The Success of Stainless Steel Crowns

An Evidence based Report

Swati Ajwani*
F. Emel Arat*
Valerie DSilva*
Mandana Many*
Golaleh Nasri*
Mehran Shahabi*
Ardalan Zahedi*

*University of Toronto, Faculty of Dentistry, IDAPP Programme, Toronto, Ontario,

Canada

Abstract
Background: Stainless steel crowns (SSCs) are strongly recommended for multiple
surface lesions by American Academy of Pediatric Dentistry. However, the utilization of
SSCs is less frequent than multisurface amalgam restorations. Also, general practitioners
are reluctant to use SSCs and prefer amalgam restorations.
Aim: We aimed to review the current database to assess the effectiveness of SSCs on
primary molars compared to other filling materials. Our key questions are: (1) What is
the expected longevity of SSCs compared to other restorations? (2) Is the quality of SSC
in terms of biocompatibility, marginal leakage and preserving the health of surrounding
tissues better than other restorations?
Material and method: An extensive database search was conducted using Ovid
Medline. Also, reference lists and relevant journals were searched. Study selection was
done at title, abstract and full text screening stages by using PICO-C form. Then each
study was reviewed using appropriate checklist forms as a guideline. Studies having less
than 10 score were excluded.
Results: Of selected 14 articles, three of them were rejected, three of them were
systematic reviews and 8 of them were accepted.
Conclusion: According to our study, there is strong level of evidence to conclude that
SSCs and GIC have similar survival rates and patients treated with SSC have less
gingival bleeding compared to GIC restorations. There is moderate level of evidence to
support longer survival rate of SSCs comparing to amalgam restorations. There is low
level of evidence indicating no direct effect of SSC on the health of the surrounding
tissues.

Introduction
Stainless steel crowns (SSC) were introduced in the 1950s by Humprey 1. SSCs are
strongly recommended by American Academy of Pediatric Dentistry 2 in the treatment of
children with extensive decay, large lesions, or multiple-surface lesions in primary
molars. However, according to Children In Need of Treatment (CINOT) Dental Program
report 3, the frequency of use of SSCs on a primary molar ranked 5th after 2-surface
amalgam on primary teeth. In addition, Threlfall et al 4 stated that of 93 general
practitioners, 87 of them reported that they would not use SSC whereas they should treat
it with a SSC. The reasons given for not using SSCs were that they are inappropriate for
many children, time consuming to fit, difficult to manipulate, expensive and ugly.
In pediatric dentistry literature, SSCs are shown to be superior to multi-surface
amalgam5-11 and resin modified glass ionomer 12, 13 restorations. However, the design of
these studies is not ideal to assess the efficacy of a treatment. In evidence based practice,
questions related to interventions or therapies are best answered by systematic reviews
and randomized clinical trials (RCTs) 14. These study designs represent the highest level
of evidence. Lower level of evidence can be reached by non-randomized trials with
contemporary controls, non-randomized trials with historical controls, cohort studies,
case-control studies. On the other hand, the latest systematic review on this subject in
2007 15 reported that there were no RCTs available assessing the effectiveness of SSCs
compared with other filling materials.
In the anticipation of valid and current information about the use of SSCs, we aimed to
review the current database to assess the effectiveness of SSCs on primary molars
compared to other filling materials. Our key questions are:

I)

What is the expected longevity of SSCs compared to other restorations?

II)

Is the quality of SSC in terms of biocompatibility, marginal leakage and

preserving the health of surrounding tissues better than other restorations?

Material and Methods

Step 1: Data Sources
In an effort to indentify all the published articles assessing the SSCs on primary
posterior molars, we searched the Ovid MEDLINE database (1950 to June 2008), AMED
(1985 to June 2008), CINAHL (1982 to June 2008), All EBM reviews (Cochrane DSR,
ACP Journal Club, DARE, CCTR, CMR, HTA, and NHSEED), EMBASE (1980 to 2008
week 25), Health and Psychosocial Instruments (1985 to March 2008), Journals@Ovid
Full text (June 2008), Ovid Healthstar (1966 to May 2008), EBM Reviews-Cochrane
Methodology Register (2nd Quarter 2008), EBM Reviews-Health Technology Assesment
(2nd Quarter 2008), EBM Reviews-NHS Economic evaluation Database (2nd Quarter
2008), EMBASE (1974-1979) and EMBASE Classic (1947-1973).
The key words used for executing the search were primary dentition, primary tooth,
primary molar, molar teeth, primary teeth, stainless steel crown and metal crown.
The search strategy is shown in Table 1.
After that we ran the Pubmed search with different combination of Mesh terms including
molar, stainless steel, randomized clinical trial and primary dentition.
Step 2: We asked the opinion of an expert (Dr. MJ Sigal) in this field.
Step 3: We manually searched the reference lists of the retrieved articles.

Step 4: We hand-searched the following journals which were thought to be important:

British Dental Journal, International Journal of Pediatric Dentistry, BMC Oral Health and
Evidence Based Dentistry.

Type of studies:
Inclusion criteria: Randomized clinical trials (RCTs) that assess the effectiveness of
SSCs on primary molars compared to other restorations, studies in English language and
human studies.
Exclusion criteria: SSCs for primary anterior teeth, SSCs for permanent teeth, stainless
steel esthetic crowns.
Study selection:
Study selection was done independently by two authors (SA, FEA) at title, abstract and
full text screening stages by using PICO-C form (Figure 1). In case of disagreement, a
consensus was made.
Study Quality Assessment:
Each study was independently reviewed by two groups authors (VD, GN, MS, AZ) using
Checklist to assess evidence of efficacy of therapy or prevention and Checklist for a
review article forms as a guideline (Figure 2a, 2b). Each question in the checklist
marked 1 point with the maximum possible score 17. Studies having less than 10 score
were excluded.
Results
Step 1:

We retrieved 67 articles after the data base search. Fifty-five of them were rejected at title
stage. Of the 12 remaining articles, 11 of them were rejected at abstract stage. The
remaining 1 article was also rejected at full text stage.
Then we chose to go for the next best level of evidence and reevaluated the retrieved
articles. The results are as follows: Of 67 articles, 55 of them were rejected at title stage.
Of the 12 remaining articles, 6 were accepted at abstract stage. Of 6 articles, we were
able to locate 5 of them in the library. After grading of these articles, we accepted two of
them, rejected one article. The remaining two of them were systematic reviews.
Pubmed search results with different combinations of Mesh terms varied from 0 to 139
articles. Evaluating the result of Pubmed search did not give any additional articles.
Step2:
Also, on consultation of an expert in the field, we retrieved 1 systematic review article.
Step 3:
From the available references we included 10 more articles. Of 10 articles we were able
to locate 6 of them in the library. After grading of these articles we accepted 4 of them.
Step 4:
We retrieved two articles by hand-searching the above mentioned journals. After grading
we accepted them.
Flow chart of study selection is presented in Figure 3.
The rejection table for three articles is presented in Table 2.
Evidenced based tables were made for eight articles (Appendix 1). We followed the
guidelines provided by Canadian Task Force on Preventive Health Care 16. Including a
hierarchy of evidence, this system starts from the highest level, Level I, with properly

randomized controlled trials to the Level III with opinions of respected authorities, based
on clinical experience, descriptive studies or reports of expert committees. Furthermore,
this system includes a classification of recommendations for specific clinical preventive
actions (Grade A-E with Grade A being the good evidence to recommend the clinical
preventive action and Grade E representing good evidence to recommend against the
clinical preventive action).
Discussion
After a detailed database search to assess the success of SSCs on primary molars
compared to other restorations, we selected eight articles5,9,10,12,13,17,18,19. In this study, we
also retrieved three systematic reviews done in 2000, 2006 and 20086,11,15. In comparison
to these systematic reviews, we were able to locate more articles two of which were
RCTs18,19. In our opinion, the reason behind this might be the larger data base we had
access to, and RCTs being a more current form of evaluation.
What is the expected longevity of SSCs compared to other restorations?
For each of the eight accepted articles5,9,10,12,13,17,18,19, the hierarchy of evidence and
recommendations is listed in Appendix 1.
In the strongest article in this series (Level I, Grade A recommendation), Momen18 found
that there was no statistically significant difference in survival rates between SSC and
GIC. Author suggests that modified open sandwich restoration is a suitable alternative to
SSC in restoration of primary molars in children.
The second strongest study in this series (Level II-2, Grade A recommendation), Einwag
and Dunninger5 reported 90% survival rate in 4.5 years for SSCs and 40% survival rate
for amalgam restorations. For 8 years, the survival rate was 83% for SSCs.

Third study with Level II-2 and Grade A recommendation by Roberts et al13 showed no
significant difference in survival rates of SSC and GIC restorations.
Fourth study in this series (Level II-2, Grade B recommendation), OSullivan and
Curzon12 stated 3% failure rate for SSCs and 29% for amalgam and composite
restorations.
In the light of these studies, the longevity of SSCs is better than amalgam restorations
and not significantly different in case of GIC restorations. However, SSCs were placed
on more extensively carious teeth as opposed to the GIC restoration. Even then, SSCs
had 95 % survival rate18.
Is the quality of SSC in terms of biocompatibility, marginal leakage and preserving the
health of surrounding tissues better than other restorations?
In the strongest article in this series (Level I, Grade A recommendation), Momen18 stated
that gingival bleeding in cases treated with SSC was significantly less than GIC
restorations. There were no statistically significant differences in terms of proximal
contact, marginal integrity and occlusion between SSC and GIC, although slightly higher
prevalence of recurrent caries in GIC.
In the second strongest article (Level I, Grade A recommendation), Innes19 reported
statistically significant difference in signs and symptoms of irreversible pulpal disease,
caries progression and pain between Hall technique (SSCs) and other restorations, all
favoring Hall technique.
Third article with Level II-2, Grade B recommendation by Gruythuysen and Weerheijm9,
reported higher success rate for pulpotomized teeth restored with SSC than amalgam,

however concluded that further studies were required to support the higher success rate of
SSC.
Fourth article with Level II-2, Grade B recommendation by Holan et al10, showed no
statistically significant difference in radiographic pathologic findings between the
pulpotomized teeth restored with SSC and amalgam.
Fifth article with Level II-3, Grade B recommendation by Sharaf and Farsi17, showed that
interproximal bone resorption was not significantly affected by either crown marginal
extension or adaptation, preserving tight proximal contact between molars, oral hygiene
level or duration of presence of the crown. According to the authors, SSCs are valuable
procedure for restoring primary molars with no direct effect on the health of the gingival
or interproximal bone. Oral hygiene level is the main risk factor on the health of the
gingiva surrounding SSCs.
In the light of above studies, we have sufficient scientific evidence to support that SSC is
biocompatible with surrounding tissues. Moreover, SSCs showed less gingival bleeding
comparing to GIC restorations. However, we need more evidence to support the higher
success rate of SSCs than amalgam on pulpotomized teeth.
Conclusions and recommendations
1) We have strong level of evidence to conclude that SSCs and GIC have similar
survival rates.
2) We have moderate level of evidence to support longer survival rate of SSCs
comparing to amalgam restorations.
3) We have strong level of evidence to conclude that cases treated with SSC have
less gingival bleeding compared to GIC restorations.

4) We have low level of evidence indicating no direct effect of SSC on the health of
the surrounding tissues.
5) We need more evidence to assess the efficacy of SSCs on pulpotomized molar
teeth.
Acknowledgement: The authors wish to thank Dr. Carlos Quinonez and Dr Amir
Azarpazhooh for their support and guidance.

References
1) Macdonald RE, Avery DR. Restorative dentistry. In: Macdonald RE, Avery DR,
Dean JA. Dentistry for the child and adolescent. St. Louis: Mosby Inc.; 2004:
379-81.
2) http://www.aapd.org/media/policies.asp
3) Bennett, SL. (2001). Recent Changes and Evolution in Care Patterns in the
Children In Need Of Treatment (CINOT) Dental Program: 1990 - 1999. Public
Health & Epidemiology Report of Ontario - PHERO, 12(3):105-112.
4) A G Threlfall, L Pilkington, K M Milsom, A S Blinkhorn & M Tickle. General
dental practitioners' views on the use of stainless steel crowns to restore primary
molars. British Dental Journal 199, 453 - 455 (2005)
5) Einwag J, Dunninger P. Stainless steel crown versus multisurface amalgam
restorations. J Quintessence Int 1996; 27(5): 321-3.
6) Randall RC, Vrijhoef MMA, Wilson NHF. Efficacy of preformed metal crowns
vs. amalgam restorations in primary molars: A systematic review. JADA
2000;131;337-343.

7) Braff MH. A comparision between SSC and multisurface amalgams ASDC

Journal of Dentistry for Children 1975;42(6):474-8.
8) Dawson LR, Simon JF Jr, Taylor PP. Use of amalgam and stainless steel
restorations for primary molars. ASDC J Dent Child. 1981 Nov-Dec;48(6):420-2.
9) Gruythuysen RJ, Weerheijm KL. Calcium hydroxide pulpotomy with a lightcured cavity-sealing material after two years. ASDC Journal of Dentistry for
Children 1997; 64: 251253.
10) Holan G et al. Success rate of formocresol pulpotomy in primary molars restored
with SSC vs amalgam.. Pediatric Dentistry 2002;24(3):212-6.
11) Hickel R, Kaaden C, Paschos E, Buerkle V, Garcia-Goday F, Manhart J.
Longevity of occlusally stressed restorations in posterior primary teeth. Oral
Health 2006;96:21-48.
12) OSullivan EA, Curzon ME. The efficacy of comprehensive dental care for
children under general anesthesia. Br Dent J. 1991 Jul 20;171(2):56-8. Erratum in:
Br Dent J. 1991 Sep 7:171(5):122.
13) Roberts JF, Attari N, Sherriff M. The survival of resin modified glass ionomer
and stainless steel crown restorations in primary molars, placed in a specialist
pediatric dental practice. Br Dent J 2005;198:427-431.
14) Shutherland SE. Evidenced based dentistry: Part IV. Research design and levels
of evidence. J Can Dent Assoc 2001; 67:375-8
15) Innes NPT, Ricketts DNJ, Evans DJP. Preformed metal crowns for decayed
primary molar teeth. Cochrane Database of Systematic Reviews 2007, Issue 1.
Art. No.: CD005512. DOI: 10.1002/14651858.CD005512.pub2.

16) Canadian task force on preventive health care. Canadian Task force
methodology. Table 2. Levels of evidence-research design rating. Available:
www.ctfphc.org/ctfphc&methods.htm ( accessed july, 2008).
17) Sharaf AA, Farsi NM. A clinical and radiographic evaluation of stainless steel
crowns for primary molars. J of Dent 2004;32:27-33.
18) Momen, A. Stainless steel crown versus modified open-sandwich restorations
for primary molars: a 2-year randomized clinical trial. International Journal of
Paediatric Dentistry 2008.Published online on 6 Mar 2008.
19) Innes NP, Evans DJ, Stirrups DR. The Hall Technique; a randomized clinical trial
of a novel method of managing carious primary molars in general dental practice:
acceptibility of the technique and outcomes at 23 months. BMC Oral Health. 2007
Dec 20;7:18

Table 1.
Search History (26 searches)
#

Searches

Results

primary dentition {Including Limited Related Terms}

1033

primary tooth {Including Limited Related Terms}

1985

primary molar {Including Limited Related Terms}

4574

molar teeth {Including Limited Related Terms}

2998

exp primary dentition/

3251

exp primary teeth/

13521

exp primary tooth/

11791

1 or 2 or 3 or 4 or 5 or 6 or 7

20976

stainless steel crown {Including Limited Related Terms}

2218

10

metal crown {Including Limited Related Terms}

1778

11

9 or 10

3688

12

8 and 11

240

13

remove duplicates from 12

152

14

limit 13 to english [Limit not valid in: DARE,CCTR,CLCMR; records were retained]

137

15

limit 14 to english language [Limit not valid in: CDSR,ACP Journal

Club,DARE,CCTR,CLCMR,Journals@Ovid; records were retained]

137

16

limit 15 to human [Limit not valid in: AMED,CINAHL,CDSR,ACP Journal

Club,DARE,CCTR,CLCMR,HAPI,Journals@Ovid; records were retained]

112

17

limit 16 to humans [Limit not valid in: AMED,CINAHL,CDSR,ACP Journal

Club,DARE,CCTR,CLCMR,HAPI,IPAB,Journals@Ovid; records were retained]

112

18

limit 17 to randomized controlled trial [Limit not valid in: AMED,CINAHL,CDSR,ACP

Journal
58
Club,DARE,CLCMR,CLHTA,CLEED,EMBASE,HAPI,IPAB,Journals@Ovid,EMBAS
E Classic; records were retained]

19

limit 17 to meta analysis [Limit not valid in: AMED,CINAHL,CDSR,ACP Journal

Club,DARE,CLCMR,CLHTA,CLEED,EMBASE,HAPI,IPAB,Journals@Ovid,EMBAS
E Classic; records were retained]

20

limit 17 to clinical trial [Limit not valid in: AMED,CDSR,ACP Journal

Club,DARE,CLCMR,EMBASE,HAPI,IPAB,Journals@Ovid,EMBASE Classic; records 44
were retained]

21

limit 17 to controlled clinical trial [Limit not valid in: AMED,CINAHL,CDSR,ACP

Journal Club,DARE,CLCMR,CLHTA,EMBASE,HAPI,IPAB,Journals@Ovid,EMBASE 45
Classic; records were retained]

22

limit 17 to multicenter study [Limit not valid in: AMED,CINAHL,CDSR,ACP Journal

Club,DARE,CLCMR,CLHTA,CLEED,EMBASE,HAPI,IPAB,Journals@Ovid,EMBAS
E Classic; records were retained]

46

23

limit 17 to clinical trial, all [Limit not valid in: AMED,CINAHL,CDSR,ACP Journal
Club,DARE,CCTR,CLCMR,CLHTA,EMBASE,HAPI,IPAB,Journals@Ovid,EMBASE
Classic; records were retained]

58

24

limit 17 to evaluation studies [Limit not valid in: AMED,CINAHL,CDSR,ACP Journal

Club,DARE,CCTR,CLCMR,CLHTA,CLEED,EMBASE,HAPI,IPAB,Journals@Ovid,E
MBASE Classic; records were retained]

61

25

18 or 19 or 20 or 21 or 22 or 23 or 24

67

26

remove duplicates from 25

67

46

Table 2.
Excluded studies and reasons for exclusion.
Citation
Barberia E, Arenas M, Gomez D. Commun
Dent Health 2007;24:55-58.

Braff MH. ASDC Journal of Dentistry for

Children 1975;42(6):474-8.

Reason for exclusion

Score = 9
Retrospective study
Not all clinically important outcomes were
considered
Small sample size
Score = 9
Retrospective study
Not all clinically important outcomes were
considered
Small sample size

Dawson LR, Simon JF Jr, Taylor PP.

ASDC J Dent Child. 1981 NovDec;48(6):420-2.

Score = 9
Retrospective study
No decent statistical analysis, only reported
percentages

Figure 1.
PICO-C Form
Population
Intervention
Comparison
Outcome
Critical appraisal

Primary molars
Stainless steel crown, preformed metal
crown
Multisurface amalgam/composite/GIC
restorations
Longevity, biocompatibility, marginal
leakage, health of surrounding tissue
RCT study design, non-randomized trials,
cohort studies, case-control studies

Figure 2a.
Checklist to Assess Evidence of Efficacy of Therapy or Prevention

Citation: ____________________________________________________
____________________________________________________
1. Was the study ethical? ___
2. Was a strong design used to assess efficacy? ___
3. Were outcomes (benefits and harms) validly and reliably measured? ___
4. Were interventions validly and reliably measured? ___
5. What were the results?
Was the treatment effect large enough to be clinically important? ___
Was the estimate of the treatment effect beyond chance and relatively precise? ___
If the findings were no difference was the power of the study 80% or better ___
6. Are the results of the study valid?
Was the assignment of patients to treatments randomised? ___
Were all patients who entered the trial properly accounted for and
attributed at its conclusion?
i) Was loss to follow-up less than 20% and balanced between test and controls ___
ii) Were patients analysed in the groups to which they were randomised? ___
Was the study of sufficient duration? ___
Were patients, health workers, and study personnel blind to treatment? ___
Were the groups similar at the start of the trial? ___
Aside from the experimental intervention, were the groups treated equally? ___
Was care received outside the study identified and controlled for ___
7. Will the results help in caring for your patients?
Were all clinically important outcomes considered? ___
Are the likely benefits of treatment worth the potential harms and costs? ___
Adapted from: Fletcher, Fletcher and Wagner. Clinical epidemiology the essentials. 3rd
ed.
1996, and Sackett et al. Evidence-based medicine: how to practice and teach
EBM. 1997

Figure 2b.
Checklist for a Review Article

Citation: ____________________________________________________
____________________________________________________
1. Was the question stated clearly and relevant? ___
2. Were the methods stated clearly? ___
3. Was the search for studies comprehensive (Medline, etc., selection from
bibliographies, contact with investigators)? ___
4. Were the inclusion/exclusion criteria for studies clearly stated
and relevant (population, intervention, outcomes, study designs)? ___
5. Was the validity of the primary studies assessed (e.g., independent reviewers,
scoring of articles)? ___
6. Was the assessment of the primary studies reproducible and free from bias? ___
7. Were results of primary studies combined appropriately using:
summary tables ___
meta - analysis (watch that patients etc., are similar in the studies combined) ___
8. Was the homogeneity of the primary studies analysed? ___
9. Were the conclusions consistent with results and strength of the primary studies? ___
Adapted from: Fletcher, Fletcher and Wagner. Clinical epidemiology the essentials. 3rd
ed.
1996, and Sackett et al. Evidence-based medicine: how to practice and teach
EBM. 1997

Figure 3.
Flow-chart of the study

STEP 1

STEP 1A
N= 67 articles

66 articles were rejected

after title and abstract
screening stages
N=1

STEP 1B
N= 67 articles

61 articles were rejected

after title and abstract
screening stages
N=6

STEP 1C
N= 0-139 articles

No additional articles
N=0

STEP 2

1 systematic review was

retrieved
N=0

STEP 3

STEP 4

6 articles were retrieved

2 articles were rejected
4 articles were accepted
N=4
2 articles were retrieved
2 articles were accepted
N=2

TOTAL

8 articles were accepted

3 articles were rejected
3 articles were systematic reviews

1 article was rejected at

full text stage
N=0

1 article was rejected,

1 article was not in local holdings
2 articles were systematic reviews
2 articles were accepted
N=2

Appendix 1.
Studies

Momen
2008
RCT

Populati Compariso Grade

on
n

Outcome
Longevity

Pulpotomy Level I, SSC=GIC

87
Children + SSC vs. A
, 4-7 yrs Pulpotomy
+GIC

Biocompat Marginal
ibility
Leakage
Marginal Recurrent
carries
Integ.
Prox.
Contact
Occlusion SSC < GIC

Health of
Surrounding
Tissues
Gingival
bleeding

SSC < GIC

Innes et 132
al., 2007 Children
RCT
,
6.8 yrs

Level I,
SSC vs.
A
other
restoration
s

SSC=GIC
Irreversibl Caries
e pulpal progression
disease
SSC<Other
SSC <
Other

Einwag 106
Level II- Survival rate
SSC vs.
and
Children amalgam 2, A
SSC>
Dunning
er, 1996
Amalgam
Roberts 1972
et al.,
Primary
2005
molar
teeth
Holan et 513
al., 2002 Patients

SSC vs.
GIC

Level II- Survival rate,

2, A
SSC=GIC

Pulpotomy Level II+ SSC vs. 2, B

Pulpotomy
+Amalgam

Gruythuy 57
Pulpotomy Level IIsen and Children + SSC vs. 2, B
Weerheij
Pulpotomy
m, 1997
+Amalgam
OSulliva
n and
Curzon,
1991
Sharaf
and
Farsi,
2004

Success
rate,
SSC=Ama
lgam
Success
rate,
SSC>Ama
lgam

80
Various
Level II- SSC>
Children treatment 2, B
Amalgam and
Composite
procedures
177
SSC
Children

Level II3, B

NS effect
On interproximal
bone level
S effect
[Marginal
adaptation and
OHI]
On gingival
index