STAINLESS STEEL

CROWNS IN PEDIATRIC
DENTISTRY


PRESENTED BY:
RISHU CHWLA
MDS STUDENT
DEPT. OF PEDIATRIC &
PREVENTIVE DENTISTRY

CONTENTS
INTRODUTION
DEFINITION
GOALS AND OBJECTIVES
IDEAL CHARACTERISTICS OF CROWNS
CLASSIFICATION
STAINLESS STEEL CROWNS
Classification
Composition
Indications
Contraindications
Advantages
Disadvantages
Preoperative evaluation
Clinical procedure




STAINLESS STEEL CROWNS FOR PERMANENT MOLARS

SPECIAL CONSIDERATIONS FOR STAINLESS STEEL CROWNS:
o Quadrant dentistry
o Crowns in areas of space loss
o Preparing a stainless steel crown adjacent to a class-ii amalgam restorations
STAINLESS STEEL CROWN MODIFICATIONS

The undersized tooth or the oversized crown
The oversized tooth or the undersized crown
Deep subgingival caries
Open contact
Open faced stainless steel crowns



COMPLICATIONS OF STAINLESS STEEL CROWN
RESTORATIONS

CAUSES OF STAINLESS STEEL CROWN FAILURES

CONCLUSION

REFERENCES

INTRODUCTION
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
While originally intended for the restoration of posterior
primary and young permanent teeth, its use was expanded to
badly decayed anterior teeth



CROWN

Full coverage restoration given in grossly carious
tooth so as to prevent loss of remaining tooth
structure and to maintain normal form and
function of the tooth.

Anterior teeth
Posterior teeth







Goals:

To achieve biologically compatible, masticatorily
competent and clinically acceptable restoration.

To maintain the form and function and where
possible, the viability of the tooth.

Objectives:

Elimination of all carious tooth structure
To reestablish proper occlusal contacts.
To reestablish normal mesio-distal and coronal dimension
for maintenance of arch length and spatial relationship.
To cause no periodontal pathosis due to coronal contours
or marginal fit.
Minimum of treatment time for crown placement.
Avoid patient discomfort during or after crown
placement.
To create a restoration that will not require further
clinical treatment before natural exfoliation of the tooth.

IDEAL CHARACTERISTICS OF CROWNS:

Represent the natural tooth.
Match with the color of the adjacent teeth.
The dimension of the crown i.e. the mesiodistal width
should be in proportion.
Restore the function and esthetics of the tooth it
represents and should help in maintaining adequate
arch length.
Biocompatible with the surrounding structures.
Economical.

CLASSIFICATION

According to form and Contour:

Untrimmed, uncontoured, uncrimped crowns.

Pre-contoured and untrimmed crowns.

Pretrimmed, precontoured and precrimped crowns.


According to materials used:

Stainless Steel Crowns.

Nickel Chromium Crowns.

Polycarbonate crowns.

Pedo strip crowns.

According to the location:

Crowns for anterior teeth.

Crowns for posterior teeth.


STAINLESS STEEL CROWNS
Introduced by Humphrey as chrome-steel crowns in 1950.

Provides a simple and expeditious means of restoring extensively
carious primary teeth.

Introduced by Humphrey as
chrome-steel crowns in 1950.

Provides a simple and expeditious
means of restoring extensively
carious primary teeth.
Preformed Metal Crowns (PMCs)
Classification:

According to Trimming

Untrimmed Crowns e.g. Rocky Mountain

Neither trimmed nor contoured
Require lot of adaptation
Are time consuming

According to Trimming

Pretrimmed Crowns e.g. Unitek & Denovo

Have straight non contoured sides
but are festooned to follow
a line parallel to the gingival crest

Still require some contouring
& festooning


According to Trimming

Precontoured Crowns
e.g. Nickel-Chrome Ion crowns & Unitek

Are festooned & precontoured, though
minimal amount of festooning & trimming
may be necessary

Preveneered SSC:

Resin based composite bonded to occlusal and
buccal surface of crown.

More acceptable esthetically
II. According to Composition:

SSC - 3M

Nickel-chromium Crowns - Iconel

According to Occlusal Anatomy:

Ion - Compact Occlusal anatomy

Unitek - Best Occlusal anatomy
Rocky mountain - Occlusally small
Ormaco - Smallest and least occlusally
carved
COMPOSITION
Stainless Steel Crown

17 19 % Chromium
10 13 % Nickel
67 % Iron
4 % Minor elements (0.08 0.12% carbon)

Austentic type provide the best corrosion resistance of all stainless steels.

COMPOSITION
Nickel Base Crowns
Inconel 600 type of alloy

72 % Nickel
14 % Chromium
6 10 % Iron
0.04 % Carbon
0.35 % Manganese
0.2 % Silicon

These alloys have good formability & ductility necessary for clinical adaptation
of crowns & wear resistance to resist opposing forces.

COMPOSITION
Stainless steel are low carbon alloy steels that contain at
least 11.5% chromium. There are three general classes of
stainless steel :
Heat hardenable 400 series martensitic types
Non heat hardenable 400 series ferrite types
Austenitic types of chromium nickel manganese 200 series
Chromium nickel 300 series.

Rocky mountain and Unitek stainless steel crowns use the
austenitic types for their crowns referred to as 18-8
since they contain about 18% chromium and 8% nickel.

The austenitic types have high ductility , low yield strength ,
which make them outstanding for deep drawing and forming
procedures.

They are readily welded and can be work hardened to high
levels.

The austenitic types provide the best corrosion resistance of
all of the stainless steels.

Chromium contribute to the formation of a very thin surface
film , probably oxide that protects against corrosive attack.

INDICATIONS OF STAINLESS STEEL CROWNS

Extensively carious primary or young permanent teeth



For teeth deformed by developmental defects or anomalies
Enamel dysplasias
Dentinogenesis imperfecta




Following Pulp therapy
Large, Deep Caries
Caries on 3 or more surfaces
Temporary Restoration of a Fractured Tooth
As a part of Space Maintainer
In severe cases of Bruxism (an
additional layer of solder is added on to
the occlusal surface. This is called as
Crolls Technique)
For teeth with Hypoplastic defects
As a Preventive Restoration
In a Handicapped Child
Single tooth Crossbite
For Replacing Prematurely Lost Anterior
Teeth
Pinkenon suggested that indications for placement of
PMC should include child patients who are unlikely
to attend regular recall appointment

Teeth approaching exfoliation within 6 to 12 months
should not be fitted within PMC
AAPD Consensus on Use of SSCs
Children at high risk exhibiting anterior tooth decay and/or molar
caries may be treated with SSCs to protect remaining at-risk surfaces.

Extensive decay, large lesions or multiple surface lesions in primary
molars should be treated with SSCs.

Strong consideration for use of SSCs in children who require GA

INDICATIONS IN PERMANENT MOLAR
TEETH
1. Interim restoration of a broken down or a traumatized tooth until
construction of a permanent restoration can be carried out

2. Financial considerations

3. Teeth with developmental defects

4. Restoration of a permanent molar which requires full coverage but is
only partially erupted.

Requirement of SSC is more frequently in deciduous
than permanent teeth because :

In a relatively small deciduous tooth, neglected caries can destroy the
tooths integrity faster than in the larger permanent tooth.

The morphology of primary molar differs from permanent :
o Enamel and dentin are much thinner than permanent tooth
o Greatest convexity at the cervical third of the crown
o Pulp is large with prominent pulp horn








Primary vs. Permanent
CONTRAINDICATIONS:

relative contraindications include:

For anterior teeth due to poor aesthetics.

Primary posterior teeth in which conservative amalgam
restorations can be placed.

Tooth near to exfoliation (in deciduous teeth in which half
of roots have resorbed).

As permanent restoration in permanent dentition.


ADVANTAGES
superior to multisurface amalgam restorations with respect to both life
span and replacement and most advantageous system, of restoration
because of its retention and resistance.

They are acceptable to both the patient and the dentist.

cost effective
DISADVANTAGES

Untrimmed crowns: (Rocky Mountain):

These are neither trimmed nor contoured.

Require lot of adaptation and thus are time
consuming

AVAILABILITY OF STAINLESS STEEL
CROWNS:

six sizes for each primary tooth and permanent first
molars.

Sizes 4 and 5 .. most often used.

size 7 extra large teeth.

Also available for primary incisors and canines and
permanent incisors form

Armamentarium
Crown cutting burs- pear shaped,
tapered fissure burs

Howe pliers, No-114 contouring plier,
crimping plier, No.112 ball & socket
plier.

Crown and bridge scissors.

Crown remover.

Stone, finishing burs.

Miscellaneous: Straight hand piece
micromotor, articulating paper etc.

Green stone, rubber wheel, wire brush
PREOPERATIVE EVALUATION

Dental Age of the Patient

Co-Operation of the Patient

Motivation of the Parents

Medically Compromised/Disabled Children

STAINLESS STEEL CROWNS VS. AMALGAMS

70% - 75% of large multi surface silver amalgams placed
at ages 2-5 will need replacement before the age of 8.

Have a longer clinical life span than 2 or 3 surface
amalgam restorations (survival time up to 40 months as
compared to amalgam which is 30-32 months).

Rate of replacement is also low
( 3%) as compared to Class II amalgam restorations (
15%).

Braff in 1975 reported success rate of 70% for crowns
and 11% for amalgams.

Gordon 1978, Lilienfeld & Lilienfeld 1980 showed that
crowns placed in children age 4 or younger
demonstrated a success rate approximately twice that
of Class II amalgams, for each year up to 10 years of
service

Dawson ( 1981) compared lifespan of SSC and two
surface amalgams. It was determined that SSC was
the restoration of choice for primary molars,
especially for multisurface restorations in the first
molar before the eruption of the 1
st
permanent molar.

data form studies Comparing Preformed Metal Crowns with Multisurface Amalgam Restoration in Primary Molar Teeth
Study reference and date Multisurface amalgam Preformed metal crown Study duration
Number Placed Failures Number Placed Failures Years
Braff 1975 150 131(87%) 76 19 (25%) 2.5
Dawson et al 1981 102 72 (71%) 64 8(13%) 2 minimum
Messer & Levering 1988 1177 255(22%) 331 40(12%)) 5
Roberts and Sherriff 1990 706 82 (12%) 673 13(2%) 10
Einwag and Dinninger 1996 66 38 (58%) 66 4(6%) 8
Raw data total (raw data %) 2201 578 (26%) 1210 84(7%) Mean=5y
Advantages of stainless steel crowns over amalgam restorations.
low cost
less chair time
protection of tooth from further decay
Availability of many sizes
Durability
resistance to tarnish
absence of mercury
the ability to regain vertical dimension and retain occlusion,
maintenance of morphologic form to preserve the health of
gingival tissues
the ability to preserve arch length
1. Administer L.A

2. Isolation

3. Remove the decay

4. Selection of crown = mesial-distal dimensions of the tooth
The crown must be large enough to fit over the height of contour
of the tooth

If the crown is not selected before the tooth reduction, then after
the tooth reduction it can be selected as a trial and error
procedure which approximates the mesial-distal width of the
crown. The smallest crown that completely covers the preparation
should be chosen.

CLINICAL PROCEDURE FOR POSTERIOR TEETH

Impingement upon the primate space by an
oversized crown may prevent early mesial
migration of the mandibular first permanent
molar from a cusp to cusp occlusion into an
Angle Class I relationship (Baume 1950).

Similarly, overcontoured and oversized steel
crowns on second primary molars can prevent
the normal eruption of the first permanent
molars.




CONSIDERATIONS ABOUT TOOTH PREPERATION
Humphrey (1950) recommended that the cusps be reduced if
necessary , and that the four sides of the tooth be reduced but as
much as tooth structure as possible be left for retention.

Rapp advises that the occlusal of the tooth be reduced so the
height of the preparation is approximately 4mm from the gingival
margin.

Mink and Bennett, suggest a uniform occlusal reduction of 1 to
1.5mm using 1mm bur to make grooves in the occlusal surface to
guide the reduction.

Troutman (1976)recommends the occlusal surface to be reduced to
1mm and Kennedy (1976) recommended the reduction to be 1.5 to
2mm.


Aims of tooth preparation

Provide sufficient space for the steel crown.

Remove the caries

Leave sufficient tooth for retention of the crown.

Occlusal Reduction

69 L or 169 L bur or
a tapered diamond
bur

Depth cuts of 1.0-1.5
mm


Proximal reduction.

Wedges are used to separate
the adjacent teeth

10 degree convergent to the
occlusal surface

Feather edge margin


Buccal/Lingual reduction

Generally not required ( infact undercut aids in retention).


Prominent buccal bulge in 74,84


Done in cases of

Prominent cusp of carabelli in
55,65 & first molars.

Round all line angles:

By holding bur at 30- 40
0

angle.

Sweeping motion in
mesio distal direction
Evaluation Criteria for Tooth Preparation:


The occlusal clearance is 1.5 to 2mm. (A sheet of wax may be
used to indicate areas of insufficient reduction.)

The proximal slices converge towards the occlusal and
lingual, following the normal proximal contour.

An explorer can be passed between the prepared tooth and
the proximal tooth at the gingival margin of preparation.
The buccal and lingual surfaces are reduced at least 0.5
mm with the reduction ending in a feather edge, 0.5 to
1mm into the gingival sulcus.

The buccal and the lingual surfaces converge slightly
towards the occlusal.

All the point and the line angles in the preparation are
rounded and smoothed.

The occlusal third of buccal and lingual surfaces are
gently rounded.


Which surface should be reduced first

Proximal or Occlusal ??????
If proximal reduction is done first , some gingival bleeding will occur.

If blood gets on preparation, it will make diagnosis of very small pulp
exposure difficult.

Occlusal reduction first, removing any caries along.

perform pulp therapy and then proceed with proximal reduction.

Reducing supragingival bulge with reduction
extending 0.5mm below the gingival crest
helps to obtain acceptable gingival response
SEATING THE CROWN

Seat the lingual first and applying
pressure in a buccal direction so
that the crown slides over the
buccal surface into the gingival
sulcus.

Resistance should be felt as the
crown slip over the buccal bulge.
No blanching of gingival tissue should occur.

Adjacent proximal contact must be maintained.

The occlusal relationship must be reestablished as per the
original status.

Adjacent marginal ridge heights should
be at the same level.

If there is a discrepancy in marginal ridge heights,
following situations may exist:

The selected crown may be too long
A gingival ledge may be present
Contact may still exist between the adjacent
teeth
There may be inadequate occlusal reduction
Gingival blanching slight
trimming of the crown with
scissors or a wheel stone.

The crown normally
extends 1mm into the
gingival sulcus.

level of the gingival crest is
marked on the crown using
a sharp instrument and the
crown is trimmed 1mm
below this mark.


ADAPTATION OF THE CROWN:

Crown Contouring

Ball and socket pliers in the middle 1/3
rd

of the crown to produce a belling effect.

Gives the crown a more even curvature.

Adaptation of the gingival 1/3
rd

of the crown is done with the 137
Gordon pliers to reduce the marginal
circumference of the crown.

Principles for obtaining optimal adaptation
(by Spedding 1984)
1. Crown Length:
- Be 1mm sub-gingivally.
- Extend slightly apical to tooths height of
contour

2. Shape of the crown's gingival margins

Outline for the buccal and lingual gingiva for 2
nd

primary molars is similar to a smile.
The buccal gingiva of the 1
st
primary molar is that of
a stretched out S
The proximal contours of the primary teeth
approximates that of a frown.



CROWN CRIMPING

Done for final close
adaptation of crown to
tooth surface.

Done in cervical margin
1 mm circumferentially.

No. 137 plier, No. 800-
417 (Unitek) plier can be used.


Before crimping & after crimping.
Mechanical retention of the crown

Protection of cement from exposure
to oral fluids

Maintenance of gingival health

Checking the Final Adaptation of the Crown:

snap into place & an audible click under biting pressure on a
tongue blade / band seater should be there.

no rocking on the tooth.

The properly seated crown will correspond
to the marginal ridge height of the adjacent
tooth

Crown is in proper occlusion

The crown margin extends about 1 mm gingival to gingival
crest.

No opening exists between the crown and the
tooth at the cervical margins.



Restoration enables the patient to maintain
oral hygiene.

FINISHING AND POLISHING

Done to avoid complications associated with plaque accumulation &
gingival inflammation due to rough & unpolished restoration

A broad stone wheel should run slowly, in light brushing strokes, across
the margins towards the center of the crown. Blunt margins

draw the metal closer to the tooth without reducing the crown height and
thus improves the adaptation of the crown.

wire brush .polish the margins to a high shine.
rouge whiting or fine polishing material . To give a fine luster to
crown


RADIOGRAPHIC CONFIRMATION OF THE
GINGIVAL FIT:

To verify proximal marginal integrity.

If the crown is too long, there is still an opportunity to reduce the
length.

If it is too short, then adding orthodontic band or adaptation of another
crown is indicated.


CEMENTATION OF THE
CROWN:



Rinse and dry the crown and tooth

Fill the cement to approx. 2/3rd of
crown from inside.

Apply Pressure by opposite end of
mouth mirror or tongue blade.

Ask the patient to close in centric
occlusion before final setting of
cement.

Remove all excess cement when it
sets.
CLINICAL PROCEDURE FOR ANTERIOR TEETH
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.
Remove decay with a medium to large round bur in a
slow speed handpiece. If pulp therapy is required, do
it at this time


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.


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 of Howe
no. 110 pliers to increase the facio-lingual dimension.

Reseat the crown. The crown should extend 1mm under the
gingival margin. The fit of the crown should be snug without
rocking
Trimming, if necessary, is best done with a heatless stone on
a straight slow speed handpiece followed by polishing with a
rubber point.


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.

TRENDS IN STAINLESS STEEL CROWNS:
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.
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
Smooth the cut margins of the crown with a fine green
stone or white finishing stone.

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 polymerize.

Add additional material in 1mm increments and polymerize.
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.
Choice of cement
o Glass ionomer are hybrid of silicate and
polycarboxylate.
o comparable strengths with zinc phosphate
o release fluoride as do the silicophosphate
o chelate or bond to tooth structure and
pulpally compatible as polycarboxylates.

Disadvantage include the radiolucency and
present lack of long term clinical efficacy

Luting Cement Film thickness S.time Comps(mm)
(min.) strength (MPa)
ZnPO4 18 5.5 103.5
ZnOE 25 4-10 27.6
Polycarboxylate 21 5.5 55.2
GIC 24 6.5 86.2
No significant difference in retentivity of stainless steel crown
with the use of either of the three (glass ionomer, Zinc
phosphate and zinc polycarboxylate) luting agents.
Berg et al evaluated microleakage of three luting agents used with
stainless steel crowns. They found that glass ionomer cement provides
comparable protection to that of polycarboxylate and zinc phosphate
cements
Placement technique in permanent
molars
The anatomical variations and practical considerations that
alter the rationale of the preparation for a permanent
tooth compared with that of a deciduous tooth such as:

There are no gross cervical bulges on permanent teeth
that facilitate retention of the crown.

Cusp heights are much greater in permanent teeth.

Conservation of tooth structure is more crucial for teeth
of the permanent dentition
Unlike the primary molar crowns , those for permanent
teeth cannot be left in hyperocclusion

When a caries lesion has extended subgingivally , the
original tooth morphology should be restored either
with bonded composite resin or with amalgam
restoration before commencing the crown preparation.
It is nor recommended to use cement only in these
areas.
For each permanent molar in the arch there are 6 sizes of crowns,
ranging in mesio-distal dimension from 10.7 mm to 12.8 mm,
increasing in approximately 0.4 mm increments.
Principles for obtaining optimal adaptation
(by Spedding 1984)
1. Crown Length:
- Be 1mm sub-gingivally.
- Extend slightly apical to tooths height of contour

2. Shape of the crown's gingival margins

Outline for the buccal and lingual gingiva for 2
nd

primary molars is similar to a smile.
The buccal gingiva of the 1
st
primary molar is that of a
stretched out S
The proximal contours of the primary teeth
approximates that of a frown.



Hall technique
Researchers in the UK have attempted to cement
stainless steel crown without any caries removal or
tooth preparation directly over the carious tooth.
The results to date show that this simple
technique can provide successful restorations in
the short term.
This technique of stainless steel crown placement, is
not advocated at present, the findings of ongoing
studies using this technique may change the
recommendations for its use in the coming years.


Concerns about exfoliation
These crowns donot interfere in any way with
normal exfoliation of primary molars
Stainless steel crown and primary molar crown
being exfoliated together
Retention of stainless
steel crowns
Savide et al compared five different types of preparations for retention
capabilities :

A. occlusal third of both buccal and lingual surfaces is reduced.
(Mink and Bennett)

B. That incorporating class II preparations, in which the buccal and lingual walls
of the boxes converge towards the occlusal.

C. That which reduces the buccal and lingual supragingivally to the gingival crest.

D. That which removes the supragingival bulge, extending 0.5mm below the
gingival crest (Troutman), with all undercuts on the buccal and lingual surfaces
removed

E. That which removes all supragingival tooth structure, permitting only part of
the anatomic crown to remain.


They concluded that mechanical retention does not significantly
contribute to the separation resistance of steel crown.


The results were consistent with Mathewson et al who
concluded that retention was related more to the
cementation than to mechanical adaptation.


Humphrey and Full et al suggested that retention of
stainless steel crowns is related to minimal tooth
reduction and contact between the margins of the
crown and the tooth.

Mathewson et al reported that mechanical retention alone
is not a significant factor contributing to crown
retention

Yates and Hemberee found that the Unitek crown is
significantly more resistant to removal than the Ion
and Rocky Mountain crowns
Myers et al reported that crown retention with cement was
significantly higher than mechanical retention alone.
Stainless steel crown retention with polycarboxylate or zinc
phosphate cement was significantly greater than crown
retention with zinc oxide eugenol cement.

Savide et al observed that tooth preparations which maintain
the greatest amount of buccal and lingual tooth structure
are the most retentive.

Rector et al noticed no significant difference in the retention
of stainless steel crowns using five different tooth
preparations.
LONGEVITY OF STAINLESS STEEL
CROWNS FOR PERMANENT TEETH:


The major factors concerning the longevity of the crown are gingival
recession,
o recurrent marginal caries
o dissolution of the cement
o wearing through on the occlusal surface of the crown.


Stainless steel crown for permanent teeth are not substitute for the
precision cast restoration
SPECIAL
CONSIDERATIONS FOR
STAINLESS STEEL
CROWNS:


QUADRANT DENTISTRY:

Prepare the occlusal reduction of one tooth completely before
beginning the occlusal reduction of the other tooth
Reduce the adjacent proximal surface of the teeth being
restored more than when only one tooth is restored.
Both crown should be trimmed, contoured and prepared for
cementation simultaneously to allow for adjustments in the
interproximal spaces and establish proper contact areas.
To get these adjustments, adapt and seat the crown on the
most distal tooth first and proceed mesially.
CROWNS IN AREAS OF SPACE LOSS (MC EVOY 1977):

Extensive and long standing caries, the primary teeth shift into the
interproximal contact areas. crown required will be too wide M-D
over the M-D space will be too small in circumference.

Select a larger crown which will fit over the tooths greatest
convexity.
Reduce the M-D width by grasping the marginal ridges of the crown
with Howe utility pliers and squeezing the crown.
Recontour the proximal, buccal and lingual walls of the crown with
the No. 137 or No. 114 pliers.


Or The crown is rotated slightly mesiobuccally so that it is rotated
slightly out of the arch.

PREPARING A STAINLESS STEEL CROWN ADJACENT
TO A CLASS-II AMALGAM RESTORATIONS (MC. EVOY
1985)

Crown reduction is complete and the crown is adapted.

matrix band and wedges are placed. Amalgam is inserted and
carved.

With the matrix band in place, the crown is removed safely without
fracturing the amalgam.

Then remove the matrix band and the final carving of amalgam is
done, as there is good visibility and access to the proximal box area.

Now complete the crown adaptation and cement the crown.
STAINLESS STEEL CROWN
MODIFICATIONS
THE UNDERSIZED TOOTH OR THE OVERSIZED CROWN:
- space loss as a result of long standing interproximal caries.

- The crown is cut vertically along the buccal wall.

- The free crown margins are approximated and spot-welded
to reduce the crowns dimensions.



THE OVERSIZED TOOTH OR THE UNDERSIZED CROWN:

- A vertical cut is made on the buccal surface of the crown.

- The margins are pulled apart and an additional piece of
stainless-steel band material is spot-welded to the buccal
surface, increasing the dimensions of the crown.

- After contouring, solder is applied to fill any microscopic
deficiency in seal.

-The crown is polished and cemented.
DEEP SUBGINGIVAL CARIES:

interproximal caries ..

o The unfastened Rockey Mountain crown

o Lengthening the crown with a spot welded and
soldered piece of band material
OPEN CONTACT:

food packing increased plaque retention and subsequently gingivitis.

o Select a larger crown

o Alternatively, exaggerated interproximal contour can be obtained with
a No. 112 (ball-and-socket) plier to establish a closed contact .

o Localized addition of solder can also build out the interproximal
contour.

COMPLICATIONS OF
STAINLESS STEEL
CROWN
RESTORATIONS:

INTERPROXIMAL LEDGE:

Crown does not seat proximally
It is removed using a tapered fissure bur.

CROWN TILT:

Destruction of a complete lingual or buccal wall by caries or overzealous
use of cutting instruments may result in the finished crown tilting
towards the deficient side.

Commonly seen on lingual aspect of mandibular primary molars.

Placement of an amalgam alloy, or glass-ionomer cement restoration

POOR MARGINS:

Imperfect adaptation.

Open margins.

Recurrent caries
plaque retention and subsequent gingivitis

Premature exfoliation of that tooth
PERIODONTAL CONCERNS:

Henderson (1973) reported that the plaque accumulation index
for stainless steel crowned teeth was generally lower than
that for the entire mouth.

A higher degree of gingivitis associated with crowns having a
poor fit.

Myers (1975) reported a close relationship between the
presence of marginal gingivitis and defects in the adaptation
of the crown margin.


AESTHETICS:

First primary molars.

Mesiobuccal facing can be placed after the
crown has been cemented into place.

Roberts (1983)


NICKEL ALLERGY:

Feasby et al (1988), reported an increased nickel-positive patch
test result in children 8 to 12 years of age who had received old
formulation nickel-chromium crowns.

Nickel hypersensitivity is more prevalent in females than males and
is considered to be associated with pierced ears or metal
buttons in clothing.

Two studies (Kerosuo H. 1996 and Hoogstraten IMW 1991)
reported that orthodontic treatment with nickel-containing
stainless steel appliances, if carried out before ear piercing,
appeared to reduce the prevalence of nickel hypersensitivity.

INHALATION OR INGESTION OF THE CROWN:

Immediate chest X-ray is mandatory
If the crown is in the bronchi or lung, medical consolation and
referral will probably result in an attempt to remove it by
bronchoscope.
The presence of a cough reflex in the conscious child
fortunately reduces the chances of inhalation, ingestion of
the crown being more likely.
The Stainless steel crown will usually pass uneventfully through
the alimentary tract within 5-10 days. The parent should
assume the unpleasant task of locating the expelled crown.


Allen described the most common errors in using
stainless steel crowns as
Unnecessary destruction of hard tissue in
preparation
lack of a feather edge around the entire
circumference,
Failure to round all line angles which may
prevent correct seating of the crown
incorrect selection of the crown size.
More and Pink described the causes of stainless steel
crown failure
pulp necrosis
ectopic eruption,
improper contact which may cause space loss,
gingivitis around the crown
insufficient retention leading to loss of a crown
excessive occlusal wear
CARE AFTER TOOTH RESTORATION WITH SSC

Regular diet may be resumed after anesthetic effects
are worn off.
Warm saline rinses.
Proper brushing and flossing
Stainless steel crowns on permanent teeth may need to
be replaced by a cast crown when the child is in his/her
mid to upper teens or later in life.



CONCLUSION
The stainless steel crown enjoys a wide range of use in clinical
Pediatric Dentistry and will continue to be an asset in the
management of the primary and permanent teeth in young
children. However, there is a need for further clinical and basic
science research into the various aspects of the stainless steel
crowns with the advancement of technology and techniques of
conservative dentistry.


References:

Pediatric Dentistry: Infancy Through Adolescence. Pinkham.
Fourth Edition.

Dentistry For The Child & Adolescent. Mc Donald, Avery
Eighth Edition..

Kennedys Paediatric Operative Dentistry. Curzon, Roberts,
Kennedy. edition.

Restorative Techniques in Pediatric Dentistry. Duggal, Curzon, Fayle,
Pollard, Robertson. Second edition

Handbook of Pediatric Dentistry. Acameron.

Pediatric Dentistry. Welburg. Second Edition.

Stainless steel crown in clinical pedodontics: a review. F Salama. The Saudi
Dental Journal, Volume 4, Number 2, May 1992

Efficacy of preformed metal crowns vs. Amalgam restorations in primary
molars: a systematic review . Ros C. Randall. J Am Dent Assoc, vol 131, no 3,
337-343. 2000




A Comparison Between Preformed Stainless Steel Crowns and Simple
Restorations On Primary Molars In A Public Health Dental Program.
Middle east journal of family medicine. June 2008 - Volume 6, Issue 5

UK National Clinical Guidelines in Paediatric Dentistry: stainless steel
preformed crowns for primary molars. S. A. Kindelan International
Journal of Paediatric Dentistry 2008; 18 (Suppl. 1) : 2028

Dental Cements for Definitive Luting: A Review and Practical Clinical
Considerations Edward E. Hill. Dent Clin N Am 51 (2007) 643658