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91Dental Caries Management Using the Hall Technique
https://t.me/med1917
FIGURE6.1 (a) Lower right second primary molar with primary molar hypomineralization and post-eruptive break-
down. (b) Hall technique PMC placed on the second primary molar to restore the tooth and protect it from further posteruptive breakdown. Lower left second primary molar was extracted due to the inability to restore the tooth as a result of
sub-gingival caries. The image also shows the successful eruption of the lower right rst permanent molar a year later.
FIGURE6.2 Left-side bitewing radiography showing dental caries in upper and lower left rst and second primary
molars. Upper left rst and second primary molars as well as lower left rst primary molars have clear band of dentine
separating the advancing front of the carious lesion from the pulp; therefore, these teeth can be managed with the Hall
technique. Whereas no clear band of dentine is visible in the lower left second primary molar, which is also associated
with bifurcation radiolucency, indicating loss of pulpal vitality. This tooth, therefore, requires either pulpectomy or
extraction.
Steps for the Placement of a PMC Using the Hall Technique
Readers are advised to refer to the ‘Hall Technique, a child centred approach to managing the carious primary molar, a user’s manual’, developed by the University of Dundee, for further details on
the procedure of placing the Hall technique (https://upload.wikimedia.org/wikipedia/commons/9/91/
HallTechGuide_V4.pdf).
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The following steps should be followed when placing a Hall technique PMC (Figures6.3–6.9):
1. Explanation of the technique and its rationale. Informed consent should be obtained from
the child and parents prior to placing the Hall technique. It is important for the child and
parent to be briefed on the procedure before the Hall technique PMCs are tted, including short-term disturbance in bite/occlusion and the aesthetic aspects of a PMC restoration.
Children should be shown the crown and allowed to handle a spare one, as young children
sometimes respond to the idea of the crown being ‘a shiny helmet’, just like a ‘soldier’s helmet’, a ‘precious, shiny, princess crown’, or a ‘twinkle tooth’. Children should be aware that
they have to help, by biting the crown into place when asked to do so, and the strange taste
of the cement.
2. Placement of orthodontic separators. Orthodontic separators should be placed through the
mesial and distal contacts of the tooth to be crowned in order to create an interproximal
space for PMC placement. This is very important in cases where there has been a loss of the
mesio-distal width of a tooth due to marginal ridge breakdown. Separators can be placed
using dental oss or the elastic separating pliers and left in place for 3–5 days (Figure6.4).
3. The following instruments and material should be prepared:
• Dental mirror
• Preformed metal crowns (PMC) of all sizes
• Glass ionomer cement, such as 3M™ Ketac™ Cem Radiopaque glass ionomer luting
cement
• Straight probe to remove separators as well as excess cement following tting the PMC
• Excavator to remove PMC if necessary, and also for cement removal
• Flat plastic to load the PMC with cement
• Cotton wool rolls to wipe away excess cement
• Orthodontic biting stick, which can be helpful in seating PMCs
• Band-forming pliers, which can be used for adjusting the PMCs, particularly where the
primary molar has lost its mesio-distal dimension as a result of caries
• Gauze, to protect the airway and wipe off excess cement
• Elastoplast, which can be helpful to secure the PMC for airway protection
4. Removal of the orthodontic separators. Orthodontic separators placed through the mesial
and distal contacts of the teeth are removed using a dental probe. If the separator appears to
have fallen out, the interproximal area of the gingiva should be inspected to check that the
separator has not been displaced below the contact point.
FIGURE6.3 Right bitewing radiography of an 8-year-old patient with mesial caries in upper right second primary
molar, extending into the outer third of dentine. Aclear band of dentine is visible between the advancing front of the
carious lesion and the pulp.
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93Dental Caries Management Using the Hall Technique
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FIGURE6.4 Where contact points are tight or there has been loss of mesio-distal width of a tooth due to marginal
ridge breakdown, placing orthodontic separators through the mesial and distal contacts can be useful when tting the
Hall technique PMCs. Two lengths of dental oss should be threaded through the separator (a). The separator should
then be stretched taut and ossed through the contact point briskly and rmly until the leading edge only is felt ‘popping
through’ the contact point (b). The uppermost part of the separator should stay above the contact points (c, d); otherwise,
it will be less effective in opening up the space and hard to remove. Separators should be removed after 3–5 days.
5. Patient airway protection. The child should be seated upright. Agauze swab can be used to
protect the airway by placing it between the tongue and the tooth where the crown is to be
tted (Figure6.5). The gauze should extend to the palate and around the back of the mouth
in front of the fauces. Aclean piece of Elastoplast tape can be used alternatively to secure
the crown.
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6. Crown selection. The smallest crown size covering all tooth cusps, approaching the contact
points, with slight feeling of ‘spring back’ on seating should be selected. No attempt should
be made to fully seat the crown through the contact points during the trial stage, as they can
be very difcult to remove for cementation (Figure6.5). To help size the crown, the mesiodistal width of the tooth can be measured with periodontal probe. Using these measurements, the crown size can be picked using the crown size guide available in the PMCs kit.
7. The crown should be dried and lled with glass ionomer luting cement, ensuring the crown
is well lled, with no air inclusions (Figure6.6).
8. If possible, the tooth should be dried prior to crown cementation. If the cavity is large, some
cement may be placed within it, just before placing the crown.
9. The crown should be seated by the clinician with nger pressure, followed by the child
biting on it (Figure 6.7). It is crucial that the orientation of the crown relative to the tooth
is checked either during or immediately after seating the crown. If it does not appear to be
FIGURE6.5 The smallest size of the crown which covers all the cusps of the molar, approaching the contact points,
with slight feeling of ‘spring back’ on seating should be selected. No attempt should be made to fully seat the crown
through the contact points during the tting stage, as they can be very difcult to remove for cementation.
FIGURE6.6 The glass ionomer luting cement should be mixed to a luting consistency. The crown should be com-
pletely lled with cement.
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FIGURE6.7 The crown should be placed evenly over the tooth engaging the proximal contact points using nger
pressure. The child should then bite down on the crown for 2–3 minutes. The child could be asked to bite on a cotton
wool roll to help fully seat the crown in position. Care should be taken to ensure the crown is seated evenly over the
tooth. Blanching usually disappears within minutes. If the crown is not seated sufciently, it should be removed using
an excavator before the cement sets.
going on straight, then the clinician must reseat the crown. If it is not possible to reseat the
crown, the crown should be removed before the cement sets.
10. Excess cement should be wiped off with a cotton wool roll. If a gauze swab has been used
to protect the airway, this can be used to wipe away excess cement from the lingual/palatal
side of the tooth as it is being removed.
11. The patient should be asked to bite rmly on the crown for 2–3 minutes, or the crown should
be held down with rm nger pressure as an alternative. This is important, because the
crowns can spring back, sucking back the cement form the margins and potentially causing
breaches in the seal.
12. Excess cement should be removed. The occlusal discrepancy might appear uncomfortable at
rst, but children seem to adapt to this quickly, and occlusal discrepancy should completely
resolve in a few weeks. The main concern for the patient might be the altered bite/occlusion
due to the crown being placed without performing any occlusal clearance of the primary
molar. It should be clearly explained to the child and the parent that the crown will feel
‘high’ for a few days only.
13. Tooth brushing instructions should be given to ensure effective plaque removal to prevent
development of gingival disease around the primary molar on which the PMC has been
placed.
Some Concerns Expressed by Clinicians about the Hall Technique
One concern is related to the lack of tooth occlusal reduction, which could lead to premature contacts
after the cementation of the PMC and increase occlusal vertical dimensions (OVDs), particularly
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FIGURE6.8 Excess cement should be removed. The occlusal discrepancy might appear uncomfortable at rst, but
children seem to adapt to this quickly, and occlusal discrepancy should completely resolve in a few weeks.
FIGURE6.9 (A) Increase in OVDs immediately following placement of Hall technique PMC on the second primary
molar. (B) Three weeks following placement of Hall technique PMC, the occlusion has equilibrated, with no TMJ pain
or problems reported by the patient.
with the second primary molars. However, studies have shown that adequate occlusal contacts are
re-established within a few weeks (within 30 days), with no temporomandibular joint (TMJ) pain or
problems reported among children (Figure6.9). The reduction in OVDs seems to be caused mainly
by the intrusion of the crowned molar and its antagonist.
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97Dental Caries Management Using the Hall Technique
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In addition, no evidence of damage to the permanent successor or increased risk of impaction
of unerupted adjacent permanent molar against the margins of the Hall technique PMC has been
reported in any of these studies. If the latter does occur, it can often be managed with orthodontic
separators if detected early.
Another concern to the Hall technique is the appearance of the metal crown. In one study, concerns
over the aesthetics of Hall technique PMCs were reported by 5% of parents. However, children did not
seem to mind the appearance and commonly report very positively on their crowns, referring to them
as their ‘special’, ‘shiny space princess’, ‘Iron Man’, ‘pirate’, or ‘star’ tooth.
Clinical tips and troubleshooting:
1. Placement of Hall technique PMCs on the rst and second primary molars in the same quad-
rant at the same appointment can be challenging. It is preferable to place them at separate
appointments (Figure6.10).
2. The placement of two opposing PMCs at the same appointment can prop open the bite
beyond the level which is comfortable to the child. However, Hall technique PMC placement
in contralateral quadrants can be tted at the same appointment with minimal discomfort, as
contralateral occlusion tends to even out and be tolerated more easily by the patient.
FIGURE6.10 Fitting PMCs using the Hall technique to the rst and second primary molars in the same quadrant can
be challenging. In this case, the second primary molar was restored rst using Hall technique, and the separator distal
to the rst primary molar was left for another 3–5 days to create interproximal space. Separator was removed in the
subsequent dental visit, and a Hall technique PMC was tted on the rst primary molar.
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3. Where the distal marginal ridge on the rst primary molars has been lost due to caries
and the second primary molar has migrated mesially into the cavity, placing PMCs using
the Hall technique can be challenging. In this case, a band-forming pliers can be used to
increase the bucco-lingual width of the crown at the expense of the mesio-distal length. In
addition, the distal margin of the crown can be altered from a convex to a straight shape by
gently squeezing the margin with the pliers. Alternatively, rotating the PMC slightly, usually
mesio-buccally, can sometimes be helpful.
What Is the Success Rate of the Hall Technique, and How
Well Is It Accepted by Children and Parents?
Several clinical studies, systematic reviews, and more recently, an umbrella review, aimed to assess
the effectiveness, cost, and acceptability of Hall technique to children, parents, and clinicians, have
been published. Overwhelming evidence exists that clearly shows that Hall technique PMCs have
been associated with reduced discomfort at time of treatment, reduced risk of major failure (pulp
treatment and extraction needed), and pain compared to conventional restorations, including amalgam, GIC, and resin composite. In addition, Hall technique appears to be cost-effective. The high
success rate of over 93% puts this technique as one of the treatment methods of choice rather than a
compromise option in circumstances where the conventional approach of complete caries removal
and pulp therapy is not possible due to cooperation or cost in managing carious primary teeth in
children.
The Use of Silver Diamine Fluoride (SDF)
The use of silver diamine uoride to arrest the progression of the carious lesion has become popular,
with several European and American guidelines endorsing its use. SDF has an antimicrobial effect
against cariogenic bacteria, inhibits further demineralization and aids in remineralization, and also
prevents the breakdown of the collagen matrix. Upon application to the carious lesion, it reacts with
hydroxyapatite to form silver phosphate and also calcium uoride, which then acts as a uoride and
phosphate reservoir which subsequently aids remineralization. The silver ions also penetrate into the
carious lesion, thereby maintaining this effect for a long period of time.
Although SDF is an excellent way to arrest caries progression, it also severely effects the colour
of the lesion, with the lesion turning black in colour. This causes a severe aesthetic concern for some
parents and children, especially if applied in the aesthetic zone (Figure6.11).
It is an extremely useful tool as a public health measure where caries prevalence is high in a population and the prevalent socio-economic conditions are not conducive to other interventions.
Its use in paediatric dentistry clinical practice is indicated in the following situations:
1. Pre-cooperative children who have one or more carious primary teeth which if left untreated
might become symptomatic
2. Severe early childhood caries (ECC) in very young uncooperative children where it is felt
that that general anaesthesia is not indicated due to age, medical reasons, or unavailability
3. Severe ECC in pre-cooperative or uncooperative children where parents are not willing to
consider rehabilitation under general anaesthesia
4. As a temporary measure while waiting for denitive treatment
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99Dental Caries Management Using the Hall Technique
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FIGURE 6.11 (a) Showing severe caries affecting upper primary anterior teeth before application of SDF. (b) One
week after application of SDF.
5. As a part of the silver-modied atraumatic restorative technique (SMART) described in the
following section
Silver-Modified Atraumatic Restorative Technique (SMART)
The SMART technique refers to the application of SDF to primary teeth with caries, followed by
restoration with a material such as glass ionomer. In this approach, only the soft caries is excavated
gently, and without the use of local analgesia, followed by application of SDF. To avoid a second
appointment for the glass ionomer placement, the curing light can be used after application of SDF
on the dentine and the tooth restored in the same visit. Visible darkening of the dentine can be seen
immediately with the application of the light. It is likely that the heat generated through the use of
light on the tooth after SDF application accelerates the action of SDF on dentine.
This technique is useful in pre-cooperative and uncooperative children with caries on a few or
several primary teeth which are asymptomatic and where other restorative options are not possible
or available.
FURTHER READING
Altoukhi, D.H.; El-Housseiny, Z.A. Hall technique for carious primary molars: Areview of the literature.
Dentistry Journal 2020;8:11. https://doi.org/10.3390/dj8010011.
BaniHani, A.; Deery, C.; Toumba, J.; Duggal, M. Effectiveness, costs and patient acceptance of a conven-
tional and a biological treatment approach for carious primary teeth in children. Caries Research
2019;53(1):65–75. https://doi.org/10.1159/000487201.
BaniHani, A.; Deery, C.; Toumba, J.; Munyombwe, T.; Duggal, M. The impact of dental caries and its
treatment by conventional or biological approaches on the oral health-related quality of life of children and carers. International Journal of Paediatric Dentistry 2018;28(2):266–276. https://doi.
org/10.1111/ipd.12350.
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FIGURE 6.12 (a) Upper arch in a 5-year-old uncooperative patient where SDF was used to manage severe ECC in
asymptomatic severely decayed primary molars. Only the 55, which had a pulp polyp, needed to be extracted, while
others could be retained with the use of SDF to be restored when cooperation was gained. (b) Lower arch showing use
of SMART approach where 74 and 75 were restored with glass ionomer cement after application of SDF.
BaniHani, A.; Duggal, M.; Toumba, J.; Deery, C. Outcomes of the conventional and biological treat-
ment approaches for the management of caries in the primary dentition. International Journal of
Paediatric Dentistry 2018;28(1):12–22. https://doi.org/10.1111/ipd.12314.
BaniHani, A.; Santamaría, R.M.; Hu, S.; Maden, M.; Albadri, S. Minimal intervention dentistry for man-
aging carious lesions into dentine in primary teeth: An umbrella review.European Archives of
Paediatric Dentistry 2021;23(5):667–693. https://doi.org/10.1007/s40368-021-00675-6.
Elamin, F.; Abdelazeem, N.; Salah, I.; Mirghani, Y.; Wong, F. A randomized clinical trial compar-
ing Hall vs. conventional technique in placing preformed metal crowns from Sudan. PLOS ONE
2019;14(6):e0217740.
Innes, N.P.; Evans, D.J.; Hall, N. The Hall technique for managing carious primary molars. Dental Update
2009;36:472–478.
Innes, N.P.; Evans, D.J.; Stirrups, D.R. The Hall technique; a randomized controlled clinical trial of a novel
method of managing carious primary molars in general dental practice: Acceptability of the technique and outcomes at 23 months. BMC Oral Health 2007;7:18.
Innes, N.P.; Stewart, M.; Souster, G.; Evans, D. The Hall technique; retrospective case-note follow-up of
5-year RCT. British Dental Journal 2015;219:395–400. https://doi.org/10.1038/sj.bdj.2015.816.
Innes, N.P.; Stirrups, D.; Evans, D.; Hall, N.; Leggate, M. Anovel technique using preformed metal crowns
for managing carious primary molars in general practice—a retrospective analysis.British Dental
Journal 2006;200(8):451–454. https://doi.org/10.1038/sj.bdj.4813466.
Ludwig, K.H.; Fontana, M.; LaQuia, A.; Jeffrey, A.P.; Jeffrey, A.D. The success of stainless steel crowns
placed with the Hall technique. JADA 2014;145:1248–1253.
Santamaria, R.; Innes, N.; Machiulskiene, V.; Evans, D.; Alkilzy, M.; Splieth, C. Acceptability of differ-
ent caries management methods for primary molars in a RCT. International Journal of Paediatric
Dentistry 2015;25:9–17.
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