Professional Documents
Culture Documents
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.
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.
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
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.
Demineralization
The mineral component of enamel, dentine and cementum
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
Protective factors
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
- Xerostomia
- Cervical caries due to decreased salivary flow
Medications
- Anticholinergics
- Antihypertensives
- Antidepressants
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
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.
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.
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.
2-D image
superficial remineralization not seen
fracture of one lingual cusp is seen as radiolucency of
proximal cavity.
Mount’s classification
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
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
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
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
Cavity preparations
Site 1 lesions
Fissures on occlusal surface of posterior teeth.
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
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.
Restoration – advantages
GIC
Adhesion fluoride release
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
Restoration
GIC as it can reinforce undermined enamel and it can be
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.
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.
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
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.
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
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
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.
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.
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.
Preparation
Entry by small tapered diamond cylinder bur. Access
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.
Preparation
Begin just medial to marginal ridge using very fine
diamond point (# 200). Remove caries with small round bur
(008 to 012).
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.
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
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
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
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.
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.
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
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.
Site 3 size 1
Occurring in the gingival one-third of the crown or on the
exposed root surface of any tooth.
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
Restoration
The material of choice is a type II.1 restorative aesthetic
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
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
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
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
Examples
Filled - Kerr sealants
Unfilled - Contact seal
Chemically - Concise white (3M) Delton
Light cured - Prisma shield Helio seal