PULP THERAPY IN PRIMARY TEETH

PULP THERAPY IN
PRIMARY TEETH
Dr Feda Zawaideh
BDS, ADC(Vic), GradDipClinDent, DClinDent(Melb), FRACDS,
FRACDS (Paed), JDB
PULP BIOLOGY
Pulp-dentine complex
 Primary dentinogenesis
 Secondary dentinogenesis
 Tertiary dentinogenesis
Reactionary dentine
Reparative dentine

Tziafas, Smith, Lesot. Designing new treatment strategies in vital pulp therapy.
Journal of Dentistry 2000; 28: 77-92.
Tziafas, Smith, Lesot. Designing new treatment strategies in vital pulp therapy.
Journal of Dentistry 2000; 28: 77-92.
PULP THERAPY
The goal of pulp therapy in the primary
& mixed dentitions are:




Successful treatment of the cariously
involved pulp to maintain the tooth in a nonpathological state
Maintenance of arch length and tooth space
Restoration of comfort with the ability to
chew
Prevention of speech abnormalities and
abnormal habits
INDICATIONS &
CONTRAINDICATIONS OF
PULP THERAPY
Factors influencing the decision to retain
primary teeth:

Medical history

Behaviour factors

Dental factors
MEDICAL HISTORY
CONTRAINDICATIONS:

Congenital cardiac disease

Immunosuppressed patients

Children with poor healing potential
MEDICAL HISTORY
INDICATIONS:

Bleeding disorders and coagulopathies

Oligodontia as in Ectodermal
Dysplasia
BEHAVIOUR FACTORS
CONTRAINDICATIONS:

Uncooperative or non-compliant
patient/parent
INDICATIONS:

Dentally aware patient/family

Cooperative child
DENTAL FACTORS
CONTRAINDICATIONS:

Grossly neglected dentition

Acute odontogenic infection

Unrestorable tooth

Advanced tooth mobility/root
resorption
DENTAL FACTORS
INDICATIONS:
 Well-maintained arch with intact
primary dentition
 Orthodontic considerations and space
maintenance
 Lack of a permanent successor
 Minimal root resorption and no
mobility
CASE ASSESSMENT

Chief complaint and pain history
- Area involved
- Duration of the problem
- Precipitants and relieving factors
- Duration of pain
- Spontaneous or precipitated by a
stimulus
- Analgesia required
CASE ASSESSMENT
Medical history
 Dental history and attitude to
treatment
 Clinical examination
 Special tests
- Pulp sensitivity tests
- Mobility and tenderness on
percussion
- Radiographic examination
- Direct visual examination of the pulp
chamber

PULPAL DIAGNOSIS
Healthy
 Reversible pulpitis
 Irreversible pulpitis
 Total pulp necrosis
Differentiation between reversible and
irreversible pulpitis is extremely
difficult

PULP THERAPY OPTIONS
Conservative or vital
pulp therapy
- Indirect pulp treatment
- Direct pulp treatment
- Pulpotomy
 Radical or non-vital pulp
therapy
- Pulpectomy

DIRECT PULP CAPPING
―The placement of a dressing or
medicament on a pulp exposure in an
attempt to preserve pulp vitality‖
It is generally not recommended in
primary molars due to its un
predictable results, high failure rate
and high incidence of internal
resorption or acute dentoalveolar
abcesses
INDIRECT PULP
TREATMENT
―The procedures or steps taken to
protect or maintain the vitality of
the carious tooth that, if
completely excavated, the decay
would result in a pulp exposure‖
Al-Zayer M. Pediatric Dentistry, 25(1): 29-36, 2003
INDIRECT PULP
TREATMENT

Indicated in an asymptomatic tooth
that has a carious lesion near the
dental pulp, a protective dressing or
cement is placed over a layer of the
remaining carious dentine to prevent
pulpal exposure and stimulate healing
and repair
INDIRECT PULP
TREATMENT
INDIRECT PULP
TREATMENT
All caries at the DEJ must be removed
 Remove the infected dentine
(superficial layer) This layer contains the majority of

microorganisms and their toxic products that are also the source of
continuous insult to the pulp. The infected layer must be removed
to allow the healing of the dental pulp.

Leave the affected layer (the deep
decalcified layer) this layer

has only a few microorganisms. The affected layer can be left in
place without any adverse effect on the dental pulp
Apply liner/base
 Restore the tooth

Clinical Technique
INDIRECT PULP
TREATMENT

Re-entry into the cavity after 6-12
months demonstrated no evidence of a
pulp exposure, the existence of only
few microorganisms (reduced by 70100%), medium to hard consistency of
the residual dentine
Al-Zayer M. Pediatric Dentistry, 25(1): 29-36, 2003
INDIRECT PULP
TREATMENT
Re-entry into the cavity has been
questioned especially if a durable
restoration is placed initially and no
adverse symptoms develop
 An excellent coronal seal is required to
ensure good success rate with this
technique
 Stepwise excavation technique-reentry in 2-3 weeks (unjustified)

Stepwise Excavation
Diagrams demonstrating the
less invasive stepwise excavation
procedure. A closed lesion
environment before and after
first excavation (a, b) followed
by a calcium hydroxide–
containing base material and a
provisional restoration. During
the treatment interval the
retained demineralized dentin
has clinically changed into signs
of slow lesion progress,
evidenced by a darker
demineralized dentin (c, d).
After final excavation (e) the
permanent restoration is made
(f ). Red zones indicate plaque.
Bjorndal L. Indirect pulp therapy and stepwise excavation. Pediatric Dentistry 2008;
30:225-9.
Example of using glass ionomer caries control to diagnose reversible
pulpitis or food impaction in a mandibular first primary molar with
a history of pain to chewing sweets and solid foods for 2–3 weeks. (a)
Preoperative view. (b) Preoperative radiograph. (c) View
immediately after glass ionomer placement. (d) Two months after
caries control. Pain stopped from day glass ionomer placed. No
clinical or radiographic sign of irreversible pulpitis. (e) View of IPT
with a glass ionomer base. (f ) Tooth 16 months after treatment
without signs of pain or irreversible pulpitis clinically or on the
radiograph.
Prognosis




Variable 75-100%, recent studies over 90%
Farooq et al (2000) using GIC for IPT had
a success rate of 93% vs single visit
pulpotomy with formocresol 74% followed
for 2-7 years
In addition, formocresol puloptomy
hastened the exfoliation of treated primary
molars whereas IPT did not
Al-Zayer et al (2003) had a success rate of
95%
INDIRECT PULP
TREATMENT
Success rates improved when:
 A base is used over the liner
 A SSC is used to restore the tooth
 Treatment performed on second
primary molar than a first primary
molar
Al-Zayer M. Pediatric Dentistry, 25(1): 29-36, 2003
INDIRECT PULP
TREATMENT


The ideal material for vital pulp treatment should
be able to resist long-term bacterial leakage and
stimulate the remaining pulp tissue to return to a
healthy state, promoting the formation of dentin
Materials used
- Calcium hydroxide Cement (CH)
- Zinc Oxide Eugenol Cement (ZOE)
- Glass Ionomer Cement (GIC)
- Adhesive resin system
- MTA
Radiographic evaluation of a mandibular first and second primary molar that received indirect pulp
treatment with adhesive resin only and were considered successful outcomes after 2 years. Preoperative
radiograph (a), immediate postoperative (b), and 6 months (c), 12 months (d), 18 months (e) and 24
months (f) after indirect pulp treatment.
Radiographic evaluation of a mandibular first primary molar that received indirect pulp treatment with adhesive
resin only and was considered a failure after 18 months. Preoperative radiograph (a), immediate postoperative (b),
and 6 months (c), 12 months (d) and 18 months (e) after indirect pulp treatment. The interradicular lesion
accompanied by external and internal root resorption observed in panel (e) was indicative of treatment failure.
Radiographic evaluation of a mandibular second primary molar that received indirect pulp treatment with
calcium hydroxide and was considered a successful outcome after 2 years. Preoperative radiograph (a),
immediate postoperative (b) and 6 months (c), 12 months (d), 18 months (e) and 24 months (f) after IPT
Radiographic evaluation of a mandibular second primary molar that received indirect pulp treatment with calcium
hydroxide and was
considered a failure after 18 months. Preoperative radiograph (a), immediate postoperative (b) and 6 months (c), 12
months (d) and 18 months (e)
after indirect pulp treatment. The interradicular lesion accompanied by external root resorption observed in panel (e)
was indicative of treatment failure.
PULPOTOMY
―Involves the amputation of the coronal
portion of the affected or infected dental
pulp. Treatment of the remaining vital
radicular pulp tissue surface should
preserve the vitality and function of all or
part of the remaining radicular portion of
the pulp. The coronal pulp chamber is filled
with a suitable base and the tooth restored‖
The American Academy of Pediatric Dentistry Reference
Manual
PULPOTOMY
Indications:
 Large carious lesion involving more
than 1/3 of marginal ridge in a
restorable tooth
 Vital tooth free of radicular pulpitis
with pain of short duration, no
swelling, mobility, tenderness or pus
discharge, no periapical pathosis or
inter-radicular bone loss
 At least 2/3 of root remaining
PULPOTOMY
Clinical contraindications:
 Unrestorable tooth
 History of spontaneous/persistent pain
 Irreversible pulpitis or pulp necrosis
 Pus discharge
 Pathological mobility
 Swelling of pulpal origin
 Sinus tract or fistula
 Hyperaemic pulp
PULPOTOMY
Radiographic contraindications:
 External or internal root resorption
 Periapical or furcal pathology
 Radicular bone loss
 Pulp calcification
 Less than 2/3 root left
 Permanent tooth close to eruption
PULPOTOMY MATERIALS

1.
2.
3.
Ranly D 1994 stated that pulpotomy therapy has
been developed along three lines according to the
method of action of the material used:
Devitalization with the use of formocresol and
electrosurgery where the intent is to destroy the
radicular pulp
Preservation of the remaining radicular pulp with
the use of gluteraldehyde and ferric sulphate
Regeneration of the radicular pulp by stimulation
of a dentinal bridge that, in humans, has been
accomplished with the use of calcium hydroxide,
MTA and bone morphogenic proteins and enamel
matrix proteins
PULPOTOMY-MATERIALS










Formocresol
Ferric sulphate
Gluteraldehyde
CH cement
Ledermix Cement
Sodium Hypochlorite
Electrosurgery
Laser therapy
Mineral Trioxide Aggregate (MTA)
Bone morphogenic proteins (BMPs)
FORMOCRESOL
PULPOTOMY
Buckley’s Formocresol
Tricresol-35%
Formaldehyde-19%
glycerol-15%
water-31%
 1:5 dilution
 The pulp remains half dead, half vital, and
chronically inflamed.
 Success rate ranges from 70-97% but
diminishes with time.

FORMOCRESOL
PULPOTOMY
Fixation of the pulp
tissue by direct contact
 Bactericidal
 3 layers form: fixation,
coagulation necrosis,
vital tissue
 Concern regarding
systemic toxicity,
carcinogenicity and
mutagenicity
Success rate:70-100%

Irrigate the pulp chamber with saline to remove debris
Control the haemorrhage with slightly damped cotton
wool pledget
FERRIC SULPHATE
PULPOTOMY




Was first used with CH to aid in the control
of haemorrhage, now used without CH
A ferric ion complex is formed in contact
with blood which promotes haemostasis
Clinically proven to be as effective as
Formocresol
Less toxic
GLUTERALDEHYDE
PULPOTOMY
Rapid fixation of the pulp tissues
 Less penetration into the periapical
tissues
 Toxicity concerns
 Eye irritation and allergic reaction
 Short shelf life
 Higher success rates than Formocresol

CALCIUM HYDROXIDE
PULPOTOMY
Antibacterial activity
 Surface layer of coagulation necrosis
 Associated with high rates of internal
resorption
 Success rate of 60%
 Recently questioning low success rate
attributing that to incorrect diagnosis
and contact with the blood clot

Treatment Outcome with different
agents


When outcomes of ferric sulphate were compared to ZOE RCT’s
at 2 & 3 year follow up periods following carious exposures in
primary teeth, the reported outcomes for FS were poorer than RCT
outcomes at 2 years; however, at 2 years, the survival rates were not
statistically different. On the other hand, no statistical difference in
outcomes was demonstrated at 3-year assessment, however, RCTtreated molars demonstrated significantly greater survival than FS
treated molars 3 years after treatment. Casas et al ( 2002 & 2003)
Pulpotomies performed with either FC or FS are likely to have
similar clinical and radiographic successes. The mean clinical and
radiographic success rates of treatment with ferric sulphate were
91.6% and 73.5%, respectively. Due to the deleterious effect of FC,
it is suggested that FS be recommended as a replacement. (Peng
2007)
MTA
Mineral trioxide aggregate (MTA):
 It has excellent sealing ability, biocompatibe, induces hard
tissue formation, has antimicrobial properties, maintains pulp
integrity & promotes healing without cytotoxic effect, It has
higher long term clinical and radiographic success rate than
pulp dressing materials like FC.
 MTA is a powder composed of a mixture of a refined Portland
cement and bismuth oxide, reported to contain trace amounts
of SiO2, CaO, MgO, K2SO4, and Na2SO4.
 MTA powder is mixed with sterile water in a 3:1 powder/liquid
upon hydration, a colloidal gel is formed that solidifies to a
hard structure in approximately 3–4h, with moisture from the
surrounding tissues assisting the setting reaction.



Hydrated MTA products have an initial pH of 10.2, which
rises to 12.5 three hours after mixing. MTA’s compressive
strength after setting is 70 Mpa—comparable to that of IRM
and Super-EBA but less than that of amalgam.
Preparation with saline and 2% lidocaine anesthetic solution
increases setting time without significantly affecting the
compressive strength.
Ragarding leakage, MTA frequently performs better than
amalgam, IRM or Super EBA. Compared with composite
resins placed under ideal conditions, MTA’s leakage patterns
are similar & the presence of blood has little impact on the
degree of leakage.




(GMTA) and White MTA (WMTA) have been introduced.
WMTA has a lighter color, smaller particle size, being
significantly less soluble & more radiopaque than GMTA.
MTA vs FC: procedure requires less time & risk of rebleeding is absent.
MTA is costly, it cannot be kept once the envelope is opened
so its use in pediatric dentistry becomes almost prohibitive.
Evidence on MTA

MTA vs FC:
MTA-treated teeth showed no clinical or radiographic
pathology whereas internal resorption was detected in the FC
group after follow up periods ranging from 6-30 months .
(Eidelman & Holan 2000)
The success rate of pulpotomy was 97% for MTA and 83%
for FC after a follow up period of 74months , internal
resorption occurred more in FC pulpotomy. (Holan 2005)
MTA was superior to FC in pulpotomy and might be FC’s
suitable replacement resulting in a lower failure rate & lower
undesirable responses. (Peng 2006)

GMTA vs WMTA & FC:
GMTA appeared to be better than WMTA and FC because
it presented the closest to normal pulp architecture.
(Agamy 2004)

FC vs FS, WMTA ,WPC :
Beta-TCP, WMTA are histologically more effective
pulpotomy agents than FC and FS in primary pig teeth since
FC & FS provoked more pulp inflammatory response.
(Shayegan 2008)
Enamel Matrix Derivative (EMD)

Emdogain gel has been successfully employed for
pulpotomies in noninfected teeth in animal studies. Its effect
was also investigated on experimentally exposed human
permanent pulps, but seems ineffective for formation of
hard tissue barriers.
Emdogain gel is a bioinductive material that is compatible
withvital human tissues. It offers a good healing potential
and is capable of inducing dentin formation, leaving the
remaining pulp tissue healthy and functioning, it may act in
a multitude of ways on mesenchymal cells that provide pulp
protection.
(Sabbarini 2006)

EMD vs FC: success rates at 6 months didn’t differ.
However, after 6 months the radiographic success rates for
FC and EMD were 13% and 60 %, respectively. EMDtreated teeth had less periodontal membrane widening, less
periapical and/or furcation Radiolucencies & no pulp
calcifications. Therefore, When compared with FC, EMD
appears to be clinically and radiographically superior.
(Sabbarini 2008)

EMD disadvantages: difficult application due to the gel
consistency, almost impossible to condense any material over
it, the whole amount of gel should be used within 2 hours or
it will lose its effect therefore it’s not cost effective.


Calcium Hydroxide: pulpal repair vs internal resorption,
success rate reaches 70%.
The greater the area of carious exposure, the lower the
success rate in pulpotomies at follow up period of 1 year.
Internal resorption being the main reason for failure,
however, it was not affected by physiological root resorption.
(Sönmez 2007)

When Ca(OH)2 was compared to FC, FS & MTA in
pulpotomies at a follow up period of 2 years, the success rate
was 76.9% for FC, 73.3% for FS, 46.1% for Ca(OH)2, and
66.6% for MTA. Therefore, Ca(OH)2is less appropriate for
primary teeth pulpotomies than the other pulpotomy agents.
(Sönmez 2008)
ND:YAG vs FC pulpotomy

Nd:YAG laser may be considered as an alternative
to formocresol for pulpotomies in primary teeth
giving success rates of 85.71% & 71.42% vs
90.47% for FC pulpotomy at 12 months.
(Odabas 2007)
B4 ttt with ND:YAG
9 months after ttt
36 months after ttt
International Congress Series 1248 (2003):
251– 256
PULPOTOMY-PROGNOSIS
Regardless of the
material used
success depends on
pulp status
 Reasons for failure:
- Incorrect diagnosis
- Inadequate coronal
seal

PULPECTOMY
―Involves gaining access to the root
canals which are then debrided,
enlarged and disinfected. The canals
are filled with a resorbable material‖
The American Academy of Pediatric Dentistry Reference Manual
PULPECTOMY
Indications:
 Tooth with irreversible pulpitis or
necrotic pulp tissue
 Non-vital tooth with prolonged history
of pain, swelling, mobility,
radiolucency involving the furcation
area…
 Persistent bleeding during a
pulpotomy
PULPECTOMY
Contraindications:
 Periradicular involvement extending
to the permanent tooth bud
 Pathological resorption of > 1/3 root
 Excessive internal root resorption
 Perforation of the floor of the pulp
chamber

In 1992, Salama et al
attempted to determine the
length of the root canals of
primary maxillary incisors
and mandibular molars
Table. Root canal length of maxillary
incisors and mandibular molars
Length in mm
Mean
Range
Tooth
Central
16.5
16-17
Lateral
15
14-16
Tooth and
Canal
First molar
Mesiobuccal
16.4
15-17
Mesiolingual
14.2
9-15
Distobuccal
13.1
12-15
Distolingual
12.7
10-15
Second molar
Mesiobuccal
15.8
13-17
Mesiolingual
14.4
11-16
Distobuccal
14.9
13-16
Distolingual
14.9
12-16
SINGLE STAGE
PULPECTOMY
Step 6: Dry the canals
TWO-STAGE PULPECTOMY
Presence of an acute abscess
 Persistence of discharge
 Patient is in pain
 2 stage pulpectomy with Formocresol
intermediate dressing and antibiotics

Criteria for an ideal filling in primary teeth









It should resorb at the same rate as the primary root;
be harmless to periapical tissue and the permanent tooth
germ;
resorb readily if pressed beyond the apex;
be antiseptic;
easily fill the canals and adhere to canal walls;
not shrink;
be easily removed;
be radiopaque;
not discolor the tooth; and be nontoxic.
Historical review of root filling materials for
primary teeth




Pure ZOE.
A mixture of ZOE with formocresol and glycerine.
Iodoform paste.
Kri paste; a mixture of iodoform, camphor, parachlorophenol &
menthol.
The Overall success rate for KRI paste was 84% versus 65% for
ZOE, Overfilling with ZOE led to a failure rate of 59% as
opposed to 21% for KRI, Conversely, underfilling led to similar
results, with a failure rate of 17%f or ZOE and 14% for KRI.
(Holan & Fuks 1993)
Vitapex, a commercial
product containing a viscous
mix of calcium hydroxide
and iodoform in a syringe
with disposable tips. The
main ingredients are
iodoform, calcium
hydroxide, and silicone.
Pediatr Dent 2000; 22:517-520.

Vitapex vs ZOE: Vitapex appears to resolve
furcation pathology at a faster rate than ZOE at 6
months as demonstrated by a success rate of 78%
vs 48%, while at 12 months, both materials yield
similar results of 89% vs 85%.
(Trairatvorakul 2008)
Failure of zinc oxide-eugenol (ZOE) long-filled tooth.
(A) Immediate postoperative X-ray of ZOE-overfilled primary mandibular RT D
showing thickening of periodontal space at the furcation area.
(B) Accelerated resorption of supporting bone at 6 months, showing large
radiolucent area at the furcation and resorption of the entire mesial root
considered a failure at 6 months.
(C) Retained ZOE with premature eruption of the first premolar.
Failure of zinc oxide-eugenol-treated tooth at 6 months, which turned out
to be successful at 12 months.
(A) Immediate postoperative X-ray of primary mandibular RT E with
radiolucency involving more than half of the distal root length.
(B) At 6 months, although there is an increase in radiopacity of the
furcation area from bone regeneration, the tooth was considered a
failure due to a large rarefied area at the mesial root apex involving the
crypt of the underlying permanent tooth bud.
(C) At 12 months, the consistent radiopacity of the furcation area and the
complete resolution of the rarefied area at the mesial root along with
reunion of bony crypt walls of first premolar. The fulfillment of these 2
criteria constitutes success.
Root filling materials for primary teeth, Cont’d


Calcium hydroxide pastes:
Sealapex showed less leakage than ZOE and Apexit in sealeronly obturation of pulpectomized primary teeth. (Kielbassa 2006)
The overall success rate for sealapex was 92.3% during a followup period of 3 years, sealapex didn’t show evidence of complete
resorption in the canals. (Sar 2008)
Maisto paste; similar to kri paste but with added thymol & ZnO.
PROBLEMS IN PULP
THERAPY
Pain/poor patient cooperation
 Acute infection
 Persistent draining sinus

RESTORATIONS
Ideally SSC
 Amalgam
 Resin-modified GIC
 Composite resin

SEQUELAE OF PULP
THERAPY
Effect on eruption time of permanent
successor
 Enamel defects on permanent
successor possible related to the preexciting infection

Stainless Steel Crown
procedures for Primary
Molars
Indications
•
•
•
Extensive caries
Pulpotomy/pulpectomy
Malformed teeth
•
•
•
If used as an attachment for
•
•
•
•
•
•
Hypoplasia
Hereditary Conditions (AI, DI)
a crown and loop SM
Habit-breaking Appliance
Distal Shoe appliance
Fractured teeth
Severe attrition of primary teeth
Mesial lesions on first primary molars
Contraindications
•
•
•
•
Esthetics
Teeth that are nearing exfoliation
Mechanical problems
• space loss
• caries beneath the level of the bone
Permanent restoration in the permanent
dentition
Use of Stainless Steel Crowns
•
•
Introduced to pediatric dentistry by Dr. William
Humphrey in 1950
• prior to that orthodontic bands filled with
amalgam were a last resort
• “necessity is the mother of invention”
Considered superior to large multisurface amalgam
restorations and have a longer clinical lifespan than
two or three surface amalgams (Dawson et al., 1981)
Composition of Stainless Steel
Crowns

Alloy: nickel- chrome (ion crowns, 3M®)



77% nickel
15% chromium
7% iron
What you will need


Burs and Stones
Flame shaped diamond (Occlusal reduction)
Tapered diamond (Proximal reduction)
Heatless stone
Pliers and instruments
 Crimping
plier
 Contouring plier

Polishing
Step By Step



Caries Removal
Complete pulp therapy if necessary
Proceed with crown preparation
Overview
•
•
•
•
•
Occlusal reduction
Proximal reduction
Buccal and Lingual
reduction
Beveling
Round all sharp line
angles and corners
Occlusal Reduction
1.0 – 1.5 mm
Completed Occlusal Reduction
Check reduction with
opposing arch
Proximal Reduction
•
•
•
•
Contact with adjacent teeth must be broken gingivally
and buccolingually
proximal slices converge slightly toward the occlusal
and lingual
• DO NOT OVER TAPER
The gingival margins should have a feather-edge finish
line
Adjacent tooth structure must not be damaged
Proximal Slices
Angulation of Slices
Ledging

Proximal slice must be
extended below tissue to
avoid leaving a ledge
Buccal-Lingual Reduction



Reduction is optional and is undertaken only if the
buccal or lingual bulges are so prominent that the
constricted margin of the crown will not go over he
height of contour
When required, no more than .5-1mm should be
removed
Reductions must end in a feather edge
Beveling

A bevel at an angle of 30-45 degrees removes
the sharp cusp tips and creates a gentle slope
in the occlusal third of the lingual and buccal
surfaces
Round Sharp Line Angles


The buccal and lingual proximal line angles
are rounded by holding the bur parallel to the
tooth’s long axis and blending the surfaces
together
The finished contour should conform to the
internal contour of the stainless steel crown
Round Sharp Line Angles
Selection of the Crown

Goal: to place the smallest crown that can be
seated on the tooth and to establish preexisting proximal contacts


Hint: Size 4 is the most frequently used crown
size for molars
The selected crown is seated ligually first
then buccally.

Friction should be felt as the crown slips over the
buccal surface into the gingival sulcus
Selection of the Crown Size


The smallest crown that completely covers
the preparation should be chosen
Two important principles to produce well
adapted crown


Establish correct occlusogingival crown length
The crown margins should follow the natural
contours of the tooth’s marginal gingiva
Crown Adaptation

Mark gingival line with a
scaler and trim 1 mm
beneath the mark using C
& B scissors.

Margins should be trimmed
to lie parallel with the
contour of the gingival
tissue and consist of a series
of curves without sharp
angles.
Gingival Contours
Buccal gingival contour of second primary molar-smile
Buccal gingival contour of first
primary molar-- stretched-out S
Proximal gingival contour of
primary molars -- frown
Contour the Crown

Use contouring pliers,
bend the gingival third
of the crown’s margins
inward to restore
anatomic margins and
to reduce the marginal
circumference ensuring
a good fit
Crimp the crown

With the crowncrimping plier (ball &
socket plier) crimp the
margin

Replace crown on tooth
and check margins with
an explorer
Guidelines

Resistance in seating without tissue blanching.


Check for
 high spots on occlusal surface
 ledges
Resistance in seating with tissue blanching.

Check for
 crown too wide (preliminary contouring)
 crown too long
 tissue caught in margin
Finishing and Polishing



Use heatless stone to
smooth jagged edges
Then use a rubber
wheel to remove small
scratches and make it
smooth
Polish surface of crown
to a high shine with
tripoli and rouge
Cementation




Clean crown and tooth
Fill crown with the
appropriate cement
Seat crown, expressing
cement form all margins
and press into occlusion
Remove excess cement
when partially set
Post-op instructions ?


Although a welladapted and cemented
crown should not come
off under these
circumstances, patients
and parents should be
warned of the
possibility
Pain & analgesics
Managing Clinical Variations
Space Loss
Managing Space Loss


May need to increase
the buccal and lingual
reductions
May need to compress
crown form on mesial
and distal with Howe
pliers
Clinical Variations


“Back-to-back” chrome
crowns
Second primary molars
Complications
Any Questions???