You are on page 1of 53

CURRENT CONCEPTS IN CLASSIFICATION,

INDICATION, PRINCIPLES AND PROCEDURES OF


CAVITY PREPARATION WITH RESPECT TO ADHESIVE
RESTORATIONS

Introduction
Macrodentistry is the density that has been practiced for
centuries with the conventional concept of “Extension for
prevention” or cutting for immunity. A patient who has been
assessed as having a high caries risk is immediately worked on
and preventive restorations have been given.

Microdentistry
In the past few years the emerging techniques of
operative density dedicated to minimal invasion and minimal
sacrifice of sound tooth structure have been explored and
documented and they have become part of the mainstream
dentistry. As new techniques emerge and are adapted into
dental disciplines, the usual intent and purpose of the original
technology often change in the course of adaptation.

Microdentistry, the dental science of diagnosing,


intercepting and treating dental decay on the microscopic level
is now emerging as an operative tool in science-based
microdentistry. The ultimate goal is prevention of extension
and restriction with conviction.
Historical aspects

1. Historical aspects of G.V. Blacks – Concept of cavity


preparation

a. Introduction
When Black defined the parameters for his classification,
the cavity designs were controlled by a number of factors,
many of which no longer apply. Caries was rampant and the
significance of fluoride was not understood. There were
limitations in the available instruments for cavity preparation
as well as in the selection of restorative materials. The five
categories of carious lesion were related to the site of the
lesion and to the nature of the intended restoration, but they
did not take into account the increasing dimensions of a cavity
nor the complexity of the method of restoration.

b. G. V. Black’s classification
Class I
All pit and fissure restorations are class I and they are
assigned to the three groups as follows
1. Restorations on occlusal surface of premolars and molars.
2. Restorations on occlusal two thirds of facial and lingual
surfaces of molars.
3. Restorations on lingual surface of maxillary incisions.
Class II
Restorations on proximal surfaces of posterior teeth

Class III
Restorations on proximal surface of class III which do
not involve the incision angle

Class IV
Restorations on proximal surface of anterior teeth which
involve incisal edge

Class V
Restorations on gingival third of the facial or lingual
surfaces of all teeth

Class VI
Restorations on the incisal edge of anterior teeth or the
occlusal cusp heights of posterior teeth

c. Materials
Amalgam, Direct filling gold, Cast metal

d. Principles
 To remove tooth structure to gain access and visibility.
 To remove all trace of affected dentine from the floor of
the cavity.
 To make room for the insertion of the restorative material
itself.
 To provide mechanical interlocking retentive designs.
 To extend the cavity to self-cleansing areas to avoid
recurrent caries.

The result was that, by today’s standards, all such


restorations were large. In his designs, Black showed
commendable respect for remaining tooth structure as well as
occlusal and proximal anatomy but it was necessary to
sacrifice relatively extensive areas of enamel to achieve his
goals.

e. Earlier concepts of conservation

1. Occlusal convergence
It aids in retention as well as conversation of occlusal
tooth structure. This design of cavity preparation exposes
minimal amount of restorative material to occlusal loading.

2. Reverse curve

3. Double pulpal floor


Here one level of pulpal floor is at ideal depth (1.5mm
for amalgam) and others will be at a deeper level as dictated by
the pulpal extent of decay. The deeper part of pulpal floor is
called ledge. It can be circumferential, interrupted or opposing.

iv. Preservation of oblique ridge


Oblique ridge is included in cavity preparation only when
(i) undermined by caries, (ii) directly affected by caries and
(iii) when less than 0.5mm.

v. Enameloplasty
If less than one third of enamel depth is involved by
carried the fissure may be removed by enamel plaster without
extending the tooth preparation. Enamel is reshaped into a
saucer form so that the area becomes cleanable, finishable and
allows conservative placement of preparation margins.

vi. Prophylactic odontotomy


Proposed by Hyart in 1924. It is characterized by
minimally preparing and filling with amalgam, developmental,
structural, imperfections of the enamel, such as pits and
fissures, to prevent caries originating in these sites.

The demineralization and remineralization cycle

Demineralization
 The mineral component of enamel, dentine and cementum

is hydroxyapatite, Ca 1 0 (PO 4 ) 6 (OH) 4 in a neutral


environment, hydroxyapatite is in equilibrium with the
local aqueous environment, which is saturated with Ca 2 +

and PO 4 3 ions.
 Hydroxyapatite is reactive to hydrogen ions at pH 5.5

(the critical pH for hydroxyapatite) and below. Hydrogen


preferentially with the phosphate groups in the aqueous
environment immediately adjacent to the crystal surface.

The process can be thought of as conversion of PO 4 3 to

HPO 4 2 by the addition of hydrogen and the hydrogen
being buffered at the same time.

 The HPO 4 2 ions is then not able to contribute to the
normal hydroxyapatite equilibrium because it contains
PO 4 , not HPO 4 and the hydroxyapatite crystal therefore
dissolves. This is termed demineralization.

Remineralization
 The demineralization process can be severed if the pH is

neutral and there are sufficient Ca 2 + and PO 4 3 ions in the
immediate environment.
 Either the apatite dissolution products can reach

neutrality by buffering or the Ca 2 + and PO 4 3 ions in
saliva can inhibit the process of dissolution through the
common ion effect.
 This enables rebuilding of partly dissolved apatite
crystals and is termed remineralization.
 This interaction can be greatly enhanced by the presence
of fluoride ion at the reaction site.
Acid reaction with apatite at the tooth surface
 Following eruption there is a process of continuing
mineralization of enamel from salivary calcium and
phosphate.
 Initially, enamel apatite contains many carbonate and
magnesium ions, which are highly soluble in even mild
acidic conditions. However, there is a rapid and extensive
exchange of hydroxyl and fluoride ions as the magnesium
and carbonate are dissolved, leading to a more mature
enamel with a greater resistance to acid ion challenge.
 This level of maturity or acid resistance can be greatly
enhanced by the presence of fluoride.
 As the pH decreases the acid ions react, principally with

the phosphates in saliva and plaque (or calculus) until the


critical pH for dissolution of hydroxyapatite is reached at
approximately pH 5.5 – 5.2.
 Further decrease in pH results in progressive interaction
of the acid ions with the phosphate groups of
hydroxyapatite, causing partial or full dissolution the
surface crystallite.
 Stored fluoride released in this process reacts with the

Ca 2 + and HPO 4 2 ion breakdown products, forming
fluorapatite or fluoride – enriched apatite.
 If the pH decreases further below 4.5, which is critical

pH for fluorapatite dissolution even fluorapatite will then


dissolve.

 If acid ions are neutralized and the Ca 2 + and HPO 4 2 ions

are retained the reverse process of remineralization


occur.

Factors contributing to maintenance of de- and


remineralization

Saliva with its buffering capacity



Ca 2 + and PO 4 levels
Fluoride application

Protective factors

Oral clearance of proteins &


Glycoproteins
Buffering and
Remineralization potential

Diet + plaque  acids

Decreased salivary flow Decreased buffering


capacity and oral
clearance rate
Destabilizing factors
Acidic saliva erosive acids
To detect accurately the prime cause of an imbalance in a
particular patient. It is essential to be familiar with the precise
nature of each of the factors and the activity that occurs on the
tooth surface.

The various factors are:


1. Bacterial flora – Streptococcus mutans
2. Plaque retention – contact areas, overhangs, over
contours, pits and fissures, sticky foods.
3. Thickness of plaque
4. Salivary buffers
5. Fluorides
6. Frequency of carbohydrate intake

Effect of plaque on pH of saliva


Fermentable carbohydrate entering the oral environment
go into solution in saliva and become available to plaque
microbes  2 – 4 point drop in pH at tooth surface. Amount of
pH drop depends on plaque thickness, number and type of
plaque bacteria, efficiency of salivary buffering.

Recovery to normal resting pH takes from 20 minutes


average to several hours for those with increased caries
susceptibility.
Acids from carbohydrate fermentation are weak organic
acids and will cause only chronic low grade caries.
Other sources of acids are from
 Carbonated drinks
 Citrous fruits
 Gastric reflux

Protective factors
 Natural factors – role of saliva
 Diet factors
- Increased fat in diet  decreased plaque attachment
- Milk products like cheese
- Fibrous foods  increased chewing  increased
flow of saliva

Saliva and its protective factors


Saliva plays an important role in protecting teeth against
acid challenge. Normal salivary flow = 3ml/min, in xerostomia
– it is 0.3ml/min  increased caries risk.

Factors decreasing salivary flow


 Physiologic
- age – decreased secretory cells
- sleep
 Xerostomia
- Sjogren’s syndrome
 Radiation therapy

- Xerostomia
- Cervical caries due to decreased salivary flow
 Medications
- Anticholinergics
- Antihypertensives
- Antidepressants

Unstimulated saliva contains little bicarbonate buffer


with fewer calcium ions and more phosphate ions.

Reflex stimulation of saliva by chewing or through the


presence of acidic foods can increase the flow by a factor of
more than 10. Bicarbonate buffer concentration increased 60
times upon stimulation. Calcium ions increased but PO 4 ions
do not increased in proportion to flow rate reduction of
maximum salivary flow to less than 0.7ml/min  increased
caries risk.

Salivary protective factors

1. Ca and PO 4 ions
It is usually the saliva is supersasturated when the enamel
apatite is at neutral pH. PO 4 ions also provides a significant
buffering capacity at resting pH and in early stage of acidic
challenge.
2. Pellicle
Origin from saliva. Protects against acid challenge. Acts
as a barrier to diffusion of acid ions into the tooth. Also may
inhibit mineralization of apatite to form supersaturated levels
of Ca and PO 4 in saliva.

3. In stimulated saliva

Good HCO 3 buffering system

4. Salivary flow and oral clearance rate


Influence removal of food debris and microorganisms

5. Fluoride content of saliva is low


0.03 ppm or 1.6 µ mol/litre but still contribute to
protection and repair of tooth minimal.

Effect of fluoride on enamel


In acidic environment, fluoride ion reacts with free Ca + +

and HPO 4 2 ions forming fluorapatite crystals. Fluoride
replaced hydroxyl ions since the ionic radii of fluoride

(1.36A 0 ) and OH (1.4A 0 ) are similar. Fluorapatite is less
soluble because of better submit stacking. It gets dissolved at
pH of 4.5. In tooth structure, its concentration is as high as
2500 – 4000 ppm. Daily consumption of water contain fluoride
at 1mg/lit  increased caries resistance.
Fluoride
 Fluorapatite (less soluble)
 Inhibits bacterial metabolism
 Decreased demineralization
 Increased remineralization
 Decreased plaque formation
 Decreased wettability of tooth structure

Increased concentration of fluorides  stored as CaF 2


around apatite crystals  heavy remineralization at surface
lesions.

Effect on established lesions


1. Contribute to remineralization of incipient enamel caries.
2. Partly remineralize carious dentin and therefore slows
down assets carious process in the cavitated lesion.
3. Remineralize root surface lesions to the extent that they
may not need a restoration.

Topical fluoride is more effective in inhibiting smooth


surface caries and in aiding remineralization of enamel, dentin
and cementum. Less effective in fissures. Daily application of
topical fluoride to demineralzie root surfaces over a period of
2 – 4 months  leads to significant hardening of exposed
dentin. Deep and extensive root caries can be hardened with in
the same period of time but required a higher concentration of
fluoride.

Level of remineralization

Enamel
 Till actual cavitation has not occurred.
 Only if some crystal structure is present.

Dentin
 Early stages of development of lesion.
 Till the collagen matrix has not collapsed.

Breakdown within dentin can be divided into two


identifiable zones.

1. Infected dentine
 Surface layer closest to oral environment.
 Heavily infected with bacteria.
 Collagen matrix collapsed.
 Stain red with basic Fuschindye.
 Dark brown / black in color
 Soft consistency can be readily removed with sharp
excavator.
 Not remineralizable.

2. Affected dentine
 In the advancing front of caries following course of
dentinal tubules.
 Colorless, relatively soft
 Basic structure of collagen matrix present and intact
 Sterile with very few pioneer bacteria
 Can be remineralized to some degree
 Regarded as precarious, not removed and left to be healed
 Also not removed entirely as pulp immediately subjacent
to approaching caries will be initiated and inflamed by
presence of bacterial toxins and mechanical exposure will
lead to pulpal death.

Potential for remineralization


Once the cavitation has occurred, the infected layer is
removed and the lesion is completely isolated from the oral
environment with an adhesive restoration, which will prevent
microleakage. Remaining pioneer bacteria left in the affected
dentin will become dormant and pulpal irritation will cease.

The deep affected layer that had been demineralized will


be subject to remineralization because collagen matrix is still
intact.
In the past zinc oxide and eugenol paste was used as a
sealant because of its antibacterial properties, but now glass
ionomer is preferred as it completely seals cavity and releases
fluoride, Ca + + , phosphate ions thus encouraging
remineralization and healing of dentin.

 Demineralized enamel and dentin can be remineralized


but not cavitated lesions.
 White spot lesions on the visible surfaces of tooth can be
remineralized.

Radiographic assessment
 Minimal depth of detectable lesion on the radiograph is

about 500µ m.
 60% of teeth with proximal radiographic lesion on the
outer half of dentin are non-cavitated and hence should
be remineralized than restored.

Classification of approximal radiolucencies assessing


caries based on radiographs.

E1 - outer half of enamel


E2 - inner half of enamel
D1 - outer third of dentin
D2 - middle third of dentin
D3 - inner third of dentin
E0 - no carious lesion

Dentin is divided into three zones, as it enables more


conservation criteria to be established.

Using this minimally invasive technique, restorations are


not indicated until lesion has extended to D 2 region.
Disadvantages
 overlapping proximal contacts
 lengthening of image  wrong idea on depth of lesion

 2-D image
 superficial remineralization not seen
 fracture of one lingual cusp is seen as radiolucency of
proximal cavity.

1. In case of incipient or minimal lesion involving limited

pit and fissures  preventive resin restoration (sealant


alone / sealant and filled resin).
2. Decalcified appearance of pits and fissures indicative of

incipient / minimal caries  Sandwich preventive resin


restoration (Glass ionomer liner, filler resin and sealant).
3. Involvement of adjacent pit and fissure enamel with

possible minimal involvement of underlying enamel and


dentin  glass ionomer PRR (GIC liner, GIC restorative
and sealant)
4. No minimal undermining isolated pits and fissured. No

radiographic / clinical evidence of interproximal caries


but possible radiographic evidence of occlusal caries 
sealant amalgam PRR (Amalgam in isolated pits and
fissures without extension for prevention and sealant).

New cavity classification


The understanding of the effect of fluoride on the
demineralization – remineralization cycle as well as the advent
of true long term, adhesion with restorative materials, has
made it possible to reconsider the classification of carious
lesions and cavity designs first rationalized by G.V. Black.

Mount’s classification

The three sites of carious lesions

Site 1
Pits, fissures and enamel defects on occlusal surfaces of
posterior teeth or other smooth surfaces

Site 2
Approximal enamel immediately below areas in contact
with adjacent teeth

Site 3
The cervical one-third of the crown or following gingival
recession, the exposed root

The four sizes of carious lesions


Regardless of site or origin of lesion

Size 1
Minimal involvement of dentin just beyond treatment by
remineralization alone

Size 2
Moderate involvement of dentin. Following cavity
preparation, remaining enamel is sound, well supported by
dentin and not likely to fail under normal occlusal load

Size 3
The cavity is enlarged beyond moderate involvement.
Remaining tooth structure is weakened to the extent that cusps
or incisal edges are split or are likely to fail if exposed to
occlusal load. The cavity needs to be further enlarged so that
the restoration can be designed to provide support to remaining
tooth structure.

Size 4
Extensive caries and bulk loss of tooth structure has
already occurred.
Minimal Moderate Enlarged Extensive
Size 1 2 3 4
Site
Pit/fissure 1.1 1.2 1.3 1.4
1
Contact area 2.1 2.2 2.3 2.4
2
Cervical 3.1 3.2 3.3 3.4
3

Black’s classification did not allow for size 1 lesion in


either site 1 or site 2 because of absence of adhesive
restorative materials.

In the past, most restorative treatment was due to carries


(dacay) and the term cavity was used to describe a carious
lesion in a tooth that had progressed to the point that part of
the tooth structure had been destroyed. Therefore, when the
affected tooth was repaired the cutting or preparation of
remaining tooth structure was referred to as a cavity
preparation.

Nowadays many indications for treatment for teeth are


not due to caries and therefore the preparation of the tooth is
no longer referred to as cavity preparation but as tooth
preparation.
Tooth preparation is defined as the mechanical alteration
of defective, injured or diseased tooth to best receive a
restorative material that will reestablish a healthy state for the
tooth, including esthetic corrections where indicated, along
with normal form and function.

Earlier Black advocated the principle of extension for


prevention i.e. in tooth preparations for smooth-surface caries,
the restoration should be extended to areas that are normally
self-cleansing to prevent reoccurrence of caries and to include
full length of enamel fissures in pit and fissure cavities.

This extension for prevention has been reduced to


restriction with conviction by treatments that conserve tooth
structure, therefore restored teeth are stronger and more
resistant to fracture. Such treatments are enameloplasty, pit
and fissure sealants, preventive resins and conservative
composite restoration.

Earlier preventive measures included prophylactic


odontonomy i.e. developmental, structural imperfections of
enamel, such as pits and fissures were minimally prepared and
filled with amalgam to prevent caries originating in these sites.

Guiding principles of adhesive cavities


 Black’s concept of extension for prevention is no longer
valid. The current paradigm is rather prevention of
extension.
 Cavity outline form  cavity outline internal and
external, is only dictated by the extent of the carried.
Once caries dentin is removed, no further removal of
tooth substance is required.

Resistance
 Resistance of both tooth and restorative material to resist

fracture.
 Loose and fragile enamel rods should be moved, but
unsupported tooth structure may conserved and weakened
tooth may be reforced by the bonded restoration.
 90-degree cavosurface angles are given for GIC.
 Long level design for composite.
 If the margin is under functional loading the margin in

that area might have a cavosurface angle that approaches


60 to 80 degrees.
 Occlusal bevels should not be utilized for posterior
composite preparations.
 After caries removal, the internal cavity features rounded
characteristics, straight internal walls and defined line
angles are no longer required for adhesive materials.

Retention
 Macroretentive interlocking designs have changed to
retention by means of micromechanical (interlocking of
resin tags into the retentive pattern of erched tooth
tissues), submicromechanical (hybrid layer, horizontal
branching between dentin tubules, surface roughness of
tubules) and chemical adhesion (ion-exchange layer of
glass ionomers).
 Placement of a bevel increase by the potential surface
area for retention by a more transverse cut of enamel
prisms (enhanced etch pattern) and by extending the
surface area of the preparation available for bending.
 Cervical margins should only be beveled if the margin is
well above the cementoenamel junction.

Convenience
 The concept of convenience continues to apply, as the

clinician should have access to the work area for efficient


execution of techniques and manipulation of the
materials.
 The concept of self cleansing areas has been discarded
and removal of all affected dentine from the axial wall of
the cavity is strictly contra-indicated because of the
potential for remineralization and healing.

Cavity preparations

Site 1 lesions
 Fissures on occlusal surface of posterior teeth.

 Pits on lingual of upper anterior teeth


 Pits on buccal surface of lower molars
 Pits on lingual extension of distal occlusal groove of
upper molars

Size 1
Small defect in one section of a pit or fissure, it is of ten
combined with placement of a fissure seal on remainder of the
fissure system.

Size 2
Moderate size lesion with most fissures involved or
replacement of an existing Black class 1 restoration.

Size 3
Larger lesion requiring incorporation of protection for
one or more cusps in the design.

Size 4
Extensive lesion with one or more cusps already missing

Size 1 and size 2


No equivalent in G.V. Black classification

Preparation
Extent limited, most of fissure system free of caries.
Other sections of fissures deep and convoluted and subject to
later attack require protection through sealing at this time.

Fine tapered diamond point


Enter fissure till the extent of lesion

Small round burs


It is used to clean walls of infected enamel and dentin. It
is unnecessary to remove the affected, demineralized dentin on
the floor of the cavity, but it is essential the walls are
completely clean and free of caries. Enamel margins should be
sound and free of microcracks and loose enamel rods.

Restoration – advantages

GIC
 Adhesion  fluoride release

 Use strongest cement


 High powder liquid ration to ensure optimal physical
properties
 Condition cavity will 10% polyacrylic acid to ensure
optimal adhesion
 Placement of cement with a syringe is desirable to ensure
positive adaptation into the depths of cavity.
Autocure cement Resin modified glass ionomer
cement
Apply positive pressure using lightly No matrix required. No need to seal
lubricated gloved finger as matrix. as long as it has been light
↓ activated for 40 secs.
After seating, seal the cement with ↓
resin sealant to maintain water balance Restoration polished immediately
↓ after light activation at
Trim occlusion with round steel bur at intermediate high speed under air-
low speed with no air water spray water spray

Seal again
Erosion, abrasion lesions on occlusal surface of
posteriors and incisal edges of anteriors not instruments as free
of caries and smooth.

Restoration  lamination technique

Conditioning

Autocure GIC on dentin as base

Both enamel resin build up

Conditioning

Resin modified GIC

Only enamel etching

Chemical union between GIC and composite

Site 1 site 2

Preparation
New cavity or replace old restoration
 Tapered or parallel sided diamond bur  to explore

extent
 Round burs  to remove caries from walls

 Affected dentin on floor left


 Occlusal enamel retained, even though it is unsupported,
so long the margin are sound and there are no microcraks.

Restoration
 GIC as it can reinforce undermined enamel and it can be

laminated as required with composite resin if occlusal


load is excessive.
 Composite resin should not be used alone because of its
shrinkage on curing with the consequent risk of micro-
leakage. Lamination over GIC provides a combination of
two materials sufficient to restore the physical properties
of tooth very close to original conditions.
Site 1 site 3

Preparation
Do not remove all affected dentin from floor of cavity to
avoid problems arising from pulp exposure. Indirect pulp
capping may be required, seal with GIC for 12 weeks and then
reassess.

Temporary restoration
Old New
On affected layer give ZnOE GIC
Advantages Advantages
 Provide adequate seal.  Relatively insoluble
 Eugenol kill residual  Sufficiently strong to
bacteria and diffuse through withstand occlusal load
dentin into pulp space to  Easily placed and easy to
inhibit inflammation and remove
pain.  Release fluoride which has
potential to kill bacteria in
dentin and promotes
remineralization of adjacent
hard tissues with exchange
of Ca, PO 4 and fluoride ions
between GIC and
demineralized dentin.
Disadvantages
 Limited mechanical strength
 Limited durability for longer
term as it degrades through
hydrolyses
Advocated by Masster 40 years  GIC adheres to enamel and
ago used ZnOE as provisional dentin through an ion
restoration. It was antibacterial exchange mechanism, thus
and isolated lesion from eliminating microleakage.
bacterial invasion, pulp  It adheres to collagen of
recovered from inflammation but demineralized dentin on
remineralization did not occur. cavity floor through either
hydrogen bonding or
metallic-ion bridging. In
absence of bacterial activity
the pulpal inflammation
subsided.
 In the presence of water
from the positive dentinal
fluid flow that follows, there
will be Ca, PO 4 and fluoride
ion exchanged between glass
ionomer and demineralized
dentin. Further ions will be
available from pulpal fluid
and dentin will remineralize.
 GIC has relatively low
fracture resistance, therefore
provide a layer of 3mm if
soft demineralized dentin
remains on floor.
 Reinspected after 3 months
(12 weeks) and laminated
with another material like
composite which as high
strength, satisfactory wear
resistance and adhesion to
sound well supported
enamel.

Next, check the remaining cusps


1. If a cusp has a column of sound dentine providing
adequate support for enamel and there is more than one
half of medially facing cuspal incline still present, it can
remain standing without protection.
2. If a cusp is undermined and medial incline is subject to
occlusal load, it requires protection otherwise it will
develop a split at the base.

Therefore retentive elements such as grooves and ditches


are placed in remaining sound dentin to ensure that a
restoration is soundly locked in.

Restoration
Plastic material – amalgam

Advantages
 Easier to build and cause occlusal anatomy
 Wear factor similar to natural tooth
 Superior resistance to flexure and is better able to
provide positive protection to weakened tooth structure
 Make more satisfactory base for crown which will be
required at later stage.

GIC liner ≤ 0.5mm thick to minimize thermal exchange


greater thickness of base will reduce bulk of restorative mat.
Carefully modify the length of opposing working cusp to
minimize the depth of intercupation between two teeth and
reducing splitting stresses on restored tooth and eliminating
undesirable contacts during lateral excursions.

Site 1 site 4

Preparation
Extensive on molar. Complete loss of one or more cusps.
Restorative material amalgam. Later full or three quarter
crown will be required. Preparation same as 1:3 and indirect
pulp capping may be required.

Restoration
 If amalgam used  mechanical interlocks like ditches

and grooves placed in gingival area.


 GIC base 0.5mm thick as thermal barrier.
 Place matrix to compensate for missing enamel wall.
 Build up.

Site 2 lesions
Proximal surface of anterior or posterior teeth beginning
immediately below contact area

Size 1
Minimum dentin involvement which has reached a point
beyond healing through remineralization identified by
radiography or transillumination.
Size 2
More extensive involvement of dentin with marginal
ridge weakened or broken down but still sufficient tooth
structure remaining to support the restoration

Size 3
On posterior tooth  considerable involvement of
dentin with split at the base of cusp or at least the potential for
split – need to protect one or more cuspal inclines from
occlusal load.

On anterior tooth  extensive proximal caries with loss


of support for incisal corner which will be deeply undermined.

Size 4
Complete loss of at least one cusp from a posterior teeth
or loss of part of incisal edge of an anterior tooth as a result of
either caries or trauma

Site 2 size 1
No equivalent in G.V. Black classification
 Lesion commences in enamel
 Extends facially and lingually in elliptical shape
controlled by extent of contact area
 Does not involve contact area
 Does not undermine marginal ridge or incisal corner
 If prism structure of enamel has not collapsed it can be
remineralized

a. Internal occlusal fossa (Tunnel) – 1 s t approach


 When enamel lesion is at least 2.5mm apical to crest of

marginal ridge
 Entry through the occlusal fossa just medial to marginal
ridge

Preparation

Posterior teeth
 Enter occlusal fossa just medial to marginal ridge aiming
towards expected carious lesion
 Lean bur facially and lingually to form funnel shaped

access cavity. Triangular in outline with apex towards


central occlusal fossa and base along medial aspect of
marginal ridge.
 Remove carious dentin with round burs
 Removal of all affected dentin on axial wall is
unnecessary, if there is risk of exposing pulp
 If enamel demineralized and not cavitated – it is left
alone to be supported and remineralized through cement
 If enamel cavitated and needs to be broken down, short
length of metal matrix placed interproximally and
wedged. Small round burs and hand instruments used to
complete cavity.
Anterior teeth
 Access through labial or lingual (esthetic) side
 Labial approach only if crowding and overlapping present
 Enter medial to marginal ridge

Restoration
GIC  both anterior and posterior
Lamination with composite if the load bearing area of
restoration involves occlusal support against the opposing
tooth.
If using type II  resin modified GIC  should be
radioopaque  mixed at high P.L ratio  use mylar strip as
matrix for good proximal contour.

 Place cement in 2 increments using a syringe.


 Tamp the first increment into the depths of the cavity
using a small dry plastic sponge.
 If enamel cavitated, some excess cement should be
extruded between matrix and tooth.
 Add the second increment and tamp again to ensure firm
adaptation to entire cavity wall.
 Light activate the cement from several directions for to
see.
 Trim restoration apply surface glase to seal

If autocure used
It should be sealed to maintain water balanced as soon as
the matrix is removed because these cements remain
susceptible to water loss and water uptake for several hours
after placement. Cover restoration with low viscosity, single
component, light activated resin bond.

Adjust occlusion with a round bur at slow spread with no


air-water spray. Add further resin bond to ensure adequate
isolation of the cement form oral environment, finally light
activate the resin.

If lamination with composite required


 Remove GIC to a thickness of 2mm
 Expose entire enamel wall.
 Bevel the enamel as required
 Acid etch for 15 seconds both enamel and autocure GIC
 Wash, apply enamel bonding agent and build composite.

Site 2 size 1 (slot cavity) – 2 n d approach


 When carious lesion commence high on the proximal
surface of posterior teeth leaving less than 2.5mm of the
marginal ridge occluso-gingivlly or its may be cracked or
otherwise very seek.

Preparation
 Lesion approached from marginal ridge and small box
shaped cavity prepared not extending beyond
demineralized enamel.
 Contact may be maintained on adjacent tooth on facial,
lingual margin or both.
 Do not extend medially more than half-way through the
marginal ridge.
Restoration
Resin modified GIC or lamination with composite mylar
strip used as matrix.

Size 2 size 1 (Proximal approach) – 3 r d approach


When preparation of a larger site 2 size 3 or 4 cavity will
allow good access and visibility to the proximal surface of an
adjacent tooth with a site 2, size 1 lesion no need to involve
marginal ridge.

Preparation
 Entry  by small tapered diamond cylinder bur. Access

to lesion and entry angle will be dictated and controlled


to some degree by the cavity in the adjacent tooth but as
the caries is progressing into the dentine in an apical
direction and normally doesn’t undermine marginal ridge
at this size, there is no problem removing all infected
layer without involving marginal ridge.
 Round bur is used to clean along circumference of walls.

Restoration
Restorative material should be radiopaque. Restoration
not under load and esthetics not a problem, type II to autocure
cement is used. With resin modified GIC, there may be
problems with access for activating light.
Site 2, size 2 – G. V. Black – Class II (posterior), Class III
(anterior)
 Marginal ridge and proximal surface broken down.

 Sound enamel, particularly fro the gingival floor, is not


removed just because it is undermined following removal
of caries. The enamel at the gingival is not under occlusal
load and can be retained, thus keeping the restoration
margin out of gingival crevice.
 No need for dovetail retentive element final proximal
outline form will often be curved rather than dovetail and
generation of sharp line and point angles is
contraindicated because the angles complicate the
placement of restorative material and lead to stress
concentration.
 Weekend enamel around the proximal box, particularly
along the gingival floor, can be supported and reinforced
with GIC, but facial and lingual enamel must be soundly
based on dentine if it is to be a significant factor in
retention and prevention of microleakage when placing a
composite resin restoration.
 In anterior teeth, if no fissure involved, prepare a slot.
Do not remove entire contact area.
 Unsupported enamel will be maintained through adhesion
with restoration.

Preparation
Begin just medial to marginal ridge using very fine
diamond point (# 200). Remove caries with small round bur
(008 to 012).

 Leave affected dentin on axial wall to be remineralized.


 Walls need no be free of contact with adjacent tooth.
 Retain as much gingival enamel as possible even if it is
undermined and weekend. Because this enamel is not
subjected to occlusal load, it can be supported and
reinforced through adhesion with GIC.
 Weekend and unsupported enamel should not be involved
in adhesion using composite resin with the etching
technique because it is likely to fail under setting
contraction of resin.
 If amalgam is used for restoration, prepare retentive
features and involve occlusal fissures.

Restoration
If with amalgam
a. Base of GIV 0.5mm thick as thermal insulators.
b. Cavity and lining covered by a single, application of
copal varnish which will wash out over a short period of
time and this will allow deposition of corrosion products
to seal interface.
c. Resin or GI amalgam bonding agent over lining and
cavity which will provide some degree of adhesion
between amalgam and tooth structure.

If GIC restoration - used alone or laminated with


composite resin in posterior teeth where occlusal load is too
great for GIC to remain without support.

Site 2, size 3 – Black’s class III and II

For anterior teeth


 Extensive proximal caries with loss of support for incisal
corner which will be deeply undermined.

Preparation
 Retain all possible enamel even though unsupported by
dentin.
 Don’t remove affected dentin from axial wall.
 Remove friable enamel rods.
 No dovetail preparation
 Bevel as required to enhance retention with composite
resin.
 Undermined enamel should be supported with GIC and it

will then provide degree of retention to composite resin.


If composite resin alone to be used enamel must be well
supported with sound dentin around the full
circumferences.

Pins contraindicated as
1. Difficult to disguise under esthetic restoration, shadow
casted through restoration.
2. Lead to microleakage in future.

Restoration
 If there is satisfactory enamel margin around full
circumference of the cavity, it will be sufficient to cover
and protect the exposed dentine with GIC as dentin
substitute. The microchemical attachment of composite
resin to enamel through acid etching will then retain
restoration.
 Cavity extensive and gingival enamel is insufficient or

too week, begin restoration with GIC as dentin substitute


(strongest GIC with high powder liquid ratio).

As soon as cement is set, cut back to expose enamel


margins and make room for composite resin. Rebuild the
contact area in composite but leave gingival extension of
proximal box in GIC.

For posterior teeth


Considerable involvement of dentin with split at base of
cusp or at least potential for splitting.
Split
Generally the result of frequent loading on sharp angled,
medially facing cusp inclines, often through working side
contacts in lateral excursions. Patient will report pain on
pressure or possibly following release of pressure.

If 2.2 cavity, there was sufficient strength in both buccal


and lingual walls to support the restoration, whereas in 2.3 it is
necessary to rely on the restoration to protect the remaining
tooth structure.

Preparation
Material of choice for this type is amalgam due to large
size of cavity. Both tooth structure and most restorative
materials, apart from gold are relatively brittle. They are
strong enough in bulk to withstand masticatory stress but in
their section will fail easily. Therefore modification to cavity
design should aim at
1. Provision of restorative material in bulk to provide
protection for the tooth structure which is now regarded
as weak.
2. Remove weakened tooth structure from undue occlusal
load.
 The combined effect can be developed by leaving the

facial and lingual walls out from the gingival floor, in a


straight line to or just beyond the tip of the cusp.
 Eliminate the medially facing inclines form the occlusal
end of the cusp and at the same time retaining as much as
possible of the original cusp height.
 A non working cusp does not require great deal of
support so it is sufficient to provide approximately
0.5mm of coverage.
 Working cusp will be subject to heavy load and therefore
required up to 2.01mm of coverage depending on type of
occlusion.
 By turning the walls outwards in this fashion restorative

material can be built over the cusp with a cavosar face


margin close to 90 0 without compromising strength of the
cusp at gingival end.
 Use # 168 diamond bur for this preparation.
 Retentive grooves and ditches can be prepared for
amalgam.

Restoration
Amalgam material of choice with a lining of GIC (low
powder content) for thermal protection shape buccal and
lingual contour before carving occlusal surface. Correct
occlusion.

If GIC used it is laminated with composite normally not


used as GIC is too brittle; composite resin is flexible and the
enamel to which it would gain adhesion is unsupported and
brittle.

Site 2 size 4 for anterior teeth – G.V. Black’s class IV


 Incisal half of the crown lost
 Occlusal load not heavy

Preparation
Access achieved by # 168 or #156 bur unsupported
enamel can be supported to some degree with GIC, so trim the
margins to a smooth finish. Remove caries around wall only
and leave affected dentin on the axial wall.

In traumatic fracture protect expose dentin with GIC.


Bevel enamel margins and place composite restoration.

Restoration
GIC laminated with composite.
 GIC high powder content reinforced or resin modified.
 If gingival margin has no enamel left or is too weak to
allow retention with composite resin, let it be covered by
GIC.
 Bevel the enamel.
 Begin with hybrid resin on the lingual for optimum
strength and laminate with microfilm resin on the labial
to enhance esthetics.
In posterior teeth
 Entire cusp has failed, either from extensive carious

attack or as a result of a split and it generally leaves at


least one margin close to the epithelial attachment.

Preparation
The cusps are undermined or split they should be
protected as in the design for a #2.3 cavity. Retention must be
developed in the gingival floor wherever possible using ditches
and grooves.

Restoration
Amalgam is the material of choice. GIC is not used as it
requires support from the remaining tooth structure. Composite
not used as sound enamel for adhesion is not available.

For bicuspids lamination technique can be used as


occlusal load is not excessive.

Site 3 size 1
Occurring in the gingival one-third of the crown or on the
exposed root surface of any tooth.

G. V. Black classification – Class V

Preparation
 Remove the carious dentine only, using small round burs

(# 008 or #012).
 Do not remove demineralized enamel
 If GIC to be used the state of enamel is not important

because the continuing fluoride release will encourage


remineralization. If the cavity is to be restored with
composite resin, the outline will need to be extended to
reach sound, fully mineralized enamel which can be
safely etched to provide microchemical attachment.
 No instrumentation is required for the restoration of an
erosion lesion.
 Control of gingival seepage and haemorrhage with an
application of trichcoroacetic acid.
 Gingival retraction cord.

Restoration
 The material of choice is a type II.1 restorative aesthetic

glass-ionomer, either autocure or resin modified and a


gingival margin in dentine can be laminated with
composite resin.
 Clean cavity with a brief scrub of pumice and water on a
small rubber up to remove the pellicle.
 Then condition with 10% polyacrylic acid for 10 seconds,

washed thoroughly and dry lightly when using light


activated resin modified cement, contour and polish
immediately with a very fine diamonds under an air-water
spray. Apply a thin coat of the appropriate glaze to seal
any remaining surface porosities and scratches.
 When using an autocure glass-ionomer with a high
powder: liquid ratio, cover the cement with a layer of a
single component, very low viscosity resin enamel bond
to stabilize the cement and avoid water uptake or water
loss. Complete the contour and polish after 1 week, if
after a few days, the aesthetics of the glass-ionomer is
unsatisfactory laminate with a composite resin.

Site 3, size 2
More extensive than 3.1, treatment same

Site 3, size 3
Approximal lesions that have developed either as primary
root surface caries after gingival recession or recurrent caries
at the gingival margin of an existing restoration.

Treatment same.

Site 3, size 4
Combination of two or more cavities around the cervical
margin of any tooth. Example lone-standing lower canine
where a labial # 3.2 lesion is joined by another # 3.3 lesion on
the distal side possibly even another # 3.2 on the lingual side.
Restoration
 The greatest problem will be to construct suitable matrix

to facilitate placement of the cement. One technique is to


cut a soft tin matrix to shape and then cut a small hole in
an appropriate to syringe the cement.
 An alternative technique is to use a resin-modified
cement and build the restoration incrementally with
carefully light curing at each stage.

Pit and fissure sealants

Definition
Pit and fissure sealants are cements or resin materials
which are introduced into unprepared occlusal pit and fissures
of caries susceptible teeth forming a mechanical and physical
protective layer against the action of acid producing bacteria
and their substrate.

Mode of action
1. Mechanical sealing of pits and fissures with acid resistant
material.
2. Annulling the preferring habitat of streptococcus mutants
and lactobacillus.
3. Allowing better cleaning of pits and fissures.

Selection of patient
Child with extensive caries on primary teeth is indicated
for sealing all the 1st permanent molars. Medically
compromised, physically / mentally retarded children fall
under special category for sealant placement.

Tooth selection
 Child with occlusal caries on one of the 1 s t permanent

molars – seal the rest of the 1 s t permanent molars.


 Child with more than one carious first permanent molar –

seal the 2 n d permanent molars as soon as they erupt.


 Diagnosis – it is important to know which tooth is sealed.
 Visual and tactile – they still play an important role
despite an improvement in technology.

Drawbacks
Cavitations can be diagnosed by binding of explorer.
Mechanical binding of explorer in pits and fissures may be due
to non-carious causes like
 Shape of fissure
 Sharpness of probe
 Force of application
 Injudicious exploring causes cavitations
 Probing may vary from one operator to other

 Detecting fissure caries by probing is only 24% efficient


(Penning).
Criteria for diagnosis
 Softening at the base of fissure

 Opacity surrounding the fissure


 Softened enamel that may flake away during probing

Treatment plan based on exploring

I. Caries free surface (no explorer wedging)


 Well coalesced self cleansing
- Observe and recall 6 months
 Stained fissure
- Observe and recall
 Stained minimal opacity
- Sealant placement

II. Caries free (explorer wedging) sealant placement

Materials

1. Resins
The 1 s t use of sealant was an unfilled resin BIS-GMA but
because of its viscous nature it was discontinued. Later
diluents like methylmethacrylate made resin effective aw
sealants. Two types of polymerization – chemical and light
cured.
Differences
Light cured Chemical cure
1. Working time – 10-20 1. 1 – 2 minutes
seconds 2. Voids can be incorporated
2. No mixing is needed, no 3. Starts immediately after
voids formation mixing
3. Polymerization starts until
light activated

Sealants differ from restorative resins by the amount of


filler added which increase the wear resistance.

Examples
Filled - Kerr sealants
Unfilled - Contact seal
Chemically - Concise white (3M) Delton
Light cured - Prisma shield Helio seal

Light cure resin show better retention rates in comparison


to unfilled / filled chemically cure sealants.

 Laser curing of sealants was introduced by Powell in


1989.
 Laser curing of visible light activated sealant shows

increased tensile bond strength of resin material and


increased resistance to caries.
Sealants with fluorides
It was perceived that addition of fluorides to sealants
may improve caries resistance. But no study documented the
beneficial effect with fluoride sealants.
 Fluoridated sealants release fluoride to the greatest extent

in the 1 s t 24 hours after mixing and the release falls


sharply on the 2 n d day and slowly decreased later (Garcia
Goday) caries reduction of both fluoridated and non-
fluoridated sealant are not statistically significant (Koch
1997).
 Caries reduction of sealants is mainly due to mechanical
sealing of fissures and blocking nutrients for bacteria
from oral environment.

Glass ionomer sealants


because of its fluoride releasing ability, considered to be
effective in reducing caries. So this cement was tried as
sealant, but conventional GIC has very less wear resistance and
in a comparative study between GIC and resin as sealants the
latter showed better caries reduction than GIC.

Resin modified GIC compomer


are also used as sealants nowadays as they have better
wear resistance than conventional GIC.
Ionosit seal compomer pit and fissure sealant
Contains an ionomer glass in polymerizable polycarbonic
acid.
 Opaque appearance, fluoride releasing. Releases zinc ions
after set and thus produce antibacterial effect.
 Available with fine long tipped nozzles which allows

precise application (BDJ 2003).