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. Classification
according to
bonding or luting
of full coronal
restoration
Luted
-SSC
-SSC with facing
-Ceramic crowns
Bonded
-Resin based
-Composite based
-Natural tooth

8. 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

9. 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.

10. 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.

11. 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.

12. 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.

14. • 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.

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

16. Advantages Disadvantages
It provides superior aesthetics & the
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.

17. 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.

18. • 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.

19. • 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.

20. 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.

21. • 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.

22. • 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.

23. • 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.

24. • Tate et al., (2002) found 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.

25. • 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
• .

26. • 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.

27. 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

28. 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

29. 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:
i. brittle and
ii. did not resist strong abrasive
forces, exhibiting frequent
fracture and dislodgement.

30. 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.

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

32. 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.

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

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

35. • Remove the ID Tab and tab connector with a
scissor.

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

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

38. 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

39. • 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.

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

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

42. 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.

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

44. 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 .

45. 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.

46. 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.

47. 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.

48. • 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.

49. • 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).

50. 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.

51. 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.

52. • 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.

53. • 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.

54. • 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.

55. • 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.

56. 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.

57. 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

58. • 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).

59. 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

60. 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

61. 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

62. 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.

63. 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)

65. 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

66. 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

67. ZIRCONIA PEDIATRIC
CROWNS
Ceramic/
Zirconia
crowns
ZIRKIZ crown EZ crown Kinder krown

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

69. • 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.

70. 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- 1st and 2nd molar
Rough external
surface for easy
handling
Length- regular & short
No
contamination
provides better
retention
Shade pedo 1 and pedo 2

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

72. • 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.

73. • 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.

74. • 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.

75. • 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.

76. • 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.

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

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

79. 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.

80. • 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)

81. • 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.

82. • 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.

83. 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

84. • 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.

85. • 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

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