Making a permanent difference with zirconia paediatric crowns A five-year follow-up
Dr Ana Vînău, Romania

Patricia first came to our clinic with her mother when she was 7 years old. She was quite shy, and I could tell that she felt very uncomfortable. Her mother told me that her daughter had experienced a great deal of dental pain before at another dental clinic and did not want to endure a similar experience again.

When examining Patricia, I could see that several of her teeth were affected by caries. I could see that teeth #75 and 85 were the most affected, showing evidence of massive dental destruction. I noticed that tooth #85 also had a vestibular abscess. I was almost certain that we would need to extract those teeth owing to the extensive damage. Furthermore, the lesions had already led to infection.

At the next appointment, I examined the panoramic radiograph so that I could see all of Patricia’s teeth and assess the amount of root resorption in order to know how to treat her teeth. Upon viewing the radiograph, I was surprised, disappointed and challenged all at the same time. I saw that the respective permanent teeth were missing and noted accompanying extensive bone damage (Figs. 1 & 2). Patricia’s parents were shocked and dis-couraged when they found out that she had hypodontia in addition to caries-affected primary second molars.

I knew right away that I needed a second opinion on this case, so I asked orthodontic specialist Dr Teodorina Secara for some advice. She advised me to try to keep the two damaged teeth in Patricia’s mouth if at all possible, given the fact that she already had too much space between her teeth. The loss of these two primary molars would disrupt the relationship between the rest of her teeth and, in the end, impact her entire occlusion. 

I took on the task of resolving this case as a personal challenge. Because the permanent adult teeth were missing, we could not afford to lose the primary second molars. I did not know how this case would end up, so I started by taking it one step at a time. In the beginning, I treated the root canals of the two damaged and infected teeth with antibiotics and anti-inflammatory medication.

After ten days, I filled the root canals of both teeth using the standard procedure for permanent teeth. On tooth #75, I also encountered a furcal perforation, and although it was very difficult to stop the haemorrhage, we managed eventually to place mineral trioxide aggregate on the perforation. We filled tooth #75 with EQUIA (GC) and tooth #85 with GRADIA DIRECT (GC). 

Two weeks later, while I was treating the rest of Patricia’s teeth, I saw through the enamel that tooth #75 had begun to turn black underneath the EQUIA filling. Also, tooth #85, owing to the extensive filling and the small amount of healthy dental structure remaining after removing the carious tissue, had begun to exhibit fissure lines. It was just a matter of time until that tooth would break, requiring an extraction, in spite of all the hard work done to save it. This was not a scenario I was willing to accept. At that point, I knew I had to come up with an alternative idea in order to help retain the primary second molars, and I had to do it fast.

I knew I had to reinforce these damaged molars if we wanted to keep them, but what I most wanted for Patricia was an aesthetic solution for her situation that would prove durable over time, because these primary molars would never be replaced by permanent teeth. In addi-tion to being aesthetic, the ideal restoration would need to be extremely strong, able to withstand all occlusal forces over a lifetime. At the time, we only had stainless-steel crowns available in our clinic, but they would not be an option. I refused to believe that I had reached the end of the road, so I began doing some research to find out what aesthetic paediatric options were available.

I discovered that such a restorative option with all the characteristics that I had been hoping for did in fact exist. EZCrowns (Sprig Oral Health Technologies) would satisfy both the needs of my patient and the desires of her parents. Usually, when you diagnose a young patient with 

“I was impressed by the fact that both crowns looked so natural that you could barely notice any difference between the zirconia crowns and natural teeth.”

hypodontia and talk to the parents about it, they perceive the diagnosis as a handicap, or they feel ashamed for having done something wrong that led to the situation. Now, however, it was such a joy and a relief to be able to share the option of using zirconia crowns when faced with such a difficult circumstance.

After assessing Patricia’s situation, I shared the good news of my discovery with her parents and proposed using EZCrowns. They were excited about the fact that the crowns had the same colour as natural teeth and gave me permission to proceed. I told Patricia that she would no longer feel any pain. She was excited to learn that instead of two damaged teeth, she would be getting two beautiful pearl-like teeth.

Anticipating the treatment, I was nervous because this would be the first time I had ever used zirconia crowns. However, I managed to seat both crowns in the same session. In the end, Patricia was extremely excited with the result. During the entire process of discovering zirco-nia crowns and preparing for the treatment, I found the Sprig team to be most helpful and responsive in communicating with me.

At Patricia’s two-week check-up, I was surprised to see how beautifully the gingival margin had healed and to dis-cover that the crown contour was nearly perfect. I was impressed by the fact that both crowns looked so natural that you could barely notice any difference between the zirconia crowns and Patricia’s natural teeth. I was thrilled with the result and so were her parents, but what I most anxiously wanted to see was how well these crowns would perform over time. Would my patient be able to retain these two crowns over the long term? 

Therefore, I monitored the crowns to see how they would hold up after prolonged use. I saw Patricia regularly for follow-up examinations and carefully examined her. At the six-month and 18-month follow-up appointments, I took photographs and radiographs of her teeth (Figs. 3a–d). They still looked impeccable. Her permanent first molars had erupted in their right places. I could not detect any wear of the opposing teeth, and the crown margins were subgingivally placed, revealing healthy surrounding tis-sue. The radiographs showed that the bone had remineralised and healed.

In summary, Patricia uses her new crowns as if they are her natural ones. After we placed the zirconia crowns, Patricia began taking personal responsibility for and paying more attention to proper dental hygiene. She now enjoys coming to her appointments because she knows we will take photographs every time. I think zirconia crowns are a necessity in this kind of situation with missing permanent teeth.

I now feel confident recommending zirconia crowns to parents, and these crowns enable me to honour the trust which parents have placed in me by providing the best available solution when treating special dental conditions such as hypodontia. By incorporating all the benefits of zirconia crowns into your practice, you too will increase your chance of success. Above all, you will have the professional satisfaction of knowing that you can overcome even the most difficult situation. 

Every time, a patient revisits our clinic for a check-up appointment after a long absence, I feel a sense of excitement. I am eager to check each patient’s dental status to see how the treatment plan we adopted has impacted his or her quality of life. Now, almost five years later, our choice to use zirconia crowns has been rewarded, and Patricia’s teeth continue to look astonishingly natural (Figs. 4–6).

Based on the latest radiographs taken during a recent follow-up examination (Fig. 7), I can confirm that the final results continue to look amazing, despite the rough start.

Patricia, who is almost 12 years old now, is no longer shy, and I can tell by the brightness of her smile that she is full of confidence. Since her initial visit, she has developed into a young girl with abundant enthusiasm and is not the timid child who first stepped into our office (Fig. 8).

As the pièce de resistance of the treatment, the EZCrowns have literally demonstrated their quality. Although both primary second molars were treated endodontically as if they were permanent teeth and the mesial root of tooth #85 shows evidence of resorption, Patricia has experienced no clinical symptoms.

The contour of the gingival margin is still placed at a physiologically appropriate height. Compared with Patricia’s natural teeth, there are only insignificant signs of gingival inflammation, likely due to her still superficial personal dental hygiene habits.

One of my greatest concerns when I initially placed Patricia’s zirconia crowns was how they would hold up over the long term. Would they be abrasive and damage the opposing natural teeth? Although zirconia crowns are glazed and smoothly polished, they still have a harder surface than natural teeth do. However, to my surprise, every time Patricia arrived for a clinical examination, I was unable to observe any notable pathological sign of dental abrasion on her opposing teeth. 

Today, Patricia has no difficulties with her mastication or occlusion. Furthermore, and most importantly, she enjoys the amazing aesthetics of a beautiful smile. She has excellent oral health, and when I talk to her, I sense her feeling of well-being at having a beautifully restored smile. Although both molars had a guarded prognosis, five years later, we are still pleased with the results of her zirconia restorations.