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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 4  |  Page : 83-87

Anterior and posterior crowns in primary dentition: A contemporary review


1 Oi/c Dental Centre, INHS Sanjivani, Kochi, Kerala, India
2 INHS Sanjivani, Kochi, Kerala, India

Date of Submission09-Aug-2020
Date of Acceptance20-Sep-2020
Date of Web Publication27-Nov-2020

Correspondence Address:
Dr. Dempsy Chengappa MM
Oi/c Dental Centre, INHS Sanjivani, Naval Base, Kochi 682004, Kerala.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJO.INJO_35_20

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  Abstract 

One of the most common problems faced by clinicians in pediatric dentistry is to provide restorations in primary and young permanent teeth which are aesthetically acceptable, durable and cost effective. A wide range of crowns are available for this purpose and the selection of the most appropriate crown will help achieve better final outcomes of treatment. The vary widely from being the directly bondable to the tooth surface to crowns which are luted onto the tooth surface. They may also vary in composition from metal crowns with or without facings to resin, polycarbonate, and ceramic crowns. This review attempts to assimilate and bring out the varied array of pediatric crowns available in the published data for utilization by the pedodontist as per the needs of the patient. The knowledge of the available resources and the various advantages, disadvantages and properties of the same will go a long way in enhancing the clinician’s ability to make the most appropriate choice for the patient.

Keywords: Aesthetic crowns, pediatric crowns, pediatric zirconia crowns, primary dentition, stainless steel crowns


How to cite this article:
Chengappa MM D, Kannan A, Sharma D. Anterior and posterior crowns in primary dentition: A contemporary review. Int J Oral Care Res 2020;8:83-7

How to cite this URL:
Chengappa MM D, Kannan A, Sharma D. Anterior and posterior crowns in primary dentition: A contemporary review. Int J Oral Care Res [serial online] 2020 [cited 2021 Jan 24];8:83-7. Available from: https://www.ijocr.org/text.asp?2020/8/4/83/301701




  Introduction Top


Early childhood caries (ECC) is the presence of one or more cavitated or noncavitated carious lesions before a child’s sixth birthday. Severe early childhood caries (S-ECC) is smooth surface caries in a child less than three years old.[1] Recent reports from several studies show that the incidence of ECC in India is about 40%–60%.[2] ECC has consequences not only for the teeth of the affected child but also for the child’s general health as brought out by the Surgeon General of the USA stating “You cannot be healthy without good oral health.”[3] The consequences of ECC can range from pain, sepsis, space loss, disruption of quality of life, disruption of growth and development, possible disruption of intellectual development, higher incidence of hospitalization, increased treatment costs, and greater risk of new carious lesions in both primary and permanent dentition.[4],[5],[6],[7],[8],[9] Thus, it becomes the responsibility of the Pedodontist to restore teeth affected by ECC to repair or limit the damage from caries, protect and preserve tooth structure, re-establish adequate function, restore aesthetics, and provide ease in maintaining good oral hygiene.[10],[11]

Restoration of primary teeth differs from the restoration of permanent teeth, due to the differences in tooth morphology. Mesiodistal diameter of a primary molar crown is greater than the cervicoocclusal dimension. There is a convergence of buccal and lingual surfaces towards the occlusal surface. Enamel and dentin are thinner in comparison to the permanent dentition. The cervical enamel rods slope occlusally, ending abruptly at the cervix rather than being oriented gingivally and gradually becoming thinner as in permanent teeth. As compared to permanent dentition the pulp chambers of primary teeth are proportionately larger and closer to the occlusal surface. The contact areas in primary dentition are broad and flattened as compared to a small distinct circular contact point in permanent teeth. The shorter clinical crown heights of primary teeth also affect ability of these teeth to adequately support and retain intracoronal restorations. Even young permanent teeth exhibit characteristics that are unique and need to be considered in restorative procedures, such as large pulp chambers and broad contact areas that are proximal to primary teeth.[12]

Aesthetic crowns and stainless-steel crowns for primary teeth offer a practical alternative with distinctly enhanced success rates as compared to multisurface restorations. The lifespan of multisurface amalgam restorations is markedly shorter in the primary dentition than in the secondary dentition.[13] This review article aims to provide the dental practitioner with the various alternatives available to manage carious lesions related to ECC in the primary dentition.


  Crowns for Anterior Teeth Top


A variety of aesthetic restorative materials are available for restoring primary incisors. Knowledge of the specific strengths, weaknesses, and properties of the materials will help the clinician to make the best choice for each situation. The class III and class V restorations in primary dentition are highly technique sensitive and depend largely on isolation, hemorrhage control from the gingiva morphology and anatomy of primary dentition.[14] The anterior aesthetic crowns are a more reliable alternative and can provide the child with a more esthetic alternative.

Indications for anterior full coronal restorations:

(1) multisurface carious lesions are present, (2) the incisal edge is involved, (3) large cervical areas of decalcification, (4) in cases where pulpal involvement and pulpal therapy is indicated, (5) when caries is incipient, but oral hygiene is very poor, and (6) the child exhibits behavior management problems making moisture control very difficult.

The various types of crowns available for restoring anterior teeth can be divided into two main types (1) those that are preformed and held onto the tooth by a luting cement, and (2) those that are bonded to the tooth [Table 1].
Table 1: Esthetic crowns for primary teeth

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Anterior stainless-steel crowns

Preformed stainless steel crowns (SSC) are considered to be the most durable and reliable for restoring severely carious deciduous incisors. SSCs have been found to be easy to place, fracture proof, wear resistant, and attached firmly to the tooth until exfoliation. The silver metallic appearance was the main disadvantage as brought out by Croll. The other alternative was the use of a stainless-steel crown in which a labial fenestration was made in which a resin or composite material was placed to improve the aesthetics. This technique provided a great improvement in aesthetics although it was time-consuming and the metal margins could be seen.[15],[26]

Resin-veneered stainless-steel crowns

The resin-veneered stainless-steel crowns were introduced in the early 1990s. There are many commercially available brands of veneered SSCs in the market today, for example, Kinder Krowns, NuSmile, and Cheng Crowns. The lingual margins can be crimped improving the marginal fit of the crowns [Table 1]. More recently, a resin-veneered crown—Dura Crown (Success Essentials Space Maintenance Laboratory, Chatsworth, Calif)—was introduced. This crown has the labial gingival margin crimped and resin adapted to the gingival edge of the anterior aspect of the crown. The failure of the resin veneer and metal bond leading to chipping off exposing the metal margins is a major disadvantage. Most of the failures were observed commonly at the resin-resin margins and resin-metal interface.[16],[17]

New millennium crowns

These crowns are made up of Lab enhanced composite resin material which is expensive. They are quite similar to Pedo jacket crowns. They can be trimmed easily but are brittle. These crowns are bonded to the tooth. There are no long-term studies available with respect to these crowns.[18]

Polycarbonate crowns

Polycarbonate crowns are heat-molded acrylic resin used to restore anterior primary teeth. Although more esthetic than the SSCs, the polycarbonate crowns are easy to trim and can be adjusted with pliers. These crowns do not resist strong abrasive forces thus leading to occasional fracture.[19]

Strip crowns

Strip crowns are celluloid crown forms, which are a popularly used for restoring primary anterior teeth. These crown forms provide superior aesthetics when compared to other forms of full coronal anterior coverage. The procedure of their placement is very technique sensitive and care must be taken in patient selection, moisture and hemorrhage control, tooth preparation, adhesive application, and resin composite placement. These crowns rely on dentin and enamel adhesion for retention, the presence of enough tooth structure for bonding of the composites is essential for the long-term success of these crowns. The name strip crown has been coined because after the composites are cured on the tooth surface the colloid crown forms are stripped from the surface.[20]

Artglass crowns

These crowns contain bifunctional and new multifunctional methacrylates forming a cross-linked, three-dimensional polymers. The filler content in these polymers is 75% and the fillers used are microglass and silica which provide greater durability and aesthetics. They are color stable, wear of polymer glass is like enamel, kind to opposing dentition, and is plaque resistant. They are available in one shade and in 6 sizes for primary central, lateral, and cuspid teeth. The major cause of failure regarding these crowns is due to bond failures.[21]

Zirconia crowns

These crowns are new to pediatric dentistry and have the advantage of superior aesthetics. They are commercially available in the market as various brand names, for example, EZ Pedo, Nu Smile ZR, Zirconia Kinder Krowns, and Cheng Zirconia Crowns. Zirconia is one of the most promising ceramics with enhanced mechanical properties and excellent aesthetics. It has the added advantage when used for pediatric crowns over preveneered stainless steel crowns of higher fracture resistance and flexural strength.[22]


  Crowns for Posterior Teeth Top


Morphology of a primary molar tooth differs significantly from its permanent successor, especially with respect to its greatest convexity at the cervical third of the crown. This undercut can be utilized for the retention of the crown whose margin can be crimped to fit into the cervical constriction. Enamel and dentin of the primary molar crown are proportionally much thinner than in the permanent tooth and are relatively susceptible to caries attack. Primary pulp is large with prominent pulp horns and is situated near the mesial surface of the tooth crown, particularly in mandibular primary molars. This is important as it makes cavity design to be very conservative. This design coupled with difficulty in isolation and hemorrhage control is the cause for most failures in restorations in posterior primary dentition. Variety of crowns available for restoration of posterior primary teeth include stainless steel crowns, custom made composite, and acrylic crowns.

Stainless steel crowns

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 their advent, the treatment for grossly decayed primary teeth was by means of extractions. Stainless steel crowns are prefabricated crown forms that are adapted to individual teeth and cemented using a biocompatible luting agent.

Full coverage coronal restorations may be indicated in posterior primary teeth when:

  1. Children at high risk exhibiting anterior tooth caries and/or molar caries may be treated with crowns to protect the remaining at-risk tooth surfaces.


  2. Children with extensive decay, large lesions, or multiple-surface lesions in primary molars, developmental defects (e.g., hypoplasia, hypocalcification) should be treated with crowns.


  3. Strong consideration should be given to the use of crowns in children who require general anesthesia, for example, special children who may not be able to maintain good oral hygiene.[23]


In children with high caries-risk, the definitive treatment of primary teeth with SSCs has shown better results over time than multi-surface intra-coronal restorations. Review of the literature comparing SSCs and Class II amalgams concluded that, for multi-surface restorations in primary teeth, SSCs are superior to amalgams.[24]

Composite crown-form

With increased expectations of parents and children towards aesthetics as well as function, together with improved diagnostic and material advances, aesthetics has become particularly important. These developments include the availability of improved composites for anterior and posterior use. Composite crown-form crowns can be used to restore severely decayed primary molars. Etching is performed followed by bonding and curing with halogen light. Crown form matrices are filled with a composite resin and placed over the decayed teeth from lingual to buccal. The crowns are then cured for 20s on each side of the tooth. The crown form matrix is removed with a sharp carver, margins are polished, and occlusion is checked using an articulating paper and high points reduced.[25]

Zirconia crowns

Zirconia crowns for restoration of primary posterior teeth are a more aesthetic option compared to SSC’s. The other advantage of zirconia crowns is that they have good mechanical properties in terms of high fracture resistance and flexural strength; however, to achieve these properties these crowns are thicker compared to stainless steel crowns and hence have the disadvantage of greater tooth preparation. The other significant drawback is the increased cost of zirconia crowns in comparison to stainless steel crowns. These crowns are available in the market in brand names such as EZ Pedo, Nu Smile ZR, Zirconia Kinder Krowns, and Cheng Zirconia Crowns.[26],[27]


  Conclusion Top


ECC is a significant public health problem in both developing and industrialized countries which continues to affect babies and preschool children worldwide.[2] ECC is not life-threatening but causes symptoms, for example, tooth ache, systemic infection, effect on speech articulation, growth, and dietary practices. This ultimately influences nutrition, concentration, and subsequently school participation. Many options exist to repair carious primary teeth, as restorations in primary teeth are more difficult to do and may not last for a long period because of their anatomical and morphological considerations. There are a variety of crowns available for restoration of deciduous teeth and these crowns have been in use for years with much success. 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 outcome is chosen.[28] It is therefore very important to take into account the findings of various clinical studies before choosing the restorative techniques for a child. The Pedodontist needs to keep abreast with the latest restorative techniques and keep in touch with the newer techniques available to provide comprehensive care for children using these crowns to not only restore function but also to provide superior esthetics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Waggoner WF Restorative dentistry for the primary dentition. In: Pinkham JR, editor. Pediatric Dentistry: Infancy through Adolescence. 2nd ed. Philadelphia, PA: WB Saunders; 1994. p. 298-325.  Back to cited text no. 14
    
15.
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17.
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18.
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Webber DL, Epstein NB, Wong JW, Tsamtsouris A A method of restoring primary anterior teeth with the aid of a celluloid crown form and composite resins. Pediatr Dent 1979;1:244-6.  Back to cited text no. 20
    
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24.
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25.
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