Full Coverage Crowns on Primary Teeth: Pros, Cons, and Best Practices

And it's a fine line to walk because we can't full coverage everything. That's over-treatment. And yet to be minimally invasive or to be more conservative on a kid that you're doing an intracuronal restoration on, and then they're coming back and now they're back with more decay and another surface where they would have been better off with full coverage. Welcome to the Phil Klein Dental Podcast. When faced with extensive decay or structural compromise in a primary tooth, full coverage restorations are often the go-to solution. But which material is best? Traditional stainless steel or newer options like resin-based and zirconia? And what about those gray areas where we can opt for either full coverage or direct restorative techniques? We'll talk about all of this in today's episode, including factors like durability, aesthetics, and ease of placement of full coverage crowns. By understanding the pros and cons of different restorative approaches, we can ensure primary teeth remain functional and pain-free until they naturally exfoliate, making way for the permanent dentition. Our guest today is Dr. Carla Cohn. She's a general dentist devoted solely to the practice of dentistry for children. She owns and operates Kids Sleep Dentistry Winnipeg, a private practice. In fact, she has an upcoming hands-on program in Vancouver on June 7th. You can get all the details at litsmileacademy.com. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Dr. Cohn, it's a pleasure to have you on the show. Thank you. Thank you for having me. It's a pleasure to be here. Yeah, so a lot has happened in the evolution of... treating pediatric patients when it comes to restorative dentistry. And, you know, back in the day when I practiced, everything was stainless steel crown, but there's a lot of other options now. There's zirconia crown, there's resin-based crown, and there's even other options besides full coverage restorative treatment. So tell us what factors determine in your practice whether a pediatric patient would benefit from one of those types of crowns that I just mentioned or even a different restorative option. Sure. That's a great question. So we're looking at full coverage in general. And I think that to sort of preface this whole conversation, this is something that general dentists shy away from when they're seeing their pediatric patients in doing a full coverage because they just don't feel confident. And the statistics show us that they graduate dental school, we graduate dental school with only a small number of full coverage procedures for primary dentition. pediatric patients under our belt so of course we don't feel comfortable and stainless steel crowns are are are were the standard of care it's going to be arguable of whether they still are the standard of care when it comes to full coverage but so many different options out there and and all of these options have really stemmed from the need and the desire and the demand for aesthetics from our parents and from the kids in our practice. So lots of different options for aesthetic full coverage out there that have evolved over time in the last probably 15, 20 years. So what is it about full coverage crowns on pediatric patients that makes... general dentists feel uncomfortable. I mean, they're doing much more sophisticated dentistry. And I don't mean to in any way say this is not sophisticated, but putting a full coverage crown on a primary tooth is not the most complicated procedure. Correct me if I'm wrong. It's not. We'll be right back with Dr. Cohn in a moment. But first... As a dental healthcare professional, you might already know that 3M Healthcare is now solventum, and one of its next-generation products is 3M ClinPro Clear Fluoride Treatment, available in a new rosin-free water-based formula, with soluble fluoride ions immediately available to deposit on the tooth. ClinPro Clear Fluoride treatment needs only 15 minutes of contact time. Plus, with less waiting time to eat or drink after application, it's even easier for your patients to say yes. Its uniquely designed LPOP delivery system ensures a smooth and professional application process. In clinical studies, hygienists found it fast and easy to apply. and patients rated their experience an impressive 98 out of 100. So if you're looking for effective fluoride uptake in a rosin-free, water-based formula, try 3M ClinPro Clear Fluoride Treatment from Solventum. To learn more, visit solventum.com. No, you're absolutely right. It's not technique sensitive. It's easy to do and doesn't take long. And like you said, maybe sophisticated is an interesting word, but maybe call it more technique sensitive. And I always say when I'm teaching my classes to workshops or lectures or whatever, this is not hard stuff to do. The intimidating part, I think, is number one, they don't have the experience doing it. And number two, you're doing it on a kid that can potentially be a challenge to manage the behavior, to keep that child still, to pain control, all of the things that are involved in seeing children as patients. So yeah, it's easy stuff to do. If you know what you're doing and you're confident in the procedure, then you can spend your energy managing the child's behavior. And you put those two things together and it quickly becomes something that becomes very big concern to our dentists that are trying to deliver this care. And they feel so comfortable doing composite resins that they... They think that they can create all of these huge restorations with composite resins. And you can on an adult, but not on a kid. There's so many factors that come into play that make it not an appropriate material to use for kids for a large restoration. Yeah, give us an example of why that is. So you've got the strength of the material. You don't have the strength of the tooth. The anatomy is different on a primary tooth versus a permanent tooth. And you can do a great big, huge composite resin that looks beautiful and have the tooth break. because of what's remaining structure of the tooth. The other thing is keeping the material dry. So kids that are moving that their tongue is all over their tooth or they're crying, you can't keep it dry. Composite resins need to have a dry field for them to be successful. And then the other factor too is teeth that are treated with a pulpotomy. You need to have a material that's going to seal completely the tooth and full coverage is still. the standard of care for a pulpotomized, if that's a word, tooth. So take out the factor of a parent who's extremely conscious of aesthetics for their kid. And they say to you, Dr. Cohn, I just want the best thing for my child, you know, noting that the tooth is fully... blown out and it's you know severe carious lesion you want to keep it there as a space maintainer you want to keep it there because they have maybe three or four years or maybe more where they have to have that teeth in there before the permanent one comes in so give us the ideal situation as far as your choices in full coverage material wise So ideally, we want something that's going to be retained in that child's mouth and functional throughout that child's time period that they need that tooth. When we have stainless steel crowns, we can still crimp them and squeeze them and to some degree make the crown fit the tooth versus the... aesthetic crowns that we have out there full coverage primary dentition where we're cutting the tooth to fit the crown we have no ability to crimp zirconia to change it in any way these resin based crowns you know a little bit of a nuance to that because we we line them with resin but still you have the best retention from a stainless steel crown because you can modify it you can change the shape Having said all of that, if it is an issue for the child and an issue for the parent to have stainless steel in their child's mouth, and mostly because of the aesthetics, because it's a fairly inert material, bar those patients that have nickel allergies, you need to consider these other alternatives because they all still... do have good retention, not better than good retention. They still have successful placement and the aesthetics on top of it. And if you're not comfortable having the stainless steel in your mouth and the child's mouth, you're not going to be confident with that restoration. And I've had zirconia restorations last the entire time that they need to last, 10 years. is pretty much the longest that we need to have a primary tooth hang around after it's been restored in the mouth. What do you typically use to cement your stainless steel crown in with? Yeah, so cement for my stainless steel crowns are resin-modified glass ionomer cement. So there's lots. of different options that are out there i use a lot of fujisam gca product i i use a lot of reliax such as 3m which is now solventum product so so those two and you need to have a cement that's going to withstand, again, the moisture. Because anytime we're placing a stainless steel crown or these aesthetic crowns, we're doing subgingival reduction. So it's going to bleed. And you're not going to be able to control the hemorrhage. And there's no reason that you need to, because you're using these resin-modified glass ion or cements that are going to withstand that hemorrhage. And of course, what's nice about stainless steel crowns is that you don't really have to remove very much tooth structure. In some cases, none at all. Correct me if I'm wrong. So you don't need to remove a whole lot. You can remove less than a millimeter and then just do your interproximal slices, mesial and distal. But even having said that, there's this technique that was developed by this dentist in Scotland called a hall technique, where she was putting these crowns on top of teeth that weren't prepared at all, not prepared, and no decay was removed. And the success rate of that was huge. And you compared the major failures, minor failures of that to the control, and the hall technique went out. So are we even going to be removing any tooth structure in the future? You know, it's still not considered our standard of care. And I still, you know, I've spent the last two days in the operating room working and cutting my stainless steel crown, my teeth for my stainless steel crowns like I do in the traditional way. When is that going to stop? When is that going to change? I don't have that crystal ball, but I think that at some point it will. Yeah, it's amazing that stainless steel crowns are still being used at all, considering how long they've been. I mean, that's what I use in dental school. We took them, these were prefabricated, right? Is that what they are? They still come right out of a box. Yeah, right out of a box from 1950, I think is when they started, we started using them. So yeah, right out of a box. And they've improved in terms of the shape and the cervical portion. You don't have to, we used to have to cut all of them and crimp them and huge pain in the, yeah, we don't need that. We don't have to do that anymore. Get a good stainless steel crown and you just put it on. We'll be right back with Dr. Cohn in a moment, but first, if you're on the lookout for a versatile material that serves as both a protective liner for composites and is ideal for direct and indirect pulp capping, let me introduce you to Theraquel LC from Bisco. Its unique hydrophilic resin-modified calcium silicate formulation provides a strong, stable liner that reduces post-op sensitivity. It's radiopaque and incredibly easy to apply. Once light-cured, Theracal LC is ready for use with any bonding technique. What's even better... TheraCal LC is non-soluble, meaning it won't wash out over time. Plus, it promotes calcium release, which supports secondary dentin bridge formation. And that's perfect for those tricky pulp exposures. When you're working deep in a tooth prep, you want reliable protection for the dental pulpal complex. You want TheraCal LC. a top choice among independent evaluators and thousands of dental clinicians. For more information on Bisco's full line of pulp protection products, head on over to bisco.com. So other than the fact that zirconia can't be crimped and resin can't be crimped, how do they compare regarding their strength? Aesthetics is obvious. They're obviously more aesthetic. What about ease of placement as far as handling and also the chair time for you and also the strength? Sure. So placing them requires a little bit more preparation. So we need to do a full circumferential reduction for a zirconia crown. I need to take off about a millimeter and a half off the occlusal. And then about, you're taking about 20% off of the tooth structure. And, you know, so again, when I'm teaching these in workshops, the participants, after having placed the stainless steel crown, because that's the order I teach it, we'll do the stainless steel crown, so minimal preparation. Then we'll cut for a zirconia crown. Oh my God, there's so much tooth structure that I'm taking off. Well, first. of all, there's not. There's a minimal amount just compared to the one you just did. But also, you look at the tooth that you're doing this on is because the tooth is decayed. So there's not a lot of tooth structure to begin with. There's no reason to be minimally invasive when we're cutting for our zirconia crowns. So it's about 20% tooth reduction. And we go subgingival for those zirconia crowns in order to get really more retention from the height of the tooth. So once they're placed, if it takes me about 60 to 90 seconds to cut and place a stainless steel crown, a zirconia crown is probably about maybe five minutes, five to seven minutes. And then to cement it. Strength-wise, they're stronger than stainless steel crowns because they're harder. And so I've had kids, as many of the listeners, I'm sure, will have had kids too that will chew through their crowns. it brux right through them and they come back to you in time and you've got holes in the stainless steel crowns. That doesn't happen to zirconia crowns. They're not going to brux through them. So in terms of strength, they're very, very strong. And then to cement them, when we started doing zirconia crowns, which was probably about 15 years ago, I was cementing them with a resin-modified glass ionomer, the same thing that we are cementing our stainless steel crowns with. And they were fine. There were no issues. as we continued to do them and it got to be more of a mainstream thing in pediatric dentistry then the cement started to to change to become things that were you know supposedly more retentive you know i don't have many issues with with same amount of issues with my zirconia crowns that come off as do my stainless steel crowns. So, you know, there's not a big difference in my loss of crowns or the failures that come in, whether it's a stainless steel crown or a zirconia crown. So they're reliable, they're durable, they're strong, they're aesthetic, and they do go the distance. Now, the resin ones, is it unreasonable to think that you can actually use adhesive dentistry with the resin ones, considering the lack of moisture control that usually goes along? with these kids so this is something that is the resin crowns are something that are just making their way into the north american market now so these crowns are distributed by directa usa they're called ceramere crowns don't confuse them with the cement it's completely different so they distribute them directa usa distributes them and there's a company that that makes them and so directa has named them ceramere crowns And so we line them. And as I said, these are really new. These are within the last six months. And so now we're being told to line them with resin. So yes, to your point, we're going to... look and see are these going to be issues with moisture control and retention but the difference is that these resin crowns these ceramere crowns i don't need to remove as much tooth structure as i do with the zirconia crown so where i'd have to take off a good 20 of the tooth and go sub gingival for my resin crown which isn't you know mandatory i can do it super gingival but i'm going to get better retention if i'm sub gingival And I don't have to do all of that with my resin crowns. So maybe I don't have the hemorrhage problem that I would have had previously. You can think of it more as a strip crown where we would have done a strip crown and it's always going to be or almost always going to be super gingival so that there are no issues with hemorrhage and we can be more minimally invasive. So I think that these resin crowns are paving the way towards that more. minimally invasive preparation, which is good for our kids that more apprehensive, right? Particularly when we're looking at an anterior tooth. Now you mentioned, I think you meant zirconia when you said subgingival, but you said, did you mean zirconia? Yes, yes, yes. Zirconia goes subgingival versus zirconia. Right. Okay. So now if there's any endodontic suspicions, like if you think and anticipate there's going to be an endodontic problem with the tooth because the tooth has decayed. It's so deep and maybe you left some affected dentin in there. Maybe you used some silver diamine fluoride on top and then went ahead with your resin modified glass armor on top of that as a liner for the stainless steel crown. Do you tend to stay away from zirconia and stick to stainless steel if you're anticipating possibly going in and doing a pulpotomy later? No, absolutely not. If I've got a pulpotomy, I can do a zirconia crown, no problem on top of that tooth. I mean if you haven't done if you haven't done it yet You haven't done the polpotomy yet, but you're thinking you might have to Isn't it easier to go through a stainless steel crown than going through zirconia? I've gone through zirconia crowns before. It's not that hard. You know, you've got a 0.8 millimeter thickness of that zirconia on the occlusal portion. It doesn't take much to go through it with a high speed burr. Yeah. You should say it's not that difficult because it is hard. It's just not that difficult. It's pretty hard. Well, well put. It is pretty hard, but it's not difficult. Well, I just, I just, I know there are new burrs out there that are just going through this stuff. In fact, these burr companies are advertising and marketing their product by saying, you know, cuts like butter through zirconia. But as an endodontist, if I'm looking at something that I anticipate being, you know, the patient's going to be coming back. possibly with a toothache and I want to do a palpotomy, I'd rather have a stainless steel crown, but that's just me. Yeah. But think about it this way too. If I've got a kid in the chair and there's a chance that they're going to come back with something that's a problem, I'm going ahead and doing that palpotomy at that appointment. I want to mitigate my risk here. I don't want that kid back for a second appointment. And it happens. I wouldn't send the kid away with the anticipation of them. coming back, maybe, maybe not, you know, I mean, we all do things that. But also, of course, Dr. Cohn, you've got the patient in the surgery center, so they're under sedation. So when in doubt, of course, I guess in that case, without a doubt, I would do it. What do you normally use for pulpotomy? What kind of material? So pulpotomy material, if we're going to use a pulpotomy material underneath the zirconia crown, for sure, we need to have something that is going to seal well. So it has to be a calcium silicate. So it's either the Theracal PT, the Bisco product, Curon in Canada, or else biodentine. There's others out there that I've used in the past as well. You know, MTA, MTA-like materials, Neo-MTA, Neo-Putty. But those are my two right now, my two go-to. or my TheraCal PT for a pulpotomy or my biodentine for a pulpotomy. And then I know that I've got a seal from that calcium silicate. Yeah. So space maintenance is a big issue with kids. We know we have to maintain that because it affects the whole eruption process. Now, you could make an argument that it's important or it should be a priority to think about full coverage on these. kids for these teeth that are really severely impacted by decay because full coverage will maintain the space better than a direct restorative as we talked about earlier in the episode so talk about the considerations of space maintenance regarding full coverage and also in the event that the tooth has to be extracted yeah so obviously we want to maintain that space with the tooth that's the best space maintainer is to maintain the the space with the natural tooth so really it comes down to the question of what is the best restorative for that tooth what's going to give us the best longevity so you've got a kid that's high caries risk and you you know that they're um at risk for a repeat offender, right? So I can't tell you the amount of times that we go in and we try and be conservative. We'll do an MO or we'll do a DO and they're back again in six months, 12 months with more decay. Now it's on the distal of the tooth. Now it's on the mesial of the tooth. And it's a fine line to walk because we can't full coverage everything. And that's overtreatment. And yet to be minimally invasive or to be more conservative on a kid that you're doing an... intracuronal restoration on, and then they're coming back, and now they're back with more decay and another surface where they would have been better off with full coverage is a hard thing to justify either way. But we do know that in terms of success rate and longevity, full coverage is going to give us better success and better longevity as a restoration on a primary tooth than an intracuronal restoration would. So you get the kids that come in that are high caries risk. You've got a quadrant of dentistry, four quadrants of dentistry to do. And you should be looking at that high risk kid. That's an indication for full coverage. So whether you're doing that with a stainless steel crown or whether you're doing it with one of the newer aesthetic crowns that are on the market, you should be considering that. And if you're not doing it, you've got a little young kid in your practice, like four years old, five years old. They've got to have a molar in there. the next seven years, eight years, whatever their lifespan of that tooth is, you know, that's a long time for an intracuronal restoration to hang around in that child's mouth. So full coverage is a real option. And what about space maintenance when the tooth has to come out? Yes, the space maintenance on the that's a whole other episode. Yeah, we can't fit that in another five minutes. So not in five minutes. So so I can switch to this question. So as we get to the bottom of this podcast episode, I do want to mention that you're not a pediatric dentist. You're not a specialist. You're a GP, but you do pediatric dentistry 100%. So tell us about how that all happened. So yeah, I'm a general dentist. I just do pediatric dentistry. And right out of school, I did an internship in pediatric dentistry. I saw adults for the first tiny little bit of my practice, which was, you know, 30 some years ago. And then I realized that kids were the way to go. And I've never looked back. So I only see kids in my practice. And that didn't stress you out at all? Having the kids crying and they won't open their mouth, it didn't stress you out? No, the adults stressed me out. So you must be like the, you know, there's something called the horse whisperer. Oh, yeah. You get near a horse and the horse just, whatever the person wants the horse to do, the horse is fully obedient. You must connect with these kids in a way where, because I know the little bit of pedo that I did in dental school, it was like, I can't do anything in this kid's mouth. They barely open their mouth and they're squirming, they're moving. It was very stressful. So I don't know how you do it. or how you did it. I think a horse whisperer, I think I'm a lot less mystical than that. You know, it becomes a matter of, I think, connecting with the kids and just figuring out how to talk to them and how to... do the right procedure and to be confident in that procedure so that once you've got that minute and a half or whatever it is that you've got of cooperation, you can get it done and move in like a ninja and get it done fast. So can I explain how and why I like doing this? I don't think that I can, just that I do. It's natural. It just works for you. Just that I do. It just works for me. So tell us about your training program that you offer. Yeah, so I started a CE platform, a continuing education platform called Lit Smile Academy just a couple of years ago. And I go out and I teach workshops and I give lectures. And I've got one coming up on June 7th in Vancouver. I've got just a few spots left. And what we'll do in that course is we're going to do everything pediatric dentistry from minimally invasive and all of these new products that are out there. to treat your really uncooperative kids to glass ionomers, resin modified glass ionomers, my intracuronal restorations with composite and how I do them and pulpal therapy and also full coverage and a couple of other things thrown in there. So you'll get like a whole little mini series of procedures that you can take home. I really wanted to create something that was very practical so that the dentists that come into it can... leave that day go in the next day to their practice and do the stuff that the kids need because i think it's it's so important to not just put a band-aid on on these kids but to treat them properly yeah there's a hands-on component to this yes so this this is a hands-on component so we'll do a full day and this is what i typically do in my courses where i'll talk about the procedure we'll talk about the theory the materials why we're doing it what kind of kids are good we're going to do it on in terms of cooperation wise And, and then they get a chance to work with the materials and touch and feel everything that I use in my practice is what I take with me to my workshops. Okay. And these are done on dentiforms, these procedures? Yes. Okay. So is this like in a hotel room, a hotel facility? Yes. The next one that's coming up is going to be at the Curion headquarters in Richmond, BC. And so we've got a, yeah, British Columbia. And so we've got a room, a continuing education room for it. It's like a little lecture hall. We could, we've got hand pieces. We're going to be able to cut the crowns on the typodont or to cut the teeth to put the crowns on the typodont. We'll cement them on everything, everything that's involved. So all of the different procedures that, that are necessary. And it's, it's a great comprehensive course. Yeah, very cool. That's June 7th. And if they want to get in touch with you, it's litsmileacademy.com, right? That's it. Litsmileacademy.com. So on that website are all of the details for that course and the registration link. Very good. I really appreciate the time, Dr. Cohn. We know how busy you are. Thank you. Very, very good information. Hope to have you on soon. Thank you very much. Always a pleasure talking with you. Thank you.