Although advances in the application of preventive dentistry techniques, widespread acceptance of community fluoridated water, and increased dental education in parents have reduced the incidence of caries in children, there is still a high prevalence of early childhood caries (ECC), especially in the lower socioeconomic population.

EEC (formerly termed “nursing-bottle caries” and “baby-bottle decay”) is the term currently used to describe the occurrence of caries in young children’s teeth. It affects 1-12% of pediatric population in developed countries and up to 70% in underdeveloped countries. It is defined by the American Academy of Pediatric Dentistry (AAPD) as the presence of 1 or more decayed (non-cavitated or cavitated) lesions, missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger. Severe ECC is defined as any sign of smooth-surface caries in a child younger than 3 years of age or 1 or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth, or a decayed, missing, or filled score of >4 (age 3), >5 (age 4) or >6 (age 5) surfaces.1

It is a result of excessively frequent ingestion of liquids containing fermentable carbohydrates (milk, formula, juice, soda) by the child at sleep time particularly through a bottle. Prolonged breast feeding has also been implicated in ECC.

The clinical appearance of severe EEC follows a definite pattern. There is early carious involvement of the maxillary incisors followed by the maxillary and mandibular first primary molars and the mandibular cuspids.

Image: roof of child's mouth

Aesthetic treatment of severely decayed primary teeth is one of the greatest challenges to pediatric dentists. In the last half century the emphasis on treatment of extensively decayed primary teeth shifted from extraction to restoration. Early restorations consisted of placement of stainless steel bands or crowns on severely decayed teeth. While functional, they were unaesthetic and their use was limited to posterior teeth. The mesial buccal surfaces of the first primary molars and maxillary-second primary molars may be seen when the child smiles.

Over the last two decades there has been an explosive interest by adults in aesthetic restoration of their compromised dentition. Similarly, a higher aesthetic standard is expected by parents for restoration of their children’s carious teeth. One survey revealed pediatric dentists report pressure from parents to place a tooth colored restoration, sometimes or often 69% of the time.1 Thus, the choice of full coverage restorations for primary teeth must provide an aesthetic appearance in addition to restoring function and durability.

Aesthetic full coverage restorations are available for anterior and posterior primary teeth. This continuing education course will concentrate on aesthetic full coverage restorations for posterior primary teeth.

Indications for full coverage of posterior primary teeth are:

  • Teeth with large carious lesions
  • First primary molars with mesial interproximal lesions due to the tooth morphology does not provide adequate support for intracoronal restorations
  • Teeth with hypoplastic defects or with developmental anomalies such as dentinogenesis or ameliogenesis imperfecta
  • Teeth that have undergone pulp therapy
  • Restoration in individuals with poor oral hygiene and failure of intracoronal restorations is likely
  • As an abutment for a space maintainer1,2

The types of full coverage for posterior primary teeth currently available are:

  • Stainless steel crowns
  • Open-faced steel crowns
  • Pre-veneered steel crowns
  • Zirconia crowns

Table 1 summarizes the properties and selection criteria of various full coverage techniques currently available to practitioners.

Table 1. Comparison of Full Coverage Techniques for Posterior Primary Teeth.
Restoration & Placement Area Aesthetics Durability Time for Placement Selection Criteria
Stainless steel crowns Poor. Very good.
Very retentive.
Wears well.
Aesthetics not a concern.
Aesthetics not involved.
Severely decayed teeth.
Use when unable to control gingival hemorrhage or moisture and less than ideal patient cooperation.
Open-faced stainless steel crowns Good.
Metal shows through facing.
Crown retentive but facing may dislodge.
Two-step process:
– Crown cementation.
– Composite placement.
Severely decayed teeth.
Good durability and retention needed (bruxism, trauma prone child).
Parent concerned about aesthetics.
Pre-veneered stainless steel crowns Very good. Good.
Crown retentive but facings may break.
Longer than SSC due to more tooth reduction and adaptation.
Severely decayed teeth.
Good durability and retention needed (bruxism, trauma prone child).
Parent concerned about aesthetics.
More expensive.
Zirconia crowns Excellent. Requires adequate tooth structure for retention.
Crown fracture may occur during placement if there is inadequate tooth reduction.
Comparable to or better than pre-veneered crowns. Aesthetics are a great concern.
Adequate tooth structure.
Patient cooperative.
More expensive than other crowns.