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82 Restorative Techniques in Paediatric Dentistry
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Step 10: Make a Final Check of Completed Restoration
FIGURE 5.22 Finally, the crown should be checked for occlusion and lightly polished with a prophylaxis paste. Any minor
discrepancies in the occlusion should be ignored, since once crowned, the primary molars seem to be able to adjust themselves very quickly. (a) Completed restoration on 85. (b) Completed restorations of 84 and 85 accomplished in the same visit.
(c) Diagrammatic representation of the completed restoration in the bucco-lingual section: (1) occlusal surface of crown;
(2) occlusal preparation; (3) cement; (4) adaptation to natural bulge; (5) gingival margin; (6) adaptation to natural undercut.
Follow-Up
FIGURE 5.23 (a, b) At each recall appointment, the crowns should be checked for occlusion, t, and seating. Particular
attention should be given to the condition of the gingival margins around the crowns. Well-adapted and crimped margins facilitate plaque removal with routine oral hygiene measures. The photographs show excellent gingival health
around well-adapted crowns on primary molars.
Some Problems and Their Solution
Crown Does Not Seat Proximally
This usually means that there is a ledge, as discussed before. It is removed using a tapered ssure bur.
Loss of Space
Sometimes, loss of space has occurred because of proximal caries in the tooth being restored and
movement of the tooth distal to it into the space. In this situation, a preformed metal crown that will
t on the tooth bucco-lingually is too large mesio-distally. There are two possible solutions to this
problem: Figures5.24 and 5.25.
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FIGURE 5.24 The crown is rotated slightly mesio-buccally so that it is rotated slightly out of the arch.
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83Preformed Metal Crowns for Primary Molars
FIGURE 5.25 The closest tting crown is held in the beaks of the Adams plier (a) and squeezed mesio-distally to
reduce this dimension. This is an effective way of attening the contact points (b) and reducing the crown mesiodistally, but careful crimping of the crown margins is required later because the crown margins will be distorted by
this method.
FIGURE 5.26 It is sometimes tempting not to prepare the distal surface of the second primary molar when the rst
permanent molar is yet unerupted. This can cause the erupting rst permanent molar to get impacted under the distal
margin of the preformed metal crown. Therefore, a distal slice should always be made on the second primary molar,
even when it is the last tooth in the arch, before the eruption of the rst permanent molar.
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84 Restorative Techniques in Paediatric Dentistry
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Parents’ Concern about Aesthetics
Figure5.27 shows carious primary incisors, canines, and rst primary molars restored using zirconia
crowns.
FIGURE 5.27 Parents rarely object to the placement of preformed metal crowns. However, if they are concerned
about this aspect, the crowns can be made more aesthetic by cutting a window in the buccal aspect (a) and placing a
composite resin facing (b) or using a white crown such as zirconia crowns (c).
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85Preformed Metal Crowns for Primary Molars
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Concerns about Exfoliation
Preformed metal crowns do not interfere in any way with the normal exfoliation of the primary
molars, with the preformed metal crown and the primary molar crown being exfoliated together
(Figure5.28).
FIGURE 5.28 (a) Radiograph showing normal resorption of 74 restored with a preformed metal crown. (b) Normal
exfoliation of a molar. (c) The exfoliated 75. This is the norm rather than an exception.
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86 Restorative Techniques in Paediatric Dentistry
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Success Rates of Preformed Metal Crowns Compared
with Other Restorations in Primary Molars
Research has shown that preformed metal crown restoration of primary molars is superior to that
achieved with amalgam, composite resin, or glass ionomer cement. Once tted, the crowns seldom
need replacing. Our own research has shown that ve years after placement, over 80% of preformed
metal crowns are still in place (Figure1.12).
In paediatric dentistry, only those techniques that need to be performed once in the lifetime of the
primary tooth are justied. Repeated replacement of restorations in children is traumatic and can put
the child off future dental treatment. In view of the reported superiority of the preformed metal crown
(Figure5.29) for the restoration of large cavities in primary molars, all clinicians who treat children
should be familiar with this technique.
FIGURE 5.29 Meta-analysis demonstrating the superiority of preformed metal crowns as the restoration of choice in
primary molars. (From Randall RC, Vrihoef MA, Wilson NHF. J Am Dent Assoc [2000] 131:337–43.)
Completing Both Pulpotomy and Preformed Metal Crown in the Same Visit
Efforts should be made to complete both pulpotomy and preformed metal crowns in the same visit,
under rubber dam. This will reduce the number of times the child requires the administration of local
analgesia. The following sequence (Figures5.30–5.39) shows how this can be accomplished in the
shortest possible time.
FIGURE 5.30 Remove caries and identify exposure, as discussed in Chapter4.
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FIGURE 5.31 Amputate coronal pulp using a large spoon excavator, as shown, or a large round bur with a slow-speed
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handpiece.
FIGURE 5.32 Place pulpotomy medicament in the pulp chamber (depending on the pulpotomy techniques used).
FIGURE 5.33 Occlusal reduction should be performed as described earlier (Figure5.13).
FIGURE 5.34 The mesial and distal reduction is carried out as described earlier in the chapter (Figure5.14). Distal
reduction can be accomplished by slipping a at plastic instrument under the edge of the rubber dam sheet and pulling
it away from the distal surface of the tooth.
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88 Restorative Techniques in Paediatric Dentistry
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FIGURE 5.35 Apreformed metal crown is selected and tried on the tooth, and any necessary adjustments are
carried out.
FIGURE 5.36 The pulp chamber is restored with appropriate material (dependent on the pulpotomy technique used).
FIGURE 5.37 The rubber dam is now removed, and the crown full of cement is seated on the tooth.
FIGURE 5.38 Finished restoration on 85.
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6
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Dental Caries Management Using
the Hall Technique
Alaa BaniHani and M S Duggal
Introduction
The concept of minimal intervention dentistry (MID) for managing dental caries in children is composed of a set of biological management techniques that aim at increasing access to dental care,
decreasing prevalence of untreated dental caries and decreasing the number of patients requiring
dental treatment under general anaesthesia. MID, of which the Hall technique is one, aims to alter the
environment of carious lesion, preventing its progression by isolating it from the cariogenic biolm.
These contemporary approaches include a range of child-friendly and less-invasive techniques ranging from no carious tissue removal to selective carious tissue removal, preserving as much of the tooth
structure as possible.
The Hall technique was developed in 1988 by DrNorna Hall, a general dental practitioner from
Scotland, in response to an overwhelming amount of caries among the children under her care and
was subsequently introduced into the literature and then clinical practice. With this technique, a
carious lesion in a primary molar is sealed within the tooth by cementing preformed metal crowns
(PMCs) without local anaesthetic, caries removal, or any tooth preparation. This has the advantage
of minimizing the risk of upsetting the child and causing treatment-induced anxiety, which are more
widely associated with the conventional restorative approaches.
The Hall technique is considered quick, easy to use, effective, and acceptable to the majority of
children and their parents. However, for success, the Hall technique requires careful case selection,
a high level of clinical skills, and excellent patient management. In addition, it should always be provided to children within a full and effective caries preventive programme.
The Rationale behind the Use of Hall Technique
The Hall technique seals dental caries into the tooth by placing the PMC and its cement, therefore
isolating it from the substrates it would normally receive from the host’s diet. This results in slowing,
arresting, and even reversing the carious process, protecting primary molars until shedding.
The Hall technique assumes that the management of dental caries does not necessitate complete
removal of the biolm and carious tooth tissue to stop its progression. Instead, allowing a cariogenic
biolm to mineralize with the establishment and maintenance of an effective caries preventive programme can successfully slow and arrest the progression of the carious lesion.
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89DOI: 10.1201/9781003273646 -6
90 Restorative Techniques in Paediatric Dentistry
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Advantages of Hall Technique
The Hall technique has several advantages over conventional restorations, including conventional
PMCs, as follows:
1. A non-invasive procedure in which the PMC is placed without local anaesthesia, caries
removal, or tooth preparation.
2. Seals in carious lesion, resulting in slowing, arresting, and even reversing the carious pro-
cess, protecting primary molars until exfoliation.
3. Increases access to dental care, decreases prevalence of untreated dental caries and number
of patients requiring dental treatment under general anaesthesia.
4. Considered more cost-effective than conventional restorations and is acceptable to the
majority of children, their parents, and clinicians.
5. Time needed to place the orthodontics separators and Hall technique PMC is minimal com-
pared to other restorations.
6. Eliminates the potential damage to adjacent rst permanent molars when preparing a second
primary molar for a conventional PMC.
When Should the Hall Technique Be Considered?
As with every treatment decision, clinicians should use their clinical judgement and careful case
selection in deciding whether Hall technique is appropriate for the patient. In addition, for long-term
success, this technique should be part of a comprehensive caries preventive programme.
Prior to use of Hall technique, full history and clinical examination, including bitewing radiography, should be carried out. Hall technique is indicated in the following cases:
• Primary molar with early to moderately advanced active dentinal caries, extending up to the
inner third of dentine, affecting the occlusal or proximal surface, with no clinical or radiographic signs or symptoms suggestive of pulp involvement.
• Primary molars with enamel or dentine defects, including primary molar hypomineralization, amelogenesis imperfecta, and dentinogenesis imperfecta (Figure6.1).
• Primary molars with sufcient sound tooth structure to retain the PMC (Figure6.1).
• A clear band of dentine should be identied between the advancing front of the carious
lesion and the pulp on radiographs. Where no clear band of dentine is visible on the radiograph, it is likely that the carious lesion has encroached signicantly on the dental pulp, and
other treatment options, including pulpotomy, might be required (Figure6.2).
• Sufcient patient cooperation to allow the cementation of the Hall technique PMCs without
endangering the patient’s airway.
Contraindications to the use of Hall technique involve the following:
• Primary molars with unusual morphology which would complicate the tting of a PMC of
standard shape.
• Very anxious or young patient who do not understand the procedure or tolerate biting the
PMC into its position.
• Patients with a nickel allergy.
• Patients at increased risk of infective endocarditis. In these cases, the carious tooth should
be managed with conventional restoration.
• Clinicians who are not condent or skilled in carrying out the procedure.
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