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219]

Original Article

Clinical Evaluation between Zirconia Crowns and Stainless Steel Crowns

in Primary Molars Teeth

Abstract Bashaer S.
This randomized clinical trial compared the clinical outcomes of two full‑coronal Abdulhadi,
restorations  (stainless steel crowns  [SSCs] and zirconia crowns Nu/ZR) in carious primary molars Medhat M.
teeth. Children attending the King Abdulaziz University, Faculty of Dentistry clinics who need
restorations will be screened for inclusion criteria till 120 teeth are recruited  (60 teeth for SSC Abdullah,
restorations and 60 for Nu/ZR restorations). Split mouth technique will be used to ensure equalizing Sumer M. Alaki,
variables for both groups. Randomization will be done using SPSS software version 20.0 (Armonk, Najlaa M. Alamoudi,
NY; IBM Corp., USA). A  simple descriptive statistic will be used for analysis using Wilcoxon Moaz H. Attar
Signed‑Rank test. The level of significance will be set at  (α =  0.05) and level of confidence Department of Pediatric
at  (95%). While looking at the improvements in gingival health relative to interventions, both Dentistry, Faculty of Dentistry,
Zirconia and SSC have significant changes through all time points. However, Zirconia performed King Abdulaziz University,
better at the 3rd  month with 80% compared to SSC with only 13.3% improvement with P <  0.001 Jeddah, Kingdom of Saudi
and 0.005, respectively. At 6th  month, all samples under group zirconia already improved whereas Arabia
only 73.3% from SSC show improvement. The remaining samples happened to have positive
changes at the 12th  month. Regarding the plaque retention also the Zirconia Crowns shows
improve performance than SSC. As both SSC and Zirconia crowns presented to be an excellent
choice for posterior teeth restorations, however, we can conclude that Zirconia crowns performed
better regarding gingival response to the material of restoration and plaque retention despite its
high cost.

Keywords: Primary posterior teeth, stainless steel crown, zirconia crown

Introduction probable  (e.g., interproximal caries ranging

Early childhood caries  (ECC) is a
protracted multifactorial disorder which
continues to be dominant in children,
especially in the families with low
socioeconomic class.[1‑6] ECC is construed
as “the existence of one or more tooth
decays  (noncavitated or cavitated lesions),
removed  (due to caries), or filled tooth
surfaces in any primary dentition of
children under the age of 6  years.”[7] ECC
remains to be a global health problem,
involving the foremost carious lesion of
the primary maxillary incisors, then the
mandibular, maxillary first primary molars
and mandibular cuspids.[8] Stainless steel
crowns  (SSCs) has been utilized for the
restoration of primary dentition affected
by caries, decalcification in the neck of
the tooth, and developmental defects  (e.g.,
hypoplasia, hypo calcification).[9] It is
also used when the downfall of further
accessible restorative supplies is more
This is an open access article distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0
License, which allows others to remix, tweak, and build upon the
work non‑commercially, as long as the author is credited and the
new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
farther than line angles, children with
bruxism).[9] Moreover, next to pulpotomy or
pulpectomy, SSC is used in the restoration
of a primary tooth which will be exploited
as an abutment to maintain space or to be
used as interposed rehabilitation of severed
teeth.[9]
In children with high‑caries‑risk, absolute
management of primary dentition with
SSCs is indicated over time compared to
multi‑surface intra‑coronal restorations.
After scrutinizing of available literature
Address for correspondence:
concerning the comparison of SSCs and Dr. Bashaer Salem Abdulhadi,
Class  II amalgams the conclusion is that, Faculty of Dentistry, King
for multi‑surface restorations in primary Abdulaziz University, Jeddah,
teeth, SSCs are superior to amalgams.[10] Kingdom of Saudi Arabia.
E‑mail: dr.bashaer@yahoo.com
SSCs have a success rate greater than that
of amalgams in children under the age
of 4  years. Over the years, numerous Access this article online
clinical studies including the longitudinal Website: www.jpediatrdent.org
studies by Messer and Levering, 1988[11]
DOI: 10.4103/jpd.jpd_21_17
and Einwag and Dünninger 1996[12]
Quick Response Code:
have demonstrated the superiority of
How to cite this article: Abdulhadi BS, Abdullah MM,
Alaki SM, Alamoudi NM, Attar MH. Clinical evaluation
between zirconia crowns and stainless steel crowns
in primary molars teeth. J Pediatr Dent 2017;5:21-7.

© 2017 Journal of Pediatric Dentistry | Published by Wolters Kluwer - Medknow 21

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Abdulhadi, et al.: Clinical evaluation between zirconia crowns and stainless steel crowns in primary molars teeth
SSCs in restoring primary molars with multi‑surface
involvement.[10‑14]
Usage of SSCs should also be accounted in patients with
heightened risk of caries whose participation is distressed
by age, behavior, or medical history. Most often, these
patients obtain treatment under sedatives or general
anesthetics. SSCs tends to last long in patients with
developmental or medical conditions that do not improve
as they age thus reducing the possible usage of sedatives
and general anesthetics considering that it is costly and
its inherent perils. However then again, severely damaged
primary dentitions among pediatric patients is deemed to be
one with immense difficulties, to treat esthetically. During
the past 50 years, the prominence on taking care of mostly
degenerating primary dentition changed from removal
to rehabilitation. Early recovery includes employment of
stainless steel binding or crowns on critically damaged
dentition. While working, they were unesthetic, and its
usage is confined to posterior dentures. The mesial buccal
area of the first primary molars and second maxillary
primary molars may be seen when the child smiles.
During the past 20  years, there was an increased demand
by adults in the esthetic restoration of their jeopardized
dentures. Equivalently, a higher esthetic standard is
expected by parents for the recovery of their children’s
carious teeth. More recently, zirconia esthetic crowns
appeared on the market. Zirconia is a crystalline dioxide of
zirconium that has mechanical properties similar to those of
metals, and its color is similar to that of teeth. Ready‑made
first zirconia crowns are now available for both, primary
incisors and molars.
The aim of this clinical research is to evaluate and compare
two full coronal restorations on primary posterior molars
over 3, 6, and 12 months regarding recovery failure, marginal
integrity, proximal contact, secondary caries, occlusion,
and gingival response. The restorations type included are
prefabricated SSCs and prefabricated primary zirconia crowns.
Materials and Methods
Study design
The study is a randomized regulated clinical trial that
followed the standards published by Consolidated Standards
of Reporting Trials.[15]
The study is authorized by the Research Ethics Committee
of King Abdulaziz University Faculty of Dentistry with
reference no.  076‑16 before enrolment, a consent form
were distributed to the children’s parents or guardians.
This study is also registered at ClinicalTrials.gov under
registration number NCT03067337.
Sample size
Using G*Power 3.1.9.2 software  (Franz Faul, Universität
Kiel, Germany, 2014)[16] for power analysis, it was indicated
22
that we need a total of 120 teeth  (corresponding to around
60 children to achieve 80% power with 95% confidence)
assuming medium effect size in the mean change in
gingival health 6  months after crown application between
Zirconia and SSC group with the assumption of nonnormal
distribution. The number of crowns in each arm will be 60.
Sample selection
A sample of 120 contralateral primary molars in 26 patients
were treated in the Pediatric Dental Clinics, King Abdulaziz
University, Faculty of Dentistry, Jeddah. All patient who
presented from August 1, 2015, until September 30, 2015,
and met specific inclusion criteria were included in the
study [Figure 1].
Inclusion criteria
• Patient within the age group of four to 8 years
• Patient with at least two matched bilateral carious
primary molars indicated for full coverage
• Healthy children free of any systemic disease or any
developmental disturbances of the teeth and jaws
that would have affected dietary patterns, caries,
susceptibility or the selection of restorative materials to
the best of the current knowledge
• Minimal of two surfaces of caries in the targeted tooth
• Patient with ECC as defined by the American Academy
for Pediatric Dentistry
• Cooperative patient who had the behavioral rating
“no undercuts or ledges are remaining” or “definitely
positive” according to the Frankl behavior classification
scale[17]
• Penned authorization was obtained from the parent/
guardian after explaining the full details of the treatment
procedure and its possible outcomes, discomfort, risks,
and benefits
• No patient was excluded by gender, race, social, or
economic background [Figure 1].
Clinical procedure
One operator completed all teeth preparations and
restorations procedures. Local anesthesia was achieved
using lidocaine hydrochloride 2% with epinephrine
1:100,000. The teeth were isolated using a rubber dam.
After caries, excavation tooth was prepared according to
manufactural instructions.
Teeth restored were assigned to a certain group according
to the type of crown applied to each tooth. Sixty teeth
were assigned to Group A and restored with SSCs, another
sixty teeth were assigned to Group  B which restored with
zirconia crowns.
Group A (stainless steel crown)
Reduction of the occlusal surface by about 1.5  mm using
a flame shape or tapered diamond bur to produce uniform
occlusal reduction. Employing gilt‑edged, long, and tapered
diamond bur, adhered marginally convergent to the remote
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Abdulhadi, et al.: Clinical evaluation between zirconia crowns and stainless steel crowns in primary molars teeth
access of the denture and cut interproximal slices mesially
and distally. The reduction should allow the probe to pass
through the contact area.
An appropriate size was chosen according to mesiodistal
width of the prepared tooth and trail fit carried out before
cementation. The crown should remain no more than 1  mm
subgingivally if there is an excessive shrinking of the gingival
tissues the segment of the crown should be decreased.
The margins should be smoothed after reduction with white
stone.
Group B (zirconia crowns)
After anesthesia execution and rubber dam placement next
was the crown size selection. Suitable crown size can be
identified using NuSmile  (Houston, TX, USA) Try‑In
Crowns and should always be selected on the start of tooth
reduction.
Occlusal, proximal, and supragingival reduction
Decrease the occlusal surface next to the natural occlusal
profile by roughly 1–1.5  mm. Unfasten the interproximal
contacts. The proximal abatement should be enough to
permit the chosen crown to fit passively. The tooth should
be trimmed down circumferentially by around 20%–30%,
or 0.5–1.25 mm as needed.
Figure 1: A consort diagram showing the flow of patients
Journal of Pediatric Dentistry | Volume 5 | Issue 1 | January-April 2017
Such procedures can be administered with the use, of
course, tapered diamond or carbide burs; a coarse football
diamond bur can be utilized to decrease the occlusal area
of hindmost dentition.
Subgingival reduction
The anticipated edge should be anxiously stretched out
and polished to a feather‑edge so that no undercuts or
subgingival ridges stay roughly 1–2  mm subgingivally
on every area. A  slim, narrowed diamond bur should be
utilized to prevent the breaking up of tissue during the
execution of such subgingival tooth modifications.
Completion of the preparation
Eliminate line and point angles to allow all areas of the
prepared denture to be marginally rounded. Now analyze
once more for adequate occlusal allowance with the
divergent teeth as well as to ensure the lack of undercuts or
ledges subgingivally.
Crowns seating
Prepared teeth should be free from any blood or residues,
saliva, and gingival blood. Compression or hemostatic
tools can be utilized for such intent as needed. NuSmile
BioCem® Universal BioActive cement, resin cement,
or resin‑modified glass ionomer can be employed to sit
NuSmile ZR Crowns. If pulpal therapy was enforced
using a eugenol based substance in the pulp compartment,
conceal the eugenol substance using glass ionomer before
cementation.
Evaluation criteria
The evaluation of each crown restoration was assessed at
the baseline which is the same day of the procedure, 3, 6,
and 12  months. Clinical failure parameters were evaluated
with visual assessment of the restoration, according to
the United States Public Health Service  (USPHS), alpha
criteria rating system.[18] As if the crown appears normal,
no cracks, chips, or fracture, or small but noticeable area of
loss of material, or large loss of crown material and finally
if there was a complete loss of crown.
The performance of the two restorations was evaluated
using the modified USPHS criteria, in terms of marginal
integrity, gingival health, secondary caries, proximal
contact, and occlusion.
The gingival health and plaque index were assessed using
a blunt periodontal probe  (Double ended probe Williams
1‑2‑3‑5‑7‑8‑9‑10 Goldman Fox Flat) according to the
Löe.[19]
Statistical analysis
This study will be analyzed using IBM SPSS
version  23  (Armonk, NY, USA). Simple descriptive
statistics will be applied to characterize the variables of the
study through tally and percentages for the definitive and
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nominal variables, whereas mean and standard deviations
will represent the constant variable. In comparing the
distributions of two variables, two‑related‑samples tests
with Wilcoxon signed‑rank will be used. These tests are
assumed to be observing normal distribution. In rejecting
the null hypothesis, the standard P < 0.05 will be applied.
Results
Application of full coronal restorations was done on
maxillary and mandibular first and second primary molars
summing to 120 molar teeth  (60  males and 60  females).
The average age at the baseline was 5.57 with no drop out
happened until the 12 months follow up [Table 1].
Regarding the gingival health, all teeth were examined at
the baseline, 3, 6, and 12  months and scored according
to the gingival health status. All molar teeth included
in the study showed no gingival bleeding with a probe
at the baseline examination. On the other hand, during
the 3  months follow‑up, 80% of the teeth restored with
zirconia showed no gingival bleeding compared to the 13%
no bleeding in the group of teeth restored by SSC. During
the 6 months follow‑up, the percentage of the teeth covered
by zirconia crowns reach 100% healed gingivae with all
teeth shows no gingival bleeding upon probing. However,
the SSC group still had 26.7% bleeding with probing on
the 6  months’ follow‑up. Finally, all teeth gingival health
on both groups were no signs of gingival inflammation
when they reach the 12 months follow‑up [Table 2].
Table 1: Demographics
n Minimum Maximum Mean
Age 120 4.0 8.0 5.57
Demographics Count (%)
Total 120 (100.0)
Nationality
Saudi 94 (78.3)
Non‑Saudi 26 (21.7)
Gender
Male 60 (50.0)
Female 60 (50.0)
SD: Standard deviation
Both groups were checked regarding the plaque index and
scored according to Silness, and Loe criteria at the baseline
all showed 100% no plaque as the treatment started after
prophylaxis was done to all teeth and also dental health‑care
instructions to the patients and their parents. Although oral
hygiene training has been done for all the patients under
their parents’ supervision, 73.3% of teeth covered by zirconia
crowns showed a plaque film sticking to the free gingival
margin which can only be observed with the use of the probe
in the three months’ follow‑up. Contralaterally, the teeth
covered with SSCs presented at the same follow‑up period
with 53% having moderate deposit accumulations within the
gingival compartment, on gingival border and neighboring
tooth façade, visible to the eye. After three more months of
the 6 months follow‑up, the majority of the zirconia covered
teeth improved reaching 83.3% without plaque accumulation
on crowns surfaces. On the other hand, 66.7% of the teeth
covered with SSCs still presented a plaque film sticking
to free gingival margin that cannot be seen with the naked
eye at the 6  months follow‑up. Finally, at the 12  months
follow‑up of the zirconia group all teeth scored zero with
100% no plaque accumulations, whereas in the SSC group,
75% of the teeth have no plaque accumulations [Table 3].
All teeth on both groups were presented at the 12  months
follow‑up without caries and showed normal occlusion and
with normal appearance; no crack, chips, or fractures in the
crowns [Table 4].
The proximal contact of all teeth was restored after crowns
placement to the same situation before restoration. All the
criteria of resistance were met when passing floss except two
SD teeth that were spaced before doing the restoration as they
1.1 showed floss passage without resistance but contact is present.
Moreover, all teeth included in the study showed no
recurrent caries after the whole 12 months follow‑up period.
This is also explained by the success of all restoration over
the 12 months as the teeth under full coverage crowns.
Discussion
After the 12  months follow‑up, the success rate of both
crowns tested in this study (Zirconia and SSC for posterior

Table 2: Gingival health

Variables Gingival health 0 month (zirconia) Gingival health 0 month (SSC)
Bleeding with probe (%) Z P Bleeding with probe (%) Z P
Total 60 (100.0) 60 (100.0)
Gingival health 3 months
No gingival bleeding 48 (80.0) −6.928 <0.001a 8 (13.3) −2.828 0.005a
Bleeding with probe 12 (20.0) 52 (86.7)
Gingival health 6 months
No gingival bleeding 60 (100.0) −7.746 <0.001a 44 (73.3) −6.633 <0.001a
Bleeding with probe 0 16 (26.7)
Gingival health 12 months
No gingival bleeding 60 (100.0) −7.746 <0.001a 60 (100.0) −7.746 <0.001a
a
Significant using Wilcoxon‑rank test at <0.05 level. SSC: Stainless steel crowns

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teeth) showed 100% success with all crowns appear healthy
with no chips, cracks, or fractures. Regarding the SSCs
our result comes along with many studies tested the SSCs
and compared it with many different restorative materials.
In 2008, Atieh[20] did a randomized control trial for
2  years concerning the restoration of primary teeth from a
pulpotomy procedure with a survival rate for restored teeth
having performed metal crowns to be 95%. On the other
hand, no published data yet available about zirconia crowns
restorations success for next primary molar teeth except
for the studies done by the product company  (Nusmile,
Houston, TX, USA).
Results showed that gingival health was better in teeth
restored with Zirconia crowns than those which treated with
SSCs during 3 and 6 months follow‑up, but later 12 months
follow‑up revealed both groups presented with healthy
gingiva. These results could be explained as Zirconia used
for tooth component exhibits remarkable biocompatibility
as well as shows smooth plus polished exterior which lead
to the lower tendency of plaque build‑up and thus lower
chance of gingival irritation. Earlier publications on fixed
partial dentures using zirconia structure on fixed dentition
observed similar outcomes: decreased plaque build‑up.[21,22]
While another study done by Walia, et  al., in 2014[23]
examined Zirconia teeth on primary anterior teeth shows
favorable gingival health toward those crowns.
Regarding gum condition with preformed SSC, a year‑long
arbitrarily regulated test revealed a lack of disparity in
gum inflammation comparing preformed metal crowns
plus composite restorations on pulpotomy.[24] An arbitrary
clinical research with a duration of 2  years revealed
an increased gum bleeding on preformed metal crowns
compared to composite/glass ionomer reinstallations.
Insufficiently shaped crown as well as set cement debris
staying associated with gum sulcus result to gingivitis
linked to preformed metal crowns, hence precautionary
routine which includes oral hygiene teaching is suggested
to be added to the treatment plan.[10]
This may justify the improvement of the gingival health
adjacent to SSCs with time as the remnant cement materials
washed away and degraded with time and oral fluids.
Regardless, the oral hygiene instructions have been given
to the patients and their parents. However, they still keep
coming with plaque accumulations in each follow‑up but
with different percentages between the two tested groups.
As mentioned earlier in the results, the Zirconia crowns
group presented fewer plaque accumulations during the
follow‑up periods and also improved with time. On the
other hand, SSCs showed more plaque accumulations,
and statistically significant difference between the two
groups regarding the plaque index toward the zirconia
group  (P  <  0.001) was observed. Some researches have
been conducted regarding the gingival health of primary
teeth restored with SSCs. Goto, et  al., in 1970[25] recorded
that the frequency of gingivitis in primary dentition
replaced with nickel‑chromium crowns. It was disclosed
that the rate of gingivitis identified including a crown above
the posterior portion of the mouth rather than the anterior is
greatly correlated with badly fitted crowns. The occurrence
of gingivitis in controlled teeth was not disclosed.
In 1973,[26] Henderson stated that the plaque index for
SSC teeth is relatively lower than that in the whole oral
cavity. Degrees of marginal gingivitis neighboring the
crowns measured for the fixture as “good” or “fair” were

Table 3: Plaque index

Variables Plaque index 0 month Plaque index 0 month
No plaque (zirconia) (%) Z P No plaque (SSC) (%) Z P
Total 60 (100.0) 60 (100.0)
Plaque index 3 months
No plaque 8 (13.3) −6.798 <0.001a 4 (6.7) −6.730 <0.001a
A film of plaque adhering to the free gingival 44 (73.3) 24 (40.0)
margin cannot be seen with the naked eye
Moderate accumulation of deposits in the 8 (13.3) 32 (53.3)
gingival pocket, on gingival margin and/or
adjacent tooth surface, seen by eye
Plaque index 6 months
No plaque 50 (83.3) −3.162 0.002a 18 (30.0) −6.345 <0.001a
A film of plaque adhering to free gingival 10 (16.7) 40 (66.7)
margin can’t be seen with naked eye
Moderate accumulation of deposits within the 0 2 (3.3)
gingival pocket and margin is seen by naked eye
Plaque index 12 months
No plaque 60 (100.0) 0.000 1.000 45 (75.0) −3.873 <0.001a
Film of plaque adhering to the free gingival 0 15 (25.0)
margin can’t be seen with naked eye
a
Significant using Wilcoxon‑rank test at <0.05 level. SSC: Stainless steel crowns

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