2010 National Primary

Oral Health Conference

October 24-27
Gaylord Palm, Orlando, Florida

The use of stainless steel

crowns on primary molars
Enrique Bimstein
Professor of Pediatric Dentistry
University of Florida College of Dentistry.
The use of SSC on primary molars
Goal
The participants will become
familiar with the basic
knowledge and procedures
required for the restoration
of primary molars with
preformed stainless steel
crowns.
Topics
1. Introduction:
crown types, definition, rationale,
indications and contraindications.
2. Characteristics, advantages and
disadvantages.
3. Clinical procedures:
tooth preparation, crown adaptation
and cementation.
4. Summary and conclusions.
 Crown types for primary teeth
Cast : Gold crowns

Stainless steel: occlusal anatomy

trimmed
contoured
pre-veneered

Composite: plastic matrix

Cast crowns - gold
Cast crowns - gold
Cast crowns - gold
 Stainless steel crowns
• Preformed metal crowns
or stainless steel crowns
(SSC) have been in use for
about 60 years.
• SSC are an invaluable
restorative material in the
treatment of badly
decayed primary teeth.
Definition of SSC

Full coverage
metallic ,
definitive
restoration for
primary teeth.
(Or temporary for
permanent teeth)
Definition of SSC

Is a metal shell
with preformed
anatomy that
can be adapted
to the tooth.
 Rationale for using a SSC

Perio health Good Good

# of visits Several One
Time Hours Minutes
Difficulty Difficult Easy
Lab required Yes No
Cost Expensive Cheap
Esthetics “Bad” “Bad”
 Rationale for using a SSC

Stainless steel crowns

are used to restore
primary molars in which
the failure of an amalgam
or composite restoration
is clear in your mind.
 Rationale for using a SSC
The use of SSC is indicated in
cases in which the prognosis for
long term success of “regular”
restorations is reduced by a high
possibility of:
a. restoration fracture
b. recurrent caries.
 Indications for using a SSC
Extensive caries destruction.
An adequate
isthmus is
difficult to obtain
with a small
occlusal surface
a wide contact
and large pulp .
 Indications for using a SSC
Extensive caries destruction.
An adequate
isthmus is
difficult to obtain
with a small
occlusal surface
a wide contact
and large pulp .
 Indications for using a SSC
No gingival floor possible for a
proximal – occlusal restoration

Sidney B. Finn: Pediatric Dentistry book

Indications for using a SSC
Early childhood caries
Indications for using a SSC
High caries incidence
Indications for using a SSC
 Indications for using a SSC
After endodontic treatment

Pulpotomy

Pulpectomy
 Indications for using a SSC
After endodontic treatment
A
l
Pulpotomy
w
a
y
Pulpectomy s
?
 Indications for using a SSC

Pulpotomized primary
molars can be successfully
restored with one surface
amalgam if their natural
exfoliation is expected within
not more than 2 years.
Holan et al. Success rate of formocresol pulpotomy in primary molars
restores with stainless steel crowns vs amalgam. Pediatr Dent 24:212, 2002.
 Indications for using a SSC
Delopmental abnormalities

Enamel hypoplasia

Enamel hypoplasia and caries

Indications for using a SSC
Compliance and behavior?
 Indications for using a SSC
Space maintainer

As an abutment for space

maintainers or prosthetic
appliances.
 Indications for using a SSC
Fractured molars due to trauma
Tejani Z, Johnson A,
Mason C, Jane
Goodman J. Multiple
crown-root fractures in
primary molars and a
suspected subcondylar
fracture following
trauma: a report of a
case.
Dental Traumatology 2008; 24: 253–256.
 Indications for using a SSC
Multi-surface restorations?
 Indications for using a SSC
Preformed metal crowns
demonstrate greater
longevity and reduced re-
treatment need compared
with (multi-surface)
amalgam.
 Indications for using a SSC
The literature demonstrates evidence
of a more favorable outcome for SSCs
than for amalgam restorations in
primary molars requiring multi-surface
restorations.
10 Studies, 1.6 to 10 years follow-up
failure rates, ranged from 1.9 to 30.3 %
for SSCs and 11.6 to 88.7 % for
amalgam restorations.
Efficacy of preformed metal crowns vs. amalgam restorations in primary molars: a
sistematic review. JADA 131:337-43, 2000.
 Indications for using a SSC
Failure before the age of 8 years
1st primary 2nd primary
molar molar
One surface 70% 32%
restorations
Two surface 75% 71.4%
restorations
Stainless 12.8% 11.0%
steel crowns
Dawson et al. ASDC J Dent Child 1981.
Multi-surface restorations VS SSC
1. Type of tooth (first vs second molar)
2. Dental age of patient.
3. Caries incidence.
4. Patient’s compliance (brushing etc.).
5. Water fluoridation.
6. Bucco-lingual extent of cavity.
7. Other (esthetics, parents compliance, etc.).
 Contraindications for SSC
Primary tooth close to exfoliation
 Contraindications for SSC
2. Extensive dental caries:
a. there is not enough
crown structure left.
b. the caries (gingival)
extent does not allow
for adaptation.
c. excessive mesial drift.
 Contraindications for SSC
No restorability due to
extensive crown destruction
 Contraindications for SSC
No restorability due to
caries gingival depth
 Contraindications for SSC
No restorability due to
caries gingival depth
 Contraindications for SSC
No restorability due to
excessive mesial drift
 Contraindications for SSC
3. Esthetics.
 Contraindications for SSC
4. Allergy to nickel
Stainless steel crowns (Unitek and Rocky
Mountain) crowns composition consist of 17-19%
chromium, 9-13% nickel and 0.08-0.1 carbon.
Nickel based crowns (Ion Ni-chro from 3M)
composition consists of 76% nickel, 8% iron, 0.04
carbon and 0.35% manganese.
MS Muthu- N Sivakumar. Pediatric Dentistry. Principles and practice. Elsevier 2009.
 Contraindications for SSC
4. Allergy to nickel
Nickel is one of the most common
causes of allergic contact dermatitis
and produces more allergic reactions
than all other metals combined. There
may be a risk of sensitizing patients
to nickel with long-term exposure to
nickel-containing appliances as in
orthodontic therapy.
Bass JK, Fine H, Cisneros GJ. Am J Orthod Dentofacial Orthop. 1993 Mar;103(3):280-5
 Contraindications for SSC

http://www.hugginsappliedhealing.com/story5.php
 Contraindications for SSC
4. Allergy to nickel (???)
Nickel, has its
problems with human
biochemistry.
Children have to start
wearing glasses within
a few months of
receiving the crowns.
http://www.hugginsappliedhealing.com/story5.php
 Contraindications for SSC
4. Allergy to nickel (???)
If your child becomes
cranky and misbehaves
after the crowns were
placed while previously
he had a pleasing
personality, check it
out.
http://www.hugginsappliedhealing.com/story5.php
 Characteristics of SSC
Stainless steel crowns may
be with:
Occlusal anatomy
Trimmed
Contoured
Crimped?
Pre-veneered
 Characteristics of SSC
Occlusal anatomy only (Unitek)

They require trimming,

contouring and crimping.
 Characteristics of SSC
Oclussal and pre-trimmed (Unitek)
• Festooned to allow a line
parallel to the gingival crest.
 Characteristics of SSC
Oclussal and pre-trimmed (Unitek)
• Festooned to allow a line
parallel to the gingival crest.
• They require
contouring
and
crimping.
 Characteristics of SSC
Occlusal, pre-trimmed and pre-
contoured:
(Ion-Nichro)

• Some trimming, contouring and

crimping may be necessary.
• When trimmed, re-contouring,
crimping and polish are required.
 Characteristics of SSC
3M Stainless steel ION Ni-Chro
Shape

Length

3M Stainless steel ION Ni-Chro

Cervical
constriction
 Characteristics of SSC
Pre-veneered: metal with esthetic facing
(NuSmile).

• Have a resin-composed facing

bonded to Occ. and B. surfaces.
• Expensive, require more tooth
reduction, and allow only for
minimal crimping.
 SSC in primary teeth: topics
1. Introduction:
crown types, definition, rationale,
indications and contraindications.
2. Characteristics, advantages and
disadvantages.
3. Clinical procedures: tooth
preparation, crown adaptation and
cementation.
4. Summary and conclusions.
 Clinical procedures for SSC
• Rationale
• Tooth preparation.
• Crown selection
• Crown adaptation.
• Complications.
• Cementation.
• Cleaning
 Rationale for SSC tooth
preparation and adaptation
The tooth preparation and crown
adaptation of SSC in primary (and
permanent) molars is based (among
other) on the crown’s:
Flexibility: easily bent or shaped.
Elasticity: the tendency of a body to
return to its original shape after it
has been stretched.
 Rationale for SSC tooth
preparation and adaptation

• Preformed metal crowns are flexible and

elastic (they snap).
• The tooth cervical bulge is “surrounded”
by the crown.
 Rationale for SSC tooth
preparation and adaptation
 Rationale for SSC tooth
preparation and adaptation
a. do not require the retention
features that are incorporated in
cavity design of cast crowns.
b. obtain their retention from the
flexibility and elasticity of the
thin, contoured and crimped
crown margins, and
cementation.
 Rationale for SSC tooth
preparation and adaptation
Subgingival depth

≈ 1.5 mm

C. E. J.
 Clinical procedures for SSC
• Rationale
• Tooth preparation.
• Crown selection
• Crown adaptation.
• Complications.
• Cementation.
• Cleaning
Check Occlusion before
starting tooth reduction.
Armamentarium - Burs
Armamentarium for adaptation

114 Crimping Sharp Round

plier plier scaler scissors
 Tooth preparation for SSC
• General considerations
Extent.
Caries removal.
Pulp treatment.
• Occlusal surface
• Buccal andreduction)
(1-1.5 mm lingual surfaces
• Proximal surfaces
• Finish
Occlusal preparation (a)
 Occlusal preparation (a)
Create a “channel” 1.25 mm deep
between the cusps.
 Occlusal preparation (a)

Reduce the cusps to the depth of the

channel.
Occlusal preparation (b)
Occlusal preparation (b)
Occlusal preparation (b)
 Tooth preparation for SSC
• General considerations
Depth and extent.
Caries removal.
Pulp treatment.
• Occlusal surface
• Buccal and lingual surfaces
• Proximal surfaces
• Finish
Buccal and lingual reduction.
Prepare a slight bevel, at the occlusal 1/3
portion of the surface.
 Tooth preparation for SSC
• Buccal and lingual surfaces
a)Limited to occlusal 1/3 of the B
& L surfaces at a 45º bevel.
b)Round off all line angles.
c)A large mesio-buccal or
cervical bulge may require
more buccal and lingual
reduction.
Buccal and lingual reduction.
Prepare a slight bevel, at the occlusal 1/3
portion of the surface.
Buccal and lingual reduction.
Prepare a slight bevel, at the occlusal 1/3
portion of the surface.
What’s next?
Caries removal
Pulp therapy (if required)
Proximal surfaces

Proximal surfaces
Caries removal
Pulp therapy (if required)
Caries removal
Apply a liner or perform
pulp therapy
 Tooth preparation for SSC
• General considerations
Depth and extent.
Caries removal.
Pulp treatment.
• Occlusal surface
• Buccal and lingual surfaces
• Proximal surfaces
• Finish
 Tooth preparation for SSC
Proximal surfaces
a) 169L tapered fissure or thin tapered
diamond bur.
b) Break proximal contacts at appropriate
depth in single sweeping motion (or
gradually).
c) Vertical proximal walls with slight
convergence in an occlusal and
lingual/palatal direction.
d) Feather-edge finish line; common
error: ledge formation.
Proximal surfaces
Proximal reduction: “open” the
proximal contacts, flat surfaces.
Proximal reduction: “open” the
proximal contacts, flat surfaces.
Proximal surfaces
Proximal surfaces
Proximal surfaces
Rounding angles.
Rounding angles.
 Clinical procedures for SSC
• Rationale
• Tooth preparation.
• Crown selection
• Crown adaptation.
• Complications.
• Cementation.
• Cleaning.
 SSC selection
3M Stainless steel

3M Stainless steel
 SSC selection
General considerations
a)Place or “seat crown” from
lingual to buccal.
b)Push crown over the buccal
buldge for a snap fit.
c)Check margins for close
cervical adaptation extending
1-1.5 mm subgingivally
(blanching).
 SSC selection
1. Choose the crown that fits
MD.
Select the smallest crown that
restores the pre-existing
contacts (if present).
The most common used
crowns are size # 4
 SSC selection
Too small M-D
 SSC selection
Too big M-D
 SSC selection

Radiograph in
which crown
adaptation is
adequate in
tooth 64 and
inadequate in
65 and 74.
 SSC selection
Crowns which
are to big M-D
may prevent the
adequate
eruption of
adjacent
permanent
tooth.
Crown adaptation

Contour

Crimping
 Crown adaptation

114 Contouring Pliers

 Crown adaptation

Buccal and lingual

 Crown adaptation

Proximal
 Crown adaptation

Proximal
 Crown adaptation

“Extra” countour
Crown adaptation
Crown adaptation
 Crown adaptation

Crimping Pliers
 Crown adaptation

Crimping Pliers
 Crown adaptation

Crimping Pliers (extra crimping)

 Crown adaptation
Examine the crown for sharp angles
or irregularities. Re- contour and/or
re-crimp were necessary
 Examine the occlusion.

The occlusion
should be the
same before
starting the
procedure.
SSC Cementation and cleaning
SSC Cementation and cleaning
Complications
 Additional crown adaptation
To crown is too long
• over the gingiva.
• no space with antagonist
• no space interproximal.
• sharp angles
Additional crown adaptation

Sharp scaler
 Additional crown adaptation
• Crown and Bridge Scissors
 Additional crown adaptation
• Crown and Bridge Scissors
 Additional crown adaptation

Polish the crown

with a heath less
stone.
 Additional crown adaptation
• Buccal and lingual surfaces
Due to carious proximal contact loss,
the crown that fits M-D may be too
small B-L; this may be solved with more
buccal or lingual reduction.
 Additional crown adaptation
• Buccal and lingual surfaces
Due to carious proximal contact loss,
the crown that fits M-D may be too
small B-L; this may be solved with more
buccal or lingual reduction.
 Additional crown adaptation

Due to carious proximal contact loss,

the crown that fits M-D may be too
small B-L; this may be solved with more
buccal or lingual reduction.
 Additional crown adaptation
Too high
Fits MD but does not cover the buccal
surface: modify a larger crown.
• over the gingiva.
• no space with antagonist
• no space interproximal.
• sharp angles
 Additional crown adaptation
Too high
Over the gingiva (or loose).
• over the gingiva.
• Additional
no space with antagonist
• contour
no space interproximal.
• sharp angles and/or
crimping
are
required.
 Additional crown adaptation

Howe Plier: to rotate crowns

 Complications
Aspiration
 Complications
Aspiration

Adewumi A. Kays DA. Stainless steel crown aspiration during

sedation in pediatric dentistry. Pediatr Dent 30:59-62, 2006.
 Complications
Gingival and periodontal diseases
 Complications: Allergy
The nickel content in the
formulation of nickel
chromium crowns is around
70% greater than that of
contemporary stainless steel
crowns that contain 9-12%
nickel similar to that of many
orthodontic band and wires.

http://www.slideshare.net/den
tistryinfo/stainless-steel-
crown
 Complications: Allergy
Pazzini CA, Pereira LJ, Marques LS, Generoso R, de Oliveira G
Jr. Allergy to nickel in orthodontic patients: clinical and
histopathologic evaluation. Gen Dent. 2010 Jan-Feb;58(1):58-61
Kolokitha OE, Chatzistavrou E. A severe reaction to ni-containing
orthodontic appliances. Exposure to nickel-containing orthodontic
appliances may cause intra- or extraoral allergic reactions. Nickel
is the most typical antigen implicated in causing allergic contact
dermatitis, which is a Type IV delayed hypersensitivity immune
response. Angle Orthod. 2009 Jan;79(1):186-92
Bruce GJ, Hall WB. Nickel hypersensitivity-related periodontitis.
Compend Contin Educ Dent. 1995 Feb;16(2):178, 180-4; quiz
186
Ehrnrooth M, Kerosuo H. Face and neck dermatitis from a
stainless steel orthodontic appliance. Angle Orthod. 2009
Nov;79(6):1194-6
Pre-veneered: metal with esthetic facing

• have a resin-composed facing

bonded to O and B surfaces.
• expensive, require more tooth
reduction, and allow only for
minimal crimping.
Pre-veneered: metal with esthetic facing
Ram D et al. Long-term
clinical performance
of esthetic primary
molar crowns. At the 4
year evaluation all the
esthetic crowns (n=10)
showed chipping of
the esthetic facing,
with poor esthetic
appearance.
Pediatr Dent 25:582-4, 2003
Composite crowns
Composite crowns
 SSC in primary teeth: topics
1. Introduction:
crown types, definition, rationale,
indications and contraindications.
2. Characteristics, advantages and
disadvantages.
3. Clinical procedures: tooth
preparation, crown adaptation and
cementation.
4. Summary and conclusions.
 Summary and conclusions
 SSCs represent a long term, easy
one appointment full coverage
restorations of primary molars.
 The tooth preparation and
adaptation are relatively easy, in
most cases.
 Durable and cost effective ($34
for 5) .