Clinical Outcomes for Primary Anterior Teeth Treated with Preveneered Stainless Steel Crowns

Resident’s Name: Ara Cho

Author(s): MacLean, JK et al.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2007. 29. 377-381.

Type of article: Retrospective Study.

Major topic: Anterior Primary Teeth, Early Childhood Caries, NuSmile Crowns

Purpose: To determine the clinical outcomes for a sample of NuSmile crowns used to treat anterior teeth with early childhood caries.

Overview of method of research:

Patients of either a private pediatric dentist or public health clinic and had NuSmile crowns were selected for the study. First- or second- year pediatric dental residents or a dentist in private practice placed the NuSmile crowns. The crowns were placed by 10 clinicians total. The children were evaluated at a followup appointment and three nonblinded, calibrated examiners evaluated the crowns. The parent or guardian completed a written survey to assess parental satisfaction.

Findings:

A total of 226 NuSmile crowns were evaluated in 46 patients. Mean age of crown placement was 4 years of age. Mean time of evaluation was 13 months after placement of the crowns. Each patient had an average of 5 crowns. 91% of the patients were treated under G.A., 4% with nitrous oxide, 2% with oral conscious, 2% with behavior management. 96% had positive behavior and 4% had negative behavior. 24% of patients had history of bruxism and 28% of patients had history of trauma to the crowned teeth.

91% of all patients maintained a good to excellent overall appearance after at least 6 months. NuSmile crowns are a clinically successful complete coverage restoration for anterior primary teeth as evidenced by: 86% resistance to fracture, 71% resistance to attrition, 99% retention, 99% resistance to crazing, and 99% color stability over a minimum of 6 months.

When comparing shade of the NuSmile crown to the natural teeth, only 2 patient’s shades matched. The NuSmile crown was lighter in 88% of the patients.

Key points/Summary:

1. NuSmile crowns are a clinically successful restoration for anterior primary teeth.
2. Despite some negative clinical changes, 91% of NuSmile crowns retain a good to excellent overall appearance after 6 months.
3. Canine NuSmile crowns are the least clinically successful. They are most likely to fracture, wear, and appear bulky.
4. There is an increased incidence of attrition with increased time and with bulky crowns.
5. Successful results with NuSmile crowns may be obtained by both the experienced operator and the novice.

Assessment of Article:

This article highlights the advantages of NuSmile crowns, however, does not really address the esthetic concerns of the crown. The fact that only 2 patient’s shades matched is quite significant. Only 37% of patients had excellent overall appearance; 50% had good overall appearance.

The Use of Stainless Steel Crowns

Resident: Swan

Article Title: The Use of Stainless Steel Crowns

Author: N. Sue Seale

Journal: Pediatric Dentistry

Volume (Number): 24:5 2002

Major Topic: A discussion of the indications for and efficacy of stainless steel crowns for primary molars

Main Purpose: Discuss both clear-cut and not so clear-cut instances where an SSC would be a good treatment option

Type of Article: Position Paper

Main Points of Discussion:

--Advantages of Stainless steel Crowns: Extremely durable, relatively inexpensive, minimal technique sensitivity, offers full coronal coverage.

--Main Disadvantage: Esthetics

--Clear cut applications: following pulpectomy/pulpotomy, and in teeth with developmental defects, large multisurface carious lesions, or fractures.

--Where it becomes more difficult: In treating lesions small enough to allow other restorative options. We need to consider caries risk, restoration longevity, and cost effectiveness

Caries Risk: Study cited that reported 8X increase in buccal/lingual/approximal caries over a two year period in 3 year olds with decay on the maxillary anterior teeth. Another study reported that 57% of children with proximal molar carious lesions in the primary dentition developed additional interproximal primary molar lesions in the mixed dentition. Conclusion: kids develop predictable caries patterns over time.

“High Risk” Indicators: dmfs greater than child’s age, 2 or more new carious lesions in 1 year, numerous white spot lesions, high S. Mutans counts, low socioeconomic status, relatives with high caries rates, appliances in mouth, and history of sugary diet. Also consider ability to recall child on a regular basis.

**With high risk patients, more aggressive treatment with SSCs is better over time

Restoration Longevity: Studies have documented the superior durability and life span of SSCs over class II amalgams. Study by Randall: In 5 published sets of data with average follow up time of 5 years, amalgam failures rate was 2 to 7 times more than that of SSCs.

-Studies show amalgam life expectancy to be approx. 2 years. When restoration needs to last more than 2 years, according to this author, best practice would be to chose an SSC in multisurface restorations of molars. Also, SSCs can be placed with little compromise in a difficult child, where moisture control is unrealistic.

Cost Effectiveness: Randall found 3 studies that examined the cost effectiveness of SSCs vs. amalgams. Two reported the SSC was more cost effective, one reported SSC to be more expensive over time (last study included both Cl I and Cl II amalgams). In studies, most common failure for SSCs is when crown falls off (can often re-cement same crown,= less cost, whereas replacement for a failed amalgam is often an SSC,=more cost). SSCs are recommended for children who require tx under GA=more cost effective, likely we’ll see them in the OR less often.

Summary and Assessment: SSCs are durable, long-lasting restorations that outperform Cl. II amalgams across the board. While there are several clear cut situations that call for their use, oftentimes we need to judge for ourselves. When making tx decisions and discussing with parents, we should consider caries risk, restoration longevity, and cost effectiveness. I liked this article because it succinctly summarized what should be going on in our minds when we are making these types of treatment decisions.

Clinical Evaluation of and parental satisfaction with resin-faced stainless steel crowns

Resident: Roberts

Date: 12/1/10

Article title: Clinical Evaluation of and parental satisfaction with resin-faced stainless steel crowns.

Author: Roberts, Charles et al.

Journal: Pediatric Dentistry

Volume: 23:1 pages: 28-31

Year 2001

Discussion: Stainless steel crowns for the maxillary anteriors present with some advantages and disadvantages. They are retentive, easy to place, durable, but may be esthetically displeasing to the parent/ child. Stainless steel crowns with a resin facing offer the most esthetics. This can be achieved chair side by the operator who manually cuts a window into the facing and places the resin, or prefabricated crowns with a resin facing can be purchased. These usually come with a composite resin attached to a mesh facing or a thermoplastic resin that has been bonded to the crown. Pre- veneered crowns are substantially more expensive than traditional ones, and offer little flexibility in comparison to traditional ones when crimping or contouring the crown to fit the tooth. They also cannot be heat sterilized due to the potential damage to the veneer.

Purpose:

This study evaluated the clinical success and parental acceptance of anterior primary dentition caries treatment with prefabricated resin-faced stainless steel crowns.

Methods: A retrospective analysis of maxillary anterior primary dentition caries treatment using Whiter Biter @ Crowns was performed. Each crown was evaluated for retention, fracture, interface failure, color match, marginal integrity, and surface texture. Parental satisfaction regarding the esthetics of the crowns was evaluated by survey.

Results: Thirty-eight crowns were evaluated in 12 children. The average crown age at time of evaluation was 20.7 months. Twelve crowns (32%) showed loss of at least some facial resin. Nine crowns (24%) had complete loss of the resin facing Overall parental satisfaction with the treatment was excellent, however, satisfaction with crown esthetics received the lowest rating.

Type of veneer facing loss

Entire facing - 9

Site of resin failure

Resin-resin - 4

Resin - metal - 3

Metal - metal - 1

could not be determined - 1

Veneer fracture tear - 3

Incisal 1/3 - 2

Incisal 1/2 - 1

Category (1-5 Mean *1 very dissatisfied, *5 very satisfied)

Appearance - 3.6

Color - 3.9

Shape - 4.3

Size - 4.2

Durability - 3.9

Conclusions: While parental satisfaction with treatment of anterior primary dentition with prefabricated resin-faced stainless steel crowns is excellent the high failure rate of the resin facings is problematic.

Assessment: I would like to see a study that evaluated failure of resin facings among various crown companies like Cheng vs. Nusmile.

The Repair of Preveneered Posterior SSC’s

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: The Repair of Preveneered Posterior SSC’s
Author(s): Yucel Yilmas DDS, PhD. Taskin Gurbuz DDS, PhD, etc al.
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2008. V30 No 5. 429-435
Major topic: Repairing preveneered posterior SSC’s

Overview of method of research: The study’s purpose was to determine the shear bond strength (SBS) for and to perform dye penetration (microleakage) and scanning electron microscope (SEM) evaluations of preveneered posterior SSC’s Twenty-two crowns were use in total. Eleven were repaired by one method (group 1), eleven by another (group 2) and 2 of each group were sectioned for dye analysis. All of the crowns were soaked in saliva for 30 days and then thermocycled. An occlusal force was applied to the crowns to induce a fracture.
Group 1 was repaired using a method designed by Weidenfield for veneering anterior SSC’s. An opaque cement called Panavia, and Tetric Flow composite were used. The fracture margins were prepared with a diamond bur, and an exposed metal was sandblasted, leaving the metal with frosted appearance. The teeth were etched, rinsed, dried, bonding agent was applied and set for 60 seconds, then air dried. The Panavia was then applied to mask the metal color, and the Tertic Flow was added on top.
Group 2 was prepared the same as group 1, however Monoopaque light curing opaquer and Tetric Flow was used. After the bonding agent was completed, .5mm of the Monoopaque was applied to the metal surface and cured for 40 seconds. The Tetric Flow was then applied.
The crowns were then subjected to the dye penetration and SBS test again. Bond failure was scored as adhesive failure (steel /resin interface), cohesive failure (within the facing), or mixed. Also, fractured extent was scored as no cracking, loss of one third, loss of one half, and complete loss.

Findings: The original unrepaired crowns had a higher SBS than either group. In group 1, there was a 4% reduction, and in group 2 there was a 9% reduction. These results, however, were not statistically significant. When all of the fractures were compared, again, there was no statistical significance. It should be noted that there were no adhesive failures.

Key points/Summary:
Most veneered crowns show some chipping within four years.
Dye penetration was seen in 20% of all repaired specimens. It was assumed that the bur did not create a sufficient enough micromechanical area for interlocking to occur between the original veneer material and the repair material.
The fractures observed were either cohesive or mixed. No adhesive fractures occurred.
There was statistically different ranges between group 1 and 2 in terms of fracture extent, with Group 2 being the source of this difference.

Assessment of Article: Overall a good article. Lots of researchy stuff to read through, but definitely good info. If I ever use posterior veneered SSC’s, and have to replace them, I will know how.

Parental Satisfaction with Preveneered Stainless Steel Crowns for Primary Anterior Teeth

Resident’s Name: Jessica Wilson

Article title: Parental Satisfaction with Preveneered Stainless Steel Crowns for Primary Anterior Teeth

Author(s): Champagne et al.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2007. 29:6. 465-469.

Major topic: Preveneered Stainless Steel Crowns (PVSSCs)

Overview of method of research: Survey

Purpose:
To evaluate parental satisfaction with preveneered stainless steel crowns (NuSmiles) placed on their child.

Background:
The authors reported that at the time only 4 manufacturers fabricated PVSSCs (too bad Whiter Biter, Inc. crowns are no longer available, that would be fun to say). These crowns use a composite or thermoplastic resin facing. The disadvantages of this product are a reduced retention from limited crimping, greater expense and availability in only in 2 shades.

Methods:
A questionnaire was administered by a trained assistant to 58 parents at a recall visit at least 6 months after the NuSmile crowns were placed. The questionnaire asked about durability, size, color, and shape. The crowns were placed by pediatric dental residents or private pediatric dentists and all cemented with Ketac-Cem.

Findings:
54 questionnaires were used and the average age of the patient at recall was 5 years, 2 months. A total of 238 crowns with an average of 5 crowns per child were accounted for and the crowns were present for an average of 13 months. The overall acceptance of the PVSSCs was 93% and no parents reported overall dissatisfaction. When evaluating each individual characteristic of the crowns, 97% of parents were satisfied with size, 94% shape, 89% shade and retention, 74% metal visibility and 70% durability. 80% of the parents reported that their children were satisfied with the crowns.
59% of parents said their child never reported any discomfort with the crowns and 39% reported occasional discomfort and only 1 parent said their child complained on a regular basis although they did not seek additional care for their child.
91% of parents said that they would choose the NuSmile restorations again, 7% would choose a completely different type of restoration and only 1 parent would choose extraction.
When the parents were asked if the child experienced any injury to the restored teeth, 78% reported no injury, 22% reported some injury including chipped veneers or completely dislodged crowns. Another 2 parents reported the crowns being dislodged while eating rather than injury. Upon clinical exam, only 27 of 238 crowns demonstrated any shipping/fracturing of the veneer and 6 were completely dislodged.
When comparing the level of the practitioner and the parent’s level of satisfaction, there was no statistical significance, however the parents of male patients were significantly less satisfied overall than those of female patients.

Key points/Summary:
Parental satisfaction with PVSSCs was highly positive with the highest satisfaction with size and shape and the lowest being in durability and metal visibility.
Parental satisfaction was not influenced by clinical experience or level of practitioner.

Assessment of Article:
The article was pretty straight and to the point which I appreciated. One limitation to the study the author mentioned is that there may be a doctor-patient relationship that might have prevented the parent from being more critical of the restorations. I was surprised that more parents were not more dissatisfied with the color, but thought the findings were interesting. Me likey Adam.

Efficacy of Pre formed Metal Crowns Vs. Amalgam Restorations in Primary Molars: A Systematic Review.

Meghan Sullivan Walsh November 28, 2010

Literature Review - St. Joseph/LMC Pediatric Dentistry

Efficacy of Pre formed Metal Crowns Vs. Amalgam Restorations in Primary Molars: A Systematic Review.

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center- Providence

Article Title: Efficacy of Pre formed Metal Crowns Vs. Amalgam Restorations in Primary Molars: A Systematic Review

Authors: Ros C. Randall, B.CH.D., M.PHIL; Matthias M. A. Vrijhoef, PH.D; Nairn H.F. Wilson, PH.D,

Journal: JADA

Volume (number), Year, Page #’s; 131, March 2000, pages 337-343.

Major Topic: Efficacy of pre formed metal crowns vs. amalgam restorations in primary molars.

Overview of Method of Research: Literature review and meta-analysis were used to provide data regarding PMC and amalgam restorations. The data collected ranged from 1.5 to 10 years. A table of outcomes was constructed comparing successful and failed restorations. Using this data, the odds ratio, (OR), and 95 percent confidence interval, (CI) was calculated to estimate the treatment effect.

Findings: A total of 10 studies were available for quantitative analysis. True and false failure rates were discussed in 6 of these articles. False failures were classified as teeth requiring orthodontic extractions, extractions due to pulp pathology unrelated to the restoration and caries in a restored tooth remote from the restoration. True failures were loss of a PMC leading to need for recementation and secondary caries and fracture in the case of an amalgam. Across all of these studies, PMC’s consistently had a lower failure rate as compared to amalgam varying between 1.5 to 9 failed amalgam for every failed PMC. Should you understand the meta analysis math used in this article the OR and CI were calculated as ORmh = 0.23; 95 percent. CImh = 0.19-0.28.

Key Points: Summary: Despite the differences in the date used for this study, PMC’s consistently showed the same positive effect when compared to amalgam. One of the longest and largest studies used in this analysis recorded the lowest failure rate for PMC and amalgam restorations. Amalgams in this study were used for minimal tooth preparation and the remainder were restored with a PMC. The failure rate of an amalgam reported as 11.6 while the failure rate of a PMC was 1.9 over 10 years. Another study performed by Braff showed the highest failure rate for both restorations. However, the average age of his patients were 4.2 years old. In addition, failure rates of many of the PMC were contributed to pulp inflammation. There is difficulty establishing correct cause of failure of a PMC when pulp pathology is involved as it may be multifactiorial in origin. The majority of the articles were retrospective which can often creates difficulty relying on the accuracy of patient records and documentation. Despite all the differences in these articles, PMC’s still remain and statistically show that they are the restoration of choice for a primary molar with multi surface cavities.

Assessment of the Article: The authors do mention how in many of these studies the decision process by which a tooth would be restored with a PMC or an amalgam was not discussed. This may create a bias leading to the success of a PMC when we are aware that a PMC is the restoration of choice for a tooth with multi surface decay. In addition they understand the difficulty behind a well-designed clinical trial which would justify treating a child’s tooth randomly with either a PMC or an amalgam. The article was well written, the results were carefully evaluated and I thought it was a great comparison of the two materials. In addition, it is confirmation that, when in doubt, a PMC is the restoration of choice for a primary tooth when considering the longevity of the restoration.