Asthetic crowns in pediatric dentistry

Asthetic crowns in pediatric dentistry

1. Aesthetic full coverage restorations for anterior primary teeth

2. Introduction Aesthetic treatment of severely decayed primary teeth – A challenge for pediatric dentist!! Treatment shifted from extraction to restoration, with placement of stainless steel bands or crowns. Functional, but unaesthetic and use was limited to posterior teeth.

3. Higher esthetic standard is expected by parents. Full coverage restorations provide an aesthetic appearance  restoring function and durability .

4. Indications for Full Coverage Tooth with large interproximal lesions Unaesthetic tooth due to discoloration Tooth that have undergone pulp therapy with significant loss of tooth structure Tooth with small carious lesions and with large areas of cervical discoloration

5. Classification Of Crowns

6. Stainless steel crowns with facing Resin crowns/composite crowns Pre-veneered SSC Ceramic ( zirconia ) crown Strip crowns NuSmile crowns ZIRKIZ crown Composite shell crown Pedo pearls EZ-crown New millennium Cheng crown Kinder Krowns Polycarbonate crowns Dura crown CEREC crown Kudos crown Whiter biter crown Ceramo basemetal crown Pedo natural crown Flex crown Pedo jacket crown Artglass crowns According to material used

7. Full coronal restoration in children Crowns can be made from: All metal Metal crown with facing All ceramic All resin preformed plastic crowns Composite based crowns

8. Stainless steel crowns with facing 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 but time to place.

9. Advantages Disadvantages The aesthetics are fair. The time for placement is long. They are very durable, wear well and retentive. Placement of the composite facing may be compromised when gingival hemorrhage or moisture is present or when the patient exhibits less than ideal cooperation. The materials are fairly inexpensive.

10. Technique for Stainless steel crowns with facing (HARTMANN 1983) Initial crown preparation as suggested by Mink & Bennett (1968) . Once the cement is set, cut a labial window in the cemented crown using a no. 330 or no.245 bur .

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

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

13. Composite Strip Crowns These are composite filled celluloid crowns forms . Lack of tooth structure, & the presence of moisture or hemorrhage contributes to compromised retention.

14. Advantages Disadvantages It provides superior aesthetics & t he cost of materials are reasonable (approx $6/crown). It is extremely technique sensitive. The time for placement is reasonable. Simple to fit and trim. Adequate moisture control might be difficult on an uncooperative patient. Leaves smooth shiny surface. Not recommended on patients with a bruxism habit or a deep bite.

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

16. Reduce the interproximal surfaces by 0.5 to 1.0 mm and walls should be parallel and the gingival margin should have a feather edge. Reduce the facial surface by 1mm and the lingual surface by 0.5mm & create a feather-edge gingival margin. Round all line angles .

17. Trim the selected crown by removing the collar and the gingival excess material with scissors. Place a small vent hole on the mesial distal edge surface with a bur or explorer to allow escape of trapped air when the composite filled crown is seated.

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

19. Etch the tooth with acid gel for 15 seconds, wash and dry the tooth, and apply bonding agent . Seat the filled crown form on the tooth .

20. 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.

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

22. Tate et al., (2002) f ound that composite strip crowns had a failure rate of 51% compared to an 8% failure rate of SSC. Resin crowns are much weaker than SSC and there is an increased chance that a piece or corner of the crown may fracture off.

23. Ram D. et al., (2006) assessed retrospectively the longevity of resin-bonded composite strip crowns placed in primary maxillary incisors. Records for 200 out of 387 children, aged 22–48 months, treated in a private paediatric dental practice with follow-up of at least 24 months were included in the study .

24. The failure rate was higher in central incisors with 4 affected surfaces & lateral incisors with 4 carious surfaces. Thus concluded that this treatment modality is an aesthetic 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.

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

26. Advantages Disadvantages Esthetics Very expensive compared to strip crown and pedo jacket crown. Can be trimmed and reshaped with high speed finishing bur Brittle Adequate moisture control

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

28. Advantages Disadvantages They are very aesthetic/U62 shade. Greater durability & strength. They are not recommended in patients that are heavy bruxers . They are not as technique sensitive as composite strip crowns. Greater tooth reduction is required. Same amount of time to place as SSC Contours and crimp similar to metal crowns.

29. Polycarbonate crown Manufacturers of polycarbonate crowns 3M ESPE Direct dental products Swedish dental supplies lab (SWE Den) PedoNatural crowns Crest Oral-B

30. Polycarbonate Crowns Technique Select a crown that fits easily over the tooth and has the appropriate mesiodistal dimension. Reduce the incisal edge a minimum of 1 or 2mm. Reduce the labial surface & lingual surface a minimum of 0.5mm.

31. Stewart et al (1974) a definite finish line in the form of chamfer. Myers et al (1975) there be no finish line.

32. For the interproximal reduction all contact must be broken. If the crown does not seat without incisal interference additional tooth reduction is necessary .

33. Remove the ID Tab and tab connector with a scissor.

34. Reseat the crown form onto the prepared tooth & adjust the margins & occlusion . Remove the crown from the tooth .

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

36. Cementation Immediately prior to cementation, thoroughly rinse the tooth with a high speed water spray. Once the tooth is clean place a gauze over the tooth with firm pressure on the gingival tissues to control any bleeding, as necessary while the crown is being loaded with self-adhesive resin cement. Fill the crown will self adhesive resin

37. Seat the crown fully & completely. Maintain finger pressure on the crown & light cure the buccal and lingual margins for 2-3 seconds. Remove excess cement with an explorer. Occlusion is checked & adjusted.

38. KUDOS CROWNS Temporary paediatric crowns. Newer generation polycarbonate crowns. Produced from Hong Kong based company Kudos International Holdings limited

39. Advantages Disadvantages Aesthetically acceptable Chances of breakage Less chair side time Dislodgement Improved retention Discoloration Better adaptability

40. PEDO JACKET ADVANTAGES: DISADVANTAGES:  Crown placement can be done in one sitting Only one size and one color available Crown will not split, not stain or crack. Cannot be trimmed or reshaped with high speed finishing bur as the material melt to bur Can be trimmed with scissors.

41. Manufacturers and availability Space maintainers laboratory. Crown size- D, E, F, G, L, U as 1-6 numbers.

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

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

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

45. Pre-veneered Stainless Steel Crowns They were introduced in the mid 1990’s. Aesthetic Placement & cementation are not significantly affected by hemorrhage and saliva and can be placed in a single appointment .

46. 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 .

47. There is limited shade choice. They are more expensive to purchase than stainless steel crowns, strip crown forms and polycarbonate crowns (approximately 18 vs. 6 dollars).

48. Advantages Disadvantages They are aesthetically pleasing. They are 3 times more expensive than stainless steel, strip and polycarbonate crowns They have the durability of a steel crown. 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.

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

50. Refine the prep to fit the crown . Do not force the crown on the tooth . A properly fitted crown has a passive fit . The crown should extend 1mm past the gingival margin .

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

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

53. Shah et al (2004) evaluated the clinical success of and parental satisfaction with treatment using prefabricated resin-faced stainless steel crowns (Kinder Krowns ). 46 teeth were evaluated in 12 children. 24% -resin fracture resulting in partial or total facing loss. 61% - No resin facing fracture or visible wear.

54. 6- total facing loss from fracture 5-partial facing fracture. 7- Wear limited to less than the incisal one third of the crown. Conclusions : Kinder Krown prefabricated resin-faced SSCs showed a low failure rate, and the parental satisfaction with treatment was positive.

55. NuSMILE CROWNS Specially Formulated Hybrid Composite Substructure 2 Shades for Anterior Crowns(XL and NL); Posterior Crowns(XL only) Centrals and Laterals sizes 1-6, Cuspids Sizes 0-6, 1st & 2nd Primary Molars Sizes 1-7

56. Waggoner and Cohen [1995] reported Cheng Crowns , Kinder Crowns , NuSmile Primary Crowns have resin composite facings whereas Whiter Biter Crown II has a flexible thermoplastic veneer( exhibiting greatest shear force and retention compared to other brands).

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

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

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

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

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

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

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

64. ZIRCONIA PEDIATRIC CROWNS

65. KINDER KROWNS 1988 by pediatric dentists 1997 introduction of incisal lock. natural shades and contour available Great depth and vitality from the lifelike composite

66. Available in 2 shades; PEDO 1 & PEDO 2 Zirconia is a crystalline dioxide of zirconium. In particular, yttrium-oxide-partially-stabilized zirconia (3Y-TZP)  similar mechanical properties as those of metal  color similar to tooth.

67. Benefits Anterior crowns Posterior crowns Autoclavable Left and right Shade- pedo 1 and pedo 2. Pedo 1- lighter bleached shade. Pedo 2- natural AI/BI blended Precisely manufactured to ensure proper fit Universal and contoured Midsizes - 1 st and 2 nd molar Rough external surface for easy handling Length- regular & short No contamination provides better retention Shade pedo 1 and pedo 2

68. Holsinger et al (2016) Zirconia crowns are clinically acceptable restorations in the primary maxillary anterior dentition. Parental satisfaction with zirconia crowns is high .

69. Salami A et al., ( 2015) evaluated and compared the parental satisfaction among resin composite strip crown, preveneered SSC and pre-fabricated primary zirconia crown for restoring maxillary primary incisors. 39 children with carious or Traumatized primary maxillary incisors were randomly and equally distributed in 3 groups.

70. Children were recalled to evaluate and compare parental satisfaction about performance of crowns after one year through a questionnaire Parental overall satisfaction highest for zirconia primary > resin composite strip crowns > pre-veneered SSCs.

71. Parents were least satisfied with durability of resin composite strip crowns and colour of pre-veneered stainless steel crowns. However, this did not affect their overall satisfaction with these crowns.

72. Clark et al.,(2016) Determined if aggressiveness of primary tooth preparation varied among different brands o f zirconia and stainless steel (SSC) crowns. 100 primary typodont teeth divided into 5 groups (10 posterior and 10 anterior) and assigned to:Cheng Crowns (CC); EZ Pedo (EZP); Kinder Krowns (KKZ); NuSmile (NSZ); & SSC.

73. Zirconia crowns required more tooth reduction than stainless steel crowns for primary anterior and posterior teeth. Tooth reduction for anterior zirconia crowns was equivalent among brands. For posterior teeth, reduction for three brands (EZ Pedo , Kinder Krowns , NuSmile ) did not differ, while Cheng Crowns required more reduction.

74. Waggoner.Restoring primary anterior teeth. Pediatr Dent. 2002;24(5):511-16

75. Crown Starter kit Individual crowns NuSmile 16= 17,367rs 1200rs 2305rs Cheng crowns 16= 18,704rs 1265rs 2330rs Kinder krowns 16=17245rs 1196 rs Dura crowns 24 =26,356 rs 1099 rs New millenium crowns 24(anterior)= 19309 rs 12 (posterior)= 11286 rs Ant= 663 rs Post= 863 rs Pedo jacket 96(anterior)= 14582 rs 24 ( first molar) = 4295 rs Ant/post (5)= 833 rs Strip crowns 96 (anterior)= 13982 rs 48 ( first molar )= 7724 rs 48 ( sec molar) = 7724 rs Ant/post (5)= 733 rs

76. Conclusion Many options exist to repair carious primary teeth, but there is insufficient controlled, clinical data to suggest that one type of restoration is superior to another. This does not discount the fact that dentists have been using many of these crowns for years with much success .

77. Operator preferences, esthetic demands by parents, the child’s behavior, and moisture and hemorrhage control are all variables which affect the decision and ultimate outcome of whatever restorative treatment is chosen. ( Pediatr Dent . 2002;24:511-516)

78. Crowns remain the best restoration in many cases, and esthetic crowns will have a larger role in pediatric dentistry if improvements are made to reduce the bulk, lessen the thickness of the veneer, improve the bonding between the metal and the esthetic facing, and reduce the cost. These techniques are relatively new and need to pass the test of long-term clinical use .

79. 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.

80. References Stewart R. Pediatric dentistry. St. Louis: Mosby; 1982. Babaji P. Crowns in pediatric dentistry. Holsinger D M, Wells M H, Scarbecz M, Donaldson. Clinical Evaluation and Parental Satisfaction with Pediatric Zirconia Anterior Crowns. Pediatr Dent 2016;38(3):192-7

81. Ram D & Fuks A. B. Clinical performance of resin-bonded composite strip crowns in primary incisors: a retrospective study, Int J Paeditr Dent. 2006;16:49-54. Shah P V, Lee J Y, Wright J T.Clinical Success and Parental Satisfaction With Anterior Preveneered Primary Stainless Steel Crowns. Paeditr Dent. 2004;26:391-95.

82. Salami A, Walia T, Bashiri R. Comparison of Parental Satisfaction with Three Tooth- Colored Full- Coronal Restorations in Primary Maxillary Incisors. J Clin Pediatr Dent. 2015; 39(5): 423-28

83. Thank u

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