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NO DRILL DENTISTRY NO DRILL DENTISTRY

NON-ROTARY METHODS OF CAVITY PREPARATIONS

Contents
Introduction Classification Harmful effects of

Contents

Air Abrasion Air Polishing

drilling

Ultrasonics
Sono-abrasion

Changing concepts in

treatment of caries

Contents
Laser therapy Chemo-mechanical

Contents
Ozone therapy Enzymes References Conclusion.

means of caries removal

Atraumatic

restorative technique

Introduction

Drilling- Good or bad??

1. It is a familiar well known procedure. 2. It offers precision cutting.. outlines 3. The practitioner has tactile perception of the extent of cutting. 4. Debris can be controlled by water and high velocity evacuation. 5. Practitioners vision while cutting is relatively good. 6. Fast

Drilling- good or bad??

Overcutting

Low torque

Why Non-Rotary?? The Changing concepts!!

Macro-dentistry to ultraconservative micro-dentistry

An old argument!!!
Tomes in 1859

G V Black in 1908

Transformation of preparation concepts: past to present!!

Prevention of extension prevention, remineralization and MI

1881,

Webb

G.V Blacks extension for prevention

Late 20th century.. Adhesives

Mid of 20th century.. clinicians challenged

classification
Classification of various tooth-cutting techniques
Mechanical, rotary Handpieces + burs

Mechanical, non-rotary

Hand excavators, Airabrasion, Airpolishing, Ultrasonics, Sono-abrasion Caridex, Carisolv, Enzymes

Chemo-mechanical

Photo-ablation

Lasers

 Noack et al

classification

Disinfection techniques

Excavation techniques

*Manual rotary *Sono abrasion

*Ozone treatment *Photodynamic therapy *Antibacterial therapy

Sealing techniques

*Fluoride releasing materials

*Air abrasion
*Chemomechanical excavation *Enzymatic digestion *Photobalation

*Dentin adhesives
*Antibacterial resin materials

classification
Mechanical: Atraumatic restorative technique (ART) Rotary (High/low speed bur) Sonic oscillation (SONICSYSmicro)

Chemomechanical: Carisolv

Kinetic: Air abrasion

Hydrokinetic: Lasers

Air abrasion
Micro-abrasion/ kinetic cavity preparation 27.5 aluminum oxide powder.. compressed air Kinetic energy principle

History
1940s Dr. Robert Black
1945articles 1951..Airdent by S.S White 1955..more Reclined

Revived1970s, Dr. Tim Rainey + Dr. Black, and in 1985

Metering systemshigh speed evacuation systems Bonded restorations. concerns over the use of amalgam

Mechanism of action:
Kinetic cavity preparations Hard & soft material interaction

Rainey ridge
The sub-occlusal oblique transverse ridge.. DL & MB cusps

The changed model concept

Advantages
Reduced pain & need for anesthetics. Reduced patient apprehension. No vibration and no noise Rapid cutting. Minimally invasive. Better bonds. Explores incipient carious lesions.

disadvantages
Unfamiliar
Precise clearly identifiable outlines???

Tactile perception.. minimal

Expenses.

Class II and Class III areas.. more extensive learning.

Small tooth preparations only.. No crown preparations

Cannot remove large amalgam using air abrasion.

Does not remove soft decay???

Debris accumulates.. Excellent suction and air filtration devices..

indications
Class I, IV, V.. Class II, III Children.. no psychological trauma Local anesthesia not indicated due to health reasons

Mentally disabled
Geriatric pts

Contraindications
Severe dust allergy Asthma Ch. Pulmonary disease Recent extraction

Open wound
Periodontal surgery or compromised status Subgingival caries Emphysema risks

Dynamics of air abrasion

E= mass x velocity2

Variables
Air pressure: 60 psi 80psi Powder flow: 1.8-2.5g/min Particle size: 27m..50m10m The type of machine: continuous mode without exhaust and with exhaust Tip size: 0.011-0.032 inch0.018..0.014..0.011 Tip angle: 458..678 ....908 .... Tip distance from the tooth: 1-2mm

Recommended: 458 , 0.014 inch

technique
Focused & defocused mode Do not move back and forth

3 second bursts
Observe Deeper.. short bursts.. Less air prr.. Safety..

Commercially
Micadent Prepstart Whisperjet Aquacut Quattro Air Abrasion System (Velopex)

Accessories
Air abrasion resistant mouth mirrors (CrystalMark) Sand trap

Power plus booster: 135psi

Disposable air abrasion headpiece: Airbrator..high, medium and low

performance Super high volume evacuation system MicroVibe

Recent advances
Softer abrasives.. crushed polycarbonate resin.. sizes: 60# (338)..80# (215).. [Oper Dent. 1998 Sep-Oct;23(5):236-43.Selective caries removal with air abrasion. Horiguchi S, Yamada T, Inokoshi S, Tagami J.]

Parallel water technique: hydroabrasion.. Hydrojet and Rondoflex by Kavo

Deeper penetration & efficient.. dust over spray.. warm water

Air polishing
Soluble particles of Na-bicarbonate + tri-calcium phosphate (0.08%) Air pressureshrouded in a concentric jet of water Choked flow.. beyond 90psi

Indications: Satins Carious dentin at the end Pit & fissure prep..

MicroProphy II

ultrasonics
1950s.. Nielsen et al.. Magnetostrictive inst. With 25kHz Conjunction with thick aluminum oxide and water slurry

MOA Kinetic energy of water to tooth via abrasives Harder tissue easy to cut Soft not removed.. However Reduced vibrations and noise CVD tips Advantages Formation

Sono-abrasion
Development of high-frequency sonic air scalers with modified abrasive tips. Sonicsys micro unit..by Drs. Hugo, Uterbrink, Mosele < 6.5kHz

Elliptical motion.. 0.08-0.15mm Longitudinal motion.. 0.055-0.135mm Diamond coating..40m & flow rate 20-30ml/min Operational prr: 3.5bar Torque: 2N.. If > damping..

 Tips:

lengthways halved torpedo shaped ( 9.5 mm long, 1.3 mm wide) small hemisphere (1.5 mm in diameter). large hemisphere ( 2.2 mm in diameter).

SONICflex microinvasive: proximal regions

SONICflex angle: tunnel prep

SONICflex bevel:

Each cavity design..

lasers
Light Amplification by Stimulated Emission of Radiation

HISTORY: 1960- Maiman..1st laserred from ruby 1970- CO2 and Nd:YAG 1987- model of Nd:YAG May 1997.. Er:YAG 1998: Er:YSGG

properties
Coherence Collimation Mono-chromaticity

Interaction with target tissues:

Types of lasers
Tissue interaction: Hard & soft lasers Power output: High & low power lasers Lasing media: Solid, liquid & gas Emission modes: Continuous Gated Free-running
Contact or non-contact mode

Mechanism of action
Enamel: 12% waterErbium based laser.. ablation well below

the melting and vaporization temperatures of enamel

Removes composite and GICs Popping sound on hard tissues propagation of an acoustic

shock wave within the tooth.. and varies..

Er,Cr:YSGG laser system creates a loud snapping sound..

plasma de-coupling due to??

The rear surface of atomized water molecules

HydroKinetic cutting

Explosive subsurface expansion of interstitially trapped

water

Hard tissue lasers

Infrared spectrum Biolases Millennium: (2780nm wavelength).. erbium, chromium, yttrium, scandium, gallium

& garnet. (Er,Cr:YSGG)

Continuum Biomedicals DElight dental laser: (2940nm wavelength) combines erbium with

yttrium, aluminum & garnet (Er:YAG).

similarities
Since 1999 Solid state lasers

Use water to accomplish their task

No need of anesthesia, hence quadrant dentistry Abrades surface, but requires etching Conservative Tolerable, light, popping noise is produced No touching the tooth, hence no vibrations Unlike air abrasion cuts, removes, or ablates soft

tissue Both the wavelengths are placed in the beginning of the mid infrared, invisible and non ionizing portion of the spectrum. Both the wavelengths are emitted in free running pulsed mode.

differences
Erbium: YAG (Delight)
Delivery by hollow waveguide or fiber
optic bundle or articulated arm. Er: YAG has a 20 % higher absorption Lower absorption in hydroxyapatite in hydroxyapatite

Erbium, Chromium: YSGG (Biolase)

Er,Cr: YSGG use only fiber optics.

Higher absorption in water

Mass removal of dentin is greater Causes less of pulpal temperature

Lower absorption in water.

Mass removal of dentin is lesser. Causes more of pulpal temperature

increase.
Thinner hand piece so that there is good access & visibility. Pulse can be adjusted from 3-30Hz

increase
Emulates the traditional hand piece design. Fixed pulse repetition rate at 20Hz.

 Non-contact mode Quieter Less vibrations Sterilizes Seal the periphery

Cracking of enamel Severe carbonization of

dentine Irreversible damage to adjacent tissues Expensive No tactile sensation

safety
Protective glasses Warning signs

Class IV lasers.. registration and inspection

 Higher waterlower energy Erbium laser:

guidelines

Enamel> dentin, caries & soft tissue

Enamel: 4-8 W Dentin: 2-5 W Caries: 1-3 W Bone: 1.5-3 W Soft tissue: 1-3 W End cutting devices.. Slow lateral movements Deeper lesions.. broad tip 1st Always kept in motion Water spray.. slow and steady Contact and non-contact mode Focal point Popping sound.. controversial Anesthesia Tech.: Erbium lasers defocused at high energy (5-6W) for 2 mins Gradual increase from 0.2W upwards

Laser abrasion
Theoretical extension of water based laser ablation.. Er:YAG laser energy accelerates the movement of sapphire 30-50m

Brittle splitting.. hence tooth removal

Velocities range of 50-100m/s Dispensing systems Ceramic restorations

Chemo-mechanical means of caries removal

Definition:

Structure of collagen

Carious lesion & collagen

indications
Tooth preservation Removal of root/ cervical caries

Caries removal at the margins of crowns and bridge abutments

Completion of tunnel prep LA contraindicated Anxious pts Deciduous dentition ART

Evolution of chemo-mechanical agents

NaOCl: Goldman and Kronman working in New Jersey, U.S. in the 1970s.

So combined it with Sorensens buffer (which contains glycine, sodium chloride

and sodium hydroxide)

NMG: N-monochloroglycine by cholrination of glycine GK 1019

More effective if glycine was replaced by amino butyric acid,

N- monochloroaminobutyc acid (NMAB).

 Role of NMG and NMAB on collagen

Hydroxyproline to pyrrole 2 carboxylic acid. Cleavage by oxidation of glycine residues

US.. FDA.. CARIDEX

technique
Delivery: Reservoir Heater Pump
Tech: 5-10mins Dentin surfaceoverhangs & undercuts Dentine scales

GK 101 (NMG): collagen status Fraying fibrils Spinaling fibrils Dissociating fibrils Amorphous material

 Painless
Conservative DiscolorationMillards

Access to caries,

reaction Reduced need for LA Reduced risk of pulpal exposure Anxious, medically compromised, pediatric pts

interproximal caries Existing restoration Non adhesive rests need cavity prep Large vol of soln (200500ml) Time (10-15mins) Bulky delivery system

carisolv

Mechanism of action
Alkaline Amino acids gets chlorinated due to prs of NaCl and NaOH constitutes Proteolytic degradation of collagen Gel..adv??

Insts and technique

Insts and technique

Insts and technique

Insts and technique

papacarie
Papain, chloramines, toluidine blue, salts, thickening vehicle

Papain: is a proteolytic enzyme.. bacteriostatic, bactericide and anti-

inflammatory characteristics.. accelerates the cicatricial process.

Chloramies: bactericide and disinfectant.. These are broadly used to

chemically soften the carious dentine.. secondary &/or quaternary structure of the collagen are affected due to disruption of hydrogen bonding.

Mechanism of action & technique

Anti-trypsin

30-40 sec and the removal can be started using excavator in pendulum motion.

Advantages: Proven effectiveness The methods safety Elimination of bur and local anesthesia Low anxiety seen in patients Conservation of sound tooth structure Easy to manipulate, economical and simple Ideal consistency to work with Fast action

Atraumatic restorative technique

South Africa by a Dutch inventor, Prof. Jo Frenken..mid 1980s and introduced into

clinical setting in 1990s

technique

 Recommendation:..

Indications..
Survival rate..3yrs..85-88%

Ozone tehrapy
O3 Sterilization & remineralization

Production: Ultraviolet system Corona discharge system Cold plasma system

Safety limits=0.06ppm for 8hrs/day,

5 days a week OR 0.3ppm for 15mins Fatal=50ppm for 60mins

Principles of ozone therapy

The niche environmental theory Demineralization remineralization

10s application of 2200ppm..99% elimination

14 weeks of elimination followed by remineralization

Mechanism of action
Removal of ecological niche Antimicrobial

Removes acidity
Removes proteins Oxidizes poly unsaturated fatty acids

Indications & contraindications

Pit & fissure Early occlusal Hidden caries Proximal lesions

Open accessible caries around

crowns & bridges Accessible root caries

healozone

enzymes
In 1989, Goldberg and Keil successfully removed soft carious dentine using

bacterial Achromobacter collagenase.

This did not affect the sound layers of dentin beneath the lesion. Also a more recent study has used the enzyme pronase, a non-specific

proteolytic enzyme originating from Streptomyces griseus, to help remove carious dentine.

conclusion

references
Air abrasion: An emerging standard of care in conservative

operative dentistry. J. Tim Rainey, Dent Clin N Am 2002; 46: 185209 Chemochemical caries removal: A review of the techniques and latest developments. J. A. Beeley, H. K. Yip, and A. G. Stevenson. British dental journal 2000; 188(8): 22 Dentine caries excavation: a review of current clinical techniques A. Banerjee, T. F. Watson, and E. A. M. Kidd. British dental journal 2000; 188(9): 13 The cutting edge: instrumentation and preparation concepts Douglas A. Terry. Fundamentals of Adhesion The current status of laser applications in dentistry LJ Walsh. Australian Dental Journal 2003;48(3):146-155 Lasers in Dentistry from Beginning to Automatic Systems Institut fr Lasertechnologien in der Medizin und Messtechnik an der Universitt Ulm www.uni-ulm.de/ILM Lasers and air abrasion. New modalities for tooth preparation. Robert Reyto. Dent Clin N Am 2001; 45: 189206 Chemo-mechanical caries removal: a comprehensive review of the literature. International dental journal 2001; 51: 291-9.

references
Air-abrasion enamel microsurgery to treat enamel white spot lesions

of traumatic origin. Lambrechts et al. Journal of esthetic and restorative dentistry 2002; 14(3): 167-87 Filling without drilling-not a myth but a reality. Dr. Farhan k. Shah, Dr. R. K. Tiwari. JIDA 2003; 74: 563-4 Minimally invasive operative care. II contemporary techniques and materials: An overview. Mathilde C. Peters/ Mary Ellen McLean. J of Adhesive Dent 2001; 3: 17-31 A new dimension to conservative dentistry: Air abrasion. Vivek S Hegde, Roheet A Khatavkar. 2010; 13(1): 4-8 An overview of the use of lasers in general dental practice: 1. laser physics and tissue interactions. Munther Sulieman. Dental update 2005; 32: 228-36 Nogales CG, Ferrari PH, Kantorovich EO, Lage-Marques JL. Ozone Therapy in Medicine and Dentistry. J Contemp Dent Pract, 2008; 9: 75-84. Azarpazhooh A, Limeback H. The application of ozone in dentistry: A systematic review of literature. J Dent, 2008; 36: 104-16. Papain gel: a new chemo-mechanical caries removal agent. J Clin pediatr dent 2005, 30 (20): 115-20.

Thank you!!!