Preformed metal crowns

Fiona Gilchrist Clinical Lecturer in Paediatric Dentistry

Aims
To discuss the indications and contraindications of preformed metal crowns To discuss different techniques for placing preformed metal crowns

Learning objectives
Participants should:
Understand the reasons for using preformed metal crowns Have knowledge of different preparation techniques

What are they?

Preformed metal crowns No impressions, no laboratory stage
Pre-contoured and pre-crimped

Preformed metal crowns (PMC)

3M ESPE surgical grade stainless steel primary molar crowns 6 different sizes per tooth (sizes 2-7) Size located on the buccal aspect

When to use primary teeth

Teeth with large or multisurface carious lesions Pulp treated teeth Trauma Enamel and dentine defects Abutment for crown-loop space maintainer Infraoccluded teeth to maintain mesial/distal space height of the tooth is lower

and when not to use in primary teeth

Unrestorable tooth Failed pulp therapy Soon to exfoliate Cautions
Severe wear / severe space loss Poor cooperation Poor motivation? Multiple grossly carious teeth

When to use permanent teeth

Hypomineralised molars Amelogenesis imperfecta Dentinogenesis imperfecta Severe erosion Temporary restoration

Advantages of PMCs
Straightforward technique Quick and cheap Evidence of excellent longevity, low failure rates, compare well with other materials Failure, if occurs, is easily corrected

Disadvantages
Poor aesthetics May impede eruption of adjacent teeth if too big May cause gingival inflammation if cement not removed completely Theorectical nickel allergy risk

Evidence
Randall, Vrijhoef and Wilson (2000)
Systematic review Ten studies, 1975 -1997, duration 1.6 - 10 yrs Failure rate 1.9 30.3% for SSCs vs. 11.6 88.7% for amalgam SSCs had greater longevity, reduced retreatment need All studies favoured treatment with SSCs

Selling them
Parents often dont like the look of them Children love them!
Princess/Barbie teeth Tooth jewellery Pirate tooth Bling!

Things to tell the patient/parent

They stay on until the tooth falls out They need to be brushed just like normal teeth The glue tastes a bit like lemons/salt and vinegar crisps They feel a bit funny to bite on to start with

Patient/parent experiences
I say Im from Mars Call it a pirate tooth

Special tooth My tooth feels better Makes me feel like a princess

I dont really like the look of the silver crowns but if they are helping my sons teeth then thats all that matters

Childs opinion
What do you think about your silver tooth?
I really like my silver tooth 64%
I don't mind my silver tooth 29% I really hate my silver tooth 7%

Parents opinion
I have no concerns about how the silver crown looks
0% 7% 7% Strongly agee Agree No opinion 29% 57% disagree strongly disagree

Chris, age 5

Age 7, at follow-up, 2 years after completion of treatment

Conventional technique

You will need

Essential materials
Whole box of crowns Topical/LA Diamond burs Adams pliers Cement Dental tape - knotted

You will need

Optional materials
Rubber dam Crown scissors Crimping pliers Orthodontic band seater

Airway protection
Child sitting slightly upright Rubber dam Gauze Adhesive handle

Innes et al. 2007

Technique
1. 2. 3. 4. 5. 6. 7. Topical/LA Remove caries Pulpotomy/pulpectomy if needed Prepare tooth Select crown Adapt crown or modify prep Cementation

Occlusal reduction

Mesial and distal reduction

Finishing touches

Select a crown

Adapt the crown / modify the prep

Coping with:
Poorly adapted crown margins Space loss Gingival blanching Occlusal discrepancies

Cementation
Choice of cement Glass ionomer (Aquacem) Polycarboxylate (Poly F) Zinc oxide eugenol (Kalzinol)

Clotted cream consistency Enough to fill the crown Remove excess with knotted floss

James, age 8

Liam, age 6

The Hall technique

The Hall Technique

No tooth preparation No local analgesia No try-in Not for extensively carious teeth Caries not removed, but sealed into the tooth to isolate it from the mouth

The Hall Technique

Tooth asymptomatic Child not at risk of endocarditis Pre-operative radiograph +/- separators Airway protection Occlusion

The Hall Technique

Innes N, Evans DJP, Stirrups DR (2007)
Split mouth RCT 132 children, aged 3-10 17 GDPs in Tayside, Scotland Clinical and radiographic follow-up

Main outcomes after 2 years

(n=124 conventionally treated teeth + 124 Hall teeth)

Innes and Evans (2007)

Dentists' estimation of discomfort experienced by child

(n = 132 children) Innes, Evans and Stirrups (2007)

Patient/carer/dentist treatment preference

(n = 396 for 132 treatment events)

Innes, Evans and Stirrups (2007)

Technique
If necessary place separators 1 week before Measure space Topical Choose crown Airway protection Try crown to contact point only

Technique
Fill crown with glass ionomer cement Push down as far as possible Allow child to bite on band seater/cotton wool roll
Innes et al. 2007

Technique
Remove excess cement with wet gauze Get child to bite together Remove further cement with gauze Knotted floss between contact points

Patient instructions
May be a little uncomfortable afterwards Advice about analgesia Occlusion will be propped open but will settle

Further reading
Innes N, Evans D. The Hall Technique. A child centred approach to managing the carious primary molar. A Users Manual. University of Dundee. www.scottishdental.org/?o=1404 Welbury R R, Duggal M S, Hosey M T. Paediatric Dentistry. Oxford Medical Publications, 2005, Ch 9. Kindelan SA et al. Stainless steel preformed crowns for primary molars, UK National Clinical Guidelines in Paediatric Dentistry. International Journal of Paediatric Dentistry, 1999; 9:311-314. http://www.bspd.co.uk/publications.html