowns

t
bonded composite strip crowns in primary Set box only: C-000
incisors: a retrospective study. Int J Paediatr

h
Polycarbonates are aromatic linear
Dent. 2006;16(1):49-54.
polyesters of carbonic acid. They exhibit high
8. Sahana S, Vasa AAK, Skhar R. Esthetic crowns for
impact strength and rigidity. Polycarbonate
primary teeth: a review. Annals and Essences of
Dentistry. 2010;2(2):87-93.
9. Steven Schwartz. Full Coverage Aesthetic
TABLE 3.9 Polycarbonate crowns
Restoration of Anterior Primary Teeth. http://
www.dentalcare.com/en-US/dental-education/ Crown type Sizes Available in
continuingeducation/ce379/ce379.aspx?Modul mm
eName=coursecontentandPartID=6andSection Upper central incisors 7 7.710.1
ID=-1 Upper lateral incisors 6 5.87.6
10. Tate AR, Ng MW, Needleman HL, Acs G. Failure
Lower incisors 10 4.96.3
rates of restorative procedures following dental
Cuspids 7 7.59.0
rehabilitation under general anesthesia. Pediatr
Bicuspids 10 6.27.5
Dent. 2002;24:69-71.
86 Crowns in Pediatric Dentistry
p
.
iv p
crowns are heat-molded acrylic resin shells
that are adapted to teeth with self cured acrylic
/: /
resin. They were popular in the 1970s, they
are more esthetic than stainless steel crowns.
Polycarbonate crowns are hollow, tooth-shaped
p
with walls about 0.3 mm thick. Polycarbonate
t
crowns are usually available in two tooth-
t
colored shades (dark and light). These crowns
h
do not resists strong abrasive forces, leading to
occlusal wear, fracture or dislodgement. With the
advent of composite strip crowns they lost their
popularity. In the 1990s new manufacturing
techniques made them thinner and more
flexible resulting in stronger restoration.
Availability of Polycarbonate Crowns
Available in a variety of shapes and sizes for
anterior and posterior teeth.
Available for maxillary and mandibular
teeth, right and left sides, incisors through
premolars.
r/
s .i
n s
is a
e r FIGURE 3.39 Polycarbonate
crown kit and individual
crowns
Polycarbonate crowns for posterior teeth
are packaged separately. They are generally
more difficult to use due to variations in
tooth size and shape.
Polycarbonate crown (a form of synthetic
resin) is widely used for temporary crowns
for several reasons:
It is strong yet flexible enough to contour
easily.
It bonds chemically to a self-curing acrylic
resin material used to fill the shell. Although
plastic crowns do not bend and draw as
metal crowns do.
They have almost perfect bonding
properties.
Any area of a plastic crown, including the
incisal edge, can be extended by adding
layers of acrylic.
Plastic crowns are commercially produced to
conform to standard surface contours of teeth
and are available in a range of sizes sufficient
to cover most preparations. Although the

manufacturers have no sizing convention,
the sizes of most polycarbonate crowns vary
by increments of approximately 0.5 mm
mesiodistally. Incisal crowns, when fitted to
preparations mesiodistally, are generally too
wide faciolingually. Lining a polycarbonate
crown ensures good marginal adaptation.
Cold cure acrylics chemically bond with
polycarbonate crowns. Bis-acrylic composite
or other composite materials need retention
by mechanical roughning the inside surface of
crown.
Advantages
Crowns are made up of polycarbonate resin
with microglass fibers which permit crown
adjustment with pliers, good durability and
strength.
Contours and crimps similar to metal
crowns.
Esthetic/U62 shade.
Good anatomic form.
Esthetic with universal shade which is
translucent to allow shade adjustment by
the type of lining material used.
The crowns have smooth surface to
minimize plaque accumulation.
Available in wide range of sizes for incisor,
canine and premolars.
Indications
Primary maxillary incisors with extensive
caries
Malformed teeth
Fractured teeth
FIGURE 3.40 Placing a preformed polycarbonate temporary crown on premolar
Different Crowns Used in Pediatric Dentistry 87
Discolored teeth
Endodontically treated teeth.
Contraindications
Bruxism
Inadequate spacing
Anterior crowding
Teeth with excessive abrasion
Deep overbite
Evidence of abrasion in anterior teeth.
Placement Procedure for Posterior
Polycarbonate Crown (Fig. 3.40)
Crown selection: Select a polycarbonate
crown to fit the prepared tooth.
Remember that the gingival margins of the
polycarbonate will be trimmed until the
occlusal surface is even with that of the
adjacent teeth. If a choosen crown size is
too small, then crown will not seat without
internal adjustments. If the crown is too
large, the interproximal diameter may keep
the crown from seating. The interproximal
distance of the area to be restored may be
measured with calipers and then used to
select the proper size polycarbonate crown
from kit. Another useful guide for the
selection of the correct size crown is to use
the patients diagnostic cast.
Crown adjustment: Seat the selected
polycarbonate crown over the prepared
tooth. Crown should be trimmed at the
gingival margins to seat fully on the tooth
and have the occlusal plane correspond
with that of the arch.
88 Crowns in Pediatric Dentistry
Using an acrylic bur, greenstone or white
stone, adjust the gingival contours of the
crown. Remember that the axial walls
extend down toward the gingiva on the
buccal and lingual surfaces, and are
shorter in the interproximal areas.
It may be necessary to slightly adjust
the internal surfaces of the crown as
well in order for it to seat fully on the
preparation.
Reseat the crown periodically to check
the contouring of the margins.
Trim until occlusal surface is close to
that of the adjacent teeth. If the proximal
contacts are not closed, acrylic may
be added to these areas later in the
procedure. Be sure that the margins
of the polycarbonate crown cover the
finish line of the prepared tooth.
While adjusting the crown, it is helpful
to keep the handle attached to the
buccal cusp tip. This will aid in trying the
crown on and off. Remove the handle
once adjustments are made.
Crown cementation: An acrylic resin is then
mixed and placed in the crown, which is
subsequently seated on the preparation.
The viscous resin fills the spaces between
the prepared tooth and the crown and as
the acrylic resin hardens, the contours of
the preprepared tooth are replicated. With
the crown in place, occlusion is checked;
then extra resin removed from the margin
of the crown. Finally, the crown is cemented
in place and a last occlusion check is made.
Success in placing this crown depends on
careful trimming and contouring of the
polycarbonate crown shell and the acrylic
resin.
Polycarbonate crown form direct dental
company produces crowns with various
opacities ranging fromtranslucent and
opaque polycarbonate crowns available
for anteriors and molars. Several sizes are
available for each quadrant. Company
says that, these crowns are easy to handle,
select and dispense with help of directa
mold guide. Polycarbonate crown is a hard
material that is resilient in the mouth and
allows adjustement of the crown without
risk of breakage. This company uses
universally acclaimed coding system for
crown selection.
Custom Resin Crowns
The custom resin crown is tooth colored and is
completely fabricated by the operator. The fit
and external contours of the crown are superior
to those of any other temporary crown, since it
is made in an impression of the patients mouth.
This crown can be adapted to any tooth and
is esthetically pleasing. The disadvantage to
this crown is that some operators feel it takes
longer to produce. The choice of an appropriate
temporary crown depends on which tooth is to
be restored; the patients concern for esthetics,
and the length of time a temporary restoration
must serve. The commonly used resin is a
combination of a polymer (powder) and a
monomer (a liquid). Five major categories for
temporary resin materials are:
1. Methyl methacrylates
2. Ethyl methacrylates
3. Vinyl ethyl methacrylates
4. Epimines
5. Composites.
KUDOS CROWNS
Kudos crowns (temporary pediatric crowns) are
newer generation polycarbonate crowns. It is
easy to use and handle along with considerably
reducing the chairside working time and at the
same time overcomes the difficulties reported so
far pertaining to placement and retention. It is
more user friendly and esthetically acceptable.
Figures 3.41A and B show commercial Kudos
crowns. Figures 3.42A and B show Kudos crown
preparation and postoperative placement.
 Different Crowns Used in Pediatric Dentistry 89

A B
FIGURES 3.41A AND B Kudos crowns for primary teeth

A B
FIGURES 3.42A AND B Kudos crown [Source: Karthik et al. (www.kudoscw.hk.in/images)]

Advantages Package includes:

1 F/F Regular Size Tmp C and B
Esthetically acceptable 1 F/F Large Size Tmp C and B
Less chairside time 5ea 20 regular size single crowns
Improved retention 5ea 20 large size single crowns
Flexible A2, A3, C3 shades are available
Better adaptability. 200ea pediatric crowns + 4ea C and B per
pack.
Disadvantages
Technique of Crown Placement
Chances of breakage
After initial examination select proper size
Dislodgement
of the crown which snugly fits mesiodistally
Discoloration. After a trial fit the crown is checked for its
proper fit, marginal adaptability, overall
Availability coverage and mesiodistal width.
Necessary adjustments are made either
Kudos crowns are produced from Hong Kong using crown scissors or with a trimming
based company-Kudos International Holdings bur or stone. Care must be taken to seat the
Limited. crowns on to the prepared margins.
90 Crowns in Pediatric Dentistry
After the final fit is done the crown is relined
using a cold cure acrylic material and placed
it over the prepared tooth and removed till it
starts to set. This type of relining technique
is done so that cold cure acrylic chemically
bonds to the polycarbonate crowns.
After complete setting of the material, the
margins are trimmed and finished and the
crown is cemented using a luting cement or
composites.
The firmness of the crown allows it to serve
as a provisional crown up to several months
Kopel et al. (1976) concluded from
their investigation that 1. A composite resin
processed directly against a roughened stainless
steel dye, similar in shape to a primary anterior
tooth, which has been shaped to receive a
polycarbonate crown, shows the highest
PEDONATURAL CROWN
The PedoNatural Crown is not a composite
restoration and is never used with composites.
All components of the PedoNatural Crown are
hydrophilic (moisture tolerant). The Pedo-
Natural Crown is a polycarbonate crown unlike
any other polycarbonate application previously
available in pediatric dentistry. These are ultra
thin crown form that is: anatomically correct,
flexible, easy to fit, extremely strong, durable
and automatically correctable polycarbonate
crown form.
The materials that are used in creating the
PedoNatural Crown form have been in clinical
use since 1997. Originally designed as a method
of providing long-term provisional splinting for
crown and bridge patients, the technique was
adapted for use in the primary dentition and
successfully endured 3 years of clinical studies
as the PedoNatural Crown.
PedoNatural Crowns provide the clinician
with a superior esthetic alternative to the
retentive force measured in pounds per square
inch (psi). 2. A polymethacrylate resin, when
used as a cement, also shows high values,
probably due to its ability to unite chemically
with polycarbonated acrylic and to its low film
thickness. 3. Composite resins of low viscosity,
low film thickness, and high compressive and
tensile strengths provide good retentive values
and would contribute insolubility to a greater
degree than the unfilled resin. 4. Polycarboxylate,
zinc phosphate, and reinforced zinc oxide-
eugenol cements are not to be recommended as
agents for cementing polycarbonate crowns. 5.
It can be recommended on the basis of retention
only, composite crowns should be fabricated
directly onto the tooth preparations of carious
primary anterior teeth.
Anju Bansal
composite strip crown or composite veneered
stainless steel crown. These crowns can be
easily used in crowded situations as well as
Class III occlusions. Self-adhesive resin cements
are available in several shades. For anterior
PedoNatural Crowns the translucent shade
works best. For posterior crowns the translucent
shade will also look great but in addition shade
A-1 gives an excellent result.
Advantage of the PedoNatural Crown over
the stainless steel crown and veneered crowns
isthe ability to easily adapt it in situations
where there has been loss of mesial-distal
dimension. Unlike stainless steel crowns, the
flexibility of the PedoNatural Crown allows
for easy application. Chances of breakage of
PedoNatural Crown are less if occlusion is
properly checked. For anterior restorations the
patient must be in posterior occlusion with only
minimal anterior contact.

The PedoNatural Crown Consists
of Three Components
1. Ultra-thin polycarbonate crown form
2. Hybrid acrylic fill material
3. Glass ionomer cement.
Availability of Crown (Fig. 3.45)
Available for both anterior and posterior
primary teeth.
The PedoNatural Crown is anatomically
correct for each primary tooth.
There are 5 sizes for each posterior tooth, 3
sizes for the maxillary central incisors and 2
sizes each for the maxillary lateral incisors
and cuspids.
The cost of an individual PedoNatural
Crown form is $9.45.
Advantages
Greater durability than composite strip
crowns.
Preveneered crowns.
No need to use composite strip crowns and
have the hassle of moisture contamination
with etching and bonding.
Ease of application over any other esthetic
full crown restoration.
No need to use bulky and unsightly resin
veneered stainless steel crowns which are
difficult to place and usually chip.
Not as technique sensitive as composite
strip crowns as the fabricated crown is
cemented with self adhesive resin cement
rather than bonding.
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.
Cost-effective.
Superior marginal integrity.
Excellent retention.
High tensile strength.
Different Crowns Used in Pediatric Dentistry 91
Trimmable.
Crimpable.
Anatomically correct shape and size.
Flexible.
Easy to fit.
Extremely strong and durable.
Superior marginal integrity.
Excellent retention.
High tensile strength.
Disadvantages
They are not recommended in patients with
heavy bruxism.
Greater tooth reduction is required.
Tooth Preparation
Tooth preparation and crown adaptation differs
with PedoNatural Crown compared to SSC in
that it require more amount of tooth reduction
including buccal and lingual reduction.
Anesthetize the tooth
Isolate the tooth with rubber dam isolation
Select appropriate crown size
Begin tooth preparation with incisal or
occlusal reduction for minimum of 2 mm.
Proximal slice/reduction is done to break
the contact point to create adequate
clearance for crown placement. Remove all
remaining decay and perform any necessary
pulp tissue treatment. Reduce the labial
surface a minimum of 2 mm and place all
the margins subgingivally.
Crown Adaptation
Select crown by measuring mesiodistal
diameter of tooth preparation. Identify the
tab in crown to verify correct size. After
selection of appropriate crown remove the
tab with sharp scissor and trim it with slow
speed hand piece.
Place the crown over tooth and mark and
trim the excess (Figs 3.43A and B).
92 Crowns in Pediatric Dentistry

C
FIGURES 3.43A TO C PedoNatural Crown placement (polycarbonate crown) (Courtesy: Steven Schwartz)

FIGURE 3.44 PedoNatural crown placement for primary molar
Later crimp all the gingival margin of the
crown using crimping pliers and check
for final fit of crown. Check for snug fit of
crown. The fully seated crown should be
below the occlusal plane for posteriors.
For anteriors finger pressure is sufficient to
seat the crown. Crown Grabber instrument
should be used to remove crown from tooth
to avoid damage to crown margins. Take
care to avoid any occlusal interference due
to crown.
The PedoNatural Crown can be prepared
chairside by filling the crown from with
specially formulated acrylic hybride mater-
ial that seamlessly units with the crown form
during curing. This Crown is cemented with
any commercially available self-adhesive
resin cement, such as Relyx Unicem by 3M,
Smartcem by Dentsply, or GC Automix by
GC. These self-adhesive resin cements are
moisture tolerant, fluoride releasing and
do not require etching and bonding. To
facilitate the adhesion and retention of the
cement to the crown, GC Coat Plus (made
by GC) is applied to the inside of the crown
prior to loading the crown with cement.
PedoNatural Crown is used to restore
pulpally treated teeth.
Before cementation of crown clean and dry
the tooth surface and selected crown. Apply
varnish adhesive agent to internal surface
of the crown using brush, followed by light
curing.
Different Crowns Used in Pediatric Dentistry 93
Fill the crown with self adhesive resin (e.g.,
Rely X smartcem or G-Cem Automic). Seat
the crown in position over tooth and hold
it for few minutes, remove excess material
from gingival surface and light cure the
material (Fig. 3.43 C).
Procedure for PedoNatural Crown
Placement (Polycarbonate Crown) Figure 3.44
shows image of posterior pedo natural crown.
Procedure
The PedoNatural Crown is fabricate chair-
side by filling he crown form with a especially
formulated hybrid acrylic material
That seamlessly unites with the crown form
during curing.
The finished crown is cemented with a glass
ionomer cement
Resulting in a full crown restoration that is truly
esthetic, strong, long lasting and durable
PEDO JACKET CROWN
Pedo Jacket crown is like a strip crown. It is
handled similar to a celluloid crown form. It is
made up of tooth-colored polyester material
which can be filled with resin and left on the
tooth after polymerization. It comes only in a
single shade which makes matching to adjacent
94 Crowns in Pediatric Dentistry
A B
FIGURES 3.45A AND B Pedo Jacket crown (anterior and posterior)
nonrestored tooth difficult, since the crown
is made up of copolyester, it can be trimmed
with scissors, adaptable over irregular teeth.
It cannot be trimmed or reshaped with a high
speed finishing bur otherwise the material will
melt to the bur. Older types of crowns used were
polycarbonate crown forms. They are thin yet
strong, interproximal wall will allow placing
multiple adjacent restorations with a minimum
amount of tooth reduction. These crowns will
not split, stain, or crack. Cementation is easy.
Using a plastic primer, they can either bonded
into place with composite resin or cemented
with a glass ionomer cement. Identification and
sizing is easy because they are made to match
the standard 3M Unitek stainless steel crowns.
Pedo Jackets are ideal for both the upper
and lower dentition. Pedo Jacket crowns are
available as anterior and posterior crowns (Figs
3.45A and B).
Advantages
Crown placement can be done in one sitting
Cost-effective
Multiple adjacent restorations can be done
with minimal tooth reduction
Crown will not split, not stain or crack
Crowns can be trimmed with scissors.
Disadvantages
Available in single color hence color match-
ing is difficult.
Cannot be trimmed or reshaped with high
speed finishing bur as the material melt to
bur.
Manufacturers
Success essential, Space maintainers laboratory.
Availability
Anterior crown sizes-D, E, F, G, L, U as 1-6
numbers.
Replacement crowns: 5 per box costs $16.00.
ARTGLASS CROWNS/
GLASTECH CROWNS
These are forms of full coronal restorations
with esthetic value for the deciduous dentition.
Glastech presents the most esthetic crowns
available for pediatric dentistry, which is made
up of artglass. Artglass is a polymer glass, which
provides the natural feel, bond ability associated
with composite but the esthetics and longevity
of porcelain.

FLOW CHART 3.3 Properties of Art glass crowns
Artglass is made up of bifunctional and
new multifunctional methacrylates. The
Artglass matrix has the ability to form three-
dimensional molecular networks with a highly
cross-linked structure. Such highly cross-
linked, amorphous organic polymers are
known in the chemical literature as organic
glasses. The total filler content of Artglass
is only 75 percent (55% microglass and 20%
silica filler) but when the matrix is cured, the
amorphous, highly cross-linked organic glass
A B
FIGURES 3.46A and B Artglass crowns
Different Crowns Used in Pediatric Dentistry 95
forms, which is called polymer glass. The result
is a tough, elastic material. Most Artglass
parameters exceed those of conventional
composites significantly and with tough, elastic
properties, of porcelain as well. Flow chart 3.3
gives information about properties of Art glass
crowns. Figures 3.46A and B show art glass and
cases photos. Figures 3.47 and 3.48 show pre
operative and postoperative images with art
glass crowns.
Availability
Artglass crowns are available in a single shade
with six sizes for the each anterior teeth.
Features
Esthetics is comparable to the natural
dentition
They are durable
No metal-composite interface to fail, crack
or craze
Its wear is similar to enamel, kind to
opposing dentition
The unique filler materials of microglass
and silica are proposed to provide greater
durability and esthetics than strip crowns
96 Crowns in Pediatric Dentistry
FIGURE 3.47 Art glass crowncase-1 (preoperative)
FIGURE 3.48 Art glass crowncase-2 (postoperative)
High inorganic filler, makes Artglass color
stable and plaque resistant.
Matched to the Vita shade system, simplifies
shade selection
Flexural strength over 50 percent higher
than porcelain, less chance of fracture.
Easily adjusted or repaired intraorally
Crowns are crafted exclusively with Artglass
Provides the esthetics and lasting qualities
of porcelain
Offers the ease and bondability of a
composite
Requires minimum chairside work
No impression required
No metal to interfere with patients natural
smile.
Disadvantage
Crown failure is usually due to result of bond
failure.
BIBLIOGRAPHY
1. American Academy of Pediatric Dentistry.
Pediatric Dentistry Reference Manual, vol. 31
(60), 40-46, 2009-10.
2. http://www.pedonaturalcrown.com.
3. http://www.pedotoothdocs.com.
4. Karthik Venkataraghavan, John Chan.
Polycarbonate Crowns for Primary teeth
Revisited Restorative options, Technique and
Case reports , www.kudoscw.com.hk.In.
5. Kopel HM, Batterman SC. The retentive ability
of various cementing agents for polycarbonate
crowns. ASDC J Dent Child. 1976;43(5):333-9.

6. Lee JK. Restoration of primary anterior
teeth: review of the literature. Pediatr Dent.
2002;24(5):506-10.
7. MacLean JK, Champagne CE, Waggoner
WF, Ditmyer MM, Casamassimo P. Clinical
outcomes for primary anterior teeth treated with
preveneered stainless steel crowns. Pediatr Dent.
2007;29(5):377-81.
8. McDonald RE, Avery DR, Dean JA. Dentistry for
the Child and Adolescent, 8th edn. Mosby. 2004.
PREVENEERED STAINLESS STEEL CROWNS
Because of lack of esthetic function of stainless
steel crown, an idea of white facing on stainless
steel crown has developed. In this technique
tooth colored materials are bonded to the
labial surface of the stainless steel crowns.
These crowns come as preveneered stainless
steel crowns. Preveneered stainless steel
crowns (PVSSCs) are stainless steel/nickel
chrome crowns that has an esthetic facing,
mechanically and/or chemically bonded. A
resin or porcelain veneer restoration is a thin
layer of restorative material bonded over the
facial or buccal surface of a tooth. Veneer
restorations are considered conservative in that
minimal, if any, tooth preparation is required.
PVSSC were introduced in the early 1990s. They
were initially developed for anterior teeth, but
later developed for primary molars. Some of
the PVSSC for posterior primary molars on the
market are Nusmile Primary Crowns (Houston
TX), Kinder Krowns (St Louis Park, MN), and
Cheng Crowns (Exton PA).
Preveneered stainless steel crown
(PVSSC) come with inherent advantages and
disadvantages. The most common concern
of these veneered crowns is the retention of
the esthetic facing. The facings can be prone
to fracture and in some cases complete loss. If
these crowns are forced on to a preparation with
a lot of pressure, it may cause the white facing
to break, crack or chip. Over the years since
their introduction the facings have become
more resistant to fracture and loss is less of
Different Crowns Used in Pediatric Dentistry 97
9. Pinkham JR, Casamassimo PS, McTigue DJ,
Fields HW, Nowak AJ Pediatric Dentistry: Infancy
through Adolescence. 4th edn. Philadelphia, PA.
WB Saunders Company; 2005.
10. Steven Schwartz. Full Coverage Aesthetic
Restoration of Anterior Primary Teeth. http://
www.dentalcare.com.
11. www.austinglastech.com.
problem. Repair of the facing is possible but it
is suggested that the crown be replaced with the
facings fracture.
Yucel et al. (2008) conducted a study to
determine the shear bond strength (SBS) dye
penetration (microleakage) and scanning
electron microscope (SEM) evaluation of
preveneered posterior stainless steel crowns
(SSCs) that were repaired using 2 different
materials. They concluded that posterior
stainless steel crowns may be repaired using
either repair material types tested such as
Panavia opaque cement and Tetric Flow or
Monoopaque and Tetric Flow. Ram et al. (2003)
evaluated long-term clinical performance of
esthetic primary molar crowns and compared
them to that of SSC. They concluded that
after 4 years all the esthetic crowns presented
chipping of the facing and consequently a very
poor esthetic appearance. Fracture resistance
investigations showed that the crowns should be
able to resist occlusal forces over short clinical
periods, however, long-term loading and fatigue
failures must be taken into account. The clinical
outcomes for PVSSC are promising. Roberts et
al. (2001) and Champagne et al. (2007) from
their study found excellent parental satisfaction
with prefabricated resin-faced stainless steel
crowns.
The PVSSC has the limited crimpability
of the crowns. They are relatively inflexible as
the resin facing is brittle and tends to fracture
when subjected to heavy forces or crimping.
98 Crowns in Pediatric Dentistry
Hence, care must be taken to have as close fit
as possible in order to eliminate the need for
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 in preveneered crowns. They are
more expensive to purchase than stainless steel
crowns, strip crown forms and polycarbonate
crowns (approximately 18 vs. 6 dollars).
Croll and Helpin (1996) described the
technique for preformed resin veneer stainless
steel crowns for restoration of primary incisors.
A study cast was poured in dental stone. A crown
form that fit the proposed preparation and had
suitable mesiodistal and labiolingual dimension
was selected. Preformed resin veneered
stainless steel crowns were cut to proper length
with straight angle diamond wheel and crimped
in the regions where there was no bonded resin
and the crowns were adapted successfully on
the incisors.
Fuks et al. (1999) conducted a study to
assess the clinical performance of esthetic
crowns and to compare these to conventional
stainless steel crowns (SSC). The crowns were
evaluated clinically and radiographically after
6 months for following parameters; gingival
health, marginal extention, crown adequacy,
proper position or occlusion, proximal contact,
chipping of the facing and cement removal. They
concluded that the esthetic crowns assessed
had several inconveniences, as they resulted
in poor gingival health, are very expensive and
although not measured are bulky and without
natural appearance. Waggoner and Cohen
(1995) concluded that the Whiter Biter veneered
crown is significantly better able to resist a
shearing force on the veneer than the other
crowns tested (Cheng, Kinder and NuSmile
crown). Monika et al. (2008) concluded that the
veneer resistance to fracture for the crimped
crowns was comparable to noncrimped crowns.
The crimped crowns, however, were associated
with greater veneer surface area loss.
Rona et al. (2011) evaluated the success of
posterior NuSmile and Kinder Krown and
determined the level of parental satisfaction
with this treatment option. They concluded
that these crowns combine the durability
of conventional stainless steel crowns with
improved esthetics and are proposed as a
suitable alternative where esthetic demand is
increased. Wickersham et al. (1998) concluded
that the two steam technique (121C (15 psi)
for 20 min and 132C (30 psi) for 8 minute)
tested can be used by clinicians to sterilize
either Kinder Krown or NuSmile preveneered
stainless-steel crowns without any change in
fracture resistance and color stability. Yumikom
et al. (2002) measured colorimetric values of two
different kinds of esthetic stainless steel crowns
and compared with the colorimetric values of
primary anterior teeth in Japanese children.
The colorimetric values of resin composite-
faced stainless steel crowns (Kinder Krown) and
epoxy-coated stainless steel crowns (White Steel
Crown) were measured with a color difference
meter. They concluded that the color difference
between Pedo II crowns and Japanese primary
anterior teeth was relatively high, but the color
of Pedo II might be acceptable for clinical use.
Studies suggests that extent of caries is the
main factor to use anterior veneered SSCs,
where esthetics is a concern.
These veneered crowns can be more difficult
to adapt (due to their limited crimping area)
and are subject to fracture or loss of the facing.
In some cases veneered SSCs possess a major
advantage over conventional SSCs due to their
superior esthetics and high parental satisfaction.
MacLean et al. observed for preveneerd
SCC success as, 1 percent dislodgement and
14 percent fracture rate. No matter which crown,
a certain percentage will fail (<15%). Some are
spontaneous fractures and some are trauma
induced. Failure rate is probably similar to strip
crowns, may be lower, however, is likely higher
than open-faced SSCs. Ram et al. (2003) found
that after 4 years esthetic primary molar crowns
presented chipping of the facing and a poor

esthetic appearance. Failure rate of preveneered
crowns is less than 10 percent. There is no study
to show which type of preveneered crown
is better. However, NuSmile crowns shows
promising results. Coloma et al. evaluated
color changes of preveneered incisor crowns
in different staining solutions. In this in-vitro
study, crowns were soaked in water, cola, grape
juice and coffee for 2 weeks. It was concluded
that none of the crowns were completely stain
resistant. Grape juice and coffee caused the
most staining of veneers however, rubber cup
prophylaxis removed most of the stains on
most of the crowns to return crowns to baseline
color. MacLean et al. (2007) observed clinical
outcomes for primary anterior teeth treated with
preveneered stainless steel crowns. The study
included 46 patients and 226 NuSmile crowns
for period of 12.9 months. It was concluded
that NuSmile crowns are clinically successful
restoration for primary anterior teeth.
Recommendations
Children at high-risk exhibiting anterior
tooth caries and/or molar caries may be
treated to protect the remaining at-risk
tooth surfaces.
Children with extensive decay, large lesions,
or multiple-surface lesions in primary
molars.
For example:
NuSmile primary crown
Cheng crowns
Whiter Biter crown
Dura crown.
Advantages
Esthetically pleasing
Less moisture sensitive
Durable
Less chairside time
Easy to place
Full coronal coverage
Parent satisfaction.
Different Crowns Used in Pediatric Dentistry 99
Disadvantages
Possible loss of esthetic facing
Wide mesiodistally
There is limited dentists choice on the resin
shade
The labial section of the margin cannot be
crimped otherwise the bonded resin can
detach.
Crown forms cannot be sterilized under
heat pressure because heat would destroy
the resin.
Difficult to fit
Chances of fractures
Difficult to repair
Excess tooth reduction has to be done
Occasionally part of veneer may chip off by
putting excusive pressure of crown on to the
tooth
Crimping is limited primarily to lingual
surface
Proper marginal seal is not obtained
Expensive (3 times than SSC)
Few published clinical data available
regarding the durability of the crowns.
General Steps of Preveneered Crown
Placement
Preparation for placement of a PVSSC requires
more additional tooth reduction to allow for
the thickness of the crown due to the esthetic
facing. Due to this pulp therapy can be required
more frequently. Tooth preparation for PVSSC
is similar to that of SSC preparation. But they
require little excess tooth reduction and no
crimping or contouring of crown.
The shape of the PVSSC is not alterable and
in cases in which there is a loss of space, usually
due to caries, the crown cannot be squeezed
mesiodistally. Hence, careful case selection is
necessary to avoid difficulties. Steam technique
of sterilization is suitable and can be used to
successfully sterilize the crowns to minimize
exposure to the stress of sterilization on the
facing.
100 Crowns in Pediatric Dentistry
The first step is to estimate the crown size
needed. This is best done prior to tooth
preparation.
Next step is occlusal reduction. Minimum
of 2 mm of occlusal reduction must be
accomplished. This can be done with a high
speed tapered diamond, football diamond
or with simple straight fissure carbide.
Circumferential reduction should be done
with tapered fissure bur. Care must be
taken to remove enough tooth structure to
allow for the bulk of the crown. Preparation
should be a feather edge and extend slightly
subgingivally.
Upon try-in, the crown should fit passively
with no resistance to the fully seated
position. Snap fit of these crowns should
not be achieved since forcing can produce
micro fractures of the veneer and ultimately
loss of veneer.
Prepare and adjust the tooth rather than
adjusting the crown to fit the tooth.
Occlusion must be checked as a high
restoration would lead to premature fracture
of the facing.
Cementation of crown can be done with a
glass ionomer cement.
BIBLIOGRAPHY
1. Carla Cohen. Pre-Veneered Stainless Steel
Crowns-An aesthetic alternative. 2012.pp.1-6.
www.dentaleconomics.com.
2. Fuks AB, Ram D, Eidelman E. Clinical performance
of esthetic posterior crowns in primary molars: a
pilot study. Ped Dent. 1999;21(7):445-8.
3. Guideline on Pediatric Restorative Dentistry.
REFERENCE MANUAL. Pediatric Dentistry.
2013;34(6):214-21.
4. Monica, Jung-Wei C, Joe OC. Veneer retention
of preveneered primary stainless steel crowns
after crimping. Journal of Dentistry for Children,
2008;4:44-7.
5. Rama D, Fuks AB, Eidelman E. Long-term
clinical performance of esthetic primary molar
crowns. Ped Dent. 2003;25(6):582-4.
6. Robers C, Lee JY, Wright JT. Clinical evaluation
of and parental satisfaction with resin-faced
stainless steel crowns. Ped Dent. 2001;23(1):28-31.
7. Rona L, Anne Oc. A clinical study evaluating
success of 2 commercially available preveneered
primary molar stainless steel crowns. Pediatric
Dentistry. 2011;33(4):300-67.
8. Waggoner WF, Cohen H. Failure strength of four
veneered primary stainless steel crowns. Ped
Dent.1995;17(1):36-40.
9. Wickersham GT, Seale NS, Frysh H. Color change
and fracture resistance of two preveneered
stainless-steel crowns after sterilization. Ped
Dent. 1998;50(5):336-40.
10. Yucil Y, Taskin G, Ozge E, Nihal B. The repair of
preveneered posterior stainless steel crowns. Ped
Dent. 2008;35(7):429-35.
11. Yumikom H, Koichi O, Michal SA. Colorimetric
values of esthetic stainless steel crowns.
Quintessen ce International. 2002;33(7):537-41.
NuSMILE CROWNS
These are stainless steel crowns with the most
natural looking facing. These are anatomically
correct stainless steel crowns, are less technique
sensitive and offer excellent durability and color
stability. These crowns are having facing on
labial surface and metal portion on lingual side
for crimping to achieve better seal. NuSmile
crowns available as anterior and posterior
crowns. MacLean et al. (2007) and Jeanetterr
et al. (2007) concluded that NuSmile anterior
preveneered crowns (Figs 3.49 and 3.50) are
a clinically successful restoration for primary
incisors with early childhood caries.
Advantages
Give most natural looking smile
Eliminates extra steps
Ensures successful results
Autoclavable
Designed for optimum zirconia-cement
retention
Esthetically acceptable
Long lasting
Patientparents satisfaction
Less chairside time
Extremely compatible to natural tooth color
and translucency
 Different Crowns Used in Pediatric Dentistry 101

Will not discolor with age coating. These are widely used, dependable,
Superior performance of composite bond- easy restorative option to traditional
ing to the stainless steel crown. stainless steel and composite strip crowns
(Fig. 3.49).
Disadvantages
NuSmile ZR Crowns
May resulted in poor gingival health
Very expensive Houston, TexasNuSmile pediatric crowns
Bulky has introduced NuSmile ZR. These are perfect
Lacks natural appearance balance of art and science. These are made from
Crimping may cause fracture. zirconia ceramic. Superior esthetic, durability,
easy to place compared to composite restoration
NuSmile Crown is and strip crown.
NuSmile ZR (Fig. 3.50) is a new zirconia
Available in Two Forms
crown that represents a balance of art and
1. NuSmile signature. science for pediatric dentistry. It is made from
2. NuSmile ZR. monolithic zirconia, NuSmile zirconia crowns
are said to be like ceramic steel while mimicking
NuSmile Signature Crowns the anatomical contours of natural primary
teeth to achieve a natural clinical outcome.
They are anatomically correct stainless steel NuSmile ZR launched in US as NuSmile
crowns with a natural looking, tooth color pediatric crowns. Using patent pending and

A B
FIGURES 3.49 A AND B (A) NuSmile anterior primary crowns; (B) labial and lingual view

A B
FIGURES 3.50A AND B NuSmile crownzirconia type
102 Crowns in Pediatric Dentistry
proprietary technology, NuSmile ZR delivers
superior esthetics to meet the demands of even
the most challenging cases. Its high-strength
formula is nine times stronger than dentin and
enamel to provide a superior result to composite
strip crowns. Available in two shades and
numerous sizes, NuSmile ZRs zirconia material
is optimized for translucency and strength.
Queis H et al. (2010) done a study to assess
the use of anterior esthetic stainless steel
crown (AVSSC) among pediatric dentist by
questionnaire survey on 2600 AAPD members.
It was found that NuSmile crown used more
among PVSSC that is 61 percent NuSmile,
28 percent Cheng crown, 35 percent Kinder
krowns. Lee et al. evaluated fracture resistance
of anterior NuSmile crowns in biomaterial
Research Centre in 2004. They found fracture
resistance of NuSmile crown is 9 to 10 of incisal
force for a child 5 to 10 years old.
A B
D E
G H
FIGURES 3.51A to I NuSmile crown placement procedure for incisor
Procedure for placing NuSmile crown
Case selection/precautionary measures
Avoid anterior cross-bite, Class III malocclu-
sion and severe crowding
Select tooth with restorable crown structure
Procedure
Extrapreparation required on lingual, mesial
and distally compared to SSC
Select shorter crown to fit
Select shorter crown for 2 years old child,
and longer for above 2 years old child
To avoid crown fracture do only snap fit
Do not cement crown with noticeable craze
line
Be careful while crimping.
Figures 3.51A to I indicates NuSmile crown
placement procedure for anterior primary
teeth. Figures 3.52 and 3.53 indicate primary
canine and molar NuSmile crown placement.
C
F
I
 Different Crowns Used in Pediatric Dentistry 103

A B
FIGURES 3.52A AND B Canine NuSmile crown

A B
FIGURES 3.53A and B Primary molar NuSmile crown. B. Nusmile posterior crown after cementation
(Courtesy: www.dentaleconomics.com)

BIBLIOGRAPHY 4. Waggoner WF. Restoring primary anterior teeth.

1. Cohen C. Preveneered stainless steel crowns-an
aesthetic alternatiVe. 2012-01-01. http://www.
pdwg-ng.org/materials/anterior%20crowns.pdf
2. Jeanette MJK, Cariann CCE, Willium WF, Marcia
Dm, Paul C. Clinical outcomes for primary
anterior teeth treated with preveneered stainless
steel crowns. Ped Dent. 2007;5:377-81.
3. MacLean JK, Champagne CE, Waggoner
WF, Ditmyer MM, Casamassimo P. clinical
outcomes for primary anterior teeth treated with
preveneered stainless steel crowns. pediatr dent.
2007;29(5):377-81.
Las Vegas, Nevada.
5. www.nusmilecrowns.com.
FLEX WHITE FACED
PEDIATRIC CROWN
Flex white-faced stainless steel pediatric crowns
are made of new material that can be crimped
on facial and lingual, and can also be squeezed
on the mesial and distal to allow for better
adaptation without the fear of compromising
the bond strength. Posterior crowns are
104 Crowns in Pediatric Dentistry
A B
FIGURES 3.54A AND B Flex crowns (anterior and posterior)
TABLE 3.10 Features of flex crown
Sizes 16
Color/Shades White-faced
Quantity 24
Product brief Pediatric crowns
Special features Available in upper right and left
centrals and laterals, sizes 16.
Kit includes 1 of each size
fabricated in the same manner as anterior
flex crown. These posterior flex crowns are
completely covered with especially formulated
highland dental plan (HDP) material. They may
be crimped around the entire crown, flexed
and contoured without compromising the white
materials bond strength Figures 3.54A and B
indicate anterior and posterior flex crowns.
Table 3.10 indicates features of flex crowns.
Manufacturer
Success essential space maintainer laboratory.
Available for incisor and primary molars.
Available as left, right, upper and lower size
1 to 6.
Kit includes 1 of each size = 24 crowns
470-501-24 flex crowns costs for $ 396.
Single crown cost$ 12.50
Features and Benefits
Squeeze-able on the mesial and distal
Crimpable on the facial and lingual
May be trimmed with scissors or green stone
1 mm shorter than standard SSC crowns
Matches natural dentition
Pediatric white shade
Saves chair time
No changes in bond strength after crimping
or squeezing.
Procedure of Crown Placement
Tooth preparation and crown placement is
similar to that of SSC.
BIBLIOGRAPHY
1. http://www.sourceonedental.com/products/
pediatric-flex-crowns-4.
PEDO PEARLS (ALUMINUM
CROWNS WITH FACING)
Pedo pearl crown is a metal crown form similar
to the stainless steel crown but it is completely
coated with tooth colored epoxy paint. The
crowns are made from aluminum instead of

stainless steel because the epoxy coating adapt
better to aluminum. This technology develops
in 1980. Aluminum crown forms are frequently
used as temporary crowns in the permanent
dentition. These aluminum crowns are relatively
soft and this may create problem with long-
term durability. Additionally in areas of heavy
occlusion, the white coating will wear off.
These crowns are constructed of heavy gauge
aluminum and coated with (FDA food grade
powder) an organic enamel that is both flexible
and durable. The color coating will not chip or
peel. They are available as universal anatomical
types which can be used on either side, thus
reduce time and cost for selection. Any crown
cement can be used for their cementation
but glass ionomer and self-curing composites
enhance their performance and durability.These
crowns are easy to cut and crimp which adjusts
to the perfect fit without chipping or peeling.
Durable coating with excellent adhesion and high
performance enamel coating bonds exceptionally
well with the heavy gauge aluminum crowns. If
cosmetic touch-up is ever needed, a light cured
composite may be used. Natural primary tooth
color-provides an attractive smile.
Advantages
Cost: The price of a pedo pearl crown is much
less than the cost of any other esthetical metal
crown on the market. They fit all economic
situations and have an infinite shelf life.
Inventory: The anterior pedo pearl crowns
have universal anatomy. This drastically
reduces inventory and therefore saves the
dentist money and can be used on either side.
Crown coating: The pedo pearl crown
coating will not chip or peel. The dentist can
cut and crimp the crown without damaging
the coating.
Natural look: Pedo pearl crowns are not
bulky and fit easily to the tooth. This avoids
a chicklets in the mouth appearance.
Flexible packaging: Pedo pearl crowns
come in three kits for the dentist; the anterior
Different Crowns Used in Pediatric Dentistry 105
kit, the posterior kit, and the complete arch
kit. Crowns are also sold in refill packages of
three crowns for all of sizes.
Maintenance: Pedo pearl crowns, if
needed, can be touched-up or repaired
easily. A self-cured or dual-cured composite
is recommended.
Easy to cut and crimp, without chipping or
peeling.
Composite can be added.
Disadvantages
They are relatively soft thus creating a
problem for long-term durability.
In areas of heavy occlusion, the white
coating will wear off.
Less durability.
Techniques to Make Pedo
Pearls Cost-effective
Cut, crimp, and fit to the tooth.
Fill the crown with a self-curing composite
of same color as the crown and place on the
tooth.
After composite sets, remove crown, and
trim off excess composite.
Coat the tooth with five air dried layers of
Copalite varnish.
Permanently cement the crown with Docs
best red or white copper cement. The
antimicrobial properties in this clinically
proven cement will protect the tooth for
as long as it is in contact with the tooth
structure.
Company Recommends or company has
recommended few Suggestions for using Pedo
Pearls to Maximize their Performance
Recommend filling them with either self-
cure or dual-cure composite rather than
using a regular crown cement, good results
observed with using Ketac-cem, RelyX
Unicem, and other composites that will
adhere to both tooth and crown. The crown
should be completely filled with the material
106 Crowns in Pediatric Dentistry

to ensure maximum structural integrity of Pedo pearl kit-Anterior-36 number-$ 348,

the crown. posterior kit-36 number-$ 322 (Figs 3.55 A and B).
Both the coating and the aluminum Complete arch kit-72-$ 513.80 each crown
crown will wear on the contact points with costs $ 5.50.
opposing teeth. The parents of patients
should be made aware that this could Anterior Kit (Figs 3.55A and B)
happen. However, with the composite filling Item number: 2001PP
the crown, the tooth will remain protected. 36 maxillary anterior crowns
(The crowns coating and the metal will wear Centrals (sizes 1 to 4)
at the point of contact with the opposing Laterals (sizes 2 to 5)
tooth. The tooth colored composite then will Cuspids (sizes 1 to 4)
blend with the crown. These crowns can be All with universal anatomy.
patched with more composite if needed).
These crowns have been in patients mouths
for more than three years with the facial and
buccal surfaces maintaining their attractive
appearance. To reduce any potential
wear of the coating or metal, placement
with minimal occlusion or if possible no
occlusion is recommended.
Avoid using pedo pearls on patients with
severe malocclusion or heavy bruxism.

Availability of Crowns (Table 3.11)

Complete arch kit contains: 75 maxillary
crowns combined contents of both anterior and
FIGURE 3.55 Pedo Pearls kit box
posterior kits.

TABLE 3.11 Pedo Pearls available sizes

Centrals* Laterals Cuspids

PPC1-Size U1 (6.4 mm)
PPC2-Size U2 (6.8 mm)
PPC3-Size U3 (7.2 mm)
PPC4-Size U4 (7.6 mm)
*Size U1 laterals are not included in kits
1st Molars
PP1ML3-Size L3 (7.4 mm)
PP1ML4-Size L4 (7.8 mm)
PP1ML5-Size L5 (8.2 mm)
PP1MR3-Size R3 (7.4 mm)
PP1MR4-Size R4 (7.8 mm)
PP1MR5-Size R5 (8.2 mm)
PPL1-Size U1 (4.6 mm) PPCU1-Size U1 (6.2 mm)
PPL2-Size U2 (5.0 mm) PPCU2-Size U2 (6.8 mm)
PPL3-Size U3 (5.4 mm) PPCU3-Size U3 (7.2 mm)
PPL4-Size U4 (5.8 mm) PPCU4-Size U4 (7.8 mm)
PPL5-Size U5 (6.0 mm)
2nd Molars
PP2ML3-Size L3 (9.4 mm)
PP2ML4-Size L4 (9.8 mm)
PP2ML5-Size L5 (10.2 mm)
PP2MR3-Size R3 (9.4 mm)
PP2MR4-Size R4 (9.8 mm)
PP2MR5-Size R5 (10.2 mm)
 Different Crowns Used in Pediatric Dentistry 107

A B C
FIGURES 3.56A TO C Pedo Pearls (anterior and posterior); A. Anteriro pedo pearl crown;
B. Posterior pedo pearls crowns

Posterior Kit
Item number: 2002PP
36 maxillary posterior crowns
1st molars (sizes 3 to 5)
2nd molars (sizes 3 to 5)
Both left and right anatomies.

Complete Arch Kit A

Figure 3.56A shows images of anterior pedo
pearls. Figure 3.56B indicates posterior pedo
pearl crowns.

BIBLIOGRAPHY
1. Anterior crowns used in children. Morenike
Ukpong. Dep of Paediatric Dentistry, Obafemi
AwolowoUniversity, Ile-Ife, Nigeria.
2. http://pedopearls.net/products.htm
3. Waggoner WF. Restoring primary anterior teeth.
Ped Dent. 2002;24(5):511-6.
CHENG CROWN
Cheng Crowns from Peter Cheng Orthodontic
Laboratories, Inc. made its public debut in 1987
to provide an esthetic alternative to stainless
steel crown. The crowns are named after the
president of the company 'Mr Peter Cheng'.
These are stainless steel pediatric anterior
crowns faced with a high quality composite,
mesh-based with a light cured composite. There
are no long-term clinical trials to assess the
durability of these crowns.
B
FIGURES 3.57A AND B (A) Cheng crown;
(B) Zirconia checng crown
Baker et al. (1996) conducted a study to
ascertain the amount of shering force necessary
to fracture, dislodge or deform the esthetic
veneer facing of four commercially available
veneered primary incisor SSCs,(Cheng crown,
Whiter Biter crown, Kinder Krown and NuSmile
crowns. A force was applied at the incisal edge
of the veneer at 148 degrees until the veneer
either fractured, dislodged or deformed.
From the study it was concluded that Cheng
Crowns were better which was stastically
significant compared to Whiter Biter crowns.
Figure 3.57 shows anterior Chengs crowns, and
108 Crowns in Pediatric Dentistry

Master primary anterior starter kit: 96 crowns,

centrals and laterals, left and right, sizes 1 to 6 (2
of each), sizes 2 to 5 (5 of each)$1500.00.
Basic primary anterior starter kit: 16 crowns,
centrals and laterals, left and right, sizes 2 to 5
(one of each size) $280.00.

Posterior Crowns
Second primary molar crowns starter kit: 12
crowns, upper and lower, left and right, sizes
FIGURE 3.58 Cemented Cheng crown on primary 3 to 5 (one of each size) $400.00.
upper anteriors Primary molar crowns for left and right
upper and lower area available as sizes 2 to 7.
Figure 3.59 indicates Cheng crowns for primary
Figure 3.58 shows cemented primary maxillary anterior and posterior teeth.
anterior cheng crown.
Benefits/Advantages
Commercial Company
Single visit procedure
Peter Cheng Orthodontic Laboratories, Inc. Less technique sensitive procedure-having
pure resin facing on SSC
Availability Natural-looking
They can undergo heat sterilization without
It is available for the right and left central and significant effect on their bond strength and
lateral as well as cuspids with 6 sizes. color.
They are economic
Crown Sizes Stain resistant
Manufacturer claims it to be durable, color
Anterior Crowns stable, and matches pedoshades
Centrals laterals and cuspids: Sizes (1 to 6) left It does not cause wear of opposing teeth
and right Less patient discomfort.

FIGURE 3.59 Cheng crowns for anterior and posterior teeth

 Different Crowns Used in Pediatric Dentistry 109

Disadvantages PEDO COMPU-CROWN

Fracture of veneers during crimping
They are expensive.
Fitting Instructions to Determine the
Correct Size of Cheng Crown to use
Tooth preparation and crown placement is
similar to SSC
First check the crown size on patient with a
plain 3M Unitek stainless steel crown
When a correct size crown has been found,
replace with corresponding size Cheng
Crown to fit the patient
This will deter unnecessary loading and
eliminate the need for sterilization.
BIBLIOGRAPHY
1. Baker LH, Moon P, Mourino AP. Retention of
esthetic veneers on primary stainless steel crowns.
ASDC J of Dent for Children. 1996;63(3):185-9.
WHITER BITER CROWN
It is preveneered SSC. A dental crown that
includes a stainless steel shell sized to cover
a tooth portion of a patient and a polymeric
coating including a polyester/epoxy hybrid
composition. The coating can be a very thin
layer that will remain adhered to the crown
during the manipulation. Coating does not
peel or chip under normal use and mastication.
These crowns are no longer used now. Roberts et
al. (2001) found 32 percent of the crown loosing
some of the esthetic white facing.
These are stainless steel pediatric anterior
crowns faced with a high quality composite,
mesh-based with a light cured composite
crowns. These crowns are color stable, plaque
resistant, match natural pediatric shades.
Available as white colored crowns (Fig. 3.60).
Available as Sizes
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).
Sizes upper left CI-F1-F6, upper right CI-
E1-E6, upper left lateral-G1-6, upper right
lateral-D1-6, upper cuspid-U1-6, lower
cuspid-L1-6.
Benefits
Does not wears opposing dentition
Easy to adjust
Color stable
Feels natural
Shade matches to natural dentition.

Manufacturer
Whiter Biter Inc.

BIBLIOGRAPHY
1. Roberts C, Lee JY, awright JT. Clinical evaluation
of parental satisfaction with resin faced stainless
steel crowns. Pediatr Dent. 2001;23(1):28-31. FIGURE 3.60 Pedo anterior Compu-crown
110 Crowns in Pediatric Dentistry
BIBLIOGRAPHY
1. http://www.appliancetherapy.com/Global_Center
/se/tools_product.aspx? pid=468andcategory=
HIGH DENSITY POLYETHYLENE
VENEERED CROWNS FOR
CHILDREN
These are an esthetic preformed crown for
children. The veneer is comprised of high
density polyethylene, which is thermoformed
over a preformed stainless steel crown to obtain
the desired appearance (Fig. 3.61).
Properties and Uses
High elastic limit.
Greater flexural strength.
Ability to withstand great shearing force
when mechanically bonded to a preformed
crown.
Natural appearance of a vital tooth.
High density polyethylene (HDPE) once
engaged by the mechanical retention,
does not separate unless the mechanical
retention is broken from its weld points.
High density polyethylene (HDPE), is
compatible with the base metal.
Chipping, crazing, and splitting not occurs
at human mouth temperatures.
FIGURE 3.61 High density polyethylene (HDPE) crown
The high density polyethylene veneer has
greater bond strength than other facing
material currently used on childrens
esthetic stainless steel crowns.
DURA CROWNS
Dura crowns are pediatric white-faced crowns.
These crowns can be crimped labially and
lingually, can be easily trimmed with crown
scissors, easily festooned and has got a full-
knife edge margin. If the facing chips or breaks
after placement, esthetic repair is difficult and
usually requires replacement of the crown.
Study has shown that these crowns with veneer
facings were significantly more retentive than
the non-veneered ones when cement and
crimping were combined. Table 3.12 indicates
features of Dura crowns.
Availability
Available as upper, right and left for centrals and
laterals with 6 sizes for each tooth Dura crowns
are available as anterior and posterior crowns
(Figs 3.62A and B).
TABLE 3.12 Features of dura crown
Shades available White-faced crowns
Crown sizes Available for the upper, right
and left centrals and laterals
with 6 sizes for each tooth
Anterior/Posterior Anterior and posterior (Figs
available 3.62 A and B)
Quantity Starter kit includes: 24 crowns
Centrals, left and right sizes
2,3,4 (2 of each)
Laterals, left and right sizes
3,4,5 (2 of each)
Adjustable Facial and lingual may be
crimped
Facial and lingual surface
easily trimmed with crowned
scissors
Easily festooned
Product number 470300

A B
FIGURES 3.62A AND B Anterior and posterior dura crown
Advantages
Facial and lingual margins can be crimped
Easily trimmed with crown scissors
Easily festooned
Full knife edge margin capabilities
These preveneered crowns are esthetic
and can be placed with poor moisture or
hemorrhage control.
ALL CERAMIC/PORCELAIN/ZIRCONIA JACKET CROWN
Today, all-ceramic/zirconia crowns offer
numerous advantages over traditional ceramic
fused to metal crowns. They contain no metal. In
addition to their undeniable esthetic qualities,
all-ceramic crowns have biological and
functional characteristics that ensure a much
longer lifetime. A porcelain jacket crown is
usually the ultimate restoration for a root canal
treated permanent incisor or fractured incisor.
In vital teeth, porcelain jacket crown restoration
should be delayed until the child is at least
18 years old, by which time pulp horns will have
receded and reduction can be done safely.
It has limited use in children before age of
18 years because:
It is expensive
Can fracture easily
Different Crowns Used in Pediatric Dentistry 111
Commercial manufacturers: Mayclin dental
studios, Space maintainer laboratory.
BIBLIOGRAPHY
1. www.pattersondental.com
Use is limited to the permanent dentition
since primary teeth has prominent pulp
horns and thin enamel and dentin.
Several studies showed that commercial
zirconia crowns can be used for primary teeth
with esthetic and functional qualities. Flow
chart 3.4 shows examples of commercial
pediatric zirconia crowns.
ZIRKIZ CROWNS
Zirconia crowns are new, unique, esthetic
pediatric dental crowns available on the market
today. Zirconia crown has created a new
approach to restoring the natural appearance
of a childs smile with a minimally invasive
technique. Zirconia crowns have superior
112 Crowns in Pediatric Dentistry
FLOW CHART 3.4 Zirconia pediatric crowns
esthetics and natural appearance with short
chair time. Zirconia is a crystalline dioxide
of zirconium. In particular, yttrium-oxide-
partially-stabilized zirconia (3Y-TZP) has
mechanical properties very similar to those
of metals, yet it has a color similar to that of
teeth. Its mechanical properties, which are
similar to those of stainless steel, allow for
a substantial reduction in core thickness.
Cyclical stresses are also well-tolerated by this
extremely biocompatible material. Ready-made
primary zirconia crowns are now available for
restoration of primary incisors including those
that are directly bonded onto the tooth (Figs
3.63A to C).
Manufacturer
ZIRKIZ, HASS Corp; Korea.
Clinical Technique in
Crown Placement
Crown selection: Select the appropriate
crown size prior to tooth preparation
Occlusal check
Anesthetizing the tooth
Isolation with rubber dam
A B
FIGURES 3.63A TO C ZIRKIZ crown
Tooth preparation: After clinical and
radiographic evaluations; caries should be
removed with stainless steel round burs
under local anesthesia. Reduce incisal
surface for 1 mm. Reduce 0.5 to 1.0 mm
on facial and lingual surface. The facial
and lingual preparation should meet
in a thin incisal edge corresponding
to the planned incisal edge of the final
restoration. Occlusion should be checked
for adequate clearance from opposing
dentition. Interproximal reduction can be
carried out and it involves creating parallel
mesial and distal walls extending from
1 to 2 mm subgingivally to the incisal edge
of the preparation. After tooth preparation
zirconia crown should fit passively.
Zirconia crowns are ceramic and cannot
be trimmed with scissors like a traditional
stainless steel crown (SSC). Glass ionomer
cement should be used to fill the crown
completely, to eliminate any internal
voids. Light-cure resin cement is also
recommended for cementation of ZIRKIZ
crowns.
No clinical studies concerning anterior
crowns on primary teeth were identified
that met all or even a majority of criteria,
indicating that there was little scientific
support. Based on the limited number of
short-term in vivo studies, zirconia appears
to be suitable for the fabrication of single
crown. More recently, a new type of ceramic
material, based on zirconium dioxide,
has been developed. Yttria-stabilized
tetragonal. Zirconia polycrystal, Y-TZP, has a
C
 Different Crowns Used in Pediatric Dentistry 113

unique ability to resist crack propagation by

being able to transform from one crystalline
phase to another and the resultant volume
increase stops the crack and prevents it from
propagating. This material has the potential
to be used for larger restorations and in the
molar area.

FIGURE 3.64 EZ-crown box

BIBLIOGRAPHY
1. Serhat Karaca, Gizem Ozbay, Betul Kargul.
Primary Zirconia Crown Restorations for Children
with Early Childhood Caries. Acta stomatol Croat.
2013;47(1):64-71.

EZ-CROWN
EZ-pedos pioneering achievement is revolu-
tionizing the appearance of pediatric dental
FIGURE 3.65 EZ-crowns
crowns and renewing happy and healthy smile
on pediatric patients. EZ-pedo company first
developed monolithic zirconia pedo crowns as
anterior and posterior crowns (Figs 3.64 and
3.65). EZ-pedo is the first company worldwide
to offer fully white, prefabricated, ceramic
crowns especially designed for children.
These crowns are made of solid zirconia, a
biocompatible material. It is composed entirely
of one solid tooth-colored material; they look
extremely esthetic, both from the front view
and on the inside of the mouth. Each crown
is glazed with a hint of natural color, making
them very smooth, shiny and impermeable to
staining. They are exceptionally strong, and FIGURE 3.66 John P Hansen and Jeffrey P Fisher
their unsurpassed esthetics allows them to
blend in seamlessly with surrounding natural esthetically pleasing crowns like those typically
teeth. Tooth preparation for EZ-crown is similar custom-crafted for adults. Hansen said the
to that of SSC. crowns placed on his sons teeth were bulky,
did not match in color and presented a smile
Development of EZ-Crown that showed metal at the gumline. Then Hansen
thought of making esthetic crowns for children.
In 2004, Hansens 3-year-old son, John Paul, fell Local dentists Jeff Fisher and John Hansen did
in the bathtub and seriously injured four of his years of research with local dentists before
front teeth. Hansen sent his son to a pediatric founding all ceramic crown; EZ-Pedo Inc., in
dentist to have the boys smile reconstructed Loomis, California, in 2010. Jeffrey P Fisher
and was stunned to learn that there were no and John P Hansen (Fig. 3.66), of Sacramento,
114 Crowns in Pediatric Dentistry

Califormia, started EZ-Pedo Inc. in 2010, and

today their relatively small manufacturing site
in Loomis, California, produces thousands of
ceramic dental crowns for children.
EZ-crowns got clearance from US Food and
Drug Administration and clearance from FDA
for use in 2009. The company states that, it had
about 10 percent of the US nations pediatric
crown market.

Manufacturing of EZ-Crowns
The zirconia crowns are first milled in an exotic-
looking, custom-made machine (Fig. 3.67).
About 35 to 50 crowns placed in a disc can be
shaped simultaneously. From there, the crowns
will be smoothed, polished, put through a
FIGURE 3.67 Manufacturing of EZ-crown
staining solution, hardened in a 4,000-degree
chamber, microblasted and glazed. Every
crown gets a label, which can be scratched
off by a dentist before placement (Fig. 3.65).
There are 96 shapes and up to six sizes for each
specific tooth. Zirlock technology has been
implemented within the EZ-pedo crown to
improve retention (Fig. 3.68).

Advantages
Zirlock technology increases the internal
surface area for long lasting clinical success
Provides glazed facial surface for better
esthetic
Ultra low wear
Avoids chances of chipping, or fractured
facing
Biocompatible
FIGURE 3.68 Zirlock inside crown for retention
Provides better strength
Autoclavable.
Crown selection
Procedure for EZ-Crown Placement Tooth preparation-on lingual , incisal, facial,
proximal surfaces
for Primary Teeth
Checking for crown fit and crown cementa-
The tooth preparation and crown placement for tion.
anterior and posterior teeth are similar to that Figure 3.69 diagrammatically explains the
for SSC, i.e. procedure of EZ-crown placement.
 Different Crowns Used in Pediatric Dentistry 115

For Primary Anterior Tooth

FIGURE 3.69 Anterior EZ-crown adaptation

BIBLIOGRAPHY from the lifelike composite reveal a natural

1. http://www.ezpedo.com.
2. Waggoner WF. Restoring Primary Anterior Teeth.
Las Vegas, Nevada.
3. www.sunnysmileskids.com.
KINDER KROWNS
Kinder Krowns offer the most natural shades
and contour available for the pediatric patient.
Kinder Krowns are made available to market
from past 23 years. The great depth and vitality
smile without the bulky Chiclet look of other
restorations. Kinder Krowns are available as
anterior and posterior crowns (Figs 3.70 to 3.72).
The original Kinder Krowns were introduced
to the market in 1989. Much like logo, Kinder
Krowns have evolved over the years, staying
current with new materials and processes. The
introduction of IncisaLock in 1997 revolutionized
esthetic pediatric dentistry, combining the
already unmatched esthetics with state-of-the-
art strength. Kinder Krowns are designed with
116 Crowns in Pediatric Dentistry
FIGURE 3.70 Kinder Krowns (anterior and posterior)
FIGURE 3.71 Different Kinder Krowns for anterior
and posterior teeth
FIGURE 3.72 Kinder Krown for primary molars
IncisaLockthe optimal union of state-of-
the-art bonding procedures and mechanical
retention (Fig. 3.73). By adding mechanical
retention and more composite, Kinder Krowns
become strong without sacrificing form or
function.
Proprietary polishing system to provided
with a microscopically scratch free surface
which minimizes wear on the opposing. Dr
John Burgess, examined the wear of enamel in
both polished and glazed in the comparison to a
commonly used porcelain and nature enamel. In
his study, the polished zirconia demonstrated 8
times less wear on enamel than glazed zirconia.
Durable and lifelike zirconia posterior
crowns are rated at 1234 MPa (178,976 psi)
and are designed to be consistent with other
restorative options to make the transition
FIGURE 3.73 IncisaLock for mechanical retention

to Kinder Krowns easier. These crowns are
consistent, easy to use, beautiful restorations
every time. Kinder Krowns delivers a
superior solution. The teeth in pedo bridges
are constructed completely out of composite,
making them more durable than acrylic teeth
and they are repairable at chairside. They match
any bioform or vita shade for shade selection.
Custom pedo bridges are even made available
from company. Kinder krowns can also be
used in fixed bridge farication for replacing
lost primary incisors (Fig. 3.74). Figures 3.75 to
3.77 show clinical image of cemented Kinder
anterior Krown cases.
Features
Esthetics pedo 1 and 2 shade.
Durability: Crowns are faced with a special
bonding agent and a durable, high-flexural
strength dental composite.
Ease of seating: Anterior crowns are a time-
saving, less technique sensitive alternative
to other esthetic crowns, open-faced
window crowns and strip crowns. To better
FIGURE 3.74 Kinder Krown for bridge
FIGURE 3.75 Kinder Krown case-1
Different Crowns Used in Pediatric Dentistry 117
meet seating needs and preference, Kinder
Krowns are available in regular or 1 mm
short length.
Benefits
Autoclavable, easy to identify outer label
Precisely manufactured to ensure proper fit
Rough external surface for easy handling
No contamination provides better retention.
Available as (Fig. 3.71)
Available for anterior and posterior primary
teeth (Tables 3.13 and 3.14)
Sizes D/E 1-6, in Pedo 1 or Pedo 2
Pedo 2 shade is the most natural shade,
while Pedo 1 shade is for those cases when
the bleached white shade is wanted.
Anterior Crown (Fig. 3.70)
Anterior crowns are available as:
Left and right
Universal and contoured types
Lengthregular and short
Shade-Pedo 1 and Pedo 2.
Posterior Crowns (Fig. 3.70)
Shade: Available in two shades, Pedo 1 and
Pedo 2. Pedo 1 is a lighter bleached shade
and Pedo 2 is a natural A1/B1 blended shade
which will matches natural dentition.
Midsizes: Midsizes designed for first and
second primary molars to alleviate seating
issues in situations for placing crowns back
118 Crowns in Pediatric Dentistry

FIGURE 3.76 Kinder Krown case-2

FIGURE 3.77 Kinder Krown case-3

TABLE 3.13 Kinder krown posterior kit TABLE 3.14 Anterior Kinder krown kit

Posterior master kit (128 crowns) Anterior master kit

Size B I S L A I T K Size Centrals Laterals Cuspids
1.3 1 1 1 1 1 1 1 1 L R L R
2 2 2 2 2 2 2 2 2 1 2 2
2.5 1 1 1 1 1 1 1 1 2 4 2
3 2 2 2 2 2 2 2 2
3 4 4
3.3 1 1 1 1 1 1 1 1
4 4 4
4 2 2 2 2 2 2 2 2
4.5 1 1 1 1 1 1 1 1 5 2 4
5 2 2 2 2 2 2 2 2 6 2 2
5.5 1 1 1 1 1 1 1 1
6 1 1 1 1 1 1 1 1
6.3 1 1 1 1 1 1 1 1
Product Description
7 1 1 1 1 1 1 1 1
36 Crowns
to back or significant space loss. The mid- Centrals 2, 3, 4 (4 of each)
sized crowns retain their buccal-lingual Laterals 3, 4, 5 (4 of each)
width, while the mesial-distal has been Centrals 1, 5, 6 (2 of each)
reduced to allow for easier placement. Laterals 1, 2, 6 (2 of each).
 Different Crowns Used in Pediatric Dentistry 119

128 Crowns CAM technology thus eliminating the second

Sizes: 1.5, 2.5, 2.5, 4.5, 5.5, 6, 6.5, 7 (1 of each B,
I, S, L, A, J, T, K).
Sizes: 2, 3, 4, 5 (2 of each B, I, S, L, A, J, T, K).
Manufacturer
Orthodontic technologies-Kinder Krown.
BIBLIOGRAPHY
1. http://www.kinderkrowns.com.
CEREC CROWNS-ALL CERAMIC
CROWNSCAD/CAM SYSTEM
CAD/CAM restorations in most cases found to be
clinically superior to man-made restorations in
terms of fit and accuracy. Chairside economical
restoration of esthetic ceramics (CEREC)
crowns are all ceramic crowns prepared by
CAD/CAM technology. CEREC crowns are
made up of enamel-like feldspar and glass
ceramics, cementable lithium disilicate and
high-performance polymers. These materials
are tooth-conserving, biocompatible, clinically
proven and long lasting. CEREC crowns can
vary in price from 380 up to 700+ per tooth.
Conventional method of ceramic crown
placement takes two visit; during first visit
involves the tooth preparation, impression
making and delivery of temporary and cast used
for laboratory crown fabrication. On second
appointment, the temporary is removed and the
durable crown is placed on tooth.
appointment and the temporary crown.
Tooth preparation procedure is similar to
that for SSC crowns (Fig. 3.79). A digital image
of the prepared tooth will be taken using a
special camera. This image is then converted
into a 3D computerized model of tooth (Figs
3.80 and 3.81), which is used as a guide to
design new restoration (Fig. 3.80). This newly
designed tooth data is sent to an onsite milling
machine, which fabricates new tooth from a
high-quality ceramic block. The milling process
can take anywhere from as little as 6 minutes to
30 minutes depending on the exact technology
and complexity of the tooth (Fig. 3.82). The
latest CEREC MCXL machine can mill a crown
in as little as 6 minutes. The ceramic blocks
come in a wide variety of shades and colors,
and tooth will be selected to match surrounding
teeth (Fig. 3.78). Once the crown or veneer has
been milled, the it may characterize it and stain
it to match surrounding teeth, before either
FIGURE 3.78 Ceramic blocks for crown preparation

CEREC One-visit Crown Placement

Procedure (CAD/CAM Method)
CEREC crown uses CAD/CAM (Computer-
Assisted Design/Computer-Assisted Manufac-
ture) technology for crown fabrication and all
the procedure of crown placement will be done
in single visit. The crown is made by a CAD/ FIGURE 3.79 Prepared tooth for crown
120 Crowns in Pediatric Dentistry

r/
s.i
n s
is a
FIGURES 3.80A AND B A. Cerec crown-CAD CAM procedure; B. Computer generation cerec model

e r
.p
iv p
/: /
tt p
h
FIGURE 3.81 Computer generated tooth model

FIGURE 3.82 Milling of prepared CEREC crown

 Different Crowns Used in Pediatric Dentistry 121

surfaces. The American Dental Association has

three classes of Crown and Bridge Alloys. They
are as follows:
High noble alloys: High noble ceramo-
metal alloys are usually the color of
white gold (silver color). The white gold
appearance is due to the addition of metals

/
such as platinum and palladium. These

.i r
metals improve the strength and rigidity
of the prosthesis, making it better suited to

s
support the cosmetic layer of porcelain that
is applied to its outer surface.

s
FIGURE 3.83 Final prepared crown and after Noble alloys: Noble alloys have little
cementation

n
or no gold. The gold was replaced by
other precious metals such as silver and

is a
polishing it or glazing it in a furnace. Figure 3.83 palladium. This originally resulted in an
shows clinical photographs of final adapted alloy that was significantly cheaper than
primary crown. high noble alloys. Recently, the price of

r
palladium has escalated and the price

e
Advantages of CEREC Crown differential is no longer significant.
Base metal alloys: Base metal alloys contain

.p
Single visit appointment for crown pre- no noble metals. Consequently, they are
peration and placement significantly cheaper in price than high

iv p
Time saving noble and noble alloys. Over the years these
No need of temporary crown alloys have proven to function well as dental

/: /
Esthetically acceptable prostheses. They are generally an alloy of
Durable. nickel and chrome, which results in their
being very rigid. This can be a significant

p
Disadvantages advantage in the fabrication of long span

t
bridges. The microscopic surface roughness

t
They look greater on posterior teeth, but do of this alloy after it has been etched with acid

h
not have the esthetic quality of laboratary
made crowns.
Unique CEREC technology requires extra
training on the part of the dentist.
BIBLIOGRAPHY
1. http://www.sirona.com/en/products/digital-
dentistry/cerec-chairside-solutions/?tab=241.
CERAMO BASE METAL CROWN
Ceramo-metal alloys are those used to create
the substructure of a bridge or crown which
will have cosmetic porcelain fused to its visible
makes it the alloy of choice in the fabrication
of Bonded (Maryland) Bridges.
Since, these alloys usually contain nickel,
it is preferable to avoid using this alloy for
patients with a nickel allergy. Allergies are not
a problem with high noble and noble alloys.
Noble and base metal alloys evolved for dental
use during the period after the regulation of
gold prices was lifted and the price of gold
escalated dramatically. Recently the price
of metals used in noble alloys has escalated;
consequently, there is only minimal difference
in price between high noble and noble alloys.
Base metal alloys still remain substantially less
expensive.
122 Crowns in Pediatric Dentistry
BIOLOGIC CROWN
In 1964 Chosak and Eildeman published the
first case report on reattachment of a fractured
incisor fragment, which was endodontically
treated by cast post and core. Fragment
reattachment using natural teeth is a technique
known as biologic restoration. The biologic
restoration meets the esthetic and standard
of natural teeth. Biological restorations are an
alternative treatment for primary teeth. Biologic
restorations are made from tooth fragments
selected from natural extracted teeth or from
a bank of tooth tissues and bonded with dual-
cure composite cement to prepared teeth.
Biologic post and core are made from natural
extracted teeth radicular dentin. Presence of
similar structure might enable to absorb and
dissipate stress. Biologic restoration using
p
natural post and core can provide natural
.
esthetics. Biologic post and core, crown and
veneer restoration are comparatively cheaper to
iv p
other esthetic materials. These restorations are
performed easily without need of sophisticated
/: /
equipment.
There are 2 methods of restoring tooth with
biologic restorations
tt p
1. Autogenous biological restoration-done
when fractured fragment is available in
satisfactory condition. Tooth fragment
h
obtained from the patient itself.
2. From donated extracted teeth. Tooth
fragment obtained from donor or tooth
bank. The biologic tooth can be obtained
from tooth bank where it is stored and
sterilized after thorough scaling and removal
of soft tissue, periodontal remnants, pupal
tissue from root canals. Teeth were kept at
40C in Hanks balanced salt solution with
donor identification like tooth parameters
such as dimensions, color, shape, size and
age. The combination of tooth fragment,
adhesive and restorative material provides
good functional and esthetic result. In case
of severe loss of tooth structure, intra canal
post of natural tooth can be done. Use of
biologic restoration as a post and core has
shown promising results. It is cost-effective
/
alternative.
.i r
LIMITATIONS
s
Lack of patient acceptance
s
Lack of availability of teeth with similar
n
structure and color
Fabrication of post needs technically sound
is a
system
Adaptation of natural post to root canal may
be less accuratedifficulties in getting crack
r
free structure
e
Longevity affected by many factors like,
design, length, diameter of root, ferrule
effect cementation, quality and quantity of
remaining tooth structure.
A biochemical property of biologic rest-
orations needs to be determined for long term
clinical use.
TOOTH PREPARATION
Prepare the coronal portion of tooth to receive
biologic crown (Fig. 3.84D).
FABRICATION OF
CROWN PORTION
Select the biologic crown by measuring
mesiodistal dimension. Autoclave the se-
lected biologic tooth at 121 C for 15 minute.
Coronal portion of selected sterilized tooth
should be cut-off at CEJ and biologic crown
prepared by hollowing both internally
as well on the cervical portion, leaving
approximately 1 mm dentin with enamel
(Figs 3.84A and B).
 Different Crowns Used in Pediatric Dentistry 123

Procedure for biologic tooth adaptation

A B C D

E F G H
FIGURES 3.84A to H Biologic restoration procedure. (A) Crown sectioning; (B) Biologic crown; (C) Tooth
preparation to receive biologic crown; (D and E) Trying biologic crown; (F) Radiographic evaluation of crown
adaptation; (G) Crown cementation; (H) Final radiographic evaluation of cemented biologic crown
[Source: Babaji P, et al. J Clin Diag Research. 2014;8(11):ZD11-13]

Place biological crown on prepared tooth
and adjust biologic crown to fit on the
prepared tooth (Figs 3.84C to E).
RADIOGRAPHIC EVALUATION
Confirm the fitting of biologic crown on
prepared tooth with radiograph (Fig. 3.84F).
Benefits
CEMENTATION OF BIOLOGIC
CROWN
The coronal portion of tooth to be fitted
and inner surface of biologic crown are
conditioned with 37 percent phosphoric
acid, followed by application of adhesive
and light curing. Later apply dual cure resin
cement and position the biologic crown
in place until polymerization completes.
Clinically, evaluate the crown after
cementation (Fig. 3.84G).
Take radiograph after cementation again to
confirm proper adaptation and cementation
(Fig. 3.84H).
Retention comfortable
Esthetic as natural tooth
Natural enamel has physiologic wear
Superficial smoothness and cervical
adaptation compatible with those of the
surrounding teeth.
Avoids long clinical appointments
Avoids laborios technique
124 Crowns in Pediatric Dentistry
Shorter treatment time
No lab procedure
Inexpensive
Less chance of galvanic corrosion
Preservation of natural tooth structure.
Disadvantages
The difficulty in obtaining teeth with
the required coronal dimensions and
characteristics.
Problems in matching fragment color with
tooth remnant color.
Having fragments from other peoples teeth
in their mouth is not a pleasant idea for
some patients.
Possible chances of crown fracture.
Degradation between the margins of the
fragment and the tooth surface.
Ribeirao Preto(2007) conducted a study to
evaluate biological restorations as a treatment
option for primary molars with extensive coronal
destruction. He found that biologic restoration
as possible alternative. Barcelos et al. (2003)
reported the cases of two young children aged
4 and 5 years, in whom biological restorations
using tooth fragments were placed in primary
molars with severely damaged crowns due to
extensive carious lesions. After radiographic
and clinical evaluation, tooth fragments
obtained from extracted teeth in stock were
autoclaved adjusted to the prepared cavity and
bonded to the remaining tooth structure with
either adhesive system or dual-cure resin-based
cement over a calcium hydroxide layer and a
glass ionomer cement base.
It is important that the parents are
informed that the tooth fragments used for
biological restoration are previously submitted
to a sterilization process that completely
eliminates any risk of contamination or disease
transmission to the child receiving the fragment.
BIBLIOGRAPHY
1. Barcelos R, Neves AA, Primo L, de Biological
restorations as an alternative treatment for
primary posterior teeth. J Clin Pediatr Dent.
Summer. 2003;27(4):305-10.
2. Ribeiro Preto. Biological restorations as a
treatment option for primary molars with
extensive coronal destruction-report of two
cases. Braz Dent J. 2007;18(3):1-4.
3. Wadhwani KK, Hasija M, Meena B, Waghwa
D, Yadav R. Biological restorations: option
of reincarnation for severely destructed
teeth. Europian Journal of General Dentistry.
2013;2(1):62-6.
4. Babaji P, Khanna P, Shankar S, Chaurasia VR,
Masamatti VS. Biologic Restoration: a treatment
option for reconstruction of anterior teeth. JCDR.
2014;11:11-13.
 C hapter 4
Restoration of Destructed Primary
Teeth with Post and Core
Prashant Babaji, Vishwajit Rampratap Chaurasia, Ranjithkumar Rampratap Chaurasia,
Vinaykumar S Masamatti, Vikram Shetty K

MANAGEMENT OF SEVERELY Early loss of primary anterior teeth may result

DAMAGED TEETH
Extensive destruction of primary maxillary
anterior teeth occurs commonly in early
childhood caries. Endodontic treatment is
necessary in such teeth due to chances of pulpal
involvement prior to restoring with crown. In
extreme cases of early childhood caries, there is
total loss of the crown structure. Until recently,
the only treatment option in management of
early childhood caries has been extraction of
the affected primary anterior tooth, which has
severe coronal destruction.
Early childhood caries (ECC) (Fig 4.1A and
B) involves the upper anterior teeth early in
life and by the time child visits the dentist most
of the coronal structure would have been lost.
in reduced masticatory function, loss of vertical
dimension, development of parafunctional
habits (tongue thrusting, speech problems),
space loss, esthetic-functional problems such
as malocclusion and psychologic problems. It is
necessary to restore the integrity of the primary
dentition until its exfoliation and eruption of the
permanent teeth.
Esthetic management of severely damaged
anterior teeth is challenging to dentist not
only because of the available materials and
techniques, but also from the point of view of
pediatric patients, who are usually among the
youngest and least manageable group. Anterior
primary teeth, when grossly decayed, there will
be lack of sufficient crown structure to build
crown. The procedure of restoration of severely
damaged teeth should provide-durable,

A B
FIGURES 4.1A AND B Early childhood caries (ECC)

04.indd 125 30-01-2015 11:29:07

 126 Crowns in Pediatric Dentistry

retentive, patient satisfaction, comfort and Factors in Selection of

esthetic restoration. Usually esthetic restoration Dowel Core and Post
can be done with use of GIC (Glass Ionomer
Cement), resin, composite and esthetic crowns, Thickness of tooth structure around the
but in case of severely damaged teeth with canal
insufficient sound crown structure, there is Bulk and height of remaining supragingival
need of post and core to build up tooth structure tooth structure
for future crown restoration. The techniques The diameter of the tooth
such as pin retained core; post and core are Root morphology
necessary to provide dentin substance to crown. Bone support
Post is needed to retain core and core is needed Tooths role in the final restoration
to retain crown. If the crown can be successfully Nature of resorption of primary tooth root.
retained on the remaining tooth structure, then
there is no need of core, similarly if core can Types of Posts (Figs 4.5 and 4.6)
be retained on the remaining tooth structure,
post is not needed. Successful bonding of post Based on Materials Used
to root canal area minimizes wedging effect of
the post within the root canal. Bonding of fiber Metallicstainless steel, nickel-chromium,
post with composite in root canal requires less cast metal
dentin removal to accommodate a shorter and Non metallic:
thinner post. Post and core technique is difficult Resin/fiber-composite post, fiber
in primary anteriors as compared to permanent post, glass fiber reinforced composite
since primary teeth are resorbable. resin posts (GFRP), polyethylene fiber
Posts for primary incisors are placed in post, ribbon or tapes used along with
cervical third of the root canal space to avoid composite resin
interference with the process of permanent Ceramic
tooth eruption. The post should extend Carbon post
3 to 4 mm below gingival margin to retain the Natural-biologic tooth.
post material. The width of the space should
not be larger than 1/3rd of the diameter of Based on Type of Post Space Design
the root. Due to physiological resorption that
occurs in primary dentition, there is need for Mushroom, tapered, onion shape.
short retentive posts, instead of long post and
core used in adult dentition. The technique to Based on Post Design
construct post and core for children should be
simple, less time consuming, long lasting and Threaded, non-threaded, alpha, omega shape,
appropriate with remaining tooth structure. half omega-shaped.
The dentist should consider almost 3 mm of
the existing root for obtaining enough retention Based on Fabrication
and resistance of the severely damaged tooth.
A combined technique of glass fiber post and Direct method-metallic, fiber post (ready
composite, with final morphology achieved made posts)
with strip crowns, was found to be a simple and Indirect method-resin composite post,
efficient technique with excellent esthetics. custom made post

04.indd 126 30-01-2015 11:29:07

 Restoration of Destructed Primary Teeth with Post and Core
POST SPACE DESIGNS
Mushroom-shaped Post Space
It is introduced by Ludd PL et al. (1990). This
technique is quite unpractical approach since
the anatomical features of the root of the incisor
is tapered in apical direction. It needs removal
of deep dentin to create heal of mushroom at the
wall of root which may leads to stress induction
and weakening of root. Inadequate fabrication
of mushroom head may result inadequate
retention of the crown (Fig. 4.2A).
Taper-shaped Post Space
It is developed by Grosso. It is less retentive
since it is short; generate stress concentration
in the root around them as occlusal forces are
transmitted outward in a wedge-like fashion
(Fig. 4.2B).
Onion-shaped Post Space
It is developed to minimize stress generating
effect from the occlusal force and derives
optimal retentive features with maximum
strength to support restoration. Round bur is
used to create onion-shaped bottom of post
A B
FIGURES 4.2A TO C Post space shapes (Mushroom, tapered and onion shapes)
04.indd 127
127
space. This technique is relatively simple and
less time consuming (Fig. 4.2C).
DIFFERENT TYPES OF POSTS
Biologic Post and Core
These are natural teeth obtained from patient or
from tooth bank. If it is not acceptable by many
patients. It is easy to perform and economical.
It has some of the disadvantages like the need
of tooth bank, donor and recipient acceptance
and cross-infection make this treatment option
largely impractical.
Fiber Post
These posts are available commercially in
various diameter and length. Appropriate size
of post can be selected based on root canal
morphology of tooth to be restored for crown.
Polyethylene Fiber Post
Polyethylene fibers are preferred as they improve
the impact strength, modulus of elasticity and
flexural strength and are almost invisible in
the resinous matrix, in contrast to glass fibers,
which fail to stick to the resinous matrix, carbon
C
30-01-2015 11:29:07
 128 Crowns in Pediatric Dentistry
and Kevlar fibers, which interferes with the
esthetics.
Use of a resin based composite reinforced
with polyethylene fibers is preferred and
the technique is referred to as the short post
technique, which requires root canal treatment
and a short composite post (Fig. 4.3).
Glass Fiber Reinforced
Composite Resin Posts (GFRP) (Fig. 4.7)
It is a new generation of fiber posts composed
of densely packed silanated E glass fibers in
a light curing gel matrix. The fibers are 710
micrometer in diameter. It is available in
different configurations, including braided,
woven and longitudinal. Its flexural strength
(1280 MPa) is closer to that of dentin and can
decrease in incidence of root fracture. It has
greater ease of handling, can be used in high
FIGURE 4.3 Polyethylene fiber post
(Source: Jain, et al. JISPPD. 2011;4(29):32732)
A B
FIGURES 4.4A TO C Composite post
04.indd 128
stress bearing areas and can bonded to any type
of composites when compared to other posts
these are invisible in resinous matrix. Hence,
they are most suitable for esthetic need.
Composite Posts (Figs 4.4A to C)
Composite posts are fabricated directly in post
space. Composite resin posts provide satisfactory
esthetics but retention owing to polymerization
contraction could be a risk.
Metallic Post
These posts are made up of stainless steel
wire of 22 gauze/0.7 mm. It is very rigid, but
esthetic quality is compromised. The post
part of wire can be smooth or retention can be
increased with serration. Various designs are
made on coronal part of wire to build core part
to receive crown. Even though conventional
prefabricated metal posts is a fast, low-cost
and simple technique, but is not accepted in
pediatric dentistry because of the potential
interference with physiologic root resorption.
Orthodontic wire designs such as omega, alpha
and half omega can be designed (Figs 4.5 and
4.6). The use of stainless steel orthodontic wire
as an intracanal post has also been a simple and
fast technique for reconstruction of primary
anterior teeth. However, in most cases, the wire
adaptation to the internal walls of the canal is
not adequate, leading to detachment of the wire
and restoration or radicular fracture, especially
in cases with excessive masticatory forces.
C
30-01-2015 11:29:07
 Restoration of Destructed Primary Teeth with Post and Core 129

Omega-shaped Post Advantages

Omega-shaped post is fabricated using 22 gauze Posts helps to build-up core

stainless steel wire with omega shape of wire Severely decayed teeth can be restored to
towards coronal direction to hold composite maintain esthetic need.
core for crown.
Advantages of Fiber Posts
Half Omega-shaped Post Over Metal Posts
These posts are fabricated with 22 gauze stainless Translucency
steel wire with post length of 3 to 4 mm into root Resin composite crown reinforcement
portion (radicular)and remaining part (coronal) Ease for manipulation.
of 2 to 3 mm above the gingival margin. Coronal
part of post is serrated for better retention of Disadvantages of Posts
composite core.
in Primary Teeth
Alpha Type Difficulties in extension of post length due
to short length of primary roots and primary
Threaded post: These post have threads in teeth roots can resorb over a period of time.
the radicular part of post for better retention. Due to short post length retention is
Presence of threads increases stress con compromised
centration. Chances of loss of crown due to trauma.
Nickel-chromium cast posts with macroreten-
tive elements: The nickel-chromium cast posts, Procedure/Fabrication of Post and
which have been utilized are not only expensive
Core for Crown (Figs 4.6 and 4.8)
and require an additional laboratory stage. They
also could pose problems during the natural Local anesthesia
tooth exfoliation. Rubber dam isolation
Preformed and cast metal posts: It can be Removal of remaining soft dental structure
threaded or no threaded (Fig. 4.5). with round steel bur

FIGURE 4.5 Different types of posts (from left to FIGURE 4.6 Different posts in primary anteriors
right, Fiber, threaded, half omega and omega-shaped) (Fiber, reverse screw, half omega posts)

04.indd 129 30-01-2015 11:29:08

 130 Crowns in Pediatric Dentistry
Partially remove (34 mm) root canal filling
material 1 week after obturation. Root
canal preparation can be done followed by
irrigation and canal drying
Selected post (fiber or stainless steel wire
of # 22 gauze) tried into prepared canal and
post should be cut at the length 3 to 4 mm
above the gingival margin of the tooth.
The prepared canal should be etched with
37 percent phosphoric acid gel for 15 to 30
second and rinsed with water spray and air
dried.
Apply thin layer of liquid bonding agent
inside canal space and cure it with light cure
unit.
Pack dual cure composite resin into
prepared post chamber using incremental
layering technique (0.5 mm depth each
layer). After first layer of composite was
compressed into canal, the prepared
stainless steel wire should be inserted in
the middle of canal space. The viscous mix
consistency of composite resin in the canal
helps to stabilize stainless steel wire. Light
cure the composite. Compress further layers
of composite material with plugger and
light cure it. Condense additional layer of
composite around the stainless steel wire
that penetrated above the root in order
to fabricate the core portion. In this way,
prepare core portion and polymerize resin
with light curing.
Confirm the post position and extent with
radiograph
Then proceed for core build, crown
preparation and adaptation. Select appro
FIGURE 4.7 Post and core case-1
04.indd 130
priate celluloid strip crown forms, trim the
crown border to fit individual tooth and
create small vent in crown form and fill it
with selected shade composite material
and position it over selected tooth, remove
excess around margin and light cure the
resin all around.
Once composite sets remove the crown
form with explorer and do light finishing or
polishing of crown, if necessary.
Check for occlusion and correct, if necessary.
Modification in Post and
Core Fabrications (Figs 4.7 and 4.8)
Flowable composite material with fiber
posts: If you use flowable composite resin,
insert it in canal space along with selected
post and light cure. Then build up the
coronal part (core) with flowable composite
3 to 4 mm above gingival margin to receive
crown
Reverse metal post-insertion technique
(RMPT): In this technique prefabricated
metal screw post is inserted in root canal
space in reverse position. Before insertion of
post in the canal semi bevel the sharp angles
of post to prevent stress concentration. Post
can be cemented in the canal with zinc
phosphate cement. At least 3 mm of metal
post left coronally for core build up with
flowable composite resin.
Composite post: Composite posts are
fabricated directly by direct method in
post space using composite in incremental
layering technique (Figs 4.4A to C).
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 Restoration of Destructed Primary Teeth with Post and Core 131

FIGURE 4.8 Post and core case-2 (Fiber, reverse metal and omega-shaped posts)

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 132 Crowns in Pediatric Dentistry
A B
FIGURES 4.9 A AND B Fiber reinforced composite crown with artificial tooth (pontic)
[Source: Jain, et al. JISPPD. 2011;4(29):32732)]
Artificial teeth bonded to adjacent natural
tooth: It involves bonding composite
artificial teeth directly to the adjacent
natural teeth reinforced with high density
fibers, without metal frameworks. It can be
done by passing a fiber splint from center
of the strip crown and crown along with
splint loaded with composite cured outside
the oral cavity then splinted to adjacent
teeth with composite. This technique has
advantage of little tissue removal and low
laboratory cost (Figs 4.9A and B).
Casellato et al. (2002) from their in vitro
study reported that, threaded posts (FKG, FKG
Dentaire), Ni-Cr posts with macroretentions,
alpha-shaped orthodontic wire, biologic posts
and root canal filled with resin composite
showed similar fracture resistance values when
submitted to shear bond strength tests. Parrela
et al. (1995) reported that threaded posts and
alpha-shaped orthodontic wire showed an
average success rate of 76.47 percent after 10
months of clinical and radiographic follow-up
in primary anteriors. Missing primary teeth can
04.indd 132
be replaced using fiber reinforced strips (Figs
4.9A and B).
BIBLIOGRAPHY
1. Eshghin A, Esfahan RK, Khoroushi M. A simple
method for reconstruction of severely damaged
primary anterior teeth. Dental Research Journal.
2011;8(4):2215.
2. Jain M, Singla S, Bhushan BAK, Kumar S, Bhushan
A. Esthetic rehabilitation of anterior primary
teeth using polyethylene fiber with two different
approaches Journal of Indian Society of Pedodontics
and Preventive Dentistry. 2011;4(29):32732.
3. Leena Verma, Sidhi Passi. Glass Fibre-Reinforced
Composite Post and Core Used in Decayed
Primary Anterior Teeth: A Case Report. Case
Reports in Dentistry Volume 2011, Article ID
864254, 4 pages, 2011.doi:10.1155/2011/864254.
4. Mendes FM, De Benedetto MS, Del Conte
Zardetto, CG, Wanderley MT, Correa MSN. Resin
composite restoration in primary anterior teeth
using short-post technique and strip crowns:
A case report. Quintesence International.
2004;35(9):68992.
30-01-2015 11:29:08
 C hapter 5
Management of Complications
Prashant Babaji, Senthilnathan S, Nitin Sharma, Suresh BS

CROWN TILT evaluating with explorer before crown

placement. Knife edge finish line is advised in
Destruction of complete lingual or buccal wall primary than shoulder. Ledge can be removed
by caries or over instrumentation may result by extending the slice subgingivally.
in crown tilting towards deficient side. This
may result in finished crown tilting towards the POOR MARGINS (FIG. 3.26C)
deficient side. Placement of an amalgam alloy
or GIC restoration prior to crowning provides When the crown is poorly adapted, its marginal
support to prevent crown tilt. The clinical integrity is reduced. Recurrent caries may
significance of crown tilting is minimal unless occur around open margins. Chances of plaque
it occurs on young permanent molars, where retention and subsequently gingivitis increases
supraeruption of the opponent tooth may occur. with marginal discrepancy. The tolerant
potential of young periodontal ligament tissues
INTERPROXIMAL LEDGE is very high to an extreme amount of ZnPO4
cement pushed into lingual sulcus during the
A ledge (Fig. 5.1) will be produced instead cementation procedure. The foreign body was
of a shoulder free interproximal slice, if
the angulation of the tapered fissure bur is
incorrect. Failure to remove this ledge will
result in difficulty in seating the crown. When
the adjacent tooth is partially erupted, and the
contact is poorly established, the interproximal
slice is difficult to prepare. To clear the contact
area, extensive subgingival tooth reduction
is required which may result in formation of a
ledge or damaging the erupting tooth. In such a
case, it may be advised to delay crowning until
contact areas are properly established.
Ledge can be avoided by extending the
slice subgingivally by holding the thin tapered
bur parallel to long axis of tooth and carefully FIGURE 5.1 Proximal ledge formation

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 134 Crowns in Pediatric Dentistry
incorporated without any signs of gingivitis
and discomfort to the patient. According to
Henderson (1973), a patient with poor oral
hygiene exhibits a high plaque and debris
index, accompanied by an increase in marginal
gingivitis. To minimize gingival problems, it is as
important to stress oral hygiene in a patient with
preformed stainless steel crown.
Harrison indicates that the finish line of
the full veneer crown should be at the crest of
the gingival tissue rather than beneath it, to
prevent the constant irritation that results in
varying degrees of inflammation. Since primary
teeth are short occluso-cervically, the cervical
border of the stainless steel crown must often
be carried subgingivally to acquire sufficient
mechanical retention. Henderson reported that
inflammation of the gingiva might be due to
irritation from the material per se, overhanging
margins, rough surfaces, retained bacterial
plaque, or a combination of these factors. He
concluded that gingival inflammation adjacent
to restorations is due to bacterial plaque rather
than to mechanical irritation. To minimize
mechanical irritation, it is suggested that the
operator pay close attention to the criteria listed
under Evaluation of the crown. These criteria
referred to the contour, the cervical adaptation,
the sulcular depth, and the length of the crown.
The patient should be taught about proper oral
hygiene and the importance of continued oral
health should be stressed.
The studies of Goto (1970) and Henderson
(1973) indicated that there may be inflammation
of the gingival tissues surrounding stainless
steel crowns. In children, ages two to nine years,
gingivitis was associated with 23.6 percent of
all crowns with good marginal adaptation and
the most (33%) associated with those crowns
exhibiting poorly adapted margins. The authors
proposed that uncleanliness of the area, perhaps
due to the ill-fitting margins, accounted for the
higher percentage of gingivitis in the latter group.
Myers (1975) stated that enhanced Plaque
accumulation accounting for the association
05.indd 134
between gingivitis and stainless steel crowns.
Henderson, after examining children ages four
to thirteen years, concluded that no matter how
accurately the preformed stainless steel crown
was trimmed, adapted, and polished some
inflammation was always observed because of
the differences in form and contour between
the tooth and crown.
The results of the study by Durr et al.
(1982) indicated that the majority of stainless
steel crowns placed by undergraduate dental
students were clinically functional and
acceptable. However, most of the crowns had
one or more observable defects, ninety-five
crowns in forty-four patients were judged non-
ideal. Errors in crown crimping were the most
common, with defects in crown length, contour,
position, polish, contact, and cementation
following in order of decreasing frequency.
Only six crowns in six patients were judged
ideal.
In the retrospective study by Fuks et al.
(1983), the gingival health around the per
manent successors of crowned primary molars
was not different from that of the rest of the
mouth. This would suggest that even, if gingivitis
was present around the crown of primary
teeth it was resolved with the exfoliation and
subsequent eruption of the permanent teeth.
This conclusion should not be misinterpreted as
a justification for ill-fitting and poorly contoured
preformed crowns.
OVER EXTENSION
OF THE CROWN
Over extension of crown (Fig. 3.26B) can be
identified with gingival blanching, which can
leads to loss of periodontal attachment and
periodontal problems due to food lodgment.
This can be corrected by identifying the
adequate (1 mm) gingival extension of the
crown margin, scratching the line, trimming the
excess and crimping followed by polishing.
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 Management of Complications 135

INGESTION/INHALATION alimentary tract within 5 to 10 days. Parents

OF CROWN should be advised for constant check until
its passage through stool. Advise abdominal
Accidental ingestion of crown can occur due to X-ray, if crown not found in chest or in stool.
uncooperative behavior of child or negligence Immediate emergency management (Flow
from dentist. chart 5.1) can be advised in case of airway
Possible methods to prevent ingestion of obstruction. Flow chart 5.2 indicates CPR
crown are: method for children.
Rubber dam for isolation till crown
cementation. It prevents accidental swallo
FLOW CHART 5.1 Emergency management after
wing or aspiration of a crown.
airway obstruction
Throat pack with gauze piece.
Floss attachment by means of impression
compound on the occlusal surface of the
crown is the preferred practice by some
clinicians.

Management
Immediately after ingestion of crown check
for its location in mouth.
Attempt to removal of ingested crown can
be made by holding the child upside down
as soon as possible.
Advice posteroanterior (PA) radiograph of
chest to check the presence/location of crown
(Fig. 5.2). If crown is not found in radio
graph, then assume its passage through

FIGURE 5.2 Chest X-ray showing inhaled crown

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 136 Crowns in Pediatric Dentistry
FLOW CHART 5.2 CPR method for children
OBSTRUCTED AIRWAY
IN CHILDREN
Perform the following steps when basic
procedures have proved ineffective:
Heimlich Maneuver (Fig. 5.3)
Knee at childs feet if child is on the floor, or
stand at childs feet if child is on a table.
Place the heel of one hand against the childs
abdomen in the midline, slightly above the
navel and well below the tip of the sigmoid
process.
Place the second hand directly on top of the
first hand.
Press into the abdomen with 6 to 10 thrusts.
05.indd 136
Foreign Body Check (Figs 5.4A to F)
Keep the childs face up.
Use the tongue-jaw lift to open the mouth.
Look into the mouth and with the finger
sweep or the Magill intubation forceps,
remove the foreign body, if it is visible.
Attempt to Ventilate
Open the airway, using the head tilt-chin lift
technique (Figs 5.5A and B).
Attempt to ventilate.
If unsuccessful. Repeat the preceding steps
until successful.
Consider a surgical cricothyrotomy (Figs
5.6A and B) to establish airway in children
older than 3 years.
30-01-2015 17:22:25

FIGURE 5.3 Heimlich maneuver in children
Because of its frequently sudden and critical
nature, acute obstruction of the airway must be
recognized and managed as quickly as possible.
For this reason an immediate diagnosis of
complete or partial airway obstruction must
be made and treatment initiated as quickly
as possible. During dental treatment, there
are greater chances that objects may fall into
the posterior portion of the oral cavity and
subsequently into the pharynx. All dental office
personnel must become familiar with proper
management of acute upper airway obstruction.
In most cases, the object causing the acute
airway obstruction is lodged firmly in the airway
where it can neither be seen nor felt through the
mouth without the use of special equipment,
such as a laryngoscope or a pair of Magills
intubation forceps (Fig. 5.7), items that are not
normally available. The doctor therefore must
05.indd 137
Management of Complications 137
be able to recognize the problem instantly and
act rapidly to dislodge the object.
Several manual, noninvasive procedures are
available for use in acute airway on obstruction.
The technique is as follows:
Back Blows
Manual thrust
Chest thrust
Finger sweep.
If the crown is in bronchi or lung,
medical consultation will probably result in
attempt toremove it by bronchoscopy. The
presence of cough reflex in the conscious
child will reduce the chances of inhalation
and ingestion of the crown is more likely.
Ingestion is of less consequence, as the
30-01-2015 17:22:25
 138 Crowns in Pediatric Dentistry

A B

C D

E F

FIGURES 5.4A TO F Foreign body check in children mouth

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 Management of Complications 139

A B

FIGURES 5.5A AND B Head tilt-chin lift technique

A B

FIGURES 5.6A AND B Cricothyrotomy procedure

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 140 Crowns in Pediatric Dentistry

FIGURE 5.7 Laryngoscopy

crown will usually pass uneventfully through BIBLIOGRAPHY

the alimentary tract within 5 to 10 days. But it 1. Stanley F Malamed. Medical emergency in
should be diagnosed by absence of the crown the dental office, 6th edition. Mosby Elsevier
on a chest radiograph. Publication, 2012.

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 C hapter 6
Tables and Charts
Prashant Babaji

TABLE 6.1 Comparison between pedo crowns

Crown Manufacturers Phone Starter Individual Additional Disadvantages
number kit crown information
NuSmile Orthodontic 1800- 16 crowns Anterior Available in Expensive
Technologies 3465133 $ 260.00 $17.98 different length Bulky
Posterior with resin facing Not crimped
$34.50 on SSC crown.
Crimp only on
lingual surface
Has Zirlock
technology
Autoclavable
Stain resistant
New Space 1800- 24 crowns Anterior Lab-enhanced Cannot be
Millennium Maintainers 4233270 (ant) $ 9.95 composite resin crimped
crown Laboratory $ 290.00 Posterior crown form
12 crowns $ 12.95
(Post)
$ 169.50
Cheng Peter Cheng 1800- 16 crowns Anterior Are preveneered Veneering
crowns Orthodontic 2886784 $ 280.00 $19.00 SSC with can fracture
Laboratory Posterior composite during
$35.00 facing. One crimping
length, one
shade resin
facing on an SSC.
Crimp only on
lingual surface

Contd...

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 142 Crowns in Pediatric Dentistry

Contd...

Crown Manufacturers Phone Starter Individual Additional Disadvantages

number kit crown information
Dura Space 1800- 24 crowns Anterior May be crimped
crown Maintainers 4233270 $ 396.00 $16.50 on labial and
Laboratory lingual, flexible
facing
attached to SSC
Pedo Jacket Space 1800- 96 crowns Ant/post 5 Copolymer Less durable
Maintainers 4233270 (ant) for $12.50 crown form one
Laboratory $ 219.00 shade
24 first Crack and
molars stain proof
$ 64.50
Pedo Perls Ant/post Has universal Not crimpable
Ant-36 anatomy. Relatively soft
crown $348 Made up of Less durable
heavy gauze
Post-36- aluminum
$322 crown with
72-$513.8 epoxy paint
coverage
Cost effective
SSC 3M ESPE 48 crowns Ant/Post Not technique Unesthetic
Uniteck primary Primary/ sensitive
Permanent Good
adaptability
Can be
trimmed,
crimped,
contoured
Flex crown Space 24 sizes, Anter-R Coverage of
Maintainers $396, and L HDP material
Laboratory single- can be crimped
$12.5 and contoured,
squeezable
Pedo Ant-R, L Are SSC with
compu composite
facing
Not wear
opposing
teeth

Contd...

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 Tables and Charts 143

Contd...

Crown Manufacturers Phone Starter Individual Additional Disadvantages

number kit crown information
EZ crown Zir-lock  eeds excess
n
technology for tooth reduction
retention
High strength
Not wears
opposing
teeth
Kinder Mayclin Dental 1800- 16 crowns Anterior Different Excess tooth
Krown Studios 5227883 $ 259.00 $17.95 lengths reduction
available 2
shades
resin facing
on an
SSC crimp
only on lingual
surface
Aluminum Pearson Dental 60 bicuspid- Easy to adjust Low strength
crown gold Supplies $35 Unesthetic
anodized 3M, Uniteck Single-
crown $1.9
Strip Space 1800- 96 crowns Ant/Post 5 Seamless  re technique
A
Crown Maintainers 4233270 (ant) for $11.00 plastic crown sensitive
Laboratory $ 210.00 form without
48 first long cervical
molars collars other
$ 116.00 strip crowns
forms (3M) are
48 second also available
molars through other
$ 116.00 major dental
suppliers
Fractured
one can be
repaired
Product Name Manufacturer
NuSmile crowns (NSC) NuSmile Primary Crowns. 5524 Cornish, Houston, Texas 77007-4304,USA
Kinder krowns (KK) Mayclin Dental Studio, 2629 Louisiana Ave S, St Louis Park, MN 55426,USA
Pedo pearls crowns (PP) Pedo Pearls, 6111 FM 1960 West Suite 215 Houston, TX 77069, USA
manufacturers

06.indd 143 30-01-2015 11:36:09

 144

06.indd 144
TABLE 6.2 Comparison of full coverage restoration to primary anterior

Technique Strip crown SSC Open faced crowns Prefabricated Ceramic/ Polycarbonate Biologic
veneered SSC Zirconia crown crown crown
Esthetics Very good Poor Good but some metal Good Very good Average Very good
initially, may portion appears
discolor over a gingivally
period of time
Durability Retention Very good. Good like SSC but Good but facing good Poor Average
Crowns in Pediatric Dentistry

depends on Crimped and facing may be can break

remaining cemented crowns dislodged occasionally
amount of tooth are very retentive
structure and
acid etching.
Can dislodge
upon traumatic
injury
Time Requires Fastest crown to Requires longest time Time consuming Faster crown Time consuming Comparable
consump- more time place for placement due to compared to placement
tion for isolation, two steps procedures SSC
acid etching, Crown placement
placement and Composite
finishing placement
Selection When esthetic Severely Severely decayed Esthetic is When esthetic is Temporary When natural
criteria is prim decayed teeth teeth prime concern prime concern restoration preservation
consideration Little concern Need for durability Difficult esthetic
Adequate for esthetic Active accident to control Cost
tooth structure Difficult to prone child hemorrhage consideration
Moisture and control gingival Severe bruxism Acceptance
hemorrhage hemorrhage of biologic
control and moisture tooth
Uncooperative fragment
patient for fine
preparation

Contd...

30-01-2015 11:36:09
06.indd 145
Contd...

Technique Strip crown SSC Open faced Prefabricated Ceramic/ Polycarbonate Biologic crown
crowns veneered SSC Zirconia crown crown
Crimping, Trimmed with Can be crimped, Can be crimped Cannot be Not possible Can be trimmed, Crimping,
contouring, scissors trimmed and trimmed trimmed or crimped, contouring not
trimming crimped contoured possible,
trimming can be
done
Types Anterior and Untrimmed, All ceramic SSC Anterior and Anterior
posterior uncontoured with ceramic posterior
Pretrimmed facing
Recontoured
For anterior
and posterior
Manufacturers 3M ESPE 3M ESPE 3M ESPE
Disadvantages Technique Unesthetic Time Difficult to Can not Temporary Patient
sensitive consuming crimp, and trimmed or crown acceptance not
Needs trim crimped Strength no up there
moisture Difficult Needs to mark Availability
control to repair if more tooth No study
fractured reduction to check
Expensive durability and
strength
Advantages Esthetic Not technique Esthetic Easy to place  ery good in
V Economical Economical
Repaired easily sensitive Not technique esthetic Easy to adapt  Easy to
if fractured Can be done sensitive perform
minimal tooth
structure
Tables and Charts
145

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 146 Crowns in Pediatric Dentistry

CROWN ORDER FORMS

Form 1: 3M SSC, Primary (molar, anterior), Permanent (molar, bicuspid), Unitek.

FIGURE 6.1 SSC order form

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 Tables and Charts 147

Form 2: Crown order form for iso-crown for (molar, bicuspid), Gold anodized (molar/bicuspid
crown), Polycarbonate crown, Strip crown.

FIGURE 6.2 Order from for preformed crowns

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 148 Crowns in Pediatric Dentistry

FIGURES 6.3 3M stainless steel crowns order form

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 Tables and Charts 149

FIGURES 6.4 3M Unitek stainless steel crown order form

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 150 Crowns in Pediatric Dentistry

FIGURES 6.5 3M iso-form crowns order form

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 Tables and Charts 151

FIGURES 6.6 3M gold anodized crowns order form

06.indd 151 30-01-2015 11:36:12

 152 Crowns in Pediatric Dentistry

FIGURES 6.7 Strip crown order form

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 Index
Page numbers followed by t refer to table and f refer to figure

A shell crown 21, 75, 83

Abrasion 27 fabrication of 83f
Acrylic resin 51 Computer generated tooth model 120f
Allergic reaction 5 Copper, zinc and silicophosphate cement 18
Aluminum crown 70f Cricothyrotomy procedure 139f
adaptation 71t Crolls technique 58
Anesthesia 38, 63 Cross-bite correction 28
Art glass crown 95f, 96f Crowns
Aseptic technique 5 acrylic jacket 22
adaptation 10f, 43, 49, 73, 91
adjustment 87
B aluminum 70
Biologic restoration procedure 123f and loop space maintainer 60, 28f
Bruxism 28, 87 anterior 108, 117
art glass 21, 85, 94, 95
C biologic 21, 122
Canine NuSmile crown 103f care for 5
Caries 26 cementation 51, 16
extensive 62 procedure 51
Caulks adhesive 75 ceramic 21
Cementoenamel juction 30 classification of 21
Ceramic blocks 119f coating 105
Ceramo basemetal crown 21 composite 23, 75
CEREC crown 21, 119, 121 composition of 23
CEREC one-visit crown placement procedure 119 contouring 45
Cheng crown 21, 99, 107 crimping 45
Clamp in rubber dam, bow of 15 cutting scissor 10f
Complete arch kit 107 dura 21, 99, 110
Composite 88 festooning and adaptation of 47
insertion of 73 finishing 47
kit 9f fit 48
post 128, 128f, 130 flex 21
resin 51 glastech 94

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 154 Crowns in Pediatric Dentistry
grabber instrument 93
height of 38
high density polyethylene 110
inhalation of 62
ion 25
loose 5
marginal adaptation of 49
morphology 59
nickel-based 23, 31
nickel-chromium 25, 34
NuSmile 21, 99-101
over amalgam restoration 30
over extension of 62, 134
pediatric 2, 7, 103
pedo jacket 21, 85, 93
PedoNatural 21, 85, 90
placement 7, 80
procedure of 78, 104
technique of 89
polycarbonate 85, 85t
portion, fabrication of 122
posterior 108, 117
pretrimmed 32
resin 75
retention 49
scissors 9
selection 8, 35, 36, 78, 87, 112
and adaptation of 64
method of 37
sizes 60, 108
stainless steel 67
sterilization of 52
strip 21, 77
tilt 61, 133
tin-based 23, 34t
ZIRKIZ 21, 111
Curved scissor 10f
D Mandibular molar tooth 55
Deep proximal caries 57f
Dental dams, traditional 11
Dental floss 12f
E Multiple crown placement 56f
Early childhood caries 125f
Index_Prashant Babaji.indd 154
F
Festooning scissor 10f
Fiber posts over metal posts 129
Finishing 48, 73
Flex crowns 104f
G
Gingival contour 46
Gingival finish lines 6f
Gingival health 6
Glass fiber reinforced composite resin posts 128
Glass ionomer 51
cement 19, 29, 91, 126
crown 21, 84
H
Head tilt-chin lift technique 139f
Heimlich maneuver 136, 137f
High density polyethylene crown 21, 110
Howe pliers 9
Hybrid acrylic fill material 91
Hypoplastic defects 27
I
Incisors and molars 2f
Isolation procedure 10
J
Johnsons ball and socket contouring pliers 9
K
Kinder krown kit 118t
Kudos crown 21, 85, 88, 89f
L
Laryngoscopy 140f
M
Metal crowns, anatomical 37
Methyl methacrylates 88
Molars
permanent 34
primary 34
Mushroom-shaped post space 127
2/3/2015 12:51:37 PM
 Index 155

N S
Natural tooth, adjacent 132 Sensitivity 6
Nusmile anterior primary crowns 101f Silicophosphate cement 19
Nusmile crown 101f Split dam method 16f, 79
placement procedure for incisor 102f Stainless steel crown 2, 21, 23, 26, 31, 33t, 41f, 43f,
54, 74, 97
O adjacent 54
classification of 31
Omega-shaped post 127, 129 for permanent teeth 66
placement, modifications of 53
P restoration 51
Pedo jacket crown 94f traditional 112
Pedo pearls 21, 104, 107f Stainless steel refill box 37f
kit box 106f Straight crown cut scissor 10f
Pedonatural crown placement 92f Strip crown 83f
Polishing 48, 73 order form 152f
Polycarbonate crown 21, 85, 86, 86f, 92f placement procedure 81f
Polycarboxylate cement 19
Polyethylene fiber post 128f T
Post and core fabrications, modification in 130 Threaded post 129
Post space design, type of 126 Tooth
Post, types of 126, 129f isolation, individual 15, 79
Primary molar NuSmile crown 103f preparation 73, 80, 91, 112, 122
Primary teeth, importance of 4, 5 reduction of 39
Proximal ledge formation 133f restoration, fractured 28
Pulp therapy 26 Troutmans preparation 47
Punching sheet, method of 13f
U
R Ultra-thin polycarbonate crown form 91
Resin cement 17, 20
Resin modified glass ionomer 17, 51
V
Restoration, temporary 62 Vinyl ethyl methacrylates 88
Restoring primary teeth, importance of 4
Reverse metal post-insertion technique 130 W
Rubber dam 11 Wedging 39
apparatus 11 Wipe excess cement 60
application 10
clamps 11, 13 Z
forceps 11, 13 Zinc oxide eugenol 17f, 51
frame 11, 12, 12f cement 17, 18, 70
isolation 129 Zinc phosphate 17, 17f, 18, 20, 51
napkin 12f, 15 cement 18
placement 15, 79 Zinc polycorboxylate cement 17
punch 11, 12, 13f Zinc silicophosphate 51
sheet 11, 12f Zirconia pediatric crowns 112
template 11, 12 ZIRKIZ crown 112f

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