Conservative Operative Dentistry

Operative dentistry science have been transformed and advanced in recent

few years and is expected to undergo further and far-reaching changes in years
to well come. This is the attraction of operative dentistry as a core element of the
past, present and the future of the oral health care and rehabilitation.
For years ago, operative dentistry was strictly based upon the surgical
intervention through elimination of the carious diseased and decayed tissues
with subsequent of the lost dental structures. Opposite this model of
intervention, another medical preventive sequences model intervention was
applied and centered on PRESERVATION OF TOOTH STRUCTURES.
So, two restorative models for the treatment of carious lesions have
coexisted, the older conventional model which related to the utilization of the
non-adhesive material of amalgam restorations and still in use in posterior teeth
and on the other hand, the principles applied are the ones that BLACK (1908)
theorized more than a century ago. This model truly is completely centered and
depends upon the resistance of the restoration rather than the tooth structures
and lead to unnecessary cutting and removal of tooth structures enamel and
dentin. The more recent model and trends is conservative model, which was
applied and built-up through the increasing utilization of adhesive restorative
materials that were firstly developed for the anterior esthetic purposes and
cervical lesions of buccal surfaces of posterior teeth, further-more nowadays
extended this model have been extended to the restoration of posterior teeth.

One of the most advantages of this adhesive model is drifting clinicians and
dentist further away from some of BLACKs principles especially those
concerned with the macro-retention means ( example undercuts area, grooves
and boxes ) and the cutting for immunity or extension for prevention principle.
On the other hand, this conservative model is truly concerned to the integrity
and strength of restoration and the tooth structures rather than the restoration
only and finally this conservative operative dentistry approach, providing the
most convenient direct access to the carious lesions and eliminate the diseased
tissues with preservation and conservation of the remaining tooth structures.
Recent modalities of prevention methods of dental caries and treatment
have been introduce example, fluoridation, diet control, oral hygiene measures,
and immunization based upon molecular biology principles. Another
conservative approach and modality is the ART technique (Atraumatic
Restorative Treatment). Another alternative modality is the conservative
management of suspected carious lesions by fissure sealants, preventive resin
restorations and enamelo-plasty.
Conservative operative dentistry is dependable item upon a pyramidal cone
shape, its base depend on:
*the early detection of the incipient and primary lesions,
*remineralization of the hard tooth structures,
*advanced cavity tools and designs
*and finally at the apex is the follow up periodic examination of Individual

Prevention in dentistry is preferable to treatment as a general rule, and the

individuals should do the best for them-selves to achieve and maintain oral
health and dental health care.
Only plaque-free teeth are protected from caries, so bacterial plaque
should be removed completely as possible as can by oral hygiene procedures
and attention must viewed for the inter-proximal surfaces.
Several chemical compounds have been used as antibacterial agents to
control the bacterial activity during the process of caries as a disease, and
chlorohexidine chemical agent now-days used and have beneficial effects to
reduce the number of respective bacteria (streptococci).
On the other hand patient should inform about the relationship between
diet and dental health and caries. The cariogenicity of the diets not determined
by absolute amounts of ingested fermentable carbohydrates, but rather by the
frequency of their intake, so the reduction of the number of intakes of cariogenic
snacks is very important method for reduction the possibility of induction caries
lesions.
The caries-protective effect of fluorides (fluoride prophylaxis) is
considerable and documented. Caries as a disease is not a fluoride deficiency
disease. The methods of application are geared by need e.g. drinking water and
salt fluoridation are recommended methods of collective supply, using
fluoridated containing toothpaste, mouth-rinses, gels, and varnishes.

Fluoride is known to be a very effective agent to fight dental caries, even low
fluoride concentration above 0.1 ppm in saliva able to protect enamel surface
against caries attack.
Apart from the traditional methods for patient examination and diagnosis, a
new methods and devises and techniques have been applied that not only help in
reaching a prompt and adequate diagnosis for the case but also facilitate the plan
of treatment.
A recently introduced digital radiography which now-days able to
construct a radiographic slices and cross sections through the tooth, using the
fiber-optic and laser transillumination by which the teeth are transilluminated
for detection of caries related to the hidden surface and undetectable areas of the
teeth, using the caries activity tests, caries detector dyes and using caries
detector probes.
There is introduction of a newly computerized radiographic model which
able to construct a radiographic slices and cross sections through the tooth and
viewed the tooth in a three-dimensional ways.
Some researchers studying the mineral deposition in enamel defects and
reported that this may be result in a total or partial replacement of the lost
minerals and is called remineralization through using and increasing the oral
fluorides levels and calcium and phosphate levels.

Approaches to increase oral fluoride, calcium and phosphate levels:

Dentifrices that contain 250 and 1000 ppm of sodium fluoride which
clinically considered a dose of anticaries effect.
Mouth rinse with 10 ml of 12 or 13 mol/L sodium fluoride.
Two component oral rinse (sodium fluoride Na2SiF6 and calcium
chloride CaCl2 that precipitate Calcium fluoride on teeth, plaque and
saliva.
Using of a fluoride releasing restoration.
Chewing gums and candies are considered a potential delivery vehicle for
calcium and phosphate ions which increase the anticaries resistance; on
the other they increase the flow of saliva, thus inducing a rise in pH of
saliva and plaque.

Advanced cavity tools and designs:

The surgical approach and treatment of carious lesions and its
subsequent filling is still necessary, as it is prevent further growth of bacteria
within the infected dentin, preserve the biological integrity of the tooth, and
restore function and esthetic. But some of its characteristics should be
refined and redefined, taking into consideration that the modern standards of
restorative materials are necessarily adhesive properties and possibly
bioactive.
Some authors recently, (1997-1998) rejected Blacks mechanistic
conception, designs and principles and advocated a novel classification
taking into consideration and account the size, morphology and topography

of the tooth substances loss, generated freedom of designing preparation, on

the other hand based on the principles of adhesive dentistry. That is
sites/stages (SI/STA) concept which includes THREE sites, locations and
FOUR stages, penetration.

Advances in tools for cavity preparation:

The development and using ultrasonics in tooth preparation at high
frequencies and using partially diamond coated working tips with different
shape; allow cutting and finishing of very small interproximal cavities, even
in situations where the cavity margins are in direct contact with neighboring
tooth surfaces.
The least invasive and substance-saving method is certainly the internal
class II cavity preparation leaving the proximal wall and marginal ridge of
the respective treated tooth intact (TUNNEL PREPARATION). If the
decision is to remove the enamel wall of the marginal ridge, due either to the
extent of the area of demineralization and destruction or to actual perforation
in the enamel wall, the modified adhesive SLOT PREPARATION
recommended and may be in order. The slot preparations are characterized
by a closely defect-related extension form and preservation of sound
proximal enamel portion.
Using air-abrasive technology for removal of diseased tooth structures
and dental applications, considered popular for a short while since it
eliminate heat production, vibration and noise of the belt driven hand-piece,
its ability to conserve tooth structures. Air abrasion removes tooth structures

using stream of aluminum oxide particles generated from compressed air or

bottled carbon dioxide or nitrogen gas. It is advantageous for the majority of
small lesions. Air abrasion has been shown to enhance the enamel bonding
as it is act as etching agent for enamel before application of bonding agents.
Laser cutting have been incorporated into patient treatment in many
different forms. Laser dentistry help in minimizing patient discomfort and
eliminate the need for local anesthesia and some authors reported that, in
most cases during removal of tooth structures, don not cause the cracks and
fissures that the traditional drills may be create in the tooth during cutting,
which weaken the tooth structure over time.
Chemo-mechanical caries removal; on the basic knowledge that the
infected highly damaged carious dentin should be removed leaving the
affected dentin which can be remineralized from the conservative point of
view for tooth structure (to avoid unnecessary dentin tissue removal) and
pulp vitality, RECENTLY recommended the chemical-mechanical removal
of carious infected dentin by a non-specific proteolytic sodium
hypochlorite agent via a gel commercially named CARISOLV GEL
AGENT. Sodium hypochlorite can be dissolved and removed partly the
demineralized tissue of infected dentin of carious lesion.
CARISOLV GEL, marketed in two syringes,
1) One containing 0.5% sodium hypochlorite solution

2) Other is a pink gel formed of three amino acids together with

carboxymethyl cellulose to make it viscous and erythrocin to
make it visible in use.
The two contents are mixed immediately before use, and then applied to the
carious lesion. After 30 seconds, the carious dentin gently removed using
specially designed hand excavator instruments which are Atraumatic having
sharp edges with a blunt angle to just scraping away softened carious dentin
with depth control. The procedure is repeated until no more carious dentin
remains within the cavity.
Fluorescence-Aided Caries Excavation (FACE); which depends upon the
visible violet-blue light fluorescence (fiber-optic hand piece) could be used to
identify residual dentin caries which have orange-red color and can be easily
removed by low speed stainless steel large sized round bur 4 or 6.
Ozone treatment; using ozone (O3) application for 10-20 seconds
(through medical device known as Heal Ozone) over the primary caries lesions
was found to be killed about 99% of the causative microorganisms of dental
caries or reduce its number by break up the acidic product of cariogenic bacteria
which may be is the most important in the etiology of developing dental caries.
Atraumatic Restorative Treatment (ART); which considered as
alternative conservative method for treatment of the carious lesion instead of
surgical model intervention, drilling and restoration (WHO). It involve the
removal of carious material by hand sharp hand instruments, followed by

restoring the cavities with a fluoride-releasing restorations e.g. glass ionomer

filling material with preservation and conservation of the sound or slightly
decayed tooth structures enamel and dentin with stopping progress of the dental
caries.
Over the last view years (20 years), there has been considerable
modifications of the understanding of the initiation and progress of caries and
the direct reduction effect of fluoride and other ions example calcium and
phosphate ions on the dental caries and remineralization of the primary lesions.
On the other hand, the instrumentation available for cavity preparation has been
changed and now; there are alternative restorative material that are capable of
long term adhesion to tooth structures. So, Blacks classification is no longer a
useful guide to management of dental caries and there have already been
attempts to modify the system. Therefore, the profession adopts a new
classification based on the site and size (SI/STA) of the carious lesion and that
the two descriptions are used together.
Proposed classification:

I)

Site, which describes the location and position of the dental carious
lesion and it is accurate and comprehensive. We have three sites:

site 1
Which describe all carious lesions originated in pits and fissures
(grooves) and other defects on otherwise smooth surfaces of enamel of the

crown of a tooth So it includes class I Blacks classification design as well as

erosion lesions on incisal edges of anterior teeth beside the occlusal surfaces of
posterior teeth.

site 2
Which describe all carious lesions associated with proximal marginal ridges
and contact areas and includes both anterior and posterior teeth. This site
includes all of Blacks class II, III, IV lesions.

site 3
Which describe all carious lesions originated close to the gingival margins in
either enamel or dentin (cementum) around the full circumference of tooth i.e.
carious lesions include the cervical on third of the crowns of all teeth or the
roots. This site include class V Blacks classification and also extended to the
root surface lesions following gingival recession.

II) Size,(stage)

which describe the depth of penetration of dental

caries within enamel and dentin and describe the amount of tooth
structure have been destructed. So the size description of carious
lesion gives guidance for the management of any site.
It is now accepted that, under certain circumstances, it is possible to recover and
heal an initial carious lesions through the remineralization processing (fluoride
application and calcium and phosphate ions), on the other hand, surgical model
intervention may be avoided and not included. With modern preparation design,
techniques, tools, materials, and equipments, it is possible to prepare a very

limited access and cavity for the carious lesions with preservation completely
much more natural sound tooth structures enamel and dentin.
The four stages in extension of the carious lesion can be defined as follow:

Size 0,

no signs and symptoms of caries penetration through the tooth

structures enamel and dentin. Tooth surface is free.

Size 1,

there is minimal penetration of dental caries within enamel and

dentin of the tooth surface so surgical model intervention is required and

indicated.

Size 2,

there is a moderate and larger carious lesion but still there is a

sufficient sound tooth structures remaining to support the restoration without

further modifications of the cavity beyond caries removal, i.e. the remaining
tooth structures gives support and resistance for the restorative filling material.

Size 3,

there is over-moderate or enlarged and more extensive carious

lesion that leaves the remaining tooth structure weakened, so choose restorative
filling material that able to completely protect the weakened tooth from undue
and further split stresses.

Size 4,

there is extensive and highly spread of caries with a mutilated

and badly broken-down tooth which there has already been serious loss of tooth
structures.