Full Coverage Aesthetic Restoration of

Anterior Primary Teeth

Steven Schwartz, DDS
Continuing Education Units: 3 hours

Online Course: www.dentalcare.com/en-US/dental-education/continuing-education/ce379/ce379.aspx

Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or
procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy.

Aesthetic treatment of severely decayed primary teeth is one of the greatest challenges to pediatric dentists.
Aesthetic full coverage restorations are available for anterior and posterior primary teeth. This continuing
education course will concentrate on aesthetic full coverage restorations for anterior primary teeth.

Conflict of Interest Disclosure Statement

Dr. Schwartz is a member of the dentalcare.com Advisory Board. He did not receive compensation or
products from any companies whose products are featured in this course.

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ADA CERP is a service of the American Dental Association to assist dental professionals in identifying
quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses
or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

Concerns or complaints about a CE provider may be directed to the

provider or to ADA CERP at: http://www.ada.org/cerp

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 Approved PACE Program Provider
The Procter & Gamble Company is designated as an Approved PACE Program Provider
by the Academy of General Dentistry. The formal continuing education programs of this
program provider are accepted by AGD for Fellowship, Mastership, and Membership
Maintenance Credit. Approval does not imply acceptance by a state or provincial board
of dentistry or AGD endorsement. The current term of approval extends from 8/1/2013 to
7/31/2017. Provider ID# 211886

Overview
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 severe early childhood caries (ECC) especially in the
lower socioeconomic population.

Aesthetic treatment of severely decayed primary teeth is one of the greatest challenges to pediatric dentists.
Aesthetic full coverage restorations are available for anterior and posterior primary teeth. This continuing
education course will concentrate on aesthetic full coverage restorations for anterior primary teeth.

The topics covered in this course are fabrication and placement of:
Stainless steel crowns/open faced stainless steel crowns.
Composite strip crowns.
Pre-veneered stainless steel crowns.
Zirconia crowns.

Learning Objectives
Upon completion of this course, the dental professional should be familiar with the following restorative
techniques:
Stainless steel crowns/open faced stainless steel crowns.
Composite strip crowns.
Pre-veneered stainless steel crowns.
Zirconia crowns.

Course Contents education in parents have reduced the incidence

Introduction of caries in children, there is still a high prevalence
Indications for Full Coverage of early childhood caries (ECC) especially in the
Rubber Dam Application lower socioeconomic population.
Stainless Steel Crowns/Open Faced Stainless
Steel Crowns ECC, formerly termed nursing bottle caries and
Composite Strip Crowns baby bottle decay, is the term currently used
Pre-veneered Stainless Steel Crowns to describe the occurrence of caries in young
Zirconia Crowns childrens teeth. It affects 1-12% of the pediatric
Conclusion population in developed countries, and up to 70%
Course Test Preview in underdeveloped countries. It is defined by the
References American Academy of Pediatric Dentistry as the
About the Author presence of 1 or more decayed (noncavitated
or cavitated) lesions, missing (due to caries), or
Introduction filled tooth surfaces in any primary tooth in a child
Although advances in the application of preventive 71 months of age or younger. Severe ECC is
dentistry techniques, widespread acceptance of defined as any sign of smooth surface caries in
community fluoridated water, and increased dental a child younger than 3 years of age or 1 or more

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cavitated, missing (due to caries), or filled smooth
surfaces in primary maxillary anterior teeth, or a
decayed, missing, or filled score of >4 (age 3), >5
(age 4) or >6 (age 5) surfaces.

ECC is a result of excessively frequent ingestion

of liquids containing fermentable carbohydrates
(milk, formula, juice, soda) by the child at sleep
time particularly through a bottle. Prolonged breast
feeding has also been implicated in ECC.1

The clinical appearance of severe ECC follows a

definite pattern. There is early carious involvement
of the maxillary incisors followed by the maxillary
and mandibular first primary molars and the
mandibular cuspids.2

Aesthetic treatment of severely decayed anterior

primary teeth is one of the greatest challenges
to pediatric dentists. In the last half century the
emphasis on treatment of extensively decayed
primary teeth shifted from extraction to restoration.
Early restorations consisted of placement of
stainless steel bands or crowns on severely decayed
teeth. While functional, they were unaesthetic and
their use was limited to posterior teeth.
Over the last two decades there has been an
explosive interest by adults in aesthetic restoration
of their compromised dentition. Similarly, a higher
esthetic standard is expected by parents for
restoration of their childrens carious teeth. Thus
the choice of full coverage restorations for primary
teeth must provide an aesthetic appearance in
addition to restoring function and durability.
Aesthetic full coverage restorations are available for
anterior and posterior primary teeth. This continuing
education course will concentrate on aesthetic full
coverage restorations for anterior primary teeth.
Indications for Full Coverage
Indications for full coverage of anterior teeth are:
Incisors with large interproximal lesions.
Incisors with hypoplastic defects.
Unaesthetic incisors due to discoloration.
Incisors that have undergone pulp therapy with
significant loss of tooth structure.
Incisors with significant tooth loss due to trauma
or caries.
Incisors with small carious lesions and with
large areas of cervical discoloration.
The types of full coverage for anterior primary
teeth currently available are:
Stainless steel crowns.
Open faced steel crowns.
Resin (composite) strip crowns.
Pre-veneered steel crowns.
Zirconia crowns.
Table 1 summarizes the properties and selection
criteria of various full coverage techniques
currently available to practitioners.
Rubber Dam Application
The use of rubber dam in pediatric restorative
dentistry is strongly recommended as better
access and visualization is attained by retraction
of soft tissues and moisture control. Rubber dam
placement prevents the swallowing and aspiration
of foreign bodies and protection of the soft
tissues. For many children placement of a rubber
dam results in enhanced cooperation. The rubber
dam acts as a barrier so that the procedures
are perceived as less invasive and reduces the
handpiece water spray from accumulating in the
mouth. It enhances the effectiveness of nitrous
oxide, when needed for behavior management, by
forcing the child to engage in nasal breathing.
There are three components to the rubber dam
apparatus: the rubber dam, the rubber dam
frame and rubber dam clamps.

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 Table 1. Comparison of Full Coverage Techniques for Primary Teeth.
Rubber Dam
The rubber dam is available in various sizes and
shapes. Most rubber dams are made of latex
although non latex rubber dams are available. A
size 5 X 5 inch medium gauge rubber dam is best
suited for use in children. The darker the color, the
better the contrast between the dam and the tooth.
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Rubber Dam Frame
Rubber dam frames are available in plastic and metal and
various sizes corresponding to the size of the dam. 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.
The holes for the teeth are punched so the rubber
dam is centered horizontally on the face and the
upper lip is covered by the upper border of the
dam without blocking the nostrils. The size 1 hole
punch is used for the mandibular incisors, the
size 2 hole punch is used the maxillary incisors
and the size 3 hole punch is used for the canines.
Punch the minimum number of holes necessary to
adequately isolate the tooth. For class I or class V
restorations only the tooth or teeth to be restored
need to be isolated. When treating interproximal
lesions adjacent teeth are also isolated. When The 14 clamp for clamping fully erupted permanent
isolating several teeth, some clinicians will cut the molars.
interproximal dam material to create a slit. The
two techniques will be discussed in detail later.

Rubber Dam Clamps

Rubber dam clamp selection is important for
stabilizing the rubber dam. Some frequently used
clamps used in pediatric dentistry are:

The 12A clamp for clamping the maxillary left

second primary molar and the mandibular right
second primary molar (Ivory, Miles Inc., Dental
Products, South Bend, IN). The 14A clamp for clamping partially erupted
permanent molars.

The 13A clamp for clamping the maxillary right

second primary molar and the mandibular left After selecting the appropriate clamp, place a 12-inch
primary second molar (Ivory, Miles Inc., Dental piece of dental floss on the bow of the clamp to aid in
Products, South Bend, IN). retrieval of the clamp if it is dislodged from the tooth
and falls into the posterior pharyngeal area.

The 2A clamp for clamping the first primary

molars (Ivory, Miles Inc., Dental Products, South Rubber Dam Placement for Anterior Teeth
Bend, IN; Hygienic Corp, Akron, OH). The two most popular techniques for isolating anterior
teeth are individual tooth isolation and the slit technique.

Individual Tooth Isolation

The advantage of individual tooth isolation is that it
provides greater deflection of gingival tissues and
better moisture control. The disadvantages 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.

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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 above. 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 around the cervix of the
tooth and have the dental assistant hold the floss
gingivally on the lingual with a blunt instrument.
The floss is drawn interproximally to the facial
surface, and tightened with a surgical knot below
the cervical budge. If the dam is not sufficiently
stabilized, additional holes are added and rubber
dam clamps are placed on the molars.
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 above. The interproximal rubber dam
material is cut with scissors connecting the holes.
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 rubber band may be bilaterally placed
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.3

Upon completion of treatment, the rubber 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.3

Slit Dam Method

The advantages of the slit 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 for moderate moisture control.

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An isolation device of increasing popularity is
the high speed vacuum ejector system (Isolite
Systems, Santa Barbara, CA). The system
consists of two components; a disposable
mouthpiece and a vacuum and illumination source.
The mouthpiece keeps the patients mouth open,
tongue and cheek retracted. It is constructed out
of a polymeric material specifically selected for
being softer than gingival tissue while being nearly
optically clear. The mouthpiece comes in a full
range of sizes and may be used in both pediatric
patients of all ages and adults. The vacuum
component is available with or without a light
source and controls oral moisture and humidity
thus reducing sources of oral contamination.
Unlike rubber dam isolation, the system does not
require the use of local anesthesia and allows
visibility in multiple quadrants.
Photos and description courtesy of Isolite Systems, Santa Barbara, CA
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Stainless Steel Crowns/Open Faced
Stainless Steel Crowns
Stainless steel crowns were introduced to pediatric
dentistry by the Rocky Mountain Company in 1947
and made popular by W. P. Humphrey in 1950. Until
then the treatment for grossly decayed primary teeth
was extractions. Stainless steel is composed of iron,
carbon, chromium, nickel, manganese and other
metals. The term stainless steel is used when the
chromium contents exceeds 11% (usually a range
of 12 to 30%. The chromium oxidizes and forms
a protective film of chromium oxide which protects
against corrosion. While originally intended for the
restoration of posterior primary and young permanent
teeth, its use was expanded to badly decayed
anterior teeth. Although, more durable and retentive
than amalgam or composite they are unaesthetic,
especially on the anterior teeth. With aesthetics of
their childs smile of extreme importance to parents,
many opted for extraction and prosthetic replacement
of severely decayed teeth rather than placement of
stainless steel crowns. The advent of composite
bonding, allowed for a composite facing to be placed
on the facial surface of the tooth, thus improving
aesthetics. Open faced stainless steel crowns
combine strength, durability and improved aesthetics,
however they are time consuming to place as the
composite facing cannot be placed until the stainless
steel crown cement sets. Bleeding of the color of
the metal margins surrounding the composite adds a
grayish tinge to the tooth that is accentuated next to
the white enamel of an adjoining or opposing primary
tooth.
Manufacturers of anterior stainless steel crowns
are: 3M Espe-Unitek Crowns, St. Paul, MN; Cheng
Crowns, Exton, PA; Hufriedy Manufacturing Inc,
Chicago, IL and Acero Crowns, Seattle, WA.
The advantages and disadvantages of stainless
steel crowns and open faced stainless steel crowns
are summarized as follows:
Stainless Steel Crowns
Advantages
They are very durable, wear well and are retentive.
The time for placement is fast compared to other
techniques.
They may be used when gingival hemorrhage or
moisture is present or when the patient exhibits
less than ideal cooperation.
 They are fairly inexpensive (approximately $6/
crown).
Disadvantages
Aesthetics are extremely poor. Some parents
may opt for extractions in lieu of restoration of
the teeth.
Stainless Steel Crown Technique
Anesthetize the teeth to be restored and place
the rubber dam.
Select a primary stainless steel crown with a
mesio-distal incisal width equal to the tooth to be
restored by placing the incisal edge of a stainless
steel crown against the unprepared tooth.

Open Faced Crowns

Advantages
The aesthetics are fair. (The metal shows
through the composite facing.)
They are very durable, wear well and retentive.
The materials are fairly inexpensive.

Disadvantages
The time for placement is long as it involves
a two-step process (crown cementation/ Remove decay with a medium to large round
composite facing placement. bur in a slow speed handpiece. If pulp therapy
Placement of the composite facing may be is required, do it at this time.
compromised when gingival hemorrhage
or moisture is present or when the patient
exhibits less than ideal cooperation.

Although stainless steel crowns, as a standalone

technique for anterior restorations, are rarely
used, mastering the technique is necessary for
fabrication of the more aesthetic open faced
stainless steel crown.

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 Using a 169L bur or a fine tapered diamond,
reduce the incisal edge by 1.5mm.

Reduce the facial surface by 1mm and the

lingual surface by 0.5mm. Create a feather-
edge gingival margin. Round all line angles.

Try the pre-selected crown on the tooth.

Reseat the crown. The crown should extend

1mm under the gingival margin. The fit of the
crown should be snug without rocking.

Anterior crowns are manufactured with

an ovoid shape with a small facio-lingual
dimension. Change the shape to allow the
crown to passively slip on the tooth. Squeeze
the crown slightly mesio-distally with a pair Trimming, if necessary, is best done with a
of Howe no. 110 pliers to increase the facio- heatless stone on a straight slow speed handpiece
lingual dimension. followed by polishing with a rubber point.

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 Contouring and crimping are necessary to
insure a good marginal fit. Use a no. 137
Gordon plier to adapt the margin. Check the
marginal fit with an explorer.
Seat and cement the crown. Remove excess
cement from the crown with a wet gauze. The
cement must be completely set before preparation
and placement of the open faced veneer.
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Open Faced Stainless Steel Crown Technique
Once the cement is set, cut a labial window in the
cemented crown using a no. 330 or no. 35 bur.
Extend the window:
Just short of the incisal edge.
Gingivally to the height of the gingival crest.
Mesio-distally to the line angles.
Using a no. 35 bur remove the cement to a
depth of 1mm.
Place undercuts at each margin with a no. 35
bur or with a no. round bur.
 Add additional material in 1mm increments
and polymerize.

Smooth the cut margins of the crown with a fine

green stone or white finishing stone.

Finish the restoration with abrasive disks.

Run the disks from the resin to the metal at
the margins so as not to discolor the resin with
metal particles.

After using a glass ionomer liner to mask differences

in color between remaining tooth structure and
cement place a layer of bonding agent.

Place resin based composite into the cut window

forcing the material into the undercuts and Repeat the procedure for the remaining teeth.
polymerize. While more aesthetic than a conventional
stainless steel crown, a shortcoming of
an open faced stainless steel crown is the
bleeding of the metal color from the lingual and
interproximal surfaces through the composite
resulting in a grayish tinge to the facing.

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Composite Strip Crowns
Composite strip crowns are composite filled
celluloid crowns forms. They have become a
popular method of restoring primary anterior teeth
because they provide superior aesthetics as
compared to other forms of anterior tooth coverage.
Composite strip crowns rely on dentin and enamel
adhesion for retention. Therefore the lack of tooth
structure, the presence of moisture or hemorrhage
contributes to compromised retention. They are
less resistant to wear and fracture more readily Remove decay with a medium to large round
than other anterior full coverage restorations. A bur on a slow speed handpiece.
2002 study by Tate, et al., found that composite If pulp therapy is required do it at this time.
strip crowns had a failure rate of 51%, compared to
an 8% failure rate of stainless steel crowns.4

With a cooperative patient, the time required for

placement is comparable to that of a stainless steel
crown and less than veneered and zirconia crowns.

Advantages
It provides superior aesthetics.
The cost of materials are reasonable
(approximately $6/crown).
The time for placement is reasonable.

Disadvantages
It is extremely technique sensitive.
It is not as durable or retentive as stainless
steel/open faced crowns, pre-veneered crowns
or zirconia crowns and is not recommended on
patients with a bruxism habit or a deep bite.
Adequate moisture control might be difficult on
an uncooperative patient.
Reduce the interproximal surfaces by 0.5 to
Composite Strip Crowns Technique 1.0mm.
Select a primary celluloid crown form (Unitek The interproximal walls should be parallel
Strip Crown, 3M, St. Paul, MN, Nowak Crowns, and the gingival margin should have a feather
Nowak Dental Supplies Inc., Carriere, MS) with edge.
a mesio-distal incisal width equal to the tooth to Reduce the facial surface by 1mm and the
be restored by placing the incisal edge of the lingual surface by 0.5mm.
crown against the incisal edge of the tooth. Create a feather-edge gingival margin.

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 Round all line angles.

Etch the tooth with acid gel for 15 seconds, wash

Trim the selected crown by removing the collar and dry the tooth, and apply bonding agent.
and the gingival excess material with crown OR
and bridge shears. Use a self-etching bonding agent.
Place a small vent hole on the lingual surface Polymerize.
with a bur or explorer to allow escape of trapped
air when the composite filled crown is seated.

Seat the filled crown form on the tooth.

Fit the crown on the prepared tooth.
The crown should extend 1mm below the
gingival margin.
Maxillary lateral incisors are usually 0.5 to
1.0mm shorter than central incisors.
Remove the excess material from the vent hole
and the gingiva.
Repeat the procedure with the adjacent teeth.
Polymerize the material from both the facial and
lingual directions.

Select the appropriate shade of composite

(extra light).
Fill the crown with resin material approximately
two thirds full.

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 Remove the celluloid form by cutting the
material on the lingual with either a composite
finishing bur or scalpel.
Pry the celluloid form off the tooth.
Very little finishing is required except for adjusting
the occlusion and smoothing gingival margins.
Use flame shaped and rounded composite
finishing burs for finishing.
Repeat the procedure for adjacent teeth.
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Pre-veneered Stainless Steel Crowns
Pre-veneered stainless steel crowns resolve some
of the problems associated with stainless steel
crowns, open faced stainless steel crowns, and
composite strip crowns. They were introduced in
the mid 1990s. They are aesthetic, placement
and cementation are not significantly affected by
hemorrhage and saliva and can be placed in a single
appointment. The stainless steel crown is covered
on its buccal or facial surface with a tooth colored
coating of polyester/epoxy hybrid composition.
A clinical disadvantage is they are relatively inflexible
as the resin facing is brittle and tends to fracture
when subjected to heavy forces or crimping.
Because only the lingual portion of the crown can
be adjusted (crimped), significant removal of tooth
structure must be performed to fit the tooth to the
crown rather than the crown to the tooth. There is
limited shade choice. They are more expensive to
purchase than stainless steel crowns and strip crown
forms (approximately $18 vs. $6) yet less expensive
than zirconia crowns ($18 vs. $25).
Pre-veneered stainless steel crowns are available
from various manufacturers (Kinder Krowns,
Mayclin Dental Studios, Minneapolis, MN; Dura
Crowns, Space Mainttiners Laboratory, Van
Nuys, CA; NuSmile Primary Crowns, Houston,
TX; Cheng Crowns, Peter Cheng Orthodontic
Laboratories, Philadelphia, PA).
Advantages
They are aesthetically pleasing.
They require relatively short operating time.
They have the durability of a steel crown.
They are less moisture sensitive during
placement than composite strip crowns.
Disadvantages
They are 3 times more expensive than stainless
steel and strip crowns ($18 vs. $6) but less
expensive than zirconia crowns ($25-$30).
The technique does not allow for major
recontouring and reshaping of the crown.
The tooth is adjusted to fit the crown, rather
than adjusting the crown to fit the tooth.
As crimping is limited to lingual surfaces there
is not close adaptation of crown to tooth.
There are reports of the veneer facing fracturing,
however it can be easily repaired using the open
faced stainless steel crown technique.
Pre-veneered Stainless Steel Crown Technique The length of the crown is altered by trimming
Size the crown to the tooth by placing the the gingival margin with a diamond bur and
incisal edge of the crown against the incisal water spray.
edge of the tooth.

The lingual aspect of the crown may be

Prepare the tooth as for a standard stainless crimped slightly with a no. 137 Gordon plier.
steel crown, however more circumferential Too much crimping of the metal substructure
tooth reduction required. may cause fractures in the veneer material.

Refine the prep to fit the crown. The crown is cemented with glass ionomer
Do not force the crown on the tooth. cement.
A properly fitted crown has a passive fit.
The crown should extend 1mm past the
gingival margin.

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The excess cement is removed and the
remainder is allowed to set.
After cementation the incisal edges may be
contoured with a finishing disk or point.
The smaller lateral crowns may be used on
lower anterior teeth.
Cold sterilization in glutaraldehyde is
recommended.
If the veneer fractures a similar technique to
the open-faced crown may be used for repair.
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Zirconia Crowns
Zirconia (zirconium dioxide) crowns are made
of solid monolithic zirconia ceramic material.
Although discovered in 1789 by the German
chemist Martin Heinrich Klaproth, zirconia has
been used as a biomaterial since the late 1960s.
Its use as a dental restorative material became
popular in the early 2000s with the advent of CAD-
CAM technology. In the later part of the decade
they became available as preformed crowns for
primary teeth.5
Advantages
They are very aesthetic, with greater durability
than composite strip crowns and pre-veneered
crowns.
They are not as technique sensitive as
composite strip crowns as the fabricated crown
is cemented with self-adhesive resin cement
rather than bonding.
They take a bit longer to place than stainless
steel crowns and composite strip crowns, about
the same as pre-veneered crowns, and less
than open faced stainless steel crowns.
Disadvantages
They are not recommended in patients that are
heavy bruxers.
Greater tooth reduction is required.
Zirconia Crown Technique (technique description
and illustrations courtesy of EZ Pedo Crowns)
Select the correct crown size by placing the
incisal edge of the crown against the incisal
edge of the tooth.
 Reduce the incisal edge 1.5 - 2mm.
Reduce the labial surface a minimum of 0.5-
1.0 of tooth structure in three planes (gingival-
middle-incisal thirds). These three planes
extend from 1-2mm subgingivally all the way to
the middle of the incisal edge of the prep.
Reduce the lingual surface by removing .75-
1.25mm of tooth structure from the lingual
surface, extending from 1-2mm subgingivally
to the middle of the incisal edge of the prep
following the natural contours of the existing
clinical crown. The facial and lingual preps
should meet in a thin incisal edge. Check the
occlusion to insure there is adequate clearance
from opposing dentition.
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The red arrows mark the most common areas of
internal interference that, if under-prepared, will
make it difficult to seat zirconia crowns. Lingual
and facial reductions should meet at a thin incisal
edge of the final restoration. This thin incisal edge
helps to reduce internal interferences between the
tooth and the internal surface of the crown.
Completed tooth preparation. The circumference
of the overall prep should be ovoid when
viewed from the incisal edge. Facial and
lingual surfaces should not be prepared flat, but
rather curved interproximally. Removing extra
material in these areas will insure an easier fit
with less internal interference and allow mesia/
distal rotation for a better alignment of the crown
during final cementation.

Ceramic crown adjustment. It is possible
to adjust a pedo ceramic crown. However
because it is ceramic and cannot be trimmed
with scissors like a traditional stainless steel
crown, it is necessary to use a high speed, fine
diamond with lots of waters because excessive
heat could cause fractures in the crowns
ceramic structure. Occlusal and interproximal
adjustments are not recommended, as these
will remove the crowns glaze and possibly
create a weak area of thin ceramic.
Passive fit. It is very important that zirconia
pedo crowns fit passively. Because they are
zirconia and do not flex, pushing harder will not
work. Do not attempt to force a crown to fit.
Excessive pressure may fracture the crown. The
appropriate size crown should fit passively and
completely subgingivally without distorting the
gingival tissue. EZ- Pedo Crowns have internal
ZirLock grooves that increase the overall
surface area of the restoration, providing more
retention and improving overall clinical success.
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Preparation for Cementation
Rinse the preparation and remove all blood and
residue from the tooth. If bleeding continues,
squeeze the preparation with a moist 2x2 gauze
or carefully apply Superoxol to the tissue using
a micro brush. Using peroxide or alcohol,
thoroughly clean the internal surface of the crown
so that all blood residue is removed.
Cementation
Cementation is the most important step to
creating a beautiful smile. Tooth orientation
and emergence profile are key. Centrals should
always be cemented together first and then the
laterals. Apply consistent, firm finger pressure
during cementation using glass ionomer cement.
The crown should remain undisturbed until
the cement has completely hardened. Wiping
excess cement from the facial embrasure will
allow a clearer facial view and insure a better
final alignment, dramatically improving the final
esthetic result. Tooth labeling can be scratched
off with a spoon or polished off with coarse
prophy paste.
With all full coverage restorations parents must
be advised to institute appropriate preventive
health practices (elimination of sugar containing
drinks, regular tooth brushing and topical fluoride
application) to maximize gingival health and
minimize the recurrence of caries under the
restorations.
Conclusion Pre-veneered crowns.
Mastering these techniques will help the dental
health professional meet todays parents demand
for their childrens teeth to be restored for function
and aesthetics. The four techniques described
should accommodate parent and patient
requirements for aesthetic restorations at an
affordable cost

Open faced stainless steel crowns.

Zirconia crowns.

Composite strip crowns.

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Crest Oral-B at dentalcare.com Continuing Education Course, Revised March 26, 2015
Course Test Preview
To receive Continuing Education credit for this course, you must complete the online test. Please go to:
www.dentalcare.com/en-US/dental-education/continuing-education/ce379/ce379-test.aspx

1. Severe early childhood caries is defined as:

a. Any sign of smooth surface caries in a child younger than 3 years of age.
b. 1 or more cavitated, missing (due to caries) or filled smooth surface surfaces in primary
maxillary anterior teeth.
c. A decayed, missing (due to caries), or filled score of greater than 5 in a four year old.
d. All of the above.

2. The most frequently involved teeth in early childhood caries are:

a. The maxillary and mandibular first primary molars.
b. The maxillary and mandibular second primary molars.
c. The maxillary incisors.
d. The mandibular cuspids.

3. An indication for full coverage of anterior teeth is:

a. Incisors that have undergone pulp therapy.
b. Incisors with large interproximal lesions.
c. Teeth that will exfoliate within three years.
d. A and B

4. The most sensitive technique procedure for restoring primary anterior teeth is:
a. Open faced stainless steel crowns.
b. Pre-veneered stainless steel crowns.
c. Composite strip crowns.
d. Zirconia crowns.

5. The most costly procedure for restoring primary anterior teeth is:
a. Open faced stainless steel crowns.
b. Pre-veneered stainless steel crowns.
c. Composite strip crowns.
d. Zirconia crowns.

6. When treating an anterior tooth with interproximal lesions only that tooth needs to be
isolated with a rubber dam.
a. True
b. False

7. A 12A rubber dam clamp is used for clamping the:

a. Maxillary left second primary molar and mandibular right second primary molar.
b. Maxillary right second primary molar and mandibular left second primary molar.
c. The first primary molars.
d. A partially erupted first permanent molar.

8. The advantage of individual tooth isolation with a rubber dam is:

a. It provides for greater deflection of gingival tissues.
b. It allows for easier removal of the rubber dam.
c. It does not interfere with placement and finishing of crowns.
d. All of the above.

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Crest Oral-B at dentalcare.com Continuing Education Course, Revised March 26, 2015
9. When using slit rubber dam isolation, the rubber dam may be stabilized by using a
____________.
a. wooden wedge
b. small piece of rubber dam material
c. household rubber band
d. All of the above.

10. Stainless steel crowns are not usually placed on anterior teeth because:
a. They are unaesthetic.
b. They are less durable than other restorations.
c. They are more expensive than other restorations.
d. All of the above.

11. An advantage of an open faced stainless steel crown is:

a. Moisture and hemorrhage is not a factor when placing the facing.
b. Placement time is less than other techniques.
c. Durability, retention are good and aesthetics are fair.
d. None of the above.

12. When selecting the correct size stainless steel crown:

a. Fit the crown after decay removal.
b. Fit the crown after preparation of the tooth.
c. Before removal of decay place the incisal edge of the crown against the incisal edge of the tooth.
d. Measure the unprepared tooth with a caliper.

13. When preparing a tooth for a stainless steel crown, ____________.

a. reduce the lingual surface by 1mm and the facial surface by 0.5mm
b. reduce the facial surface by 1mm and the lingual surface by 0.5mm
c. all surfaces are reduced by 1mm
d. all surfaces are reduced by 0.5mm

14. Anterior stainless steel crowns are manufactured with ____________.

a. an ovoid shape with a small facio-lingual dimension
b. an ovoid shape with a small mesio-distal dimension
c. symmetrical dimensions requiring minimal adjustment
d. crimped gingival margins requiring no adjustment

15. The facing on an open faced stainless steel crown may be placed ____________.
a. immediately after the stainless steel crown is cemented
b. once the cement is set
c. when saliva is present
d. when blood is present

16. The window on an open faced stainless steel crown is extended ____________.
a. just short of the incisal edge
b. gingivally to the height of the gingival crest
c. mesiodistally to the line angles
d. All of the above.

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Crest Oral-B at dentalcare.com Continuing Education Course, Revised March 26, 2015
17. When finishing the composite facing on an open faced stainless steel crown, ____________.
a. run an abrasive disk from the metal to the resin
b. run an abrasive disk from the resin to the metal
c. place flowable composite over the filled composite prior to finishing
d. reduce the composite just short of the incisal edge

18. To adapt the margin of a preveneered crown to the tooth:

a. Crimp the margins of pre-veneered crowns with a 137 Gordon plier.
b. Crimp only the labial margin of the pre-veneered crown with a 137 Gordon plier.
c. Crimp only the lingual margin of the pre-veneered crown with 137 Gordon plier.
d. Never crimp the margins of a pre-veneered crown.

19. Which statement is true about composite strip crowns:

a. They can be placed in the presence of blood and saliva.
b. They are not as durable as other full coverage anterior restorations.
c. They are more expensive to place than other full coverage anterior restorations.
d. They take significantly longer to place.

20. When preparing a tooth for a composite strip crown, ____________.

a. reduce the lingual surface by 1mm and the facial surface by 0.5mm
b. reduce the facial surface by 1mm and the lingual surface by 0.5mm
c. all surfaces are reduced by 1mm
d. all surfaces are reduced by 0.5mm

21. To prevent voids in the composite when seating composite strip crowns, ____________.
a. place a small vent hole on the lingual surface of the crown
b. overfill the crown with composite
c. after initially seating the crown, remove and reseat it
d. cure the composite from the lingual and then the labial surface

22. A disadvantage of pre-veneered stainless steel crowns is:

a. They are significantly more expensive than stainless steel crowns, composite strip crowns and
zirconia crowns.
b. They take significantly more time to place than stainless steel crowns, composite strip crowns
and zirconia crowns.
c. The tooth is adjusted to fit the crown rather than adjusting the crown to fit the tooth.
d. A and C

23. Which statement is true about zirconia crowns:

a. They are more technique sensitive than composite trip crowns.
b. They are more durable than composite strip crowns.
c. They are less aesthetic than open faced stainless steel crowns.
d. They are recommended for patients that are bruxers.

24. When preparing a tooth for a zirconia crown, ____________.

a. reduce the incisal edge 1.5-2mm
b. reduce the labial surface 0.5-1.0mm
c. carry the preparation subgingivally
d. All of the above.

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Crest Oral-B at dentalcare.com Continuing Education Course, Revised March 26, 2015
25. Zirconia crowns are cemented using ____________.
a. glass ionomer cement
b. IRM
c. self adhesive resin
d. flowable composite

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Crest Oral-B at dentalcare.com Continuing Education Course, Revised March 26, 2015
References
1. American Academy of Pediatric Dentistry Reference Manual. Policy on ECC: Classification,
Consequences, and Preventive Strategies. Pediatric Dent V35/No 6, pp50-51, 2013/14.
2. Dean JA, Avery DR, McDonald RE. McDonalds and Averys dentistry for the child and adolescent.
9th Ed, St. Louis, Mo. Mosby/Elsevier, 2011.
3. Casamassimo PS. Pediatric dentistry: infancy through adolescence. 5th Ed, St. Louis, Mo. Elsevier/
Saunders, 2013, pp 307-309, 326-328.
4. Tate AR, Ng MW, Needleman HL, Acs G. Failure rates of restorative procedures following dental
rehabilitation under general anesthesia. Pediatr Dent. 2002 Jan-Feb;24(1):69-71.
5. Vagkopoulou T, Koutayas SO, Koidis P, et al. Zirconia in dentistry: Part 1. Discovering the nature of
an upcoming bioceramic. Eur J Esthet Dent. 2009 Summer;4(2):130-51.
6. EZ Pedo. Ceramic Crowns for Children. Clinical Resource Guide to EZ-Pedos Anterior Crown
Collection, Loomis, CA.

About the Author

Steven Schwartz, DDS

Dr. Steven Schwartz is the director of the Pediatric Dental Residency Program at
Staten Island University Hospital and is a Diplomat of the American Board of Pediatric
Dentistry.

Email: sschwartz11@nshs.edu

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Crest Oral-B at dentalcare.com Continuing Education Course, Revised March 26, 2015