What are 5 treatment options for severely damaged baby front teeth?

Front teeth are exciting!  Incisors are one of the first baby teeth to appear (generally between 6-12mths) signalling our babies’ growth and development from infant to toddler and the journey of exploring the wonderful world of solid foods. Incisors are also one of the first baby teeth to become loose (generally between 6-7yo) and fall out, making way for adult incisors (1,2).

Baby incisors, especially ones in the top jaw, are particularly prone to damage. Chipping and fracturing of teeth from falling over, dental decay, enamel defects, severe grinding and unusually shaped front teeth, are some of the many reasons parents seek treatment for their children’s damaged front teeth (1-3).

Baby teeth are important and worth fixing if possible. The 5 most commonly recommended treatment options for severely damaged baby front teeth are (1-3):

1. No treatment – leave the tooth to fall out
2. Extraction
3. Filling the damaged part of the tooth with a white restorative material
4. Placing a white composite resin strip crown over the entire tooth
5. Cementing a white prefabricated crown over the entire tooth

No treatment / leave the tooth to fall out

Leaving the tooth to fall out is generally only recommended if the child is older and is not in any discomfort, and the tooth is not infected and near the time of its natural exfoliation.

Extraction

Extraction is often the treatment of choice if the damaged baby front tooth is infected, or where the lost of tooth structure is so severe that a filling or crown cannot be retained.

Filling the damaged part of the tooth with a white restorative material

Putting in a filling to replace the damaged part of the tooth and restore function and appearance is a common option where pulp therapy of the damaged front tooth is not required. Most often the filling is done using white adhesive restorative materials such as composite resin, glass ionomer, giomer, compomer, etc. (1-3)

Depending on the skills of the dental practitioner, white fillings can be very aesthetic and functional. The longevity of white fillings varies greatly, from months to years, depending on the choice of material, the exact techniques used to prepare and restore the damaged tooth, how top and bottom teeth contact, and whether there are habits such as heavy chewing, grinding or nail biting present. Fillings can be repaired or replaced if they are chipped, worn or “fall out”.

Placing a white composite resin strip crown over the entire tooth

A composite resin strip crown is probably most frequently recommended by paediatric dentists in Australia, for the treatment of severely damaged baby front teeth (including pulp damaged baby teeth requiring pulp/root canal therapy). It is also the recommended treatment for full crown coverage by the American Academy of Pediatric Dentistry (4-5). The treatment involves construction of a crown using a specifically shaped and sized crown proforma filled with composite resin that is seated over the entire damaged tooth, set by light until the composite resin is hardened and then the proforma is removed. Strip crowns are technique sensitive and treatment success is dependent upon the skills of the dental practitioner (6).

The complete coverage of the damaged tooth creates excellent protection and strength, so strip crowns tend to be more durable than a filling (5-8). Strip crowns can be repaired by adding more composite resin to areas that have been worn or chipped over time. Strip crowns are aesthetic, as the natural tooth shape is reproduced using the proforma and different shades of white composite resins are available to match the colour of adjacent teeth as closely as possible. However, as with all composite resin-based restorations, discolouration can occur if there is blood contamination during placement and/or over time (8-9).

There is also the option of composite resin bonded crowns ("sticking" the crown to the tooth using composite resin dental filling material) e.g. Lifelike Pediatric crowns made of laboratory-cured high-density composite, and Pedo Jacket crowns made of copolyesters. Lifelike crowns can be adjusted in a similar way to strip crowns but Pedo Jacket crowns cannot. Both are available in 1 shade of white. To place these crowns, the baby teeth must be significantly reduced to facilitate a relatively thick layer of composite resin for bonding and colour. Both Lifelike crowns and Pedo jacket crowns are not available in Australia.

Cementing a white prefabricated crown onto the entire tooth

Prefabricated white crowns are available for treatment of severely damaged baby front teeth as per strip crowns. Prefabricated white zirconia crowns have been available for some years now, although more popular in other parts of the world e.g. America, than in Australia. Recently, a new type of prefabricated  white crowns made of fibreglass and resins (Figaro Crowns), which are lower cost and relatively less technique sensitive compared to prefabricated zirconia crowns, have become available in America and Canada.

The treatment procedures of both types of prefabricated white crowns are similar to prefabricated zirconia crowns used for primary molar teeth (please refer to Tooth Bunny’s article on white zirconia crowns for primary molar teeth). Briefly, the dental practitioner prepares the damaged tooth to fit the prefabricated crown, the most fitting crown size is selected and cemented onto the tooth. As extensive tooth reduction and preparation is required to fit a prefabricated white crown (6,10-11), pulp treatment prior to crown placement may be necessary in some cases, in order to accommodate the crown.

Similar to strip crowns, prefabricated white crowns provide excellent protection and strength as the entire damaged tooth is covered. Prefabricated white crowns do not wear easily, but may cause minor wear on opposing natural teeth in contact with the crowns (6). However, the surface can be chipped; but repair is difficult. Durability of prefabricated white crowns is not known exactly, as there is only very limited research in this area.

Zirconia crowns and fibreglass resin crowns both provides pleasing aesthetics (9,11-12), especially when all 4 incisor teeth in the top jaw require restoration.  When a single baby front tooth is crowned in this way, the crown may stand out because prefabricated crowns only come in one or two shades of white, which may or may not closely match the colour of neighbouring teeth. Also discolouration can occur if there is blood contamination during placement. However, the initial colour of prefabricated crowns, especially zirconia crowns is generally stable over time.

Zirconia crowns are radiopaque, meaning they are visible on xrays. Fibreglass resin crowns are more radiolucent, i.e. much less visible on xrays. Not being radiopaque may be a cause for concern in the unlikely event when a fibreglass resin crown is lost or swallowed.

In Australia, prefabricated zirconia crowns are available but prefabricated fibreglass resin crowns are not yet available.

Best way to decide on the treatment of choice?

Many factors must be considered in order to determine the best treatment option for any severely damaged baby front tooth of a child: nature and severity of the damage, dental age of tooth, chronological age of child, presence or absence of other dental or medical conditions, occlusion (how the top and bottom teeth and jaw meet), cooperation, cost, etc . Decision making is often difficult. It is important to discuss your concerns and priorities, as well as your child's concerns (especially if they are >3yo), with your dental practitioner, so that these can be taken into account. Discuss treatment options and decide on the treatment of choice for your child based on priorities and treatment aims. Communication between you and your dental practitioner, is key to optimizing treatment and care for your child.

REFERENCES

1. Nowak AJ, Casamassimo PS. (Eds). The Handbook of Pediatric Dentistry. 5th Edition. Chicago: American Academy of Pediatric Dentistry, 2018.
2. Cameron AC, Widmer RP. (Eds). Handbook of Pediatric Dentistry. 4th Edition. Australia: Mosby Elsevier, 2013.
3. Waggoner WF. Restoring primary anterior teeth: updated for 2014. PEdiatr Dent 2015; 37(2): 163-170.
4. Kupietzky A. Bonded resin composite strip crowns for primary incisors: clinical tips for a successful outcome. Pediatr Dent 2002; 24: 145-148.
5. Kupietzky A, Waggoner WF, Galea J. The clinical and radiographic success of bonded resin composite strip crowns for primary incisors. Pediatr Dent 2003; 25: 577-581.
6. Walia T, Salami AA, Bashiri R, Hamoodi OH, Rashid F. A randomised controlled trial of three aesthetic full-coronal restorations in primary maxillary teeth. Eur J Paediatr Dent 2014; 15(2): 113-118.
7. Ram D, Fuks AB. Clinical performance of resin-bonded composite strip crowns in primary incisors: a retrospective study. Int J Paediatr Dent 2006; 16(1): 49-54.
8. Kupietzky A, Waggoner WF. Parental satisfaction with bonded resin composite strip crowns for primary incisors. Pediatr Dent 2004; 26(4): 337-340.
9. Salami A, Walia T, Bashiri R. Comparison of parental satisfaction with three tooth-colored full-coronal restorations in primary maxillary incisors. J Clin Paediatr Dent 2015; 39(5): 423-428.
10. Clark L, Wells MH, Harris EF, Lou J. Comparison of amount of primary tooth reduction required for anterior and posterior zirconia and stainless steel crowns. Pediatr Dent 2016; 38(1): 42-46.
11. El Shahawy OI, O’Connell AC. Successful restoration of severely mutilated primary incisors using a novel method to retain zirconia crowns – two year results. J Clin Pediatr Dent 2016; 40(6): 425-430.
12. Ashima G, Sarabjot KB, Gauba K, Mittal HC. Zirconia crowns for rehabilitation of decayed primary incisors: an esthetic alternative. J Clin Pediatr Dent 2014; 39(1): 18-22.