Anatomy of the fissure system

Fissures form during calcification of the crown of the tooth. Within

the tooth bud, calcification commences at the tip of the cusps and,
as the cusps grow, they fuse together to some degree at the completion
of the occlusal surface of the crown. Fusion will not always
be complete and in a high percentage of cases there will be defects
within the area of fusion, ranging from single deep pits to extended grooves. Often there will be
limited opening to the outer surface
but relatively large defects in the depths of the fissure. Defects may
extend through most of the thickness of the enamel.
It is virtually impossible to determine the anatomical complexity,
and, in particular, the depth, of a particular fissure system
by direct visual or radiographic examination. Augmented
illumination and laser fluorescence methods have been developed
to assist in the detection of early carious lesions within pits
and fissures, as will be described in more detail below. However,
none of these can be relied upon, either alone or in combination,
for complete accuracy in the detection of carious lesions.

Early stages of the Site 1 carious lesion:

intact surface

In the earliest stage of a carious lesion, there is no cavitation,

that is, no breakdown on the outer tooth surface. The enamel
surface is essentially intact macroscopically but there will be
sub‐surface demineralization. This sub‐surface demineralization
may extend through much or all of the thickness of enamel
before the surface breaks down.
Be Aware
It is important, for all sites, to distinguish between an initial
carious defect (i.e. sub‐surface demineralization, with an intact
surface; non‐cavitated) and a carious cavity (i.e. a frank loss of
tooth structure; surface breakdown and cavitation). These two
lesions may be managed in very different ways. This circumstance
is clearly evident in histological sections of teeth.
Detection of early lesions
For the early lesion to be detected clinically by visual examination,
the tooth must be cleaned and dried. With good illumination
and, ideally, with magnification such as a clinical microscope,
the enamel surface will appear to be intact but there
may be a change in appearance, most commonly an increase in
whiteness, or opacity (see Figures 2.2 and 2.3).

While sensory input from touch, using an appropriate instrument,

can be helpful in understanding the nature and status of
a pit or a fissure system, compressive force with a sharp instrument
must be avoided. Direct compressive force applied through
a sharp instrument, such as an ‘explorer’, may result in collapse
and irreparable damage to the partially demineralized enamel
surface. A light scratching motion over the enamel surface with
a less‐than‐sharp explorer or fine periodontal probe may reveal a
‘roughened’ surface by touch, indicating partial demineralization.
For much of the past hundred years it was common practice for
dentists, during the examination of teeth, to force a sharp, pointed
instrument into pits or fissures to feel whether the explorer tip
would ‘catch’ or ‘stick’, that is, become difficult to remove. This was
taken to be evidence of the presence of an initial carious lesion. It
most cases this was probably so, and occurred because the enamel
surface, weakened by sub‐surface demineralization, collapsed or
fractured as a result of the force applied. The sharp instrument then
jammed into the resultant defect. By this action, further damage
was caused, ensuring the need for placement of a restoration. This
technique cannot now be justified as part of an examination.
In addition to vision, using incident light and low‐pressure
touch, several new techniques are available to increase the accuracy
of detection of Site 1 carious lesions:
• Intense transillumination with closely focused, whole spectrum,
high intensity light, delivered through a fibre‐optic system,
allows visualization of changes in enamel density through light
scattering and changes in colour. Early carious lesions appear
more opaque than intact enamel because of decreased mineral,
and therefore, increased water content. More advanced lesions
appear darker because of bacterial ingress. Careful observation
over a period of several seconds, while moving both the light
source and mirror, allows development of a three‐dimensional
appreciation of the fissure system.
• Laser fluorescence uses a laser light source of fixed wavelength.
Such light passes through intact enamel essentially unchanged.
However, some bacterial components fluoresce at appropriate

wavelengths. But so do some non‐bacterial stains, so this method

does not have high specificity for the presence of caries. It may,
however, add useful information to other methods of detection.
• Intact enamel has very low electrical conductance, or high resistance
to an electrical pulse. As porosity increases, so does conductance.
Electrical conductance measurement may therefore aid
in the detection of early lesions. The tip of a narrow metal probe
can be placed in contact with the tooth surface and conductivity
measurements made relative to a soft tissue reference.
• Radiographs are unlikely to show change in enamel density in
very early lesions in pits or fissures because of the very small
fraction of the total tooth structure that is initially involved in the
path of the beam. However, as noted below, they can be of significant
value in confirming the presence of more advanced lesions.
Despite the uncertainties of each of the methods of detection
described above, it has been demonstrated that there is good
correlation between the diagnostic opinion developed in trained
examiners. Although none of these techniques is perfect on its
own, the trained professional can use one or other, in combination,
to reach a clinically satisfactory diagnosis.
Pit and fissure sealing
Sealing pits and fissures is a very effective and economical way
of reducing the risk of caries in these systems. It is also a safe
and effective component of treatment for early carious lesions
in those sites, in combination with ongoing measures to limit
demineralization and promote remineralization.
It is very difficult to determine with certainty whether or not
early carious lesions exist within the enamel walls of pits and
fissures so the procedure of fissure sealing is justifiable with any
patient at risk at any age (see Figures 2.4–2.7).

Fissure sealing halts the progress of the disease at that site

because it changes the local biochemistry, preventing access of
simple sugar substrate to any bacteria that may remain in the
biofilm within the sealed fissure. It is a logical, ethical and effective
preventive treatment and has been used for many years with
a long history of success. Pit or fissure sealing is appropriate in
any circumstance where there is the perception of risk of development
of caries, or where the presence of early carious lesions
is suspected or known.
Fissure sealing is desirable in any patient with a high risk of
caries development. Caries risk assessment is described in detail
in Chapter 3. In modern societies, all young children should
be considered at risk of developing caries, principally because
immature enamel is relatively soluble. It takes several years in
the oral environment, and significant contact with fluoride, for
enamel to mature. Fissure sealing is relatively simple to perform
and the cost is low, so there is no reason for failing to provide
this service to all children, and to any other patient at risk.
Many materials and techniques, ranging from silver nitrate
precipitation to melting of enamel with lasers, have been used to
seal fissures. The most popular sealant over recent decades has
been resin in various forms [1], and now glass‐ionomer cements
are also proving to be of value.
Resin sealants
Resin, either unfilled or lightly filled, was originally used over
30 years ago and was demonstrated to be safe and effective
in well‐conducted clinical trials. It now has a long history of
success. There are resin materials now available in both a lightcured
or an auto‐cured form and many are tinted for easier
identification. The aim is to flow the resin into the depths of
the fissure to obtund it completely so preventing the future
admission of more plaque and bacteria.
Prior to placement, the enamel should be cleaned, then acidtreated
or etched to remove residual biofilm, reduce the surface
energy of the enamel and dissolve the outer layer of the enamel
rods. This induced porosity will allow penetration of unfilled
resin into the spaces leading to micro‐mechanical attachment of
the resin. Unfortunately, the walls of a fissure are covered with
an amorphous layer of enamel rods, as described in Chapter 1,
and they may not accept a good etch pattern. This means that,
in some patients, attachment of the cured resin may be tenuous.
The presence of biofilm can interfere with the infiltration of
resin into the depths of a fissure. It has been suggested that the
occlusal surface should be well cleaned prior to placement but
it is apparent that most methods of cleaning will only add to the
debris trapped in the opening to the fissure. Also, it is apparently
not possible to flow the resin into the fissure beyond the point
where the fissure is less than 200 μm wide, so complete penetration
is unlikely.
Loss of resin sealant may occur through partial lifting or
fracture, with consequent exposure of one segment or another
of the fissure. It must be noted that a resin sealant has no antibacterial
properties. In spite of the possible limitations, the clinical outcomes of resin fissure sealing have
been shown to be very good.