Successful Multi-tooth Restorations in Pediatric Patients
Restoring the smile of a child with dental caries sometimes requires placing crowns on multiple teeth. In some cases, the teeth requiring treatment and restoration will be adjacent, and in others, not. Regardless, using well-designed aesthetic pediatric crowns can help reduce chair time for this process while providing long-lasting results.
In the cases presented here, the patients are under anesthesia and intubated. Preparation includes placement of a gauze throat pack with radiopaque strings to protect the airway and esophagus during the procedure. Prior to beginning the dental restoration procedure, a prophylaxis was completed to provide a clean view of the teeth.
Case #1: Teeth E & F
Joshua Bresler, DMD, of Doc Bresler’s Cavity Busters and an assistant professor of pediatric dentistry at both Temple University Kornberg School of Dentistry and the University of Pennsylvania School of Dental Medicine, talks about a case in which the patient presented with caries on the facial and lingual sides of both upper central incisors, E and F, as well as some additional cavities in posterior teeth.
After prepping the posterior teeth, address the incisors.
“Make sure you track the lips very well,” he says. “You can use a mouth prop if you like, but if the patient’s asleep, sometimes I’ll just use my finger to hold the lower jaw open.”
Begin with the occlusal reduction—in this case, about 1.5mm to 2mm. Remove the decay. To shape the tooth for the crown, cut around the tooth, starting with the facial surface, then the interproximal, then the distal and finally wrapping around the palatal, going subgingival all the way.
“Essentially, that’s the prep,” he says. Repeat the steps for the adjacent incisor. “Round everything off—you want everything rounded. The whole prep is subgingival, and you want to make sure you take enough off the palatal that the crown fits. Sometimes I go back and take a little extra off just to make sure.”
Pediatric Crowns with a large internal cavity require less prepping and tooth removal than conventional crowns—however, the material of the crown itself must be strong enough, with even thickness, to provide maximum structural integrity.
Try the crowns on for size. Sometimes the right crown is smaller than you think.
“You don’t want them fitting too snug, because it puts too much pressure on the facing—but you want to make sure that you can get them straight and aligned.” Pre-crimped crowns can save time. If the crown is still a little loose, put a small crimp in with a bird beak crimper.
“You want a little notch—almost like a heart—that will hold on to the palatal of the tooth.”
After fitting the crowns, remove them from the facial to avoid scratching the facing, and then proceed with the pulpectomies using a 700 burr (or a 169 if the canal is smaller). Dr. Joshua uses a paper point with formocresol in the canal, and then fills it with zinc oxide eugenol (ZOE) and plugs it in with a piece of cotton.
Finally, cement the crowns in place using glass ionomer, making sure there are no air bubbles. Remove any extra cement by rubbing toward the gingiva to avoid displacing the crown. Use a band seater to make sure the crowns are fully seated and adjust rotation if necessary. Check the bite.
“The whole thing takes a couple minutes,” he says.
Case #2: Teeth D, G, and H
Jason Bresler, DMD, named in 2018 as one of Incisal Edge Magazine’s top 40 dentists under the age of 40 in the United States, talks about a pediatric aesthetic restoration in two lateral incisors and a canine. He talks about a multi-tooth dental restoration involving teeth D, G, and H. In this case, he starts with the upper canine.
After prophylaxis, begin the occlusal reduction and then cut the interproximal, making sure to go subgingival all around the tooth.
“A good rule of thumb is to put the cutting edge of the burr at the reduced occlusal height table,” he says. “That’s how I know how far to go subgingival.”
Adjust the reduction as appropriate, depending on the location of the decay and how extensive it is, and then bevel the lingual. Cheng Crowns have a shape similar to a natural tooth, with a lingual bevel. Finally, ensure that the tooth has no sharp angles.
Perform the pulpotomy or pulpectomy access, going straight in with a size 80 file. Repeat as necessary to ensure that the canal is clean, and then insert a formocresol point.
Dr. Jason uses Vitapex injectable filling material, placing it at the apex and retracting as he squeezes to fill the tooth.
“You get a nice, perfect fill every time, but because this washes away a little bit easier than regular ZOE, I like to cap it off to give it a little more sturdiness,” he says. It is also bactericidal.
Follow the same steps to prep the other teeth, reducing the tooth as necessary to remove decay and provide solid tooth structure to receive the crown. In this case, Dr. Jason preps the molar and then the incisor, always beveling the lingual and rounding off any sharp edges.
When fitting the crowns, try a couple sizes to get the best results. For example, a 4 right lateral might fit fine, but a 3 might be a better choice for a patient who had some more space between teeth. The goal is to reproduce the size and shape of the original tooth as much as possible. Cement them, and that’s it.
“The restoration turns out pretty well. It’s extremely stable and durable,” he says. “In my opinion, it’s one of the nicest restorations you can do.”
For more information on pediatric dental restoration and working with Cheng Crowns pediatric crowns, view our Cheng Crown Academy How To Videos.