DOI: 10.1111/ipd.
12348
Survival of extensive restorations in primary molars: 15-year
practice-based study
BATTSETSEG TSEVEENJAV 1,2, JUSSI FURUHOLM2,3, AIDA MULIC2, H

AKON VALEN2,
TUOMO MAISALA , SEPPO TURUNEN , SINIKKA VARSIO , MERJA AUERO1 &
1 1 1
€
LEO TJADERHANE 3
1
Department of Social Services and Health Care, Oral Health Care, City of Helsinki, Helsinki, Finland, 2Nordic Institute of
Dental Materials, Oslo, Norway, and 3Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki,
Finland
International Journal of Paediatric Dentistry 2017
Background. Caries decline in the western world
is accompanied by strong polarization among chil-
dren; 8% of Finnish 5-year-olds having 76% of
untreated caries. This high caries risk group needs
preventive and restorative strategies.
Aim. To explore survival of extensive restorations
in primary molars.
Design. This study was based on health records
from 2002 to 2016 of children under 18 years.
Results. Of severely affected primary molars
(n = 1061), 41% were restored with preformed
metal crowns (PMCs), 38% with glass-ionomer
cement (GIC)/polyacid-modified resin composite
(PAMRC)/resin-modified GIC (RMGIC), and 21%
Introduction
Dental caries is one of the most widespread
chronic conditions regardless of age1. Exten-
sively decayed teeth have a negative impact on
children’s mental, physical, and social well-
being as well as quality of life1,2. In Western Eur-
ope, the prevalence of dental caries has declined
since mid-1970s3–5. At the national level in Fin-
land, for instance, on average two-thirds of 5-
year-olds, almost half of 12-year-olds and about
one-fifth of 17-year-olds were caries free6. The
decline in caries prevalence is, however, accom-
panied by strong polarization. Among Finnish 5-
year-olds, 8% had 76% of all untreated caries3.
When carious and developmental defects
require operative therapy, there are several
Correspondence to:
Battsetseg Tseveenjav, Department of Social Services and
Health Care, Oral Health Care, City of Helsinki, P.O.B
6440, 00099 Helsinki, Finland.
E-mail: battsetseg.tseveenjav@helsinki.fi
© 2017 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
with resin composites (RC). Younger children (3–8)
received 97% of the PMCs and 86% of GIC/PAMRC/
RMGIC; older ones (≥9) 91% of the RC restorations.
Neither amalgam nor indirect restorations were reg-
istered. General dentists (GDs) engaged in primary
care restored with GIC/PAMRC/RMGIC (52%) or
RC (48%). GDs in general anesthesia care service
placed 66% and specializing/specialized dentists
31% of PMCs. PMCs had lower failure rate (1.4% vs
3.0%) than GIC/PAMRC/RMGIC (P = 0.001).
Choosing PMCs reduced patient visits compared to
other restorations (P < 0.001).
Conclusions. Severely affected primary molars of
children at high caries risk are better managed,
using PMCs to optimize the resources in public
oral health services.
different materials and techniques available7–10:
resin composites (RC), glass-ionomer cements
(GIC), polyacid-modified RC (PAMRC)/com-
pomer, resin-modified GIC (RMGIC), amalgam,
different types of preformed crowns and tech-
niques as well as indirect restorations. Pre-
formed metal crowns (PMCs) in primary teeth
are recommended in current guidelines of pro-
fessional associations and societies such as
American Association of Paediatric Dentistry7
and British Society of Paediatric Dentistry
(BSPD)11. Indications for PMCs are develop-
mental defects, extensive carious lesions, or
fractured teeth involving multiple surfaces8,12.
PMCs are also recommended in occlusally-
stressed posterior primary teeth13, following
pulpotomy14 and in children who require den-
tal care under general anesthesia11,15. Regard-
less of the recommendations, a study among
general dentists (GDs) in United Kingdom
revealed that they did not follow BSPD guideli-
nes11. The GDs considered that these crowns
were unsuitable for most of the children, and
1
2 B. Tseveenjav et al.
the technique is impractical in busy daily prac-
tice16. GICs are hydrophilic and recommended
to use in pediatric dentistry because of several
properties7, such as biocompatibility, decreased
moisture sensitivity when compared to resins,
chemical bonding to both enamel and dentin,
thermal expansion similar to that of tooth struc-
ture, and uptake and release of fluoride, though
exhibit poor wear resistance. RMGICs have
superior wear resistance and strength to tradi-
tional GICs, indications of GICs/RMGICs for pri-
mary molars being class II cavities. RCs/PAMRC
are more esthetic and allow conservative tooth
preparation, although technique sensitive, indi-
cations in primary molars being also class II cav-
ities, which do not extend beyond the proximal
line angles. Amalgam restorations are generally
less technique sensitive, esthetic and require
macro-retention in cavity preparation, thus,
more loss of healthy tooth tissue, indications in
primary molars being extensive lesions7–9.
The aim of this study was to explore survival
of extensive restorations placed in primary
molars of children and adolescents under the
age of 18 years in the public oral health service
in Helsinki, based on 15-year practice.
Fig. 1. Study subjects and materials of this study.
© 2017 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Material and methods
Study design, participants, setting, and eligibility
criteria
This retrospective study was based on elec-
tronic health record (EFFICA) in the Oral
Health Care (OHC) of the City of Helsinki
from 2002 to 2016. Eligibility criteria were all
children and adolescents under 18 years of
age, attended the OHC service during the
study period and had in their treatment
record of primary molars at least one proce-
dure code used to register restoration extend-
ing to four or more surfaces of tooth (SFA40).
Based on these criteria, 717 children with his-
tory of extensive restoration were selected;
54% (n = 386) were boys. Materials used for
extensive restorations were divided into three
different material groups (Fig. 1), according
to the electronic health record system classifi-
cation: (1) Preformed metal crowns (PMCs),
(2) glass-ionomer cement (GIC)/polyacid-
modified resin composite (PAMRC)/resin-
modified GIC (RMGIC), and (3) resin com-
posite (RC). In most EU member states,

dental services are largely produced by pri-
vate sector. However, the Nordic model is
characterized by a fairly large public sector. In
Finland, public sector has a market of about
50% of total oral healthcare production17,
highly subsidized by taxation, and run by
municipalities. Children and adolescents up
to 18 years enjoy free-of-charge oral care,
whereas adults pay mostly out-of-pocket for
oral health services. The OHC of the City of
Helsinki, the biggest public oral health service
provider in Finland, organizes oral health ser-
vices for residents living in Helsinki, has two
organizational units, Local and Centralized
Services. In the OHC, primary oral health
care for children is provided by GDs in local
clinics. Only the most severe cases, medically
compromised or behaviorally challenging
children are referred to the Unit of Special-
ized Oral Care, where specializing/specialized
dentists (SDs) in pediatric dentistry provide
care. Anesthesia care is carried out by SDs or
GDs experienced in this field depending on
the level of severity of the cases. Dental stu-
dents (DSs) at the Faculty also take care of
children under supervision of clinical instruc-
tors.
Following data of the selected study sub-
jects were further gathered: age, gender,
tooth with extensive restoration, and number
of patient visits after the restorations. If there
were more than one restoration codes for a
single tooth because of renewal, the last
extensive restoration was chosen for further
analyses. We assumed that individuals of this
study belong to the high caries risk group
based on the presence of extensive restora-
tions in their primary molars. Age was further
sub-grouped into four categories. For data
reporting, primary molars were numbered,
according to universal tooth numbering sys-
tem. Operators were DSs, GDs engaged in pri-
mary care or in general anesthesia service
and SDs in pediatric dentistry.
Ethical considerations
This study was based on encrypted summary
data of electronic health records. No individu-
als could be identified, and ethical permission
was therefore not required. The use of data
© 2017 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Survival of extensive restorations 3
for this study was approved by the City of
Helsinki (Research permission decision HEL-
2017-000965).
Statistical evaluation
The extracted data were compiled into statisti-
cal software package IBM SPSS Statistics for
Windows (version 24.0, IBM Corp., Armonk,
NY, USA) program to be analyzed. For
descriptive statistics, chi-square test for differ-
ences in groups and one-way ANOVA test for
differences in means were used. Numbers of
patient visits after extensive restorations,
according to materials used, were tested by
one-way ANOVA. Games-Howell post hoc
tests for multiple comparisons were used to
find out differences between materials.
Kaplan–Meier analyses were used to create
survival means and curves. For survival of
extensive restorations, one extensive restora-
tion of each child or adolescent was selected
to obtain independent units for calculating
the failure rates. Thus, Kaplan–Meier analyses
included 557 teeth, 264 PMCs, and 293 GIC/
PAMRC/RMGIC restorations. RC restorations
were placed mainly in adolescents (≥9 years),
therefore being excluded from the survival
analyses. Tooth extraction was considered as
failure, and the follow-up period ended at the
tooth extraction or when the child turned
14 years of age. Empirical failure rates were
calculated from life tables with 3-year inter-
vals. Mean annual failure rates werepcalcu- ffiffiffiffiffiffiffiffiffiffiffi
lated according to the formula: 1
15 1
x ;
where ‘x’ expresses the total number of fail-
ures.
Results
Preformed metal crowns were most commonly
used for restoring extensive lesions; 97% of
PMCs and 86% of GIC/PAMRC/RMGIC being
placed in the primary and early mixed denti-
tion periods (P < 0.001), whereas 91% of the
RC restorations in children aged 9 years or
older. No gender difference was observed
for the materials used for extensive restora-
tions (P = 0.204; Table 1). Neither amalgam
nor indirect restorations were registered. Of
all extensive restorations (n = 1061), 36%
4 B. Tseveenjav et al.

Table 1. Filling materials used [preformed metal crowns (PMCs), glass-ionomer cement (GIC), compomer (PAMRC), resin-
modified GIC (RMGIC), resin composite (RC)] for extensive restorations (n = 1061), according to children’s age and gender
during 2002–2016.

PMCs GIC/PAMRC/RMGIC RC All

n (%) n (%) n (%) n

All 437 (100%) 406 (100%) 218 (100%) 1061 (100%)

BY AGE
3 to 5-year-olds (primary dentition) 282 (64%) 165 (41%) 8 (4%) 455 (43%)
6 to 8-year-olds (early mixed dentition) 142 (33%) 183 (45%) 10 (5%) 335 (32%)
9 to 13-year-olds (late mixed dentition) 13 (3%) 55 (14%) 77 (35%) 145 (13%)
14 or older 0 3 (<1%) 123 (56%) 126 (12%)
BY GENDER
Male 261 (60%) 222 (55%) 133 (61%) 616 (58%)
Females 176 (40%) 184 (45%) 85 (39%) 445 (42%)

specializing/specialized care (SDs), 3% by

Fig. 2. Filling materials used (preformed metal crowns
(PMCs), glass-ionomer cement (GIC), compomer (PAMRC),
resin-modified GIC (RMGIC), resin composite (RC)) for
extensive restorations (n = 1061) by tooth type among
children during 2002–2016.
(n = 380) were placed in children in general
anesthesia by GDs and 42% (n = 437) of the
extensively restored teeth (n = 1034) had
pulpotomies prior the restorations.
The lower second primary molar on the left
side (tooth 75), followed by the lower second
primary molar on the right side (tooth 85)
were the teeth that most commonly received
extensive restorations (Fig. 2). The use of
PMCs was highest in the year 2004, followed
by the year 2016 (Fig. 3).
Of all PMCs (n = 437), 66% were placed by
GDs in general anesthesia care, 31% by
DSs, and <1% by GDs in primary care ser-
vices (Fig. 4); choice of restorative materials
differed by operator (P < 0.001). The GDs
engaged in primary care restored extensive
lesions with GIC/PAMRC/RMGIC (52%) or
RC (48%).
Estimated survival time of PMCs (n = 264)
was, in average, 125 months (CI 95% 122–
128) and of GIC/PAMRC/RMGIC group
116 months (CI 95% 111–120; n = 293;
P = 0.001; Fig. 5). For PMCs, the mean annual
failure rate was 1.4% compared to 3.0% for
GIC/PAMRC/RMGIC. Empirical cumulative
failure rates with 3-year intervals differed by
restorative materials (Table 2).
The numbers of patient visits after the
extensive restorations differed statistically sig-
nificantly according to materials (Table 3),
Welch’s F (2, 453.831) = 30.475, P < 0.0005.
Post hoc multiple comparisons between mate-
rials also showed the differences were statisti-
cally significant between PMC and GIC/
PAMRC/RMGIC (P < 0.001) and between
PMC and RC (P < 0.001), but not significant
between GIC/PAMRC/RMGIC and RC
(P = 0.052).
Discussion
Preformed metal crowns (PMCs) were pre-
dominantly used for treating younger chil-
dren, during their primary (≤5 years) and
early mixed (6–8 years) dentition periods.
This is in accordance with the recommenda-
tions from a recent Cochrane review8. The

© 2017 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Fig. 3. Extensive restorations (n = 1061)
by materials (preformed metal crowns
(PMCs), glass-ionomer cement (GIC),
compomer (PAMRC), resin-modified GIC
(RMGIC), resin composite (RC) and year
of placement during 2002–2016.
Fig. 4. Extensive restorations (n = 1061)
by material used (preformed metal
crowns (PMCs), glass-ionomer cement
(GIC), compomer (PAMRC), resin-
modified GIC (RMGIC), resin composite
(RC)) and by operator: specializing/
specialized dentists (SDs), general
dentists (GDs), dental students (DSs).
use of PMCs was highest in general anesthe-
sia service, followed by the use in specialized
care service, reflecting also recommendations
of pediatric dental associations7,11,18. Of the
high numbers of PMC placement in 2004, a
majority was carried out by specializing den-
tists in pediatric dentistry. The increased use
of PMCs during years 2014–2016 may be
explained by twice weekly service of general
anesthesia, instead of earlier once weekly ser-
vice at the OHC level.
The use of RC was rare in younger children
(<9 years); 97% of RC restorations being
placed in adolescents (≥9 years) during the
study period. Based on the age of children,
some of these RC restorations were probably
placed in persisting primary molars or pri-
mary molars without permanent premolar
successors. Amalgam restoration was not reg-
istered in this study, as reported in a previous
Finnish study on primary molar restora-
tions19. The finding, of lower primary second
molars being filled more frequently than
lower primary first molars, may be explained
© 2017 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Survival of extensive restorations 5
by the fact that the second primary molars
are affected by caries more frequently than
the first primary molars20,21.
Expected mean survival time of PMCs was
longer than the other materials used. This
finding is in accordance with the Canadian
and American pediatric dentists’ opinion for
choosing PMCs18. Annual failure rate for
PMCs in our study was 1.4% compared to
0%–14% in occlusally-stressed primary
teeth13. Similarly, mean annual failure rate of
GIC/PAMRC/RMGIC group in this study was
3%, compared to reported failure rates of 12%
for PAMRC and 13% for GIC22. in 4-year fol-
low-up study and 0%–11% for PAMRC and
0%–26% for GIC in occlusally-stressed restora-
tions in primary molars13. Based on the
Cochrane reviews, there is very little high-
quality evidence to support the use of one
type of restoration material over another for
primary teeth8. However, PMCs are recom-
mended because of their cost-effectiveness,
ease of placement, and longevity23,24. It is
important that the absence of evidence for
6 B. Tseveenjav et al.

Restoration survival is influenced by differ-

ent properties inherent to dental materials as
well as patient-related factors such as type of
tooth, position in dental arch, size of lesion,
level of oral hygiene, and individual’s caries
risk26. In interpretation of the survival times of
the restorative materials in the present study
are comparable with those previously reported
for high caries risk group, as caries risk is asso-
ciated with the survival time of restorations19.
Our assumption of high caries risk for this
study population is based on the evidence that
past caries experience is shown to be the pow-
erful single predictor of further caries27.
The strength of this study is that all children
with extensive restorations, including PMCs
since 2002, when the OHC exchanged into
electronic health record system, till 2016 were
included. Thus, magnitude of extensive
Fig. 5. Survival time (in years) of PMC (preformed metal
restorations and numbers of children are well
crowns; n = 264) vs GIC (glass-ionomer cement/compomer/
resine-modified GIC; n = 293).
represented. In addition to limitations inher-
ent to any retrospective research design, in
this study, the materials used for extensive
Table 2. Empirical cumulative failure rates with 3-year
intervals: PMCs (preformed metal crowns; n = 264) vs GIC/
restorations were grouped and compared
PAMRC/RMGIC (glass-ionomer cement/compomer/resin- according to the health record system classifi-
modified GIC; n = 293). cation (EFFICA). This may partly explain non-
significant difference of patient visits found
PMCs GIC/PAMRC/RMGIC
between RC and GIC/PAMRC/RMGIC restora-
Time Failure Failure tions, as the latter group included three mate-
(years) rate (%) 95% CI rate (%) 95% CI rials of different longevity22. It could have
3 1.9 0.8–4.5 9.6 6.7–13.6
been interesting to compare these materials
6 8.9 6.0–10.4 18.6 14.5–23.7 separately, especially in further prospective
9 12.3 8.7–17.1 22.2 17.5–27.9 design study, in terms of longevity.
Although PMCs are durable, relatively inex-
pensive, subject to minimal technique sensi-
Table 3. Patient visits after extensive restorations by tivity, and cemented with biocompatible
material used. luting agent, the placement seems to be not a
routine for GDs28. Many GDs find them diffi-
n Mean SD
cult to fit due to lack of patient cooperation,
PMC 432 0.12 0.370 prolonged chairside time, a lot of drilling and/
GIC or PAMRC or RMGIC 391 0.44 0.702 or need to administer local anesthesia to a
RC 206 0.33 0.692
Total 1029 0.27 0.599
pediatric patient16. In a multi-centric ques-
tionnaire survey among 400 GDs, the reason
Test: one-way ANOVA. for non-usage of preformed crowns (62%)
was patients’ noninterest in the crowns,
PMCs is not misinterpreted as evidence for although only 13% of the same dentists were
their lack of efficacy25. In a recent study aware of full coverage of such crowns in pri-
among pediatric dentists in Canada and the mary teeth29. Exploring, in further study, the
United States, PMCs were the most preferred reasons why PMCs are not widely used might
material for primary molars or medically com- give answers. For example, a survey of com-
promised patients18,21. munity dental officers in two large Trusts in

© 2017 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Wales concluded that a postgraduate course
in the use of PMCs would meet dentists’
needs, and it should address their concerns
about the use of crowns28.
Conclusion
The use of PMCs in public oral health services
in Helsinki was high, especially in the general
anesthesia service by GDs and in the special-
ized care service by SDs. PMCs are the best
choice for extensive lesions of primary molars
in high caries risk children, when the restora-
tion is performed as early as in primary or
early mixed dentition period because of
expected lifespan of teeth, based on the pre-
sent 15-year practice-based retrospective fol-
low-up. The use of PMCs in primary care
could be encouraged so that severely affected
primary teeth could be managed better to
optimize the use of the resources.
Why this paper is important for paediatric
professional community
The importance of this study is that we revealed.
• PMCs have longer survival time and lower annual
failure rate, both in short- and long-term, compared
to other restorative materials used in extensive lesions,
based on 15-year practice-based experience
• Choosing PMCs reduces future patient visits and, thus,
increases cost-effectiveness of oral health services to
optimize resources
Acknowledgements
We would like to thank all general and special-
izing/specialized dentists engaged in pediatric
dentistry care in the Oral Health Care, of the
Department of Social Services and Health Care
of the City of Helsinki in Finland. Their work
made this study possible. In addition, we
would like to thank Professor Jon Einar Dahl,
managing director of NIOM, for valuable com-
ments and support during this project and the
development of the present manuscript.
Authors’ contributions
BT led the project and writing of the manu-
script, JF led statistical analyses and commented
throughout the writing, AM and HV led
© 2017 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Survival of extensive restorations 7
“Material and methods” section and com-
mented throughout the project, TM extracted
the data, ST, SV and MA participated in design-
ing and SV also commented, LT supervised.
None of the authors has a conflict of interest
and each one has signed the Wiley Author Dis-
closure form.
Conflict of interest
The authors declare no conflict of interest.
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