Strategies for Management of Posterior Deciduous and Young Permanent Teeth with Developmental Defects of Enamel - Systematic Review and Meta-analysis

doi:10.21203/rs.3.rs-5226296/v1

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Systematic Review

Strategies for Management of Posterior Deciduous and Young Permanent Teeth with Developmental Defects of Enamel - Systematic Review and Meta-analysis

https://doi.org/10.21203/rs.3.rs-5226296/v1

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Objectives: To assess the management strategies for treating deciduous and young permanent teeth with Developmental defects of enamel (DDE) presenting post-eruptive breakdown or atypical cavitated carious lesions.

Methods: Electronic databases searches were conducted up to May 31, 2023, identifying clinical studies related to the treatment strategies for posterior deciduous or young permanent teeth with DDE in children up to 14 years old. Results: Sixteen studies were included: 12 focusing on molar incisor hypomineralization (MIH), 1 on hypomineralization, 1 on imperfect amelogenesis, and 2 incorporating different types of DDE. Esthetic Crowns, Metal Crowns, Composite Resin (CR), Glass Ionomer Cement (GIC), and Metal and CR Onlays were the most used restorative treatments. Only similar studies for MIH were found, and meta-analyses were conducted. Over a 24-month follow-up period, a proportion of success rate of 96% (95% CI 92%-100%) was identified. Subgroup analysis did not reveal a difference among the restorative treatments (p = 0.922).

Conclusion: Aesthetic and metal crowns, CR, and GIC can be used with high longevity. However, the certainty of evidence is low, and most studies exhibited a high risk of bias.PROSPERO database CRD42021204415

Health sciences/Health care/Dentistry/Paediatric dentistry

Health sciences/Health care/Dentistry/Restorative dentistry/Bonded restorations

Dental Enamel Hypoplasia

Molar Hypomineralization

Tooth

Deciduous

Dentition

Permanent

Dental Restoration

Permanent

Systematic Review

Choice of restorative treatment: For primary or young permanent teeth with DDE, aesthetic and metal crowns, composite resin, and glass ionomer cement can be used.

Longevity of restorative treatments: For young permanent teeth with MIH and post-eruptive dentin fracture, longevity is technique-dependent rather than material-dependent.

Future research: Encourage further research with reduced methodological bias, covering different types of developmental defects of enamel, not just MIH, and promote research focused on patient and caregiver perceptions.

Developmental defects of enamel (DDE) may arise due to genetic, systemic, environmental, or local factors. The occurrence and nature of the alteration in amelogenesis depend on when it occurred, both quantitatively and qualitatively¹. Irrespective of their origin, these defects are linked to an increased susceptibility to cavities or post-eruptive fractures²⁻⁴, making them a significant factor for seeking treatment.

These defects can raise significant concerns, not only due to their impact on the deciduous dentition but also in mixed dentition when they affect young permanent teeth. This is not merely a matter of aesthetics but also because of the excessive sensitivity reported by many patients⁵, which can significantly influence the quality of life for the entire family unit. Specific characteristics can be found in the enamel, such as hypomineralized second primary molar (HSPM), Molar-Incisor Hypomineralization (MIH), hypoplasia, or amelogenesis imperfecta, depending on their severity. This complexity makes the rehabilitative treatment of affected teeth even more challenging^6,7. However, up to the present moment, only systematic reviews focusing on the management of MIH have been identified^8,9.

At present, diverse therapeutic approaches are available for posterior teeth affected by DDE, whether accompanied by fractures and cavities resulting from associated carious lesions. As a result, metallic crowns to zirconia crowns^10–12, direct and indirect composite resin restorations, assisted by celluloid crowns¹³, inlays and onlays¹⁴, as well as minimal intervention strategies^15–18 have been the focus of studies in an attempt to develop effective approaches for use by pediatric dentists and dental surgeons.

However, for a long time, it was believed that deciduous dentition did not warrant rehabilitative efforts, especially from an aesthetic perspective, as it would soon be replaced by permanent dentition. The perception and values of patients and caregivers, as they have become a crucial factor in the decision-making process for interventions, have encouraged a new perspective on rehabilitative approaches for deciduous teeth^19,20.

Furthermore, the presence of DDE in young permanent teeth, particularly in the posterior region, poses a challenge for dentists. There appears to be a lack of consensus regarding the optimal approach and timing of intervention, which is further complicated by the unique challenges presented during childhood and adolescence^21–23. Nevertheless, while the evidence may not be definitive, there appears to be a stronger body of research supporting MIH or generalized DDEs.^24,25 For this reason, our study specifically focused on DDEs with cavities in dentin or post-eruptive fractures.

Thus, considering the difficulty of interpreting and synthesizing data from various individual studies and determining the best strategy, the aim of this study was to investigate the best available management strategy for the treatment of deciduous and young permanent teeth with DDE, presenting post-eruptive fractures or dentin cavities concerning their longevity, and the perception/acceptance by caregivers and children. The obtained results may contribute to offering guidance and programs to healthcare professionals and providers, with the aim of implementing sustainable approaches.

Protocol and registration

The study protocol was registered and is available in PROSPERO (International Prospective Register of Systematic Reviews) under the registration number CRD42021240984 and reported in accordance with the PRISMA 2020 Statement²⁶.

Deviation from protocol

As per our research protocol, we had initially planned to research both topics together: Extensive caries lesion and DDE; however, due to the complexity of the search, it was adapted only to teeth with DDE and the economic analysis was not conducted. Therefore, the eligibility criteria and PICO question used were revised.

As the included studies did not always present comparative groups for the treatment of DDE, deviating from what was initially planned in the registry, it was not possible to conduct a network meta-analysis.

Search sources and strategy

The systematic search of the available studies was conducted up to May 31, 2023, in the electronic databases MEDLINE/PubMed, Scopus, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL). Additionally, the reference lists of potentially eligible studies were checked to ensure that all relevant studies were analyzed. Grey literature search was carried out in the ProQuest database. For the development of the search strategy, the following PICO question was formulated:

What is the best management strategy (I) when compared among the available options (C) concerning longevity and perception/acceptability (O) for posterior deciduous or young permanent teeth with enamel developmental defects presenting post-eruptive fractures or dentin cavities in children up to 14 years old (P)?

The search strategy was developed for the MEDLINE/Pubmed database and then adapted for each consulted database, as described in SI Table 1.

Table 1

– Characteristics of Studies on Molar-Incisor Hypomineralization (MIH).
Authors (Year/Country)	Patient Count	Patient Age	Treatment Count per Group	Involved Tooth Type	Type of Cavity / Severity	Number of Involved Surfaces	Study Design	Evaluated Intervention	Evaluated Outcome	Success Assessment Tools	Follow-up Time	Longevity Rate	Treatment Acceptability Rate	Economic Analysis Conducted	Perception
Biondi et al.,2022¹/Argentina	153	-	236 with HM/359 without HM = 595	Firts permanent molars	Moderate/Severe	-	Retrospective	glass ionomers, steel crown, onlay,inlay, composite resins	Longevity	Clinical examination - modified Ryge criteria /USPHS	61.7 ± 20.1 without MH/ 57.5 ± 23.9 with MH	77% with MH/ 100%without MH.	-	-	-
Dhareula et al.,2019³⁴/India	30	8–13 years	21 per group = 42	First permanent morlar	Severe	> 2	RCT	Metal onlay/ indirect resin onlay	Clinical Success	Clinical and radiographic examination - (USPHS)	36 months	87.6% for both the groups combined and 90% for metal and 85.7% for the composite group	-
Farias et al.,2022³⁵ /Colombia	115	7–10 years	61 Composite resin/ 54 Stainless steel crown	First permanent molars	Mild, Moderate, Severe	At least 1	Retrospective	RC/SSC	Longevity	Clinical evaluated with the criteria proposed by Innes et al., to assess restorations of SSC and CR	24 months	SSC 94,4%/ RC 49.2%	-	-	For CR, 1 patient (1.6%) classified it as very low, 3 (4.9%) as low, 27 (44.3%) as moderate, 23 (37.7%) as intense and 7 (11.5%) as very intense. For SSC, 18 patients (33.3%) rated the discomfort as very low, 19 (35.2%) as low, 14 (25.9%) as moderate, 3 (5.6%) as intense and none as very intense.
Fragelli et al.,2015³⁶ /Brazil	21	6–9 years	48	First permanent molars	Morderate/Severe	-	Prospective	5% fluoride varnish + Glass ionomer cement	Clinical success	Clinical examination - USPHS-Modified	12 months	78%	-	-	-
Gatón-Hernandéz et al.,2020³⁷/Spain	326	6-8years	281	First permanent molar with open apex	Severe	Occlusal with or without proximal involvement	Longitudinal	Glass ionomer cement and after 6 months Resin Composit	Clinical Success	clinically and radiographically ex- amination	24 months	In 272 teeth (96.8%), clinical and radiographic success	-	-	-
Grossi et al.,2018³³ /Brazil	44	7–13 years	60	First permanent molar and Incisors	Severe	> 1	Prospective	ART - glass hybrid restorative	Longevity	Clinical examination - using the modi- fied ART criterion	12 months	Success rate was 98.3%,	-	-	-
Kotsanos et al.,2005³⁸ /Greece	36	mean age 7.5	136 HMI/130 control	First permanent molars	-	At least 1	Retrospective	RC fillings, Stainless steel, Amalgam, sealants, RC restorarion	Longevity	Clinical examination	2–5 years	HMI 75% CG 87,7%	-	-	-
Lygidakis et al.,2003³⁹ /Greece	46	8–10 years	52 Composite restorations	Permanent Molars	Atypical	> 2	Prospective	Composite restorations	Longevity	Clinical examination - The criteria of Ryge	48 months	49 49 teeth reassessed, none requiring retreatment; 4 (8%)with changes in positioning.	-	-	-
Linner et al.,2020⁴⁰ /Germany	52	Mean age 11.2	28 GIC restorations/ 126 non-invasive composite restorations/ 27 conventional composite restorations/ 23 CAD/CAM-fabricated ceramic restorations = 204	Permanent incisors and molars teeth	Moderate/Severe	-	Retrospective	GIC restorations/ non-invasive composite restorations/ conventional composite restorations/ CAD/CAM-fabricated ceramic restorations	Longevity	Clinical FDI criteria for fracture of material and retention examination	42.9 months	CAD/ CAM group 100.0%/ Conventional composite 76,2%/non-invasive composite restorations29.9%/ GIC restorations 7.0%	-	-	-
Rolim et al.,2020⁴¹ /Brazil	35	7–16 years	33 total etch/31 self etch	First permanent molars	Moderate/Severe	At least 1	RCT	SE/TE both with universal adhesive and bulk-fill resin composite	Longevity/dental pain/dental anxiety	Clinical examination - USPHS modified	12 months	80.8% (TE) and 62.3% (SE)	-	-	Reduction in self-reported pain after 12 months in both groups
Singh et al., 2021³¹ /India	46	8–15 years	20 per group = 60	First permanent molars	Severe	> 2	RCT	zirconia, lithium disilicate, and cast metal crowns	Clinical Success	Clinical examination - USPHS criteria	24 months	6–12 months 100% / 24 months: Metal crown 100%; lithium disilicate and and zirconia crowns 98,3%	Parents: 80% of parents were highly satisfed and 20% were satisfed with the treatment. As for the child, 78.3% were highly satis- fed and 18.3% and satisfed.		-
Souza et al.,2017³² /Brazil	18	6–8 years	SEA 19/ TEA 22 = 41	First permanent molars	Severe	-	RCT	self-etching adhesive (SEA) and total-etch adhesive (TEA) + RC	Longevity	Clinical examination - the USPHS-modified criteria	18 months	were 68% for SEA and 54% for TEA	-	-	-

Eligibility criteria

The articles were considered eligible when they met the following inclusion criteria:

Being related to the scope of the review in question: Evaluating the treatment of DDE with dentin cavities or post-eruptive fractures in posterior deciduous and/or young permanent teeth, up to 14 years of age.

Evaluating the child's or caregiver's perception/acceptability or treatment longevity.

After the initial assessment, articles that met the inclusion criteria were read in their entirety. Articles showing at least one of the following exclusion criteria were considered ineligible:

Being conducted in specific groups (patients with special needs or undergoing medical treatment).

Not providing separate data for posterior deciduous or young permanent teeth.

Not evaluating management strategies for teeth with DDE with dentin cavities or post-eruptive fractures.

Not being a clinical study.

There were no restrictions on the language or publication date of the included studies. The authors have proficiency in comprehending articles in both Portuguese and English. In cases where articles in other languages were available, an online website (www.deepl.com) was used.

Study selection

The article selection process was conducted using the Rayyan program (Ouzzani et al. 2016) by two independent reviewers (AMPC, BTAS) in duplicate and blinded. Initially, both reviewers assessed the titles and abstracts in accordance with the inclusion criteria. In cases where there was insufficient data to make a decision, in the absence of an abstract, or when the abstract did not provide clear information, the article was then selected for the next phase. Subsequently, the two reviewers (AMPC, RMR), independently, in duplicate and blinded, evaluated the eligible articles in their entirety based on the exclusion criteria. A third researcher (TKT), with experience in systematic reviews related to restorative treatment, was consulted in cases of conflict or uncertainty.

Data extraction

The same reviewers (AMPC, BT, RM), independently and in duplicate, conducted data extraction from eligible articles, including: publication details (authors and year), sample characteristics (number and age of participants, number of treatments performed per group, type of tooth involved, cavity type/severity, number of surfaces involved, and type of enamel development defect), study methodology (design, evaluated interventions, evaluated outcomes, assessment tools for success), and outcome information (follow-up time, longevity rate, and treatment acceptability). Additionally, it was collected the perception/acceptability of the child and/or their caregivers.

Risk of bias assessment

The risk of bias in the included studies was assessed by 2 reviewers (AMPC and TKT), independently and in duplicate, using the Cochrane risk-of-bias tool for randomized trials 2 (RoB 2.0) for randomized clinical trials and the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) for non-randomized intervention studies.

The RoB 2 tool comprises five domains: bias in the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in outcome measurement, and bias in the selection of reported results. Reviewers categorized the domains as "low risk of bias," "high risk of bias," or "some concern regarding bias." When all domains received a low risk of bias rating, the study was considered low risk. If at least one domain received a "some concern regarding bias" or "high risk of bias" rating, the studies were then given these respective classifications²⁷.

On the other hand, the ROBINS-I tool consists of seven domains: bias due to confounding, bias in the selection of participants, bias in the classification of interventions, bias due to deviations from intended interventions, bias due to missing data, bias in outcome measurement, and bias in the selection of reported results. In this tool, the domains were categorized as low, moderate, serious, or critical risk of bias, or "no information" (unable to identify information or uncertainties about possible bias)²⁸. The overall risk of bias rating received, similar to the RoB 2.0 tool, the least favorable categorization among the risks assessed for each domain.

Data synthesis and statistical methods for meta-analyses

Since only similar studies on restorative treatments for MIH were found, meta-analyses were conducted considering this substrate type. Qualitative data synthesis was performed for the other DDE.

The I2 test was conducted to assess heterogeneity among the studies, and the tau2 test was used to estimate the variance within the studies. Subsequently, single-arm meta-analyses were conducted to assess the cumulative success rate of restorative treatments according to the follow-up time – 6, 12, and 24 months. Success was evaluated in alignment with the criteria delineated by the included articles. Subgroup analyses were conducted to explore the influence of different types of restorative treatment on the success rate. Sensitivity analyses were performed to investigate the potential influence of individual studies on outcome estimates when there was moderate or high heterogeneity. Publication bias was investigated through visual funnel plot asymmetry analysis and the Begg test when ten or more studies were included.

The meta-analyses were conducted using the "meta," "metafor," "metaprop," and "metabias" packages in the RStudio Team software (RStudio Team, 2022, Boston, MA). The cumulative proportion rate and corresponding 95% confidence intervals (95% CI) were then calculated.

Certainty of evidence

The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) tool was used to assess the certainty of evidence for the results through GRADEpro in the meta-analyses according to the outcome, classified as high, moderate, low, or very low²⁹. The following parameters were considered for the analysis of the certainty of evidence: methodological limitations (risk of bias), inconsistency, indirect evidence, imprecision, and publication bias.

Study selection

Initially, 1246 articles were identified, of which 529 were duplicates. Then, 717 articles were evaluated, and after reading the title and abstract, 146 articles were eligible for full-text reading. Of these, 130 were excluded, primarily because they were not clinical studies (80%), resulting in 16 articles included in the systematic review. Figure 1 describes the process of selecting the included articles.

Characteristics of studies

Of the 16 included articles, 12 (75%) focused on MIH, 1 (6.25%) on hypomineralization, 1 (6.25%) on imperfect amelogenesis, and 2 (12.5%) included different types of DDE in the same study. Regarding the study design, only 4 out of 16 (25%) were randomized controlled trials, all of which were related to MIH. As for the type of teeth evaluated, 14 out of 16 (87.5%) assessed permanent molars, while only 1 study on hypomineralization and 1 study on imperfect amelogenesis evaluated deciduous molars.

In the studies on MIH, the evaluated restorative materials included esthetic crowns, metal crowns, composite resin (CR), glass ionomer cement (GIC), and metal and composite resin onlays. In the hypomineralization group, the studied materials were metal crowns, CR, GIC, and metal onlays. The study on imperfect amelogenesis evaluated composite crowns and veneers, and finally, the group that included different types of DDE assessed metal, esthetic, and gold crowns, as well as CR. Overall, there was a high success rate for these materials when studied individually in all groups (an average of 80%). However, due to the study's designs, it was not possible to compare the best type of material between the DDE groups, except for MIH.

The age of patients included in the studies on MIH ranged from 6 to 16 years old, while in the other three types of DDE, the average baseline age was 3 years until 13 years old. In 100% of cases, the evaluated outcome was clinical success and/or longevity, with the clinical follow-up time in the studies ranging from a minimum of 6 months to a maximum of 60 months. The most frequently used tool to assess treatment success and longevity was the USPHS criteria (7/16, 43.8%). However, only 4 out of 16 (25%) studies assessed the perception of pain and/or aesthetics by caregivers and children, with positive responses for treatment with esthetic and metal crowns, as well as for treatment with CR. Tables 1, 2, 3 and 4 provide a description of all the collected data from each study according to the type of DDE evaluated.

Table 2

– Characteristics of studies on Hypomineralization.
Authors (Year)	Number of participants	Age	Treatment Count per Group	Involved Tooth Type.	Type of Cavity / Severity	Number of Involved Surfaces	Study Design	Intervention	Evaluated Outcome	Success Assessment Tools	Follow-up Time	Longevity (Success Rate)	Perception/Acceptability
Declerck & Mampay, 2021 [33]	15	3–7 years	39	Second primary molars	Moderate/Severe	-	Prospective	Preformed metal crowns using Hall Technique	Clinical Success	Clinical and radiographic success from Innes et al.,2007	12 months	25 crowns (64.1%) categorized as successful, 14 (35.9%) as acceptable and none as a failure.	Aesthetic aspect resulted in a mean score of 8.3 (SD ± 2.6) for patients and 7.2 (± 2.9) for parents, on a scale from 0 to 10.

Table 3

– Characteristics of Studies on Amelogenesis Imperfecta.
Authors (Year)	Number of participants	Age	Treatment Count per Group	Involved Tooth Type.	Type of Cavity / Severity	Number of Involved Surfaces	Study Design	Intervention	Evaluated Outcome	Success Assessment Tools	Follow-up Time	Longevity (Success Rate)	Perception/Acceptability
Vitkov et al., 2006[41]	5	3.5–10 years	5	Primary teeth	Moderate/Severe	-	Prospective	Composite crowns and veneers	Clinical Success	Clinical examination	6 months	100%	-

Table 4

– Characteristics of studies on Development defects of enamel together (localized opacity / localized enamel hypoplasia / hypomineralized defects / amelogenesis imperfecta).
Authors (Year)	Number of participants	Age	Treatment Count per Group	Involved Tooth Type.	Type of Cavity / Severity	Number of Involved Surfaces	Study Design	Intervention	Evaluated Outcome	Success Assessment Tools	Follow-up Time	Longevity (Success Rate)	Perception/Acceptability
Koch & Garcia-Godoy, 2000[42]	12	6–8 years	Gold crowns 29 / Tooth-colored crowns 4/ leucite-containing heat- press ceramic 8	Young permanent molars	-	-	Retrospective	Gold crowns/and tooth-colored composite/ ceramic crowns	Longevity/Success	Clinical examination - USPHS modified	5 years	100% Except Marginal adaptation = 93% Gold Crown.	-
Zagdwon et al., 2003[43]	17	6–13 years	23 cast adhesive coping (CAC) / 19 stainless steel crown (SSC)	Permanent molars	Severe	At least one with enamel absence	Prospective	CAC / SSC	Longevity/Success	Clinical examination	24 months	94.7% SSC and 91.3% CAC	-

Risk of bias assessment

The risk of bias in the 4 RCT studies was assessed using the ROB2 tool (Fig. 2), which showed that only 1 had a low risk of bias, another had some concern, and 2 others had a high risk of bias, one for not having pre-registered the study³⁰ and another for not concealing the treatment allocation after randomization³¹.

As for the 12 longitudinal studies, these were evaluated using the ROBINS-I tool (Fig. 3), and only 1 had a low risk of bias³². In common, all the other articles did not have a pre-registration protocol and had a high risk of bias.

Data synthesis

Analyses were conducted according to the follow-up time − 6, 12, and 24 months for restorative treatments on MIH.

6 months of follow-up

We conducted a meta-analysis with 17 groups of eleven articles to assess the success rate of restorative treatments. In the overall analysis, a pooled proportion of success rate of 91% (95% CI 84%-99%) was found. Heterogeneity was considered high (I2 = 90%) and statistically significant (p < 0.01) (SI Fig. 1).

Thus, a sensitivity analysis was proposed, and no influence on heterogeneity was observed. Furthermore, the subgroup analysis showed no difference in the pooled proportion of the success rate among the types of restorative treatments (p = 0.154) (SI Fig. 2).

Visual inspection of the funnel plot suggested asymmetry (SI Fig. 3), and the publication bias analysis confirmed the asymmetry in the funnel plot (p < 0.001).

12 months of follow-up

We conducted a meta-analysis with 15 groups from ten articles to assess the success rate of restorative treatments. In the overall analysis, a pooled proportion of success rate of 90% (95% CI 82%-98%) was found. Heterogeneity was considered high (I2 = 88%) and statistically significant (p < 0.01) (SI Fig. 4).

Visual inspection of the funnel plot suggested asymmetry (SI Fig. 6), and the publication bias analysis confirmed the asymmetry in the funnel plot (p = 0.0011).

24 months of follow-up

We conducted a meta-analysis with 11 groups from six articles to assess the success rate of restorative treatments. In the overall analysis, a pooled proportion of success rate of 91% (95% CI 82%-99%) was found. Heterogeneity was considered high (I2 = 89%) and statistically significant (p < 0.01) (SI Fig. 7).

Thus, a sensitivity analysis was conducted. One study35 significantly influenced the results. After removing this study, the value of I2 reduced to 66.2%. Therefore, a new meta-analysis was performed with the remaining studies, resulting in a pooled proportion of success rate of 96% (95% CI 92%-100%) (SI Fig. 8). Moderate heterogeneity (I2 = 66%) remained statistically significant (p < 0.01).

On the other hand, the subgroup analysis did not identify a difference in the pooled proportion of the success rate among the types of restorative treatments (p = 0.922) (Fig. 4).

Visual inspection of the funnel plot suggested asymmetry (SI Fig. 9), and the publication bias analysis confirmed the asymmetry in the funnel plot (p = 0.025).

Certainty of evidence

The certainty of evidence in the meta-analysis was assessed according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. The classification of the 5 studies at 24 months of longevity was rated as low (SI Table 2).

Patients with DDE face numerous challenges, including a higher likelihood of post-eruptive fractures, an increased incidence of caries, excessive sensitivity, as well as alterations in enamel structure color^1,33,30. In this context, this systematic review with meta-analysis addressed the types of treatment for teeth with DDE that had dentin cavities or post-eruptive fractures. Among the 16 articles included, a trend towards the use of prefabricated aesthetic or metal materials, as well as materials manufactured after dental preparation and the use of GIC and CR, was observed. However, due to the limited number of studies and methodological differences among the articles in the groups of hypomineralization (3), amelogenesis imperfecta (1), and different DDE (2), it was not possible to conduct a meta-analysis to assess them. Nonetheless, qualitatively, these studies showed a high success rate (80%) over a range of 6 to 60 months.

On the other hand, a meta-analysis was conducted on the studies of MIH at 6, 12, and 24 months, and the types of treatments evaluated were aesthetic crowns, metal crowns, composite resin, and GIC. In the first 6 months, the studies showed a high success rate of 91% (95% CI 84%-99%), with no significant difference in relation to the types of restorative treatments. These trends of results were maintained in the other evaluations (12 months – 90; 24 months − 96%). The data found in the study indicate that for teeth with MIH which present dentin cavities or fracture, the success of the treatment in terms of longevity is not dependent on the material used but rather sensitive to the technique employed. This finding is important in the sense of expanding the possibility of using different materials in various situations (depending on the location, patient behavior, and financial resources), as long as the specific technique for each material is respected and carried out properly.

Treating these patients still raises questions about the best technique and material longevity. For instance, metal crowns have been widely recommended in these cases due to their cost-effectiveness and durability³⁴. Nevertheless, when it comes to young permanent teeth, there are still doubts about whether they are the most suitable choice, and crowns made from various aesthetic materials are being more extensively studied and utilized³⁰. However, considering the need for cavity preparation and the overall cost of treatment, the use of less invasive materials might be more appealing.

Regarding the perception of parents and children, more studies should be encouraged to assess this aspect. However, of the three studies included in this research, all presented satisfactory data for all restorative materials. The aesthetic crowns showed slightly better qualitative data, but the sample size for this comparison was small and cannot be generalized^35–37. Additionally, only one included article assessed the acceptability of treatment³⁰.

This study has certain limitations, including challenges in classifying the specific types of DDE to be included in the research. Notably, defects like fluorosis were not reported. In addition, during the meta-analysis, aesthetic crowns were represented by different materials like lithium disilicate and zirconia, both prefabricated crowns and those requiring cavity preparation. Another potential limitation is the wide age range of the studied patients, which could influence tooth mineralization and patient behavior during the restorative procedure. Furthermore, the high heterogeneity among the articles indicates challenges in combining and interpreting results.

On the other hand, to enhance the credibility of this research, it followed the PRISMA 2020 guidelines, and three researchers were involved in data collection. Additionally, assessing the risk of bias in the articles and identifying where this risk occurred can provide more reliable data. In the case of this study, it was observed that a high percentage of articles (81.25%) were classified as high risk primarily due to the lack of prior study registration.

The results presented in this study indicate the need for more randomized controlled trials on restorative materials for teeth with dentin cavity on DDE. This is particularly crucial for conditions such as amelogenesis imperfecta and molar hypomineralization. The findings of our study have the potential to guide future well-designed research which may encourage the enhancement of professional techniques and the adoption of high-quality materials.

Over the course of 24 months, the best management strategy for success and longevity of techniques for teeth with MIH post-eruptive dentine fracture do not seem to be dependent on the specific material chosen. Both aesthetic and metal crowns, composite resin, and glass ionomer cement can be used with high longevity. However, the level of evidence certainty was classified as low. It was not possible to conduct a meta-analysis for other types of DDE, but qualitatively, the previously mentioned materials showed a good success rate. Nevertheless, most studies included in this systematic review had a high risk of publication bias. Regarding the perception/acceptance by parents and children, more studies need to be published as there is insufficient data in this regard.

Author contributions

A.M.P.C., T.KT. and D.P.R. contributed to the study’s idea and design. Data collection was performed by A.M.P.C., R.M.R. and B.T.A.S. Analysis were performed by T.K.T and T.F.N. A.M.P.C. and T.KT. drafted the manuscript. D.P.R., T.F.N, M.B.F, S.J.C.B, I.F., and E.MS. revised and gave final approval of the manuscript.

Ethics declarations

Not applicable.

Available of data and material

Data will be made available by email contact with the corresponding author.

Funding

The authors have no relevant financial or non-financial interests to disclose.

Conflict of interest

The authors declare that they have no conflicts of interest.

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Strategies for Management of Posterior Deciduous and Young Permanent Teeth with Developmental Defects of Enamel - Systematic Review and Meta-analysis

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Abstract

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Introduction

Methods

Protocol and registration

Deviation from protocol

Search sources and strategy

Eligibility criteria

Study selection

Data extraction

Risk of bias assessment

Data synthesis and statistical methods for meta-analyses

Certainty of evidence

Results

Study selection

Characteristics of studies

Risk of bias assessment

Data synthesis

6 months of follow-up

12 months of follow-up

24 months of follow-up

Certainty of evidence

Discussion

Conclusion

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References

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