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Pediatric Restorative Dentistry

Purpose

The American Academy of Pediatric Dentistry (AAPD) intends this guideline to help practitioners make decisions regarding restorative dentistry, including when it is necessary to treat and what the appropriate materials and techniques are for restorative dentistry in children and adolescents.

Methods

A thorough review of the scientific literature in the English language pertaining to restorative dentistry in primary and permanent teeth was completed to revise the previous guideline. Electronic database and hand searches, for the most part between the years 1995-2013, were conducted using the terms: restorative treatment decisions, caries diagnosis, caries excavation, dental amalgam, glass ionomers, resin modified glass ionomers, conventional glass ionomers, atraumatic/ alternative restorative technique (ART), interim therapeutic restoration (ITR), resin infiltration, dental composites, pit and fissure sealants, resin-based sealants, glass ionomer sealants, resin based composite, dental composites, compomers, stainless steel crowns (SSC), primary molar, preformed metal crown, strip crowns, pre-veneered crowns, esthetic restorations, clinical trials and, randomized controlled clinical trials.

Those papers that were used to evaluate clinical efficacy on specific restorative dentistry topics (e.g., amalgam, resin-based composite) initially were evaluated by abstract by two individuals. Criteria for evaluation included if the paper fulfilled the qualification of a controlled clinical trial, meta-analysis, or systematic review. Full evaluation and abstraction included examination of the research methods and potential for study bias (e.g., patient recruitment, randomization, blinding, subject loss, sample size estimates, conflicts of interest, statistics). Research that was considered deficient or had high bias was eliminated. In those topic areas for which there were rigorous meta-analyses or systematic reviews available, only those clinical trial articles that were not covered by the reviews were subjected to full evaluation and abstraction. This strategy yielded 35 meta-analyses/systemic reviews and 62 randomized controlled clinical trials that primarily made up the evidence for this guideline.

The assessment of evidence for each topic was based on a modification of the American Dental Association’s grading of recommendations: strong evidence (based on well-executed randomized control trials, meta-analyses, or systematic reviews); evidence in favor (based on weaker evidence from clinical trials); and expert opinion (based on retrospective trials, case reports, in vitro studies, and opinions from clinical researchers).1

This guideline was developed by the Restorative Dentistry Subcommittee of the Clinical Affairs Committe and adopted in 1991. The last comprehensive revision of this document was in 2014. 

When to restore
 Historically, the management of dental caries was based on the belief that caries was a progressive disease that eventually destroyed the tooth unless there was surgical and restorative intervention.2   It is now recognized that restorative treatment of dental caries alone does not stop the disease process3 and restorations have a finite lifespan. Conversely, some carious lesions may not progress and, therefore, may not need restoration. Consequently, contemporary management of dental caries includes identification of an individual’s risk for caries progression, understanding of the disease process for that individual, and active surveillance to assess disease progression and manage with appropriate preventive services, supplemented by restorative therapy when indicated.4

With the exception of reports of dental examiners in clinical trials, studies of reliability and reproducibility of detecting dental caries are not conclusive.5  There also is minimal information regarding validity of caries diagnosis in primary teeth,2 as primary teeth may require different criteria due to thinner enamel and dentin and broader proximal contacts.6  Furthermore, indications for restorative therapy only have been examined superficially because such decisions generally have been regarded as a function of clinical judgment.7  Decisions for when to restore carious lesions should include at least clinical criteria of visual detection of enamel cavitation,visual identification of shadowing of the enamel, and/ or radiographic recognition of enlargement of lesions over time.4,8,9

The benefits of restorative therapy include: removing cavitations or defects to eliminate areas that are susceptible to caries; stopping the progression of tooth demineralization; restoring the integrity of tooth structure; preventing the spread of infection into the dental pulp; and preventing the shifting of teeth due to loss of tooth structure. The risks of restorative therapy include lessening the longevity of teeth by making them more susceptible to fracture, recurrent lesions, restoration failure, pulp exposure during caries excavation, future pulpal complications, and iatrogenic damage to adjacent teeth.10,11,12  Primary teeth may be more susceptible to restoration failures than permanent teeth.13  Additionally, before restoration of primary teeth, one needs to consider the length of time remaining prior to tooth exfoliation

Recommendations:

  1. Management of dental caries includes identification of an individual’s risk for caries progression, understanding of the disease process for that individual, and active surveillance to assess disease progression and manage with appropriate preventive services, supplemented by restorative therapy when indicated.
  2. Decisions for when to restore carious lesions should include at least clinical criteria of visual detection of enamel cavitation, visual identification of shadowing of the enamel, and/or radiographic recognition of enlargement of lesions over time. 

Deep caries excavation and restoration
 Among the objectives of restorative treatment are to repair or limit the damage from caries, protect and preserve the tooth structure, and maintain pulp vitality whenever possible. The AAPD Guideline on Pulp Therapy for Primary and Immature Permanent Teeth states the treatment objective for a tooth affected by caries is to maintain pulpal vitality, especially in immature permanent teeth for continued apexogenesis.14

With regard to the treatment of deep caries, three methods of caries removal have been compared to complete excavation, where all carious dentin is removed. Stepwise excavation is a two-step caries removal process in which carious dentin is partially removed at the first appointment, leaving caries over the pulp, with placement of a temporary filling. At the second appointment, all remaining carious dentin is removed and a final restoration placed.15  Partial, or one-step, caries excavation removes part of the carious dentin, but leaves caries over the pulp, and subsequently places a base and final restoration.16,17  No removal of caries before restoration of primary molars in children aged three to 10 years also has been reported.18

Evidence from randomized controlled trials and a systematic review shows that pulp exposures in primary and permanent teeth are significantly reduced using incomplete caries excavation compared to complete excavation in teeth with a normal pulp or reversible pulpitis. Two trials and a Cochrane review found that partial excavation resulted in significantly fewer pulp exposures compared to complete excavation.19-21  Two trials of step-wise excavation showed that pulp exposure occurred more frequently from complete excavation compared to stepwise excavation.15,20  There also is evidence of a decrease in pulpal complications and post-operative pain after incomplete caries excavation compared to complete excavation in clinical trials,15,20,22,23 summarized in a meta-analysis.24

Additionally, a meta-analysis found the risk for permanent restoration failure was similar for incompletely and completely excavated teeth.24  With regard to the need to reopen a tooth with partial excavation of caries, one randomized controlled trial that compared partial (one-step) to stepwise excavation in permanent molars found higher rates of success in maintaining pulp vitality with partial excavation, suggesting there is no need to reopen the cavity and perform a second excavation.16 Interestingly, two randomized controlled trials suggest that no excavation can arrest dental caries so long as a good seal of the final restoration is maintained.18,25

Recommendations:

  1. There is evidence from randomized controlled trails and systematic reviews that incomplete caries excavation in primary and permanent teeth with normal pulps or reversible pulpitis, either partial (one-step) or stepwise (two-step) excavation, results in fewer pulp exposures and fewer signs and symptoms of pulpal disease than complete excavation.
  2. There is evidence from two systematic reviews that the rate of restoration failure in permanent teeth is no higher after incomplete rather than complete caries excavation.
  3. There is evidence that partial excavation (one-step) followed by placement of final restoration leads to higher success in maintaining pulp vitality in permanent teeth than stepwise (two-step) excavation.

Pit and fissure sealants†
 Pit and fissure caries account for approximately 80 to 90 percent of all caries in permanent posterior teeth and 44 percent in primary teeth9. Pit and fissure sealant has been described as a material placed into the pits and fissures of caries-susceptible teeth that micromechanically bonds to the tooth preventing access by cariogenic bacteria to their source of nutrients,27 thus reducing the risk of caries in those susceptible pits and fissures.

With regard to evidence of effectiveness, a Cochrane review found that sealants placed on the occlusal surfaces of permanent molars in children and adolescents reduced caries up to 48 months when compared to no sealant.28  According to a metaanalysis of 24 studies, the overall effectiveness of autopolymerised fissure sealants in preventing dental decay was 71 percent.29  Another Cochrane review calculated that placement of resin-based sealant in children and adolescent reduces caries incidence of 86 percent after one year and 57 percent at 48 to 54 months.30  Sealants must be retained on the tooth and should be monitored to be most effective. Studies incorporating recall and maintenance have reported sealant success levels of 80 to 90 percent after 10 or more years.31,32

There are many systematic reviews and clinical trials regarding optimizing the effectiveness of dental sealants. Sealants are more cost-effective in children with caries risk and generally are recommended to be placed only in those children at caries risk.4,9,26  The best evaluation of high caries risk is done by an experienced clinician using indicators of low socio-economic status, high frequency of sugar consumption, prior caries, active white spot lesions and enamel defects, and low salivary flow.4

Pit-and-fissure sealants lower the number of viable bacteria, including Streptococcus mutans and lactobacilli, by at least 100-fold and reduced the number of lesions with any viable bacteria by about 50 percent.33  This evidence supports recommendations to seal sound surfaces and non-cavitated enamel lesions.9,33

Evidence-based reviews have found that caries risk for sealed teeth that have lost some or all sealant does not exceed the caries risk for never-sealed teeth. Therefore, it has been recommended to provide sealants to children even if followup cannot be ensured.33

Systematic reviews and clinical trials have evaluated techniques for placement of sealants. According to a systematic review, isolation of the tooth is an important aspect of sealant placement and use of rubber dam improves the retention rates of light-cured resin based sealants.34  Moisture control systems (IsoliteTM, VacuEjectorTM) produce sealant retention rates comparable to cotton roll isolation or rubber dam, while decreasing procedure time.35,36  Another systematic review has shown that four-handed technique has been associated with higher retention of resin based sealants.37  Two systematic reviews have shown that teeth cleaned prior to sealant application with a tooth brush prophylaxis exhibited similar or higher success rate compared to those sealed after hand piece prophylaxis.37,38  Additionally, there is limited and conflicting evidence to support mechanical preparation with a bur prior to sealant placement, and it is not recommended.9  There is evidence that mechanical preparation may make a tooth more prone to caries in case of resin-based sealant loss.39

With regard to primer placement before sealant application, there is one randomized clinical trial that suggests that acetone or ethanol solvent based primers, especially the single bottle system, enhanced the retention of sealants, whereas water-based primers were found to drastically reduce the retention of sealants.40  With regard to self-etch bonding agents that do not involve a separate step for etching, a systematic review found that self-etch bonding agents may not provide as good retention as acid etch technique;34 however, one recent randomized clinical trial reported similar retention rates of self-etch system compared to acid etch group.41

Based on a systematic review and clinical trials, there is substantial data regarding the use of resin-based and glass ionomer-based sealants. One meta-analysis and a Cochrane review show high retention rates of resin-based sealants compared to glass ionomer-based sealants.28,42  However, glass ionomer sealants exhibited good short term retention comparable with resin sealants at one year, and they may be used as an interim preventive agent when resin-based sealant cannot be placed as moisture control may compromise such placement.9,28  Another systematic review of the caries-preventive effects of glass ionomer and resin-based fissure sealants suggests no difference between these two products.43

There is insufficient data to support use of fissure sealants in primary teeth. One trial reported retention rate of 76.5 percent for light polymerized fissure sealants in the follow-up time of 2.8 years.44 Another randomized clinical trial studied effectiveness of glass ionomer sealants in primary molars and found retention rate as low as 18.7 percent in 1.38 years and no statistically significant caries reduction.45

Recommendations:

  1. Based on a meta-analysis and Cochrane reviews, sealants should be placed on pit and fissure surfaces judged to be at risk for dental caries or surfaces that already exhibit incipient, non-cavitated carious lesions to inhibit lesion progression.
  2. According to a systematic review and a randomized clinical trial, sealant placement methods should include careful cleaning of the pits and fissures without mechanical tooth preparation.
  3. Based on a systematic review, resin-based sealants require placement in a moisture controlled environment, often facilitated by four-handed technique.
  4. There is evidence from a randomized clinical trial that a low-viscosity hydrophilic material bonding layer, as part of or under the actual sealant, is better for longterm retention and effectiveness.
  5. There is evidence from a Cochrane review and a systematic review that resin-based materials achieve better retention and, therefore, may be preferred as dental sealants, but glass ionomer sealants could be used as transitional sealants when moisture control is not possible.

Resin infiltration
 Resin infiltration is an innovative approach primarily to arrest the progression of non-cavitated interproximal caries lesions.46,47  The aim of the resin infiltration technique is to allow penetration of a low viscosity resin into the porous lesion body of enamel caries.46

Most randomized clinical trials done on resin infiltration had industrial support with potential of conflict of interest. One such trial evaluated infiltration and sealants versus placebo and found significant differences between infiltration versus placebo with lesion progression 32 percent versus 70 percent respectively.48  Another randomized clinical trial reported significant difference between infiltration (seven percent) versus placebo (37 percent) in the percentage of progression in lesion depth.46  A systematic review on randomized clinical trials on resin infiltration rated the quality score to be low to moderate. The review concluded that resin infiltration has a potential consistent benefit in slowing the progression or reversing non-cavitated carious lesions.49

An additional use of resin infiltration has been suggested to restore white spot lesions formed during orthodontic treatment. Based on a randomized clinical trial, resin infiltration significantly improved the clinical appearance of such white spot lesions and visually reduced their size.50

Recommendation:
From randomized controlled trials, there is evidence in favor of resin infiltration as a treatment option for small, noncavitated interproximal carious lesions in permanent teeth.

Dental amalgam
 Dental amalgam has been the most commonly used restorative material in posterior teeth for over 150 years and is still widely used throughout the world today.51  Amalgam contains a mixture of metals such as silver, copper, and tin, in addition to approximately 50 percent mercury.52  Dental amalgam has declined in use over the past decade,51 perhaps due to the controversy surrounding perceived health effects of mercury vapor, environmental concerns from its mercury content, and increased demand for esthetic alternatives.

With regard to safety of dental amalgam, a comprehensive literature review of dental studies published between 2004 and 2008 found insufficient evidence of associations between mercury release from dental amalgam and the various medical complaints.53  Two independent randomized controlled trials in children have examined the effects of mercury release from amalgam restorations and found no effect on the central and peripheral nervous systems and kidney function.54,55  However, on July 28, 2009, the Food and Drug Administration (FDA) issued a final rule that reclassified dental amalgam to a Class II device (having some risk) and designated guidance that included warning labels regarding: (1) possible harm of mercury vapors; (2) disclosure of mercury content; and (3) contraindications for persons with known mercury sensitivity. Also in this final rule, the FDA noted that there is limited information regarding dental amalgam and the long-term health outcomes in pregnant women, developing fetuses, and children under the age of six.52

With regard to clinical efficacy of dental amalgam, results comparing longevity of amalgam to other restorative materials are inconsistent. The majority of meta-analyses, evidence-based reviews, and randomized controlled trials report comparable durability of dental amalgam to other restorative materials,56-61 while others show greater longevity for amalgam.62,63  The comparability appears to be especially true when the restorations are placed in controlled environments such as university settings.56

Class I amalgam restorations in primary teeth have shown in a systematic review and two randomized controlled trials to have a success rate of 85 to 96 percent for up to seven years, with an average annual failure rate of 3.2 percent.60,63,64  Efficacy of Class I amalgam restorations in permanent teeth of children has been shown in two independent randomized controlled studies to range from 89.8 to 98.8 percent for up to seven years.60,62

With regard to Class II restorations in primary molars, a 2007 systematic review concluded that amalgam should be expected to survive a minimum of 3.5 years and potentially in excess of seven years.65  For Class II restorations in permanent teeth, one meta-analysis and one evidence-based review conclude that the mean annual failure rates of amalgam and composite are equal at 2.3 percent.56,59  The meta-analysis comparing amalgam and composite Class II restorations in permanent teeth suggests that higher replacement rates of composite in general practice settings can be attributed partly to general practitioners’ confusion of marginal staining for marginal caries and their subsequent premature replacements. Otherwise, this meta-analysis concludes that the median success rate of composite and amalgam are statistically equivalent after ten years, at 92 percent and 94 percent respectively.56

The limitation of many of the clinical trials that compare dental amalgam to other restorative materials is that the study period often is short (24 to 36 months), at which time interval all materials reportedly perform similarly.66-70  Some of these studies also may be at risk for bias, due to lack of true randomization, inability of blinding of investigators, and in some cases financial support by the manufacturers of the dental materials being studied.

Recommendation:
There is strong evidence that dental amalgam is efficacious in the restoration of Class I and Class II cavity restorations in primary and permanent teeth.

Composites
 Resin-based composite restorations were introduced in dentistry about a half century ago as an esthetic restorative material71,72, and composites are increasingly used in place of amalgam for the restoration of carious lesions.73  Composites consist of a resin matrix and chemically bonded fillers.74  They are classified according to their filler size, because filler size affects polishability/esthetics, polymerization depth, polymerization shrinkage, and physical properties. Hybrid resins combine a mixture of particle sizes for improved strength while retaining esthetics.75  The smaller filler particle size allows greater polishability and esthetics, while larger size provides strength. Flowable resins have a lower volumetric filler percentage than hybrid resins.76

Several factors contribute to the longevity of resin composites, including operator experience, restoration size, and tooth position.77  Resins are more technique sensitive than amalgams and require longer placement time. In cases where isolation or patient cooperation is in question, resin-based composite may not be the restorative material of choice.78

Bisphenol A (BPA) and its derivatives are components of resin-based dental sealants and composites. Trace amounts of BPA derivatives are released from dental resins through salivary enzymatic hydrolysis and may be detectable in saliva up to three hours after resin placement.79  Evidence is accumulating that certain BPA derivatives may pose health risks attributable to their estrogenic properties. BPA exposure reduction is achieved by cleaning filling surfaces with pumice, cotton roll, and rinsing. Additionally, potential exposure can be reduced by using a rubber dam.79  Considering the proven benefits of resin based dental materials and minimal exposure to BPA and its derivatives, it is recommended to continue using these products while taking precautions to minimize exposure.79

There is strong evidence from a meta-analysis of 59 randomized clinical trials of Class I and II composite and amalgam restorations showing an overall success rate about 90 percent after 10 years for both materials, with rubber dam use significantly increasing restoration longevity.74  Strong evidence from randomized controlled trials comparing composite restorations to amalgam restorations showed that the main reason for restoration failure in both materials was recurrent caries.60,77,80

In primary teeth, there is strong evidence that composite restorations for Class I restorations are successful.60,64  There is only one randomized controlled trial showing success in Class II composite restorations in primary teeth that were expected to exfoliate within two years.68  In permanent molars, composite replacement after 3.4 years was no different than amalgam,60 but after seven to 10 years the replacement rate was higher for composite.78  Secondary caries rate was reported as 3.5 times greater for composite versus amalgam.77

There is evidence from a meta-analysis showing that etching and bonding of enamel and dentin significantly decreases marginal staining and detectable margins in composite restorations.74  Regarding different types of composites (packable, hybrid, nano, macro, and micro filled) there is strong evidence showing similar overall clinical performance for these materials.81-84

Recommendations: 

  1. In primary molars, there is strong evidence from randomized controlled trials that composite resins are successful when used in Class I restorations. For Class II lesions in primary teeth, there is one randomized controlled trial showing success of composite resin restorations for two years.
  2. In permanent molars, there is strong evidence from meta-analyses that composite resins can be used successfully for Class I and II restorations.
  3. Evidence from a meta-analysis shows enamel and dentin bonding agents decrease marginal staining and detectable margins for the different types of composites.

Glass ionomer cements
Glass ionomers cements have been used in dentistry as restorative cements, cavity liner/base, and luting cement since the early 1970s.85  Originally, glass ionomer materials were difficult to handle, exhibited poor wear resistance, and were brittle. Advancements in conventional glass ionomer formulation led to better properties, including the formation of resin-modified glass ionomers. These products showed improvement in handling characteristics, decreased setting time, increased strength, and improved wear resistance.86,87  All glass ionomers have several properties that make them favorable for use in children including: chemical bonding to both enamel and dentin; thermal expansion similar to that of tooth structure; biocompatibility; uptake and release of fluoride; and decreased moisture sensitivity when compared to resins.

Fluoride is released from glass ionomer and taken up by the surrounding enamel and dentin, resulting in teeth that are less susceptible to acid challenge.88,89  One study has shown that fluoride release can occur for at least one year.90  Glass ionomers can act as a reservoir of fluoride, as uptake can occur from dentifrices, mouth rinses, and topical fluoride applications.91,92  This fluoride protection, useful in patients at high risk for caries, has led to the use of glass ionomers as luting cement for SSCs, space maintainers, and orthodontic bands.93

Regarding use of conventional glass ionomers in primary teeth, one randomized clinical trial showed the overall median time from treatment to failure of glass ionomer restored teeth was 1.2 years.63 Based on findings of a systematic review and meta-analysis, conventional glass ionomers are not recommended for Class II restorations in primary molars.94,95  Conventional glass ionomer restorations have other drawbacks such as poor anatomical form and marginal integrity.96,97  Composite restorations were more successful than glass ionomer cements where moisture control was not a problem.95

Resin modified glass ionomer cements (RMGIC), with the acid-base polymerization supplemented by a second resin light cure polymerization, has been shown to be efficacious in primary teeth. Based on a meta-analysis, RMGIC is more successful than conventional glass ionomer as a restorative material.95  A systematic review supports the use of RMGIC in small to moderate sized Class II cavities.94 Class II RMGIC restorations are able to withstand occlusal forces on primary molars for at least one year.95  Because of fluoride release, RMGIC may be considered for Class I and Class II restorations of primary molars in a high caries risk population.97  There is also some evidence that conditioning dentin improves the success rate of RMGIC.94  According to one randomized clinical trial, cavosurface beveling leads to high marginal failure in RMGIC restorations and is not recommended.80

With regard to permanent teeth, a meta-analysis review reported significantly fewer carious lesions on single-surface glass ionomer restorations in permanent teeth after six years as compared to restorations with amalgam.97  Data from a meta-analysis shows that RMGIC is more caries preventive than composite resin with or without fluoride.98  Another meta-analysis showed that cervical restorations (Class V) with glass ionomers may have a good retention rate, but poor esthetics.99  For Class II restorations in permanent teeth, one randomized clinical trial showed unacceptable high failure rates of conventional glass ionomers, irrespective of cavity size. However, a high dropout rate was observed in this study limiting its significance.100  In general, there is insufficient evidence to support the use of RMGIC as long-term restorations in permanent teeth.

Other applications of glass ionomers where fluoride release has advantages are for interim therapeutic restorations (ITR) and the atraumatic/alternative restorative technique (ART). These procedures have similar techniques but different therapeutic goals. ITR may be used in very young patients,101 uncooperative patients, or patients with special health care needs102 for whom traditional cavity preparation and/or placement of traditional dental restorations are not feasible or need to be postponed. Additionally, ITR may be used for caries control in children with multiple open carious lesions, prior to definitive restoration of the teeth.103  In-vitro caries-affected dentin does not jeopardize the bonding of glass ionomer cements to the primary tooth dentin.104  ART, endorsed by the World Health Organization and the International Association for Dental Research, is a means of restoring and preventing caries in populations that have little access to traditional dental care and functions as definitive treatment.

According to a meta-analysis, single surface ART restorations showed high survival rates in both primary and permanent teeth.105  One randomized clinical trial supported single surface restorations irrespective of the cavity size and also reported higher success in non-occlusal posterior ART compared to occlusal posterior ART.106  With regard to multi-surface ART restorations, there is conflicting evidence. Based on a metaanalysis, ART restorations presented similar survival rates to conventional approaches using composite or amalgam for Class II restorations in primary teeth.107 However, another meta-analysis showed that multi-surface ART restorations in primary teeth exhibited high failure rates.105

Recommendations:

  1. There is evidence in favor of glass ionomer cements for Class I restorations in primary teeth.
  2. From a systematic review, there is strong evidence that resin-modified glass ionomer cements for Class I restorations are efficacious, and expert opinion supports Class II restorations in primary teeth.
  3. There is insufficient evidence to support the use of conventional or resin-modified glass ionomer cements as long-term restorative material in permanent teeth.
  4. From a meta-analysis, there is strong evidence that interim therapeutic restoration/atraumatic restorative technique (ITR/ART) using high viscosity glass ionomer cements has value as single surface temporary restoration for both primary and permanent teeth. Additionally, ITR may be used for caries control in children with multiple open carious lesions, prior to definitive restoration of the teeth.

Compomers
 Polyacid-modified resin-based composites, or compomers, were introduced into dentistry in the mid-1990s. They contain 72 percent (by weight) strontium fluorosilicate glass and the average particle size is 2.5 micrometers.108  Moisture is attracted to both acid functional monomer and basic ionomer-type in the material. This moisture can trigger a reaction that releases fluoride and buffers acidic environments.109,110  Considering the ability to release fluoride, esthetic value, and simple handling properties of compomer, it can be useful in pediatric dentistry.108

Based on a recent randomized clinical trial, the longevity of Class I compomer restorations in primary teeth was not statistically different compared to amalgam, but compomers were found to need replacement more frequently due to recurrent caries.60  In Class II compomer restorations in primary teeth, the risk of developing secondary caries and failure did not increase over a two-year period in primary molars.69,111  Compomers also have reported comparable clinical performance to composite with respect to color matching, cavosurface discoloration, anatomical form, and marginal integrity and secondary caries.112,113  Most randomized clinical trials showed that compomer tends to have better physical properties compared to glass ionomer and resin modified glass ionomer cements and in primary teeth, but no significant difference was found in cariostatic effects of compomer compared to these materials.63,111,114

Recommendations:

  1. Compomers can be an alternative to other restorative materials in the primary dentition in Class I and Class II restorations.
  2. There is not enough data comparing compomers to other restorative materials in permanent teeth of children.

Preformed metal crowns
 Preformed metal crowns (also known as SSCs) are prefabricated metal crown forms that are adapted to individual teeth and cemented with a biocompatible luting agent. Preformed metal crowns have been indicated for the restoration of primary and permanent teeth with extensive caries, cervical decalcification, and/or developmental defects (eg, hypoplasia, hypocalcification), when failure of other available restorative materials is likely (eg, interproximal caries extending beyond line angles, patients with bruxism), following pulpotomy or pulpectomy, for restoring a primary tooth that is to be used as an abutment for a space maintainer, for the intermediate restoration of fractured teeth, for definitive restorative treatment for high caries-risk children, and used more frequently in patients whose treatment is performed under sedation or general anesthesia.115

There are very few prospective randomized clinical trials comparing outcomes for preformed metal crowns to intracoronal restorations.116,117  A Cochrane review and two systematic reviews conclude that the majority of clinical evidence for the use of preformed metal crowns has come from nonrandomized and retrospective studies.13,118-120  However, this evidence suggests that preformed metal crowns showed greater longevity than amalgam restorations,13 despite possible study bias of placing SSCs on teeth more damaged by caries.118,119,121  Five studies which retrospectively compared Class II amalgam to preformed metal crowns showed an average five year failure rate of 26 percent for amalgam and seven percent for preformed metal crowns.119

A two-year randomized control trial regarding restoration of primary teeth that had undergone a pulpotomy procedure found a non-significant difference in survival rate for teeth restored with preformed metal crowns (95 percent) versus resin modified glass ionomer/composite restoration (92.5 percent).116  In another prospective study, significantly less restoration failure and improved calcium hydroxide pulpotomy success was found with preformed metal crowns (79.7 percent) versus amalgam restorations (60 percent) after one year.122  However, a systematic review did not show strong evidence that preformed metal crowns were superior over other restorations for pulpotomized teeth.123

With regards to gingival health adjacent to preformed metal crowns, a one year randomized controlled trial showed no difference in gingival inflammation between preformed metal crowns and composite restorations after pulpotomy.118 Yet, a two year randomized clinical study showed more gingival bleeding for preformed metal crowns vs. composite/glass ionomer restorations.116 Inadequately contoured crown and residues of set cement remaining in contact with the gingival sulcus are suggested as reasons for gingivitis associated with preformed metal crowns, and a preventive regime including oral hygiene instruction is recommended to be incorporated into the treatment plan.119

There is one randomized control trial on preformed metal crowns versus cast crowns placed on permanent teeth,124 and this report found no difference between the two restoration types for quality and longevity after 24 months. The remaining evidence is case reports and expert opinion concerning indications for use of preformed metal crowns on permanent molars. The indications include teeth with severe genetic/ developmental defects, grossly carious teeth, traumatized teeth, along with tooth developmental stage or financial considerations that require semi-permanent restoration instead of a permanent cast restoration.120,121,124  The main reasons for preformed metal crown failure reportedly are crown loss13,122,125 and perforation.125

Hall Technique (HT).  The Hall technique calls for cementation of a SSC over a caries-affected primary molar without local anesthetic, caries removal or tooth preparation, This technique was developed for use when delivery of ideal treatment was not feasible. While HT has gained some popularity in the United Kingdom (UK),126 the technique is highly controversial in the U.S. All prospective investigations on the effectiveness of HT have been by general dentists in UK who provide care for the majority of young children. Traditional  use of SSC’s to restore caries in primary teeth has not been a popular or a frequently used technique in the UK, in spite of the existence of guidelines and policy statements from the British Society of Paediatric Dentistry that SSC’s are the restoration of choice for primary molars with multisurface lesions or extensive caries, or when pulp treatment has been performed.127-130

Results of a 2003 repeat questionnaire of general dentists showed that the use of amalgam had declined with an increase in the use of glass ionomer cement (GIC) and very little change in the use of SSC’s.127  Placement of GIC restorations or observation without treatment was the management approach of choice, and the use of local anesthesia to provide dental care to children was infrequent.128  A recent systematic review indicates that HT is more effective when compared to GIC restorations in compromised, caries-affected primary molars,131 but it points out that reliable studies that compare this technique to traditionally placed SSCs using radiographic assessment and caries removal are needed.132

Recommendations:

  1. There is evidence from retrospective studies showing greater longevity of preformed metal crown restorations compared to amalgam restorations for the treatment of carious lesions in primary teeth.
  2. There is evidence from case reports and one randomized controlled trial supporting the use of preformed metal crowns in permanent teeth as a semi-permanent restoration for the treatment of severe enamel defects or grossly carious teeth.

Anterior esthetic restorations in primary teeth
 Despite the continuing prevalence of dental caries in primary maxillary anterior teeth in children, the esthetic management of these teeth remains problematic.133  Esthetic restoration of primary anterior teeth can be especially challenging due to: the small size of the teeth; close proximity of the pulp to the tooth surface; relatively thin enamel; lack of surface area for bonding; and issues related to child behavior.133

There is little scientific support for any of the clinical techniques that clinicians have utilized for many years to restore primary anterior teeth, and most of the evidence is regarded as expert opinion. While a lack of strong clinical data does not preclude the use of these techniques, it points out the strong need for well designed, prospective clinical studies to validate the use of these techniques.134  Additionally, there is limited information on the potential psychosocial impact of anterior caries or unaesthetic restorations in primary teeth.133

Class III (interproximal) restorations of primary incisors are often prepared with labial or lingual dovetails to incorporate a large surface area for bonding to enhance retention.135  Resin-based restorations are appropriate for anterior teeth that can be adequately isolated from saliva and blood. Resin-modified glass ionomer cements have been suggested for this category, especially when adequate isolation is not possible.136,137  It has been suggested that patients considered at high-risk for future caries may be better served with placement of full tooth coverage restorations.137

Class V (cervical) cavity preparations for primary incisors are similar to those in permanent teeth. Due to the young age of children treated and associated behavior management difficulty, it is sometimes impossible to isolate teeth for the placement of composite restorations. In these cases, glass ionomer cement or resin-modified glass ionomer cement is suggested.136,137

Full coronal restoration of carious primary incisors may be indicated when: (1) caries is present on multiple surfaces, (2) the incisal edge is involved, (3) there is extensive cervical decalcification, (4) pulpal therapy is indicated, (5) caries may be minor, but oral hygiene is very poor, or (6) the child’s behavior makes moisture control very difficult.135  Successful full-coronal restorations of extensively decayed primary teeth have been reported; however, due to the lack of available clinical studies, it is difficult to determine whether certain techniques of restoring carious primary anterior teeth are effective.134,138  A retrospective study showed that 80 percent of strip crowns were completely retained after three years, and 20 percent were partially retained, with none being completely lost.139 Another retrospective study, with 24-74 months follow-up, reported 80 percent retention of strip crowns.140

Pre-veneered stainless steel crowns also are among the options of restoring primary anterior teeth with full coronal coverage. Three retrospective studies report excellent clinical retention of these types of crowns, yet with a high incidence of partial or complete loss of the resin facings.133,141,142  Preformed stainless steel crowns and open-faced stainless steel crowns are other options; however, there appears to be no published data on the use of either crown on primary anterior teeth.127

Recommendations:

  1. There is expert opinion that suggests the use of resinbased composites as a treatment option for Class III and Class V restorations in the primary and permanent dentition.
  2. There is expert opinion that suggests the use of resinmodified glass ionomer cement as a treatment option for Class III and Class V restorations for primary teeth, particularly in circumstances where adequate isolation of the tooth to be restored is difficult.
  3. There is expert opinion that suggests that strip crowns, pre-veneered stainless steel crowns, preformed stainless steel crowns, and open-faced stainless steel crowns are a treatment option for full coronal coverage restorations in primary anterior teeth. 

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