Page 14
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 longterm 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 supporting the use of preformed metal crowns in permanent teeth as a semi-permanent restoration for the treatment of severe enamel defects or grossly carious teeth. Anterior esthetic restorations in primary teeth Despite the continuing prevalence of dental caries in primary maxillary anterior teeth in children, the esthetic management of these teeth remains problematic.127 Esthetic restoration of BEST PRACTICES: RESTORATIVE DENTISTRY 346 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY primary anterior teeth can be especially challenging due to: the small size of the teeth; close proximity of the pulp to the tooth surface; relatively thin enamel; lack of surface area for bonding; and issues related to child behavior.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 Resinbased 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