Journal of Dentistry (2004) 32, 27–33

www.elsevier.com/locate/jdent

A clinical and radiographic evaluation

of stainless steel crowns for primary molars
Aly A. Sharaf, Najat M. Farsi*

Faculty of Dentistry, Pediatric Dentistry Department, King AbdulAziz University,

P.O. Box 80209, Jeddah, Saudi Arabia

Received 4 April 2003; revised 24 June 2003; accepted 21 July 2003

KEYWORDS Summary Aim. this study was performed to evaluate clinically and radiographically
Stainless steel crown; the effect of stainless steel crowns placed on primary molars on gingival and bone
Pediatric dentistry; structures.
Primary molars Sample. 254 crowns were evaluated in a sample of 177 children aged 3.5 –12 years
old with a mean age of 7 years.
Method. the clinical parameters that were evaluated were, crown marginal
extension, crown marginal adaptation, intact proximal contact, gingival index and
the duration of presence of the crowns, together with the oral hygiene index of the
child. Bitewing radiographs were viewed for extension and adaptation of crown
margins and for evaluating the interproximal bone level.
Results. the results of the study showed that interproximal bone resorption was not
significantly affected by either crown marginal extension or adaptation, preserving
tight proximal contact between molars, oral hygiene level or duration of presence of
the crown. On the other hand, there was significant bone resorption when the crown
was judged radiographically as non-satisfactory. While oral hygiene level had a
significant effect on the gingival index, presence or absence of proper proximal
contact did not have an effect on the gingival index.
Conclusion. it was concluded from this study that stainless steel crowns are still a
valuable procedure that has no harmful effect on the gingiva and bone provided that
good oral hygiene level was maintained.
q 2003 Elsevier Ltd. All rights reserved.

Introduction durability of stainless steel crowns over multi-

Chrome steel crowns were introduced to pediatric
dentistry by Humphrey in 1950.1 Since that time,
stainless steel crowns have become an invaluable
restorative technique for the treatment of badly
broken down primary teeth. The superiority and
*Corresponding author. Tel.: þ966-2-623-1122.
E-mail address: n_farsi@yahoo.com
surface amalgam and other restorations in the
primary dentition has been documented in the
literature.2 – 9
Despite the widespread use of stainless steel
crowns, there have been a small number of studies
in the literature that evaluated the quality of such
restorations 10 and their effect on gingival
health.11,12 Salama13 reported that almost 42% of
stainless steel crowns placed on primary molars

0300-5712/$ - see front matter q 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S0300-5712(03)00136-2
28
showed open or defective margins. Durr et al.14
reported that the most common errors were in
marginal crimping and length adjustment.
Studies done by Webber,11 Durr et al.14 and
Machen et al.15 have failed to show any increase in
supra-gingival plaque accumulation associated with
stainless steel crowns. However crowns with defec-
tive margins, or crowns where excess cement has
been retained have been shown by Myers16 and Goto
et al.17 to be associated with an increased degree of
plaque accumulation. Several studies have investi-
gated gingival health in association with stainless
steel crown restorations. Two studies17,18 have
suggested higher levels of gingivitis around teeth
restored with stainless steel crown restorations. In
both these studies, however, no direct comparison
was made with unrestored matched control teeth.
On the other hand, when matched control teeth
were used, no difference in the level of gingivitis
around stainless steel crowns was demon-
strated.14,15 The relationship between gingivitis
and marginal defects, such as poor marginal adap-
tation and incomplete removal of excess cement,
has been clearly demonstrated by several
workers.11,14,15
In the primary dentition, alveolar bone loss has
been associated with inadequate preformed crowns
as well as with proximal caries.19 However, a direct
correlation could not be established by other
authors.20 – 23
The aim of the present study was to evaluate,
clinically and radiographically, the effect of stain-
less steel crowns placed on primary molars on the
surrounding gingival and bone structures.
Materials and methods
This study was conducted as retrospective review of
patients who had worn stainless steel crowns at the
clinics of Pediatric Dentistry Department, Faculty
of Dentistry, King Abdulaziz University, Saudi
Arabia. Children aged three to twelve years, with
at least one primary molar restored with a stainless
steel crown were selected for the study. Under-
graduate dental students under closed supervision
of faculty staff had treated all the subjects. All
crowns were placed according to manufacturer’s
instructions on traditional crown preparations. The
crowns had been in mouth for periods ranging from
one month to 38 months with a mean of 17 months.
Data collected from patient’s files included
patient’s age and life span of the stainless steel
crowns. Children with a systemic disease were
eliminated from the study. Out of 177 children aged
3.5 – 12 with a mean age of 7 years, a total of 254
A.A. Sharaf, N.M. Farsi
stainless steel crowns were evaluated both clini-
cally and radiographically.
Clinical evaluation
Clinical evaluation was carried out visually and with
a mirror and explorer. The following parameters
were recorded
1. Oral hygiene index was determined using simpli-
fied Green and Vermillion oral hygiene index24.
Six teeth were examined (teeth number
55,51,65,85,71 and 75) by running the side of
the explorer over the buccal tooth surface and
scores were recorded as follows: 0 ¼ no debris,
1 ¼ soft debris covering less than one third of
tooth surface, 2 ¼ soft debris covering more than
one third but not more than two thirds of tooth
surface, 3 ¼ soft debris covering more than two
thirds of tooth surface.
Oral hygiene was referred to as: Good for
score 0 to , 1, Fair for score 1 to , 2, Poor for
scores 2 – 3.
2. Gingival index was measured by passing the
explorer tip gently within the sulcus around
each crowned tooth. Scoring was as follows:25
0 ¼ no bleeding, 1 ¼ Only one bleeding point
appearing some seconds after probing, 2 ¼
Bleeding points appearing immediately after
probing, 3 ¼ Profuse bleeding appearing
immediately after probing spreading towards
the marginal gingiva.
3. The proximal contact area between first and
second primary molars was recorded as intact or
open by passing a dental floss. When the
neighbouring tooth was not present this cri-
terion was ignored.
4. Crown marginal adaptation was measured at
buccal and lingual walls and was either good
with sealed margins or poor when the explorer
detected an open margin.
5. Crown marginal extension was either at gingival
margin, below the gingival line (apical to
gingival margin), or above the gingival line
(occlusal to gingival margin).
6. The duration of time that the stainless steel
crown has been present on the primary tooth
has been viewed from the patients records.
The time intervals were designed as follows:
Less than 6 months, 6 –12 months and more
than 12 months.
Radiographic evaluation
Radiographic examination was done using bitewing
radiographs. A standardized angulation of the X-ray
A clinical and radiographic evaluation of stainless steel crowns for primary molars 29

was either adequate when all the margins

appeared smooth and well adapted covering all
dentin.
2. Crowns were considered inadequate when crown
margins appeared too short or extend below the
cemento enamel junction or away from tooth
surface by a distance of more than one mm or
when any critical defects in the crown were
detected. 10,14

All examinations were done by the two authors,

Figure 1 Stainless steel crowns distribution.
cone was applied using the Rinn XCP positioning
device. The radiographs were selected on the
following basis: (1) minimal evidence of distortion;
(2) minimal overlapping between the adjacent
molar proximal surfaces; (3) a clear image of the
cemento-enamel junction and the alveolar bone
crest between the primary molars.
The following radiographic criteria were
viewed:
1. Interproximal bone level was considered normal
or non resorbed when the distance between the
crest of interdental bone and the cemento
enamel junction was 2 mm or less. Bone was
considered resorbed when this distance
was more than 2 mm.19 Quality of the crown
an inter rater and intra rater calibration was done
before running the experiment until readings and
measurements were standardized. Data were col-
lected, tabulated and statistical analysis was done
using SPSS version 8. Pearson x square test was
applied to test the difference between the groups.
When P value was less or equal to 0.05, the
difference was considered significant, whereas,
when P value was more than 0.05, the difference
was considered as non significant.
Results
The study sample consisted of 254 stainless steel
crowns. Fig. 1 shows the distribution of the sample
according to the tooth number. Table 1 presents
the effect of crown marginal adaptation, marginal
extension and oral hygiene level as evaluated
clinically and crown adequacy as judged by

Table 1 The effect of parameters of stainless steel crown on gingival index N ¼ 254:

Parameter N Gingival index P value

0, n (%) 1, n (%) 2, n (%) 3, n (%)

Crown marginal adaptation

Good 223 102 (45.74) 65 (29.15) 43 (19.29) 13 (5.83) 0.027*
Poor 31 7 (22.58) 17 (54.84) 6 (19.36) 1 (3.23)

Crown marginal extension

At gingival 58 24 (41.38) 18 (31.04) 9 (15.52) 7 (12.07)
Below gingival 183 82 (44.81) 60 (32.79) 36 (19.68) 5 (2.74) 0.056
Above gingiva 13 3 (23.08) 4 (30.77) 4 (30.77) 2 (15.39)
Crown radiographic evaluation
Adequate 228 99 (43.43) 75 (32.90) 41 (17.99) 13 (5.71) 0.448
Non-adequate 26 10 (38.47) 7 (26.93) 8 (30.77) 1 (3.85)

Oral hygiene level

Good 57 39 (68.42) 14 (24.56) 1 (1.75) 3 (5.26) 0.00*
Fair 148 49 (33.11) 55 (37.16) 35 (23.64) 9 (6.08)
Poor 49 21(42.85) 13 (26.53) 13 (26.53) 2 (4.08)
Time
,6 months 83 36 (43.37) 31 (37.34) 13 (15.66) 3 (3.61) 0.262
6 –12 months 43 18 (41.86) 14 (32.55) 11 (25.58) 0 (0.00)
.12 months 128 55 (42.97) 37 (28.91) 25 (19.53) 11 (8.59)

*Significant difference.
30 A.A. Sharaf, N.M. Farsi

Table 2 The effect of parameters of stainless steel crowns on inter proximal bone level N ¼ 254:

Parameter N Bone level P value

No resorption 159, n (%) Resorption 95, n (%)

Crown marginal adaptation

Good 223 135 (60.54) 88 (39.47) 0.069
Poor 31 24 (77.42) 7 (22.58)

Crown marginal extension

At gingiva 58 33 (56.89) 25 (43.10) 0.486
Below gingiva 183 117 (63.93) 66 (36.06)
Above gingiva 13 9 (69.23) 4 (30.76)
Crown radiographic evaluation
Adequate 228 152 (66.67) 76 (33.34) 0.00
Nonadequate 26 7 (26.93) 19 (73.08)

Oral hygiene level

Good 57 35 (61.40) 22 (38.60) 0.108
Fair 148 87 (58.78) 37 (25.00)
Poor 49 37 (75.51) 12 (24.49)
Time
,6 months 83 58 (69.88) 25 (30.12) 0.115
6–12 months 43 22 (51.16) 21 (48.84)
.12 months 128 79 (61.72) 49 (38.28)

radiograph together with the time of service of the Table 3 summarizes the effect of maintaining
crown on the gingival condition. Both crown proper proximal contact on the gingival index and
marginal adaptation and oral hygiene level showed the interproximal bone level. In 47 crowns it was
a significant effect on the gingival index. Neither not possible to determine the contact, as the
the crown marginal extension, nor the radiographi- neighbouring tooth was not present. These cases
cal quality of the crown nor the time of service of were excluded from analysis making the total
the crown had a significant effect on the gingival number of evaluated crowns 207. Whether contacts
condition. were open or intact, it had no significant effect on
Table 2 shows the effect of the same previous gingival health or interproximal bone level.
parameters as in Table 1 on the level of
interproximal bone shown by radiograph. Neither
crown marginal adaptation, marginal extension,
oral hygiene level nor time of service of the Discussion
crown had a significant effect on the interprox-
imal bone level. Whereas crowns that were The association between stainless steel crowns and
judged radiographically inadequate were signifi- gingivitis has not been fully explained in the
cantly related to interproximal bone resorption. literature. Our results revealed that crowns that
were evaluated clinically to have poorly adapted
margins showed signs of gingivitis while variations
Table 3 The effect of maintaining proper contact on the in crown marginal extension and adequacy of the
gingival index and interproximal bone level N ¼ 207: crowns as judged radiographically had no effect on
Property N Contact area P value the gingival health. This agrees with the work of
Henderson,18 Myers16 and Checcio et al.12 who
Intact 168, n (%) Open 39, n (%)
reported high incidence of gingivitis around poorly
Gingival index
fitting and improperly contoured crowns due to
0 91 69 (75.83) 22 (24.18) failure of maintaining a clean area around such
1 68 62 (91.18) 6 (8.83) 0.06 crowns. Again, Durr et al. 14 postulated that
2 35 28 (80.00) 7 (20.00)
3 13 9 (69.23) 4 (30.77) undetected subgingival plaque can accumulate in
the space between crown margins and the tooth
Bone level
No resorption 135 114 (84.44) 21 (15.56) 0.108 which would contribute to gingival inflammation.
Resorption 72 54 (75.00) 18 (25.00) It was the opinion of Myers et al.26 that stainless
steel crowns should be carefully fitted to avoid
A clinical and radiographic evaluation of stainless steel crowns for primary molars
mechanical irritation to the gingival tissues. On the
other hand, Webber11 found no relation between
stainless steel crowns and gingival health and
Machen et al.15 found no significant difference in
gingival tissues surrounding teeth restored with
stainless steel crowns and tissue surrounding
uncrowned antimeres. Other studies that were
performed on crowns on permanent teeth had
again conflicting results. On one hand Wiland27
and Marcum28 found that the improper marginal
length and contouring of the crowns caused gingival
inflammation and on the other hand Richter and
Ueno29 found that margins of the crowns had no
effect on the gingival tissues.
Palomo and Peden30 noted that crowns with
subgingival extensions produced more gingival
inflammation than those placed supra gingivally.
Our results showed no significant effect of crown
marginal extension on gingival health. As long as the
morphologic form of the stainless steel crown is
maintained, the gingival health will be preserved,
which was also the opinion of Correl and Tanzilli31
and Einwag32 who reported insignificant, clinically
acceptable, irritation of the gingivae around pre-
crimped stainless steel crowns.
The effect of plaque accumulation on gingivitis
and periodontal disease has been documented in the
literature.33,34 Our study showed that oral hygiene
factor affected the gingival health. Children with
poor oral hygiene showed higher incidence of
gingivitis while children with good oral hygiene
maintained healthy gingivae around stainless steel
crowns. Even the condition of the proximal contact
area whether intact or open had no effect on gingival
health. These findings are in agreement with
Checcio et al.12 who concluded that individuals
with poor oral hygiene showed pronounced tissue
degeneration despite of the quality of the stainless
steel crowns and that improperly contoured restor-
ations predispose the gingivae to more severe
inflammation. Again Myers et al.26 reported that
plaque will readily form on the surface of stainless
steel crowns regardless of the polishing procedures,
therefore, oral hygiene procedures should be
emphasized to minimize accumulation of plaque.
Salama13 reported that only 8.5% of stainless steel
crowns demonstrated plaque accumulation. Our
results agree with Webber 18 who stated that
preformed stainless steel crowns can be used
successfully to restore primary molars without
adversely affecting the health of the gingiva
provided that good status of the patient’s oral
hygiene is maintained.
In our present study alveolar bone loss was
associated with stainless steel crowns that were
judged radiographically as non satisfactory which
31
was in agreement with the literature as Beimstein
et al.19 reported an association between alveolar
bone resorption and inadequately placed stainless
steel crowns and also in sites adjacent to proximal
caries. Again, Guelman et al.35 stated that a well
adapted crown in a primary second primary molar
does not facilitate the appearance of marginal
alveolar bone loss on the adjacent first permanent
molar. However, the number of inadequate crowns
in our study was comparatively low (only 26 out of
254) and reaching a conclusion could be deceiving
as out of this number 18 had fair to poor oral
hygiene, therefore, other factors may have played a
role in causing bone resorption.
Again our findings showed that crown extension
and adaptation or even maintaining intact contact
between teeth had no effect on interproximal bone
level which again agrees with published work that
did not confirm a direct correlation between
stainless steel crowns and interproximal bone
resorption.20 – 23 Alveolar bone resorption in the
primary dentition is not uncommon and can be
caused by other factors as reported by the
committee on research, science and therapy of
the American Academy of Periodontology.36 In
present study, interproximal bone resorption was
related to crowns judged inadequate radiographi-
cally. While no resorption was related to the crown
extension or adaptation that was measured clini-
cally. This could be explained by the fact that the
method used to measure crown extension and
adaptation was applied buccally and lingually
while radiographic evaluation measured crown
adaptation on the proximal surfaces.
It was the opinion of Checcio et al.12 that initial
inflammation due to local irritation may result after
placement of the crown. This inflammation resolved
by time as tissues accommodated to local irritation.
In our present study the duration of time that the
stainless steel crown has been present on the tooth
had no significant effect on either the gingival
condition or the interproximal bone level. This
could be explained by the work of Checcio et al.12
who suggested that the initial inflammation due to
local irritation may result after placement of the
crown. This inflammation resolved by time as
tissues accommodated to local irritation.
The influence of the skill of the clinician in
placing stainless steel crowns has been emphasized
by Salama13 as being an important factor in
minimizing defects in stainless steel crowns. He
reported a high percentage (42.5%) of defective and
opened margins in crowns which were placed in
different health centers by various dentists with
various degrees of knowledge, skill and experience.
Durr et al.14 reported that the most common
32
defects were related to marginal crimp and length.
In our present work the percentage of stainless
steel crowns that were judged radiographically to
be inadequate was only 10% (26 crowns) this could
be attributed to the fact that these crowns were
placed by students under close supervision where
defective crowns were not approved.
Conclusions
† Results of the present study showed that inter-
proximal bone resorption was not significantly
affected by either crown marginal extension or
adaptation, preserving tight proximal contact
between molars, oral hygiene level or duration of
presence of the crown.
† There was significant bone resorption when the
crown was judged radiographically as non-satis-
factory.
† Stainless steel crowns are still a valuable
procedure for restoring primary molars with no
direct effect on the health of the gingiva or
interproximal bone.
† Oral hygiene level has to be monitored and
controlled as it poses the main risk factor on the
health of the gingiva surrounding stainless steel
crowns.
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