J.
Adv Oral Research
All Rights Res
Indirect composite shell crown: An
Esthetic Restorative Option for Mutilated
Primary Anterior Teeth
Prashanth Sadashiva murthy* Seema Deshmukh*
*MDS Reader, Department of Pedodontics and Preventive Dentistry, JSS Dental College
and Hospital, JSS University, Mysore, Karnataka, India.
Email:prashanth.pedo@gmail.com
Abstract:
Rehabilitation of the mutilated primary
anterior teeth in management of early childhood
caries poses a major challenge to the Paediatric
dentists. The article describes a novel technique of
custom made indirect composite shell crowns
along with a silicone positioner for easier, faster
and accurate rehabilitation of such teeth. The
custom made silicone positioner provided accurate
clinical repositioning of the shell crowns indirectly
prepared. The prepared restorations can be
cemented with the resin luting cement. Not only is
the explained technique faster, it also helps in
restoring teeth with accuracy as the anatomic form
and occlusion could be checked from the lingual
aspect which is never possible clinically. This
technique of restoration is mainly advantageous in
rehabilitation of teeth in very young children.
Apart from the advantages of indirect composite
restoration technique over the direct composite
restorations, the custom made positioner helps in
simultaneous restoration of multiple teeth.
Keywords: Custom made shell crowns, silicone
positioner, indirect composite restoration.
Introduction:
Functional and aesthetic rehabilitation of
the carious mutilated deciduous anterior teeth is a
challenge to the Paediatric Dentist even with
advent of improved restorative material.[1,2]
Changing dietary patterns and habits leading to
increased exposure to cariogenic food substances,
Serial Listing: Print- ISSN (2320-2068)
Online-ISSN (2320-2076)
Formerly Known as Journal of Advanced Dental
Research
Bibliographic Listing: Indian National Medical
Library, Index Copernicus, EBSCO Publishing
Database, Proquest, Open J-Gate.
Journal of Advanced Oral Research, Vol 4; Issue 1: Jan - Apr 2013
CASE REPORT
limited abilities to adequately adopt self-oral
hygiene care practices in children and hectic work
schedule of the parents have all contributed
negatively to the oral health status in children in
developing and developed countries. The relatively
smaller tooth structure in deciduous dentition leads
to faster involvement and loss of the tooth material
in terms of surface area.[3] Following a definite
pattern of existence, the caries in deciduous
dentition, affects the maxillary central and lateral
incisors and in more severe cases also does involve
the maxillary canines.
Rehabilitation in such cases becomes
difficult as multiple teeth are involved. Lesser
dimensions of remaining tooth structure and
normally found deep bite in deciduous dentition
leaves the dentist with very little clearance area for
placement of the anterior restoration. To achieve a
perfect restoration in children, in spite of all these
challenges, requires meticulousness and increased
chairside time.[4,5] The cooperative behaviour in
children being inversely proportional to the
appointment time, it all comes down to the speed
of the dentist and behaviour management skills to
achieve a perfect anterior restoration.
Direct composite restorations, anterior
stainless steel crowns, stainless steel crowns with
composite facing, metal crowns with labial
window covered with direct composites,
polycarbonate crowns and strip crowns are among
the various restorative options available for the
rehabilitation of the carious deciduous anterior
teeth. Restoration using strip crowns is one of the
ideal methods as it overrides the other techniques
with respect to aesthetics, chair side time and
economy. However, strip crowns also has innate
disadvantages like
. It is a direct restorative method with bulk pack
technique which can lead to post-operative
sensitivity.
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. The bulk packing of the material may lead to
incomplete polymerisation 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.
v. In cases of multiple carious teeth restoration, it
is more reliable to restore teeth individually with
strip crowns which require longer chairside time.
To overcome the above mentioned
drawbacks, a novel technique for aesthetic
rehabilitation of the maxillary anterior teeth with
custom made composite shell crowns with an
indirect approach is described. Being an indirect
technique, much of the restorative process is
carried out on the cast reducing the net chairside
time. Further to add to the advantage of time
management and also achieve the desired
perfection of the restoration, a silicone positioner
is used along with the shell crowns.
Case Report:
In this present case report, a 4 year old boy
presented with early childhood caries affecting the
maxillary anterior teeth (Figure 1). After a
thorough case history recording and investigations,
pulpal involvement was ruled out. After caries
excavation with a spoon excavator, full arch
impressions of the maxilla and mandible were
made (as this helps to assess the integrity of the
indirect restoration at occlusion). With the cast
poured and set, double coating of the separating
media was applied (Figure 2A). This acts as a
spacer for the luting resin during the cementation
process. Composite build up was done on the cast
in harmonious relation to the mandibular anterior
teeth such that it covered all the cavitated areas of
the teeth and formed a thin layer on the sound
enamel (Figure 2B). As it forms a complete shell
like structure over the affected teeth, it is called as
Composite Shell Crown. After completion of
indirect restoration on all the teeth the shell crowns
were finished and polished. Before separating the
shell crowns from the cast, a silicone based
positioner was fabricated (Figure 3). The following
features were incorporated during the fabrication
of the positioner.
. The extent of the positioner Bilaterally it
should cover at least one tooth distal to the last
tooth being restored. In The present case for
restoration of 52, 51, 61, 62; the positioner was
made extending from 53 to 63. Such coverage
assists in accurate re-positioning.
. Palatal extension It should cover the rugae
area and at least half of the palatal slope. This
Journal of Advanced Oral Research, Vol 4; Issue 1: Jan - Apr 2013
30
mechanically isolates the teeth to be restored from
the tongue and also aids in stabilization during the
restorative process.
. Labial extension The positioner should cover
only the incisal third of labial surface. Adequate
visualization of the cervical and middle thirds is
essential to assess the proper placement of the
shell crowns as well as to have adequate access to
remove excess luting resin during cementation
process.
v. If spacing is present between the restored teeth,
the silicone should flow and record the details
without any voids.
Once the positioner was prepared, the shell
crowns were then carefully detached from the cast
(Figure 4 A and B). The shell crowns were ready
to be cemented. The silicone positioner was
checked intraorally for accurate fit, initially
without the shell crowns. The teeth to be restored
were etched, rinsed, dried, followed by application
of bonding agent and curing. The shell crowns
were filled with flowable luting resin, placed in the
positioner and transferred intraorally (Figure5).
Excess luting resin was removed with an
applicator tip moistened with bonding agent. Light
curing was done individually over each shell
crown. The positioner was then removed gently
and additional curing of the shell crown was done
from the lingual aspect to ensure complete
polymerization. Since the finishing and polishing
of the shell crowns had been done earlier, there
was very little need for the same clinically (Figure
6).
Discussion:
For the teeth requiring large restorations in
children, crowns are preferable over direct
restorative options. When used as direct
restorations, composites have certain
disadvantages like post operative sensitivity, lack
of patient cooperation for longer procedures
compromising the success of the treatment,
difficulty in restoring the normal anatomic forms
and requiring multiple visits if many teeth are
involved. Hence in these cases indirect restorative
options are preferred. Although various treatment
options are present in children for aesthetic
rehabilitation, most of these are technique
sensitive[6,7]. Restoration of teeth with strip crowns
or polycarbonate crowns is common treatment
option. But these techniques require elaborate
procedure and critical isolation[8,9,10]. Moreover
post operative adjustments cannot be avoided with
these techniques. The technique described in this
paper is a simple restorative option in children
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Figure 1- Early childhood caries affecting 53,
52, 51, 61, 62, 63 in a 4 year old boy
Figure 2- A: Prepared cast after caries
excavation, B: Composite build up on the cast.
Figure 3-Fabrication of the Silicone Positioner.
with minimum chair side time and ability to
restore multiple teeth at the same time. This
method is less technique sensitive and cost
effective. There is no need for post cementation
adjustment as the occlusion can be checked on the
cast from the lingual aspect. It also provides
durable, aesthetic and functional restorative option
for paediatric patients.
Journal of Advanced Oral Research, Vol 4; Issue 1: Jan - Apr 2013
31
Figure 4- A: Composite shell crowns, B: Shell
crowns seated on the positioner.
Figure 5- Cementation of shell crowns using the
positioner
Figure 6- Completed restoration: 52, 51, 61, 62
restored with Composite shell crowns
Conclusions:
To summarise, the technique of custom
composite shell crown restoration with positioner
is one of the convenient techniques to restore
carious mutilated deciduous anterior teeth. The
advantages of the technique being
i) Reduced chairside time.
ii) Better patient compliance.
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iii) Ease of fabrication of accurate restoration
as it is done on the cast.
iv) Visualization of restoration form and
integrity from the lingual aspect on the
cast, which cannot be done clinically.
v) Reduced polymerization shrinkage effect
(post-operative sensitivity) as the curing
process is extraorally done.
vi) Isolation becomes essential only during
cementation, which can be easily achieved
with the positioner.
vii) Multiple restorations can be seated and
cured simultaneously as a custom made
positioner is used.
viii) Minimal intervention with less amount of
tooth preparation ensuring minimal
mechanical pulpal irritation.
ix) Functional contacts can be achieved in
closed dentition cases unlike in strip
crowns where achieving functional
contacts is not possible as removal of strip
crown results in development of spaces.
x) Relatively better adaptation and less
marginal microleakage compared to direct
composite restorations.[11]
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Source of Support: Nil
Conflict of Interest: No Financial Conflict
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