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176]
Original Article
A randomized controlled clinical trial to evaluate
and compare three chairside techniques of veneering
stainless steel crowns
Deepti Khurana, KR Indushekar, Bhavna Gupta Saraf, Neha Sheoran, Divesh Sardana
Department of Paediatric Dentistry, Sudha Rustagi Dental College, Faridabad, Haryana, India
ABSTRACT
Background: With the increasing patient demands
of esthetics in paediatric dentistry, pre-veneered
stainless steel crowns (SSCs) have been made available
commercially. However, they suffer from technique
sensitivity, limited ability to crimp and associated higher
costs. Aim: The present study was planned to clinically
evaluate and compare the success of preformed
SSCs in which esthetic modification was done using
three different techniques of composite veneering.
Materials and Methods: A total of 60 primary molars
selected from patients between the age group of 4–9 years
were randomly divided into three groups having
20 samples each: Group A (composite veneering done
using the open face technique), Group  B  (composite
veneering done after sand‑blasting SSCs), and
Group  C  (composite veneering done after preparing
retentive grooves on SSCs). The patients were evaluated
at 1, 3, 6, and 9  months as per evaluation criteria.
Statistical Analysis: Kruskal–Wallis and ANOVA were
used to compare means among three groups at different
time intervals. Results: All 60 SSCs were retained at
the end of the study, thereby demonstrating 100%
success of SSCs. Open window technique of veneering
significantly showed maximum retention of composite
veneers; therefore, highest level of parental satisfaction.
Overall, the most common fracture was of adhesive type
seen at the metal composite interface. Conclusions: All
the three techniques used provide a chairside and easy
method for esthetic modification of the SSCs. The open
window is the most successful of the three methods of
veneering and may be clinically useful technique for
dental practitioners and pediatric dentists.
KEYWORDS: Composites, esthetics, stainless steel
crowns, veneering
Introduction
The loss of primary teeth in individuals may
compromise esthetics, function, and guidance of
198 © 2018 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow
Address for correspondence:
Dr. Divesh Sardana,
Department of Paediatric Dentistry, Faculty of Dentistry, Prince
Philip Dental Hospital, University of Hong Kong, Hong Kong,
S.A.R, China.
E‑mail: diveshsardana@gmail.com
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DOI:
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the erupting permanent dentition. When restoring
primary teeth, dental professionals seek to restore oral
function such as speech, mastication, dental anatomy
as well as esthetics. Various types of restorative
materials and crowns have been used to restore grossly
decayed primary and permanent teeth both. These
include amalgam, resin‑based composite restorative
material, preformed stainless steel crowns  (SSCs),
polycarbonate crowns, and strip crowns. The strip
crown form, resin‑based composite restoration, now
allows the reconstruction of even the most badly
decayed primary incisors and their use to restore
posterior teeth also has been reported,[1] However, the
use of strip crowns in posteriors is not as popular as
it is in anteriors, probably because of the associated
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For reprints contact: reprints@medknow.com
How to cite this article: Khurana D, Indushekar KR,
Saraf BG, Sheoran N, Sardana D. A randomized controlled
clinical trial to evaluate and compare three chairside techniques
of veneering stainless steel crowns. J Indian Soc Pedod Prev Dent
2018;36:198-205.
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technique sensitivity compared to prefabricated SSCs.
In severely damaged primary molars and young
permanent molars, the preformed SSCs are considered,
in most of the cases as the best treatment option and
have been most widely used since the 1950s. They are
intended mainly to restore hypoplastic teeth, teeth with
extensive caries, teeth after pulpotomy or pulpectomy,
and when teeth become brittle and are prone to fracture.
Preformed SSCs have improved over the years: better
luting cements have been developed, and different
methods of crown manipulation have evolved.[2]
Despite the favorable qualities mentioned, SSCs have
a major drawback of poor esthetic appearance. One
of the modifications of preformed SSCs used for
restoring badly broken down primary posterior teeth
are the commercially available preveneered SSCs,
but they have disadvantages of being bulky, with
no or limited ability to crimp and contour the facial
surface.[3] Thus, the composite facings can fracture
and wear over time, thereby reducing esthetics and
gingival health. Several esthetic improvements of
SSCs with chairside procedures have been developed
and used. Some of these procedures are the open face
technique, sandblasting the preformed SSC, making
retentive grooves on the SSC surface, soldering metal
cleats, and the use of micromesh on the surface of
SSC to be veneered.[4,5] Hence, this study was planned
to clinically evaluate and compare the success of
preformed SSCs in which esthetic modification was
done using three different techniques of veneering
using composite resin. The null hypothesis supposed
in the present study was that all three techniques of
veneering are similar in success rates.
Materials and Methods
The study was carried out in the Department of
Paediatric Dentistry, SRDC, Faridabad, after obtaining
ethical approval from the committee of the institution.
This preliminary study for the clinical evaluation and
comparison of three different techniques for veneering
primary SSCs using composite resin was conducted
on sixty primary preformed SSCs  (maxillary and
mandibular) which were placed on primary molars
indicated for SSC. A total of 60 primary molars selected
from patients between the age group of 4–9 years were
randomly allocated to three groups having 20 samples
using systematic randomization each with a parallel
design of the study. Inclusion and exclusion criteria
were defined as shown in Table 1.
1. Group  A comprised of 20 primary SSCs with
composite resin veneering done using the open
face technique [Figure 1]
2. Group  B comprised of 20 primary SSCs which
were sandblasted and veneered using composite
resin [Figure 2]
3. Group  C comprised of 20 primary SSCs with
retentive grooves which were veneered using
composite resin [Figure 3].
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 2 | April-June 2018
Khurana, et al.: Chairside techniques to veneer SSCs
Patient and parents were explained about the study and
written informed consent was taken from the parents.
Preoperative radiographs  (intraoral periapical) and
clinical photographs were taken. For all three methods,
tooth preparation was done in the usual manner,
crown was adapted and occlusion was verified before
final cementation.
Group A (stainless steel crowns veneered with
composite resin by the open face technique)
In the first visit, SSCs were adapted and cemented
on the prepared tooth using glass ionomer luting
and lining cement  (GC Gold Label). The second
visit was scheduled after 2  days. In the second visit,
the patient was asked for any discomfort felt and an
observation was made for any alteration in the occlusal
anatomy of the cemented preformed SSC and a clinical
photograph (Occlusal Surface) of the SSC was taken to
note the same. Isolation of the tooth was done using
rubber dam. A  window was prepared on the buccal
surface of the SSC using tapering fissure diamond bur
ISO 160/012  (Mani TC‑26), leaving 1  mm margin on
Table 1: Inclusion and exclusion criteria
Inclusion criteria Exclusion criteria
Patients Fit and healthy Medically compromised
High caries risk Bruxism
Parent/child willing to Children with special
participate in the studyhealth care needs
Parent/child not willing to
participate in the study
Primary Multisurface caries Acute infection
molars Postendodontic treatment Infraocclusion
Developmental defects on Mobility
tooth surface Internal root resorption
Severe erosion Exfoliation imminent
Presence of opposing tooth Absence of opposing tooth
Root resorption less than/ Root resorption greater
equal to 1/3rd than 1/3rd
a b c
d e f
Figure 1: Group A (a) stainless steel crowns cemented (b) window
preparation and rubber dam isolation (c) etching of exposed tooth
surface  (d) application of bonding agent  (e) composite veneering
(f) postoperative
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Khurana, et al.: Chairside techniques to veneer SSCs
all four sides (mesial, distal, occlusal, and gingival) of
the SSC and the underlying tooth was made visible
by completely removing the surface‑luting cement.
The exposed tooth structure was then etched using
37% phosphoric acid for 15 s, washed, and dried.
Using a disposable applicator tip, the bonding agent
(Single Bond Universal Adhesive, 3M, 7th generation)
was applied as per the manufacturer’s directions:
directly on the entire exposed tooth surface and
rubbed in for 20 s. Furthermore, bonding agent was
also applied directly on the borders of the stainless
steel window (without etching) in the same way as on
the tooth surface. Care was taken to avoid any contact
between adhesive and oral mucosa. A  gentle stream
of dry/compressed air was directed over the surface
where the bonding agent was applied for 5 s until it no
longer moved and the solvent evaporated completely.
The adhesive was then polymerized using curing light
for 10 s. Resin composite (Filtek Z350, 3M ESPE) was
then placed incrementally and each layer was cured
with visible light. The thickness of the placed esthetic
material, together with the SSC was maintained
approximately close to 1.5–2  mm. Care was taken to
avoid the extension of the veneering material up to the
gingival margin. Both the composite material and the
gingival margin of the SSC were finished and polished
using Sof‑Lex discs.
Group B (Sandblasted stainless steel crowns
veneered with composite resin)  with glass ionomer luting and lining cement (GC Gold
In the first visit, SSCs were adapted on the prepared
tooth surface and cemented using temporary
cement (Zinc Oxide‑Eugenol). A  clinical photograph
(Occlusal Surface) of the cemented crown was taken.
The second visit was scheduled after 2  days. In the
second visit, the patient was asked for any discomfort
felt and an observation was made for any alteration in
the occlusal anatomy of the cemented preformed SSC.
A clinical photograph (Occlusal Surface) of the SSC was
taken to note the same. The SSC was then removed and
a b c a
d e f
Figure 2: Group B (a) temporarily cemented stainless steel crowns
(b) stainless steel crowns removed at 2nd visit (c) sandblasted buccal
surface  (d) application of bonding agent  (e) composite veneering
(f) postoperative
200 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 2 | April-June 2018
its buccal surface was sandblasted using aluminum
oxide particles (particle size of 250 µm, pressure 4 psi
at a constant distance of 1.5 inches for 40 s). Using a
disposable applicator tip, bonding agent (Single Bond
Universal Adhesive, 3M, 7th  generation) was applied
directly on the entire sandblasted SSC surface as per
the manufacturer’s directions, i.e., without etching the
metal surface and rubbed in for 20 s. A gentle stream
of dry/compressed air was directed over the surface
where the bonding agent was applied for 5 s until it no
longer moved and the solvent evaporated completely.
The adhesive was then hardened using curing light for
10 s. Composite resin (Filtek Z350, 3M ESPE) was then
applied incrementally on the buccal surface – leaving
0.5 mm of SSC exposed next to the gingival area – and
was polymerized. The thickness of the placed esthetic
material, together with the SSC, was maintained
approximately close to 1.5–2  mm. Care was taken to
see that the veneering material did not extend up to the
gingival margin. The bonding procedure was carried
out within 30 min of sandblasting. Both the composite
material and gingival margin of the SSC were finished
and polished with Sof‑Lex discs. The SSCs were then
cemented using Glass ionomer luting and lining
cement (GC Gold label).
Group 3 (stainless steel crowns with retentive
grooves veneered with composite resin)
In the first visit, SSCs were adapted and cemented
Label). A  clinical photograph  (Occlusal Surface) of
the cemented crown was taken. The second visit was
scheduled after 2 days. In the second visit, the patient
was asked for any discomfort felt and an observation
was made for any of the alteration in the occlusal
anatomy of the cemented preformed SSC. A  clinical
photograph  (Occlusal surface) of the SSC was taken
to note the same. The tooth with the SSC was then
isolated using rubber dam. On the buccal surface of
the SSC, four parallel grooves in the occlusogingival
b
c d
Figure 3: Group C (a) stainless steel crowns cemented (b) preparation
of buccal grooves and rubber dam isolation (c) application of bonding
agent (d) postoperative
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Khurana, et al.: Chairside techniques to veneer SSCs

direction and one groove horizontal to these vertical 3 months (i.e., at 3, 6, and 9 months) as per evaluation
grooves, in the mesiodistal direction (in the midline of criteria [Table 2].
the tooth mesiodistally), were prepared for retention
by means of a diamond straight fissure bur ISO The findings at each time interval were noted, tabulated,
111/012  (Mani SF‑11) using light strokes taking care compared, and subjected to statistical analysis using
that the cemented crowns are not perforated. Using a SPSS (IBM SPSS Statistics for Windows, Version 22.0.
disposable applicator tip, bonding agent (Single Bond Armonk, NY: IBM Corp) statistical analysis software.
Universal Adhesive, 3M, 7th  generation) was applied The Kruskal–Wallis and ANOVA tests were used.
directly on the entire buccal surface of SSC  (without
etching) and rubbed in for 20 s. Care was taken to Results
see that contact between adhesive and oral mucosa
was avoided. A  gentle stream of air was directed Table  3 shows the follow‑up results of three groups
over the metal surface where the bonding agent was over a period of 1, 3, 6, and 9  months. There was a
applied for 5 s until the agent no longer moves and the drop out of 1 from the open window group, 2 from
solvent evaporated completely. The adhesive was then the sandblasting group, and 2 from the buccal grooves
polymerized using curing light for 10 s. Composite group at the end of 9 months. No failures were observed
resin  (Filtek Z350, 3M ESPE) was then applied in Group A in the first 3 months, and at the 6th month
incrementally on the buccal surface – leaving 0.5 mm follow–up, 3 out of 20 crowns showed <50% chipping
of metal exposed next to the gingival area – and was and at the end of 9  months, 2 out of these 3  cases
polymerized using curing light. The thickness of the showed little more loss of veneer, resulting in  >50%
placed esthetic material, together with the SSC, was loss of veneer and the 3rd case remained the same. All
maintained approximately close to 1.5–2  mm. Care three fractures observed at the end of 6 months were at
was taken to see that the veneering material did not the metal composite marginal interface, i.e., adhesive
extend up to the gingival margin. Both the composite type of fracture. At the 9th month follow‑up, in 2 out of
material and gingival margin of the SSC were finished these 3 cases, fracture extended within the composite
and polished with Sof‑Lex discs. veneer‑mixed type of fracture and 16 veneers were
intact. Of all veneered crowns, maximum crowns – 17
Postoperative care and routine oral hygiene out of 19 showed a gradual increase in staining over
instructions were given to all the patients. Children the 9  months with noticeable yellow staining of the
were followed up over the next 9  months  –  first at composite veneer. In Group B, at the end of 1 month,
the end of the 1st  month and then at an interval of 10 out of 20  cases showed loss of composite veneer:
5 cases each showed <50% and >50% loss of the veneer.
Table 2: Evaluation criteria There was a complete loss of the veneer in 3 out of
20  cases, 6 out of 19  cases, and 10 out of 18  cases at
Criteria Code/score the end of 3rd, 6th, and 9th  month, respectively, thus
Retention of stainless steel 0=Present showing an adhesive type of fracture, such that only
crown 1=Present, but partially dislodged four veneers were intact at the end of the study. Surface
2=Absent, completely dislodged loss of the composite veneer was seen in 8, 6, 5, and
Retention/fracture of 0=Intact 3 cases at the end of 1, 3, 6, and 9 months, respectively:
composite veneer 1=<50% surface chipped indicating cohesive type of fracture in these cases.
2>50% surface chipped In Group  C, only four veneers were intact at the
3=Complete loss end of 1  month, 10 showed  >50% surface chipped, 4
Site of fracture 0=Metal Composite marginal showed <50% surface chipped, and 2 showed complete
interface loss of the veneer: all cases indicating adhesive failure.
1=Partial loss of veneer A progression was seen in the loss of composite veneer
2=Surface loss such that, at the end of 9  months, no veneer was
3=Complete loss of veneer intact, two cases showed  <50% chipped surface and
Type of fracture 0=Adhesive three cases showed  >50% surface chipping. Thus, at
1=Cohesive the end of the study, five cases showed partial loss of
2=Mixed the composite veneer and rest of the 13 cases showed
Stain resistance of the 0=No staining complete loss of veneer all crowns thus all showing
composite veneer 1=Minor staining adhesive fracture.
2=Noticeable staining
Marginal gingival status 0=Not inflamed Discussion
(of the veneered SSC) 1=Inflamed
2=Other findings Esthetic SSCs are essentially SSCs with a composite or
Parental satisfaction 0=Happy porcelain coating that is chemically or mechanically
1=Satisfied attached to a metal coping where the composite is used
2=Unhappy to hide the metallic appearance of the base structure.
SSC=Stainless steel crown However, esthetic SSCs have several shortcomings

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Khurana, et al.: Chairside techniques to veneer SSCs

Table 3: Evaluation of all three groups over a period of 9 months

Follow‑up period 1 month 3 months 6 months 9 months Kruskal–Wallis P
Groups A B C A B C A B C A B C test
20 20 20 20 20 20 20 19 19 19 18 18
Retention of stainless steel crown
0=Present 20 20 20 20 20 20 20 19 19 19 18 18 0.000 at all Non-significant (P=1.000 at 1
1=Present, but partially dislodged 0 0 0 0 0 0 0 0 0 0 0 0 follow‑up month, 3 months, 6 months and
2=Absent, completely dislodged 0 0 0 0 0 0 0 0 0 0 0 0 intervals 9 months)
Retention/fracture of composite veneer
0=Intact 20 10 4 20 9 2 17 7 1 16 4 0 1 month=23.76 Significant (P< .001 at 1 month,
1=or <50% surface chipped 0 5 10 0 2 6 3 0 1 1 3 2 3 months=28.16 3 months, 6 months and 9
2>50% surface chipped 0 5 4 0 6 6 0 6 5 2 1 3 6 months=29.55 months)
9 months=29.65
3=Complete loss 0 0 2 0 3 6 0 6 12 0 10 13
Fracture site
0=Metal composite marginal interface ‑ ‑ ‑ ‑ ‑ ‑ 3 ‑ ‑ 1 ‑ ‑ 1 month=28.47 Significant at 1 month, 6 months
1=Partial loss of veneer ‑ 2 14 ‑ 2 12 ‑ 1 6 2 1 5 3 months=2.14 and 9 months (P< .001)
2=Surface loss ‑ 8 ‑ ‑ 6 ‑ ‑ 5 ‑ 3 ‑ 6 months=34.32 Non-significant at 3 months
9 months=17.07 (P=0.144)
3=Complete loss of veneer 0 0 2 0 3 6 0 6 12 ‑ 10 13
Type of fracture
0=Adhesive ‑ ‑ 16 ‑ 3 18 3 6 18 1 10 18 1 month=42.91 Significant (P< .001 at 1 month,
1=Cohesive ‑ 8 ‑ ‑ 6 ‑ ‑ 5 ‑ ‑ 3 ‑ 3 months=29.70 3 months, 6 months and 9
2=Mixed ‑ 2 ‑ ‑ 2 ‑ ‑ 1 ‑ 2 1 ‑ 6 months=12.37 months)
9 months=21.87
Stain resistance
0=No staining 16 10 13 9 5 5 0 0 0 0 0 0 1 month=5.31 Significant (P= .001 at 6 months
1=Minor staining 4 4 5 4 6 5 8 3 3 2 2 1 3 months=2.44 and P<.001 at 9 months)
2=Noticeable staining 0 6 0 7 6 4 12 10 4 17 6 4 6 months=14.21 Non-significant at 1 month
9 months=17.08 (P=0.07)
Non-significant at 3 months
(P=0.296)
Marginal gingiva status
0=Not inflamed 20 18 19 20 18 19 18 18 16 18 15 16 1 month=2.07 Non-significant at all intervals
1=Inflamed 0 2 1 0 2 1 2 1 3 1 3 2 3 months=2.07 with P=0.355 (1 month), P=0.355
6 months=1.12 (3 months), P=0.571 (6 months)
9 months=1.21 and P=0.547 (9 months)
Parental satisfaction
0=Happy 18 10 17 18 10 10 17 9 6 17 7 6 1 month=10.80 Significant at all intervals with
1=Satisfied 2 5 2 2 4 8 1 4 7 1 4 6 3 months=9.71 P=.01 at 1 month, 3 months and
2=Unhappy 0 5 1 0 6 2 2 6 6 1 7 6 6 months=9.83 6 months and P<.01 at 9 months
9 months=13.79

relative to SSC restorations.[6] They require a greater
reduction of tooth structure during preparation than is
the case for traditional SSCs. In addition, esthetic SSCs
are expensive, cannot always be crimped to fit to the
prepared tooth, and repair of fractured coatings may
entail complete replacement. There is also a greater
need for occlusal reduction for placing esthetic SSCs,
which can increase the risk of exposing vital pulp. The
shape of an esthetic SSC cannot be altered, because
this would change the rigid metal coping structure
beneath the somewhat brittle composite, leading to the
possibility of future fracture.
For all three methods, tooth preparation was done
in the usual manner including adaptation, occlusion
verification: the standard procedure was done till the
SSC was ready for cementation. For 20  cases each of
open face technique and buccal grooves, the crown
was cemented using glass ionomer luting and lining
cement  (GC Gold Label), and for the 20 sandblasted
crowns, luting was done using a temporary cementing
media: zinc oxide eugenol. The patient was thereafter
recalled for the 2nd  visit; after 2  days, changes in the
occlusal anatomy were verified and the buccal surface
preparation and veneering were done. The preformed
3M SSC used in the study exhibits an anatomy similar
to that of the primary teeth, but it is not exactly the same
as the primary tooth replaced. Moreover, masticatory
forces play an important role in the occlusal anatomical
changes that occur in the cemented primary molar SSC.
The force generated during routine mastication of food
such as carrots or meat is about 70–150 Newton  (16–
34 lbf). The maximum biting force is around 500–700
Newton (110–160 lbf).[7] These forces may cause changes
in the occlusal morphology and also influence the veneer
retention. Since in the present study, the retention of
the composite veneering was to be evaluated; therefore,
the veneering of the buccal surface of the cemented

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SSC was done after 2  days, when the occlusion has
somewhat stabilized and adjusted. The investigator
observed changes in the occlusal anatomy observed in
20 of the 60 crowns. These findings can be corroborated
with those of Gallagher et al.,[8] who found maximum
intercuspation position was disturbed by the placement
of a SSC in seven of twenty cases studied and in most
cases returned to preoperative status within 4  weeks
of crown placement. The technique used for the buccal
surface preparation for both open window and buccal
grooves is similar to the method used by Yilmaz and
Kocogullari[9] but with certain following modifications:
first, in the present study, the window was prepared
in the 2nd  visit, whereas in the technique used by
Yilmaz and Kocogullari, the window preparation was
carried out in the 1st visit which was then covered by
a temporary restorative material. Second, preparation
of buccal grooves and veneering was done intraorally
on the cemented SSC in the 2nd  visit in our study as
compared to extraoral preparation of the buccal surface
of the SSC by Yilmaz and Kocogullari. Furthermore,
in the present study, window and buccal grooves’
preparation was done using tapering fissure diamond
bur ISO 160/012 and diamond straight fissure bur ISO
111/012, respectively, instead of a diamond round bur
no. 12. However, buccal grooves should be prepared
carefully with bur else it may result in perforation of
the crown.
After the window preparation, the GIC luting cement
left on window area was removed using hand or
rotary instrument to expose the underlying tooth
structure. Apart from bonding agents, various surface
treatment options can be used to enhance the bond
strength between the SSC surface and the composite
veneering, of which sandblasting is one which is easily
available and not technique sensitive.[5] Sandblasting
of the metal surface can be done using alumina oxide
of varied particle size  (25, 80, 110, and 250 μm) at a
specific pressure for a particular period of time: which
results in the exposed metal surface to have dull frosty
appearance. Gomes et al.[10] quoted that although no
study has been found on the effect of the sandblasting
particle size on the bond strength to zirconia and
stainless steel, an investigation on the optimal surface
treatments for carbon/epoxy composite adhesive joints
concluded that the surface roughness, eroded length,
and eroded depth increased as the particle size of
sandblasting increased, as rough surfaces increase the
area of the adhesive joint and the effect of interlocking.
For sandblasting, the temporarily cemented SSC was
removed after 2  days using a small spoon excavator
on the lingual side such that the marginal adaptation
on the buccal side was not much altered. The buccal
surface of the removed SSC was sandblasted using
aluminum oxide particles size of 250 µm, under
pressure of 4 psi at a constant distance of 1.5 inches
for 40 s. The procedure of veneering was carried out
extraorally and immediately as McCaughey[11] found
that strength of sandblasted metal was affected
Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 2 | April-June 2018
Khurana, et al.: Chairside techniques to veneer SSCs
adversely by more time interval between sandblasting
and bonding composite.
All 60 SSCs were retained at the end of the study. This
is in accordance with a study conducted by Roberts
et al. (2005)[12] where SSCs whose maximum and mean
follow‑up period was 7.69 and 2.13 years, respectively,
showed a success of 97%. In the present study, the
retention/fracture of the veneer was assessed according
to the classification given by Leith and O’Connell[13]
and the type of fracture was recorded as adhesive,
cohesive, and mixed as described by Yoshida et al.[14]
The open window technique showed a success rate of
84.2% (16 out of 19 veneers intact at the end of 9 months)
which was in accordance with the study conducted
by Yilmaz and Kocogullari,[9] who found that crowns
veneered with the open window technique had a
success of 95% at the end of 18 months. The high success
rate for this technique may be attributed to (1) chemical
bonding of resin to tooth; (2) use of dentin bonding
agent: single bond universal, a self‑etch, and total etch
adhesive. Yoshida et  al.[14] showed that self‑etching
adhesives that utilize 10‑methacryloyloxydecyl
dihydrogen phosphate form self‑assembled nanolayers
at the tooth‑bond interface, which could be the reason for
their higher bond strengths to tooth; and (3) phosphoric
acid etching: following the manufacturer instructions,
the prepared tooth structure was etched and the metal
surface was not etched before application of bonding
agent. therefore, etching and use of bonding agent both
may result in greater bonding of the composite resin
with the tooth.
In cases where sandblasting was done before
veneering, the success rate at the end of 9  months
was approximately 25%  (4 of 18  cases showed a
completely intact veneer). Complete adhesive failure
was seen in ten cases: majority of which showed
cohesive failure and a few had partial adhesive failure
initially which then progressed to complete adhesive
failure. These findings are similar to those found by
Hattan et al.,[15] who used another universal bonding
agent (scotch bond universal adhesive) for composite
veneering in 20 sandblasted crowns, and on in vitro
testing using a universal testing machine found
adhesive, cohesive, and mixed type of failure in 9,
2, and 9  cases, respectively. Another in vitro study
conducted by Khatri et al.[16] for the evaluation of bonded
conventional and nanocomposite resin on sandblasted
anterior SSCs using the bonding Prime and Bond NT
revealed that, in the conventional composite group,
the fracture site distribution observed was adhesive
failure 6 (40%), cohesive failure 6 (40%), and combined
failure 3  (20%), and in the nanocomposite group, the
fracture site distribution observed was adhesive failure
6  (40%), cohesive failure 4  (26.66%), and combined
failure 5  (33.34%). Therefore, in both these studies,
the percentage of cases exhibiting adhesive failure is
similar to what is seen in the present study (55.5%).
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Khurana, et al.: Chairside techniques to veneer SSCs
On comparing veneer retention in sandblasting and
buccal grooves techniques, veneer was retained in
more cases of sandblasting as compared to grooves
and this better outcome may be attributed to the
complete surface preparation by sandblasting as
compared to placement of five grooves at a distance
in the 3rd  group to aid in the retention of the veneer
along with the universal bonding agent used. Salama
and el‑Mallakh[5] in an in vitro study found that the
mean shear bond strength of sandblasted SSC bonded
to  Dyract (a compomer resin material) was 9.518
MPa as compared to compomer bonded directly to
the metal surface (shear bond strength of 2.998 MPa).
Apart from the aforementioned reasons for the better
retention of the veneer in the open window technique,
another reason may be that metal (thickness of 0.2 mm)
is not removed from the buccal surface in cases of
sandblasting and buccal grooves and although an
attempt has been made to maintain the thickness of the
veneer at 1.5–2  mm approximately, greater thickness
at the buccal surface in these groups might lead to
overcontouring of the restoration and thus result in
greater cases of veneer fracture.
Almost all composite veneers which were retained
showed gradual yellow staining over the period of the
study. The staining gradually increased in intensity
over the period of 9 months. This yellow staining can
be attributed to food, mainly turmeric that is used
extensively in almost all preparations mainly in this
part of the country. This was in accordance with a study
conducted by Yew et al.,[17] who conducted a study
to evaluate color stability of a resin composite upon
exposure to spices: turmeric, paprika, and tamarind
and found that the highest color deviation was
obtained in the turmeric group. Another reason for the
noticeable yellow staining can be improper oral hygiene
maintenance and therefore plaque accumulation.
The gingival health around the crowns was optimal
in most cases during the duration of the study.
A total of 6 cases in all groups (1 case – open window,
3  cases  –  sandblasting, and 2  cases  –  buccal grooves)
showed slight gingival marginal inflammation, i.e.,
reddening of the gingiva around the crown at the end
of the study. This inflammation may be attributed to
retentive areas for plaque accumulation on the veneer
which were a result of chipping of the same, more so
at the borders of the veneer, and patients following
an improper method of brushing. The rough edges
of the veneer were smoothened and oral hygiene and
brushing instructions were reinforced at subsequent
visits. There were several limitations associated
with the study, the most important being the short
follow‑up. However, considering that SSCs were
retained in 100% of the cases with veneer failure in all
groups and presence of staining in composites veneers,
the patients might tend to ask for replacement of the
composite veneers as they might be dissatisfied with
the esthetics and hence this study might be clinically
relevant considering 9‑month follow‑up. Blinding of
204 Journal of Indian Society of Pedodontics and Preventive Dentistry | Volume 36 | Issue 2 | April-June 2018
the operator is not possible in such clinical trials which
theoretically might create a source of bias.
Conclusions
In the present study, the open window technique of
veneering showed maximum retention of composite
veneers; therefore, the highest level of parental
satisfaction. To conclude, based on the present study,
open window technique of veneering SSCs can be
adjudged as the best method of veneering SSCs for
esthetic purposes. The most common fracture type
was adhesive seen at the metal composite interface.
Gradual yellow staining of the composite veneer was
seen over the period of the study. Most cases showed
an optimal gingival health at the end of the study.
Though all the 3 techniques used to provide a chairside
and easy method for esthetic modification of the SSC,
the open window is the most successful of the three
methods of veneering.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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