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 Table of Contents  
Year : 2022  |  Volume : 10  |  Issue : 3  |  Page : 140-145

Immediate customized zirconia crown in deciduous tooth by digital workflow

1 Wisdom Dental Clinics, Jaipur, Rajasthan, India
2 Govt Dental college, Jaipur, Rajasthan, India
3 Saanchi Pediatric Hospital Surat, Gujarat, India
4 Department of Paediatric Dentistry at Jaipur Dental College. Jaipur, Rajasthan, India

Date of Submission29-Mar-2022
Date of Decision23-Jul-2022
Date of Acceptance06-Jun-2022
Date of Web Publication21-Feb-2023

Correspondence Address:
Gaurav Gupta
Wisdom Dental Clinics, Sector - 10, Plot number - 15, Vidhya Dhar Nagar, Jaipur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/DYPJ.DYPJ_22_22

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Catering a tooth colour restoration is the fundamental objective of chairside digital Dentistry in a single sitting with computer-aided design or computer-assisted manufacturing (CAD/CAM) technology, which has become a legitimate reality with the initiation of the CEREC workflow. Nowadays, CAD/CAM of dental restorations has become an ingrained fabrication process, especially for customized Zirconium restorations. In this case report, we will discuss the clinical use of chairside digital dentistry in grossly decayed primary canine treated by pulpectomy followed by CEREC workflow for the fabrication of customized Zirconia crown thus restoring the form, function, and occlusion.

Keywords: CEREC workflow, chair side digital dentistry, customized zirconium crown, single sitting

How to cite this article:
Gupta G, Gupta D K, Gupta P, Shah P, Khairwa A, Gupta N. Immediate customized zirconia crown in deciduous tooth by digital workflow. D Y Patil J Health Sci 2022;10:140-5

How to cite this URL:
Gupta G, Gupta D K, Gupta P, Shah P, Khairwa A, Gupta N. Immediate customized zirconia crown in deciduous tooth by digital workflow. D Y Patil J Health Sci [serial online] 2022 [cited 2023 Mar 23];10:140-5. Available from: http://www.dypatiljhs.com/text.asp?2022/10/3/140/370114

  Introduction Top

Use of stainless-steel crowns (SSCs) in paediatric dentistry is a common practice for management of heavily decayed and deformed primary teeth.[1],[2] These crowns provide a solution for a restoration with the highest success rate, without causing secondary caries and are cost effective.[3] The metallic appearance of SSCs, cause possible damage to gingival tissues, and possibility of cytotoxic and allergenic phenomena due to release of nickel and chromium ions into saliva may promote biocompatibility issues.[4]

In 2010 Prefabricated zirconia crowns for primary teeth were introduced as an alternative and more aesthetic option to SSCs.[5] Manufacturers offer a significant range of zirconia crown sizes, along with a specific preparation and cementation protocol.[6] Zirconia crown unlike SSC, cannot be modified in any way, as they are incapable of withstanding flexure, and may fracture on cementation.[5]

Some deficits of prefabricated zirconia crowns were that it requires significantly more tooth reduction of 2 mm – subgingival, labiolingual, proximal, and occlusal. This induces bleeding from the gums thus prolonging the treatment time.[7] These crowns are highly aesthetic, plaque resistant but are non-adjustable. Because of this, the affected primary tooth has to be prepared irrespective of the coronal tooth structure present. Tooth preparation of these crowns is far more extensive in terms of both all-around tooth and subgingival.

Computer-aided design and manufacturing (CAD/CAM) technology have made enormous improvements since its introduction by Dr Francois Duret and Dr Werner Mormann.[8],[9]

This technology nowadays is available directly in dental clinics and is capable, via its software, of fabricating (customized) full ceramic crowns, inlays, onlays, and veneers for permanent dentition at one appointment. Materials used in CAD/CAM include ceramic, resin ceramic, hybrid ceramic, and zirconia blocks. Mechanical properties of these materials are very superior which support use of CAD/CAM as a trustworthy method for dental patients because it results in a high survival rate of restorations with low rate of fracture and has long-term clinical survivability.[10]

Digital impression for crown fabrication is done using CEREC. CEREC (Chairside Economical Restoration of Aesthetic Ceramic) is the method of manufacturing dental restorations in the dental office. The digital workflow is integrated by the intraoral scanners which take the impression. These are powerful devices that can easily send the models to the laboratory using e-mail, thus reducing expense and time. Until now this technology was used only in adults but now it’s use is extending in Paediatric Dentistry also.[11]

The digital impression technique is also helpful to solve behavioural issues of the uncooperative patient compared to the conventional impression technique. Conventional impression technique requires full mouth impression whereas, in digital impression, we need to take an impression of the particular arch /segment /quadrant we need to treat. The use of the digital intraoral impression technique eliminates the need for a conventional alginate impression. Conventional impressions are considered an unpleasant experience by some children because they cause gaging due to which impression has to be repeated to get the accurate result, thus switching to digital impression procedure have a long-term positive impact on patient perceptions of dental procedures.[12]

The purpose of this paper is to illustrate a case report for the fabrication of customized zirconia crown by CAD/CAM for a decayed primary maxillary canine in a 7-year-old boy. Restoring primary teeth in a single sitting with a customized Zirconium crown which was fabricated chairside with the help of the CEREC workflow and intraoral scanning in order to restore with form, function, and aesthetics in the paediatric patient.

  Case Report Top

A 7-year-old boy came to the clinic with multiple decayed teeth, pain and abscess in the lower right tooth region. A medical, as well as clinical history, was taken along with the radiographic examination, which showed the presence of deep dentinal caries with pulpal exposure and extensive loss of tooth structure in the right mandibular primary canine (83). [Figures 1]a, b, c
Figure 1: (A), (B) Preoperative intra-oral photograph. (C) Radiograph showing Early Childhood Caries destruction

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Looking at the intraoral condition two treatment options were possible either extraction of affected tooth or pulpectomy. The major challenge, in this case, was to restore the tooth with a zirconia crown because no coronal structure was present. Post and core could be another treatment option but it may lead to more weakening of tooth structure. Extraction of this canine would create a need for space maintainers in near future. Space maintainer fabrication is important in mixed dentition because once the primary tooth is lost it may lead to supra eruption of the contralateral tooth, premature exfoliation of a permanent tooth, mesial drifting of the adjacent tooth, and also require orthodontic treatment in the future. In this case, we decided to restore the canine with CEREC Zirconium customized crown after doing a pulpectomy of 83.

NOIS (Nitrous Oxide Inhalational Sedation) was carried out to secure LA to reduce the anxiety of the patient. A single-visit pulpectomy was performed. [Figure 2]
Figure 2: X-ray showing pulpectomy done in 83

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The patient was recalled after 7 days. After 7 days when the patient was an asymptomatic tooth, preparation was started. In this case, the less coronal structure was present so, CEREC customized crowns are preferred here because these crowns require minimal tooth preparation to achieve desirable aesthetic and functional output. The only apical extension was done for the prosthesis to increase the surface area, provide stability and resistance to mechanical load with no other preparation (occlusal, labiolingual, and proximal).

Scanning was done by intraoral scanning (Dentsply Sirona Omnicam) to capture a digital impression for further processing in CEREC software [Figure 3]. A Digital record of the segment with opposing arch was recorded. Scanning provides easier, more intuitive, and precise 3D models in natural colours in less than 2 minutes.
Figure 3: The patient’s dentition and mucosa captured with intraoral scanner

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Designing was done in 5 minutes followed by milling in the prime mill which took around 11minutes. Wet milling was carried out on lithium disilicate block (Dentsply Sirona) The milling process was extremely precise, definitive and created smooth surfaces and margins compared to the lab process. This is INDIA first house latest generation CEREC Prime mill. After milling the sprue detachment was done from the block followed by sintering and glazing. Sintering was done for strength which took around 12–15 minutes.

A trial was done in the patient’s mouth to check for fit and occlusion, followed by glazing process in CEREC speed fire. Both sintering and glazing were simultaneously done in speed fire. Glazing was done to provide aesthetic and gloss in speed fire which took around 8–10 minutes.

Fitting, aesthetics, and characterization were checked in the patient’s mouth. [Figure 4]a, [Figure 4]b then, the tooth was cleaned and prepared for luting with translucent resin luting cement.
Figure 4: (A), (B) Delivered Prosthesis

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Excess cement was removed from interdental spaces and group function occlusion was checked. [Figure 5]. The patient was given post-operative instruction.
Figure 5: Occlusion achieved

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In a matter of less than 45 minutes, complacent, enjoyable, and acceptable results were achieved. As shown in this case, we reconstituted not only the form and function of primary teeth but also the aesthetics with minimally invasive dentistry in a single sitting with the help of the CEREC workflow

  Discussion Top

This case report describes single-visit fabrication of a hybrid ceramic crown on mandibular primary canine. To limit chairside time and promote quality of care given, CAD/CAM technology is beneficially used in cases where crown on primary tooth is needed and option of extraction is rejected by parents of patient, while cost of extraction and placement of a space retainer is equivalent to the fabrication of a CAD/CAM crown. The standardized treatment option in young patients for heavily decayed primary teeth is SSCs[13]

SSCs are used in cases where a primary tooth has multi surface lesions, is anticipated to exfoliate in the far future, or has been treated with pulpotomy/pulpectomy. The biggest disadvantage of using SSCs is that they show aesthetically unattractive result. To overcome the poor aesthetics, new materials were developed, such as the open-faced crowns or pre-veneered SSCs.[14],[15] Another deficiency of using SSCs is that there is a potential for nickel and chromium ion to be released into the intraoral environment or into tooth root tissue and can result in an allergic reaction or may be cytotoxic.[16],[17]

When CEREC workflow and intraoral scanner are installed in the clinic space, the whole process of CAD/CAM will take place in the clinic space only and can be accomplished in a single sitting. The dentist can execute the scanning, designing, milling, and firing process chairside. Simultaneously, in the meantime dentist can finish the pulpectomy procedure in paediatric cases to reduce chairside time and increase comfort for the patient. We carried chairside procedures to treat our patient to save time and increase comfort for the paediatric patient.[18]

Digital impression making is one of the benchmarks in this CEREC workflow, as it yields good results concerning accuracy, precision, shade selection, and ease to learn. It has been shown in multiple studies that digital workflow dispenses the restoration of equal fit and accuracy in a broad range of indications. Various studies are done to compare the time efficiency of digital 3D scanning over conventional impression methods but only a few are done yet to compare the entire workflow. There is a requirement for new comparative studies in this field with the introduction of the latest CEREC software.[11]

Digital impressions are routinely used in other areas of the dental field, and now expanding their use in paediatric dentistry could be beneficial for both patients as well as providers. One of the studies conducted by Vasudevan et al. stated that 77% of patients preferred intraoral scans over traditional alginate impressions. Digital impressions are often found to be more comfortable for the patients.[19],[20]

The main limitation of digital dentistry is cost, to adopt new technology often requires a higher capital investment. Also uncontrolled tongue movement and excessive salivation are relative limitations.[21]

Our article aimed to portray the time efficiency and specificity of chairside workflow to fabricate hybrid restoration as per the need, in comparison with a conventional treatment plan for single-unit restorations (prefabricated) in paediatric patients. Digital impressions are more comfortable especially in cases with paediatric patients to save time, increase comfort with desired results.

  Conclusion Top

This case report concludes that the CEREC chairside system is a better and more useful tool for the clinician. The digital 3D impression with the software design and the milling unit in the same working unit allows producing highly aesthetic as well as reliable restorations in a single visit while improving patient’s acceptance and comfort for such procedures. We can assert that the restorative treatment with digital CAD/CAM chairside workflow represents as a valid alternative to rehabilitate non cooperative paediatric patients, as it is a safe, predictable, and personalized procedure which is easier, faster, and cheaper as compared to the traditional protocol in long run.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

  References Top

Kindelan SA, Day P, Nichol R, Willmott N, Fayle SA; British Society of Paediatric Dentistry. UK national clinical guidelines in paediatric dentistry: Stainless steel preformed crowns for primary molars. Int J Paediatr Dent 2008;18:20-8.  Back to cited text no. 1
Randall RC Preformed metal crowns for primary and permanent molar teeth: Review of the literature. Pediatr Dent 2000;24: 489-500.  Back to cited text no. 2
Seale NS The use of stainless steel crowns. Pediatr Dent 2002;24:501-5.  Back to cited text no. 3
Basir L, Meshki R, Behbudi A, Rakhshan V Effects of restoring the primary dentition with stainless-steel crowns on children’s salivary nickel and chromium levels, and the associations with salica pH: A preliminary before–after clinical trial. Biol Trace Elem Res 2019:187:65-73.  Back to cited text no. 4
Townsend JA, Knoell P, Yu Q, Zhang JF, Wang Y, Zhu H, et al. In vitro fracture resistance of three commercially available zirconia crowns for primary molars. Pediatr Dent 2014;36:125-9.  Back to cited text no. 5
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Collares K, Corrêa MB, Laske M, Kramer E, Reiss B, Moraes RR, et al. A practice-based research network on the survival of ceramic inlay/onlay restorations. Dent Mater 2016;32:687-94.  Back to cited text no. 10
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Hutcheson C, Seale NS, McWhorter A, Kerins C, Wright J Multi-surface composite vs stainless steel crown restorations after mineral trioxide aggregate pulpotomy: A randomized controlled trial. Pediatr Dent 2012;34:460-7.  Back to cited text no. 14
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Marks JG Jr, Belsito DV, DeLeo VA, Fowler JF Jr, Fransway AF, Maibach HI, et al; North American Contact Dermatitis Group. North American contact dermatitis group patch-test results, 1998 to 2000. Am J Contact Dermat 2003; 14:59-62.  Back to cited text no. 17
Beuer F, Schweiger J, Edelhoff D Digital dentistry: An overview of recent developments for CAD/CAM generated restorations. Br Dent J 2008;204:505-11.  Back to cited text no. 18
Vasudavan S, Sullivan SR, Sonis AL Comparison of intraoral 3D scanning and conventional impressions for fabrication of orthodontic retainers. J Clin Orthod 2010;44:495-7.  Back to cited text no. 19
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Heba Soffar. Computer Technology in Dentistry (Digital dentistry) Uses, Types, Cons & Pros. Available from: https://www.online-sciences.com/computer/computer-technology-in-dentistry-digital-dentistry-uses-types-cons-pros/. [Last accessed on July 17, 2020].  Back to cited text no. 21


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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