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Paediatric Dentistry Clinical Procedure Guide_formatted_text

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Stainless Steel Crown Procedure

The technical procedure for placing a Stainless Steel Crown (SSC) involves several critical phases to ensure successful restoration and patient comfort.

Technical Procedure1

Clinical Preparation

  • Administer local anaesthesia
  • Use a bite block
  • Isolation: preferably rubber dam

Procedural Sequence

  1. Check the occlusion
  2. Check the size
  3. Place wedges
    • Separate adjacent teeth
    • Reduce risk of iatrogenic damage
    • Depress the gingival tissues and rubber dam
  4. Tooth preparation: occlusal and proximal reductions
  5. SSC selection
  6. SSC contouring and trial fit
  7. Cementation

Step 3 Tooth Preparation2

Occlusal Reduction

  • Reduction by at least 1.5mm is necessary to provide clearance for the crown.
  • Reduction must follow the occlusal contours to ensure maximum resistance to displacement.
  • Depth cuts can be made to assist uniform reduction.

Proximal Reduction

  • Perform near vertical slices to clear the contact areas and create space for the crown.
  • Enough clearance is confirmed by passing an explorer through the space.
  • AVOID:
    • Excessive taper
    • Creating a shoulder at the gingival margin
  • The ideal preparation should have a feather edge margin.

Buccal and Lingual Reduction

  • In most cases, the buccal and lingual surfaces do not require significant preparation as they are important for mechanical retention.
  • Occasionally, on first primary molars where there is a prominent mesio-buccal bulge, this can be reduced to allow for adequate seating of the crown.

Finishing

  • All sharp line angles and corners should be rounded off.

Step 4 SSC Selection3

Contouring and Crimping

SSCs gain their retention from a “snap fit” achieved by the margin of the crown engaging the height of contour and undercuts in the crevice region.

  • Contouring:

    • General contouring of the SSC is achieved by closing the jaws of the pliers.
    • Smooth wrinkles by drawing the jaws around the margin of the crown.
    • Note: This is not usually required in pre-contoured SSCs.

  • Crimping:

    • Crimp the last 1-2mm of the gingival margin of the crown.
    • Crimp by closing the jaws and holding the crown still while moving the pliers inwards.
    • Ensure the right side of the pliers are used! If not used correctly, the pliers can cause flaring of the margin.

Step 5 Trial Fit

  • Ensure the stainless steel crown covers the tooth completely.
  • The cervical margin of the crown should be no more than 1mm below the gingival margin.
  • The crown will often “click” as it engages the height of contour.
  • Once fully seated, it should be stable with minimal rocking and resistance to dislodgement.

Step 6 Cementation4

Application

  • Ensure adequate isolation and that the tooth is dry and free of any debris.
  • Cement using a conventional glass-ionomer cement (e.g., Fuji IX, Ketac Cem).

Post-Cementation Care

  • Remove all excess cement.
  • Ensure to floss between the contact points while keeping pressure on the crown to prevent dislodgement.

Step 7: Evaluation

  • Correct buccal and lingual contouring
  • Close cervical fit
  • Correct sulcus depth
  • Correct crown length
  • Full coverage

Pulpotomy Procedure5

Initial Preparation

  1. Pre-operative Radiograph: Assess the tooth and surrounding structures prior to starting the procedure.
  2. Local Anaesthesia and Rubber Dam Isolation: Ensure patient comfort and maintain a sterile, dry working field.
  3. Caries Removal and Occlusal Reduction: Remove all decayed tooth structure and reduce the occlusal surface in anticipation of a Stainless Steel Crown (SSC) placement.

Access and Pulp Removal

  1. Removal of the Roof of the Pulp Chamber: Gain full access to the coronal pulp.
  2. Coronal Pulp Amputation: Use a sterile, slow-speed large round bur to remove the coronal pulp tissue.
  3. Bleeding Control: Use moistened cotton pellets to control hemorrhage.

Assessment and Medicament Application

  1. Hemostasis Assessment: Successful hemostasis indicates that the radicular pulp remains healthy and vital.
  2. Medicament Application: Apply Ferric Sulphate to the pulp stumps.

Restoration and Finalization

  1. Base Placement: Apply Cavit as a protective base over the pulp stumps.
  2. Core Build-up: Place Fuji II LC (Glass Ionomer Cement) to create a solid core.
  3. Final Preparation: Complete the stainless steel crown preparation for definitive restoration.

Resin Composite Strip Crown Procedure6

Clinical Workflow Overview

  1. Administer local anaesthesia
  2. Check occlusion, baseline crown size and position
  3. Tooth preparation: incisal, proximal, buccal and palatal reduction
  4. Composite crown form selection and trimming
  5. Trial fit (must seat passively)
  6. Rubber dam placement
  7. Etch, bond, fill crown form
  8. Cementation - maintain gentle pressure, remove excess and ‘tack’ cure
  9. Remove any residual excess prior to final curing
  10. Strip off celluloid crown form
  11. Final polishing and occlusal assessment

Tooth Preparation Guidelines

  • Caries removal
    • Measure the mesio-distal dimensions of the crown first to assist with selecting the correct crown size later.
  • Incisal Reduction: Approximately 1.5mm
  • Proximal Reduction: 0-1mm reduction with parallel proximal walls
  • Facial and Palatal Reduction:
    • Facial: 1mm
    • Palatal: 0.5mm
  • Finishing Details:
    • Knife edge margin
    • Rounded line angles

Crown Selection

Select the appropriate composite crown form based on the pre-operative measurements and the prepared tooth dimensions.

Trimming

  • Use curved crown scissors gently to avoid squashing the form.
  • Remove the tag while cutting along the CEJ (Cementoenamel Junction) of the crown form.
  • Margins should be trimmed to achieve a uniform, smooth finish.

Trial Fit7

  • The crown form must slide over the preparation passively with no resistance.
  • The form should extend just below the gingival crest.
  • Verify that the crown height and width are appropriate.
  • Note on Space: Ensure adequate space exists between the crown form and the preparation. Insufficient space results in a thin layer of composite, which increases the risk of fracture.

Isolation and Final Preparation

  • Rubber Dam Isolation:
    • For multiple anterior teeth, the primary first molars (D’s) can serve as anchor teeth.
    • Use single tooth isolation rather than a slit technique to ensure superior moisture control.
  • Trial Fit Under Rubber Dam:
    • Ensure the rubber dam is not caught or impinging on the clamp.
    • 9T or 212 clamps can be used to retract gingival tissues and increase the surface area for retention.

Bonding and Loading

  • Acid Etch: Apply phosphoric acid.
  • Bonding: Apply a thin layer of dentine bonding agent.
  • Loading the Form:
    • Fill the crown form approximately 2/3 full with resin composite.
    • Fill evenly to avoid voids or air inclusions.

Cementation and Finishing

  • Seating:
    • Seat the crown firmly onto the tooth.
    • Remove excess resin material using a probe or flat plastic.
    • Avoid excessive force to prevent cracking the form or creating marginal inconsistencies.
    • Maintain steady pressure; lifting the finger during seating can cause voids or moisture contamination.
  • Curing:
    • Once labial excess is removed, ‘tack’ cure the labial surface for a few seconds.
    • Complete the final light-cure of the composite crown.
  • Crown Form Removal:
    • Use an excavator, probe, or Hollenback carver to remove the strip crown.
    • Scoring the palatal or proximal surface (to avoid scratching the buccal) can help nudge the form away.
  • Final Finishing:
    • Complete final finishing and polishing of the margins after the rubber dam is removed.

Intracoronal Restoration Procedure8

Clinical Preparation and Isolation

  1. Identify the tooth (described below for 84DO restoration).
  2. Insert a bite-block (in a clinical scenario).
  3. Administer topical and local anaesthesia (in a clinical scenario).
  4. Isolate the tooth using a rubber dam:
    • Clamp 12A on 85, 13A on 75.
    • Use the slit technique (from second molar to canine).

Preparation and Bonding

  1. Cavity preparation.
  2. Matrix band placement.
  3. Apply etchant (H3PO4 for 15 seconds).
  4. Wash and dry the tooth.
  5. Apply the bonding agent:
    • Light cure for 10 seconds.

Restoration and Finishing

  1. Placement of the restorative material:
    • Composite (Z100).
  2. Application of fissure sealant on the occlusal and buccal surfaces (Filtek Flow).
  3. Finishing and polishing.

Cavity Preparation and Restoration

The following procedural steps outline the sequence for cavity preparation and the subsequent restoration of the tooth structure.

Illustrations9

Procedural Stages

  1. Cavity preparation
  2. Matrix band placement
  3. Composite placement
  4. Finishing and Polishing

Footnotes

  1. Original PDF page 1: Paediatric Dentistry Clinical Procedure Guide, p.1 ↩

  2. Original PDF page 2: Paediatric Dentistry Clinical Procedure Guide, p.2 ↩

  3. Original PDF page 3: Paediatric Dentistry Clinical Procedure Guide, p.3 ↩

  4. Original PDF page 4: Paediatric Dentistry Clinical Procedure Guide, p.4 ↩

  5. Original PDF page 5: Paediatric Dentistry Clinical Procedure Guide, p.5 ↩

  6. Original PDF page 6: Paediatric Dentistry Clinical Procedure Guide, p.6 ↩

  7. Original PDF page 7: Paediatric Dentistry Clinical Procedure Guide, p.7 ↩

  8. Original PDF page 8: Paediatric Dentistry Clinical Procedure Guide, p.8 ↩

  9. Original PDF page 9: Paediatric Dentistry Clinical Procedure Guide, p.9 ↩

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