STAINLESS

STEEL
CROWNS

SHREEPRIYA SINGHANIA
SECOND YEAR PG
 CONTENTS

 INTRODUCTION
 HISTORY
 INDICATIONS FOR PRIMARY TEETH
 INICATIONS FOR PERMANENT TEETH
 RATIONALE FOR MORE FREQUENT USE IN PRIMARY TEETH
 CONTRAINDICATIONS
 CLASSIFICATION
 STAINLESS STEEL CROWNS VS. AMALGAM
 CONTENTS

 ARMAMENTARIUM
 PLACEMENT OF CROWNS FOR PRIMARY MOLARS
 RETENTION OF STAINLESS STEEL CROWNS
 PLACEMENT OF CROWNS FOR PERMANENT MOLARS
 HALL’S TECHNIQUE
 SPECIAL CONSIDERATIONS FOR STAINLESS STEEL CROWNS
 COMPLICATIONS
 REFERENCES
 INTRODUCTION

 Definition: Stainless steel crowns can be defined as prefabricated

crown forms that are adapted to individual teeth and cemented
with a biocompatible luting agent.
 They were often referred to as Chrome steel crowns as the
alloy used contains 18% chromium, 8% nickel and carbon content
of 0.8% - 20%.
(AAPD Special Issue Reference Manual 21:105. Revised 2008)
  1947- Stainless steel crowns were
introduced by Rocky Mountain
Company.
 1950s – Their use for primary molar
was popularized by Engel and
Humphrey.

HISTORY  1968- Crown preparation introduced

by Mink and Bennet (still being used)
 Other techniques frequently quoted
in the literature include the simplified
ones presented by Rapp and Castaldi
 However the Mink technique remains
the most comprehensive and
successful.
 INDICATIONS: PRIMARY TEETH

1. After pulp therapy;

2. For restorations of multisurface
caries and for patients at high
caries risk;
3. Primary teeth with
developmental defects;
4. Where an amalgam is likely to
fail;
5. Fractured teeth;
6. Teeth with extensive wear;
7. Abutment for space
maintainer.
Preformed metal crowns for primary and permanent molar teeth: review of the literature
Ros C. Randall, PhD, MPhil, BChD. Pediatric Dentistry – 24:5, 2002
 INDICATIONS: PRIMARY TEETH

 Carrying out a crown preparation of a tooth solely for use as an abutment

is destructive to tooth tissue and that bands are preferable to support
appliances to preserve arch space.
 When both a crown and space maintainer are required, the space
maintainer should be attached to a band cemented over the crown;
with this arrangement, subsequent removal of the space maintainer leaves an
intact and smooth crown surface. (Nash 1981)
 Pinkerton suggested that indications for placement of a PMC should include
child patients who are unlikely to attend regular recall appointments or
who are unlikely to be reliable preventive patients.
 INDICATIONS: PERMANENT TEETH

1. Interim restoration of a broken-down or traumatized tooth until

construction of a permanent restoration can be carried out or the eventual
orthodontic status is established;
2. When financial considerations are a concern, they are useful as a medium-
term, economical restoration in clinically suitable cases;
3. Teeth with developmental defects. The crowns are beneficial for restoring
the occlusion and reducing any sensitivity caused by enamel and dentin dysplasia
in young patients;
4. Restoration of a permanent molar which requires full coverage but is
only partially erupted.
 1. The enamel and dentin of the primary
molar crown are proportionally much
thinner than in the permanent tooth and are
relatively susceptible to caries attack.
2. In addition, the primary pulp is large with
prominent pulp horns and is situated in
SSC IS MORE close proximity to the mesial surface of the
FREQUENTLY tooth crown, particularly in mandibular primary
molars, placing exacting demands on cavity
REQUIRED IN design.
DECIDUOUS  Also, in a primary molar tooth the greatest
THAN convexity lies at the cervical third of the
crown. The thin metal of the preformed
PERMANENT crown margin is flexible enough to spring into
TEETH and be retained by this undercut area.
BECAUSE
 CONTRAINDICATIONS

 Duggal listed an exclusion criterion for fitting a primary molar crown—

namely, an inability to fit one. This encompassed:
1. The amount of tooth tissue remaining
2. The ability of the patient to cooperate with the treatment.
 It has also been recommended that teeth approaching exfoliation within
6 to 12 months should not be fitted with a Preformed Metal Crowns.
 For anterior teeth due to poor aesthetics.
 Primary posterior teeth in which conservative amalgam restorations
can be placed.
CLASSIFICATION OF STAINLESS STEEL
CROWNS

According to Trimming

According to Composition

According to Position

According to Occlusal Anatomy

ACCORDING TO TRIMMING
1. Untrimmed crowns
 These crowns are neither trimmed nor contoured
and require lot of adaptation , thus are time
consuming.
 Eg The rocky mountains

2. Pretrimmed crowns
 They have straight , non-contoured sides but are
festooned to follow at line parallel to the gingival
crest.
 They require contouring and some trimming . Eg
unitek , 3M CO, Denovo crowns

3. Precontoured crowns
 These crowns are festooned and precontoured
though a minimal amount of festooning and
trimming may be necessary .
 Eg : Unitek stainless steel crown, Ni-Chro ion crowns
 Stainless Steel Crown – Nickel – Base Crowns –
Inconel 600 type of alloy
 17 – 19 % Chromium  76% Nickel
 10 – 13 % Nickel  15% Chromium
 67 % Iron  6 – 10 % Iron
 4 % Minor elements (0.08  0.08 % Carbon
– 0.12% carbon)
ACCORDING  0.35 % Manganese
 0.2 % Silicon
TO
COMPOSITION  Austentic type have high
ductility, low yield  These alloys render greater
strength and high difficulty in contouring
ultimate strength. and adaptation due to
higher hardness & wear
 Chromium contributes to resistance to resist
formation of a thin oxide opposing forces.
film that provides the best
corrosion resistance.  Example: Ni-chro Ion
Crowns, Inconel
 Example: Unitek Stainless
Steel crowns, 3M Co.
 ACCORDING TO POSITION

Crowns for Posterior Teeth:

Unitek Stainless Steel Crowns, 3M Co

Crowns for Anterior Teeth:

NuSmile Crowns, Orthodontic Technologies,
USA
ACCORDING TO OCCLUSAL ANATOMY

01 02 03 04
Ion Unitek The Rocky Ormaco
Mountain
Compact Occlusal Best Occlusal Smallest and least
anatomy anatomy Occlusally small occlusally carved
STAINLESS STEEL CROWNS VS. AMALGAMS

 70% - 75% of large multi surface silver amalgams placed at

ages 2-5 will need replacement before the age of 8.

 Have a longer clinical life span than 2 or 3 surface amalgam

restorations (survival time up to 40 months as compared to
amalgam which is 30-32 months).

 Rate of replacement is also low (3%) as compared to Class II

amalgam restorations (15%).
  Braff in 1975 reported success rate of
70% for crowns and 11% for amalgams.

STAINLESS  Gordon 1978, Lilienfeld & Lilienfeld

1980 showed that crowns placed in
STEEL children age 4 or younger
demonstrated a success rate
CROWNS approximately twice that of Class
II amalgams, for each year up to 10
VS. years of service
AMALGAMS
 Dawson (1981) compared lifespan of
SSC and two surface amalgams. It was
determined that SSC was the
restoration of choice for primary
molars, especially for multisurface
restorations in the first molar before
the eruption of the 1st permanent
molar.
DATA FORM STUDIES COMPARING PREFORMED METAL CROWNS WITH
MULTISURFACE AMALGAM RESTORATION IN PRIMARY MOLAR TEETH

STUDY REFERENCE AND MULTISURFACE PREFORMED STUDY

DATE AMALGAM METAL CROWN DURATION

NUMBER FAILURES NUMBER FAILURE YEARS

PLACED PLACED S

BRAFF 1975 150 131(87%) 76 19 (25%) 2.5

DAWSON ET AL 1981 102 72 (71%) 64 8(13%) 2

MESSER & LEVERING 1988 1177 255(22%) 331 40(12%)) 5

ROBERTS AND SHERRIFF 706 82 (12%) 673 13(2%) 10

1990

EINWAG AND DINNINGER 66 38 (58%) 66 4(6%) 8

1996

RAW DATA TOTAL (%) 2201 578 (26%) 1210 84(7%) MEAN=5Y
 ARMAMENTARIUM
TABLE 3.4 Different crown adapting equipment
Pliers name Nomenclature of pliers Use of pliers
Contouring occlusal and
Johnson contouring plier no 114
middle third of crown
Contouring gingival third
Gordon plier no 137
of crown
Crimping plier (Unitec
no 800-417 Marked gingival crimping
corp)
Exaggerating
interproximal contour in
Ball and socket plier no 112
open contacts , for bell-
shaped contouring
Flattening interproximal
Howe plier no 110
contour of crown

Cutting excess material

Crown and bridge scissor
at gingival third of crown
BURS AND HAND-PIECE

1.Green stone
2.Rubber wheel
3.Wire brush
 PREFORMED METAL CROWNS FOR PRIMARY AND PERMANENT
MOLAR TEETH: REVIEW OF THE LITERATURE
ROS C. RANDALL, PHD, MPHIL, BCHD
DR. RANDALL IS MANAGER, CLINICAL AFFAIRS, 3M ESPE, ST PAUL, MINN.

Pediatric Dent. 2002

 An extensive literature review of the use and efficiency of preformed

metal crowns for primary and permanent molar teeth was done.
 A literature search of English language journals only was carried out
using MEDLINE. Keywords used were stainless steel crowns, preformed
metal crowns, primary molar crowns, permanent molar crowns.
 Papers were considered appropriate to include in the review if they
addressed one or more of the following areas related to use of PMCs: (1)
indications for use, (2) placement techniques, (3) risks, (4) longevity, (5)
cost effectiveness, and (6) utilization.
 Eighty-three papers were retrieved, which fulfilled the review criteria.
 PLACEMENT
PROCEDURES FOR
PRIMARY MOLAR
CROWNS
 PRIMARY MOLAR TOOTH PREPARATION

Local Anaesthesia
 Effective local anesthesia of the tooth under preparation is generally
recommended.
 Even with a root-treated tooth, preparation of the mesial and distal contact areas
will traumatize the local gingival tissue
 A topical analgesic applied to the gingival area may be sufficient.
Wooden wedges
 A number of authors recommended placement of wooden wedges before
commencing tooth preparation. These serve both to
1. Separate neighboring teeth and to reduce the risk of iatrogenic damage to the
enamel of these teeth.
2. In addition, they help to depress the gingival tissues and easy rubber dam placement
in case of tight contacts.
 PLACEMENT SENSITIVITIES

Rubber Dam
 The general advice from the literature was that the use of rubber dam is
preferred.
 Difficulties may arise if the tooth being prepared for a PMC is the tooth to be
clamped.
 In this instance, it is suggested that all necessary tooth preparation, except for
the distal reduction, be carried out under rubber dam.
 The distal slice and crown fitting are then completed after rubber dam
removal. (Duggal MS et al)
 The amount of occlusal reduction obtained can be checked by comparison with
neighbouring teeth. (Nash DA)
 More and Pink recommended cutting the interproximal portions of the
dam to prevent entanglement of the bur in these areas.
 CONSIDERATIONS ABOUT TOOTH
PREPARATION

 Humphrey (1950) recommended that the cusps be reduced if necessary ,

and that the four sides of the tooth be reduced but as much as tooth
structure as possible be left for retention.

 Rapp advises that the occlusal of the tooth be reduced so the height of
the preparation is approximately 4mm from the gingival margin.

 Mink and Bennett, suggest a uniform occlusal reduction of 1 to 1.5mm

using 1mm bur to make grooves in the occlusal surface to guide the
reduction.

 Troutman (1976) recommended the occlusal surface to be reduced to

1mm and Kennedy (1976) recommended the reduction to be 1.5 to 2mm.
 OCCLUSAL AND
PROXIMAL
PREPARATION
 Full et al, considered that preparing the
occlusal surface first allows better access
to the proximal areas of the tooth.
 The occlusal surface of the tooth should be
reduced by about 1.5 mm, maintaining its
occlusal contour or until the tooth is out
of occlusion.
 If much of the occlusal surface has already been
lost to caries, then reference can be made to
the marginal ridges of neighbouring
teeth.
 Proximally, tooth reduction is made through
the mesial and distal contact areas, the plane of
the preparation being cut at a sufficient angle
to avoid the creation of ledges at the gingival
finishing line.
 Lastly, the clinician should ensure that all line
angles are rounded.
 Steps in the
preparation of a
primary molar for a
stainless steel crown
restoration with a
.

No. 69L bur in the

high- speed
handpiece.
 A, Mesial reduction.
 B, Distal reduction.
 C, Occlusal
reduction.
 D, Rounding of the
line angles

Dean, Jeffrey Alan_ Jones,

James Earl_ McDonald,
Ralph E._ Vinson, LaQuia A.
Walker - McDonald and
Avery's Dentistry for the
Child and Adolescent, 10e-
Elsevier, Mosby (2016)
Buccal and lingual wall preparation
 Some authors suggested preparing buccal and
lingual walls to produce a gingivally inclined
long bevel to facilitate placement of the
crown.(Full et al, Page et al and Das et al)
 Others, however, recommended that minimal
or no preparation be carried out on the
buccal and lingual sides of the tooth crown
unless there is a pronounced enamel
convexity, and, if present, this should be
reduced by only a limited amount. (Mink JR,
Bennett IC)
 Duggal and Curzon recommended trying
the selected crown for size before carrying out
any lingual or buccal reduction.
 Gingival proximal margin should have feather
edge finish line.
 Any ledge or step present at the proximal
finishing line will create difficulty in seating the
crown so that the clinician may remove the ledge
or step.
 Preformed metal crowns for primary molars are not close fitting,
except at the margin, so the preparation coronal to the gingivae
does not need to be precise. (Page J 1973)
 The most bulbous part of the primary molar tooth is at its cervical
third, and it is this undercut area at the gingival margin,
particularly buccally and lingually, which gives retention to the crown.
(Mink and Bennet)
 The mesial and distal slices should end slightly below the gingivae,
leaving an undercut area of intact enamel at the cervical
circumference of the tooth.
 The flexible crown wall allows it to spring into these undercut areas,
thus gaining retention.
 To obtain retention, the crown must seat subgingivally to a
depth of about 1 mm.
 A tight marginal fit aids in:
 I. Mechanical retention
II. Protection of cement from exposure to oral fluids.
III. Maintenance of gingival health.
 A degree of gingival blanching seems to be inevitable
(Duggal and Curzon)

 Although some authors interpreted gingival blanching as an

indication that further contouring of the crown is necessary. (More et
al and Myers)
 A crown that is high in the occlusion (1-1.5 mm) is acceptable, as it is
considered that primary teeth can spontaneously adjust for this
amount of occlusal discrepancy over a week or so. (Duggal et al and
Fayes)
Croll TP (1999) suggested cutting vertical grooves around the
prepared tooth crown periphery to increase the surface area
and perhaps enhance crown retention by providing resistance
against any rotational forces during mastication.

Placement of a PMC immediately after completion of a

pulpotomy procedure was recommended.
 SELECTION OF CROWN SIZE

 The selected crown should restore the contact areas and occlusal
alignment of the prepared tooth.
 The crown selection can be done by
1. Trial and error,
2. Measuring the mesiodistal dimension of the tooth space with dividers.
 It can also be helpful to measure the dimension of the contralateral
tooth.
 A correctly fitting crown should snap or click into place at try-in.
 More and Pink recommended a bite-wing radiograph at the crown
try-in stage to check for any margin overextension in the
interproximal area.
CROWN MODIFICATION

 Modern anatomically contoured crowns need no

modification. (Duggal et al)
 Croll and Riesenberger also stated that the
majority of PMCs do need adjustment to obtain
optimal adaptation to the primary molar tooth.
 Crowns with little or no festooning at the margin
will routinely need adjustment.(Brook et al)
 If the crown does not fit well, the preparation
should be checked for steps at the finishing line,
which could cause the crown to bind. (Croll)
 CROWN MODIFICATION

 Crown trimming can be carried out with

crown scissors or an abrasive wheel, the
latter considered to give better control
than scissors.(Allen 197, Croll TP 1999)
 Brooke and King added the sensible
reminder to carry out all crown trimming
procedures away from the patient’s
face, and to ensure that the patient has
adequate eye protection.
 After trimming, the crown must be crimped
to regain its retentive contour, and special
crimping pliers are available for this
procedure.
 No. 137 plier, No. 800- 417 (Unitek) plier can
be used.
 SEM evaluation of
Once these
polishing procedures
adjustments are
for PMCs has
completed, the
demonstrated that
crown margins
the use of rouge for
should be thinned
the final polishing
and smoothened, final
step results in the
polishing being done
most evenly smooth
with a rubber wheel,
surface.(Peterson et
followed by a rouge.
al)
PRINCIPLES FOR OBTAINING OPTIMAL ADAPTATION
(BY SPEDDING 1984)

1. Crown Length:
 - Be 1mm sub-gingivally.
 - Extend slightly apical to tooth’s
height of contour

2. Shape of the crown's gingival

margins
 Outline for the buccal and lingual
gingiva for 2nd primary molars is
similar to a smile.
 The buccal gingiva of the 1st
primary molar is that of a stretched
out S
 The proximal contours of the
primary teeth approximates that of a
frown.
 CEMENTATION

 PMCs need a generous mix of cement to adequately fill the crown

space prior to seating. (two-thirds of the crown)
 It is recommended that the crown be first seated over the lingual
or buccal wall and rolled over onto the opposite wall, which will also
help to minimize damage to the crown margin.
 Once seated onto the prepared tooth, the crown should be maintained
under pressure while the cement sets.
 Excess cement should be seen to extrude from around the entire
crown margin, and this is removed after setting.
CEMENTATION
 Removal of excess cement from the contact
area is facilitated by means of a length of
dental floss or tape with a single knot
tied in it.
 Croll has suggested removal of excess set
resin-modified glass ionomer cement
(RMGIC) by means of an ultrasonic scaler.
 Over the time period of the literature
surveyed, different authors have
recommended various cements, for
example, zinc phosphate, fast- setting zinc
oxide, and polycarboxylate.
 The most recent publications (1997 and
1999) recommended RMGI cements.
 1 2 3
Nano composite Siddhanth Pathak et Mathewson :
resin used along al reported that Retention of SSC is
with sandblasted retentive strength of due to cementing
SSC had more shear dual-polymerized self medium than due to
bond strength than adhesive resin cement mechanical
was better then adaptation.
conventional RMGIC.
composite resins.
(IJCPD 2016)
(A Khatri B Nandlal 2007)
 RETENTION OF STAINLESS STEEL
CROWNS

 Humphrey and Full et al suggested that retention of stainless steel

crowns is related to minimal tooth reduction and contact
between the margins of the crown and the tooth.

 Mathewson et al reported that mechanical retention is due to

cementing medium than due to mechanical adaptation.

 Yates and Hemberee found that the Unitek crown is

significantly more resistant to removal than the Ion and
Rocky Mountain crowns
 Myers et al reported that crown
retention with cement was
significantly higher than mechanical
retention alone.

 Stainless steel crown retention with

polycarboxylate or zinc phosphate
cement was significantly greater than
crown retention with zinc oxide eugenol
cement.

 Savide et al observed that tooth

preparations which maintain the greatest
amount of buccal and lingual tooth
structure are the most retentive.
 PLACEMENT
PROCEDURES FOR
PERMANENT MOLAR
CROWNS
 PERMANENT MOLAR TOOTH
PREPARATION
 The preparation of a tooth for a permanent molar PMC is essentially the same as for a
cast metal crown but with a reduction in the amount of tooth tissue removed.
 An occlusal reduction of about 1.5 to 2 mm is needed, and carrying this out first enables
the proximal reduction to be done more easily.
 The walls of the crown are prepared minimally so that they are slightly tapering with the
finishing line ending in a smooth feather edge and placed just below the level of the free
gingival tissue.
 Sharp line angles should be smoothened to ensure that the crown does not bind on
seating.
 Radcliffe and Cullen recommended preparation of proximal slices but no preparation of the
buccal or lingual tooth walls.
 This procedure allows the extra option of future placement of an onlay, rather than only a
full coverage crown.
 CROWN MODIFICATION FOR PERMANENT
MOLAR PMCS

 The selected crown should establish a good contact area with

neighbouring teeth and snap into place cervically.
 If required, the crown margin can be trimmed with crown scissors or by
means of a dental stone.
 The crown gains its retention from the cervical margin area so the crown
margin must be recrimped after any adjustments to ensure an accurate
fit to the tooth.
 Once recrimped, the crown margins should be thinned, smoothed, and
polished.
 The occlusion should be carefully checked and adjustments made if
needed. Unlike the primary molar crowns, those for permanent teeth
cannot be left in hyperocclusion.
 A bitewing radiograph is recommended at the final try-in stage, before
cementation, to check the marginal fit proximally.
 CEMENTATION

 RMGI cement has been recommended as the preferred material for

cementation of permanent molar PMCs.
 All excess cement at the margins should be carefully removed by means of an
explorer, and a piece of knotted dental floss passed interproximally to dislodge
excess cement in these areas.
 Preformed crowns for permanent teeth can function as an interim restoration
for many years causing the occlusal surface of the crown to become perforated
from wear.
 In some instances, repair can be carried out using amalgam or bonded
composite resin, alternatively, the internal aspect of the occlusal part of the
crown can be reinforced by the addition of solder prior to cementing the
crown.(Croll Technique)
 CEMENTATION

 Murray and Madden describe a technique where, prior to fitting

the crown, the occlusal surface is removed, retaining the marginal
ridges.
 After cementation, a bonded amalgam core is built up within the
crown to restore the occlusal surface.
 This technique minimizes the risk of occlusal perforation.
 However, a greater occlusal reduction in tooth height (of 3- 4 mm)
is required to provide adequate space for the amalgam.
 LONGEVITY OF STAINLESS STEEL
CROWNS FOR PERMANENT TEETH:

 The major factors concerning the longevity of the crown are

o gingival recession
o recurrent marginal caries
o dissolution of the cement
o wearing through on the occlusal surface of the crown.

 Stainless steel crown for permanent teeth are not substitute for
the precision cast restoration.
 HALL
TECHNIQUE
THE HALL TECHNIQUE 10 YEARS ON: QUESTIONS AND ANSWERS
N. P.T. INNES ET AL
BRITISH DENTAL JOURNAL | VOLUME 222 NO. 6 | MARCH 24 2017
HOW DID THE HALL TECHNIQUE COME ABOUT
AND WHEN DID IT START BEING USED?

 During an audit of paediatric dental service provision in the north east of

Scotland in 1997, one general dental practitioner, Dr Norna Hall was
found to be the only dentist, out of 150 in the regional audit, regularly
placing preformed crowns in children.
 During discussion, it became apparent that Dr Hall was using the crowns in
an unconventional way – not placing local anaesthesia, removing caries or
preparing the tooth.
 Dr Hall worked in an area with high levels of caries and low treatment
acceptance. She had gradually adapted conventional crown placement to this
technique in an attempt to respond to the demand for treatment that was
quick, and did not involve local anaesthesia.
 From her meticulously kept and detailed notes, data was collected and a
retrospective analysis was published on the survival of the teeth she had
been treating that way in the British Dental Journal.
 WHAT IS THE HALL TECHNIQUE?

 The Hall Technique is a method for using preformed metal (also known as stainless
steel) crowns to manage carious primary molar teeth, by seating a correctly sized
crown over the tooth and sealing the carious lesion in, using a glass ionomer luting
cement. Local anaesthesia is not required, tooth preparation is not carried out, and
no carious tissue is removed
 Although conventional preformed crowns are used to carry out the Hall Technique,
and it is simply a different way of using these crowns, crowns fitted this way are
usually referred to simply as Hall crowns.
Table 1 Indications and contra-indications for (teeth) using the Hall
Technique for managing primary molars with caries lesions assessed as at
risk of progressing and causing pain/sepsis before exfoliation

Proximal lesions, cavitated or non-

cavitated
Occlusal lesions, non-cavitated if the child
Indications include teeth with:
is unable to accept a fissure sealant
Occlusal lesions, cavitated if the child is
unable to accept selective caries removal

Where no ‘clear band of dentine’ can be

seen on a radiograph
Signs or symptoms of irreversible pulpitis,
or dental infection (sepsis)
Clinical or radiographic signs of pulpal
Contra-indications include teeth with:
exposure, or periradicular pathology
Crowns/teeth so broken down they would
be unrestorable with conventional
techniques Children where the airway
cannot be managed safely
Radiograph of a five year old showing 84 with distal carious lesion. A ‘clear
band of dentine’ is visible between the advancing edge of the lesion and
the dental pulp and fitting a crown at this stage has a high chance of
success.
HOW CAN SEALING CARIES INTO A TOOTH BE
SUCCESSFUL?

 When a carious lesion is sealed into a tooth, the biofilm is physically

prevented from accessing nutrition from its main substrate, dietary
carbohydrate. This means that the actively carious/cariogenic lesion becomes a
non-cariogenic lesion.
 By sealing in the carious lesion, the aim is arresting the lesion before it
advances far enough to cause irreversible inflammation of the dental pulp.
 A retrospective analysis of 161 children attending Dundee Dental Hospital found
that when the clear band of dentine is used as an indication, there is over a 97%
chance of success in treatment over an average of 3 years (range 1-6 years).
 HOW DO CROWNS PLACED USING THE HALL
TECHNIQUE COMPARE WITH CROWNS
PLACED USING CONVENTIONAL TECHNIQUES?

 One retrospective study of a US paediatric practitioner’s records had assessed

success rates of conventional and Hall Technique-placed crowns.(Ludwig FH et al)
 Success was defined as no further treatment being required, the crown remaining
in place and no pulp pathology (assessed clinically and radiographically). There was
no statistically significant difference between either method for placing crowns.
 A total of 65 out of 67 Hall crowns (97%) were successful and 110 of 117 (94%)
of conventionally-placed crowns were successful.
 Another US retrospective study, also found high clinical and radiographic success
for crowns placed on primary molars using the Hall Technique. At the second
follow-up (mean time 20.1 months), 74 of 76 (97.4%) Hall crowns were clinically
successful and 94.9% were radiographically successful.
WHAT HAPPENS TO THE OCCLUSION
WHEN A CROWN IS FITTED USING THE HALL
TECHNIQUE?

 In a prospective study of 10 children’s occlusions following placement of a Hall

crown, clinical photographs, study model and intra-oral measurement follow-ups
were carried out at two weeks, six weeks and six months.
 There was a mean increase in the Overall Vertical Dimension of 1.1 mm immediately
following crown placement.
 This reduced to 0.3 mm after two weeks, with the dentition appearing to have
equilibrated to its pre-crown state, and staying at this level.
 It appeared that the compensation was mainly from the intrusion of the crowned
tooth with some intrusion of the opposing tooth. There is no evidence of damage to
the permanent successor.

So D, Evans D J, Borrie F et al. Measurement of Occlusal Equilibration Following Hall Crown

Placement A Pilot Study. J Dent Res 2015;
SPECIAL CONSIDERATIONS
FOR
STAINLESS STEEL CROWNS:
 QUADRANT DENTISTRY:

 Prepare the occlusal reduction of one tooth completely before beginning

the occlusal reduction of the other tooth
 Reduce the adjacent proximal surface of the teeth being restored more
than when only one tooth is restored.
 Both crown should be trimmed, contoured and prepared for
cementation simultaneously to allow for adjustments in the
interproximal spaces and establish proper contact areas.
 To get these adjustments, adapt and seat the crown on the most distal
tooth first and proceed mesially.
 CROWNS IN AREAS OF SPACE LOSS
(MC EVOY 1977):

In cases of extensive and long standing caries, the primary teeth shift into
the interproximal contact areas. Crown required will be too wide M-D
compared to the M-D space available.

 Select a larger crown which will fit over the tooth’s greatest convexity.
 Reduce the M-D width by grasping the marginal ridges of the crown
with Howe utility pliers and squeezing the crown.
 Recontour the proximal, buccal and lingual walls of the crown with the
No. 114 pliers.
 Or The crown is rotated slightly mesiobuccally so that it is rotated
slightly out of the arch.
 PREPARING A STAINLESS STEEL CROWN ADJACENT TO
A CLASS-II AMALGAM RESTORATIONS (MC EVOY 1985)

 Crown reduction is complete and the crown is adapted.

 Matrix band and wedges are placed.Amalgam is inserted and carved.
 With the matrix band in place, the crown is removed safely without
fracturing the amalgam.
 Then remove the matrix band and the final carving of amalgam is
done, as there is good visibility and access to the proximal box area.
 Now complete the crown adaptation and cement the crown.
 STAINLESS STEEL CROWN
MODIFICATIONS

 THE UNDERSIZED TOOTH OR

THE OVERSIZED CROWN:

- The crown is cut vertically along

the buccal wall.
- The free crown margins are
approximated and spot-welded to
reduce the crown’s dimensions.
 THE OVERSIZED TOOTH OR THE
UNDERSIZED CROWN:

- A vertical cut is made on the buccal

surface of the crown.
- The margins are pulled apart and an
additional piece of stainless-steel band
material is spot-welded to the buccal
surface, increasing the dimensions of
the crown.
- After contouring, solder is applied to
fill any microscopic deficiency in seal.
-The crown is polished and
cemented.
 DEEP SUBGINGIVAL CARIES:

o The unfastened Rocky Mountain crown

o Lengthening the crown with a spot welded and soldered piece of
band material
 OPEN CONTACT:

Food packing increased plaque retention and subsequently gingivitis.

o Select a larger crown

o Alternatively, exaggerated interproximal contour can be obtained with a

No. 112 (ball-and-socket) plier to establish a closed contact .

o Localized addition of solder can also build out the interproximal

contour.
 COMPLICATIONS OF
STAINLESS STEEL
CROWN RESTORATIONS:
1.INTERPROXIMAL LEDGE:
 Crown does not seat proximally.
 It is removed using a tapered fissure bur.

2.CROWN TILT:
 Destruction of a complete lingual or buccal wall by caries or
overzealous use of cutting instruments may result in the finished crown
tilting towards the deficient side.
 Commonly seen on lingual aspect of mandibular primary molars.
 Placement of an amalgam alloy, or glass-ionomer cement restoration
3.POOR MARGINS:

 Imperfect adaptation.
 Open margins.
 Recurrent caries plaque retention and subsequent gingivitis
 Premature exfoliation of that tooth

4.PERIODONTAL CONCERNS:

 Henderson (1973) reported that the plaque accumulation index for

stainless steel crowned teeth was generally lower than that for the entire
mouth.
 A higher degree of gingivitis associated with crowns having a ‘poor’ fit.
 Myers (1975) reported a close relationship between the presence of
marginal gingivitis and defects in the adaptation of the crown margin.
5.AESTHETICS:

 Some parents have expressed dislike of the appearance of a PMC with crowns for the
lower first primary molars causing the most comment.
 Mesiobuccal facing can be placed after the crown has been cemented into place.
Roberts (1983)

6.NICKEL ALLERGY:

 Feasby et al (1988), reported an increased nickel-positive patch test result in

children 8 to 12 years of age who had received old formulation nickel-chromium
crowns.
 Nickel hypersensitivity is more prevalent in females than males and is considered
to be associated with pierced ears or metal buttons in clothing.
7. INHALATION OR INGESTION OF THE CROWN:
 Immediate chest X-ray is mandatory
 If the crown is in the bronchi or lung, medical consolation and referral
will probably result in an attempt to remove it by bronchoscope.
 The presence of a cough reflex in the conscious child fortunately
reduces the chances of inhalation, ingestion of the crown being more
likely.
 The Stainless steel crown will usually pass uneventfully through the
alimentary tract within 5-10 days. The parent should assume the
unpleasant task of locating the expelled crown.
ALLEN DESCRIBED THE MOST COMMON
ERRORS IN USING STAINLESS STEEL CROWNS AS

 Unnecessary destruction of hard tissue in

preparation
 Lack of a feather edge around the entire
circumference,
 Failure to round all line angles which may prevent
correct seating of the crown
 Incorrect selection of the crown size.
More and Pink described the causes of
stainless steel crown failure:
 pulp necrosis
 ectopic eruption,
 improper contact which may cause space loss,
 gingivitis around the crown
 insufficient retention leading to loss of a crown
 excessive occlusal wear
 CARE AFTER TOOTH RESTORATION WITH SSC

 Regular diet may be resumed after anesthetic effects are worn off.

 Warm saline rinses.

 Proper brushing and flossing

 Stainless steel crowns on permanent teeth may need to be replaced by

a cast crown when the child is in his/her mid to upper teens or later
in life.
 REFERENCES:
 Pediatric Dentistry: Infancy Through Adolescence. Pinkham. Fourth Edition.
 Dentistry For The Child & Adolescent. Mc Donald, Avery Eighth Edition..
 Kennedy’s Paediatric Operative Dentistry. Curzon, Roberts, Kennedy. Fourth Edition

 Restorative Techniques in Pediatric Dentistry. Duggal, Curzon, Fayle, Pollard, Robertson.

Second edition
 Handbook of Pediatric Dentistry. A Cameron.
 Pediatric Dentistry. Welburg. Second Edition.

 Stainless steel crown in clinical pedodontics: Areview. F Salama. The Saudi Dental Journal,
Volume 4, Number 2, May 1992

 Efficacy of preformed metal crowns vs. Amalgam restorations in primary molars: a

systematic review . Ros C. Randall. J Am Dent Assoc, vol 131, no 3, 337-343. 2000
• A Comparison Between Preformed Stainless Steel Crowns and Simple
Restorations On Primary Molars In A Public Health Dental Program. Middle east
journal of family medicine. June 2008 - Volume 6, Issue 5

• UK National Clinical Guidelines in Paediatric Dentistry: stainless steel preformed

crowns for primary molars. S. A. Kindelan International Journal of Paediatric
Dentistry 2008; 18 (Suppl. 1) : 20–28

• Dental Cements for Definitive Luting: A Review and Practical Clinical

Considerations Edward E. Hill. Dent Clin N Am 51 (2007) 643–658
• The hall technique 10 years on: questions and answers N. P. T. Innes et al
British dental journal | volume 222 no. 6 | march 24 2017