Diagnostic Techniques

First, a radiograph is obtained to find out if the decay is close to the pulp. Second, the history is carefully reviewed with the parents. The diagnosis is based on the information obtained from the history, the dental radiographs, and the soft tissue examination. The visual and tactile examinations are very important. The dentist may not be able to see a sinus tract, but careful palpation can sometimes reveal small craters on the labial side, indicating that the pulp is involved.

Pulp Considerations

If pinpoint bleeding develops, direct pulp capping or pulpotomy on primary anterior teeth is contraindicated. A pulpectomy is required.

Treatment of Choice

Resin Composite (Strip) Crowns

Resin composite crowns are the most esthetically desirable anterior restorations for primary anterior teeth but are also among the most technique-sensitive procedures. With crowding of the anterior teeth, it is quite challenging to perform a direct composite restoration. Also, primary teeth are whiter than permanent teeth. Most of the time, shade A1 or Extra White must be used. If in doubt, a tab of composite can be placed on the tooth and light cured to account for the shade changes occurring during polymerization. Once the proper shade has been selected, the process continues using that composite. Figure 30-1 presents an example of adhesively bonded resin composite (strip) crowns.

FIGURE 30-1 Resin composite (strip) crowns. A, Clinical photograph shows extensive caries lesions and white spot lesions on all four incisors. Left untreated, these lesions will develop into larger lesions and possibly affect the adjacent teeth and the underlying permanent successors. B, Palatal view. Caries lesions are found in all the interproximal areas of the incisors. Wear facets are seen on the lingual aspect close to the gingival line. These wear facets result from the grinding of teeth, which is very common in primary teeth. C, Rubber dam isolation technique. Dental floss is used to secure the elastic rings. The procedure is performed using general anesthesia. Decayed areas are removed and the area restored. In this case, the lingual surface was prepared and tooth reduction was performed mainly on the facial and interproximal surfaces. The pulp was not exposed in these four incisors after complete removal of decay. D, Immediate post-treatment photograph shows gingival bleeding from the sulcus. E, Post-treatment photograph shows a slightly open bite. In restoring the case, the bite was intentionally opened slightly to eliminate the wear on the lingual facets of the maxillary anterior teeth.

Preparation Design

Preparation design for primary anterior teeth is different from what is needed for permanent anterior teeth because the teeth are small and more amenable to good esthetically desirable results. There should be sufficient incisal reduction (about 1.5 mm) to avoid incisal fracture. In the preferred design, more reduction on the labial surface is required. A small undercut on the facial surface in the gingival third of the tooth is recommended to serve as a mechanical lock. On the lingual surface there is often minimal reduction (about 0.5 mm) and a feather-edged gingival margin.

Isolation Technique

Because placing composite is so technique sensitive, it is necessary to use rubber dam isolation to achieve a good result. Many isolation techniques have been used by clinicians. Traditionally the most popular techniques are the use of ligature ties with dental floss to retract the gingival tissue or gingivectomy with electrosurgery. A simplified technique using orthodontic elastomers was recently proposed and shown to be both efficient and effective.³

Summary—Primary Anterior Teeth

Esthetically, resin composite crowns are the best option among the other substitutes. In terms of gingival health, properly finished resin composite crowns are also better than either stainless steel crowns with window facings or veneered stainless steel crowns. However, adequate remaining tooth structure and controllable gingival hemorrhage are crucial for their success. Studies have reported high parental satisfaction with veneered stainless steel crowns.^4,5 The failure of the resin facings can be problematic, and these crowns cannot be repaired easily, as opposed to resin composite crowns. The stainless steel crowns with window facings are very retentive and can be used for teeth with minimal remaining structure. The facings may be dislodged as with veneered stainless steel crowns. Owing to their time-consuming and compromised esthetics compared with other options, stainless steel crowns are not very promising for a future in which alternative and easier solutions may be available.