PEDIATRIC DENTISTRY V 37 / NO 2 MAR / APR 15

Conference Paper
The Use of Stainless Steel Crowns: A Systematic Literature Review
N. Sue Seale, DDS, MSD1 Ros Randall, PhD, MPhil, BChD2

Abstract: Purpose: The purpose was to review the published literature on stainless steel crowns (SSCs) from 2002 to the present as an update
to an earlier review published in 2002. Methods: Included were published papers on clinical studies, case series, and laboratory testing on SSCs
(including esthetic SSCs and the Hall technique) in peer-reviewed journals. Study quality and strength of evidence presented were assessed for
papers reporting clinical results for SSCs as a primary study outcome using a list of weighting criteria. Results: Sixty-one papers fulfilled the
inclusion criteria (24 papers on 22 clinical studies, three case reports, 21 reviews and surveys, and 13 laboratory testing reports on SSCs and
esthetic preformed metal crowns for primary and permanent molar teeth). Ten clinical studies achieved weighting scores ranging from 68
percent to 26 percent, with the two highest scoring studies (68 percent and 63 percent) considered good quality. Conclusions: Within the con-
fines of the studies reviewed, primary molar esthetic crowns and SSCs had superior clinical performance as restoratives for posterior primary
teeth, and the Hall technique was shown to have validity. No clinical studies were available on zirconia crowns. Further well-designed pro-
spective studies on primary molar esthetic crowns and the Hall technique are needed. (Pediatr Dent 2015;37(2):147-62)
KEYWORDS: STAINLESS STEEL CROWNS, SYSTEMATIC REVIEW

Preformed metal crowns for primary molar teeth have been
available since 1950.1,2 Over time, design modifications have
simplified the fitting procedure and improved the morphology
of the crown so that it more accurately duplicates the anatomy
of primary molar teeth. The morphology of a primary molar
tooth differs from the permanent successor, particularly by
having its greatest convexity at the cervical third of the crown.3
Traditional and esthetic stainless steel crowns (SSCs)
and zirconia crowns are available in a range of sizes to match
primary first and second molar teeth. The traditional SSC is
flexible enough to allow trimming, crimping, and shaping to be
done as needed to obtain a good fit, with the crown margin
giving retention by springing into and being retained by the
undercut cervical area.4-6 Esthetic-coated SSCs tend to have
stiffer margins are less versatile regarding trimming and crim-
ping, and, to varying extents, require the tooth to be prepared
to fit the crownleading to greater technique sensitivity in
placement. Permanent molar traditional SSCs are also avail-
able and are mainly sized to fit the permanent first molar
tooth. These crowns have morphology to match the adult denti-
tion and invariably need trimming and crimping to obtain an
adequate fit.
The purpose of this study was to conduct a systematic lit-
erature review of recent published papers on stainless steel
crowns for effectiveness in clinical performance and laboratory
testing as an update to the American Academy of Pediatric
Dentistry (AAPD) review published in 2002. 7,8 In addition,
literature was searched and included that pertained to new
techniques, uses, and/or materials associated with SSCs used as
a restorative option for primary or permanent molars.
Methods
Search terms used were crowns and stainless steel, SSC, pre-
formed metal crown combined with primary, deciduous, pos-
1Dr. Seale is Regents Professor, Texas A&M University Baylor College of Dentistry, Dallas,
Texas; and 2Dr. Randall is a Clinical Research Manager, 3M ESPE, St. Paul, Minn., U.S.A.
Correspond with Dr. Seale at SSeale@bcd.tamhsc.edu.
terior and molar, in vivo, and in vitro. Medline, EmBase, Em-
Care, Pascal, and Biosis databases were searched as well as Google
Scholar. References from retrieved papers were scanned;
however, no hand searching of literature was done. The litera-
ture search included papers published between 2000 and 2014.
Criteria for eligible studies were published papers on clin-
ical studies, cases or case series, and laboratory testing of SSCs
and esthetic crowns. All papers had to have been published in
peer-reviewed journals, and only English language papers were
included. Excluded were abstracts, unpublished data, SSCs
and esthetic crowns for anterior primary teeth, and SSCs used
in orthodontic procedures. Abstracts of publications retrieved
during the search were read to determine eligibility of each
paper based on inclusion and exclusion criteria. All papers that
appeared to fulfill the inclusion criteria were selected, and a full
copy of the paper was obtained. The papers were then reviewed
in detail by both authors, and the data were evaluated for the
present literature review.
Validity of papers and weighting criteria. Papers report-
ing clinical results (excluding case reports and case series) were
given the greatest emphasis. Weighting criteria (Table 1) were
used to assess the clinical research literature reporting on SSCs
and esthetic crowns as a primary end point of the study.
Weighting points were allocated as appropriate to grade study
quality and validity of evidence. A threshold of 60 percent was
set, above which a studys results could be considered good
quality and validity; the strength of evidence for each individual
study was evaluated based on this preset value.
Results
Sixty-one papers fulfilled the inclusion criteria, consisting of
24 papers on 22 clinical studies, three case reports, 21 reviews
and surveys, and 13 laboratory testing reports on SSCs and
esthetic preformed metal crowns for primary and permanent
molar teeth.
Clinical studies. A total of 12 papers were retrieved that
reported on 10 studies on SSCs or preveneered SSCs for pri-
mary and permanent molar teeth as a primary endpoint of the

USE OF STAINLESS STEEL CROWNS 147

PEDIATRIC DENTISTRY V 37 / NO 2 MAR / APR 15
Table 1. WEIGHTING ASSESSMENT CRITERIA
A clearly stated study aim/hypothesis
Ethics approval and informed consent obtained
Prospective study
Appropriate control
Approximate matching numbers of control and test device
Justification for sample size used in study
Representative of average patient population of interest
Inclusion and exclusion criteria listed
A clearly described and valid randomization scheme
Standardized operator and placement procedures
One or more independent examiners
Blinded examiner(s)
Examiner calibration method and results given
Study duration adequate to obtain valid results
Objective as well as subjective recording of data
Appropriate statistical analysis reported
Report on patient loss from study and reasons for drop-out
or statement that no drop-out occurred
Description of unexpected adverse events or statement that none occurred
Description of protocol deviations or statement that none occurred
study, with a further 12 papers presenting results for SSCs as a
secondary outcome of the research. No clinical papers report-
ing on zirconia crowns for primary molar teeth were found.
Update on literature review of clinical studies compa-
ring SSCs with other materials. Six studies directly compared
SSCs with other direct restorative options, three of which also
reported on SSC use in patients treated under general anes-
thesia (GA). Atieh9 compared SSCs with a modified sandwich
technique restoration using resin-modified glass ionomer
(RMGI) to restore primary molars that had received pulpo-
tomy therapy in a randomized clinical trial (RCT). A total of
160 restorations were placed in 87 four- to seven-year-olds
(mean equals 5.5 years old), consisting of 77 SSCs and 75
sandwich restorations, which were evaluated at one and two
years. A total of 10 restorations failed over the two years of
the study: four SSCs and six sandwich technique restorations.
There was no statistically significant difference between the two
techniques at any time point, except for gingival bleeding at
two years, where 13 SSCs rated Bravo and eight scored Charlie
compared to the sandwich technique rating of 10 Bravo and
one Charlie score, with a statistically significant difference of
P>.01. The authors commented that many of the study sub-
jects had pre-existing gingivitis. At two years, the survival rate
for SSCs was 95 percent, which was not significantly different
from 93 percent for the sandwich technique; however, only
patients with good behavior patterns had been selected for the
study to permit the use of a rubber dam. The authors consid-
ered that the sandwich technique was technique sensitive
compared to SSCs but had the advantage of fluoride release
and esthetics.
Roberts et al.,10 in a retrospective record review, compared
SSC and RMGI restorations in primary molar teeth over seven
148 USE OF STAINLESS STEEL CROWNS
years duration. The RMGI restorations were placed in Class I
and minimal Class II cavities, and the margins were etched and
sealed with fissure sealant; SSCs were placed to restore larger
cavities. The authors reviewed 1,698 RMGI restorations and
1,107 SSCs for a mean follow-up time of two years (maximum
of 7.5 years). SSCs were successful for restoration of larger
cavities and teeth that had received pulp therapy, and it was
considered that RMGI showed promise as a restorative for
smaller Class I and II cavities.
A recent paper by Milsom et al.11 retrospectively evaluated
the types of restorations placed to restore two-surface caries in
primary molar teeth using data from 260 patient records.
Nearly 40 percent of all treatments for two-surface caries was
amalgam, with SSCs placed in approximately seven percent of
teeth, which included pulpotomies. Among the amalgam re-
stored teeth, 50 percent required no further attention, 35 per-
cent were eventually extracted, and 25 percent had further
treatment. For the SSC group, 80 percent needed no further
treatment, one crown needed further attention, and one crown
was extracted. The success rate, defined as not requiring further
treatment, was higher for SSCs than amalgam or glass ionomer
cement (GIC); however, the number of SSCs evaluated was
small. The authors concluded that teeth restored with SSCs
may have improved outcomes, but more work was needed to
clarify the benefits.
Drummond et al.12 ran a retrospective evaluation of treat-
ment results for high caries-risk patients younger than six years
old after treatment under GA. Data were analyzed after two,
three, and four years had elapsed, and additional treatment
requirements were also documented. Different types of restora-
tive procedures were evaluated, including composites, com-
pomers, GICs, and SSCs. Patient records for 277 children, with
a mean age of 4.3 years old at baseline, were examined, which
included 133 records at two years, 69 at three years, and 75 at
four years. At two years post-treatment, nearly two-thirds of
the subjects needed new restorations due to caries. Mean success
rates of various types of restorative material were: amalgam 57
percent; composite 73 percent; compomer 85 percent; and SSC
93 percent. The authors concluded that the majority of re-
storative materials evaluated had shown satisfactory clinical
outcomes in primary teeth.
Al-Eheideb et al.13 also reported a retrospective study on
longevity of restorations placed under GA. Posterior teeth re-
stored with SSCs had the highest success rate (96 percent)
compared with amalgam or composite (50 percent) when fol-
lowed for six to 27 months. The authors concluded that SSCs
were likely to last longer than multisurface amalgam or com-
posite restorations in children treated under GA.
Sheller et al.14 evaluated reasons for repeat dental treatment
under GA, using records of 23 children who had treatment
under GA twice, and compared these data with records of 23
children requiring only a single treatment session (controls).
The mean age at first GA treatment was 2.6 years old for
study subjects and 2.7 years old for controls; the mean age at
the second GA treatment was 4.7 years old, with a mean
interval between treatments of 2.1 years. SSCs showed
generally satisfactory clinical performance in both the subject
and control groups, whereas success among other kinds of
restorations was lower.
Case reports on SSCs. One report 15 described aspira-
tion of an SSC by a child patient during conscious sedation.
While removing the SSC being fitted to a primary maxillary
first molar, the crown became dislodged behind the throat
 PEDIATRIC DENTISTRY V 37 / NO 2 MAR / APR 15

pack in the patients airway. Despite placing the patient in a 57 fulfilled the criterion of a longitudinal clinical study of at
prone position with slaps to the back and performing the least two years. The results showed considerable variability in
Heimlich maneuver, the crown could not be retrieved. The success rates, and the authors concluded that an SSC was still
patient was admitted to the hospital, and a diagnostic laryngo- the restorative procedure of choice for severely caries-affected
scopy with rigid bronchoscopy was performed under GA to primary molar teeth. For smaller cavities, however, an adhesive
retrieve the crown. Surgery was uneventful, and the patient restorative technique with a compomer or composite could be
was discharged from the hospital the same day. used in a cooperative child.
A recent case study16 discussed a four-year-old child with a
history of severe pain and inability to eat or carry out oral hy- New techniques or materials since the last review
giene. The child had recently suffered a fall, with a direct There have been three new developments impacting use of pos-
blow sustained to the lower cheek area. Subsequent evaluation terior SSC restorations since the last report in 2002. They
showed a vertical and oblique fracture in both the primary include the Hall technique for SSC placement, the recognition
maxillary and mandibular second molars. The treatment plan of molar-incisor-hypomineralization (MIH) in permanent
included endodontic therapy for these teeth followed by SSCs. teeth, and the availability of esthetic posterior crowns for pri-
At 15 months follow-up, the treated teeth were in normal mary molars.
clinical function, with no pain or discomfort. The authors com- Hall technique. One remarkable change over the past 10
mented that crown root fractures in primary molar teeth are years in the use of SSCs has been the introduction of the Hall
rare. In this case, both teeth had appeared sound and the injury technique (HT). The HT was predominately reported in the
was not recognized for a few weeks, as there were no obvious international literature and identified during an audit of child
symptoms. dental care in general practice in Scotland. A general practi-
Systematic and other literature reviews. Eight literature tioner had been placing SSCs since 1988 using a novel technique
reviews on SSCs were retrieved, four of these being systematic where she cemented a crown over a caries-affected primary
reviews and the remainder more simple literature reviews; how- molar without local anesthetic (LA), caries removal, or tooth
ever, all reported a scarcity of well-controlled clinical studies. preparation. 25,26 The technique involved selection of an ap-
A Cochrane review17 was conducted that compared clinical propriately sized SSC (Figure 1), which was then filled with
outcomes for primary molars restored with SSCs or filling ma-
terials, but no studies fulfilling the inclusion criteria were
found. The authors concluded from the available evidence that
SSCs may last longer than fillings for primary molar teeth. The
same research group published a systematic literature review18
of RCTs but found no reports available in the literature for
appraisal. Another Cochrane review19 of studies through 2009
comparing outcomes for restorative materials used to treat
caries in primary teeth found only one RCT investigating SSCs,
which was published prior to the present study literature search
start date.
A systematic review of the literature from 1996 to 200520
concluded that SSCs were indicated for restoring badly broken
down primary molars and had a success rate superior to other
restorative materials; however, there was a lack of well-controlled
clinical studies. One review21 evaluated the literature on SSCs
versus amalgam in primary teeth and concluded that SSCs were
1
underused, undervalued, and a cost-effective restoration with
greater longevity and reduced maintenance needs versus amal-
gam. A review of restorative materials indicated for the primary
dentition22 discussed difficulties in using some of these materials
in the child patient; it recommended SSCs after endodontic
therapy and in severely decayed teeth as an appropriate alterna-
tive to a direct restoration.
In another review of SSCs in pediatric dentistry,23 it was
considered that placement of SSCs can reduce overall chair
time for the patient. The authors advised avoidance of SSCs in
patients undergoing magnetic resonance imaging of the head
and neck, as the metal could create artifacts in the scan; addi-
tionally, patients with nickel allergy should first be seen by a
dermatologist or allergy specialist before placing SSCs. The 2
esthetics of SSCs were not popular with parents, but the
authors concluded that these crowns remained a vital compo-
nent of pediatric dentistry with good longevity and reliability
in clinical service. Figure 1. Appropriate size SSC is chosen.*
A review of the literature24 from 1971 to 2003 evaluated Figure 2. SSC is filled with glass ionomer cement.*
outcomes for occlusally stressed restorations in primary molars *By permission of Hall Technique Guide, A Users
over time. One hundred forty-nine papers were retrieved, and Manual, Version 3, University of Dundee, Scotland.

USE OF STAINLESS STEEL CROWNS 149

PEDIATRIC DENTISTRY V 37 / NO 2 MAR / APR 15

GIC (Figure 2) and seated over the caries-affected primary
molar initially using finger pressure (Figure 3) and then the
childs own occlusal force (Figure 4). Excess cement was re-
moved, and the occlusion was allowed to adjust to the increased
occluso-vertical dimension over time. Orthodontic spacers were
occasionally needed in the interproximal areas of the tooth to
be crowned to create the spacing necessary to allow easy place-
ment of the crown; the spacers were left in place for several
days prior to the crown appointment. No preparation of the
tooth was performed, and no caries was removed.25
Clinical studies on the HT. The first outcome reporting
for the HT was a retrospective investigation of Halls practice
records between March 1988 and January 2001. 26 There were
978 SSCs placed in 259 children (mean age equals five years,
nine months) over this 13-year period. Using the HT, crowns
were fitted over teeth with marginal ridge breakdown due to
caries, and radiographs were not routinely taken. A survival
analysis for all tooth types indicated a 73 percent probability
of the SSCs surviving for three years (tooth not extracted or
crown de-cemented) and 68 percent probability of survival for
five years. The probability of a tooth surviving without being
extracted (e.g., excluding crowns becoming de-cemented or
lost) was 86 percent at three years and 81 percent at five years.
Since that first retrospective study, there has been one
RCT and two retrospective evaluations published assessing the
HT,27-30 with the RCT results being reported at two different
follow-up times and with slightly different outcomes empha-
sized. The first of these27 reported 23-month outcome data for
clinical effectiveness of the technique and satisfaction levels of
the dentist, child, and caretaker. Child patients with caries in
paired primary molars were randomly allocated to the HT or
a conventional restoration of the clinicians choice. Seventeen
general dentists (GDP) recruited 132 patients. The control re-
storations included glass ionomer, amalgam, compomer, and
composite. Mean follow-up time was 28 months for 124 sub-
jects (94 percent). Failures were categorized as major or minor;
major failures included irreversible pulpitis, dental abscess
needing extraction, restoration loss with tooth unrestorable, or
internal resorption on radiograph. Minor failures were filling
lost and tooth restorable, recurrent caries or new caries, restora-
tion wear, SSCs lost, or caries progress visible on radiograph.
At the 23-month recall, there were 19 major failures among
the controls versus three for the HT and 57 minor failures for
the controls compared with six for the HT (Table 2). The HT
was preferred over a conventional restoration by the majority of
children and GDPs. At two years, the HT showed more favor-
able outcomes for pulp health and restoration longevity than
conventional restorations, and the conclusion was that the HT
appeared to offer a treatment option for caries-affected primary
molar teeth.
The second paper by Innes et al.28 was a continuation of
the original study with a minimum of 48- and up to 60-months
follow-up. It focused more on pulpal outcomes of the tech-
nique. For the 91 patients (69 percent) with a 48-month min-
imum follow-up, 18 teeth experienced at least one major
failure, 15 (17 percent) in the control teeth and three (three
percent) in the HT teeth. Among the controls, 12 teeth were
abscessed, two had irreversible pulpitis, and one restoration
was broken with the tooth unrestorable; in the HT group,
two teeth were abscessed and one had irreversible pulpitis. For
minor failures, 38 (42 percent) control teeth and four (five
percent) HT teeth were involved (Table 3). Success rates were

Table 2. MAJOR AND MINOR FAILURES AT 23 MONTHS

Category Controls Hall Statistically
n (%) technique significant
3 n (%) difference
(P-value)

Major failures 19 (15) 3 (2) <.00

Minor failures 57 (46) 6 (5) <.00
Pain 13 (11) 2 (2) .003

Table 3. MINOR FAILURES AT 48 MONTHS

Failure mode Controls Hall

(n) technique (n)
4
Restoration lost 21 1
Caries 13 1
Figure 3. SSC is seated over the caries affected tooth using finger
pressure.* Fracture or wear 3 1
Figure 4. The SSC is seated using the childs own biting force.* Impacting on permanent crown 1
*By permission of Hall Technique Guide, A Users Manual, Total 38 4
Version 3, University of Dundee, Scotland.

150 USE OF STAINLESS STEEL CROWNS


92 percent in the HT group and 52 percent for the controls.
Results showed that there was a statistically significant greater
risk of major failure in the control group compared with the
HT (P<.001) and similarly for minor failures (P<.001). The
authors concluded that the HT was a predictable restorative
option with low re-treatment rates.
Santamaria et al. 29 retrospectively assessed childrens be-
havior and pain perception when proximal dentinal caries was
managed using three treatment strategies: (1) conventional
restorations (CRs; n equals 65, compomer was placed under
LA with conventional cavity preparation); (2) the HT (n equals
52); and (3) non-restorative caries treatment (n equals 52, the
approximal caries lesion opened, overhanging enamel removed
to enable effective oral hygiene measures in the area, fluoride
varnish applied, and the patient given oral hygiene instructions).
Twelve dentists took part in the study, and 169 three- to eight-
year-olds were randomized to one of the three treatment arms
aforementioned. The childrens, parents, and dentists percep-
tions and opinions of treatment were assessed immediately fol-
lowing treatment. More negative behavior was reported by
dentists for the CR group. Childrens pain perceptions and
dentists/parents acceptability were similar for all techniques.
No data were provided for success of the treatments over time.
Ludwig et al. 30 retrospectively assessed the clinical and
radiographic success of SSCs placed to restore caries-affected
primary molars using both the traditional placement tech-
nique for SSC (n equals 117) and Hall crowns (n equals 67).
The crowns were placed by a single operator or by his expanded-
function dental auxiliary. Restoration failure was defined as
crown lost (i.e., SSCs became uncemented) or further treat-
ment required (i.e., further treatment apart from recementation
and based on radiographic evidence of pulpal pathology or
clinical evidence of recurrent caries). Mean follow-up time was
15 months for the Hall crowns versus 52 months for tradi-
tional SSCs. Bitewing radiographs obtained every 12 to 24
months were available for two thirds of the HT group children.
Results showed that success rates for the HT (97 percent) and
traditional SSCs (94 percent) were not significantly different.
No information was reported about occlusal status or perio-
dontal health.
An open bite is a feature of the HT secondary to no tooth
reduction to accommodate the SSC. Van der Zee et al.31 eval-
uated the effect of the HT on occlusal vertical dimension in
the primary dentition in vivo. The vertical distance was mea-
sured between the most prominent mesio-incisal points of the
opposing canine teeth on the same side of the mouth as an
indicator of overbite. Forty-eight children with 114 SSCs were
evaluated with measurements taken at pre-treatment, baseline,
15, and 30 days. The authors concluded that HT-placed crowns
opened the occlusion, and the occlusion returned to pre-
treatment levels after 15 to 30 days. It appeared that the crown
length of both the treated molar and its opponent were re-
duced. The authors commented that it was known anecdotally
that premature contacting SSC restored teeth will equilibrate
over time; however, this was the first known paper to provide
evidence of this effect.
Review papers on the Hall technique. A review32 of the
Innes et al. five-year study28 called for more randomized studies
on this topic with standardized control restorations. The
authors considered that the evidence from the study was level
2, according to SORT criteria, 33 with no major failures re-
ported in the HT group. A recent review paper by Innes et al.34
PEDIATRIC DENTISTRY V 37 / NO 2 MAR / APR 15
evaluated the clinical literature on the minimal interventionist
approach for removal of caries in primary teeth using stepwise,
partial, or no caries removal methods compared with conven-
tional caries management. A literature search produced seven
papers that fulfilled the inclusion criteria. Despite the inevi-
table variations in study design and methodology, the results
from the various caries removal methods were consistently
equivalent with the proviso that the restoration could provide
adequate sealing. The authors commented that evidence from
studies on HT aligns with the positive outcomes from less
invasive, biological caries removal procedures; in addition, they
considered that the HT offers another method of managing
early to moderately advanced caries in primary molars.
Although it is not a reviewed paper, a short communica-
tion by Nainar35 on concerns about the clinical study on the
HT questioned its success and made the point that the con-
trols27,28 had been restorative materials routinely used by the
study clinicians, two thirds of which were Class II cavities
restored with glass ionomer. It was argued that this was not a
(gold) standard control, as GIC had a high failure rate. In addi-
tion, the restorations had been scored by the clinicians who
placed them rather than by an independent examiner, and few
or no radiographs had been taken to assess the Hall crowns.
The author commented that routine radiographs were needed
to be able to rule out pathology. He considered that these
points reduced the power of the five-year study and made the
evidence inconclusive.
Use of SSCs in the United Kingdom. The HT has gained
popularity in the United Kingdom since it was first discovered
in Halls practice. There are a number of papers that provide
insight into how it has been received by the U.K. practicing
community and why it has become popular there. The use of
SSCs was not frequent in the U.K. prior to the advent of the
HT. A 2003 repeat questionnaire survey36 used 10 years earlier
was sent to 1,290 general practitioners in the U.K., producing
a 53 percent response rate. Results showed that use of amal-
gam had declined from 80 percent to 35 percent, with an
increase in the use of GIC, and that SSC placement had in-
creased from two percent to over eight percent. U.K. GDPs
were surveyed in 2005 37 on the use of SSCs for restoring
caries-affected molars. Of the 93 dentists who responded, three
routinely used SSCs, 14 used them infrequently, and 76 never
used them. Reasons given for non-use of SSCs included the
cost, impracticality of the technique in a busy dental practice,
and their opinion that they were not esthetically pleasing.
Placement of GIC restorations or observation without treat-
ment was the treatment approach of choice, and use of LA to
provide dental care to children was also infrequent. Another
U.K. survey in 200838 compared clinical outcomes for SSCs in
primary molars with alternative filling materials or leaving the
tooth untreated. The authors concluded that SSCs should
continue to be used to restore primary teeth. They commented
that, although most of the evidence for their conclusion came
from retrospective clinical data, and may not meet modern
expectations, the literature lent support to the longevity and cost
effectiveness of SSCs.
The first report on the HT26 was followed by further papers,
including: a review of the HT placement procedure39; a discus-
sion40 on the HT as a novel treatment option that added to
the information base on trends in sealing caries in teeth; and
further comment describing the HT as a hybrid method for
treatment of primary molar caries.41
USE OF STAINLESS STEEL CROWNS 151
PEDIATRIC DENTISTRY V 37 / NO 2 MAR / APR 15
Introduction of the HT triggered a change in attitude to-
ward use of SSCs in the U.K. A survey42 of 14 of the 17 GDPs
who had been involved in the RCT study on the HT28 reported
their views on the technique. They perceived the HT to be
easy to use, have high patient acceptance, and be clinically
effective; 13 of the 14 said they would continue to use the HT
routinely. A 2011 questionnaire survey 43 of Scottish dentists
on their opinion of the HT resulted in a 54 percent response
rate, with 86 percent of respondents aware of the HT and 48
percent using it. Of the practitioners who had never used the
technique, 46 percent were interested in including it in their
practice. Dental schools began to incorporate teaching the HT
in the pediatric dentistry curriculum.
Gilchrist et al.44 retrospectively evaluated the number of
SSCs placed by undergraduates in a U.K. dental school. The
HT had been introduced to the curriculum in 2009, and the
study evaluated students attitudes toward SSCs before and
after introduction to the new technique and their subjective
experiences of it. Data were extracted from student logbooks
for 2005, 2009, and 2010. In 2005, a total of 241 restorations
were placed, of which one was SSC (0.4 percent). In 2009,
students placed 361 restorations in the dental hospital and
1,799 restorations in an outreach clinic; respectively, 65 (18
percent) and 12 (0.7 percent) were SSCs. In 2010, 453 and
2,350 restorations were placed in hospital and outreach clinics,
which included 167 (37 percent) SSCs in the hospital setting
and 27 (one percent) in the outreach clinic. Only one student
in the 2005 group placed an SSC compared with 56 percent in
2010. Students liked the HT, as it was less traumatic for the
child and easier to place the crown with no preparation or
LA being needed. However, some students expressed concern
about remaining caries and the need to place a separator in
some cases.
A 2010 online questionnaire45 sent to 59 post-graduate den-
tists in pediatric dentistry in the U.K. resulted in a 64 percent
response rate. Respondents were asked for their treatment
preferences in four cases of varying caries severity and levels
of patient anxiety. Results suggested that, for a non-anxious
child, either a traditional restoration or SSC would be selected;
an anxious child, on the other hand, would receive a Hall
crown. The author commented that there was little consistency
in responses, with wide variation observed among post-graduates
regarding management of caries in primary molars. The HT
seemed to be a preferred option for symptomatic caries in a
primary molar in an anxious child in approximately half the
students, and there was a trend for extraction of pulpally in-
volved teeth.
One U.K. review paper by Rodd46 commented that SSCs
were not popular among dental practitioners, but there was
growing interest in the HT for restoring primary molars in
general practice. The technique was being taught in dental
schools, but the author felt it remained to be seen whether it
would be widely adopted in practice. A 2010 U.K. question-
naire 47 on parent and child acceptance of SSCs found that
84 percent of parent respondents had no concerns about the
appearance of SSCs, and 56 percent of children liked the silver
tooth color. Some parents, however, expressed concern that
SSCs were a reminder that their child had decayed teeth, and
it would be better if the crowns were white.
152 USE OF STAINLESS STEEL CROWNS
Molar incisor hypomineralization and SSCs for hypoplastic
posterior teeth
The second development since the last review paper has been
increasing reporting on molar incisor hypomineralization
(MIH), which is a developmentally derived dental defect in-
volving hypomineralization of one to four permanent first
molars that also often involves incisors.48
Review papers. Hypomineralization can be caused by dis-
orders in calcification or maturation of the affected tooth; in
severely affected teeth, breakdown of enamel results in atypical
cavitation or complete loss of areas of enamel, exposing dentin
and requiring extensive restoration.49 A light microscopy and
X-ray microcomputed tomography evaluation50 of 13 MIH-
affected teeth showed hypomineralized areas to be mostly in
the mesio-buccal cusps, with the most severely affected enamel
found in the mesial part of the crown. The hypomineralized
area started at the amelodentinal junction and continued to the
enamel surface and had a high degree of radiolucency. These
results suggested that affected ameloblasts produced enamel of
normal thickness but with reduced ability for enamel maturation.
Some recent studies have reported on the prevalence of
MIH as being approximately nine percent51 to 16 percent.52 A
study in Brazil53 considered that the environment may be an
important factor in MIH. A retrospective analysis54 found that
79 percent of subjects with MIH had decayed or restored teeth
compared with 34 percent of non-MIH dentitions (P<.001),
with 62 percent of MIH-affected molars being in need of treat-
ment versus 24 percent of non-MIH teeth. The authors con-
sidered that hypomineralized molar teeth required more than
twice the amount of restorative care than unaffected molars.
A literature review55 on MIH in permanent first molars listed
SSCs as a restorative option for these patients but considered
there was no best method of restoring these teeth.
Clinical studies. Zagdwon et al. 56 compared SSCs and
nickel-chrome (NiCr) alloy cast crowns for restoration of per-
manent first molars with amelogenesis imperfecta or severe
hypomineralized enamel defects (MIH). Seventeen six- to 13-
year-olds were recruited, and 42 restorations were placed: 19
SSCs and 23 NiCr crowns. Restorations were evaluated over 12
to 24 months, with a mean of 17 months. Three crowns failed
and needed replacement: one SSC and two NiCr crowns. The
failed SSC was likely the wrong size, and among the two NiCr
cases, one study tooth was extracted by an orthodontist and
one patient failed to attend for follow-up; these crowns were
not included in the analysis (Table 4).
Table 4. COST EFFECTIVENESS ANALYSIS AT TIME
OF STUDY (2003)
Factor Stainless steel Nickel-chrome
crown
Time taken (mins) 30 90
Clinical fee $75 $225
Materials Crown: $3.50 Impression: $6
cost Cement: $1 Adhesive cement: $15
Lab fee Coping: $65
Total cost $79.50 $311

The authors considered that it was possible to do a minimal
preparation design for the NiCr crowns with margins that
could be kept supragingival; however, it was a more technique-
sensitive procedure than SSCs and required more than one
visit. SSCs required subgingival extension, especially in teeth
with short crowns, and were more cost effective.
Esthetic posterior SSCs
The third new development since the 2002 report is the wide
availability of esthetic alternatives to the traditional silver pos-
terior SSC. They have taken the form of preveneered SSCs and
zirconia crowns; however, there is little in the way of long-term
outcome studies for these new crowns.
Clinical studies on esthetic SSCs and zirconia crowns
for primary molar teeth. Ram et al.57 reported long-term re-
sults on a clinical study comparing pre-veneered NuSmile
crowns, which are currently branded as NuSmile Signature
crowns (NuSmile Ltd., Houston, Texas, U.S.A.) with SSCs.
Twenty crowns were available for recall at four years, and the
teeth were evaluated clinically and radiographically. In gen-
eral, all the study crowns were satisfactory for gingival health,
margin extension, and occlusion; all 10 NuSmile Signature
crowns, however, showed some degree of chipping, which re-
sulted in a poor esthetic appearance. There were no differences
between the two types of crown for any other parameter
evaluated.
OConnell et al.58 recently reported on three-year outcomes
for preveneered posterior SSCs NuSmile Signature and
Kinder Krown (Mayclin, Minneapolis, Minn., U.S.A.)as
a follow up to an RCT published in 2011.59 Twenty patients
with a mean age of 5.4 years old had 27 pairs of crowns placed
at the start of the study, and 17 sets of paired crowns in 14
patients were available for review at three years. There was no
difference in plaque retention or gingival health between the
two groups, and no radiographic changes were seen over the
study duration. Bite-wing radiographs taken at the one-year
recall showed margin overhangs in eight crowns; no relationship
was seen, however, between the presence of margin overhang
and gingival index score for either type of crown. At three years,
eight Kinder Krowns were intact, seven had less than 50 per-
cent facing loss, and two had complete facing loss. For NuSmile,
10 crowns were intact, five had less than 50 percent facing loss,
one had lost more than 50 percent of the facing, and one had
complete loss. The incidence of fractured facings increased
from approximately 22 percent at one year to 47 percent at three
years. Kinder Krowns tended to fracture more often and more
extensively than NuSmile crowns, but the difference was not
statistically significant. The authors concluded that SSCs pre-
veneered with composite resin provided an esthetic alternative
to traditional SSCs.
Publications on clinical application of zirconia crowns was
limited to one case report60 involving two young children with
severe caries in the primary dentition. After pulp therapy, the
teeth were restored with zirconia crowns luted with GIC. The
authors described the placement technique they used and
stressed the need for the mesial and distal crown walls to be
parallel and extend one mm to two mm subgingivally. The
crown should fit passively over the preparation and have its
margins subgingival without distorting the gingival tissue. The
crowns were evaluated at regular intervals up to exfoliation,
and clinical performance and esthetics were considered to be
satisfactory.
PEDIATRIC DENTISTRY V 37 / NO 2 MAR / APR 15
Revisiting gingival health, pulp therapy, and luting cements
in light of new literature on SSCs in relation to techniques/
materials
Clinical studies on SSCs and gingival health. Two studies,
one an RCT and one retrospective, were found that assessed
gingival health following placement of SSCs. Sharaf et al. 61
studied the effects of primary molar SSCs on the health of
gingiva and bone in the vicinity of the crown. Two hundred
fifty-four SSCs in 177 three- to 12-year-olds were evaluated.
The study crowns were placed by dental students and had
been in function for an average of 17 months. Clinical evalu-
ation criteria and standardized bite-wing radiographs were
used to assess the crowns. Results indicated that crowns with
poorly adapted margins were associated with signs of gingivitis;
however, variations in crown margin extension and adequacy of
the crown as judged radiographically had no effect on gingival
health. The authors considered that, as long as the morphologic
form of the crown was maintained, gingival health remained
satisfactory. The condition of the proximal contact area, whether
open or closed, had no effect on gingival health; children with
poor oral hygiene generally had a higher incidence of gingivitis.
The quality of SSC placement, based on unsatisfactory radio-
graphic scores, showed the number of inadequate SSCs to be
low at 10 percent. The authors concluded that oral hygiene
levels should be monitored and controlled as needed, as this
poses the greatest risk factor to the health of gingiva sur-
rounding the SSC.
The gingival health of patients with primary molar teeth
restored with various types of crowns was monitored over 18
months.62 Seventy-six five- to eight-year-olds needing a crown
in at least two primary molars were recruited. Teeth were ran-
domly assigned to be restored with either an SSC, open-faced
SSC, NuSmile Signature, or Pedo Pearl (Cooley and Cooley,
Houston, Texas, U.S.A.) crown, with a total of 265 crowns being
placed. In each subject, at least one primary molar was restored
with an SSC, and one was restored with an esthetic crown.
Crowns were evaluated both clinically and radiographically
for periodontal health and oral hygiene at intervals up to 18
months. Two hundred fifteen crowns were available for review
at 18 months. Periodontal health of control teeth was consis-
tently better than the crowned teeth. All crowns in the study
were associated with mild gingivitis, which was independent of
crown type. For SSCs at 18 months, gingival crevicular fluid
(GCF) volumes were higher than at 15 months. Periodontal
probing depth increased in a time-dependent manner for all
study teeth and was greatest around Pedo Pearl crowns. There
was a strong correlation between probing depth and GCF
values; in general, oral hygiene and gingival health around the
primary molar crowns deteriorated over time. Pedo Pearls had
the highest plaque and gingival index scores, the deepest pro-
bing depth, and the largest GCF volume. Teeth restored with
SSCs or NuSmile Signature crowns had the lowest plaque
index scores, and teeth restored with open-faced SSCs had the
lowest gingival index scores, smallest probing depth, and lowest
GCF volume. The authors suggested that SSCs, open-faced
SSCs, or NuSmile Signature crowns were the preferred types
of crown for restoring primary molars.
Clinical studies on SSCs following pulp therapy. Five
studies, four retrospective and one RCT, were retrieved that
dealt with the use of SSCs following pulp therapy. Guelmann
et al.63 carried out a retrospective study on whether immediate
placement of SSCs after emergency pulpotomy gave a better
USE OF STAINLESS STEEL CROWNS 153
PEDIATRIC DENTISTRY V 37 / NO 2 MAR / APR 15
outcome than a temporary restoration. Ninety-eight emergency
pulpotomy procedures were reviewed with a mean interval be-
tween first and second appointments of 256 days (range equals
eight to 866 days). Survival estimates for temporary restoration
of pulpotomy-treated teeth were 168 days and 173 days, re-
spectively, for zinc oxide-eugenol (ZOE) alone and ZOE/glass
ionomer restoration, and 410 days for SSCs, a statistically sig-
nificant difference at P<.001.
Al-Zayer et al.64 published a retrospective analysis of clin-
ical and radiographic outcomes of indirect pulp capping in
132 patients. Of the 187 teeth that received pulp therapy, 109
had a base of either ZOE or RMGI, 54 percent of teeth had
SSCs placed, 36 percent were restored with amalgam, and nine
percent were restored with composite or RMGI. Over the study
time frame (two weeks to 73 months), one SSC and seven
amalgams failed. Amalgam was nearly eight times more likely
to fail than SSCs, and SSCs resulted in a significantly better
outcome than amalgam (P<.03); the data also suggested that
use of a liner base, in addition to SSCs, further increased the
success of indirect pulp capping therapy.
Moskovitz et al.65 reported a retrospective study on the
success of root canal treatment of primary molars restored
with SSCs, amalgam or composite, or a temporary restoration.
Among 139 children, 139 teeth were included in the study; 98
were restored with SSCs, 13 with composite or amalgam, and
28 with temporization. Of the SSC-restored teeth, 96 percent
were clinically successful versus only 29 percent of teeth with
a temporary restoration, a statistically significant difference
at P=.000.
Guelmann et al. 66 retrospectively evaluated the clinical
performance of pulpotomies in primary molars restored with
composite and compared these results with data from previ-
ously published studies on pulpotomy restoration with SSCs or
amalgam. Fifty-two patients with 59 teeth treated via pulpo-
tomy were followed for an average of 21 months. The overall
performance of composite restorations for pulpotomy was
inferior to the reported success rates for SSCs. More recently a
group of authors67 reviewed the literature on esthetic restora-
tion of primary molars after pulpotomy and concluded that
contemporary bonded tooth-colored restorations held promise
as alternative materials to SSCs; however, additional long-term
studies were needed.
Hutcheson et al. 68 evaluated the success rate of white
mineral trioxide in 80 pulpotomy-treated primary molars in 40
subjects. Paired study teeth were restored with SSCs or multi-
surface composite; the composite restoration and margins were
sealed with unfilled resin. Thirty patients with 60 teeth were
available for review at one year. All study teeth had acceptable
clinical performance, and all the pulpotomies were radiographic-
ally and clinically satisfactory at six months and one year. There
were margin changes in the composite group at both six months
and one year (P<.001) compared with SSCs, but this was the
only significant difference between the groups. The authors com-
mented that the composite-restored teeth needed more mainte-
nance than SSCs, and over half these restorations had margin
staining at 12 months. The SSC-restored teeth were all retained
and intact at one year but had slightly more gingival inflam-
mation than the composite group, which was considered sec-
ondary to poor oral hygiene. The authors commented that, for
high caries-risk children, SSCs may be a preferable restorative
choice after pulpotomy.
154 USE OF STAINLESS STEEL CROWNS
Clinical studies on SSCs and luting cements. One clinical
study was available on evaluation of luting agents for SSCs.
Yilmaz et al.69 compared two luting cements used with SSCs;
152 crowns were cemented in primary molar teeth in 86 chil-
dren, 69 crowns were cemented with conventional GIC, and
83 with RMGI cement. Evaluations were carried out up to 24
to 30 months. SSCs had an average lifespan of 26 and 24
months for the two respective cements. Two crowns had occlu-
sal perforation (RMGI group), and one was lost at 18 to 24
months (conventional GIC group). There was no significant
difference between the two cements, and the success rate for
SSCs was over 99 percent.
Laboratory testing reports on SSCs and luting cements.
Six laboratory studies assessed luting cements for SSCs and
one also included a clinical component, which was reported
previously. A microleakage study70 compared adhesive and non-
adhesive cements for SSCs, including GIC, RMGI, and RMGI
with a bonding agent in the adhesive cement group and poly-
carboxylate and zinc phosphate cements in the non-adhesive
group. The cemented crowns were thermocycled and stained
with methylene blue. Mean microleakage scores were most
favorable for the RMGI cement with a bonding agent and
the bonded resin cement group; polycarboxylate cement had
the most microleakage. No cement was able to completely seal
the teeth.
One study71 reported on retention, microleakage, and ten-
sile strength of SSCs cemented with three different luting ma-
terials. Sixty-three extracted primary first molars were prepared
and fitted with SSCs. Twenty crowns each were cemented with
conventional GIC, RMGI, or bonded resin cement. Specimens
were subjected to pull-out tensile testing, and the microleak-
age specimens were stained in basic fuchsin dye and sectioned
mesiodistally for microleakage measurement. Representative
samples were evaluated under a scanning electron microscope
(SEM). The resin cement had the highest tensile strength and
the lowest microleakage score but was not statistically differ-
ent from the conventional GIC. Some gaps at the material
interfaces were seen on SEM for the glass ionomers tested but
were not apparent in resin-cemented crowns. It was considered
that the presence of voids may result in microfracture within
the cement due to chewing forces, leading to cementation fail-
ure over time. The authors concluded that the higher the
crown retentive force, the lower the possibility of microleakage.
A similar paper by Subramaniam et al.72 compared retentive
strength of luting cements used with SSCs. Forty-five prepared
primary molars received one of three cementsconventional
GIC, RMGI cement, or adhesive resin cementand were stored
in artificial saliva for 24 hours. Crown retentive strength values
for the adhesive resin and RMGI cements were statistically sig-
nificantly higher than the conventional GIC (P<.001).
Erdemci et al. 73 compared microleakage in conventional
SSCs and HT SSCs using three different cements: conventional
GIC, a self-adhesive resin cement, and a polycarboxylate ce-
ment. Crowns were luted to extracted prepared primary molar
teeth, thermocycled, and measured for microleakage. The HT
crowns had statistically significantly greater microleakage than
the conventional SSCs for all tested cements (P<.05). The
lowest microleakage scores were seen with the self-adhesive
resin cement. SEM evaluation of the margins of representative
crowns showed the presence of a marginal gap in all the crowns,
regardless of placement technique.

Yilmaz et al.69 evaluated SSCs both in vitro and in vivo
(the in vivo portion of the study was reviewed previously in this
paper). For the in vitro part, 34 SSCs were cemented in pre-
pared primary molars, using either conventional GIC or RMGI
cement, and subjected to tensile testing. There was no statis-
tically significant difference between the two cements for tensile
strength (P>.05). A number of samples were evaluated under
SEM for quality of the interface between cement and tooth
tissue and between cement and stainless steel. The SEM showed
intimate contact between the cements and tooth tissue, with
some gaps between the cements and the inner metal surface of
the crown.
Reddy et al.74 described test results for the bond strength
of SSCs cemented with zinc phosphate, polycarboxylate, or
conventional GIC. Thirty primary molars had standardized
preparations for SSCs; crowns were fitted to each tooth and
luted in place with one of the test cements. Specimens were
subjected to a pull-out test showing that the retentive strengths
of zinc phosphate and GICs were statistically significantly
better (P<.05) than polycarboxylate cement.
General laboratory study results for SSCs
Seven papers were found that involved laboratory testing of
different aspects associated with clinical use of crowns. These
included morphological and elemental changes, wear and repair,
leakage, sterilization and disinfection, and fracture strength.
Zinelis et al.75 studied morphological and elemental changes
in retrieved SSCs after clinical service. Seventeen SSCs were
available after in vivo function of three to 101 months duration
and were compared with eight unused crowns as controls. An
SEM observation of the in vivo crowns showed substantial
surface alterations compared to the controls. Eight crowns had
biting imprint marks, and two had extensive wear tracks with
occlusal perforation. No statistically significant change in ele-
mental analysis was seen between the aged in vivo crowns and
controls (P>.05). The authors concluded that morphological
changes seen in the study were mainly due to plastic deforma-
tion without changes in elemental composition.
Keinan et al.76 reported on the potential for metal ions to
leach from SSCs into the surrounding root surface. Seventeen
extracted or exfoliated primary molars restored with SSCs,
which had been in place for a minimum of two years, were
compared with 17 intact exfoliated primary molars. A chemical
analysis of the outer aspect of the mesial or distal root, one mm
below the crown margin or one mm below the cementoenamel
junction in control teeth, was carried out using energy disper-
sive X-ray spectrometry. The most prevalent elements found
in all teeth were calcium, phosphate, oxygen, and carbon, with
no statistically significant difference noted between the SSC and
intact tooth groups. For the SSC group, traces of nickel, chro-
mium and iron were found in the cementum of these teeth,
and the concentration of these elements was five to six times
higher in the crowned teeth than the controls (P<.001). The
authors concluded that the influence of these elements on the
systemic health of children should be investigated further.
Yilmaz et al.77 evaluated wear of SSCs in children and de-
termined the extent of microleakage in crowns repaired with
either a glass ionomer cermet or packable composite. The study
consisted of both an ex vivo and in vitro component. For the
ex vivo part of the study, 31 SSCs, which had been in clinical
service for an average of 20 months, were collected on exfolia-
tion. The thickness of the occlusal surfaces of the test crowns
PEDIATRIC DENTISTRY V 37 / NO 2 MAR / APR 15
was measured and compared with the occlusal thickness of
18 unused matched control crowns. The occlusal thickness of
the exfoliated crowns was 5.3 m less than the controls, which
was significantly different statistically at P<.02. The mean
occlusal wear rate of ex vivo crowns was 3.2 m. SEM evalu-
ation showed wear in both the occlusal contact areas and
contact-free areas.
For the in vitro part of the study, 20 extracted primary
molars were prepared for SSCs, and crowns were uniformly
contoured, crimped, and cemented using a conventional GIC
material. After water storage, a standardized hole was cut in
the occlusal surface and repaired with either a cermet or bonded
packable composite. The repaired crowns were thermocycled
and measured for microleakage. Neither of the repair materials
prevented leakage; however, the SSCs repaired with cermet
glass ionomer had significantly less microleakage statistically
than the packable composite (P<.05).
Guelmann et al.78 evaluated microleakage of different re-
storative materials used after pulpotomy treatment of primary
molars. Class II cavities were cut, followed by access to the pulp
chamber. After placement of a pulpotomy dressing, the teeth
were restored with a compomer, reinforced zinc oxide eugenol,
reinforced glass ionomer, amalgam, or SSC cemented with GIC
cement. Teeth were thermocycled and scored for microleakage,
with the compomer group having significantly less leakage than
the other groups followed by the SSC group, which showed
dye penetration at the proximal gingival margins. The remain-
ing groups demonstrated marked microleakage.
Kramer et al.79 reported on margin quality and wear of pri-
mary molar crowns after thermocycling and simulated chewing.
Crowns tested included SSCs, NuSmile, Protemp Crown (3M
ESPE, St. Paul, Minn., U.S.A.), and laboratory fabricated com-
posite crowns. Prepared primary molars had the correctly sized
crown fitted and cemented using different luting cements; after
thermocycling, they were mechanically loaded with a stearite
ball as antagonist for 100,000 cycles at 50 N. Occlusal contact
wear was measured as average vertical height loss. No margin
gaps were seen prior to thermocycling. After wear testing, adhe-
sively bonded crowns had significantly better margin quality
than the GIC luted crowns. SSCs had the lowest rate of wear
compared with resin composite. There was no statistically sig-
nificant difference in wear between SSCs (45.3 m [nine m])
and NuSmile Signature (51.3 m [eight m]). It was concluded
that wear of the crowns studied was at an acceptable level.
Sterilization and disinfection of veneered SSCs80 were evalu-
ated for NuSmile Signature crowns and Kinder Krowns. The
crowns were autoclaved at two different temperature/pressure
regimes and disinfected in an ultrasonic bath, or they had no
treatment. Facial surfaces of the crowns were evaluated for
change by means of SEM. Statistically significant alterations
in crazing were seen for the two crowns (P<.05) both between
individual crowns and groups. The authors commented that the
manufacturers recommendation was chemical disinfection with
gluteraldehyde. All the steam autoclave methods tested caused
surface crazing, as seen under SEM.
Townsend et al.81 reported in vitro testing outcomes for
primary molar zirconia crowns. Fracture strength values and
crown dimensions were measured for three types of zirconia
crownsNuSmile Zr, EZ-Pedo (EZ-Pedo Inc., Loomis, Calif.,
U.S.A.), and Zirconia Kinder Krown (Mayclin)and compared
with a preveneered SSC (NuSmile Zirconia). Fracture strength
was measured using a stainless steel ball, 7.9 mm diameter, at
USE OF STAINLESS STEEL CROWNS 155
PEDIATRIC DENTISTRY V 37 / NO 2 MAR / APR 15

Table 5. WEIGHTING SCORES FOR THE 10 CLINICAL STUDIES REPORTED study aspects did not necessarily mean they were not car-
IN 12 PAPERS EVALUATING STAINLESS STEEL CROWNS AND ried out and could have resulted from space constraints in
ESTHETIC VENEERED POSTERIOR CROWNS AS A PRIMARY END a journal. Three papers10,56,61 did not indicate whether Ins-
POINT (Reference nos. 9, 10, 26, 27, 27, 30, 55, 56, 57, 58, 60, titutional Review Board approval or informed consent had
and 62) been obtained prior to starting the study, with two of these
studies being prospective.10,56 Two papers justified the sam-
Weighting Reference no.
assessment
ple size used9,27; however, in one study,9 only subjects with
criteria 9 10 26 27, 28 30 55 56 57, 58 60 62 good behavior patterns were included, so they were unlikely
to be representative of the population at large, thereby
1 restricting interpretation of the results. 82 The relatively
2 small sample sizes recruited in a number of papers30,57-59 also
3 cannot be considered representative of the population.83
4 Randomization of treatments is important in helping
5 to minimize bias84; four studies9.27,56,57 carried out random-
6 ization to allocate treatments to teeth and described the
7 randomization method used. Sharaf and Farsi61 adopted a
8 method of consecutive assignment of treatments. However,
9 true randomization requires that the treatment assign-
10 ments have no identifiable pattern and cannot be predicted;
11 consequently, sequential treatment allocation cannot be
12 considered true randomization.83
13 Independent examiners were utilized in three
14 studies. 57-59,63 It would not have been possible to blind
15
the examiners to the restorations in two of the studies,57,63
16
but use of independent examiners in these situations will
17
help to reduce bias. The examiners were blinded in an
18
evaluation of esthetic crowns.58,59 These researchers also
19
carried out examiner calibration and testing and reported

the results. Two other studies56,61 performed examiner cali-
Total 9 7 5 12 7 9 9 13 5 5 bration but did not report the results. Four studies26,30,60,62
%* 47 37 26 63 37 47 47 68 26 26 were retrospective. Ludwig et al.30 compared conventional
SSCs and Hall crowns. Results showed similar success
rates for the two placement techniques; however, the dif-
* Percent weighting score. Indicates study met that criteria.
ference in study duration for the HT (mean equals 15
months) and conventional SSCs (mean equals 53 months) may
have been a confounder. To some degree, each of these retro-
a crosshead speed of one mm per minute. There were notable spective studies had the disadvantage of all retrospective studies:
differences in crown dimensions, with EZ-Pedo crowns having the presence of inherent bias due to data having been collected
a significantly greater occlusal thickness of approximately for some other purpose. 85 Retrospective studies look back in
0.7 mm compared to approximately 0.5 mm for the other time and have to rely on the accuracy and completeness of the
two crowns (P<.05). EZ-Pedo crowns also showed statistically available patient data, which often contains missing information,
significantly greater fracture strength than the other two zirconia and can tend to be more inaccurate compared to prospectively
crowns; however, all three crowns had fracture strength values obtained measures.85
less than the preveneered NuSmile Signature SSCs (P<.001). Among the 12 clinical studies where outcomes for SSCs
The authors considered that additional tooth tissue removal was in primary molar teeth were a secondary end point, six papers
needed to accommodate the increased thickness dimension of reported a notable success of SSCs compared with con-
zirconia crowns compared with SSCs, especially for EZ-Pedo, trols,12-14,63-65 and one paper reported a 99 percent success rate
and commented that any clinical significance of a more at two years for SSCs luted with either a conventional GIC
aggressive crown preparation has not been studied. or an RMGI.69 Interestingly, the most recent study68 using a
more modern restorative and bonding system found that
Results multi-surface composites with sealed margins compared well
Weighting criteria. Twelve papers 9,10,26-28,30,56-59,61,62 reported with SSCs at one year in restorations of primary molars after
on 10 clinical studies that had outcomes for SSCs as a primary mineral trioxide aggregate (MTA) pulpotomy.
end point; six studies were prospective evaluations, 9,10,56-59 in-
cluding three reports on the HT27,28,30 The papers were evaluated Discussion
against the weighting criteria (Table 1), and results are given Clinical studies. The earlier literature review7 found only non-
in Table 5. Scores ranged from 26 percent to 68 percent; two randomized or retrospective clinical studies and determined that
studies27,28,58,59 fulfilled the criterion for a good quality study all results were in agreement that SSCs outperformed amal-
(score greater than 60 percent), and three further studies scored gam restorations for multisurface cavities in primary teeth. The
47 percent9,56,57 and were categorized as moderate quality. current review has identified study designs with higher levels
Weighting criteria scores could only be allocated when there of evidence concerning the use of SSCs in the past 12 years.
was appropriate mention of them in the paper. Unmentioned

156 USE OF STAINLESS STEEL CROWNS


The weighting criteria were chosen because of their rele-
vance to study design and importance in minimizing bias. It
was noticeable that criteria dealing with study objectives such
as the study aim/hypothesis, control, and inclusion and exclusion
criteria, tended to score well for most of the reviewed papers,
whereas criteria reflecting conduct of the study, such as stand-
ardized operator and placement procedures, examiner calibra-
tion, or obtaining ethics committee approval, received fewer
scores. Absence of certain design features in a clinical study can
introduce bias, making the results unreliable.85 Furthermore, it
could be considered that some items in the weighting criteria
may be of greater importance than others for study validity;
however, this seems of more relevance when differentiating
among a number of high-scoring studies.
Hall technique. The HT presents potential problems for
the practitioner. The lack of removal of any tooth structure
prior to fitting the SSCs results in two issues: (1) leaving decay
in the tooth; and (2) an increase in occlusal vertical dimension,
as no occlusal reduction is done to accommodate the SSCs.
Leaving any decay in teeth, as advocated for indirect pulp ther-
apy (IPT) and partial excavation forms of pulp therapy, has
been met with resistance from many in the dental community.
Some consider both to be unacceptable, in spite of strong evi-
dence supporting these techniques.27,28 Innes et al.28 reported
five-year data from an RCT on sealing caries in primary molars
using the HT compared with GDPs standard restorations,
used as controls. Their success rate of 98 percent for absence of
pulpal involvement with the HT is impressive.27 So long as the
pulp is not already irreversibly inflamed and the SSC remains in
place with an intact biological seal over the decay,86-88 the tech-
nique is really the ultimate in IPT, and it is not surprising the
success rate was high. There is abundant good evidence that
IPT works so long as the pulpal status is properly diagnosed
prior to treatment.89-94 To that end, high-quality radiographs
showing the furcation and a thorough clinical history for symp-
toms are mandatory in selecting teeth to receive the HT.
The increased vertical dimension caused by the lack of
occlusal tooth reduction is another area of concern. In their
23-month paper,27 Innes et al. reported that, for all 129 cases
where data were available, an even occlusal contact had re-
established at the one-year recall. In addition, no children re-
turned to their dentist, following placement of a Hall crown,
with signs or symptoms of occlusal dysfunction, and no child
or parent reported difficulty with eating or symptoms of tem-
poromandibular joint dysfunction syndrome when questioned
directly by the dentist at the one- or two-year recall. A
retrospective observational study31 reporting on the influence of
Hall crowns on occlusal vertical dimension found that overbite
had equilibrated 30 days after placement of the SSC, which was
likely due to intrusion of the crowned molar and antagonist
teeth. This investigation was not well controlled, and the sample
at 30 days was small. More long-term studies are needed to
determine the effect of this occlusal disharmony for children
being treated with the HT.
Another potentially controversial issue associated with the
HT is the question of who may place these crowns. Since they do
not involve any irreversible procedures and resemble placement
of an orthodontic band, dental assistants in the United States
could place them. State dental boards determine which proce-
dures can be done by dental assistants, and this varies widely
by state. However, the prevailing rule is that dentists may dele-
gate to a dental assistant the authority to perform only acts or
PEDIATRIC DENTISTRY V 37 / NO 2 MAR / APR 15
procedures that are reversible. The HT fits that definition, since
no tooth structure is altered and no caries is removed. One
study 30 reported that an expanded function dental auxiliary
placed some of the HT SSCs. It remains to be seen how the
U.S. dental community will accept this technique. The HT is
not widely known in this country, and dental schools currently
teach traditional SSC placement involving administration of
LA, preparation of the tooth, and removal of caries.
It is noteworthy that use of SSCs in the U.S. by GDPs,
although not as limited as in the U.K., is still much less than
the evidence would support is appropriate. Studies into practice
patterns of GDPs provide interesting data. An investigation into
utilization of SSCs by GDPs and pediatric dental specialists
in Indiana found that SSCs are being significantly underutil-
ized in general dental practices. 95 Another study 96 assessing
practice patterns of general dentists treating children in Ken-
tucky reported that only 37 percent saw children with more
than three caries-affected teeth and only 14 percent saw children
with extensive decay. Only 15 percent of the dentists reported
using SSCs, with most preferring composite followed by amal-
gam as restorative materials.96 Barker et al.s96 findings paralleled
those of an older study in 2003 by Seale and Casamassimo,97
who found in a national survey that only 17 percent of GPDs
placed SSCs often or very often. These SSC usage patterns will
hopefully change as general dentists assume greater responsibility
in caring for children with greater levels of dental disease.
A recent change in practice patterns has occurred as large,
corporately managed dental centers are opening around the
U.S. These clinics treat substantial numbers of children
funded by government programs such as Medicaid. It is a well-
established fact that the greatest levels of dental disease are
found in low-income children.98,99 These clinics tend to hire
newly graduated dentists and may be placing greater demands
on them in terms of caring for children with high levels of dental
disease. These young practitioners may have limited experience
in conventional placement of SSCs and feel more comfortable
with the HT, resulting in Hall crowns becoming more popular.
It will be interesting to see how the HT is implemented in these
circumstances.
All prospective investigations on the effectiveness of Hall
crowns have been in the U.K. by GDPs who provide care for
the majority of young children. Use of traditional SSCs to
restore caries in primary teeth has not been a popular or a fre-
quently used technique, in spite of the existence of guidelines
and policy statements from the British Society of Paediatric
Dentistry that SSCs are the restoration of choice for primary
molars with multisurface lesions and extensive caries and when
pulp treatment has been performed.36,37,100,101 Barriers to the
use of SSCs include cost, time to fit, and patient cooperation.37
Placement of GIC or observation without treatment are the
treatment approaches of choice.37 The use of LA to provide
dental care to children is also infrequent. With the advent of the
HT, newer surveys indicate interest on the part of practitioners
and requests for additional training in the technique.42,43,102
In summary, the HT presents advantages for practitioners
who do not wish to use LA and who desire a simplified approach
to crown placement over traditional tooth reduction and caries
removal. There are no RCTs to date that compare this tech-
nique to a traditionally placed SSC using conventional methods
of radiographic assessment and caries removal. Current studies
indicate that Hall crowns are more effective than GIC restora-
tions in compromised, caries-affected primary molars.
USE OF STAINLESS STEEL CROWNS 157
PEDIATRIC DENTISTRY V 37 / NO 2 MAR / APR 15
Esthetic SSCs. The main disadvantage of SSCs is the ap-
pearance, and many papers have commented on the increas-
ing demand for esthetic restorative solutions for primary
teeth.17,23,37,47,57 New findings since the last conference have been
the development and availability of esthetic preveneered SSCs
and zirconia posterior crowns. Only two investigations, however,
were available to assess the clinical outcomes, over time, of
preveneered posterior SSCs compared with traditional SSCs.57,58
In both studies, all the crowns were generally satisfactory for
gingival health and occlusion. However, both studies reported
some degree of chipping, which resulted in a poor esthetic
appearance; also, the incidence of fractured facings rose with
increasing years of service. Kinder Krowns tended to fracture
more often and more extensively than NuSmile crowns, but
the difference was not statistically significant. These authors
concluded that SSCs preveneered with composite resin provided
an esthetic alternative to traditional SSCs. It was disappointing,
however, that only one case report by Karaca60 on Zirconia
crowns for primary teeth was found. No published clinical
studies are apparently available to date, despite these crowns
having been launched by a number of companies over the last
two years or so.
Luting agents. With the advent of the preveneered and
zirconia esthetic crowns (which cannot be crimped) and the
HT (in which crowns are neither trimmed nor crimped), the
luting agent has assumed more importance in both retention
and sealing properties. Six new studies examined microleakage,
retention, and tensile strength of various luting agents used for
SSCs on primary molars.69-74 The results indicated that resin-
bonded cements had the highest scores for tensile strength and
retention and the least microleakage.71-73 The next best luting
agent was RMGI used in conjunction with a bonding agent69
followed by regular RMGI and conventional GIC.69-71,73 The
least effective cement in all three categories was polycarboxyl-
ate.70,73,74 Application of these results may be problematic for
some children, as the multiple steps involved with using resin-
bonded cements and RMGI in conjunction with a bonding
agent require additional time and excellent control of the oral
environment in which the SSCs are to be cemented. When be-
havior is not an issue and good moisture management is pos-
sible, the best luting agents are bonded resin cements and RMGI
used in conjunction with a bonding agent. When the time
available for cementation is affected by the childs behavior or
attention span and less-than-optimal control of the oral environ-
ment is the reality, RMGI or GIC offer the best retention and
least microleakage.
Restoration following pulp therapy. SSCs are traditional-
ly recommended as the final restoration following pulp therapy
to ensure the biological seal so important to its success. Five
new investigations assessed the effect of restoration with SSCs
on the success of various forms of pulp therapy.63-66,68 Success of
pulpotomies in primary molars restored with SSCs was evalu-
ated in four studies.63-65,68 Three studies determined SSCs to be
superior to other choices, while Hutcheson et al.68 found that
the success rate of MTA pulpotomies in molars restored with
SSCs or multisurface composite was the same at one year.
Clinical and radiographic assessment of outcomes of indirect
pulp capping determined that using SSCs to restore teeth re-
sulted in a significantly better outcome than amalgam.67 With
the exception of the MTA pulpotomy-treated teeth, 68 SSCs
show superior outcomes compared with other restorations fol-
lowing pulp therapy in primary teeth.
158 USE OF STAINLESS STEEL CROWNS
Laboratory studies. A total of 13 papers reporting labora-
tory testing were retrieved. As previously discussed, four studies
that focused on SSC retention and bonding with different types
of cement69,71-73 came to the conclusion that RMGI and resin
cements had better bond strength than conventional GIC.
However, all these materials seem to be suitable for clinical use,
as confirmed by Yilmaz et al.69 where in vitro evidence, backed
up clinically, showed that GIC is suitable for cementation of
SSCs for periods of longer than two years. Guelman et al.,78 re-
porting microleakage after different methods of restoring pulpo-
tomized primary molars, found that SSCs cemented with GIC
could not totally prevent microleakage, whereas the resin-based
restoration seemed to provide the best marginal seal and protec-
tion. A study71 on microleakage postulated that the higher the
retentive force, the lower the microleakage. These researchers
found that the tested adhesive resin and conventional GIC ce-
ments yielded significantly better retention and less microleak-
age than RMGI. This was surprising and discussed by the
authors, who considered that use of an additional bonding step
would have improved the results for RMGI.
Keinan et al.76 described metal ion release from SSCs into
tooth root tissue. As this can potentially result in an allergic
reaction and influence microbial resistance (e.g., with nickel),
the authors recommended reducing the amount of leachable
ions to a minimum. It was stated that the newer stainless steel
3M ESPE crowns had been tested; however, the crowns were
described as 3M Ion crowns in the paper, and it was not clear
whether the tested crowns were the older NiChro type with a
higher content of nickel or the newer stainless steel crowns with
significantly reduced nickel levels. Zinelis75 reported that the
chemical composition of SSCs, after several months to several
years of clinical wear, was more or less unchanged. Townsend et
al.81 evaluated fracture strength for three types of zirconia pri-
mary molar crown by means of a traditional crunch the crown
test. Recent research has suggested that this test method is
not reflective of bulk failure of crowns, as seen clinically, 103,104
and may explain why the zirconia crowns had lower values than
NuSmile Signature crowns.
A substantial body of literature has been reviewed for the
present study. It is possible that some papers were missed due
to limitations of database coverage; however, the authors are
confident that the majority of all relevant published studies in
English language journals were retrieved. In conclusion, it is
clear that SSCs still have an important place in childrens clin-
ical dentistry23 for primary molars in need of a multi-surface
restoration and in high caries-risk patients.
Summary
Ten clinical studies had weighting scores between 68 percent
and 26 percent, of which two were considered to be of good
quality regarding validity and study design and three further
studies were considered to be of moderate quality. Within the
confines of these studies, primary molar esthetic crowns and
stainless steel crowns had acceptable clinical performance as
restoratives for posterior primary teeth, and the Hall technique
was shown to have validity. The Hall technique appears to be
gaining ground in usage among clinicians; however, it remains
controversial. Further well-designed prospective studies on
primary molar esthetic crowns and the Hall technique would
be desirable to enable a meta-analysis. No clinical studies were
available on zirconia crowns, and well designed studies are
urgently needed.

This update of the literature on stainless steel crowns has
shown no evidence to refute the previous findings from the
2002 publications.7,8 The previously identified issues of indi-
vidual caries susceptibility are basically the same, and there has
been an actual increase in caries since the last report.105 Clinical
reports in the 2002 review compared SSCs with amalgam
restorations, and newer resin-based restorative materials are
now more commonly used for proximal occlusal restorations in
primary molars. However they have not shown improved
durability or longevity compared to SSCs for this class of re-
storation, especially in primary first molars. The issues of recur-
rent caries and marginal fracture remain, and more maintenance
is required over time.68 For patients with limited ability to be
routinely compliant with recalls, the need for maintenance is a
problem. SSCs continue to offer the advantages of full coverage
to combat recurrent caries and provide strength as well as long-
term durability with minimal maintenance.
The following statements from the 2002 review paper 8
appear to continue to be supported and favor use of SSCs:
1. SSCs are superior in durability and longevity to Class
II amalgam or resin-based restorations in primary
teeth.
2. There is minimal evidence to support the economic
value of Class II restorations over SSCs for primary
molar teeth.
3. Dental rehabilitation under general anesthesia is ex-
pensive and places the child at increased risk for
morbidity or mortality.
4. A primary tooth with two or more surfaces involved
may receive an SSC if the tooth is anticipated to ex-
foliate in two years or more.
5. SSCs are recommended following pulpotomies in pri-
mary teeth.
6. SSCs are recommended for severely broken down
permanent molars in young patients.
Additional summary statements can be made, based on
the findings of this systematic review: 2002;24:501-5.
1. The Hall technique is supported by good quality evi-
dence and appears to have validity as a technique for
placement of SSCs.
2. Preveneered posterior crowns have limited numbers of
long-term studies, which indicate that chipping of the
veneer facings increases over time with continued use.
3. Zirconia posterior crowns have no prospective clinical
studies; therefore, no evidence-based recommenda-
tions for their use can be made.
4. Luting agent recommendations for posterior crowns
are supported by laboratory studies and limited clini-
cal studies and indicate that bonded resin cements are
best, followed by resin-modified glass ionomer and
traditional glass ionomer.
5. Primary tooth pulp therapy outcomes continue to
be reported as best when teeth are restored with
SSCs. Composite restorations show promise fol-
lowing pulp therapy with agents that provide a
biological seal, such as mineral trioxide aggregate.
6. Permanent tooth SSCs are viable interim restorations
for permanent molars that have extensive breakdown
from caries or developmental defects.
PEDIATRIC DENTISTRY V 37 / NO 2 MAR / APR 15
Recommendations
The findings from this systematic review support the use of
stainless steel crowns (SSCs) in the following situations:
1. Primary molars that have caries lesions, in children at
high risk, may be treated with SSCs.
2. Children with extensive decay, large lesions, or multi-
ple surface lesions in primary molars should be treated
with SSCs.
3. Strong consideration should be given for the use of
SSCs in children who require general anesthesia for
restorative dental care.
4. There is evidence from case reports and randomized
controlled trials supporting the use of SSCs in
permanent teeth as a semi-permanent restoration for
the treatment of severe enamel defects or teeth with
gross caries.
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