Restoration of Primary Teeth with crowns:
a systematic review of the literature.
N. Attari, J.F. Roberts, Specialist Paediatric Dental Practitioners, Private practice, London, England.
Abstract
Aim: To review the literature concerning the restoration of
primary teeth with pre-formed crowns (PMC). Methods: A
search of the dental literature was made electronically using
the key words: stainless steel crowns primary molars, nick-
el-ion crowns primary molars, nickel chrome crowns primary
molars, preformed crowns primary molars, esthetic crowns
primary molars, aesthetic crowns primary molars, and metal
crowns primary molars. All papers were read and assessed
for their relevance to paediatric dentistry and then graded
according to a predetermined set of criteria. The relevant
papers that met nearly 100% of the criteria were graded A;
75% grade B1; more than 50% graded B2 and all others
were graded C. Results: Using all the search key words, 112
papers were found, and fourteen were acceptable. Of these
none were rated grade A or B1, seven B2 and seven C.
Failure rates of PMC varied between 1.9 and 30.3%. In all
studies the failure rate of PMC was lower than other compa-
rable restorations and in some studies this was statistically
significant. The review indicated there is some evidence as
to the efficacy and value of using pre-formed metal crowns
for primary molars. Conclusion: Preformed metal crowns
were indicated for the restoration of badly broken down pri-
mary molars and their success rate was superior to all other
restorative materials. However, there was an obvious lack
of prospective well-controlled studies and more research
is needed
Introduction
Historically there have been two different types of crowns
available for the restoration of primary teeth, metal and aes-
thetic. The oldest type of crown is the preformed metal
crown, also described as a stainless steel crown, ion crown,
metal crown, and faced-metal crown but herein after denot-
ed by the acronym PMC. The PMC was first introduced by
Humphrey [1950]. Since that time many thousands of
crowns have been used to restore carious broken down pri-
mary molars. Anecdotally PMC have been considered the
ideal restoration for restoring primary molars and the tech-
nique is widely taught internationally, [Duggal et al., 1995;
McDonald, et al., 2004; Welbury and Duggal, 2005].
Nevertheless despite the widespread advocacy of the use of
PMC there are still articles in the literature which do not sup-
port their use, particularly by general dental practitioners
[Threlfall et al., 2005]. This is disappointing as the literature
on PMC is so extensive. Also, agencies that are responsible
for the payment of dental treatment, either as insurance
Key words: primary teeth, restorations, crowns
Postal address: Dr J.F. Roberts, 33, Weymouth Street, London, W1G 7BY England
Email: john@paediatric-dentistry.co.uk
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European Archives of Paediatric Dentistry // 1(2). 2006
companies or government, are increasingly demanding evi-
dence for the efficacy of dental treatment approaches. The
demand for evidence based dentistry means that dental
professionals, including specialists such as those in paedi-
atric dentistry now need to provide such evidence. Thus the
need for a review as reported here is timely.
For many years, because of parental criticism of the aesthet-
ics of posterior metal crowns (Figure 1), attempts have been
made to develop alternatives approaches. These include fit-
ting a PMC then cutting a window and bonding a compos-
ite facing [Roberts, 1983] (Figure 2), or else laboratory-bond-
ed composite to the metal (Figure 3). Recently ongoing
research has seen the production of crowns made entirely of
plastic materials. These have not been fully reported on, and
have not yet been included in paediatric dentistry textbooks.
The indications for the use of crowns have expanded over
the years to include:
l restoration of multiple surface caries and for children
at high caries risk,
l after pulp treatment,
l primary teeth with developmental defects, such as
amelogenesis imperfecta,
l fractured teeth, and restoration of fractured cusps,
l space maintainer abutments, and for teeth with
extensive wear.
Previously there have been two papers reviewing the use of
PMC both by Randall et al. [2000; 2002]. The first paper only
reviewed the use of the PMC without attempting to assess
the literature in a systematic way, whereas the second paper
was much more comprehensive and set out to assess each
publication on a set of criteria which lead to inclusion or
exclusion in a final table of assessment. The conclusion of
Randall [2002] was that overall PMC demonstrated greater
longevity and reduced treatment time when compared with
amalgam restorations as a control. However, it is some years
since the paper by Randall [2002] was published and since
that time there have been several more publications on
PMC. In addition the need for evidence-based dentistry, as
noted above, emphasised the need for a further review.
 Crowns for primary teeth

Methods
Literature search. Published scientific literature on the use of
crowns for primary teeth was identified through MEDLINE
for a 39-year period (1966-2005). A combination of key
words and MesH headings were used to try and identify all
relevant studies. These key words are summarised as follows:
Stainless Steel/Metal Crowns
l preformed crowns molars primary molars,
l stainless steel crowns primary molars,
l nickel ion crowns primary molars,
l nickel chrome crowns primary molars, Figure 1 Intra-oral photograph showing aesthetic covered
Nusmile crowns in place on teeth 64 and 65.
l metal crowns primary molars,
l veneered crowns primary molars,
l esthetic crowns primary molars,
l aesthetic crowns primary molars.
The literature search was further limited to peer-reviewed
journals published in the English language. While there were
some papers where the abstract was in English, this was not
the case for the main paper and so could not be studied
adequately for meeting the set criteria. Thus the paper
Schenker et al. [1986] which is available only in English as a
brief abstract, was not included in this review.
Assessment criteria. The assessment criteria used to grade Figure 2 Laboratory bonded veneered posterior crown.
all the relevant papers are listed in the introductory paper to
this issue of the European Archives of Paediatric Dentistry
[Curzon and Toumba, 2006]. Thus there were 25 criteria for
papers concerned with restoring primary teeth.
Grading. All papers were graded according to the number of
criteria that were met in the design, methodology, results
and conclusions given in each paper. If a paper met 20 of the
23 criteria (90%) then it was assessed as Grade A. If a paper
met 17 or more of the criteria (75%) it was graded as B1;
meeting 12 criteria or more (50%) gave a grade of B2. All
other papers were graded as Grade C. Normally in such an
exercise as this report, grade C papers are not included in
the final assessment; the decision was made here that for
completeness and because of very limited papers in higher
categories, these lower graded papers would be included. Figure 3 Comparison of traditional plain metal crown with
new style aesthetic crown (photograph courtesy of Nusmile
Results Crowns Inc).
Literature search. There were 112 reports in the literature on
the use of all the different types of metal crowns. Of these
the key word breakdown was as follows with the indication Stainless steel crowns molars
of how many were suitable for further assessment: 112 papers of which 28 suitable.
Metal crowns primary molars Stainless steel crowns primary molars
58 papers of which 16 suitable. 71 papers of which 19 suitable.
Preformed crowns primary molars Metal ion crowns; nickel-chrome crowns; ion crowns
16 papers of which 7 suitable. 6 papers of which 2 were suitable.

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Attari/Roberts
However, while the largest number of 112 papers was in one
assessment, a cross-checking of the results for each cate-
gory showed that there was a great deal of overlap. By far
and away the greatest proportion of papers were concerned
with the technique, or variation of the technique, for using
PMC. Then there were a large number of case reports
whereby PMC could be used for teeth with defects such as
amelogenesis imperfecta, but involving one or a few children.
From these papers a subset of 26 papers was selected for
further review. Once each had been read the subset was
reduced to just 14 papers which report on the assessment,
either retrospectively or prospectively of the use of PMC and
where there was evidence of some sort of organised study
involving more than just a few subjects or teeth.
Grading. The 14 selected papers were then read again in
detail and assessed according to the criteria established by
Curzon and Toumba [2006].
No Grade A or B1 papers were identified that fulfilled the
90% or more criteria needed. Seven Grade B2 and seven
Grade C papers were identified (Tables 1 and 2). The paper
scoring the highest number of criteria, 15 (65%), was that of
Papanathasiou et al. [1994]. This was a retrospective study
in which the operators consisted of undergraduate and
postgraduate students, junior and senior members of staff.
However, there was no evidence of training or calibration of
the operators, nor of a power calculation to determine how
many patients records needed to be surveyed to find a sta-
tistically significant result. The assessment of records was
carried by one person, the senior author. Again there was no
evidence in the paper that he had been trained or calibrated
in the assessments, or what his reproducibility was in
assessing and recording the results of screening from the
patients records. Finally, details of the fluoride background
of the patients were not given, and the authors failed to
address any possible financial incentive from organisations
or other parties in order to carry out the study.
There were two papers scoring 13 on the criteria scale. The
earlier paper by Roberts and Sherriff [1990] was a prospec-
tive study but with no power calculation or a stated list of
inclusion and exclusion criteria as to why each child was
chosen. This study was carried out by a single-handed spe-
cialist paediatric dentist, and it covered all children seen with
a specific time period in the practice. However, no reference
was made to the caries status of the children treated, nor
their fluoride background. Obviously if all the PMCs and
other restorations were placed by the one operator and that
same operator assessed the survival/failure rate of the
restorations, the assessment was not in a blind manner. The
assessor was therefore neither blind nor calibrated.
Sharaf and Farsi [2004] reported on a retrospective study
but again there was no power calculation to determine how
many restorations of each type needed to be assessed. The
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European Archives of Paediatric Dentistry // 1(2). 2006
caries and fluoride status were not reported. The outcome
measure, i.e. the success or failure, was given for a twelve-
month period only, which is not sufficient for such a study.
As with the other studies already discussed the assessment
was not blind. It appears that the assessor did undertake a
form of calibration but no Kappa scores were provided.
The remaining studies rated B2 all scored 12 on the assess-
ment scale. The oldest of these studies was that of
Ericcsson et al., [1988]. This was a prospective study but yet
again with no power calculation and no inclusion-exclusion
criteria. The caries status and fluoride background were not
reported. The assessment was not carried out in a blind
manner nor was the assessor calibrated, although there is
some indication that success was discussed by the authors
at some time during the study.
The paper by Fuks et al., [1999] actually concerned the use
of regular PMC and some with facings so it could be said
that it did not fully comply with the aims of this review.
Nevertheless, as these authors did report on success of
PMCs it was retained in the paradigm. This was a prospec-
tive study but not based on a power calculation. Caries sta-
tus and fluoride background were not reported. There was
no training or calibration of the examiners and the time
frame of less than two years follow-up was too short. The
paper by Ram et al., [2003] in which aesthetic crowns were
assessed had the same shortfalls as the Fuks et al., [1999]
paper. It was a retrospective study with no power calcula-
tion, exclusion criteria or caries and fluoride status. The
post-operative assessments were not carried out in a blind
manner with calibration.
The latest paper to be assessed was that of Roberts et al.,
[2005] with over 1,000 PMCs being assessed. This study
was a prospective one following the same format as that of
the previous paper by this group [Roberts and Sherriff, 1990]
and has the same merits and draw backs.
All of the papers graded C suffered from similar drawbacks.
Details are lacking for the type of operators carrying out the
restorations and how the success rates were assessed.
Inclusion and/or exclusion criteria were either lacking or
incomplete. Caries status and fluoride background were
completely lacking. The assessment was in all cases not
properly blinded, nor attempts made to calibrate examiners
and report on reproducibility. Many of the studies did how-
ever have a follow up of at least two years.
Discussion
Considering the substantial number of papers while con-
ducting the literature search, it was disappointing to find that
so few were suitable in assessing the evidence for the suc-
cessful use of PMC. As the use of PMCs throughout North
and South America and in Australia is known to be exten-
sive, an enormous number must have been fitted over the
past fifty years. Despite this, very few studies have been
 Crowns for primary teeth

Table 1 Results of review of the literature on preformed metal crowns for primary molars: studies graded as B1 or B2.

Author(s)/ Rating/ Design Control n Operators* Examiners Study Subject PMC Failure Notes
Year score Group Calibrated Duration ages Control Rate %

Papanathasiou B2/17 retro amal 183 PMC Mixed(?) NG 60 mths 3-10 yrs 20.2 29.3
et al.,1994 198 Amal records

Roberts B2/13 pros amal 673 PMC Specialist. 1, NG 10 yrs 6-7 yrs 1.9 11.6
& Sherrif, 1990 706 Amal (1)

Sharaf & Farsi B2/13 retro none 207 PMC Undergrads. 2, Yes 38 mths 3.5-12 yrs 26/207 12.5%
2004 (?)

Eriksson et al., B2/12 retro cont. 104 PMC Paedo. (?) NG 7 yrs 6-7 yrs 21.2 78.6
1988 molar 84 Amal

Fuks et al., B2/12 pros faced 11 PMC Postgrads NG 6 mths NG all PMC survived
1999 11 Faced (?) 1 faced PMC replaced

Ram et al., B2/12 retro Nusmile 10 PMC Postgrads. NG 4 yrs NG all PMC survived
2003 PMC 10 Nusmile (?) Nusmile all chipped

Roberts et al., B2/12 pros other 1,010 PMC Specialist 1, NG 7 yrs NG 3% 1.7% Class I,.
2005 rest. 544 Class I (1) 2.7% Class II
962 Class II

Notes.
Retro = retrospective study; pros = prospective study.
* = a mixture of operators of different skills; ** Paedodontist; Specialist = specialist paediatric dentist; (?) number not given; NG = information not given.
PMC = preformed metal crown; faced = metal crown with plastic facing; amal = amalgam; rest = all other restorative materials.

Table 2 Results of review of the literature on preformed metal crowns for primary molars: studies graded as C.

Author(s)/ Rating/ Design Control n Operators* Examiners Study Subject PMC Failure Notes
Year score Group Calibrated Duration ages Control Rate %

Braff C/10 retro amal 76 PMC Specialist 1, NG 2.7 yrs mean 30.3 88.7
1975 150 Amal (1) 4.2 yrs

Dawson et al., C/8 retro amal 64PMC Paedo (?) NG 2 yrs mean 12.5 70.6
1981 102 Amal records 5.5 yrs

Messer C/? pros amal 331 PMC Mixed (?) NG 5 yrs 4-7 yrs 12.1 21.7
& Levering 1,117 Amal records
1988a,b

OSullivan C/9 retro rest. 210 PMC Mixed (?) NG 2 yrs median 3.3 16.0
& Curzon 106 Amal records 4.5 yrs
1991

Einwag C9 retro rest. 66 PMC Paedo (1) NG 8 yrs NG 6.1 57.6

& Dunninger 66 Amal records
1996

Grutthuysen C/? retro amal 67 PMC NG NG 2 yrs mean 5.5 14.9 32.0 all pulpotomies
et al., 1997 25 Amal

Holan et al., C/6 retro amal 287 PMC Specialist NG 16 yrs NG 13.0 20.0 all pulpotomies
2002 54 Amal (1) records

Notes.
Retro = retrospective study; pros = prospective study.
* = a mixture of operators of different skills; Paedodontist; Specialist = specialist paediatric dentist; (?) number not given; NG = information not given.
PMC = preformed metal crown; amal = amalgam; rest = all other restorative materials

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European Archives of Paediatric Dentistry // 1(2). 2006
Attari/Roberts
published. This may be due to the attitudes of specialist
paediatric dentists and dental practitioners with an interest
in paediatric dentistry who use PMC more frequently and
have experienced a high success rate with this technique
which has led to an international understanding that PMCs
are successful.
Subjects. Details need to be reported in these types of stud-
ies as to how the children are selected, their caries status
and fluoride background. In a group of children with no flu-
oride use and a high caries rate, the success of the restora-
tions may be compromised and hence the need to report
these parameters. When comparing PMCs with other mate-
rials ideally a power calculation would be made of how many
restorations need to be assessed to check for statistically
significant results.
Placement of restorations. Few papers gave details of the
methods of placement such as whether local analgesia or
rubber dam was used.
Duration of studies. Primary teeth are often restored in chil-
dren as young as three years of age; therefore a study on the
success of restorations should follow them through until the
time of exfoliation. This would be for a minimum of five
years, but it is recognised that such duration is impractical,
as loss of subjects would be considerable. However, it is
reasonable to ask that restorations should be followed for at
least two years.
Operators. Many studies were retrospective and used what-
ever operators were working in the clinic(s) concerned.
There would therefore have been a great disparity of skills.
On the one hand this might be more realistic in reflecting the
real world, but another variable is thereby introduced. One
operator would be best, or where many are used, each oper-
ator should be individually assessed for their success rates.
Methods of assessment. These need to be clearly defined in
a report. The criteria need to be set up before implementa-
tion of a study and there should ideally be an independent
assessor who did not place any of the restorations. Clearly
blind examination is a problem as PMCs are very obvious
versus plastic restorations. This can however be dealt with
by repeated assessment with a sufficient time interval
between examinations so that a reproducibility of findings
can be reported. Assessors must be trained and calibrated.
Tooth type. This question was not addressed in any of the
studies reviewed here. Ideally like should always be com-
pared with like. Therefore, restorations in maxillary first or
second primary molars should only be compared with first or
second maxillary primary molars. As in many studies radi-
ographs are taken for longer term post-operative assess-
ment; mandibular radiographs can be taken in a more stan-
dardised manner by comparison with maxillary radiographs.
Ideally, therefore, studies should be confined to mandibular
teeth if radiographs are to be used.
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European Archives of Paediatric Dentistry // 1(2). 2006
Conclusion
There is some evidence that pre-formed metal crowns are
the restoration of choice for badly broken down primary
molars. The data for success and failure rates indicates that
the failure rate for these crowns is very low by comparison
with other plastic restorations. However, the lack of substan-
tial prospective clinical trials needs to be rectified.
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