The Black classification was welcomed by a profession that was actively seeking

guidance for improvement. The classification initially had many beneficial effects. During the
first half of the twentieth century, there was increasing acceptance within the profession that, in
terms of long‐term patient health and well‐being, restoration of carious defects was preferable to
tooth extraction. This was a very positive change that profoundly influenced the dental
profession and has brought improved health to many hundreds of millions of people.
However, some important limitations with the Black classification system have been
acknowledged. On the one hand, it is much less precise in describing the size or stage of
development of early lesions than is desirable for optimal patient care. The Black classification
system did not describe the lesions, rather it described the final restoration location. This made
abundant sense at the time as there was essentially only one treatment for dental caries: surgical
intervention. As a consequence, Black’s classification became strongly linked conceptually to
prescribed cavity forms that today are recognized as being substantially larger than necessary to
restore both the form and function of teeth, both with both modern materials and the amalgam
and gold of Black’s era. Further, Black’s classification did not allow monitoring of lesion size,
progress and activity. For these reasons, other systems for describing and assessing acquired
defects have been developed.
In this text it is suggested that the continued use of the Black classification system is no
longer appropriate. It is, however, important for students and practitioners of dentistry to
understand its fundamentals because it has profoundly influenced the care that many patients
have received in the past and, in many cases, up to the present day.

Black’s Classification of Carious Lesions

Black’s [1] classification is as follows.
• Class I lesions are those originating in pits or fissures on the tooth crown (including the lingual
pits of maxillary incisors and the facial pit of madibular molars).
• Class II lesions are those originating at or near approximal contact areas in posterior teeth.
• Class III lesions are those originating at or near approximal contact areas in anterior teeth.
• Class IV lesions are those originating at or near approximal contact areas in anterior teeth to the
extent that the incisal edge of the tooth crown has been compromised or failed.
• Class V lesions are those originating on surfaces in the gingival one third of the tooth crown, or
on exposed root surfaces.
The cavity forms that Black recommended were linked to the classification system. He
offered a thoughtfully formulated set of principles for cavity preparation. The resultant cavity
preparations were of a predetermined minimum size, each very large by today’s ethical
standards.
Several factors probably contributed to the strong linkage between lesion classification
and relatively large cavity form:
1 The system of classification, cavity design and preparation was created before the use of either
radiographs or clinical magnification, so carious lesions were not detected until they were visible
to the naked eye. That is, by present‐day standards, relatively large.
2 There was no understanding of caries that allowed effective non‐surgical control, either arrest
or reversal. Debridement and restoration were the primary methods of disease control, the only
alternatives being to allow caries to progress unchecked, or to extract the tooth.
3 There were limitations in the equipment available for cavity preparation and restoration, and
dentists had difficulty seeing fine detail in the absence of artificial illumination and
magnification.

Black therefore advised that it was necessary to do the following:

1 to remove additional tooth structure to gain access to the lesion for good visibility;
2 to remove all trace of demineralized enamel and dentine from the floor, walls and margins of
the cavity, because remineralization or healing was not then possible;
3 to extend the cavity outline to allow bulk in the restorative material to provide strength in the
restoration;
4 to provide mechanical interlocks for retention of the restoration within the tooth crown. Neither
ion exchange nor other forms of adhesion were available.
5 to extend the cavity to ‘self‐cleansing’ areas in an attempt to avoid recurrent caries, a concept
called at the time ‘extension for prevention’.
In his recommended cavity designs, Black showed commendable respect for the
remaining tooth structure wherever this was possible, but for the reasons outlined above it was
necessary to sacrifice relatively extensive areas of enamel and dentine to achieve his goal of
creating restorations that would last for several years, rather than a few months.
The result of these factors was that, regardless of the size of the lesion itself, a specific
and prescribed cavity design was recommended for each class of lesion. The resultant cavities
and restorations were, by today’s standards, very large.
Current knowledge offers alternatives to the approach that Black described:
• earlier diagnosis of caries activity;
• effective control of the disease;
• healing through remineralization of early lesions;
• application of adhesive and bioactive restorative materials;
• better illumination and magnification;
• smaller instruments for cavity preparation.
At this time it seems it is clear that the system of lesion classification requires
modification to bring it into good alignment with present‐day standards of care. In the presence
of a better understanding of caries and other causes of loss of tooth structure, it is appropriate to
consider alternative methods of describing and classifying carious and other lesions on the tooth
crown.