The advent of the primary prefabricated

zirconia crown
September 12, 2017
Carla Cohn, DMD
If you are a general dentist who cares for children, you are the rule rather
than the exception. In 2016, the number of dentists in the United States was
196,441.1 Of these, 155,102 were general practitioners and 7,337 were
pediatric dentists.1Given that the majority of children are treated in family
practices, it is imperative that general dentists remain current with advancing
pediatric dental technology. From preventive modalities to restorative
materials, pediatric dentistry has seen significant innovations in recent years.
In my opinion, one of the most revolutionary changes is the advent of the
primary prefabricated zirconia crown.
Increasingly, parents and children are demanding better esthetic restorations.
These demands are described in a study by Peretz and Ram,2 while another
study by Zimmerman et al. documents changing parental attitudes toward
pediatric restorative materials.3 As these studies and clinical experience have
shown, the demand for improved esthetic restorative dentistry for children is
here. General dentists have the ability to supply that demand with the latest
esthetic materials such as primary prefabricated zirconia crowns. These
crowns are made of excellent material, and when combined with proper
technique, they give dentists the ability to restore anterior and posterior
carious dentition both functionally and esthetically.
Primary prefabricated zirconia crowns are available for all primary teeth:
molars, cuspids, and incisors. The following manufacturers supply primary
prefabricated zirconia crowns: Cheng Crowns, EZPedo/Sprig, Kinder
Krowns, and NuSmile. They are either milled (Cheng Crowns,
EZPedo/Sprig, and Kinder Krowns) or injection molded (NuSmile).
Zirconia as full coverage offers many advantages over other materials.
Zirconia offers flexural strength that is far greater than that of natural
tooth4 while wearing at a similar rate.5 Prefabricated zirconia crowns are
autoclavable, allowing for trial and error when choosing and fitting the
correct size.
Fracture load studies from Townsend et al. show variances in fracturability
between manufacturers.6 The differences were found to be significant, but all
required 5–10 times the amount of force to cause fracture of the mean
maximum biting force of a 10- to 12-year-old child in the molar area.
Above all, these crowns offer full-coverage advantages, and are by far the
most esthetic alternative in full-coverage primary dentition restoration
available to date. They make for a reliable and beautiful restorative option for
full coverage for our pediatric patients.
CASE STUDY
The following case study is presented to illustrate the ease of tooth
preparation and crown cementation: A 5-year-old patient presented with
caries of her primary dentition. The mandibular left primary molar required
full coverage due to a failed composite restoration and extensive decay
(figure 1). Both the child and her mother had a desire for a tooth-colored
restoration. A primary prefabricated zirconia crown (NuSmile ZR) was
chosen as the restorative material of choice.
Figure 1: Mandibular left primary molar

The steps for preparation and cementation were as follows. First, local
anesthesia was delivered. Second, isolation was achieved with an isolation
system (Isodry). Third, preparation steps were undertaken: Occlusal
preparation was completed using a high-speed handpiece with copious
amounts of water and a coarse, long-tapered diamond bur (NuSmile) to
achieve an occlusal reduction of 1.5–2 mm. Circumferential reduction of
approximately 15–20% was carried out using the same bur. In order to
visualize the completeness and evenness of the preparation, a full
circumferential reduction supragingivallywas completed at this stage. A
subgingival preparation was again completed using a high-speed handpiece
with copious water and a finer, more tapered diamond bur (NuSmile). As
required, a full subgingival reduction to approximately 1.5 mm depth was
achieved, ensuring no ledges and a smooth featheredge margin (figure 2). It
was essential that the crown fit passively and be able to be seated completely
unencumbered. In order to ensure fit and occlusion and to prevent
contamination of the zirconia crown to be cemented, a Try-In crown
(NuSmile) was used (figure 3). Refinements to the preparation to facilitate fit
and occlusion were done at this point.

Figure 2: Full subgingival reduction to approximately 1.5 mm depth

Figure 3: Try-In crown (NuSmile)
Cementation was then achieved as follows: Once satisfied with fit and
occlusion, the prepared tooth was washed and dried but not desiccated. The
NuSmile zirconia crown to be cemented was filled with cement (BioCem;
NuSmile). Working time was approximately 60 seconds. The crown was set
into the correct position. BioCem was photo cured with a tack cure of 10
seconds to the facial and 10 seconds to the palatal aspect. The cement was
then cleaned interproximally using floss. Once all cement was removed, a
final photo cure of 10 seconds to the facial and palatal was applied. One-
month postoperative occlusal view and occlusion are pictured in Figures 4a
and 4b.
Figures 4a and 4b: Final restoration
The ability to understand and provide primary prefabricated zirconia crowns
to your patients is an immense benefit to the children in your practice as well
as their parents. It is a simple and satisfying procedure that will help to grow
and maintain your successful family dental practice.