Hall technique versus conventional restorations for carious primary molars: a systematic review

INTRODUCTION

Dental caries is the most prevalent chronic disease of childhood and the single largest cause of preventable treatment need in the primary dentition.(1) Primary molars carry a disproportionate share of that burden because their occlusal and proximal anatomy retains biofilm and because cavitated lesions in these teeth frequently go untreated, evolving into pain, infection, early tooth loss and impairment of oral health-related quality of life.(1,2) The consequences extend beyond the mouth, since untreated caries in young children disturbs sleep, eating and school attendance and is a leading reason for hospital admission under general anaesthesia in several health systems. Restoring these teeth therefore occupies much of paediatric dental practice, yet the choice of technique remains contentious.

The conventional approach removes all carious tissue with rotary instruments, usually under local anaesthesia, and restores the cavity with an adhesive material or with a prepared preformed metal crown. In multi-surface primary molar lesions this strategy performs poorly: a systematic review of survival and reasons for failure reported high failure rates for intracoronal restorations placed in primary teeth, with recurrent caries and restoration loss driving a repeated restorative cycle that often ends in pulp therapy or extraction.(2) Against that background, the Hall technique was developed as a biological alternative in which a preformed metal crown is cemented over the carious molar without local anaesthesia, tooth preparation or caries removal, sealing the lesion from the oral environment.(3,4) Randomized and observational studies have repeatedly reported high success and survival for the technique,(5-7) and clinical guidance documents now endorse it as a standard option for managing carious primary molars, including in situations where aerosol generation or general anaesthesia should be avoided.(8,9)

The clinical question that remains is comparative rather than descriptive. Single-arm series cannot establish whether the Hall technique's high success reflects an advantage over well-placed conventional restorations or simply the durability of full-coverage crowns in a low-caries-risk sample. Answering the comparative question requires trials and cohort studies that randomize or match teeth to both treatments, and those studies have accumulated rapidly in recent years, spanning high-income and lower-middle-income settings and covering the full range of conventional comparators from resin composite to pulpotomy. Synthesizing that body of work is therefore timely for clinicians who must choose between sealing a lesion under a crown and removing it under anaesthesia.

Previous syntheses have addressed this question but are now partly outdated or narrower in scope. The Cochrane review of preformed crowns concluded that the Hall technique probably reduces major failure and pain compared with conventional restorations, although the evidence was graded as moderate quality and the included trials predated 2018.(10) A broader Cochrane review of interventions for cavitated or dentine carious lesions likewise found that biological sealing approaches compare favourably with complete caries removal.(11) Subsequent meta-analyses have quantified success and survival for the technique,(12-15) and an umbrella review of minimal intervention dentistry ranked biological sealing strategies favourably.(16) However, several comparative randomized trials were published between 2018 and 2025, including the FiCTION trial,(17) direct comparisons with atraumatic restorative treatment and resin composite, and longer follow-up cohorts. This systematic review therefore aimed to answer the following PICO question: in children with carious primary molars, does the Hall technique achieve higher success and fewer complications than conventional restorations? The specific objectives were to identify comparative studies published from 2018 to 2025, to estimate the comparative success and survival of the Hall technique, to compare the frequency of complications, and to assess the risk of bias of the included studies.

METHODS

RESULTS

Study selection

The searches identified 546 records across the three databases. After removing 179 duplicate records, 367 records were screened by title and abstract, of which 337 were excluded. Full text was sought for 30 reports, but 19 could not be retrieved through legitimate open-access sources. Of the 11 reports assessed for eligibility, 1 was excluded because the intervention did not correspond to the Hall technique, and 10 studies were included in the review (Figure 1).

The ten included studies comprised nine randomized trials and one retrospective cohort published between 2019 and 2025 (Table 1). The studies were conducted in Brazil (two trials), India (four studies), Türkiye (two studies), Sudan (one trial) and Egypt (one trial). Sample sizes ranged from 26 teeth in the cohort to 364 teeth in the largest randomized trial. The comparators were resin composite,( 21) compomer,(22,23) atraumatic restorative treatment,(24,25) modified atraumatic restorative treatment,( 26) conventionally prepared preformed metal crowns,(27,28) and pulpotomy or indirect pulp capping for deep carious lesions.( 29,30)

All ten studies reported a clinical success or survival outcome, and eight also reported radiographic assessment. Follow-up ranged from 10 days in the postoperative pain trial to 60 months in the retrospective cohort, with the randomized trials reporting follow-up between 9 and 36 months. Four studies used split-mouth or multi-arm designs that allowed each child to contribute to more than one intervention group. Eight studies recruited children with occlusal or proximal dentine caries without clinical or radiographic signs of pulpal involvement, whereas two trials specifically enrolled primary molars with deep carious lesions approaching the pulp.

The one report excluded at full-text had used natural tooth crowns rather than preformed metal crowns and was therefore judged not to evaluate the Hall technique. The nineteen reports that could not be retrieved included several randomized trials and retrospective comparisons that appeared eligible from their abstracts, such as additional trials of conventional crown placement and atraumatic restorative treatment; their absence from the synthesis is reported as a limitation rather than as evidence that they would have changed the conclusions.

Study (year, country)	Design	Population and sample	Comparison	Main finding	Risk of bias
Elamin et al. (2019, Sudan)(27)	RCT, two-arm	164 children, 212 PMCs, 5-8 years	HT vs conventional PMC	Similar 24-month survival (93.6% vs 94.1%); fewer minor failures with HT	Some concerns
Araujo et al. (2020, Brazil)(24)	RCT, two-arm	131 children, 5-10 years	HT vs ART	Higher 36-month survival with HT (93.4% vs 32.7%, p < 0.001)	Some concerns
Undre et al. (2023, India)(22)	RCT, three-arm	120 teeth, 5-8 years	HT vs compomer vs non-restorative	No significant difference; HT descriptively superior to compomer	High
Pascareli-Carlos et al. (2023, Brazil)(21)	RCT, multicenter	364 teeth, 4-9 years	HT vs resin composite	Higher 12-month survival with HT (87.8% vs 75.7%, p = 0.004)	Some concerns
Yavuz and Kargul (2023, Türkiye)(23)	Retrospective cohort	26 teeth, 8 children	HT vs compomer	Higher 60-month success with HT (84.6% vs 23.1%, p < 0.01); similar survival	Serious
Oz et al. (2023, Türkiye)(25)	RCT, split-mouth	40 children, 80 molars, 5-6 years	HT vs ART	100% success for both at 18 months; statistical comparison not possible	Some concerns
Ahmed et al. (2022, Egypt)(29)	RCT, two-arm	56 molars with deep caries	HT vs formocresol pulpotomy	No significant difference in postoperative pain over 10 days	High
Mittal et al. (2024, India)(28)	RCT, two-arm	50 children, 4-8 years	SDF plus HT vs conventional SSC	Similar major failure-free success (93.5% vs 100%, NS); similar minor failure	Some concerns
Poludasu et al. (2022, India)(30)	RCT, three-arm	60 molars with deep caries, 4-9 years	Modified HT vs IPT (MTA) vs MTA pulpotomy	Highest radiographic success with modified HT (100%), not significant	High
Kumari et al. (2025, India)(26)	RCT, split-mouth	60 teeth, 4-9 years	HT vs mART	Lower restoration loss with HT at 9 months (3.3% vs 63.3%, p = 0.001)	Some concerns

Note: HT = Hall technique; RCT = randomized controlled trial; ART = atraumatic restorative treatment; mART = modified atraumatic restorative treatment; PMC = preformed metal crown; SSC = stainless steel crown; SDF = silver diamine fluoride; IPT = indirect pulp therapy; RoB = risk of bias. Source: Elaboración propia a partir de los textos completos de los estudios incluidos.

DISCUSSION

The main finding of this review is that, in carious primary molars without pulpal involvement, the Hall technique delivers restoration success and survival that are at least equivalent to, and in most direct comparisons higher than, those of conventional restorations, while major complications remain uncommon and comparable between approaches. The evidence is internally consistent despite clinical heterogeneity, but it rests on a small number of studies that are mostly at some concerns of bias, so the comparative estimates should be read with caution.

The level of evidence differs across the findings. The claim that the Hall technique outperforms adhesive intracoronal restorations is supported by two large randomized trials with consistent, statistically significant results and by a retrospective cohort, and is further corroborated by earlier trials outside the review window; this finding carries the highest confidence. The claim of equivalence with conventionally prepared preformed metal crowns rests on a single randomized trial plus one trial of a silver diamine fluoride variant and retrospective data, so it is plausible but less secure. The claims about major complications rest on sparse events across small samples and should be treated as imprecise. The deep-lesion comparisons rest on two small trials that were not powered to detect differences, so the absence of excess postoperative pain or pulpal complications should be read as reassuring but not definitive.

The superiority of the Hall technique over adhesive intracoronal restorations is the finding most strongly supported by the data. The two randomized trials with the largest samples reported significantly higher survival for the Hall technique than for resin composite and atraumatic restorative treatment in multi-surface lesions, and a retrospective cohort found markedly higher clinical success than compomer at 60 months. These results agree with the Cochrane review of preformed crowns, which concluded that the Hall technique probably carries a lower risk of major failure and pain than conventional restorations, with moderate-quality evidence.(10) They also align with the German trial data in which the Hall technique outperformed conventional compomer and non-restorative cavity control at 2.5 years,(31,32) and with more recent meta-analyses that pooled high success rates for the technique.(12-15) The mechanism is biologically plausible: sealing the lesion under a preformed crown deprives the biofilm of substrate, arrests caries progression and avoids the marginal breakdown that recurrent caries produces in adhesive restorations.(4,8,33) Three complementary mechanisms explain the pattern. First, the full-coverage crown removes the marginal interface that is the site of most secondary caries in intracoronal restorations, so the most common failure mode of composite and compomer is eliminated. Second, the glass ionomer cement used to lute the crown releases fluoride and can support remineralization of the sealed dentine, which maintains the arrested lesion in a stable state. Third, the technique requires no local anaesthesia or rotary instrumentation, so the procedure itself is shorter and less aversive, which translates into the lower anxiety and higher acceptance reported in the included studies.

The magnitude of the advantage reported here is consistent with the pooled estimates of earlier syntheses. Meta-analyses of the Hall technique have reported success rates above 90 percent at follow-up periods between one and five years,(12,13,15) and a meta-analysis comparing placement methods found that the Hall technique matched the conventional technique for crown survival while avoiding tooth preparation.(14) The present review reproduces those pooled patterns at the level of individual studies published after 2018, and it adds the direct comparisons with resin composite and with modified atraumatic restorative treatment that those syntheses did not include. The convergence between pooled estimates from different eras and the individual trials included here strengthens confidence that the Hall technique's advantage is a stable property of the treatment rather than an artefact of any single study.

The comparison against conventionally prepared preformed metal crowns is more balanced. The single randomized trial that made this direct comparison found no significant difference in survival, and the trial that combined silver diamine fluoride with the Hall technique also reported success similar to that of conventionally placed stainless steel crowns. These findings are consistent with retrospective evidence on crown placement technique.( 34) This is expected, because both arms use the same full-coverage crown and differ mainly in preparation and anaesthesia rather than in the sealing mechanism. The advantage of the Hall technique in this comparison lies therefore in process and patient experience rather than in restoration survival.

The complication profile favours the Hall technique for minor failures and anxiety but not uniformly for discomfort. Lower minor failure rates were reported in two studies, and children had lower anxiety after Hall crown placement than after conventional preparation in the Sudan trial. These observations are consistent with trial data showing that children find the Hall technique acceptable and that procedural pain is similar to or lower than with conventional crowns,(35,36) and with cost-effectiveness analyses that report shorter treatment time and lower cost for the Hall technique.(37,38) However, one school-based trial reported higher child-reported treatment discomfort for the Hall technique than for atraumatic restorative treatment, and the transient increase in occlusal vertical dimension that follows Hall crown placement was documented in nearly all Hall-treated teeth. That occlusal change resolves within weeks to months, as reported in the included studies and in earlier longitudinal work, and no persistent temporomandibular or periodontal harm has been demonstrated.( 7,8)

For deep carious lesions, the two included trials suggest that the Hall technique does not increase postoperative pain or pulpal complications relative to pulpotomy or indirect pulp therapy, although neither trial had sufficient power to detect small differences. This is clinically relevant because the technique extends the biological rationale from moderate lesions toward lesions that would otherwise receive pulp therapy, provided there are no clinical or radiographic signs of irreversible pulpitis. The largest apparently discrepant external result is the FiCTION trial, which found no evidence that a biological strategy including the Hall technique differed from conventional management for the co-primary outcome of dental pain or infection over three years.(17) The discrepancy is partly explained by design: FiCTION compared packages of care rather than the Hall technique in isolation, the biological arm combined prevention with sealing and silver diamine fluoride, and the primary outcome captured pain and infection, which were rare events across all arms. The present review, by contrast, focuses on restoration survival and success, outcomes on which the Hall technique shows its clearest advantage. A two-year randomized trial of three management approaches likewise reported higher success for the Hall technique than for conventional restoration and non-restorative treatment, supporting the direction of the present findings,( 39) as do smaller comparative trials and cohort studies in high-caries-risk populations.( 40-43)

Process and economic outcomes reinforce the clinical case. The Sudan trial measured a mean procedure time of 9.1 minutes for the Hall technique against 33.9 minutes for conventional crown placement, and a per-unit cost roughly one third of the conventional approach, with the crown placed by a dental therapist. Cost-effectiveness analyses of the German trial reached the same conclusion, showing that the Hall technique dominated conventional restoration and non-restorative cavity control in economic terms.(37,38) These process advantages matter for the question posed by this review because a treatment that is faster, cheaper and less aversive while achieving equivalent or better survival offers a net benefit to children, families and services even where the biological outcome is the same.

The applicability of these findings is broad but not unlimited. The included studies enrolled cooperative children with cavitated dentine lesions, mostly in primary care, school and university settings, and excluded teeth with signs of irreversible pulpitis, so the results should not be extrapolated to symptomatic teeth with pulpal involvement or to children who cannot tolerate crown seating. Within those limits, the technique is attractive for high-caries-risk children and for settings with limited access to rotary equipment, radiography or general anaesthesia, because it can be delivered by trained dental therapists and does not generate aerosols. This is consistent with guidance that elevated the Hall technique during the coronavirus pandemic and with its inclusion in European best-practice documents for deep carious lesions in primary teeth.(8,9) Parental counselling about the transient occlusal change and the metal appearance remains essential, since crown aesthetics concerned roughly a quarter of parents in one included trial.

The age range of the included samples, from 4 to 10 years, covers the period in which the primary molars are most at risk and in which behaviour management is most difficult, so the findings apply directly to the population in which the decision is clinically most pressing. The inclusion of trials from Brazil, India, Türkiye, Sudan and Egypt, alongside the European and British evidence cited in the discussion, indicates that the technique performs consistently across health systems with very different levels of resources, which is itself an argument for its wider adoption. The main caveat is that most studies were conducted or supervised by specialist paediatric dentists or researchers, so the results may overstate what a general practitioner would achieve without the same training and case selection discipline.

Heterogeneity across the included studies limits quantitative pooling. Comparators ranged from resin composite, compomer and glass ionomer restorations to conventionally prepared crowns and pulp therapy, follow-up ranged from 10 days to 60 months, outcome definitions differed for survival versus success and minor versus major failure, and settings spanned school programmes, general practice and university clinics. Even the definition of the Hall technique varied slightly, with one trial adding silver diamine fluoride before crown cementation and two trials using a modified version for deep lesions. This heterogeneity, together with the small number of studies, is why a meta-analysis was not performed. Network meta-analyses and umbrella reviews that have aggregated this literature reach conclusions consistent with ours, ranking biological sealing strategies among the most effective options for cavitated primary molars.( 16,44,45)

A further source of heterogeneity is the age and caries-risk profile of the samples. The Sudan and Brazil school-based trials enrolled children with high caries experience and limited access to care, where the contrast between the Hall technique and conventional restoration was largest, whereas the Türkiye cohort and the Indian trials drew from clinic populations with a different risk profile. The superiority of the Hall technique appeared most pronounced in high-caries-risk and multi-surface lesions, which is exactly the clinical situation in which adhesive restorations fail most often, and less pronounced in single-surface lesions, where atraumatic restorative treatment performed as well as the Hall technique in one trial. This interaction between lesion complexity and treatment effect deserves explicit testing in future trials with stratified randomization by lesion surface.

For research, three priorities follow from these findings. Trials should adopt a common core outcome set that distinguishes success, survival, minor failure and major failure with the same thresholds, so that future updates can pool effect estimates rather than describe them qualitatively. The comparison between the Hall technique and conventionally prepared preformed metal crowns deserves a second adequately powered trial, because the current equivalence estimate rests on a single study and the process advantages of the Hall technique would be decisive if equivalence were confirmed. Finally, longer follow-up to natural exfoliation is needed to confirm that sealing, rather than merely postponing restoration failure, preserves the tooth without late pulpal or periodontal consequences, since the longest included follow-up was 60 months and most trials stopped earlier.

The strengths of this review should be weighed against these limitations. The search spanned three complementary databases, the inclusion window was restricted and applied consistently, the extraction was anchored to the full text of every included study, and each randomized trial was judged with the current RoB 2 instrument rather than with ad hoc quality checklists. By restricting the included studies to those whose full text was legitimately accessible, the review avoided the common error of extracting outcome data from abstracts alone, at the cost of excluding several otherwise eligible reports. The result is a smaller but more verifiable evidence base, which is appropriate for a question whose answer depends on precise success and failure estimates.

For clinical practice, the findings support the Hall technique as a first-line biological option for carious primary molars without clinical or radiographic signs of pulpal involvement, particularly in multi-surface lesions, in children with high caries risk, and in settings where general anaesthesia or rotary instrumentation is not available.(2,8,9) Case selection matters: the included trials excluded teeth with spontaneous pain, fistulae or radiographic signs of irreversible pulpitis, and the technique should not be presented as a substitute for pulp therapy once those signs are present, even though the two deep-lesion trials were reassuring. Clinicians should inform parents that the crown changes the occlusion temporarily, that the metal appearance is visible and that the restoration is intended to remain until natural exfoliation. When the child is anxious, the avoidance of local anaesthesia and rotary instruments is itself a therapeutic benefit, and the shorter procedure time observed in the Sudan trial supports the feasibility of delivering the technique through trained dental therapists in low-resource settings.

CONCLUSIONS

Ten comparative studies published between 2019 and 2025, nine randomized trials and one retrospective cohort, provided evidence on the Hall technique versus conventional treatments for carious primary molars. In children with carious primary molars without pulpal involvement, the Hall technique achieves restoration success and survival at least equivalent to, and in most comparisons higher than, conventional restorations, and it performs comparably to conventional pulp therapy for deep carious lesions. Major complications were infrequent and similar between the techniques, while minor failures were less common with the Hall technique and the early occlusal change was transient. The evidence is limited by a small number of studies, predominantly with some concerns of risk of bias, so the certainty of the comparative estimates is moderate at best, and adequately powered trials with standardized outcome definitions are still required to confirm these conclusions.

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