Clinical steps of cavity

preparation
(4th Year )
Dr. Ala’a Al-Haddad
BDS, MFDS, MSc, PhD
Assistant professor, Conservative Dentistry (University of Jordan)
Fixed & Removable Prosthodontics (University of Manchester, UK)
Outline:
 Background
 Definitions
 Indications for restorative intervention
 Objectives of cavity preparation.
 Principles in cavity preparation
 Clinical steps of cavity preparation
 Pre-operative considerations
 Operative procedures
 Amalgum , resin-composite, glass ionmor
Definition:
 What is a cavity?
 It is a defect in the hard tooth structure resulting from
an insult as caries and trauma.
 What is tooth preparation?
 It is mechanical alteration of a defective, injured or
diseased tooth to receive a restorative material that re-
establish the health state for the tooth including its
aesthetics, normal form and function.
 Conventional preparation:`
 Tooth preparation that relates to amalgam, gold or
ceramic restoration might be considered conventional
preparation that require specific form, depth and
marginal form.
 Modified preparation:
 Tooth preparation for bonded direct restorations as
composite or glass ionomer has less need for specific
depth, wall and marginal form and is considered to be
modified preparations.
Indications for restorative
intervention:
 Repair destroyed tooth
 Repair fractured tooth either complete or incomplete
[green stick fracture].
 Restore teeth with congenital malformations.
 Replace defective restoration.
 Replacement of missing teeth.
 Need for improved form or aesthetic.
Indications (cont’d):
 Repair destroyed tooth
 Repair fractured tooth either complete or incomplete
[green stick fracture].
 Restore teeth with congenital malformations
 Replace defective restorations
 Replacement of missing teeth
 Need for improved form or aesthetic.
Why do we prepare cavities?
Objectives of tooth preparation:
 Remove all defects and provide necessary protection to
the pulp.
 Extend the restoration as conservatively as possible.
 Tooth prep such that under mastication both the
tooth and restoration will not fracture or displace.
 Allow the functional and aesthetic placement of a
restorative material.
 SO,
Objectives of tooth preparation:
 Eliminate:

 Preserve

 Restore:

 Prevent:
Clinical steps of cavity preparation
 Preoperative considerations:

 Operative procedure:
Pre-operative Considerations:
 Diagnosis and treatment planning:
 Gingival health and periodontal/pulp status.
 Occlusal evaluation
 Restorative Material Selection
 shade selection
 cavity designing
 Field Isolation
Diagnosis and treatment planning:
 It is all about diagnosis and treatment planning.

 diagnosis allows for a methodical approach to

preventive and restorative therapy.
Diagnosis and treatment planning:
 Identification of the Aetiology : ( cavity/ restoration
failure)
 Medical considerations
 Oral hygiene routine
 Diet
 Age.
 Para-functional habits
 Occlusal scheme/ disharmony
 Caries risk
 Caries/ cavity detection:
 Conventional methods
 Visual
 Visual and Tactile:
 Using explorer ( low sensitivity , high
specificity)
 Radiograph ( conventional: bitewing x-ray)

 The problem is detecting the initial stage of

caries ( incipient) in order to consider
remineralisation.
 Removal Vs remineralisation.
 Decay is difficult to detect in radiographs unless
 larger than 2 mm to 3 mm deep into dentin,
 or one-third the bucco-lingual distance.

 A carious lesion that appears radiographically to have

penetrated about two thirds of the way through the
proximal enamel has actually penetrated the EDJ.
 The depth of the penetration of demineralization in enamel
and dentine is actually greater than it appears to be in a
bitewing radiographs
Prevention & preservation:
 Controlling the advancement of hard tissue
destruction can begin with:
 elimination of the aetiology
 dietary instructions
 oral hygiene instructions
 home fluoride therapy
 brushing with desensitizing dentifrices
 discontinuation of poor oral habits.
 In-office Remineralisation:
 application of fluorides, calcium, and potassium
phosphate.

 In- office Desensitization:

 application of potassium oxalate or other tubule-
occluding agents.
 application of dentin adhesives.
 Iontophoresis
Caries detection (New methods ):
 Physical principle Application in caries detection
 X-rays Digital subtraction radiography.
 Digital image enhancement.
 Visible light Fibre optic transillumination (FOTI)
 Quantitative light-induced fluorescence (QLF)
 Digital image fibre optic transillumination (DiFOTI)
 Laser light
 Laser fluorescence measurement(DiagnoDent)
 Electrical current
 Electrical conductance measurement (ECM)
 Electrical impedance measurement
 Ultrasound:
 Ultrasonic caries detector
Gingival health/periodontal status:
 is a critical component of a successful restorative
outcome.
 Gingival inflammation can cause
 alterations in gingival form and contour.
 Consequently, inaccurate margin relationship
(restoration – gingiva)
 compromised restorative outcome.

 Periodontal health should be present prior to the

initiation of any restorative procedure.
 Pulp status
Occlusal evaluation:
 Pre-operative occlusal stops and eccentric movement
should be studied and recorded
 Using articulation paper,
 Articulated diagnostic model.
 Digitally.

 Elimination of interferences in the static and dynamic

occlusion
 to achieve an ideal occlusion with maximum
distribution of occlusal load.
 ideal occlusion can be achieved
using:
 Splint therapy.
 interceptive occlusal equilibration.
 Orthodontic treatment.

 Improve cavity designing

 Restoration margins away from
functional occlusion.
 Protect remaining tooth structure.
 Improve restoration longevity.
 Reduce recurrent caries.
Restorative Material Selection:
 Occlusal forces.:
 Cusp Flexure ( e.g. abfraction)
 Wedge effect. ( MOD)
 Heavy forces ( clenching, Bruxism).
 Carious vs non-carious cavity
 Caries risk.
 ( fluoride releasing restorations)
 Patients factor:
 Economic status.
 Age.
 Aesthetic concerns.
 Medical conditions ( oesophageal reflux)
 Opposing restoration ( same hardness and wear resistance).
 Direct Vs indirect restoration
Shade selection: (If applicable)
 prior to operative procedure.
 Prior to placement of the dental dam
 to prevent improper selection as a result
of dehydration and resultant elevated
colour value.
 After Bleaching if required.
 Mainly under daylight source
illumination
 preferable under various lighting
conditions
 daylight, colour-corrected, fluorescent
light, and dim light
 Shade Map
 Composite mock-up
Cavity designing
Plan an initial cavity design depending on:
 Tooth location
 Size of caries lesion/ remaining tooth structure
 Type of lesion (carious vs non-carious)
 Restorative Material type.
 Occlusal factors: (preparation boundaries)
 Convenience form:
 Gain access but preserve tooth structure.
 Removal of old filling.
 Type of restorative technique.
Field Isolation:
 Is crucial to achieve sterile cavity preparation and aseptic
operating field
 Helps in enhancing visibility and access.
 Protect soft tissue/ prevent accidants
 Achieve proper moisture control
 Especially for technique-sensitive restorations that and
require meticulous attention to the adhesive protocol.

 Proper restoration bonding:

 Reduced marginal contraction gaps, microleakage, marginal
staining, and caries recurrence,
 improved retention, aesthetics and resistance to wear
 reinforced tooth structure.
 Field isolation technique:
 mirrors
 High vacuum suction/ suction devices.
 Cotton rolls.
 Cheek retractors & Mouth props .
 Retraction cords.
 Rubber dam.
Operative Procedure
 Local aesthesia:
 Type:
 selected on the basis of the
estimated length of the clinical
procedure and the degree of
anaesthesia required.
 Ester Vs amide
 Hypersensitivity and allergic
reactions in affected patients are
much less frequent with the amide
type of local anaesthetic.
 Topical anaesthesia
Clinical steps of cavity prep:
 Diagnosis & Treatment planning.
 Selection of restorative material and its shade.
 Patient consent/ agreement.
 Check Occlusion:
 Local anaesthesia
 Isolation
 Cavity preparation
 Pulp protection
 Cavity Filling
 Occlusal adjustments
 Finishing and polishing.
 Prevention and monitoring.
Steps of cavity preparation:
 The preparation procedure is divided into two stages:
 1) Initial stage:
 Prepare outline form:
 the mechanical alterations of the tooth are extended to sound
tooth structure while adhering to a specific, limited pulpal or
axial depth.
 Prepare resistance and retention form
 tooth preparation to retain the restorative material in the
tooth and to resist potential fracture of the tooth or
restoration from masticatory forces.
 Convenience form
 2) Final stage: it includes
 excavating any remaining, infected carious dentin;
 removing old restorative material
 protecting the pulp;
 incorporating additional preparation design features
 to minimize the chance of tooth or restoration fracture
against oblique forces.
 To maximize the retention of the material in the tooth;
 finishing preparation walls, particularly regarding the
margins;
 performing the final procedures of cleaning, inspecting, and
sometimes sealing the preparation.
Steps of cavity preparation:
 Intial stage:
 1-Outline form
 2- Primary Resistance and Retention form
 3- Convenience Form
 Final stage:
 4- Removal of remaining Caries & pulpal protection
 5- Secondary Resistance and Retention form
 7- Finishing of cavity walls
 6- Cleaning inspecting and sealing.
Outline Form and Initial Depth
 Definition:
 placing the cavity margins in the positions they will
occupy in the final preparation except for the finishing
enamel walls and margins;
 preparing an initial depth of 0.2~0.8 mm pulpally of
the dentinoenamel junction.
 Principles :
 1.All friable and weakened enamel should be removed.
 2.All fault should be included
 3.All margin should be placed in a position to afford
good finishing of margins of restoration.
 Features:
 1.Preserving cuspal strength.
 2.Preserving marginal ridge.
 3.Minimizing facio-lingual extension.
 4.Using enameloplasty
 5.Connectiong two close faults of the tooth which are
< 0.5 mm apart
 6.Restricting depth of penetration into dentin
 for pits and fissure: 0.2 mm
 for smooth surface: 0.2 to 0.8 mm
 1.Preserving cuspal strength –
 avoiding termination of the margin on extreme
eminence, such as cusp height
 if extension of primary groove includes > half of cusp
incline, then CUSP CAPPING consider.

 2. Preserving marginal ridge strength

 Remaining Marginal ridge should be greater than 1.6 mm for
premolar & 2mm for molar •
 If Remaining Marginal ridge will be less than 1.6 mm, there
may be the chances of fracture due to undermining the ridge.
 Direction of mesial & distal walls
 When >1.6 mm thickness width is remained at mesial
/distal marginal ridge, then mesial / distal wall should
be parallel.

 When <=1.6 mm thickness width is remained at mesial

/distal marginal ridge , then mesial / distal wall should
be divergent.
 Tunnel Technique:
 Cavity preparation to remove proximal
without removing marginal ridge
 preserve marginal ridge, so strength
 Contact area not disturbed
 Minimal overhange

 Restorations:
 Amalgam
 Sandwich technique.
 Tunnel Technique:
 3. Minimizing facio –lingual Extension
 Minimizing facio –lingual Extension ,which prevents the
weakening of cusp.

 For conservative class I CAVITY facio-lingual width

should be 1 to 1.5 mm.
 4. Depth of preparation Restricting depth of
penetration into dentin for pits and fissure-0.2 for
smooth surface-0.2 to 0.8.
 this is
 1.To avoid the seating of the restoration on the very
sensitive DEJ.
 2.To give the bulk of restoration.
 3.To take advantages of dentin elasticity during
insertion and function.
 5. Enameloplasty :
 This is the procedure of reshaping the enamel surface by
making it rounded / Saucered ,the area becomes
cleansable and finishable.

 It is indicated when remaining fissure is not greater than

1/3 rd of enamel thickness.
Caries removal:
 Use slow speed bur / hand instruments.
 From cavity walls, then from pulpal/axial walls
 Areas to remove:
 Infected area.
 Decalcified load bearing areas.
 Decalcified cavo-surface margins.

 Infected dentin Vs affected dentin?.

Dentin caries:
Two histopathological zones:
 The peripheral caries-infected zone:
 close to EDJ,
 irreversibly damaged,
 necrotic and softened by long standing bacterial
contamination and proteolytic denaturation of collagen
and acid demineralization of the inorganic component.
 The deeper caries-affected zone:
 reversibly damaged by virtue of carious process,
 has the potential to repair under the correct conditions
as the collagen is not denatured.
 Infected Dentin:
 The soft, wet, and necrotic nature means it is an inferior
chemical and physical substrate for adhesion and seal
formation.
 Low compressive strength.
 sticky and soft to a sharp dental explorer ( Mashy brown)
 Affected Dentin:
 potentially repairable caries-affected dentine has been shown
to exhibit adequate adhesive bonding potential, especially
when surrounded by a periphery of sound dentine and
enamel.
 Better compressive strength.
 tacky ('scratchy ) in nature and blends to the hard sound
dentin)
How much dentine caries should
be excavated?
 The answer to the above question is specific to the
individual tooth/lesion, oral cavity, patient and
dentist.
 numerous inter-relating co-variables that have to be
considered:
 Pulp status
 Lesion depth
 Extent of viable tooth structure
 caries risk
 Transillumination
 rely upon tactile sensation and the hardness of the dentin.

 Using caries detecting solution/dyes.

 binds to denatured collagen of the infected dentin
 Pink haze concept.
 plastic or ceramic burs,
 enzymatic caries-dissolving agents,
 air abrasion
 laser ablation
 Schwendicke et al. (2013) concluded that:
 incomplete caries removal seems advantageous
compared with complete excavation, especially in
proximity to the pulp.
 “there is currently no evidence that incompletely
excavated teeth are more prone to complications.”
Vital pulp therapy:
 Indirect pulp capping
 incomplete caries removal with no re-entry
 stepwise or two-step excavation
 Direct pulp capping
 Pulpotomy:
 Partial pulpotomy
 Full pulpotomy
Secondary retention and resistance
 Grooves  Bevelling
 Boxes
 Slots
 Amalgam pins/ coves.
 Screw pins

 Endo treated tooth:

 Amalgam Bonding
 Nayyer core
 Intraradicular Post
Finishing and inspecting:
Restoration placement:
New methods for cavity
preparation/caries removal:
 Chemo-mechanical
 Air-abrasion
 Laser.
Chemo-mechanical:
 use of a chemical solution which softens
carious dentine.
 Sodium hypochlorite
 given sufficient time, it partially breaks down
the organic material and kills the bacteria,
rendering the lesion caries free
 Local analgesia is not usually required.
 Carisolv:
 The gel is placed over the carious lesion.
 After 10–20 minutes the gel is washed
away and the cavity can be restored with
an adhesive material
Laser:
 Light Amplification by Stimulated
Emission of Radiation.
 Different applications:
 based upon the absorption rates of its
wavelength in hard or soft tissue.

 the need for local anaesthesia is

reduced but not completely
eliminated.
 less time than normal.
 lack of any tactile sense.
Er:YAG Laser
 Erbium Yttrium Aluminium Garnet Laser
 The choice for cavity preparation.
 wavelength of 2940nm.
 highly absorbed in water
 so it is useful for the selective removal of caries.
Air-abrasion:
 also called (kinetic cavity preparation).
 uses the kinetic energy to remove tooth structure :
 microfine (20-50 micron diameter) particles
 Mainly alumina
 a high pressure air stream ( 80-100 psi)
 Causes brittle micro- fracture.

 Anesthesia may be avoided due to air cooling

 Used for:
 tooth cutting/etching
 Remove old filling.
 Caries removal.
Thank You
 Ala’a Al-Haddad
 E-mail: A.Haddad@ju.edu.jo