ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Resin Composite Restorations May be Promising Esthetic Alternatives to Stainless Steel Crowns in Pulpotomized Primary Molars
Clinical Question On a pulpotomized primary molar in a healthy patient, is resin composite as effective as stainless steel crowns as the final restoration?
Clinical Bottom Line SCC steel crowns have long been considered the gold standard for the final restoration of pulpotomized primary molars; however, the demands on more esthetic alternative restorations has increased in recent years. One of the esthetic restorative options for pulpotomized primary molars is resin-based composite. Studies on the efficacy of resin-based composite restorations in pulpotomized primary molars have shown promising results, particularly on teeth with minimal to moderate structure loss and when esthetic considerations are important. However, additional long-term studies with larger sample sizes are necessary to further assess the success of resin composite as the final restoration after pulptomy in primary molars. The risks of resin composite failure due to coronal micro-leakage may increase with the number of the surfaces involved.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 23265162Hutcheson/201240 Subjects needing pulpotomy of primary molar involving multiple surfaces.Randomized Controlled Trial
Key resultsAll pulpomotized primary molars were treated with white MTA medicament. The primary molars were matched and contralateral. All lesions have at least 2 surfaces involved. For both the resin composite restorations and stainless steel crowns, all were radiographically and clinically successful restorations at both recall intervals, 6 months (37 subjects) and 12 months (31 subjects). More changes to the margins were noted for resin composite restorations at both recall intervals (P<.001); 3 failed margins for the composite and 0 failed margins for the stainless steel crowns at one year. No pain was reported. Preoperative and postoperative radiographs were taken, and at 6 months and 1 year, 97% and 81% of composite restorations scored “no change” radiographically. In addition, 94% of the resin composite restorations expressed grey discoloration of variable intensity, thought to be caused by the white MTA, which was originally used for esthetic purpose.
#2) 18328050Atieh/200887 Pediatric patients needing pulpotomy of 1 or more primary molar.Randomized Controlled Trial
Key resultsAll pulpotomized primary molars were treated with formocresol (1:5 Buckley's solution) medicament. The 2 year RCT, with follow-ups every six months, compared stainless steel crowns and open-sandwich restorations (RMGIC/CRRs). Upon conclusion, only six RMGIC/CRRs and four SSCs failed; none of the pulpotomies failed. Atieh's study used a 95% confidence interval, finding the survival rate of both materials to be nearly the same; between 23.4 month and 24.2 for SSCs, and between 23.7 months and 24.1 months for RMGIC/CRRs (Survival rates - SSCs = 95% and RMGIC/CRRs = 92.5%). Neither were found to be statistically different (log rank test P=0.50).
#3) 17073200Cehreli/200684 patients with at least 2 primary molars needing occlusal or two-surface restoration.Prospective Cohort Study
Key resultsCehreli’s study compared the efficacy of resin composite or compomer restorations in pulpotomized (formocresol) primary molars. The study followed the participants for 2 yrs; follow-up every 3 months, assessing the molars clinically and radiographically. In total, 2% of the composite restorations and 17% of the compomer restorations failed. Resin composite restorations displayed less marginal failures (P=0.001), marginal discoloration (P=0.001), and less occlusal flattening (P<0.05) compared to compomers. Also, the study success rates equal to 100% for occlusal restorations and 97% for the 2 surfaces resin-bases composite restorations.
#4) 23265162Guelmann/200552 patients between 44 and 118 months old receiving resin based restoration post-pulpotomy.Case Series
Key resultsGuelmann’s study radiographically assessed 59 teeth in 52 patients whom received a resin-based restoration after pulpotomy of a primary molar. Preoperative and postoperative radiographs (bitewings and periapicals) were utilized to assess pulpotomized molars compared to untreated molars on the opposite side of the arch. Guelmann found that none of the single surface restorations failed, but that 17% of the multi-surface resin based restorations failed when using an IRM/glass ionomer combination and 31% failed when using IRM only; 26% failure rate overall (P=0.259). The study also noticed an accelerated absorption for 2 teeth, pathologic failure for 10 teeth, and exfoliated normal physiologic resorption patterns for 47 teeth when comparing pulpotomized versus non-pulpotomized molars. Lastly, the average follow-up for the study was 21 months.
Evidence Search primary molars AND stainless steel crowns AND composite AND pulpotomy
Comments on
The Evidence
Validity: 3 clinical trials and one retrospective study are included in this review. Hutcheson and colleagues RCT researched the outcome of stainless steel crowns compared to composite restorations on pulpotomized primary molars. Hutcheson’s study also used MTA medicament post-pulpotomy, which is a relatively new material in pulpotomies; was originally thought to be an esthetic alternative to formocresol but turned to not due to grayish staining. As well, the study included split mouth and matched design. Each subject was carefully accessed for inclusion into the study, upon which adequate follow-up was noted for the RCT. Though, one concern with the study is that Hutcheson’s follow-up did not extend beyond 12 months, a short amount of time, even for primary molars. This study only included lesions involving multiple surfaces and the success rate of resin composite at one year follow up time is satisfactory, however, the long term outcome of these restorations remain to be seen. Atieh’s RCT showed no statistical difference between RMGIC/CRRs and SSCs, along with follow-ups every 6 months for 24 months; length of follow-up is one of the study’s strengths. This study comprised a relatively large sample, however does not include split mouth design. In addition, his study used formocresol medicament, which is currently and widely used as the medicament of choice for pulpotomized primary molars for pediatric dentists. Each subject, for Atieh’s study, was individually assessed for inclusion, and were found to exhibit adequate compliance. However, the teeth pairs included in this study are not matched in same individual and no radiographic assessment of the success was done or presented. One other thing to be noted in this study is that open sandwich technique is slight different from traditional resin restoration, with RMGIC open to oral environment providing better margin and fluoride releasing cariostatic effect. Cehreli’s clinical trial also followed his subjects for a long period of time – 24 months. His study included a large sample size that examined resin composite restorations and compared them to compomer restorations, both of which were examined by two calibrated clinicians, and evaluated radiographically. Although, this trial did not compare the performance of SSCs and resins directly, the success outcome of resin restorations is established. Guelmann’s study took pre- and post-operative radiographs to to evaluate the resin-based restorations in post-pulpotomized primary molars; basing success on lack of root resorption, bone loss, and radiolucencies. His study also revealed 100% success rate for single surface restorations and 83% success rate for multi-surface. As a retrospective case series study, no controls are included and the results was compared with previous reported success rates of SSC. This study demonstrated number of surfaces involved may affect the outcome which can be of great interest to practitioners, and this is the only study we found discussed the different outcome of resin restoration between class I and class II preparations. Perspective: Evidently, high quality RCT with larger sample size and adequate follow up time is needed to establish the efficacy and longevity of resin restorations in pulpotomized primary molars.
Applicability Both SSCs and resin-based restorations are feasible options for restoring primary molars in pediatric dental setting. Stainless steel crowns are the preferred restoration and considered the gold standard. Though stainless steel crowns lack esthetics, the patient may benefit more from its increased longevity; rarely demonstrate failed margins. The patient may also benefit from a potential incresase in esthetics with a composite restoration; and a success rate nearing that of stainless steel crowns. In addition, there is a high demand for esthetic restorations in children in modern society. And according to the literature, resin can be a viable option to SSC when adequate tooth structures remains and resin can be placed successfully. RCT with large samples and longer follow up time need to be done to further assess, in particular, the outcome of resin restorations involving multiple surfaces. Some discoloration was noted for MTA medicament and no discoloration was mentioned for forocresol. Single surface/occlusal restorations rarely exhibit breakdown, whereas, multi-surface display at least some failures.
Specialty/Discipline (General Dentistry) (Pediatric Dentistry)
Keywords Primary molars, pulpotomy, composite resins, deciduous tooth, stainless steel crown
ID# 2691
Date of submission: 03/12/2014spacer
E-mail flippen@livemail.uthscsa.edu
Author Roger Flippen
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author Zheng Xu, DDS
Faculty mentor/Co-author e-mail xuz@uthscsa.edu
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