Journal of Minimum Intervention in Dentistry 2012; 5: 7 - 10

Available online at www.jmid.org

Midentistry cc - ISSN 1998-801X

Minimal intervention in dentistry: How should a cavity be

prepared?
Graham Mounta
a

13 MacKinnon Parade, North Adelaide, South Australia 5006 Australia, e-mail: gjmount@ozemail.com.au

ABSTRACT
The cavity design as dictated by GV Black had to be quite geometric with flat floors and walls, sharp internal line angles
and some level of retentive undercuts to ensure stability in the restorative material. Now, in the light of current
knowledge of the disease of caries, it is accepted that cavity design should be dictated entirely by the position and extent
of the lesion itself.
Keywords: Operative dentistry; tooth restoration; minimal intervention

1. INTRODUCTION
The cavity design as dictated by GV Black had to be quite geometric with flat floors and walls, sharp internal line angles
and some level of retentive undercuts to ensure stability in the restorative material. Now, in the light of current
knowledge of the disease of caries, it is accepted that cavity design should be dictated entirely by the position and extent
of the lesion itself.
Previously hand instruments were regarded as essential to develop the fine geometric detail but, since the
development of higher speeds for rotary cutting instruments along with diamond and tungsten carbide burs, hand
instruments have lost favour. In recent years there have been a number of alternative methods developed, such as lasers
and air abrasion, both of which have received mixed levels of acceptance. Whilst there is no ideal technique receiving
universal acceptance from operators and patients alike each of the techniques has their individual advantages. The
following basic principles need to be kept in perspective regardless of which is chosen.
Rotary cutting instruments moving at ultra high speed are capable of very rapid bulk removal of tooth structure but
are probably too fast for precise cavity design and over-extension is a common fault. The same instruments used at
intermediate high speed will remove hard tooth structure very efficiently while at the same time allowing a good
measure of tactile sense and therefore better control. This is the preferred method for refining a cavity design including
polishing the cavity surface. Slow speed is probably the least comfortable technique from the patient point of view but is
a good way for defining the careful removal of softened demineralised dentine.

Speed grouping
Low speed
Intermediate speed
Ultra-high speed

Colour coding for handpieces

RPM
Handpiece colour
500-25000
Green/Blue
20000-120000
Red/Orange
250000-400000

Lubricant
Optional
Mandatory
Mandatory

Figure 1 Air abrasion used for a minimally invasive approach to a small fissure caries lesion. A) The initial situation. B)
Air abrasion nozzle in place. C) Final preparation before restoration.

Journal of Minimum Intervention in Dentistry 2012; 5: 7 - 10

Available online at www.jmid.org

Midentistry cc - ISSN 1998-801X

Figure 2 Air abrasion used for a minimally invasive approach to an occult (hidden) lesion detected using laser
fluorescence. A) The initial situation showing an apparently intact fissure system. B) Air abrasion nozzle in place. C) Access gained through the
occlusal enamel into the carious lesion. D) Preparation after caries removal using rotary instruments. E) Material placement. F) Final restoration.

Figure 3 False positive staining with acid fast red caries detector dye.
A) Extracted tooth prior to caries removal using an Er:YAG laser. After caries removal, the tooth was sectioned along the plane shown. B) After caries
removal. C) Dye applied to the cavity gives a consistently strong false positive stain because of the lack of smear layer. D) Demonstration of the same
effect on an extracted sound premolar tooth sectioned horizontally with a disk. The left side has then been lased and the right side untreated, before dye
has been applied. False positive staining is present on the lased dentine surface

Figure 4 Restorative procedures using the Er:YAG laser, in anxious dental patients, without local anesthesia.
The Er:YAG laser was used with a non-contact handpiece. A) Pre-operative appearance of a 22-year-old male with salivary dysfunction, and
associated cervical and approximal caries. B) Areas of caries and defective resin composite have been removed. The intense white appearance of the
margins is typical of laser etching. C) The restored teeth immediately post-operatively. The etched appearance of the margins disappears once bonding
resin has been placed. D) 30-year-old female patient with areas of hypoplastic enamel. E) The enamel surface has been peeled using a series of pulses
from the laser. F) The two areas have been restored with resin composite. G) 65-year-old female patient undergoing anti-cancer chemotherapy, with
recurrent caries at the margins of several restorations. H) Areas of caries and undermined resin composite have been removed. I) The cavity
preparations have been restored. From the Australian Dental Journal 2003; 48:151. Used with permission.

2. LASERS AND AIR ABRASION

Both lasers and air abrasion are very effective in removing hard tooth structure but there is no tactile sense available at
all (Figure 1 - 4). At the same time neither instrument is very effective in removing softened carious dentine. This means
that the operator needs to retain visual contact with the area being prepared to ensure that there is no excessive removal
of tooth structure particularly for control of cavity depth. Neither of these techniques will leave a surface that is ideal for
adhesive restorative materials so further polishing is required. Both of these are demanding techniques for the operator
but there is reasonable patient acceptance [1].
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Journal of Minimum Intervention in Dentistry 2012; 5: 7 - 10

Available online at www.jmid.org

Midentistry cc - ISSN 1998-801X

3. CHEMO-MECHANICAL CARIES REMOVAL

There is an alternative technique designed strictly for removal of softened demineralised dentine using a chemomechanical technique [2], which is claimed to remove only the infected layer. It is relatively safe and simple but a little
more time consuming than using a slow speed rotary cutting tool (Figure 5 and 6).
Figure 5 Treatment of rampant caries with Carisolv.
A) The initial situation. B) After caries removal using gel followed by the specially designed hand excavators. C) The lesions restored with glass
ionomer.

Figure 6 Caries removal on anterior teeth using Carisolv.

A) A star-shaped hand instrument is used to whisk away softened carious dentine. The gel is opaque because of proteolysis. This dye has a red
colouring agent present. B) After caries removal has been completed. The outline of the preparation is the shape of the carious lesions and not a preconceived outline form.

4. PLACING THE RESTORATION

As adhesive restorative materials will be placed in the majority of cavities it is essential that the entire cavity be as
smooth as possible (Figure 7 - 9).
Figure 7 An SEM illustration to show the difference in the finish of the enamel margin of a cavity
following the use of a diamond stone with 80 grit (on the left) and a 25 grit diamond stone on the
right.

Figure 8 The 80 stone is being used to open a cavity and to remove an old amalgam restoration.
The resultant margin will be rough and not suitable for placement of an adhesive restorative
material.

Figure 9 The 25 diamond is being used rapidly and lightly to polish the margins to an acceptable
finish for use of an adhesive restorative material.

Journal of Minimum Intervention in Dentistry 2012; 5: 7 - 10

Available online at www.jmid.org

Midentistry cc - ISSN 1998-801X

All types of adhesion will be more efficient on a smooth surface so a very fine diamond bur at intermediate high speed
should be the final instrument used in cavity preparation. Placement of an adhesive on a rough surface will inevitably
entrap air bubbles and therefore incorporate faults and weaknesses.
Effective placement of an adhesive material requires a clean cavity surface. Following preparation there will be a
smear layer remaining over the entire cavity surface, which must be removed to allow the restorative material to develop
intimate contact with natural tooth structure. It will depend upon the chemical and physical nature of the adhesive
material how the surface is to be cleaned. If there is to be a chemical union with the tooth then only the smear layer
should be removed. If there is to be a mechanical union developed then it will be necessary to demineralise the cavity
surface and render it porous to some degree.
Having prepared the surface to the desired texture it is essential that it be not contaminated again. Different materials
have different requirements and there should be no confusion.
When developing adhesion between composite resin and enamel it is necessary to develop some level of porosity
down the ends of the enamel rods to allow the resin to penetrate and adhere. Adhesion to the long sides of the rods will
be notably less efficient. As enamel consists of rods that lie parallel to each other and at right angles to the enamel
surface it is rather brittle and if it is to be used for adhesion it should be well supported by sound dentine. It may
therefore be necessary to remove unsupported enamel rods from the margins of a cavity, thus extending the cavity
outline, so that proper adhesion is assured.
It is important to note that the dentine is actually an extension of the pulp and is therefore a living vital substance.
Once it is exposed on the floor of the cavity the dentine surface will always be wet because there is a continuous flow of
fluid from the pulp through the dentine tubules. Removal of the smear layer will enhance the fluid flow and this is
difficult to control.
It is also important to understand the difference between infected and affected dentine. Infected dentine is the outer
layer of a demineralised lesion and is completely without form or substance and is loaded with bacterial flora. It needs to
be removed because it cannot be reconstituted or healed. Affected dentine will be partly demineralised but relatively free
of bacterial invasion.
Though softened and possibly stained it can be remineralised effectively from both the positive fluid flow from the
pulp and/or the restorative material placed over it. It can therefore be retained thus minimizing the risk of damage to the
pulp during cavity preparation [3]. This means that, when treating a new lesion, cavity preparation should be very
conservative relative to the principles laid down by GV Black.
The most important requirement is that the strength and integrity of both the remaining tooth structure and the
restorative material are considered. Weakened tooth structure will need to be protected from occlusal load and, at the
same time, it is necessary to provide sufficient thickness in the restoration to be able to accept the predicted occlusal
load.

REFERENCES
[1] Mount GJ, Walsh LJ, Brostek A. Instruments used in cavity preparation. In: Preservation and restoration of tooth
structure 2nd Ed. Knowledge Books and Software, Brisbane 2005, Chapt.9, page 128-43.
[2] Mount GJ, Walsh LJ, Brostek A. Instruments used in cavity preparation. In: Preservation and restoration of tooth
structure 2nd Ed. Knowledge Books and Software, Brisbane. 2005, Chapt.9, page 138.
[3] Mount GJ, Hume WR. Vital pulp therapy. In: Preservation and restoration of tooth structure 2nd Ed. Knowledge
Books and Software, Brisbane. 2005, Chapt. 16.

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