Primary Zirconia Crown As Posterior Esthetic

Restorative Materials - A New Paradigm Shift

Dr. Shoeb A. V. Mujawar completed his B.D.S degree from A.C.P.M. Dental College, Dhule & M.D.S in Pedodontics
and Preventive Dentistry from M.A. Rangoonwala Dental College and Research Center, Pune. Currently, he is
working as an Assistant Professor in A.C.P.M. Dental College, Dhule. He is been actively performing extensive
clinical researches on various topics like pulp therapies, laser treatment in pediatric patients, etc. He is one amongst
few Pedontist who had performed successful research study on C.B.C.T Scan on primary teeth and his article was
published in an European journal. He has many national and international publications in reputed journals to his
credit. He is proprietor of “Kids Dental Clinic” at Dhule, Pune and Mumbai. Under the banner “Pedo Skills”, he Dr. Meena Syed Dr. Shoeb AV
conducts 2 days course on Pulpectomy, S.S. crowns, Pedodontic Restorations and emergency in Pediatric Dentistry Mujawar
with live demonstration and hands-on. He has been invited as guest speaker for Pediatric Emergency in Dental Practice several times. Dr. Shoeb has been
honored as BEST PEDODONTIST OF THE YEAR 2015 award by FAMDENT EXCELLENCE IN DENTISTRY AWARDS.
Dr. Meena Syed

Abstract
Due to the demand for more esthetically acceptable crowns, the use of
stainless steel crowns for anterior teeth is taking a backseat in pediatric
dentistry. Various esthetic pediatric crowns which are available can be
divided into two groups based on their mode of adhesion. Zirconium
dioxide ceramics can be used as an alternative option for stainless steel
crowns in posterior primary teeth. The aim of this study was to report
zirconia restoration for primary posterior teeth. The patients and their
caregivers had verbal information about the procedure and signed an
informed consent form. The intraoral and radiographic assessment was
done for evaluating the pre-operative status. The tooth was prepared
and zirconia crown was adapted with self-etching adhesive cement.
These clinical trials of very young patients provide successful results of
esthetic rehabilitative treatment of posterior primary teeth with deep
proximal caries. The findings after 6 and 12 months follow up could be
useful for improving the clinical approaches in subsequent studies. In the
results, the patients and their caregivers were satisfied with zirconia crown
as a posterior tooth restoration.
Introduction
In the past, the importance of esthetics was ignored in favor of concepts
such as function, structure and biology. However, esthetics has become a
respectable concept in dentistry today.
Esthetic restoration of primary teeth can be challenging due to the small
size of the teeth, close proximity of pulp to tooth surface, relatively thin
enamel and surface area for bonding, child behavior management
problems and cost of treatment.1 Apart from compromising esthetics,
dental destruction may also lead to parafunctional habits like tongue
thrusting, psychological problems, reduced masticatory efficiency and
loss of vertical dimension of occlusion.2 Hence it is essential to restore
the teeth destroyed by caries until the eruption of permanent teeth.
The greatest challenge to the clinician is to re-establish teeth with a long
lasting, retentive and esthetic restoration. The primary teeth have a life
span of 6-8 years so a restoration should last for this much time without
much upholding.
In 1950’s stainless steel crown were the most reliable restoration of
choice for full coverage in both anterior and posterior teeth as they
were competent for mastication.3 However, parents nowadays are more
concerned about esthetics even in posterior teeth and hence attention
is now shifted to zirconia crowns that are the only available alternative
option for esthetic rehabilitation of posterior primary teeth as compared
to anterior teeth for which a number of esthetic durable crowns are
available in the market.
Zirconia crowns were introduced by John P Hansen & Jeffery P in 2010.4
It is a form of crystalline dioxide of zirconium. These are metal free
crowns with mechanical properties similar to stainless steel crowns and
the translucency of Zirconia ceramic provides excellent esthetics.5 Apart
from the achieved dental benefits, esthetic rehabilitation also contributes
towards the improvement of general as well as psychological well being
of the patient.
Hence, the following clinical trials of young patients provides successful
results of esthetic rehabilitative treatment of a posterior primary tooth
affected by caries after 6 months and 12 months follow up which could
be useful for the betterment of clinical approaches in subsequent cases
in future as well.
The purpose of these case reports was to describe the clinical application
and the rehabilitation of decayed mandibular primary posterior teeth in
3 and 5-year-old children using esthetic ready-made primary zirconia
crowns (ZIRKIZ, HASS Corp; Korea).
CASE REPORTS
Here, we describe two cases of a chief complaint of decayed primary
lower posterior teeth. The children were referred to the private clinic at

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pune, India. These case reports describe the treatment of children with
caries. The treatment was oral rehabilitation of the primary molar with
ready-made primary zirconia crowns.

Case Report 1
A three year old girl who was suffering from food lodgment in the
lower left first molar tooth visited a private dental clinic at Pune. On
clinical examination, the tooth had proximal caries on the distal side.
A periapical radiograph revealed that tooth #74 had caries in the
proximal area approaching the pulp. Local infiltration was given and
rubber dam application was done. During excavation of caries, 1 mm
healthy dentin remained and hence, proximal restoration was planned
with composite restoration (Dentisply A2 shade) and bonding with self-
etch adhesive (Fig. 1). After restoration was completed, the tooth was
prepared for Zirconia crown with a diamond coated bur. For Zirconia
crown preparation, the occlusal surface was reduced by 1.5 mm and at
the same time, the cuspal anatomy was maintained. The bucco-lingual
reduction of 1 mm was done and then the proximal contact was broken.
Next the sub gingival preparation was done which was extended 1 mm
from the free gingival margin and extended till the proximal area. The
Fig. 2 After crown pre-paration.
bleeding was controlled using ferric sulphate. The gingival margin of
the tooth was shaped into a feather-edged finish line which was then
evaluated using a thin probe. After the preparation was completed, the
depth of sub gingival preparation (which should be 1mm) was checked
using a periodontal probe. The finish line was then polished using a
bur. Finally the bleeding was controlled and the tooth irrigated with 2
percent chlorhexidine (Vishal). After that, the pink crown (trial crown)
was selected. The crown selection was done by checking the mesio-
distal width by using vernier calipers in the same way as stainless steel
crown selection is done. Once crown selection was done, the number
size 4 crown (NU SMILE) was found to fit properly. After that, proper
isolation was done and permanent crown was checked and evaluated
for occlusion. The selected crown was then cemented with resin modified
glass inomer cement (GC). The extra cement was then removed from the
subgingival margin with a floss and an explorer (Fig. 2). Fig. 3 Post-operative crown cementation.
Case Report 2
A five year old girl who had suffered from painful symptoms in the lower
right first molar tooth reported to the private dental clinic at Pune. On
clinical examination, the tooth had proximal caries on the distal side. A
periapical radiograph revealed that tooth #84 had caries in the proximal
area involving the pulp and a peri-radicular radiolucency around the
tooth. Based on the clinical examination and investigation, pulpectomy
of #84 tooth and rehabilitation using zirconia crowns was performed
under local infiltration and rubber dam. The single sitting pulpectomy was
performed using Sx file rotary (Dentsply) for biomechanical preparation
of canals. Irrigation was done using chlorhexidine and normal saline.
The working length was determined using an apex locator (Root Zx J
morita). The smear layer was removed using EDTA. The canals were then
dried with paper points and obturated with metapex. After obturation,
Fig. 1 Pre-operative before crown preparation (proximal filing the tooth was restored with dual core cement (Laxacore) (Fig. 3) and
done pre-operative vital tooth). tooth was prepared for zirconia crown in the same way as before. Once

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crown selection was done, the number size 4 crown (NU SMILE) was
found to fit properly. After that, proper isolation was done and permanent
crown was checked and evaluated for occlusion. The selected crown was
then cemented with resin modified glass inomer cement (GC). The extra
cement was then removed from the subgingival margin with a floss and
an explorer (Fig. 4).
Fig. 4 Pre-operative before crown preparation.
Fig. 3 Pre-operative before crown preparation (Pulpectomy).
Fig. 4 Post-operative after crown cementation.
Results
After treatment, the teeth in both cases showed good esthetic result when
it was compared to adjacent teeth and the parents were satisfied with the
Famdent Practical Dentistry Handbook
outcome. At the 7 month and 12 month follow up, the patients continued
to be asymptomatic and the restorations were successfully retained on
clinical and radiographic examination.
Discussion
Nowadays the demand for all types of cosmetic services has continued
to rise annually for adults as reported by a survey conducted by the
American Academy of Cosmetic Dentistry.6 As parents begin receiving
cosmetic dental services, their desire for esthetic restoration of their
children’s teeth also increases.
When restoring badly broken down primary molars, Pediatric Dentists had
many options that were in use before the advent of zirconia crowns such
as stainless steel crowns. Although Croll reported that these crowns were
easy to place, resistant to fracture and wear and bonded firmly to the
tooth,7 their main disadvantage was the unsightly metallic appearance.
As the population has become more conscious about appearance, SSC’s
have now become less desirable for parents.
Recently, a new type of ceramic material, based on zirconium dioxide, is
available which has the potential to be used for large restorations and in
the molar area. Yttria-stabilized tetragonal zirconia polycrystal, Y-TZP, has
a unique ability to resist crack propagation by its ability to transform from
one crystalline phase to another and thus, the resultant volume increase
prevents the crack from propagating.8 Zirconia crowns have a long
history as a proven biocompatible material for crowns, endodontic posts
and implant abutments in adult patients for at least 15 years. However, in
the case of pediatric crowns, they have only been used as early as 2010,
when the first primary zirconia crown came into the market.
The most important advantage of zirconia crowns is their excellent
esthetics which is superior to other pediatric crowns. Moreover, their
flexural strength is 900 to 1100 MPa, which is twice as strong as
alumina oxide ceramics and 5 times greater than standard glass
ceramics.9 Another important property is their fracture toughness, which
is responsible for their durability.10 Zirconia also possesses a polished
and a smooth surface that leads to less plaque accumulation and better
gingival health as compared to other crowns.11
The potential disadvantage of zirconia crowns is that on exposing them to
saliva and blood during the try-in stage, it can impair the bond strength
between the crown and the cement. The phosphate groups found in the
saliva will bond with the zirconia surfaces and thus make the surface less
reactive to bonding with the cements used with zirconia. This problem
can be avoided with the use of NuSmile ZR zirconia crown. While using
these crowns, a pink try-in crown is used first to verify the fit, which can
be autoclaved and reused later. The NUSmile ZR zirconia crown enters
the patient’s mouth for the first time during cementation itself, thus
ensuring maximum bond strength of the luting cement to the zirconia
crown. Moreover, these crowns can also not be used in cases with severe
crowding or space loss or when there is very little sound tooth structure
as they cannot be manipulated easily.
Thus, newer variations of posterior esthetic crowns are a boon to pediatric
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dentistry and the Zirconia crowns can be considered as an alternative
treatment option to achieve esthetic rehabilitation and improve both the
general as well as psychological well being of the child.
However, there is not much significant data published regarding the
comparison of long-term clinical results from the use of different kinds
of zirconia-based crowns. Moreover, the studies published so far are
laboratory-controlled investigations and have reported data on small
numbers of patients.12 Hence, further clinical evaluations and long-term
studies are still required.
In conclusion, we suggest that in children in whom full coverage crowns
are indicated, zirconia crowns can be both practical and successful.
The treatments described in the case reports are simple, effective and
represent a promising alternative for rehabilitation of severely decayed
primary posterior teeth due to their unparalleled advantages, including
esthetics, durability, biocompatibility, improved microstructure and much
less expensive equipment.
Conclusion
As early as 1990’s, children requiring crowns to restore severely carious
Famdent Practical Dentistry Handbook
teeth had no other option than stainless steel crowns. Today’s Dentists
have several esthetically pleasing options to offer with zirconia crowns at
the head of the class. Zirconia crowns are unique and esthetic pediatric
dental crowns available in the market today which have created a new
way of restoring the natural appearance of a child’s smile with minimally
invasive technique.
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