C O V E R
STORY
A ir-A b ra s iv e Technology:
Its new role in restorative dentistry
Air-abrasive technology has
re-emerged in dentistry. The
history, characteristics and
clinical applications of this
approach are reviewed,
including advantages and
limitations for the removal of
stain, enamel, dentin and
decay. Air-abrasive technology
may be especially suited for
use in bonded restorations.
R O N A L D E. G O LD S T E IN , D .D .S .;
F R E D E R IC K M . P A R K IN S , D.D .S.,
M .S .D ., P H .D .
he basic concepts of cavity preparation for
amalgam restorations were introduced by Dr. G.V.
Black nearly 100 years ago.1,2 Extension of
preparations was incorporated to prevent marginal and recurrent
caries. Mechanical retention was required to secure the restorative
material. The outline forms developed by G.V. Black and others
since have provided an effective approach to successful amalgam
restorations. Unfortunately, the extension and retentive undercuts
often require the removal of healthy tooth structure.
Several recent developments have started a trend toward the
conservation of tooth structure. Bonding techniques developed by
Buonocore, Bowen and others provide an alternative to mechanical
retention.3-6Pit and fissure sealants were developed with bonding
methods to prevent the development of pit and fissure caries.3
The introduction of self-cured composite resins followed and
light-cured composites with improved physical properties became
available later.79 Composites allow restoration without requiring a
preparation depth below the dentinoenamel junction or the
placement of retentive undercuts. Bonded composites also help
restore the structural integrity of a carious tooth.1011
JADA, Vol. 125, May 1994 551
COVER STORY
Figure 1. This lower premolar has minimal staining, to which the
explorer does not stick and is unable to penetrate.
Fluoride use likewise has
contributed to teeth th a t are
more structurally sound. As a
result of greater exposure to
fluoride, there has been a
decided decrease in smooth
surface caries, especially among
children and adolescents.
However, according to recent
studies, pit and fissure caries
comprises more than 80 percent
of the restorative needs of
younger patients.1213
This course toward enamel
conservation has prompted a
second look at air-abrasive
cavity preparation. This
technique, introduced in the
1950s, uses a high-speed stream
of purified aluminum oxide
(alpha alumina) particles
propelled by air pressure.
(Alpha alumina is a non-toxic
substance often used in
medicine and foods, including
some whitening toothpastes.)
Two alpha alumina particle
sizes, driven by a choice of three
air pressures, can be selected
depending on the procedure.
Air-abrasive technology can
prepare enamel and dentin for
552 JADA, Vol. 125, May 1994
bonding, similar to etching by
acidic gels and solutions.
Longer treatm ent can excavate
pit and fissures, preparing the
tooth for immediate placement
of bonded resin materials.
In December 1992, the U.S.
Food and Drug Administration
granted a 510(K) clearance for
m arketing a newly designed
air-abrasive cavity preparation
system. Reportedly, an applica­
tion for a second air-abrasive
system also has been submitted
to the FDA for consideration.
The commercial availability of
air-abrasive equipment has
prompted a re-examination of
this technology. We discuss this
system, its history and its
applications in this review.
BACKGROUND
Early in 1943, Dr. Robert Black
began his pioneering studies
using air-abrasive technology in
dentistry. In 1945, he published
a series of articles on the use of
air-abrasive technique for
cavity preparation and
prophylaxis.1416 At the time,
alternatives to the slow-speed,
belt-driven handpieces were
being vigorously sought.
By 1951, an air-abrasive
instrum ent, the Airdent (S.S.
White Co.), was introduced.
Twenty dental schools across
the country immediately
initiated postgraduate courses
in air-abrasive technique, which
were attended by hundreds of
dentists.17Articles evaluating
the new technology—both
clinically and scientifically—
appeared in major journals.18'23
By 1955, the Airdent was being
used by more than 2,000
dentists.16 Some textbooks
devoted sections to air-abrasive
technique.24
Early evaluations of the
technology revealed advantages
in patient comfort. Goldberg
reported th at of 1,141 patients,
50.3 percent experienced no
pain. Of the 49.7 percent who
reported pain, 81.7 percent
described it as mild, while 18.3
percent said it was severe. The
majority of patients who
experienced discomfort
indicated it was less than th at
experienced with conventional
bur treatm ent. More than 92
percent of the patients surveyed
preferred to have future dental
treatm ent performed with the
air-abrasive technique. Even
among the patients who
described the pain experienced
during air-abrasive treatm ent
as severe, 73.3 percent said
they would prefer air-abrasive
use over the bur for future
treatm ent.25
In a 1953 survey, Morrison
and Berman received responses
from 43 dentists concerning the
use of local anesthesia in
conjunction with the Airdent.
Seventeen of those dentists
indicated they never used
anesthesia with the Airdent. Of

the remaining 26 dentists, eight
used anesthesia in 10 percent of
the cases, four said they used it
in 20 percent of the cases, three
said they used it 30 percent of
the time and eight dentists said
they used anesthesia in
conjunction with the Airdent in
50 percent of the cases. Three
dentists used anesthesia
between 80 and 100 percent of
the tim e.17
Investigators reported th a t
air-abrasive technology
appeared to eliminate the
vibration, pressure, heat and
bone-conducted noise associated
with rotational methods.141618'
21,24,26They also observed cutting
speeds th a t seemed equal to or
greater than even the fastest
rotary instrum ents of th a t time.
But there were drawbacks,
ju st as there were advantages.
Filling m aterials in the 1950s
were primarily limited to gold
and amalgam. The classic G.V.
Black cavity preparation forms
preferred for these materials
were difficult to complete with
air-abrasive technique alone
and often required rotary
instrum entation for finishing.17'
is,2i The walls of preparations
created by an air-abrasive
instrum ent tended to be slightly
rounded and uneven, and burs
or hand instrum ents were
needed to add the sharp angles
and margins considered
essential to a classic
preparation.
The Airdent was also a t a
disadvantage to rotary instru­
ments when it came to the
removal of existing gold or
amalgam fillings. Practitioners
tried to compensate with
techniques such as using the
Airdent to cut around the
circumference of the restora­
tion, destroying its retention
and allowing removal. This
COVER STORY
approach,
however,
negatively
affected the
structural
integrity of the
tooth.18
The
relatively
primitive state
of air-abrasive
technology and
lack of high­
speed evacua­
tion in those
days also m eant
th a t the
Airdent
sometimes
produced an
excessive
amount of
abrasive
powder.18,20
Some thought
the procedure Figure 2. During preparation, the tip of the air-
would be even abrasive system is held about 3 millimeters from the
tooth surface.
more comfort­
able if warmed
gas was used to propel the prompted clinicians to seek
particles.20 alternative restorative
By the late 1950s, these m aterials and easier methods
drawbacks and others caused for their placement. The desire
the Airdent to lose favor and continues for treatm ent
become overshadowed by the modalities th a t are more
newly developed high-speed comfortable, interceptive and
handpieces, which were better conserving of healthy tooth
suited for amalgam and gold structure. These changes set the
materials. stage for a re-examination of
Air-abrasive technology has air-abrasive technology in
seen major changes between the dentistry.
1950s and the 1990s. Sophisti­
T O O T H P R E P A R A T IO N
cated metering systems have U S IN G A IR -A B R A S IV E
been developed to control the TECHNOLO G Y
flow of abrasive particles with
microscopic precision. Modern While incorporating a number
high-speed evacuation systems of new technological advances,
also limit powder accumulation. the 1990’s version of the air-
Bonded restorations have abrasive system shares a
reduced the need for precise number of im portant charac­
outline forms to achieve teristics with its 1950’s
retention. Patient concerns over precursor. Forty years ago,
the use of amalgam also have Peyton and Henry reported
JADA, Vol. 125, May 1994 553

Figure 3. Decay can be seen after the air-abrasive system removes the
initial stain. Note the depth of the preparation and the remaining
caries.
Figure 4. Caries is completely eliminated after a three-second burst of
the air-abrasive instrument.
minimal tem perature change in
teeth treated with an air-
abrasive unit. They noted a
range increasing from 4 or 5 F
in the tooth being cut, to a drop
in tem perature of as much as 3
or 5 F.26 These tem perature
changes were “small in
comparison to the elevations
observed when the cutting was
done with rotary instrum en­
554 JADA, Vol. 125, May 1994
tation.”26
Likewise, histological studies
using the current air-abrasive
instrum entation reveal minimal
heat generation. Laurell,
C arpenter and Beck reported
th a t air abrasion “is as kind or
kinder to the pulp than conven­
tional high-speed preparation
using copious w ater spray.”27
This reduction of temper­
ature elevation, along with the
elimination of bone-conducted
noise and vibration, may
explain in part why most air-
abrasive procedures can be
performed without anesthesia.28
When the procedure extends
into the dentin, some patients
experience sensitivity while
others do not.
One aspect of patient
discomfort frequently noted
during treatm ent with rotary
instrum ents is the smell of
carious material being removed.
This smell is not apparent
during air-abrasive treatm ent.
Like the earlier Airdent unit,
the new air-abrasive cavity
preparation system is subject to
the properties of kinetic energy:
the harder the substance, the
faster the cutting speed; the
softer the substance, the slower
the speed.28 While it rapidly
cuts harder m aterials such as
enamel, dentin or porcelain, air-
abrasive equipment is much
slower at cutting softer, less
brittle m aterials such as gold or
amalgam.18 Some of the energy
is lost to their resilience. While
this lack of effect on softer
surfaces has been seen as an
advantage in term s of safety to
oral soft tissues,19it is a
disadvantage during the
removal of any restorative
m aterials th a t are soft or
resilient in nature.
With its wide variety of
shapes and sizes of burs, rotary
instrum entation remains
unsurpassed in its versatility
and ability to shape tooth
structure and create sharp,
well-defined margins. With air-
abrasive technique, it is
difficult to achieve the classic
amalgam outline form and
virtually impossible to complete
a crown prep without using a
bur for finishing. But air-
 COVER STORY

abrasive technique can

reportedly create preparation
surfaces and margins th a t are
appropriate for bonded
restorations.28
The width of the cutting path
of the air-abrasive particle
stream when most focused is
500 microns. By moving the
handpiece nozzle a greater
distance away from the tooth
surface, th a t cutting radius can
be increased to 1 to 2 milli­
meters. The enamel in th at
path is removed rapidly,
possibly faster than with a
handpiece and bur.24 This small
cutting diameter puts the air-
abrasive method at a Figure 5. The premolar is then restored with a hybrid composite resin.
Note the restored anatomy of the tooth.
disadvantage compared to large
burs in the removal of large
areas of tooth structure. For solution is to use disposable surfaces similar to the values
smaller, conservative mirrors. obtained with acid etching and
preparations to be restored with Surface preparation and found higher dentin bond
resin materials, however, this bond strength. Contemporary strengths.30
precision may be advantageous. bonded resin materials require Studies assessing the sheer
surface preparation to improve bond strength of composite
L IM IT A T IO N S A N D
ADVANTAGES
attachm ent and retention. resins to air-abrasive-modified
Researchers are studying the enamel have been conducted by
Several additional factors use of the air-abrasive systems Keen, von Fraunhofer and
should be considered when Parkins.31 The forces required to
using air-abrasive equipment. It now appears that air- break the enamel-to-composite
The nozzle of the air-abrasive abrasive m ethods are bond were measured, using
instrum ent does not come into orthodontic brackets attached
suited to restorations with by composite resin. The bond
actual contact with the tooth,
providing no tactile guidance.19,21 current bonded resin strengths were similar to
Also, the size and shape of a bur m aterials and f it well into measurements of surfaces
partially define the shape of a conventionally prepared with
a philosophy of enamel phosphoric acid and were
cut made by a rotary
instrum ent, while air-abrasive conservation. stronger with dentin. This
equipment depends more on the suggests an option of
clinician’s ability to envision the for mechanical etching or performing bonded restorations
param eters of the preparation modifying the surface of without the use of chemical
before cutting.19,21 enamel, dentin and restorative etchants. Since this etching
In addition, when the materials. In the early 1980s, effect is achieved as the tooth is
aluminum oxide powder used in Katora, Jubach and Polimus prepared, it could represent
the air-abrasive system strikes conducted preliminary significant time savings. Air-
the glass surface of an intraoral investigations of air-abrasive abrasive technology also is able
mirror, the mirror becomes technology as an alternative to to etch the surfaces of inlays,
frosted. A number of acid etching of enamel.29 onlays and other indirect
approaches have been Recently, Laurell, Lord and restorations before bonding.28
suggested to avoid destroying Beck observed bond strengths P it and fissu re sealan ts.
mirrors. Perhaps the simplest to air-abrasive treated enamel Sealant protection of pit and

JADA, Vol. 125, May 1994 555

COVER STORV
fissures is widely advocated.32'40
The incidence of interproximal
caries has decreased over the
years, requiring placement of
fewer multiple surface
restorations.1112 Class II
preparations usually extend
onto part or all of the occlusal
grooves for retention.
Clinically, the use of air-
abrasive technique in conjunc­
tion with pit and fissure
sealants appears to offer
advantages. Bonded m aterials
may be effectively placed
directly onto enamel
conditioned by the air-abrasive
particles. The time and effort
required for the application of
an etchant, a thorough rinsing
with w ater and the reisolation
of the tooth may be eliminated.
The time saving and reduced
m anipulation could be helpful
particularly with patients who
gag easily or salivate heavily.
F issu re caries. While air-
abrasive technology applies to
many types of composite
restorations, it seems especially
suitable in the early intercep­
tion of pit and fissure lesions.
The air-abrasive stream can be
directed to the bottom of pits or
grooves, with negligible
widening between the walls.
Darkened areas at the bottom
of pits and grooves may be
misdiagnosed as stains. When
these areas are left untreated
and excavated later, we may
find they were actually signs of
decay.
Air-abrasive technology
provides a method of
conservatively eliminating
these darkened areas. If carious
or pre-carious defects are
observed, the tooth can be
restored with either an unfilled
or filled resin material, or a
combination of both.41 The new
diagnostic capabilities provided
556 JADA, Vol. 125, May 1994
by intraoral cameras can
inspect areas exposed by air-
abrasive cleansing.
C om posite repairs. The
lack of a reliable method of
modifying the composite surface
to enhance bonding has limited
repairs of composite resin
restorations. Acid etching alone
has not yielded maximum bond
strengths.42Therefore, some
clinicians roughen the surface
with a diamond bur.
Air-abrasive surface
treatm ent may provide a faster
and improved method of
preparing the existing com­
posite surface for bonding. The
study by Keen, von Fraunhofer
and Parkins with composite
bonded orthodontic brackets
revealed a significantly higher
bond strength with the air-
abrasive modified composite
surfaces than with acid etched
surfaces.31
In addition to the repair of
composite restorations, air-
abrasive methods offer a
conservative option of repairing
defective margins of old
sealants while leaving sound
sealant material in place.
L am inate repair. Air-
abrasive technology also may be
used to repair
margins of
porcelain-
laminated
veneers
attached by
composite
D r. G o ld s t e in is
c lin ic a l p r o f e s s o r ,
D e p a r t m e n t o f O ral
R e h a b ilit a t io n ,
M e d ic a l C o l l e g e o f
G e o r g ia , S c h o o l o f
D e n tis try , A u g u s t a .
A d d r e s s re p r in t
r e q u e s t s t o D r.
G o ld s t e in , W e s t
P a c e s P ro fe s sio n a l
P a rk , 1 2 1 8 W e st
P a c e s F e r r y R d .,
S u it e 2 0 0 , A tla n ta
30327.
*•*
h dentin after preparation may
Dr. P a r k in s is
p ro fe ss o r o f
p e d ia tr ic d e n t is tr y ,
S c h o o l o f D e n t is t r y ,
U n iv e rs ity o f
L o u is v ille .
retention. In laminates, leakage
or margin ditching can occur at
the junction of the lam inate and
the tooth. In these instances, it
is less desirable to use a bur or
other repair technique that
might compromise the bond
between lam inate and tooth.
There is a danger of micro­
cracks in porcelain veneers
from the bur action. Leakage at
open margins of composite
veneers is also a problem.
Air-abrasive action readily
removes composite m aterials as
well as debris. With the narrow
cutting path and lack of
vibration and heat, air-abrasive
technology may provide an
alternative method for these
repairs.
CONCLUSION
The emergence of composite
resins as an im portant
restorative m aterial has
inspired a re-examination of
air-abrasive technology. This
technology had been less
desirable than conventional
techniques with the metallic
restorative m aterials when it
was first introduced in the
1950s.
It now appears th a t air-
abrasive methods are suited to
restorations with current
bonded resin m aterials and fit
well into a philosophy of enamel
conservation. Air-abrasive
technology also reportedly
minimizes heat, vibration and
bone-conducted noise, providing
a reduced need for anesthesia.
The surface of enamel and
permit the effective placement
of composite restorations
without chemical etching. Its
precision may facilitate a
conservative new approach to
the interception of decay.
Further scientific studies

examining areas such as bond
strength, composite repair,
marginal leakage and other
properties are needed to fully
understand both the limits and
strengths of this technology. ■
The opinions expressed or im plied are
strictly those of the au th o rs and do not
necessarily reflect th e opinion or official
policies of th e A m erican D ental Association.
N eith er th e au th o rs nor the Am erican D ental
A ssociation h as any commercial in terests in
the products m entioned.
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