Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2019; 64:(1 Suppl): S22–S36

doi: 10.1111/adj.12682

Restorative treatment of primary teeth: an evidence-based

narrative review
D Finucane*†‡
*Consultant Paediatric Dentist, Hermitage Medical Clinic, Dublin, Ireland.
†Lecturer and Examiner, Faculty of Dentistry, Royal College of Surgeons in Ireland, Dublin, Ireland.
‡Clinical Tutor, Dublin Dental University Hospital, Dublin, Ireland.

ABSTRACT
Various methods, with a variety of materials, exist for restoring carious primary teeth. Successful restoration of primary
teeth is dependent on accurate diagnosis, knowledge of the caries process, knowledge of dental materials, and treatment
choice. The purpose of this evidence-based review is to present evidence that will help clinicians to make an appropriate
diagnosis, from which the optimum treatment plan can be made; to explore the literature regarding restoration of cari-
ous primary teeth; and to try and draw conclusions as to which materials and methods can be recommended. This
review will primarily deal with the restoration of carious cavities in primary molars. A short discussion on restoration of
primary incisors is included, with presentation of what limited evidence there is relating to this.
Keywords: Primary teeth, diagnosis, restoration, materials.

studies, Duggal et al., and later Kassa et al., demon-

INTRODUCTION
Dental caries in childhood continues to affect a signifi-
cant percentage of young children worldwide, with
potentially serious consequences for the child’s dental
and general health, wellbeing and, possibly, intellec-
tual development. Rehabilitation of the child’s carious
dentition can restore him/her to health and function.1
Regardless of any issues related to patient compli-
ance or management, the restoration of primary teeth
can be technically difficult, given that they are so
much smaller than permanent teeth (Fig. 1). The thin-
ner enamel and high pulp horns of primary teeth is
associated with increased risk of caries progression
into dentine, and risk of pulp exposure during opera-
tive intervention (Table 1).2
History, Examination, and Special Tests (radio-
graphs) are key elements in establishing an accurate
diagnosis. In this regard, the clinician must question
the child and his/her parents/carers re symptoms
related to the carious tooth. A history of spontaneous
pain, for example, may indicate irreversible pulpitis,
which will dictate the treatment plan.
The site and extent of caries can also alert the clini-
cian to the possibility of pulpal pathology, as revealed
by a series of studies, including histological assessment
of teeth, at Leeds Dental Hospital, U.K.3,4 In these
S22
strated that pulp inflammation in carious primary
molars, where caries has caused occluso-proximal cav-
itation, precedes pulp exposure, and that in a primary
molar with a broken-down marginal ridge, due to car-
ies, the adjacent pulp horn is inflamed (Fig. 2). Kassa
et al. demonstrated that a primary molar with proxi-
mal caries extending more than half-way into dentine
exhibits more pulpal inflammation (of the adjacent
pulp horn), than is seen in pulps of primary molars
with only occlusal caries of the same extent (Fig. 3).
The authors recommended that pulpotomy, and place-
ment of a pre-formed crown be performed for such
teeth (see later).
Radiographs (most commonly, bitewings) are essen-
tial aids to establishing correct diagnosis of primary
molar caries, without which the pathology is likely to
be underdiagnosed. Kidd et al. demonstrated that at
least 50% of proximal lesions in primary molars of
children aged 3–7 years are undetected without radio-
graphs.5 Likewise, Newman and Seow’s research
revealed that the visual-tactile technique detected
43% of proximal caries in primary teeth, compared
with 91% detection when bitewing radiographs were
used.6 Occlusal caries, however, is poorly diagnosed
with bitewing radiographs, until it has progressed into
dentine.7 Sensitivity & specificity of bitewing
© 2019 Australian Dental Association

(a)
(b)
Fig. 1 How primary molars differ from permanent molars. (a) Bulbous
crown. 1. Cervical constriction. 2. Narrow occlusal table (Fig. 1b). 3.
Thin enamel. 4. Pulp horns. 5. Narrow root canals. 6. Thin and porous
pulpal floor. 7. Developing permanent tooth. (b) Narrow occlusal table.
Table 1. Keys to successful restoration of carious
primary molars
1 Accurate, ideally early, diagnosis
2 Teeth restored properly, with appropriate materials.
3 Due consideration given to pulpal involvement.
4 Pulp therapy performed when indicated.
5 Pre-formed (usually stainless steel) crowns used when indicated.
6 Rubber dam isolation employed.
radiographs for detection of occlusal lesions is poor,
with a value of only 35%.8 Careful interpretation of
radiographs is necessary, in order to help establish a
correct diagnosis, and thereby form an optimum treat-
ment plan (Fig. 4).
Having made a diagnosis and treatment plan, the
clinician must decide how to restore the tooth, and
what materials to use. Restoration may be intracoro-
nal (a “filling”), or extracoronal (a “crown”). The
decision to use intracoronal or extracoronal restora-
tion depends on several factors, including caries risk,
extent of caries, age of patient, method of treatment
(e.g. in-office, or under general anaesthesia), etc.
A recent paper,9 and a Cochrane review,10 has
demonstrated that clinical success is greater when
© 2019 Australian Dental Association
Restorative treatment of primary teeth
Fig. 2 Carious destruction of distal marginal ridge of mandibular left 1st
primary molar (tooth 74).
restorations are placed using rubber dam isolation,
however Wang noted, in the Cochrane review, that
the evidence is at present of very low quality.
The number and variety of dental materials avail-
able may seem bewildering. When choosing the
appropriate material for a given situation, the clini-
cian should consider the desirable factors illustrated
in Tables 2 and 3.
Following the recommendations of the Minamata
Convention on Mercury, Amalgam is no longer indi-
cated for use in children (viz. European Union regula-
tion 2017/852, Article 10).
There follows a discussion of the advantages and
disadvantages of the various materials used in restor-
ing primary teeth, with presentation of relevant evi-
dence pertaining to each material:
(CONVENTIONAL) GLASS IONOMERS are
derived from organic acids (usually aqueous polymeric
acid) and a glass component (most commonly fluoroa-
luminosilicate glass). These materials set by acid-base
reaction, initiated by mixing the components.
The advantageous properties of glass ionomer
materials include their ability to bond chemically to
dentine and enamel, via covalent bonds. These
bonds are dynamic, meaning that if a bond breaks,
a new one can form.11 Pre-treating dentine with
conditioning agents, to remove the smear layer, has
been shown to increase bond strength of glass iono-
mer to dentine.12 Proprietory materials are available
for this purpose, most of which contain 10–20%
polyacrylic acid (e.g. GC Fuji conditioner), while
ESPE Ketac conditioner contains 25% polymaleic
acid.
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D Finucane

(a) (b)

Fig. 3 Proximal caries implies more extensive pulp inflammation (of adjacent pulp horn), Fig. 3a, than is seen with occlusal caries (Fig. 3b), when caries
extends more than half-way through dentine.

(a) (b)

(c)
(d)

Fig. 4 Interpretation of radiographs: Pulp responses. (a) Reduced distal pulp horn (reparative dentine laid down ahead of caries). Pulp may be vital. (b)
Caries extending to pulp. Inter-radicular radiolucency. Pulp is non-vital. (c) Caries extending to pulp. Inter-radicular radiolucency. Internal resorption of
mesial root. Pulp is non-vital. (d) BEWARE! Extensive distal caries (ICDAS C5), but no retraction of distal pulp horn. Pulp is probably non-vital. A tooth
presenting such signs is NOT suitable for Hall crown technique.
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Table 2. Desirable factors, to consider when choosing
appropriate dental materials
1 Ease of handling in practice
2 Adhesion to tooth structure (enamel & dentine)
3 Physical and chemical qualities
4 Longevity of restorations
5 Anti-caries effect
6 Biologic properties of material
7 Cost effectiveness
8 Aesthetics
Table 3. Materials, currently available, for restoration
of primary molars
1 Pre-formed (usually Stainless Steel) Crowns
2 Resin-modified Glass Ionomer (RMGIC)
3 Compomer (Polyacid modified composite resin)
4 Resin based Composite
5 Conventional Glass Ionomer (GIC)
Another advantage of GIC materials is their bio-
compatiblity. Sidhu et al.13 determined, in a literature
review, that most aspects of glass ionomer cements
allow a reasonable margin of tolerability in terms of
biocompatibility, but pointed out that biological prop-
erties of GICs are product specific. In a review paper,
Sidhu12 noted that the long-term effects of direct
application of GIC to pulp tissue are largely
unknown. This may be of relevance in the pulpotomy
technique, if GIC is applied directly to amputated
pulp stumps, though GIC is a biocompatible material,
and no evidence was found, in this review, of prob-
lems arising from such use of GIC. The leaching of
aluminium from GICs has been shown to occur to
varying degrees, however it is largely excreted, and is
believed to pose negligible hazard to health.14
Fluoride uptake and release is another major advan-
tage of GICs. Fluoride is used as a flux during the
manufacture of the glass powder component of GICs.
It gradually leaches from the set cement, within the
first few months. The set GIC has the capacity, there-
after, to take up more fluoride from the oral environ-
ment, which is then gradually leached from the
material, seemingly for the entire time the restoration
remains in situ. The GIC restoration, therefore, acts
as a fluoride reservoir.12
Conventional GICs, however, exhibit relatively
poor compressive and tensile strength, compared to
other materials. Surface roughness, relatively poor col-
our stability, and poor resistance to wear can also be
a problem. These factors have been shown to
adversely affect the clinical performance of conven-
tional GIC restorations. When used as 2-surface
(Class II) restorations in primary molars, conventional
GICs have been shown to perform poorly.15 (Fig. 5).
RESIN-MODIFIED GLASS IONOMER CEMENT
was introduced to dentistry in the late 19800 s, in an
© 2019 Australian Dental Association
Restorative treatment of primary teeth
Fig. 5 Failed conventional GIC 2-surface restoration. The restoration has
fractured at the isthmus, due to poor tensile strength of the material.
attempt to improve the properties of glass ionomers.
RMGICs are glass ionomer cements into which small
quantities of monomer are incorporated, together with
initiators involved in the polymerisation reaction.
RMGICs share the desirable properties of conventional
GICs (adhesion to tooth substance, fluoride release,
biocompatibility, and reasonably good aesthetics),
while the addition of monomer, and initiators of poly-
merisation, confers on the materials higher fracture
toughness, better wear-resistance, and higher resistance
to moisture. With some RMGICs, it is possible to
obtain initial photo-polymerisation of the material by
exposure to visible light, while later curing of the mate-
rial occurs via acid-base reaction.12,16
In 2003, Hubel and Mej
are published the results of
a split-mouth randomised prospective 3-year study
comparing clinical performance of conventional GIC
(Fuji II) with RMGIC (Vitremer), for class II restora-
tions in primary molars.16 They found the cumulative
success rates, after 36 months, to be: Vitremer
RMGIC = 94%, and Fuji II Conventional GIC = 81%
(P < 0.05), the difference being statistically significant.
The authors noted that the risk of a failed restoration
was more than five times greater with conventional
GIC (Fuji II) than with RMGIC (Vitremer) as the
restorative material.
In a systematic review of the literature, Chadwick
and Evans compared class II restorations in primary
molars using conventional GICs, and resin-modified
GICs.15 They found that conventional GICs performed
poorly (failure rates 6.6–60%), compared to RMGICs
(failure rates 2–24%). The authors concluded that con-
ventional GICs cannot be recommended for class II
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D Finucane
restorations in primary molars. They noted, however,
that evidence supports the use of RMGIC for small to
moderate sized class II restorations.
COMPOMERS, or poly-acid modified composite
resins are light-cured restorative materials having
properties in common with both glass ionomer
cements and hybrid composites. Acid-etching is not
required, yet adhesion to enamel and dentine is made
possible by means of conditioning/bonding agents
(e.g. Prime & Bond NT - Dentsply).
A systematic literature review of compomer restora-
tions of class II cavities in the primary dentition, by
Marks, et al.17 determined that compomers can be
recommended for class II restorations in the primary
dentition, but are not recommended for restoration of
pulpotomised or pulpectomised primary teeth. The
advantages of compomers are: adhesion to tooth sub-
stance (by means of priming and bonding agents), bet-
ter aesthetics than glass ionomers (though inferior to
resin composites), the material can be light-cured, rel-
atively high clinical success rates, and better mechani-
cal properties than glass ionomers (lower fracture
rates, and less wear). Disadvantages, however, include
that placement of compomers is more time-consuming
and technically demanding than placement of glass
ionomer materials (though less demanding than resin
composite placement), isolation with rubber dam is
recommended, wear properties of compomers are
inferior to those of resin composites, marginal dis-
colouration is worse than for composites, and they
are not recommended for restoration of primary
molars that have had pulpotomy or pulpectomy.17,18
Compomers, like glass ionomers, release fluoride, but
the amount of fluoride released by a compomer is
only approximately 10% that released by GIC or
RMGIC.19 Various studies have shown compomers to
have a failure rate, after 2 years, of 2–30%.20–24
Qvist, et al.25 found, in a series of prospective, prac-
tice-based studies with long follow-up times, that the
main reason for failure of compomers was loss of
retention. They noted that loss of retention was less
common when conditioning of class II cavities was
performed, prior to placing the compomer restoration.
RESIN-BASED COMPOSITES are aesthetic. They
are not inherently adhesive, but can be bonded to
enamel with proprietary resins, following acid-etching,
washing, and drying of enamel, a time-consuming
process when restoring primary molars. They have
reasonable wear properties, and can be command-set
by photopolymerisation. They are, however, tech-
nique-sensitive materials, and should, ideally, be
placed using rubber dam isolation. They do not
release fluoride, and are relatively expensive materials.
A major disadvantage of resin-based composites is
polymerisation shrinkage, which can lead to leaking
restoration margins, with potential for secondary
S26
caries. This is particularly problematic when compos-
ites are used to restore occluso-proximal cavities in
primary molars, as the cervical enamel of these teeth
is very thin, with an aprismatic surface layer, which
results in difficulties in bonding the restorative mate-
rial in this area, leading to potential marginal leak-
age.26 As resin-based composites are the most time-
consuming and most technique-sensitive materials,
and have potential for marginal leakage, they are gen-
erally unsuitable for class II intra-coronal restorations
in primary teeth, particularly if the child is uncoopera-
tive, and/or at high caries risk.26,27
INVESTIGATIONS OF CLINICAL PERFORMANCE
AND DURABILITY OF VARIOUS RESTORATIVE
MATERIALS IN PRIMARY MOLARS:
In the following discussion, studies are arranged
chronologically. The author has selected studies that
were, mainly, published within the past 10 years as,
due to improvements in dental materials over time,
earlier studies may not be comparable with more
recent ones.
Due to its obsolescence, studies of amalgam are not
included, other than when amalgam is compared to
alternative materials.
In the first meta-analysis of tooth coloured restora-
tions in proximal lesions of primary molars, Toh and
Messer28 sought to determine which tooth coloured
restorative material (GIC, RMGIC, Composite resin,
or Compomer) has the highest success rate in restor-
ing proximal (caries) lesions in primary molars, when
followed for at least 1 year. Their investigation of the
literature yielded 21 studies (14 Randomised Con-
trolled Trials, 7 clinical trials) that provided data suit-
able for meta-analyses. The authors concluded that:
In human primary molars with proximal cavities, use
of RMGIC, compared with GIC, Composite, and
Compomer, resulted in the highest clinical success
rates (89%) when followed for at least 1 year. They
noted that there were few appropriate articles to
determine the best material for proximal lesions in
primary molars, and that, improvements in materials
since 1990 meant earlier data may not have been
comparable. They found that RMGIC had the fewest
studies and restorations, and only 1 product (Vitre-
mer, 3M) was assessable. The authors recommended
that prospective RCTs should be of at least 5 years
duration to correctly determine the success rate of
class II restorations in primary molars.
A 2009 Cochrane review of dental fillings for the
treatment of caries in the primary dentition, by Yen-
gopal et al., was inconclusive.29 The authors found
only three studies that were suitable for inclusion in
the review. One study compared the clinical perfor-
mance of RMGIC and amalgam, another (a pilot
© 2019 Australian Dental Association

study) investigated the clinical performance of aes-
thetic posterior crowns on primary molars, while the
third study evaluated compomer versus amalgam class
II restorations in primary molars. The authors noted
that there was no significant difference in the clinical
performance of the restorative materials tested in the
three studies. They also noted deficiencies in the three
studies included in their review, given that they had
large drop-out rates, low sample size, and results were
obtained over a short period. Yengopal, et al. con-
cluded that there was insufficient evidence to make
any recommendations about which filling material to
use. They stated that well designed RCTs comparing
different types of filling materials for similar outcomes
are urgently needed.
In 2010 Qvist, et al.25 published the results of a ser-
ies of long-term, prospective, practice-based studies
on the longevity of different restorative materials in
primary teeth. For the initial three studies, lasting 7–
8 years, in which 1807 restorations were placed, the
materials were randomly allocated to the practition-
ers. The materials used for the initial studies were:
Amalgam, GIG, RMGIC, and Compomer, but the
specific brands of the materials were not stated. The
cavity design employed consisted of “small, conven-
tional cavity preps” which were not bevelled. The
authors stated that, “during the planning phase of the
studies, the clinicians. . .participated in meetings dis-
cussing criteria for diagnosing caries and restora-
tions,” yet they also stated that “clinical calibration
exercises for diagnosing caries and evaluating restora-
tions were not performed.” Although it is not specifi-
cally stated, it appears from the narrative that the
clinicians who placed the restorations also assessed
them, which may have introduced an element of bias.
Rubber dam and acid etching were not employed.
Cavity conditioning was performed randomly for
50% of the RMGIC and compomer restorations in
the first 3 studies. The majority of cavities (57%) had
a calcium hydroxide liner placed, though it is not sta-
ted what restorative materials were then placed. The
possibility that this may have had a bearing on
results, due to the calcium hydroxide lining resulting
in less exposed tooth material for tooth-coloured
materials, if used, to bond to, was not addressed in
the published paper.
In the fourth study, conducted 4 years after the ini-
tial studies, and lasting almost 5 years, the clinicians
were free to choose the restorative materials. In this
fourth study, 476 restorations were placed, though
numbers of each cavity type were not clearly defined.
The materials selected were: Conventional Glass Iono-
mer, (Ketac Molarâ, 3M Espe) n = 57; and Com-
pomer, (Dyract AP, Ivoclar Vivadent AG, and
Compoglassâ, Dentsply) n = 419. The numbers of
restorations using each particular brand of compomer
© 2019 Australian Dental Association
Restorative treatment of primary teeth
were not stated. Cavity conditioning was performed
prior to all compomer placements in the final study.
Qvist et al. reported the results of the combined
studies of class II restorations in terms of 75% sur-
vival times. They found that compomer had a survival
time of 4 years, followed by RMGIC and Amalgam
(3.8 years), while conventional GIC demonstrated sig-
nificantly poorer survival time (1.4 years). The main
reason for failure of GICs was restoration fracture
while, in the case of compomer restorations, loss of
retention was the cause. The authors concluded that
compomer and RMGIC are appropriate alternatives
to amalgam, having similar or increased longevity.
A recently-published systematic review of the litera-
ture on survival of restorations in primary teeth, by
Chisini, et al. has investigated the longevity of such
restorations, and reasons for failure.9 The authors
searched electronic databases, and hand-searched eli-
gible studies, to find longitudinal clinical studies eval-
uating the survival of class I and class II intra-coronal
restorations placed with various materials, and stain-
less steel crowns (SSCs). Included studies evaluated
the clinical performance of seven different materials:
Amalgam, Compomer, Composite resin, Conventional
glass ionomer, Metal-reinforced glass ionomer, Resin-
modified glass ionomer, and Stainless steel crowns.
Following systematic review, thirty-one studies were
included in the qualitative analysis, and the authors
stated that a high bias risk was observed. Success
rates for the various materials were reported as: SSC
(96.1%), RMGIC (93.6%), Compomer (91.2%), Con-
ventional GIC (88.7%), Amalgam (82%), Composite
(79.3%), and Metal-reinforced GIC (57.4%). The
authors found that, regardless of the material used,
restorations placed under rubber dam showed greater
success rate (93.6%) than those placed without RD
(77.5%). They also noted that Class I restorations
failed less (7.6%) than Class II restorations (14.7%).
When all included studies were considered, high varia-
tion in annual failure rate (AFR) was observed (0–
29.9%), with composite resin showing lowest AFRs
(1.7–12.9%), and Metal-reinforced GIC exhibiting
highest AFRs (10–29.9%).
In their discussion of results, the authors advised
that the different evaluation criteria adopted in the
studies contributed to the heterogeneity of Annual
Failure Rates. They also cautioned that, “The calcula-
tion of total success rate was used to summarise data,
without considering the follow-up time, which is a
strong limitation of these results.” They explain that
the wide range of AFR among studies which consid-
ered time in their calculation reinforces this observa-
tion. Reasons for failure of restorations on primary
teeth were found to be: Secondary caries (36.5%),
Loss of restoration (19.6%), and (poor) Marginal
adaptation (15.6%).
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DO FLUORIDE-LEACHING RESTORATIONS
PREVENT CARIES?
Several studies have addressed this topic, and results
have been equivocal.
In 1999, Donly, et al.30conducted a practice-based
prospective clinical study to compare class II restora-
tions in primary molars, using experimental RMGIC
material (subsequently marketed as Vitremer Restora-
tive, 3M), and amalgam (Tytin, Kerr Manufacturing
Co.). Children requiring two class II restorations in pri-
mary molars, diagnosed with aid of radiographs, were
recruited (n = 40, mean age 8 years  14 months).
Each child received one RMGIC class II restoration,
and one amalgam class II restoration, in different quad-
rants. Treatment was provided by Dr Donly, using local
analgesia, and rubber dam isolation. No randomisation
or blinding was undertaken. The authors evaluated the
restorations at 6-month, 1-year, 2-year, and 3-year
recall appointments, according to USPHS criteria (Ryge
G. Clinical criteria. Int Dent J 1980; 30: 347–358.). On
exfoliation, teeth with experimental restorations were
retrieved, and examined microscopically for inhibition
of demineralisation at restoration margins (n = 13
RMGIC, 13 AMG. Mean time in mouth: RMGIC =
26.2  16.3 month. AMG = 26.4  15.5 month).
Polarised light microscopy revealed that the RMGIC
cement had significantly less enamel demineralisation
at restoration margins than did amalgam (P < 0.0001).
A paper, published in 2010 by Qvist, et al.31 investi-
gated the effects, on adjacent teeth, of fluorides leach-
ing from restorative materials. Practice-based clinical
studies, in which un-restored proximal surfaces of
1341 primary teeth, recorded initially as: Sound, hav-
ing Active caries with or without cavitation, or
Arrested; in contact with Class II restorations of vari-
ous materials, (Amalgam, GIC, RMGIC, or Com-
pomer), were reviewed for up to 8 years, to assess the
effect of caries development on the un-restored sur-
faces. A decreased rate of caries development & pro-
gression on surfaces contacting fluoride-releasing
materials was observed. Surfaces in contact with amal-
gam showed a greater need for restorative treatment
compared to all other materials (P < 0.002), while the
differences among surfaces adjacent to GIC, RMGIC,
and Compomer were not significant (P > 0.05). Fluo-
ride-releasing materials were shown to have reduced
the development and progression of primary caries on
adjacent proximal surfaces, and curtailed the progres-
sion of existing caries lesions.
Kotsanos, et al.32 undertook a prospective, practice-
based split mouth control study, (published 2004), in
which two class II restorations were placed in oppo-
site sides of the mouth, the test restoration being
RMGIC (Vitremer, 3M), and the control restoration
either amalgam, or composite resin. Restorations were
S28
placed adjacent to molar teeth that had been radio-
graphically diagnosed as sound, or with caries con-
fined to enamel. Radiographs, exposed 2 years after
placement of restorations, revealed that differences
between test and control teeth were not significant
(P > 0.1). The authors concluded that, under the con-
ditions of their study, fluoride release from class II
RMGIC restorations did not affect the rate of caries
progression at the enamel of proximal primary teeth.
In 2009, a paper by Trachtenberg, et al.33 posed the
question: “Does fluoride in compomers prevent future
caries in children?” A prospective split-mouth ran-
domised control study was conducted to compare the
incidence of new caries, after children were randomised
to receive compomer (Dyract, Dentsply Caulk) or
amalgam (Dispersalloy, Dentsply Caulk) occlusal
restorations in primary molars. 534 children, aged 6–
10 years, with ≥ 2 carious posterior teeth were
recruited for the trial. The duration of the trial was
5 years, during which the children were scheduled for
complete dental examination every 6 months. Average
follow-up of restorations (n = 1085 compomers, 954
amalgams) was 2.8  1.4 years. The bonding agent
used for all materials was Optibond, (Kerr Manufactur-
ing Co.), which is fluoride-releasing. Fluoride-releasing
sealants (XT plus, Ultradent) were placed on all sound
permanent and primary molars with deep pits and fis-
sures, and were repeated as needed in all children.
Restorations were continually placed during the course
of the trial, as needed. No significant difference
between materials was found in the rate of new caries
on different surfaces of the same tooth. Incident caries
on other teeth appeared slightly more quickly following
compomer placement (P = 0.007), but the difference
was negligible after 5 years. The authors concluded
that no preventive benefit to fluoride-releasing com-
pomer, compared with amalgam, was found. The
authors declared limitations in their findings, due to all
restorations having been placed using fluoride-releasing
Optibond adhesive; and all sealants used on children in
both treatment groups releasing fluoride. All restored
surfaces, therefore, received some fluoride exposure, so
the study was a comparison of compomer and amal-
gam in an oral environment in which there was an
unmeasured, but relatively constant, base level of fluo-
ride. They pointed out, however, that the route of fluo-
ride exposure from bonding agent, which releases
fluoride into the tooth, and from compomer restora-
tion, which releases fluoride into the mouth, is differ-
ent. They surmised that either the fluoride released into
the tooth by the Optibond liner protects against future
caries with a magnitude similar to the fluoride-release
from compomer, or that compomer is no more success-
ful at preventing future caries due to other factors,
among which microleakage, a common problem of
composites and compomers, may be significant.
© 2019 Australian Dental Association

Many authors have concluded that the reasons why
fluoride-leaching restorations may not prevent further
caries are primarily related to microleakage, which is
a known problem with compomers, despite their fluo-
ride-releasing properties.33–36 The problem was sum-
marised by Wiegand, et al.37 who stated: “Despite the
cariostatic effects possibly achieved from fluoride-
releasing materials, secondary caries is still one of the
main reasons for clinical failure of restorations.”
A recent systematic literature review and meta-analy-
sis, by Raggio, et al.38 sought to determine if fluoride,
released from glass ionomer materials, could prevent
marginal caries in occlusal and occluso-proximal
restorations in primary molars, compared with other
restorative materials (amalgam; composite; compomer;
resin-modified glass ionomer, and high viscosity glass
ionomer, using Atraumatic Restorative Technique).
The authors observed that all restorative materials
behaved similarly on occlusal surfaces, however GIC
was better able to prevent caries lesions in the margins
of occluso-proximal restorations. They also noted that
the longer the follow-up period, the better RMGIC
tends to perform, compared with other non-fluoride
releasing restorative materials. They explained this as
being due to the ability of glass ionomers to take up,
and release fluoride (i.e. to act as fluoride reservoirs).
The authors noted a trend of RMGIC restorations per-
forming better than compomers, which they attributed
to compomer materials behaving more like resin com-
posites, and their lower rate of fluoride release, com-
pared to glass ionomer materials. The authors
concluded that there is moderate strength of evidence
for a positive association between GIC materials and
the prevention of caries lesions only in the margins of
occluso-proximal restorations of primary teeth.
A systematic review and meta-analysis, by De
Amorim, et al.39 of the Atraumatic Restorative Tech-
nique (ART) using high viscosity GIC materials, pub-
lished 2012, revealed success rates for 1-surface
(occlusal) ART restorations in primary teeth, over the
first 2 years, of 93% (CI, 91–94%). Success rates for
multi-surface ART restorations in primary teeth, over
the first 2 years were only 62% (CI, 51–73%). The
mean annual dentine lesion incidence rate, in pits &
fissures previously sealed using ART, over first 3 years
was 1%. The authors concluded that ART can safely
be used in single-surface cavities in primary (and per-
manent) teeth; and ART sealants have a high caries
preventive effect.
PRE-FORMED (USUALLY STAINLESS STEEL)
CROWNS HAVE MANY APPLICATIONS FOR USE
ON PRIMARY MOLARS
A Cochrane review of pre-formed crowns for primary
molars, conducted in 2007 by Innes, et al.,40 found
© 2019 Australian Dental Association
Restorative treatment of primary teeth
that no RCTs were available for review. The authors
noted, however, that “The lower levels of evidence
(from published studies) have some strength, as clini-
cal outcomes are consistently in favour of Stainless
Steel Crowns, despite many studies placing SSCs on
the more damaged of the pair of teeth being anal-
ysed.” (Table 4).
An updated Cochrane review by Innes et al.,41 in
2015, included 5 RCTs published since the 2007
review. The RCTs included evaluated: Conventional
pre-formed metal crowns (PMCs) v fillings; PMCs v
Open sandwich restorations; and Hall technique PMCs
v Fillings. The authors of the 2015 Cochrane review
found: Risk of major failure was lower in the crowns
group, in the long term (moderate quality evidence);
Risk of pain was lower in the crowns group, in the
long term (moderate quality evidence); and Procedural
discomfort was lower for Hall Technique crowns than
for fillings. They concluded that “Crowns placed on
primary molar teeth with carious lesions, or following
pulp treatment, are likely to reduce the risk of major
failure or pain in the long term, compared to fillings.”
AESTHETIC PRE-FORMED CROWNS are avail-
able. These can be SSCs with a composite veneer (e.g.
NuSmile, www.nusmile.com; Kinder, www.Kinde
rKrowns.com), or Zirconia porcelain crowns (NuS-
mile, www.nusmile.com; Kinder, www.Kinde
rKrowns.com). SSCs with composite veneer are more
bulky than conventional SSCs, and more tooth reduc-
tion is required when fitting them. The preparation
and fitting technique is more demanding than for con-
ventional SSCs, and less adaptation is possible as only
non-veneered areas of the crown can be crimped or
contoured. Composite may wear, or fracture from
veneered crowns, particularly when opposing veneered
crowns are in contact.42,43
Ram et al.44 reported long-term results of a clinical
study comparing pre-veneered SSCs (NuSmile Signa-
ture crowns) with SSCs. Twenty crowns (10 NuSmile,
10 SSC) were available for review at 4 years. All 10
NuSmile crowns showed evidence of chipping of the
veneers. There were no differences between the differ-
ent crown types for any other parameter assessed.
A study of posterior composite-veneered crowns
(NuSmile Signature crowns & Kinder Krowns), by
Table 4. Indications for use of pre-formed crowns
1 A carious primary molar with more than two surfaces requiring
restoration
2 Where there is insufficient remaining tooth substance to retain
an intra-coronal restoration
3 Following pulp therapy
4 For restoration of teeth affected by severe erosion
5 As abutments for crown & loop space maintainers
6 For patients with certain disabilities, or high caries susceptibility
7 For pre-cooperative or anxious patients (the “Hall technique”)
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D Finucane
O’Connell, et al.43 (n = 34 paired crowns, in 14 chil-
dren) revealed that, after 3 years, veneer fracture had
occurred in 47% of crowns, (compared to 19% frac-
tured at 1 year review). No difference was reported in
clinical performance, between the two crown types.
Seale and Randall,45 in their systematic literature
review of SSCs, noted that pre-veneered posterior
crowns have limited numbers of long-term studies,
which indicate that chipping of the veneer facings
increases over time with increased use.
Zirconia porcelain crowns have very good aesthetic
properties, and demonstrate good adaptation to gingi-
val margins. The preparation technique for these
crowns, however, is demanding; more tooth reduction
is required than for alternative crowns, and no adap-
tation of the crown is possible (the tooth is cut to fit
crown). As noted by Seale and Randall,45 there are no
prospective clinical studies relating to Zirconia poste-
rior crowns; therefore, no evidence-based recommen-
dations for their use can be made.
SSCs: THE “HALL TECHNIQUE”. The clinician,
when employing the Hall technique, places a stainless
steel crown on a primary molar, without local anaes-
thesia, caries removal, or tooth preparation, and seats
it with finger pressure. Excess cement is wiped away,
after which the child further seats the crown by bit-
ing on a cotton roll placed on the occlusal of the
crown.46,47 When first proposed as a treatment
option for children, many clinicians expressed con-
cerns regarding the Hall technique. In an opinion
piece, Nainar48 raised concerns regarding the method-
ology of RCT performed by Innes, et al.49 in which
the authors concluded that “sealing in caries by the
Hall Technique statistically and clinically outper-
formed General Dental Practitioners’ standard restora-
tions, in the long term.” According to Nainar,48 two
issues undermined the validity of conclusions of Innes
et al.:49 Firstly, concerns were expressed that control
restorations were not compared to standard control
restorations. Restorations that were placed, by multi-
ple dentists using various materials, frequently used a
restorative material with known high failure rate
(68% of restorations placed were Class II conven-
tional GIC restorations). Secondly, Nainar expressed
concerns that the outcomes assessment had question-
able validity, as assessments were conducted by multi-
ple dentists in a non-calibrated manner; as stated in
the preliminary report of this RCT: “GDPs monitored
the success or failure of the restorations using their
usual clinical criteria.”47
A study comparing the Hall technique to standard
SSC preparation was subsequently conducted by Lud-
wig et al.50 The study was a retrospective investigation
of patient records from a paediatric dental private
practice, where asymptomatic carious primary molars,
with no radiographic evidence of pulpal pathology,
S30
were restored with conventionally placed SSCs, or with
SSCs using the Hall technique. SSCs placed using the
Hall technique were found to have a success rate of
97% (65/67, mean observation time of 15 months);
compared to 94% success (110/117) for SSCs placed
using conventional technique, (mean observation time
53 months). The differences were not significant.
Other concerns, expressed by clinicians, regarding
the Hall technique concerned the lack of caries
removal, and the possibility of increase in the occlusal
vertical dimension.
Concerns about lack of caries removal were
addressed, with relevant evidence presented, in the
2015 systematic review of Seale, et al.45 who noted
that the Hall technique is, in effect, indirect pulp ther-
apy (IPT), for which good evidence for success exists,
provided pulp status is correctly diagnosed prior to
treatment.
Regarding increased vertical dimension due to lack
of occlusal reduction, Innes, et al.47 reported that, for
all 129 cases where data were available, occlusal con-
tact had re-established at the 1-year recall. No signs
or symptoms of occlusal dysfunction, difficulty eating,
or temporo-mandibular joint dysfunction were
reported by any child, or parent, following placement
of a Hall crown.
Van der Zee V, et al.51 in a retrospective observa-
tional study on the influence of the Hall crown tech-
nique on occlusal vertical dimension, reported that
occlusion had returned to pre-treatment status within
thirty days of Hall crown placement (n = 48 children,
age range 5–7 years, with 114 SSCs placed). Some
children (number not stated) had received more than
one, and up to four Hall crowns, some on opposing
primary molars. This may have influenced the results,
as opposing Hall crowns are likely to have caused a
greater increase of occlusal vertical dimension than
single Hall crowns. Consequently, time to occlusal
equilibration in children who had opposing Hall
crowns is likely to have been greater. The authors
acknowledged the limitations of their study. They sur-
mised that occlusal equilibration occurred due to
intrusion of both the molar on which a crown had
been placed, and its opposing tooth.
Seale and Randall,45 summarising their systematic
literature review of SSCs noted, with regard to the
Hall technique, that it is “supported by good quality
evidence and appears to have validity as a technique
for placement of SSCs.”
The Hall crown technique can also be used to pre-
vent caries of the mesial surface of a first permanent
molar (FPM) adjacent to a second primary molar with
distal caries, thus also avoiding risk of iatrogenic
damage to the mesial surface of FPM. It is known
from the studies of Mejare et al.52 that the caries rate
for the mesial surface of a FPM is 15 times greater if
© 2019 Australian Dental Association
 Restorative treatment of primary teeth

the distal surface of the adjacent 2nd primary molar
has developed enamel/enamel-dentine border caries,
compared to a sound distal surface of 2nd primary
molar. This implies that a carious lesion on the distal
of a 2nd primary molar should be treated to prevent
caries of the mesial surface of FPM. If restorative
treatment is indicated for the 2nd primary molar (i.e.,
the lesion has cavitated), intra-coronal restoration of
the distal cavity of the 2nd primary molar, or tradi-
tional SSC placement on the 2nd primary molar risks
iatrogenic damage to the mesial surface of FPM.
Restoration of the 2nd primary molar using a Hall
crown would obviate this risk. Should a Hall crown
be placed, in this circumstance, while the FPM is still
erupting, it is important to crimp and contour the dis-
tal margin of the crown to prevent impaction of the
FPM (Fig. 6).
PULP THERAPY FOR PRIMARY MOLARS
Pulp status can be: Healthy, Reversible pulpitis, Irre-
versible pulpitis, or Necrotic. Without histological ver-
ification it is extremely difficult to distinguish between
reversible and irreversible pulpitis, yet treatment suc-
cess depends on the accuracy of pre-op diagnosis
(Table 5).53
INDIRECT PULP CAP (IPC) is indicated when
the pulp is affected by reversible pulpitis. Tradition-
ally, the recommended technique is to remove all
decayed dentine, except that which would cause pulp
exposure if removed. (The Hall technique differs in
having no caries removal, see above). The base of the
cavity is then lined with GIC or Calcium hydroxide,
and then a base is placed over the liner, and the tooth
restored. Al Zayer, et al. (2003)55 and Vij, et al.
(2004)56 found the success rate of indirect pulp cap to
be 95%, but observed that the technique was more
likely to succeed if a base was used (Glass ionomer
was found to be more successful than IRM, reinforced
zinc-oxide & eugenol cement); more likely to succeed
if the tooth was restored with a SSC; and more likely
to succeed with 2nd primary molars, than 1st primary
molars. The Hall technique of IPC has been discussed
previously.
PULPOTOMY (amputation of vital, inflamed coro-
nal pulp) of a primary molar is indicated for reversi-
ble pulpitis, when the pulp is vital, but not viable;
when there has been carious destruction of the mar-
ginal ridge in a primary molar; and when there is
radiographic evidence of caries extending more than
2/3rds through dentine (ICDAS 5).
According to Fuks, the ideal pulpotomy medica-
ment should be bactericidal, yet harmless to pulp and
surrounding structures; it should promote healing of
the radicular pulp; and should not interfere with the
physiological process of root resorption.57 A
Cochrane review in 2003 concluded that “The ideal
pulpotomy medicament has yet to be found.”58

(a) (b)

(c) (d)

Fig. 6 Preventing mesial caries and preventing iatrogenic damage of 1st permanent molar by use of Hall crown technique. (a) The caries rate for the
mesial surface of 1st permanent molar (FPM) is 15 9 higher if the distal surface of the 2nd primary molar has developed enamel/enamel-dentin border
caries, compared to a sound distal surface of the 2nd primary molar.(Mejare I, et al. Caries Res 2001; 35: 178–185). (b) Restoration of the 2nd primary
molar with a Hall SSC avoids iatrogenic injury to the mesial surface of FPM. (c & d) Crimp & contour distal margin of Hall crown to prevent impaction
of erupting FPM (Fig. 6d).
© 2019 Australian Dental Association S31
D Finucane
Table 5. Pulp treatment options for primary teeth
1 Indirect pulp cap (of which the Hall technique is an example)
2 Direct pulp cap. (This technique is NOT currently
recommended for primary teeth, due to poor success rate).54
3 Pulpotomy
4 Pulpectomy
Formocresol was formerly the “gold standard”
medicament, applied to the radicular pulp stumps fol-
lowing pulpotomy, with success rates of formocresol
pulpotomy exceeding 90%.59 Formocresol is bacterici-
dal, but does not promote pulpal healing (the pulp is
mummified). Formaldehyde, a constituent of
formocresol, was in 2004 declared to be a carcinogen,
by the International Agency for Research on Cancer.60
The justification for use of formocresol, therefore, is
open to question, given that alternatives are available
that perform equally well, if not better.
Ferric sulphate was widely accepted as a replace-
ment pulpotomy agent for formocresol in the early
20000 s. It is a haemostatic agent, but has no therapeu-
tic effect on the pulp; therefore ferric sulphate pulpo-
tomy is liable to fail if the diagnosis of pulpal
condition is not accurate. Ferric sulphate has been
shown, in medium-term studies, to be effective for
pulp therapy in primary molars, with success rates
reported in the range 88–97% up to 36 months.61
Mineral Trioxide Aggregate (MTA) has, in recent
years, gained acceptance as a suitable material for
pulpotomy in primary molars. Ng and Messer,62 in a
meta-analysis, compared primary molar pulpotomy
performed with MTA, Ferric Sulphate, Calcium
hydroxide, and Formocresol; and determined that
MTA resulted in significantly higher clinical and
radiographic successes in all time periods up to exfoli-
ation. They concluded that: “of the 4 agents studied,
MTA is recommended as the medicament of choice.”
In a systematic review and meta-analysis, published
2015, of pulpotomy in primary teeth; comparing
MTA, Calcium hydroxide, Ferric sulphate, and Elec-
trosurgery with Formocresol, Stringhini Junior E,
et al.63 found the success rate of MTA (94.6%) was
higher than that of formocresol (87.4%), with a sta-
tistically significant difference (OR = 0.39; 95%.
CI = 0.25–0.62). Ferric sulphate and electrosurgery
success was similar to formocresol, but they found no
evidence to support the use of calcium hydroxide for
pulpotomies in primary teeth.
Calcium hydroxide is not a suitable material for
pulpotomy in primary molars, having consistently
been shown to be inferior to alternative materials.
Calcium hydroxide exhibits higher failure rates, and
greater risk of internal resorption than other medica-
ments applied to the pulp.54
In 2007, in the University of Iowa, the formocresol
pulpotomy technique was replaced with 5% sodium
S32
hypochlorite (NaOCl) technique. The technique is
similar to that traditionally used with formocresol,
other than 5% NaOCl, rather than formocresol, is
applied to the pulp stumps. A retrospective chart
audit of NaOCl pulpotomies revealed Clinical suc-
cess rate at 21 months was 95% (n = 125), and fail-
ure rate 5% (n = 6). Radiographic success at
21 months was 82% (n = 72), and failure rate 18%
(n = 16). The authors observed that most clinical
failures occurred within the first 12 months. Radio-
graphic success rate was seen to decrease over
time.64
A prospective randomised clinical study by Ruby,
et al.65 published 2013, compared clinical and radio-
graphic success of pulpotomy in primary molars
(n = 65 primary molars in 44 children), at 6 months,
and 1 year post-op, using 3% NaOCl, or formocresol
(1/5 dilution of Buckley’s formulation). At 6 and
12 months post-op, clinical success was 100% for
both NaOCl and Formocresol groups. Radiographic
success for the NaOCl group at 6 months was 86%
(19/22), and at 12 months was 80% (12/15). Radio-
graphic success in the formocresol group was 84%
(21/25) at 6 months, and 90% at 12 months (9/10).
The authors stated that no significant differences were
found in the radiographic outcomes between the two
groups at 6 and 12 months (Fisher’s exact test;
P = 0.574 and P = 0.468, respectively). Their conclu-
sion was that NaOCl demonstrated clinical and radio-
graphic success comparable to formocresol, at
12 months. It should be noted, however, that numbers
recruited into the study, and numbers of teeth evalu-
ated were small. Numbers of teeth assessed were only
45/65 (72%) at 6 month recall, and 25/65 (38%) at
12 months. Numbers assessed for radiographic suc-
cess were also small.
A recently-introduced material, BiodentineTM (Septo-
dont Ltd. Saint Maur des Fausses, France), a calcium-
silicate-based inorganic cement, has been promoted as
being a suitable medicament for use in pulpotomies.
Most evidence to date, however, is from in vitro stud-
ies, and case reports, and strong clinical outcome evi-
dence is currently lacking.66,67
Rajasekharan S, et al.68 carried out a double blind,
parallel design, randomised control trial comparing
BiodentineTM, ProRootTM (white MTA), and Tempo-
horeTM (Iodoform paste), at 1-year follow-up. Sixty
patients (mean age 4.8 years), treated under General
Anaesthesia, had pulpotomy of 81 teeth, using one of
the above materials as pulpotomy agent. The tooth
was then restored with GIC, and a SSC was placed.
At 1 year follow-up, 46 patients (63 teeth) were avail-
able for analysis. Clinical and radiographic success
rates were: BiodentineTM, 94.7%; ProRootTM, 100%;
and TempohoreTM, 100%. The difference was not sta-
tistically significant.
© 2019 Australian Dental Association

A recently published literature review of the mate-
rial characteristics and clinical applications of Bioden-
tine, by Rajasekharan S, et al.69 determined that it
overcomes the major drawbacks of MTA, in having
superior compressive strength, microhardness, flexural
strength, sealing ability, push-out bond strength, and
calcium ion release than other tricalcium silicate based
cements. The authors attributed this to the finer parti-
cle size of Biodentine, use of zirconium oxide as a
radiopacifier, purity of tricalcium silicate, absence of
dicalcium silicate, and the addition of calcium chlo-
ride and hydrosoluble polymer. The Initial setting
time of BiodentineTM (approximately 12 min) is much
less than that of MTA.
While Biodentine appears to have potential for
pulpotomy, and various other treatment modalities in
paediatric dentistry, high quality long-term clinical
studies are required before this material can be defini-
tively recommended.
PULPECTOMY of a primary molar is indicated
when the pulp is non-vital, cellulitis is not present,
and the tooth is still restorable. Extirpation of both
the coronal pulp chamber, and the root canals is per-
formed, the tooth is filled with a semi-permanent,
resorbable, dressing, and restored with a SSC. The
pulp canal dressing was traditionally slow-setting pure
zinc oxide and eugenol with no filler particles. Con-
cerns have been expressed about this material, how-
ever, due to its slow removal if extruded through the
apex, and the differential rate of resorption between
zinc oxide/eugenol (ZOE) and the tooth.70 Vitapex
(Iodoform/calcium hydroxide paste; Neo Dental Intl.
Japan) is more easily removed from the body, if
extruded through the apex. The success rate of
pulpectomies using Vitapex has been shown to exceed
that of ZOE (100% vs. 78.5%, at 16 months;
P < 0.05).71
A Cochrane review in 2003 of pulp treatment for
extensive decay in primary teeth, by Nadin, et al.58
included trials that investigated: Formocresol pulpo-
tomy; Ferric sulphate pulpotomy; Electrosurgical
pulpotomy; and ZOE pulpectomy in asymptomatic,
cariously exposed teeth. The authors reported that no
conclusions could be made regarding optimum treat-
ment or techniques for pulpally involved primary
molar teeth, due to the scarcity of reliable scientific
research. They noted that high quality RCTs, with
appropriate unit of randomisation and analysis were
needed.
An updated Cochrane review of pulp treatment for
extensive decay in primary teeth was published in
2018 by Smail-Faugeron, et al.72 Pulp treatment
techniques assessed were: Direct pulp cap; Pulpo-
tomy; and Pulpectomy. The authors reported that
evidence suggests MTA may be the most efficacious
medicament for healing radicular pulp post
© 2019 Australian Dental Association
Restorative treatment of primary teeth
pulpotomy of a primary tooth. No conclusive evi-
dence was found that one medicament or technique
is better than another for pulpectomy; and the small
number of studies and low quality of evidence lim-
ited interpretation in the case of direct pulp cap for
primary teeth.
RESTORATION OF PRIMARY INCISORS is
most commonly achieved by use of composite strip
crown technique, or by placement of pre-formed
crowns (composite-veneered SSCs or zirconia porce-
lain crowns). Very little scientific evidence is available
regarding the restoration of primary incisors. An evi-
dence-based systematic literature review of anterior
restorations for primary teeth, by Waggoner,73 pub-
lished 2006, revealed that failure rates for strip
crowns ranged from 0 to 50%; while the failure rate
for veneered anterior SSCs ranged 32–39%. Other
authors have reported, from retrospective studies, the
retention of anterior strip crowns on primary teeth to
be 80% after 24–36 months.74,75
In a later review paper, published 2015, on restora-
tion of primary anterior teeth, Waggoner76 noted that
since the publication of his systematic review in 2006,
only one prospective clinical study had been pub-
lished, that compared primary anterior crowns (com-
posite strip crowns; composite-veneered SSCs;
zirconia crowns), and that the follow-up of that study
was only 6 months.77 In that study, by Walia, et al.
none of the zirconia crowns had been lost or fractured
after 6 months, but 22% of strip crowns had frac-
tured or been lost, and 5% of veneered crowns had
suffered partial loss of veneer. Waggoner76 noted also,
in relation to zirconia primary anterior crowns, that
there was virtually no information in the literature
regarding their clinical performance. Waggoner76 con-
cluded that, though many options are available for
restoration of anterior primary teeth, there is insuffi-
cient evidence to suggest that one type of restoration
is superior to another. He noted that good quality evi-
dence is required regarding the restoration of primary
anterior teeth.
CONCLUSIONS
Children deserve healthy teeth, and so it is incumbent
on the dental practitioner to provide optimal restora-
tive treatment for a child, when necessary. To this
end, the key to successful paediatric restorative den-
tistry is accurate diagnosis, from which the operator
can make an appropriate treatment plan, using the
most suitable methods and materials. This evidence-
based review has demonstrated the diagnostic criteria
that help to establish an appropriate treatment plan,
which should result in optimal outcome for the child.
Various methods, with a variety of materials, exist for
restoring carious primary teeth, but not all are
S33
D Finucane
appropriate. This evidence-based review has presented
evidence of materials and methods that are currently
considered suitable for the restoration of children’s
teeth.
Acceptable materials for restoration of carious pri-
mary molars, with good supporting evidence, are: Pre-
formed (stainless steel) crowns; Resin-modified glass
ionomer; Compomer; Resin Composite (but difficulty in
bonding in the cervical area, and technique sensitivity,
make this material less suitable for paediatric dentistry
than alternatives); and Conventional glass ionomer (suit-
able primarily for interim occlusal dressings).
Acceptable materials for pulpotomy in primary
molars, with good supporting evidence, are: MTA,
and Ferric sulphate.
Materials/agents with potential for use in pulpo-
tomy of primary molars, but with limited supporting
evidence, include: Sodium hypochlorite (3–5%), and
Biodentine.
The most suitable root filling material, following
pulpectomy of primary molars, may be Iodoform/Cal-
cium hydroxide paste (Vitapex),71 though a recent
Cochrane review72 found no conclusive evidence from
which to make a recommendation regarding root fill-
ing materials for primary teeth.
There is insufficient evidence to support any particu-
lar material, or method of restoration, for primary
anterior teeth. Reported failure rates for primary inci-
sor strip crowns range from 0 -50%, while the reported
failure rate for veneered anterior SSCs is almost 40%.73
Appropriate restorative methods for primary teeth
are: Intracoronal restoration (a “filling”) using suit-
able materials; Extracoronal restoration (“pre-formed
crown” – SSCs have the greatest evidence base); Indi-
rect pulp cap + SSC; Pulpotomy + SSC; and, when
irreversible pulpitis is diagnosed and the tooth is
deemed restorable, Pulpectomy + SSC.
ACKNOWLEGEMENT
The author acknowledges, with gratitude, the assis-
tance of Mr Mohammad Kadhim in presentation of
images.
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Address for correspondence:
David Finucane
Consultant Paediatric Dentist, Hermitage Medical
Clinic, Lucan, Co. Dublin, Ireland
Email: info@hermitagedental.ie
© 2019 Australian Dental Association