Purpose

The American Academy of Pediatric Dentistry (AAPD) intends these recommendations 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

These recommendations originally were developed by the Restorative Dentistry Subcommittee of the Clinical Affairs Committee and adopted in 1991.1 The last comprehensive revision by the Council of Clinical Affairs of this document was in 2014,2 and an addition regarding the Hall technique (HT) for preformed metal crowns was added in 2016.3 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 2000-2019, were conducted using the terms: dental caries, intra-coronal restorations, 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 infiltrations, resin based composite, dental composites, compomers, full coverage dental restorations, stainless steel crowns (SSC), Hall technique, primary molars, preformed metal crowns, strip crowns, preveneered crowns, zirconia crowns, esthetic restorations; parameters: clinical trials, randomized controlled clinical trials (RCTs). 

Full evaluation and abstraction included examination of the clinical efficacy on specific restorative dentistry topics, 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. 

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 RCTs, meta-analyses, or systematic reviews); evidence in favor (based on weaker evidence from clinical trials).4 

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.5 It is now recognized that restorative treatment of dental caries alone does not stop the disease process,6 and restorations have a finite lifespan. Conversely, some caries lesions may not progress and, therefore, may not need restoration. 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.7,8 

With the exception of reports of dental examiners in clinical trials, studies of reliability and reproducibility of detecting dental caries are not conclusive.9 There also is minimal information regarding validity of caries diagnosis in primary teeth,5 as primary teeth may require different criteria due to thinner enamel and dentin and broader proximal contacts.10 

Furthermore, indications for restorative therapy only have been examined superficially because such decisions generally have been regarded as a function of clinical judgment.11 Decisions for when to restore caries lesions should include at least clinical criteria of visual detection of enamel cavitations, visual identification of shadowing of the enamel, and/or radiographic recognition of enlargement of lesions over time.7,12,13 

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 reducing 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.14,15 Primary teeth may be more susceptible to restoration failuresthan permanent teeth.16 Additionally, before restoration of primary teeth, one needs to consider the length of time re-maining 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 progression of lesions. 

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's Guideline on Use of Vital Pulp Therapies in Primary Teeth with Deep Caries Lesions17 and Best Practices for Pulp Therapy for Primary and Immature Permanent Teeth18 state the treatment objective for a tooth affected by caries is to maintain pulpal vitality, especially in immature permanent teeth for continued apexogenesis.19 

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.19 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.20,21 No removal of caries before restoration of primary molars in children aged three to 10 years also has been reported.22 

Evidence from RCTs 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.23-25 Two trials of step-wise excavation showed that pulp exposure occurred more frequently from complete excavation compared to stepwise excavation.19,24 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, summarized in a meta-analysis.28 

Additionally, a meta-analysis found the risk for permanent restoration failure was similar for incompletely and completely excavated teeth.28 With regard to the need to reopen a tooth with partial excavation of caries, one RCT 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.20 Interestingly, two RCTs suggest that restoration without excavation can arrest dental caries so long as a good seal of the final restoration is maintained.22,29 

Recommendations: 

1. There is evidence from RCTs 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 (one-step) excavation followed by placement of final restoration leads to higher success in maintaining pulp vitality in permanent teeth than stepwise (two-step) excavation. 

Resin infiltration 
Resin infiltration is used primarily to arrest the progression of non-cavitated interproximal caries lesions.30,31 The aim of the resin infiltration technique is to allow penetration of a low viscosity resin into the porous lesion body of enamel caries.30 Once polymerized, this resin serves as a barrier to acids and theoretically prevents lesion progression.32 

A systematic review and meta-analysis evaluated the effectiveness of enamel infiltration in preventing initial caries progression in proximal surfaces of primary and permanent teeth. This review identified eight studies for inclusion for quantitative analysis.33 Seven of the eight studies found that infiltration was significantly more effective than placebo treatment. The meta-analysis compared 470 teeth in the resin infiltration group and 473 in the control group. Caries progression was seen in 61 of the infiltration group and 185 of the control group. Current American Dental Association clinical practice guidelines for non-restorative treatment for non-cavitated interproximal caries lesions conditionally recommends enamel infiltration for treatment of these lesions, (low to very low certainty).34 Few RCTs evaluate the long-term effectiveness of resin infiltration, and further research is recommended. An additional use of resin infiltration has been suggested to restore white spot lesions formed during orthodontic treatment. Based on a RCT, resin infiltration significantly improved the clinical appearance of such white spot lesions and visually reduced their size.35,36 

Recommendation: 

1. There is low to moderate evidence in favor of resin infil-tration as a treatment option for small, non-cavitated in-terproximal caries lesions in primary and permanent teeth. 
2. Further research regarding long-term effectiveness of resin infiltration is needed

Dental amalgam 
Dental amalgam has been the most commonly used restorative material in posterior teeth for over 150 years.37 Amalgam contains a mixture of metals such as silver, copper, and tin, in addition to approximately 50 percent mercury.38 Dental amalgam has declined in use over the past decade,37 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.39 Two independent RCTs in children have examined the effects of mercury release from amalgam restora-tions and found no effect on the central and peripheral nervous systems and kidney function.40,41 However, on July 28, 2009, the U.S. 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.38 

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 RCTs report comparable durability of dental amalgam to other restorative materials,42-47 while others show greater longevity for amalgam.48,49 The comparability appears to be especially true when the restorations are placed in controlled environments such as university settings.42 

Class I amalgam restorations in primary teeth have shown in a systematic review and two RCTs to have a success rate of 85 to 96 percent for up to seven years, with an average annual failure rate of 3.2 percent16,46,49 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.46,48 

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.50 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.42,45 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.42 

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.51-55 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 material56,57, and composites increasingly are used in place of amalgam for the restoration of carious lesions.58 Composites consist of a resin matrix and chemically bonded fillers.42 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.59 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.60 

Several factors contribute to the longevity of resin composites, including operator experience, restoration size, and tooth position.48 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.61 

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.62 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 and cotton roll and rinsing. Additionally, potential exposure can be reduced by using a rubber dam.62 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.62 

There is strong evidence from a meta-analysis of 59 RCTs 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.42 Other isolation techniques (e.g., dental isolation suction systems) may be used. Strong evidence from RCTs comparing composite restorations to amalgam restorationsshowed that the main reason for restoration failure in both materials was recurrent caries.46,48,63 

In primary teeth, there is strong evidence that composite restorations for Class I restorations are successful.16,46 There is only one RCT showing success in Class II composite restorations in primary teeth that were expected to exfoliate within two years.53 In permanent molars, composite replacement after 3.4 years was no different than amalgam,46 but after seven to 10 years the replacement rate was higher for composite.61 Secondary caries rate was reported as 3.5 times greater for composite versus amalgam.48 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.42 Regarding different types of composites (packable, hybrid, nanofilled, macrofilled, and microfilled) there is strong evidence showing similar overall clinical performance for these materials.64-67 

Recommendations: 

1. In primary molars, there is strong evidence from RCTs that composite resins are successful when used in Class I restorations. For Class II lesions in primary teeth, there is one RCT 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 (GIC) 
Glass-ionomers cements have been used in dentistry as restorative cements, cavity liner/base, and luting cement since the early 1970s.68 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.69,70 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.71,72 One study has shown that fluoride release can occur for at least one year.73 Glass ionomers can act as a reservoir of fluoride, as uptake can occur from dentifrices, mouth rinses, and topical fluoride applications.74,75 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.76 

Regarding use of conventional glass ionomers in primary teeth, one RCT showed the overall median time from treatment to failure of glass ionomer restored teeth was 1.2 years.49 Based on findings of a systematic review and meta-analysis, conventional glass ionomers are not recommended for Class II restorations in primary molars.77,78 Conventional glass ionomer restorations have other drawbacks such as poor anatomical form and marginal integrity.79,80 Composite restorations were more successful than GICs where moisture control was not a problem.78 

Resin-modified glass-ionomer cements (RMGICs), with the acid-base polymerization supplemented by a second resin light cure polymerization, have 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.78 A systematic review supports the use of RMGIC in small to moderate sized Class II cavities.77 Class II RMGIC restorations are able to withstand occlusal forces on primary molars for at least one year.78 Because of fluoride release, RMGIC may be considered for Class I and Class II restorations of primary molars in a high caries risk population.80 There is also some evidence that conditioning dentin improves the success rate of RMGIC.77 According to one RCT, cavo-surface beveling leads to high marginal failure in RMGIC restorations and is not recommended.63 

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.80 Data from a meta-analysis shows that RMGIC is more caries preventive than composite resin with or without fluoride.81 Another meta-analysis showed that cervical restorations (Class V) with glass ionomers may have a good retention rate, but poor esthetics.82 For Class II restorations in permanent teeth, one RCT 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.83 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 ITR and ART. These procedures have similar techniques but different therapeutic goals. ITR may be used in very young patients,84 uncooperative patients, or patients with special health care needs47 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.85 In-vitro, leaving caries-affected dentin does not jeopardize the bonding of glass ionomer cements to the primary tooth dentin.86 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.87 One RCT supported single surface restorations irrespective of the cavity size and also reported higher success in non-occlusal posterior ART compared to occlusal posterior ART.88 With regard to mult-surface ART restorations, there is conflicting evidence. Based on a meta-analysis, ART restorations presented similar survival rates to conventional approaches using composite or amalgam for Class II restorations in primary teeth.89 However, another meta-analysis showed that multi-surface ART restorations in primary teeth exhibited high failure rates.87 

Recommendations: 

1. There is evidence in favor of GICs for Class I restorations in primary teeth. 
2. From a systematic review, there is strong evidence that RMGICs 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 RMGICs as long-term restorative material in permanent teeth. 
4. From a meta-analysis, there is strong evidence that 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.90 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.91,92 Considering the ability to release fluoride, esthetic value, and simple handling properties of compomer, it can be useful in pediatric dentistry.90 

Based on a recent RCT, 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.46 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.54,93 Compomers also have reported comparable clinical performance to composite with respect to color matching, cavo-surface discoloration, anatomical form, and marginal integrity and secondary caries.94,95 Most RCTs 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.49,93,96 

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 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 (e.g., hypoplasia, hypocalcification), when failure of other available restorative materials is likely (e.g., 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, and for definitive restorative treatment for high caries-risk children. They are used more frequently in patients whose treatment is performed under sedation or general anesthesia.97-99 

There are very few prospective RCTs comparing outcomes for preformed metal crowns to intra-coronal restorations.100,101 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.16,97-99 However, this evidence suggests that preformed metal crowns showed greater longevity than amalgam restorations,16 despite possible study bias of placing SSCs on teeth more damaged by caries.98,99,102 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.98 

A two-year RCT 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).100 In another prospective study, significantly fewer restoration failures and improved calcium hydroxide pulpotomy success were found with preformed metal crowns (79.7 percent) versus amalgam restorations (60 percent) after one year.103 However, a systematic review did not show strong evidence that preformed metal crowns were superior over other restorations for pulpo-tomized teeth.104 

With regards to gingival health adjacent to preformed metal crowns, a one year RCT showed no difference in gingival inflammation between preformed metal crowns and composite restorations after pulpotomy.99 Yet, a two year randomized clinical study showed more gingival bleeding for preformed metal crowns vs. composite/glass ionomer restorations.100 Inadequately contoured crown and residues of set cement remaining in contact with the gingival sulcus aresuggested 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.98 

There is one RCT on preformed metal crowns versus cast crowns placed on permanent teeth,105 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, and traumatized teeth, along with tooth developmental stage or financial considerations that require semi-permanent restoration instead of a permanent cast restoration.97,102,105 The main reasons for preformed metal crown failure reportedly are crown loss16,103,106 and perforation106

One method of providing preformed metal crowns is known as HT.107 This method calls for cementation of a SSC over a caries-affected primary molar without local anesthetic, caries removal, or tooth preparation. It is a less invasive caries management procedure for treating carious primary teeth and involves the concept of caries control by managing the activity of the biofilm.108 This technique was developed for use when delivery of ideal treatment was not feasible. Using the HT may reduce discomfort from local anesthetic and caries removal at the time of treatment compared to fillings,107 but it may add the discomfort of placement of separator bands prior to the SSC, as well as the pain from biting the crown into place.109 The HT has gained some popularity in the United Kingdom (UK),107 primarily from use by general dentists (who provide the majority of care for young children).110 All prospective investigations on the effectiveness of HT have been by general dentists in UK, and comparison groups include restorative treatment as traditionally provided in those settings, where traditional use of SSCs to restore caries in primary teeth has not been a popular or a frequently used technique.111-114 This is in spite of the existence of guidelines and policy statements from the British Society of Paediatric Dentistry that SSCs are the restoration of choice for primary molars with multi-surface lesions or extensive caries or when pulp treatment has been performed.115,116 

Results of a 2003 repeat questionnaire of general dentists in the UK showed that the use of amalgam had declined with an increase in the use of GIC and very little change in the use of SSCs.111 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.112 Given the differences in treatment approaches in health care settings and system between countries, the HT has not been widely adopted in the U.S., and it usually is limited to individual situations where proven methods of caries management cannot be used.117 Studies that compare this technique to traditionally placed preformed metal crowns using radiographic assessment and caries removal are needed.117 

Recent retrospective studies118,119 for cost-effectiveness combined with a cross-sectional evaluation of patient acceptance showed that 95.8 percent of primary teeth restored using the HT remained asymptomatic after a follow-up period of up to 77 months, compared to 95.3 percent in the conventional methods (caries removal with placement of SSC or other restoration); they did not, however, report a breakdown by follow-up time. Although HT and conventional restorative methods had similar successful outcomes, using the HT was associated with reduced treatment costs if general anesthesia or sedation is considered. Both approaches were accepted favorably by the children and care providers.119 

SSCs continue to offer the advantage of full coverage to combat recurrent caries and provide strength as well as long-term durability with minimal maintenance, which are desirable outcomes for caries management for high-risk children. 

The interest in esthetic options for full coverage restoration of primary posterior teeth is increasing by clinicians and patients.120,121 Scientific studies that evaluate esthetic options for restoring teeth with large caries lesions are not widely reported in the literature. The most popular options are opened-face SSCs, pre-veneered SSCs, and zirconia crowns.122 There are several preformed pediatric zirconia crowns available on the market, and each brand has different material composition, fabrication, surface treatment, retentive feature, and cementation method. The amount of tooth reduction and technique for tooth preparation varies significantly.123 There is need for more circumferential tooth reduction requirements for proper fit and placement for zirconia crowns compared to SSCs. The indications for the preformed esthetic crowns are generally the same as those of the preformed SSCs but with consideration of esthetics.124 SSCs have comparatively better retention, but recent studies demonstrate that the gingival health and plaque accumulation around zirconia crowns are better than SSCs.124,125 

Recommendations: 

1. There is evidence from retrospective studies showing greater longevity of preformed metal crown restorations compared to amalgam or resin-based restorations for the treatment of caries lesions in primary teeth. Therefore, use of SSCs is supported on high-risk children with large or multi-surface cavitated or non-cavitated lesions on primary molars, especially when children require advanced behavioral guidance techniques126 including general anesthesia for the provision of restorative dental care. 
2. There is evidence from case reports and one RCT sup-porting 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.127 Esthetic restoration ofprimary 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.128 

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.129 Additionally, there is limited information on the potential psychosocial impact of anterior caries or unaesthetic restorations in primary teeth.127 

Class III (interproximal) restorations of primary incisors can be prepared with labial or lingual dovetails to incorporate a large surface area for bonding to enhance retention.129 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.130,131 It has been suggested that patients considered at high-risk for future caries may be better served with placement of full tooth coverage restorations.131 

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 guidance difficulty, it is sometimes impossible to isolate teeth for the placement of composite restorations. In these cases, GIC or RMGIC is suggested.130,131 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.129 Successful full-coronal restorations of extensively decayed primary anterior 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.128,132 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.133 Another retrospective study, with 24-74 months follow-up, reported 80 percent retention of strip crowns.134 

Preveneered SSCs 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.127,135,136 Preveneered SSCs have the concerns of color stability and surface roughness changes,137 so long term clinical studies are required to establish their comparative effectiveness. Preformed SSCs and opened-face stainless steel crowns are still options for treatment on primary anterior teeth, but published studies reporting their effectiveness and use are sparse111 given the availability of more esthetic and easier-to-use alternatives. 

Preformed pediatric zirconia crowns are another option for esthetic full coronal coverage restoration.122 As they require a passive fit, the amount of tooth reduction is greater than that required for SSC (minimum of 1.5-2.0 mm), and technique for tooth preparation does vary significantly among different brands.123 Although a RCT with a follow-up of only six months suggests that zirconia crowns gave significantly better results than the others with regard to gingival health and crown fractures124, a systematic review on the topic125 concluded that due to the small number of RCTs on this topic and their risk of bias, future RCTs with better study design are required to compare differences between the dif-ferent types of pediatric preformed zirconia crowns and between other esthetic treatment options. 

Recommendations: 

1. There is expert opinion that suggests the use of resin-based 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 RMGIC 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, preveneered SSCs, preformed SSCs, and opened-face SSCs are a treatment option for full coronal coverage restorations in primary anterior teeth. 

References

1. American Academy of Pediatric Dentistry. Guidelines for pediatric restorative dentistry 1991. In: American Academy of Pediatric Dentistry Reference Manual 1991-1992. Chicago, Ill.: American Academy of Pediatric Dentistry; 1991:57-9. 

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