PaediatricDentistry

Helen J Rogers

Haris A Batley and Chris Deery

An Overview of Preformed Metal

Crowns Part 1: Conventional
Technique
Abstract: This article details the clinical techniques for conventional preformed metal crown placement. It aims to increase the readers’
awareness of the clinical advantages of preformed metal crowns and the indications for their use. The second part will discuss the Hall
Technique.
CPD/Clinical Relevance: This two-part article aims to guide the reader through the conventional and alternative techniques available for
placement of a preformed metal crown whilst providing an update of the evidence for each.
Dent Update 2015; 42: 933–938

This two-part article will be looking at
preformed metal crowns (PMCs), also
known as stainless steel crowns (SSCs),
which have been in use since the 1950s.
They are prefabricated crown forms that can
be adapted to individual primary molars as
a definitive restoration. In this first part, the
indications, evidence and the conventional
technique will be described. The second
paper will discuss the new and innovative
Helen J Rogers, BDS, MFDS, Academic
Clinical Fellow in Paediatric Dentistry,
Unit of Oral Health and Development,
School of Clinical Dentistry, University of
Sheffield, Haris A Batley, BDS, Specialty
Registrar in Orthodontics, Glasgow
Dental Hospital, Glasgow, G2 3JZ and
Chris Deery, BDS, MSc, FDS(Paeds),
PhD, Professor/Honorary Consultant
in Paediatric Dentistry, Unit of Oral
Health and Development, School of
Clinical Dentistry, University of Sheffield,
Claremont Crescent, Sheffield, S10 2TA,
UK.
December 2015 DentalUpdate 933
technique for placing these crowns known
as the ‘Hall Technique’, together with
aesthetic crowns.
Primary teeth in young children
are vital to their development as they:1
 Are natural space maintainers for
permanent teeth;
 Help with speech and eating;
 Help to provide self-confidence and a
good oral health quality of life.
However, the most important
reason to restore the primary dentition
is the management of caries in children,
which can otherwise progress to pain,
infection/sepsis and hospital admissions.2
PMCs are widely accepted by
paediatric dentists, including the American
Association of Paediatric Dentistry (AAPD)
and the British Society of Paediatric
Dentistry (BSPD) as the restoration of choice
for primary molars.3,4
The indications for PMCs are:4
 (Extensive) caries (or fracture) in more
than two surfaces;
 Following pulpotomy or pulpectomy
procedures;
 Localized or generalized (dental)
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developmental problems;
 Restoration and protection of teeth
exhibiting extensive tooth surface loss;
 In patients with infra-occluded primary
molars to maintain mesio-distal space;
 Space maintainer abutment.
They are contra-indicated in
situations where:5
 The prognosis is poor due to irreversible
pulpal involvement;
 The tooth is close to exfoliation (with
more than half the roots resorbed);
 In a patient with a known nickel allergy
or sensitivity;
 Patient is pre-cooperative;
 Parent or child is unhappy with the
aesthetics.
Although PMC is the preferred
term, these crowns were traditionally called
stainless steel crowns. This is a misnomer,
as they are actually nickel chromium. The
constituents of 3M ESPE (Seefeld, Germany)
preformed metal crowns, the market leader,
are as follows:6,7
 65−74% iron;
 17−19% chromium;
 9−3% nickel.
 PaediatricDentistry
Nickel is one of the constituents
and therefore nickel allergy is one of the
contra-indications to the use of PMCs. It is
suggested that 11% of young female adults
and 2% of young male adults are nickel
sensitive.8 From the orthodontic literature, it
is estimated that only 0.1−0.2% of patients
show a harmful response to nickel. This is
because it is thought that much greater
concentrations of nickel are required intra-
orally than on the skin to elicit a reaction.
Further, it has been shown that only small
amounts of the metal constituents leach
from PMCs.6
Evidence supporting the use of
PMCs
A questionnaire study of
a random sample of general dental
practitioners (GDPs) drawn from the
Midlands of England and Scotland reported
6% potentially using PMCs to restore
primary teeth.9 An interview study the same
year of GDPs in the North West of England
reported again only 6% placing PMCs.10 In
this study, the commonest reasons cited
for the low uptake included cost, time
consuming to fit and patient co-operation
issues. Appearance and parental acceptance
were also cited as a concern.
The longevity of preformed
metal crowns is their key advantage
over multi-surface restorations. One
retrospective study conducted in NHS
general practice found the 5-year survival
rate of conventional technique preformed
metal crowns to be 100%; over twice that
of the multi-surface amalgams, though the
small number of only 18 PMCs sampled is
a valid criticism of this study.11 This issue
was rectified in a five-year retrospective
study, conducted in a private specialist
Figure 1. Show the crown to the patient and
carer.
934 DentalUpdate December 2015
paediatric practice, that found only 2.1%
of preformed metal crowns required
replacement, compared to 14.7% of Black’s
Class II amalgams over a 10-year period. A
second prospective study conducted in the
same specialist practice found very similar
survival rates between PMCs and intra-
coronal restorations, but the mean follow-
up was only just over two years.12
These observational studies have
a number of drawbacks and confounders,
including a lack of standardization on use
of local anaesthetic, variable use of rubber
dam and, most importantly, the PMC
tended to be selected for larger carious
lesions.
This longevity and the
consequent reduction in the need
for replacement can have significant
implications in terms of time- and cost-
effectiveness, along with patient and parent
satisfaction.
None of these studies is a
randomized controlled trial. A Cochrane
review on PMCs found that there were no
studies that met the inclusion criteria and
therefore no relevant data were available
for analysis.13 Therefore, no conclusions
could be made as to whether PMCs were
more successful than alternatives for
Figure 2. A primary tooth with caries prior to
tooth preparation.
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restoring primary molar teeth. However, ‘it
is important that the absence of evidence
for PMCs is not misinterpreted as evidence
for their lack of efficacy’, especially as the
‘evidence[s] that have been produced …
have strength in that the clinical outcomes
are consistently in favour of PMCs’.13
Conventional PMC technique
The conventional crown
technique requires a good degree of
patient co-operation. This is necessary
firstly to allow the administration of local
anaesthetic.
Step 1 Explanation
Show the crown to the child and
his/her carer and describe the procedure
(Figure 1).
Step 2 Anaesthesia
Local anaesthetic is best
provided following application of topical
anaesthetic.
Step 3 Tooth preparation
Figure 2 shows a tooth prior to
preparation. The tooth is reduced occlusally
by 1.5 mm, using a diamond fissure bur.
This reduction should take into account the
extent of tooth surface loss already present,
as further reduction in a tooth already
displaying signs of significant erosion or
attrition could compromise the pulp further.
Approximal reduction is the
most technically-challenging aspect of the
conventional technique. A visible space
should be created with a fine-pointed
diamond bur, ensuring that only the enamel
of the tooth to be crowned is reduced
Figure 3. Approximal reduction of the primary
tooth, taking care to avoid iatrogenic damage of
adjacent teeth.

(Figure 3). The adjacent tooth should not
be contacted by the bur, unless, of course,
it is to be extracted or crowned in the
same treatment session. Even the slightest
iatrogenic damage approximally has been
shown to increase risk of development of a
a Any remaining caries is then
b
b finger and thumb.
Figure 4. (a) Occlusal view following reduction
and caries removal. (b) Buccal view of primary
tooth following preparation, showing reduction
in height.
December 2015 DentalUpdate 935
carious lesion at that site.14 This is clearly
highly likely in an existing cariogenic
environment.
Buccal and lingual reduction
is not normally required. However, it
is frequently necessary to remove the
buccal prominence on first primary
molars, particularly in the lower arch.
removed (Figures 4a and b). The final
preparation should be free of ledges,
steps or shoulders, with smooth and
rounded edges to facilitate placement of
the crown.
Step 4 Crown selection and adaptation
There are two main
techniques employed by dentists to
select the appropriate choice of crown.
The first involves measuring the mesio-
distal space with either dividers or a
periodontal probe. The second utilizes
trial and error, a process which becomes
easier with experience.
The crown which adequately
restores the space with a snug fit to the
tooth should be selected. Occasionally,
adjustment may be required in the form
of crimping or trimming the crown. The
former tends to be required when the
Figure 5. (a) Crimping the crown with size 114
crimping pliers. (b) Crimping the crown with size
112 crimping pliers.
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PaediatricDentistry
tooth requires a crown between two sizes.
Crimping of the larger crown to engage
interproximally and beneath any bulbosities
can often solve the problem (Figures 5a
and b). Alternatively, manual adjustment of
the crown form can be undertaken simply
by squeezing the crown slightly between
finger and thumb (Figure 6). Trimming
followed by polishing with a stone may be
necessary in cases where there is extensive
tooth surface loss occlusally, which has
reduced the crown height. Trimming should
be avoided whenever possible, as this
reduces retention and, even with stoning,
it can be hard to remove rough sharp
edges. Moreover, trimmers should be used
as opposed to scissors, as the latter can
produce distortion.
Step 5 Cementation
The prepared tooth should then
be washed and dried. The crown chosen is
generously filled with the luting material
and fully seated (Figure 7). Whilst resin-
modified glass ionomer cement is reported
to have superior bonding properties as a
luting agent for PMCs, conventional glass
ionomer cements are widely used.7,15 Excess
Figure 6. Manual adjustment of crown form with
Figure 7. PMC filled with luting cement.
 PaediatricDentistry
cement should be removed with damp
gauze and an instrument; knotted floss
passed interproximally may be helpful
(Figure 8a and b).
Consideration must be given to
airway protection during both try-in and
a the Hall Technique in more depth.17 Only
b be repaired by use of glass-ionomer
Figure 8. (a) Buccal view of fully seated PMC −
note the blanching of the gingivae. (b) Occlusal
view of fully seated PMC with excess cement
removed.
936 DentalUpdate December 2015
cementation. This can be done by sitting
the patient upright, using a sheet of gauze
as a physical barrier or using tape to hold
the crown.
Acceptability
Durability, plasticity and
malleability are some of the key properties
of preformed metal crowns that contribute
to their clinical success and ease of use.
These properties hail from the metallic
components that in turn produce the silver-
coloured appearance. Clearly, one would
expect aesthetics to be a potential issue
for parents and children alike. This issue
was noted by Page and colleagues, who
sought opinions from both children and
their parents on the appearance of their
Figure 9. Layer of luting cement protecting the
tooth from iatrogenic damage during removal of
a PMC from a first permanent molar.
Figure 10. When the PMC is split it can be peeled
away from the tooth.
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PMC(s).16 Whilst the children interviewed
gave generally positive or neutral feedback,
a few parents were concerned that their
child’s PMC would be viewed by adult
peers as an indicator of dental neglect.
Bell et al’s questionnaire study looked at
the views of children and their parents, on
conventional PMCs and those placed by
8% of children did not find having the
crown placed ‘okay’, and approximately
16% seemed to have concerns about its
appearance, particularly other people
commenting on it. A small number of
parent’s (5%) reported strong concerns
about the appearance.
For this reason, it is important
that parents and children can view a crown,
or a photo of a crown, in situ prior to
placement and are aware of on which tooth
it is planned to be placed.
PMC removal
Rarely, instances may arise
where PMC removal is indicated. Reasons
for this include:
 Trapping of an erupting first permanent
molar on the distal surface of a PMC;
 Perforation of the PMC occlusal surface
due to wear (which is too extensive to
cement);
 Child or parent unhappy with
appearance despite discussions prior to
placement.
Removal is relatively simple and
does not require anaesthesia because the
luting cement insulates and protects the
tooth.
The technique for crown
removal involves:
 Cutting into the crown in the middle
of the occlusal surface using a fissure
diamond bur. At this point, there is a
large layer of cement present protecting
the tooth from the bur so iatrogenic
damage is extremely unlikely (Figure 9);
 Move the bur two-thirds of the way
towards the lingual surface;
 Next extend the cut buccally along the
occlusal surface and down the buccal
aspect with a pointed diamond bur
until the crown has been split. It is at
the gingival margin where the crown is
closely adapted that iatrogenic damage
is more likely to occur. Fortunately,
 PaediatricDentistry
visibility is usually excellent and this can
be avoided;
 Once the crown is split in this way it can
be unpeeled and removed in one piece
with an excavator (Figure 10);
 The remaining cement is then easily
removed.
Tooth-coloured crowns
As discussed, aesthetics is an
issue with PMCs. In the past it has been
suggested that, following placement, a
window could be cut in the buccal surface
of the crown to improve its aesthetics.
This compromises the PMC integrity and
has a limited improvement on aesthetics.
Therefore, anterior and posterior tooth-
coloured crowns have been developed.
These are usually veneered, although all-
ceramic crowns such as zirconium are also
available. Owing to the thickness of these
aesthetic crowns, a more extensive tooth
preparation is required. In primary teeth this
is significant due to the enamel/dentine/
pulp ratio. There is also an issue with the
loss of the veneer over time, although
these crowns are improving in quality
with advancements in manufacturing
techniques.
Conclusion
The use of PMCs has been
shown to be a successful restorative option,
accepted by patients and their carers. The
technique of conventional PMC placement
is, in the authors’ opinion, relatively simple
and certainly much simpler to carry out
than intra-coronal restorations in primary
teeth.
The second of these papers
will discuss the Hall Technique, which
does not involve tooth preparation. Some
practitioners will have a preference for
either the conventional or Hall technique.
For those who adopt the latter, it is essential
938 DentalUpdate December 2015
to understand the conventional technique
for instances when the Hall Technique is not
possible. These occasions include, amongst
others, the presence of a ledge or significant
space loss, preventing a crown from seating
without preparation.
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