PEDIATRIC DENTISTRY

V 36 ' NO 3

M A Y ; JUN 14

Clinical Article

RANDOMIZED CONTROL TRIAL

Posterior Preveneered Stainless Steel Crowns: Clinical Performance after Three Years
Anne C. O'Connell, BA, BDentSc, MS' Evelina Kratunova, BDentSc, MFD(RCSI), DChDent, FFD^ Rona Leith, BA, BDentSc, MFD(RCSI), DChDent^

Abstract: Purpose: The purpose of this study was to evaluate the clinical performance of posterior preveneered stainless steel crowns after three years.
Methods: NuSmile crowns and Kinder Krowns were randomly allocated on paired molars using a split-mouth design. Variables such as fracture, wear,
gingival heaith, and esthetics were recorded. (P<.05). Results: Statistical analysis was compieted on 34 paired crowns in M children. After three years, 53
percent of crowns were fracture free compared to 81 percent at one year. There was minimai esthetic impact for most fractures due to the location
of the veneer fracture, but five crowns had extensive fracture. No difference was reported in the clinical performance between the two crown types.
Fracture was more likely to occur where the adjacent tooth was missing. Parents reported a satisfaction rating of 83 out of 10. Conclusions: Clinical
performance of both crown types was similar and successful for three years. Facing fracture occurred in 47 percent of crowns but had minimal
impact on the esthetic value or parental satisfaction in the majority of cases. These crowns offer an esthetic alternative to the traditional stainless
steel crown, but parents should be alerted to the possibility of veneer ioss over time.
Revision Aprii 7, 2013

(Pediatr Dent 2014:36:254-8) Received January 23, 2013 i Last

I Accepted April 16,2013

KEYWORDS: DENTAL ESTHETICS, POSTERIOR CROWN, PRIMARY DENTITION, LONGEVITY, PREVENEERED STAINLESS STEEL CROWNS

Stainless steel crowns (SSCs) provide durable and reliable full

coverage restorations and are retained for the lifetime of a ptimary tooth. Their main disadvantage is that their metallic
appearance is disliked by parents and children.'"* Many attempts
have been made to produce a comparable esthetic replacement
for the SSC, including composite, polycarbonate, thermoformed
plastic, and zirconia. Currendy, the most commonly used esthetic
crowns for posterior teeth are standard SSCs preveneered with
composite resin (VSSCs).'''' The veneer increases the bulk of
the crown, and manufacturers suggest a passive fit so that
increased tooth preparation is required. In addition, retention
does not rely on the natural contour of the tooth, as crimping
is not possible on the composite facing.
The introduction of esthetic crowns has been welcomed by
many practitioners and parents; however the long-term clinical
performance of these crowns has not been adequately evaluated. The only other long-tetm clinical study examined 10
posterior NuSmile crowns, where all crowns showed chipping
after four years'
Previously, we reported the clinical performance at 12
months of two commercially available posterior crowns,
NuSmile (Othodontic Technologies, Houston, Texas, USA)
and Kinder Krowns (Mayclin Dental Studios, Minneapolis,
Minn., USA).' All 48 crowns were retained at 12 months with
81 percent of the veneers intact. Parental satisfaction was high,
despite the facing loss.
The purpose of this study was to further evaluate the clinical performance and level of parental satisfaction of two commercially available posterior preveneered crowns, NuSmile and
Kinder Krowns, after three years in function.

Methods
Two types of commercially available VSSCs were used in a
'Dr. O'Connell is an associate professor and consultant. Pdiatrie Der.tistry: ^Dr. Kratunova is a clinical instructor. Pdiatrie Dentistry: and 'Dr. Leith is a lecturer. Pdiatrie
Dentistry, all in the Division of Publie and Child Dental Health. Dublin Dental University Hospital. Trinity College. Dublin, Ireland.
Correspond with Dr. O'Connellat anne.oconnell@dental.tcd.ie

254

CLINICAL SUCCESS OF PREVENEERED CROWNS

prospective clinical study with a split-mouth design: (1) NuSmile

Primary Crowns; and (2) Kinder Krowns. Pair-matched molars
were randomly assigned to receive either a NuSmile or a Kinder
Krowns, as previously described.' Crowns are available with a
composite veneer on both the buccal and occlusal surfaces and
also with buccal veneer only for primary second molars. In this
study, full coverage was used on all first molars and buccal-only
coverage was used for second molars. In addition, no back-toback SSCs were placed and no occlusal modification was performed following crown placement. The method of attaching
the composite is proprietary, but Kinder Krowns include
perforations in the SSC substructure to allow resin penetration.
The contour of the proximal veneer also differs between the two
crown types.
Participants were recalled for examination at six-month
intervals for 36 months. Figure 1 summarizes the patient fiow
throughout the study. The original and two additional examiners were calibrated and blindly assessed the crowns during the
three years using the original clinical and radiographie criteria,
as outlined in Table 1 (Figure 2a-b).'''*'' The site and extent
of occlusal wear facets and veneer fractures were evaluated, as

Original Sample
64 crowns 8nd 20 participants

Publication (Leith & O'Conneil) ^ H

48 crowns and 18 participants

Excluded Sample
6 crowns and 2 participants

Exfoliated/extracted teeth/lost
pairing/ Participant did not return
20 crowns and 6 participants

Three Year Sample

34 crowns (17 pairs) and 14 participants

Figure 1. The pathway of patients throughout the three-year study.

PEDIATRIC DENTISTRY

Table 1. CLINICAL AND RADIOGRAPHIC OUTCOMES MEASURED'

Crown retention
Gingival health; modified gingival index,^ plaque index"*
Facing fracture location: buccal and/or occlusal
Facing fracture extent: intact, <50 percent loss, >50 percent loss, complete
loss
Facing wear: none, wear at cusp tips, beyond cusp tips
Gingival margin extension: subgingival, supragingival
Occlu.sion: opposing tooth stattis/proxima! contacts
Crown alignment: normal alignment, rotated mesiodistally
Staining of veneer: present or absent
Radiographie evaluation: presence of horizontal overextension, bony
changes
VAS* to parents'
* VAS = Visual analogue scale.

previously described (Table 1).' Loss or fracture of the composite facing was measured separately for the buccal and
occlusal surfaces and recorded as intact, less than or greater
than 50 pereent loss, or eomplete loss of eomposite veneer
(Table 1). Wear was not seored in a site when the eomposite
veneet had fraetured. Intraexaminer and interexaminer reliability were analyzed using Cohens kappa test.
Statistieal analysis was eompleted using SPSS 20 statistieal
software (SPSS Ine, Armonk, N.Y., USA). Cross-tabulation
analysis of the elinieal data was performed on multiple variables.'" MeNemar's test for paired data and Fisher's exaet test

Figure 2. (a) Clinical appearance of full coverage-veneered crowns on

the ptimary first molars after three years (maxillary NuSmile ctowns
and mandibular Kinder Krowns). (b) Bitewing radiograph of the same
child showing margin adaptation of tbe maxillary NuSmiie crowns and
mandibular Kinder Krowns on the primary first molars.

V 36

NO 3

M A Y ! JUN

were used to determine statistieal signifieance, with the level

of significance set at P<.05.
The visual analogue scale (VAS) was used to score levels
of parental satisfaction at each teview visit.'' Parents were
presented with a horizontal VAS by an independent person
and were asked to consider the size, shape, and shade of the
crowns in their overall assessment.

Results
Twenty participants were recruited in the initial study, and 54
VSSCs (27 pairs) were placed (Figure 1). One patient was lost
to follow up, but several patients had exfoliated one or two
of the crowns (five tooth pairs and two single teeth) by the
three-year review. One crown was extracted as a precaution
following a medical diagnosis. Although all tteated ehildren
were periodieally examined, only intaet pairs of erowns were
ineluded in statistieal analysis. After 36 months, the remaining
34 VSSCs (17 pairs) in 14 participants were statistically compared to the same crowns at 12 months. Five female patients
had 14 crowns, and nine males had 20 erowns, with a mean
age of 5.4 years old at the time of the crown placement
(range=two to nine years old). All examiners were trained and
calibrated on two separate occasions, and kappa scores for each
variable ranged between 0.8 and 1, indieating almost perfeet
agreement.'"
Eight VSSCs were placed on primary second molars and
26 VSSCs were placed on primary first molars. Three patients
had four VSSCs for evaluation at 36 months, but the majority of participants (79 percent) had just one pair of VSSCs. Almost all crowns had a film of plaque at the gingival margin,
and only approximately three percent were plaque free at three
years. Hiere was no statistically significant difference in plaque
retention (P<.50) or gingival health {P=.7l) between the two
commercially available VSSCs after 36 months.^'* There was
no significant deterioration in gingival health measured via

Figure 3. (a) A smooth outline shows occlusal wear on the cusp tip of the
primary maxillary left fitst molat NuSmile crown compared to the sharp
edges showing an occlusal fracture on the palatal margin of the ptimaty
maxiilary right Kinder Krowns. (b) Irregular loss of veneer on tbe ptimary
mandibular first motat NuSmile ctowns (tight) and Kinder Krowns (left).

CLINICAL SUCCESS OF PREVENEERED CROWNS

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PEDIATRIC DENTISTRY

V 36 ' NO 3

MAY I JUN 14

had fractured by one year compared to two NuSmile

crowns, but by three years the fracture incidence had increased to nine Kinder Krowns and seven NuSmile crowns,
with only three crowns showing fracture on both occlusal
and buccal surfaces (two NuSmile crowns had shown comCrown type
Intact
<50%
>50%
Complete Total
bined fracture already at year one in one patient: Figure 4).
facing loss facing loss
loss
After three years, two Kinder Krowns showed comKinder Krotvns
plete veneer loss and one NuSmile crown lost an entire
Maxillary
1
4*
0
7
2t
occlusal surface. The remaining fractures in the VSSCs
Mandibular
7*
3
0
0
10
involved small metal sutface exposures (<50 percent) for
Total
8
0
7
2
17
the majority of crowns. Statistically, there was no difi^erence
.^^^^
between fracture rate of each type of crown {P=.68), AlNtiSmile ' j ^ ^i ta
though not included in statistical analysis due to loss of
Maxillary
2* ' '
1
0
5
Mandibular
a paired crown, the excluded sample showed fractures in
0
1
3*
12
8t
Total
10
1
three of eight Kinder Krowns retained at three years, with
5
1
17
no ftactures in the retained NuSmile crowns.
Total for NuSmile
18 (53)
12 (35)
34
1(3)
3(9)
and Kinder
Seven pairs of crowns had no fractures, six pairs fracKrowns N (%)
tured both crowns, and four pairs showed only one crown
fractured (one NuSmile crown and three Kinder Krowns).
* Eaeh asterisk represents one primary second molar crown (N=8).
There was no difference in the fracture incidence between
t Indicates each second molar crown {N=8).
maxillary and mandibular crowns (Table 2; P=.25). The
type of primary molar, first or second, restoted with
the modified gingival index (MGI) scores'" over the three-year VSSC had no statistically significant association with the inperiod, with 75 percent observed at year one, 69 percent at cidence of facing fracture over the three years (Table 2;
year two, and 67 percent at year three. There were no radio- P=A3). There was no statistically significant correlation begraphic changes noted, and the presence of overhanging mar- tween the type of opposing tooth (natural or restored with
composite, SSC, or VSSC) or existence of wear to the incidence
gins interproximally did not influence the MGI scores.
Veneer fracture resulted in the underlying metal being ex- of occlusal facing fracture in the three-year sample {P=.52).
posed with sharp edges to the veneer, thereby distinguishing it However, the absence of a proximal contact with an adjacent
from wear (Figure 3a). Kinder Krowns showed no wear on the molar has a statistically significant (P<.02) association with
occlusal facing; however, four NuSmile crowns exposed metal
due to wear at the cusp tips by 36 months (not significant;
P=,\0). There was also no evidence that prior facing wear predisposed the veneer to subsequent fracture {P=.47). The site
and extent of occlusal wear facets and veneer fractures are
shown in Figure 3, 4 and Table 2.
Three years after placement, approximately 77 percent
of VSSCs had intact buccal veneers versus approximately 91
percent at one year. Fractures present at 12 months became
more substantial over time. The extent of buccal veneer loss
was less than 50 percent for four NuSmile crowns and one
Kinder Krown, with only one NuSmile crown exhibiting
substantial (>50 percent) facing loss. However, two Kinder
Krowns (primary mandibular second molars) showed complete buccal facing loss at three years. Overall, there was no
statistical difference (P=.\4) between buccal fracture incidence in NuSmile crowns and Kinder Krowns after three
years in use.
Intact occlusal veneers were observed in approximately
58 percent of VSSCs at three years, reduced from approximately 77 percent at 12 months. When veneer loss occurred,
less than half the occlusal surface was exposed in nine of 11
crowns. The most extensive fractures occurred in one child
who had four VSSCs placed on primary first molars and all
second molars extracted at the same visit (Figure 4a, b). All
four crowns had fractured by 12 months and progressed over
time, with two NuSmile crowns showing extensive surface
loss (Figure 4). When the crowns with both buccal and
occlusal veneer fractures were combined, approximately 53
percent of VSSCs had completely intact veneers following
Figure 4. (a) Maxillary view of a child at three years showing extensive fracthree years in the oral cavity versus approximately 81 perture of the left NuSmiie crown compared to the tight Kinder Krowns.
cent at 12 months. Table 3 shows the increased incidence of
(b) Smile of the same child at three years showing the esthetic impact of
fracture and wear throughout the study. Five Kinder Krowns
fractuted ctowns on her smile.
COMPARISON OF CROWN TYPE AND SCORES FOR VENEER
(dSS DUE TO FRACTURE OF BOTH OCCLUSAL AND BUCCAL
FANGS FOR PRIMARY FIRST AND SECOND MOLARS'
AFTER THREE YEARS : :
:
'

256

CLINICAL SUCCESS OE PREVENEERED CROWNS

PEDIATRIC DENTISTRY

PERFORMANCE OVER TIME OF PAIR-MATCHED

NUSMILE AND KINDER KROWN STAINLESS STEEL
CROWNS PRE\/ENEEREDWI m COMPOSITE RESIN
Year 1 (%)

Year 2 (%)

Facing wear

15

15

Fracture: buccal surface

19

24

Fracture: occlusal surface

23

39

42

Combined facing fracture

Year 3 (%)

a veneer facing fracture of the VSSC at three years. Six teeth

(-18 percent) had no adjacent teeth, and all exhibited fractures of either the occlusal or buccal veneer (four of these
crowns were in one child who exhibited fractures in all four
crowns by year one).
Parental satisfaction had decreased from a VAS score of
9.3 at 12 months to 8.28 at 36 months. The appearance of
metal in the smile reduced the satisfaction level; however, no
parent or child asked if any crown could be repaired or replaced. The loss of occlusal veneer had no impact on the parental report of satisfaction when metal was not visible in the
smile (Figure 4a,b). Wear of the facing did not reduce the
score given by the parents. Parents expressed preference for the
white crowns where additional SSCs had been provided during
comprehensive care (Figure 2a).
Discussion
Conventional SSCs are considered a gold standard for full
coverage restoration of primary molars."'" The main disadvantage, however, is their poor color, which prompts many dentists,
parents, and children to request other options.^''' The VSSC
has a conventional crown core to which a composite veneer has
been attached and combines the esthetic appeal parents demand
with the functionality of the traditional SSC. Despite their
widespread use in past years, there is a dearth of clinical research
investigating their durability and esthetics over time. Most of
the current literature investigates anterior restorations only.
Posterior primary molars often have to function until 10 to 12
years old, yet only three clinical studies have been published on
the use of VSSCs in primary molars."''
Both NuSmile crowns and Kinder Krowns were successfully retained up to three years and maintained the integrity
of the tooth in the same way as the conventional SSC. The
increase in tooth reduction to ensure a passive fit did not compromise the integrity of the pulp, and no teeth required pulp
therapy due to accidental pulpal damage.' There was no subsequent loss of pulp vitality over three years. No back-to-back
VSSCs were placed in this study, and buccal-only coverage
for primary second molars was provided for participants by
design. Full coverage primary second molar crowns are available
with similar tooth preparation for both types of crowns.
Provision of full coverage crowns on primary mandibular second
molars ensures maximum esthetic value.
Participants and their parents were very positive about the
white crowns. Only one person was lost to follow up, so that
50 crowns were evaluated. The loss of some teeth over time via
exfoliation disrupted the pairs, so additional intact functional
crowns had to be eliminated from the data analysis, but all
children were examined. Exfoliated teeth returned by the parents showed good marginal adaptation with minimal hori-

V 36 ' NO 3

MAY ( )UN

zontal overextension, and three of the crowns fractured (all

Kinder Krowns).
Maintenance of esthetics is an important measure of success for these crowns. The two commercially available VSSCs
chosen in this study proved to be very similar in the majority
of their clinical aspects, including shape of crown, color stability, placement procedure, gingival health, plaque accumulation,
and crown retention rate. The VSSCs showed excellent facing
color stability; approximately 96 percent and 94 percent of
the crowns, respectively, remained stain free in the first year
and third year. Wear was only observed on NuSmile crowns
(four crowns at year three). Facing wear had little esthetic
impact for parents, as it was usually minimal and located on
the occlusal surface and typically not visible in normal function.
We found no evidence to correlate sites of prior wear with fracture occurrence (P=.47). It had been reported previously' that
facing wear was more likely to occur when the opposing tooth
was also a VSSC. Both the location and extent of the veneer
fracture has an impact on the esthetic expectations of the parent
and child. The buccal surface of the primary maxillary first
molar and the occlusal and buccal surface of the primary mandibular first molar are most visible during facial function."'"
Fractures occurred in both NuSmile crowns and Kinder
Krowns, and the incidence of fractures increased over time from
approximately 22 percent at one year to approximately 47 percent at three years (Table 3). Not all fractures had the same
esthetic impact (eg, fractures on the palatal side of the occlusal
surface had no effect on esthetics; -91 percent retained intact
buccal surfaces at one year versus -77 percent at three years;
Figure 4). Other fractures that were more extensive and visible
in the smile line also resulted in a decreased satisfaction rating
from the parents (Figure 4), although no parents wanted these
crowns replaced.
Kinder Krowns fractured earlier, more often, and more extensively Among the entire cohort of patients, 12 Kinder
Krowns fractured versus seven NuSmile crowns; however, in the
analysis of the paired data at three years, there was no statistical
difference in either occlusal or buccal fracture rates between
the two types of crowns. A number of factors that might influence fracture rates were investigated, but no statistically significant difference was noted for the type of molar, condition of
opposing tooth, or presence of wear facets in the veneer. The
only statistically significant correlation of fracture discovered was
the loss of the proximal contact of the adjacent primary molar.
One child, who had all second molars extracted, experienced veneer failure on all crowns at 12 months. Similarly
another child who had adjacent primary first molars extracted
experienced early veneer fractures that progressed over time.
This finding indicates that esthetic ctowns for children, where
extractions are also planned, may be at increased risk of veneer
failure. This may be due to the increased occlusal loading on
the occlusal table of individual teeth. The clinical relevance of
this observation will need to be validated with larger numbers
of patients.
Loss of veneer from NuSmile crowns exposed the crown's
metal surface, suggesting adhesive failure. The perforations in
the Kinder Krowns were exposed by the veneer loss, and these
perforations remained filled with composite resin, thus maintaining the integrity of the full coverage restoration. Fracture
of Kinder Krowns revealed an opaque coated layer, which was
also subsequently lost, suggesting cohesive failure within the
composite reported previously by Beattie et al."" The thickness
and pattern of the composite coverage for the veneer differed

CLINICAL SUCCESS OF PREVENEERED CROWNS

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PEDIATRIC DENTISTRY

V 36 / NO 3

MAY I JUN 14

between crowns and may be a factor in the fracture incidence.

NuSmile has a uniform thickness of composite, while Kinder
Krowns have thinner facing occlusopalatally. The composite
veneer on the proximal surface of the NuSmile crowns has a
rounded outline compared to a more angular pattern for Kinder
Krowns Clinically, this resulted in metal being visible on the
mesial proximal surface more often with Kinder Krowns, especially if a crown was fitted with a slight mesial rotation due to
mesiodistal space loss in the arch or the primary canine had
exfoliated (Figure 2a).
The level of parental satisfaction with VSSCs was very
high throughout the study. The VAS score reduced from 9.42
and to 8.28 in three years. Most parents and patients were
impressed with the natural appearance of VSSCs after their
placement and could not identify any differences between the
two brands. In this study we also used buccal-only coverage
on primary second molars. Parents reported that they would
prefer not to see any metal at all.
We would now advise full coverage crowns on primary
second molars, particularly mandibular molars for maximum
esthetic value. Despite veneer loss exposing metal over time,
parents maintained a very positive attitude about the crowns.
This may be because they were accustomed to the crowns, unaware of the fractures, or had few concerns, as the tooth remained asymptomatic and closer to exfoliation. The parent of
the child who experienced major fractures of all first primary
first molar crowns reported satisfaction with the esthetics of
the smile after three years (Figure 4).
The manufacturers of these VSSCs have continued to develop and improve features of preveneered SSCs, and it is
hoped that these modifications will redtice the fracture rates for
NuSmile crowns and Kinder Krowns. We suggest that the fracture rate of the buccal veneer-only crowns may be reduced if
full coverage crowns are placed on primary mandibular second
molars so that an increased thickness of composite is in contact
with the opposing tooth rather than the composite margin. To
date, only one in vitro protocol has been published about repair of the fractured facings and with limited success.''
Manufacturers currently suggest replacement of the crown when
esthetics are compromised.
Since the integrity of the restoration was not compromised,
we have commenced an investigation of the clinical success of a
novel chairside repair protocol for posterior facings. VSSCs are
a suitable alternative for traditional SSCs, but parents musr be
advised of the possibility of facing loss over time. The location
and extent of facing loss may compromise esthetic expectations,
which is more likely in children where extractions of adjacent
teeth are also planned.

3.
4.

References
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2.

3.

4.

5.

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Conclusions
Based on this study's results, the following conclusions can be
made:
1. The clinical performance of posterior NuSmile crowns
and Kinder Krowns was comparable; both provided
successful full coverage restoration for a minimum of
three years.
2. Stainless steel crowns (SSCs) preveneered with composite
resin provided an esthetic alternative to traditional
SSCs, but parents must be advised that facing fracture
occurs over time in 47 percent of crowns.

258

CLINICAL SUCCESS OF PREVENEERED CROWNS

Very few of the fractured crowns had an esthetic impact, according to parents.
Fracture was more likely if the adjacent tooth was
absent.

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