The Hall Technique by Dr. Natalie Bradley

Introduction
Stainless steel crowns (SSCs) are preformed crowns, which have been used in paediatric dentistry since 1950. Until relatively recently, however, the uptake of use in primary care has been unpopular. This was primarily due to the need to extensively prepare primary teeth, the risk of damage to adjacent permanent teeth and the challenge of administering the local anaesthetic in a young child.

Dr. Norma Hall popularised a nonpreparatory technique which over the past 10 years has increased in popularity and support, as a result of research papers from Innes and Evans. The technique involves no preparation or caries removal, and aims to arrest caries by sealing it from the oral environment.
No (or little) preparation reduces the risk of damage to other teeth, and often removes the need for local anaesthetic.

A modified technique could be considered in some cases—for example, breaking through a contact point to create space if separators are not available or have fallen out.
Case selection is essential in deciding whether to provide SSCs, as well as ensuring that any questions are answered in order that parents/guardians can give informed consent.

Case study
A 5-year-old patient was referred to Community Dental Services requiring treatment for multiple carious lesions. Her dentist reported poor cooperation and an abscess on the lower right side. Following an urgent appointment for an emergency nonvital pulpotomy on the lower right first deciduous molar (LRD), assessment and treatment planning was carried out.

Fig. 1. Bitewing radiographs showing multiple carious lesions and emergency pulp therapy to the LRD. Note the band of intact dentine visible between the pulp and caries on the LRE, compared with no visible band on the LLD.

Extensive preventative advice was completed with a hygiene therapist. The restorative treatment plan included multiple Hall crowns on the restorable carious molars. Extractions were eventually indicated for both lower first primary molars. These were ultimately performed under inhalation sedation.

Hall technique to restore LRE
The following series of clinical photographs demonstrate the restoration of the lower right second primary molar (LRE) using the Hall technique.

• 

  Fig. 3a. Placement of separator.

• 

  Fig. 3b. Removal of separator 3–5 days after placement.

• 

  Fig. 3c. Space achieved once separator is removed.

• 

  Fig. 3d. Trial seating of crown. Note the airway is protected with gauze. This particular crown size is deemed too large, because it fully seats with no resistance.

• 

  Fig. 3e. The appropriate crown size has been selected. Never fully seat the crown at this stage, because it is unlikely you will be able to remove.

• 

  Fig. 3f. Glass ionomer luting cement mixed to chewing gum-like consistency for the cementation of the crown.

• 

  Fig. 3g: Crown filled with cement ready to be seated.

• 

  Fig. 3h: Crown seated firstly with finger pressure and secondly with patient’s occlusal pressure. This can be aided with a cotton wool roll (as pictured), a wooden tongue spatula or an orthodontic biting stick.

• 

  Fig. 3i. Cleanup of excess cement. Note the slight blanching of the buccal gingival, which indicates an optimal subgingival margin.

After cementation, it is important to give postoperative instructions to the patient and parents/guardians, which will include:

• Instructions for a soft diet for the rest of the day.
• Recommendation for analgesia for up to a week after placement as required.
• Reassurance that any blanching will dissipate within a day and the occlusion will stabilise over the following weeks.
• Reassurance that any changes to the bite will self-resolve.

Conclusion
The Hall technique is a simple and child-friendly technique that general dental practitioners should provide under the newly commissioned paediatric dental services (NHS England, 2017) for appropriate cases.

As a young dentist, I found learning this method and implementing it is actually much less technical than many of the treatments we provide every day.

What is more challenging for many dentists is managing the patient. Treating children doesn’t always come naturally, but after practice you will learn what works for you. After a while, fitting ‘twinkly teeth’ will be second nature!

Natalie Bradley BDS MFDS RCSEd qualified from Newcastle University in 2014 and is now a community dental officer working in East London. She also works part time in general practice as a dental associate and is a study club director for Dentinal Tubules. She has her own blog at atoothgerm.co.uk