Textbooks in Contemporary Dentistry

Carlos Rocha Gomes Torres   Editor

Modern
Operative
Dentistry
Principles for Clinical Practice
Textbooks in Contemporary Dentistry
This textbook series presents the most recent advances in all fields of dentistry, with the aim of bridging the gap
between basic science and clinical practice. It will equip readers with an excellent knowledge of how to provide
optimal care reflecting current understanding and utilizing the latest materials and techniques. Each volume is
written by internationally respected experts in the field who ensure that information is conveyed in a concise,
consistent, and readily intelligible manner with the aid of a wealth of informative illustrations.

Textbooks in Contemporary Dentistry

will be especially valuable for advanced students, practitioners in the early stages of their career, and university
instructors.

More information about this series at http://www.­springer.­com/series/14362

Carlos Rocha Gomes Torres
Editor

Modern Operative
Dentistry
Principles for Clinical Practice
Editor
Carlos Rocha Gomes Torres
Institute of Science and Technology
São Paulo State University – UNESP
São Paulo, Brazil

The Work is based on a Portuguese language edition that has been first published in 2013 by Santos
Editora, São Paulo with the following title: Odontologia Restauradora Estética e Funcional: Princípios para a
Prática Clínica

ISSN 2524-4612     ISSN 2524-4620 (electronic)

Textbooks in Contemporary Dentistry
ISBN 978-3-030-31771-3    ISBN 978-3-030-31772-0 (eBook)
https://doi.org/10.1007/978-3-030-31772-0

© Springer Nature Switzerland AG 2020

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 V

To my wife, Adriana Cristina de Mello Torres, and to my daughter, Letícia de Mello Torres, who participated on
my daily battle to finish this work, being always by my side, giving me support at all moments and strength to
persevere.
To my parents, Alfredo Gomes Torres Filho (in memoriam) and Josepha Rocha Gomes Torres, who always
motivated me to study, to work, and to never give up. You were always an example to be followed.
To my sister, Sonia Rocha Gomes Torres, the person who introduced me the dentistry and inspired me to
follow this path, which brought me lots of satisfaction and professional fulfillment. Thank you for your support
on many important moments of my life.

Carlos Rocha Gomes Torres

Foreword
The discipline of Operative Dentistry on São José
dos Campos Dental School was created in 1973
and is now more than 45 years. During this time,
its growth and consolidation are evident, which
resulted from the hard work of its pioneers, who
with different personal characteristics, on hard
times and with rudimentary technology, were able
to conduct and improve it. In relation to that, it is
important to highlight the names of these distin-
guished professors: Newton José Giachetti, Delcio
Pasin, José Benedicto de Mello, and João Cândido
de Carvalho.
Many difficulties were overcome, but the lemma of
the discipline has always been the dedication to
the students, offering them quality of knowledge,
modern approaches, and evidence based on the
dental research results. Other differential from the
discipline, which prevails until today, is the respect
and harmony among professors and staff, main-
taining a pleasant and favorable environment.
Since 1992, the discipline has a postgraduation
program in Restorative Dentistry, which has
already prepared hundreds of masters and doctors
who now occupy important positions in Brazilian
and international universities. To write the fore-
word of this book, created by the current profes-
sors of the Operative Dentistry discipline, makes
me very proud, because it is an example of great
professional work.
This book, edited by Prof. Carlos Rocha Gomes
Torres and contributors, comes to improve the
available dental literature, adding new points of
view, with chapters correlating important dental
specialties. Some chapters talk about classic topics
like cariology, diagnosis, prevention, instruments
and equipment, restorative techniques with differ-
ent materials, and dental hypersensitivity, besides
principles of ergonomics, so essential to the clini-
cal practice. The content is based on a vast litera-
ture and the experience of the professors. The
chapters are illustrated with schematic drawings
and pictures of the clinical cases, allowing the
readers a better understanding about the tech-
niques and procedures described on the text.
I consider that this book assembles valuable infor-
mation for the dentists. It represents the compe-
tent work from a group of professors from the
Institute of Science and Technology of São José dos
Campos, School of Dentistry, that with great care
share their knowledge.
Before ending, I would like to mention part of a
poem from Dom Helder Camara that says:
»» More important than gain roads, cross seas or
reach supersonic speed, it is important to
open yourself to the others, discover them
and go toward their direction.
Maria Amélia Máximo de Araujo
Full Professor of Operative Dentistry
Institute of Science and Technology,
São Paulo State University – UNESP,
São Paulo, Brazil

Preface
Perhaps, the work of an educator is one that can
bring more satisfaction to a human being. The
opportunity to transmit what we have learned to
many people, who will use that information
throughout their lives, makes us feel that we are
doing something meaningful. Since the begin-
ning of my career as a university professor, I tried
to improve the assimilation of knowledge by the
students, using different strategies in several
ways, to teach specific subjects of dentistry, some
of which are extremely complex. Despite the con-
tent of my lectures, at the end, I was frequently
asked by the students the same question: “Profes-
sor, which book should I use to study that sub-
ject?” However, the topics and content presented
in a lecture come from many different sources,
such as those we learned from our own profes-
sors, from several books and papers we read, and
even from our own professional experiences.
Therefore, the answer to that question was always
very hard. That inspired me to start creating this
book.
On my everyday professional life, I have the oppor-
tunity to follow students from their first contact
with Operative Dentistry discipline. It is necessary
to transmit them from basic knowledge about
nomenclature of cavities and principles of tooth
preparation to the most advanced information,
such as aesthetics analyses and restorative tech-
niques. The idea of this book is to offer, in a single
place, all the basic information necessary for a stu-
dent, which is starting his studies about Dentistry
to perform different types of direct dental restora-
tions. The content of this book also aims to help
the clinicians who desire to update their knowl-
edge, improving the quality of the treatments they
perform.
VII
The diagnosis of different dental problems is pre-
sented, teaching how to create an accurate treat-
ment plan for the patients. The cariology is
discussed, in a way to give the reader a broad
knowledge about the etiology of caries disease, as
well the invasive and noninvasive treatment indi-
cation. The dentist must keep in mind that success
in Operative Dentistry is only possible if associ-
ated with the preventive dentistry. In other words,
the restorations should be considered part of the
caries disease treatment and not the treatment by
itself.
The ergonomics principles for dentistry were
added, because it is on the Operative Dentistry
discipline that students start to practice dental
treatments and should learn how to sit and work in
a healthy way. Lack of information at this moment
can lead to acquisition of deleterious habits, which
will negatively affect the dentist´s health. The non-
carious-related tooth sensitivity, mainly dentin
hypersensitivity and cracked tooth syndrome,
were also approached, trying to help the dentists
on the difficult diagnosis of those conditions.
This book would not be possible without the part-
nership of many colleagues, professors, and experts
from the Institute of Science and Technology of
Sao Paulo State University (UNESP) and from
other 19 dental schools around the world, of 13
different countries, who joined the project and
make it possible.
With the support of all, several years of intensive
work, awaken nights, and extra work on weekends
and holidays, the book was concluded. I hope that
it can contribute for the professional life of all
readers.
Carlo Rocha Gomes Torres
São Jose dos Campos, São Paulo, Brazil
Acknowledgments
To the Institute of Science and Technology of São
Paulo State University (UNESP) at São José dos
Campos City, which welcomed me with open arms
and gave me all the opportunities and support to
obtain my bachelor and PhD degrees.
To the current and retired professors of São José
dos Campos School of Dentistry, who throughout
the years, with hard work and a lot of devotion,
created and developed this renowned school that I
am honored to belong and always with willingness
transmitted their knowledge for hundreds of stu-
dents graduated as dentists.
To the secretary and technicians of the Restor-
ative Dentistry Department, Rosângela da Silva
de Melo, Liliane Marques Franchitto, Fernanda
Maria de Brito Cunha and Josiana Maria Alves
Carneiro, for their daily support on my profes-
sional activities.
To my colleagues’ professors of Operative Den-
tistry, Sergio Eduardo de Paiva Goncalves, Maria
Filomena Rocha Lima Huhtala, José Roberto
Rodrigues, Cesar Rogério Pucci, Clóvis Pagani,
Claudio Hideki Kubo, Taciana Marco Ferraz
Caneppele, Karen Cristina Kazue Yui, and Edu-
ardo Bresciani, for the constant support during the
years dedicated to the preparation of this book.
To my colleague’s professor, Alessandra Buhler
Borges, whose support and encouragement were
essential to conclude this book.
To the retired professors of Operative Dentistry,
Newton José Giachetti, Delcio Pasin (in memo-
riam), José Benedicto de Mello, João Candido de
Carvalho, Regina Célia dos Santos Pinto Silva, and
Rosehelene Marotta Araújo. I hope that this book
is consistent with the legacy left by you.
To the librarians of the Institute of Science and
Technology for their support to this work, spe-
cially to Maria das Dores Nogueira, who was
always willing to help me, since my days as under-
graduate student.
To our former undergraduate and graduate stu-
dents, who contributed to obtain some pictures
used in many chapter´s illustration.
To the patients of Operative Dentistry Clinic, who
kindly permitted to use those pictures obtained
during their treatment in this book.
To the contributors from other universities, Doctors
Ali Ibrahim Abdalla (University of Tanta, Egypt),
Ana Carolina Botta (Stony Brook School of Dental
Medicine, USA), Andrea Baldi (University of Turin,
Italy), Anna Greta Barbe (University of Cologne,
Germany), Ana Raquel Benetti (University of
Copenhagen, Denmark), Annette Wiegand (Uni-
versity of Göttingen, Germany), Anuradha Prakki
(University of Toronto, Canada), Azam Bakhshan-
deh (University of Copenhagen, Denmark), Deepak
Mehta (V. S. Dental College & Hospital, India), Edo-
ardo Alberto Vergano (University of Turin, Italy),
Eliel Soares Orenha (Sao Paulo University, Brazil),
Falk Schwendicke (Charité University Berlin, Ger-
many), Graziela Ribeiro Batista (A.T. Still University,
USA), Jukka Pekka Matinlinna (University of Hong
Kong), Michael J.  Noack (University of Cologne,
Germany), Michael J. Wicht (University of Cologne,
Germany), Nadine Schlueter (University of Freiburg,
Germany), Nicola Scotti (University of Turin, Italy),
Pekka Vallittu (University of Turku, Finland), Rayssa
Ferreira Zanatta (University of Taubate, Brazil),
Satoshi Imazato (University of Osaka, Japan), Shan-
kargouda Patil (Jazan University, Saudi Arabia),
Shilpa H. Bhandi (Jazan University, Saudi Arabia),
and Thomas Attin (University of Zurich, Switzer-
land), experts on their field, who shared their knowl-
edge to improve the different chapters.
To Professor Rayssa Ferreira Zanatta for her out-
standing work on the bibliography organization of
all chapters.
To Professor Shankargouda Patil for his inestima-
ble partnership and support, since the first idea of
translating and publishing this book into the Eng-
lish language.
To Professor Maria Amelia Maximo de Araujo,
who inspired me to become a professor and was
my advisor during undergraduate and postgradu-
ate training. Without her presence in my life, I
certainly would not be a professor and have the
privilege to teach others what I learned. Thanks for
the friendship and support during all these years.
 IX

Contents

1 Diagnosis and Treatment Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Carlos Rocha Gomes Torres, Anna Greta Barbe, Michael Johannes Noack, and Michael Jochen Wicht

2 Ergonomics Principles Applied to the Dental Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Karen Cristina Kazue Yui, Cristiani Siqueira Barbosa Lencioni, Eliel Soares Orenha,
and Carlos Rocha Gomes Torres

3 Cariology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Taciana Marco Ferraz Caneppele, Alessandra Bühler Borges, Carlos Rocha Gomes Torres,
José Roberto Rodrigues, and Thomas Attin

4 Instruments and Equipments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

Sergio Eduardo de Paiva Gonçalves, Cesar Rogério Pucci, Carlos Rocha Gomes Torres,
and Anuradha Prakki

5 Nomenclature and Classification of Cavities and Tooth Preparations . . . . . . . . . . . . . . . . . . . . 167

Carlos Rocha Gomes Torres and Ana Carolina Botta

6 General Principles of Tooth Preparation and Carious Tissue Removal . . . . . . . . . . . . . . . . . . . . 183

Carlos Rocha Gomes Torres and Falk Schwendicke

7 Isolation of the Operating Field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

Alessandra Bühler Borges, Carlos Rocha Gomes Torres, Ana Raquel Benetti,
and Azam Bakhshandeh

8 Matrix and Wedge Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261

Cesar Rogério Pucci, Carlos Rocha Gomes Torres, and Ali Ibrahim Abdalla

9 Protection of the Dentin-Pulp Complex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

Adriana Cristina de Mello Torres, Ana Paula Martins Gomes, Claudio Hideki Kubo,
and Carlos Rocha Gomes Torres

10 Tooth Preparations for Amalgam Restorations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335

Carlos Rocha Gomes Torres and Deepak Mehta

11 Amalgam Restorations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373

Carlos Rocha Gomes Torres, Shankargouda Patil, and Graziela Ribeiro Batista

12 Extensive Amalgam Restorations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

Carlos Rocha Gomes Torres, Shilpa Hanamaraddi Bhandi, and João Cândido de Carvalho

13 Light-Curing Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435

Nicola Scotti, Andrea Baldi, Edoardo Alberto Vergano, Claudio Hideki Kubo,
and Carlos Rocha Gomes Torres

14 Composite Restoration on Anterior Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465

Carlos Rocha Gomes Torres and Rayssa Ferreira Zanatta

15 Composite Restoration on Posterior Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577

Carlos Rocha Gomes Torres, Marcelo Balsamo, and Satoshi Imazato
 X Contents

16 Preventive Measures and Minimally Invasive Restorative Procedures . . . . . . . . . . . . . . . . . . . . 631

Alessandra Bühler Borges, Carlos Rocha Gomes Torres, and Nadine Schlueter

17 Aesthetic Veneers: What Are They and How to Handle Them? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 667
Maria Filomena Rocha Lima Huhtala, Clovis Pagani, Carlos Rocha Gomes Torres,
Pekka Kalevi Vallittu, and Jukka Pekka Matinlinna

18 Dentin Hypersensitivity and Cracked Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691

Eduardo Bresciani, Carlos Rocha Gomes Torres, and Annette Wiegand

Supplementary Information
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707
 XI

Contributors

Ali Ibrahim Abdalla Shilpa Hanamaraddi Bhandi
Department of Restorative Dentistry Department of Restorative Dental Sciences
Faculty of Dentistry, Tanta University Faculty of Dentistry, Jazan University
Tanta, Egypt Shwajra, Jazan, Saudi Arabia
ali_abdalla79@yahoo.com shilpa.bhandi@gmail.com

Thomas Attin Alessandra Bühler Borges
Clinic of Conservative and Preventive Dentistry Department of Restorative Dentistry
Center of Dental Medicine, University of Zurich Institute of Science and Technology of São Jose dos
Zurich, Switzerland Campos, São Paulo State University – UNESP
thomas.attin@zzm.uzh.ch São Jose dos Campos, São Paulo, Brazil
alessandra.buhler@unesp.br
Azam Bakhshandeh
Department of Odontology, Section of Cariology Ana Carolina Botta
and Endodontics & Section of Oral Radiology Division of Operative and Dental Materials
Faculty of Health and Medical Sciences Department of General Dentistry
University of Copenhagen Stony Brook School of Dental Medicine
Copenhagen, Denmark Stony Brook, NY, USA
azamba@sund.ku.dk anacarolina.deoliveira@stonybrookmedicine.edu

Andrea Baldi Eduardo Bresciani
Department of Cariology and Operative Dentistry Department of Restorative Dentistry
Dental School Lingotto, University of Turin Institute of Science and Technology of São Jose dos
Turin, Italy Campos, São Paulo State University – UNESP
andrea.baldi.od@gmail.com São Jose dos Campos, São Paulo, Brazil
eduardo.bresciani@unesp.br
Marcelo Balsamo
Private Practice in Esthetic Dentistry Taciana Marco Ferraz Caneppele
Technical consultant of Voco GmBh Dental materials Department of Restorative Dentistry
São Paulo, São Paulo, Brazil Institute of Science and Technology of São Jose dos
balsamo@uol.com.br Campos, São Paulo State University – UNESP
São Jose dos Campos, São Paulo, Brazil
Anna Greta Barbe taciana.caneppele@unesp.br
Department of Operative Dentistry and Periodontology
University Hospital, University of Cologne João Cândido de Carvalho
Cologne, Germany Department of Restorative Dentistry
anna.barbe@uk-koeln.de Institute of Science and Technology of São Jose dos
Campos, São Paulo State University – UNESP
Graziela Ribeiro Batista São Jose dos Campos, São Paulo, Brazil
Missouri School of Dentistry and Oral Health jccarvalho901@gmail.com
A.T. Still University
Kirksville, MO, USA Adriana Cristina de Mello Torres
grazielabatista@atsu.edu Department of Restorative Dentistry
Institute of Science and Technology of São Jose dos
Ana Raquel Benetti Campos, São Paulo State University – UNESP
Department of Odontology, Section of Dental Materials São Jose dos Campos, São Paulo, Brazil
Faculty of Health and Medical Sciences adrianacrismt@gmail.com
University of Copenhagen
Copenhagen, Denmark
arbe@sund.ku.dk
 XII Contributors
Sergio Eduardo de Paiva Gonçalves
Department of Restorative Dentistry
Institute of Science and Technology of São Jose dos
Campos, São Paulo State University – UNESP
São Jose dos Campos, São Paulo, Brazil
sergio.e.goncalves@unesp.br
Ana Paula Martins Gomes
Department of Restorative Dentistry
Institute of Science and Technology of São Jose dos
Campos, São Paulo State University – UNESP
São Jose dos Campos, São Paulo, Brazil
paula.gomes@unesp.br
Maria Filomena Rocha Lima Huhtala
Department of Restorative Dentistry
Institute of Science and Technology of São Jose dos
Campos, São Paulo State University – UNESP
São Jose dos Campos, São Paulo, Brazil
mf.huhtala@unesp.br
Satoshi Imazato
Department of Biomaterials Science
Graduate School of Dentistry, Osaka University
Osaka, Japan
imazato@dent.osaka-u.ac.jp
Claudio Hideki Kubo
Department of Restorative Dentistry
Institute of Science and Technology of São Jose dos
Campos, São Paulo State University – UNESP
São Jose dos Campos, São Paulo, Brazil
chkubo@gmail.com
Cristiani Siqueira Barbosa Lencioni
Department of Restorative Dentistry
Institute of Science and Technology of São Jose dos
Campos, São Paulo State University – UNESP
São Jose dos Campos, São Paulo, Brazil
cristianisbarbosa@yahoo.com.br
Jukka Pekka Matinlinna
Dental Materials Science, Applied Oral Sciences &
Community Dental Care, Faculty of Dentistry
The University of Hong Kong,
Prince Philip Dental Hospital
Sai Ying Pun, Hong Kong SAR, China
jpmat@hku.hk
Deepak Mehta
Department of Conservative Dentistry and Endodontics
Vokkaligara Sangha Dental College and Hospital
Bangalore, India
drdeemehta@gmail.com
Michael Johannes Noack
Department of Operative Dentistry and Periodontology
University Hospital, University of Cologne
Cologne, Germany
michael.noack@uk-koeln.de
Eliel Soares Orenha
Department of Pediatric Dentistry,
Orthodontics, and Community Dental Health
Bauru School of Dentistry, Sao Paulo University – USP
Bauru, São Paulo, Brazil
eliel@usp.br
Clovis Pagani
Department of Restorative Dentistry
Institute of Science and Technology of São Jose dos
Campos, São Paulo State University – UNESP
São Jose dos Campos, São Paulo, Brazil
clovis.pagani@unesp.br
Shankargouda Patil
Department of Maxillofacial Surgery and Diagnostic
Sciences, Faculty of Dentistry, Jazan University
Shwajra, Jazan, Saudi Arabia
sbpatil1612@gmail.com
Anuradha Prakki
Dental Research Institute, Faculty of Dentistry
University of Toronto
Toronto, ON, Canada
a.prakki@dentistry.utoronto.ca
Cesar Rogério Pucci
Department of Restorative Dentistry
Institute of Science and Technology of São Jose dos
Campos, São Paulo State University – UNESP
São Jose dos Campos, São Paulo, Brazil
cesar.pucci@unesp.br
José Roberto Rodrigues
Department of Restorative Dentistry
Institute of Science and Technology of São Jose dos
Campos, São Paulo State University – UNESP
São Jose dos Campos, São Paulo, Brazil
jroberto@ict.unesp.br
Nadine Schlueter
Division for Cariology, Department of Operative
Dentistry and Periodontology
Medical Center-University of Freiburg, Faculty of
Medicine, University of Freiburg
Freiburg, Germany
nadine.schlueter@uniklinik-freiburg.de
 XIII
Contributors

Falk Schwendicke Michael Jochen Wicht
Department Operative and Preventive Dentistry Department of Operative Dentistry and Periodontology
Center of Dental Medicine, Charité University Berlin University Hospital, University of Cologne
Berlin, Germany Cologne, Germany
falk.schwendicke@charite.de michael.wicht@uk-koeln.de

Nicola Scotti Annette Wiegand
Department of Surgical Sciences Department of Preventive Dentistry,
Dental School Lingotto, University of Turin Periodontology and Cariology
Turin, Italy University Medical Center, University of Göttingen
nicola.scotti@unito.it Göttingen, Germany
annette.wiegand@med.uni-goettingen.de
Carlos Rocha Gomes Torres
Department of Restorative Dentistry Karen Cristina Kazue Yui
Institute of Science and Technology of São Jose dos Department of Restorative Dentistry
Campos, São Paulo State University – UNESP Institute of Science and Technology of São Jose dos
São Jose dos Campos, São Paulo, Brazil Campos, São Paulo State University – UNESP
carlos.rg.torres@unesp.br São Jose dos Campos, São Paulo, Brazil
karenyui@hotmail.com
Pekka Kalevi Vallittu
Department of Biomaterials Science Rayssa Ferreira Zanatta
Institute of Dentistry, University of Turku Department of Restorative Dentistry
Turku, Finland School of Dentistry, University of Taubaté – UNITAU
pekka.vallittu@utu.fi Taubaté, São Paulo, Brazil
zanatta.rayssa@gmail.com
Edoardo Alberto Vergano
Department of Cariology and Operative Dentistry
Dental School Lingotto, University of Turin
Turin, Italy
edoardo.vergano@gmail.com
 1 1

Diagnosis and Treatment
Planning
Carlos Rocha Gomes Torres, Anna Greta Barbe, Michael Johannes Noack,
and Michael Jochen Wicht

1.1 Introduction – 2

1.2 Subjective Exam – 3

1.2.1  hief Complaint – 3
C
1.2.2 Medical History – 4
1.2.3 Dental History – 6

1.3 Objective Exam – 7

1.3.1  eneral Aspects and Vital Signals – 7
G
1.3.2 Extraoral Exam – 7
1.3.3 Intraoral Exam – 7
1.3.4 Esthetic Evaluation – 23

1.4 Evaluation of Caries Risk – 28

1.5 General Treatment Plan – 29

1.6 Planning Restorative Treatment – 31

1.7 Interdisciplinary Aspects – 32

1.8 Oral Health Records – 32

References – 40

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_1
 2 C. R. G. Torres et al.
Learning Objectives
1 After completion of this chapter, the reader is competent to:
55 Understand the importance of unfolding the patient’s chief
complaint
55 Use open-ended questions and periodical summaries as
communication tools during the medical interview
55 Apply active listening as a stylistic means to keep patients
talking
55 Recognize medical conditions that may interfere with dental
treatments
55 Identify indications of antibiotic prophylaxis in risk patients
to prevent bacterial endocarditis
55 Identify medicinal product interactions and most prevalent
diseases in a patient
55 Describe challenging conditions when treating elderly
patients
55 Structure the dental assessment in different sections, i.e.,
anamnesis, self-reported complaints, extra- and intraoral
examination
55 Highlight the most important criteria when assessing caries
and non-carious lesions, periodontal and endodontic
conditions
55 Differentiate between pathologic and within biological
variation conditions
55 Differentiate assessment criteria for different types of
restorations
55 Identify biological risks and discriminate harmful from
harmless conditions
55 Explain the multifactorial genesis of non-carious lesions and
know operative and non-operative treatment options
55 Explain conditions that lead to extrinsic and intrinsic staining
55 Reproduce basic knowledge about occlusion concepts and
function in general
55 Understand the basics of dental esthetics
55 Identify risk factors that promote the onset or progression of
oral diseases and calculate the individual caries and peri-
odontal risk
55 Come to a patient-centered personalized treatment plan
according to shared decision-making concepts
55 Apply ASA classification to categorize patients according
their general state of health
55 Differentiate stages within the treatment concept and stick
to them
55 Create a patient file and know about the importance of
detailed documentation
1.1 Introduction
Diagnosis describes the process of determination and judg-
ment of variations from what is normal [55]. Abnormal situ-
ations can bring up discomfort, pain, and loss of function
and may compromise esthetics. Therefore, diagnoses of
alterations from what is normal in the stomatognathic sys-
tem is fundamental to execute an efficient dental treatment,
aiming the re-establishment of the patient’s health. However,
abnormal situations may also be a biological variation and
not harmful to the patient’s health. Based on the most prob-
able diagnosis, a treatment plan can be compiled in close col-
laboration with the patient [66]. Planning the clinical
procedures is crucial since mistakes both in treatment plan-
ning and in the practical execution of such plan will lead to a
result that is far from the ideal [17, 66].
In modern dentistry, treatment planning should be
guided by patients’ wishes and demands in the first place.
Based on patients’ chief complaints and findings of the clini-
cal examination, a list of diagnoses is formulated. One by
one, the problems are analyzed regarding options for treat-
ment, each one with their inherent advantages and disadvan-
tages. The best solution for each problem is chosen and
written in sequence; so, this list of solutions will lead to the
treatment plan [66].
The process to reach a treatment plan is primarily driven
by dental problems presented by the patient. However, com-
prehensive evaluation of the patients’ general health, socio-
economic status, and individual preferences is mandatory to
reach consent about the most suitable and personalized treat-
ment option.
Items included on the treatment plan can be classified by
topics, as endodontic, periodontal, restorative, etc. The list is
dynamical and can be modified if new problems occur or the
patient changes his or her opinion during the course of treat-
ment [66]. The treatment for each individual problem has
the objective to reach the idealized final result, in other
words, the individually desired oral rehabilitation of the
patient. If the proposed treatment for any individual prob-
lem conflicts with the proposed general treatment, the indi-
vidual or general plan has to be modified until it coincides to
each other [66].
The patients’ interview should usually begin with the
evaluation of the chief complaint and patients’ expectations
relative to the treatment outcome. Next, a medical and dental
history has to be recorded. On the medical history, the pres-
ence of systemic diseases including allergies and medications
that affect the patient and more importantly the subsequent
dental treatment has to be investigated. On the “dental his-
tory,” previous treatments should be evaluated as well as the
degree of success that was obtained.
Actually, most dental patients are anxious to a certain
degree. Agitation is usually observed especially during the
first appointment. As dental professionals, we have to know
that agitation can lead to speechlessness, and frightened
patients tend to forget about what they really want to explain.
Therefore, we need to be trained in professional interviewing
and how to get to the core of patients’ demands and expecta-
tions.
The objective part of the evaluation begins with the anal-
ysis of the patients’ general aspect followed by the vital signs
checking such as blood pressure among others, an extraoral
exam of head and neck region, visually or by touch. Then, the
dentist follows to the intraoral exam, checking the soft tissue,
gingiva, and tooth structure. The goal of the exam is to distin-
guish the normal from the abnormal, determining which
abnormal findings are a problem and require treatment or it
Diagnosis and Treatment Planning
will influence the treatment. The nonclinical part of the exam
is performed by the analysis of radiographies, plaster models
on articulators, and photographs [66].
Nowadays, the clinical approaches should be based on a
so-called evidence-based clinical practice, on which the cli-
nician guides their decisions related to the patient’s health on
published findings on scientific researches. Therefore, this
approach can be defined as the conscious, explicit, and
insightful use of the best available scientific evidence when
taking decisions about the care of the patients. This vision
allows the integration among individual clinical quality of
the dentist, the patient’s preferences, and the best basis found
on scientific researches [17, 43].
1.2 Subjective Exam
The data from the so-called subjective exam, also called
anamnesis, come from the interview with the patient. It
derives from the Greek words, ana (open) and mnesis
(memory). In a medical context, anamnesis means recorda-
tion, reminiscence, that is, the group of information that is
part of the clinical history of the patient up to the moment
of the exam [24]. On this exam, crucial information is gath-
ered to determine the patient’s desires and the causal fac-
tors of many oral diseases, as well the safety of dental
procedures.
1.2.1 Chief Complaint
The chief complaint is the motive why a patient consults the
dentist. The answer should be registered on the file, prefera-
bly using the exact patient’s wording (. Fig.  1.12). During
 
discussion and registration of the chief complaint, the
patient will notice that his problem was acknowledged.
Focusing on the chief complaint and paraphrasing it with
our own words ensure that patients would feel correctly
understood and dentists do not lose sight of the major con-
cerns. Concomitantly it positively affects the doctor-patient
relation showing that we listen carefully and really want to
get to the core of a patient’s complaint [54, 66]. If the dentist
too quickly interrupts the patient or tries to focus on other
problems, omitting the discussion of the chief complaints,
patients may question the dentist’s professional competen-
cies. The patient should be encouraged and guided to discuss
all the aspects of the problems in that matter including loca-
tion, duration, and quality of symptoms, as well as any
related factors. These information are called the history of
the present illness.
It is advisable to start the interview with an open-ended
question that allows the patient to explain their chief com-
plaints. “How may I help you” and “what can I do for you
today?” are very nice opening questions since patients
desire opportunities to present concerns in their own
time [56]. In contrast to closed-ended questions (“I under-
stand you have an aching tooth”), patients will provide sig-
3 1
nificantly longer problem presentations when the doctor
initiates the interview with an open-ended question.
Thereby a patient is respected as an autonomous person
rather than a passive, confirmative authority. Patients
should not be interrupted when presenting their chief com-
plaint but rather be encouraged to provide as much perti-
nent information as possible.
Active listening is a communication competency that
helps health-care professionals to deeply reveal the patients’
concerns, ideas, and explanations about a given disease [38].
In the first step, it is important to present our undivided
attention to the patient and encourage them to talk. Nodding
and any other open nonverbal communication, including eye
contact and an open posture, will help to make the patient
feel comfortable and welcome. Telephone calls, ambient
noises, or distractions of any other source should be avoided
at any time. Just as well, taking notes on a file or in the com-
puter may unsettle the patient while talking. In case there is
an urgent need to do so, we should comment on that before-
hand and explain to the patient that it is inevitable to take
down notes, but we pay full attention notwithstanding. Active
listeners avoid interrupting at all costs. After the patient has
explained the chief complaint, it is wise to rephrase it with
our own words to ensure we have fully understood the cen-
tral point. We may encourage the patient to correct or add
something whenever appropriate.
Perception of verbal and nonverbal cueing plays a central
role when we try to disclose hidden messages from another
person. Signal words like “painful,” “expensive,” “time-­
consuming,” etc. might be a hint for worries a patient does
not want to unfold straight away. Observing a person’s body
language will help us to get a vision about their mental and
emotional state.
Addressing a patient’s feelings is the third step that in
most cases will lead to a trustful and overt doctor-patient
relationship. Potential longer lulls in a conversation may feel
awkward for both of the interlocutors. It is not wise to bridge
that break immediately nor to pose a second question when
the answer is not given immediately. Allowing pauses is a
rhetorical device that can inspire a patient to disclose further
information. We should always keep in mind that most
patients feel tense at least which can cause confusion or
short-term oblivion.
At the end of medical interview, it is highly recommended
to summarize the essential points and ask the patient whether
there is anything they would like to address or which has
been stated incorrectly. A final summary appears highly pro-
fessional and marks the end or a new phase within the con-
versation. In longer consultations, intermediate summaries
will help the professional to structure the interview and high-
light the most relevant points not only to the patient but also
to himself or herself.
>> The chief complaint is the motive why a patient
consults the dentist. The answer should be registered
on the file, preferably using the exact patient’s
wording.
 4 C. R. G. Torres et al.
>> It is advisable to start the interview with an
1 open-ended question that allows the patient to
explain their chief complaints. “How may I help you? ”
and “what can I do for you today?” are very nice
opening questions since patients desire opportunities
to present concerns in their own time.
>> Patients should not be interrupted when presenting
their chief complaint but rather be encouraged to
provide as much pertinent information as possible.
>> Perception of verbal and nonverbal cueing plays a
central role when we try to disclose hidden messages
from another person.
>> At the end of medical interview, it is highly
recommended to summarize the essential points and
ask the patient whether there is anything they would
like to address or which has been stated incorrectly.
1.2.2 Medical History
Before planning an oral examination or dental treatments,
the general medical history of the patient has to be checked
thoroughly; general health problems or medication may
influence therapeutic decisions or the results of dental treat-
ment and may even threaten the patient’s life. Also, dentists
have the responsibility of guaranteeing that the dental treat-
ments do not produce systemic consequences by interacting
with previous diseases or medication intake. Initially, the
patient or legal guardian should answer a comprehensive
questionnaire concerning the patient’s medical history
(. Figs.  1.12 and 1.13), preferably in a quiet environment
such as the waiting room. Some dental institutions either
send these forms to the patient or offer an online version to
be completed prior to the first appointment. During the visit,
the dentist will check the answers and address any open
question directly with the patient [62]. The form helps to
identify conditions that may interfere, complicate, or contra-
indicate dental procedures [54]. Questionnaires should be
modified according to the specialty of the clinician and the
category of patient (i.e., elderly, children, etc.), and additional
surveys may be added if necessary. Patients or legal guard-
ians should sign the questionnaires. This information needs
to be updated on a regular risk-adapted basis [3].
The clinician may identify infectious and contagious dis-
eases of compulsory notification, allergies, current and past
medication that may interact with drugs prescribed or
injected by the dentist, or systemic diseases (i.e., endocardi-
tis) that may demand preoperative antibiotic treatment [54].
A meticulous record of the medical history should avoid life-­
threatening incidents and identify conditions that require
medical consultation. In individuals who present with several
systemic diseases and take many medications, the dentist
should closely collaborate with a general practitioner to min-
imize the overall health risk during dental treatment [54].
>> Before planning an oral examination or dental
treatments, the general medical history of the patient
has to be checked thoroughly; general health
problems or medication may influence therapeutic
decisions or the results of dental treatment and may
even threaten the patient’s life.
1.2.2.1  ompulsory Notification of Infectious
C
Diseases
When reviewing the medical history, the dentist may identify
clinical manifestations of infectious and contagious diseases
that put the life of a patient at risk or which involve a delay in
dental treatment. It may be that the dentist is the first health
professional to identify patients with those diseases. Apart
from arranging medical consultation followed by medical
treatment, the governmental health system has to be notified
of some of these cases, following the rules established by each
country. Often, the general health practitioner will take care
of the procedures, but the dentist should confirm these
actions. The disease control system requires certain infec-
tious and contagious diseases to be reported, so that they can
trace a map with the number of cases within a specific region
and check the risk of an epidemic, enabling initiation of pub-
lic health measures, such as vaccination to ameliorate the
spread of the disease. The list of compulsory notification dis-
eases is frequently revised and changes according to each
country.
>> When reviewing the medical history, the dentist may
identify clinical manifestations of infectious and
contagious diseases that put the life of a patient at
risk, or which involve a delay in dental treatment.
1.2.2.2 Systemic Diseases
Patients with systemic diseases may require special care,
especially those with cardiac disorders. Dental procedures
that cause bleeding may allow oral bacteria to penetrate the
bloodstream (bacteremia) and establish themselves on
abnormal or damaged valves, thus increasing the risk of bac-
terial endocarditis. According to the guidelines, patients with
prosthetic cardiac valves or prosthetic material used for car-
diac valve repair, and those with a previous infective endocar-
ditis, are at high risk of bacterial colonization. Other patients,
who should receive an antibiotic prophylaxis prior to highly
invasive dental procedures [1], include those with congenital
heart diseases involving unrepaired cyanotic defects (includ-
ing palliative shunts and conduits), completely repaired
defects with prosthetic material or devices during the first 6
months after the procedure, and repaired defects with resid-
ual defects at or adjacent to the site of the prosthetic patch or
device. These procedures comprise extractions and peri-
odontal treatments, probing, scraping, gingival surgeries,
implants, reimplantation of displaced teeth, and routine den-
tal prophylaxis when bleeding is likely. Patients who have
taken a combination of fenfluramine and phentermine, as an
appetite suppressor to lose weight, are more susceptible to
Diagnosis and Treatment Planning
cardiac valve diseases. Patients that have a joint prosthesis are
also at high risk of developing problems associated with bac-
teria, because they may establish themselves up to 2  years
after they have entered the bloodstream [54]. However, in
general administration of prophylactic antibiotics cannot be
recommended prior to dental procedures to prevent pros-
thetic joint infection [64], because of the risk of antibiotic
resistance; a careful risk-benefit analysis remains necessary.
Therefore, antibiotic prophylaxis is not indicated for proce-
dures that present low bacterial incidence, such as dental res-
toration procedures, placement of a rubber dam, local
anesthesia, removal of sutures, radiographies, post cementa-
tion, installation of prosthesis, impressions, etc. [54].
Tip
Take your time and try to keep the patient’s medical history
comprehensive and up to date. It might save lives.
1.2.2.3 Medications
A patient’s medication may have a broad impact on the sto-
matognathic system or, in the case of polypharmacy, lead to
substance interactions. Certain drugs are known to change
the salivary composition or flow rates, increase tissue bleed-
ing, produce lichenoid reactions, lead to gingival hyperpla-
sia, or change the overall appearance of the soft tissues [54,
66]. The reduction in salivary flow is associated with the pre-
scription of over 400 medications, including anticholiner-
gics, adrenaline blockers, antipsychotics, antihistamines,
diuretics, and antihypertensives. A reduced salivary flow
increases the risk of developing (root) caries, some altera-
tions of the mucosa, an increase in biofilm retention, and
reduced quality of life due to xerostomia [10, 54, 65]. Dentists
should recognize the use of medications that increase the risk
for xerostomia and hyposalivation and should initiate corre-
sponding treatment concepts. Close communication with
the general practitioner and the use of alternative medica-
tions that have fewer adverse effects on salivary flow may be
helpful, accompanied by treatment of the dry mouth symp-
toms [9]. Tricyclic antidepressants can sensitize patients to
epinephrine, a very common vasoconstrictor on local anes-
thesia. Antiepileptic agents can predispose to gingival hyper-
plasia in the presence of bacterial biofilm, and antibiotics can
reduce the effectiveness of contraceptives [54].
There are restrictions on the use of dental anaesthetic solu-
tions that contains sympathomimetic amine vasoconstrictors
(i.e., adrenaline, noradrenaline, levonordefrin, phenyleph-
rine) in patients having hypertension and serious cardiac
problems, uncontrolled diabetes mellitus, hypothyroidism,
pheochromocytoma, sensitivity to sulfites, use tricyclic anti-
depressants, phenothiazine compounds or non-selective beta
blockers or are crack and cocaine users [4, 54]. Medication
for hypertension that contain propranolol, when associated
with adrenaline-containing anesthesia, may cause a sud-
den increase in arterial blood pressure and induce a serious
5 1
hypertensive crisis. In such cases, it is recommended to use a
non-adrenergic vasoconstrictor such as felypressin. However,
its use is contraindicated in pregnant women because it
may lead to uterine contractions. The anesthetic substance
prilocaine, when used in patients with cardiac arrhythmias
who use antiarrhythmic medications such as tocainide, can
increase the toxicity of the antiarrhythmic drugs. Prilocaine
must not be used in patients with anemia or pregnant women
because of the risk of methemoglobinemia [4].
Retraction cords with adrenaline used as vasoconstric-
tors have been abandoned due to the availability of better
alternatives for hemostasis [54]. In addition, use of epineph-
rine in patients with antidepressants needs to be analyzed
with caution due to its potential for interactions [54]. When
oral hypoglycemic drugs are swallowed and absorbed, they
are released into the bloodstream. Some molecules are free in
the blood and produce its therapeutic effects, while the rest
are bound to plasma proteins. However, nonsteroidal anti-­
inflammatories can compete with oral hypoglycemic drugs
for these plasmatic bonds, increasing the fraction of free
molecules, which may result in hypoglycemia.
1.2.2.4 Allergies
The patient’s reports regarding allergy history and anamnes-
tic allergic reactions must be investigated, especially with
regard to previously injected anesthesia. It is well-known that
many problems related to anesthesia occur because of acci-
dental intravascular injection, high dosages, and excessive
use of anesthetic. Some individuals present allergic reactions,
especially to the preservatives of the injected solution.
Naturally, patients that report allergy problems with local
anesthesia should not receive this type of medication until
further investigation has been performed by a specialized
doctor. The patient’s opinion should always be trusted until
those additional tests have excluded the risk of allergy. This
­precaution is necessary, considering that anaphylactic shock
can put the patient’s life at risk, requiring immediate treat-
ment with basic life support measurements and necessitating
removal to a hospital [54].
>> Some individuals present allergic reactions, especially
to the preservatives of the injected solution.
Some patients report latex allergies; in those cases, it is rec-
ommended that the clinician uses vinyl gloves and a rubber
dam without latex. Other allergies with relevance to dental
treatments include allergic reaction to restorative materials,
such as amalgams or resinous monomers, and will dictate the
choice of dental materials to be used. Some individuals also
present allergy to hydrogen peroxide, which contraindicates
bleaching treatments, especially those techniques that are
available at home.
1.2.2.5 Older Patients
Because of the well-known demographic changes, particu-
larly in western countries, the number of older patients that
need to be treated in dental practice will continue to
increase over the coming decades. These patients represent a
 6 C. R. G. Torres et al.
vulnerable and heterogeneous patient group, due to a great
1 number of changes related to aging, behavior, diet, and oral
and systemic health; accordingly, this group requires special
attention. The prevalence of multimorbidity and polyphar-
macy is high and has a negative impact on daily oral hygiene
capabilities. Neurodegenerative or mental disorders such as
depression, Alzheimer’s disease, and Parkinson’s diseases
play a major role in reduced oral health [8]. Furthermore,
around 50% of individuals over the age of 75  years take at
least two medications [12, 54], increasing the risk of reduced
salivary flow rates and oral diseases [9].
>> Because of the well-known demographic changes,
particularly in western countries, the number of older
patients that need to be treated in dental practice will
continue to increase over the coming decades.
>> Around 50% of individuals over the age of 75 years
take at least two medications, increasing the risk of
reduced salivary flow rates and oral diseases.
The aging process in older patients produces physiological
changes that are not pathological. Attrition, erosion, and
abrasion of enamel reduce its thickness so that it becomes
more mineralized and translucent; the underlying dentin
becomes more apparent, resulting in a yellow appearance of
the teeth, and the pulpal chamber reduces in size. The chro-
mogenic substances from the diet penetrate the enamel’s
microcrystalline structure, making it darker. The gum may
become inflamed and friable, associated with gum recession
and consequent exposure of the root.
The oral alterations associated with malnourishment,
immunosuppression, dehydration, smoking, alcohol con-
sumption, diseases, medications, and dental problems reduce
the ability to feel the taste and smell in older patients [54].
The perception of salt and bitterness and the olfactory senses
lower with age, while the perception of sweet and sour is
unchanged. As a result, food becomes less tasty and unappe-
tizing. Therefore, sugar, fat, and salt are added in an attempt
to improve the taste. It is crucial to evaluate dietary habits in
older patients to identify malnutrition, give suggestions for
improvement while lowering the risk for dental diseases at
the same time. For example, aromatic herbs can improve the
taste of food in place of sugar and salt. Saliva stimulants,
candy, sugar-free gum with citrus aromas that contain xylitol
or other sugar substituents, and brushing or scraping the
tongue can improve the sense of taste, while smoking cessa-
tion can improve the olfactory perception of older people.
Periodontal diseases can progress faster in older patients,
and root caries is the most significant reason for dental loss
in these patients. Inefficient removal of the biofilm, reduced
salivary flow rates, a diet rich in refined sugar, the presence of
fixed or removable prosthetic appliances, abrasion of the
cementoenamel junction (CEJ), gingival recession, and bone
loss due to periodontal disease mean that the root surface is
more prone to caries. Accordingly, dental restorations are
hard to perform, satisfactory filing materials are missing, and
the restorations are at a high risk of caries recurrence [54].
1.2.2.6 Psychological and Social Aspects
During anamnesis, the clinician should analyze the patient’s
expectation and priorities relative to the treatment and his
oral health in general. Knowing about a patient’s priority is
crucial when it comes to treatment decisions. Patient’s expec-
tations are highly variable and in the vast majority of cases
not congruent with those of the attending dentist. Accepting
that patients have different views than ours leaves the
decision-­making process much easier and both doctors and
patients much more satisfied. Therefore, we have to evaluate
what is important for an individual patient. Esthetics, com-
fort, time-consumption, monetary aspects, longevity, success
rate, and biocompatibility are among the most important
categories that should be discussed before we start discussing
treatment options.
Social inequality in many countries leads to diminished
access and lower financial means for medical treatment of
the socially deprived. Caries, however, the most prevalent
chronic disease worldwide most often affects underprivi-
leged members of our society [59]. In order to overcome
this obvious inconsistency, health-care systems should
become aware of this immanent problem and try to make
dental health services accessible and affordable for those
who are in need of it. Overtreatment of people in higher
socioeconomic positions reflects the flip side of modern
health-care systems.
>> Social inequality in many countries leads to diminished
access and lower financial means for medical
treatment of the socially deprived.
1.2.3 Dental History
The patients’ dental history comprises the registration of pre-
vious experiences in terms of dental treatments as well the
current oral problems (chief complaint). Those reports give
us valuable information about previous and existing prob-
lems, positive and negative experiences with the dental treat-
ment, how often a patient visited the dentist, and the patients’
attitude toward past dental treatments. Integration of the
information will give us an overall view of a patient’s attitude
and level of significance about his oral health status. The
patient can report problems with specific types of dental pro-
cedures, which may be modified, if possible, to allow more
comfort [54, 66].
The patient may not spontaneously give the information
that we might need, and it is necessary that the clinician
directs the interrogatory, asking some specific questions in
relation to (thermal) sensitivity or discomfort during chew-
ing, if he presents some type of pain; if he has had any trauma
on the face, infections, lost or fracture of restorations, tooth
fractures, and impaction of food in between the teeth; and if
he presents difficulties during the hygiene or bleeding when
doing the oral hygiene. It should also be asked whether a
patient uses dental floss, and how often, asking information
about the areas that he cannot pass the dental floss or if the
Diagnosis and Treatment Planning
dental floss rips when passing between the teeth. Additionally,
it should be asked whether the patient is satisfied with the
oral esthetic, the shape and color of their teeth, or any other
aspect that he or she may want to point out. In case there is a
report of any problem, complementary exams are used to get
to a specific diagnosis [54, 66]. One example of a question-
naire about the dental history can be seen in . Fig. 1.13 and
 
may be answered by the patient alongside with the medical
history questionnaire.
Tip
The more patient-related information you get, the
more reliable your diagnosis will be.
1.3 Objective Exam
After anamnesis and subjective examination, a clinician con-
ducts the objective clinical examination. Records obtained
from the subjective exam can help to guide the clinical exam,
allowing that the most probable diagnosis is reached [54].
The clinical exam consists of the general evaluation of the
patient, outside and inside the mouth, and the esthetic analy-
sis. From the reports of the subjective exams and the changes
found on the objective exam, the clinician will elaborate a
problem list that needs to be addressed for a complete reha-
bilitation of the patient.
1.3.1 General Aspects and Vital Signals
As soon as the patient enters the office, his general appear-
ance may be observed. He may present as a healthy rather
unremarkable person or present signs of debility, malnutri-
tion, malformation, or signals that suggest a congenital syn-
drome. Deficiency on the general self-care, as the lack of
personal hygiene, can be associated with the lack of compro-
mise on the maintenance of the oral health.
Vital parameters, such as blood pressure and heart rate,
may easily be checked during the first or any follow-up
appointment. Instant blood sugar analysis can indicate the
presence of diabetes. Patients presenting signals or symp-
toms of systemic problems should be referred to a general
practitioner prior to dental treatment, except in case of an
emergency.
1.3.2 Extraoral Exam
Before any intraoral examination, the head and neck region
should be checked first. The exam comprises visual assess-
ment and palpation. Visual aspects can show us sores,
asymmetries, swollen areas, redness, or fistulas. The palpa-
tion of the submandibular and cervical lymphatic glands
can show swelling of lymph nodes, sore or not, hard or with
7 1
mobility, and it can indicate the presence of infections or
neoplasia. Muscles should be palpated, searching for rigid
or sensitive areas. The mastication muscles can present
trigger points that may be related to temporomandibular
disorders. The region of the temporomandibular joint
(TMJ) should be palpated, asking the patient to open and
close the mouth, to verify the presence of pain, clicks, or
crepitation.
1.3.3 Intraoral Exam
During the intraoral clinical exam teeth, soft tissues and peri-
odontal structures are examined.
1.3.3.1 Evaluation of the Soft Tissues
A visual and/or tactile analysis is performed on the cheeks,
lips, palate, dorsum, and, under the tongue, the vestibule
regions, and the tonsils. The presence of ulcer lesions or
nodes, vesicles, or inflammation has to be thoroughly inves-
tigated. In some cases, the dentist is the first to detect infec-
tious and contagious diseases, as well as neoplasia, that can
put the patient’s life at risk. Many infectious diseases present
their first signals inside the oral cavity. Every clinician should
be prepared to diagnose or at least suspect any alterations
and direct the patient to a specialized dentist or doctor for
further analysis [54].
1.3.3.2 Periodontal Evaluation
A thorough periodontal evaluation is essential for all patients,
not only to determine the periodontal situation and its effects
on possible dental restorative treatment plans but also to
establish the potential effect of existing or planned restora-
tions on periodontal health [66]. Also, it is well-known that
many diseases such as diabetes have an impact on periodon-
titis and should therefore be treated. Visually, a healthy gum
is pink and firm, with the attached gingiva presenting the
aspect of an orange peel; in contrast, inflamed gum is usually
red, soft, swollen, and smooth. The depth of the gingival sul-
cus must be verified with a probe. In healthy gums, no bleed-
ing should occur after probing, and the gingival sulcus should
be 1–2 mm deep. The presence of calculus and periodontal
pockets with a sulcus deeper than 3 mm, as is the case with
inflammatory active pockets associated with bleeding, is an
indicator of periodontal disease [54]. The periodontal chart
is a schematic representation of the depth of the periodontal
pockets and should be filled out correctly to determine the
necessity for periodontal treatment (. Fig. 1.15). The calcu-
lation for the gingival bleeding index should be executed and
registered on a clinical chart. Surfaces that present bleeding
are registered, and their percentage in relation to the total
surfaces that were analyzed is calculated. The involvement of
bifurcations on the posterior teeth is evaluated, mobility of
teeth as a result of bone loss or excessive occlusal forces; these
factors should be taken into account when performing risk
assessment for each tooth and when making therapeutic
decisions [54].
 8 C. R. G. Torres et al.
>> A thorough periodontal evaluation is essential for all
1 patients, not only to determine the periodontal situation
and its effects on possible dental restorative treatment
plans but also to establish the potential effect of existing
or planned restorations on periodontal health.
A radiographic exam may be indicated to analyze bone
topography. Then the presence of gingival recession areas
and regions with a small quantity or lack of attached gum is
evaluated, which is registered on the clinical chart. Presence
of biofilm and residues indicates deficiency of oral self-care.
The existence of gingival inflammation impairs dental restor-
ative procedures, because of the difficulty in obtaining a dry
field, risking the success of the treatment; the disease needs
to be controlled and the situation improved before planning
further treatments [54].
The presence of dental restorations with an inadequate
contour can result in periodontal problems. Overcontouring
and the resulting overhangs in the proximal area, due to an
excess of restorative material that pours out during applica-
tion, result in inflammation and pain during cleaning by the
patient (. Fig. 1.5b). Open approximal contacts, particularly
in the posterior region, foster food impaction and increase
biofilm accumulation. These conditions may lead to gingi-
val inflammation, tooth dislocation, increased mobility and
bone loss [54]. In cases of deep caries lesions or necessary
restorative treatment, radiography should be used to estimate
the position of the cavity margin, to assess whether there
will be an invasion of the biological width [66]. Teeth that
need restorative treatment, but have a doubtful periodontal
prognosis, should be noted on the clinical chart and added
to the problem list. Until the diagnosis of this particular
tooth becomes positive, the restorative treatment should be
as minimal as possible, and the treatment plan has to remain
flexible [66].
1.3.3.3 Dentition Evaluation
The dentition is subject to a broad range of alterations, which
can lead to loss of structure, pain, or pulpal symptoms. Others
are related to the formation of dental structures, such as ame-
logenesis and dentinogenesis, the position of a tooth in the jaw
or agenesis. In general, the visual exam should be performed
after air-drying the teeth and under good lightening condi-
tions. Additional isolation of the area during examination can
be achieved with cotton rolls and saliva ejectors. However, cot-
ton rolls may hinder the view on the soft tissues. All teeth
should be clean, without residues of bacterial biofilm and
extrinsic stains, which might require a previous prophylaxis.
Unwaxed dental floss may be passed through all approximal
contact areas. In case the floss rips or tears apart, it indicates a
rough surface, excess restorative material, or cavities.
Tip
Meticulous examination of periodontal conditions is as
fundamental as assessment of the teeth.
Detection of Caries Lesions
Caries lesions are clinical symptoms of the disease “caries,”
resulting from the unbalance of demineralization and rem-
ineralization processes. Early stages impose as subsurface
lesions in the enamel, eventually progressing toward the
dentinoenamel junction (DEJ) and later on into the den-
tine. Surface cavitation occurs at a rather late stage as a
result of mechanical instability. Caries lesions usually prog-
ress very slowly in enamel and take up speed past the
DEJ.  Detection and diagnosis of caries lesions are a chal-
lenging process. On the occlusal site, a seemingly intact
surface can overlay a rather extensive lesion, a phenomenon
that is referred to as “hidden caries.” Examination of inter-
proximal sites is challenging as well, because we do not
have a direct view on the surface. Meticulous cleaning and
air-drying prior to visual examination and utilization of a
validated caries classification are reported to be sufficient
and accurate [26]. However, bitewing radiographs are
extensively used as an adjunct caries detection method.
Bitewing radiographs are highly accurate for cavitated
proximal lesions and suitable to detect dentinal caries
lesions [61]. Although repeated bitewing radiographs may
result in overdiagnosis and hence overtreatment, radio-
graphs are a suitable method for monitoring interproximal
non-cavitated lesions that are treated non-­operatively or
microinvasively.
On root surfaces, especially in patients with periodontal
pockets, lesions can progress fast, affecting the pulp tissue.
Detection of such lesions may be complicated by the pres-
ence of the gingival tissue, and here radiography plays a very
important role, too. Progression of a caries lesion depends on
many variables, for which many detection methods are avail-
able. For detailed information, see 7 Chap. 3.
>> Bitewing radiographs are highly accurate for detection
of cavitated proximal lesions. They are also a suitable
method for monitoring interproximal non-cavitated
lesions that are treated non-operatively or
microinvasively.
Non-carious Lesions
Non-carious lesions result from the loss of dental structure
without the participation of bacterial biofilm. They can be
divided accordingly to its etiology in erosion, abrasion,
abfraction, and attrition, even though in many cases the ori-
gin is multifactorial.
The term dental erosion is used to describe the physical
result of a pathologic, chronic localized, and usually painless
loss of hard tissues that is chemically attacked by acids with-
out the involvement of bacteria [7]. The acids attacking
enamel and later on dentin may be of extrinsic (diet) or
intrinsic (reflux) origin. The acids promote loss of structure
and softening of the surface layer, which is then worn by the
friction of the food bolus or brushing, characterizing the ero-
sive tooth wear (ETW). According to the etiology, the lesions
can be classified as extrinsic, intrinsic, or idiopathic
Diagnosis and Treatment Planning
(unknown origin). As an example of extrinsic acidic sources,
the frequent consumption of sour fruits, low-pH juices or
sodas, sports drinks, and alcoholic beverages is to be men-
9 1
typical signs. In advanced situations, the morphology may
completely transform into concave surfaces. Restorations are
not affected and become exposed (. Fig. 1.1b). On smooth

tioned. Other sources are the work environment (as indus-
trial acids), pool water, and some medication as effervescent
tablets of vitamin C (. Fig. 1.1a) may be the cause for dental
 
erosion. The main characteristic of ETW is the loss of con-
tour and natural surface morphology. On occlusal surfaces,
the flattening of the structures and cupping of the cusps are
surfaces, typical characteristics are surface flattening and an
intact rim of enamel along the gingival margin. Concavities
usually wider than deep can be observed in some cases [33].
>> Non-carious lesions result from the loss of dental
structure without the participation of bacterial biofilm.

a b

c d

e f

..      Fig. 1.1  Non-carious lesions. a Dental erosion caused by the very d erosion of the lingual surfaces because of regurgitation of gastric
frequent ingestion of lemonade; b erosion resulting from the abusive acid; e abrasion by excessive brushing; f, g abfraction on anterior and
ingestion of cola based soda; c erosion on the tip of the cusps on posterior teeth; h, i intense attrition in patient with bruxism
patients with gastroesophageal reflux associated with attrition;
 10 C. R. G. Torres et al.
1 g
..      Fig. 1.1 (continued)
As example of the intrinsic source, gastric acids produce an
erosive challenge during vomiting, constant regurgitation, or
reflux. The gastric acid has a pH of 1–1.5 and hence is much
lower than the critical pH for enamel dissolution. Intrinsic
erosive challenges are associated with psychosomatic disor-
ders or psychogenic eating disorders, such as nervous
anorexia or bulimia. Somatic causes comprise pregnancy,
alcoholism, treatment for alcoholism and gastrointestinal
dysfunction, hiatus hernia, peptic and duodenal ulcers, and
gastroesophageal reflux. Dental erosion due to chronicle
regurgitation often hits the internal region of the arches, cor-
responding to the track of the regurgitated acid over the dor-
sum of the tongue, along the palatal surfaces of the maxillary
teeth and the occlusal sites of the posterior mandibular teeth
(. Fig. 1.1c, d) [7]. Even though it may affect the occlusal and
 
lingual surfaces of every maxillary tooth, it is confined to the
buccal and occlusal sites of the mandibular premolars and
molars. Buccal surfaces of maxillary teeth are usually not
affected, and the posterior teeth are protected by the neutral-
izing saliva from the parotid gland. Lingual surfaces of the
mandibular teeth are covered by the tongue and thereby pro-
tected from the acidic challenge [7].
Eliminating or reducing the causative factor, i.e., the
source of acid, is crucial for patients with erosive problems.
This can include medical treatment for any intrinsic prob-
h
lem. Some studies suggested that those patients should not
brush their teeth immediately after acid exposure, although
others did not confirm this recommendation. The tooth-
brush should have extra soft bristles, and the toothpaste
should contain little abrasive substances. Additionally,
fluoride-­containing mouth rinses may be used on a regular
basis. A neutral 2% sodium fluoride gel or 5% fluoride var-
nish can be applied on dental visits. The use of sugar-free
chewing gums can stimulate salivary flow. Deeply eroded
lesions might benefit from a mechanical barrier against acid
attacks by adhesive restorations [46]. Dentin sealants also
seem to be rather resistant against erosive conditions and
might serve as an intermediary treatment option for exposed
dentin surfaces [6]. Acidic drinks should not be held in the
mouth, especially not being “swished” around the teeth.
Using a non-plastic straw will minimize the fluids’ contact
time with the teeth and save our environment at the same
time.
>> Eliminating or reducing the causative factor, i.e., the
source of acid, is crucial for patients with erosive
problems.
Abrasion is defined as tooth wear induced by substances or
objects other than food. Tooth brushing is the main etiologi-
cal factor of abrasion depending on tools, dentifrices, and
Diagnosis and Treatment Planning
techniques used for the cleaning procedure (. Fig. 1.1e). In
 
addition, the type of material, hardness of the bristles,
whether these bristle tips are rounded or not, and their flex-
ibility have an impact on abrasive wear, as well as abrasivity,
pH, and the quantity of toothpaste used [28].
Abfraction derives from the Latin word frangere which
means to break. It is used to describe the specific wedge-­
shaped defects in the cervical region, resulting from occlusal
forces applied to the tooth, leading to its flexion (. Fig. 1.1f g,
 
g). Parafunctional forces especially during lateral movements
of the mandible expose teeth to intense flexion and shear
forces, resulting in substance loss in the cervical region,
which is the weakest part of the tooth. Lesions are located on
the CEJ, caused by microfractures on the enamel, growing
perpendicularly to the long axis of the affected tooth. The
resulting damages have the wedge shape and sharp edges [7].
The incisal/occlusal wall generally has sharp cavosurface
angles, forming a right angle to the external tooth surface.
The gingival cavosurface angle are located on the root surface
[33]. Apart from dynamic occlusion parameters, the use of
hard toothbrushes and a horizontal brushing technique are
frequently associated with the occurrence of non-carious
cervical lesions [30].
Differential diagnosis and origin of non-carious cervical
lesions is not always unequivocal. There is a high chance
that a lesion’s etiology has more than one origin; however,
some fundamental properties can be observed. Abrasive
lesions are more frequently on the buccal surfaces and above
the gum, while abfractions can be located partially or com-
pletely under the gum. The abrasive lesion is characterized
by a rather shallow and rounded morphology, whereas
abfractions have a wedge shape with sharp edges. Abrasions
usually involve many neighboring teeth, while the abfrac-
tion can occur in just a single tooth. Abfraction is always
associated to some occlusal interference, while the abrasion
is not necessarily accompanied by an occlusal interference.
As abrasion intensifies structural loss of a tooth under ero-
sive conditions. Erosion and abrasion may be important
secondary factors on the progression of lesions induced by
the abfraction. It is important to control the etiological fac-
tors of non-carious cervical lesions, because restorations
will be subjected to the same factors that initially caused the
lesion [7].
>> Differential diagnosis and origin of non-carious
cervical lesions is not always unequivocal.
Depending on the size, location, and presence of sensitivity,
treatment of non-carious (cervical) lesions particularly con-
sists of controlling the etiological factors. Additionally, this
causal therapy can be flanked by the use of desensitizers or
ultimately the restorations of these lesions. The restorations
should be placed when the lesion is active, and non-­operative
treatment is not capable to arrest the lesion. A restoration can
be advantageous when the structural tooth integrity is com-
promised, there is a risk of pulp exposure, or the defect is
11 1
esthetically unacceptable for the patient. Further indications
for restorations may be remaining dentin sensitivity after
non-­operative care, periodontal problems, the use of the
tooth as an abutment for prosthesis or due to caries lesions
[7, 54]. Restorative procedures in the cervical part of a tooth
are demanding, since moisture control and contouring might
be challenging. The indication should thoroughly be weighed
against potential disadvantages, especially for periodontal
health.
Attrition is defined as wear by tooth-to-tooth contact
without the impact of any other substance. It can result from
physiological or pathological etiological factors. Physiological
wear is considered a slow degradation of the dental shape,
manifested as a flattening of the tips of the cusps in posterior
teeth and the incisal curve of the anterior teeth (. Fig. 3.16c, d)
[66, 70]. Characteristic features are opposing wear facets
with sharp margins. When the wearing becomes excessive, it
may be related to pathological causes. Excessive attrition is
primarily caused by bruxism that will result in facets on the
opposing teeth (. Fig. 1.1h, i). Since elimination of the para-
functional habits is very hard to achieve, occlusal acrylic
resin splints are used to prevent the patient from further
tooth wear. The clinician has to identify patients with exces-
sive tooth wear, especially younger individuals. Significant
attrition areas that resulted on exposition of dentin and pres-
ent sensibility or discomfort might be considered for restor-
ative treatment. However, a previous analysis of the occlusion
and the causal factors of the wearing should be carried out
previously [54].
The resulting wear of an antagonistic tooth against a res-
toration very much depends on the restorative material used.
Wear analysis showed that amalgam would cause a slightly
increased wear to the opponent tooth [66]. Microfilled com-
posites result in wear similar to the enamel, while hybrid
composites generate a slightly increased wear compared to
enamel. The microhybrid and nanofilled composites seem to
induce a similar wear than the enamel. Cast gold restorations
are usually softer than enamel and amalgam, resulting in less
wear of the antagonistic tooth. Feldspar ceramics produce
extensive antagonistic tooth wear; however, modern dental
ceramics are significantly less abrasive [66].
It is not rare to have patients complaining of sensibility
on the root surface, characterized by an acute pain, gener-
ally associated with a gingival recession and exposition of
the cementum or dentin. The most accepted theory to
explain this phenomenon is called the hydrodynamic the-
ory, claiming that pain results from the movement of fluids
inside the dentinal tubules, stimulating the mechanical
receptors within the pulp tissue [14]. Fluid movements may
be initiated by thermal changes, air-drying, osmotic pres-
sure, or mechanical contact. Any treatment that reduces
this movement of fluids closing the tubules partially or
completely can help to reduce the sensitivity [50]. Further
details relative to dentine sensitivity can be obtained in
7 Chap. 18.
 12 C. R. G. Torres et al.
Tip
1 the cracked tooth. Cracked teeth mostly respond to vital-
The clinical management of non-carious cervical
lesions should always include elimination or reduction
of the causative factors rather than just restoring the
defect.
Pulpal Diseases
Unhindered progression of a caries lesion may lead to
pulpal symptoms which manifest as pain and at a later
stage can turn into pulpal inflammation and necrosis.
Patients with pulpal diseases consult the dentist because
they suffer from pain. Non-symptomatic necrosis of the
pulp is frequently overseen or incidentally detected on a
radiograph. Partial removal of the pulp (pulpotomy) can be
a sufficient therapy for reversible forms of pulpitis or expo-
sure of the pulp during caries excavation. Irreversible
pulpal inflammation and pulpal necrosis however require
endodontic ­ treatment of the entire root canal system.
Pulpal diagnosis is primarily based on reported symptoms,
the reaction to thermal and percussion tests and ultimately
radiographic examination. Conducting pulp sensitivity
testing on each tooth is not recommended. However, teeth
with a symptomatic history, questionable periapical radio-
graphic findings, or those considered for restoration might
be tested for signs of pulpal vitality. It is embarrassing for
both clinician and patient to discover that a recently
restored tooth had a necrotic pulp before the treatment and
becomes symptomatic after it [66]. A more detailed
description about diagnosis of the pulpal alterations can be
found in 7 Chap. 9.
Dental Integrity and Fractures
When submitted to occlusal load, dental cusps tend to
undergo deflection, which is strongly increased when a
restoration is present. The greater the amount of sub-
stance loss, the bigger the cuspal deflection will be. The
quantity of movement depends on the intensity of the
force acting on the tooth. The force is determined by the
muscular strength of the individual and correlates with
parafunctional activities such as bruxism, clenching, and
grinding. Under the influence of repetitive loads, cusps
suffer fatigue and may happen to fracture, losing that por-
tion of the dental structure. Cracking of a tooth as a result
of mechanical overload oftentimes cannot be visually
detected, originating a painful process called “cracked
tooth syndrome” [42]. When cracked teeth are submitted
to masticatory or occlusal loads, the crack line opens,
resulting in movement of the dentinal fluid. According to
hydrodynamic theory, this movement can cause pain.
Patients generally report acute and sharp pain, upon load-
ing and unloading forces, usually when chewing hard or
granulated food. The patient is usually capable to localize
ity tests and can present sensitivity when eating cold, hot,
sweet, or acidic food. Usually no alterations can be seen
radiographically; teeth are either clinically intact or
restored. Diagnosis is performed with a device that allows
placing pressure on each cusp separately or by removing
the restoration and inspecting the cavity wall. Dye can be
applied into the cavity in attempt to visualize a potential
crack. For more details about the cracked tooth syndrome,
see 7 Chap. 18.
>> Cracking of a tooth as a result of mechanical overload
oftentimes cannot be visually detected, originating a
painful process called “cracked tooth syndrome.”
Complete tooth fractures can be due to trauma or progres-
sion of a crack. It should be verified which tissues are
involved, as the fractures may be having affected the enamel,
enamel/dentin, enamel/dentin/pulp, or enamel/dentin/pulp/
periodontal tissues. Fractures that involve only the enamel or
the enamel and the dentin can usually be treated with resto-
rations. Fractures involving the pulp may need an appropri-
ate endodontic treatment. Preserving vitality of the pulpal
tissue is preferred whenever feasible and particularly in cases
with incomplete root formation. Fractures involving peri-
odontal structures, including infrabony defects, may need
surgical crown lengthening or an orthodontic extrusion
therapy prior to restoration. Root fractures may occur as a
side effect of endodontic treatment or due to trauma. Detec-
tion and treatment of such fractures is challenging, and these
cases are often called hopeless. Multidisciplinary approaches
in terms of combined orthodontic, surgical, and restorative
treatment can lead to complete rehabilitation of complicated
crown-root fractures. . Figure  1.2a–d shows examples of
cracks and fractures in anterior and posterior teeth. For
details, see 7 Chap. 14.
Shape and Position Abnormalities
Teeth can present deviations in shape or size. Such alterations
can have genetic origins, such as conical teeth, dens in dente,
and microdontia or can be related to infectious diseases dur-
ing odontogenesis period, such as congenital syphilis that
results in in screwdriver-shaped incisors (Hutchinson inci-
sor) or mulberry molars. Disproportion between tooth size
and size of the jaw can result in crowding or dental gaps
called diastema. Gaps are usually closed with orthodontic
procedures. In some cases, remaining gaps particularly in the
anterior region can be corrected with direct or indirect resto-
rations. Transposition or ectopic eruption describes the phe-
nomenon when teeth do not erupt at their predetermined
position within the jaw. Missing teeth may occur due to
agenesis or avulsion, bearing the potential risk of adjacent
tooth migration (. Fig. 1.3a–i).
Diagnosis and Treatment Planning
13 1

a b

c d

..      Fig. 1.2  Dental fractures. a, b Cracks and fractures on the anterior teeth; c, d cracks and fractures on posterior teeth

a b

c d

..      Fig. 1.3  Abnormalities on the shape and position. a Diastemas incisor; d, e dens in dente; f anodonty of the lateral incisors; g left maxillary
between anterior teeth; b cone-shaped right lateral maxillary incisor; c canine positioned in place of the lateral incisor; h hypoplasia of the enamel
transposition of the maxillary canine on the place of the right lateral on the incisal third of the anterior teeth; i imperfect amelogenesis
 14 C. R. G. Torres et al.

1 e f

g h

..      Fig. 1.3 (continued)

Color Changes the enamel surface. For example, staining can be observed
Most patients are unsatisfied with their tooth color and feel after regular coffee or tea consumption and tobacco smoking,
esthetically impaired. Consequently, the desire for tooth whit- due to ingestion of iron-containing vitamin compounds or
ening is among the most often heard demands when assessing from chromogenic bacteria in the biofilm (. Fig. 1.4a). Some
 

the patients’ chief complaints. Color changes can be of extrin- substances capable to cause extrinsic discoloration can also
sic or intrinsic origin. Extrinsic staining is frequently caused penetrate to some extent into the tooth, resulting in a mostly
by food and beverages, where chromogenic agents attach to yellowish appearance. Intrinsic staining occurs when chro-
Diagnosis and Treatment Planning
mophores are incorporated into the hard tissues during tooth
development or caused by conditions acquired later in life,
such as endodontic treatment, dental trauma, or caries. In
15 1
In cases where tooth whitening is not sufficient to fulfill
the patients’ need, veneers may be an option to enhance the
anterior teeth esthetics, a procedure described in 7 Chap. 17.

most cases application of an oxidant bleaching agent is the

therapy of choice, like hydrogen peroxide or carbamide per-
oxide, diffusing into the enamel and dentin and breaking the
chromophores, leaving the tooth with a significantly lighter
appearance. Tooth whitening can be performed at the dental
office or at home, in a single visit or over a longer period.
Peroxide concentrations vary considerably among products
and are strictly limited in several countries.
>> Most patients are unsatisfied with their tooth color and
feel esthetically impaired. Consequently, the desire for
tooth whitening is among the most often heard
demands when assessing the patients’ chief complaints.
Some people have naturally darker teeth than others do.
Intrinsic color changes can be caused by problems during
tooth formation. Excess of fluoride intake can result in hypo-

a b

c d

e f

..      Fig. 1.4  Color changes of tooth structure. a Extrinsic staining due to trauma and intrusion of the deciduous teeth; g, h darkening of tooth
to smoking; b dental fluorosis; c, d amelogenesis imperfecta; e staining 22 by pulp calcification after the orthodontic traction. i Darkening of
due to ingestion of tetracycline; f hypomineralization on enamel due the tooth 11 due to pulpal necrosis after trauma at the region
 16 C. R. G. Torres et al.
..      Fig. 1.4 (continued)
1 g
mineralization during enamel formation, resulting in whit-
ish areas of enamel, up to a surface with porosities or pits
in the more severe situations (. Fig.  1.4b). This side effect
 
of a chronic fluoride overdose during tooth formation is
called dental fluorosis. Different in origin, amelogenesis and
dentinogenesis imperfecta result in great esthetic problems,
which may require extensive operative care (. Fig.  1.4c,  d).
 
When ingested during odontogenesis, tetracycline, an
antibiotic widely used in the past, deposits itself inside the
dental structure and results in horizontal striped pattern
(. Fig. 1.4e).
>> Excess of fluoride intake can result in hypominer-
alization during enamel formation, resulting in whitish
areas of enamel up to a surface with porosities or pits
in the more severe situations.
Trauma or infection in deciduous teeth can result in hypo-
mineralization or hypoplasia in the following permanent
teeth (. Fig.  1.4f). Trauma or orthodontic movements can
 
result in dystrophic calcification of the pulpal tissue, also pro-
moting dental darkening (. Fig.  1.4g, h). In other cases,
 
trauma can lead to pulpal necrosis, which decomposition
products darken the crown (. Fig. 1.4i). As mentioned above,
 
aging as a natural process results in darkening of teeth because
of a higher degree of dentin mineralization and the enamel
becoming thinner and more translucent at the same time.
h
It should be noted that in cases where dental bleaching is
included in the treatment plan, it should precede any restor-
ative procedure on anterior teeth. A washout phase of mini-
mum 2 weeks should be observed after the bleaching, to
allow the color stabilization and peroxide release from inside
the tooth structure. Besides, the patient should be informed
that restorations and existing prosthetic appliances will not
be bleached and probably need to be replaced afterward.
Tip
Most patients are dissatisfied with their tooth color.
Therefore, whitening procedures should be part of the
portfolio of modern dentists.
Analysis of Existing Restorations
The decision whether to keep or to replace an existing resto-
ration is a demanding process in everyday routine.
Overtreatment, in terms of random or premature replace-
ment of an existing restoration, would invariably result in an
unnecessary removal of the tooth structure, including the
risk of accidental pulp exposure. Re-dentistry, i.e., replace-
ment of restorations, is reported to be the dentist main duty
[47]. The diagnostic process and decision tree in favor or
against restoration replacement should be primarily based on
Diagnosis and Treatment Planning
health risks for the patient and always be a result of a shared
decision-­making process [37]. From an ethical point of view,
it is inacceptable that clinicians take decisions for their
patients and even worse without providing any justification.
Therefore, transparent findings and diagnoses as well as
patients’ preferences should be the basis in the decision-mak-
ing this process.
>> The decision whether to keep or to renew an existing
restoration is a demanding process in everyday
routine. Overtreatment in terms of random or
premature replacement of an existing restoration
would invariably result in an unnecessary removal of
the tooth structure, including the risk of accidental
pulp exposure.
>> Transparent findings and diagnoses as well as patients’
preferences should be the basis in the decision-making
this process.
Clinical assessment of restorations should be carried out
under dry and well-illuminated conditions, isolated with cot-
ton rolls and saliva ejectors. The clinician first may visually
inspect the restoration, followed by a tactile examination
with an exploratory probe and probably the use of dental
floss. Bitewing radiographs can yield additional information
in particular areas that cannot be assessed clinically.
For evaluation of amalgam restorations, many conditions
should be observed, such as transparency through the enamel,
marginal integrity, fracture lines, improper anatomic shape
(overcontour, undercontour, proximal overhangs, inappro-
priate height of the marginal ridge relative to the adjacent
tooth, and inadequate interproximal contacts), recurrent car-
ies, inadequate occlusal contact, undesirable surface rough-
ness, and violation of the biological width [54, 66].
Facial walls of proximal boxes of the Class II preparations
happen to be very thin in many cases and not supported by
dentin. Due to enamel translucency, shining through
­amalgam restorations may impair the esthetics. However,
this does not necessarily indicate that the restoration needs
to be replaced, unless it is among the patient’s chief complaint
(. Fig. 1.5a) [54]. When there is no apparent marginal degra-
 
dation, the discoloration appears gray or blueish. However,
when the discolored area is yellow or brownish, and it seems
to have communication with the cavosurface margin, pres-
ence of a caries lesion in the interface is likely, indicating a
health risk for the patient. Consequently, replacement of this
restoration should be discussed with the patient [66].
Proximal overhangs, because of inadequate use of the
matrix and wedge system during restoration, create condi-
tions favorable for biofilm adhesion and niches that are dif-
ficult to access during oral hygiene (. Fig. 1.5b). Diagnosis of
 
such overhangs is usually performed with radiographs and
the use of an exploratory probe or dental floss. The clinician
can try to remove the excess of restorative material with a
steel abrasive strip or with an oscillating diamond-coated file
(EVA system) in a handpiece (. Fig. 4.36). However, in most
 
cases, replacement of the restoration may be necessary.
17 1
The margins of the restorations may be examined with an
exploratory probe, moved perpendicularly to the interface
tooth restoration. It should be moved from the restoration
toward the dental surface and the other way round, working
along the whole margin [70]. In case the explorer gets stuck
from the tooth toward the restoration, there is an excess of
restorative material, which can be removed by finishing and
polishing (. Fig. 1.5c). In case it gets stuck from the restora-
tion toward the tooth, there is a lack of material. It should be
evaluated whether these margins are accessible to oral
hygiene and whether dentin is exposed. The latter may be an
unfavorable condition and be considered for either repair or
replacement of the restoration.
When the probe gets stuck both ways, there is a ditch on
the interface [66]. Marginal ditching is a result of wear or
fractures, either in amalgam or in the enamel, mostly due to
improper cavity preparation (. Fig. 1.5d, e). The presence of
marginal ditching does not necessarily implicate the presence
or an increased risk for developing a caries lesion [35].
Corrosion products of amalgam may seal the interface and
keep the restoration intact for a long time. Ditches going deep
into the interface, with or without dentin exposure, may
increase the risk of biofilm accumulation and secondary car-
ies. It should be weighed out whether marginal sealing, repair,
or entire replacement of this restoration would increase tooth
longevity and enhance the patients’ quality of life.
The occlusal surface of a restoration is examined thor-
oughly for fracture lines (. Fig. 1.5f). Fractures mostly occur
in the isthmus region, between the occlusal and proximal
boxes or where the cavity is rather shallow or irregular, caus-
ing the restorative to fracture. In general, fractures mostly
result from an incorrect cavity preparation. In cases where
restorations have been repaired, the junction between the old
and new amalgam can be visible, similar to a fracture line. In
other situations, parts of the fractured restoration have been
lost (. Fig. 1.5g, h). In some cases, the restoration is still in
place, but the remaining tooth structure fractures (. Fig. 1.5i).
This usually happens when the remaining tooth structure is
too fragile and likely to fracture under occlusal load.
The restoration should mimic the individual anatomical
shape of the intact tooth structure, to allow optimal esthetics
and function. Therefore, height and volume of the restored
cusps will guarantee adequate chewing efficiency avoiding
extrusion of the antagonist (. Fig.  1.5j). Location of the
height of curvature on the buccal and lingual surfaces is also
very important because it deflects the food bolus, so that the
passing food may stimulate the gingival tissues. Restorations
with under or overcontour on the buccal and lingual surfaces
can result in gingival lesions [54]. Undercontouring may
cause food impaction over the gingival tissue, resulting in
gingival inflammation or recession in the worst case.
Overcontouring deflects food from gingiva and results in
understimulation of the supporting tissues, promoting the
deposit of biofilm in the cervical region and gingival inflam-
mation [54].
The marginal ridge of a restoration should be adjusted to
the height of the adjacent tooth, creating adequate occlusal
 18 C. R. G. Torres et al.

embrasures that allow the passage of food toward the buccal
1 and lingual surfaces. Adequate marginal ridges allow proper
contact of the opposing tooth in an occlusion of 2:1. Marginal
ridges of neighboring teeth at a different height may cause
food impaction, resulting in gingival inflammation.
Furthermore, the patient may face difficulties when using
dental floss [54]. The proximal contact area of Class II resto-
rations should be located in the occlusal third of the proximal
surface, with an occlusal embrasure to allow the insertion of
dental floss and a tightness to avoid food impaction.
>> The proximal contact area of Class II restorations should
be located in the occlusal third of the proximal surface,
with an occlusal embrasure to allow the insertion of
dental floss and a tightness to avoid food impaction.
The restored proximal surfaces should present a natural
convex contour, to guarantee the formation of a perfect
contact area with the convex surface of the adjacent tooth.
However, when a proximal carious cavitation remains
unrestored, adjacent teeth might show the tendency to drift

a b

c d

e f

..      Fig. 1.5  Analysis of the amalgam restorations. a Visualization of degradation exposing the dentin; f fracture line. g, h Fracture in the
the amalgam by translucency; b cervical overhang (arrow); c excess on restoration body; i fracture of the remaining cusp; j mesiolingual cusp
the margins of the proximal restorations (arrow); d marginal degrada- in amalgam with inadequate height; k inadequate proximal contour;
tion being checked with an exploratory probe; e intense marginal l restoration with open proximal contact
Diagnosis and Treatment Planning
19 1

g h

i j

k l

..      Fig. 1.5 (continued)

into the open cavity (. Fig. 6.21a, b and . Fig. 1.5k). Restor-

   
ative treatment without previous orthodontic treatment
most likely results in a concave contact area, which is unac-
ceptable for reasons outlined above. Therefore, orthodontic
movement of these teeth, for instance, with the help of
separation rubbers, is needed before a final restoration is
placed.
Open interproximal contacts may foster food impaction
resulting in discomfort, increased biofilm deposit, and
hence gingival inflammation and tooth migration
(. Fig.  1.5l). On the other hand, the contact point should
 
not be too tight, in order to avoid the shredding and impac-
tion of dental floss fibers or periodontal trauma induced by
excessive force applied during flossing [36]. In situations
where repair of the restoration will not be the solution, the
total replacement would be necessary. The interproximal
contacts are best evaluated with waxed dental floss, explor-
ing its resistance when passing through the contact area,
and using a dental mirror in many angulations, keeping it
on the lingual position and observing the teeth from the
buccal aspect, reflecting the light to the contact region, so
that the clinician can see whether there is space in-between
the teeth. For that, the contact area should be dry and free of
saliva [54]. Creating an anatomic contact point is an impor-
tant quality factor of a restoration and should be paid par-
ticular attention.
 20 C. R. G. Torres et al.
Tip
1 degradation, but also due to color mismatch of the compos-
Creating an anatomic contact point is an important
quality factor of a restoration and should be paid
particular attention.
Many restorations show some defects in relation to the ana-
tomic shape, but they provide adequate clinical function and
do not require replacement. When considering the replace-
ment of an existing restoration, it is crucial whether this res-
toration has caused damage or is likely to be a risk for the
patients’ health.
The presence of recurrent caries on marginal areas is
detected visually and/radiographically. It is common to find
secondary caries lesions in regions where marginal gaps
occur in gingival walls, and those indicate replacement [54].
Lesions on the buccal or lingual walls are generally not
detectable in radiographic images due to superposition of the
radiopaque restorations. For details about diagnosis of caries
lesions, see 7 Chap. 3.
 
Occlusal contacts of a restoration are evaluated to
determine whether they are serving its chewing function,
without causing a symptomatic or pathogenic occlusion. In
the absence of gingival inflammation, a traumatic occlu-
sion does not trigger bone loss. However, in the presence of
a periodontal disease, the traumatic occlusion may inten-
sify progression of the disease and bone resorption.
Restorations with traumatic occlusal contacts should be
adjusted or replaced. On the other hand, restorations with-
out occlusal contact may foster overeruption of the antago-
nistic tooth [66].
The desirable surface roughness of a restoration should
be similar to the intact tooth surface, giving the patient com-
fort and preserving gingival health. Rough areas, next to the
gingival margin, promote an increased biofilm deposit and
should be repolished. On damaged restorations, polishing
may not be efficient, and replacement is supposedly the best
solution. Restorations with gingival margins violating the
biological width are associated with gingival inflammation
and bone resorption. Surgical crown lengthening is indicated
when the cervical restoration margin invades the connective
tissues [20].
Cast metallic restorations should essentially be evaluated
the same way as amalgam restorations. However, they hardly
suffer from external degradation, and the main problems
happen in the marginal region. Other than amalgam that
tend to fracture when extended secondary caries is present,
they do not present any visual signals unless the restoration is
displaced.
Direct tooth-colored composite restorations and indirect
ceramic or composite restorations should be assessed analo-
gously. Other than metallic restorations, color match is a
quality parameter here. It is highly appreciated to have resto-
rations not clearly discernable as such that perfectly blend
into the natural dentition. Some restorations present an
unsatisfactory color match because of extrinsic staining or
ite or inadequate translucency (. Fig. 1.6a). In regular hybrid
composite materials, wear of the organic matrix exposes the
filler particles, resulting in a dull appearance of the restora-
tion (. Fig. 1.6b, c). Usually surface repolishing is sufficient
to bring back the lost gloss. However, depending on the
patients’ diet, consumption of staining substances or tobacco
smoking, there might be a tendency toward superficial stain-
ing of the restoration. Color mismatch per se is not a bio-
logical hazard; therefore, it is solely incumbent upon the
patient whether they feel impaired or not. Change in color
may also be the result of the degradation of the polymeric
matrix, usually an indication for restoration replacement
(. Fig. 1.6d–f).
Marginal staining is an indicator that there are marginal
gaps at the tooth restoration interface associated with micro-
leakage. These can be superficial and not influence the esthet-
ics, or intense, extending deep into the interface. Most
superficial stains can be eliminated by repolishing, while the
deeper ones might need repair or even replacement of the
restoration (. Fig. 1.6g, h). The presence of a marginal stain
does not always indicate the need for replacement, unless
there is an esthetic impairment that cannot be solved by pol-
ishing or when a secondary caries lesion is present
(. Fig.  1.6i). Opaque areas, along the cavity margins, and
underlying dark shadows may indicate a carious process
underneath the restoration alongside the cavity walls. Usually
these lesions are active because the ecosystem is nearly sealed
and inaccessible to oral hygiene. Progression therefore can-
not be controlled, which is potentially detrimental for the
hard tissues and tooth vitality [66]. Bacterial growth has been
shown to progress faster under composite resin restorations
than under amalgam and glass ionomer [67]. However, mar-
ginal gap size needs to pass a threshold of approximately
200  μm to allow sufficient fluid exchange for bacterial sur-
vival under the restoration [60].
Requirements of the anatomical shape, including contact
points, marginal ridges, and shaping of buccal and lingual
surfaces that were earlier described, also apply for composite
and indirect restorations. (. Fig. 1.6j–l).
The esthetic assessment of a restoration performed by a
dental professional may differ from the patient’s perspec-
tive. As we strive to establish a collaborative partnership
with our patients and oblige ourselves to respect patients’
autonomy, it is self-evident that patients exclusively decide
whether they suffer from esthetic impairment of a restora-
tion or not. What seems perfect in the eyes of a profes-
sional does not necessarily reflect the individual’s
perception and vice versa. If the patient voices dissatisfac-
tion, the dentist should evaluate quantifiable medical rea-
sons and whether there is a chance of improvement and
how this can be achieved. First, the reasons why restora-
tions have an unfavorable esthetic result should be deter-
mined. Probably the reason for an esthetic failure is not
the restoration itself but the shade or discoloration of the
Diagnosis and Treatment Planning
remaining tooth. In this case, replacement may lead to a
restoration with the same unsatisfactory result. In case a
restoration is medically impeccable from the dentist’s but
unpleasant from the patient’s perspective, we have to per-
ceive patients’ concerns notwithstanding. When we intend
to replace a restoration because of mere esthetic matters,
the clinician needs to inform the patient in detail about
21 1
risks and side effects, for instance, additional preparation
of the tooth may lead to pulpal symptoms or even an acci-
dental pulp exposition [66].
>> What seems perfect in the eyes of a professional does
not necessarily reflect the individual’s perception and
vice versa.

a b

c d

e f

..      Fig. 1.6  Defects on composite restorations. a Improper restora-
tions by the lack of the color match; b large class IV restorations
performed on the central incisors with hybrid composite at the 6th
year recall, with satisfactory shade but lost of the surface gloss; c class I
restorations with loss of gloss and rough surface; d–f color changes in
the body of the restoration. g, h Marginal staining due to lack of
marginal sealing; i deep marginal staining with a darkened aspect
under the restoration; j restoration with inadequate color/translucence
match and anatomic shape; k overhang of restorative material
trespassing the contour on the buccal surface of the first molar;
l aspect of gingival inflammation immediately after the overhang
removal
 22 C. R. G. Torres et al.

1 g h

i j

k l

..      Fig. 1.6 (continued)

Tip the treatment plan [66]. In complex cases, occlusion analysis

Always remember that a patient’s perception may differ
significantly from that of a clinician and medical
requirements may vary too.
1.3.3.4 Occlusal Analysis
Before planning restorative treatment, it is advisable to ana-
lyze the occlusal conditions. Any interferences of intended
restorations on the occlusion should be considered before-
hand, as well as the impact occlusal conditions will have on
is preferably performed on plaster models.
>> Before planning restorative treatment, it is advisable
to analyze the occlusal conditions.
The static occlusal analysis should be registered in maximal
intercuspation, including the vertical relation of molars and
canines (Angle’s Classes I, II and III), including overbite and
overjet. The absence of teeth, migration and inclination of
crowns, as well the presence of turned or overlapped teeth
should be registered. Midline shift of the mandible and the
maxilla and the shape of the occlusal plane are to be registered.
Diagnosis and Treatment Planning
Functional evaluation of the dynamic occlusion, during
lateral movements to the right and left as well as protrusion,
should be executed. Additionally, the difference between
position of the jaw in centric relation and centric occlusion is
evaluated. During lateral movements, disocclusion guide is
registered as to canine or group guide and how much ante-
rior guide is involved. Contacts that may interfere on the
non-working side need to be identified and possibly adjusted.
The presence of deviation during opening or temporoman-
dibular joint (TMJ) cracking is regarded as a potential indica-
tive for temporomandibular disorder [54].
The reasons of abnormal occlusal surface wear need
to  be explored. Most probably, the underlying causes are
parafunctional habits such as bruxism. Matching wear fac-
ets on the opposing teeth because of parafunction or a gen-
eral wear on the occlusal surface can be noticed. The
treatment of those patients may include the use of protec-
tive occlusal splint so that the further tooth wear is slowed
down. Results of the occlusal analysis are registered on a
clinical chart and included for treatment planning
(. Fig.  1.14). Positive aspects of the occlusion need to be
 
preserved and should not be altered during treatment.
However, improvement of the occlusal relation is desired,
and abnormalities should not be perpetuated on the restor-
ative treatment [54, 66].
Number and position of the occlusion contacts in the
position of maximal intercuspation, intensity of the biting
force, and the way that the opposing teeth occlude and disoc-
clude on excursive movements may influence the choice of a
restorative material. When the occlusal stress is high, the
dentist rather selects restorative materials that are more resis-
tant, performing the restorations in a way that they can allow
more strength on the load areas [66].
1.3.4 Esthetic Evaluation
During clinical examination, it is fundamental to explore the
patients’ estimate of dental esthetics. According to Rufenacht
[58], the smile represents the most primitive and purest form
of communication between human beings, appearing in the
early youth, observable already in babies. A smile as all facial
expressions transmit feelings and emotions. A pleasant smile
can produce an aura that improves the beauty of a face, and it
is part of the qualities and virtues of the human personality.
The perception of those qualities generates the power of attrac-
tion, a necessary component for success in our society [58].
>> According to Rufenacht [58], the smile represents the
most primitive and purest form of communication
between human beings, appearing in the early youth,
observable already in babies.
As beauty is primarily a matter of personal taste, modified by
social norms, its visualization is a subjective experience [66].
However, some objective parameters can be used to identify
the most expressive changes that may compromise oral
esthetics. Many characteristics of teeth and gingiva, such as
23 1
..      Fig. 1.7  Relation of the occlusal frontal line, commissural line,
interpupillary line, and the facial midline
tooth dimension, clinical crown width-to-length ratio, color,
shape, and gloss, among others, as well as gingival shape,
contour, embrasure, zenith, and height (position or level), are
part of what is called microesthetics. These parameters can-
not be analyzed separately, although being very important to
result on a pleasant smile (miniesthetics) but in association
with a harmonious face (macroesthetics) to result in good
self-esteem (hyperesthetics) [13].
Dental and gingival esthetics are inseparable to create a
pleasant smile. Therefore, good restorations cannot compen-
sate for (esthetic) problems of the surrounding soft tissues
[41]. The opposite turns out to be true as well. The most com-
mon esthetic problems are changes in tooth color, contour-
ing of anterior teeth (length, width, incisal edge shape, and
axial contour), unesthetic position or space between the
teeth, caries lesions or defective restorations, excessive buccal
corridor space, a gummy smile, etc. [66].
Apart from these factors, asymmetry creates visual ten-
sion on the observer side. The occlusal frontal plane or line is
a connection between the tips of both maxillary canines. This
line should be parallel to the interpupillary line and to the
line that connects both labial commissures, the commissural
line (. Fig. 1.7). The facial midline is perpendicular to those
two lines [58].
The dental midline is traced between both maxillary cen-
tral incisors, and it should be perpendicular to the occlusal
frontal line (. Fig. 1.8a, b). Other than that, it should be coin-
cident with the facial midline of the patient, even though
small asymmetries do not impair a great deal of the esthetic.
The facial midline and dental midline coincide in only 70%
of the people, while the dental midlines of the upper and
lower arches do not coincide in almost three-quarters of the
population [41, 45].
The borderline of the dental crown and the gingival tissue
determines the so-called gingival line, which also interferes
with the harmony of the smile. For its evaluation, a straight
line is traced from the highest point of the interface between
the tooth and the gum, known as the gingival zenith, from
the right to the left maxillary canine (. Fig. 1.9a). The tooth-­
gum interface of both central incisors should be on this line,
 24 C. R. G. Torres et al.
a
1 b
..      Fig. 1.8  Relation between the dental midline and occlusal frontal line. a Midline perpendicular to the occlusal frontal line; b midline inclined
in relation to the occlusal frontal line
a b
..      Fig. 1.9  Gingival contour. a Gingival line; b gingival zenith
while the lateral incisors are approximately 1.5  mm below
this line [2, 66]. The gingival line is preferably parallel to the
occlusal frontal line. The gingival zenith of the homologous
teeth should be on the same plane, guaranteeing the sym-
metry of the dental-gingival composition.
Since the long axis of the anterior maxillary teeth is
slightly inclined to the distal, the gingival contour does not
form a symmetric arch, and the gingival zenith is slightly dis-
placed to the distal side (. Fig.  1.9b) [66]. Visibility of the
 
gingival contour during a broad smile largely contributes to
facial esthetics. Corrections on the gingival contour can be
obtained by surgical techniques, such as gingivectomy or
coronally advanced flaps.
The relation between lips and teeth is also fundamental
for the beauty of a smile. The quantity of dental exposition
while smiling depends on many factors such as muscle con-
traction, the gingiva level, skeleton particularities, tooth
shape, and the presence of dental wear [58]. The incisal edges
of the anterior maxillary teeth form a curve, called incisal
line or smile line, with the lowest part in region of the central
incisors. During a maximum smile, those edges are supposed
to softly touch the lower lip (. Fig. 1.10a, b). That means the
 
curve formed should be parallel to the curve of the lower lip
[58, 66]. The degree of curvature of the incisal line is more
prominent in women than in men [58]. The incisal edges
should never be hidden by the lower lip, as shown in
. Fig. 1.10c. In this case, it is probable that there is a problem
with the vertical position of the maxilla, as a dental overerup-
tion or a very large maxilla on the vertical way [66]. The pres-
ence of an inverted incisal line curvature is generally related
to aging due to anterior teeth wear (. Fig. 1.10d). If there is a
reverse incisal curve in relation to the lower lip or a very large
space between the lower lip and the edges of the anterior
maxillary teeth, the esthetic might be improved increasing
the length of the incisal edge [66].
The line formed by the upper lip border is called upper lip
curvature or lip line. On a maximum smile, the upper lip
should translate up to the gingival line, which happens in
70% of the population. The ideal upper lip curvature is
obtained when the lip reaches the edge of the interdental
gum (. Fig. 1.10a, b) [58]. About 10% of the people have a
very high upper lip curvature. Every time this line surpasses
more than 2 mm of the gingival line, an esthetic impairment
is noticed, causing the so-called “gingival smile” or “gummy
Diagnosis and Treatment Planning
smile” (. Fig.  1.10e) [66]. The modalities for treatment of
 
this situation are limited. Orthodontic intrusion and surgical
crown exposition are treatment options to be considered
[58]. Another option is the application of botulinum toxin
(Botox-A) in the muscles that control the upper lip move-
ment, which is a minimally invasive and effective option.
25 1
not translate up to the gingival line during a maximum smile,
a loss of the smile dynamics will result [66].
If the patient presents an asymmetric movement of the
upper lip when smiling, this will result in excessive one-sided
gingival exhibition, besides misalignment between the
­commissural and the interpupillary lines (. Figs. 1.10g and

About 20% of the individuals have a very low upper lip cur- . Fig. 14.42a). In this case surgical crown lengthening may
 

vature (. Fig. 1.10f) [66, 69]. Every time the upper lip does
  help to improve the esthetics, although Botox application,

a b

c d

e f

..      Fig. 1.10  Esthetic analysis of the maximum smile. a Incisal edges
of the anterior maxillary teeth touching the lower lip and the upper lip
curvature exposing the gingival papilla; b small exposure of the
gingival tissue and the presence of a small and homogeneous space
between the edges of the maxillary anterior teeth and the lower lip;
c incisal edges of the maxillary anterior teeth covered by the lower lip;
d inverted incisal line; e excessive exposure of the gingival tissue; f low
upper lip curvature. g Asymmetric movement of the upper lip, greater
on the left side; h straight upper lip curvature; i inverted upper lip
curvature; j inclined occlusal plane downward on the right side;
k excessive buccal corridor; l loss of gradation because of the
inadequate position of the teeth 24 and 25
 26 C. R. G. Torres et al.

1 g h

i j

k l

..      Fig. 1.10 (continued)

notwithstanding its temporary effect, involves less risk and
costs. If the asymmetric movement occurs on the lower lip, a
greater space between the incisal edges and the lower lip will
result in one of the sides, impairing the symmetry of the
smile. In those cases, the maxillary teeth can slightly be
lengthened to compensate for this problem [66].
In repose or when the patient says “M,” there should be an
exhibition of 3–4 mm of the incisal edge of the central maxil-
lary incisors in young women or 1–2  mm in men. After
40 years of age, the quantity of exposition of the incisal edge
If less than 50% of this space is occupied by the maxillary
central incisors, probably, a lengthening of the tooth will
improve the esthetic of the smile. On the other side, if more
than 70% of space is occupied by the maxillary incisor, the
lengthening of the incisor will not be pleasant [66]. When the
patient says “V” or “F,” the edges of the upper central incisors
should slightly contact the border of the lower lip [66].
From the middle to the corners of the mouth, the upper
lip curvature should form a curve facing upward, due to the
activity of the facial muscles during the smile (. Fig. 1.10a–c).

decreases in about 1 mm per decade, while it increases the However, some people have a straight (. Fig. 1.10h) or even
 

exposition of the lower incisors [58, 66, 71]. When the patient downward curvature (. Fig.  1.10i), affecting the attractive-
 

says “E,” a space between the upper and lower lips will form. ness of those smiles. In those cases, some improvement can
Diagnosis and Treatment Planning
a b
c d
..      Fig. 1.11  a Incisal embrasures with progressively increasing sizes
as they distance from the midline; b incisal embrasures with similar
sizes, giving a less natural aspect and an aged look; c cervically located
be obtained using techniques of muscle training when the
other components of the smile do not compensate for this
deficiency [58].
The incisal edges of the incisors and cusp tips of posterior
teeth form the occlusal plane, which is actually a curved sur-
face. When analyzing the esthetics of a smile, the cuspal tips
of the maxillary posterior teeth should present a visual pro-
gression, in general upward, starting from the tip of the
canine cusp, without high or low points. The right and left
sides must be symmetric [66]. In . Fig.  1.10i, the occlusal
 
plane is inclined downward on the right side, breaking the
harmony of the smile. The space between buccal surfaces of
the posterior maxillary teeth and the cheeks is called buccal
corridor, which becomes visible during smiling and mouth
opening. During a broad smile, the corridor is almost com-
pletely occupied by teeth with a small lateral space toward the
cheek. A constricted maxillary arch (. Fig. 1.10k) can cause
 
an excessive buccal corridor and thereby impair the esthetics
[66]. Conversely, the complete absence of the smile corridor
can also negatively affect the esthetics.
Facing a patient from the front, as the eyes move laterally
from midline, each tooth must seem proportionally thinner
than its mesial neighbor. This is called the principle of grada-
tion [39]. The distal half of the maxillary canine must not be
27 1
contact, causing a very large incisal embrasure; d very small contact
causing a dark triangular space
visible when viewing the patient from the front. Inadequate
contouring or misalignment may break the front teeth har-
mony (. Fig. 1.10l) [66]. The proportion between height and
width of each individual tooth also influences the dental
esthetic and is further discussed in 7 Chap. 14.
The size of the incisal and gingival embrasures changes
with age. In young individuals, the incisal embrasures are
large and open increasing from the midline to the canine,
while gingival embrasures are little visible (. Fig. 1.11a). With
aging, the size of the incisal embrasures decreases and may
disappear completely because of tooth wear (. Fig.  1.11b).  
Simultaneous to the incisal wearing, gingival papilla suffers
from recession, increasing the size of the gingival embrasures.
In some cases, abrasion happens before gingival recession,
leaving the teeth shorter and apparently wider. In other cases,
the gingival recession happens first, giving the teeth an appar-
ently longer appearance. Both cases contribute to an aging of
the smile [7].
>> The size of the incisal and gingival embrasures
changes with age. In young individuals, the incisal
embrasures are large and open increasing from the
midline to the canine, while gingival embrasures are
little visible.
 28 C. R. G. Torres et al.
If the interdental contact is positioned too far away from the
1 incisal area, a too large embrasure leaves an unnatural
appearance (. Fig. 1.11c). If the contact does not extend far
 
enough toward the gum, the interproximal space will be
open, creating a dark triangle (. Fig. 1.11d).
 
>> Aging has a tremendous impact on teeth, alveolar
bone, and connective tissues.
1.4 Evaluation of Caries Risk
Untreated dental caries is the most prevalent chronic condi-
tion worldwide [34]. It is known that the etiology is multifac-
torial and associated with behavior, socioeconomic status,
and physical, environmental, microbiological, and other
host-related factors. Each patient can present a combination
of different factors that will determine the characteristics of
the current disease and the likelihood of progression referred
to as caries activity [54]. The higher the number of risk fac-
tors, the higher his caries risk will be. However, caries risk
assessment is not a standardized process in clinical practice
and is based on various techniques; the most prevalent is the
visual-tactile assessment [21]. This evaluation can help to
guide the treatment. Elimination or control of etiological fac-
tors should be the primary goal in high-risk patients, whereas
monitoring and re-evaluation might be sufficient guidance
for patients with lower caries risk [54].
>> Untreated dental caries is the most prevalent chronic
condition worldwide. It is known that the etiology is
multifactorial and associated with behavior,
socioeconomic status, and physical, environmental,
microbiological, and other host-related factors.
Caries risk factors can be divided into oral and non-oral
parameters. For the oral aspects, dental anatomy can foster
biofilm deposit (presence of deep fissures and pits), no contact
with fluoride, inadequate oral hygiene, presence of restora-
tions (that may indicate a past history of high caries activity),
and the presence of defective restorations that allow the
deposit of biofilm, contributing to a higher caries risk. Non-
oral factors, associated with an increased caries risk, are age,
low socioeconomic status, systemic diseases (Sjogren’s syn-
drome, diabetes, chronicle stress, radiotherapy, etc.), intake of
medications that reduce the salivary flow, high consumption
of carbohydrates, smoking [51], and alcohol abuse [53],
besides systemic debilitating diseases that reduce self-­care
ability [54]. Among all the factors, the most important indica-
tors for caries activity are the presence of active or recently
treated caries lesions, a great quantity of cariogenic biofilm,
frequent sugar consumption, and low saliva flow [66, 72].
In patients with active lesions, microbiological biofilm
analysis, evaluation of dietary habits, and salivary flow are
important to assess the susceptibility to caries and predic-
tion of the likelihood of success for any restorative treat-
ment. Salivary flow rate can easily be determined, asking the
patient to chew on a gum or a piece of wax for about 5 min,
spitting inside a graduated cylinder of 20  ml. To eliminate
the foam of the saliva and have a precise measurement, some
drops of dimethicone can be added to the collected content.
This addition does not interfere with the measurement
because the volume used is very small [18]. The result is
divided by 5, which is the flow rate per minute. The normal
values must be between 1.5 and 3 ml/min. Values between 1
and 1.5  ml/min indicate a slight hyposalivation, while a
value between 0.5 and 1  mm/min indicates a moderate
hyposalivation. A flow between 0.05 and 0.5 indicates a
severe hyposalivation [18, 68]. Based on a 7-day dietary pro-
tocol, patients’ nutrition habits can be evaluated. Presenting
a full nutrition record, including the amount of food, snacks,
and beverages to most patients, is a very intimate and per-
sonal matter. A trustful doctor-patient relationship is there-
fore the ultimate prerequisite for unaltered protocols.
Professionals must not be judgmental and demoralizing or
must not point an incriminating finger at a person but
should offer help and support patients who want to change
their habits for the better. Motivational interviewing is a
counseling method that gradually helps patients to develop
discrepancies and establish solutions for behavior change
[25]. In dentistry, there are numerous fields of application,
starting with oral hygiene motivation and diet counseling,
culminating in smoking cessation, or establishing a respon-
sible drinking behavior.
Biofilm control is one, if not the key, issue in the preven-
tion of dental caries. Therefore, it is a standard practice to
register plaque formation over time. Many indices are pro-
posed for daily routine or epidemiologic purposes (API, QHI
and PI, PFRI). The O’Leary index, for example, is based on
the presence or absence of biofilm on four surfaces (buccal,
lingual, mesial, and distal). After disclosing the biofilm with
a dye, presence of plaque is marked the diagram as shown in
. Fig. 1.15 [52]. Missing teeth should be marked with an X
on the diagram, so they are not taken into consideration for
the calculation. The result is expressed as the percentage of
surfaces with biofilm in relation to the entirety of examined,
surfaces using the following formula:
Quantity of dyed surfaces ´100
O¢Leary Index =
Total surfaces analyzed
( number of present teeth ´ 4 )
The use of a plaque index objectively visualizes biofilm deposit
and enables monitoring changes over time. Indices between
0% and 12% are acceptable; values between 13% and 23% are
considered increased. Values from 24% to 100% express inef-
fective oral hygiene. Results of a biofilm index, however, are
just one tessera of the complex caries risk assessment. In order
to obtain an overall impression, as many possible risk factors
should be gathered and weighed. The software Cariogram
integrates risk parameters calculating the probability of future
lesion development. However, it was found to be inferior to
identify high-risk patients compared with clinical judgment
based on decayed surfaces and incipient lesions [29].
Diagnosis and Treatment Planning
Biofilm indices can be collected on several occasions dur-
ing treatment course and on every recall appointment when
appropriate. Improvement of oral hygiene is, like any other
behavioral change, a delicate matter that cannot be achieved
by simply telling the patients to do so. Instructions can be
helpful for those who are capable and willing to implement
new routines. Frequent recall interval, including professional
tooth cleansing, is an effective alternative for those who have
a lack of motivation or are manually incapable of maintain-
ing efficient oral hygiene.
Tip
Try to gather as many risk and protective factors, and,
for practicality, organize your patients into groups of
high, moderate, or low caries risk. Re-evaluate factors
in defined intervals.
1.5 General Treatment Plan
The treatment plan is a series of treatments planned to elimi-
nate or to control etiological factors, to repair existing damage
and create a functional oral environment, possible to be main-
tained [54]. A precise prognosis for each tooth and the general
oral health of the patient is fundamental for its success. To
establish a treatment plan, the dentist should be capable to
foresee the outcome of treatment procedures, regarding best
available evidence as well as risks and side effects of different
treatments, based on the individual risk of a patient [54].
One principle of medical ethics is to ensure patienty’s
safety, preventing any injury to them (non-maleficence),
which also applies to dentistry [11]. Clinicians should have
profound knowledge of the current evidence about risks and
benefits of treatments being offered. As mentioned above,
invasive therapy is flanked by more or less unwanted side
effects that need to be taken into consideration, as well as the
wanted benefits of operative treatment. Replacement of a res-
toration causes additional substance loss, leading to larger
restorations. This may happen many times during the
patient’s life, resulting in what is called the repetitive restor-
ative cycle, which leads more invasive restorations with every
treatment, endodontic treatment, and tooth loss as the final
consequence and worst-case scenario [15, 54].
>> One principle of medical ethics is to ensure patienty’s
safety, preventing any injury to them (non-maleficence),
which also applies to dentistry [11].
Tip
Invasive treatment should be considered with caution,
since the so-called repetitive restorative cycle leads to
continuous substance removal and premature loss of
teeth as final consequence.
29 1
Having an initial list of patient-centered problems and know-
ing about the patients’ preferences, the clinician should pro-
pose treatment alternatives to the patient. Following the rules
of shared decision-making, advantages and risks of each
option should thoroughly be evaluated [5]. Shared decision-­
making basically aims at achieving mutual agreement about
the clinical procedure, diagnostic methods, and therapy of
choice between the caregiver and the patient and/or their
legal guardians. Both doctor and the patient rather act as
partners, trying to overcome the natural asymmetry of
knowledge. The clinician should enable the patient to make a
self-determined therapy decision and to comprehend the
risks and benefits that are associated with this choice or any
other alternative. The outcome of this process is ideally an
informed choice that is recorded on a chart (. Fig. 1.16). The
treatment process should follow a reasonable order. The
sequence of treatments is ordered as follows: systemic phase,
urgency phase, control phase, re-evaluation phase, definitive
phase, and maintenance phase [22, 54, 66]. Following this
treatment concept will guarantee a structured and biological
sequencing of therapy steps.
>> Shared decision-making basically aims at achieving
mutual agreement about the clinical procedure,
diagnostic methods, and therapy of choice between
the caregiver and the patient and/or their legal
guardians.
Objective of the systemic phase is to determine whether there
is a medical risk for the patient or for the professional team
during dental treatment. According to their physical condi-
tions, patients can be classified according the American Soci-
ety of Anesthesiology (ASA), employed to evaluate surgical
risk [23]. According to this system, the patients are classified
into six categories:
55 ASA I – Healthy patient, without any physiological,
biochemical, or psychical disturbs and little or no
anxiety. No risk for dental treatment.
55 ASA II – Patient with slight or moderate systemic and
controlled diseases, not compromising his normal
activities. Conditions may affect surgical and anesthesia
procedures. Healthy patients (ASA I) with extreme
anxiety or fear for the dental treatment can also fall into
this category. They present a minimum risk during
treatment. For example, well-controlled diseases as
prehypertension, non-insulin-dependent diabetes,
epilepsy, asthma or thyroid problems, patients ASA I
with active allergies, breathing problems, or pregnancy.
They might need a previous medical consultation.
55 ASA III – Patients have severe systemic diseases that are
hard to control, limiting their normal activities, but it
does not incapacitate them, presenting impact on the
surgical procedures and anesthetics. There are, for
example patients who suffered or currently suffer from
angina pectoris, myocardial infarction, cerebrovascular
accident, congestive heart failure more than 6 months
before the dental appointment, hypertension, controlled
insulin-­dependent diabetes or chronic obstructive
 30 C. R. G. Torres et al.

pulmonary disease of little intensity. They need a toration or integration into full mouth rehabilitation; or they
1 previous medical consultation. might have had a negative response and should rather be
55 ASA IV – Patients with incapacitating life-threatening extracted. Then, the rehabilitating plan should be modified,
systemic diseases with great impact on surgical anesthe- including possible prosthetic replacement of the mentioned
sia. These patients have a significant risk during dental teeth. Control of bacterial biofilm usually results in improve-
treatment; hence, any elective treatment should be ment of gingival health and a reduced risk of developing fur-
dropped or postponed. ther caries lesions. In some cases however, strategies could
55 ASA V – Dying patients with life expectancy less than not have been efficient and may require modification before
24 h notwithstanding any medical treatment. They have the next step. At the end of this phase, the patient should be
terminal diseases and are almost always at the hospital. orally healthy without an active disease [22].
Dental treatment is definitively contraindicated, but an The corrective treatment focuses on restoring mastica-
emergency palliative care might be provided in the tory function and esthetics concerning the patients’ expecta-
hospital. tions in these matters. A favorable prognosis is highly
55 ASA VI – Declared cerebral death and kept alive for depending on controlling the disease causing factors in the
organ donor. longer term and hence requires informed patients who are
willing and capable to maintain good oral health [22].
After completion of the systemic phase and in the event a Another reason to change the initial treatment plan may be
patient can be safely treated, urgent treatments are usually financial matters. Treatment costs may actually not fit the
given the first priority [22]. The urgent phase is dedicated to patient’s financial situation at that moment. It is wise to
pain relief and infection control. These conditions should be address costs for dental treatment overtly and nonjudgmen-
eliminated prior to realization of any further treatment [66]. tal and provide less expensive treatment options whenever
Esthetic problems can also be considered as urgency treat- possible. No treatment at all or postponing cost-intensive
ment; in particular, when anterior teeth are involved [22]. procedures is usually preferable to losing a patient due to
Another important reason to treat urgent problems first is obscure pricing strategy.
that, in general, patients are not capable to take adequate Before follow-up maintenance, the definitive or correc-
decisions when they suffer pain [22]. tive phase is the final phase of the treatment concept [54, 66].
When the patient is pain-free, the treatment plan might It aims to reconstitute the dentition to a comfortable, esthetic,
be re-evaluated regarding the definitive phase. It might hap- and functional situation, as defined by the patient’s demands
pen that patients take different decisions when pain and dis- [22]. Many procedures that fall into the control phase, like
comfort are no longer present. During the control phase, restoration of carious teeth, may control the disease and act
etiological risk factors of a disease are eliminated or reduced as definitive restoration at the same time [66]. In addition,
[66]. In order to achieve and later on maintain healthy oral some procedures improving esthetic and function, such as
conditions, an individual program is designed to establish prosthetic, orthodontic, cosmetic restorative, or surgical
oral hygiene measures and possibly support the patient to treatments, may be indicated. This part is frequently the most
refrain from health endangering habit [54]. The ultimate suc- cost intensive.
cess of any rehabilitating treatment plan depends on how The maintenance phase aims to stabilize treatment results
well diseases are controlled over time [22]. Treating the and hinders diseases to reoccur. The frequency of the re-­
symptoms of a disease is doomed to fail since persisting etio- evaluation intervals will greatly depend on the patient’s risk
logical factors will jeopardize the treatment outcome [22]. to oral diseases. A longer interval of approximately 1 year can
Examples for causal-therapeutic measures comprise infec- be recommended for patients with a very low documented
tion control, establishment of oral hygiene, periodontal and risk for developing periodontal diseases and caries lesions
endodontic therapy, (provisional) restoration of open cavities [54]. On the other side, high-risk patients may benefit from
or defective restorations, removal of cervical overhangs, and more frequent recall intervals, for example, every 3–4 months
extraction of hopeless teeth. Based on the individual caries [54]. It is expected that this phase is the longest of the treat-
risk, the dentist should develop an individual treatment plan ment, and it is focused on keeping the oral health for the
aiming at arresting and preventing caries and periodontal whole life of the patient [22].
diseases, as well as any other oral disease or detrimental con- Bitewing radiographs may flank oral examination in risk-­
dition [54]. Again the definitive treatment should be re-­ orientated intervals as well. There is no general agreement
evaluated after this phase and amended if necessary [22]. about the frequency of radiographic re-evaluation. The
higher the risk for the development of new lesions and the
>> It might happen that patients take different decisions
more differentiated the treatment concept for caries lesions
when pain and discomfort are no longer present.
are, in particular in non-operative care, the more frequent
Time should be allowed between the control and definitive bitewing radiographs may be beneficial for the patient. On
phase in order achieve oral conditions that are free of pain the downside, a higher frequency of radiographs may lead to
and inflammation. For example, teeth with pulpal or peri- overdiagnosis and overtreatment, initiating the abovemen-
odontal doubtful diagnosis may have responded positively to tioned repetitive restorative cycle [31]. Frequently patients
causal treatment and may be considered for a definitive res- are skeptical about radiographic examinations because of
Diagnosis and Treatment Planning
radiation exposure, which has to be taken into consideration
for the decision whether and, if yes, how frequent bitewing
radiographs will improve oral health.
Tip
The treatment concept enables clinicians to structure a
treatment into biological stages, in a logical order, aiming
at creating and maintaining healthy conditions and
improving a patient’s oral health-related quality of life.
>> Frequently patients are skeptical about radiographic
examinations because of radiation exposure, which
has to be taken into consideration for the decision
whether and, if yes, how frequent bitewing
radiographs will improve oral health.
1.6 Planning Restorative Treatment
Planning an individual and tooth-specific restoration is the
final step in the restorative treatment plan. It requires the
consideration of four main factors and a number of modify-
ing factors. The main factors are quantity and shape of the
remaining tooth structure, functional requirement of an
individual tooth, and the superordinate objective of the treat-
ment plan in general [66]. Above all this, it is of course the
patients’ demands that largely provide the direction which
kind of restoration is preferred.
The quantity of remaining tooth structure determines its
resistance and possibility of retention for the restorative
material and thereby influences the drawing of the final res-
toration. Since longevity of a restoration is an ultimate treat-
ment goal in most scenarios, the design of a restoration
should prevent fracture and displacement. Small and medium
Class II cavities can easily be restored with amalgam or resin
composites. However, when the amount of lost tooth struc-
ture is greater than one-third of the intercuspal distance, the
tooth is more susceptible to fracture. Indirect restorations
claimed to be a solution for those problems. However, mod-
ern concepts of adhesive dentistry advocate the unlimited
use of direct composite restorations even in endodontically
treated teeth [44]. Doctrines differ considerably, yet direct
adhesive suppresses increasingly indirect restorations.
Besides the width, the depth of the preparation is also funda-
mental. On large and deep preparation, the need to protect
the cusps from fracture is greater either with direct amalgam
restorations or with indirect restorations.
In anterior teeth, the amount of the remaining tooth
structure as well will determine the success of a restoration.
Direct composite restorations are sufficient in most cases and
can be seen as the standard anterior restoration. In cases of
severe loss of tooth structure, extreme malpositioning or
overal esthetic impairment, veneers, or full crowns may be
indicated. However, masters of their craft are capable to solve
31 1
even the most complex cases using direct restoration tech-
niques [66].
When choosing the material for a dental restoration, it
needs to be considered whether a patient suffers from exces-
sive occlusal load and parafunction or not. Patients with
bruxism, deficient disocclusion guide, worn facets, or severe
attrition due to heavy occlusal stress are probably not the best
candidates for delicate and fragile ceramic restorations.
Therefore, signals of excessive functional load should be
carefully evaluated during the clinical exam [66].
Even though the indication of indirect metallic restora-
tion has decreased significantly, they present excellent prop-
erties and acceptable longevity [48]. They may also be
favorable on preparations with deep subgingival margins.
Indirect restorations are fabricated and polished outside the
mouth, which makes it easier to obtain a convex and smooth
contour compared to direct restorations [54]. The longevity
and hence the clinical success of restorations depend on
numerous variables including materials-, patient-, and
dentist-­related factors [27].
>> The longevity and hence the clinical success of
restorations depend on numerous variables, including
materials-, patient-, and dentist-related factors.
Indirect restorations can be performed with light-curing
composites designed for laboratorial use, feldspar porcelain,
pressed ceramic, or ceramic/composite blocks for computer-­
generated restorations (computer-aided design/computer-­
assisted machining  – CAD/CAM). They present physical
properties that are superior in relation to the direct compos-
ite restoration. However, they are associated with higher
costs, because materials are more expensive and laboratorial
work and more treatment time are required. Even though
composites for laboratorial use have improved resistance, no
difference regarding longevity compared to direct composite
restorations can be found [19]. The restorations of feldspar
porcelain are an alternative for large Class II cavities and have
predictable esthetics, even though it has a relatively high inci-
dence of fractures, especially when they are exposed to occlu-
sal stress. They also wear the opposing tooth because of
higher microhardness in relation to natural enamel or other
restorative materials. Pressed ceramics offer an excellent
marginal adaption, low abrasion of the opposing tooth, and
superior resistance if compared to the indirect composites or
feldspar porcelain. It offers an alternative to indirect metallic
restorations. The restorations made with CAD/CAM tech-
nology are indicated from Class I and II cavities up to single
crowns and have higher resistance to occlusal stress and low
abrasion than direct composites [54].
The choice of a restorative material has to be in line with
the superordinate treatment plan. For example, restoration of
a tooth that later on serves as an abutment for prosthetic
rehabilitation might be different from a permanent restora-
tion without further treatment [66].
After shared decision-making and after the patient has
made an informed choice on the treatment, the whole pro-
cess should be brought to a logical order. The adequate
 32 C. R. G. Torres et al.
sequence is many times critical for the success of the treat-
1 ment, avoiding unnecessary complications. Most of the
restorative treatments will be in the phase of disease control
or definitive rehabilitation. Restorative interventions aiming
to control the disease mostly comprise direct restorations
with amalgam, composites, or glass ionomer cement. The
treatment sequence should be coordinated with the patient’s
preferences. Symptomatic teeth, those with severe decay or
esthetically compromised teeth, are usually treated first.
However, it is highly recommended to fulfill a patient’s chief
complaint at a very early stage, signaling a patient-centered
and professional demeanor. Restorative procedures in the
definitive rehabilitation phase may go beyond the necessity
to stabilize the disease and may include treatments destined
to improve esthetics, for instance, placing veneers for closing
diastemas or offering adequate function by replacing missing
teeth [66]. The treatment sequence should be registered on
the clinical chart as presented in . Fig. 1.16.
 
1.7 Interdisciplinary Aspects
Dentistry today consists of highly specialized disciplines,
which bring up the need for interdisciplinary teamwork. In
complex cases where more than one dentist is involved, one
colleague has to have the coordinating role. Usually the fam-
ily or general dentist takes the lead and refers patients to spe-
cialists.
>> Dentistry today consists of highly specialized
disciplines, which bring up the need for interdis-
ciplinary teamwork.
Periodontal treatment frequently precedes restorative treat-
ment, creating more favorable environment and facilitating
operatory maneuvers. Teeth with unsatisfactory periodontal
prognosis should not be considered for comprehensive pros-
thetic rehabilitation. Restorations may precede periodontal
treatment in inflammation-free periodontal conditions or in
the presence of open cavitation or lost restorations. Treatment
of deep caries lesions may require a temporary filling, to pro-
mote oral hygiene capability and prevent from caries progres-
sion. Self-explanatory endodontic treatments should be
performed prior to definite restoration and periodontal treat-
ment. If surgical periodontal treatments become necessary,
indirect restorations and prosthetic measures are postponed
until complete healing of the operated area. Teeth planned for
indirect restoration should receive temporary restorations
before periodontal surgery, defining the position of the margins
and improving access for surgery. Preparations which margins
invade the biological width should be submitted to crown
lengthening surgery, before a definitive restoration is placed. A
minimum of 3 months and possibly up to 6 months is necessary
before initiation of definite prosthetic treatment [32].
Orthodontic pretreatment may be the prerequisite to
achieve optimal function and/or esthetic results in complex
cases. Minor interventions comprise single tooth movement,
uprighting molars, or extrusion therapy. Caries and peri-
odontal diseases need to be controlled adequately before
comprehensive orthodontic treatment over a longer period.
Indirect restorations should preferentially be postponed until
removal of orthodontic appliances [54].
Surgical interventions like tooth extraction or removal of
impacted teeth should precede restorative treatment. This is
particularly important in the cases of third molars, where, as
a side effect, surgical procedures can lead to damage or dis-
placement of restorations on second molars [54]. Occlusal
analysis can evince a lack of disocclusion guide or interfer-
ences, which might be treated before restorative and pros-
thetic procedures. If necessary, the occlusal adjustment is
initiated before the definitive phase [54]. It might be easier to
place direct restorations before indirect ones; however it also
works in reverse order.
1.8 Oral Health Records
A detailed documentation of anamnestic and patient-related
information is fundamental for quality control when plan-
ning the treatment. This also applies for documentation of
treatment procedures and incidents, as well as discussions
and telephone calls with the patient or relatives. The patient
file serves as the basis in case of legal disputes, as documenta-
tion to a third-party payment, and in the case of forensic
identification [54, 63, 66]. Patient’s oral health records should
contain a central document, which might be flanked by sup-
plementary documents [3]. Additionally intraoral camera
image and photography are excellent features for documen-
tation [54, 66]. Documentation should follow the statutory
requirements of the Federal Council that control a clinician’s
activity in each country [3]. The complete oral health record
allows the clinician to analyze the case, even when the patient
is not present, and to anticipate the treatment at the following
appointment [54, 66].
>> A detailed documentation of anamnestic and
patient-related information is fundamental for quality
control when planning the treatment. This also applies for
documentation of treatment procedures and incidents as
well as discussions and telephone calls with the patient or
relatives. The patient file serves as the basis in case of
legal disputes, as documentation to a third-party
payment, and in the case of forensic identification.
Every clinical chart contains the clinician’s and the patient’s
identification, patient’s master data, anamnesis, clinical find-
ings, treatment plan, and records about the progress and
intercurrences during the treatment. It is mandatory to have
the clinician’s identification including name and registration
number of the Federal Dental Council, on all printed papers.
As to patients’ identification, the following information are
essential to meet legal requirements according to each coun-
try: complete name, address, national identification number,
social security number, health insurance information, place
and date of birth, civil status, nationality, and gender. The
way a patient chose a specific clinician should also be
Diagnosis and Treatment Planning
r­ egistered. When the patient is underage or has been declared
incompetent, it is necessary to register contact data of his
legal guardian. It may be important to record the name of
clinicians whom the patient previously attended and, if pos-
sible, date and place of attendance (. Fig. 1.12).
 
Anamnestic records contain the chief complaint, the his-
tory of the present illness, and medical and dental history as
it has already been described (. Figs.  1.12 and 1.13). Find-
 
ings of the clinical examination (objective examination) are
noted as objective signals and symptoms divided in extra-
and intraoral diagnostic findings (. Fig. 1.14). Recordings of
dental and periodontal findings are best registered on charts,
which graphically provide a number of information in a
clearly arranged manner (. Fig.  1.15). Furthermore, these
records become indispensable in the communication with
third parties or a fellow colleague [57, 66]. The condition of
every tooth, restorations, defects, caries, and soft and hard
tissues are registered. A detailed record of nature, place, and
even the size of restorations should be performed [16].
Tip
No matter how busy you are in a day, take your time
for documentation; it is worth the effort and can save
you money and trouble in the event of a legal dispute.
During shared decision-making, different treatment options,
including their benefits and potential risks, are discussed
with the patient. Ultimately both the patient and the doctor
come to a therapeutic solution both parties support and
agree upon. It might be useful to briefly note all options,
including those services the clinician cannot provide himself,
since it may happen that patients regret their decision. There-
fore, it will be helpful to refer to the notes of the decision-­
making process. It is highly recommended to explain and to
describe treatment options thoroughly, registering the teeth,
procedure, and materials involved. Risk communication
includes the discussion of limitations and potential harms of
every treatment option, based on the best available evidence
and more importantly in a clear and nontechnical language
(. Fig.  1.16) [3]. The best way to document the result of a
shared decision-making is an informed consent signed by all
parties involved. The patient has the right to receive clear,
simple, and comprehensible information about diagnoses
and possible therapeutic actions. In a consumer point of
view, the offering and presentation of the treatment should
be correct, clear, precise, ostensive, and in patient’s language,
informing the characteristics, quality, quantity, composition,
price, and guarantee, as the risks that they might present to
his health and safety [49].
>> During shared decision-making, different treatment
options, including their benefits and potential risks,
are discussed with the patient. Ultimately both the
patient and the doctor come to a therapeutic solution
both parties support and agree upon.
33 1
>> The patient has the right to receive clear, simple, and
comprehensible information about diagnoses and
possible therapeutic actions. In a consumer point of view,
the offering and presentation of the treatment should be
correct, clear, precise, ostensive, and in patient’s
language, informing the characteristics, quality, quantity,
composition, price, and guarantee, as the risks that they
might present to his health and safety.
Apart from risk communication, costs and length of the
treatment should be transparent and overtly discussed. As
mentioned before, it is the patients’ inherent right to decide
what treatment they prefer and, perhaps more importantly,
which option is unwanted. Medical laypersons often dread to
take decisions because they feel overstrained, helpless, and
uneasy to be responsible for their decision. It is therefore the
clinicians’ duty to enable a patient to take part in the decision-­
making process according to their medical literacy. In con-
clusion, patients do not have to become professionals in
order to take a self-determined therapy options, but doctors
need to learn how to transfer the existing evidence into easily
consumable facts and how to carve out the patients’ very own
interests.
Tip
Risk communication seems to be unpleasant, especially
for inexperienced dentists. Patients, however, have a
right to learn about the risks involved in a particular
treatment option and usually appreciate clear-cut
information.
Every treatment is documented separately and in detail in the
patients’ file including date, which tooth surface has been
treated and what procedure has been carried out mentioning
all materials (. Fig.  1.17). Changes of the initial treatment
plan, nonattendance, and new information should be
recorded. Whenever needed the patients’ signature may be
added as a sign of mutual agreement [3].
Oral health records are legal documents. They might
become key component of a legal dispute. Hence, clarity and
completeness in documentation are quintessential [66].
Erasing text passages is not allowed and impossible in elec-
tronic patient files. Mistakes are marked as such and correc-
tions should follow below, dated and signed [40, 66]. In many
ethical proceeding of the Dental Councils, dentists did not
do technical mistakes but failed to adequately state risks and
alternatives to the proposed treatment [3]. . Figures 1.12 and
1.17 display an example of clinical charts following the guide-
lines of the Dental Federal Council.
In the course of progressive digitization and networking,
various documentation and accounting software have
become available for dental offices and universities. While
handwritten documents may have their veracity proven by
graphological methods, and a photography finds its proof on
the negative film, a digital document may lack proof [3].
 34 C. R. G. Torres et al.

DENTIST'S NAME
1 DENTIST'S SPECIALITY
REGISTRATION NUMBER
Complete address

Name: ID: Social security:

Date of birth: / / Gender: ( )M ( )F City of birth: Nationality:
Marital status: Profession: Phone (res):
Phone (com): Cell number: E-mail:
Home address:
Business address:
Spouse name: ID: Social security:
Recommended by: Insurance company: Insurance number:
Last dentist: Last consult: / /
Legal guardian: Name: ID:
Social Security: Marital Status:

ANAMNESIS
Chief Complain:

History of the present illness:

MEDICAL HISTORY
YES NO DON’T KNOW
CARDIOVASCULAR PROBLEMS YES NO DON’T KNOW

Are you under any medical treatment? ( ( ( ( ( ( Do (Did) you have any of the following problems?
Cardiac problems? ( ( ( ( ( (
What? Pacemaker? ( ( ( ( ( (
Doctor's name: Chest pain? ( ( ( ( ( (
Taking any medication? ( ( ( ( ( ( Cardiac transplant ( ( ( ( ( (
What? Shortness of breath or easily tired? ( ( ( ( ( (
Have taken or is taking: How many pillows do you use?
Blood thinner? ( ( ( ( ( ( Cardiac valve problems? ( ( ( ( ( (
Anticonvulsants? ( ( ( ( ( ( Heart murmur? ( ( ( ( ( (
Tranquilizer? ( ( ( ( ( ( Hypotension? (Low blood pressure) ( ( ( ( ( (
Antihistamines? ( ( ( ( ( ( Hypertension? (High blood pressure) ( ( ( ( ( (
Analgesics? ( ( ( ( ( ( Bleeds much when gets cut or extracts a tooth? ( ( ( ( ( (
Corticosteroids? ( ( ( ( ( ( Varicose veins? ( ( ( ( ( (
Have you received dental anesthesia? ( ( ( ( ( ( Infarction (Heart attack)? ( ( ( ( ( (
Have you been submitted to a surgery? ( ( ( ( ( ( Cerebrovascular accident? ( ( ( ( ( (
What? Feet or legs swelling? ( ( ( ( ( (
Have you been hospitalized? ( ( ( ( ( ( Heart problems? ( ( ( ( ( (
Why? What?
Gained or lost weight quickly recently? ( ( ( ( ( ( ALLERGIES
Why? Are you allergic or had a reaction to:
Do you practice sports or physical activity? ( ( ( ( ( ( Dental anesthesia? ( ( ( ( ( (
What? Penicillin or other antibiotic? ( ( ( ( ( (
How often? Sulfamethoxazole (Bactrim)? ( ( ( ( ( (
Since when? Aspirin? ( ( ( ( ( (
Do you drink alcoholic beverages? ( ( ( ( ( ( Dipyrone? ( ( ( ( ( (
What? Metals? ( ( ( ( ( (
How often? Latex (rubber)? ( ( ( ( ( (
Since when? Iodine? ( ( ( ( ( (
Do you smoke? ( ( ( ( ( ( Animals? ( ( ( ( ( (
Did you receive chemotherapy or radiotherapy? ( ( ( ( ( ( Food? ( ( ( ( ( (
Why? Resins? ( ( ( ( ( (
BREATHING PROBLEMS Oxygenated water? ( ( ( ( ( (
Do (Did) you have any of the following diseases? Other ? What ?
Pneumonia? ( ( ( ( ( ( KIDNEY PROBLEMS
Sinusitis? ( ( ( ( ( ( Do (Did) you have any of the following problems?
Rhinitis? ( ( ( ( ( ( Nephritis? ( ( ( ( ( (
Bronchitis? ( ( ( ( ( ( Kidney failure? ( ( ( ( ( (
Asthma? ( ( ( ( ( ( Hemodialysis? ( ( ( ( ( (
Hemoptysis (spit blood)? ( ( ( ( ( ( Polyuria? (large amounts of urine) ( ( ( ( ( (
Pneumoconiosis (Disease caused by inhaling dust)? ( ( ( ( ( ( Pollakiuria? (extraordinary daytime urinary frequency) ( ( ( ( ( (
Lung Emphysema? ( ( ( ( ( ( Dysuria? (Painful urination) ( ( ( ( ( (
Other breathing problem? ( ( ( ( ( ( Cystitis (inflammation of the bladder)? ( ( ( ( ( (
What? Any other kidney problem? ( ( ( ( ( (
Cough for more than 3 weeks? ( ( ( ( ( ( What?

..      Fig. 1.12  Template of clinical chart (identification data, anamnesis, medical history)
Diagnosis and Treatment Planning
35 1
ONLY WOMEN YES NO DON’T KNOW BLOOD PROBLEMS YES NO DON’T KNOW

Are you pregnant? How far? ( ( ( ( ( ( Do (Did) you have anemia? ( ( ( ( ( (

Are you breastfeeding? ( ( ( ( ( ( Do (Did) you have Leukemia? ( ( ( ( ( (
Are you taking birth control pills? ( ( ( ( ( ( Do you have hemophilia? ( ( ( ( ( (
Are you under hormone replacement therapy? ( ( ( ( ( ( Did you receive blood transfusion? ( ( ( ( ( (
Is it regular your menstrual cycle? ( ( ( ( ( ( Why?
HEPATIC PROBLEMS Do (Did) you have hemorrhage? ( ( ( ( ( (
Do (Did) you have cirrhosis? ( ( ( ( ( ( Where?
Do (Did) you have other hepatic problem? ( ( ( ( ( ( Why?
What? Do (Did) you have any blood problem? ( ( ( ( ( (
JOINT/BONE PROBLEMS What?
Did you fracture any bone? ( ( ( ( ( ( SALIVARY PROBLEM
Where? Do you have excessive production of saliva? ( ( ( ( ( (
Did you have any facial trauma? ( ( ( ( ( ( Do you have xerostomia? (little or no saliva) ( ( ( ( ( (
Do (Did) you have arthritis? ( ( ( ( ( ( Did you have salivary stone? ( ( ( ( ( (
Do (Did) you have arthrosis? ( ( ( ( ( ( NEUROLOGIC PROBLEMS
Do (Did) you have rheumatism? ( ( ( ( ( ( Do you have frequent fainting? ( ( ( ( ( (
Do (Did) you have rheumatic fever? ( ( ( ( ( ( Do you have frequent headache? ( ( ( ( ( (
Do (Did) you have osteoporosis? ( ( ( ( ( ( Do (Did) you have facial neuralgia? ( ( ( ( ( (
Do (Did) you have any bone calcification problem? ( ( ( ( ( ( Did you have convulsions? ( ( ( ( ( (
Do (Did) you have join problems? ( ( ( ( ( ( Do you have epilepsy? ( ( ( ( ( (
Do (Did) you have other joint or bone problem? ( ( ( ( ( ( Do (Did) you receive psychiatric treatments? ( ( ( ( ( (
What? Since when?
TRANSMISSIBLE DISEASES Why?
Do (Did) you have gonorrhea? ( ( ( ( ( ( Are you stressed? ( ( ( ( ( (
Do (Did) you have syphilis? ( ( ( ( ( ( Do (Did) you have any other neurologic problem? ( ( ( ( ( (
Do you have AIDS? ( ( ( ( ( ( What?
Do (Did) you have hepatitis? ( ( ( ( ( ( GASTROINTESTINAL PROBLEM
Do (Did) you have tuberculosis? ( ( ( ( ( ( Do (Did) you have gastritis? ( ( ( ( ( (
Do (Did) you have any childhood disease? ( ( ( ( ( ( Do (Did) you have stomach ulcers? ( ( ( ( ( (
Other? What? ( ( ( ( ( ( Did you vomit blood? ( ( ( ( ( (
ENDOCRINE DISORDERS (hormonal disorders) Do (Did) you have any other gastrointestinal problem? ( ( ( ( ( (
Do you have polyphagia (excessive hunger)? ( ( ( ( ( ( What?
Do you have polydipsia (excessive thirst)? ( ( ( ( ( ( FAMILY HISTORY
Do you have diabetes? ( ( ( ( ( ( Is there any one sick in your family? ( ( ( ( ( (
Do you have hypothyroidism? ( ( ( ( ( ( What disease?
Do you have hyperthyroidism? ( ( ( ( ( ( In your family, was there any case of:
Do you have Hyperparathyroidism? ( ( ( ( ( ( Cancer? ( ( ( ( ( (
Do (Did) you have any other endocrine problem? ( ( ( ( ( ( - Diabetes? ( ( ( ( ( (
What? - Infarct? ( ( ( ( ( (
OPHTHALMIC PROBLEMS - Hypertension? ( ( ( ( ( (
Do (Did) you have glaucoma? ( ( ( ( ( ( - Renal Problem? ( ( ( ( ( (
Did any doctor recommend the use of antibiotic before the dental treatment? ( ( ( ( ( (
Did you have any other health problem not mentioned in this questionnaire? ( ( ( ( ( (
What?

DENTAL HISTORY YES NO DON’T KNOW YES NO DON’T KNOW

Did you receive professional oral hygiene instructions? ( ( ( ( ( ( Did you have cold sores in the lips? ( ( ( ( ( (
How many times do you brush your teeth a day? Have you lived -erg a place without water treatment? ( ( ( ( ( (
Do you use dental floss? ( ( ( ( ( ( Do you grind or ciench your teeth (day or night)? ( ( ( ( ( (
How often? Do you chew in just one side? ( ( ( ( ( (
Does your gum bleed? ( ( ( ( ( ( Why?
Are your teeth sensitive to temperature changes? ( ( ( ( ( ( Do you hear a clicking when open your mouth? ( ( ( ( ( (
Are your teeth sensitive to sweets? ( ( ( ( ( ( Do you feel pain in the ear, head, face or neck? ( ( ( ( ( (
Are your teeth sensitive when biting? ( ( ( ( ( ( Do you have difficulty to open your mouth? ( ( ( ( ( (
Are you feeling any pain on teeth? ( ( ( ( ( ( When waking up, feel face muscles and/or teeth in pain? ( ( ( ( ( (
Where? Did you have any problem with dental treatment? ( ( ( ( ( (
Do you have the habit of nail biting and thumb sucking? ( ( ( ( ( ( What?
Do you have the habit of biting objects? ( ( ( ( ( ( Do you have mouth sores ( ( ( ( ( (
Do you often bite tongue, lips or cheeks? ( ( ( ( ( ( Do you practice any sports ( ( ( ( ( (
Do you breathe through the mouth? ( ( ( ( ( ( Did you have any impact on the mouth? ( ( ( ( ( (
Do you drink coffee/soda during the day? ( ( ( ( ( ( Do you feel food deposit between teeth? ( ( ( ( ( (
Do you frequently have mouth sores? ( ( ( ( ( ( Did you have any other oral problem? ( ( ( ( ( (
Do you have any tooth mobility? ( ( ( ( ( ( What?
Did you receive orthodontic treatment? ( ( ( ( ( (
Are you satisfied with your oral aesthetics? ( ( ( ( ( ( How often do you visit the dentist?
Did you have any mouth infection? ( ( ( ( ( (
I certify that every answer, including personal information, above written is true. I compromise to inform any change in my current health status.
, , of 20

Patient's/legal guardian's signature

..      Fig. 1.13  Template of clinical chart (medical and dental history)

 36 C. R. G. Torres et al.

CLINICAL EXAM
1 General aspect: ; Glycemic index: ( / / ); ( / / ); ( / / );
Vital signs: Pulse: bpm ( / / ); Blood pressure: ( / / ); ( / / ); ( / / );
EXTRAORAL
Lymph nodes: Swelling and asymmetry:
Muscle palpation: TMJ palpation:
Lesions: Other:
INTRAORAL
Occlusion evaluation
Static evaluation: Angle classification: ; Overbite: Overjet:
Tooth extrusions? ; Tooth migration or leaning?
Anterior open bite? Loss of molar support? Loss of vertical dimension?
Functional evaluation: Relation between CR and CO: ; TMJ snaps?
Disocclusion guidance: Anterior: ; Right lateral: ; Left lateral:
Wearing facet from attrition? ; Abfraction?
Non-working side interference? ; Protrusion interference?
Amount of mouth opening: ; Deviation when opening?
Soft tissues evaluation
Lips: ; cheeks: ; Vestibule:
Dorsum of the tongue: ; Ventral surface of the tongue: ; Floor of the mouth:
Palate: ; Tonsils:
Teeth evaluation
DENTAL CHART IN / /

CE CE COM COM COM COM AR FPD FPD FPD COM AM

1.8. 1.7. 1.6. 1.5. 1.4. 1.3. 1.2. 1.1. 2.1. 2.2. 2.3. 2.4. 2.5. 2.6. 2.7. 2.8.

4.8. 4.7. 4.6. 4.5. 4.4. 4.3. 4.2. 4.1. 3.1. 3.2. 3.3. 3.4. 3.5. 3.6. 3.7. 3.8.
AM AM AM DT COM COM COM GIC CM CE FSP FSI

= Lesion (carious/non carious) AM = Amalgam MC = Metal-ceramic

= Deficient restoration COM = Composite resin FPD = Fixed partial denture

= Satisfactory restoration GIC = Glass ionomer cement RPD = Removable partial denture

X = Absent tooth CM = Cast metal FSI = Fissure sealant is indicated

= Endodontic treatment is necessary CE = Ceramic FSP = Fissure sealant is present

= Endodontic treatment is present AR = Acrylic resin DT = Darkened tooth

= Implant TR = Temporary restoration WSL = White spot lesion

..      Fig. 1.14  Template of clinical chart (clinical examination – extraoral and intraoral)
Diagnosis and Treatment Planning
37 1
Periodontal evaluation
Date: / /

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
Probe Depth
GM to CEJ
Attachment Loss

B
U
C
C
A
L

L
I
N
G
U
A
L

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
Probe Depth
GM to CEJ
Attachment Loss

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Probe Depth
GM to CEJ
Attachment Loss

L
I
N
G
U
A
L

B
U
C
C
A
L

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Probe Depth
GM to CEJ
Attachment Loss

Gingival bleeding index

1.8. 1.7. 1.6. 1.5. 1.4. 1.3. 1.2. 1.1. 2.1. 2.2. 2.3. 2.4. 2.5. 2.6. 2.7. 2.8.
/ /
GBI:
4.8. 4.7. 4.6. 4.5. 4.4. 4.3. 4.2. 4.1. 3.1. 3.2. 3.3. 3.4. 3.5. 3.6. 3.7. 3.8.
1.8. 1.7. 1.6. 1.5. 1.4. 1.3. 1.2. 1.1. 2.1. 2.2. 2.3. 2.4. 2.5. 2.6. 2.7. 2.8.
/ /
GBI:
4.8. 4.7. 4.6. 4.5. 4.4. 4.3. 4.2. 4.1. 3.1. 3.2. 3.3. 3.4. 3.5. 3.6. 3.7. 3.8.

O’Leary plaque index

1.8. 1.7. 1.6. 1.5. 1.4. 1.3. 1.2. 1.1. 2.1. 2.2. 2.3. 2.4. 2.5. 2.6. 2.7. 2.8.
/ /
PI:
4.8. 4.7. 4.6. 4.5. 4.4. 4.3. 4.2. 4.1. 3.1. 3.2. 3.3. 3.4. 3.5. 3.6. 3.7. 3.8.

1.8. 1.7. 1.6. 1.5. 1.4. 1.3. 1.2. 1.1. 2.1. 2.2. 2.3. 2.4. 2.5. 2.6. 2.7. 2.8.
/ /
PI:
4.8. 4.7. 4.6. 4.5. 4.4. 4.3. 4.2. 4.1. 3.1. 3.2. 3.3. 3.4. 3.5. 3.6. 3.7. 3.8.

..      Fig. 1.15  Template of clinical chart (clinical examination – periodontal evaluation, bleeding index, plaque index)
 38 C. R. G. Torres et al.

TREATMENT PLAN
1 Advantage/ Patient's
Problems List Treatment option Fees Time
Disadvantage option
a)Amalgam restoration > Durability 100.00 1h X
1 17 – Carious lesion OL (2 surfaces) b)Composite restoration > Aesthetic 200.00 1h
c) ---------- ---------- ---------- ----
a)Amalgam restoration > Durability 100.00 1h X
14 – Deficient restoration OD (2
2 b)Composite restoration < Durability 200.00 1h
surfaces)
c) ---------- ---------- ---------- ----
a)Endodontic treat. + Compos. Only option 800.00 4h X
3 13 and 33 — Pulpal necrosis b) ---------- ---------- ---------- ----
c) ---------- ---------- ---------- ----
a)Composite restoration Only option 400.00 3h X
11, 21 and 41 – Defective
4 b) ---------- ---------- ---------- ----
restorations (4 surfaces)
c) ---------- ---------- ---------- ----
a)Metal free full crown > Aesthetic 1000.00 3h X
5 22 – Defective total crown b)Metal ceramic crown > Resistence 800.00 3h
c) Metallic-plastic crown < Aesthetic 300.00 3h
a)lndirect ceramic rest. >Aesthetic, >Resist. 1000.00 2h X
6 26 – Defective MODV restoration b)Amal. rest.+ comp. veneer < Aesthetic 250.00 1h
c)Composite restoration < Resistence 500.00 1h
a)Amalgam restoration > Durability 150.00 1h
46 – Carious MOD lesion (3
7 b)Composite restoration > Aesthetics 300.00 1h X
surfaces)
c) ---------- ---------- ---------- ----
a)Amalgam restoration > Durability 100.00 1h
8 45 – Defective MO restoration b)Composite restoration > Aesthetic 200.00 1h X
c) ---------- ---------- ---------- ----
a)lnternal bleaching Less Invasive 200.00 4h X
9 43 – Darkened tooth b)lndirect veneer Dental wearing 400.00 3h
b)Direct veneer Dental wearing 200.00 1h
a)Composite restoration > Aesthetic 300.00 1h X
46, 44 and 32 – Non carious
10 b)GlC restoration <Aesthetic 150.00 1h
cervical lesion (3 surfaces)
c)Amalgam restoration < Aesthetic/>wearing 150,00 1
TOTAL 3400.00 21h

Treatment sequence: 3, 1, 7, 6, 2, 4, 8, 10, 5, 9

INFORMED CONSENT DECLARATION

I state that after being informed about of the purposes, risks, costs and treatment alternatives, according to what is
presented above. I agree, accept and authorize the treatment, and declare to follow the professional instructions and pay
the costs that are mentioned on the presented budget.

, , of 20

Patient's or Legal Dentist's signature

Guardian signature

..      Fig. 1.16  Template of clinical chart (treatment plan, informed consent)

Diagnosis and Treatment Planning
39 1

..      Fig. 1.17  Template of clinical chart (records of procedures and relevant information about the dental visit)
 40 C. R. G. Torres et al.
Other than that, current legislation in some countries still
1 oblige dental services that patient documents must be hand-
written or have a “physical existence” [3]. However, as this
new tendency seems to be irreversible, it has been calling
researchers and legislators to change the system to legally
recognize electronic documentation, without the possibility
of adulteration or violation of medical confidentiality [3].
The Dental Council gave dentist the choice between hand-
written or computerized documentation [3]. Information and
requirements have to be supplied, inside a pattern of authen-
ticity regardless of the documentation mode [3]. In recent
years, many countries create a system of digital certification,
designated to guarantee the authenticity, the integrity, and the
juridical validation of the documents in electronic form [3].
This is a method to recognize the authenticity of a digital
document (Digital Certificate) similar to an “authentication”
by a notary. After the identification and the registration of the
user by an official authority, they receive a “key” (called token
or a smart card), a type of identity card. Technically, an exter-
nal device that is connected to the computer liberates, through
a pin code, a text that is incorporated into the document that
needs to be authenticated. A type of an “electronic stamp” that
declares its authenticity. This signature is achieved or printed
together along with the document and can be sent with the
document to the receiver. However, if for some reason there is
an alteration of at least one letter, the certificate is excluded,
disappearing the authentication registration and canceling the
recognition. On this way, the document is protected against
adulterations [3]. However, the contract of service, authoriza-
tion for the treatment (in case of minors or incapable), anam-
nesis, and any further documents that may need the signature
in paper still need to be printed, unless patients or their legal
representatives also have their digital signature [3].
Conclusion
Patients seeking for dental treatment present actual com-
plaints and have their own theories of a disease and personal
preferences regarding treatment options. It is the clinician’s
duty to uncover this information and to develop a personal-
ized treatment plan in accordance with the patient. The
patient has to be an equal partner in this process, even though
not being a dental professional. Therefore, dentists need to
avoid technical language and always should be aware of anxi-
eties and concerns. Active listening is a basic communication
skill that encourages people to talk and keep them interactive.
Identification of the chief complaints and knowing a patient’s
medical attitude and expectation build a reliable and solid
fundament for an intact doctor-patient relationship. Empathy
and respecting patients’ autonomy are simple to adopt pre-
requisites to build up an equal partnership. They are also an
essential precondition for shared decision-­making.
Apart from the interpersonal level, a sound examination
allows proposal of a most probable diagnosis, which in turn is
the fundament for the treatment plan. Dentists need to
accept that diagnoses may be false, and they need to explain
that to their patients giving likelihood ratios at the best. It is
advisable to follow a certain systematic during the clinical
examination. After the interview, it is best to start with the
extraoral and then proceed with the intraoral assessment.
Dental findings are recorded separately from periodontal and
endodontic findings using hard copies or digital files. Many
patients are unsatisfied with their esthetic appearance and
possibly state these concerns during the medical interview.
Analysis of dental, periodontal, and facial esthetics may
round off a comprehensive clinical examination.
Based on clinical findings and in conjunction with the
patient’s complaints, a treatment plan is developed. In a mod-
ern doctor-patient relationship, an empowered patient takes
a self-responsible informed choice after discussing advan-
tages and risks of potential options. Clinicians need to be up-­
to-­date with the best available evidence, in order to provide
actual information needed to take a treatment decision.
Sometimes no treatment can be an option as well and dis-
plays a deliberate choice as well. Shared decision-making is
opposed to a paternalistic model where doctors dictate
patients what choice is best for them. In many countries,
shared decision-making is made mandatory by law. After
shared decision-making, patients are informed better, have
more control, and stick to their therapy of choice.
Implementation of the treatment plan is sequenced in
different phases, systemic, urgency, control, corrective, and
maintenance phase. Each phase helps the patient to establish
oral health and improve or maintain masticatory function or
dental esthetics. Ultimately, every intervention should
improve oral health-related quality of life.
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 43 2

Ergonomics Principles Applied

to the Dental Clinic
Karen Cristina Kazue Yui, Cristiani Siqueira Barbosa Lencioni,
Eliel Soares Orenha, and Carlos Rocha Gomes Torres

2.1 Introduction – 44

2.2 Ergonomics in Dentistry – 44

2.2.1  orking Posture – 45
W
2.2.2 Positioning of the Delivery Unit and Dental Chair – 50
2.2.3 Positioning of the Patients on the Chair – 53
2.2.4 Positioning of the Patient’s Head – 54
2.2.5 Positioning the Operating Field in Relation to the Dentist – 55
2.2.6 Positioning of the Operating Field in Relation to the Assistant – 56
2.2.7 The Use of Overhead Chair Light – 57
2.2.8 Vision of the Teeth to Be Treated – 58
2.2.9 Types of Movements During the Dental Treatment – 58
2.2.10 Ways to Grasp the Hand Instruments – 59
2.2.11 Rest Places – 61
2.2.12 Work Environmental Conditions – 63

2.3 Work-Related Musculoskeletal Disorders – 65

2.3.1  ccupational Diseases Epidemiology – 67
O
2.3.2 WMSD Prevention – 68

2.4 Exercises to Prevent Osteomuscular Problems – 69

2.5  urrent Panorama of Dental Ergonomic: Challenges,

C
Proposals, and Goals – 74

References – 75

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_2
 44 K. C. K. Yui et al.
Learning Objectives
The learning objectives of this chapter are related to the fol-
lowing topics:
2 55 The principals of ergonomics in dentistry
55 How to ergonomically seat during the dental treatment
55 How to properly position the patient in the chair in order
to have the operating field facing the operator and
assistant
55 How to grasp the instruments and rest the fingers in the
oral environment, in order to have the full control of the
hand during treatment
55 How to deal with the work environmental condition in
order to protect the dental team health
55 How to prevent the most common work-related
musculoskeletal disorders in dentistry
2.1 Introduction
We, human beings, are provided of a force that drives us to a
continuous search of the knowledge of ourselves and to bet-
ter adapt to the environment in which we live, aiming to
improve and ease the development of our activities, so we can
reach superior levels of interaction, satisfaction, and internal
and external well-being, socially and individually. This
power, which at the same time drives and is driven by this
search, enhances our capacity to transcend and develop; and
nowadays, it has come to proportions never imagined before
[29]. Throughout the last few years, we have noticed a rapid
transformation in our society due to the huge quantity, avail-
ability, and transference of information. This has allowed a
significant improvement at work and life conditions. Multi-
and transdisciplinary strategies have each day been more
used to break barriers that once before hindered the acquisi-
tion, transference, and availability of knowledge.
The ergonomics, by its own nature, has benefited on this
context, enclosing and interconnecting the knowledge of
physiology, psychology, sociology, architecture, semiotics,
industrial design, anthropometry, engineering, physical ther-
apy, anthropology, medicine, communications, and many
other neighboring sciences, applied to the work and on
human being activities, with the purpose to improve the
adaptation of the methods, means, and environment work to
men [20]. Ergonomics is the study of the adaptation of the
job to men, and it has been defined as “the group of scientific
knowledge about men that are needed to conceive an instru-
ment, a machine and tools that can be used with maximum
comfort, safety and efficiency” [30, 36, 64]. What has been
seen on most of the professions is an adaptation of men to the
job and not the inverse. However, the human being is not
always capable to adapt to the job. Therefore, it can be seen
that men should be the center of the attentions to elaborate
projects for each job, adapting it to the human being capacity
and limitations [60]. Therefore, for the ergonomic studies, it
is important for us to know human being’s characteristics
(physical, physiological, psychological, social aspects and
age, gender, training, and motivation), characteristics of the
machine (equipment, tools, furniture, and spatial arrange-
ment), and characteristics of the worker’s environment (tem-
perature, noise, vibrations, light, colors, gases, etc.), besides
the consequences of the job, among other things.
In dentistry, as in any other health professions, this inter-
action between the worker, the environment, and the tool has
very special characteristic. The goal of the activity is not to
produce or manufacture a product or an object but to offer a
service. This service is very special, because it is performed
for and to a human and not for nor to an object; this fact,
obviously, leads to very specific aspects, where the emotional
aspects relative to the environment, the clinician, and the
patient play a very fundamental role. That is why a satisfac-
tory adaptation between the dentist and his job requires an
environment that is emotionally positive and pleasant; where
the feelings to go further than comfort and productivity
flourish such as desire, pleasant surprises, interest, delight,
admiration, satisfaction, fascination, kindness, acceptance,
tolerance, proactivity, motivation, and confidence [29]. A
good adaptation does not occur where there is negativity
and is not pleasant and where feelings such as indignation,
disdain, grief, unpleasant surprise, excessive competition,
dissatisfaction, frustration, intolerance, suspicion, subor-
dination, monotony, and fear flourish. Giving emphasis to
the emotional aspects and using the knowledge on human
sciences as psychology and sociology, the contemporary
ergonomics aims to turn the dental service more pleasant
and enjoyable, and that way demystify the image people
have about the dentist, untying it from unpleasant feelings
and experiences. For that, it needed a more humanized den-
tistry, where more empathy, affection, love, and satisfaction
are noticed. Positive sensations and good feelings must be
instilled on the dentistry character and on the development
of the dental attention to reach those sublime goals [29].
Ergonomics is the study of the adaptation of the job to
human being. What has been seen on most of the
professions is an adaptation of human being to the job
and not the inverse. However, the human being is not
always capable to adapt to the job.
2.2 Ergonomics in Dentistry
The knowledge on dental ergonomics has advanced much on
the last decades, revealing its importance for the dentist.
However, we observe the non-implementation and practice
of this knowledge. Some studies show that it is high the
occurrence of joint, muscles and lumbar problems, and many
clinicians’ diseases related to the bad posture, lack of ergo-
nomic planning of the dental treatment unit, work
­environment, work systems, among others [27]. This has
caused many of the dentists to work on a low productivity
rate, without comfort and especially without the quality of
Ergonomics Principles Applied to the Dental Clinic
45 2
life and, in many cases, it has even drive them to abandon the >> The rationalization of the job can be obtained by
career prematurely. means of organizing the clinical procedures, applying
There is no doubt the dentistry is a weary and stressful the corporate management concepts and ergonomic
profession, which causes damage to the health, both physical principles, space arrangement, and four-handed
and psychic [10, 37, 39, 41, 46]. Studies about the musculo- dentistry.
skeletal disorders among dentists have been performed since
International standards on the ergonomic field were elabo-
the 1950s, and they are responsible for the first proposes to
rated aiming to promote significant improvement and to
change their working process, including the changes on the
assure that the standard procedures, for a healthy and safe
orthostatic position to the sitting position [61]. The actual
job, are established. The ISO 11226:2000/Cor 1:206 estab-
postural awkwardness at the dental work has been subject to
lishes the health limits for a static sitting job [31]. The ISO
many discussions [12]. Non-ergonomic dental workspace
6385:2004 presents a glossary of the main ergonomic terms,
and awkward postures cause musculoskeletal disorders,
requirements and necessary procedures for the development
which are common among dentists. This context is the theme
of working systems and places [33]. In 2009, the ISO 4073
for studies, especially in the ergonomics area. The posture
was revised and updated, and even though its first edition has
adopted by the dentist on their tasks has changed throughout
been published about 40 years ago, not all clinicians apply its
the world over the last 30 years [40]. However, the require-
principles on the spatial arrangement of their work environ-
ments of the dental practice, as the restrict visual field and
ment [15, 32]. In . Fig. 2.1, a correctly spatial arrangement of
adoption of awkward postures, increase the predisposition
 

the dental office according to the ISO 4073, in which we can

for the dentist to get musculoskeletal diseases [40, 51, 58].
notice a correct division of working zones on the floor, will
Therefore, more research is needed, which can define the
be described further in this chapter.
impacts of the muscular and nervous diseases on those clini-
cians, with the aim to prevent their development. With that,
there will be a better quality of life and a better service [52].
2.2.1 Working Posture
There is a consensus among authors in relation to the
causes of repetitive strain injuries (RSI) and work-related
The posture is defined by the American Academy of
musculoskeletal disorders (WMSD) among the dentists and
Orthopedics as a reactive arrangement of the body parts;
it can be highlighted:
the good posture is related to the balance between the sup-
55 Factors with organizational nature: Movement concen-
port structures, the muscles, and bones, protecting them-
tration on the same person, extra work hours, double
selves from aggression (direct trauma) or progressive
shifts, accelerated work rhythm, lack of necessary
deformity (structural changes) [1]. It is called postural
pauses, pressure from the boss, and others
work, the invisible effort that the back, shoulders, and arms
55 Factors with biomechanical nature: Excessive strength,
muscles do in silence against gravity. When we are sitting,
intense repetitiveness of the same movement pattern, the
there is a continuous effort of the back muscles to maintain
wrong posture of the upper limbs, compression on the
the torso erect, any other way, the body would collapse. This
lower limb structures, static posture, and others
muscular effort generated is in disadvantage because it
55 Factors with psychosocial nature: Excessive pressure for
blocks the blood flow. To have postural comfort, uncom-
results, excessively tense work environment, interper-
fortable positions for the torso, head, and arms should be
sonal relation problems, excessive rigidity at the work
avoided [5]. During the dental procedure, it should be
system, and others
­permitted to alternate between the sitting and standing
55 Factors of work conditions: Temperature, vibration,
furniture, noise, illumination, space, tools, and others

For the described factors to be considered a risk to cause RSI/

WMSD, it is important to observe their intensity, duration,
and frequency [44, 45]. Among those predisposed elements,
it can be pointed out the factors with organizational nature.
The way in which the work is organized can cause a greater
impact on the well-being of the individuals when compared
to the other factors.
The ergonomics applied to dentistry has the primary goal
to find mechanisms to reduce the physical and mental stress
on the dentist, to prevent diseases related to the dental prac-
tice, increasing the productivity  but also the quality of life
[52]. The rationalization of the job can be obtained by means
of organizing the clinical procedures, applying the corporate
management concepts and ergonomic principles, space ..      Fig. 2.1  Dental clinical room built observing the criteria of the ISO
arrangement, and four-handed dentistry. 4073:2009 standard
 46 K. C. K. Yui et al.
positions. When only one of the positions needs to be cho-
sen, the sitting position must be preferred.
Another important aspect is the interchange of the body
2 posture to avoid prolonged muscular static tension, that will
lead to fatigue. On the same way, a good balance between the
body movements should be established, and the movement
must be preferred against the prolonged immobility. The
high precision movements, common in dentistry, should not
involve a significant muscular force.
The healthy posture for the dental job is sitting, also called
“finger control posture” or “pianist posture.” The working
position should be similar to the positions that we adopt
when we are reading a book, in a way that the visual field is
perpendicular to our visual axis [26]. To reach this healthy
posture, three basic work positions can be used [26, 28].
55 Active (dynamic): Static positions are only possible
when the object to be seen by the dentist can face his
visual axis. For example, when the dentist is adjusting a
temporary crown outside the mouth, all the surfaces can
be easily seen by rotating the tooth completely without
having to change the visual axis. On the other hand,
when the dentist makes a preparation on the buccal and
lingual surfaces of the tooth 46, it is necessary to change
his position and the position of the patient’s head in a
way that it is possible to look in a perpendicular manner
to the working field. This frequently happens during the
intraoral procedures. Therefore, it is frequent the
necessity to visualize different sites, which cannot be
completely positioned in the direction of the visual axis
of the dentist, being necessary to move to get adequate
vision without excessive inclination. For that, it is
necessary to have enough space under the back of the
patient’s dental chair that will allow the dentist to freely
move, without obstructions and where the legs will not
be “hindered and restrained” under the back of the
chair.
55 Symmetric (stable and balanced): The working field
must be positioned in front of and centralized in relation
to the chest of the dentist. Every time that the working
field is not centralized in relation to the chest of the
dentist, an asymmetric work posture will occur. It
requires more muscular effort to maintain the balance
and it will generate more fatigue and tiredness. The
inclination and effort will lead to scoliosis. Other
important disadvantage will be the difference in distance
among the objects focused by the left and right ocular
globe [62]. This difference in distance leads to more
effort on the ocular muscles to correct the distortion of
the image that will be generated, which will predispose
prematurely the dentist to a presbyopia condition [24]. A
symmetrical position is reached when there is a parallel
relation to the imaginary lines that go through the
pupils, shoulders, hips, knees, and feet completely laying
on the ground. This also requires that the foot control of
the chair is closely positioned to the foot of the dentist,
so it is not necessary to stretch the leg to reach it.
55 Erectus: It is reached when we intentionally position
the forward and upward, with the vertebral column in a
neutral position, and the closest as possible to the shape
that it has when it is in the orthostatic position (stand-
ing). This avoids overload of the intervertebral discs,
herniated disc, hyperlordosis, hyperkyphosis, and sco-
liosis of the vertebral column. This way, when passively
seated, the correct support on the upper and lateral parts
of the pelvis, which must be proportioned by the support
of the dental stool, is fundamental to increase stability
and reduce the muscular overload.
>> The healthy posture for the dental job is sitting, but
this working position has also to be erectus, active,
and symmetric.
The ISO 11226:2000/Cor 1:2006: standard “Ergonomics  –
Evaluating the posture of static work” establishes the healthy
limits for a job performed sitting and static and determines
the ideal position considering the head, the torso, the arms,
and the legs angles [31]. To reach an ideal posture, according
to this standard, the column must be erect, the legs must
remain perpendicular to the ground, and the tights must be
parallel to the ground or slightly leaned, forming a 90° to a
125° angle on the knees and hip angle (. Fig. 2.2a). The head
can lean up to 20° forward in relation to the column, while
the torso can lean up to 10° forward (. Fig. 2.2a). The upper
arms must present a maximum angulation of 20° on the for-
ward inclination (. Fig. 2.2a).
Tip
The dentist must pay attention to his body. The head
should not lean more than up to 20° forward in
relation to the column, while the torso can lean up to
10° forward. The upper arms must present a maximum
angulation of 20° on the forward inclination.
The patient must be positioned in a way that the forearms of
the operator are leaned, at least, 10° and the most to 15°
upward, when the hands are in a position of operating
(. Fig.  2.2a). This inclination of the forearms avoids the
excessive frontal inclination of the torso, so it is possible to
have a good vision of the operating field [26]. The elbows
must be close to the body with a maximum lateral distance
of 20° (. Fig. 2.2b) [26, 28]. It is very common to observe
that the dentist and the dental students usually work with
an excessive distance between the elbows, and always that
the patient’s mouth is positioned above the recommended
distance from the ground, which is 5–10  cm below the
elbows when the dentist is well positioned in the stool. This
patient’s position can avoid that the dentist leans the torso
beyond the 10° forward, in the anteroposterior direction.
To lean the body forward produces a reduction of body’s
agility and increase the static load. The back and neck of the
dentist should not lean or rotate laterally, and the top of the
Ergonomics Principles Applied to the Dental Clinic
a b
..      Fig. 2.2  Healthy work posture for the dentist according to the ISO 11226:2000 standard. a Side view; b back view
shoulders should stay parallel to the ground, which charac-
terizes a symmetric and equilibrated posture, without mus-
cular overload (. Fig. 2.2b) [26, 28].
 
On the other hand, the effective application of the rules to
the postural needs of the dentist demonstrates a great chal-
lenge, because the working field (surface, tooth, quadrant, or
region) cannot always be directed perpendicularly to the
visual axis. In many cases, the use of the clinical mirror is
essential because it facilitates the visualization without the
need to lean laterally or forward, especially in procedures
performed on the upper jaw, and even that, it is not always
enough [28].
One difficulty is related to the angles formed by the thigh
and the leg. When a 90° knee angle is adopted (. Fig. 2.3a),   and downward. When this angle is lower, close to 90°, there
the space under the back of the chair is limited, especially
when the patient is sitting down, forcing the dentist to back
up from the patient and to lean forward to approach the
working field, causing a compression on the abdominal
region that will lead to a diminishing of the venous circula-
tion [26]. This space becomes greater when we increase the
angle to 110°, and it can go up to 125° (. Fig.  2.3b, c).
 
Another additional benefit is that this increase, to at least
110°, propitiates less compression on the abdominal region,
facilitating the blood circulation on this region. It also per-
mits that the work posture of the dentist become more
dynamic, prone to the movement, permitting the alternation
of the position on a simple way, naturally and without obsta-
cles, which is an essential condition, for example, when a
procedure is performed on the first quadrant, comprehend-
ing the buccal, lingual, mesial, and distal surfaces. This
47 2
mobility and freedom of movements are necessary when we
do a cavity preparation that comprehends two or more sur-
faces, or even the preparation for a full crown that compre-
hends all surfaces of the tooth. On those cases, only asking
for the patient to move the head left or right, backward or
forward, may not be enough and requires that the dentist
move himself more to the right or behind the patient.
Consequently, there is a need for a work posture that is at the
same time symmetrical, erect, balanced, and stable, but
prone to the movement [26, 28].
Other benefit in using an angle greater or equal to 110°
between the thigh and lower part of the leg is that this leads
to a neutral positioning of the pelvis, slightly leaning forward
is an upper and backward leaning of the pelvis. Therefore,
when the pelvis is raised and forced back, there is more ten-
sion on the lumbar region of the vertebral column, reducing
its normal curvature and causing a compression on the inter-
vertebral discs [31].
Kinematic chain balance and neutral working posture is
most easily achieved by working in a higher sitting posture,
with a 125° knee/hip angle, because it allows the patient’s
chair to be raised, creating the necessary space for proper
movement of the legs of the dentist under the back of the
chair. However, currently, most of the dental stools offered
on the global market have a flat seat; hence working in a
higher sitting posture leads to a greater compression on the
returning venous circulation, and, consequentially, there are
more chances to have varicose veins because there is a
greater support on the legs and less support on the coccygeal
 48 K. C. K. Yui et al.

a b c

..      Fig. 2.3  Angle between the leg and the thigh. a 90° angle. Distance between 5 and 10 cm between the height of the elbows and the mouth
of the patient; b 110° angle. The inadequate stool leads to a compression of the thigh (arrow). c Use of the saddle shaped stool (Salli System)

a b c d

..      Fig. 2.4  Dental stool with design of two-inclination seat, which allows the dentist to adopt a healthy work posture. a, c Stools with straight
seats; b, d stool with double inclination. (Courtesy from Professor Paul A. Engels)

region (. Fig. 2.3b – arrow) [2]. So that does not happen, it

 
is necessary that the dentist’s stool comprises a seat pan, con-
sisting of a horizontal rear part for the pelvis, and an inclin-
able sloping down front part for the upper legs, with a
vertically and horizontally adjustable back rest [13, 28].
. Figure 2.4 shows the Ghopec dental stool with an appro-
 
priate design, that allows the dentist to assume a passive as
well as a dynamic posture [28].
Other option would be to use stools shaped like a horse’s
saddle (Salli System), as it can be shown in . Fig. 2.5. On this
 
type of seat, the support happened at the ischium bones in a
simulation as if the individual was standing up, and because
of that, there is no back in the stool. The angle on the knee
region is found to be more adequate, which lowers the pres-
sure on the knees, improves the joint metabolism (knee and
hips), and lowers the risks of future problems, also contribut-
ing to improve the circulation on the legs. Because it is com-
posed of two separate pars, it ventilates the genital region of
the woman, which reduces the occurrence of infections and
reduces the pressure on the masculine genital organ. This
system also reduces pressure on the chest, on the ribs, and on
the upper part of the column, increasing the inhaled oxygen
Ergonomics Principles Applied to the Dental Clinic
..      Fig. 2.5  Saddle-shaped stool (Salli System)
quantity. Furthermore, lowers the pressure on internal
organs, especially on intestine and stomach (. Fig.  2.3c).
 
Limitations are attributed to saddle stool which are related to
increased angle in the lumbar spine when sitting with a 135°
hip angle and muscle fatigue in the same region by the
absence of the backrest [13]. A recent systematic review [50]
has revealed that there is a limited number of studies and
insufficient scientific evidence that using saddle stool leads to
improved dentist’s sitting posture, and there are no studies on
its effect to reduce neck pain and musculoskeletal pain.
Therefore, prospective longitudinal studies that are necessary
to strengthen the scientific evidence about its contribution
and effect.
However, the recommendation to use an angle >90° con-
tinues to be a problem for most of the dentist around the
world, who may not have a stool with a proper design avail-
able on the market. In the case the stool does not have one of
the mentioned designs and an angle >90° is used, the result-
ing forces on the tripod legs stool can push the stool back-
ward and also result in the compression and venous
obstruction on the thigh region. Therefore, in the abscence of
an adequate stool, a 90° angle should be used. The incorrect
drawing of the stool can seriously affect the health of the cli-
nician, leading to an irreversible deformation of the vertebral
column [2].
49 2
Vianna and Arita [63] described a working position that
is based on the logic performance concept, which is a scien-
tific model of improved performance by means of emphasis
on a more natural position, to do a finite task on a balanced
posture. Studying the space relation between the operator
and his work plane, it can be concluded that the dental work
is much better performed on the midsagittal plane, with the
hands, on the chest or heart level, in myocentric harmony
(. Fig. 2.2).
The dentist must sit with his feet completely supported on
the ground, providing a position of equilibrium and a posi-
tive physiologic condition.  The greater the area in which a
force acts on, the smaller the pressure and better distribution,
so more favorable to the health of the feet. The feet must be
parallel to the ground, in a way where the right foot is slightly
ahead of the left foot, and this position can be alternated. The
right foot must be free on a plane area to reach the command
of the dental chair, without diverting the attention from
the operating field. Furthermore, the shoes must be comfort-
able and loose [19]. The dentist should not sit on his legs and
should always sit on the gluteus region, with the support on
the ischium bones, which is part of the hip bones [2]. The
whole seat surface must be used to support the operator’s
weight. The compression of the tissues varies with the type of
seat, been greater on the stools with a flat surface and lower
on a saddle-shaped stool, as it can be seen on the . Fig. 2.6a,
b. In relation to the angle formed by the gap between the legs,
it can be between 25° and 45° (. Fig. 2.14).
>> The dentist must sit with his feet completely supported
on the ground, providing a position of equilibrium.
In relation to the leaning of the body on the anteroposterior
position, the ideal is to maintain the sitting positioning on a
medium posture (. Fig.  2.7a). On this position, it is reco-
mended a support on the upper pelvic region or lumbar [28],
which alleviates the abdominal cavity, an important region
for blood flow and digestion [2]. A slight leaning forward
<10°, on a relaxed position, decreases the electrical activity of
the muscles, and so it is favorable. However, if the forward
leaning of the chest is too high, there will be a compression
on the abdominal cavity (. Fig. 2.7b). On the anterior posi-
tion, the large saphenous vein can be compressed, causing an
obstruction of the veins of the leg and undesirable effects on
the internal organs, which can reflect on the chest or on the
groin [2]. In addition, this leaning pushes the organ upward,
which impairs the well-functioning of the lungs and heart
due to a less volume on the thoracic cavity. If the dentist is
leaning backward, in a posterior position, there will have a
displacement of the equilibrium point with its tragic conse-
quences (. Fig. 2.7c).
According to Ferreira [17], there is a consensus among
researchers that working on a seated position allows a more
comfortable condition for the clinician. On the other hand, it
is fundamental to point out that the bad posture at a seated
job, can be potentially more harmful to the individual than to
work in the standing up position. In other words, the dentist
 50 K. C. K. Yui et al.

a b

..      Fig. 2.6  Relation between the kind of seat and the compression on the soft tissues. a Straight surface stool; b Saddle-shaped stool. The red
areas represent greater compression regions. (Images kindly supplied by the Salli System Company)

a b c

..      Fig. 2.7  Leaning of the body on the anterior-posterior direction. a Medium sitting posture; b Anterior sitting position with excessive leaning; c
Posterior sitting position

who works standing up has less harmful consequences than
the one who works sitting down in a wrong position. In sum-
mary, to work on a healthy way, the dentist needs to work
symmetrically erect on active and stable position, avoiding
lifting and curving the shoulders and only making small
movements with the arms. To make this possible, the operat-
ing field must be positioned on the correct height, in sym-
metrical position in relation to the dentist, facing his visual
2.2.2  ositioning of the Delivery Unit
P
and Dental Chair
There are four basic concepts to build dental treatment unit.
On concept 1, the most commonly used dental delivery unit
(treatment cart or instrument bridge) is positioned to the
right of the dental chair and to the right of the dentist
(. Fig. 2.8).

field in a way that he/she is capable to see the field in a most
perpendicular way as possible. The instruments must be
positioned on the correct working height, inside the vision
field, at 30° angle to the left and right. As a result of all that,
the dentist will be able to reach the instruments without
extreme movements. Finally, the dynamic working method
must be applied instead of a static method.
To analyze the dental treatment unit according to its posi-
tion in the dental office, the ISO/FDI is established to divide
the room into areas, like a clock face. The center, correspond-
ing to the axis of rotation  of the clock, is located in the
patient’s mouth (the most important point in the dental
office). Around the center, three concentric circles are drawn,
named A, B, and C, with a radius of 0.5, 1, and 1.5 m, respec-
Ergonomics Principles Applied to the Dental Clinic
51 2

..      Fig. 2.8  Basic concept 1 for delivery unit and chair. (Scheme kindly supplied by the Dabi-Atlante company)
 52 K. C. K. Yui et al.
12
11 1
2 C
10 B 2
A 50cm
50cm
50cm
9 3
4 Operator area
8
7 5
..      Fig. 2.9  Functional work circles at the dental office. (Scheme kindly supplied by the Dabi-Atlante company)
tively (. Fig. 2.9) [2]. The A circle is called the transference
 
zone, where the instruments, handpieces, and stools must be
placed. The B circle is the working zone, where the cart and
the body of the dental delivery unit are placed. The C circle is
the rest of the useful area of the dental office, where the sink
and stable furniture are placed. The position 12 o’clock is
always marked by the head of the patient, in other words, the
back of the chair.
The use of the zone of activity concept is the best way to
identify the work position for the working dental team. The
6–12 h line divides the room into two areas (. Fig. 2.9). The  
operator’s zone is where the dentist will be positioned, to the
right of the patient, going from 7 to 12 o’clock for cases of
right-handed clinicians and from 5 to 12 on the left-handed
cases. The ideal work position is reached when the clinician
is positioned in front of the patient’s mouth and is able to
place the working field the closest as possible and facing his
visual axis.
The 9 o’clock position is considered by most authors as
the basic for the dentist’s job (. Fig. 2.10a). At this position,
 
one of the best places for the dental delivery unit is to the
right. This way, the dentist can reach the high and low-speed
handpieces and the 3-way syringe with only one movement
of the forearm, with the elbows in a comfortable position
near the body, without rotating the head. The 7 and 8 o’clock
positions are not appropriate for the intraoral procedures,
only for the external procedures or when the clinician is talk-
ing to the patient, for example, during the anamnesis
(. Fig. 2.10b) [34]. The attempt to work on the mouth being
 
in one of those positions will lead to an asymmetrical pos-
ture, leaning laterally and with the dentist’s right elbow lifted
A - Transference zone (instruments, handpieces, stool)
B - Work zone (auxiliary table and delivery unit)
C - Useful office area (sinks and furniture)
Assistant area
above 20°. On those positions, the working field will not be
located in front of the dentist’s body, forcing him to execute
lateral flexion movements of the body to the side of the
patient. That will generate an overload of the intervertebral
discs on the lumbar region and on the cervical column, and
may cause scoliosis and herniated disc. This may also  pro-
duce, further than tiredness, a lot of muscle fatigue on the
right shoulder.
The 12 o’clock position may permit the operator to work
on a labial surface of the anterior maxillary teeth and to use a
direct vision. However, it presents disadvantage that the
movement of the instruments will occur above the patient’s
face, exposing him to the risk of an accident, being not used
more than 10% of the dentist’s time. The dentists work mainly
on a 9–11 o’clock position. As an advantage of those posi-
tions, the direct vision of almost all surfaces of all teeth  is
possible, with a minimum leaning of the column forward
and never laterally, being more natural and better to the ver-
tebral column. The operators can also use direct vision mov-
ing to the 8 o’clock position, when working on an occlusal
surface of the posterior mandibular teeth on the right side.
The assistant’s zone is the area of auxiliary activities, situ-
ated to the left of the patients for the right-handed clinician. In
that area the furniture, auxiliary equipment, and all equip-
ment used by the assistant are placed, such as the vacuum suc-
tion tip and the 3-way syringe. The assistant position varies
from 2 to 4 o’clock for the right-handed (generally is 3 o’clock),
and from 8 to 10 o’clock for the left-handed. Nothing in this
zone can interfere on the access of the assistant to the instru-
ments and handpieces (. Fig. 2.10a–c). The static zone is the
limit between the operator and auxiliary areas on the region
Ergonomics Principles Applied to the Dental Clinic
a b
12 12
11 1 11
10 2 10
9 3 9 3
8 4 8 4
7 5 7 5
6 6
Dentist: 9 o´clock Operator area Dentist: 7 o´clock
Assistant: 3 o´clock Assistant area Assistant: 3 o´clock
..      Fig. 2.10  Working zones for the dentist and assistant. a Dentist at 9 o’clock and assistant at 3 o’clock; b dentist at 7 o’clock and assistant at
3 o’clock; c static areas and transference areas. (Scheme kindly supplied by the Dabi Atlante company)
behind the chair, being from 12 to 2 o’clock for the right-­
handed and from 10 to 12 o’clock for the left-handed [2]. It is
a zone of less activity, and, in general, it is used to place emer-
gency materials for the dentist and auxiliary equipment, as
amalgamator, ultrasonic scaler, and curing light, among oth-
ers. The transference zone is located from 4 to 7 o’clock for the
right-handed and from 5 to 8 o’clock for the left-handed clini-
cian (. Fig. 2.10c).
During the procedure, the operator must be capable to
keep hands and eyes on the working field, without being wor-
ried about from where the next instrument will come. Care
should be taken so that members of dental team do not inter-
fere on the activity of each other inside the designated zones,
avoiding unnecessary movements that could interfere on the
procedure. Both team members sitting correctly must have
all the material and instruments in a minimum reaching dis-
tance, inside the working areas, and in the radius of circle A
which is the size of the forearm (. Fig. 2.9) [2].
>> During the procedure, the operator must be capable to
keep hands and eyes on the working field without
being worried about from where the next instrument
will come.
The  concept that the less movement done, the less use of
energy and the greater the productivity should be adopted
[2]. The working surfaces to place the instruments must be in
front of the patient, more or less 20 cm from his chin, on the
frontal transference zone, next to the working area. The oral
cavity of the patient, the dentist’s delivery unit, the assistant’s
delivery unit, the top of the furniture with the equipment,
and the trays with the instruments, must be placed on a
hypothetical horizontal plane, from 5 to 10  cm above the
elbow of the dentist (. Fig. 2.3a).
 
53 2
c
12
1 11 1
2 10 2
9 3
8 4
7 5
6
Operator area STATIC AREA
Assistant area TRANSFERENCE AREA
2.2.3 Positioning of the Patients
on the Chair
The patient must be, always as possible, positioned in a
supine position (lying on his back), so that the dentist and
the assistant can have a direct vision on the operating
fields. One of the advantages of the supine position is that
the patient’s tongue falls behind, blocking the pharynx,
this way, even when the patient’s mouth is full of water he
does not have the need to swallow. In addition, if any mate-
rial or tool escapes the hands of the dentist, the chances of
being swallowed are minimum, since the deglutition is
harder on this position (. Fig.  2.11a, b) [2]. The working
field on the mouth of the patient can be turned to the visual
axis of the dentist in an easier way if the patient is in a
supine position.
On the supine position, the knees and the legs of the
patients must be at the same level as the head (. Fig. 2.12).  
This replicates the position that most people adopt when they
are sleeping for many hours without blocking the blood flow.
The position of the patient when the legs are higher than the
head for a prolonged time is not recommended [7].
Once the patient is in a supine position, the operator can
lower the chair up to the point where the patient’s head is at
his lap, so he will not have to raise the forearm above 15° or
lean himself more than 10° to work at the patient’s mouth [7].
The dentist will have to lean excessively forward when the
patient is at the same height or lower than his elbows. On the
other side, when the mouth is positioned much higher than
the level of the dentist’s elbow, the dentist will have to raise
the shoulders, arching them and moving the elbows far away.
As it has already been mentioned, the mouth of the patient
must be 5–10 cm above the elbows of the dentist.
 54 K. C. K. Yui et al.
a b
..      Fig. 2.11  Relation between the leaning of the head and the opening of the digestive and respiratory way. a Patient sitting with the orophar-
ynx opened; b patient laying down with the oropharynx closed by the backing up of the tongue
..      Fig. 2.12  Adequate positioning of the patient on the supine
position
It is important that both legs are positioned under the back
of the chair, without being “restrained” or “blocked,” with the
head of the patient, who is on the supine position, being able to
alternate the position from 9 to 12 o’clock and keeping his pos-
ture. As it has already been mentioned, this is attained by
adjusting the angle between the leg and the thigh above 90°
using an appropriated stool. Therefore, the correct working
height depends on the dentist’s height and when he is posi-
tioned correctly on the stool. This way, the dentist and the assis-
tant must be at compatible heights, so that the adjustment of
the chair for the dentist is not uncomfortable for the assistant.
The final visual adjustments and the access to all quarters
of the mouth can be reached by rotating the head of the
patient. The torso of the dentist must be the closest as possi-
ble to the back of the chair; this way, the head of the patient
will be leaning on his lap at a distance of 30–40 cm below the
eyes/safety glasses, providing comfort for the vision and con-
tributing to the infection control. The operator will also not
invade the breathing space of the patient, and this way will
show consideration about his comfort throughout the treat-
ment.
For the working position currently recommended, the
leaning of the chair’s back depends on where the dentist will
be working in the oral cavity of the patient. The leaning of the
articulated headrest of the chair must change according to
the arch that is being treated. On the upper jaw, the patient
must be on the supine position, and the headrest must be
leaning backward. For procedures on the lower jaw, the head-
rest must be leaning forward (. Fig. 2.13a, b).
>> One of the advantages of the supine position is that
the patient’s tongue falls behind, blocking the
pharynx.
2.2.4 Positioning of the Patient’s Head
The patient’s head must be placed in a way that the working
field is facing the dentist’s visual axis, considering that he is
correctly positioned on the stool. To reach this position, the
patient’s head can be moved in three axis and three directions
(. Fig. 2.13a–f):
55 Forward, by flexion, for a horizontal position of the
lower jaw. Backward, by extension, so that the occlusal
plane of the upper jaw can be switched in some cases on
a 20–25° angle in relation to the vertical plane. The
further the head is positioned backward, the more
favorable is to work with a direct vision in a correct
posture on the upper jaw (. Fig. 2.13a, b).
55 To the left or right by the side flexion, positioning the
head of the patient on a 30–40° angle sideways in
relation to the body’s long axis. This movement is
Ergonomics Principles Applied to the Dental Clinic
55 2

a b

c d

e f

..      Fig. 2.13  Movement of the patient’s head in three ways to place the working field perpendicularly to the visual axis of the dentist. a Forward;
b backward; c leaning to the left; d leaning to the right; e right rotation; f left rotation

necessary to put the operating field on the patient’s 2.2.5  ositioning the Operating Field
P
mouth on a symmetrical plane of the dentist in Relation to the Dentist
(. Fig. 2.13c, d).
 

55 To the left or right, rotating along the longitudinal axis
of the head (. Fig. 2.13e, f).
Tip
It is easier to move the patient’s head than try only to
adjust the dentist’s position to see the operating field.
It is frequent for us to see that the operating field on a patient’s
mouth is not directed toward the dentist, and it is placed asym-
metrically in front of him, resulting in an asymmetric and
stressful operating posture. This must be avoided in a way that
the symmetrical posture can be kept. The principles for the
correct positioning of the operating field are described next:
55 The operating field must be placed symmetrically,
straight in front of the chest of the dentist, at a distance
 56 K. C. K. Yui et al.
of 20–25 cm from the sternum bone. In addition, it must
be placed in a height that allows a correct working
posture.
2 55 The clinician must look perpendicularly to the operating
field or to the mirror. If this is not possible, as it happens
on the posterior region of the mouth or when using a
handpiece, the field or the mirror must be as perpen-
dicular as possible. The rotation of the patient’s head
allows the good positioning on the visual field. It can be
turned in three directions, according to the previous
description, to promote this vision.
If the head of a bur or instrument is positioned on the sight-
line, interfering with the good visualization, the patient’s
head is rotated and the dentist position is adjusted instead of
the dentist moving his torso and head laterally to reach more
visibility.
After defining those general rules, taking in consider-
ation the position of the operating field in the patient’s
mouth, the question is how it can be reached and how the
arches of the patient must be placed. This position depends
completely on the procedure to be performed:
55 When a procedure is done on the mandibular occlusal
plane, the dentist must sit on the side of the patient on a
position between 9 and 10 o’clock, for the right-handed
people, and the occlusal plane will be placed more or less
horizontally. The patient’s head will be turned to the
dentist in a way that he looks perpendicularly to the
occlusal plane. If the lower jaw is not placed like that, but
in an oblique way, the dentist will have to raise the right
arm to reach the operating field.
55 When a procedure is done on the mandibular occlusal
plane, from behind the patient (on the position from
10:30 to 12 o’clock for the right-handed people), the
occlusal plane on the lower jaw is placed approximately
40° in relation to the horizontal plane, in a way that the
operating field is viewed perpendicularly, with the help
to the head’s rotation.
55 When treating the maxillary occlusal plane, with an
indirect vision from behind the patient, the occlusal
plane of the upper jaw is turned around 25° backward in
relation to the vertical plane. Followed by a rotation of
the head, it is placed on the correct position in relation
to the mirror. Those 25° of rotation promote a great
adjustment for the necessary position of the mirror. The
problem with most headrests is that it is impossible to
position the upper jaw occlusal plane at 25° backward.
Hence, the dentist is forced to lean the torso forward to
obtain a better visibility of the operating field.
55 When procedures are done on the buccal and lingual
surfaces of the teeth, the dentist must place himself on
the side of the patient, on a position between 9 and 11
o’clock, with a direct vision, except for the anterior teeth.
55 The more the dentist wants to work on the upper jaw
with direct vision, the more the patient’s head needs to
be turned backward. However, the possibility to do that
must be evaluated.
Tip
The more the dentist wants to work on the upper jaw
with direct vision, the more the patient’s head needs to
be turned backward.
2.2.6  ositioning of the Operating Field
P
in Relation to the Assistant
The assistant plays an important role on the productivity and
on the improvement of the work quality inside a dental office.
Therefore, the dentist divides with her some of his secondary
attributions, such as some complementary tasks, saving the
time of the clinician and leaving to him the work that only he
can do [21]. As advantages of the assisted work, there is the
reduction on the movement quantity, that the dentist would
have to perform if he was working alone, reducing the physi-
cal and mental fatigue. In addition, the work at four hands
allows a higher performance, reducing the duration of the
treatment [21]. It will be the assistant’s duty to accommodate
the patient’s head and to open his mouth, putting away his
tongue and cheeks, suctioning the blood and saliva, always
placing the operating field to the direct vision field of the
dentist [2].
>> The assistant plays an important role on the
productivity and on the improvement of the work
quality inside a dental office. Therefore, the dentist
divides with her some of his secondary attributions,
saving the time and leaving to him the work that only
he can do.
The dentist’s assistants must be capable to work sitting down at
a healthy position, similar to the posture described for the
dentist. However, she should occupy the position that goes
from 2 to 4 o’clock [2]. When the dentist sits at the 12 o’clock
position, this is almost impossible. The assistant will have to sit
with the legs slightly separated, and so it does not interfere
with the movement. The assistant’s legs must be synchronized
with the dentist’s legs (. Fig. 2.14) [2]. At this position, she will
avoid the torsion of the column to the left and the raising of the
arms during the operative procedures, being better located in
relation to the delivery unit, to reach with the left hand her
elements and to help the dentist. Her back should rest on the
back of the stool and slightly leaning forward. Her head must
be leaned downward, visualizing the working field [2].
Both the dentist and the assistant must have all the mate-
rial to the reach of their hands. The assistant should not move
the whole arm, and for that, it is suggested that a third assis-
tant to prepare and bring the materials that are more distant
[2]. Another way to reach this goal is to do an effective previ-
ous planning of the tray, and placing it on the ideal distance,
to reach all the material and instruments that will be neces-
sary during treatment.
The adjustments on the patient’s  position must be per-
formed with the aid of the assistant, up to the point where
Ergonomics Principles Applied to the Dental Clinic
..      Fig. 2.14  Synchronization of the dentist’s and assistant’s legs
those relations are established. When a deviation on the pos-
ture is noticed, she can communicate politely with the clini-
cian asking: “Are you comfortable?” This is a sign that maybe
a rearrangement on the position is needed. The assistant
needs to be capable to see and have favorable access to the
oral cavity, at least of the teeth or the area that is being treated.
To increase visibility, the height of the assistant’s stool could
be at least 10–15 cm above the dentist’s head (. Fig. 2.15). To
 
make it possible, it is necessary that the assistant’s stool has
footrest. However, when this special stool is not available, it
must be adjusted so that the head of the assistant is at the
same height of the dentist’s head.
2.2.7 The Use of Overhead Chair Light
The visual performance influences directly the efficiency of
the dentist’s work. The better the clinician can see, the faster
and more reliable the work will be. The main components of
the visual performance are the ability to see small details
(visual sharpness) and the ability to see small contrast (con-
trast sensitivity). The light at the work environment must be
well planned to allow a good dentistry to be performed, a
professional activity that requires accuracy and details. The
perfect light at the dental office will reduce the fatigue and
the incidence of visual fatigue. The environment next to the
mouth of the patient must be lighted with at least 1/10 of the
light over the mouth. For example, if the light over the
mouth has a illuminance of 20,000 LUX (lx), then the sur-
roundings must be lighted with at least 2000 lx and the room
with 1000 lx.
>> The better the clinician can see, the faster and more
reliable the work will be.
One of the most frequent mistakes done by the dentists is in
relation to the incorrect positioning of the dental overhead
light, putting it in front of the patient and perpendicularly to
the visual axis. This causes the formation of shadows by the
interposition of the hands and instruments between the light
and the object to be seen [62]. The light beam must be
57 2
..      Fig. 2.15  Adequate vertical relation between the assistant and the
dentist for better visualization
directed nearly parallel to the dentist’s line of sight, without
shadows, with a maximum deviation of 15°. Proper position-
ing of the dental operating light will avoid shadows behind
the lips, teeth, and face, under the hand and on the operating
field or around it (. Fig. 2.16a, b).
Visual sharpness does not indefinitely get better with
crescent light levels; there is a peak when the luminance is
around 1000 cd/m2 (candela per square meter). Therefore,
the illumination above this value does not bring any benefit
in terms of vision sharpness. A best level of illumination also
does not exist, because it depends from each observer and
on the reflexivity of the working area. The illumination from
the dental light must go from 8000 to 24,000 lx, which cor-
responds to 200 to 2000 cd/m2 of the light inside the mouth.
The illuminance of 8000 lx is enough to visually discrimi-
nate a white tooth, and 24,000 lx is more appropriate for the
visualization during procedures done in darker areas inside
the patient’s mouth, for example, during the procedures on
the molars. The light level from the dental chair light must
be easy to adjust. In combination with other sources, the
illuminance of the mouth must not exceed 30,000 lx. Greater
light levels cause visual discomfort and reduction of visual
sharpness.
The correct distance of the overhead light to the operat-
ing field (patient’s mouth) must be around 70–80 cm, and the
environment’s light must be compatible with the illumina-
tion inside the oral cavity, allowing the gradual accommoda-
tion of the eyes [17]. When the dental light is positioned at
70 cm apart from the patient’s mouth, it must form a rectan-
gle of light with the concentrated area and limited by 10 cm
height and 20 cm width, in a way that there is no direct light
beam to the patient’s eyes, which causes dazzle and discom-
fort. Therefore, when the patient leans laterally together with
the rotation of the head, it is important that the light beam
may follow this position of the mouth without causing dis-
comfort for the patient.
Near the mouth, instrument that have a reflectivity simi-
lar to mouth should be choosen. Instruments with dull sur-
faces are preferable to avoid strong reflection, that will cause
 58 K. C. K. Yui et al.
a b
..      Fig. 2.16  Correct positioning of the dental light to avoid the appearance of shadows and to improve the illumination
tension on the eyes and reduction of the eye sharpness. In
addition, white and black objects should also be avoided.
Other important factor for the correct positioning of the
light beam of the dental chair light is the need to have three
rotating axis. This is important so the beam of light can fol-
low the movement of the patient’s head and, consequentially,
his mouth. It is common that the mouth is placed on an
oblique manner in relation to the headrest, on the vertical,
horizontal, and depth ways. The length of the chair light’s
arm must be enough to place the light on the side and above
the head of the dentist, even if he is in any position between
9 and 12 o’clock. Especially, when he places himself at 12
o’clock, the light must be placed according to the clinician’s
visual axis, being at most 15° laterally or above the den-
tist’s head, being this information little known and applied by
most clinicians.
2.2.8 Vision of the Teeth to Be Treated
The operator can use two forms to see the operating field in
the oral cavity, the direct and indirect vision. The direct
vision occurs when the operator looks directly to the cavity
preparation or the place to be treated; the indirect vision
requires the operator to look through a mirror to see the area
to be treated. The indirect vision eliminates the need for the
operator to lean to see the operating field. To treat the occlu-
sal surface of the second upper molar on the right side, even
with the patient on the supine position, maybe the clinician
will need to lean a little to have a direct vision. The use of a
mirror will allow the operator to be seated in a healthy pos-
ture and observe the operating field satisfactorily using an
indirect vision.
>> The direct vision occurs when the operator looks
directly to the cavity preparation or the place to be
treated; the indirect vision requires the operator to
look through a mirror to see the area to be treated. The
indirect vision eliminates the need for the operator to
lean to see the operating field.
Even if the dentist is in an adequate posture, the patient and
operating field are on a correct position, and it is hard not to
lean the head more than 20° as recomended. Due to that, spe-
cial glasses were developed for the dentist, so it can allow an
adequate position of the head and neck (. Fig.  2.17a–f).
Those glasses have a piece of a prism on the lower part of the
lens, and they are tilted. This way, when the dentist directs his
vision to this area of the glasses, there is no need to lean the
head and the neck. Others also present magnifying lens to
enlarge the image.
2.2.9  ypes of Movements During
T
the Dental Treatment
The movements executed by the dentist and the assistant
can be divided into five classes, with increasing complexity
order [6]:
55 Class 1 – Finger movement. For example, the root canal
preparation
55 Class 2 – Finger and wrist movement. For example,
cavity preparation
55 Class 3 – Finger, wrist, and elbows (forearm). It is
important that this occurs inside the ideal space in the
transference zone. For example, to reach the high-speed
handpiece at the delivery unit
55 Class 4 – Movement of the whole arm. It is the maxi-
mum reaching area. For example, open an auxiliary
drawer when it is slightly farther than the transference
zone and inside the functional working circle
(. Fig. 2.18)
55 Class 5 – Torsions of the body and displacement. For
example, to reach the suction across the patient, at the
assistant’s side
From all those movements, the ones in Classes 4 and 5 are the
ones more difficult and time-consuming, because they need
more muscle activity, new visual accommodation, and new
focus on the operating field. Movement 5 is eliminated by the
Ergonomics Principles Applied to the Dental Clinic
59 2

a b

c d

e f

..      Fig. 2.17  a Special glasses with a prism segment to correct the leaning of the head; b glasses with image magnification and correction the
head position; c posture without the glasses; d posture with the prismatic glasses; e–f posture with the image magnification glasses

work with an assistant, and in case she is efficient, it can even
eliminate the movements Class 4, leaving for the dentist only
movements Class 1, 2 and 3. Therefore, movements 4 and 5
must be always avoided, and this rule is applied to the dentist
and the assistant [2]. The correct posture can be easily main-
tained if the operator remembers that the operating field
must be positioned in his direction.
>> The movements of the whole arm, torsions of the body,
and displacements produce more tiredness and are
most time-consuming, because they need more
muscle activity, new visual accommodation, and new
focus on the operating field. Therefore, they should
always be avoided, and this rule is applied to the
dentist and the assistant.
2.2.10  Ways to Grasp the Hand Instruments
During the dental procedure, the hand instruments can be
grasped by the hands in different ways, depending on the
dental arch to be treated and the work to be performed. To
guarantee the correct positioning and the precision of the
job, the hands must be rested, which also avoids accidents.
 60 K. C. K. Yui et al.

2
12

11 1

10 2

9 3

4
8

7 5

..      Fig. 2.18  Class 4 movement. (Scheme kindly supplied by the Dabi-Atlante company)
Ergonomics Principles Applied to the Dental Clinic
61 2
On the lower teeth, a modified pen grasp is used handles are placed on the palm of the hand and held tightly
(. Fig.  2.19a). It is a grasp that allows more gentle move-
  by all fingers except the thumb, which will rest on a tooth
ments. The name means that it is similar to the one when we right next to it, on the same arch, for firmness. For an ade-
hold a pen, but not identical. The pads of thumb, index, and quate control, this grasp form requires careful use [56].
middle fingers contact the instrument, while the tip of the
>> During the dental procedure, the hand instruments
ring and little finger is slightly placed on a dental sur-
can be grasped by the hands in different ways,
face nearby, at the same arch, as a rest point. The palm of the
depending on the dental arch to be treated and the
hand is not facing the operator. The pad of the middle finger
work to be performed.
is placed on the topside of the instrument, and its work,
together with the wrist and the arm, produces the pressure
on the blade of the instrument. The instrument must not rest
on the first articulation of the middle finger, as a conven- 2.2.11  Rest Places
tional pen, which restrings the pressure applied [56]. On the
upper teeth, a modified and inverted pen grasp must be To obtain a correct rest place for the instrument is funda-
applied (. Fig. 2.19b). The position of the fingers is the same
  mental for a precision dental procedure. Extra oral rest and
position of the modified pen grasp. However, the hand is the rest at the opposing arch should be avoided due to the
turned, and the palm of the hand faces the operator [56]. For possibility of the patient to move. Whenever possible, the
the upper teeth, when more force is needed, a palm-and- dentist should opt for a rest point on the teeth nearby the
thumb grasp can be adopted (. Fig. 2.19c). It is similar to the
  place where the treatment is being performed. The closest
position used to hold a knife when peeling an orange. The the rest to the area of working, the more thrust worthy it is.

a b

..      Fig. 2.19  Ways to grasp the hand instruments. a Modified pen grasp; b inverted and modified pen grasp; c palm-and-thumb grasp
 62 K. C. K. Yui et al.
However, in some situations, it is not possible to establish a
rest place on a tooth structure and the soft tissues must be
used. Neither the soft tissue nor the hard tissues farther
2 from the operating area allow a reliable control. Occasionally,
it is also not possible to establish a regular rest using the
fingers of the same hand that is grasping  the instruments.
On those cases, the control can be reached using an index
finger  of the other hand, touching the instrument on the
handle, or using an indirect rest. That means that the operat-
ing hand will rest on the other hand, which will rest on a
stable oral structure [56].
On the anterior teeth, there is the possibility to directly
visualize the surfaces to be treated. However, in some regions
of the mouth, this can become very difficult, if not impossi-
ble, that is the reason we opt for an indirect vision, through
the reflected image on an oral mirror.
Tip
To properly grasp the instrument and rest the hand is
essential for stability and precision while working. Rest
your finger on teeth nearby the place where you are
doing out intervention.
a b
..      Fig. 2.20  Rest areas using modified pen grasp of dental instruments at the lower arch. a Rest on the teeth from the same arch; b check
musculature displacement; c tongue displacement
2.2.11.1  Lower Arch
At this arch, the modified pen grasp  is recommended,
with rest place on the teeth of the same arch, next to the
cavity preparation, using the ring and little finger
(. Fig.  2.20a). When working on the buccal surface, the
mirror is used  to displace  the check musculature to
improve the visualization  (. Fig.  2.20b). When working
on the lingual surface, the mirror  is used to displace the
tongue (. Fig. 2.20c).
2.2.11.2  Upper Arch
On this arch, the modified and inverted pen grasp is recom-
mended. On the right side of the patient, the use of the clini-
cal mirror improves the illumination of the operating field
when using the direct vision or allows the indirect vision. The
rest place is on the neighboring teeth on the same arch
(. Fig. 2.21a). On the left side, the use of the clinical mirror
improves the illumination at the operating field and allows
the indirect vision, besides helping to displace  the check
musculature. The rest place is at the same arch, on the oppos-
ing side (. Fig. 2.21b). When the palm-and-thumb grasp is
used, the tip of the thumb is placed on the tooth that is being
treated in a neighboring tooth or on a convenient area at the
same arch.
Ergonomics Principles Applied to the Dental Clinic
a b
..      Fig. 2.21  Rest areas for the use of instruments on the upper dental arch. a Rest on the neighboring teeth on the same arch at the right side;
b work on the left side of the patient and rest on the right side
2.2.12  Work Environmental Conditions
High stress sources at work are the unfavorable environmen-
tal conditions, such as the excessive heat, noise, and vibra-
tions. Those factors raise the risk of accidents and produce
discomfort and damage to the health [30]. The environmen-
tal comfort is an extremely important point for the dentist,
who spends his whole day inside a closed room and concen-
trated on the treatment of his patients.
Studies developed by Heimstra and McFarling [23] have
already mentioned the complexity involved on the creation
of a satisfactory environmental condition, for a group of
people who work at the same place, because each worker
presents a different level of physical and psychological sensi-
tivity. The authors report that the noise, temperature, humid-
ity, and illumination can produce comfort or annoyance,
affecting the performance of the individual.
2.2.12.1  Noise
When looking for noise definition, the literature is ambigu-
ous, but in a general way, the noise can be defined as an unde-
sirable sound. There is a subjective and a physic definition for
noise, described as followed:
55 Subjective definition: Noise is all the annoying or
unhealthy audible sensation.
55 Physic definition: Noise is all not periodical acoustic
phenomenon without harmonic components defined.
On the last decades, more people have been affected by the
noise, but since 1989, the World Health Organization
started to treat noise as a public health problem. The
human ear can notice a great range of sound frequencies
from 20 to 20,000 Hz, and the intensity (volume) of the
sound is defined by the level of sound pressure, varying
approximately from 0 to 130 decibels. The noise can cause
damage on the hearing organ, as deafness, that is charac-
terized by a deficit in the range of 3000–6000 Hz, or
fatigue, which manifests by a temporary increase of
63 2
the hearing threshold. For prevention, there are protective
hearing devices, such as earplugs and earmuffs, but on
the  other hand, they can cause deficiency on the
­communication.
When the noise happens on a nonconstant way or even in
an unexpected way, it can interfere with the concentration,
reducing the intellectual performance and making it harder
to do more complex tasks. The noises that are not so loud can
only cause a slight bothering, but the greater the intensity,
frequency/duration and the age of the individual, the more
damage the noise will cause [36].
According to Fernandes et al. [16], the dentist is subjected
to two types of noises:
55 Outside the working environment: Traffic, voices,
compressor (when outside the work environment),
telephone, bell, and sounds coming from the waiting
room
55 Inside the working environment: Dental handpieces, air
compressor (when inside the work environment),
suction, amalgamator, air conditioner, among others
According to the standards from the Occupational Safety and
Health Act (OSHA), 80 decibels (dBA) is at the maximum
tolerable limits of sound for the dentist [9]. The manufactur-
ers in general claim that the noise level of their dental treat-
ment unit (especially of the handpieces) is below 80 dBA. The
longer the dentist is exposed to the noise during his profes-
sional life, the greater will be the chances of a reduction of the
hearing capacity [49]. The noise-damaging effects can also
produce many physical, mental, and social problems on the
dentist.
Tip
The use of handpieces with low noise emission is a very
important point when deciding the purchasing of a new
one.
 64 K. C. K. Yui et al.
2.2.12.2  Temperature
The stress caused by the heat or cold at work environment is
motive of concern because it affects, besides productivity, the
2 physical and mental health of the worker. The literature the
ideal temperature to work is between 16 and 22 °C, but in
countries with a hot weather, it can be accepted up to 5 °C
more. Other standards state a temperature between 20° and
23°, emphasizing that the difference in temperature in the
same environment cannot be >4 °C. According to Bauman
[3], technically comfortable environments favor the achieve-
ment of high quality services; the worker feels more attracted
by the working post, by his activity and by the positive results
of his tasks. It  is noticed less complaints in relation to the
individual necessities and in relation to the diseases acquired
on those environments, which result in a drop on the opera-
tional costs.
According to Grandjean [20], “the excessive heat at work-
ing places leads to tiredness and drowsiness, which reduces
prompt responses and increase the chances of  mistakes  to
happen.” Therefore, the thermal factor produces a great influ-
ence in the comfort during the work. The temperature, air
speed, solar radiation, and relative humidity are fundamental
for a comfortable thermal sensation, which also depends on
the type of work being performed and the kind of  clothes
worn. The speed of air displacement should not be superior
to 0.2 m/s.
Guiton [22] states in his studies that the human body
presents its own mechanism to produce heat. The heat gener-
ated by the metabolic activity exceeds the need to maintain
the body temperature in its normal level, of approximately
37 °C. That means that we should not need any other external
heating source and that the most important thing would be
to eliminate this excess of heat, without affecting the func-
tioning of the organism.  Our working environment should
allow the control of the temperature, avoiding an extremely
hot or cold sensation.
>> The thermal factor produces a great influence in the
comfort during the work. The temperature and air
speed, solar radiation, and relative humidity are
fundamental for a comfortable thermal sensation, and
it also depends on the type of work being performed
and the clothes worn.
2.2.12.3  Relative Humidity of the air
The relative humidity must not  be below 40 or higher
than 60% in the work environment. The exposition to envi-
ronments with levels of humidity far from the ideal may cause
diseases, but can aggravate some preexisting ones,  such as
osteomuscular diseases (generally called rheumatism), the
lung, and skin diseases.
>> The exposition to environments with different
relative humidity can aggravate some preexisting
osteomuscular, lung, and skin diseases.
2.2.12.4  Illumination
In all working places, there must be adequate illumination,
natural or artificial, but always accordingly to the nature of
the activity. It should be uniformly distributed and diffuse,
avoiding obfuscation, reflection, shadows, and excessive con-
trasts. A well-illuminated environment with light colors on
the background, brings to  the environment visual comfort
and rest, improving the quality of life and at work. The light
level is measured in lux. A well-illuminated environment is
important to have visual comfort, avoiding, this way, the loss
of sight sharpness, fatigue, misreading, and work accidents.
Some studies has  shown that bad light conditions can
cause psychosomatics problems, as stress, and greater sensi-
bility to the microbial attack. The effects of the very lumi-
nous environments over the vision are significant in a
long-­term. In cases of obfuscation there is always the risk of
accidents. The lack of adequate illumination can cause
visual fatigue, characterized by the irritation and pain on
the eyes, redness on the conjunctiva, modification on the
blinking pattern, tearing, photophobia (light intolerance),
diplopy (double vision), feeling of blurred vision, percep-
tion of colored aura around objects, abnormal persistence
of after-images, and instability of the image on its optical
definition and in space. It usually comes with other symp-
toms as headaches.
The following are some very important points in relation
to the illumination:
55 Type of light bulb and luminaire: Depends especially on
the environment’s characteristics and on the activities to
be developed.
55 Quantity of light bulbs/luminaire: An adequate number
should be installed with the goal to reach the needed
illumination, with base on a technical project, which will
consider the variables from the environment.
55 Distribution and placement of the luminaires: The
luminaires must be placed on the environment in a way
to give a homogeneous and uniform illumination,
considering the physical arrangement of the place,
avoiding contrasts and shadows at the working areas.
55 Maintenance: The burnt out light bulbs or with inad-
equate illumination must be changed, and the good ones
frequently cleaned.
55 Colors: The colors of the walls, dental treatment unit,
and furniture must be chosen in a way that they have a
good light reflection in the room. The working table and
the delivery unit, for example, cannot have a very
reflexive surface because the incidence of light could
obfuscate the eyes.
55 Variation of light: The accentuated difference between
the levels of illumination between one environment and
another can damage the eyes, bringing fatigue and loss
of sharpness; this occurs due to a sudden dilatation/
contraction of the vision muscles, even in a small-time
interval. When repeated many times during the years, it
could cause an injury.
Ergonomics Principles Applied to the Dental Clinic
55 Age: The greater the age of the people at the working
place, the greater should be the light intensity.
55 Direct incidence: Windows should be positioned so that
there is no excess of natural light within the work
environment. In dental offices located in the southern
hemisphere, it is recommended that the window be
directed in a north-northeast direction, and in cases
where it faces south, it is recommended that there is a
clear wall for natural light to be reflected into the
interior of the environment. In dental offices located in
the northern hemisphere, it is recommended that
they should be facing south or north, and that the design
of the roof and windows be planned according to the
path of the sun to prevent the direct incidence of solar
rays during the summer, and allow their entry during
the winter. Regardless of which hemisphere the dental
office is located, when the window is directed to the east,
there is an excess of illumination in the morning and a
shortage in the afternoon, the opposite occurring when
the window is facing west. In these cases, it is mandatory
to use barriers (internal or external) to avoid excess
light, forcing the use of artificial lighting.
>> A well-illuminated environment, with light colors on
the background, brings to the environment visual
comfort and rest, improving the quality of life during
the working hours.
2.3 Work-Related Musculoskeletal
Disorders
The multitissue lesions of the upper limbs of the motor sys-
tem, attributed to be caused by repetitive strains at work,
previously known as repetitive strain injuries (RSI), were
renamed to work-related musculoskeletal disorders
(WMSD), because it is the most appropriate name. The
WMSD, according to Lopes [38], is characterized by the
affections of the motor system, upper limbs, shoulder and
neck, that have direct relation with the requirements for the
repetitive, fast and  continuous movements of the tasks
executed. In addition, the stress generated during the den-
tal practice is other factor that can contribute for the devel-
opment of the WMSD [1]. The WMSD is defined as a
phenomenon related to work, characterized by the inci-
dence of different symptoms at the same time or not, with
pain, paralysis, heavy feeling, and recurrent fatigue, gener-
ally on the upper limbs [45]. Those disturbances, related to
the work, initially cause pain and can evolve to the incapac-
ity to do some movements, temporarily or permanently.
Therefore, the early detection of the lesions can be essential
to avoid the worsening of the disease, long treatment, and
medical conditions that would take the professional away
from his practice [1].
65 2
When there is not a good relation among the different
parts of the body, a bad posture can happen, inducing to an
increase of aggression to the supporting structures, resulting
in a less efficient balance of the body over the legs. During the
dental work, many inadequate postures occur, which could
lead to musculoskeletal overload over some body segments,
which could cause lumbar inflammation, cervical pain, and
aches [1]. According to Rio [54], the following inadequate
posture could occur:
55 Flexion, extension, lateral leaning, and lateral rotation of
the neck
55 Abducted arms
55 Elevated arms above the shoulder levels
55 Flexion of the forearms higher than 90°
55 Pronation and supination of the upper limbs
55 Ulnar and radial deviation from the body
55 Lateral leaning and torsion of the vertebral column
The problems caused  by the incorrect work posture are a
lumbar and back pain, and affect the feet and lower limbs. It
is called lumbar pain all and any pain located on the lumbar
column. Many are the causes for the lumbar pain, and the
treatment can be conservative, which will include specific
medication, physiotherapy, back braces, and medical orienta-
tion or surgical treatment, which involves different types of
surgeries [1]. According to Knoplich [35], the work on a sit-
ting position increases the intradiscal pressure, increasing
the bad adjustment of the disc and column. In addition, the
dentist executes movements of lateral leaning, flexions, and
extensions, which lead to defects of postural origin, named
scoliosis, kyphosis, and lordosis. The scoliosis is a lateral
deviation, permanent to the vertebral column. When the
inclination can be corrected voluntarily, it is a scoliotic atti-
tude. Kyphosis is sagittal curves on the normal vertebral col-
umn on the anterior concavity, located on the dorsal and
sacrum and coccyx segment, while lordosis is the posterior
concavity, specifically in the cervical and lumbar region [19].
When a dissolution or destruction of vertebrae occurs, it is
called spondylosis.
>> Incorrect work posture causes lumbar and back pain
and affects the feet and lower limbs.
The dentists can be affected by return venous circulation
problems, as varicose veins and thickening of the nails, and
also the formation of bunion, callus, and hallux valgus, which
happens because of the use of badly dimensioned shoes that
are made from inadequate fabrics or materials. It is essential
that the dentist works with his feet completely rested on the
ground, keeping, this way, a balanced position and a positive
physiological factor on the physical condition, lowering the
pressure on the feet [1].
If hand injuries happens to the dentist, this could force
him to leave work for a short or long period  many times
throughout his professional life. The improper use of dental
instruments can promode hands injuries and are related to
 66 K. C. K. Yui et al.
constant and repetitive force, with a pinching movement of
the fingers and thumbs, combined with extreme hand move-
ments. The carpal tunnel syndrome  has the highest preva-
2 lence among the dentists. The carpal tunnel is limited by the
concave arches formed by the carpal bones of the hands and
by the transverse carpal ligament, holding the carpal nerve,
nine flexor tendons and blood vessels, as can be observed on
. Fig. 2.22a–i.
 
>> The improper use of the instruments can produce the
carpal tunnel syndrome, resulting in motor and
functional alterations, pain, swelling, and stiffness of
the hand, requiring surgical treatment by surgery.
When the hand is flexed, it extends or deviates from the
central position; the volume of the tunnel is reduced and
the internal pressure increases (. Fig. 2.23a, b). According
 
to Osamura et al. [48], the most characteristic tissue in the
carpal tunnel is the subsynovial connective tissue and its
small  permeability can explain the predisposition of the
region to increase the pressure, causing this neuropathy.
A
B C D E
..      Fig. 2.22  Hand’s sections in different levels. a Carpal bone; b thenar muscle; c transverse carpal ligament; d median nerve; e concave arch of
the carpal bones; f flexor tendons; g cubital nerve; h–i flexor tendons
a b
..      Fig. 2.23  a Correct work positioning of the hand; b flexed hand, resulting in a diminishing of the carpal tunnel volume
Oh et al. [47], verified that ultra-structural changes occur
in the subsynovial connective tissue from patients with
carpal tunnel syndrome, as deformed collagen fibers, that
appear to be in a spiral form, and phagocytosis of the elas-
tic fibers.
The tendons, when compressed, press the nerve, which,
with chronicle repetition of the movement, become
inflamed and suffer damages. This causes sensitive, motor,
and functional alterations, pain, swelling, and stiffness of
the hand. If this situation continues for a period of, for
example, 1 or 2 years, a paresthesia sensation on the wrist
level, pain, and swelling of the fingers will occur. Later, if the
situation persists, from 2 to 8 years, a reduction of the
pinching force will appear and an atrophy of the hand’s mus-
cles will  eventually result in incapacity to hold an instru-
ment. Once the damage is installed, the treatment consists
in immobilization of the hand, hydrocortisone injec-
tions  and finally surgical treatment, depending on the
degree of the nerve’s alterations. The presence of the carpal
tunnel syndrome can be confirmed by the positive result on
F H
G
I
Ergonomics Principles Applied to the Dental Clinic
the Phalen’s maneuver, which consists on the placement of
the dorsum of the hands in contact to each other, with the
individual with the shoulders and elbows in 90°. With this
maneuver, the mediated nerve is pressed against the ventral
retinaculum and reproduces the night symptoms, which is
“tingling” (hypoesthesia) [11].
2.3.1 Occupational Diseases Epidemiology
The application of the ergonomic principles in the dental
office allows rationalizing the work, allowing the elimination
of nonproductive maneuvers. This way the clinician produces
more and faster, with less stress and more results, providing
at the same time more comfort and safety to the patient [2].
Therefore, it is fundamental to avoid or to correct the wrong
working habits, the ones that can bring serious damage to the
clinician. Seventy-two percent of the dentists examined by
Rundcrantz et al. [59] reported complained about some dis-
comfort or pain on the head, neck, or shoulders. Similar
results were reports by Kerosuo et al. [14], who observed that
70% of the general dental practitioners had musculoskeletal
symptoms. They also observed that the symptoms were more
frequent on women. Some specific body areas are associated
with injuries related the dental practice as described as fol-
lowed:
55 Carpal tunnel syndrome – Problem associated with the
continuous flexion and extension of the wrist
55 Shoulder and neck ache – Tension or flexion of the
shoulders for more than 1 h/day
55 Back and neck ache – Extension or elevation of the arms
for a long period
55 Low back region ache – Torsion of the body for a long
period
According to Wagner [65], from all the occupational dis-
eases affecting the dentists, the ones that are caused by the
posture are those with the most neglected prevention,
because they will only feel its effects with the passing of the
years. It is very hard to convince the young dental students
in the universities to take prophylactic measurements in
relation to the damages to the column. Even with the ergo-
nomic coming to help the profession, there are excessive
working hours spent at the clinic. In addition, there are
idiopathic predispositions from each one to specific types
of skeletal degeneration, such as spondylosis and interver-
tebral disc flaccidity, that sooner or later compromise the
column of some individuals, while others never come to
manifest any symptom, at least, during the productive prac-
tice of his profession [18].
On the Netherlands, a study was done to evaluate the
posture adopted by 1250 dentists throughout dental proce-
dures, which was named the Sonde Project [27]. The authors
concluded that high percentages of deviations in relation to
the correct working posture are practiced by the clinicians, as
they are shown here:
67 2
55 About 89% show forward flexion of the head, exceeding
in 20°, which is considered the limit for a healthy
position.
55 About 61% show rotation of the neck combined with
strong flexion forward.
55 About 63% show flexion of the posterior part of the
body exceeding in 20°.
55 About 36% work with the neck turned combined with
the torsion of the back.
55 About 35% keep their forearms on an angle higher
than 20°.
55 About 32% keep their forearms on an angle higher
than 25°above the horizontal line.
55 About 25% rest their hands wrongly when working.
55 About 47% do not grasp correctly the instruments (on
the modified pen position).
55 About 20% show strong flexion of the wrist.
55 About 65% work with a stool with a wrong back
support.
55 About 75% of the dentists work without the head of the
patient being symmetrically in front of them.
55 About 32% work with their feet and legs farther than the
necessary from the dental chair.
55 About 55% work for more than 7 h sitting down every
day.
55 About 75% work with inadequate light and differences
in light distribution that are not according to the
standards.
Santos Filho and Barreto [61] performed a study evaluating
the prevalence and sysmtoms of osteomuscular pain on 358
dentists, using a self-reporting questionnaire, and they
observed the prevalence of pain on the upper segment was
58%, being 22% on the arms, 21% on the column, 20% on
the neck, and 17% on the shoulder; 26% reported that the
pain was daily and 40% was moderate/strong. According to
Méndez and Gómez-Conesa [43], the information about
the arrangement of the dental treatment unit and the ade-
quate posture at work can reduce the musculoskeletal symp-
toms risk. According to Melis et al. [42], there is a critical
need to insert the topics of ergonomics on the educational
system to prevent the risks for the future clinicians. A study
performed with students of a university demonstrated that
more than 70% of them report pain already on the third
year of school. It also demonstrated that this number
increased gradually from the first to the last year of the
course. The authors concluded that the teaching of ergo-
nomics needs to be better elaborated and worked through-
out undergraduate phase [55].
>> The application of the ergonomic principles on the
dental office allows rationalizing the work, allowing
the clinician the elimination of nonproductive
maneuvers. This way the clinician produces more and
faster, with less stress and more results, providing at
the same time more comfort and safety to the patient.
 68 K. C. K. Yui et al.
2.3.2 WMSD Prevention
It is important to adapt the work environment to the operator
2 instead of the operator having to adapt to the environment
[2]. This concept requires that the dentists take a favorable
sited posture and then place the patient, assistant, and deliv-
ery unit in relation to his position. This working condition is
called “balanced posture” [8]. It does not intend to have the
operators sitting like a statue but to establish a series of rules
that may help them  to obtain comfort while working. The
specialists agree when they say that the frequent change in
position, for those who work sitting down, is the key to pre-
vent problems on the column [25, 26, 28].
>> It is important to adapt the work environment of the
operator instead of the operator having to adapt to the
environment.
The adoption of a healthy posture at work is fundamental on
the prevention of WMSD.  Besides having dental treatment
unit that permits to work correctly, it is important that the den-
tist effectively know and apply the necessary knowledge about
the correct use of that unit. Only having a good dental treat-
ment unit is not a guarantee that the dentist will work on a
correct posture. Therefore, the learning/teaching process in
ergonomics is determinant to adopt a healthy work posture
[28]. A good ergonomic training during the university studies
on the preclinical phases and initial clinic is essential, so that
the student learn to identify and adopt a healthy work posture.
The use of the proprioception mechanism is fundamen-
tal, so that the dentist can effectively develop and adopt a
correct work posture [4, 57]. The proprioception is the
capacity to recognize the position in space of each part of
the body. It results from the interaction among the muscles
to keep the body position, the tactile information and on
the vestibular system, found on the internal ear, responsible
for the equilibrium.
The proprioception mechanism works automatically as
part of the chain of reflexes to keep the body balanced and
organizing the movements. It can be used to recognize and
locate the problems and adapt the posture [4, 57]. The healthy
work posture is not a condition preprogrammed by the pro-
prioception, and it does not occur without a conscious learn-
ing. Learning and training are necessary to get the adequate
posture, starting by determining the aim to a physiologically
acceptable posture, understanding how to reach that and
then executing the necessary actions, followed by a training
at the mirror for feedback, or using a biofeedback equipment
[4]. To consciously use of the knowledge about propriocep-
tion is  only possible during the preclinical training, where
low complexity work is being performed, which allows the
student to concentrate on the ergonomic training, without
having to worry with the result of the procedure itself. On
this initial phase, the student has not established bad postural
habits, which will lead the body to find alternative postures to
keep balance. Because of that, it is important that the dental
schools prioritize the teaching of ergonomics at the preclini-
cal phase or at the initial clinical phase.
It is known that the constant force during the pinching
movements of the fingers and the extreme movements of the
hands, used simultaneously, can produce the carpal tunnel syn-
drome. On the other hand, the damage can be completely
avoided with the preventive elimination of the causal factors,
which must be recognized and identified early. Therefore, aim-
ing to prevent those lesions, some measurements can be taken.
The first would be to give preference to instruments with
thicker handles (. Fig.  4.5), which diminishes the need to a
strong pinching to hold them tightly. The habit constantly to
hold the instrument strongly should also be avoided, because it
results on unnecessary fatigue and incorrect control of the
hands. The correct attitude is to hold the instruments gently,
only squeezing when necessary to perform an active move-
ment, reducing the force right after to relax the muscles. The
extreme movements of the hands should also be avoided,
because the displacements of the tendons that are compressed
during those movements compress the median nerve causing
damages. The arm should turn around its fulcrum, using as rest
place the surface to be instrumented, avoiding the excess digital
work or the turning of the hand. Regis Filho et al. [53] confirm
on their study that most dentists use instruments that do not
follow the ergonomic requirements and execute procedures
inadequately, among other factors, being submitted to adverse
work conditions, where pain and discomfort are present.
Hokwerda and Shaw [26] recommend that the dentist
should adopt a more dynamic posture of work. According to
the authors, the problem with the dentist’s work posture is the
static nature, while the human body is supposed to be in con-
stant movement. During the dynamic movement, the muscles
act as bomb for the blood supply, with high levels of oxygen,
and removal of blood with residual products from the meta-
bolic activity of the muscles. The movement is necessary to
recover the distended muscles by the static work. Therefore, the
dentists must keep a more dynamic work model, as, for exam-
ple, the incorporation of the most movements as possible in his
activities. The different activities can contribute to that [26, 28]:
55 Adopt a dynamic way to seat alternating between active
and passive seating.
55 Use various positions the maximum as possible.
55 Receive personally the patients at the waiting room.
55 Always possible, to work standing up or sitting down
alternately. This requires an office with adjustable heights
of the patient’s chair and delivery unit. In addition, it is
also possible to give instructions to the patient on a
standing up position. The computer work can also be
done on a standing up position, if it is organized for that.
55 The installation of a sink on an adequate distance from
the head of the patient, so it is always necessary to stand
up and walk to the sink.
55 The planning of the short procedures should be alter-
nated with the long ones.
55 Schedule short intervals during the treatment, when
small exercises can be done, as flexion of the fingers,
deep breathing, and stretching (more details later on).
55 Take short intervals between treatments, also taking
stretching exercises.
Ergonomics Principles Applied to the Dental Clinic
55 Take longer breaks, for coffee, tea, and lunch. Take at
least 10 min of break after each two hours of work.
55 To keep or maintain the muscles in good condi-
tions by doing exercises at least twice a week.
55 Plan short or long vacations, courses, etc. every 6 weeks.
The dental profession is very hard, so it is essential to
schedule regular breaks. It is proven that adequate
leisure and sport activities reduce stress.
55 Do not work more than 8 h/day.
Other indispensable factor to allow a healthy work posture is
the use of dental treatment unit that has the ergonomic
requirements. Significant changes on the concepts changed
the design of dental treatment units, which allow the work on
a more ergonomic way. It is important to know how to adopt
a healthier work posture and know how to recognize the
ergonomic requirements when purchasing a new  dental
treatment unit [25, 26, 28, 33]. The market for dental units is
regulated by the demand, and this means that the dentists
need to claim for units that allow an adoption of a healthy
posture.
The treatment of WMSD must be multidisciplinary, so
the doctor identifies the alteration and coordinates the treat-
ment, the physiotherapist  uses exercises to rehabilitate the
compromised movements, the occupational therapist verifies
if the work environment needs to be changed, and the psy-
chologist or psychiatrist detects the causes or factors like
anguish and anxiety at the work environment [1].
To avoid fatigue, tiredness, and stress, the dentist can fol-
low the checklist presented on 7 Box 2.1 [19, 26, 28].
>> The carpal tunnel syndrome can be avoided with the
preventive elimination of the causal factors; such as
giving preference to instruments with thicker handles;
eliminating the habit to strongly hold the instrument;
and avoiding extreme movements of the hands.
Box 2.1  Ergonomic Check List for a Good Dental
Practice (According to ESDE Document) [28]
 rgonomic Check List
E
1. Legs perpendicular to the ground.
2. Feet soles on the ground, while the pedal is positioned in a
direction in which the feet does not need to be directed
sideways during the operation.
3. The angle between the thigh and the lower part of the leg
is greater or equal to 110°, in a way that the knees are
slightly below the hip level (just if there is an adequate
stool with double inclination or a saddle stool). For the
regular stool this angle must be 90°.
4. Forearms slightly elevated at least 10° to the maximum of 15°.
5. Arms ahead at maximum of 20°.
6. Elbows next to the body and not far more than 20°
sideways.
7. Symmetrical sitting position with the shoulders lowered
and relaxed.
8. Avoid torsion of the torso and pressure the intervertebral
discs of the column.
69 2
9. Avoid forward flexion of the vertebral column.
10. Keep the legs slightly separated (between 35° and not
more than 45°).
11. Do not keep the neck bent or pulled.
12. Rest the back on the upper part of the pelvis.
13. Oral cavity of the patient from 5 to 10 cm above the height
of the dentist’s elbows.
14. Distance from 30 to 40 cm from the operator’s nose and
the patient’s face.
15. Head leaned forward not more than 20°.
16. Operating field well-illuminated and on the medium line of
the dentist.
17. The back of the patient’s chair is positioned lying down to
allow the operator to freely move the legs under the back
of the chair.
18. Avoid sudden movements and forces that cause heavy
stress of short duration.
19. Change posture and perform movements.
20. Limit the duration of any continuous muscular strength,
preventing muscular exhaustion.
21. Take short and frequent breaks.
22. Take a well-accommodated position at the seat of the
stool, in a way that it supports the whole weight of the
body.
23. The head of the patient is rotated accordingly in three
directions (backward or forward, leaning to the right or
left, and turned on the longitudinal axis) in a way that the
operating field is positioned symmetrically in front of the
dentist’s thorax. That allows to look into the mouth or to
the mirror as perpendicularly as possible.
24. The dental light must be as parallel as possible to the line
of sight, at a 15° angle, with the light being positioned to
the left or the right, very close to the side and above the
dentist’s head. When an intraoral mirror is necessary, the
light must be positioned slightly in front of the head.
25. Instruments need to be grasped with the tip of the first
three fingers, which must be arched around the instru-
ment, in a way to reach three contact points, and the
fourth and fifth fingers must be used to rest on the mouth.
If necessary, one finger of the inactive hand is used for help
the rest.
26. The instruments must be positioned at the same height to
the patient’s mouth, as much as possible inside the visual
field of the dentist (30° to the left and right). The hand
instruments must be positioned at a distance of 20–25 cm
and the handpieces at 30–40 cm.
2.4  xercises to Prevent Osteomuscular
E
Problems
The stretching exercises can be done at the office, during
intervals between sessions, to obtain flexibility of the articu-
lations, improving the circulation and loosening the tense
areas, preserving the health, and optimizing the quality of life
of the practitioners. They are recommended for prevention of
tenosynovitis, tendonitis, synovitis, myositis, fasciitis,
­epicondylitis, paralysis of the upper limbs, and tingling of the
hands. During the stretching the dentist must be alert not to
pass the expansion limit of his muscle, to hold the exercise
for 10 s and to avoid postural compensations of bad position-
ing during the exercise. Each stretching must be repeated
three times, alternating the sides (. Figs. 2.24 and 2.25).
 70 K. C. K. Yui et al.
a b
c d
..      Fig. 2.24  Stretching for the back, shoulders, chest region, arms,
and neck. a Stretching of the arms. With the arms raised above the
head and palms of the hands together, stretch out the arms upward
and a little to the back. Breathe in while stretching upward. b Stretch-
ing of the arms and thorax. Interlace the fingers, turn the palms
outward, above the head, and extend the arms. Stretch, this way, the
arms and thorax. c Stretching of the arms. Interlace the fingers, extend
the arms in front of yourself with the palms facing outward. Feel the
stretching of the arms and on the upper back. d, e Stretching of the
arms. With the arms extended above the head, hold the elbow of one
of the arms with the hand of the other arm. Pull kindly the elbow
behind the head. Stretch both sides. f Stretching of the shoulders. With
the fingers interlaced behind the head, keep the elbows facing
outward, wide open, keep the torso erect. Push the elbows backward,
one toward the other. Keep the feeling to liberate the tensions for
about 8–10 s, then relax. g, h Stretching of the arms. Hold the right arm
right above the elbow with the left hand. Now pull slowly the elbow on
the direction of the left shoulder while looking over the right shoulder.
Keep the stretching for 10 s and repeat the other side. i Stretching of
the chest. This stretching must be done with the fingers interlaced
behind the back. First, slowly roll up the elbow inward while the arms
extend. Second, elevate the arms behind the back until you feel the
arms, shoulders and chest stretching. j Stretching the back. Stand up
with the feet apart about the same distance of your shoulders and feet
pointing forward. Keep the knees slightly bent, put one of the hands
on the hip for support and the other arm extends over the head. Now
lean to the side in the same direction as the hand on the hip. Come
back slowly and keeping the control. k Stretching of the arms. Instead
of using the hand on the hip for support rise both arms above the
head. Hold the right hand with the left one and bend slowly to the
right side, using the right arm to gently pull the left arm above the
head and later downward, toward the ground. Using one arm to pull
the other is possible to intensify the stretching. l–o Stretching of the
neck. Turn the neck slowly and in case you feel a greater tension in any
position keep there for 10 s
Ergonomics Principles Applied to the Dental Clinic
71 2

e f

g h

i j k

..      Fig. 2.24 (continued)
 72 K. C. K. Yui et al.

l m

n o

..      Fig. 2.24 (continued)

a b

..      Fig. 2.25  Stretching for the hands and wrists. a Stretching of the
flexor muscle. Start the exercise with the palm of the hand facing
downward, extending the right arm. Put the left thumb over the dorsal
side of the fingers and the other four fingers over the palm side of the
fingers for support. Stretch the flexor muscle group pulling the fingers
backward (dorsal flexion). Keep this position for 10 s and then let it go.
b Stretching the external side of the forearm. Stretch the external side
of the forearm and keep the arm at this position, with the palm of the
hand facing downward. Put the four fingers of the left hand over the
dorsal surface of the right wrist. Bend the whole hand inward. Keep this
flexed position for 10 s. c Stretching of the wrists. Interlace the fingers
of both hands and extend both arms in front of you. Turn the hands
interlaced to the left, having the wrists as the fulcrum of the movement.
After, turn to the right. Each rotation must take 5 s. Turn first to the left
and then to the right, repeating every series 3 times. d–f Stretching of
the wrists. Open the hands and touch them in “praying” position. With
the fingers together, compress one hand with the other in a way that
the forces are concentrated on the wrists. Lean the palm of the hand in
the direction of the arms. Repeat to the other side. g–i Stretching of the
fingers. Open the fingers the farther as possible. Close the fingers
squeezing them with the hand extended. Squeeze the fingers against
each other, stretching them one by one. It can be done with all the
fingers at the same time. j Stretching of the fingers. Squeeze the thumb
against the other fingers of the hand, one at a time. k Stretching of the
fingers. Cross the fingers and thumbs, one by one, each finger forming
a hook. l Stretching of the fingers. Close the hands tightly as they are
holding something strongly. After open them and stretch the fingers
well. After, put the arms down and swing them, rotating to the sides
Ergonomics Principles Applied to the Dental Clinic
73 2

c d

e f

g h

i j

..      Fig. 2.25 (continued)
 74 K. C. K. Yui et al.
k l
..      Fig. 2.25 (continued)
>> The stretching exercises can be done at the office,
during intervals between sessions, to obtain flexibility
of the articulations, improving the blood circulation
and loosening the tense areas, preserving the health,
and optimizing the quality of life of the practitioners.
2.5  urrent Panorama of Dental Ergonomic:
C through manuals of ergonomics that serves as the base for
Challenges, Proposals, and Goals
The international literature reveals that the practice of the
dental profession needs more use of the existing ergonomic
knowledge. To change this picture, it is needed the imple-
mentation of a vast program to stimulate the application of
ergonomics in dentistry. This program must embrace actions
in every sector of the dental system, in a way that there is an
effective participation on the dental schools and representa-
tive associations of dentists, such as Federal and State Dental
Boards, Unions, and any other Dental Associations. It is
necessary that parameters should be defined and strategies
should be created, to allow the adequate teaching of ergo-
nomics on dental courses and that this information would
be applied when building clinics and preclinical laborato-
ries, which allow students and clinicians to work at a healthy
posture.
The manufacturers of  dental treatment unit and their
­representative associations need to stimulate the constant
search and improvement of the unit, and their suitability to
the ESDE document [28]. It is important that dental treat-
ment unit manufactures promote ergonomic studies in
their  ­laboratories and in conjunction with  the egnonomic’s
research associations. The companies should be stimulated to
commit part of their incomings to the development of ergo-
nomic research, and to create manuals that promote the
adequate use of the dental treatment unit, because only
to  manufacture a ergonomic unit does not guarantee that
they will be used in an ergonomic way.
The dental schools should promote the development
pedagogical strategies that are more efficient to allow the
proper teaching of ergonomics. The student must be stimu-
lated to appreciate and to take a healthy work posture since
the first work, performed in laboratory or preclinical and,
later on, the clinical activities. The current knowledge of
ergonomics must be spread out on the various specialties,
the students and for the professors of every area.
The clinicians must be stimulated to select and to buy
dental treatment unit that satisfy the ergonomic principles,
and to know the cost benefit relationship when taking their
decision. Only with the effective and integrated participation
of all those sectors, of this complex dental system, will  be
possible to implement the necessary improvement of the
dental work conditions.
>> The dental schools should promote the development
of more efficient pedagogical strategies to allow the
proper teaching of ergonomics. Students should be
strongly encouraged to understand and value the
importance of adopting a healthy work posture as
soon as possible, ie, from the first procedures
performed in mannikin and during the procedures
performed in patients at all clinics during the dental
course.
Conclusion
The working position in dentistry is essential to protect the
dental team health. In this chapter, the correct way of ergo-
nomically seat during the dental treatment and properly
position the patient in the chair was explained, as well how to
grasp the instruments and rest the fingers in the oral environ-
ment. The control of the environmental condition in order to
protect the health was explained. The exercises that can be
done inside the dental office were shown, helping to prevent
the most common work-related musculoskeletal disorders.
Ergonomics Principles Applied to the Dental Clinic
75 2
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archive.1985.0302.
 77 3

Cariology
Taciana Marco Ferraz Caneppele, Alessandra Bühler Borges,
Carlos Rocha Gomes Torres, José Roberto Rodrigues, and Thomas Attin

3.1 Introduction – 78

3.2 Etiology of Dental Caries – 78

3.3  ole of Microorganisms on the Development on Carious

R
Lesions – 80

3.4 Importance of the Saliva as a Protecting Factor – 81

3.5 Fluoride Action – 82

3.6 Development of the Carious Lesions – 82

3.6.1 L esions at the Occlusal Surface – 88
3.6.2 Lesions at the Proximal and Cervical Third of Smooth Surfaces – 91
3.6.3 Lesions at the Root Surface – 91

3.7 Caries Diagnosis – 93

3.7.1  ethods for Detecting and Diagnosing Dental Carious Lesion – 95
M
3.7.2 Secondary Carious Lesions – 110

3.8 Treatment Decision – 112

3.9 ICDAS – 113

References – 119

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_3
 78 T. M. F. Caneppele et al.
Learning Objectives
The learning objectives of this chapter are related to the fol-
lowing topics:
55 Carious should be understood as a disease starting
already before a cavitation appears.
55 Lesion progression is dependent on the caries risk of the
3 patient and may vary within individual lifetime.
55 Decision about how to treat carious lesions should be
based on the knowledge of the individual caries risk.
55 The final goal of the caries disease treatment is to
achieve an oral environment, in which demineralized
areas may remineralize and in which no new lesions will
appear in the future.
3.1 Introduction
Since the beginning of the history of dentistry, the treatment
of the dental caries has been focused on the restorations of
the cavities using many techniques and materials, which have
presented a great evolution throughout time. However,
patients still presented the development of carious lesions at
the margins of the restorations, called secondary caries, as
well new lesions on other dental surfaces. This happened
because the secondary caries was being considered to be a
distinct entity, closely related to the quality of the restorative
material and restorative technique. Nowadays, the secondary
caries is considered only a reflex of the caries disease that was
not completely treated, confirming the importance of the
knowledge of its etiopathogenesis so that it is possible to
establish its proper prevention, avoiding the appearance of
new lesions [27]. Therefore, the incorporation of the knowl-
edge coming from the cariology must be considered as the
base for the success of the restorative treatment [27]. The
treatment of the dental caries, which historically based itself
only on the reparation of the damage, is considered, nowa-
days, unacceptable. The modern vision is that the dental car-
ies is a bacterial disease that produces the destruction of the
dental organ, causing lesions that are nothing more than the
clinical signs of its presence. Therefore, the treatment of the
disease must precede the treatment of the signals. In any
other way, the lack of success of the treatment surely will
happen.
>> Dental caries is a bacterial disease that produces the
destruction of the dental organ, causing lesions that
are nothing more than the clinical signs of its presence.
The treatment of the disease must precede the
treatment of the lesions.
3.2 Etiology of Dental Caries
It is a proven fact that the caries disease occurs only in indi-
viduals with a diet rich in fermentable carbohydrates, espe-
cially sucrose. Among the bacteria present on the oral
biofilm, there are some that are capable to metabolize those
carbohydrates and besides reproduce themselves; they pro-
duce a large quantity of acidic substances that come in con-
tact with the dental structure. The dental enamel is essentially
built of hydroxyapatite, which is also present in the dentin,
and it is susceptible to dissolution when there is a high quan-
tity of acids in the biofilm fluid and the pH is below a level
considered critical (pH = 5.2–5.7). On those cases, the con-
centration of calcium (Ca2+) and phosphate ions (HPO42−) in
the biofilm fluid becomes lower than to the product of solu-
bility of the hydroxyapatite, promoting a physical and chemi-
cal tendency of the enamel to loose Ca2+ and HOP42− to the
oral environment, at the attempt to reach a new state of bal-
ance in function of the reached pH.  This phenomenon is
called demineralization. However, a drop of the quantity of
fermentable carbohydrate in the oral cavity may reduce
microbial activity, bringing back the “normal” status with the
biofilm fluid being oversaturated with calcium and phos-
phate ions in relation to the dental structure. This means that
the calcium and phosphate concentration in the biofilm fluid
is higher than the product of solubility of the hydroxyapatite.
As a consequence, remineralization or at least reparation will
occur since those abounded minerals tend to be reincorpo-
rated into the dental hard tissue as a phenomenon called
remineralization [27]. If there are more periods of remineral-
ization than demineralization, the dental structure keeps
itself intact. However, in the cases, in which the periods of
demineralization prevail in relation to the periods of remin-
eralization, the structural loss increases gradually, resulting
on the presence of cavities, known as carious lesions
(. Fig. 3.1).
The cycles of demineralization and remineralization are
influenced by many determinant factors, which turn the car-
ies a multifactorial disease. Basically, for the development of
a carious lesion, three factors are essential, and they are the
host (tooth), microbiota, and diet (substrate). Many studies
demonstrated that the caries does not develop in animals
completely without bacteria [74] nor in animals with oral
remineralization
pH
Ca++ Ca++
HPO4-- HPO4--
pH
demineralization
enamel saliva
biofilm
..      Fig. 3.1  Schematic drawing explaining the demineralization and
remineralization process that happen on the tooth surface due to the
pH oscillation of the oral environment
Cariology
bacteria but that are fed with a cariogenic diet through stom-
ach canulas [53]. It is evident that only the existence of the
three factors happening simultaneously does not result in an
instant mineral loss, but it is necessary that they interact for
some time, making time to be the fourth important factor.
Those factors have been called primary determinants for the
caries disease because they are essential to the process of the
development of the lesions [71, 75].
. Figure  3.2 illustrates the relation between the dental
 
biofilm and the multiple biological determinants that inter-
fere on the probability to develop a carious lesion. On the
internal and interlaced circles, the primary determinant fac-
tors for a carious lesion to occur are represented. They are the
susceptible dental structure, cariogenic microbiota, the sub-
strate for the microorganisms, and time, so that the deminer-
alization can occur. In relation to the tooth structure, it
represents the element which will be attacked in the presence
of the caries disease. The age of the patient determines the
stage of tooth eruption and the resistance of the teeth against
the demineralization, because of the presence or absence of
posteruptive enamel maturation. The presence of fluoride on
the oral cavity turns the tooth more resistant to the acidic
attack and allows better remineralization, while the dental
79 3
morphology may or may not aid the retention of the bacteria
on the surface. In relation to the microorganism, the types
present also have great influence because the existence of the
acidogenic and aciduric bacteria is essential for the process.
In addition, the adequate dental hygiene may result in the
disorganization of the biofilm, reducing the quantity of acids
produced. Depending on the concentration of fluoride on the
biofilm, the metabolic activity of the bacteria may also be
diminished. In relation to the substrate, the composition and
frequency of the diet favors or not the bacterial activity, so it
is also a decisive part of the process because they are the
nutrients so that the bacteria survive on. The adequate oral
hygiene habits can remove the food residues, reducing the
substrate available. In relation to the time, due to the diet
with high consumption of fermentable carbohydrates, there
is a variation of pH that leads to mineral loss. It is necessary
that this interaction is kept through some time so it results in
the formation of the incipient lesions initially and later on the
cavitation.
In the light blue circle, the secondary main determinant
factor is presented, which is the saliva. It is saturated in cal-
cium and phosphate and participates in the processes of
demineralization and remineralization. Its compositions, the

SCHOLARITY

SOCIAL CLASS KNOWLEDGE

SALIVA
(COMPOSITION, FLUX,
BUFFER CAPACITY)

TIME

TOOTH
(AGE, CARIOUS MICROBIOTA
FLUORIDE,
MORFOLOGY)
LESION (TYPE, QUANTITY
FLUORIDE,
HYGIENE)

SUBSTRATE
(COMPOSITION OF DIET,
FREQUENCY, HYGIENE)

SALIVA INCOME
ATTITUDES

BEHAVIOR

..      Fig. 3.2  Schematic drawing of determinant factors for caries factor, while on the dark blue circle the confounding factors are
disease. On the internal interlaced circles, the primary determinant depicted. (Adapted from Fejerskov and Manji) [26]
factors are given. On the light blue circle, the secondary determinant
 80 T. M. F. Caneppele et al.
salivary flow or flux, and its capacity to neutralize the acidity
by the buffering effect have a great influence on the occur-
rence or not of those lesions. On the dark blue circle, the fac-
tors that are not decisive for the disease but are tied to it in
some way are presented. They are called “confounding fac-
tors” because they do not always influence on the same way
3 in all societies, although the determinant factors will cer-
tainly always be the same in all populations [26]. As examples
are the social class, the financial income, and knowledge,
which can allow greater access to information about the
causes of the disease, besides the monitoring by a clinician.
In addition, the behavior and the attitudes will favor that the
patient has healthy dietary and hygiene habits.
3.3 Role of Microorganisms
on the Development on Carious Lesions
Keyes [52] investigation, at the beginning of the 1960s
decade, demonstrated the need of a specific microbiota for
occurrence of the dental caries. The researcher verified that
the hamster babies, which the mothers had been treated with
antibiotics during the breastfeeding period, did not develop
carious lesion, even receiving a diet with a great cariogenic
potential. Those “not contaminated” babies only developed
lesions when in contact with infected hamsters, or when
inoculated with material provided from the biofilm of those
animals. Until the decade of 1960, it was believed that the
caries disease was the result of the collective production of
acids by the acidogenic bacterial communities on the biofilm.
This way of seeing the process was called the “non-specific
plaque hypothesis.” However, later studies demonstrate that
the members of a colony of hamsters without caries but that
had a microbiota composed by numerous acidogenic micro-
organisms only developed caries when contaminated by spe-
cific Streptococcus, which came from lesions from hamster
that had active caries and were submitted to a diet rich in
sucrose [30]. Those microorganisms, later identified as
mutans group streptococci, are cariogenic by nature and
present a potential to produce carious lesions much higher
than any other acidogenic microorganism on biofilm. Since
those first studies until today, many researches have demon-
strated the role of this group of microorganisms on the etiol-
ogy of the caries. The biofilms removed from the areas with
cavities are bacteriologically and biochemically different
from those coming from a healthy zone, proving that there is
a more specific microbiota on the development of the carious
lesion [55]. Those observations gave origin to the “specific
plaque hypothesis.” It helps to explain the results of an epide-
miological study, performed in 2001, in the United States,
when 60% of the carious lesions happened in only 20% of the
analyzed population, while only 5% of the population was
caries free [90]. In . Fig. 3.3, the disclosed bacterial biofilm
 
can be seen in a patient with high caries activity.
These findings changed some concepts from the 1950s
when it was believed that Lactobacillus was the main sus-
pect for the initiation of the carious lesions, due to its
..      Fig. 3.3  Disclosed bacterial biofilm
capacity to produce acid and presence in high amounts on
patients with high caries experience. However, the studies
of the microbiota of the biofilm demonstrated that
Lactobacillus represents only a reduced fraction of the total
microorganisms present on the biofilm, and it was impos-
sible to claim that they were responsible for the presence of
carious lesions. In addition, they had a low adhesive capac-
ity to the acquired salivary pellicle. On the other hand,
streptococci species with a high cariogenic potential were
numerically much more significant on the biofilms that
appeared right before the initial carious lesions, keeping a
relation of 10,000:1, in relation to the Lactobacillus.
Additionally, streptococci presented a much higher adher-
ence capacity to the tooth surfaces. Nowadays, there is great
evidence that the mutans group streptococci play an impor-
tant role in the initiation of human caries. They are highly
acidogenic (capable to produce acids) and acidurics (capa-
ble to live in an acidic environment), and its cariogenic
potential is well established in animals. They preferably
colonize the teeth, and they are found in high proportions
in the grooves, fissures, contact areas, and other retentive
zones, in a way that its pattern of colonization happens in
parallel with the areas that are susceptible to caries [36].
The lactobacilli are, usually, found on the carious lesions
that already have cavitated, and its number at the saliva gen-
erally maintains a positive correlation with the caries experi-
ence. On the other hand, the rigorous restraint to the
consumption of sugars, in general, decreases significantly the
caries activity and the number of Lactobacillus in the saliva
[48]. However, as it has already been described, everything
seems to indicate that the lactobacilli are not essentially
involved at the initiation of the caries, acting mostly as “sec-
ondary invaders” that take advantages of the acidic condi-
tions and the retention that prevails inside the carious lesion.
This fact is corroborated by the observation that lactobacilli
are usually not detected in biofilms that cover incipient car-
ies. At these conditions, the detection of a high concentration
of Lactobacillus in the saliva (>100,000/ml) would work as an
excellent indicator of risk for progression of initial preexist-
ing caries. This indicator may have an important function in
Cariology
the decision to treat, restoratively or not, incipient caries,
especially in cases of interproximal caries detected by radiog-
raphy, and that does not allow a clinical evaluation of the
presence or absence of cavitations [76].
Under common circumstances, without the exaggerated
consumption of sucrose, as it happens in isolated populations
that do not have access to the modern diet with processed
food, the microbiota that colonizes the teeth presents low
cariogenic potential. The dental surface can be seen as a hab-
itat to be colonized. As soon as the teeth erupt, the pioneer
bacteria, which produce extracellular polysaccharide capable
to adhere to the surface, will bond to the salivary pellicle.
They start to reproduce, forming an initial bacterial biofilm,
so they are considered pioneer bacteria. Among them, strep-
tococci from the oralis group are present, which are aerobic
bacteria (e.g., Streptococcus sanguinis, Streptococcus mitis,
and Streptococcus oralis). Those bacteria modify the environ-
ment and allow that the biofilm becomes attractive for other
bacteria to live in, turning it more complex. In each interval,
the conditions of the environment change in a way that can
favor or disfavor the presence of certain bacterial group.
After a determined period, the biofilm reached its maximum
degree of maturity. The observation of this ecological
sequence of microorganisms gave origin to the so-called eco-
logical plaque hypothesis.
The first ecological microbial succession happens after
the teeth erupt, and it is called the primary succession.
However, every time the bacterial biofilm is disorganized or
completely removed by brushing, it will develop itself again,
through a new ecological succession, called the secondary
succession. On the other hand, every time an ecological
succession occurs, the conditions of the environment may
favor or disfavor the development of a certain group of
microorganisms. One example of that happens in individu-
als with low caries activities that for some reason begin to
consume a high quantity of sucrose and to neglect the oral
hygiene. On those cases, the acidogenic bacteria, as the
mutans group streptococci and the lactobacilli, are starting
to produce acid, which will lead to a lowering of the pH of
the biofilm. These same bacteria are aciduric and resistant
to this environment. However, this hinders that the acid-
sensitive bacteria as the Streptococcus from the oralis group
to develop, and its quantity is drastically reduced. The
capacity for the acidogenic and aciduric bacteria to perform
a natural selection during the ecological succession allows
them to be called pH strategist [13].
Some studies demonstrate that the chance of an individ-
ual to develop a pathogenic biofilm is lower when the pri-
mary ecological succession occurs in a low consumption of
sucrose and the first colonizing bacteria are not being cario-
genic. Therefore, some members of a dental biofilm are con-
sidered beneficial for the host, because they may play a role of
a protector against the colonization of exogenous species or
even to produce substance as bacteriocins, surfactants, and
hydrogen peroxide, which have antagonist effects on the
establishment of the Streptococcus mutans and Lactobacillus
[42]. This prevention is called primary or true prevention.
81 3
3.4 I mportance of the Saliva as a Protecting
Factor
Saliva is a glandular secretion with a complex composition
presenting organic and inorganic components. The organic
components consist of a variety of proteins, carbohydrates,
and enzymes, each one having an important function of con-
trol of the oral environment. The inorganic components,
such as sodium, potassium, calcium, chlorite, bicarbonate,
and phosphate, determine the relative saturation of the fluid
in relation to hydroxyapatite. Other than those inorganic
components, many cellular elements are found in the saliva,
especially epithelial cells peeled from the mucosa, leukocytes,
and neutrophils originated from the gingival sulcus, besides
microorganisms [75].
Saliva is present during the development of carious
lesions, influencing in an important way the process of tooth
decay. A study showed that an extreme deficiency of saliva
results in an increase of the cariogenic activity [33]. The
saliva acts actively on the process of demineralization and
remineralization of the dental hard tissue, through the ionic
exchange of Ca2+ and HPO42− with the biofilm and dental
mineral structure.
Saliva presents a buffering capacity, which is the capacity
of the saliva to keep its pH constant between 6.9 and 7.0. Due
to its mucinate/mucin, bicarbonate/carbonic acid, and
monophosphate/bisphosphate buffers, it counteracts the
excess of acids or bases, neutralizing the acids formed by the
bacterial metabolism [91]. Other important protector role of
the saliva is the mechanical clearance (removing food ­detritus
and bacteria) through the saliva flux. Saliva also influences
the ecological balance of the oral microorganisms, since it
serves as substrate for the bacteria, interferes on the micro-
bial adhesion by the formation of an acquired pellicle, and
has antimicrobial substances with immunological (secretory
IgA, IgG, and IgM) and non-immunological effects (lactofer-
rin, lysozyme, lactoperoxidase, and myeloperoxidase) [64].
The non-stimulated salivary flux varies between 0.25 and
0.35 ml/min, increasing from 1 to 3 ml/min when it is stimu-
lated by the chewing. The saliva flux varies during the day,
coming to its minimum during sleep, with a minimum of its
protector effect, what may additionally explain the appear-
ance of rampant carious lesion in children having a baby
bottle with sucrose as a night habit. Some systemic diseases,
such as Sjögren’s syndrome, rheumatic arthritis, diabetes
mellitus, nervous anorexia, Parkinson disease, and depres-
sion, among others, have the side effect of reducing the
production of saliva. The use of some medications as anti-
spasmodic, antidepressants, muscle relaxants, antiarrhyth-
mic, antihistaminic, antihypertensive, diuretics, and
anti-inflammatory, among others, also reduces the salivary
flux. People with reduced saliva flux lack the protective action
of the saliva, and so, they are more prone to the development
of carious lesion.
Some clinical evidence is related to the reduction of the
saliva flux, for example, reports from patients about dry
mouth, constant thirst, difficulties to talk and to swallow,
 82 T. M. F. Caneppele et al.
burning and tingling sensation on the tongue, and difficulty
to use total or removable prosthetic appliances. Additional
clinical signs of reduced salivary flux are oral mucosa irrita-
bility, presence of fissures and ulcers on the commissures, red
and fissured tongue, and carious lesions on tooth smooth
surfaces, usually places of self-cleaning, as the areas above
3 the height of curvature and incisal edge. During the manipu-
lation of the oral cavity, it can also be verified that the clinical
mirror or a gloved finger adheres to the dried-out mucosa.
3.5 Fluoride Action
Nowadays, it is known that the cariostatic effect of fluoride is a
consequence of its presence on the organic fluids during the
cariogenic attack. Because of the pH variation on the oral
environment, the dental enamel suffers a process of constant
demineralization and remineralization. Fluoride, even in a
small concentration, interferes on the cariogenic process.
Below pH 5.5 (critical level of demineralization of the enamel),
the tooth environment (biofilm fluid) becomes unsaturated
with respect to hydroxyapatite. Thus, diffusion of enamel min-
erals from the tooth to the environment occurs (demineraliza-
tion) to restore the ionic balance between them. The
hydroxyapatite of the enamel starts to dissolve at a pH around
5.3–5.5; However, fluorapatite is not dissolved until the pH is
below 4.5. When the oral environment pH is between 5.5 and
4.5, the enamel release calcium, phosphate, and hydroxyls to
the oral environment. At this pH range, if fluoride ions are
available, the minerals will be able to form fluorapatite and
fluoridated apatite, which will deposit on and in the dental
enamel. The fluoride presence at biofilm fluid promotes a rem-
ineralization without the need for the pH to reverse above the
critical pH for hydroxyapatite. Therefore, the availability of
fluoride ions for prolonged periods is important, even in low
concentrations. The demineralization process will depend on
the fluoride concentration on the tooth/biofilm interface and
on the pH of the biofilm fluid. The lower the pH of the envi-
ronment, the higher is the concentration of fluoride needed to
hinder the demineralization process of the dental structures.
However, there is a limit for the action of fluoride ions. If the
pH is below 4.5, the biofilm fluid will become unsaturated
with respect to the two apatites (hydroxyapatite and fluorapa-
tite); as consequence, mineral loss will happen [17, 63].
Besides the interference on the process, the demineraliza-
tion and remineralization, the fluoride interferes on the
growth and the bacterial metabolism. Low levels of fluoride
can change the metabolism of the carbohydrates by the bac-
teria, resulting in the reduction of the production of acids
and polysaccharides and in the bacterial adherence [39]. At
low concentration it presents bacteriostatic effects, but in
high concentration, it can have a bactericide effect.
When fluoride is applied to the dental surface in concen-
trations above 100 ppm, in an acidic formulation or with a
prolonged contact to the surface, a calcium fluoride-like layer
(CaF2) is formed on the surface. That substance per se is not
stable in the environment of the oral cavity. However, under
clinical conditions, the surface-deposited CaF2 is covered by
phosphate and proteins from the saliva, forming a type of
protection. This so-formed calcium fluoride-like layer shows
a low dissolution rate, making it to act as a slow fluoride-­
releasing agent. In case of a pH drop in the biofilm, the phos-
phate and protein layer of the deposit is solubilized, exposing
the soluble CaF2. The release of fluoride and calcium to the
environment promotes formation of fluorapatite right at the
time point of the acidic attack. That means that remineraliza-
tion directly occurs parallel to the time point of demineral-
ization. When the pH recovers to physiological values, the
remaining CaF2 is once again coated and is available to par-
ticipate in a new cycle of demineralization and remineraliza-
tion. By this, it can be considered a continuous reserve of
fluoride, with an active participation on the dynamic of the
development of the carious lesion. In order to keep the
deposit of calcium fluoride at a high level, it is fundamental
that fluoride-containing products, such as toothpaste or
mouthwash, are frequently used.
3.6 Development of the Carious Lesions
With the formation of the bacterial biofilm on the dental sur-
face and in the presence of a diet rich in fermentable carbo-
hydrates, acids will be formed by the bacterial metabolism,
which will reach the surface of the enamel, promoting its
demineralization. This accumulation of biofilm occurs espe-
cially in regions protected from friction with the soft tissues
and with the food bolus, as the bottom of the grooves, inter-
proximal regions, and cervical areas of smooth surfaces
below the height of curvature (. Fig. 3.11a). Initially, dissolu-
tion of the interprismatic enamel is started, with the accen-
tuation of the prism prominences, creating a rough surface
with surficial porosities (. Fig. 3.4a). The acids continue to
diffuse into intercrystallite water-filled spaces and the pro-
cess keeps on, following the direction of the enamel prisms.
At the surface layer of the lesion, the level of mineral loss is
lower than in the more inner regions, due to its contact with
the mineral-rich and oversaturated saliva. After some time,
an incipient carious lesion is formed in the enamel with a
relatively intact surface, with a porosity volume of approxi-
mately 1%, called surface zone, and a subsurface porous part,
with a porosity volume of 5–25%, called the lesion body (LB).
At the deepest inner portions of the lesion, the front of
demineralization (translucent zone) is created, with a poros-
ity volume of 1%. At this area the dissolution of the intact
enamel prisms is happening. The dissolved mineral salts at
this area, before leaching outward, temporarily accumulate
on the neighboring region, called dark zone, with 2–4% of
porosity. Afterward, the minerals diffuse to the LB and later
to the oral environment through the pores in the surface
zone. In . Fig. 3.4b, c, the histological aspect of a subsurface
carious lesion, pointing out the surface zone (arrow), and the
LB is depicted. . Figure 3.4d shows a schematic drawing of
the variation of porosities in the different layers of an initial
enamel lesion.
Cariology
a b
c d
..      Fig. 3.4  a Scanning electron microscopy image of human enamel
surface showing on the left a white spot lesion with many pores
(arrow), contrasting with the aspect on the right, where the enamel is
intact; b histological aspect of an enamel carious lesion observed on
the optical microscopy (2.5×); c greater magnification of the lesion
As a consequence of the presence of this subsurface
lesion, there is a modification of the optical behavior of the
dental structure. According to the laws of optics, when there
is a difference in refractive index between two materials,
there will be an interface that deviates the light waves [19].
When the enamel is intact, the whole tissue has a refractive
index of 1.62 and there are no interfaces. The light travels
through the tissue without modification on its trajectory,
until it reaches the DEJ, being then reflected back. However,
the caries lesion has many porosities filled mainly with water
from saliva, which has a refractive index of 1.33. In this case,
the light waves reach multiples interfaces between the fluid
and the mineral phase, with different refractive indices. At
each interface the light is deviated and reflected, becoming
imprisoned in an “optical maze” that is over-luminous and
therefore perceived as white, creating a so-called white spot
lesion [19]. Small subsurface lesions may not be visible when
the tooth is wet because the amount of water present on the
internal porosity of the lesion may not be capable to deviate
the light enough. However, when it is dried with a blow of
air, the water inside the porosities is replaced by air, which
has an even lower reflection index, equal to 1, making it vis-
ible for a naked eye. On the other hand, more advanced sub-
83 3
presented in the image b, showing the lesion body (LB) and the surface
zone (arrow) (10×); d scheme showing the levels of porosity on the
different zones of the enamel lesions (arrow, surface zone; LB, lesion
body of the; DZ, dark zone; TZ, translucent zone)
surface lesions are visible even when they are hydrated
because of the high amount of water inside. When such a
lesion is dried, its visible size becomes even greater
(. Figs. 3.5a–h and 3.6a–d). A study correlated the severity of
carious lesions and their histological depth. White spot
lesions, which require air-­drying, are most likely to be lim-
ited to the outer ½ of the enamel. The depth of a white lesion
which is obvious without air-drying is located some place
between the inner 1/2 of the enamel and the outer 1/3 of the
dentin [23]. When dried with a blow of air, active enamel
caries lesions present an opaque white, chalky, and dull sur-
face. In contrast, non-active, arrested initial lesions show a
glossy white surface after drying.
Every effort must be kept on the way to diagnose and stop
the lesion yet at this stage. At this moment preventive treat-
ments are mandatory to interrupt and stop the bacteria colo-
nization of the surface and to disorganize the biofilm on the
surface. However, if the surface pseudo-intact layer is
destroyed and breached, for example, by probing with a den-
tal instrument, a bacterial invasion into the body of the lesion
will occur. In such a cavitated lesion control and removal of
the biofilm is almost impossible and the lesion is going to
progress. This means that a cavitated and not cleanable lesion,
 84 T. M. F. Caneppele et al.

a b

c d

e f

g h

..      Fig. 3.5  Teeth with active carious white spot lesions. The clinical of the lesions. g, h White spot lesion on the occlusal surface, with the
aspect is modified when the tooth is wet or dry. a, c, e With the teeth surface wet and dry, respectively
wet and the lesions seem smaller; b, d, f dry teeth showing the real size

e.g., at the proximal aspect of a tooth, will be necessary to be forming a second cone, with apices directed toward the
filled up with a restoration (. Fig. 3.6a–d).
  pulpal chamber, following the dentinal tubules (. Figs. 3.7b,  

In smooth surfaces, as the mesial, distal, buccal, and lin- c and 3.8b). If the surface is still intact, no bacterial invasion
gual surfaces, the carious lesions progress with a cone shape, into the lesion body will occur, and progression of the lesion
with the base facing the external surface of the tooth, while at might be stopped simply by removing the bacterial biofilm
the region of the grooves, due to the inclination of the cuspid, from the surface, allowing its remineralization by the saliva.
the lesion at the enamel progresses with cone shape with the As soon as the surface zone of the lesion is fractured, it
base facing the dentinoenamel junction (. Figs.  3.7a and  often becomes impossible to remove the bacterial biofilm
3.8a). When the acids go through the intercrystallite spaces with common oral hygiene measures, and a restoration is
and reach the dentin, even with an intact surface zone of the indicated (. Figs. 3.7d and 3.8c, d). With time, all the adja-
 

lesion, the demineralization expands laterally along the DEJ, cent dentin is destroyed, and only the undermined enamel is
Cariology
a b
c d
..      Fig. 3.6  a Anterior teeth with great accumulation of bacterial
biofilm; b aspect after removal of the biofilm with the surface still wet;
c aspect after drying with a blow of air. It can be observed that the
white spots are more visible and seem larger than when the teeth are
left (. Fig.  3.8d). When the cavity reaches the dentin, the
 
tubules are invaded by the bacteria, and the acids and proteo-
lytic enzymes lead to a liquefaction necrosis process of the
outermost layer of dentin (. Fig. 3.8d – Asterisk). Below this
 
very soft layer of liquefaction necrosis, an intermediary
demineralized and contaminated layer, called infected den-
tin, exists. As the penetration of the acids in the tubules pre-
cedes the bacterial invasion, a deeper dentin area is already
demineralized without the presence of bacteria, called
affected dentin. With the progression of the lesion, the con-
taminated area spreads, and when there is only 0.5  mm of
remaining tooth structure covering the pulpal chamber, the
diffusion of the bacterial metabolic reaches the pulp and can
start an inflammatory reaction, called pulpitis [72]. If ­nothing
is done and the process continues, the bacterial invasion into
the pulp tissue will lead it to necrosis. In . Fig. 3.9a, and b the
 
clinical aspect of the necrotic dentin being removed with a
spoon excavator is depicted. More internally, when exca-
vated, the demineralized and contaminated dentin is
removed in chips.
85 3
dry. It can also be verified the presence of cavity on the cervical region
on the tooth 12; d sectioned extracted teeth showing the breaking out
of the surface zone of a white spot lesion, resulting in a cavity and
bacterial invasion in the lesion body
When the enamel carious lesion at the enamel comes
close to the dentinal tissue, even before the start of dentin
demineralization, the odontoblasts react trying to obliterate
the tubules by the deposition of calcium salts inside the
lumen, forming the so-called sclerotic dentin (. Fig. 3.7 –  
red arrows) [50, 89]. This could be interpreted as an attempt
to block irritating and aggressive agents from reaching the
pulpal tissue. In . Fig. 3.10, the clinical aspect of the scle-
rotic dentin can be observed at the pulpal wall. It presents
an extremely hard consistence to probing and a dark brown
or black color.
With the lesion progression, the increase of dentin
demineralization stimulates the primary odontoblasts in
contact with the affected tubules. They start the focal secre-
tion of dentin matrix tissue inside the pulpal chamber,
forming a tertiary dentin known as reactionary, which
shows tubular continuity with the secondary dentin [46].
With the increase of the injury intensity, the primary odon-
toblasts will be compromised in terms of survival until cell
death. When the pulp defense mechanism is still active,
 86 T. M. F. Caneppele et al.
a b
c d
..      Fig. 3.7  Progression of the carious lesion on smooth surface.
a Subsurface lesion limited to the enamel; b, c dentin demineralization
without the presence of cavity; d demineralization and disorganization
stem/progenitor cells may be recruited to the injury site,
creating a new generation of odontoblast-like cells secreting
reparative tertiary dentin [7]. In this case there will be a
lack of tubule continuity with the secondary dentin, creat-
ing a barrier effect that will protect the pulp tissue, until the
caries process reaches this region [46]. However, this
sequence of events only happens in the cases when the cari-
ous lesion has low-speed progression. In patients with high
caries activity, the lesions can progress so fast that there is
no time for sclerosis and much less for the formation of
reactionary or reparative dentin, increasing the risk for
development of an irreversible involvement of the pulp. In
addition, during cavity preparation of a tooth with a lesion
of fast progression, a greater chance of accidental exposure
of the pulpal tissue also occurs, due to the higher quantity
of softened dentinal tissue. In some special cases, with teeth
showing no signs of irreversible pulpitis, it may be advised
to restore the not completely carious-free cavity temporar-
ily. This intermediary step may allow remineralization of
the affected dentinal tissue, as well as formation of the
tubule’s sclerosis and of the reactionary dentin. Further
details are provided in the following chapters.
When the white spot lesion in enamel is detected before
cavitation happens, the treatment of the caries disease by
of the dentin after cavitation. The black arrows indicate the demineral-
ized dentin, while the red arrows indicate the sclerotic dentin
intensifying preventive measures along with fluoride applica-
tions will promote the deposition of calcium salts on the sur-
face and inside the lesion. By this it may happen that small
lesions completely disappear. However, once the pores of the
surface zone are closed, minerals will not be deposited homo-
geneously inside the lesion body. Thus, the bigger a lesion is,
the more likely it will stay visible, even after being arrested.
Clinical studies demonstrate that only 33 to 49% of white
spot lesions disappear when being arrested. It is known that
white spot lesions become inactive as soon as no biofilm is
present on its surface. At this inactive state, white spot lesions
present a shining surface when dried with a blow of air
(. Fig.  3.11b). During the arresting process, pigments and
dyes present in the oral cavity from the diet can deposit into
the porosity, changing the white spots to darkish or brownish
spots (. Fig. 3.12a, b).
The activity of caries disease is related to the interaction
between the determinant factors, leading to an unbalance of
the demineralization/remineralization process with more
mineral loss than gain, due to the production of acids in the
biofilm. However, this conjuncture can be changed at any
time, and a patient with a high caries activity can be changed
to low activity, resulting in an abrupt drop of the acid pro-
duction. When this happens, the existing lesions, even if
Cariology
87 3

a b

c d

..      Fig. 3.8  Progression of the carious lesion on the occlusal surface. disorganization of the dentin after cavitation. The black arrows indicate
a Subsurface lesion limited to the enamel; b dentin demineralization the demineralized dentin and the asterisk the necrotic dentin
without the presence of cavitation; c, d demineralization and

a b

..      Fig. 3.9  Clinical aspect of carious dentin. a Necrotic dentin with a “porridge” aspect; b demineralized dentin removed in chips

cavitated, change their aspect. The active cavitated lesions of of low acidogenic activity, called chronic carious lesions, no
intense acidogenic activity, called acute carious lesion, have a biofilm is visible, and the dentin looks dryer, with a darker
large quantity of bacterial biofilm and a wet appearance, and color and a consistency described as similar to leather
the dentinary tissue shows a light brown color and is (. Fig.  3.13b). In turn, as an acute lesion may become
 

extremely soft (. Fig. 3.13a). Frequently there are white spots

  chronic, the opposite may also happen, when the determi-
on the enamel margins of those cavities. However, in lesions nant factors of the caries disease may prevail again.
 88 T. M. F. Caneppele et al.

3.6.1 Lesions at the Occlusal Surface
Carious lesions located at the occlusal surface of posterior
teeth have a higher prevalence than at other tooth areas, as
3 for the growing of biofilm and the onset of a carious lesion at
..      Fig. 3.10  Clinical aspect of darkened sclerotic dentin at pulpal wall
shown in epidemiological studies [78, 79]. Clinically, it often
occurs as a localized phenomenon at one single spot of the
groove and fissure system. This happens, since the carious
lesion starts on sites where the bacterial growing is more pro-
tected against the functional contact and removal [14].
Therefore, two factors have been considered to be important
the occlusal surfaces: the eruption stage of the tooth that is
related to the functional use of the teeth and the specific
anatomy of each tooth [14–16].
Throughout the eruption process of the teeth, up to the
occlusal contact with its antagonist, these teeth are more sus-
ceptible to caries. Although the dental enamel is completely
formed at the time of eruption, it still presents high porosity.
It has been suggested that it goes through a posteruptive
enamel maturation period after its exposure to the saliva,
which will increase its resistance to demineralization [54,
96]. The nature of this maturation is still not completely
understood, but it is believed that during this period the
mineral ions and the fluoride in the oral environment diffuse
into the enamel.

a b

..      Fig. 3.11  White spot lesions in enamel. a The presence of lesions is associated to the places where bacterial biofilm occurs, as in cervical and
interproximal regions; b inactive lesions with shiny surface

a b

..      Fig. 3.12  Darkened inactive carious lesion in enamel. a Labial surface; b proximal surface
Cariology
a b
..      Fig. 3.13  Clinical aspect of a carious lesion. a Acute lesions; b chronicle lesions
The partially erupted teeth do not participate in the chew-
ing, since they do not contact their antagonists. Thus, accu-
mulation of a biofilm is more likely. This come together with
the fact that a regular hygiene of these teeth with the surface
below the level of the other teeth is more demanding [14].
Therefore, bacterial growth can be accentuated at those sites
of not fully matured enamel (. Fig. 3.5). As the tooth comes
 
close to the complete functional occlusion, the shearing
forces, coming from functional chewing, disorganize the
dental biofilm, so that no biofilm is formed on the cuspal
incline. However, the bacterial deposits, located in the deep-
est area of pits and grooves, are still protected against those
mechanical removal forces. Therefore, it is observed that the
visible signs of the caries develop at places where the bacte-
rial deposits remain protected against the removal oral forces
for a long period. One of the reasons for the greater preva-
lence of carious lesions in molars in relation to premolars is
related to the fact that they take longer to erupt, thus staying
susceptible for bacterial adherence for longer time. The
molars take from 12 to 18 months to come in contact with
the antagonist, whereas the premolars take from 1 to 2
months.
A correlation between the morphology of the occlusal
surface and the caries onset at this area exists. In the past, it
was believed that patients with deeper dental grooves were
more susceptible to develop lesions than the ones with shal-
lower grooves, since the bristles of a toothbrush would not be
capable to clean this region. . Figure 3.14a–f shows the basic
 
types of grooves that can be found in the population. Type 1
represents a shallow and open groove, while Type 2 is a nar-
row and deep one. Type 3 is the ampoule or bottle-shaped
groove, with narrowing at the entrance and an enlargement
at the base. Type 4 is a real fissure because there is no coales-
cence of the enamel from one cuspal incline with the other
and there is a direct contact between the environment and
the dentin [84]. A pit is a small fault located on the tooth’s
surface. It is generally found on the intersection of two fis-
sures or at the end of a developmental groove.
However, it was shown that a carious lesion does not
begin in the deepest part of grooves, but on the side, next to
89 3
the surface (. Fig. 3.15). For the development of the micro-
biota in the biofilm, it is necessary to have space and nutri-
tion, which is less likely at the bottom of the groove Type 2
(. Fig. 3.14c). Therefore, more important than the depth of
the pits and grooves is the form of the occlusal morphology,
which may or may not favor the retention of the bacterial
biofilm. With increasing tooth wear, teeth will show a
smoother surface, reducing the propensity to biofilm accu-
mulation (. Fig. 3.16a–d). It was noticed that this fact reduces
the risk of lesion development despite the groove anatomy.
Conversely, grooves Type 3, bottle-shaped, are a concern
because this morphology allows the growth of the microbiota
in its interior (. Fig. 3.14d). However, this fissure type is only
seen in 10% of the teeth and is associated with the presence
of very high cusps. The presence of real fissures is another
problem because it favors the carious lesion to reach the den-
tin and it has a very fast progression. However, its frequency
is even smaller than the other configurations [84]. Real fis-
sures and pits are more common at the buccal groove of the
lower molars, where lesions progress into the dentin without
external signs, resulting later in lesions like the one observed
in 7 Fig. 5.13c.
The peculiar characteristics during the developing of cari-
ous lesions at occlusal surfaces, shaped as two cones, one over
the other, base against base, favor the expansion of the carious
lesion under clinically intact enamel. This special feature may
result in the phenomenon known as hidden caries lesion
(. Fig. 3.17a–c) [12]. Externally, the structure of the enamel is
kept intact, or sometimes there is a darkened aspect on the
groove, while internally the dentin can be completely com-
promised and the enamel undermined. Sometimes those
patients report pain when chewing and when consuming cold
or sweet food. The frequent presence of fluoride in the oral
cavity, increasing the resistance of the enamel against demin-
eralization, is regarded as one of the factors that may propiti-
ate the occurrence of hidden caries. In the past, before the
intense use of fluorides, the incidence of the hidden lesions
was lower, since the demineralized enamel fractured more
likely and exposed the cavity. However, the nowadays use of
fluorides is effective to keep the enamel around the grooves
 90 T. M. F. Caneppele et al.

a b

c d

e f

..      Fig. 3.14  a Groove types. (Adapted from Roberson et al. [84]); mandibular molar showing a pit at the end of the groove suggesting
b shallow and large groove; c narrow and deep groove; d bottle-­ the presence of a fissure; f existence of a direct connection between
shaped groove; e macroscopic aspect of the buccal surface on a the oral environment and dentin, representing a real fissure

and pits stable, thus keeping the dentin lesion hidden. Because can deposit and seal those areas (. Fig. 3.18a). This phenom-
 

of that, some authors describe the great number of hidden enon is called biological sealing. In . Fig. 3.18b, a transverse
 

lesions found nowadays as the “fluoride syndrome” [12].
Even though the hidden carious lesion can clinically
manifest as darkened grooves and pits on the occlusal sur-
faces, the caries disease by itself is not the only reason for this
darkened aspect in those areas. Because of the retentive char-
acteristics of this region, residues coming from the diet, dead
bacteria, calculus, and many other dark coloring substances
cut of a darkened groove shows the presence of deposits,
without any evidence of caries. Therefore, the mere presence
of a darkened groove should not be considered as a sign for
caries.
>> Merely the presence of a darkened groove should not
be considered as a sign for caries.
Cariology
91 3
3.6.2  esions at the Proximal and Cervical
L detectable lesions. The shape of the proximal white spot is
Third of Smooth Surfaces determined by the biofilm location between the marginal
gingiva and the contact area, resulting in a lesion of an elliptic
The establishment of the proximal contact points hinders the or “kidney” shape. The cervical margin of the lesion is formed
deposition of a bacterial biofilm exactly at this region. following the contour of the marginal gingiva (. Fig. 3.19a–  

However, below the contact area, the bacteria are protected
against removing oral forces, and together with a gingival
retraction, this place can favor the appearance of clinically
d). On the buccal and lingual surfaces, the deposit of bacte-
rial biofilm happens in the region below the height of contour
(crest of curvature), where the friction with the food bolus is
not capable to remove it, following the edge of the marginal
gingiva (. Fig. 3.20a–c). From the necessity of intervention

point of view, lesions of smooth surfaces should not be

treated in an invasive approach as long as they are not cavi-
tated. Those lesions may arrest if the bacterial biofilm is regu-
larly disorganized and eating habits are changed. On the
buccal and lingual surfaces, the direct vision allows an easy
decision, and it is only mandatory that the surface is perfectly
clean. However, at the proximal surfaces, the verification of
surface integrity is more difficult.

3.6.3 Lesions at the Root Surface

The retraction of the gingival margin is a consequence of an

inadequate oral hygiene and the loss of the periodontal inser-
..      Fig. 3.15  White spot lesion progressing at the side of the groove tion happening with age. As the gingival margin retracts, the

a b

c d

..      Fig. 3.16  Occlusal macro-morphology. a, b Irregular surface that favors the deposit of biofilm; c, d worn teeth impairing biofilm deposition
 92 T. M. F. Caneppele et al.

a b

..      Fig. 3.17  a–c Hidden carious lesion with a minimal superficial opening and large cavitation in dentin

a
b

..      Fig. 3.18  a Darkened grooves by deposit of pigments; b biological sealing inside the groove

enamel-dentin junction becomes exposed. This tooth region brownish extended areas, hard or softened, which can some-
is very irregular and represents the propitious area for bacte- times surround the entire root surface (. Fig.  3.5a). The
 

rial accumulation. Consequently, most of the root caries start
at this area [25]. Root exposure, especially in wide interprox-
imal spaces, favors the growth of an undisturbed, protected
bacterial biofilm. The root caries comprehends an ongoing
sequence of clinical manifestation, starting from minuscule
areas of slightly softened and discolored dentin up to yellow-­
lesions may or may not present a cavity. Besides the mutans
group streptococci and the lactobacilli, present in lesions at
other regions, the root carious lesion also may be colonized
with filamentary bacteria of the genus Actinomyces, which
secretions have a proteolytic effect. Patients with periodontal
disease often also suffer from root carious lesions.
Cariology
a b
c d
..      Fig. 3.19  Carious lesion aspect at the proximal surface. a White spot; b brownish spot; c, d cavity
Initial root carious lesions appear as a radiolucent zone
on the root cement. Traumatic brushing, e.g., horizontal
brushing of the teeth with great pressure or scraping of the
root surfaces, damages and removes the cement exposing the
dentin. Therefore, initiation of the carious lesion happens
directly in the dentin, which was exposed to the oral environ-
ment. In contraposition to the initial lesions at the enamel,
the root carious lesions, even at its initial development, can
present a softened surface pattern. This results from the
microorganism that penetrates through the surface zones of
the lesions and because of collagen fibers that are partially
exposed by demineralization. Due to the specific microbiota,
the dentin destruction spreads much faster than in enamel
(. Figs. 3.21a–c and 3.37c, d).
The root carious lesions can be classified as active or inac-
tive [73]. The active lesions are defined as an area that dem-
onstrates a yellowish or slightly brownish appearance, with
undefined borders. Mostly, this kind of lesion shows a visible
bacterial biofilm and presents a softened or leathery consis-
tency when probing with moderate pressure (. Fig.  3.22a).  
Inactive or arrested lesions present defined borders, with a
root surface with dark brown or black discoloration. When
probing with moderate pressure, this kind of lesion appears
smooth, bright, and hard (. Fig. 3.22b, c).
93 3
3.7 Caries Diagnosis
For a long-lasting and profound treatment of caries, it is
important to detect the respective etiological and determi-
nant factors in the patient and not only to treat lesions
that are already cavitated. The diagnosis of caries is not
the end point of treatment but a moment to start with
prognostic considerations and therapeutic decisions.
Many diagnostic methods are used, and they serve the
purpose to determine the presence of the disease and its
extension in a patient, allowing to choose the most suit-
able treatment alternative, to monitor the disease progres-
sion, to evaluate the efficacy of the treatment, and to
determine the presence of factors that may favor the
establishment and the progression of the caries. The main
objective when obtaining diagnostic information is to
improve the patient’s health, and not only to find symp-
toms and local conditions [50]. The sooner the activity of
the disease can be identified, the more favorable will be
the prognosis, with greater chances of the re-establish-
ment of the health without damage and sequela. Thus, a
precise diagnosis of the activity lesions is indispensable,
since this estimation will serve as an indicator for the pro-
gression of the disease allowing the adequate treatment.
 94 T. M. F. Caneppele et al.
a b
..      Fig. 3.20  Carious lesion on the buccal surface. a Opaque active lesions; b, c inactive shiny lesions with cavitation
An ideal diagnostic tool should be trustworthy and capa-
ble to detect carious lesion at an initial stage, able to differen-
tiate between reversible and irreversible lesions, and should
permit its documentation. If the aim of the diagnosis is the
early detection of the carious lesion, the clinician must detect
the demineralized areas on the enamel yet in the stage of
incipient white spot or at least before the lesions become a
cavity. If detected at this stage, lesions might be remineral-
ized or arrested, especially with the help of fluoride applica-
tions [90]. In addition, an ideal diagnostic method should
have accessible costs, guarantee the comfort of the patient,
and be fast and easy to use. It must also to be used in every
site of teeth with the same efficacy.
In recent times, knowledge of the total number of teeth
that presented carious lesions (prevalence), or the number
of new cases that happened during a defined period (inci-
dence), were regarded as the main factors to estimate the
caries activity of a patient. That approach was only focused
on the signs of the disease and not on the etiology [95]. The
caries disease does not start at the moment, when clinically
visible lesions appear, but much before that time point.
Therefore, the activity of the caries and its associated cario-
genic factors must be considered to avoid progression of
existing or onset of new lesions. For optimal prevention, a
broader evaluation of the patient’s conditions is necessary,
including the information about the patient’s diet, salivary
factors, and microbiota composition, thereby determining
if the patient has a high or a low caries risk [2, 71, 90, 95].
Laboratorial exams to determine the buffering capacity,
salivary flux, and the number of Streptococcus mutans and
Lactobacillus were improved so that they become simpler,
faster, and easier to be conducted in the daily practice.
However, the often high costs and the limited gain of pre-
cise information have turned those tests frequently inac-
ceptable [44]. Measurement of the stimulated saliva flow,
collecting saliva during 5  min, may reveal patients with
hyposalivation or xerostomia, which indicates the necessity
of taking greater care of the teeth, medical exams, and
intensifications of the preventive measures [57].
Additionally, evaluation of the pH and the buffering capac-
ity of the saliva may provide information about the caries
risk of a patient [58]. High or very high lactobacilli counts
are associated, in many cases, with the high frequency of
ingestion of sugar or even a great number of the open cari-
ous lesions [57]. The presence of high amount of
Streptococcus mutans in the saliva is related to the risk of
getting new lesions and could be a useful tool for motiva-
tion of the patient [4, 22, 41, 59, 70, 86]. However, general
recommendations for using of the bacterial counting tests
as a risk assessment tool cannot be justified yet due to lack
Cariology
a b
..      Fig. 3.21  a–c Root carious lesion at proximal surface with preservation of enamel and destruction of the adjacent dentin
of well-designed studies [82, 92]. During the clinical exam-
ination, high-risk patients very often present multiple pri-
mary or secondary carious lesions, multiple endodontic
treatments and/or the lost teeth, and restorations on smooth
surfaces or on the root, besides a precarious oral hygiene
and complete lack of information. In contrast, the typical
low-risk patient does not present primary or recurrent
lesions, does not have a lack of teeth due to extractions or
endodontic treatment caused by caries, and presents no or
little restored surfaces and an adequate oral hygiene, with
high or good degree of information.
Tip
High caries-risk patients very often present multiple
primary or secondary carious lesions, multiple
endodontic treatments and/or the lost teeth, and
restorations on smooth surfaces or on the root, besides a
precarious oral hygiene and complete lack of
information about prevention.
>> The caries disease does not start at the moment when
clinically visible lesions appear, but much before that
time point.
95 3
3.7.1  ethods for Detecting and Diagnosing
M
Dental Carious Lesion
The word diagnostic has a Greek origin (diagnostikós), and it
means “knowledge or determination of a disease by mean of
signals and symptoms.” Nowadays, diagnosis of the carious
aims to decide if a demineralization is present, to investigate
the depth of mineral loss and the presence of cavities, besides
to the information, whether the process is progressing on a
fast or slow speed or if it is arrested [75]. For a minimally
invasive dentistry approach and maximum preservation of
tooth structure, the earliest detection of the carious lesion is
required. When detected in its initial stages, the lesion pro-
gression can be stopped [6]. Precise diagnosis of non-­
cavitated lesions is extremely valuable, as an estimation of
caries activity, to detect circumstance that needs to be treated
with a more intensive preventive program [8].
Many methods can be used to determine the presence or
the absence of carious lesions. To analyze how precisely a
diagnostic method reflects reality, dichotomous analysis can
be performed (presence or absence of the disease), and the
results can be compared with another evaluation, called vali-
dation standard or “gold” standard. The diagnostic decisions
can be positive or negative for the absence of a lesion, and
depending on the real state, four types of results can be
obtained:
 96 T. M. F. Caneppele et al.
a b
..      Fig. 3.22  Carious lesion at the cervical region. a Active; b, c inactive
55 True positive decisions – The diagnostic method used
was positive for the presence of the lesion, and the
validation standard confirmed this result.
55 True negative decisions – The diagnostic method used
was negative for the presence of the lesion, and the
validation standard confirmed this result.
55 False-positive decisions – The diagnostic method used
was positive for the presence of the lesion, and the
validation standard did not confirm this result.
55 False-negative decisions – The diagnostic method used
was negative for the presence of the lesion, and the
validation standard did not confirm this result.
This way, sensitivity of a method, its capacity to diagnose
correctly cases in which the lesion really exists (true posi-
tive results), and the specificity of a method, its capacity to
correctly diagnose the cases where the lesion is absent
(true negative), can be defined. Ideally, a diagnostic
method must not be invasive and must give reliable and
repeatable results, with a high level of sensitivity and spec-
ificity. Unfortunately, none of the available methods pres-
ent a 100% precise result in relation to the existence or not
of lesions on all surfaces [75].
3.7.1.1  Anamnesis
Diagnosis of caries and caries risk starts already with the
anamnesis of the patient. The patient needs to be asked
about the existence of pain symptom in tooth, spontaneous
or provoked. Some patients report pain when consuming
cold or sweet food or drinks, or when they touch the tooth.
The temperature variation produced by the cold and varia-
tion of the osmotic concentration by the sugar provoke a
dentin fluid movement, which leads to hypersensitivity and
pain. Presence of pain to a simple touch of a tooth may be
signs of pulpal inflammatory process, which must be fur-
ther investigated.
3.7.1.2  Visual Examination
The visual examination is the simplest way to check for
abnormalities or diseases of dental structures. It is self-­
evident that a removal of the entire bacterial biofilm and/or
extrinsic stains should precede the examination. Cotton rolls
must be placed and the surface must be completely dried
with a blow of air. A good illumination of the operating field
is also fundamental. The teeth must be analyzed with a clini-
cal mirror of good quality, preferably to the ones with a
reflexive area on the surface of the mirror, also called first
Cariology
97 3

..      Fig. 3.23  Teeth with darkened grooves showing the absence of ..      Fig. 3.24  Teeth with discolored groove showing the presence of
lesions on the transversal section arrested and pigmented carious lesions in enamel, without cavitation

surface mirror (. Fig. 4.41a–c). All tooth surfaces should be

 

inspected. Plaque disclosing agents may help to determine

the presence and quantity of bacterial biofilm. The eruption
stage of teeth should also be evaluated, and presence of gin-
giva partially covering the occlusal surface of an erupting
tooth should be noted, since it can increase the retention of a
biofilm. After the tooth cleaning, cotton roll isolation, and
drying, the existence of dark groove and groove with white
spot lesions at the entrance has to be verified.
In . Fig.  3.23, a human tooth extracted with occlusal
 

dark-colored grooves is shown. After it was sectioned in two

parts, none of them present a carious lesion, showing that the
dark discoloration was only due to staining. In . Fig.  3.24, 

the darkened areas were associated with white spot lesions

that were arrested and then stained. Even though there was a
demineralization of the dentin, a cavity was not created, and
the lesion was arrested. In . Figs. 3.25 and 3.26, teeth with
 

some grooves only stained and other with cavities are shown.
This corroborates the before-mentioned fact that darkening
of grooves is not a good indicator for the presence of a cari-
ous lesion. A darkened groove can simply be a biological
sealing or an inactive white spot lesion, which was stained by
dyeing substances in the diet. However, it can also be related
with cavities and hidden carious lesions on dentin, which
aggravates the diagnosis.
Carious lesions are cavitated when the collapse of the
undermined enamel has happened. In those cases, diagnosis
is simple, and the coloration of the dentin should be ana-
lyzed, which may give a hint to the caries activity. A dentin
..      Figs. 3.25 and 3.26  Teeth with discolored groove showing the
lesion with light brown color and wet appearance indicates absence of lesions, on the transversal section in certain region of the
an active lesion (acute), while a darkened and dry dentin may central groove, and cavitated lesion at other sites
serve as an indicator for an inactive lesion or little activity
(chronic) (. Fig. 3.27a, b).
 

Diagnose is much more impaired for un-cavitated spots (. Fig. 3.29a, b). However, some studies showed that
 

lesions with an apparently intact enamel surface. An indi-
cator for the presence of a lesion in dentin is the presence of
opacity through the enamel adjacent to a darkened groove
(. Fig. 3.28). Another indicator for the presence of dentin
 
lesions are microcavities that may be associated with white
when microcavities are clinically detectable in grooves, in
fact, only 31–42.7% of real lesions exist in the underlying
dentin. In contrast, when the microcavities were associated
to the presence of adjacent white spots, dentin lesions
were existent in 78–91.2% of the cases. This means that the
 98 T. M. F. Caneppele et al.
a b
..      Fig. 3.27  Open occlusal carious lesions. a Acute carious lesion; b chronic carious lesion
..      Fig. 3.28  Presence of opacity under enamel
association of white spots and microcavities is a strong
indicator of the need of intervention on an occlusal lesion
[75]. The visual exam of the occlusal surface by itself has a
sensitivity of 62% and a specificity of 84% [61].
On the proximal surfaces, the visual exam can be effective
in the cases where the lesion has already considerably devel-
oped toward the marginal ridge. An alteration in color right
below the ridge can be observed. In more advanced lesions,
even a rupture of the ridge might appear (. Figs. 3.30a, b and
3.31a, b). All teeth must be also observed from the buccal and
lingual aspects, searching for any changes in color and trans-
lucency.
At root carious lesion on the buccal or lingual surfaces,
the visual exam must determine whether the lesion is active
or inactive. However, the main difficulty is found at proximal
surfaces, where there is no access to direct vision, and com-
plementary examinations are necessary.
3.7.1.3  Tactile Examination
In the past, it was recommended for diagnosing occlusal
lesions that a very sharp exploratory probe was moved
through the bottom of the grooves. Retention of the probe
should indicate carious lesions needed to be treated.
However, it was demonstrated that 30–60% of the pits and
grooves, where the instrument gets stuck, did not present
carious lesions. The instrument may get retained only
because of the occlusal anatomy, leading to a wrong diagno-
sis, as shown in . Fig. 3.32a–d. The probing can also cause
destruction of the surface zone of a white spot lesion,
thereby creating a cavity with bacterial invasion into the
lesion body [21, 24]. In addition, when probing all grooves,
cariogenic bacteria can be transferred from one place to
another, contamination sites which were previously free
from this kind of bacteria [21]. Some studies also demon-
strate that the use of probing is not more precise than the
visual examination by itself, to detect occlusal incipient
lesions, showing low sensitivity [61]. Therefore, the explor-
atory probe should only be used at open lesions to check the
consistency of the dentin tissue. Probing of intact surfaces
of root caries lesions with a sharp probe may create also
small cavities, thus reducing the chance of remineraliza-
tion. Therefore, a periodontal probe with a blunt tip must
be used, such as a WHO ball-ended probe, making possible
to feel the consistency of the tissue, without damaging the
surface. On the proximal surfaces, the tactile exam can be
performed with a dental floss. In case the dental floss comes
to rip when passing this region, a cavity with sharp edges
might be present in the region.
3.7.1.4  Radiographic Examination
The radiographic examination is the most important auxil-
iary tool to diagnose carious lesion, showing whether a cer-
tain loss of dental mineral is present or not. It presents the
advantages of being not invasive, allows the detection of hid-
den lesions, and is helpful to follow progression or regression
of lesions. However, it is not capable to detect lesions at early
stages, because the little mineral loss at this stage is not high
enough to be visible on a radiographic image [77]. In addi-
tion, it does not directly distinguish between presence and
absence of cavitation. However, the depth of the lesion as
depicted on a radiograph mostly correlates with the status of
the surface. That means, the deeper a lesion is on an X-ray,
the more probable a cavitation is present. Due to the overlap-
Cariology
99 3

a b

..      Fig. 3.29  a Presence of the micro-cavitation and opaque areas below the enamel (arrow); b carious tissue removed by cavity preparation

a b

..      Fig. 3.30  Clinical signs of a carious lesion at the proximal surfaces. a Darkened aspects under the marginal ridge; b breakage of the marginal
ridge

a b

..      Fig. 3.31  Clinical signs of a carious lesion at the proximal surfaces of anterior teeth. a Darkened aspect under the marginal ridge; b open
cavity

ping of images, there is a risk of a false-positive result, gener-
ating images of ambiguous interpretation.
With respect to occlusal surface lesions, the radiographic
examination is able to detect 33% of incipient carious lesions
in dentin and 100% of deep caries lesions. The occlusal
changes are observed on a radiography, when the demineral-
ization has histologically reached the medium third of the
dentin (2–3 mm beyond the DEJ). At this stage an invasive
treatment might be required [85]. In general, the time from
the onset of an occlusal lesion until reaching a radiographic
 100 T. M. F. Caneppele et al.

a b

c d

..      Fig. 3.32  Retention of the exploratory probe in the groove due to the occlusal anatomy. a Occlusal view; b retention of the probe;
c, d transversal cut of the area, where the probe got stuck, showing the absence of lesion

evidence in dentin can take from 3 to 9  years [66]. In
. Fig. 3.33a–d, radiographic images of lesions of the occlusal
 
surfaces are shown. Monitoring of existing lesions can be
conducted as an alternative to invasive treatments. In patients
studies, injection of a silicone impression material into the
proximal space is often done. After curing and removal, the
presence or absence of cavitation could be verified in the
impression (. Fig. 3.48a–i).

with high caries risk, radiographic examination might be Based on the radiographic image, the caries lesion on the
advisable to be performed every 1–2  years, whereas in proximal surface can be classified according to its depth in
patients with low risk, it can be performed every 2–4 years. one of six scores. For that, enamel is divided into two halves,
Indication to an invasive treatment has a direct relation while the dentin is divided in three thirds (. Fig. 3.34). When
 

with the presence of a cavitation, which is not accessible to
regular removal of biofilm with oral hygiene measures. A
cavitation often makes it impossible, at least at proximal
regions, to remove the bacterial biofilm, thus rendering con-
trol of the lesion impossible. In those cases, a restoration will
turn the previously cavitated surface into a smooth surface,
which could be adequately kept clean. Following these con-
siderations, only cavitated and not accessible lesions must be
restored. White spot lesion should be treated with preventive
measures. However, at the proximal surfaces being in contact
with adjacent teeth, the surface of a lesion could not be
directly checked. Thus, decision taking must be based on
indirect methods as radiographic examination. To get confir-
mation if a proximal lesion is cavitated or not, it might be
helpful to perform a tooth separation, using orthodontic
rubbers for 1–2 days. After this the teeth may be separated
enough to allow direct vision to the proximal surfaces. In
nothing is seen, the score E0 is applied. When the lesion is
located on outer half of the enamel, it is classified as E1, while
when reaching the inner half of the enamel, it is scored E2.
The lesions located on the outer third of dentin are D1, while
reaching the middle third of dentin, they scored as D2.
Finally, when located on the inner third of dentin, they
scored as D3 [9]. Studies tried to correlate the depth of the
lesion, according to the radiographic image, and the presence
of cavitation. They observed that E1 lesions had almost no
cavitation, while E2 was cavitated in only 10–19.3% of the
cases [3, 80]. However, 32% of D1 lesions were cavitated,
while 72% of lesions extending into the inner 2/3 of the den-
tin (D2 and D3) also showed cavitation [43]. In addition,
some studies observed that when the radiolucency reaches
the inner third of dentin (D3), cavitation was present in 100%
of the cases [3, 67, 80]. Taking this into consideration, the
depth of a carious lesion on a radiographic image allows to
Cariology
a b
c d
..      Fig. 3.33  Radiographic images suggestive of carious lesions at the occlusal surfaces (arrows)
E1 E2
D1
D2
D3
..      Fig. 3.34  Classification of caries lesions according its depth. The
enamel is divided into two halves (E1 and E2), while the dentin is
divided in three thirds (D1, D2, D3)
estimate the cavitation risk, selecting between an invasive or
noninvasive intervention. Therefore, invasive restorative
treatments are not recommended until radiolucency has
reached dentin. In . Fig. 3.35a–e, examples of X-rays of vari-
 
ous situations are given. It should however be noted that the
radiographic examination of the proximal surfaces has high
specificity (95%) but only a moderate sensitivity (59%) [40].
101 3
It has to be noticed that lesions visible on a radiography
have more deeply progressed histologically. . Figure  3.36
presents a relation between the histological, radiographic,
and clinical aspects of a carious lesion at proximal surfaces.
In summary, when the carious lesion in enamel has histo-
logically reached at least half of the thickness of the enamel,
it is not visible clinically nor radiographically. Only when it
has reached more than half of the thickness of the enamel
histologically, it will appear as a radiolucent area in the outer
half of the enamel and clinically as a white spot. Only the
lesion that is radiographically already in dentin shows asso-
ciation to clinical or histological presence of a cavitation.
The radiographic examination is also valuable, in cases,
in which a lesion is hidden inside a periodontal pocket. Those
lesions present a very fast progression, and the patients
should be monitored radiographically more often than
patients with a low caries risk. In . Fig. 3.37a–d, X-rays with
radiolucent areas suggesting carious lesions at root surfaces
are depicted.
Nowadays, besides the radiographic films, sensors are
available that transfer the information of the image directly
to a personal computer. The advantage of digital radiogra-
phies is the possibility to process the image by a software,
adjusting the contrast and brightness, allowing a better
observation of the details, and performing more precise diag-
nosis [90]. There is also a possibility of using a computer-­
 102 T. M. F. Caneppele et al.

a b

c d

..      Fig. 3.35  Radiolucent images of proximal surfaces of posterior teeth. a Lesion on the outer half of the enamel, E1; b inner half of the enamel,
E2; c outer third of the dentin, D1; d middle third of the dentin, D2; e inner third of dentin, D3

aided detection tool, which is a software analyzing tooth
density and demineralization patterns for interproximal car-
ies (Logicon Caries Detector, Carestream Dental, Atlanta,
GA, USA). It extracts characteristics of the images from the
digital radiography and correlates it with a database of known
lesions, allowing to obtain more information from digital
radiography than with the naked eye. This software analyzes
shades of gray and is capable to localize and classify proximal
carious lesions, indicating the depth of the lesions [35]. The
image shows superimposing lines representing the borders of
the lesion over the image from the digital radiography,
besides graphics indicating changes of mineral density and
the probability of the presence of a carious lesion [32, 93]. A
study showed a sensitivity of 90.5% and specificity of 88.3%
Cariology
103 3
on the occlusal surface. However, this could lead to
HISTOPAHOLOGY ­ambiguous results, due to the specific morphology of this
region. Nevertheless, FOTI can be an auxiliary to the visual
exam to detect extensive hidden lesion in dentin [65, 75, 94].
Transillumination can also be used at anterior teeth to verify
NAKED EYE
the presence and the extension of composite restorations and
recurrent caries at the gingival margins. The transillumina-
tion method presents the advantage of not being invasive,
being simple and comfortable for the patients, and not
requiring radiation, being very valuable when a radiography
is not possible to be performed.
An innovation of FOTI method was the introduction of
PROBE computer-assisted image analysis of the transilluminated
WHITE SPOT
area, called digital imaging fiber-optic transillumination
CAVITY NAKED EYE
(DIFOTI, Electro-Optical Science, Irvington, NY, USA). For
that, the light from a probe is placed on one side of a tooth,
..      Fig. 3.36  Schematic drawing of the histological stages of a carious and the image in the non-illuminated opposite side is cap-
lesion correlating with the radiographic and clinical examination. tured by a camera and then analyzed by a software. This
Histological aspect of the lesion is always bigger than the clinical and
method has the potential to detect initial lesion and to evalu-
radiographic. (Adapted from Darling [18])
ate its progression, besides the possibility of image documen-
tation [97]. Under in vitro conditions, the diagnostic accuracy
when the software was used [35]. The author highlighted that of DIFOTI in detecting early approximal enamel lesions is
the software use promoted 20.2% of improvement on the greater than that of film and digital radiography, while the
sensitivity, in relation to when it was not employed [35]. potential for detecting lesions in dentin is similar for all three
methods [10].
3.7.1.5  Fiber-Optic Transillumination While the FOTI and DIFOTI use visible light, the pos-
The principle of the fiber-optic transillumination (FOTI) is sibility of using near-infrared light was also investigated
based on the fact that the teeth present different light trans- [34]. It was observed that longer wavelengths showed lower
mission indexes that may vary accordingly to its state of light scattering inside the tooth structure, being able to
healthiness, the presence or not of carious lesions, calculus, penetrate more deeply and produce a higher contrast
and restorative materials. Taking into account that a carious between the caries and the sound hard tissue [38, 51]. Thus,
lesion presents a lower light transmission index than the the near-infrared light transillumination (NILT) method
intact structure, an area affected by caries will be seen, when was created, and a new camera was developed, named
transilluminated, as a dark shadow that follows the external DIAGNOcam (KaVo, Biberach, Germany). The camera has
contour of the lesion [75]. With this examination tool, dental two light sources, using a wavelength of 780 nm, which are
calculus appears as a dark area involving the cervical third of placed buccally and lingually to the tooth to be examined,
the tooth. For adequate use of FOTI, teeth should be clean illuminating the crown from cervical to occlusal and not
and the light of the dental unit must be turned off. A light-­ directly into the interproximal space. A digital video cam-
emitting device with an optical fiber probe tip is used, with era is located above the occlusal surface and shows the
interchangeable tips of various diameters, or even a low-level scene live on the screen, in monochromatic grayscale, being
laser device emitting visible red light. possible to capture different stages of interproximal enamel
For the detection of the proximal lesion in anterior teeth, and dentin lesions and cracks, which are clearly visibly as
the probe tip must be applied on the lingual aspect, and the darker shadows (. Fig. 3.39). Studies showed a sensitivity of
 

alteration of the light transmission is observed on the labial 72.73–99.2% for lesion on DEJ [56, 98] DIAGNOcam is
side, or vice versa (. Fig. 3.38a, b). On the proximal areas of more capable of detecting initial proximal lesions than
 

posterior teeth, a small probe tip with 0.5  cm in diameter digital radiography and also has a higher sensitivity for
must be used to get information of the proximal tooth sur- dentin lesions [60].
face (. Fig. 3.38c, d). The tooth must be dry and the probe tip
 

be positioned below the proximal contact point, touching the 3.7.1.6  Electrical Conductance Measurements
gingiva from buccal or lingual sides. The changes in light This method is based on the principle that the electrical con-
transmission can be observed from the occlusal aspect, on ductance of the enamel is directly related to the degree of the
the marginal ridge. If a lesion is present, a darkened shadow porosity of the tissue. In principle, intact enamel is a good
will appear. This method diagnoses most of the proximal electrical insulator. During development of a carious lesion,
carious lesions in dentin. For the occlusal surface lesions, a mineral loss results in an increase of the porosities that, in
probe tip of 2 mm in diameter must be positioned next to the general, are filled with water and saliva ions. With the
margin of the gingiva on the buccal or lingual surface. The increase of the size of the pores, a network of interconnected
changes on the light transmission will be visible as shadows water-filled paths allows the passage of electrical current,
 104 T. M. F. Caneppele et al.

a b

c d

..      Fig. 3.37  Radiographic images associated with carious lesion on the root surfaces

reducing the insulating characteristic of the dental enamel. (3 μA) (. Fig. 3.40a, b). A study showed a sensitivity of 61%
 

Therefore, the greater the demineralization degree of the
enamel, the greater the electrical conductivity is [45]. The
device indicates the dental structural integrity through visual
and sound signals. It presents an electrode that is placed on
the dental surface and a handpiece, which is given to the
patient to hold, closing the electrical circuit of low intensity
and specificity of 86% for the diagnosis of enamel lesions on
the occlusal surfaces and sensitivity and specificity values
both of 76% for lesions in dentin [83]. Examples available on
the market are the Electronic Caries Monitor III (ECM III;
LODE, Groningen, The Netherlands) and the CarieScan
(CarieScan Limited, Dundee, Scotland).
Cariology
a b
c d
..      Fig. 3.38  Transillumination of a carious lesion. a, b Interproximal area of anterior teeth; c, d interproximal area of posterior teeth
..      Fig. 3.39  Transillumination of caries lesion on the proximal surface
(arrow) using DIAGNOcam (KaVo). (Image kindly provided by Dr. Pune
Nina Paqué (Zurich University – Switzerland))
3.7.1.7  Fluorescence Measurements
This method is based on the principle of fluorescence of
chromophores naturally incorporated in the mineralized
dental hard tissues or originating from bacteria. When those
chromophores, e.g., porphyrin or porphyrin derivatives, are
stimulated by light with specific wavelengths, they absorb
105 3
incident light and emit a light with another color, called fluo-
rescence.
For the principle of QLF (quantitative light-induced fluo-
rescence), it is important to notice that tooth fluorescence is
caused by the presence of the chromophores inside enamel
and dentin. When a sound tooth is irradiated with blue light,
the chromophores inside the dentin are excited, shining with
green dentin back-illumination. Due to the carious process,
the enamel is getting more porous, leading to scattering of the
dentin back-illumination in the enamel. Thus, the illumina-
tion is reduced in the area of the white spot lesion, providing a
“dark” reflection of the tooth at this site. The reflected light is
captured by a camera and analyzed by software that quantifies
the mineral loss (Inspektor Dental Care, Amsterdam, The
Netherlands). . Figure 3.41a, b shows an extraoral camera for
obtaining images of whole arcs of teeth (e.g., frontal, sides,
occlusal, and lingual) and an intraoral QLF camera for zoom-
ing in on specific element surfaces. The dental fluorescence
information can be stored in a computer and used for moni-
toring of initial lesions [5]. As mentioned, the incipient lesions
appear as dark spots, while more extended lesions (. Fig. 3.41d)  
and the biofilm (. Fig.  3.41f) appear in red, indicating the
presence of bacteria. This can easily be shown to the patient,
increasing the motivation for preventive daily practices [90].
The DIAGNOdent device (KaVo, Germany) works with a
different principle. It irradiates the tooth with red light at
 106 T. M. F. Caneppele et al.

655 nm coming from a diode laser. When the probe is directed direct correlation exists between the measured value and the
to a tooth surface, it induces fluorescence from chromophores, size of the lesion (. Fig.  3.42a) [28, 75]. It however shows
 

which can be captured and measured. The results are pre- some problems in the detection of lesions when organic, fluo-
sented on an electronic screen with values from 0 to 99. The rescent residues in the grooves and pits are present, giving a
lower the mineral content of the structure, the more chromo- false-positive result. Therefore, prophylaxis with a sodium
phores are incorporated and the greater the fluorescence is. A bicarbonate abrasive blast or bristle brush with pumice should
3
a b

..      Fig. 3.40  Device for caries detection using electrical conductance measurement (CarieScan)

a b

c d

..      Fig. 3.41  Quantitative light-induced fluorescence. a Extraoral QLF proximal lesions (arrows); d under blue light, the red fluorescence of
camera for obtaining images of whole arcs of teeth (Qraycam, the caries lesion (arrows) helps the diagnosis; e image of the lower arch
Inspektor Research Systems); b intraoral QLF camera (Qraypen, under natural light (the biofilm is not visible); f red fluorescence of the
Inspektor Research Systems); c image under natural light showing biofilm in molars and tongue under the blue light
Cariology
e f
..      Fig. 3.41 (continued)
a b
..      Fig. 3.42  Device to quantification of the induced fluorescence by laser. a DIAGNOdent; b The Canary System
be performed before the reading, to remove the residues of
organic material. For the use of this device, the surface to be
evaluated needs to be cleaned and dried. It has a sensitivity to
detect lesions in enamel on the occlusal surface of 79% and a
specificity of 74% [62]. It is not adequate for diagnosis of
recurrent caries next to restorative materials, and it is not
capable to differentiate active from inactive lesions [90].
The Canary System (Quantum Dental Technologies,
Toronto, Canada) uses a low-power pulsed laser light, which
is converted to heat to detect caries lesions (. Fig.  3.42b).
 
Usually, caries modifies the thermal properties and lumines-
cence of teeth. As a lesion grows, a corresponding change of
those parameters appear. When the light from The Canary
System is absorbed, these two phenomena are observed,
namely, the occurrence of fluorescence (luminescence) and
the release of heat (photothermal effect). The reflected heat
from a demineralized caries lesion site is increased, and the
fluorescence signal of a caries-affected tooth is decreased [1,
49]. The temperature rise is only 1–2 °C, and it does not cause
harm on the tooth. A study showed a sensitivity of 93.3% and
specificity of 82.5 for proximal lesions [56]. However, at the
107 3
moment there is a lack of independent studies for giving a
final judgment of the system.
A new generation of intraoral cameras came to the mar-
ket with multiple functions. They can be used as regular
intraoral cameras, with illumination provided by white LEDs,
or as special diagnostic tools when the illumination is pro-
vided by colored LEDs, capable to induce tooth fluorescence.
They also offer some software to analyze the collected images
and help the clinician with the treatment decision. One
example is Soprolife (Acteon, La Ciotat, France), an intraoral
camera that has blue LEDs capable to induce the autofluores-
cence, helping to identify caries-affected areas. The software
can work on the image, and the caries lesions are detected as
red color, while the surrounding tissue is displayed in black
and white. Another example is VistaCam iX (Durr Dental,
Bietigheim-Bissingen, Germany), which has interchangeable
heads intended for specific uses [60]. The “Proof ” head emits
violet light (405  nm) that stimulates bacterial metabolites,
causing them to glow red. The healthy enamel can be identi-
fied by green fluorescence. A software shows caries via a color
scale and numerical values (. Fig. 3.43).
 108 T. M. F. Caneppele et al.
a b
c d
..      Fig. 3.43  Intraoral camera inducing the tooth’s autofluorescence.
a View of the occlusal surface of a caries-affected tooth under natural
light; b scheme showing the occlusal surface being illuminated by
violet light, causing red fluorescence of the caries lesion. (Picture kindly
3.7.1.8  Reflection and Refraction
Measurement
The technology for measurement of the reflection and the
refraction of the tooth using LED light source (Midwest
Caries I.D., Dentsply Professional, York, PA, USA) has been
developed to detect caries lesions. The functioning of the
device is based on the fact that the whole enamel, due to the
layering of adjacent prisms, presents a translucent crystalline
nature, which allows light to pass through it. When there is a
demineralization, the crystalline structure is degraded, nar-
rowing the prisms and leaving spaces between them. As a
result of that, carious enamel is less translucent than sound
enamel. To detect a carious lesion, the device emits a light
that comes from an LED and penetrates through the enamel.
It uses three separated optic fibers inside the probe, the first
emits green light, the second emits red light, and the third is
a receptor fiber, to collect the light reflected by the tooth. If
the enamel is sound, the light is absorbed by the tooth and
the green light remains turned on. If a demineralization is
present, the light will be reflected, refracted, or spread. The
receptor fiber will capture this light, and the green light will
be turned off, while the red one will be turned on. At the
provided by Dürr Dental SE, Germany); c image obtained by VistaCam
(Dürr Dental) showing red glowing on the caries-affected area. d Image
analyzed by software, converting the fluorescent emission to different
colors according to the caries lesion depth
same time, a sound signal will be emitted, alerting the user
that the structure has changed (. Fig. 3.44). This method has
shown its capability to diagnose 92% of the occlusal lesions
and 80% of the proximal lesions [90]. For the detection of the
proximal lesions, the probe needs to be directed parallel to
the long axis of the tooth over the marginal ridge.
The same VistaCam iX (Durr Dental), previously dis-
cussed for fluorescence evaluation, has also a “Proxi” inter-
changeable head intended for detection of proximal caries by
reflection of infrared light (λ = 850 nm) (. Fig. 3.45a). That
wavelength makes healthy enamel appear translucent, while
caries lesions, by reflecting more waves, create a light opaque
appearance on the image (. Fig. 3.45b) [47].
3.7.1.9  Image Magnification Method
It seems obvious that magnification of the image sizes of the
tooth structure helps to improve diagnosis and detection of
irregularities. Studies comparing caries detection and diag-
nosis performed by dentists with naked eyes, with the results
obtained using magnifications aids, showed better results for
the groups using the support of magnifications [31, 90]. The
videoscope method uses an intraoral camera to aid the diag-
Cariology
..      Fig. 3.44  Midwest Caries ID (Dentsply)
nostic process (. Fig. 3.46a, b). Its advantage is that it gener-
 
ates an image 5–10 times bigger than the naked eye, and that
is part of a computer system, which allows adjustment of
brightness and contrast of the image. Similar to the visual
exam with naked eyes, the tooth surface must be clean and
dry. Some studies demonstrated that this method increases
the sensitivity but it reduces the specificity. Other possibili-
ties to get magnified images are the use of operative micro-
scopes, or magnifying lenses and loupes (7 Fig. 4.57a, b).
 
3.7.1.10  Temporary Elective Tooth Separation
Due to the difficulty of diagnosing carious lesions at proximal
surfaces, the technique of the temporary elective tooth sepa-
ration can be a help, allowing direct visible access to the prox-
imal surface. It can be performed by the immediate or delayed
technique. The immediate technique uses mechanical separa-
tors or wooden wedges to separate the teeth (. Fig. 3.47a–c).
 
Initially a topical anesthesia is applied on the interdental gin-
109 3
Red indicator fiber
Green indicator fiber
Receptor fiber
gival papilla, and the separator is placed and slowly closed.
However, there is some discomfort, and if it is not done care-
fully, it can cause damage to the periodontal tissues.
The slow or delayed technique consists in using orth-
odontic rubber band separators (. Fig.  3.48). They can be
positioned by two dental tweezers or two pieces of dental
floss (. Fig. 3.49a–i). When it is placed, the rubber ring must
surround the proximal contact. It should stay in position for
24 h (incisors), 3 days (premolars), and up to 1 week (molars).
The space gained varies from 0.35 to 1 mm. After this period,
there is a direct vision to the proximal surface allowing for
diagnosis of caries lesions or cavities (. Figs. 3.49f and 3.50b).
Also, a light silicone impression material can be injected into
the interproximal space, using an impression syringe with a
thin tip [87] (. Fig. 3.49g). The impression can be used for
checking presence of cavitation at this proximal area
(. Fig.  3.49i). After the rubber ring is removed, space will
close itself in about 48 h.
 110 T. M. F. Caneppele et al.
Besides the abovementioned supplementary tools for
detecting and diagnosing caries, there are others on the mar-
ket or in developmental state, which are not described in this
a
3
b
..      Fig. 3.45  Detection of caries lesion by reflection of infrared light.
a Scheme of light emission and reflection by the Proxi head of
VistaCam iX (Dürr Dental). b Image of the proximal surface. The healthy
enamel appears translucent, while the caries lesions, by reflecting more
waves, show a light opaque appearance (arrows). (Images kindly
provided by Dürr Dental SE, Germany)
a b
..      Fig. 3.46  a Intraoral camera; b camera in position to obtain an image
chapter. Generally, it should be noticed that there is no
instrument or device, which alone provides enough informa-
tion for a correct detection and diagnosis of caries. They
should be seen as supplementary devices to support the
visual and radiographic evaluation.
3.7.2 Secondary Carious Lesions
Patients may present carious lesion at the margins of exist-
ing restorations, generally called secondary carious lesions.
It is nowadays considered just another primary carious
lesion, located near to an existing restoration. They can be a
result of mistakes during the restorative procedures, as the
incorrect use of the matrix and wedge system or the incor-
rect placement of the restorative material into the cavity,
resulting in defective spaces at the interface, or the incor-
rect use of the adhesive system and light-curing, leading to
the formation of marginal gaps. One important reason for
the appearance of new secondary lesions is the fact that
only the carious lesion was treated, and not the disease of
the patient, thus leaving the caries risk on high level.
Therefore, new lesions will happen, and many of them will
begin on the interface between tooth and restorations,
because it is a propitious region for biofilm retention.
Clinical studies observed that in adults, secondary carious
lesions are eight times more frequent than the primary
ones, especially on those who are more than 50  years old
[11, 37]. Thus, secondary carious is the greatest reason for
the failure of restorations.
The difficulties on the diagnostics of the secondary lesions
are, in some aspects, similar to the one of the primary lesion.
As with primary lesions, there is a difficulty in differentiating
whether the lesion is active or inactive. There is no current
method providing an insight into the activity of secondary
lesions. Wall lesions are secondary carious lesions, which
occur at the interface between the restorative material and
the cavity wall. The color next to the amalgam restoration
represents a problem for proper diagnosis, since the gray or
bluish appearance can either be because of amalgam corro-
Cariology
a b
..      Fig. 3.47  Immediate dental separation. a Ivory (for anterior teeth) and Eliot (for posterior teeth) separators; b Ivory separator in position;
c Eliot separator in position
..      Fig. 3.48  Orthodontic rubber band separators with different
diameters
sion or due to secondary lesions [11]. On the other hand,
with composite restorations, the interfacial staining and the
presence of darkened areas under the enamel, next to the
margins, can be an indicator that marginal microleakage is
going on, and it can be associated to the presence of second-
ary lesions (. Fig.  3.51a–f). However, marginal staining of
 
composite restorations should not be considered as the key
111 3
indicator for existence of secondary caries. With time, all
adhesive interface soaks some water and saliva, accompanied
by discoloring agents. Thus, marginal staining must not be
mixed up with secondary caries.
Lesions at proximal surfaces represent 94% of second-
ary lesions at amalgam restorations and 62% at composite
restorations [69]. Due to superimpositions on a radiograph,
they cannot in all cases be detected on X-rays [29].
Therefore, the radiography must be used in conjunction
with a meticulous clinical examination, including probing
of the margins, to determine if the lesion has or has not a
cavity [11]. During probing, it must be verified if there is
lack or excess of restorative material on the margins, as well
the presence of the marginal ditches. For that, the probe
must be moved from the surface of the restoration toward
the tooth structure, and vice versa, crossing the interface. If
the probe gets stuck on both ways, there is a ditch on the
interface. If it gets stuck only toward the restoration, there is
an excess of restorative material, and it should be removed.
If it gets stuck only toward the tooth, there is a lack of mate-
rial. On those cases of lack of material and ditch, a restor-
ative intervention will only be necessary if there is an
exposure of dentin. In . Fig. 3.51a–f, clinical images of sec-
ondary carious lesions are shown, while in . Fig.  3.52a–d  
radiographic images are presented.
 112 T. M. F. Caneppele et al.

a b

c d

e f

..      Fig. 3.49  Delayed dental separation technique followed by rubber ring with dental floss straps; f separation was reached;
impression. a Radiography showing radiolucent image on the mesial g, h silicone injection into the space; i mold showing the presence of
surface; b darkened aspect under the marginal ridge; c–e placing the cavitation (arrow)

3.8 Treatment Decision in which demineralized areas may remineralize and in

For treatment decision after caries diagnoses, many factors
must be considered. Firstly the caries risk of the patient
must be taken into consideration and should be addressed.
In case of lesions imposing risk to pulpal vitality, a possible
approach might be to close cavities temporarily, e.g., with
glass ionomer cement, thus achieving an oral environment
stabilization (OES). This reduces the oral bacterial load and
allows for interventions to reduce the carious risk before
final treatment. The goal is to achieve an oral environment,
which no new lesions will appear in the future. In case of
unclear situations, which do not definitively indicate an
active cavitated carious lesion, which is inaccessible to
hygiene measures, or in patients with low caries risk, a more
restrictive and defensive attitude should be applied. Under
those circumstances the indication to perform restorative
procedures should be postponed and reevaluated after
monitoring. It should be considered that progression of ini-
tial carious lesion may take some years before approaching
inner dentin areas [68].
Cariology
113 3

g h

..      Fig. 3.49 (continued)

a b

..      Fig. 3.50  a, b Tooth separation that allowed enough space to have a direct view to the cavity, without the need of impression

Tip >> Individuals present individual caries risk, which should

55 Consider the caries risk and activity before treat-
ment decision.
55 Use different methods for caries diagnosis to prove
presence or absence of cavitated caries lesions.
55 Establish individual regimes to maintain intraoral
conditions favoring oral health.
be considered and addressed by dentists.
3.9 ICDAS
The International Caries Detection and Assessment System
(ICDAS) is a scoring system for clinical detection and assess-
ment of dental caries lesion. Its aim is to obtain quality infor-
 114 T. M. F. Caneppele et al.

a b

c d

e f

..      Fig. 3.51  Secondary carious lesions. a, b Lesion at the interface buccal enamel and more evident on the occlusal view; e caries lesion
with the buccal cavosurface margin being probed; c, d observation of a (red arrow) detected after removal of the restoration on the distal
secondary lesion on the buccal wall, seen through transparency on the surface of the canine; f staining of the tooth-restoration interface

mation for an appropriate diagnosis, prognosis of caries, and
clinical management. Based on the measurement of surface
characteristic of the lesion, mainly by visual analysis, the
potential histological depth and activity of the lesion is con-
sidered, helping the decision-making process about the most
The system has two categories, which are coronal primary
caries and root caries. For the coronal caries, the lesion is
identified by two digits: the first is related to the level of pre-
vious dental treatments performed on the tooth and receives
codes ranging from 0 to 9 (. Table 3.1), and the second digit

recommended treatment. The system has two criteria, which is used to identify the lesion extension and receives codes
are the detection and the activity of the lesions. The original ranging from 0 to 6 (. Table 3.2) [20, 81].
 

ICDAS was created in 2003, but several improvements were However, the detailed description of the lesion extension
performed, and the second version became available in 2005, is done separately, based on the place where the lesion is
named ICDAS II [20, 81, 88, 99]. located and the presence of previous restorations, since the
Cariology
115 3

a b

c d

..      Fig. 3.52  a–d Radiographic images of a secondary carious lesions at the gingival walls

visual signs associated with each code can vary, resulting in
four headings:
55 Pits and fissures
55 Smooth surface with contact – mesial or distal surfaces
that have contact with adjacent teeth and require visual
inspection from the occlusal, buccal, and lingual
directions
55 Free smooth surfaces – buccal and lingual surfaces and
mesial and distal surfaces that have no adjacent teeth
and allow direct examination of buccal, lingual, mesial,
and distal surfaces
55 CARS – caries associated with restorations and
sealants
 116 T. M. F. Caneppele et al.
..      Table 3.1  First digit of the ICDAS II coding system, related
to the previous dental intervention [20, 88, 99]
Code Previous intervention
0 Surface not restored or sealed
3 1 Partial sealant
2 Full sealant
3 Tooth colored restoration
4 Amalgam restoration
5 Stainless steel crown
6 Porcelain or gold or PFM crown or veneer
7 Lost or broken restoration
8 Temporary restoration
96 Tooth surface cannot be examined
97 Tooth missing because of caries
98 Tooth missing for reasons other than caries
99 Unerupted
..      Table 3.2  Second digit of the ICDAS II coding system,
related to the lesion extension [20, 88, 99]
Code Lesion extension
0 Sound surface
1 First visual change in enamel
2 Distinct visual change in enamel
3 Localized enamel breakdown (without clinical visual
signs of dentinal involvement)
4 Underlying dark shadow from dentin
5 Distinct cavity with visible dentin
6 Extensive distinct cavity with visible dentin
. Tables 3.3, 3.4, 3.5, and 3.6 describes the application of the
 
codes for each situation of coronal primary caries. For the
second categories of ICDAS II, related to the root caries, the
system is divided into two groups, depending if the surface
has or no restoration. Despite that, the codes are basically the
same (. Table 3.7) [20, 81, 88].
 
The ICDAS II system also assesses the caries activity to
determine the caries risk status and the prognosis of the
treatment. That allows to identify patients who may require
..      Table 3.3  Description of the ICDAS II codes for pit and
fissures [20, 88, 99]
Code Description
0 There should be no change in enamel translu-
cency after 5 seconds of air-drying
1 When seen wet there is no evidence of any
change in color. After 5 seconds of air-drying, a
carious opacity or discoloration is visible that is
not consistent with the clinical appearance of
sound enamel and is limited to the confines of
the pit and fissure area
2 When wet there is a carious opacity and/or brown
carious discoloration which is wider than fissure
(the lesion is still visible when dry)
3 When wet there is a carious opacity and/or
brown carious discoloration which is wider than
fissure. Once dried for approximately 5 seconds,
there is carious loss of tooth structure at the
entrance to, or within, the pit or fissure/fossa,
but dentin is not visible in the walls or base of
the discontinuity
4 This lesion appears as a shadow of discolored
dentin visible through an apparently intact
enamel surface, which may or may not show
signs of localized breakdown. The darkened area
may appear as gray, blue, or brown in color and is
seen more easily when the tooth is wet
5 Cavitation in opaque or discolored enamel
exposing the dentin beneath
6 The cavity is deep and wide and dentin is clearly
visible
intensive preventive intervention. . Table  3.8 shows the
activity criteria for coronal caries. For root caries, the color,
perception on probing, appearance, texture, cavitation, and
location can help the determination of the lesion activity, as
described on . Table 3.9 [20, 81].
In addition to the detection and assessment system, the
International Caries Classification and Management System
(ICCMS) was proposed for handling the patients with regard
to caries prevention, aiming to promote health and preserva-
tion of tooth structure. Besides the assessment of the caries
process, it proposes a risk-adjusted preventive care, control
of non-cavitated lesions, and conservative restoration of the
cavitated ones. The key elements of ICCMS are classification
of the lesions according to their severity and activity, man-
agement of preventive care plan and risk status, and risk-­
based recall interval including monitoring and review,
creating an optimal personalized caries management plan for
optimal long-term health outcomes [81].
Cariology
117 3

..      Table 3.4  Description of the ICDAS II codes for smooth surface with contact [20, 88, 99]

Code Description

0 There should be no change in enamel translucency after 5 seconds of air-drying

1 When seen wet there is no evidence of any change in color. After air-drying a carious opacity is visible that is not consistent
with the clinical appearance of sound enamel and is seen from the buccal or lingual surface

2 When wet there is a carious opacity and/or brown carious discoloration and the lesion is still visible when dry. Lesion may
be seen when viewed from the buccal or lingual direction. When viewed from the occlusal direction, this opacity may be
seen as a shadow confined to enamel, seen through the marginal ridge

3 Once dried for approximately 5 seconds, there is distinct loss of enamel integrity viewed from the buccal or lingual
direction

4 This lesion appears as a shadow of discolored dentin visible through an apparently intact marginal ridge, buccal or lingual
walls of enamel. This shadow may appear as gray, blue, or brown in color and is often seen more easily when tooth is wet

5 Cavitation in opaque or discolored enamel with exposed dentin

6 Obvious loss of tooth structure; extensive cavity may be deep or wide and dentin is clearly visible on both walls and at the
base. The marginal ridge may or may not be present

..      Table 3.5  Description of the ICDAS II codes for free smooth surfaces [20, 88, 99]

Code Description

0 There should be no change in enamel translucency after 5 seconds of air-drying

1 When seen wet there is no evidence of any change in color. After air-drying a carious opacity is visible that is not consistent
with the clinical appearance of sound enamel

2 When wet there is a carious opacity and/or brown carious discoloration and the lesion is still visible when dry. The lesion is
located in close proximity of the gingival margin

3 Once dried for 5 seconds, there is carious loss of surface integrity without visible dentin

4 This lesion appears as a shadow of discolored dentin, which may or may not show signs of localized breakdown. This
shadow may appear as gray, blue, or brown in color and is often seen more easily when tooth is wet

5 Cavitation in opaque or discolored enamel with exposed dentin

6 Obvious loss of tooth structure; extensive cavity may be deep or wide and dentin is clearly visible on both walls and at the
base. An extensive cavity involves at least half of a tooth surface or possibly reaching the pulp

..      Table 3.6  Description of the ICDAS II codes for CARS. The details are related to the lesions adjacent to a restoration/sealant margin [20,
88, 99]

Code Description

0 A sound tooth surface adjacent to a restoration/sealant margin. There should be no evidence of caries

1 When seen wet there is no evidence of any change in color. After air-drying a carious opacity or discoloration is visible that
is not consistent with the clinical appearance of sound enamel.

2 If the restoration margin is placed on enamel, tooth must be viewed wet. When wet there is an opacity consistent with
demineralization that is not consistent with the clinical appearance of sound enamel. The lesion is still visible when dry. If
the restoration margin is placed on dentin, discoloration can be seen that is not consistent with the clinical appearance of
sound dentin

3 Cavitation at the margin of the restoration/sealant less than 0.5 mm, in addition to either an opacity or discoloration
consistent with demineralization

(continued)
 118 T. M. F. Caneppele et al.

..      Table 3.6 (continued)

Code Description

4 Tooth has a shadow of discolored dentin which is visible through an apparently intact enamel surface or with localized
breakdown in enamel but no visible dentin. This shadow may appear as gray, blue, orange, or brown in color and is often
3 seen more easily when tooth is wet

5 Distinct cavity adjacent to restoration/sealant

6 Extensive distinct cavity with visible dentin

..      Table 3.7  Description of the ICDAS II codes for root caries [20, 88, 99]

Code Characteristic of the lesion

E If the root surface cannot be visualized directly, then it is excluded

0 The root surface does not exhibit any unusual discoloration that distinguishes it from the surrounding root areas nor
does it exhibit a surface defect at the CEJ or root surface. The root surface has a natural anatomical contour

1 There is a demarcated area on the root surface or at the CEJ that is discolored, but there is no cavitation (loss of
anatomical contour <0.5 mm) present

2 There is a demarcated area on the root surface or at the CEJ discolored, and there is cavitation (loss of anatomical
contour≥0.5 mm) present

..      Table 3.8  Activity criteria for coronal primary caries according to ICDAS II [20, 88, 99]

ISDAS code Characteristics of the lesion

Active lesion Inactive lesion

1, 2, or 3 Surface of enamel is whitish/yellowish opaque with loss of
luster; feels rough when the tip of the probe is moved
Lesion is in a plaque stagnation area, i.e., pits and fissures, near
the gingival and approximal surface below the contact point
Surface of enamel is whitish, brownish, or black
Enamel may be shiny and feels hard and smooth
when the tip of the probe is moved
For smooth surfaces, caries lesion is typically
located at some distance from the gingival margin

4 Probably active

5 or 6 Cavity feels soft or leathery on gently probing the dentin Cavity may be shiny and feels hard on gently
probing the dentin

..      Table 3.9  Activity assessment criteria for root caries lesions according to ICDAS II [20, 88, 99]

Parameters Active lesion Inactive lesion

Color Yellowish or light brown Darkly stained

Perception on probing Soft or leathery Hard texture

Appearance White matte Shiny

Texture Rough surfaces Smooth surfaces

Cavitation Non-cavitated or cavitated Cavitated

Location Close adjacent to the crest of the gingival More distant from the gingival crest
Cariology
Conclusion
The chapter underlines the understanding of caries as a pro-
gressing disease, which could be stopped at early stages and
most often be prevented by adequate interventions. Caries is
a disease caused by acidogenic biofilm due to nutritional
imbalances. The enamel demineralization promotes the loss
of hydroxyapatite from the tooth structure and development
of lesions. Starting as subsurfacial and porous areas of
enamel, with whitish appearance, they can progress to cavita-
tion and result on complete destruction of the tooth struc-
ture. Therefore, the early diagnosis and preventive treatment
is recommended. The role of saliva and fluoride on caries
prevention must be understood by the clinicians and the car-
ies risk of each patient determined. The association of differ-
ent methods of diagnosis can help to detect the lesion,
arresting them whenever possible or allowing a conservative
restorative treatment to be performed.
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 123 4

Instruments and Equipments
Sergio Eduardo de Paiva Gonçalves, Cesar Rogério Pucci,
Carlos Rocha Gomes Torres, and Anuradha Prakki

4.1 Introduction – 125

4.2 Active Hand Instruments – 125

4.2.1 I nstrument Design – 126
4.2.2 Type of Instruments, According to the Shape of the Blade – 128
4.2.3 Instrument Formulas – 130
4.2.4 Sharpening of Hand Instruments – 131

4.3 Rotary Cutting Instruments – 132

4.3.1  andpieces – 132
H
4.3.2 Parts of the Rotary Instrument – 138
4.3.3 Types of Rotary Instruments – 139
4.3.4 Materials Used on the Fabrication of Rotary Instruments – 143
4.3.5 Basic Shape of Burs, Diamond Points, and Mounted Stones – 146
4.3.6 Factors Related to the Use of Rotary Instruments – 146
4.3.7 Safety Procedures – 147

4.4 Oscillatory Abrasive Instruments – 147

4.4.1  scillatory Handpieces – 148
O
4.4.2 Types of Diamond Points – 149

4.5 Complementary Instruments – 152

4.5.1  linical Mirror – 152
C
4.5.2 Tweezers and Forceps – 153
4.5.3 Exploratory Probe – 153
4.5.4 Mixing Spatula – 153
4.5.5 Instrument for Filling and Modeling – 154
4.5.6 Condensers – 154
4.5.7 Carvers – 155
4.5.8 Burnishers – 155
4.5.9 Intraoral Carriers – 155
4.5.10 Scissors – 156
4.5.11 Matrix Retainer – 156
4.5.12 Clamps, Clamp Forceps, and Rubber Dam Punch – 156
4.5.13 Pliers – 157
4.5.14 Dappen Dishes – 157
4.5.15 Carpule Syringe – 157

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_4
4.6 Vision Magnifiers – 157

4.7 Airborne-Particle Abrasion – 158

4.8 Laser – 158

4.8.1 E rbium Lasers – 161
4.8.2 Nd:YAG Laser – 163
4.8.3 Safety Procedures – 163

References – 165
Instruments and Equipments
Learning Objectives
The learning objectives of this chapter are related to the fol-
lowing topics:
55 An overview on the evolution of operative instruments
related to the techniques and materials.
55 The description, design, formula interpretation, and
clinical applicability of the available active hand
instruments.
55 To understand the shapes, types, and compositions of
different rotary instruments and the associated cutting
tips: burs, diamond points, and mounted stones.
55 The description of the two main oscillatory devices
available, sonic and ultrasonic, and the applicability and
technology involved with the fabrication of agglutinated
or deposited diamond points.
55 The description and clinical applicability of several
complementary dental instruments.
55 To understand the technology, clinical applicability, and
limitations of alternative methods for tooth preparation
such as air abrasion and laser. For the later, distinction
between Er:YAG and Nd:YAG lasers is highlighted.
4.1 Introduction
The history of dentistry has followed concomitant to the his-
tory of medicine, where men have searched for a solution to
mitigate humanity’s greatest evil: the pain. The development
of instruments that allowed for interventions aiming for
reestablishing the health of individuals committed by some
illness has been noticed in archeological findings and artis-
tic representations (. Fig.  4.1a). Archeological evidence of
 
dental treatment dates as far back as 5000 years B.C., but
little is known about the methods and the equipment that
was used by then [4]. However, before the development of
anesthesia, the procedures represented on old paintings
seem true torture rituals, executed by barber surgeons as
part of the routine of the towns. Those picturesque scenes
were sensibly illustrated by great master painters that
reported the panic expressions of those submitted to the
interventions. Also, the surgical accessories, the applied
techniques, and the work conditions have been artistically
reported (. Fig. 4.1b–d) [4].
 
The fact that the dental enamel is the hardest tissue of all
biological systems represents a great obstacle for the proce-
dures performed on the tooth structure [5]. The instru-
ments that were mostly used until the nineteenth century
were the tooth extraction forceps, spoons to remove tartar,
and spatulas for cauterization of sores. Many hand instru-
ments were developed by the dentists themselves, in accor-
dance to their necessities. However, they were rough,
awkward, and did not follow a pattern. Professor Greene
Vardiman Black, considered to be the father of the modern
dentistry, was responsible for the development of many
hand instruments for dental purposes. Later, the develop-
ment of rotary instruments allowed a great advance on the
technique for tooth preparation while reducing the need to
125 4
use hand instruments. Nevertheless, in some specific situa-
tions, the hand instruments continue to represent the
instrument of choice for better results in complementation
to the rotary instruments [5].
The instruments used in operative dentistry, according to
their purpose, can be classified into active or complementary
[19]. The active instruments, also called excavators, cutters,
or principals, are the ones used to shape the preparation out-
line. They are capable of removing parts of the tooth struc-
ture by cutting or by abrasion. Active instruments can be
hand, rotary, or oscillatory. The hand instruments are the
ones in which the cutting action happens by the movement
of the dentist’s hand. The rotary instruments are the ones that
are attached to rotating engines or turbines, which can be a
blade bur or an abrasive point. The oscillatory instruments
are represented by diamond points that are attached to sonic
or ultrasonic devices that oscillate in contact with the tooth
causing abrasion. They also have a reciprocating action, per-
forming back-and-forth movements. The complementary
instruments (also called non-cutting or accessories) are the
ones used during clinical inspection and restorative proce-
dures. This chapter will also present alternative equipments
to perform tooth preparations such as air abrasion and laser
devices.
4.2 Active Hand Instruments
Active hand instruments or more commonly called hand
cutting instruments are used to cut, cleave, and create a flat
surface on the tooth structure or to complete the action of
rotary instruments during the tooth preparation. They can
be divided into excavators and chisels. The excavators are
used to remove carious tissue, while the chisels are primar-
ily used to cut the enamel. Before the rotary cutting instru-
ments were available, the dentist was capable of making
cavity preparations with a well-defined shape only with
hand instruments [25]. In his book published in 1908 [6],
Professor Black presented a group of 96 cutting instru-
ments, which could be condensed into an academic set of 44
instruments, or a more reduced one with 35 instruments. At
that time, adhesive dentistry and the high-speed air tur-
bines were not available. Since the restorative materials that
existed were limited to cohesive gold and silver amalgam,
the longevity of the restorations depended on the retention
and resistance obtained with the hand instruments [25].
Although with fundamental role, the use of hand cutting
instruments is very reduced nowadays, and in this book we
only recommend the use of three of them. In a specific situ-
ations, if only the drills are used to create a cavity prepara-
tion, an excessive quantity of a healthy tooth structure
would be removed to get adequate margins. In class II box
preparations, for instance, the use of burs on margins could
increase the risk of damaging the adjacent tooth structure.
The hand instruments allow this finishing to be performed
without damaging the adjacent tooth, as it is explained in
7 Chap. 10 [25].
 126 S. E. de Paiva Gonçalves et al.

a b

c d

..      Fig. 4.1  a Representation of instruments on archeological findings (Egypt, Kom Ombo temple, first century AD); b the dentist (Théodore
Rombouts); c the dentist surgeon (Peter Angilis); and d the campaign dentist (S. Cox)

For many years, the carbon steel was the primary material
used in the fabrication of hand instruments, because they HANDLE
BLADE SHANK
were harder and maintained sharpness better than stain-
less steel. However, the sterilization of carbon steel instru- a
ments in autoclave, the most recommended method
SINGLE-ENDED
currently, causes its darkening by corrosion and the forma-
tion of rust [23]. Stainless steel has become the material of b
choice for hand instruments, as they all need to be steril- DOUBLE-ENDED
ized in steam or dry heat between each patient and also
because the properties of the stainless steel have signifi-
cantly improved. There are hundreds of stainless steel for- ..      Fig. 4.2  Parts of the hand instruments (handle, shank, and blade).
mulations, all incorporating significant quantity of a Single-ended instrument; b double-ended instrument
chromium, some carbon, and iron. The chromium is
responsible for the resistance to corrosion and the bright- 4.2.1 Instrument Design
ness of the material, while the carbon is responsible for its
hardness [25]. To increase the durability of the cut, some Despite the application, the hand instrument is composed of
instruments may receive an active edge made of tungsten three parts, and they are the handle, the shank, and the blade
carbide (. Fig. 15.18a, b). Although it is harder, the carbide
 
(. Fig.  4.2a) [9, 25]. They can be single-ended (with one
 

is brittle and cannot be incorporated to all shapes of cut- blade) or double-ended (with blades on both sides)
ting edges [23]. During the manufacturing process, the (. Fig. 4.2a, b).
 

instrument receives thermal treatment known as temper-
ing, allowing adequate resistance and flexibility. For this
reason, hand cutting instruments must not be heated over
flames because the tempering and the essential properties
of the metal will be lost [23].
The blade or active part can present many shapes, charac-
terizing the type of cutting instrument. The bevel, an oblique
part on the blade’s edge, is essential because it determines the
efficiency of the cut [9]. The tip of the blade is called the pri-
mary cutting edge of the hand instrument, also known as the
Instruments and Equipments
127 4
working end (. Fig. 4.3). The thin sides of the blade can also
  of force avoiding rotation. . Figure 4.4c represents an instru-
 

present bevels; they cut tooth structure and are called sec- ment with three angles (triple-angle). The instruments that
ondary cutting edges. The blade also has two flat sides, and have two or more angulations are called contra-angled [5, 18,
the one that has the bevel angle at the borders is called the 25]. As the contra-angulation has the aim to compensate for
dorsum of the blade, while the opposite side is called the face the tendency of the instrument to rotate on the hand of the
(. Fig. 4.3). Therefore, the acute cutting angle of the blade is
  operator, it is also called the compensation angle [5, 23].
the junction of the face with the bevel [25]. Most of the hand
instruments are single-beveled, thus with one face and one
dorsum. There are, however, instruments with bevels on both a b c
sides, called bibeveled, used to prepare mechanical retention
in cavity preparations. These have a very limited application
today and will not be used on the preparations mentioned in
this book. For non-cutting instruments, the part correspond-
ing to the blade is called nib. The working surface or the end
of the nib is known as face.
The shank, intermediary, or neck connects the blade and
the handle. It can be straight or angulated so that the working
end of the blade is closer to the long axis of the instrument at
a distance of 2–3  mm (. Fig.  4.4a–c). Besides easing the
 

access of the blade to the cavity that is being prepared, it also

promotes the stability during the use of the instrument.
. Figure 4.4a represents the image of an unbalanced single-­
 

angled instrument (mon-angle), where the edge of the blade

is located farther from the center of the instrument. Its blade
must be relatively short and must be used with minimum
force because there is a tendency of the instrument to rotate.
. Figure 4.4b shows instrument with double angulation (bin-­
 

angle), in which the edge of the blade approaches the long

..      Fig. 4.4  Types of shank and its importance on the position of the
axis of the handle in approximately 2 mm. It allows balance primary cutting edge in relation to the long axis of the instrument.
to ease the control of the instrument during the application a Mon-angle; b bin-angle; c triple-angle

..      Fig. 4.3  Nomenclature of parts of the blades

 128 S. E. de Paiva Gonçalves et al.

The handle corresponds to the greatest part of the instru-
ment. Usually, it is straight, with a circular, hexagonal, or octag-
onal section, and knurled on all surfaces to facilitate the grasping
of the instrument (. Fig.  4.5a, b) [5]. There are also rubber-
 
padded handles to ease the grasp (. Fig. 4.5c, e). The standard
 
metallic instruments have a diameter of approximately 5–6 mm.
The necessary force to hold them, using a movement like twee-
zers with the fingers, favors the osteo-­muscular lesions such as
4 the carpal tunnel syndrome. Trying to give more comfort to the
4.2.2.1 Enamel Hatchets
The hatchets have the cutting edge of the blade directed in
the same plane that the long axis of the handle. The enamel
hatchets are a kind of chisel with just one bevel. The shank
can have one or more angles. It is always a double-ended
instrument, and on one end the face of the blade will be
turned to one of the sides and, on the other end, turned to the
other direction; therefore, one end cuts on the right and the
other on the left (. Fig. 4.6a, b). They are used on the finish-

dentist, the industries began to develop handles that are thicker, ing of the cavosurface angles of the buccal and lingual walls
with the diameter varying from 7.9 to 9.5 mm (. Fig. 4.5d, e). A
  of the proximal box and on the cavities for amalgam on pos-
drawback with this type of handles is that they take more space terior teeth (. Fig. 10.15a–d). The movement applied with
 

on the tray of the instruments [19, 25]. The series number, the the instrument is similar to the one applied on a hatchet to
formula of the instrument, and the manufacturer are registered cut wood (. Fig. 4.6b) [18, 23, 25].
 

on one of the surfaces, on the non-knurled spaces. The series

number indicates the position of the instrument on a specific 4.2.2.2 Hoes
collection, while the formula consists of a group of numbers The hoe excavator has the primary cutting edge of the blade
that identify the characteristics of the instrument. perpendicular to the long axis of the handle (. Fig. 4.7a, b).
 

The shank can have one or more angles. They are used for
planning cavity preparation walls similarly to a hoe for gar-
4.2.2  ype of Instruments, According
T dening [18, 23, 25]. The side of the bevel on the edge of the
to the Shape of the Blade blade determines the way of its movement during use
(. Fig. 4.7a – arrows).
 

Based on the shape of the blade, the hand cutting instru-

ments (excavators and chisels) can be of different types 4.2.2.3 Straight or Curved Chisels
according to the following description. Chisels present the primary cutting edge perpendicular to
the long axis of the handle, similar to the hoe. However, gen-
erally, they may not present an angle on the shank. When an
a angle is present, it is very small, around 12.5° (Wedelstaedt
design) (. Fig. 4.8) [6, 25].
 

b
4.2.2.4 Spoon Excavator
c It is also known as dentin spoon, because of its shape being
similar to the cutlery (. Fig. 4.9a, b). They present a curved
 

d blade and a cutting edge shaped as semicircle, which gives

the instrument an external convexity and an internal concav-
e ity (. Fig. 4.9b). The face of the blade is on the concave side.
 

Similar to the hatchet, the cutting edge of the blade is directed

..      Fig. 4.5  Types of handles of hand instruments. a Circular cross-
sectional handle (Mocar); b hexagonal cross-sectional handle (Duflex);
c rubber material-covered handle (Thompson); d thicker handle
(Hu-Friedy); e silicon handle (LM-dental)
in the same plane that the long axis of the handle. The spoons
are always double-ended instruments with the blade of the
instrument curved to the left in one end and to the right in
the other end [6, 25]. They can present an enlarged tip, on the

a b

..      Fig. 4.6  a Enamel hatchet; b wood hatchet

Instruments and Equipments
129 4

a b

..      Fig. 4.7  a Mon-angle hoes. The arrows correspond to the direction of use; b garden hoe

..      Fig. 4.8  Chisels (to the left the Wedelstaedt chisel and to the right
the straight chisel) ..      Fig. 4.9  a Dentin spoon of different shapes (1, Black; 2, Gillett; 3,
Darby-Perry); b oblique view showing the concave cutting side and the
convex side

shape of a drop or circle (. Fig.  4.9a). Spoons are used to

 

inspect the presence and consistency of dentin carious tissue, 4.2.2.5 Gingival Margin Trimmer
as well to remove it. They can also be used as auxiliaries on They are chisels similar to the enamel hatchets, except for
carving the amalgam restorations, shaping the developmen- the fact that the blade is curved and the primary cutting
tal grooves [18, 23]. edge has an additional angulation (. Fig. 4.10a – 1 and 2).
 
 130 S. E. de Paiva Gonçalves et al.
a
4
b
..      Fig. 4.10  Gingival marginal trimmers. a Lateral view of a trimmer
for a mesial box (1) and distal box (2) in comparison with an enamel
hatchet (3); b view from the cutting edge where it can be observed in
the direction of cut (red arrows). The bevels are pointed by the blue
arrows
The bevel of the cutting edge is always outside the curva-
ture, and the face of the blade is on the internal side of the
curvature (. Fig.  4.10b). They are double-ended instru-
 
ments, with the curvature facing opposite sides, in which
one of the ends cuts to the right and the other to the left
(. Fig. 4.10b). They are indicated for planning the cavosur-
 
face gingival margin of the proximal boxes of class II amal-
gam preparations (. Fig. 10.12a, b). To adapt to the margin
 
of those preparations, there are trimmers for the mesial
boxes and others for the distal boxes. For these, differently
of the enamel hatchet in which the primary cutting edge of
the instrument forms a right angle with the long axis of the
blade, those edges present various angles (. Fig. 4.10a – 1
 
and 2 versus 3). Therefore, a set of gingival margin trim-
mers is composed of two instruments or four ends: one
instrument to trim the mesial box, which one end can be
moved to the right and the other end to the left, and another
instrument to trim the distal box, with ends that can also be
moved to the right or to the left (. Figs. 10.12a, b and
 
10.13e, f).
100
90 10
80
20
70
30
60
40
50
..      Fig. 4.11  Circle dived on centigrade degrees
4.2.3 Instrument Formulas
Analyzing the shape of a blade and the angles on the shank,
one can identify with a relative accuracy the type of hand
instruments. However, those terms are only descriptive and
imprecise because they do not indicate the size or the angles.
For a complete identification, Dr. Black developed a system
that attributes numerical formulas to the instruments using
the metric system for the dimensions and centigrate degree to
indicate the angles [6]. The  centigrate degree is obtained
dividing the circle into 100 parts, different from the traditional
division of the circle in 360 parts (. Fig.  4.11). In a circle
divided into 100 parts, a right angle corresponds to 25 parts.
However, some instruments do not use the formula proposed
by Black, and the engraved number can indicate the number
of the instrument on a determined collection or a reference
from the manufacturer. Besides numbers, letters can be part
of the formula of the hand cutting instruments. Letters indi-
cate the place of the bevel and they can be L, R, or S. To inter-
pret the letters, the instruments should be observed from
behind, with the end of the handle facing the operator. The
letter L indicates that the bevel is positioned on the left side of
the instrument, and the letter R indicates that the bevel is on
the right side. The letter S (special) indicates that the bevel is
located opposite to the side of the corresponding instrument
without the letter (reverse bevel or special) [5, 18, 23].
4.2.3.1 Three-Number Formula
For the instruments with the primary cutting edge in right
angle with the long axis of the blade, as on the hatchets and
hoes, a three-number formula is used (. Fig. 4.12). The first
Instruments and Equipments
..      Fig. 4.12  Instrument with a three-number formula
number represents the width of the blade in tenths of millime-
ters, the second number represents the length of the blade in
millimeter, and the third number represents the angle that the
blade forms with the long axis of the handle in degrees [23].
4.2.3.2 Four-Number Formula
For instruments in which the primary cutting edge does not
form a right angle with the long axis of the blade, as on the
gingival margin trimmers, a four-number formula is used.
The first number represents the width of the blade in tenths
of millimeters, the second number represents the angle that
the primary cutting edge forms with the long axis of the
handle, the third number represents the length of the blade
in millimeter, and the fourth number is the angle that the
long axis of the blade forms with the handle (. Fig. 4.13). On
the gingival margin trimmers, the angle of the primary cut-
ting edge (second number) between 90° and 100° indicates
that it must be used on the distal boxes, while the angle
between 75° and 85° indicates use on mesial boxes [6, 25].
The instruments that present the second numbers of 100° or
75° are used for the preparation of cast metal restorations, as
those preparations must present very leaned marginal bevels.
The instruments with the second number of 95° or 80° are
indicated for amalgam restorations as they can produce
lightly beveled margins [23].
4.2.4 Sharpening of Hand Instruments
The sharpening is an important step for the good use of cut-
ting hand instruments. A dull instrument causes pain and
discomfort to the patient and to the operator because of the
greater force required to perform the work, increases the
working time and risks of accidents, and reduces the quality
and precision of the dental preparation. The dentist or his
assistant must always pay attention to the sharpening quality
of the instruments. It should be performed after sterilization,
to avoid that accidental injuries result in cross contamination.
Instruments should be again sterilized prior to the clinical use.
The sharpening of an instrument can be evaluated by
visual inspection of the cutting edge under proper lighting.
131 4
..      Fig. 4.13  Instrument with a four-number formula
The presence of shiny surface indicates that the edge is “dull”
or rounded. Sharpening can also be tested, with slight pres-
sure, against a plastic cap of a needle, anesthetic tube, or the
cannula of a saliva ejector. A dull blade will slide across the
plastic surface, while a sharp blade will cut the material
obstructing the movement [25]. The sharpening can be done
manually, over an abrasive stone, or mechanically with a
rotary sharpening stone [18, 19, 23]. Different abrasive stones
can be used, with fine or medium grit, depending on how
much grinding is necessary for sharpening. The Arkansas
stone is a natural mineral that contains microcrystals of
quartz, which has a very small grit and is excellent for the
final sharpening. The silicon carbide (SiC) is an industrial
abrasive more commonly used on abrasive paper, which can
also be found as stone, generally available in medium and
coarse grits. The aluminum oxide can also be used on the
production of sharpening stones, which will present coarse,
medium, or fine grits. The Arkansas, silicon carbide, and alu-
minum oxide stones are only adequate for hand cutting
instruments made of steel. The instruments with the cutting
blade made of tungsten carbide are harder and require sharp-
ening with diamonds. Metallic blocks covered with thin dia-
mond particles by electrodeposition technique are the only
ones that serve to sharpen such instruments [23].
The sharpening is performed in many different ways for
each hand instrument. When chisels, hatchets, hoes, and
margin trimmers are sharpened, the cutting edge bevel is
placed parallel to the flat stone, which must be supported by
a stable surface (. Fig. 4.14a). The instrument is pushed or
pulled so that the acute cutting angle is moved forward with
a moderate force, toward the face of the blade, and with little
or no force on the backstroke (. Fig. 4.14b, c). Care should
be taken not to change the angle of the bevel during the
sharpening, resting the fingers that hold the instrument very
well onto the stone. As the bevel of the instrument must be
made with a 45° angle with the face of the blade, it must be
positioned with an angle of 45° with the sharpening surface
of the stone. In general, unless the instrument is too neglected,
only two or three strokes are necessary. A fine mineral oil can
be used to lubricate the stone, which improves the quality of
the sharpening, hindering the filling of the stone pores and
avoiding the heating that could change the tempering of the
 132 S. E. de Paiva Gonçalves et al.

a b

c d

..      Fig. 4.14  a Grasping for sharpening; b, c more intense movement for sharpening toward the face of the blade on instrument with flat bevel;
d movement of traction and rotation for instruments with curved blades

blade [23, 25]. With continuous use, the pores of the stone
can become clogged by the residues of the abrasion. To clean
it, a piece of cloth soaked in oil can be used. If extremely
clogged, a cloth soaked in alcohol can also be used [23].
When spoons and other round instruments, such as dis-
coid and cleoid sculptors, are sharpened, the instrument is
rotated, while the blade goes over the stone. The discoid and
the spoon, which have round cutting edge, can be sharpened
with a continuous rotation of the blade (. Fig. 4.14d). In rela-
stone. When a stone is sterilized, it should not have oil on the
surface because the oil may thicken during the sterilization
process, forming a varnish-like coating that will prevent the
abrasion needed for sharpening to happen. When the sharpen-
ing stone is sterilized, only water should be used as lubricant. In
addition, it can be washed on an ultrasonic cleaner after use to
remove the metal filings before the next sterilization cycle [25].

tion to the cleoid, shaped as a claw, the rotary movement
begins in one of the sides until it reaches the tip. Then, the
movement on the opposite direction is performed on the
other side, beginning from the lateral until it reaches the tip.
For mechanical sharpening, SiC abrasive discs or stones
can be used in low-speed handpieces. It is important to
remember that the angle of the bevel must always be respected
(. Fig.  4.15a). The instruments that have one of the sides
 
convex and the other flat, such as the dentin spoons and the
discoid and cleoid sculptors, can be sharpened using flat
stone, making the grinding on the flat side, which is the face
of the blade (. Fig. 4.15b, c). This method of sharpening also
 
turns the blade thinner, and care should be taken to avoid
that it becomes so thin that it can easily break [25].
When the instruments need to be sharpened during an
operatory procedure, they should be sharpened with a sterile
4.3 Rotary Cutting Instruments
The rotary instruments represented a great impulse for the
development of the dentistry that is practiced today. The pos-
sibility to grind and cut the hard tissues with great speed
allowed for a sensible improvement on the quality of the
work and relief for the patient’s suffering [20]. There is a vari-
ety of types and shapes of rotary instruments, such as differ-
ent turbines and engines that can power them.
4.3.1 Handpieces
The rotary cutting instruments need some type of mechani-
cal device to make them turn, known as handpieces. To reach
the level of development that we have today, those equip-
Instruments and Equipments
a b
..      Fig. 4.15  Sharpening with rotary instruments. a Flat-blade instruments; b, c curved-blade instruments
ments went through a great evolution. The precursors of the
current rotary instruments date from the year 1800, and
most were developed for individual use by the inventor [6].
For example, the so-called bur ring, developed by Amos
Westcott in 1846, that rotated with the movement of the
thumb and the indicator fingers of the operator [23]. Pushed
by the development of the sewing machine that used pedals
from Isaac Singer, the inventor James Beall Morrison created
a foot engine, with a treadle that was pressed by the dentist
and the rotation that was transferred to a handpiece by a
series of pulley. It was patented in 1871 and later manufac-
tured by the American company S.S. White (. Fig. 4.16a). In
 
1872, the S.S. White launched on the market the first electric-­
powered handpiece, invented by George F. Green, where the
engine was incorporated to the handle of the instrument
[22]. Later on, different handpieces for dental use that had
separated electrical engines were developed. In these, rota-
tion was transferred to the handpiece using belts
(. Fig.  4.16b). However, effective equipment for enamel
 
preparations only became available after 1946, when the
speed of 10,000 rotations per minute (rpm) was used for the
first time, associated with the development of more effective
rotary instruments.
The greater impact on the development of the handpieces
came with the development of the contra-angles with tur-
bines inside the head or the instrument. The first model
133 4
launched out on the market in 1955 was moved by the circu-
lation of the water [23]. In 1957, John Borden introduced the
first air-driven turbine, and it was an immediate success
because of the high speed that it could reach. Nowadays,
most of the handpieces for dental use are equipped with a
turbine powered by compressed air, even though there are
some on the market that are moved by an electrical engine.
They can be classified according to its rotational speed, mea-
sured in rpm. Since its introduction in dentistry, the engines
have received many classifications based on their speed.
However, with the evolution of technology and the increase
of the power of those equipments, the classifications were
changed. Nowadays, the turbines and electrical engines avail-
able on the market can be classified in a very simple manner
in low and high rotation speed.
The low-speed turbines, also known as micromotors, turn
on a speed between 3000 and 20,000 rpm. They have a regula-
tor ring on the end near the attachment of the rose, where it
is possible to control the maximum speed or to invert the
direction of rotation (. Fig. 4.17a – arrow). The micromotors
can be attached to two types of handpieces. One of them is
known as the straight handpiece and is used outside the
mouth because the long axis of the bur coincides with the
long axis of the handpiece (. Fig. 4.17a, b). The other hand-
piece is known as the contra-angle. As the hand instruments,
its head is first turned outward and then toward its long axis.
 134 S. E. de Paiva Gonçalves et al.
a b
..      Fig. 4.16  Early rotary instruments. a Foot treadle dental engine developed by J. B. Morrison; b electrical dental engine
This allows the tip of the bur to be positioned a few millime-
ters away from the long axis of the instrument, creating a bal-
ance (. Fig. 4.17c, d). In addition, it allows the bur to be used
 
inside the oral cavity, reducing the opening of the mouth that
is needed to access even more remote regions of interest.
There are three types of contra-angles, according to its capac-
ity to transmit rotation from the motors to the tip of the bur,
and they are the conventional (1:1 ratio), the speed-­reducing
(18:1 or 20:1 ratio), and the speed multiplier (1:5 ratio). On
the conventional, the speed of the micromotor is transmitted
without modifications on the tip of the bur. On the reducing,
the speed decreases in 18–20 times or even more, depending
on the specification of the manufacturer. They are very com-
monly used in implants and endodontics procedures, and
they are largely recommended on the insertion of intraden-
tinary pins. On the multiplier, the speed is multiplied in five
times, and it is indicated specially for the finishing of cavity
preparation for indirect restorations, as it can reach an inter-
mediate speed between low- and high-­ speed rotation,
improving the control and reducing the vibration.
The coupling of the burs on the contra-angle is performed
through a notch at the end of the shank, which allows a hook
to latch onto it in the upper part of the handpiece’s head
(. Fig.  4.18a–d). However, there are already in the market
some contra-angles that allow the grip of burs by friction,
which are commonly used in high-speed handpieces. Burs
are removed when pressing a button, instead of opening a
lock. To connect the bur on the straight handpiece, first it is
necessary to unlock the fixation clamp, turning the lock
placed on the middle of the handpiece. The bur is placed and
then the lock is activated (. Fig. 4.19a–d).
Since it allows a greater tactile sensation to the operator,
the use of low speed reduces its risks of accidental pulp expo-
sure, if it is used in an intermittent way. Currently, the low-­
speed handpieces have hoses to promote refrigeration during
the cut. However, the water blow hinders the visibility and
minimizes the tactile sensation during the use, so it can be
used intermittently without water, and with a reduced speed.
The low-speed handpiece is capable of cutting the hard tis-
sue, but it produces an unpleasant experience for the patient
and for the dentist due to the vibration. Nowadays, the use of
low speed is limited to the final removal of caries on dentin,
finishing of the preparation, prophylaxis, and polishing
maneuvers.
The high-speed handpieces or turbines were launched
onto the market in 1977. A handpiece can be considered of
Instruments and Equipments
high speed when they produce a speed higher than 150,000
rpm, and they can reach to a rotation up to 450,000  rpm
(. Fig.  4.20a). They are used in almost all procedures that
 
require cutting hard dental structures, as the dental prepara-
135 4
mittent way and under refrigeration with an air/water spray
to avoid tissue overheating. They must ideally have three
spray outlets to refrigerate the active tip of the bur, especially
inside a cavity (. Fig. 6.8a, b). The coupling of the bur is per-

tion itself; removal of old direct or indirect metal restora- formed by friction of the shank into the head. There are two
tions, resin, or ceramic; reduction of cuspid; axial cut for the ways of removing the bur from the instruments. On the
prosthetic preparation; and even the finishing of restorations most modern systems, there is a button that when pressed,
with the multi-bladed burs. They must be used on an inter- releases the bur. This is known as the push-button system

a b

c d

..      Fig. 4.17  a Low-speed micromotor associated with the straight handpiece (arrow – regulation ring). b Grasping of the straight handpiece;
c micromotor associated with the contra-angle; d grasping of the contra-angle

a b

..      Fig. 4.18  Latch contra-angle handpiece. a Opening of the latch; b, c placing of the bur; d closure of the latch
 136 S. E. de Paiva Gonçalves et al.

c d

..      Fig. 4.18 (continued)

a b

c d

..      Fig. 4.19  Fixation of the rotary instrument on the straight handpiece. a Opening of the straight handpiece lock; b, c insertion of the diamond
point; d locking the rotary instrument

(. Fig. 4.20a, b). On the older systems, there is a wrench bur

  feeds a LED producing white light. They present an advan-
remover (. Fig.  4.21a–f). Some manufacturers produced
  tage that can be used in any type of dental equipment
high-speed handpieces with optical fibers to conduct the (. Fig. 4.20c). Some handpiece brands also offer the possi-
 

light from a bulb in the delivery unit to the tip of the instru- bility to illuminate the tooth with UV light, which can help
ment, improving the illumination of the operating field. the identification of residues of fluorescent restorative mate-
More recently, some handpieces were developed with an rials, during the replacement of defective composite restora-
electric generator, attached to the air-driven turbine, that tions (. Fig. 4.20d).
 
Instruments and Equipments
a b
c d
..      Fig. 4.20  a Examples of high-speed push-button handpieces; b
insertion of the bur while pushing the lock button; c high-speed
handpiece with independent light source (LED/E-generator, MASC
Both low-speed contra-angle and the high-speed hand-
pieces must be sterilized in the autoclave for the control of
cross contamination. The care with the lubrication becomes
even more important due to the sterilization process, to avoid
drying of the bearings. They must be lubricated before and
after the process of sterilization. The excess lubricant oil must
be removed before the instrument is used, by making it rotate
for about 15 s outside the mouth.
>> To avoid the overheating and maintain them in
adequate working condition, handpieces should be
lubricated prior to use with appropriate mineral
oil-based lubricants, available in bottles or in spray.
The vibrations and the noise are related to the speed of the
turbines and can cause discomfort to the patient and dentist
and eventual hearing lesions to the clinician. The vibratory
waves can be described according to the frequency and
amplitude. The frequency is the number of oscillations in an
interval, while the amplitude is the distance between two
consecutive wave peaks, and there is a reverse relation
between both. When a bur is used on a speed of up to 10,000
rpm, the amplitude is high and the frequency is low, trans-
mitting a higher vibration sensation to the patient. There-
137 4
Dental, NSK); d handpiece with UV light source (Cobra LED Ultra Vision,
Gnatus)
fore, one should never let the bur come to stop while in
contact with the tooth of the patient, because the sensation
will be very unpleasant. The rotary movement should always
start or stop before the contact with tooth structure. Like-
wise, one should never go in or come out of the mouth with
the motor working, because of the risk of hurting the soft
tissues.
Tip
The rotary movement should always start or stop
before the contact with tooth structure. In addition, it
should never go in or come out of the mouth with the
motor working, because of the risk of hurting the soft
tissues.
When the speed of the turbine is superior to 60,000 rpm, the
amplitude reduces and the frequency increases. On those sit-
uations, the patient stops feeling the vibration of the bur, but
begins to notice the noise, which is acute and uncomfortable.
The noise can cause shivering and discomfort to the patient
and acoustic lesions and psychological lesions to the clini-
 138 S. E. de Paiva Gonçalves et al.

a b

c d

e f

..      Fig. 4.21  FG high-speed handpiece associated with a wrench bur remover. a–c Sequence of bur placement; d–f sequence of bur removal

cians, who are exposed to the noise all day long and for many
years. Noise above 75 db can cause hearing damage, and tur-
bines of high speed can generate 70 and 94 db [23]. To mini-
mize the deleterious effects of the noises on the patient and
the clinician, handpieces with low levels of noise emission
should be used. Those should also be used in an intermittent
way, in a way that the periods of silence are greater than the
periods of noise. The other option is to work with ear protec-
tors while the turbines are being used, which can also be per-
>> To minimize the deleterious effects on hearing,
handpieces with low levels of noise emission should be
used. Ear protectors are also recommended.
4.3.2 Parts of the Rotary Instrument
The rotary instruments present three parts, and they are the
shank, neck, and head (. Fig. 4.22a). The shank is the longest

formed by the patient using earphones, for example. The part of the instrument and serves to connect it to the rotary
sound reflexes can be attenuated in the clinic using materials device. To connect to the straight handpiece attached to the
that protect from the noise on the floor, walls, and ceiling. low-speed micromotor, the shank is long and smooth. For the
Instruments and Equipments
a b
c d
..      Fig. 4.22  a Representation of the parts of the rotary instruments
(shank, neck, and head); b types of shanks (1, straight handpieces; 2,
contra-angle; 3, high-speed); c types of high-speed rotary instruments
straight attachments/nose cones and Doriot-type low-­speed
handpieces, the shank is long, named HP type. For the contra-
angle low-speed handpiece, the shank is short and has a latch,
being called right angle/latch type or RA/CA.  For the high-
speed handpiece, the shank is thinner, is shorter, and does not
have latches, because the connection happens by friction, being
called friction grip or FG (. Fig.  4.22b). There are burs with
 
short, conventional, or long shanks, depending on the necessity
of the access (. Fig. 4.22c). The neck, also called intermediary, is
the portion between the shank and the head, which is the active
part of the instrument. Its length and diameter are vital for the
balance of the instrument and consequent transmission of the
vibration. It has the function to improve the access and the vis-
ibility to the area to be prepared. The metallic alloy that the neck
is made of is also very important for the quality of the instru-
ment, because it is subjected to high stress due to its thinner
diameter. Its length varies according to the access, the visibility,
and the freedom to use the active part of the instrument, and it
can be short or long (. Fig. 4.22c). The active part or head cor-
responds to the functional end of the instrument. The shape
and the material from which they are made differentiate its
function and the way of action. The high-speed rotary instru-
ments can also be used in low-speed contra-angles, using a
latch-type contra-­angle adapter, as it can be seen in . Fig. 4.22d.
139 4
(1, short shank; 2, regular shank; 3, long neck; 4, long shank); d latch-
type contra-angle adapter for use of high-speed rotary instruments on
low-speed contra-angle
4.3.3 Types of Rotary Instruments
The rotary instruments used in the cavity preparation to
receive a restoration can be classified, according to the way
they act, as cutting or abrasive.
4.3.3.1 Cutting Rotary Instruments
It is called a cutting instrument the one that is capable of
separating a part of a whole by means of a blade or a sharp
edge, which concentrates the force on a small area and results
on the propagation of a fracture along the surface touched by
the blade, causing the formation of the shavings. The cutting
rotary instruments are called burs and can be manufactured
in carbon steel, which was the material used on the first
rotary instruments, or tungsten carbide which only became
available on the market in 1947. The burs have successive
blades that when touching the tooth structure remove shav-
ings, similar to what is observed on hand instruments, but on
a more efficient way. . Figure 4.23a shows a scheme of a bur
blade cutting a substrate and generating the shavings. For the
blade to begin the cutting action, it must be sharp and have
hardness and elasticity modulus greater than the material to
be cut. The high hardness and the elasticity modulus are
essential for the concentration of the applied force on a small
 140 S. E. de Paiva Gonçalves et al.

a b

..      Fig. 4.23  a Cutting action of a blade; b cross-sectional scheme of a dental bur and its parts. (Adapted from Phillips [21])

area of the blade’s edge, which must be higher than the shear a b c d e f
resistance of the material to be cut [23]. The mechanical dis-
tortion of the dental structure due to the blade produces heat,
and it is mandatory to use refrigeration, especially in high
speed [23].
In . Fig. 4.23b, there is a schematic cross-sectional view
 

of a bur for typical dental use, with six blades, showing the
names of the faces and angles. The real cutting action of a bur
happens on a very small region on the edge of the blade. Each
blade has two sides or faces, and they are the rake and clear-
ance faces. The rake face is on the same direction of the cut,
while the clearance face is on the opposite side. They also
have three important angles, and they are the rake, edge, and
clearance angles. The edge angle usually is not acute. It is
around 90° to allow resistance to the blade and increase the
longevity and the cut efficiency of the bur. The rake angle is
formed between the rake face of the blade and a line that ..      Fig. 4.24  Burs with different number of blades. a, b Regular bur
passes through the center of the instrument and the edge of with 6 blades; c crosscut bur with 6 blades; d bur with 12 spiral blades;
e bur with 12 straight blades; f bur with 30 straight blades
the blade (radius of the bur). It is said to be negative when the
rake face is in front of the radius. The scheme of the bur
shown in . Fig. 4.23b has a negative rake angle, as most of
  development of the high-speed turbines, crosscut burs were
the burs for dental use, increasing the durability and allowing very popular, which have transversal cuts on the blades to
a good performance in high and low speed. A positive cut- increase the cut efficiency (. Fig. 4.24c) [25]. This principle is
 

ting angle would produce an edge angle that is more acute,
allowing it to be used only to cut soft surfaces, such as carious
dentin. If they were used to cut hard tissues, as enamel or
healthy dentin, the edge would quickly become an irregular
surface, chip, and dull [25]. The clearance angle eliminates
the friction of the clearance face and allows a stop to avoid
that the tip of the bur excessively penetrates into the tooth
structure, besides allowing the space to the shavings being
cleared [23].
The cutting efficiency and the roughness of the resulting
justified by the fact that on crosscut burs, a smaller area of the
blade will be touching the surface at the cutting moment,
which results on a greater pressure and consequently higher
cut efficiency. Nowadays, this bur design is no longer used for
cavity preparations, but on burs designated to cut metal,
named transmetal burs, indicated to remove metallic restora-
tions. The blades can be disposed parallel to the long axis of
the burs on a spiral shape. The spiral disposition results on a
smoother surface, even though it reduces the cutting effi-
ciency (. Fig. 4.24d).

surface will depend also on the number of blades. The con-

ventional burs have 6 blades, but this number can vary to 12,
30, or even 40 (. Fig. 4.24a, e, f). The higher the number of
 
blades, the lower the cutting efficiency, but the smoother is
the resulting surface. For this reason, the so-called multi-­
bladed burs, that is, the ones with more than six blades, are
used for finishing and polishing of the restoration. Before the
4.3.3.2 Abrasive Rotary Instruments
The abrasive rotary instruments are the ones capable of
removing material from a structure by the action of friction
or fragmentation. They present irregular particles, harder
than the substrate to be abraded, deposited on a stainless
steel head. During its friction with the surface, it causes frag-
Instruments and Equipments
a
..      Fig. 4.25  Action of an abrasive grinding particle over a substrate.
a Ductile materials; b brittle material. (Adapted from Phillips [21])
mentation and consequent grinding (. Fig.  4.25a, b). The
grinding happens because of multiple points of individual
hard particles that are protruded from the surface, instead of
a continuous blade. Those particles have many sharp edges
that are randomly oriented over the surface of the instrument
head.
The material that suffers the abrasion can be classified
into ductile or brittle. The ductile materials are less hard and
suffer deformation or distention when they are pressed by
the abrasive particles. The brittle materials are harder, and
they break when they are submitted to tensions. The dentin is
an example of ductile material, specially the carious one,
while the enamel is brittle. When the abrasive instruments
are used over ductile materials, some parts can be removed in
chips, but most parts move laterally from the way that is fol-
lowed by the abrasive particle, forming a type of crest of
deformed material on the surface (. Fig. 4.25a). The repeated
 
deformation hardens the distorted material until it becomes
brittle, fracturing and removing it. The burs are preferable to
cut ductile material, like carious dentin. The interaction of
brittle materials with diamonds or other abrasive particles
occurs differently. The removal of the material results from
fracture by tension which produces subsurface cracks
(. Fig.  4.25b). The diamonds are more effective to grind
 
brittle materials and are superior to the burs to remove dental
enamel [23]. Examples of abrasive rotary instruments are
diamond points, stone points, and the abrasive discs.
Diamond Instruments
The diamond abrasive instruments or diamond points were
developed in 1935. They were fabricated in stainless steel
with the shape of heads similar to the burs. Over the head, an
agglutinant layer is applied by means of an electroplating
process that connects the steel to the diamond particles with
different dimensions. This way, when the instrument spins,
the irregular diamond particles are rubbed over the substrate,
causing the grinding. They represent the class of rotary
141 4
a b c
..      Fig. 4.26  Diamond points of different particle sizes. a Regular grit;
b fine grit; c extra fine grit
instrument that is most used on daily practice, because they
can easily grind enamel and dentin. Grinding with diamond
instrument should be performed with new points and under
refrigeration.
The size of the diamond particles electroplated has direct
relation with the efficiency of the grinding and the roughness
of the resulting surface. The greater the particle size, the more
efficient the abrasion will be and the rougher will be the sur-
face. Conversely, the smaller the particles, the smoother the
resulting surface will be. In general, six diamond grades can
be found on the market, and they are identified by colored
rings on the shank, resulting in super coarse (150 μm, black
ring), coarse (125 μm, green ring), medium or conventional
(100 μm, without a colored ring), fine (30 μm, red ring), extra
fine (15 μm, yellow ring), and ultrafine grit (8 μm, white ring)
diamond points. The medium grit is the most used on dental
preparations. The coarse or super coarse grits are indicated
when a great quantity of material need to be removed, such
as old restorations. The thin, extra fine, and ultrafine grit
points serve to finish and polish the composite resin restora-
tions (. Fig. 4.26a–c).
With time, especially if insufficient refrigeration is used,
the diamond points can become clogged by the deposit of
residues between the diamond particles, which reduces its
grinding effectiveness. The clogging is characterized by the
presence of a whitish material on the surface of the point that
is visible by naked eyes (. Fig. 4.27a). To solve this problem,
the point can be briefly rotated over a specific ceramic stone,
and the abrasive capacity is restored (. Fig. 4.27b, c). The sys-
tematic use of ultrasonic bath to clean the instruments also
prevents the clogging.
However with prolonged use, the diamond particles will
eventually become rounded, or they will debond from the
 142 S. E. de Paiva Gonçalves et al.

a b

c d

..      Fig. 4.27  a Diamond point clogged with residues after abrasion ately after cleaning; d deterioration of the diamond points (1, new; 2,
with insufficient refrigeration; b stone diamond instrument cleaning worn head showing the loss of many diamond particles)
(Limpapontas – KG Sorensen); c the same point shown in A immedi-

a b

..      Fig. 4.28  Mounted stones with different shapes. a Arkansas stones; b silicon carbide stones

agglutinant, reducing the grinding efficiency (. Fig. 4.27d).

 
On the attempt to compensate for the insufficient abrasion,
the dentist tends to apply more pressure on the instrument.
This can cause overheating of the tooth structure, with risk of
damage to the pulp tissue. The diamond points must be
Mounted Stones
They are naturally or artificially obtained stones made by
hard abrasive agents, mounted on a metallic shank that can
be adapted to a straight handpiece, contra-angle, or high
speed (. Fig. 4.28a, b). They are indicated for the finishing of

­constantly replaced, and in some countries they are used only restorative procedures performed directly inside the mouth
once. or in laboratory.
Instruments and Equipments
The Arkansas stones have white color and are naturally
obtained from a rock called novaculite, original from the
state of Arkansas (United States). They have been used for
centuries to sharpen cutting metallic instruments. Those
stones present microcrystalline quartz in its composition,
which gives its abrasive property [23]. They present excellent
performance, but they cannot be dry sterilized, as they may
lose the crystallization water and deteriorate. They must be
sterilized in humid heat (autoclave) or chemically.
Artificial stones can be made with SiC or aluminum
oxide. The SiC stones usually present a greenish color,
although some have black color. The aluminum oxide stones
can have various colors, as white, pink, beige, blue, and gray,
depending on the composition. Besides the abrasive type,
they can also vary according to the size of the particles, cor-
responding to the desired indication. The artificial stones can
be sterilized in dry or humid heat. The usual fabrication pro-
cess requires to carefully press the abrasive particle onto the
desired shape and to heat until it becomes solid. To keep the
cutting edges of the sharp particles, the fabrication process
results on a porous material. The properties of the stones
depend on the volume and the size of the pores and on the
composition and size of the abrasives that were used [23].
Abrasive-Impregnated Rubber
They are rotary instruments with the active head made of
rubber, on which many different types of abrasive particles
are interspersed such as SiC, aluminum oxide, or diamond
powder. The abrasive rubber rotary instruments are used to
polish restorations directly in the mouth or in laboratory.
Depending on the particle size of the abrasive agent, it allows
for a more or less rough surface. In general, they are sold in
kits with decreasing abrasivity. Each abrasivity is identified
by a different color. They can be used to polish metallic or
amalgam restorations, composite resin, or ceramic. The abra-
sive rubbers are available in various shapes, and the most
common are the points (cones), cups, and discs, as those can
allow the access to different sites intended to be polished
(. Fig. 4.29a–c). Recently abrasive rubber spiral wheels were
 
launched on the market, with the advantage of reaching dif-
ficult areas (. Fig. 4.29d).
 
With prolonged use, the tapered points wear off, impair-
ing the access to certain areas of the occlusal surface, such as
the cusps  inclines and the bottom of the developmental
grooves. Those points can have their shape recovered by gen-
tly rotating it over an abrasive surface, as a diamond dresser
(KG Sorensen) (. Fig. 4.29e–g), a stone used for sharpening
 
hand instruments, or a SiC disc (. Fig. 11.18a–c). The dia-
 
mond dresser can also be used to correct the shape of
mounted stones, due to the greater hardness of the diamond
particles.
Abrasive Discs
The abrasive instruments can also be found on the shape of a
disc. They are available in many diameters (1/2, 5/8, 3/4, and
7/8 inches) and require some type of mandrel so they can be
used. Many are made using a metallic or plastic disc, over
143 4
which an agglutinant and a layer of abrasive are applied. For
this reason, they are called abrasive-coated instruments
(. Fig. 4.30a, b). The discs made over a plastic base are used
for polishing flat surfaces of composite restorations on ante-
rior teeth, while the diamond metallic discs are used in labo-
ratorial work. To create a smooth surface, they are presented
in kits of discs in decreasing abrasivity identified by different
colors.
There are discs made completely by abrasive stone, simi-
lar to a mounted stone. They are much used to finish or to cut
metallic pieces outside the mouth and are generally called
Carborundum discs (. Fig.  4.30c). However, the word
Carborundum does not refer exactly to an abrasive material,
but to the name of a company founded by Edward Goodrich
Acheson in 1891, after he invented the SiC, the first artificial
abrasive.
4.3.3.3 Accessory Rotary Instruments
Some rotary instruments frequently used on daily practice
are not abrasive by themselves, but are used with abrasive
pastes. Among them are some rotary bristle brushes and the
rubber and felt instruments (. Fig. 4.31a1–4, b). The brushes
present plastic bristles and can have a flat or conic tip, gener-
ally named Robinson’s brushes. The rubber instruments can
have a conic or a cup shape, while the felt instruments can
have the shape of a disc or of a cone. The brushes as well as
the rubber cups and cones are used for dental prophylaxis
and for polishing of restorations. The felt discs are available
in various diameters. They are indicated to polish composite
restorations on anterior teeth. The felt cones are indicated to
polish the occlusal surfaces of composite resin restorations or
on the lingual surfaces of the maxillary anterior teeth.
The accessory rotary instruments are used with abrasive
pastes such as pumice, calcium carbonate (Spanish white),
zinc oxide, aluminum oxide, or diamond, among others,
depending on the purpose. As for the other abrasive instru-
ments, to reach a well-polished surface, a sequence of
pastes that contain abrasive grains with decreasing sizes
must be used, to reduce the substrate roughness on each
change. There are some brands of felt discs that already
come impregnated with an abrasive agent (. Fig.  4.31b,
asterisk), as well as of brushes that already contain silicon
carbide abrasive particles on the bristle composition
(. Fig. 4.31a, – 5 and 6).
4.3.4  aterials Used on the Fabrication
M
of Rotary Instruments
The hardness of a cutting or grinding instrument is an essen-
tial property. Of course, the cutting instrument must be harder
than the substrate. . Table 4.1 shows the hardness of some tis-
sues, abrasives, instruments, and materials involved in dental
treatment. Previously, the burs were made of carbon steel
because the hardness was almost three times higher than that
of the enamel. However, it frequently suffered from oxidation
and quick loss of cut. In 1947, the tungsten carbide burs were
 144 S. E. de Paiva Gonçalves et al.

a b

4
c d

e f

..      Fig. 4.29  Abrasive-impregnated rubber with different shapes. a Points; b cups; c discs; d abrasive rubber spiral wheels, e rubber point with
head worn after use; f sharpening of the rubber point with the diamond dresser (KG Sorensen); g rubber point after the reshaping
Instruments and Equipments
145 4

a b

..      Fig. 4.30  Abrasive discs. a Abrasive-coated discs; b diamond-­coated metallic disc; c discs made of abrasive stone

a b

..      Fig. 4.31  Accessory rotary instruments. a Robinson brushes (1 and 2); rubber cups and cones (3 and 4); brushes with bristles impregnated by
silicon carbide (5 and 6); b felt discs and cones (∗disc impregnated by abrasive agent)

launched onto the market, with a hardness almost six times more brittle, just the head of the bur is made with this material,
greater than the enamel [23]. Those showed a much greater while the shank is made with stainless steel. The diamond par-
durability and do not suffer from oxidation. Because the mill- ticles present great grinding efficiency as it is one of the hardest
ing process of tungsten carbide is difficult and the material is materials in nature, about 20 times harder than the enamel.
 146 S. E. de Paiva Gonçalves et al.

..      Table 4.1  Knoop microhardness of some material and tooth a

tissues [5]

Material/tissue Knoop Use

microhardness

Diamond 7000 Abrasive rotary

instrument

4 Silicon carbide
(SiC)
2480 Abrasive rotary
instrument

Tungsten carbide 1900 Burs

Aluminum oxide 1500 Abrasive rotary

instrument

Carbon steel 890 Burs

Silicon dioxide 800 Air abrasion b

(silica)

Feldspathic 460 Restorative material

Porcelain

Enamel 340 Tooth structure

Stainless steel 300 Hand cutting

instruments

Amalgam 120 Restorative material

Dentin 70 Tooth structure

Hybrid composite 55 Restorative material

resin
..      Fig. 4.32  Basic shapes of the rotary instruments (1, spherical or
Cement 40 Tooth structure
round; 2, cylinder os straight fissure; 3, cone; 4, long inverted cone;
Microfiller 30 Restorative material 5, short inverted cone). a Diamond points; b burs
composite resin

Silver 30 Restorative material

numbers proposed by the American National Standards
Gold 24 Restorative material Institute/American Dental Association (ANSI/ADA) and by
Acrylic resin 20 Temporary indirect the International Organization for Standardization (ISO
restorations 2157), which is related to the shape, diameter, and length of
the head, as well as the diameter and length of the shank. It is
useful to know the diameters and the length of the bur as a
reference to measure the amount of grinding and the dis-
4.3.5  asic Shape of Burs, Diamond Points,
B tances inside the tooth [25]. The use of each type of bur or
and Mounted Stones diamond point is presented in the corresponding chapters
along with the corresponding restorative technique (7 Chaps.  

The head of rotary instruments is manufactured with some 10, 11, 12, 13, 14, 15, 16, and 17).
shapes and characteristics to attend specific clinical applica-
tions. The basic shapes of the burs, diamond points, and
abrasive stones are round (spherical), cylinder (straight fis- 4.3.6  actors Related to the Use of Rotary
F
sure), cone (taper or tapered fissure), and inverted cone Instruments
(short or long) (. Fig.  4.32a, b). The cylinder- and cone-­
 

shaped instruments may have a flat, round, bevel, or point
end. Many other shapes are available, but most are modifica-
tions of the basic shapes. Another significant characteristic of
the burs and the diamond points is related to the rounding of
the corners formed between the end and the sides of the
instrument head. This characteristic creates round internal
line and point angles on a preparation, which avoids stress
concentration, reducing the chances of fracture of the tooth
structure. The burs and the diamond points are identified by
The axial rotation speed of a rotary instrument is the speed
that is developed following the longitudinal axis of the instru-
ment. However, when cutting or grinding is performed on
any dental tissue, the peripheral speed of the border of the
instrument that touches the tooth surface is more important
than the axial speed, being called cutting speed. The cutting
speed increases as the diameter of the instrument increases.
Therefore, a diamond disc of 20 mm of diameter turning on
an axial speed of 24,000 rpm will have a peripheral speed on
Instruments and Equipments
the cutting edge of 25 m/s. For a bur of 2 mm in diameter to
have the same peripheral speed and consequently have the
same cutting efficiency, there is the necessity of an axial speed
of 240,000 rpm [18, 23]. With the current practice of mini-
mally invasive dentistry, the use of rotary instruments with
small diameter became very popular, which makes the use of
a high-speed handpiece important so that an adequate cut-
ting or grinding efficiency is obtained [23].
Another very important point in relation to the action of
the rotary instrument is the concentricity. It is the symmetry
of the instrument head and is related to the neck and the
shank. If the head or the bur presents an eccentricity during
use, the neck probably is leaned in relation to the long axis of
the shank, or the connection of the shank to turbine may
have a problem. Any detected eccentricity caused by one of
those factors must be solved immediately, because it reduces
the cutting effectiveness and produces an irregular cut of the
tooth structure and more vibrational effects. This may gener-
ate working difficulties to the dentist and great discomfort to
the patient.
The torque represents the capacity of the rotary instru-
ment to resist the tendency of stopping the movement due to
the pressure produced by the contact between the instru-
ment and the cutting surface [9]. The torque is measured in
N/cm or g/cm, and the current turbines have a torque of
11–20 g/cm. When the cut or grinding of the tooth structure
is performed, part of the kinetic energy from the burs in con-
tact with the tooth is transformed into heat. One must there-
fore avoid to produce exaggerated pressure with the
instrument as it may cause excessive heating and compro-
mise the pulpal vitality. Therefore, the torque level of the
handpieces must be limited so that the instrument stops
before an exaggerated heat is produced [23]. Besides the cut-
ting pressure, the friction heat has a direct relation to the
rotation speed, type, size, quality, and time of use of the cut-
ting or grinding instrument. When it turns more than 4000
rpm, all instruments must be refrigerated to avoid pulpal
damage. The recommended refrigeration is with water/air
spray that must be directed to the head of the bur. Apart
from allowing the dissipation of frictional heat, the refrigera-
tion during the cut acts as a cleansing agent of debris gener-
ated during the cut.
4.3.7 Safety Procedures
Almost all procedures that use operatory instruments
involve some risk to the patient, dentist, and assistant. This
can be related to eye lesions because of particle projection,
ear lesions because of the noise, and the constant inhalation
of toxic substances or infectious agents. Specifically to the
patient, there is the risk of pulpal damage due to heating or
accidental exposure, besides soft tissue injuries. However,
the use of adequate security measures can reduce most of the
risk [23].
During the use of rotary instruments, particles of old res-
torations and dental fragments can be displaced and pro-
147 4
jected towards the eyes of the dentist or assistant, causing
irritation and even serious damages. This can be avoided
with the use of proper safety glasses with lateral protection
[22]. Even the individuals that use corrective glasses must
wear safety glasses, over the corrective glasses, or use protec-
tion glasses with the necessary degree of correction.
The aerosol created by the cutting procedures (contain-
ing saliva or blood, for instance) can contaminate the den-
tist and his auxiliary staff, causing cross contamination
through the working area and equipment. For this reason,
the use of surgical masks is mandatory for the dentist and
assistant to avoid aspiration of the contaminants present in
the aerosols. It is worth mentioning that the patients can
eventually have infectious diseases such as hepatitis, tuber-
culosis, and meningitis. Another measure that can contrib-
ute with the protection of the dentist and assistant is to
work under rubber dam  isolation, even during the cavity
preparation.
The rotary instruments must be sterilized before use.
For this reason, some manufacturers produce burs and dia-
mond points for single use that are previously sterilized by
gamma radiation. The burs can be sterilized by dry or
humid heat or even using antimicrobial solutions. However,
the chemical sterilization tends to lead to instrument corro-
sion. When sterilized in a stove or autoclave, the burs must
be positioned in bur block holders, which also allows for
better organization and localization during clinical proce-
dures (. Fig. 4.33).
4.4 Oscillatory Abrasive Instruments
The oscillatory instruments for dental use are metallic
shanks with heads covered by diamond and attached to an
oscillating device. Instead of producing a rotary move-
ment, they vibrate or oscillate in different directions, pro-
moting the friction of the head with the tooth structure,
resulting in grinding. The oscillatory handpieces can work
by vibration, as in the cases of sonic or ultrasonic devices,
or by back-and-forth reciprocating linear motion, called
the EVA system.
..      Fig. 4.33  Burs block holders for sterilization of the rotary
instruments
 148 S. E. de Paiva Gonçalves et al.
4.4.1 Oscillatory Handpieces
The oscillatory handpieces produce vibrational waves that
can generally be classified into mechanical and nonmechani-
cal. The mechanical waves are the ones that propagate in a
deformable or elastic environment. As examples, the sound
waves, waves on a spring, or waves on the water can be men-
tioned. They originate from a disturbance in a region of an
4 elastic environment. If the environment has elastic proper-
ties, the disturbance is transmitted successively from one
point to another. The particles of the environment vibrate
only around its position of equilibrium, without a whole dis-
placement. The nonmechanical waves, such as the electro-
magnetics, do not need a material environment for its
propagation. An example is the light, which can go through
the vacuum in the interstellar space.
The sound waves are characterized by vibrations (varia-
tions of pressure) on the air. A healthy human being can hear
and distinguish sounds on the approximate range of fre-
quency from 20 to 20,000 Hz. The ultrasound is a sound with
a frequency superior to the one that the human ear can
notice. The sonic waves are inside the range of human per-
ception, while the waves below 20  Hz are known as infra-
sound. The researchers noticed that the use of instruments
that oscillated in very high frequencies could be useful in
many dental applications, as on the removal of calculus or on
the cavity preparation. Nowadays, there are two types of
vibrational oscillating devices available for dental purposes,
and they are sonic and ultrasonic. The oscillating devices
with reciprocating movements produce a back-and-forth
movement, promoting friction of the abrasive agents with the
surface to be worn.
4.4.1.1 Sonic Devices
On the sonic systems, the work is generated from a pneu-
matic pressure applied internally on an axis supported over
rubber rings. The exit of the air happens through the holes
that exist on the axis, over which a steel bushing is fixated
and will rotate by the pressure of the air, keeping intermittent
contact with the external surface of the axis. The turning of
the bushing over the axis transmits an oscillatory movement
to the handpiece attached to the instruments, with an
approximate frequency of 6000–8000 Hz, depending on the
brand. Besides the air for propulsion used to rotate the bush-
ing, there is a water connection with exit on the handpiece
tip. The refrigerating air jet avoids overheating, keeps the
work surface clean, and reduces the sensitivity after the treat-
ment. The movement amplitude of the vibration wave can be
adjusted in some devices. The greater the amplitude, the
greater is the effectiveness of the grinding. The SONICflex
LUX 2003/L (KaVo) device allows that the amplitude is
adjusted by the operator to 120 μm (finishing and delicate
procedures), 160 μm (cavity preparation), or 240 μm (faster
and more aggressive preparations). Other examples of
devices are the SONICborden 2000  N (KaVo) and the
Cavitador Sonico Air Scaler (Microdont) (. Fig. 4.34a, b).
 
a
b
..      Fig. 4.34  Sonic devices for the cavity preparation a SONICborden
2000 N (KaVo); b Air Scaler (Microdont)
4.4.1.2 Ultrasonic Devices
The work in ultrasonic devices is generated by transducers.
Briefly, the transducer is a device that converts one type of
energy into another. The ultrasonic transducers convert elec-
trical energy into mechanical energy. There are two types of
transducers that can produce ultrasonic movement, the mag-
netoelectric or magnetostrictive as well as the piezoelectric
systems.
The magnetostrictive system consists of the passage of
electricity over special metallic blades, creating vibrations
and producing heat during the use, which requests more
refrigeration. This technology was used on the first-­generation
devices. The piezoelectric effect was discovered by Pierre and
Jacques Curie, in 1880, and it consists of a variation on the
physical dimension of specific crystalline materials that were
subjected to electrical field. When a piezoelectric material is
put into an electrical field, the electrical charge of the crystal-
line net interacts with it and produces mechanical tensions.
The quartz and the tourmaline, natural crystals, are piezo-
electrics. However nowadays, special ceramic chips made of
polycrystalline lead zirconate titanate (PZT) are used on
these devices. The crystal to be used as a transducer must be
cut in a way that an alternated electrical field, when applied
on it, produces variations on its width. Those variations pro-
duce a movement of the faces of the crystal, originating sound
waves. Each transducer has a natural resonance frequency so
that the smaller the thickness of the crystal, the greater the
vibration frequency. Most of the ultrasonic devices available
in the market use a piezoelectric system (. Fig. 4.35).
It is important to mention that patients and dentists that
have a heart pacemaker should not use ultrasonic devices,
due to undesirable interferences that they can produce to the
heart’s rhythm. This problem is more critical with the use of
magnetostrictive devices, but on a safer way, it is wise to
advice clinicians and patients who have a heart pacemaker
not to work with nor undergo treatment with any ultrasonic
device [17].
4.4.1.3 Reciprocating Movement Devices
These devices use a working principle called the vertical
reciprocating action, which is based on the conversion of the
rotary movement of the turbines on a back-and-forth move-
ment, repeated many times in a continuous way. The ampli-
Instruments and Equipments
149 4

..      Fig. 4.35  Ultrasonic device (CVDent 1000 – CVDentus) ..      Fig. 4.36  Handpiece of the EVA system (Ti-Max – NSK)

tude of this movement can vary from 0.8 to 1.4 mm,

depending on the brand of the device, and is known as the
EVA system. They promote a grinding action similar to a
sandpaper, but on a much smaller scale. It can be associated
with many types of diamond or plastic points, for different
applications, such as for finishing and polishing or cavity
preparation. The most common type is the point with the
pyramidal section, similar to a wooden wedge, that adapts
into interproximal spaces to polish or remove restoration
overhangs. The contra-angle EVA Prophylactic Head (KaVo),
Ti-Max EVA (NSK), and EVA-F (Brasseler) are examples of
this technology (. Fig. 4.36).
 

4.4.2 Types of Diamond Points

The diamond points used in sonic or ultrasonic oscillating

devices can be made by agglutination of natural diamonds,
similar to a rotary diamond point, or by deposition of the
newly formed diamond directly onto the shank.
..      Fig. 4.37  Diamond points with various shapes produced by
4.4.2.1 Points with Agglutinated Diamonds agglutination of diamond particles (SONICflex LINE Tips – KaVo)

The diamond points for use in oscillating devices can have

many different shapes, depending on the desired clinical
application, as it can be observed in . Fig.  4.37. On these
points, the natural diamond particles are bonded to the
metallic head by means of an electroplating process. The
SONICflex LINE Tips kit, produced by the KaVo company
(Germany), is recommended for the use in sonic devices. It
has many points for various applications in operative den-
tistry, such as the preparation of minimally invasive occlusal
cavities, proximal surfaces with difficult access, removal of
carious tissue, or the preparation of marginal bevels. It can
also be used in the preparation of indirect restorations, where
the buccal and lingual walls of the proximal boxes need to be
prepared with an ideal angulation and standardized cavosur-
face margin (. Fig. 15.11a–h). The recommended points for
 
proximal surfaces present diamond deposition on only one
side, which avoids the undesired grinding of the adjacent
tooth. The EMS company (Switzerland) also produces points
with agglutinated diamonds in many shapes to be used in
ultrasonic devices, while the Intensiv company (Switzerland)
produces many points with agglutinated diamond to use
with the contra-angle of reciprocating action on the EVA
­system.
4.4.2.2 Points with Deposited Diamonds (CVD)
Another alternative for the manufacturing of diamond
instruments is the deposition of artificial diamonds directly
over the metal head of the instrument, through a process
called chemical vapor deposition or CVD. The points made
by this process were developed by the DIMARE (Diamonds
and Related Materials) group from the National Institute of
Space Research (INPE) in Brazil, based on experiments that
produced the columnar growth of diamonds on metal
threads with a small diameter [27]. The CVDVale company
patented this technology for dental use in ultrasonic device,
 150 S. E. de Paiva Gonçalves et al.
a b
..      Fig. 4.38  Microscopic image of the CVD diamond point surface a, in comparison with a point with agglutinated diamonds b
and the points were launched onto the market in 2001. The
metal heads of CVD points are made of molybdenum. The
vapor chemical deposition happens due to methane and
hydrogen gases inside a reactor, under vacuum and high
temperature.
Those points have a thick and well-bonded layer of dia-
mond on the active head, without the need of an aggluti-
nant for connection (. Fig. 4.38a, b). They are very durable,
 
resisting to the ultrasound vibrations when grinding hard
materials. The points have various shapes and grits and
work together with the adapters that promote the connec-
tion with the ultrasonic devices (. Fig.  4.39a–c). They are
 
indicated for cavity preparation, removal of amalgam or
composite restorations, and bone grinding. The many
shapes and angles allow for adequate use in different appli-
cations. As these points promote the grinding through
vibration, they do not require long-axis symmetry and bal-
ance. This allows the production of heads with flat shapes or
with multiple angles, improving significantly the access to
remote sites.
The use of diamond instruments with the ultrasonic
device, on the range of frequency between 25,000 and 35,000
Hz, produces changes on the structure where the waves
propagate. The particles of the environment where the waves
are applied are energized, causing vibration and transmission
of energy also in the form of waves to the adjacent particles
[3]. In the liquid environment, the waves are transmitted and
dissipated with little resistance, causing the formation of air
bubbles (. Fig. 4.40).
 
When the ultrasonic technology is clinically used for
grinding of the tooth structure or in the removal of old res-
torations, significant differences in relation to the use of
rotary high-speed handpiece are noticed. These include the
pressure applied, the direction of the grinding head, and the
use of a continuous contact with the tissue or substrate. In
relation to the pressure applied, while on the rotary high-
speed instruments, the increase of pressure increases the
removal of the structure; with the sonic and ultrasonic
points, the increase of pressure significantly decreases the
grinding effectiveness. That increases the working time and
reduces the durability of the instrument. This is attributed to
the fact that the pressure applied by the dentist on the hand-
piece counteracts the anterior-­posterior vibration that natu-
rally happens on the device, decreasing the effectiveness of
the grinding. The ideal pressure for the handling of an ultra-
sonic device is the weight of the handpiece itself, avoiding an
extra pressure from the operator.
The reduced pressure is considered to be a factor that
contributes to the reduction of tooth sensitivity during the
use of ultrasonic points [14]. Some studies demonstrated that
the use of ultrasonic devices for cavity preparation is more
comfortable for the patient. It allows for a psychological
reprogramming and an improvement of the pain threshold,
when compared to the use of high-speed rotation, reducing
the need of anesthetics in some procedures [10, 15]. The
reduction of sensitivity should not reflect in complete elimi-
nation of the anesthetic procedure. The variations among
patients in relation to the pain threshold, the psychological
preparation, and the depth of the cavity preparation should
be taken into consideration on the choice of treatment.
Besides reduced pressure, lower teeth sensitivity can be due
to reduced dentinal fluid movement and heating of the tooth
structure. This is because in CVD devices, the water used in
irrigation slightly warms up as it passes through the hand-
piece, avoiding thermal discomfort to the dentin [7, 14, 28].
An in  vivo study has compared the dentin-pulp complex
Instruments and Equipments
a b
..      Fig. 4.39  Points with various shapes with CVD diamonds. a Regular grit; b fine grit; c adapter for the CVD diamond point to connect the
device
..      Fig. 4.40  Formation of bubbles during the use of the ultrasonic
diamond points
response between the use of CVD point for ultrasonic device
and the diamond point for high-speed handpiece in human
molars. It concluded that none of the systems caused signifi-
cant changes to the odontoblastic layers [7].
The abrasion speed of the CVD systems is slower than the
rotary instruments. Therefore, procedures that require the
cut of big amounts of substrate, such as prosthetic tooth
151 4
preparations, removal of metallic or ceramic prosthesis, or
endodontic access, are not indicated for ultrasonic points
[14]. The ultrasonic system presents an average of 2 minutes
longer working time in comparison to the rotary high-speed
handpiece [8]. However, amalgam restorations become loose
during removal with the ultrasonic device, which turns the
work easier.
All the points have a 60° angulation, and some models have
double angulation. Under the action of the ultrasonic device,
the active end vibrates back and forth on the same plane
defined by the point. This movement results in areas with dis-
tinct grinding effectiveness around the head. The anterior and
posterior areas of the head cause a greater impact and faster
grinding over the surface to be worn than the sides of the head.
Both lateral surfaces are in a perpendicular plane to the ante-
rior-posterior movement generating no impact. The oscilla-
tions of the sides produce a more characteristic movement of
polishing, resulting in a smoother surface. In a comparative
evaluation, moving the head forward grinds out faster than
backward. In general, the most efficient grinding happens
when the device is moved toward the head side. To increase
the efficiency of grinding, the head must be constantly moved,
but this movement cannot be associated with pressure. To start
a cavity preparation, the movement must begin with slight
 152 S. E. de Paiva Gonçalves et al.
pressure and circular movement, for the tip of the head to
achieve a more effective grinding. However, to enlarge the cav-
ity, an anterior-posterior movement must be used, also with a
slight pressure and avoiding the lever movement.
Another advantage of the use of the ultrasonic device is
its selective grinding. It only works on hard tissues, without
harming the soft tissues. That is why no harm or bleeding of
the lips, cheeks, and tongue, as well as no piercing of the rub-
4 ber dam, polyester matrix strips, or gauze and cotton rolls, is
usually observed.
4.5 Complementary Instruments
Most of the complementary instruments to the restorative
procedures are similar in appearance to the hand cutting
instruments, but with differences in the blade. The amalgam
carver, for example, has blades for sculpting instead of blades
for dental cutting. For the non-cutting instruments, the blade
is replaced by nibs with various applications. In the amalgam
condenser and burnisher, the blade is replaced by flat and
dull nibs, respectively. Special spatulas are used for mixing
materials and others to carry the protecting or restorative
materials into the cavity. Other complementary instruments
include the clinical mirror, exploratory probes, tweezers, and
pliers, besides the anesthetic syringe and small pots, as pre-
sented here [25].
a b
..      Fig. 4.41  a First-surface mirror; b second-surface mirror; c clinical mirror with different sizes
4.5.1 Clinical Mirror
For the procedures performed in the mouth, it is important
that the dentist has a perfect vision of the operating field.
Whenever possible, the direct vision must be used. However,
in specific areas of the mouth, the indirect vision obtained
with a clinical mirror is the only option to allow for an ade-
quate visualization of the operating field. The indirect vision
helps clinicians to keep a correct work posture, without the
need to lean the body forward or sideward. The mirror also
allows for light reflection, which helps illuminate the area
that is being examined or treated [25]. The clinical mirror
also serves to put away the cheeks, tongue, or lips to aid for
the access and visualization [25]. For clear vision, the reflex-
ive surface of the mirror must be above the glass, on the so-­
called first-surface mirror (. Fig.  4.41a). Some mirrors
present the reflexive surface under the glass, which is called
the second-surface mirror, resulting in distortions and dou-
ble and less clear images (ghost images and waviness)
(. Fig.  4.41b). To differentiate both types, an instrument
should be put in contact with the mirror (. Fig. 4.41a). If the
instrument touches the image, it is a first-surface mirror.
Clinical mirrors have a circular shape and are presented in
several sizes, related to determined reference numbers
(3–1.95 cm, 4–2.23 cm, and 5–2.43 cm). The most commonly
used in adults are the numbers 4 and 5. For the areas of hard
access or for children, the number 3 can be useful
Instruments and Equipments
153 4
a b c d e f g
a

d
..      Fig. 4.43  Exploratory probes. a–c Straight probes; d, e curved
probes; f inactive end probe; g straight probe with bended end

..      Fig. 4.42  Different types of tweezers and forceps. a, b Clinical

tweezers; c Miller articulating paper forceps; d Halstead mosquito a b c d
forceps

(. Fig. 4.41c). Most mirrors have flat surfaces creating a 1:1

 

sized image, while others have a concave surface, which

slightly increases the image size [25].

4.5.2 Tweezers and Forceps

The tweezers are other indispensable item in the routine of a

dentist. The clinical tweezer is useful to hold small items,
such as cotton rolls, and carry them into the mouth
(. Fig.  4.42a, b). Another very useful instrument is the
 

Halstead hemostatic mosquito forceps, which is similar to a

tweezer but with a lock, and is used to firmly insert or remove
items, such as the interproximal wooden wedges
(. Fig. 4.42d). The Miller articulating paper forceps was cre-
 

ated to bring into the mouth the articulating paper, in ..      Fig. 4.44  Different types of spatulas. a Spatula No. 22; b spatula
between the dental arches, to mark the contact between No. 50; c spatula No. 24; d spatula No. 36
opposing teeth (. Fig. 4.42c).
 

4.5.3 Exploratory Probe 4.5.4 Mixing Spatula

The exploratory probe or dental explorer is a pointed instru- A great variety of restorative materials need to be mixed with
ment used for tactile examination of irregularities on the tooth a spatula, over a paper block or a glass plate, before use. The
surface and restorations, and determination of the consistency spatulas are available in different sizes and thickness, depend-
of tissues. The most used type has the shape of a hook ing on the application (. Fig. 4.44a–d). The large spatulas are
 

(. Fig. 4.43e). Another common type presents a straight end

 
with a fold in a straight angle (. Fig. 4.43g). In general, these
 
two tips are associated with the same instrument. Another use-
ful probe is known as “cow horn” or “pigtail” (. Fig.  4.43d).   small quantities of resin cements. The thin spatulas are more
There are also probes with straight end for endodontics
(. Fig. 4.43a–c) or probes with dull end for checking the root
 
surfaces, on the diagnose of carious lesions or periodontal dis-
ease (. Fig. 4.13f). Most of the instruments available in the mar-
 
ket are double-ended, presenting different tips on each side.
used to mix large amounts of materials, while the small ones
are for reduced quantities, such as in the case of protective
lining materials. Small spatulas have also been used to mix
flexible than the thick ones, and the choice between one over
another depends on the material to be mixed [25]. The zinc
oxide-eugenol cement, for example, needs a more rigid spat-
ula, while the glass ionomer cement is easily mixed with a
flexible spatula.
 154 S. E. de Paiva Gonçalves et al.
4.5.5 Instrument for Filling and Modeling
The plastic filling instruments are used for carrying materi-
als into the cavities and sculpting composites or GIC, to
restore the shape of the damaged tooth structure. Various
options are available, made in many shapes and with differ-
ent materials (. Fig. 4.45a). The most used instrument has
two paddle-­shaped flat ends, in perpendicular directions,
4 which are very useful to shape anterior restorations
(. Fig.  4.45a). Some instruments are also covered with a
non-sticking coating of titanium nitride of golden color
(. Fig. 14.47k). Different combinations are available for
double-ended instruments, such as a flat nib on one side and
a plugger or a small sphere on the other side, that help to
adapt the material into cavities with difficult access (. Fig.  
14.47j). In addition, those instruments are also used to help
the rubber dam placement and for the insertion of gingival
retraction cords.
There are also sculpting instruments with silicon nibs,
which present the advantage of being non-sticky (. Fig. 4.45b,  
c). Other instruments that are very useful for modeling resin
composites are special brushes with tips in various shapes.
The best ones are made of natural Kolinsky fur or synthetic
materials (. Fig.  4.45d). The flat brushes are particularly
a b
c d
..      Fig. 4.45  a Many types of plastic filling instruments for sculpting
composites; b instruments with silicon tips (silicon brush – Micerium);
c silicon sculpting instruments (Esthetics Plus, TDV); d brushes with
­ seful to smoothen up the superficial layer of esthetic resto-
u
rations (. Fig. 14.38u).
The retraction cord packing instruments are available with
straight or round edge. Their thin edges and fine serrations
sink into the cord, preventing it from slipping off and reduc-
ing the risk of cutting the gingival attachment (. Figs. 4.46a
and 14.44c). Finally, another instrument that is used for apply-
ing protective materials is the calcium hydroxide liner place-
ment instrument (. Figs. 4.46b and 9.18g). It presents a tiny
sphere on the nib that retains the material, which can be pre-
cisely applied in areas of difficult access. This instrument is
also commonly used for the application of GIC.
4.5.6 Condensers
The condensers or pluggers are instruments used to condense
and adapt the amalgam toward the walls of a cavity prepara-
tion (. Fig. 11.6j, k). Their nibs are flat and generally circular
in cross section, even though some models can also be rect-
angular- or diamond-shaped. There are basically three types
of condensers, the ones developed by Black have a cylindrical
nib, while the ones developed by Hollenback have cone-
shaped nibs. The pluggers created by Ward have inverted
different shapes (on the left the Kolinsky fur and on the right synthetic
fur – Kota)
Instruments and Equipments
155 4

a b

..      Fig. 4.46  a Retraction cord packing instruments; b calcium hydroxide liner placement instrument

a b

..      Fig. 4.47  Amalgam condensers. a Ward; b Black

cone-shaped nibs (. Fig. 4.47a, b). The pressure of condensa-

 
a b c d e f g h
tion is related to the force applied by the operator and to the
diameter of the nib. The small ones result in more pressure
and are ideal to condense the material in places of difficult
access, such as retention areas. The large nibs are used to con-
dense large amounts of material on the occlusal surface.

4.5.7 Carvers

The carvers are used to shape amalgam restorations (. Fig.  

11.6y). The blades must be kept sharp to provide effective-

ness. The most used carvers are the No. 3 and No. 3S
(Hollenback carvers), the discoid (on the shape of a disc) and
the cleoid (claw-shaped), the set of instruments developed by ..      Fig. 4.48  Amalgam carvers (a IPC; b, c and d Frahm set; e discoid;
f cleoid; g Hollenback 3; h Hollenback 3S)
Frahm, and the interproximal carver (IPC) (. Fig. 4.48). The
 

use of each instrument depends on the site and type of anat-

omy to be reproduced, besides individual preferences during densation of the material and create a smoother surface
the use. More details will be provided in 7 Chap. 11.
  (. Fig. 11.6h, i, j). . Figure 4.49 shows examples of different
   

burnishers.

4.5.8 Burnishers
The burnisher is an instrument that has a dull nib with many
shapes. It is used by rubbing the nib on the surface of amal-
gam restorations, before and after carving, to improve con-
4.5.9 Intraoral Carriers
Intraoral carriers are instruments used to carry material into
the cavity preparation, similarly to a syringe. They have a
 156 S. E. de Paiva Gonçalves et al.

cannula with a circular cross section, where the material is 4.5.11  Matrix Retainer
compressed, and an embolus that when pressed pushes the
material out. There are many models available in the market, The matrix retainers are instruments designed to hold a
depending on the desired application. . Figure 4.50a shows
 
metallic strip, called matrix band, used to give contour to
carriers for silver amalgam, while . Fig. 4.50b shows carriers
 
restorations at the proximal surfaces (. Fig. 8.2a). There  

for powder materials, such as calcium hydroxide pro-analysis are many types available in the market, as it can be
(PA) and the mineral trioxide aggregate (MTA). observed in . Fig.  4.52a–c. More details are presented in
 

7 Chap. 8.
4
 

4.5.10  Scissors
The scissors are used in operative dentistry for many pur-
poses, such as to cut matrix strips, rubber dam, and retrac-
tion cords. The most commonly used scissors are with a fine
tip also called Iris scissors. These can reach areas of difficult
access inside the mouth, as in the moment when the septum
4.5.12   lamps, Clamp Forceps, and Rubber
C
Dam Punch
The clamps are instruments designed to adapt to the cervical
area of the tooth, allowing the fixation of rubber dam in a
rubber dam isolation (. Fig.  4.53a). Clamps are taken to

of rubber dam in the interproximal spaces needs to be cut, to position by clamp forceps, as it is shown in . Fig. 4.53b. The  

remove the rubber dam isolation. The Iris scissors have this rubber dam punch forceps is an instrument used to open
name because they were originally designed for the fine detail holes on the rubber dam (. Fig. 4.53c). More details are pre-
 

work of ophthalmic surgery. There are also the so-called scis- sented in 7 Chap. 7.
 

sors for gold, used in the past to cut gold foil for direct resto-
rations. Both types can present straight or curved ends,
depending on the application (. Fig. 4.51a, b).
 

a b c d a

..      Fig. 4.49  Amalgam burnishers (a egg shape; b Bennett;

c ­Hollenback No. 6; d Clev-Dent burnisher) ..      Fig. 4.51 Scissors. a Iris scissors; b Scissors for gold

a b

2
3

..      Fig. 4.50  a Amalgam carriers (1 10A-PF, Duflex; 2 12A-H, Duflex; 3 S.S. White model, Duflex); b powder material carriers (1, MTA carrier,
Angelus; 2, MTA 010 M carrier, Golgran)
Instruments and Equipments
a
c
..      Fig. 4.52  Matrix retainers. a Tofflemire; b Ivory; c Siqveland
a a
b
c many shapes, with or without lids (. Fig. 4.55a–f).
..      Fig. 4.53  a Clamps; b forceps for clamps; c Ainsworth rubber dam
punch
4.5.13  Pliers
Some pliers can have a very important role in restorative pro-
cedures, helping to adjust the clamps (7 Chap. 7) or to bend
the matrix strips, as it is the case of the “flat-nose” pliers
(. Fig.  4.54a). The riveting pliers (. Fig.  4.54b) are used to
157 4
a
..      Fig. 4.54  a Flat-nose plier; b riveting pliers
c d
e
b
f
..      Fig. 4.55  Dappen dishes. a Glass; b plastic; c silicon; d plastic with
lid; e stainless steel with lid; f Teflon coated
prepare a custom-made matrix and its use is explained in
7 Chap. 12 (. Fig. 12.15a–o).
4.5.14  Dappen Dishes
Dappen dishes are very useful pots that retain relatively small
quantities of materials, such as abrasive agents, gels, solutions
and adhesives, used during the restorative treatment. Dappen
dishes can be made of glass, plastic, silicon, or even metal, in
 
4.5.15  Carpule Syringe
The carpule syringe or dental syringe is used to inject local
anesthetics, which allows for the control of pain during treat-
ment. It presents a system that allows adaptation of the dental
carpules, which are small cylindrical tubes containing dental
anesthetics, and needles of small diameters which are screwed
onto dental syringes (. Fig. 4.56 – 1, 2, and 3).
4.6 Vision Magnifiers
The quality of work performed by the clinician has direct
relation with the capacity to clearly visualize the operating
field. Therefore, devices that amplify the vision are very use-
ful in restorative procedures. Among the vision magnifiers,
there are the dental loupes, which are attached to the head of
 158 S. E. de Paiva Gonçalves et al.
the dentist or on their glasses, allowing for a magnification of
up to four times the size of the original image (. Figs. 4.57a  
and 2.17f). Dental loupes with greater magnification capacity
are generally heavy and can restrict head movement and
impair the stability of the vision field. In the 1970s the use of
the dental operating microscope has been introduced in den-
tistry. Despite the name, the device does not allow for micro-
scopic observation of objects, providing a magnification that
4 can range from 3 to 20 times [18]. Similar instruments for
laboratorial use are known as stereomicroscope (. Fig. 4.57b).   1980s, the device was reintroduced to the market and it was
The use of the microscope allows the dentist to work on a
more ergonomic posture. Moreover, some models transfer
the images on to a screen and are able to record the dental
procedure on a personal computer.
Tip
There are some loupe systems associated with
headlights, which facilitates visualization of the working
environment.
4.7 Airborne-Particle Abrasion
The technique of airborne-particle abrasion consists of the
use of abrasive aluminum oxide particles expelled in high
..      Fig. 4.56  Disposable needle (1), carpule syringe (2), and dental
carpules
a b
..      Fig. 4.57  Vision magnifiers. a Dentist using dental loupes during clinical procedure; b dental operating microscope
speed by air blow of high pressure. The friction of the parti-
cles with great kinetic energy on the tooth surface promotes
an abrasion. In the 1940s, an electrical abrasive instrument
called Airdent, manufactured by the S.S.  White company,
was launched onto the market to be used on cavity prepara-
tions. However, at the time, all the restorations needed a
defined geometrical shape, which could not be obtained with
this technology. For this reason, its use was abandoned. With
the popularization of the restorative adhesive materials in the
better accepted [25]. One advantage of this method is the
absence of vibration and noise, which is a characteristic of
the high-speed handpiece, besides allowing minimally inva-
sive cavity preparations. Large particles (50 μm) can be used
to promote a faster grinding, while small particles (27 μm)
are recommended to promote a slower grinding.
One disadvantage of the previous devices was that they
generated a lot of dust, because of the spreading of particles
and debris in the oral environment. In the more modern
devices, the powder jet on the center of the tip is surrounded
by a water jet, which allows for less contamination of the
environment with the powder. Airborne-particle abrasion
devices are available as independent units or attached to the
compressed air outlet of the dental delivery units (. Fig. 4.58a,
b). Some devices can slightly heat the water to decrease the
discomfort caused by the thermal shock, in the cases where
anesthesia is not being used.
4.8 Laser
The word LASER is an acronym for light amplification by
stimulated emission of radiation. The light is electromag-
netic energy which moves through space, with specific
characteristics according to the wavelength. As examples of
electromagnetic waves with different wavelengths, from the
smallest to the greatest, there are the gamma rays, the
X-rays, the ultraviolet, the visible light, the infrared, the
microwaves, and the radio waves. On the so-called visible
light, the wavelength can vary from 390 to 770 nm, being
Instruments and Equipments
159 4

a b

..      Fig. 4.58  Air abrasion device. a PrepStart H2O (Danville); b air abrasion handpiece – RONDOflex (KaVo)

captured by human eyes and identified by the brain as vari-

a
ous colors. Each color corresponds to a range of wavelength.
However, the emitted light by the laser presents peculiar
characteristics, different for example, from the solar light or
from the ones that come from a conventional bulb. The WHITE LIGHT
laser light has monochromaticity, collimation, and coher-
ence [26]. The first of them is related to the color. While in
the white light coming from a light bulb there is a mixture
of many different wavelengths, on laser there is only one
wavelength and color, being called a monochromatic light.
. Figure  4.59a shows a schematic representation of the
 

white light and laser passing through a prism. The white LASER
light is separated in its different wavelengths, while the laser
does not separate. In addition, the regular light waves travel b
in different directions, while in the laser all the waves travel
on the same direction, forming a collimated beam
(. Fig.  4.59b). The third characteristic of the laser corre-
 

sponds to coherence. It means that the many waves that

compose the beam are emitted in a way that its crests and
valleys coincide (. Fig. 4.59c).
 

The theory of stimulated emission of radiation was pro-

posed by the physicist Albert Einstein in 1917. However, it
was only converted into reality by the studies of Charles
H. Townes in 1950, by means of amplification of the micro-
waves with the MASER device, and by Theodore Maiman in
1060, when the first laser equipment was built with the ruby
crystal [11]. The emission of the light from laser devices
happens by a quantum process. It is known that the atoms c
present a nucleus, composed of protons and neutrons, and
are surrounded by the electrosphere. On it the electrons are
disposed on energetic sublevels. The closest to the nucleus
an electron is orbiting, the less energy it has, and it is said on
the fundamental state. If this atom receives energy from an
external source, the electron goes to a more external sub-
level, entering to what is called an excited state. In normal
situations, this electron will not be able to maintain this state
and will return to the fundamental state. Therefore, the
absorbed energy is eliminated as a photon, which is a packet
of energy. This process is called spontaneous emission of ..      Fig. 4.59  Characteristics laser light. a Monochromaticity;
radiation. b collimation; c coherence
 160 S. E. de Paiva Gonçalves et al.

In the laser devices, the atoms that are responsible for the
light generation are named active laser medium, and they are
in an environment which can be solid (crystal), liquid, or gas.
When it receives energy from an external source, the elec-
trons of those atoms pass to an excited state. However, before
they eventually return to the fundamental state, they receive
more energy, so it causes the electron to be forced to return to
the most internal sublevel, releasing now two exactly similar
4 photons by stimulated emission, with the same wavelength
and coherence. Therefore, on a process of stimulated emis-
sion, there is a type of cloning of photons, increasing the
quantity of similar photons. The active medium is built
between two mirrors in a device called optical resonator, in a
way that only the photons that travel in the same direction
are used, allowing the beam to have a collimation [26].
Depending on the characteristics of the target tissue, dif-
ferent interactions between the laser and the substrate can
happen. The laser light can be reflected by the surface of the
material it hits, be transmitted through it, spread on its inte-
rior, or be absorbed. What determines which effect will take
place is the characteristics of the substrate. The most impor-
tant biological effects happen when the light is absorbed,
where the light energy is converted in heat, on the so-called
photothermal effect. Depending on the quantity of heat gen-
erated, the laser energy can be used to coagulate or vaporize
the tissue. For the light to be absorbed, the spectrum of the
laser emission has to coincide with the peak absorption of
the target tissue. However, even when the heating is low, bio-
logical effects called photochemicals may also occur.
. Table  4.3 shows the effect of different temperatures over

Depending on the material used as an active medium, the tissues.

many wavelengths can be produced. The active medium is
mixed with the other materials that compose the environ-
ment where the light is produced. For example, in the ruby ..      Table 4.3  Temperature and respective effect over the
laser developed by Maiman, the ruby is a crystal of alumi- biological tissues
num oxide that contains a little chromium inside, and the
chromium is the active medium. On the helium and neon Tempera- Effects
gas lasers, the neon atoms are the ones that generate the ture
characteristic red light. Therefore, the active medium gives 37–60 °C Heating, absence of visual change
the name to the laser. Each type of active medium is capa-
ble of generating a specific wavelength, and it can be part 60–100 °C Denaturation of the protein and coagulation,
shrinkage of the tissue, hemostasis
of the visible or non-visible spectrum of light, such as the
ultraviolet or the infrared [23]. The laser can be emitted Above Vaporization, disintegration of the tissue, cut,
continuously or in a pulsing way, in an attempt to control 100 °C ablation
the heat produced. Depending on the power output, the Above Carbonization of the organic materials, melting
devices can be classified into high- or low-power laser 400 °C and crystallization of the inorganic material
(. Table 4.2).
 

..      Table 4.2  Types of laser, active medium, power, wavelength, and operational mode

Type Active medium Power Wavelength (nm) Mode

Infrared CO2 High 10,600 Continuous

Er,Cr:YSGG High 2780 Continuous/pulse

Er:YAG High 2940 Continuous/pulse

Ho:YAG High 2060 Pulse

Nd:YAG High 1064 Continuous/pulse

Diode laser (GaAlAs) Low 850 Continuous/pulse

Visible Diode laser (GaAlAs) Low 650 Continuous

HeNe Low 633 Continuous

Argon High/low 514; 488 Continuous

Ultraviolet XeF High 351 Pulse

XeCl High 308 Pulse

KrF High 248 Pulse

Arf High 193 Pulse

Instruments and Equipments
161 4
The effects of the laser depend on its power and how the
a
irradiated tissue interacts with this energy. Therefore, the
equipment that generates low power can promote nonthermal
effects, such as an analgesic and anti-inflammatory action,
and the stimulation of the tissue repair. On the analgesic
effect, it acts from the peripheral receptors up to the stimulus
on the central nervous system. The anti-­inflammatory and
antiedema effect results from the acceleration of the micro-
circulation, promoting changes at the capillary hydrostatic
pressure, with reabsorption of the edema and the elimina-
tion of the deposit of intermediate catabolites. In addition,
the low-power laser also increases the cell functions on the
irradiated tissues, accelerating the time for mitosis. This is
mainly observed on the scarring repair of the lesion because
of its greater vascularization and abundant formation of
granulation tissue. As examples of the low-power devices,
there are the HeNe (helium-neon) laser and the low-power
diode lasers that emit on the visible red or on the infrared
spectrum [11, 24, 30]. They are used in operative dentistry
for the treatment of the tooth hypersensitivity and on cases
of pulpal inflammation. On the other hand, the high-power
devices are used in cutting and for coagulation and vaporiza-
tion of tissues in medicine and dentistry, besides other indus-
trial applications [12, 30]. The most used high-­power lasers
over the tooth structure are the erbium:yttrium aluminum
garnet (Er:YAG); erbium, chromium:yttrium, scandium, gal-
lium garnet (Er,Cr:YSGG); and neodymium:yttrium alumi-
num garnet (Nd:YAG).

4.8.1 Erbium Lasers

b
The Er:YAG and Er,Cr:YSGG are solid-state lasers, where the
active medium is formed by erbium or erbium and chro-
mium atoms, inside a synthetic crystalline material of the
garnet group, composed of yttrium and aluminum (YAG) or
yttrium, scandium, and gallium (YSGG). The Er lasers have
an excellent interaction with tooth tissues due to the
­wavelength of 2.79 and 2.94 μm, which coincides with the
maximum absorption of water, commonly available in bio-
logical tissues. Those lasers are also absorbed by collagen and
hydroxyapatite available in the tooth structure. When
absorbed, a great quantity of energy concentrated in a very
small area of the tissue causes an immediate evaporation of
water content. This results in an abrupt expansion, leading to
..      Fig. 4.60  Er:YAG Laser device (Key III – KaVo); b handpiece for
a small explosion that mechanically eliminates pieces of the cavity preparations
tissue, called photomechanical ablation [2, 13].
The Er lasers are indicated for cavity preparations. This
device has red light guide since the erbium laser is not on desired. The enamel is a more mineralized tissue and
the visible spectrum (. Fig.  4.60a, b). The standard hand-
  requires more energy for ablation, while the dentin requires
piece works without contact and must be adjusted by the less energy to produce ablation [11, 30]. A significant differ-
operator to the correct distance (. Fig. 4.60b). Innumerous
  ence in relation to the preparation with rotary instrument is
researches demonstrate that the energy used must vary that laser does not produce smear layer, leaving a clean
according to the tissue to be irradiated and the effect that is ­surface (. Fig. 4.61a–d).
 
 162 S. E. de Paiva Gonçalves et al.

a b

c d

..      Fig. 4.61  Tooth surface treated with Er:YAG laser. a Aspect of a laser pulse over enamel; b greater magnification of the prepared enamel
surface; c aspect of a laser pulse over dentin; d greater magnification of the prepared dentin surface
Instruments and Equipments
163 4
4.8.2 Nd:YAG Laser a

This laser uses as an active medium the neodymium atoms

inside a solid matrix composed of a crystal of yttrium and alu-
minum garnet, emitting a wavelength on the infrared region of
1.064 μm (. Fig. 4.62a, b). This laser is used in dentistry due to
 

its cutting, vaporization, and coagulation properties, mainly on

soft tissue surgeries. When applied over the tooth structure, it
promotes the melting and the recrystallization of the surface,
producing an antimicrobial effect. Therefore, it is used for seal-
ing the grooves and the fissures and on the disinfection of root
canals. However, since there is no refrigeration, depending on
the energy used, it can cause carbonization of the tissue or even
an undesired effect on the adjacent soft tissues. The light is
applied by means of an optical fiber. Because it is not visible, it
also uses low-power red laser as a guide light (. Fig. 4.62b).
 

The application of the Nd:YAG laser before the applica-

tion of adhesive systems has shown to cause negative effects
on the bond strength. It impairs the penetration of the adhe-
sive into the tooth substrate (enamel/dentin) as laser melts
the tissue, making it more resistant to the acid etching
(. Fig. 4.63a–d). However, favorable results were observed in
 

some studies, when the laser was applied after the etching
and the application of the adhesive system, prior to light cur-
ing [1, 12, 16]. Therefore, its use during adhesive procedures
is still extremely controversial and should not yet be indi-
cated for clinical use. The application of the Nd:YAG laser
over the enamel, with simultaneous application of topical
fluoride, has shown excellent results on the reduction of the
hydroxyapatite solubility. This technique has been recom-
mended for caries prevention [29].
b

4.8.3 Safety Procedures

Due to the fact that it is a highly concentrated light, the effects

of laser can be extremely deleterious when unintentional irra-
diation happens, as on the eye, for example. All the laser equip-
ments are accompanied by specific glasses to filter the different
wavelength emitted by each light. The safety glasses of the
Nd:YAG device, for example, must not be used during the pro-
cedure with the Er:YAG or any other, because they are abso-
lutely specific for each equipment (. Fig.  4.64). The room
 

where the devices are used must have a sensor on the door,
which automatically turn off the laser, in case any person comes
in inadvertently [26]. The devices have security keys and some
also have protected pedals, a way to guarantee that the beam is
only emitted under the total control of the operator.
..      Fig. 4.62  a Nd:YAG laser device PulseMaster 600 IQ (American
­Dental Technologies); b optical fiber to apply laser over the tooth
structure
 164 S. E. de Paiva Gonçalves et al.

a b

c d

..      Fig. 4.63  Tooth surface treated with Nd:YAG laser. a Aspect of the laser pulse over enamel; b greater magnification of the prepared enamel
surface; c aspect of a laser pulse over dentin; d greater magnification of the prepared dentin surface
Instruments and Equipments
165 4
mantada para caneta de alta rotação em molares humanos. Vale do
Paraiba University – UniVap. São José dos Campos; 2006.
8. Carone FM, Vieira DV. Comparação do tempo de trabalho no prep-
aro cavitário entre as pontas CVDentus em Ultra-som e as pontas
diamantadas em alta rotação. Técnicas Estéticas. 2007;4:42–6.
9. Corrêa AA. Dentistica Operatória. Artes Médicas: São Paulo; 1979.
10. Diniz MB, Gianotto RM, Cordeiro RC.  Remoção de tecido cariado
com pontas CVD ultrassonicas como estratégia de manejo de cri-
ança. Rev Inst Cien Saude. 2008;26:263–6.
11. Genovese WJ. Laser de baixa intensidade. Aplicações Terapêuticas
em Odontologia. Lovise Ltda: São Paulo; 2000.
12. Gonçalves SE, de Araujo MA, Damião AJ.  Dentin bond strength:
influence of laser irradiation, acid etching, and hypermineralization.
J Clin Laser Med Surg. 1999;17:77–85.
13. Gutknecht N, Eduardo CP. A Odontologia e o Laser. Quintessence:
São Paulo; 2004.
14. Lima LM, Motisuki C, dos Santos-Pinto L, dos Santos-Pinto A, Corat
EJ. Cutting characteristics of dental diamond burs made with CVD
technology. Braz Oral Res. 2006;20:155–61. https://doi.org/10.1590/
S1806-83242006000200012.
15. Mastrantonio SS, Gondim JO, Josgrilberg EB, Cordeiro RCL. Minimiz-
..      Fig. 4.64  Safety glasses for the use of high-power devices ing fear during dental treatment using ultrasonic points. Rev Gauch
Odontol. 2010;58:online.
16. Matos AB, Oliveira DC, Navarro RS, De Paula CE, Matson E. Nd:YAG
Conclusion laser influence on tensile bond strength of self-etching adhesive
The development of dental instruments and equipments systems. J Clin Laser Med Surg. 2000;18:253–7. https://doi.
org/10.1089/clm.2000.18.253.
happened concomitantly with the development of materials
17. Mesquita E, Kunert I. O Ultrassom na Prática Odontológica. Artmed:
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20. Morais ER. O medo do paciente ao Tratamento Odontológico. Rev
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ence of laser in cavity preparation and dentin pretreatment. J Clin Quintessence; 2006.
Laser Med Surg. 2001;19:325–32. https://doi. 26. Torres CRG, Borges AB, Kubo CH, Gonçalves SE, Araujo RM, Celaschi
org/10.1089/104454701753342785. S, et al. Clareamento Dental com Fontes Híbridas LED/LASER. 2nd
2. Bachmann L, Zezell DM.  Estrutura e Composição do Esmalte e ed. São Paulo: Livraria Santos Editora Ltda; 2007.
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Fisica: São Paulo; 2005. tions as ultrasound abrading devices in odontology and relates
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Guanabara Koogan; 1996. ment of enamel against an artificial caries challenge: comparison of
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 167 5

Nomenclature
and Classification of Cavities
and Tooth Preparations
Carlos Rocha Gomes Torres and Ana Carolina Botta

5.1 Introduction – 168

5.2 Nomenclature – 168

5.2.1  ental Planes – 168
D
5.2.2 Basic Components of Tooth Preparations – 170
5.2.3 Nomenclature Rules for the Tooth Preparation Components – 172

5.3 Classification of Cavities and Tooth Preparations – 173

5.3.1  lack’s Classification – 174
B
5.3.2 Mount and Hume’s Classification – 177

References – 182

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_5
 168 C. R. G. Torres and A. C. Botta
Learning Objectives
The learning objectives of this chapter are to:
55 Define the nomenclature of tooth preparation
55 Identify the section and delimitation dental planes
55 Identify the walls and angles of tooth preparations
55 Present the nomenclature rules for the tooth preparation
components
55 Describe the historical classification of lesions and tooth
preparations based on the number of surfaces involved,
anatomic location, extension, depth, and susceptibility
5 of caries lesions and other defects
5.1 Introduction
Pathological processes that occur in the oral cavity can
develop lesions on the tooth structure for various reasons: (1)
carious lesions due to the caries process; (2) fractures due to
traumas; (3) abfraction lesions due to occlusal overload asso-
ciated with an unbalanced occlusion; (4) erosive tooth
wear lesions due to the tooth contact with acidic substances
that come from the diet or gastroesophageal reflux; and (5)
abrasion lesions caused by the constant friction with hard
substances over the teeth. These lesions may require surgical
intervention due to loss of dental structure, tooth sensitivity,
and the need of reestablishment of form, esthetics, and func-
tion. Despite the cause, before  the tooth structure to be
restored and the data related to the procedures be registered
and transmitted to other dentists, the location and the com-
ponents of a tooth preparation must be easily identified
through specific nomenclature. G.V. Black (1908) created a
nomenclature system that can be used for all types of tooth
preparations, allowing it to be easily identified by differ-
ent observers [1].
Tooth preparations can be classified in different ways [3].
However, the most common classifications are still the ones
created  by G.V.  Black (1908) [1] and modified by Simon
(1956) [12] and Howard (1973) [5]. This chapter describes the
nomenclature of lesions and tooth preparations and their
historical classification based on the number of surfaces
involved, anatomic location, extension, depth, and suscepti-
bility to caries lesions and other defects.
5.2 Nomenclature
Nomenclature is a system of names or terms used in a par-
ticular science, discipline, or art, by which the professionals
working on that area are able to understand each other. In
order to have a good communication with colleagues and the
dental team, it is very important to become familiar with the
proper terminology of tooth preparations presented in this
chapter.
In the past, most restorative treatments were performed
due to cavitated caries lesions, and the term cavity was used
to describe a caries lesion that promoted a distinct disconti-
nuity or break of the tooth surface integrity. When the
affected tooth was treated, the preparation of the remaining
tooth structure was referred to as cavity preparation.
Currently, as many indications for surgical treatment of
teeth are not related to carious lesions, the preparation of the
tooth should no longer be referred to as cavity preparation
but as tooth preparation [2].
The tooth preparation is the result of a group of operative
procedures that are necessary to remove carious tissue and
produce adequate and compatible shapes to the remaining
tooth structure and to receive a proper restorative material
[3]. The objectives of tooth preparation are to (1) conserve as
much healthy tooth structure as possible; (2) remove all
defects while simultaneously providing protection of the
pulp–dentin complex; (3) create a form on the tooth prepara-
tion so that, under the masticatory forces, the tooth or the
restoration (or both) will not fracture and the restoration will
not be displaced; and (4) allow the adequate placement of a
restorative material [2].
Due to the shapeless aspect of the carious lesions and
other lesions on the hard tissues, the explanations about
nomenclature will be presented on tooth preparations, which
have a more defined geometry. However, whenever possible,
the same terms applied on the prepared cavities can be
applied to describe the parts of the pathological cavities.
5.2.1 Dental Planes
In order to apply names to the components of tooth prepara-
tion, as well to the analysis of the inclinations of preparation
walls, specific references called section and delimitation
planes must be used [10]. Three section planes are used in the
study of human anatomy (. Fig. 5.1). The anatomical plane
that divides the body into right and left portions is called sag-
ittal or median plane (longitudinal, anteroposterior), because
it is a plane parallel to the sagittal suture. The frontal plane or
coronal plane (vertical) divides the body into ventral and dor-
sal portions. The transverse or horizontal plane (lateral, hori-
zontal) divides the body into cranial and caudal portions [4].
The sagittal plane is not ideal for analysis of each tooth
separately due to the curvature of the dental arch (. Fig. 5.2).
The sagittal and frontal planes would involve different sur-
faces from the incisors to the molars [3]. Only the horizontal
plane would not have this variation. For this reason, in addi-
tion to the horizontal plane, two special vertical or axial sec-
tion planes, named axiomesiodistal and axiobuccolingual
planes, or just mesiodistal and buccolingual planes, are used.
Those dental planes are parallel to the long axis of the teeth
and extend in a mesiodistal or buccolingual direction,
respectively. They also divide the tooth into mesial and distal
halves or occlusal and cervical halves, respectively. In
. Fig. 5.3, those planes are sectioning the central position of
all tooth surfaces.
Nomenclature and Classification of Cavities and Tooth Preparations
..      Fig. 5.1  Anatomic planes. F – frontal plane; H – horizontal plane;
S – sagittal plane
..      Fig. 5.2  Difficulties of the use of the sagittal plane on the tooth
nomenclature
Besides the section planes, delimitation planes tangent to
the different tooth surfaces can be used for reference pur-
poses. They are the mesial, distal, buccal/labial, lingual, gingi-
val, and occlusal planes (commonly used as a reference during
169 5
..      Fig. 5.3  Section planes for the tooth structure
..      Fig. 5.4  Delimitation planes
tooth preparation) (. Fig.  5.4). The delimitation occlusal
plane of a tooth is different from the occlusal plane of the
dental arch, which is an imaginary plane extending from the
incisal edge of the incisors along the cusp tips of the posterior
teeth. Although not a real plane, the occlusal plane of the
dental arch represents the mean of the occlusal surfaces cur-
vature.
In order to describe the location of a lesion and tooth
preparation and its extension, the tooth surfaces can be
divided into thirds (. Fig. 5.5) [1, 10]. The occlusal surface,
on the mesiodistal direction, considering the buccolingual
section plane, can be divided into mesial, middle, and distal
thirds. On the buccolingual direction, considering the mesio-
distal section plane, the occlusal surface can be divided into
buccal, middle, and lingual thirds. The mesial, distal, lingual,
and facial surfaces of a crown can be divided into thirds, both
longitudinally and horizontally (. Fig. 5.5). In regard to the
horizontal division, each axial surface of a crown can be
divided into an occlusal (or incisal), middle, and cervical third.
In regard to the longitudinal division, each facial or lingual
surface may be divided into a mesial, middle, and distal third,
while each mesial or distal axial surface may be divided into
a lingual, middle, and facial/buccal third.
 170 C. R. G. Torres and A. C. Botta

5.2.2  asic Components of Tooth

B surface (. Fig. 5.6 – in yellow). The surrounding walls paral-
 

Preparations
Tooth preparations present two basic components: walls and
angles [1]. The walls are the prepared (cut) surfaces of tooth
preparations and can be divided into two types: external and
lel to the long axis of the tooth are named vertical surround-
ing walls, while the ones perpendicular to the long axis of the
tooth are named horizontal surrounding walls. The internal
walls are the ones facing the pulpal chamber and do not
extend to the external tooth surface (. Fig. 5.6 – in blue).

internal. The external walls, also called surrounding walls, The angles are the junction of two or more walls of the
are the prepared surfaces that extend to the external tooth tooth preparations. Although the word angle leads the reader
to imagine a “sharp edge,” in some preparations they can
have a round configuration to reduce  stress concentration.
5 Despite that, those junctions are still referred as angles for
descriptive and communication purposes [11]. They can be
of two types: line and point. A line angle results from the
junction between two walls of different orientations along a
line (. Fig. 5.7), while a point angle results from the junction
 

of three walls of different orientations (. Fig. 5.8).

 

The line angles can be subdivided in external and inter-

nal. The internal line angles are line angles whose apex points
into the tooth. They can be divided into two sets. The first set
includes the ones created by the junction of two external
walls (. Fig. 5.7 red line – 1st S). The second set includes the
 

ones created by the junction of the external and internal walls

(. Fig. 5.7 – black line – 2nd S). An external line angle is a line
 

angle whose apex points away from the tooth such as the
ones formed by the junction between the internal walls
(. Fig. 5.7d–f – blue line – E ).
 

The nomenclature of the walls and angles is based on the

tooth preparation as a cubic space, or the shape of a box.
Although the tooth preparation can have an irregular shape,
its wall and its angles are named as if they have a regular
..      Fig. 5.5  Division of the tooth surfaces in thirds
shape.

BUCCAL OCCLUSAL
a b AXIAL c
PULPAL
LABIAL
LINGUAL
MESIAL AXIAL

DISTAL MESIAL
DISTAL

LINGUAL
GINGIVAL
BUCCAL DISTAL
d e GINGIVAL f
BUCCAL INCISAL
PULPAL
BUCCAL
PULPAL DISTAL LABIAL

AXIAL AXIAL
LINGUAL
BUCCAL
GINGIVAL
AXIAL
AXIAL AXIAL
GINGIVAL
GINGIVAL GINGIVAL

..      Fig. 5.6  Tooth preparation walls. The lines point to the names of the walls. a–f preparations on different teeth and tooth surfaces
Nomenclature and Classification of Cavities and Tooth Preparations
171 5

BP (2nd S) OA (2nd S) MO (1st S)

a MB (1st S) b DO (1st S) c
FL (1st S)

DB (1st S) LA (2nd S)
MP (2nd S) FA (2nd S)
LG (1st S)
FG (1st S)
DA (2nd S) MA (2nd S)
DP (2nd S)

DL (1st S)
ML (1st S)
LP (2nd S) DG (1st S) MG (1st S) GA (2nd S)
st GA (2nd S)
d BP (2nd S) BD (1 S) e f ID (1st S)
IA (2nd S)
DP (2nd S)
BP (2nd S) IF (1st S)
BA (2nd S)
MA (2nd S) FA (2nd S)
DA (2nd S)
LA (2nd S) FG (1st S)
BA (2nd S)
LG (1st S)
BG (1st S)
AG (2nd S)
AP (E)
AG (2nd S) MG (1st S) AG (2nd S)
BG (1st S) AP (E) DG (1st S) AA (E)
AA (E)

..      Fig. 5.7  Line angles: (1st S) Internal first set – red lines; (2nd S) Internal second set – black lines; (E) External angles– blue lines. Their names
correspond to the walls associated to them. a–f preparations on different teeth and tooth surfaces

a b c FAL
MPB

DPB
MPL MAO GAL FAG
OAD
MAG
GAD
DPL

BPD DAI
AIA
d e f

FAI
BAP LAP
DAG FAG
MPA BPA
AGA
BAG
MAG APA
BAG LAG AGA

..      Fig. 5.8  Point angles surrounded by circles. Their names correspond to the walls associated to them. a–f preparations on different teeth and
tooth surfaces
 172 C. R. G. Torres and A. C. Botta

5.2.3  omenclature Rules for the Tooth

N
Preparation Components

In order to simplify the understanding of the tooth prepara-

tion components nomenclature, G.V. Black proposed general
rules [1, 3]:
55 1st rule – The cavity or tooth preparation receives the
name of the surface or surfaces where it is located.

Following this rule, a tooth preparation only on the occlusal

5 surface receives the name of occlusal or “O” preparation
(. Fig. 5.6a). Preparation involving the mesial and occlusal
 

surfaces is called mesio-occlusal preparation or “MO”

(. Fig. 5.6d). Preparation involving the mesial, occlusal, and
 

distal surfaces receives the name of mesio-occluso-distal

preparation or “MOD.” Preparation involving the occlusal
and lingual surfaces receives the name of occluso-lingual
preparation or “OL,” and so on.

..      Fig. 5.9  Sub-pulpal wall (arrow)

Tip

The description of the tooth preparation can be
abbreviated by using the first capitalized letter of the
tooth surface involved.
55 2nd rule – It is necessary to indicate the tooth where the
55 6th rule – The line and point angles receive the names of
the walls from which they are formed.
Therefore, the junction of the buccal and gingival
walls of preparation on posterior teeth with a proximal
involvement is called bucco-gingival line angle or
“BG” (. Fig. 5.7d). In this same preparation, the

cavity or the tooth preparation is located. Therefore, an junction among the buccal, axial, and gingival walls is
occluso-distal preparation on the mandibular right first called bucco-axio-­gingival point angle or “BAG”
molar must be identified with an “OD” on tooth 46 (. Fig. 5.8d). The order to mention the wall that forms
 

(. Fig. 5.6d). A mesio-occluso-distal preparation on the

mandibular right first molar must be identified as
“MOD” on tooth 46. A mesio-occluso-disto-lingual
preparation on the maxillary left first molar must be
identified as “MODL” on tooth 26 (. Fig. 5.6e).
the angle is not important. The angles formed by the
junction of the facial and lingual or facial, lingual, and
axial walls, in preparations that involve the proximal
surfaces of anterior teeth, can also be called the incisal
line or incisal point angles, respectively (. Figs. 5.7c

55 3rd rule – The external wall takes the name of the tooth
surface that the wall is facing.
55 Following this thought, the wall that faces the buccal
surface is called buccal wall. The wall facing the mesial
surface is called mesial wall, and so on (. Fig. 5.6).
55 4th rule – The internal wall next to the pulpal chamber
and parallel to the horizontal plane is called pulpal wall/
floor (. Fig. 5.6a, d, e). When the pulpal chamber is
opened and the dental pulp removed, the wall that is
parallel to the horizontal plane and corresponds to the
floor of the pulpal chamber, receives the name of the
sub-pulpal wall (. Fig. 5.9).
55 5th rule – The internal wall next to the pulpal chamber,
but not parallel to the horizontal plane, is called axial
wall. This type of wall occurs on the anterior teeth
preparations and posterior teeth with the involvement of
the smooth surfaces (. Fig. 5.6b–f).
and 5.8c).
>> The angles receive the names of the walls from which
they are formed.
The angle formed by the junction among the buccal, axial,
and gingival walls can be called BAG, GAB, ABG, and so on.
55 7th rule – The angle formed by the junction of the
external surface of the tooth and a prepared wall is
called cavosurface angle. The cavosurface angle may
differ with the location on the tooth, the direction of
the enamel rods on the prepared wall, or the type of
restorative material to be used [2]. For better identifica-
tion, it is convenient to specify the wall associated with
the cavosurface angle. Therefore, the buccal, lingual,
mesial, and distal cavosurface angles can be observed
in . Fig. 5.10a, while in . Fig. 5.10b, the occlusal,

>> The axial wall is an internal wall that is oriented parallel
to the long axis of the tooth. The pulpal wall is an internal
wall that is oriented perpendicular to the long axis of the
tooth and is located occlusally to the pulp. This internal
wall may also be referred to as the pulpal floor [2].
gingival, mesial, and distal cavosurface angles are indi-
cated. The terms preparation margin or cavosurface
margin are also used to designate the junction of the
tooth surface with the restorative material after it has
been applied [5].
Nomenclature and Classification of Cavities and Tooth Preparations
a b
d e
..      Fig. 5.10  Cavosurface angles are pointed. a–f preparations on different teeth and tooth surfaces
5.3  lassification of Cavities and Tooth
C 55Onlay – preparation that covers one or more cusps of
Preparations
The word “classify” means to arrange in groups or categories that
have similar characteristics. Many classifications of the cavities
produced by the caries lesion have been proposed throughout
history, according to its different aspects and treatments avail-
able. The simplest way to classify a cavity or a tooth preparation
is according to the number of surfaces that are involved [7, 10]:
55 Simple cavities or preparations involve only one tooth
surface. As an example, those placed exclusively on the
occlusal, facial, lingual, or proximal surfaces (. Fig. 5.6a–c).
 
55 Compound cavities or preparations involve two tooth
surfaces. As examples, the occluso buccal,
mesio occlusal, mesiolingual preparations, etc.
(. Fig. 5.6d, f).
 
55 Complex cavities or preparations involve more than two
tooth surfaces (. Fig. 5.6e). The most common example
 
is the MOD tooth preparation.
Tooth preparation can also be classified according to its
extension in the following types [7, 11]:
55 Intracoronal or inlay – preparation that is limited to the
interior of the tooth structure, without the covering of
any cusp. An inlay is usually “boxlike”, having internal
and external walls (. Fig. 5.11).
 
55 Partial coverage extracoronal – can be of two types
according to the number of cusps that are covered:
173 5
c
f
a tooth but not all of them (. Fig. 5.11b–d)
55Overlay – preparation that covers all cusps of a tooth
but does not cover all smooth surfaces, with some
parts of facial and/or lingual surfaces remaining
preserved (. Fig. 5.11e)
55 Full coverage extracoronal or full crown – preparation
that involves all the cusps and completely cover all the
smooth surfaces of the teeth (. Fig. 5.11f).
The preparations can also be classified according to the
restorative plan in [7]:
55 Therapeutic preparations are the ones made with the aim to
restore the tooth structure that was damaged by the caries
disease, erosive tooth wear, abrasion, abfraction, or fractures.
55 Prosthetic preparations are the ones that are made in intact
teeth, when it is necessary to make some indirect restora-
tion that will support artificial teeth on an edentulous
space. However, when they are made on partially
destroyed teeth, they also have a therapeutic aim.
Another way to classify the tooth cavities and preparations is
in relation to its depth and proximity to the pulp, as presented
on . Fig. 5.12a–f. The depth of the preparation is extremely
important on the determination of the restorative technique
to be used and on the protection that will be applied to the
dentin-pulp complex. According to Mondelli [6], they can be
classified in the following types:
 174 C. R. G. Torres and A. C. Botta
a b
d e
..      Fig. 5.11  Classification of the tooth preparation according to their extension. a Inlay; b–d onlay; e overlay; f full crown
55 Shallow preparation – with the internal walls at the level
before or slightly after the dentin-enamel junction (DEJ)
(. Fig. 5.12b).
 
55 Medium preparation – with the internal walls from 0.5 to
1 mm beyond the DEJ (. Fig. 5.12c)  
55 Deep preparation – with the internal walls beyond half
the thickness of the dentin but still keeping more than
0.5 mm of remaining dentin between the wall and the
pulpal chamber (. Fig. 5.12d).   of bacterial biofilm
55 Very deep preparation – the remaining tooth structure
between the internal wall and the pulpal chamber is
smaller than 0.5 mm, allowing the visualization, due
transparency, of a pink discoloration in the internal wall
because of the presence of the pulp underneath it. There
is a great probability that small pulpal exposures that
cannot be seen clinically exist (. Fig. 5.12e).   classes based on the tooth areas affected by the diseased and
55 Pulpal exposure – an evident communication between
the pulp and the tooth preparation (. Fig. 5.12f).  
Other classifications of the caries lesions are presented
in other chapters of this book. The ICDAS classification is
presented in the 7 Sect. 3.9 of 7 Chap. 3, while the radio-
   
grafic lesion depth on 7 Chap. 16 (. Fig. 16.9).
   
5.3.1 Black’s Classification
The two classifications of the cavities and tooth preparations
proposed by G.V.  Black (1908) [1] are still the most
c
f
used  worldwide, which are the etiologic and the artificial.
The etiologic classification grouped the cavities according to
the susceptibility to caries lesions in specific tooth areas, due
to the difficulty of good hygiene and the easy growth of bac-
terial biofilm. Based on this, the etiologic classification has
two categories:
55 Pit and fissures – located in zones with greater suscepti-
bility to develop caries lesions due to the accumulation
55 Smooth surfaces – located in zones with relative
immunity to caries lesions, due to self-cleaning effect
provided by the contact with the soft tissues or the food
bolus
The artificial Black’s classification arranged the cavities into
the associated type of treatment. Five classes were originally
created [1]. Lately, Simon [12] included a new class to the
original Black’s classification.
55 Class I – cavities and tooth preparations located on
regions of pit and fissures of the posterior and anterior
teeth, without the involvement of the proximal
surfaces (. Fig. 5.13a–g). These include prepara-
tions on:
55Occlusal surface of premolars and molars
(. Fig. 5.13a, b, g).
55Occlusal two-thirds of the buccal surface of the
mandibular molars (. Fig. 5.13a, c).
Nomenclature and Classification of Cavities and Tooth Preparations
a b
d e
..      Fig. 5.12  Classification of the tooth preparation, according to their depth. a Intact tooth; b shallow; c medium; d deep; e very deep; f pulp
exposure – arrow
a b
d e f
..      Fig. 5.13  a–f Class I caries lesion (arrows). g Occlusal erosive tooth wear lesion due to the abusive ingestion of acidic beverages
55Occlusal two-thirds of the lingual surfaces on
maxillary molars including the lesions on Carabelli’s
tubercle (. Fig. 5.13d).
 
55The lingual pit near to the cingulum on the lingual
surface on the anterior maxillary teeth (. Fig. 5.13e).
 
55Sockwell [13] included in this class the cavities
located on the incisal two-thirds of the labial surface
of the anterior teeth (. Fig. 5.13f).
 
175 5
c
f
c g
55 Class II – cavities and tooth preparations that involve the
proximal surfaces of the posterior teeth (. Fig. 5.14a–f).
Even if the occlusal surface or any other tooth surface is
involved simultaneously, the preparation is still named
Class II.
55 Class III – cavities and tooth preparations placed on the
proximal surfaces of the anterior teeth, without the
involvement of the incisal edge (. Fig. 5.15a–d).
 176 C. R. G. Torres and A. C. Botta

a b c

d e f
5

..      Fig. 5.14  a–f Class II caries lesions and tooth preparations (arrows)

a b

c d

..      Fig. 5.15  a–d Class III caries lesions and tooth preparation (arrows)

55 Class IV – cavities and tooth preparations that involve teeth, with the exception of the lingual surfaces of the
the proximal surfaces of the anterior teeth, with the loss anterior maxillary teeth, which are considered Class I
of the incisal edge (. Fig. 5.16a–d).
  (. Fig. 5.17a–d).
 

55 Class V – cavities and tooth preparations located on the 55 Class VI – cavities and tooth preparations located on the
gingival third of the facial and lingual surfaces of all tip of the cusps and the incisal edges (. Fig. 5.18a–d).
 
Nomenclature and Classification of Cavities and Tooth Preparations
a b
c d
..      Fig. 5.16  a–d Class IV caries and dental fracture lesions (arrows)
Black’s artificial classification revealed a chronological order,
following the sequence of carious lesions development in
individuals of different ages [3]. In young patients, the most
common carious lesions are the Class I, followed by Class II
cavities. In teenagers, Class II and Class III cavities are the
most prevalent. The Class IV cavities may be a complication
of the Class III due to trauma or progression of carious lesions.
Finally, the Class V cavities are found, more frequently, in
elderly patients [3]. Although being developed to describe the
caries lesions, the Black’s classification has been also used to
identify the preparations and restorations (e.g., a Class I amal-
gam preparation or a Class I amalgam restoration) [2].
5.3.2 Mount and Hume’s Classification
Graham J.  Mount and W.  Rory Hume [9] proposed a new
classification for cavities and preparations. Due to the modi-
fications on the cutting instruments’ technology for tooth
preparation, the development of adhesive restorative materi-
als, and the current possibility of replacement of some restor-
ative procedures by preventive measures, those authors
concluded that Black’s classification failed by omitting the
lesion extension, which is related to the decision about surgi-
cal and nonsurgical approaches [8].
177 5
This classification was based on two characteristics to
describe the lesion on the tooth structure: site and size. This
allows dentists to have a better understanding of the involve-
ment of the tooth structure by the lesion and the selection of
the most adequate treatment for each situation. This classifi-
cation also simplifies the electronic data records and subse-
quently the communication among clinicians.
According to the site, the lesions can be located on:
55 Site 1 – It describes all the lesions on located on pits
and fissures of the occlusal surfaces of the posterior
teeth, besides other defects on smooth surfaces of a
tooth [9]. This includes grooves on the buccal surfaces
of the mandibular molars, lingual groove on maxillary
molars, grooves on cingulum, pits on anterior teeth and
similar defects, as well as erosive tooth wear and
abrasion lesion on the incisal edges of the anterior
teeth and the occlusal surface of the posterior teeth
(. Fig. 5.19a–f) [9].
Tip
Site 1 includes all the lesions identified as Class I and VI
according to Black’s classification.
 178 C. R. G. Torres and A. C. Botta
a b
c d
..      Fig. 5.17  a–d Class V caries and non-carious lesions (arrows)
55 Site 2 – It describes all lesions associated with the contact
areas and placed below them, on the occlusal two-thirds
of the tooth crown, both on anterior and posterior teeth
(. Figs. 5.20a–g and 5.21a–g) [9].
 
Tip
Site 2 includes all the lesions identified as Class II, III,
and IV according to Black’s classification.
55 Site 3 – it describes all the lesions originated next to the
gingival areas, on the cervical third of the crown or areas
of exposed root, both on enamel, cement, or dentin,
around the whole circumference of a tooth, including the
proximal surfaces (. Fig. 5.22a–i).
Tip
Site 3 includes the Class V according to Black and also
lesions in root surfaces located on the mesial or distal
surfaces, after gingival recession.
According to the size, the lesions can be classified as:
55 Size 0 (incipient) – It is a small and subsurface lesion,
without cavitation, that can be remineralized or that has
already remineralized, and there is only a residual stain
[9]. No restoration is necessary for this size of lesion,
and only preventative treatments are recommended.
55 Size 1 (minimum) – It is a lesion that progressed to the
point of transition, where it cannot be exclusively treated
with a preventative approach, and an operative interven-
tion is indicated [9]. There is a small cavitation but with
minimum involvement of dentin.
55 Size 2 (moderate) – It is a large lesion, but there is still
sufficient sound tooth structure to maintain the integrity
of the remaining crown and resist to the occlusal forces,
without the need for additional changes on the tooth
preparation, other than the removal of the carious tissue
[9]. There is a moderate involvement of the dentin.
55 Size 3 (enlarged) – It is a more extended lesion. The
remaining tooth structure is weakened to the extent that
cusps or incisal edges are split or are likely to fail if left
exposed to occlusal or incisal load [9]. The tooth
preparation needs to be modified so that the restoration
can be designed to provide support and protection to the
remaining tooth structure [9].
Nomenclature and Classification of Cavities and Tooth Preparations
a b
c d
..      Fig. 5.18  a–d Class VI caries and attrition lesions (arrows)
55 Size 4 (extensive) – it is a lesion that has extensive loss of
tooth structure such as a cusp of a posterior tooth or an
incisal edge of an anterior tooth [9].
The application of this classification must include the use of
both characteristics (site and size), as can be observed in
. Table 5.1.
 
In . Figs. 5.19, 5.20, 5.21, and 5.22, examples of this clas-
 
sification are shown, applied to clinical situations. If there are
multiple lesions on the same tooth, each one of them must be
reported separately.
Example
Examples of lesions description according to the Mount and
Hume’s classification:
55 “Lesion 2.4 on the distal surface of the tooth 12” indicates
that the lesion on the distal surface of the maxillary right
179 5
lateral incisor progressed in such a way that the incisal
edge was lost. It suggests the need of a large esthetic
restoration on this tooth.
55 “Lesion 2.1 on the mesial surface of the tooth 46” indicates
that there is a small lesion on the mesial surface of the
mandibular right first molar. It suggests the need of a
minimally invasive tooth preparation.
55 “Lesion 2.2 on the OD surfaces of the tooth 36” indicates
that there is a lesion of a moderate size, involving the
occlusal and distal surfaces of the mandibular left first
molar, with enough remaining tooth structure to resist to
occlusal forces.
55 “Lesion 3.1 on the buccal surface and a lesion 2.2 on the
MOD surfaces on the tooth 47” indicates that there are two
distinct lesions on the mandibular right second molar. One
small cervical lesion on the buccal surface and one moderate
lesion involving the mesial, occlusal, and distal surfaces.
 180 C. R. G. Torres and A. C. Botta

a b c

d e f

..      Fig. 5.19  Use of the Mount and Hume’s classification at the site 1. a Size 0; b size 1; c size 2; d size 3; e, f size 4

a b c d

e f g

..      Fig. 5.20  Use of the Mount and Hume’s classification at the site 2 on posterior teeth. a Size 0; b size 1; c size 2; d, e size 3; f, g size 4
Nomenclature and Classification of Cavities and Tooth Preparations
181 5

a b c d

e f g

..      Fig. 5.21  Use of the Mount and Hume’s classification at the site 2 on anterior teeth. a Size 0; b, c size 1; d size 2; e size 3; f, g size 4

a b c d

e f g h i

..      Fig. 5.22  Use of the Mount and Hume’s classification at the site 3. a Size 0; b size 1; c–f size 2; g, h size 3; i size 4

..      Table 5.1  Possibilities of application of the Mount and Hume’s classification

Size

Site 0 1 2 3 4

Incipient Minimum Moderate Enlarged Extensive

1 – Pit/fissure 1.0 1.1 1.2 1.3 1.4

2 – Contact areas 2.0 2.1 2.2 2.3 2.4

3 – Cervical area 3.0 3.1 3.2 3.3 3.4

 182 C. R. G. Torres and A. C. Botta
Conclusion
This chapter has addressed the nomenclature of lesions and
tooth preparation and their classification. Dentistry has
developed terminology useful in the communication of all
aspects of tooth preparation, among dental students, profes-
sors, and clinicians. The nomenclature and classification of
tooth preparations effectively describe preparation aspects
with regard to complexity, anatomic location, three-­
dimensional orientation, geometry, and susceptibility of car-
ies lesions and other defects. The classification of lesions is
5 also important in regard to the patients’ treatment plan, influ-
encing whether a restorative or preventative approach
10. Ritacco AA. Operatória Dental: Cavidades Modernas. 2nd ed. Bue-
should be taken into consideration.
References
1. Black GV. A work on operative dentistry. London: Chicago Medico-­
Dental Publishing Company; 1908.
2. Boushell LW, Walter R. Fundamentals of tooth preparation. In: Ritter
AV, Boushell LW, Walter R, editors. Sturdevant’s art and science of
operative dentistry. 7th ed. St. Louis: Elsevier; 2019. p. 120–35.
. Corrêa AA. Dentística Operatória. Artes Médicas: São Paulo; 1979.
3
4. Dangelo JG, Fattini CA. Basic Dental anatomy. Rio de Janeiro: Athe-
neu; 1988.
5. Howard WW. Atlas of operative dentistry. 2nd ed. St. Louis: Mosby;
1973.
6. Mondelli J. Proteção do Complexo Dentinopulpar. São Paulo: Artes
Médicas; 1998.
7. Mondelli J, Franco EB, Pereira JC, Ishikiriama A, Francischone CE,
Mondelli RF, et  al. Dentística: Procedimentos Pré-Clínicos. 1st ed.
São Paulo: Santos; 2002. p. 265.
8. Mount GJ, Hume WR.  A new cavity classification. Aust Dent J.
1998;43(3):153–9.
9. Mount GJ, Hume WR. A revised classification of carious lesions by
site and size. Quintessence Int. 1997;28(5):301–3.
nos Aires: Mundi; 1966.
11. Roberson T, Heymann H, Swift E.  Sturdevant’s art and science of
operative dentistry. 5th ed. St Louis: Mosby; 2006.
12. Simon WJ.  Clinical operative dentistry. Philadelphia: Saunders;
1956.
13. Sockwell CL.  Silicate cement and self-curing acrylic resin restora-
tions. In: Sturdevant CM, editor. The art and science of operative
dentistry. New York: McGraw-Hill; 1968.
 183 6

General Principles of Tooth

Preparation and Carious
Tissue Removal
Carlos Rocha Gomes Torres and Falk Schwendicke

6.1 Introduction – 184

6.2 Biological Principles – 185

6.3 Mechanical Principles – 195

6.4 Prior to Tooth Preparation – 199

6.5 Steps of Tooth Preparation – 200

6.5.1  utline Form – 200
O
6.5.2 Resistance Form – 203
6.5.3 Retention Form – 210
6.5.4 Convenience Form – 213
6.5.5 Carious Tissue Removal – 215
6.5.6 Finishing of the Enamel Walls – 218
6.5.7 Cleaning of the Cavity – 218

References – 220

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_6
 184 C. R. G. Torres and F. Schwendicke
Learning Objectives
The learning objectives of this chapter are related to the fol-
lowing topics:
55 To understand the biological and mechanical principles
of the tooth preparation
55 To explain the prior procedures of the tooth preparation
55 To learn about the steps of tooth preparation
6.1 Introduction
The main goal of tooth preparation and carious tissue removal
was and remains the therapy of carious lesions. Traditionally,
6 all carious lesions were managed invasively, i.e., using cutting
or drilling action, and restoratively, i.e., with the placement of
a restoration after the preparation and carious tissue removal.
It is highly relevant to emphasize that, as discussed elsewhere
in this book, current approaches for managing carious lesions
focus on non-restorative measures and only employ invasive/
restorative means if not avoidable or due to aesthetic or func-
tional reasons. Note that tooth preparation and carious tissue
removal are further not strictly separated from each other,
but rather interlink, and that for many modern materials, the
preparation of a specific cavity shape during tooth prepara-
tion has lost some relevance given these materials being
applied defect-oriented. Traditionally, however, and still
applying to materials like amalgam (or ceramics or indirect
metal restorations), the preparation was found to be the foun-
dation for the superstructure, the restorative material; if the
foundation fails, the superstructure will easily succumb to the
stress that the tooth will undergo [1]. In a research performed
by Healey and Philips, it was observed that 56% of the failure
on the amalgam restorations that led to its replacement were
due to incorrect tooth preparations, demonstrating the
importance of this stage for the success of the restorative
treatment [2]. On the other hand, it must be kept in mind that
the tooth preparation is an irreversible surgical procedure,
where mistakes damage tissues in an irreversible way [3].
Tooth preparation is defined as the biomechanical treat-
ment of the carious lesion and other lesions on tooth hard
tissues, in a way that the remaining tooth structure can
receive a restoration that protects it, is resistant to the occlu-
sal stress, and prevents the disease recurrence [4]. Note that
tooth preparation performed for reasons other than caries,
like erosive tooth wear, abrasion, abfraction, attrition  or
other non-cariogenic hard tissue defects, will not include
the carious tissue removal step [5].
Tooth preparation is defined as the biomechanical treat-
ment of the carious lesion and other lesions on tooth
hard tissues, in a way that the remaining tooth structure
can receive a restoration that protects it, is resistant to
the occlusal stress, and prevents the disease recurrence.
The main objectives of tooth preparation are (1) provid-
ing access to and allowing removal of the carious tissue, (2)
providing clear margin (in a conservative way) where the
restoration can end, and (3), for certain materials, providing
a cavity shape so that under biting forces, the tooth and/or
the restorations do not fracture and the restoration do not
displace [5].
After the tooth preparation is ready, the restoration of the
lost structure is performed, recovering the shape, function,
and aesthetics of the tooth [4–6]. Therefore, it is the dentist’s
responsibility to reconstruct the damaged tooth structure
and complete its anatomy, reestablishing its function, allow-
ing the patient to clean the restored surface while preserving
the  sound remaining tooth structure and pulp vitality.
Especially on the anterior teeth, the restoration must present
an adequate color match with the remaining tooth structure,
recovering the aesthetic.
It is important to remember that the restorative proce-
dure just repairs the damage caused by the carious disease
and other problems; but this, by itself, does not eliminate the
etiological factors that initially caused the lesion. To recover
the patient’s health, an effective preventive program must be
established, leading to a situation of low risk to develop new
lesions [5]. Wherever possible, active lesions should be con-
verted to inactive ones, helping the processes of defense and
healing of the dentin and pulp. Before recommending an
invasive treatment, noninvasive strategies should be consid-
ered, as every restoration has statistically only a limited life-
time. The decision to restore a tooth may begin a repetitive
restorative cycle, where the restorations are changed several
times during the life of the patient, and in each replacement,
the cavity preparation gets bigger, resulting in an additional
destruction of the tooth tissue, which may eventually lead to
the extraction of the tooth. Every time that the dentist pro-
poses the replacement of a restoration, the size of the prepa-
ration tends to increase, due to inadvertently cut of healthy
tissue around the old restorations. In addition, as restoration
fails oftentimes for different reasons (mainly secondary car-
ies and fractures), that may also affect the remaining dental
tissues [7].
>> The restorative procedure just repairs the damage
caused by the carious disease and other problems; but
this, by itself, does not eliminate the etiological factors
that initially caused the lesion.
>> Before recommending an invasive treatment,
noninvasive strategies should be considered first, as
every restoration has statistically only a limited
lifetime. The decision to restore a tooth may begin a
repetitive restorative cycle, where the restorations are
changed several times during the life of the patient,
and in each replacement, the cavity preparation gets
bigger, resulting in an additional destruction of the
tooth tissue, which may eventually lead to the
extraction of the tooth.
General Principles of Tooth Preparation and Carious Tissue Removal
However, when a cavitation already exists, noninvasive mea-
sures will oftentimes not be able to arrest the lesion. The cav-
ity needs to be filled by a restorative material, which is shaped
to recover the tooth contour, allowing the control of the bac-
terial biofilm [7]. Other reasons to perform an invasive treat-
ment are when the teeth show hypersensitivity to heat, cold,
and sweet; when the attempts to arrest the lesion had failed;
when some improvement on tooth function or aesthetics is
needed; or when a dental displacement is probable to occur
due to the loss of the interproximal or occlusal contact [7].
Restorations can be performed on three different ways,
and they are the direct, the semi-direct, and the indirect tech-
niques [8]. Using the direct technique, the restorative mate-
rial is applied and shaped by the dentist directly into the
tooth preparation in the patient’s mouth, creating the final
restoration in one clinical session. Using the semi-direct
technique, the restoration is also made in one clinical session,
but the restoration is handled outside the mouth and then
cemented into the tooth. The semi-direct technique can be
intra- or extraoral. The intraoral technique consists in apply-
ing the restorative material directly into the tooth prepara-
tion, and, after curing, the restoration is removed, finished,
and polished outside the mouth. After that, it is cemented
into the tooth preparation. In the extraoral technique, an
impression or scanning of the tooth preparation is per-
formed. In the first case, an impression of the preparation
with alginate is obtained, and a fast-setting material is used to
prepare a model. Generally, a special die silicone material is
used, which is applied inside the impression, creating a flex-
ible model [9]. The restoration is made chairside by the den-
tist using composite resin and then cemented into the
preparation. On the second case, the three-dimensional
information of the preparation and surrounding teeth is
transferred to a CAD/CAM system (computer-aided design
and computer-aided manufacturing) using an intraoral scan-
ner. Then, the restoration is prepared by the machine and
cemented by the dentist. In the indirect technique, after the
tooth preparation, an impression using a silicone material or
an intraoral scanning is performed and a interim restoration
is performed. Then a plaster or digital model is obtained and
sent to a laboratory, where the laboratory technician will pre-
pare a restoration (either using conventional techniques or
digitally using CAD-CAM). After sending back to the den-
tist, it is cemented on the prepared tooth. The indirect tech-
nique requires two clinical sessions.
>> Dental restorations can be performed on three
different ways, which are the direct, the semi-direct,
and the indirect techniques.
An extremely important point when studying tooth prepara-
tions are the bonding properties presented by some restorative
materials. Based on the bonding to the tooth structure, we can
divide direct restorations in two types: adhesive and nonadhe-
sive restorations. When a tooth is restored with a nonadhesive
material, such as dental amalgam, the remaining tooth struc-
ture and the restorative material behave as two independent
185 6
structures, but in perfect contact. Therefore, under bite stress,
the adequate distribution of the force on the tooth-restoration
interface is fundamental for the preservation of the remaining
tooth structure and of the restoration itself. In this case, aspects
like uniform depth of the preparation, specific shapes of the
walls, and defined marginal configurations become important
[5]. On the other side, the adhesive capacity that some restor-
ative materials have modifies this scenario, because the forces
applied over the remaining tooth structure are transmitted
through the adhesive interface to the restorations, and vice
versa, so that both behave similar to one, not two bodies,
reducing the interference of the cavity shape. Therefore, the
very precise requirements for the tooth preparation of nonad-
hesive restorations are reduced for adhesive ones. As described
briefly above, the most common type of adhesive restoration,
the resin composite ones, requires mainly the removal of the
carious tissue, without the need to prepare uniform and spe-
cific cavity depth, designs for the walls, or marginal shapes.
This simplification of the preparations is due to the physical
characteristics of the composite and to the bond of the tooth
structure [5]. Due to that, most of the adhesive restorations
increase the fracture resistance of weakened teeth, which does
not happen with conventional amalgam, for example [10].
The general principles of the tooth preparation can be
divided into two groups, named biological and mechanical.
Biological principles are related to the preservation and the
protection of the tooth structure and periodontal tissue,
whereas mechanical principles are related to the factors asso-
ciated with stress distribution inside the remaining tooth
structure and restorative material, transmitted through the
tooth-restoration interface.
6.2 Biological Principles
The success of the clinical procedures requires a comprehen-
sion of the anatomic and biological nature of the tooth, with
its components enamel, dentin, pulp, and cement, as well as
supporting tissues. A clinical practice that violates the physi-
cal, chemical, and biological parameters of the dental tissues
can lead to premature failure of the restorations, compromis-
ing the integrity of the crown, leading to secondary caries,
discomfort to the patient, and eventually pulpal necrosis [3].
Enamel is composed mainly from hydroxyapatite crys-
tals, with about 88% per volume, organized in a pris-
matic arrangement, creating a hard and strong structure that
protects the vitalized dental tissues, namely, the dentin and
the pulp. There are about 3000–4000 prisms (or rods) per
mm2 of enamel (. Fig. 6.1a–d) [3]. Among the prisms, there
is a mineralized structure called interprismatic enamel (or
interrod) (. Fig.  6.1b). Even though most of the enamel is
organized as prisms, a more external and smaller layer has
crystals organized parallel to one another and perpendicular
to the surface, called the prismless enamel (. Fig. 6.1d).
The prisms run from the dentin-enamel junction (DEJ)
to the external surface of the tooth (. Fig.  6.1a), and each
 186 C. R. G. Torres and F. Schwendicke

a b

c d

..      Fig. 6.1  a Photomicrography showing the longitudinal section of the interprismatic enamel (red arrows); c cross section of the enamel
the enamel prisms “E” starting on the DEJ and following parallel to prisms showing the prism core “P” and the interprismatic enamel (red
each other; b greater magnification showing the prisms core “P” and arrows); d prismless enamel “PL” and prismatic enamel “P”

successive row drives through a slightly different path, fol-
lowing the pattern of a wave and a spiral course, producing a
different arrangement for each group or layer of prisms. They
change the direction horizontally and vertically, changing
from clockwise to anticlockwise directions and vice versa,
from the dentin to the external tooth surface [3, 11]. They
initially follow a curved track through 1/3 of the thickness of
the enamel next to the DEJ. Then, the prisms usually follow a
more direct track through the last 2/3 of the enamel to the
surface. The borders of the enamel prisms form natural cleav-
age lines through which the longitudinal fractures can hap-
pen [3]. On the most external layer, where they are parallel,
the enamel is more prone to fracture. This external enamel
also has bigger prisms [12]. Groups of prisms of enamel can
intertwine with other groups, creating the gnarled enamel,
which happens next to the tip of the cusps and incisal edge.
General Principles of Tooth Preparation and Carious Tissue Removal
a b
..      Fig. 6.2  a Presence of undermined enamel over an amalgam restoration (arrow); b fracture of the undermined enamel following the direction
of the prisms after receiving a load on this region
The gnarled enamel is not prone to fractures like regular
enamel, being as a result of functional adaptations of the
enamel rods in areas of high loads.
The enamel is as hard as steel, with a Knoop microhard-
ness of 340, much higher than the dentin microhardness,
which is around 70 [13]. A normal physiological contact
between opposite teeth wears the enamel in a rate of 29 μm a
year [14]. However, its effect on the vertical dimension can be
compensated by the apical cementogenesis and passive tooth
eruption [3]. Although the tooth enamel presents high
microhardness, which gives it resistance to wear, it is also
very brittle. When it is properly supported by dentin, this
characteristic is not relevant in terms of fracture resistance.
The dentin provides flexibility, and is capable to absorb the
occlusal loads received by the enamel, preserving its integrity
[15]. However, undermined enamel loses more than 85% of
its resistance [15]. If a nonadhesive restorative material (such
as the amalgam) is used under the undermined enamel, the
load applied over the enamel will not be absorbed and dissi-
pated by the material under it, and there is a great possibility
of enamel fracture (. Fig. 6.2a, b).
 
>> Although the tooth enamel presents high
microhardness, which gives resistance to wear, it is also
very brittle. When it is properly supported by dentin,
this characteristic is not relevant in terms of fracture
resistance. However, undermined enamel loses more
than 85% of its strengths.
There are two possibilities to solve the problem related to the
presence of undermined enamel. The first one is to remove it
completely, even though this represents an increase of the
final dimensions of the tooth preparation. The second possi-
bility is to create artificial support to the enamel, providing
its reinforcement, by using a restorative material that bonds
to the tooth structure and simulate the mechanical behavior
of the dentin [16]. For example, glass ionomer cements can
187 6
be used as dentin replacement (. Fig. 6.3a–c), or full com-
posite resin restorations can be performed (. Fig. 6.3d). 
For nonadhesive restorations, cavity margins should hence
follow, preferably, the same direction of the enamel prisms,
avoiding that undermined prism remains. Otherwise, mar-
ginal degradation can occur, leading to deposition of bacte-
rial biofilm and caries lesion development [15]. To reach this
goal, the direction of the prisms on all the tooth surfaces
must be known.
In order to study the direction of the enamel prisms on
the occlusal surfaces, the inner cusp inclines can be divided
into three parts (. Fig. 6.4a). The prisms on the central third
of the occlusal surfaces always lean toward the grooves in
the direction of the center of the crown. The prism below the
occlusal grooves is parallel to the long axis of the tooth, but
the prisms in each side vary about 20° [17]. The greater the
cusp angle, the greater the inclination of the prisms will be.
On the medium third of the cusp inclines, the prisms trend
to become perpendicular to the surface, whereas on the
external thirds, that is, next to the cusp tip and marginal
ridges, the prisms trend to lean to those tips. On the cusp
tip, the prisms are almost parallel with the long axis of the
tooth [15]. In the smooth surfaces, the prisms on the occlu-
sal or incisal third lean toward the occlusal or incisal sur-
face, around 24° in relation to a line perpendicular to the
tangent plane on this region [3, 17]. On the medium third,
they form a 90° angle with the tangent plane on this region,
whereas on the gingival third, they lean around of 2° toward
the cervical in relation to a line perpendicular to the tan-
gents (. Fig. 6.4b) [15, 18].
In a circumferential analysis, the prisms around the tooth
are perpendicular to the tangent plane (. Fig. 6.4c, d) [15]. In
order to create enamel walls with the margins following the
direction of the prisms, the whole direction of the cavity wall
(CW) can be modified or only the enamel margins. This last
procedure is called marginal trimming (. Fig. 6.50).  
 188 C. R. G. Torres and F. Schwendicke
a b
6
c d
..      Fig. 6.3  Different ways to treat the undermined enamel. a Carious
lesion with undermined enamel; b removal of the carious tissue
preserving the undermined enamel (dotted line); c dentin “replace-
As it has already been mentioned, the dentin is resilient,
and it presents a good capacity to bear compression, due to
its elasticity, and absorb the impact hitting the enamel, avoid-
ing its fracture [3]. This is due to the presence of a high
organic content, of about 30% by volume, mainly composed
by type I collagen fibers, associated to 45% of inorganic
­material and 25% of water [3]. The dentin has many tubules
running from the pulpal chamber to the DEJ. Encircling each
tubule is the peritubular/intratubular dentin, formed mostly
by minerals, while between them is the intertubular dentin,
where the collagen fibers are located (. Fig. 6.5a–d).
 
Another very important function of the dentin is to pro-
tect the pulpal tissue. Every time a preparation with a specific
shape is prepared, as required for nonadhesive restorations,
dentin tissue may be lost. To avoid dentin loss in deep areas
of the cavity, base materials may be used. Instead of removing
the healthy tooth structure to allow a uniform depth of the
cavity, a base material can be used to level out the cavity floor
(. Fig. 6.6a–d).
 
The dentin can be classified in  three types, namely pri-
mary, secondary, and tertiary. The primary dentin is formed
fast by the odontoblasts during the odontogenesis, until the
end of the root formation. After this point, the dentin contin-
ues to form slowly, gradually reducing the internal volume of
ment” using glass ionomer cement, followed by an amalgam restora-
tion; d completely adhesive restoration using composite resin
the pulpal chamber; this one is called secondary dentin.
Contiguously throughout the person’s life, peritubular dentin
is constantly produced by the odontoblasts. As a result, the
tubule lumen gradually becomes narrower. When external
aggression occurs, it is detected by the pulp cells, and the for-
mation of new dentin inside the pulpal chamber is increased,
generating the so-called tertiary dentin. It can be classified in
reactional or reparative. When low levels of irritative stimu-
lus occur, such as the penetration of acids from a carious
lesion through the tubules, that stimulate the odontoblasts to
react and form more dentin on the region related to the
affected tubules. Such tertiary dentin is called reactionary
dentin. However, a high level of irritative stimulus or the
pulpal exposure can destroy the odontoblastic layer. In that
case, undifferentiated mesenchymal cells in the pulp will
migrate to the area and differentiate to odontoblast-like cells,
producing a kind of tertiary dentin named reparative dentin.
In this case, the tubular organization is very different from
that of primary or secondary dentin. The formation of ter-
tiary dentin serves to protect the pulp from diffusion or pen-
etration of bacteria and metabolic products.
There is another kind of dentin named sclerotic
(. Fig. 6.7a, b) [3]. Actually, the sclerotic dentin is the same
primary or secondary dentin but with a greater mineraliza-
General Principles of Tooth Preparation and Carious Tissue Removal
a b
+ 24 °
-2 °
c d
..      Fig. 6.4  Direction of the prisms. a Longitudinal section of the
crown on the buccolingual direction and the orientation and direction
of the prism on each region; b direction of the prisms observed on the
cervical third of smooth surfaces; c transverse cross section of the
tion. It is always associated with a carious lesion that stimu-
lates the pulp reaction. The rate of peritubular dentin
deposition increases, obliterating the tubules. Moreover, cal-
cium and phosphate released from dentin hydroxyapatite, by
the bacterial acids, reprecipitate deeply inside the tubules
below the lesion, filling them up [19, 20]. The preservation of
sclerotic dentin is the best way to protect the pulp. It should
never be removed, although has a darkened color, ranging
from brown to black. It is very hard on probing, as it contains
a greater amount of minerals and radiographically appears as
a radiopaque region (. Fig. 6.7b). The sclerosis is a predict-
 
able response that protects the dentin tubules in more than
95% of the teeth with caries lesions [3].
Tip
The preservation of sclerotic dentin is the best way to pro-
tect the pulp. It should never be removed, although has
a darkened color, ranging from brown to black. It is very
hard on probing, as it contains a greater amount of miner-
als and radiographically appears as a radiopaque region.
189 6
crown showing the direction of the prisms in relation to the external
surface; d prisms oriented on a perpendicular direction in relation to
the external surface
Another important aspect to be considered during
tooth preparation is to avoid the heating of the tooth struc-
ture. The friction of the cutting or abrasion instruments,
when they are not cooled properly, can lead to very high
temperatures. This heat is easily transmitted to the pulp,
causing injuries. Zack and Cohen reported that the con-
tinuous contact of a dental bur on a tooth for 25 s, without
cooling, can produce an increase of the pulp temperature
up to 6 °C above the normal [21]. Another study from the
same authors showed that a temperature increasing of
5.5 °C above the normal situation can lead to irreversible
damage of the pulpal tissue in 15% of the cases. They also
showed that a temperature increasing of 11 °C will result in
pulp necrosis in 60% of the cases [22]. The heating can not
only occur during tooth preparation but also during pol-
ishing of restorations at high speed or with excessive pres-
sure [23–25].
To avoid such problems, the high-speed handpieces
must only be used with a strong spray of air-water, and the
contact between instrument and tooth should not be con-
tinuous but intermittent [5, 26]. In cavities with a box
shape, the use of high-speed handpieces with only one
 190 C. R. G. Torres and F. Schwendicke

a b

c d

..      Fig. 6.5  Dentin tubules. a, b Cross section; c, d longitudinal section (I, intertubular dentin; P, peritubular dentin)

water outlet may not allow sufficient cooling of the active Tip
head of the rotary instrument, because the water jet will hit
the external surface of the tooth and not enter the cavity Handpieces with several air-water spray outlets are
(. Fig. 6.8a). Therefore, handpieces with several air-water
  required, avoiding the occurrence of blind spots with
spray outlets are required, avoiding the occurrence of blind insufficient cooling of the active head of the bur.
spots (. Fig.  6.8b). Moreover, sharp burs or diamonds
 

should always be used, increasing their cutting or abrasion

efficiency and reducing the heating generation. In addition, It is also important to avoid excessive drying of the dentin with
restorative material with small exothermal curing reac- air blows [27]. As can be observed in . Fig. 6.9a–c, the dentin
 

tions and low heating light-­ curing units should be has several tubules, which have direct contact with the pulp.
employed [27]. Due to the presence of interstitial fluid in the pulp, the tubules
General Principles of Tooth Preparation and Carious Tissue Removal
191 6

a b

c d

..      Fig. 6.6  Creating a flat pulpal wall through the application of a bur; c prepared cavity with an irregular pulpal wall; d filling of the
base material. a Pulpal wall with remaining carious tissue on the irregular area with GIC (arrow)
central region; b removal of the carious remaining tissue with a round

a b

..      Fig. 6.7  Sclerotic dentin. a Clinical aspect of the darkened dentin on the pulpal wall; b radiography of the same clinical case showing the
radiopaque aspect at the floor of the cavity (arrow)

are constantly filled by the so-called dentinal fluid. A pulpal a suction force is created, which aspirate the odontoblasts kill-
pressure of about 11 mmHg creates a flux of this fluid toward ing the cells. That results in postoperative sensitivity, forcing
the outer dentin surface [28]. A very intense drying causes the the pulp to promote the recovery of the odontoblastic layer by
evaporation of the fluid inside the tubules, and, by capillarity, mesenchymal stem cell differentiation (. Fig. 6.9a–c).
 
 192 C. R. G. Torres and F. Schwendicke
a b
6
..      Fig. 6.8  a High-speed handpiece with only one water outlet, resulting in “blind” spots without irrigation (arrow); b handpiece with several
air-water sprays in different directions, producing an adequate cooling
..      Fig. 6.9  Aspiration of the odontoblastic process because of the
excessive drying of the dentin. a Cell in the normal position; b dentin
fluid being removed due to excessive drying producing the cell
aspiration; c odontoblasts completely aspirated inside the tubule
Tip
The excessive drying of the dentin with air blows can
result in odontoblastic layer death and must be avoided.
Besides avoiding damage to the tooth that will be restored,
tooth preparation procedure should also not cause damage to
the adjacent tooth. Unfortunately, iatrogenic cutting of intact
adjacent surfaces is frequent. A study showed that during the
approximal box preparation, without protection of the neigh-
boring tooth, iatrogenic damage can happen in up to 100% of
the adjacent surfaces, even if the procedure is performed
carefully [29]. The slight contact of a bur or a diamond point
over those surfaces can cause an immediate damage that the
bacteria would take years to create. Therefore, those regions
should be protected with interproximal guards, either by the
use of a steel matrix band, as it will be described on the
following chapters (. Fig. 10.13r–t), or using specific guards
for this purpose, as it can be observed on . Fig. 6.10a, manu-
factured in very strong stainless steel. There is an interproxi-
mal guard that already comes with a wedge attached to it,
protecting at the same time the adjacent tooth and the gingi-
val tissue (WedgeGuard®-Triodent) (. Fig. 6.10b). The metal-
lic strip can be removed, and the wedge be then used during
the restoration step.
It is also very important to consider the thickness of the
enamel and the dentin and their relation to the volume of the
pulpal chamber in each region of the tooth. In . Figs. 6.11a–o
and 6.12a–o, there are pictures of the same teeth obtained
from the intact structure, after complete demineralization to
exhibit the dentin and after further clearing to show the
pulpal chamber. It is possible to analyze different tooth
groups in facial, mesial, and incisal/occlusal view. It can be
observed that the enamel covers the entire anatomic crown
of the teeth with various  thicknesses in different areas.
Enamel is thicker on the occlusal and incisal areas and
becomes progressively thinner on the axial surfaces toward
the cementoenamel junction (CEJ), with a thickness of
0.2 mm on cervical areas. The thickness also varies from one
type of tooth to another, with an average of 2 mm on the inci-
sal edges, ranging from 2.3 to 2.5 mm on the premolar’s cusp
tips and 2.5–3 mm on the molar’s cusp tips. Generally, on the
occlusal surface of posterior teeth, the thickness is reduced
toward the junction of the developmental lobes. On the
internal third of the occlusal cusp inclines, the thickness var-
ies from 0.2 to 0.5 mm and sometimes zero when there is a
fissure in the junction of the lobes. The lingual layers of the
enamel generally are thinner than the facial ones. With the
aging, the enamel thickness on the occlusal surfaces decreases
due to the abrasion promoted by of the food bolus or attrition
with the opposite tooth, while the mineral content increases
making it more brittle.
The dentin thickness changes throughout the life, due to
the constant deposition of secondary dentin and, in some
General Principles of Tooth Preparation and Carious Tissue Removal
193 6

a b

..      Fig. 6.10  Interproximal guards. a InterGuard® (Ultradent); b Wedgeguard® (Triodent)

a b c

d e f

g h i

..      Fig. 6.11  Crowns of maxillary teeth in a facial, mesial, and occlusal/incisal view, showing the thickness of the enamel and the volume of the
pulpal chamber. a–c Central incisor; d–f lateral incisor; g–i canine. j–l premolar; m–o molar
 194 C. R. G. Torres and F. Schwendicke
j k
m n
6
..      Fig. 6.11 (continued)
situations, also tertiary dentin, reducing the volume of the
pulpal chamber (. Fig. 6.13a, b). It is known that the second-
 
ary dentin is deposited preferably on the pulpal horns and on
the pulpal chamber roof and floor, causing that, after many
decades, it becomes very narrow on the occlusogingival direc-
tion [30]. Therefore, the tooth preparation on the teeth of a
young patient presents a significantly greater chance of pulpal
exposure than on those of a patient with more advance age.
>> The tooth preparation on teeth of a young patient
presents a significantly greater chance of pulpal
exposure than on those of a patient with more
advance age.
It is known that the shape of the pulpal chamber follows the
morphology of the tooth cusps. Therefore, when a preparation
is performed to create a flat pulpal wall, not following the exter-
nal contour of the crown, there will be areas where pulpal tissue
is closer to the wall, resulting in a greater risk of accidental
exposure. On the mandibular first premolars, for example,
there is a very large discrepancy of the cusp volume, resulting in
a buccal pulp horn much larger than the lingual one. Therefore,
as will be presented on further chapters, the classic shape of a
cavity for silver amalgam is modified, making the pulpal wall
parallel to a plane that tangents both cusps, instead of being
perpendicular to the long axis of the tooth, in order to avoid the
accidental exposure of the pulpal tissue (. Fig. 6.14a, b).
 
Another very important biological aspect is related to the
physiological principle of biologic width, which is a natural
seal that develops around the tooth and protect the internal
medium from bacterial penetration [4]. Its preservation or
l
o
recovery is paramount to the periodontal health. The bio-
logic width is the natural distance between the bottom of the
gingival sulcus and the top of the alveolar bone crest, includ-
ing the juntional epithelium and connective tissue attach-
ments (. Fig. 6.15) [31]. In the past, it was proposed to place
the cavity margins inside the gingival sulcus, because this
region was considered an area of relative immunity to the
caries. However, nowadays, it is known that the restoration
interface will almost never be perfect and interfacial defects
and gaps will certainly exist in some regions. Those areas are
susceptible to biofilm deposition, resulting in aggression to
the surrounding gingival tissue [5]. The margins of the resto-
rations placed more than 1 mm inside the sulcus, invading
the biologic width, may be related to the inflammation,
bleeding, hyperplasia, and gingival recession. Therefore, the
preparation margins should, whenever possible, be placed
above the gingival margin [3, 4]. However, when restorations
are placed in aesthetically relevant areas, such as the maxil-
lary anterior region, the preparation margin needs some-
times to be placed a little inside the sulcus, to hide the
tooth-restoration interface, but never invading the biologic
width [3, 4]. With highly aesthetic materials (like composites
or ceramics), this is, however, usually not needed any longer.
The biologic width is the natural distance between the
bottom of the gingival sulcus and the top of the alveolar
bone crest, including the junctional epithelial and con-
nective tissue attachments.
General Principles of Tooth Preparation and Carious Tissue Removal
It is also important to avoid damage to the gingival tissue,
with cutting instruments, during the preparation procedure.
For that, wooden wedges can be inserted into the interproxi-
mal space before the preparation of the proximal boxes
(. Fig. 10.13e). This way, any unexpected contact of the cut-
 
ting instrument will happen on the wedge, and not on the
gingiva [5]. There are also some specific instruments for dis-
placement and protection of the gingival tissue during the
tooth preparation, as shown in . Fig. 6.16.
 
6.3 Mechanical Principles
The external forces applied onto both the restoration and the
remaining tooth structure produce internal stress inside the
restorative material and tooth, being transmitted through the
interface. As it has been mentioned before, for the nonadhe-
a b
d e
g h
..      Fig. 6.12  Crowns of mandibular teeth in a facial, mesial, and occlusal/incisal view showing the thickness of the enamel and the volume of the
pulpal chamber. a–c Central incisor; d–f lateral incisor; g–i canine. j–l premolar; m–o molar
195 6
sive restorations, the restorative material and the remaining
tooth structure behave as independent structures in intimate
contact, which can result in some circumstances in fracture
of the tooth and displacement of the restoration. The
mechanical principles of the tooth preparation have the
objective to avoid that such phenomenon to happen, increas-
ing the longevity of the restorations. Therefore, it is impor-
tant to analyze the adhesive capacity of the restorative
material, its physical properties, and the final characteristics
of the tooth preparation.
The restorations undergo a combination of forces, both in
axial, oblique, and transversal direction [32]. An intact man-
dibular molar requires an axial force of about 300 kg to frac-
ture [32]. However, the maximum biting force reported on
the literature was 81.6 kg [33]. The main question is what is
the resistance of the restored tooth, weakened by the destruc-
tion of its natural structure. According to Corrêa [6], even
c
f
i
 196 C. R. G. Torres and F. Schwendicke
j k
m n
6
..      Fig. 6.12 (continued)
a b
..      Fig. 6.13  a Pulpal chamber of the tooth of a young patient (arrow – pulp horn); b pulpal chamber of the tooth of an elderly patient with a
worn occlusal surface and reduced volume of the pulpal chamber
though it was possible to perform precise mathematical cal-
culation and to determine exactly the intensity of the forces
that the restorations and tooth preparations undergo under
mastication, the clinical reality does not allow such precision.
Instead of building absolute numbers, hence, knowledge
about mechanical principles of tooth preparation and resto-
ration should be applied.
The forces necessary for mastication are produced by the
muscles and are transmitted to the teeth through the alveolar
bone and periodontal ligaments. The response of the tooth is
determined not only by the magnitude of the forces but also
by the nature and position of the contact surfaces. When cer-
tain forces hit inclined planes, such as those created by con-
tacts among the smooth and masticatory cuspal inclines of a
l
o
mandibular premolar with the masticatory cuspal inclines of
a maxillary premolar, they are decomposed, resulting in
horizontal components, producing so-called wedge effect. It
can lead to the displacement or fracture of either the remain-
ing tooth structure or the restoration, depending on which
offers lesser resistance (. Fig. 6.17) [6].
It is possible sometimes  to see the consequences of
the  wedge effect in large MOD nonadhesive metallic res-
torations. When they receive occlusal loads, the forces are
partially transmitted to the surrounding walls, pushing
them and producing cuspal deflection, sometimes resulting
in oblique crack propagation from the internal line angles
toward the cervical area and cusp fractures (. Fig. 6.18a, b)
[4, 34].
General Principles of Tooth Preparation and Carious Tissue Removal
197 6

a b

..      Fig. 6.14  Modification of the cavity shape due to the tooth excessive cutting of the buccal cusp (arrows); b pulpal wall parallel to
anatomy of the first mandibular premolars. a Pulp wall parallel to the the plane that tangents the top of the cusps, avoiding pulp exposure
horizontal plane, with the consequent exposure of the pulp and

GINGIVAL
SULCUS

JUNCTIONAL
EPITHELIUM

CONNECTIVE
TISSUE
ATTACHMENT ..      Fig. 6.16  Protection of the gingiva during the tooth preparation

..      Fig. 6.15  Biologic width (junctional epithelium + connective tissue

attachment). Image kindly provided by Dr. Miguel Angel Castilho
Salgado, professor of Histology at the Institute of Science and
Technology of São José dos Campos – UNESP – Brazil

When the teeth are prepared and the reinforcing struc-

tures such as marginal and oblique ridge are removed, the
cusp elongation phenomenon occurs [35–37], resulting in
even greater cuspal deflection. On intact teeth the cusps have
a mechanic height equal to the anatomic height, measured
from the cusp tip to the bottom of the central groove
(. Fig.  6.19a). When a MOD preparation is created, the
  ..      Fig. 6.17  Wedge effect on an intact tooth
mechanical height of the cusp increases, since it has now the
distance between the tip of the cusp and the gingival wall of effect, for example, by providing an adhesive restoration or
the preparation (. Fig. 6.19b) [34]. The larger and deeper the
  by covering the cusps when the nonadhesive restoration is
cavity, the larger is the mechanical height. According to performed.
Mondelli [4], such elongation can lead to disastrous effects if Strain is the response of a system to an applied stress.
the restoration is not planned to compensate this mechanical When a material is loaded with a force, it produces a stress,
 198 C. R. G. Torres and F. Schwendicke

a b

6
..      Fig. 6.18  a Wedge effect on a restored tooth. The compressive load (vertical arrow) produces tensile stress (horizontal arrows) toward the
cavity walls; b oblique fracture of a cusp, starting on the sharp line angle

a b

..      Fig. 6.19  Phenomenon of the elongated cusps. a The anatomic and mechanic heights of the cusps are equal on intact tooth; b the mechanic
height in a prepared tooth is higher, increasing the cuspal deflection

which then causes a material to deform. In  engineering is fixed, as a cantilever beam, and it receives a lateral load on
the  strain is defined as the amount of deformation in the the free end, known as shear load, one side of the beam will
direction of the applied force divided by the initial length of show tensile and the other compressive stress (. Fig. 6.20c). 

the material.
The tooth structures and the restorations undergo a com-
bination of forces, both axial (compression and tensile) and
oblique or transversal [38]. When a material is loaded with a
force, it produces internal stress that causes a deformation on
the material. The stress is defined as the force per unit area of
a material. According to the direction of the load, the stress
can be compressive, tensile, or shearing (. Fig.  6.20a–c). If
 
the force is of compression nature, as a result of the occlusal
contact with an antagonist tooth or food, compressive stress
will occur in the interior of the material, and the strain will
result in the shortening of the structure (. Fig. 6.20a) [33].
 
If tensile load is applied, such as when chewing sticky
food, the tensile stress will occur and result in the elongation
of the body (. Fig.  6.20b). A very sticky food can generate
 
tensile forces from 5 to 10 kg [38]. If one end of the structure
This type of stress happens, for example, when the cusp elon-
gated after deep tooth preparation contact the antagonist
tooth, or when the lingual surface of maxillary incisors con-
tacts the incisal edge of mandibular incisor [6, 39].
The deformation of the structure can be elastic, which is
reversible and will disappear when the load is removed, or
plastic, when it is permanent. Each restorative material, as
well as the enamel and dentin, has a certain capacity to
undergo elastic deformation under occlusal loads, maintain-
ing its original shape. However, when an inadequate restor-
ative material is used, or the capacity of elastic deformation is
exceeded, a fracture of the restorative material or of the tooth
structure will occur.
Other aspect to be analyzed is that materials, subjected to
repeated loading above a certain threshold, will suffer fatigue
and microscopic cracks will occur at locations of stress con-
General Principles of Tooth Preparation and Carious Tissue Removal
centration. Those can propagate suddenly causing cata-
strophic failure. Fatigue can be defined as the weakening of
the materials by damage accumulation, at a specific region,
caused by repeatedly applied loads. In this situation, the
a Fatigue can be defined as the weakening of the materi-
-h
b
+h
h
d mal surface of the adjacent tooth has invaded the interprox-
c
..      Fig. 6.20  Deformation of the materials under external the forces. a
Compression; b tensile; c shear. The red arrows show the direction of
the loads, while the green arrows show the direction of the stress. h
means the height of the bar; −h shows a negative strain; +h shows a
positive strain; d shows strain under shear forces
a b
..      Fig. 6.21  a, b Mesialization of the adjacent tooth and the invasion of carious lesion cavity
199 6
material may fracture after receiving a load much smaller
than the normal nominal material strength. All occlusal con-
tact in new restorations should be properly adjusted to reduce
the cyclic stress, increasing their longevity [6, 39].
als by damage accumulation, at a specific region, caused
by repeatedly applied loads.
Tip
The occlusal contacts in new restorations should be
properly adjusted to reduce the cyclic stress and fatigue
of the material and remaining tooth structure, increasing
their longevity.
6.4 Prior to Tooth Preparation
Before starting the tooth preparation, a series of aspects
should be considered to guarantee that the best strategies of
preparation and restoration are chosen.
The adjacent tooth’s position should be considered. If
migration of the affected tooth has occurred, or the proxi-
imal space, restoring the proximal contour without
compromising the space for the interdental gingival papilla
can be impossible (. Fig. 6.21a, b). In this case, the recovery
of the space, through orthodontic movement, must be per-
formed before the final restoration is performed. Initially, a
temporary restoration of the cavity needs to be performed,
and then, orthodontic appliances or  – much simpler  – an
orthodontic elastic separator (rubber ring) is placed. That
can be repeated until a total recovery of the space is reached,
allowing an anatomically corrected final restoration to be
performed.
 200 C. R. G. Torres and F. Schwendicke
a b
6
..      Fig. 6.22  Importance of the radiographic analysis on the planning
of the preparation. a Lesion of medium depth, with a good amount of
intact dentin above to the pulp chamber (arrow); b deep lesion with a
In relation to the occusion of the  antagonist tooth, it is
important that the contacts on the maximum intercuspation
(MIC) or centric occlusion (CO) are verified. For that, a thin
sheet of articulating paper, preferably <10 μm, should be
used. It should be analyzed where the contacts occur. It is
very important that the contacts happen either over the
restorative material or over the remaining tooth structure,
but never over the tooth-restoration interface. The contact
over the interface will result in stress concentration in this
region and eventually fracture on the restoration margins
(. Fig. 6.26a, b).
 
In addition, when a cavity remains open for a long time,
with the loss of occlusal contact, the affected teeth or the
antagonist can undergo extrusion, invading the interior of
the lesion. In many cases, the only solution is to cut a portion
of extruded cusp, recovering the necessary space for the den-
tal restoration. A functional analysis of the occlusion is also
important, considering both protrusive and lateral excursive
movements, as well the presence of interferences.
Another important aspect to be assessed prior to prepara-
tion is the pulpal condition. The presence of symptoms and
radiographic signs of inflammation or necrosis must be ana-
lyzed. If endodontic intervention is necessary, the restorative
treatment should be postponed. However, in some situations,
temporary restorations or provisional crowns may be neces-
sary, to emergently recover the aesthetics or to allow mois-
ture control during root-canal treatment.
During radiographic analysis, the lesion depth and the
proximity to the pulpal chamber, besides the shape and
dimensions of the pulpal chamber, must be verified, to decide
how likely accidental exposure of the pulp during the tooth
preparation is; and to perform the  carious tissue removal
accordingly (. Fig. 6.22a, b).
 
A good periodontal health is another requirement prior
to restorative treatment. Any type of restorative treatment
should only be performed after the  oral health has been
established. However, restorative treatments often need to be
performed under suboptimal conditions (gingivitis, peri-
great risk of pulpal exposure during the removal of the carious tissue
(arrow)
odontitis), to allow proper oral hygiene and periodontal
therapy. Those restorations then may sometimes need to be
replaced in optimal conditions, after recovering of periodon-
tal health.
Before any restorative treatment to be started, preproce-
dural use of antimicrobial mouth rinses can be performed,
reducing the risk of cross infection [40–42]. The most com-
monly used antimicrobial solution is the 0.12% digluconate
chlorhexidine, because of its high antibacterial effects. Also,
anesthesia needs to be considered and planned a priori. The
use of topical anesthetic prior to block or infiltration anesthe-
sia is recommended.
6.5 Steps of Tooth Preparation
Greene Vardiman Black, in 1908, proposed to adopt specific
steps to perform tooth preparations [43]. They are a sequence
of necessary procedures, through interrelated stages, address-
ing biological, mechanical, and aesthetic requirements [3, 4].
A division into steps helps, mainly the beginners, to compre-
hend and execute the preparation sequence more adequately,
reaching the desired results in a more easily way. The steps
for tooth preparation are presented next. Note, however, that
these conventional steps mainly apply to nonadhesive resto-
ration (they were originally established for amalgams) and
that for adhesive ones, not all steps apply. Nevertheless,
understanding these steps first will allow later on to adapt the
sequence to all kind of restorative materials, which is not pre-
scriptive in all cases.
6.5.1 Outline Form
According to the speed carious lesion progression and the
presence of fluoride on the oral cavity, the caries lesions
may already be open (cavitated), allowing the visualization
of its interior, or may be closed. In the latter case, the enamel
General Principles of Tooth Preparation and Carious Tissue Removal
of external tooth surface seems intact, creating what is
called hidden caries (the “true” connection between the
outer area and the lesion inside is not visible). The opening
of the cavity is the first procedure, creating or enhancing
the access to the lesion, allowing its correct visualization
(. Fig. 6.23a, b).
 
After that, it is necessary to define the outline of the
tooth preparation [3]. Black proposed the principle of
extension for prevention that claimed that the margins of
the cavities should be placed into zones of little susceptibil-
ity to the development of lesions and where, by the action of
mastication, a self-cleaning via movement of the tongue,
lips, and cheek would occur [43]. According to this princi-
ple, all the occlusal grooves and fissures would be included
in the preparation outline, because they would certainly be
affected in the future by new lesions (. Fig. 6.24a). However,
it is important to consider that, when Black proposed this
principle, the etiology of the caries disease was not com-
pletely understood, effective preventive measurements were
not available, the appearance of new lesions in a patient was
oftentimes inevitable, and restorative options were limited.
With the knowledge available today, however, it is possible
to control the caries disease, avoiding that new lesions come
up and arresting existing ones. The principle of extension
for prevention hence neither is justifiable nor is it, under the
consideration of the principles of minimal invasive, ade-
quate. Even in patients with total incapacity, patients with
debilitating chronicle disease, and very severe xerostomia
cases (patients that undergo radiotherapy, intellectual dis-
ability, or saliva deficiency) [3, 15], extension of the cavity is
not  justified, and especially pits and fissures should be
sealed instead of included into the restoration [3]. In
. Fig. 6.24a–c, we can observe the variations on the exten-
 
sion of the preparation outline from the more invasive to
the more conservative.
a b
..      Fig. 6.23  Occlusal carious lesion. a Initial aspect; b opened cavity
201 6
Nowadays, the principle of the extension for prevention
has hence been largely abandoned; the contemporaneous
approach is to remove the minimum quantity of tooth tissue,
only enough to adequate the preparation to receive the
restorative material [7]. The outline form is primarily based
on the extension and location of the carious lesion, fracture,
or other lesions [3]. In case of a nonadhesive restoration, the
undermined enamel can be removed or artificially supported
using adhesive materials, such as glass ionomer cement [4].
The cut must be extended up to reach a healthy enamel but to
a limited pulpal and axial depth [3, 5]. The aim of the proce-
dure is to shape the cavity and allow removal of the carious
tissue (see below) in an appropriate and conservative way.
>> The contemporaneous approach is to remove the
minimum quantity of tooth tissue, only enough to
adequate the preparation to receive the restorative
material.
When preparing the outline form, the dentist should evaluate
the extension of the lesion and the consequent weakening of
the cusp. If a nonadhesive restoration is planned, cusp cover-
ing should be considered, i.e., covering the cusps with a
restorative material. To decide about cusp coverage, the dis-
tance between the central groove and the top of the cusp
should be evaluated (. Fig. 6.25a) [5]. If the extension is less
than 2/3 of the distance, the cusp covering is not necessary.
On the other side, if the extension is greater than 2/3, it
should be considered (again, mainly if using nonadhesive
materials) (. Fig.  6.25b) [5]. The cusp covering of a weak-
ened teeth with large preparations can increase the fracture
resistance considerably [4]. If a fracture happens, it will occur
in the restorative material, not the tooth, and the treatment
will be reparable. If an adhesive material is used, however,
this may allow increasing the fracture resistance even with-
out cusp coverage [5].
 202 C. R. G. Torres and F. Schwendicke

a b

6
c

..      Fig. 6.24  Variations of the outline of a Class I preparation for silver most conservative possible, restricted to the caries-­affected grooves,
amalgam. a Involving all the grooves (classic preparation); b involving for the maximum preservation of intact tooth structure
only the central groove; c restricted to the pits. The outline must be the

a b

..      Fig. 6.25  a Analysis of the lesion extension and the weakening of the cusp by evaluating the remaining tooth structure. The distance between
the central groove and the cup tip is divided in three thirds. b Restoration with cusp covering

The outline form varies according to the anatomic shape of
each tooth. As it extends over the pits and fissures on the
occlusal surface, the margins usually do not take a straight
line from one point to another, but they follow a soft line that
preserves sound tissue [5]. An abrupt change in the outline
form may increase the risk of fracture, especially if amalgam
is used as restorative material. The angle formed by the junc-
tions between the surrounding walls of a preparation (first
set of internal line angles) must also be rounded to improve
the adaptation of the restorative material and decrease the
concentration of stress. In addition, such rounding often
allows to remove undermined enamel [15].
Sometimes, a pit or groove is extremely deep and allows
retention of bacterial biofilm, and it is not favorable to have
General Principles of Tooth Preparation and Carious Tissue Removal
the interface of an amalgam restoration on this area. On the
classic technique using the extension for prevention princi-
ple, all the grooves would be included on the preparation,
resulting in cutting of healthy tooth structure. Alternative,
wearing and smoothing the enamel, thereby removing the
retentive groove, has been proposed. This procedure of mini-
mal changing the enamel shape with rotary cutting instru-
ments is known as enameloplasty, avoiding extending the
outline form of the preparation [5]. However, it also involves
removal of sound tissue. In most cases, then, sealing such
areas can be a valid option. Generally, when using adhesive
materials, such considerations play a lesser role. As it has
already been mentioned, the contact with the antagonistic
tooth should not happen exactly in the region of the interface
tooth-restoration. If this happens, the outline of the prepara-
tion should be modified to include this region, reducing the
chances of marginal fractures (. Fig. 6.26a, b) [15, 44].
Reinforcing structures, such as the oblique and marginal
ridges, should be preserved  wherever possible. However,
when there is a plan to make a nonadhesive restoration, it is
important that the remaining ridge structures have at least
1 mm thickness [4]. If it is too fragile, e.g., <0.5 mm, and in
contact with the opposing tooth, such small ridges may need
removal (. Fig.  6.27a–d) [5]. Again, for adhesive restora-
 
tions, no additional cutting is necessary even if the ridge is
fragile, due to the fact that the restoration will reinforce the
remaining tooth structure.
6.5.2 Resistance Form
It is the preparation form that allows the tooth and the resto-
ration to resist to masticatory loads, volumetric changes of
the restorative material, and the intradentinal stress [3, 4, 15].
Again, it is important to bring up the difference in behavior
between an adhesive and a nonadhesive restoration. When
using adhesive restorations, the restorative material and the
remaining tooth structure will (ideally) behave as one single
body, and the internal stress will be transmitted through the
a b
..      Fig. 6.26  Modification of the cavity outline due to the location of the contacts with antagonist tooth exactly on the cavosurface angle.
a Contacts on the margin (arrows). b Changes in the outline, allowing the contact to occur over the restorative material
203 6
adhesive interface. However, in the case of nonadhesive res-
torations, the tooth preparation must at the same time allow
the resistance of both the restoration, considering the physi-
cal characteristics of the restorative material, and the remain-
ing tooth structure, that must stay  intact during  the tooth
function. However, when necessary to choose, it is always
best to sacrifice the resistance of the restoration than the
resistance of the tooth, because this last one cannot be
replaced. To guarantee the tooth resistance, the extension of
the preparation should be as small as possible, e.g., by main-
taining cusps and ridges, as discussed [5].
Resistance forms are the preparation characteristics that
allow the tooth and the restoration to resist to mastica-
tory loads, volumetric changes of the restorative mate-
rial, and the intradentinal stress.
When performing nonadhesive restorations, the first point
that must be considered is to prepare flat and smooth walls.
The smooth walls allow to well adapt the restorative material
and increase the frictional retention [15]. Smooth walls will
further reduce the risk of remaining friable enamel prisms
which may fracture, leading to marginal defects [15]. Flat
internal walls, parallel to the horizontal plane and perpen-
dicular to the direction of the forces, allow any loads to be
distributed throughout the cavity and to direct them onto the
tooth, hence protecting the restoration during mastication
loading (. Fig. 6.28a) [15, 43, 45]. Internal walls should nev-
ertheless protect the restoration against rotational movement,
which can otherwise result in the displacement of the resto-
ration or fracture of the surrounding walls (. Fig. 6.28b, c)
[5, 6]. Similar principles must be applied on the gingival wall
of the proximal box in Class II preparation [5]. For an adhe-
sive restoration, none of these principles apply in such rigor,
while, nevertheless, adaptation and removal of friable enamel
will play a role here, too.
 204 C. R. G. Torres and F. Schwendicke
a b
6
c d
..      Fig. 6.27  Modification of the cavity outline due to a fragility of the
remaining tooth structure. a, c small thickness of the remaining of the
transverse and oblique ridges making them susceptible to fracture
(arrow); b, d modification of the contour for inclusion of the weakened
Another area where care is needed is the cavity margin, that
is, on the region of the cavosurface (CS) angle. In . Fig. 6.29,  
there is a Class I cavity on a cross section, where we can analyze
the angles on the cavity margins. The CS angle is determined
by the projection of the cavity wall (CW) on an imaginary line
and the unprepared enamel surface (ES). The restorative mate-
rial (rm) angle or margin angle is the angle formed by the
restorative material in the margin of the restoration. It can be
noticed that the opposite CS’ and rm’ angles have the same
angles as the CS and rm. An easy way to analyze those angles is
by evaluating the imaginary projections using two periodontal
probes, one resting on the external surface of the tooth and
another on the external CW (. Fig. 6.30) [5]. For nonadhesive
 
restorations, like amalgam, the dentist should remove under-
mined enamel prisms, while at the same time avoiding to leave
too thin restoration margins. This can be achieved by adjusting
the directions of the CWs. To not leave undermined enamel
prisms on the cavity margins of the occlusal surface, the CS
angle should have 90° or more. When there is a CS angle of
around 90°, the restoration margin angle is also 90°.
Although amalgam, if well condensed, shows compres-
sive strength above 350 MPa, it is brittle and has little flexural
strength [46]. Amalgam restorations frequently suffer the
area in the outline form. This procedure is only indicated for amalgam
restorations. For composite restoration, the adhesion to the tooth
structure will reinforce the weaken areas
phenomenon of marginal degradation leading to ditch for-
mation on the interface tooth-restoration. That is mainly a
result of mastication loads, leading to fracture of thin amal-
gam areas, leaving a ditch between the restoration and the
cavity margin, which can allow biofilm deposition and recur-
rent caries (. Fig. 6.31a–c) [45, 46]. The weaker the amalgam
and the smaller its margin angle, more probable is the ditch-
ing formation. By increasing the margin angle, then, dentists
can provide enough amalgam bulk in margin areas to prevent
such marginal degradation.
For occlusal preparations for amalgam, recommenda-
tions are ambiguous: Some authors like Gilmore and Lund
[47] recommend parallel vertical walls, which should be per-
pendicular to the pulpal wall (this was also proposed by
Black [43]), while others, like Markley [46], Simon [48],
Howard [49], and Hollenback [50], recommended the con-
vergence of those wall to the occlusal surface, following the
direction of the enamel prisms (and hence also achieving
undercuts). There is a consensus, though, that preparations
should not be divergent toward the occlusal surface, as even
though this would serve to remove undermined enamel, it
will lead to small margin angles, increasing the risk of ditch-
ing (. Fig. 6.43c, d).
General Principles of Tooth Preparation and Carious Tissue Removal
205 6

a b

..      Fig. 6.28  a Flat pulpal wall resulting in good stress distribution istic of the pulpal wall is only relevant for amalgam restorations. For
and stability to the nonadhesive restoration when receiving an composite ones, the adhesion to the tooth structure will prevent the
eccentric load (blue arrow); b round pulpal wall, resulting on a rotation, despite the wall shape
tendency for restoration rotation; c fracture of the cusp. This character-

..      Fig. 6.29  Measurement of the angles on the cavity margins. CW, ..      Fig. 6.30  Clinical visualization of the cavosurface and restoration
cavity wall; ES, external enamel surface; CS, cavosurface angle; rm, margin angle using two probes
restorative material angle or margin angle

an nonadhesive amalgam restoration, to resist the mastica-

The differences on the cuspal slope inclination angles tory load, especially on those teeth with the higher cuspal
can affect the cavosurface and margin angle of teeth restora- slope inclination (. Fig.  6.32a, b) [4, 49, 51]. In a clinical
 

tions (. Fig.  6.32a–d). The preparation of the vertical sur-

  study performed by Stratis and Bryant [51], the preparation
rounding walls of the occlusal box parallel to each other may of the vertical surrounding walls parallel to each other
lead to an insufficient volume, on the restoration margin of resulted, in about half of the margins, in margin angles of
 206 C. R. G. Torres and F. Schwendicke
a b
6
c
..      Fig. 6.31  a Amalgam restorations in an extracted tooth, with ditching on the margins (arrows). b Greater magnification view of the ditch;
c cross section of a ditched margin
less than 50°, compared to only 8% when the walls were pre-
pared convergent. It is important to highlight that the cusp
angles do vary not only from tooth to tooth but also on dif-
ferent areas of a same tooth. Therefore, when the dentist
uses the same rotary instrument in the same angle on the
entire CW, different margin angles of the restorative mate-
rial will be created [51, 52].
According to Symons et al. [53] and Bryant [54], the pre-
molars and the third molars have higher cusp slope inclina-
tion angles than the other posterior teeth, which can result in
a margin angle of 25–30° or less with the use of the parallel
walls. Therefore, the preparation of vertical surrounding
walls convergent toward the occlusal surface allows a greater
volume of the restoration margin. The ideal margin angle to
amalgam restorations should be 90°, to overcome the low
marginal resistance of this material [46, 48, 49, 52]. This pro-
duces the best strength for the amalgam margins and for the
tooth [47]. However, especially on the cases of the large cavi-
ties on the buccolingual direction, the small amount of
remaining tooth structure will not allow the preparation of
convergent vertical surrounding walls without complete
removal of the dentin and weakening of the cusps, predispos-
ing to fracture with the clinical use [4, 45, 51].
Elderton [55] performed a clinical study with 100 amal-
gam restorations. He observed the relationship between the
margin angle and material fractures, showing that a margin
angle of around 70–75° showed lowest fracture risk and that
this risk was highest at 58°. He recommended a margin angle
with at least 70° to minimize the marginal failure. Long-term
clinical trials also observed that the restorations performed
with the buccal and lingual walls parallel to each other pre-
sented a higher rate of marginal fracture than those conver-
gent to the occlusal surface [51, 56]. However, to obtain such
an angle, only via working on the walls inclination toward
the occlusal surface, can demand a great cut of the vertical
surrounding wall (. Fig. 6.33a). A way to obtain such resto-
ration margins and conserve the tooth structure is to reduce
the wall inclination but adapt the occlusal contour of the res-
toration with a shallower carving (. Fig. 6.33b).
It is known that the carious lesion expands laterally when
reaching the DEJ, with its extension in dentin being then
larger than that in enamel. It was formerly recommended the
complete removal of undermined enamel. For that, the out-
line form would remove caries-affected and sound enamel,
until hard dentin would be identified at the DEJ. Taking in
consideration this principle, when convergent vertical walls
are prepared, a smaller occlusal opening would be performed
in relation to a preparation with vertical surrounding wall
parallel to each other, reducing the contact of the restoration
with the occlusal loads during mastication (. Fig. 6.34) [46].
General Principles of Tooth Preparation and Carious Tissue Removal
207 6

a b

c d

..      Fig. 6.32  Analysis of different cuspal slope inclination angles on the cavosurface and margin angle of teeth preparations. a, b High cusps;
c cusps with medium cusp angle; d cusps with small cusp angle

a b

..      Fig. 6.33  Relation between the direction of the walls and carving convergence associated with a shallow carving to create the same
of the restoration with the margin angle. a Convergent walls toward margin angle
the occlusal surface in a way to create a margin angle of 70°; b smaller

However, it is possible nowadays to recover the support . Fig. 6.35a are shown the possibilities for the cavity outline.
 

of the undermined enamel by means of adhesive “dentin The first is to remove affected and sound enamel, until reach-
replacement” materials, such as the GIC or composites. This ing hard dentin on the DEJ (star), while the second is to
way, the opening of the cavity to create the outline form can remove only the caries-affected enamel (dot). In . Fig. 6.35b, 

be performed up to the point where intact enamel is reached, c, it is possible to compare the greater opening of the cavity
not necessarily sound dentin, leaving undermined enamel. In when the full removal of the undermined enamel is planned.
 208 C. R. G. Torres and F. Schwendicke
6 mance of an amalgam restoration is related to the internal and
..      Fig. 6.34  Comparison between the final dimensions of the cavities
when they are prepared with convergent or parallel vertical surround-
ing wall. The blue arrows indicate the tissue removed when the parallel
walls are prepared. The red arrows show the dentin tissue removed
when the convergent walls are prepared
In this case, when the vertical walls are convergent toward
the occlusal surface, more enamel will be preserved. In
. Fig.  6.35c, the opening was performed only until intact
 
enamel was reached, and later the carious dentin tissue
around the DEJ was removed (. Fig.  6.35d). As shown in
 
. Fig.  6.35e, the preparation of vertical walls convergent
 
toward the occlusal surface preserves more enamel on the
occlusal surface, while the dentin cut does not become rele-
vant, since the undermined enamel region can be filled with
dentin replacement material (. Fig. 6.35f). In addition, it cre-
 
ates a self-retentive cavity and a greater bulk of the restorative
material on restoration margin.
In conservative preparation with moderate size, such as
on the sizes 1 and 2, according to Mount and Hume, vertical
surrounding walls convergent toward the occlusal surface are
recommended. However, when the carious lesion is treated
on a very advanced phase, the buccolingual dimensions are
bigger than the depth of the cavity, and parallel walls are rec-
ommended to avoid an even greater weakening of the
remaining tooth structure (. Fig. 6.36a, b) [57].
 
Another place where the resistance of the restoration
margin can influence the shape of the cavity is on the proxi-
mal box of the Class II preparations for amalgam, in the
mesiodistal direction. The ideal shape for the resistance of
the restoration margin is that it forms an angle of 90° with the
external tooth surfaces, which also avoids undermined
enamel prism on the margins of the preparation. In
. Fig. 6.37, several possibilities of such configuration are dis-
 
played.
To prepare the buccal and lingual walls in a direction
convergent toward the proximal area will result in under-
mined enamel prisms (. Fig.  6.38a). To prepare the same
 
walls parallel to each other will result in undermined prisms,
mostly on the lingual wall, on teeth that have lingual surfaces
smaller than buccal surfaces (. Fig. 6.38b), and, sometimes,
 
also on the buccal wall, especially on teeth with a very convex
proximal surface. A slight divergence of the buccal and lin-
gual walls can remove undermined prisms but also can result
on the buccal wall thin margins of the restorative material,
which are predisposed to fractures (. Fig. 6.38c, e). In order
to increase the margin angle on this area, increasing the resis-
tance of the restoration, an additional cut of the buccal wall
can be performed, in a way that creates a 90° angle with the
external surface of the tooth. Proposed by George
M.  Hollenback [50], this was later called the Hollenback’s
reverse curve (. Fig. 6.38d, f). This procedure is generally not
necessary on the lingual walls of teeth but may be applicable
in various situations.
Another factor that influences the mechanical perfor-
external line angles [58]. The preparation of sharp internal
line angles results in stress concentration, predisposing to
fractures of the remaining tooth structure (. Fig.  6.39) [5,
57]. Preferably, the angles on a box-shaped preparation should
be round. The round angles offer better stress distribution
through the tooth structure during mastication than the
sharp angles, reducing the risk of fracture, especially on large
preparation (. Fig. 6.39) [5, 45, 59, 60]. In addition, the prep-
arations for amalgam with round internal angles improve the
adaptation of the restorative material to the angles during the
material condensation [57]. It is also recommended that the
external line angles should be round, avoiding the stress con-
centration inside the restoration, preventing its fracture. The
preparation of a sharp axiopulpal angle may predispose the
restoration to fracture in the isthmus region (. Fig. 6.40) [5].
During the tooth preparation, it is very important to
avoid the weakening of the remaining tooth structure. When
preparing the occlusal box of a Class I cavity for amalgam, in
case of a small to medium size lesion where the remaining
tooth structure in the marginal ridge area is more than
1.5  mm thick, the best direction of the CW is convergent
toward the occlusal surface, because it allows a self-retentive
preparation and increases the thickness of the restorative
material on the margin (. Fig. 6.41a). However, in case of a
large carious lesion, and the removal of the entire under-
mined enamel with rotary instruments, the mesial and distal
walls must be prepared slightly divergent toward the occlusal
surface, following the shape of the carious lesion, avoiding
the weakening of the region of the marginal ridge by the
excessive removal of dentin on this region (. Fig. 6.41b). The
preparation of these walls perpendicular to the pulpal wall
results in a larger removal of dentin (. Fig. 6.41c), whereas
preparation of those walls convergent toward the occlusal
surface may result in the entire removal of dentin under the
marginal ridge (. Fig. 6.41d).
In a nonadhesive restoration, the depth of the cavity must
be prepared in a way to allow a minimal bulk of the restor-
ative material [5]. For dental amalgam, the restoration must
have a minimum thickness of 1.5 mm or preferably 2 mm,
avoiding fractures due to the occlusal loads (. Fig. 6.42) [3,
5]. Especially, the transition area between the occlusal and
proximal boxes, known as the isthmus, is prone for fracture
General Principles of Tooth Preparation and Carious Tissue Removal
209 6

a b

c d

e f

..      Fig. 6.35  a Location of the limits in relation to the definition of the
outline form: removal of affected and intact enamel and all soft dentin
on the DEJ until reaching hard dentin (green star) or removal only of
affected enamel leaving soft dentin (yellow dot); b simulations of the
final dimensions on the cavity if chosen to open it until reaching hard
dentin (star) at the DEJ, using convergent or parallel wall; c opening of
the cavity up to reach the intact enamel, even leaving undermined
enamel; d removal of the carious dentin tissue with round bur; e
carious dentin tissue removed leaving undermined enamel; f filling of
the undermined enamel region with glass ionomer cement (arrows)

[57] and must have a minimum width that allows the neces-
sary resistance to the restoration (. Fig. 1.5f). Very shallow
 
preparations on the isthmus region also lead to fracture of
the restoration [5]. The depth is more critical than the width
to increase the resistance in this area [47]. Isthmus fractures
occur mainly when an antagonist supporting cusp occludes
directly on it [47, 61].
The last point related to increase the resistance form of a
restoration is simply using adhesive restorative materials. An
adhesive restoration increases the resistance of the remaining
tooth structure, reducing the susceptibility to fracture [10]. The
benefits of the adhesion may allow the dentist to not remove
weaker areas of the tooth, which will be reinforced by the res-
toration, without fracture of the cusp during mastication [5].
 210 C. R. G. Torres and F. Schwendicke
a b
6
..      Fig. 6.36  Shape of the preparations for amalgam restoration. a Vertical surrounding walls convergent toward the occlusal surface in cavities
with small or medium extension; b vertical surrounding walls parallel to each other in large cavities
E2 E2
E1 E1
P P
C C
C C
P P
E1 E1
E2 E2
..      Fig. 6.37  Different shapes possibilities of the cavity walls in the
proximal box. “C” buccal and lingual walls convergent toward the
proximal surface; “P” buccal and lingual walls parallel to each other; “E1”
slightly divergent buccal and lingual walls; (E2) more divergent walls
than the E1
Tip
A good way to increase the resistance form of a restora-
tion is simply using adhesive restorative materials. An
adhesive restoration increases the resistance of the
remaining tooth structure, reducing its susceptibility to
fracture.
6.5.3 Retention Form
Retention form is the characteristics given to the preparation
so that the restoration will not displace from the cavity, by
compressive forces due to contact with the food bolus or
antagonist tooth, tensile forces by sticky food, or any exces-
sive forces associated with parafunctional habits, such as
bruxism and teeth clenching [5, 62]. Other factor that induces
internal stress is the differences between the thermal expan-
sion coefficients of tooth structure and restorative material
[62]. When the temperature in the oral cavity suddenly
increases or reduces, due to ingestion of substances with dif-
ferent temperatures, stress is generated inside the restoration
and remaining tooth structure and transmitted through the
interface. This can, with the time, lead to the displacement of
the restorations or fracture of the remaining tooth structure.
The retention form is especially important in nonadhesive
restorations, where the preparation is the only way to retain a
restorative material. For adhesive restorations, retention is
achieved by a bonding system, with the shape of the cavity
having only little importance.
Retention form is the characteristics given to the
preparation so that the restoration will not displace
from the cavity, even under external loads during the
mastication.
Retention forms of the restorations can be classified as natu-
ral and artificial. Natural retention is created in the tooth
structure during tooth preparation, while artificial retention
refers to the use of specific artificial retention pins or posts
that are inserted in the dentin or into the root canal after end-
odontic treatment, retaining the restorative material inside
the preparation.
When analyzing the retention of a restoration, it is
­important to consider the probable direction of its displace-
ment when receiving of a specific load (compression or ten-
sile). The displacement of the restoration on a posterior tooth
may occur on the occlusal or proximal direction. In relation
to the retention toward the occlusal surface, the direction of
the surrounding vertical walls is important (. Fig. 6.43a–d).
A small conversion of only 5° is enough to lock the restora-
tion. However, even parallel walls can retain restorations by
means of frictional retention [4]. The amount of friction nec-
essary to keep this restoration in position is proportional to
the relation between the depth and the width of the cavity. As
General Principles of Tooth Preparation and Carious Tissue Removal
211 6

a b

P P
C C

C C
P P

c d

E1 E1 E1 E1

E1 E1
E2 E2

e f

E2 E2 E2 E2

E1 E1
E2 E2

..      Fig. 6.38  Different direction possibilities of the buccal and lingual wall; c, e divergent walls toward the proximal surface resulting in thin
walls on the proximal boxes. a Convergent walls toward the proximal margins for restoration in the buccal wall; d, f change of the contour of
surface, resulting in undermined enamel (in green); b walls parallel the buccal wall to increase the thickness of the amalgam in the
between themselves resulting in undermined prisms on the lingual restoration margin (reverse curve)

a principle, every time the preparation is deeper than wider,
it will be self-retentive [4, 6]. If the vertical surrounding walls
are prepared divergent toward the occlusal surface, a com-
plete lack of retention will occur. Such preparation is not
appropriate for direct nonadhesive restorations, but only for
indirect or semi-direct restorations.
Moreover, additional mechanical retentions, named
coves, can be prepared through a small cut on the buccal and
The coves can be prepared with inverted conical trunk or
round rotary instrument. The latter results in smaller stress
concentration and a better adaptation of the restorative mate-
rial on this region [6]. When the restorative material is con-
densed, its penetration on this area will form a type of anchor,
retaining the restoration. Similar natural retentions may be
prepared as holes and slots, generally on the gingival walls
(. Fig. 6.45a, b). This technique is discussed in 7 Chap. 12.

lingual walls, in the line angle below the cusps (. Fig. 6.44a, b).
  To avoid the displacement of the restoration on the occlusal
 212 C. R. G. Torres and F. Schwendicke

6
..      Fig. 6.39  Concentration of the stress on the regions of the sharp ..      Fig. 6.40  Rounding of the axiopulpal angle (three green arrows,
internal line angles of the second set (to the left) and the dissipation of rounded; one blue arrow, not rounded)
the stress with the preparation of round angle (to the right)

a b

c d

..      Fig. 6.41  Convergence of the mesial and distal walls in amalgam divergent walls; c large lesions associated to the preparation of parallel
preparations on the occlusal surface. a Presence of a great remaining walls; d large lesions associated to the preparation of the convergent
of marginal ridge (arrows) associated to convergent walls toward the walls
occlusal surface. b Large lesion associated to the preparation of the

direction, artificial retentions can also be used. They can be
of two types: the intradentinal pins and the intraradicular
post (. Fig.  6.46a, b). This topic will be discussed again in
 
7 Chap. 12. Generally artificial retention is not necessary
 
when adhesive restorations are performed.
A displacement toward the proximal surface is often
prevented by the shape of the occlusal box, following the
contour of the occlusal grooves, hence providing natural
retention. Additional retention may be obtained through
the preparation of locks on the buccoaxial and linguoaxial
General Principles of Tooth Preparation and Carious Tissue Removal
line angles (. Fig. 6.47a) or by dovetail locks (. Fig. 6.47b).
The dovetail lock on a MO or OD preparation avoids the
rotation of the restoration [4]. According to Crockett et al.
[63], the dovetail lock increases the retention fourfold,
while the locks on the buccoaxial and linguoaxial line angles
increase it by ten times, with the advantage of saving tooth
structure.
..      Fig. 6.42  Fracture of the restoration due to a too shallow preparation
a b
c d
..      Fig. 6.43  Retention versus inclination of the vertical surrounding
walls. a Convergent walls creating a self-retentive preparation; b
parallel walls creating frictional retention; c divergent walls do not
213 6
6.5.4 Convenience Form
The convenience form is the removal of sound tooth tissue to
obtain a better access and visualization of the carious lesion,
allowing the cavity instrumentation, application of the matrix
and the restorative material, and finishing the margins, among
others [3, 5, 43]. It includes adjustments on the preparations to
improve the other preparation steps [45]. Black proposed that
the cavity preparation walls, involving the proximal surface of
posterior teeth, should be divergent toward the proximal sur-
face and the contact with the adjacent tooth removed [43]. He
recommended a distance between the CS angle of the prepara-
tion and the proximal surfaces of the adjacent teeth of 0.8 and
1.2  mm. More recently some researchers recommended the
teeth a separation of only 0.2 mm [5]. Tooth separation facili-
tates the carving, burnishing, and finishing of the margins, the
isolation the operating field, placement of the matrix, and excess
removal (. Fig.  6.48a) [3, 4]. Nowadays, preservation of the
tooth structure is oftentimes prioritized over the convenience
form if possible, and the proximal contact preserved. Another
convenience form frequently performed is the preparation of
the axial wall expulsive toward the occlusal surface. That allows
visualization and the inspection of the gingival and axial walls,
to perform the correct carious tissue removal (. Fig. 6.48b).
create any retention, being contraindicated for nonadhesive restora-
tions; d displacement of the restoration due to the lack of retention
 214 C. R. G. Torres and F. Schwendicke

a b

6
..      Fig. 6.44  a Preparation of additional mechanical retention (coves)
in a cavity that is larger than deeper for amalgam restorations. In one
of the line angles, the retention was performed with a round bur (to
the left), while on the other with an inverted conical trunk; b behavior
of the tensile force over the restoration (red arrows) and the retentive
effect resulting in the preparation shape (blue arrows). This kind of
retention is not indicated and necessary when adhesive composite
restorations are performed

a b

..      Fig. 6.45  Natural retentions. a Hole for amalgapin; b 1, coves; 2, locks; 3, slot

a b

..      Fig. 6.46  a Intradentinal pin; b intraradicular post

General Principles of Tooth Preparation and Carious Tissue Removal
215 6

a b

..      Fig. 6.47  Retention form of a nonadhesive amalgam restoration dovetail lock (green arrows) and penetration on the intercuspal
toward the proximal surface. The red arrow indicated the direction of grooves (blue arrows)
displacement. a Retentive locks on the proximal box (blue arrows); b

a b

..      Fig. 6.48  Convenience form. a Removal of the contact with the adjacent tooth; b axial wall expulsive toward the occlusal surface (arrow)

6.5.5 Carious Tissue Removal
Caries is no longer understood as an infectious disease but
rather as an ecological imbalance within the biofilm, which is
shifted toward acidogenic and aciduric (acid producing and
tolerating) bacteria, mainly facilitated by a frequent intake of
carbohydrates. Hence, if the carbohydrates can be controlled,
so can the biofilm but also bacterially contaminated carious
lesions.
>> Caries is no longer understood as an infectious disease,
but rather as an ecological imbalance within the
biofilm, which is shifted toward acidogenic and
aciduric bacteria, mainly facilitated by a frequent
intake of carbohydrates.
Consequently, the management of a carious lesion does no
longer mainly rely on removal of the “infected” diseased tis-
sue and the placement of a restoration. Instead, restricting
carbohydrate intake and controlling the presence of a biofilm
via oral hygiene are emphasized. However, removing biofilms
will no longer be possible if a carious lesion is not cleanable
with a toothbrush, i.e., the lesion is cavitated, with overhang-
ing enamel/dentin preventing the toothbrush from accessing
it. Hence, for such cavitated lesions, carious tissue removal,
cavity preparation (as described), and restoration oftentimes
remain needed. The question now, however, is: How much
carious tissue do we need to remove after having prepared
the cavity and before placing the restoration?
>> Biofilms removal is not possible in cavitated carious
lesion, and carious tissue removal (cavity preparation)
and restoration remain needed.
Previously the aims of carious tissue removal were to remove
all bacterially contaminated and demineralized tissue, with-
out any discrimination about different qualities of carious
tissue (hardness, moisture, color). This was carried out
 216 C. R. G. Torres and F. Schwendicke
regardless of the consequences, and it was considered better
to remove it all, even at the expense of the dental pulp, with
high risks of pulp exposure, especially if performed in deeper
lesions (extending close to the pulp). Today, the main ques-
tion is, instead: “How can we achieve the best longevity for
the tooth?” To answer this question, a number of guiding
principles were agreed on [64, 65]:
55 Preserve non-demineralized and remineralizable tissue.
55 Achieve an adequate seal by placing the peripheral
restoration onto sound dentin and/or enamel, thus
controlling the lesion and inactivating remaining
bacteria.
55 Avoid discomfort/pain and dental anxiety.
6 55 Maintain pulpal health by preserving residual dentin
(avoiding unnecessary pulpal irritation/insult) and
preventing pulp exposure.
55 Maximize longevity of the restoration by removing
enough soft dentin to place a durable restoration of
sufficient bulk and resilience [65].
Of course, avoiding pulpal exposure is relevant mainly in
deep lesions, in teeth with vital painless pulps, as any kind of
exposure will be managed using endodontic means, which
either have a poor prognosis (like direct capping) or are
highly invasive and oftentimes shorten the lifetime prognosis
of the tooth (like root-canal treatment) [66–68].
On the other hand, leaving carious dentin beneath resto-
rations means leaving softer, bacterially contaminated,
demineralized dentin below this restoration. The lower elas-
tic modulus of such dentin and the reduced bond capabili-
ties compared with sound dentin have been found, to
varying degree, to affect the stability of the restoration [69–
71]. It is likely that this is relevant when very large amounts
of carious dentin left under a restoration are left, while small
areas of soft dentin being left to not expose the pulp will have
only limited impact [72–74]. When there is no risk of pulp
exposure, however, there is no argument against removing
carious dentin in a way which will maximize restoration lon-
gevity.
If these general principles are to be employed, dentists
need to be able to assess carious tissue removal, i.e., what was
removed, what was left, and how exactly this was done. Often,
removal strategies had been termed as “complete” or “incom-
plete.” However, this was not grounded in any evidence:
Carious tissue removal strategies should not pretend to
remove specific carious tissues, giving them names like
“complete” or “incomplete” excavation, as it remains com-
pletely unclear what is completely or incompletely removed
(bacteria? soft dentin? discolored dentin? hydrolytically
degraded collagen?), but also numerous studies found all
removal strategies to be somewhat “incomplete” “complete”
(mainly as the gradual changes between different dentin
“zones” will not be assessable clinically). Instead, strategies
should be termed according to what is done, i.e., descrip-
tively, instead of what one aims to remove or retain.
Hence, the following terms have been agreed on to
describe the dentin which is left or removed [64]:
55 Soft dentin: “Soft dentin will deform when a hard
instrument is pressed onto it, and can be easily scooped
up (e.g. with a sharp hand excavator) with little force
being required.”
55 Leathery dentin: “Although the dentin does not deform
when an instrument is pressed onto it, leathery dentin
can still be easily lifted without much force being
required. The hardness of leathery dentin is between that
of soft and firm dentin.”
55 Firm dentin: “Firm dentin is physically resistant to hand
excavation and some pressure needs to be exerted
through an instrument to lift it.”
55 Hard dentin: “A pushing force needs to be used with a
hard instrument to engage the dentin and only a sharp
cutting edge or a bur will lift it. A scratchy sound or ‘cri
dentinaire’ can be heard when a straight probe is taken
across the dentin.”
The hardness criterion has been validated against clini-
cal outcomes in several studies [75] and is assessed using
probes or via tactile feedback during excavation. There are
further criteria, like dentin color (which is highly unreli-
able and possibly affected by the incorporation of external
stains, i.e., from existing amalgam restorations, as shown
in . Fig.  6.49a, b), lesion activity status (active lesions
have yellowish or slightly brownish appearance, while
the inactive ones are often highly stained, as shown in
. Fig. 6.49c, d), fluorescence-­based methods (which target
bacterial removal, which is not a good criterion if work-
ing close to the pulp, as remaining bacteria may be sealed,
while over-invasive removal of bacteria will lead to pulp
exposure) [75], or caries detector dyes (which are not at all
recommended to be used in pulpal areas of a cavity, as they
are neither reliable nor valid, increasing the risk of pulp
exposure dramatically) [75]. In summary, using the hard-
ness criterion will allow the dentist to, somewhat reliably,
assess carious tissue removal.
Based on the agreed principles, and understanding that
bacteria may be sealed beneath restorations, five main cari-
ous removal strategies have been defined. These are described
below [76].
6.5.5.1 Nonselective Removal to Hard Dentin
Nonselective removal to hard dentin (formerly also known as
“complete removal”) aims to remove soft dentin, stopping the
removal only when hard dentin (similar to healthy dentin) is
reached. This is done everywhere in the cavity: as the same
criterion (the same endpoint) of carious tissue removal is
used both peripherally and pulpally, it is termed nonselective
(compare with selective removal; see below) [64].
Nonselective removal to hard dentin bears significant risks
for the pulp when applied to in deep lesions [77, 78] and is
not recommended any longer [65].
General Principles of Tooth Preparation and Carious Tissue Removal
217 6

a b

c d

..      Fig. 6.49  a Old amalgam restoration being removed; b stained dentin due to the metal corrosion; c brownish appearance of caries-affected
dentin in active lesion on the pulpal wall; d highly stained dentin in inactive lesions (arrows)

6.5.5.2 Selective Removal to Firm Dentin
In selective removal, not one but different criteria (end-
points) are used to assess carious tissue removal in the
periphery of the cavity and in proximity to the pulp. As
described above, one guiding principle is to allow the best
adhesive seal of a restoration in the periphery of the cavity.
Such aim can be achieved when “sound” enamel and hard
dentin are left in the periphery. This approach also serves
another guiding principle: maximizing restoration longevity.
In the pulpal area of a cavity, however, another criterion
(endpoint) is used, with firm dentin being left [64]. Such firm
dentin is physically resistant to hand excavator. This approach
is recommended for shallow or moderately deep lesions, but
guiding principle of maintaining pulp vitality. In the periph-
ery, achieving a good seal and maximizing restoration survival
are prioritized, with peripheral enamel and dentin again being
hard at the end of the removal process. Selective removal to
soft dentin has been shown to reduce the risk of pulpal expo-
sure compared with nonselective removal to hard or selective
removal to firm dentin. Note that this removal technique has
been previously known as partial or incomplete removal.
Stepwise Excavation
Stepwise excavation (or removal) involves “selective removal
to soft dentin” at Stage 1, followed 6–12 months later by “selec-
tive removal to firm dentin” for Stage 2 (. Fig. 9.19). Stage 1

not deep lesions (i.e., those extending beyond the pulpal
third or quarter of the dentin radiographically).
6.5.5.3 Selective Removal to Soft Dentin
Selective removal to soft dentin is recommended for deep
carious lesions in teeth with vital painless pulps. Here, in the
pulpal area of a cavity, to avoid pulp exposure and maintain
residual dentin thickness is prioritized (. Fig. 9.18).  
Consequently, it is accepted to leave leathery or, if needed, soft
carious dentin in the pulpal aspect of the cavity, serving the
has the same carious tissue removal aims as “selective removal
to soft dentin” with soft dentin being left pulpally. The periph-
ery of the cavity should be hard – with similar appearance and
tactile characteristics to sound dentin. A provisional restora-
tion is placed with a restorative material that is considered
suitable to last for up to 12 months. The subsequent removal of
this provisional restoration should then be followed by the
“selective removal to firm dentin” pathway with placement of a
definitive restoration aiming for longevity. This technique has
previously been also known as “two-step excavation.”
 218 C. R. G. Torres and F. Schwendicke
6.5.6 Finishing of the Enamel Walls
Even though it is the hardest tissue of the human body, the
enamel is the weakest one when undermined. The prism’s
core is stronger than the interprismatic enamel. Therefore,
when pushed, it generally cracks  in the interprismatic
enamel following the long axis the prisms. As it has already
been mentioned, while the undermined enamel can be pre-
served when performing an adhesive restoration, because it
is protected by the restorative material, for non-adhesive
restorations it is essential its removal or protection via a base
material. The purpose of the finishing of the enamel walls,
for an amalgam restoration, is to remove the irregularities
6 and undermined enamel prisms left by the initial prepara-
15 a 20°
..      Fig. 6.50  Slight marginal trimming of the enamel on the region of
the cavosurface angle of the gingival wall
a b
..      Fig. 6.51  a Smear layer covering the cavity wall; b smear plug (arrow)
tion steps, to ensure that just full-length enamel prisms
remained, creating the best marginal sealing as possible
between the restorative material and the tooth structure [4].
According to Black, it is the last cutting step to be performed
and can be done with the rubber dam isolation already in
position [4, 5, 43]. The procedure for the removal of the
undermined enamel prisms is called marginal trimming. In
order to perform this step on the CS angle of the gingival
wall, in Class II preparations, the direction of the prisms has
to be followed, cutting them about 15–20° in relation to a
line perpendicular the long axis of the tooth, creating a
slightly bevel (. Fig. 6.50). The finishing also must be per-
formed on the CS angles of the buccal and lingual walls of
proximal boxes, in Class II preparations, removing the
remaining undermined enamel that was left after the use of
rotary instrument (. Fig. 10.15).
6.5.7 Cleaning of the Cavity
The cavity cleaning is performed after the isolation of the
operating field, to remove all the residues and lose debris
that deposited during the cutting procedures, before start-
ing the restoration [5, 15]. It is known that after the end of
tooth preparation, residues of oil from the high- and low-
speed handpieces, saliva, blood, bacterial biofilm, lose
debris, and abrasive fragments from the rotary instru-
ments, among others, remain in contact with the cavity,
besides remaining fragments of enamel and dentin [4, 45].
All those residues forms over the CWs a smear layer of
about 1–3 μm (. Fig.  6.51a) as well as smear plugs
(. Fig. 6.51b) [16].
7 um
General Principles of Tooth Preparation and Carious Tissue Removal
Anionic detergents based on sodium lauryl sulfate, anti-
microbial agents like 2% chlorhexidine gluconate solution or
alkaline solutions of calcium hydroxide have been used for
cavity cleaning or disinfection (. Fig. 6.52a–e). The use of a
 
chlorhexidine solution presents also the advantage of being
able to deactivate the dentin matrix metalloproteinase
enzymes (MMP), which are released by the demineralization
promoted by the bacterial acids, responsible for the forma-
tion of the carious lesions. Those enzymes are responsible for
the hydrolysis of the exposed collagen, favoring the progres-
sion of the carious lesion. When chlorhexidine is applied on
the cavity for 10–15 s, it is capable to chelate the Zn2+ ions
and results in the inactivation of the metalloproteinases [79].
..      Fig. 6.52  Substances for cavity cleaning. a 11.5% polyacrylic acid;
b calcium hydroxide solution; c 2% chlorhexidine digluconate; d
anionic detergent; e 37% phosphoric acid gel
a b
..      Fig. 6.53  a Opening of the dentin tubules by the acidic etching on the right side of the image. The left side remained covered by the smear
layer; b Etching pattern of enamel
219 6
One option when performing amalgam restorations is to
apply a 2% neutral sodium fluoride solution on the prepara-
tion walls. This procedure will promote the deposition of
calcium fluoride over the walls, acting as a fluoride reservoir
that will be released if there is a drop in the pH. The applica-
tion of the fluoride solution reduces up to 60% of the forma-
tion of secondary caries on the amalgam restoration margins
and interface.
For adhesive restorations, the surface treatment will
depend on the bonding system used. Etch-and-rinse adhesives
require the previous etching of the preparation walls with a
32–37% phosphoric acid gel, which removes the smear layer
and open of the dentin tubules (. Fig. 6.53a), creating micro-
porosities in the enamel (. Fig.  6.53b). The enamel etching
increases the surface area available for bonding by  10 to 20
times [3]. After the application and curing of an adhesive,
resin tags will be created in the enamel and allow a microme-
chanical retention. The dentin collagen network, exposed by
the acid etching, is impregnated by the adhesive monomers
forming the hybrid layer, hence promoting the adhesion to the
dentin. For the self-etching systems, phosphoric acid gel is not
used, and the smear layer is dissolved by the acidic resinous
monomers in its composition. Self-etch adhesives are capable
to penetrate through the smear layer and interact with the
underlying dentin, creating a hybrid layer.
Overall, however, the effects of the antimicrobial agents
can be only superficial, due to the presence of the residual
bacteria inside the dentin tubules and within the smear layer.
However, considering what was explained before, the rele-
vance of the cavity disinfection is questioned anyway. Sealing
the cavity seems more relevance than performing such disin-
fection.
 220 C. R. G. Torres and F. Schwendicke
Conclusion
Caries is no longer understood as an infectious disease, but
rather as an ecological imbalance within the biofilm, which is
shifted toward acidogenic and aciduric bacteria, associated
with the high consumptions of fermentable carbohydrates.
Therefore, if the carbohydrates can be controlled, so can the
biofilm, recovering the ecological balance and the oral health.
However, in cavitated lesions, it is not possible to control the
biofilm by regular tooth cleaning techniques, such as brush-
ing and flossing. In this case, the dental restorations are still
recommended, and the cavity preparation is required. The
restorations can be performed with nonadhesive or adhesive
materials. Although the use of nonadhesive restorations per-
6 formed with dental amalgam is reducing nowadays, it is still
used in many situations. For this material, special characteris-
tics of the preparation are required, in order to provide a
long-lasting restoration. On the other hand, adhesive materi-
als, such as composite resins and glass ionomer cements, are
able to bond to the remaining tooth structure, creating its
reinforcement. In this case, the actual shape of the cavity is
less important than to provide an adequate marginal sealing
for the restoration. In this chapter, the biological and mechan-
ical principles of the toot preparation were presented, as well
as the traditional steps of tooth preparation, which can guide
the dental students to easily obtain the desired preparation
characteristics. The current principles are based on the maxi-
mum preservation of the remaining tooth structure, creating
a defect-oriented preparation.
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 223 7

Isolation of the Operating Field

Alessandra Bühler Borges, Carlos Rocha Gomes Torres,
Ana Raquel Benetti, and Azam Bakhshandeh

7.1 Introduction – 224

7.2 Isolation Using Rubber Dam – 224

7.2.1  ubber Dam – 224
R
7.2.2 Rubber Dam Frame – 225
7.2.3 Punch – 225
7.2.4 Clamps – 226
7.2.5 Forceps – 232
7.2.6 Other Retainers – 233
7.2.7 Number of Teeth to be Isolated – 234
7.2.8 Technique for Isolation Using Rubber Dam – 234
7.2.9 Modified Techniques for Isolation in Special Clinical Situations – 246
7.2.10 Sealing Leakage on the Rubber Dam Isolation – 248

7.3 Using Cotton Rolls Combined with Suction – 248

7.3.1 S aliva Ejector and High-Volume Evacuators – 250
7.3.2 Cotton Rolls and Absorbent Pads – 251
7.3.3 Cheek and Tongue Retractors – 254
7.3.4 Light-Cured Gingival Barriers – 255
7.3.5 Gingival Retraction Cords – 255
7.3.6 Cotton Roll Isolation Technique – 256

References – 260

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_7
 224 A. B. Borges et al.
Learning Objectives
The learning objectives of this chapter are related the follow-
ing topics:
55 To understand the importance of isolation of the
operating field
55 To become acquainted to the instruments and consum-
ables used for that procedure
55 To acquire knowledge about the techniques employed
for controlling the moisture on the operating field
7.1 Introduction
Certain dental treatment procedures require a clean and dry
working field. The isolation of the operating field aims pri-
7 marily to control moisture and avoid contamination from
microorganisms or saliva during treatment. It can be obtained
in two ways: (1) by application of a rubber dam or (2) by
using saliva absorbers, such as cotton rolls, saliva ejectors,
and retraction cords.
Evidence regarding which is the best method to obtain a
clean and dry operating field is limited. A systematic review
published in 2016 found only low-quality evidence studies
suggesting that the use of rubber dam during direct restor-
ative procedures may lead to a lower failure rate of the resto-
rations, when compared to the failure rate registered for
restorative procedures conducted under isolation with cot-
ton rolls [1]. Further high-quality studies investigating the
impact of the use of rubber dam during different restorative
procedures are recommended. The limited evidence is,
according to some authors, not sufficient to support changes
to current practice regarding the placement of direct restora-
tions [2]. Although it appears very difficult to scientifically
prove the impact of the use of rubber dam on the final out-
come of restorative procedures, [3] consensus exists towards
the need of a clean surface and moisture control when bond-
ing to teeth – regardless of the method used to achieve this. A
meta-analysis on the clinical outcome of non-­retentive and
cervically placed composite restorations, identified a signifi-
cantly higher retention rate of such restorations placed using
rubber dam [4]. As a rule of thumb, the use of rubber dam is
preferred over the use of cotton rolls combined with effective
suction to obtain a clean and dry operating field for a number
of restorative procedures, the reasons are explained in details
in the sections to come. Though it is valid to point out that
both techniques have advantages and limitations, thus an
individual assessment may be necessary to guarantee that the
best technique is employed for each clinical situation.
7.2 Isolation Using Rubber Dam
The use of a rubber dam was introduced by Sanford Christie
Barnum [5, 6] to completely eliminate fluids from the operat-
ing field. If well performed, the moisture control with its use
is simple and effective; hence it is highly recommended to
maintain the teeth dry during restorative procedures. Further
important advantages are obtained when isolating the oper-
ating field by using a rubber dam: this ensures (1) retraction
and protection of the patient’s soft tissues, (2) protection of
the patient’s respiratory and digestive tracts, and (3) improve-
ment of access to visualization of the operating field, thus
allowing the dentist to concentrate on the treatment to be
performed. In addition, it avoids interruptions of the treat-
ment, otherwise necessary to change cotton rolls and retract
soft tissues [7]. The use of rubber dam is also important dur-
ing excavation of deep carious tissue, as it prevents the con-
tamination of the pulp from microorganisms present in the
oral fluids, specially in the case of an accidental pulp expo-
sure during excavation. During the removal of amalgam res-
torations, the use of a rubber dam prevents the patient from
swallowing amalgam residues.
Other than allowing a clean and dry operating field, with
an adequate moisture control by exclusion of saliva, crevicu-
lar fluid, and occasional bleeding, the use a rubber dam may
aid obtaining optimal conditions for the dental materials,
whose properties may become impaired by early contact
with moisture [1]. Regarding protection of the patient, the
use of a rubber dam eliminates the risk of the patient swal-
lowing or aspirating materials or instruments that are used
during the operative procedures, and reduces the risk of
accidental damage to the patient’s soft tissues. The rubber
dam also benefits the dentist and the dental team because it
reduces dispersion of oral microorganisms to the working
environment. Improved efficiency is expected when the rub-
ber dam is in place due to simplification of the restorative
procedures, and the reduction of time spent with patient
expectoration and conversation [5, 8].
Some dentists avoid placing the rubber dam, justifying as
main reasons the lack of supporting evidence, additional
time spent with this procedure and the unwillingness of the
patients [4]. However, training leads to improvement of the
technique and consequently reduction of the working time.
Additionally, if the patients are well-informed about the
improved prospect of the dental work performed using the
rubber dam, they often accepts its use. There are, however,
cases shown impossible or very difficult to use a rubber dam.
Examples are teeth on initial stages of eruption, misaligned
teeth, patients with breathing problems, and lack of latex-free
rubber dam for patients with allergy to latex [8]. In such
cases, proper moisture control of the operating field shall be
achieved using cotton rolls and effective suction.
7.2.1  Rubber Dam
The rubber dam isolates the operating field from the oral cav-
ity. It is often fabricated with natural latex and is available in
several colors. Latex-free sheets made of silicone or nitrile
rubber are also available and are indicated for patients aller-
gic to latex. The colors that contrast with the teeth are pre-
ferred because they improve the visualization of the
preparations’ and restorations’ details. The blue color is
­generally chosen: it is the complementary color to the yellow
Isolation of the Operating Field
of the teeth, increases the perception of contrast, and is a
relaxing color to the vision [9].
Rubber dams are available generally as 13 cm × 13 cm
sheets with various thicknesses (thin, medium, thick, and
extra thick) (. Fig.  7.1). Thick rubber sheets are easier to
 
pass through tight interproximal contacts, but they tear
more easily [3]. On the other hand, thicker rubber sheets
are more tear resistant and better to retract the soft tissues
[10]. The thick rubber dam is helpful for isolating Class V
lesions associated with a cervical retainer. Medium-thick
rubber dam is most widespread and is usually preferred as
the thin one is more prone to tearing and the extra thick
one is more difficult to apply. As latex deteriorates with
time, it will tear more easily, and therefore, new rubber
sheets must be used [6].
7.2.2  Rubber Dam Frame
The rubber dam frame is used to keep the borders of the rubber
sheet in position. The rubber sheet must be stretched and fixed
on the lateral pins of the frame. Different frame shapes are
available. The Young frame has a U-shape with lateral pins used
..      Fig. 7.1  Rubber dam sheets with different colors
a b
..      Fig. 7.2  Young frames. a Plastic; b metallic
225 7
to fix the rubber sheet (. Fig. 7.2a, b). The Otsby frame has an
hexagonal shape, anatomically projected for better contouring
the face of the patient (. Fig. 7.3a, b), thus allowing some dis-
tance between the rubber dam and the patient’s nose for more
comfortable breathing [11]. Rubber dam frames are made of
metal or plastic, the latter does not interfere on the uptake of
radiographic images during the operative procedures.
There are also frames integrated to the rubber sheet, aim-
ing to simplify the placement of the rubber dam: these have
high flexibility and may reduce the need of clamps (ex.
Optradam Ivoclar-Vivadent) (. Fig. 7.4a–d).
7.2.3  Punch
The punch forceps is used to perforate the rubber sheet in
the positions where the teeth to be isolated shall fit. The
Ainsworth punch is commonly used: it has a plunger with a
sharp end and a rotating disk-shape metal table with several
holes (. Fig.  7.5a). These perforating holes have different
diameters to better fit the teeth. The Ivory punch also has a
rotating metal disk with perforating holes of distinct diam-
eters (. Fig.  7.5b). The diameter of the perforating hole
must be selected according to the cervical diameter of each
tooth, generally following the sequence presented in
. Fig.  7.6. However, variations are sometimes needed,
depending on the tooth size, the dentist choice, and rubber
sheet thickness [6].
In order to perforate the rubber sheet, the plunger
should be placed over the pre-marked positions and pressed
firmly. It is easier to perforate the rubber when the sheet is
under slight tension, but not attached to one of the sides of
the frame (. Fig. 7.7a). It is important that the punch can
deliver perfect and complete perforations (. Fig.  7.7b).
Incompletely cut perforations easily result in tear of the
rubber during manipulation or may lead to penetration of
saliva after the rubber dam is in place (. Fig. 7.7c) [12]. In
order to avoid these problems, the perforating table of the
punch shall always be sharp; if necessary, the punch can be
sharpened.
 226 A. B. Borges et al.

a b

..      Fig. 7.3  Ostby frames. a Plastic; b metallic

7
a b

c d

..      Fig. 7.4  Frame integrated to the rubber dam (ex. OptraDam, marking for punching; c application into the patient’s mouth; d rubber
Ivoclar Vivadent). a Frontal view of the set showing the extension of dam isolation finished
the sheet for lip protection; b back view of the set, showing the

7.2.4  Clamps
Clamps are used to secure the rubber sheet in place and are
generally made of a flexible metal. The clamps should be
placed on the tooth that is more distal on the arch to the tooth
else in the isolated quadrant, additional clamps can be used to
retract the gingiva whenever necessary. Clamps are available
in different sizes and specifically adapt to each group of teeth.
They are composed by the bow that connects two horizontal
jaws (. Fig. 7.8). Those jaws present prongs that grip the tooth

in which the treatment is to be performed, particularly when cervically below its largest circumference, while the round
isolating posterior teeth. The most distally placed clamp must holes, are used for fitting the forceps. They also present rectan-
resist traction from the rubber towards the frame. Anywhere gular holes, which allow placing a bold hand instrument for
Isolation of the Operating Field
227 7

a b

..      Fig. 7.5  Punch forceps. a Ainsworth; b Ivory

..      Fig. 7.6  Detail of the

perforating holes in the rotating
metal table on the Ainsworth
punch and their corresponding
group of teeth. The largest hole is
used to make perforations for
anchor molars

transposing the rubber sheet underneath the wings of the also a variety of smaller, wingless clamps and describes later
clamp (. Fig. 7.33i). Some clamps have wings (. Fig. 7.9a, c)
    their placement techniques (. Fig. 7.11d).
 

that allow attaching the clamp in the rubber dam (. Fig. 7.33a–

 
d), while others are wingless (. Fig. 7.9b, d). The clamps rec-
 
ommended for posterior teeth have one bow, while those used
in anterior teeth possess two bows (. Fig. 7.9). The clamps are
 
flexible and can be opened with the aid of the forceps to tres-
pass the largest circumference of the tooth. When in position,
the clamp is released to grip the cervical area of the tooth
(. Fig.  7.10a, b). Winged clamps are more bulky and can
 
therefore interfere with the matrix, the matrix holder, or the
In some situations a clamp can be modified to individu-
ally adapt to a specific case. This is achieved by heating the
jaws of the clamp until they become red hot and then imme-
diately submerging it in water. The necessary modifications
are made on the jaws by bending them using flat pliers or,
when necessary, cutting them with mounted stones. The
clamp is tempered by heating it again on a flame, up to a
slightly lower temperature, and submerging it in oil
(. Fig.  7.12a–g) [7]. This could be advantageous for clamp

wedges used in the restorative procedure [5, 10, 13]. no. 212 to adjust the facial jaw to a more cervical position on
Several models of clamps are available on the market; this the tooth crown, thus allowing retraction of gingiva and
chapter shows, among a variety of clamps, the winged clamps exposure of the gingival margins of the cavity.
No. 200–205 used on molars, No. 206–209 used on premo- Gingival retraction clamps (. Fig. 7.13a, b) are designed to
 

lars, and No. 210–211 used on maxillary and mandibular be used in teeth that are not completely erupted and if lesions
incisors, respectively (. Fig.  7.11a–c). The chapter includes
  are too close to the gingival level. In these clamps, the jaws are
 228 A. B. Borges et al.

a b

c
7

..      Fig. 7.7  Punching the rubber dam. a Punch in position with rubber dam under slight tension; b complete and correct perforations;
c inadequate partial perforations, which increase the risk of tearing the rubber

..      Fig. 7.8  Components of

BOW
the clamps

JAW HOLE FOR FORCEPS

WING

PRONG

RECTANGULAR HOLE
Isolation of the Operating Field
229 7
..      Fig. 7.9  a Winged clamp with
one bow; b wingless clamp with
one bow; c winged clamp with
two bows; d wingless clamps a b
with two bows. The red arrows
indicate the wings

c d

a b

..      Fig.7.10  a Winged clamp at rest; b flexibility is shown when the clamp is opened by the forceps

a b 3 7 8
0 00 2 2A

206 207 208 209

200 201 202

..      Fig. 7.11  Clamps most commonly used in operative dentistry. a Winged clamps for premolars; b winged clamps for molars; c clamps for
anterior teeth; d wingless clamps for premolars (top row) and molars (bottom row)
 230 A. B. Borges et al.

c d W2A 27 29

210 211

W8A 26 28 W56

..      Fig. 7.11 (continued)
7

a b

c d

..      Fig. 7.12  a Clamp number 212 in its original shape; b exposure is then immersed in oil for tempering; g final shape of the clamp
of the clamp’s jaws to the flame; c immersion into water; d modifica- with the facial jaw on a more apical position to retract the gingival
tions on the clamp are made using two flat pliers to bend the facial tissues
jaw apically; e the jaws are exposed again to the flame; f the clamp
Isolation of the Operating Field
231 7

e f

..      Fig. 7.12 (continued)

a b

..      Fig. 7.13  a Examples of gingival retractor clamps for posterior and 212L (lower left). Clamps 212R and 212L allow the restorative
teeth, with jaw and prongs on a more apical position (arrows); procedure to be made simultaneously in adjacent teeth
b retractor clamps no. 212 (upper image), 212R (lower right),
 232 A. B. Borges et al.

a b

..      Fig. 7.14  a Retraction clamp no. 212 with jaws at the same alignment; b clamp no. 212M modified by the manufacturer, with the facial jaw on
7 a more cervical position to improve gingival retraction during restoration of class V cavities

a b

..      Fig. 7.15  Clamp forceps. a Palmer; b Brewer; c Ivory

directed gingivally to allow anchorage on a more cervical region 7.2.5  Forceps

of the tooth. For a single cervical restoration, the regular 212
clamp is recommended, while for two restorations on neigh-
boring teeth, clamps 212R and 212L are used simultaneously
(. Fig. 7.13b). For an extra gingival retraction on anterior teeth
The clamp holding forceps is used to securely position the
clamp on the tooth. The most commonly used forceps are
Palmer (. Fig.  7.15a), Brewer (. Fig.  7.15b), and Ivory

or premolars, the gingival retraction clamp no. 212 can be cus- (. Fig.  7.15c), which vary according to the angle of the
 

tomized as mentioned earlier (. Fig. 7.12a–g) or can be pur-

 
shank and the presence or not of curvature towards the
chased already modified by the manufacturer (. Fig. 7.14a, b).
 
active tip. The Palmer forceps is mono-angled and can pres-
Isolation of the Operating Field
ent a knurled surface or notches in the active end
(. Fig. 7.16a, b) to fit the holes on the clamps.
 
7.2.6  Other Retainers
Besides using clamps, the rubber dam can be retained and
stabilized using other types of retainers.
233 7
7.2.6.1 Ligatures
Dental floss is used to stabilize the rubber dam and to retract
the gingiva. There is no need to make ligatures in every tooth;
this procedure is only needed where it is difficult to invert the
rubber dam or if gingival retraction is desired. A piece of
dental floss is then used to embrace the cervical area of the
tooth, and, with the aid of a bold hand instrument that pushes
the dental floss apically, the floss is directed towards the gin-
gival crevice. After the margins of the perforation on the rub-
ber dam are effectively inverted, the floss is tied on the facial
side with a double knot first, followed by a simple knot for
stabilization (. Fig. 7.17a–f) [14].

Tip

Ligatures with a double knot are difficult to perform

when the operator is unassisted and should preferably
a be performed with help. The operator and assistant
have to ensure that the knot is in the right position,
retracting the gingiva, and not sitting loose around
the cervical areas of the tooth.
b

..      Fig. 7.16  Detail of the tip of the Palmer forceps. a With slots; b with It is also possible to make ligatures with a running knot, where
a knurled surface a running loop is made outside the mouth and the dental floss

a b

c d

..      Fig. 7.17  Sequence to prepare ligatures using double knots with dental floss. a Introduction of the dental floss into the crevice; b, c double
knot (surgeon knot) used to stabilize; d, e simple knot used to fix the ligature; f ligatures finished
 234 A. B. Borges et al.
e f
..      Fig. 7.17 (continued)
7
is then adapted around the tooth and tied (. Fig.  7.18a–i).
 
Another simple knot is made over the first knot for fixation of
the ligature. If no additional gingiva retraction is desired, the
dental floss is then cut next to the knot.
Tip
Ligatures using a running knot are more stable and
therefore preferred. It is also possible to use this
ligature when working unassisted.
7.2.6.2  tabilizing Cords, O-rings, and Elastic
S eral incisor or canine of the contralateral hemiarch to improve
Ligatures
Dental dam stabilizing cords are made of natural latex
(. Fig.  7.19a) and available in various diameters. They can
sometimes substitute clamps or ligatures if the rubber dam is
placed on the anterior and premolar regions. The stabilizing
cords are used on the most distal tooth when isolating the
anterior teeth (. Fig.  7.19b) or on the most mesial tooth
when isolating posterior teeth (. Fig.  7.19c). Alternatively,
pieces of the rubber sheet can be used to stabilize the rubber
dam (. Fig.  7.20a–c). O-ring ligatures commonly used in
orthodontics to fixate the archwire onto the brackets are also
suitable to stabilize the rubber dam in the gingival area. The
O-rings can be stretched and brought onto the teeth by using
either the forceps or two opposing pieces of dental floss
(. Fig. 7.21a–f) [14]. Elastic ligatures can also be used to sta-
bilize the rubber dam. They are available in two shapes, for
anterior and posterior teeth, respectively, and can in some
situations replace the use of clamps (. Fig. 7.22a, b).
7.2.7  Number of Teeth to be Isolated
For some procedures in operative dentistry, it is enough to
place the rubber dam on only one tooth (. Fig. 7.23): when
there is no involvement of the approximal region or when
there is only one tooth on the hemiarch.
>> The clamp may in some situations be placed directly
on the tooth which will receive treatment, such as
single restorations of class I, class V, or sealing of
occlusal pits and fissures, as well for endodontic
treatment or internal bleaching.
In cases of class II preparations, a minimum of one tooth
mesially and one distally to the tooth being treated should be
isolated. This allows anatomical visualization of the adjacent
teeth used for reference during build up of the restoration,
and allows the placement of matrices and wedges. Some
authors suggest the isolation of the entire hemiarch of the
region that will be treated, extending the procedure to the lat-
access and visualization of the operating field [6, 8, 10, 12, 15].
However, this procedure is generally not necessary.
>> The clamp shall not be placed directly on the tooth of
interest if the restorative procedure involves the
interproximal space. This will interfere with positioning
the matrice and wedges.
For restorative procedures on anterior teeth, the isolation is
preferably made from canine to canine or from premolar to
premolar (. Fig.  7.24a, b). In such cases, the use of clamps
can often be avoided because the rubber dam can be stabi-
lized using other retainers (. Figs.  7.19b, 7.20c, and 7.21f).
Stabilizing cords, O-rings, or elastic ligatures can be tried
before deciding for the use of a clamp.
For restoration of class V cavities, no. 212 gingival retrac-
tion clamp is used to isolate and restore one tooth at a time
(. Fig.  7.25a). Clamps no. 212R and 212L can be used to
restore two adjacent teeth (. Fig. 7.25b).
7.2.8   echnique for Isolation Using Rubber
T
Dam
7.2.8.1 Preparation
Firstly, the need for anesthesia must be assessed. Isolation
with the rubber dam does not necessarily require anesthesia
Isolation of the Operating Field
of the gingival tissues, but is recommended if the gingival
retraction clamps are used and, in some cases, when the liga-
tures are necessary. However, if the restorative treatment
requires local anesthesia, this must be applied before placing
the rubber dam [14].
The next step is to test the clamp. It is necessary to choose
the one that best adapts on the anchor tooth. The choice of
235 7
>> For patient safety, a piece of dental floss (about 30 cm
long) must be tied on the clamp holes or bow before
inserting it into the mouth to avoid accidental
deglutition or aspiration. It can also be tied on both
circular holes of the clamp, increasing the safety in the
case it breaks on the region of the bow while inside the
mouth (. Fig. 7.26a, b).

clamp is simply based on the fit, which depends on the tooth

The clamp must be opened with the forceps until it trespasses
size, location on the arch, and eruption stage of the anchor
the tooth circumference and grips the cervical region. It is
tooth. The clamp bow must be directed distally to the anchor
released from the forceps, and its stability on the tooth must
tooth.

a b

c d

e f

..      Fig. 7.18  Sequence to prepare ligatures using a running knot. a–d Preparation of the running knot outside the mouth. e Placement of the
dental floss around the tooth; f tied knot; g, h additional simple knot used for fixation; i ligature finished and cut closely to the knot
 236 A. B. Borges et al.

g h

i
7

..      Fig. 7.18 (continued)

a b

..      Fig. 7.19  a Dental dam stabilizing cord roll used to stabilize the rubber dam (Wedjets – Coltène/Whaledent); b isolation of anterior teeth
stabilized distally with the stabilizing cords; c mesial placement of the cord to stabilize the rubber dam during isolation of posterior teeth
Isolation of the Operating Field
be verified, by touching the clamp slightly with the tip of the
index finger (. Fig. 7.27a, b). If there is lack of stability, the
 
clamp will move, and the efficacy of the procedure will be
237 7
Before actually placing the rubber dam, the inter-
proximal contacts must be checked with dental floss
(. Fig. 7.28). Any sharp regions, such as defective resto-

compromised. Care must be taken to not open the clamp rations or approximal carious lesions, are likely to tear
excessively: then there is a risk of the clamp not returning to the rubber sheet, and these areas should be smoothened
its original dimension [8]. with the aid of abrasive strips. Smoothing sharp margins

a b

..      Fig. 7.20  a A piece of rubber is cut from the edge of the dam; b the piece of rubber is placed distally to the canines when isolating anterior
teeth; c isolation finished using pieces of rubber dam for stabilization

a b

..      Fig. 7.21  a Orthodontic O-ring ligatures. b the O-ring can be opposing pieces of dental floss. e stretched O-ring using dental floss.
placed at the tip of the Palmer forceps. c stretching of the O-ring with f dental isolation using O-ring ligatures for stabilization
the Palmer forceps. d alternatively, the O-ring can be enlaced with two
 238 A. B. Borges et al.

c d

e f
7

..      Fig. 7.21 (continued)

a b

..      Fig. 7.22  a Elastic ligatures (Angelus) for anterior (1) and posterior teeth (2); b elastic ligature placed on a molar. Such ligatures could be
useful in cases of fissure sealants or alternatively for endodontic treatments

after removing old restorations is also recommended plates (. Fig. 7.30a, b) or by directly marking the position of
 

before placing the rubber dam. the perforations in the mouth (. Fig. 7.31a).
 

7.2.8.2 Preparation of the Rubber Dam Stamps

The rubber sheet must be perforated to adjust properly Stamps (. Fig. 7.29a, b) can be used to print the position of
 

around the teeth to be isolated. There are several techniques the teeth on the rubber dam. After wetting the stamp with
to determine the position of the perforations in the rubber ink, it must be centralized on the rubber dam to transfer the
dam, such as the use of a stamp (. Fig.  7.29a, b) and tem-
  locations of the orifices to be made. This technique allows
Isolation of the Operating Field
239 7
marking the rubber dam in advance; later only the positions of the positions of the teeth and may not be the best option in
corresponding to the teeth to be isolated need to be punched. cases of tooth misalignments or absence of teeth.
This technique is easy, but it does not allow individualization
Templates
Templates (. Fig. 7.30a, b) made of paper or plastic can also
 

be used to mark the position of the orifices on the rubber

dam. After placing the template centrally on the rubber sheet,
a marker pen is used to mark the position of the orifices. A
ballpoint pen should not be used because it does not allow
correct marking on the rubber. Similar to the use of stamps,
this technique is easy but does not account for individualiza-
tion of tooth positions in the dental arch.

Marking the Perforation Positions in the Mouth

..      Fig. 7.23  Placing the rubber dam in only one tooth is sufficient
when there is no involvement of the approximal area; here during
application of pit and fissure sealant
Although the use of stamps or templates is a rather easy way
for demarcating the perforations, they lack individualization
for the position of the teeth in the patient’s arch. Thus, by
marking the position of the perforations in the mouth, it is
possible to account for teeth that are misaligned or farther
apart from the neighboring teeth. According to this method,
the rubber dam must be attached to the frame and placed
centrally in the oral cavity. It is important to verify that the

a b

..      Fig. 7.24  Rubber dam placed to restore anterior teeth without using clamps. a The rubber dam was stabilized using only dental floss ligatures
on the canines (arrow). b The ligatures do not hinder positioning the silicone mold used for reconstruction of the fractured teeth

a b

..      Fig. 7.25  a Gingival retraction clamp number 212 applied to isolate only one tooth; b gingival retraction clamps 212L and R used for
simultaneous isolation and exposure of the cervical margins of two adjacent teeth
 240 A. B. Borges et al.

a b

..      Fig. 7.26  a A piece of dental floss is tied onto the clamp to increase the safety during the placement into the mouth. b dental floss tied on
7 both circular holes of the clamp, increasing the safety in case it breaks on the region of the bow while inside the mouth

a b

..      Fig. 7.27  a Testing the clamp onto the tooth; b verification of the clamp stability with the finger

under the rubber sheet. A marker pen is then used to mark

the center of the occlusal surface of posterior teeth
(. Fig.  7.31a) and the center of the incisal edge of anterior
 

teeth. In the absence of teeth, the corresponding space shall

remain unmarked.

7.2.8.3 Punching the Rubber Dam

The marks on the rubber dam must now be perforated by
pressing the punch firmly. The size of the perforations must
correspond to the size of the teeth, as described previously. In
order for the punch to reach all marks, the rubber sheet must
be partially removed from the frame (. Fig. 7.32).
 

7.2.8.4 Placing the Rubber Dam

..      Fig. 7.28  Verification of interproximal contacts with dental floss to
make sure it will be possible to pass the rubber between the teeth
without tearing
position of the rubber dam in the mouth leaves the nose free
from contact with the rubber [16]. Using the tip of the fin-
gers, the rubber dam must be stretched towards the teeth to
be isolated, so it is possible to see the contour of the teeth
The rubber dam can be placed in the patient’s mouth using
different techniques as described below.
Placement of the Whole Set: Clamp, Dam,
and Frame
In this technique, winged clamps must be used. The appro-
priate clamp is selected and tested beforehand, tied to dental
floss. The wings must be attached to the perforation corre-
Isolation of the Operating Field
241 7

a b Maxila

Mandibula

..      Fig. 7.29  a Stamp used to print the position of the teeth on the rubber dam; b marked rubber dam with the stamp

a b

..      Fig. 7.30  Examples of templates used to mark the rubber dam. a Vivadent; b Ivory

..      Fig. 7.31  Marking the position of the teeth directly in the mouth. ..      Fig. 7.32  Punching the marked positions on the rubber
The rubber shall be stretched over the teeth and held in position, while
the center of the tooth is marked using a permanent marker

on the tooth can impair bonding procedures or damage the

sponding to the anchor tooth, the bow directed distally rubber dam. The lubrication facilitates the passage of the
(. Fig. 7.33a–d). The perforations must be lubricated on the
  rubber dam through the interproximal contacts (. Fig. 7.33e).
 

side of the rubber sheet to be in contact with the teeth with a In sequence, the forceps must be engaged on the round
water-­soluble lubricant or the patient’s own saliva. Petroleum holes of the clamp, and the whole set containing the clamp,
jelly or oil-based products must not be used because residues the rubber dam, and the frame are placed into the mouth
 242 A. B. Borges et al.

of the patient (. Fig. 7.33f–h). The clamp must be opened

  ment is used to release the rubber sheet from the wings:
to allow adaptation onto the cervical area of the anchor the instrument is inserted into the rectangular holes of the
tooth. After releasing the clamp from the forceps, the clamp, and the rubber dam is directed underneath the
clamp stability must be tested. Thereafter, a bold instru- clamp (. Fig.  7.33i, j). The most anterior perforation is
 

a b

c d

e f

..      Fig. 7.33  Sequence to assemble the clamp onto the rubber
dam and subsequent placement of the whole set into the mouth.
a–c Fitting the clamp into the corresponding orifice for the anchor
tooth by placing the rubber under the wings; d view of the clamp
wings from the opposite side; e lubrication of the rubber dam on the
side to be in contact with the teeth; f fitting the forceps into the round
orifices of the clamp; g positioning the clamp on the anchor tooth
while bringing the whole set onto the mouth; h view of the clamp on
anchor tooth with the rubber above the wings; i the rubber dam is
moved underneath the clamp’s wings using a bold instrument; j view
of the rubber dam with good seal around the anchor tooth; k the
rubber is then passed over the most mesial tooth included in the
perforations; l thereafter, the rubber is passed between the remaining
teeth with help of dental floss, which is at the same time used to invert
the rubber into the crevice on the approximal surfaces; m if necessary,
the dental floss can be passed again in the same interproximal space to
push the rubber through; the double strand of floss is then removed
from the facial embrasure; n the rubber dam is also inverted on the
remaining dental surfaces using a bold instrument and air stream;
o rubber dam isolation finished
Isolation of the Operating Field
243 7

g h

i j

k l

m n

..      Fig. 7.33 (continued)
 244 A. B. Borges et al.
o
..      Fig. 7.33 (continued)
7
then passed through the most anterior tooth included in
the isolated field (. Fig. 7.33k) and stabilized using a piece
of elastic, stabilizing cord, ligature, or alternatively a piece
of the rubber sheet. The remaining perforations on the
rubber are then passed through the remaining teeth, one
by one, with the help of fingers, dental floss, and the bold
instrument (. Fig. 7.33l). If the interproximal contacts are
very tight, it may be necessary to repeatedly use the dental
floss until the rubber dam is successfully passed through
the interproximal contacts. In this case, it is recommended
to work with the dental floss always from the surface of
the tooth towards the edge of the perforation on the rub-
ber dam, instead of pushing the rubber between two per-
forations  – the latter increases the risk of tearing the
rubber dam.
Tip
If the interproximal contacts are too tight and multiple
passings of the dental floss are needed, a larger piece
of floss can be used to direct the rubber dam between
the teeth. After the first half of the dental floss has
passed between the teeth, it is left in position, and the
second half is pushed through the contacts. The
double strand of dental floss is then removed towards
the facial side of the tooth (. Fig. 7.33m), thus
reducing the risk of tearing the rubber.
After the dam is in place, the edges of the perforation must be
inverted into the gingival crevice. A bold hand instrument
aided by air-blowing is used for this task (. Fig. 7.33n). This
 
step is very important to secure adequate isolation of the
operating field when using the rubber dam; otherwise leak-
age will occur (. Fig. 7.33o).
 
Placement of the Dam and Frame Set Over a Pre-­
positioned Clamp
This technique is used with wingless clamps, which cannot be
attached to the rubber sheet. In this case, it is essential that the
rubber sheet is not too thick and well-lubricated. The clamp
must be previously placed on the anchor tooth. Afterwards,
the lubricated rubber dam attached to the frame is taken in
the mouth, and the most distal perforation is pushed over the
clamp using the fingertips [6]. Then, the remaining teeth are
passed over their corresponding perforations (. Fig. 7.34a–c).
Placement of the Dam and Wingless Clamp
Followed by the Frame
In this technique, after choosing the correct clamp
(. Fig.  7.35a), the bow of the wingless clamp must pass
through the most distal perforation in the rubber dam
(. Fig.  7.35b). The open clamp with the attached rubber
sheet is placed on the anchor tooth using the forceps, usu-
ally held in the one hand (. Fig. 7.35c). Generally, the other
hand is used to pull the rubber dam out of the way, so the
field is visible for placement of the clamp on the tooth
(. Fig.  7.35d). Afterwards, the frame is positioned
(. Fig.  7.35e). The rubber perforation around the anchor
tooth is stretched and passed completely over the clamp
(. Fig.  7.35f). In sequence, the remaining teeth are passed
over their corresponding perforations, following the same
steps previously described [6, 8].
7.2.8.5  lacement of the Clamp over
P
the Rubber Dam
This technique is generally performed when the rubber dam is
used to restore class V cavities or non-carious cervical lesions
using the gingival retractor clamp no. 212. This clamp is wing-
less and large, and therefore the techniques described previ-
ously do not apply. Therefore, the dam is first attached to the
frame. The perforation on the rubber dam is pushed towards
the cervical area of the selected tooth until the preparation mar-
gins are visible (. Fig. 7.36a). Clamp no. 212, engaged in the
forceps, is brought over the rubber dam; the most apical jaw is
carefully placed to retract the gingival tissue, so the margins are
completely exposed (. Fig. 7.36b). In this technique, care must
be taken not to not compress the gingiva lingually while mov-
ing the clamp facially nor damage the enamel or the cement on
the cervical region. The clamp jaw must be placed about
0.5–1 mm below the gingival cavosurface angle (. Fig. 7.36c)
[8]. In cases of cervical lesions with large gingival extension,
clamp no. 212M should be used instead (. Fig.  7.14b). This
technique is more easily performed four-handed.
Placing the clamp over the rubber dam can also be used
in posterior teeth if the dentist is working with assistance. In
that case, the punched rubber dam is placed over the tooth
and held in place by the dental assistant, while the dentist
places the clamp. A disadvantage of this technique when
working in the posterior region is the reduced visibility [8].
Isolation of the Operating Field
245 7
7.2.8.6 Inverting the Rubber Dam Edges crevicular fluid (. Fig. 7.37a, b). On the interproximal area,
 

The perforation edges of the rubber dam must be inverted the rubber dam must be inverted towards the interproximal
into the gingival crevice of all isolated teeth, [6] to obtain an papilla using dental floss. After moving the floss gingivally, it
effective seal and avoid contamination with saliva, blood, or should be removed facially or lingually, not occlusally

a b

..      Fig. 7.34  Placing the rubber dam and frame set over a pre-­positioned clamp. a Placing the clamp; b passing the most distal perforation over
the bow of the clamp; c the remaining perforations are passed over their corresponding teeth

a b

..      Fig. 7.35  Sequence for placement the rubber dam over the clamp, mouth; c fitting the forceps into the round orifices of the clamp; d
without the frame. a Testing the clamp, which is then removed; placement of the dam and clamp on the tooth; e assembling the dam
b passing the rubber dam over the bow of the clamp outside of the on the frame; f passing the rubber dam completely over the clamp
 246 A. B. Borges et al.
c d
e f
7
..      Fig. 7.35 (continued)
(. Fig.  7.33m). On the facial and lingual surfaces, a bold
 
instrument must be used to direct the rubber sheet inside the
crevice simultaneously with an air stream on the tooth, which
will dry the surfaces and direct the dam into the gingival
crevice (. Fig. 7.38a, b).
 
7.2.8.7 Removing the Rubber Dam
After the end of the restorative procedure, the clamp must be
carefully removed from the tooth. The rubber sheet is then
stretched, and the rubber in the interproximal area is care-
fully cut (. Fig.  7.39). The underlying soft tissue must be
 
protected by the dentist’s fingers, and care must be taken not
to cut the lips of the patient, which sometimes are exposed on
the perforations when the rubber dam is stretched.
After the rubber dam is removed, it must be inspected to
verify if there are missing pieces of rubber. The interproximal
spaces shall also be inspected with a dental floss. The gingiva
surrounding the clamped anchor tooth should be massaged
to stimulate blood circulation on the areas of compression.
7.2.9  Modified Techniques for Isolation
in Special Clinical Situations
If placing rubber dam is needed next to abutment teeth of
a fixed prosthesis or work needs to be done on the abut-
ment teeth, the technique is modified accordingly [6, 10].
Other special situations include the placement of rubber
dam to include teeth with fixed orthodontic retainers or
yet drying the operating field around deep subgingival
margins or gingival retractions. In such situations, it may
not be possible to place a clamp or trespass the rubber
dam individually around the teeth nor retract the gingival
tissues. Thus, the easier and most used approach when
the use of rubber dam is desired in such clinical situations
is the use of the sleeve technique. Here, the rubber dam is
not perforated but instead cut in an arch to include sev-
eral teeth. For the sleeve technique, a clamp is placed in
the most distal anchor tooth to stabilize the rubber dam,
and the rubber is folded towards the gingiva (. Fig. 7.40).
In anterior areas, the use of clamp may be unnecessary,
but instead the rubber dam can be stabilized using elastic
ligatures.
The use of the sleeve technique is beneficial in special
situations, for example, if the rubber dam must be used in the
area of bridges or orthodontic retainers. Additionally, the
sleeve technique may be advantageous when the use of con-
ventional rubber perforations may not result in a satisfactory
solution. . Figure 7.41 shows a veneer tooth preparation on
central incisor, in which proper positioning of the rubber
dam was not achieved with the regular technique. In this
case, the sleeve technique was applied to expose the gingival
margin of the preparation to allow the restoration with com-
posite. The sleeve technique can be beneficial for adhesive
Isolation of the Operating Field
247 7

a b

..      Fig. 7.36  Sequence for placement of the clamp over the rubber dam. a Fitting the punched dam over the tooth; b fitting the clamp no. 212,
retracting the gingiva on the labial surface and exposing the gingival cavosurface angle of the preparation; c isolation finished

..      Fig. 7.37 Schematic
drawings showing the impor- a b
tance of inverting the rubber
dam into the crevice. a Flow of
the gingival fluid and the saliva
through the rubber dam
perforation; b by inverting the
edge of the rubber dam inside
the gingival crevice, the passage
of fluids is blocked

restorative procedures in teeth with deep subgingival
margins or located at areas of gingival retraction, particularly
if the gingiva is thin.
Although the sleeve technique offers better moisture
control of the operating field and retraction of the soft tis-
sues than the use of cotton rolls combined with suction,
there is a possibility of salivary flow into the operating field.
That must nevertheless be controlled and is more problem-
atic when working on the lower jaw due to accumulation of
saliva. . Figure 7.42 shows a clinical case of a patient with
 248 A. B. Borges et al.
a b
..      Fig. 7.38  Inversion of the rubber dam into the crevice using a bold instrument and air stream. a The instrument is used to push the rubber
7 towards the crevice while air-blowing; b rubber dam edges were inverted inside the crevice
..      Fig. 7.39  Removal of the dam is easier by cutting the rubber whilst
protecting the patient’s soft tissues from the scissors
..      Fig. 7.40  Example of a sleeve dam technique, where the rubber is
cut to include several teeth under the opening. The sleeve dam offers
retraction of the soft tissues and is here stabilized by placing clamps on
the most distally teeth
orthodontic retainer on the lingual surface of lower inci-
sors, which impairs the regular application of the rubber
dam. In this case, the sleeve technique was associated with
a light-cured gingival barrier, to completely seal the mar-
gins of the rubber dam.
Tip
When using the sleeve technique, applying light-cured
gingival barriers at the margins of the rubber dam can
protects the gingiva and may help to improve the seal
(. Fig. 7.42).
>> Attention must be given when the clamp is placed
cervically on resin composite or ceramic crowns or
veneers, due to the possibility of edge fractures of the
material.
7.2.10   ealing Leakage on the Rubber
S
Dam Isolation
Sometimes, small undesired flaws in the rubber dam isola-
tion may compromise seal (. Fig. 7.43). Commonly encoun-
tered flaws may result from inadequate punching of the
rubber sheet, e.g., if the distance between perforations is too
small, which adversely affect the correct protection of the
papilla and inversion of the rubber dam into the crevice
(. Fig. 7.44a–c). Some of these flaws can be sealed with suc-
cess using flexible light-cured resin-based gingival barriers,
although this is not always the case.
7.3  sing Cotton Rolls Combined
U
with Suction
The use of cotton rolls combined with suction aims to con-
trol the moisture of the operating field and displace the
surrounding soft tissues around the teeth, such as the lips,
cheeks, and tongue. It is difficult to reach complete mois-
ture control during the operative procedures, and because
Isolation of the Operating Field
249 7

a b

..      Fig. 7.41  a Conventional isolation did not allow visualization of the gingival contour. b the rubber dam was removed and replaced as a
the preparation margins on the central incisor, and concern existed sleeve dam, where access to the whole preparation margin was
that the use of a gingival retraction clamp could further compromise granted

a b

..      Fig. 7.42  Conventional isolation of the upper arch combined with Pieces of rubber are used to stabilize the dam instead of using clamps.
sleeve dam isolation of the lower arch, due to the presence of an a gingival barrier was applied to protect the gingiva; b the gingival
orthodontic retainer on the lingual surface of the lower incisors. barrier is in place and a cotton roll is used on the lingual opening

this technique does not hinder the involuntary movement

of the soft tissues, it must be used with caution, during
short periods of time and preferably in four-­handed work
[5]. In favorable cases, it can adequately substitute the need
for rubber dam isolation [17]. Although the use of cotton
rolls can be relatively effective in controlling the moisture,
it does not reduce the risks of contaminations and acci-
dents [16]. The use of cotton rolls combined with suction
in operative dentistry are indicated in the following situa-
tions [11]:
55 When rubber dam isolation is impossible or impairs the
aesthetic evaluation of the operating field
55 In patients with nasal obstruction or mouth breathing
55 When rubber dam isolation has failed
55 In teeth that are partially erupted or misaligned and
..      Fig. 7.43  An undesired perforation in the rubber dam compro-
placing the clamp or other retainer is not possible
mises seal and allows flow of saliva into the operatorative field (arrow)
 250 A. B. Borges et al.

a b

c
7

..      Fig. 7.44  Sealing flaws on the rubber dam is sometimes possible using light-cured gingival barriers. a Failure on the isolation exposing of the
gingival papilla; b application of the gingival barrier; c light-cured gingival barrier in position

55 In patients who are allergic to latex, if latex-free sheets sues. Disposable saliva ejectors that have a flexible metallic
are not available rod are preferred, as they can be curved and adapted in sev-
55 For topical fluoride application eral places of the oral cavity (. Fig. 7.47a). Careful placement
 

55 In cases of temporary restorations
55 For direct veneers or large restorations on anterior teeth.
Here, the use of cotton rolls and suction allows a better
overview of the operating field and improved visualiza-
tion of the relationship between the teeth and the
gingival level
55 For multiple cervical lesions. Here several teeth can be
restored at once, while the rubber dam limits restoring
two teeth at a time
of the saliva ejectors is necessary to avoid suction, trauma, or
ulceration of the soft tissues on the cheeks or oral cavity floor.
Modified saliva ejectors with thin tips exist, and they can be
inserted inside the tooth preparation or be used for suction
of gels applied over the tooth surface. Some saliva ejectors are
anatomically designed to adapt to the mouth at the same
time as it retracts the tissues and provides suction. Hygoformic
saliva ejectors are curved, adjustable plastic devices which
are equipped with five small holes (. Fig.  7.47b, left side).

They are placed in the floor of the lower jaw, can reach the
Cotton rolls shall obstruct the exit of the salivary glands’ most posterior teeth, and push the tongue aside from the
ducts (. Fig. 7.45a–c) to reduce the moisture in the oral cav-
  working field (. Fig.  7.48a, b). Another very useful saliva
 

ity. . Figure 7.46 illustrates the path of the saliva inside of the

  ejector also offers tongue retraction (. Fig. 7.47b, right side).
 

oral cavity. It has an anatomic design that can keep the tongue away. It is
only found in one size but can fit all patients due to the good
flexibility of the plastic.
7.3.1   aliva Ejector and High-Volume
S High-volume evacuators (HVE), i.e., larger diameter
Evacuators plastic suction tips with beveled end, collect the water spray
as the tooth is being rinsed or prepared (. Fig. 7.49a, b). HVE
 

Saliva ejectors are devices used to remove saliva and water are capable of quickly removing higher volumes of liquids as
that comes from the high-speed handpiece [14]. Saliva ejec- well as small solid residues from the operating field and are
tors are usually made in soft plastic not to hurt the soft tis- ideal for four-handed work. HVE are very useful when
Isolation of the Operating Field
251 7

a b

..      Fig. 7.45  a Exit of parotid gland duct at the parotid papilla, which lies between the first and second upper molars. b Ducts of submandibular
and sublingual glands exit in the sublingual caruncles. c Visible saliva drops from minor salivary glands, which are scattered all over the mouth

removing amalgam restorations, thus minimizing the

amount of amalgam residues to be swallowed by the patient.
Tongue and cheek retraction dam (ex. Ez-Dam dry isola-
tion field) is another technology regarding saliva ejection: it
is equipped with high volume suction, tongue retractor,
cheek retractor, and biting block all in one device (. Fig. 7.50a,
 

b). The biting block is made of silicone and is available in five

different sizes.

Tip

Hygoformic saliva ejectors shall be placed on the same

side of the jaw as you work. It can preferably be
adjusted by bending the coil so it pushes the tongue
further away from the teeth. These ejectors can be
stabilized to the lower jaw by curving it around the
chin of the patient.

7.3.2  Cotton Rolls and Absorbent Pads

The cotton rolls must be highly absorbent of saliva

(. Fig. 7.51a). Long cotton rolls are used to isolate one hemi-
 

..      Fig. 7.46  Schematics of the saliva path inside the oral cavity. On arch (. Fig. 7.51b). Cotton rolls must always be used together
 

the right side, the saliva flow comes from the parotid gland, and on the with the saliva ejectors and shall be carefully replaced when
left side the flow comes from the submandibular and sublingual glands they become saturated. At the end of the procedure and
 252 A. B. Borges et al.

a b

..      Fig. 7.47  a Examples of disposable saliva ejectors for regular and more delicate to the surrounding soft tissues; the one on the right of
7 high-suction evacuation; the transparent tubes can be curved for the image also retracts the tongue (ex. Sweflex saliva ejector)
adaptation in the oral cavity. b Hygoformic saliva ejectors, which are

a b

..      Fig. 7.48  a Hygoformic saliva ejector in the mouth. b in combination with cotton roll to control moisture of the operating field

a b

..      Fig. 7.49  a High-volume evacuator combined with hygoformic saliva ejector and cotton rolls in the mouth. b High-volume evacuator used in
combination with rubber dam
Isolation of the Operating Field
253 7

a b

..      Fig. 7.50  a Tongue and cheek retraction dam is connected directly to the suction unit. b Small perforations in the silicone allow suction of
saliva while simultaneously retracting the tongue and cheek

a b

c d

..      Fig.7.51  a Examples of cotton rolls of different thicknesses; b long to be adhered to the mucosa on the exits of the parotid glands. Some
cotton rolls with an internal metallic rod to allow curving (Roeko); pads have a reflexive external side (ex. NeoDrys)
c absorbing paper rolls (ex. Septembar Group); d saliva absorbing pads

before removing the cotton rolls, it is important to check if covered by a layer of non-­woven fabric (TNT), with an iden-
they are dry. In this case, they must be moistened with water tical shape as the cotton rolls (. Fig. 7.51c). There are advan-
 

before removal to avoid undesired damage of the mucosal tages of not sticking to the oral mucosa of the patient even
epithelium. There are also absorbent rolls made of paper and when they are dry.
 254 A. B. Borges et al.

a b

c d
7

e f

..      Fig. 7.52  Examples of soft tissue retractors. a Lip and cheek and tongue retractor (ex. Arcflex – FGM); f cheek and tongue retractor
retractor (ex. J. Morita); b labial retractor for procedures on anterior combined with saliva ejector (ex. Nola Dry Field System – Great Lakes
teeth (ex. Indusbello); c labial retractor with protecting rubber (ex. Orthodontics)
Optragate – Ivoclair/Vivadent); d tongue retractor (ex. Villevie); e cheek

Absorbent pads adhere onto the cheeks’ mucosa, blocking 7.3.3  Cheek and Tongue Retractors
the exit of the parotid gland duct. Such absorbent pads tend to
retain more water than cotton rolls. They are made of cellulose The cheek retractor protects cheeks and lips while increasing
or filled with acrylate polymers that retain the moisture and the visual field (. Fig. 7.52a–c). Before using these retractors, it
 

transform it in a gel (. Fig. 7.51d). The absorbent pads must

 
is necessary to lubricate the patient’s lips with lip balm to avoid
also be moistened before their removal from the oral cavity. drying and lip fissures when the tissue is stretched. There are
Isolation of the Operating Field
a b
..      Fig. 7.53  a Biting blocks with a central orifice to tie dental floss; b biting block in the mouth
also flexible retractors made of rubber, which retract the lips
and cheeks evenly and gently (. Fig. 7.52c). The tongue retrac-
 
tor in the form of a disposable bite block restrains the tongue
and provides bilateral support (. Fig.  7.52d). Some cheek
 
retractors can be attached to a tongue retractor (. Fig. 7.52e).  by rings as knitting stitches or chains) cords are available
The cheek and tongue retractor combined with saliva ejector is
shown in . Fig. 7.52f; besides retracting the lips and cheeks, it
 
presents a tongue guard and tubes that aspirate saliva.
Biting blocks made of silicone can be used to keep the
mouth open in patients with difficulties or opening limita-
tions (. Fig.  7.53a). The biting blocks have multiple slots
 
along the lateral surfaces to stabilize on the occlusal sur-
faces of the teeth. The biting blocks must be inserted
between antagonist teeth on the opposite hemiarch to the
one that will receive treatment: the narrower edge facing
the more distal tooth. The more posterior the biting block is
placed, the more the mouth will open anteriorly [15]. It is
recommended to tie a piece of dental floss on the biting
block for safety reasons (. Fig. 7.53b).
 
7.3.4  Light-Cured Gingival Barriers
The light-cured resin-based gingival barriers are flowable
resins with pigments, which are used to protect the gingival
tissues (. Fig. 7.54a, b). Even after light-curing, these resins
 
still show certain flexibility, which makes their removal easy
(. Fig. 7.54c). The light-cured gingival barriers can be useful
 
to protect the gingiva from in-office bleaching agents, but as
mentioned earlier, they can be also used to correct small
defects in the rubber dam or in combination with rubber
dam in modified applications (. Fig. 7.42a, b).
 
7.3.5  Gingival Retraction Cords
Flexible cords are inserted into the gingival crevice to retract
the gingiva, improve the visualization and access to gingival
255 7
margins during tooth preparation and restoration, as well as
control gingival fluid or bleeding during the restorative
­procedure. Twisted (cotton thread twisted around itself),
braided (where the threads are weaved), and knitted (formed
(. Fig. 7.55a), and the choice is determined by the dentist’s
preference, even though the knitted and weaved cords are
easier to use [18]. The thicknesses of the cord to be used
depends on the depth of the gingival crevice (. Fig. 7.55b).
The cords must be packed into the crevice with a thin bold
instrument or using specific packing instruments
(. Fig. 7.55c), some with fine serrations on the working edge
to avoid slipping and damaging the gingival tissue.
Retraction cords to mechanically retract the gingiva can
be impregnated with astringent or vasoconstrictors solu-
tions, which will cause contraction of the gingival tissue,
reduce the flow of gingival fluid, and control bleeding. The
most commonly used astringent solutions are aluminum
chlorite, aluminum sulfate, zinc chlorite, or iron sulfate.
These compounds only act locally and rarely cause systemic
reactions while promoting adequate hemostasis of the gingi-
val tissues. Epinephrine can also be used, but possible risks
are the increase of the cardiac frequency and arterial pressure
as well as allergenic potential. When applying cords impreg-
nated with astringent, their use shall be limited to short peri-
ods of time, preferably up to 15 min [19]. Since procedures in
operative dentistry generally take longer, mechanical retrac-
tion is preferred using non-impregnated cords.
The thickness of the retraction cord is chosen according
to the depth of the crevice and the degree of desired retrac-
tion. The cord is cut to size (. Fig.  7.56a, b) and carefully
packed into the crevice (. Fig. 7.56c, d). Care must be taken
to not create prolonged ischemia of the tissue; if this is the
case, the cord must be replaced by a thinner one. As packing
of the cord progresses, part of the cord already inserted into
the gingival crevice tends to be displaced as the instrument
moves forward. Therefore, the instrument shall return a little
and press the previous region again, repositioning the cord.
 256 A. B. Borges et al.
a b
c
7
..      Fig. 7.54  a Light-cured gingival barrier being applied; b after curing; c removal of the gingival barrier
The gingival retraction can cause discomfort to the patient
and may lead to permanent gingival retraction. To avoid
these problems, the technique must be performed correctly,
without excessive pressure during insertion of the cord in the
crevice.
>> At end of the restorative procedure, the cord must be
carefully removed from inside the gingival crevice with
the aid of an exploratory probe.
7.3.6  Cotton Roll Isolation Technique
7.3.6.1 Maxillary Anterior Teeth
Two cotton rolls must be placed on the bottom of the vesti-
bule on each side of the labial frenulum to better accommo-
date it and to avoid their displacement (. Fig.  7.57a). On
 
patients that have a small labial frenulum, a single long cot-
ton roll can be used on the whole arch (. Fig. 7.57b).
 
7.3.6.2 Mandibular Anterior Teeth
Two cotton rolls must be placed on the bottom of the vesti-
bule, one on each side of the lower lip frenulum. Two addi-
tional cotton rolls must be placed on each side of the lingual
frenulum. These block the exit of the submandibular and
sublingual glands, as well as the exits of minor salivary
glands (. Fig. 7.58a). When the labial frenulum is small, a
single long cotton roll can be placed on the vestibule region
(. Fig. 7.58b).
7.3.6.3 Maxillary Posterior Teeth
The cotton rolls must be positioned on the bottom of the ves-
tibule on the posterior region, blocking the exit of saliva from
the parotid gland’s duct and retracting the cheek (. Fig. 7.59a).
Absorbing pads can also be used; they adhere to the cheek
mucosa and absorb the saliva (. Fig. 7.59b). Some absorbing
pads have a reflective surface that improves light distribution
inside the oral cavity. The saliva ejector must be kept at the
floor of the mouth or at the area behind the last molar [14].
7.3.6.4 Mandibular Posterior Teeth
It is the region that requires most care and attention when
using cotton rolls and suction, due to the large quantity of
saliva and the movement of the tongue, lips, and cheeks. A
cotton roll must be placed over the exit of the parotid
gland’s duct in the upper vestibule. Another cotton roll
must be paced in the lower vestibule, beside the tooth to be
treated, and one or two more cotton rolls shall be placed on
the floor of the mouth, under the tongue. This ensures that
saliva is absorbed at the same time that the tongue is dis-
placed (. Fig. 7.60a). It is important to remember that the
saliva ejectors must be placed at all times  – during the
Isolation of the Operating Field
257 7
restorative procedure  – in the oral cavity, removing the Tip
saliva and maintaining the cotton rolls in position.
Alternatively, a long cotton roll can be placed on the upper When you want to remove the cotton rolls or absorbant
and lower vestibule (. Fig. 7.60b) or the cotton roll can be
  pads, make sure that they are wet. Otherwise they
combined with absorbing pads, always under constant suc- adhere to the mucosa and can wound the epithelium.
tion (. Fig. 7.60c).
 

a b

..      Fig. 7.55  a Examples of gingival retraction cords (1, twisted; 2, braided; and 3, knitted); b cords with varying thicknesses; c instruments used
for placement of the retraction cords into the gingival crevice

a b

..      Fig. 7.56  Placement of gingival retraction cord. a Initial situation; b retraction cord cut to size and brought to the cervical region of the tooth;
c packing the cord into the crevice with a special packing instrument of round tip (ex. Millennium); d gingival retraction finished
 258 A. B. Borges et al.

c d

..      Fig. 7.56 (continued)
7

a b

..      Fig. 7.57  Cotton roll isolation of the area of maxillary anterior teeth. a Two cotton rolls placed on each side of the upper labial frenulum;
b single, long roll placed on the upper arch vestibule

a b

..      Fig. 7.58  Cotton roll isolation of the area adjacent to the the saliva ejector; b pre-curved, long cotton rolls placed over the lower
mandibular anterior teeth. a Cotton rolls are placed beside the lower arch vestibule and under the tongue
labial frenulum. Cotton rolls placed on the lingual side are stabilized by
Isolation of the Operating Field
259 7

a b

..      Fig. 7.59  a Cotton roll isolation of the area adjacent to the maxillary posterior teeth; b saliva-absorbing pad positioned onto the cheek
mucosa

a b

..      Fig. 7.60  Cotton roll isolation of the area of mandibular posterior roll positioned over the exit of the parotid duct and in the lower
teeth. a Cotton rolls positioned on the lower vestibule, under the vestibule; c cotton roll combined with absorbing pad (red arrow) and
tongue and over the exit of the parotid duct; b pre-curved, long cotton hygoformic saliva ejector (blue arrow)
 260 A. B. Borges et al.
Tip
After acid etching and rinsing of the surface during an
adhesive technique, you need to change the cotton
rolls or absorbant pads in order to avoid moisture
reaching the operating field. If the cotton rolls are
contaminated with adhesive or resin-based materials,
these must be changed to avoid contact of
unpolymerized material with the patient’s soft tissues.
Conclusion
Controlling moisture and contamination in the operating
field offer the best conditions for optimal restorative work.
The use of rubber dam is preferred for effective control of
7 moisture and preventing contamination, both essential pre-
requisites for adhesive dentistry. If the use of rubber dam is
not possible, the next best available option is the use of cot-
ton rolls combined with suction. This chapter explains the
importance of isolation of the operating field to enhance the
quality of the restorative procedures. The necessary instru-
ments and consumables for providing effective moisture con-
trol, either by using rubber dam or combining cotton rolls
with suction, have been revised. The techniques for obtaining
moisture control of the operating field have been thoroughly
explained.
References
1. Wang Y, Li C, Yuan H, Wong MCM, Zou J, Shi Z, Zhou X. Rubber dam
isolation for restorative treatment in dental patients. Cochrane
Database Syst Rev. 2016;9:CD009858.
2. Keys W, Carson SJ.  Rubber dam may increase the survival time of
dental restorations. Evid Based Dent. 2017;18(1):19–20.
3. Browet S, Gerdolle D. Precision and security in restorative dentistry:
the synergy of isolation and magnification. Int J Esthet Dent.
2017;12(2):172–85.
4. Mahn E, Rousson V, Heintze S.  Meta-analysis of the influence of
bonding parameters on the clinical outcome of tooth-colored cer-
vical restorations. J Adhes Dent. 2015;17(5):391–403.
5. Gilmore HW, Lund MR, Bales CD, Vernetti S, editors. The operating
field. Operative dentistry. 3rd ed. St. Louis: CV Mosby Company;
1977. p. 100–16.
6. Summitt JB. Field isolation. In: Summitt JB, Robbins JW, Schwarz RS,
editors. Fundamentals of operative dentistry. Illinois: Quintessence
Books; 1996. p. 109–39.
7. Barrancos Mooney J, Rodríguez GA.  Isolamento do campo oper-
atório. In: Barrancos Mooney J, editor. Operatória Dental. Buenos
Aires: Medica Panamericana; 1999. p. 395–438.
8. Wilder AD.  Preliminary considerations for operative dentistry. In:
Roberson TM, Heymann HO, Swift EJ, editors. Sturdevant’s art and
science of operative dentistry. St. Louis: Mosby/Elsevier; 2006.
p. 447–91.
9. Besek M.  Optidam, the new dimensional rubber dam. Available
from: http://www.­kerrhawe.­com/products/documents/Article_
Besek_en.­pdf.
10. Baum L, Phillips RW, Lund MR, editors. Isolation of the working field.
Textbook of operative dentistry. Philadelphia: WB Saunders Com-
pany; 1995. p. 187–219.
11. Conceição EN, Soares CG. Isolamento do campo operatório. In: Con-
ceição EN, Colaboradores, editors. Dentística: Saúde e Estética.
Porto Alegre: Artes Médicas Sul; 2000. p. 83–94.
12. Mondelli J. Fundamentos da Dentística Operatória. São Paulo: San-
tos; 2006.
13. Luz MA. Isolamento do campo operatório. In: Garone Neto N, editor.
Introdução à Dentística Restauradora. São Paulo: Santos; 2003.
p. 25–41.
14. Souza JB, Fernandes MI, Filho AV, Taveira WS, Rocha LI, Gonçalves
AM. Isolamento do Campo Operatório. In: Busato AG, editor. Grupo
Brasileiro dos Professores de Dentística. São Paulo: Santos; 2005.
p. 203–36.
15. Marzouk MA, Simonton AL, Gross RD, editors. Controle do Campo
Operatório. Dentística Operatória: Teoria e Prática Moderna. Santos:
São Paulo; 1987. p. 95–118.
16. Iorio PA, editor. Isolamento do campo operatório. Dentística Clínica:
Adesiva e Estética. Santos: São Paulo; 1999. p. 3–19.
17. Brunthaler A, König F, Lucas T, Sperr W, Schedle A.  Longevity of
direct resin composite restorations in posterior teeth. Clin Oral
Investig. 2003;7:63–70.
18. Donovan TE, Chee WW. Current concepts in gingival displacement.
Dent Clin North Am. 2004;48(vi):433–44.
19. Reiman MB. Exposure of subgingival margins by nonsurgical gingi-
val displacement. J Prosthet Dent. 1976;36:649–54.
 261 8

Matrix and Wedge Systems

Cesar Rogério Pucci, Carlos Rocha Gomes Torres,
and Ali Ibrahim Abdalla

8.1 Introduction – 262

8.2 Matrix – 263

8.2.1  etallic Matrix – 263
M
8.2.2 Transparent Plastic Matrix – 268

8.3 Matrix Retainer – 270

8.4 Wedges – 276

8.4.1 F requent Mistakes Related to the Use of Wedges – 279
8.4.2 Elastic Wedges – 280

8.5 Challenges for the Correct Use of Matrix and Wedges – 281

8.6 Custom-Made Matrices – 283

8.6.1 S pot-Welded and Riveted Matrix – 284
8.6.2 Window Matrix – 285
8.6.3 Barton Matrix – 285
8.6.4 T- band Matrix – 285
8.6.5 S-shaped Matrix – 285

References – 288

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_8
 262 C. R. Pucci et al.
Learning Objectives
The learning objectives of this chapter are related to the fol-
lowing topics:
55 To explain the definitions, characteristics, and impor-
tance of the matrix and wedge use during restorative
procedures
55 To present the different kinds of metallic and plastic
matrices (circumferential and sectional)
55 To explain the use of different matrix retainers in detail,
followed by its indications and techniques of use
55 To present the frequent mistakes related to the use of
wedges and the solution for challenging situations
55 To explain the technique to prepare custom-made
matrices, including spot-welded and riveted matrix,
window matrix, Barton’s matrix, T-band matrix, and
S-shaped matrix
8 8.1 Introduction
There are several reasons that can lead to the loss of tooth
structures, such as the caries disease, traumas, attrition, occlu-
sal overload, erosive tooth wear, among others. Regardless of
the cause, the restorations of those lost structures must
recover the lost shape, function, and esthetics using an artifi-
cial restorative material. Those materials present plastic vis-
cosity so that they can be applied into the cavity and be shaped,
before they undergo some kind of curing reaction and become
hard, maintaining the shape created and restoring the lost
tooth surfaces. In some situations, such as on the occlusal sur-
faces of the posterior teeth (Class I) or on the facial or lingual
surfaces of the posterior and  anterior teeth (Class V), the
tooth preparations present surrounding walls that will hold
the restorative material in place, simplifying the procedure
(. Fig. 8.1a). However, in the cases where the lesion, and con-
sequently the preparation, reached the interproximal surfaces,
it is impossible to guarantee the perfect restoration of the lost
surface if the material is inserted directly into the preparation,
a b
..      Fig. 8.1  Indications of a matrix system. a The preparations sur-
rounded by vertical walls are capable to hold the restorative material.
b When the proximal surface was lost, it is necessary a temporary
because it will flow into and invade the interproximal space
and facial and lingual embrasures. To solve this technical
problem, it is necessary something be used as a temporary
artificial holder for the restorative material until its setting,
allowing that the contour and smoothness of the proximal
surface are restored (. Fig. 8.1b – arrow). This device, called
matrix, is basically a strip or band made of metallic or plastic
material that works as a type of a tray, inside which the resto-
ration will be made. The use of a matrix to restore teeth was
introduced in Dentistry by Dr. Louis Jack, in 1871. In order to
keep the matrix in position around the tooth structures dur-
ing the restorative procedure, several different types of instru-
ment can be used, commonly called matrix retainer. When
the matrix is placed in position on the interproximal region, it
must be stabilized and better adapted to the remaining tooth
structure. To reach this goal, a small wedge with triangular
cross section is inserted into the interproximal space
(. Fig.  8.1b  – asterisk). The set of the three components is
known as the matrix and wedge system, which have the fol-
lowing goals: [3, 4, 6].
55 To allow the application or condensation of the restor-
ative material inside the cavity
55 To hold the restorative material until it passes through
the setting reaction and keep the desired shape
55 To allow the anatomic and physiological reconstruction
of the teeth
55 To allow the restoration of the interproximal contact
55 To allow the sculpture of the restoration
55 To prevent the restorative material extrusion at the cavo-
surface margin, resulting in excess at the margins (flash)
or overhangs in the cervical region, which would result
in the presence of and deposit of bacterial biofilm
55 To help the isolation of the prepared tooth, once it will help
to keep the rubber dam in position and retract the gingiva
The matrices and wedge system can be used in cavities that
involve proximal surfaces, such as Class II, III, and IV accord-
ing to Black classification, or even on the Class I compound
holder during the restorative procedure (the  arrow indicates
the matrix band; the wedge can be seen in the interproximal space)
Matrix and Wedge Systems
preparation, where the matrix will aid the restoration of the
buccal groove on the mandibular molars or lingual groove on
the maxillary molars. Occasionally, the matrices can also be
used for Class V restorations.
>> The correct application of a wedge can prevent the
restorative material extrusion at the cavosurface
margin, which would create overhangs in the cervical
region, promoting biofilm deposition and periodontal
inflammation.
8.2 Matrix
In order to a matrix band has an adequate performance,
some basic requirements must be present. In the first place,
they must be very thin, so they do not take too much space in
the interproximal area, but at the same time be capable to
resist the pressures applied over the restorative material, as it
occurs during the amalgam condensation. They must be flex-
ible, to adapt on the contours of the remaining tooth struc-
ture, and smooth to create a restoration with the external
surface roughness like the remaining tooth structure. In
addition, they must be rigid enough to not suffer deforma-
tion during the use and be compatible with the restorative
material, not sticking to it [6].
The matrices can be classified on several manners, which
will allow to understand better its purpose. In relation to the
involvement of the dental crown, they can be classified in the
circumferential matrix, which involves the mesial, distal,
facial, and lingual surfaces simultaneously, or partial (also
called sectional), which involves only one of the proximal
surfaces (. Fig. 8.2a, b).
 
In relation to the restorative material used, the matrices
can also be classified in matrices for silver amalgam and
matrices for esthetic materials, as composite resins or glass
ionomer cement. On the anterior teeth, the matrices for
esthetic materials need to be transparent to allow the passage
of the light from the light-curing unit through it. In relation
to the way of use, the matrices can be called universal, when
a b
..      Fig. 8.2  Classification of the matrices, according to the surrounding of the crown. a Circumferential; b sectional
263 8
they are ready-made and can be used in several different situ-
ations, or custom-made, when the dentist makes by hand a
specific matrix for a special clinical situation [5]. The matri-
ces can also be made of metal, used for posterior teeth, or
plastic that can be used for anterior and posterior teeth.
It is important to emphasize that the matrix band must
never be used more than once. When the band is used again,
there is an increase of the surface roughness and change of
the contour due to the deformation, which will significantly
jeopardize the smoothness and desired profile of the proxi-
mal surface to be restored [1].
8.2.1 Metallic Matrix
Several types of metallic matrices are available on the market,
and they can be circumferential or sectional. They can be
used on posterior teeth, both for amalgam and composite
restorations, once the light for the curing is applied occlus-
ally.
8.2.1.1 Circumferential Metallic Matrix
The most commonly used metallic matrices are the straight
bands. They are flat bands available in two thicknesses,
0.03  mm (0.0015 inch) or 0.05  mm (0.002 inch), and two
heights, 5 mm indicated for teeth with shorter clinical crowns
and 7  mm indicated for longer crowns (. Fig.  8.3a). They
need to be cut on the necessary size to wrap the crown and to
be fixated onto the matrix retainer, resulting in a cylindrical
shape (. Fig. 8.3b). There are also the metallic bands with a V
or boomerang shape, known as Tofflemire matrix band. They
are 7 cm long with various widths for different crowns sizes.
Some of them present projections in the internal border that
serve to adapt onto the preparations where the gingival walls
go far down into the cervical region (. Fig.  8.3c). The
boomerang-­shaped matrix must be assembled on the retainer
with the internal edge of its curvature facing the cervical
region. This will result on a funnel-shaped cone when
wrapped around a tooth, placed with its smaller diameter
facing the cervical area, contributing for a better adaptation
 264 C. R. Pucci et al.
a b
c d
..      Fig. 8.3  Metallic circumferential matrix bands used with the matrix retainer. a Straight strips. b straight strip assembled on the matrix retainer.
c Tofflemire matrix. d Tofflemire matrix assembled on the retainer
of the matrix (. Fig. 8.3d). It is also available pre-contoured
 
Tofflemire circumferential matrix, which follows the natural
contour of the proximal tooth surface.
Some metallic bands present an integrated retainer sys-
tem that dismisses the use of a separated matrix retainer.
They can have disposable retainers integrated with the bands
or be retainerless. The applications of the retainerless cir-
cumferential matrices are particularly interesting in the cases
where the tooth, which will be restored, is also the anchor
tooth and will receive the clamp for isolation. Some examples
can be observed in . Figs. 8.4, 8.5, and 8.6.
 
8.2.1.2 Sectional Metallic Matrix
The sectional matrices surround only one proximal surface
during the restoration, which present some advantages. As the
matrix band has a certain thickness that occupies a space
between the restorative material and the adjacent tooth, to get
a proper interproximal contact, the wedge must separate the
adjacent teeth with enough distance to compensate the thick-
ness of the band. On the cases of a Class II cavity that involves
only one proximal surface, when using a circumferential
matrix, the separation produced by the wedge must compen-
sate twice the thickness of the matrix. On the other hand,
using a sectional matrix the need of teeth separation is smaller.
The sectional matrices can be prepared cutting a piece of
the straight band with a length enough to involve the proxi-
mal surface and go further in about 1/3 of the mesiodistal
dimensions of the crown, in the buccal and lingual surfaces.
The corners of the matrix that will be facing the gingiva must
be cut, avoiding that it damages the soft tissues (. Fig. 8.7a). 
Then, it is burnished over a paper mixing pad to become
curved as the proximal surface (. Fig. 8.7b, c). After that, it
is placed and wedged, being burnished in position to
improve the contact with the proximal surface of the adja-
cent tooth (. Fig.  8.7d, e). After that, a piece of green low
fusion compound is handled as shown in . Fig. 12.16a–i and 
applied on the buccal and lingual embrasures to avoid the
extrusion of the restorative material (. Fig.  8.7f). At the
moment of compound application, the matrix must be
pressed toward the contact with the adjacent tooth with the
back of a spoon or a burnisher. This technique was proposed
by Sweeney, in 1942, and it is a type of custom-made matrix
[5, 6, 8]. The compound can be replaced by a light-cured gin-
gival barrier.
In 1986, Alvin Meyer projected and produced sectional
matrices that were ready to be used, with pre-contoured
surfaces, simplifying the anatomic reconstruction of the
proximal surface. They have a different occluso-gingival
height, adapting to different crown sizes. They also present
models with extensions in the internal edge for cavities
with a large cervical extension (. Fig.  8.8a). Analyzing it
sideways, they have a concave and a convex edge
Matrix and Wedge Systems
265 8

a b

c d

..      Fig. 8.4  a Retainerless circumferential matrix bands with a built-in tensioning ring (TDV). b Matrix in position. c The pinched aluminum
built-in tensioning ring acts as a retainer for better adaption around the tooth. d Ring folded to not harm the soft tissues or the cheek

a b

..      Fig. 8.5  a Retainerless circumferential matrix bands (AutoMatrix, around the tooth (Automate Tightening Device) as well as a snipper for
Dentsply), available in multiple heights and gauges for varied clinical removal. b AutoMatrix in place
solutions. A device is available in the set for tightening the matrix

(. Fig.  8.8a  – arrow). They also have a concave side that

  matrix must be in contact with the adjacent tooth (. Fig. 8.8c).  

must face the tooth preparation and a convex side that
faces the adjacent tooth (. Fig. 8.8b).
 
First of all, the occluso-gingival height of the sectional
matrix is chosen, and it must be compatible with the depth of
The convex edge is placed toward the cervical area. After that,
a wedge is placed, and then, using a clamp forceps, a separa-
tion ring is placed to bring the borders of the matrix in con-
tact with the tooth surface in the embrasure area (. Fig. 8.8e).

the cavity. With a clinical tweezer, it is placed into the inter- This hinders what the restorative material extrudes, and it
proximal region, observing that the concave side of the promotes the additional dental separation, simplifying to
 266 C. R. Pucci et al.

a b

..      Fig. 8.6  a Disposable circumferential matrix band and retainer to any side, depending on the tooth to be restored. b Omni-Matrix in
(Omni-Matrix, Ultradent), with different sizes identified by the color of position
the conical handle. The pivoting head allows the retainer to be turned
8

a b

c d

..      Fig. 8.7  Technique for the preparation of custom-made sectional contact with the adjacent tooth. f Application of the of low fusion
matrix. a Sectioning a piece of the matrix band. b Burnishing over a compound in the embrasures to improve the adaptation and prevent
paper mixing pad for contouring. c Contoured matrix. d Matrix in flash formation
position and wedge application. e Burnishing of the matrix toward the
Matrix and Wedge Systems
267 8

e f

..      Fig. 8.7 (continued)

a b

c d

..      Fig. 8.8  a Pre-contoured sectional matrices with different Palodent, Darway). e Separation rings being positioned using a clamp
dimensions (the arrows point to the edges). b Lateral view of the forceps. The wedge was already placed (Curvy – Voco). f Set in position
matrix showing the concave side. c Matrix taken in place by a dental
tweezer. d Different types of separation rings (1, unimatrix, TDV; 2,
 268 C. R. Pucci et al.
e f
..      Fig. 8.8 (continued)
obtain proper proximal contacts during composite restora-
8 tion. The separation rings are based on the principle of the
McKean master separator ring, developed for more than 50
years ago. The separation rings may have different configura-
tions. Some present tines with a round cross section, whereas
others present a flat rectangular cross section (. Fig. 8.8d). In
 
some cases, the tines with a round cross section may allow a
better adaptation of the matrices in the embrasure areas, but
they cannot be used in preparation where the proximal boxes
present a large buccolingual dimension (. Fig. 15.9g, h).
However, the rings with a rectangular cross section can be
used in those situations. The separation rings must be placed
over the wedges, touching the proximal surface of the adja-
cent tooth in the embrasure areas, providing an adequate
separation and more predictable contacts on posterior com-
posites (. Fig. 8.8f).
 
There are on the market several variations, based on the
idea of the sectional matrices with the separation ring, that
present some advantages in relation to the regular systems
presented. However, the basic principles are the same. As
examples, we have the V Ring® (Triodent), Composi-Tight
3D® (Garrison), Hawe Adapt® (Kerr Hawe), etc. The Tri-
Clip® system (Triodent) presents the matrix and the ring
attached in a one set and an elastic wedge integrated, sim-
plifying the process to use it. In . Fig.  8.9a–d, it can be
 
observed the Composi-Tight 3D® system, which has two
kinds of separation rings. The larger ring is for most premo-
lars and molars, and the smaller one is for short or badly
positioned teeth. The larger ring has notches on its tines
which allows the passage of the wedge through it and also
has soft silicon faces that rest on the proximal surfaces of
the adjacent teeth in the embrasures, pressing the matrix
and better adapting to the surface, reducing the possibility
to have composite flash at this area. The presence of those
soft faces allows its adaptation even on preparation with
large proximal boxes, where a regular separation ring would
not be used, because it would penetrate the preparation
through the embrasure. The matrices in this system have a
very thin layer of a nonstick material, which hinders the
composite bond to the matrix.
8.2.1.3 Metallic Cervical Matrix
They are matrices to restore the facial and lingual cervical
areas of teeth in Class V preparations using a chemical curing
material, such as conventional glass ionomer cements or self-­
curing composites. They are available in several sizes, adapt-
ing on different tooth morphologies. They have a concave
and a convex side. Nowadays, its use is reduced due to the
dentist’s preference for light-curing materials on those types
of restorations (. Fig. 8.10a, b).
8.2.2 Transparent Plastic Matrix
The clear plastic matrices have the advantage to allow the pas-
sage of the light through them and are recommended for com-
posite restorations, where there is the need to apply light
through the matrix. They are always used in restorations on
anterior teeth and may be optionally used on composite resto-
rations of posterior teeth, since the light is applied from the
occlusal surface and not through the matrix. They should
never be used for amalgam restorations, since they are not
capable to resist the condensation forces. They are made of
polyester, cellulose acetate, or polyvinyl chloride (PVC) and
can be straight or pre-contoured, circumferential, or sectional.
There are also special matrices shaped as the region that will be
reconstructed, such as the entire crowns or the cervical region.
8.2.2.1 Circumferential Plastic Matrix
The most commonly used plastic matrix is the straight poly-
ester strip or “Mylar” strip. Mylar® is generally used to
describe polyester films, although it is a trademark owned by
DuPont company. It is flat and transparent strip used on the
restoration of anterior teeth (. Fig. 8.11). It has the inconve-
nience of not presenting the natural curvature of the proxi-
mal surface of the teeth. To restore the anterior teeth, this
deficiency is easily overcome by the use of the wedge and a
careful restorative technique (. Fig. 8.11b). However, if used
for restorations of the posterior teeth associated to a matrix
retainer, it will produce a flat proximal surface, incompatible
with the original anatomy.
Matrix and Wedge Systems
269 8

a b

c d

..      Fig. 8.9  Composi-Tight 3D® matrix system (Garison). a On the left a matrices in several shapes covered with a nonstick material. c Ring in
ring with soft silicon faces to improve the adaptation of the matrix and position. d The cervical slot can be observed, which allows the passage
on the right the ring for short or badly positioned teeth. b Sectional of the wedge

a b

..      Fig. 8.10  Metallic pre-contoured cervical matrix (Hawe Neos Dental). a Different shapes. b Side view showing the concavities on one of the
sides

To be used on posterior teeth, some manufactures created
pre-contoured polyester strips, as it can be seen in . Fig. 8.12a, b.
 
Some require the use of the matrix retainer, whereas others are
retainerless. The use of the transparent matrices on posterior
teeth was proposed based on the theory that composite resin
shrinks toward the light. Therefore, to improve the marginal
sealing of the composite restoration in the gingival wall, it
would be necessary that the light was applied initially on this
region, passing through the matrix. Nowadays, it is known that
the composite shrinks toward the bonded cavity walls, despite
the light direction [9]. Therefore, the use of clear plastic matri-
ces for the composite restoration of posterior teeth has drasti-
 270 C. R. Pucci et al.
a b
..      Fig. 8.11  a Straight polyester strips; b clinical use
8 a
..      Fig. 8.12  Pre-contoured polyester strips for posterior teeth. a To use with matrix retainer (premolar strips – TDV); b retainerless (TDV)
cally been reduced, because they are thicker and more difficult
to take into position, when there is remaining of the interproxi-
mal contact, and cannot the burnished.
8.2.2.2 Special Plastic Matrices
Some plastic matrices present the shapes and sizes of the
tooth surface that will be reconstructed. As examples, there
are the cellulose acetate or PVC transparent plastic crowns
forms (or transparent strip crowns), as seen in . Fig. 8.13a, b.  
They are used as a shell matrix for the restoration or teeth
reshaping, simplifying the sculpture process. The set of
crowns presents several sizes to adapt to most teeth crowns.
The most adequate is chosen, according to the mesiodistal
dimensions and the inciso-cervical height, and then fitted by
cutting the excess with scissors.
Another type of special plastic matrix is the cervical
matrix for light-curing materials (. Fig. 8.14a, b). They can
be used for composite resin  or  modified glass ionomer
cement restorations, and it is especially indicated to the last
one, due to its viscous and sticky consistency. The technique
for use of this matrix can be seen in . Fig. 14.44a–l. 
b
8.3 Matrix Retainer
They are devices intended to hold the matrix in position and
to adjust it around the tooth that will be restored, allowing a
correct contour to be obtained, hindering the extrusion of
the material into the buccal and lingual embrasures and on
the gingival margin. They can be used with metallic or plastic
strips. There are several types on the market, even though the
most popular are the Tofflemire, Ivory, and Siqveland [5, 7].
The most commonly used is the Tofflemire matrix
retainer, developed by Joseph Benjamin Franklin Tofflemire,
also called “universal” retainer. It has two different models,
depending on the angulation of the guide posts of the head,
which has guide channels where the matrix is adapted
(. Fig. 8.15) [6]. The model with guide posts at a 90° angle
with the long axis of the instrument should be used buccally,
while the model with the guide posts contra-angled can be
used lingually when the preparation extends to the buccal
surface. This type of retainer has the advantage of being easily
separated from the band in an occlusal direction, avoiding,
for example, the fracture of the recently condensed amalgam
Matrix and Wedge Systems
271 8

a b

..      Fig. 8.13  a Polyvinyl chloride transparent strip crowns; b clinical use for reshaping of the peg-shaped lateral incisors

a b

..      Fig. 8.14  Cervical matrix. a Hand instrument with clear cervical matrix attached to the tips (TDV); b cervical matrix to be attached to the tip of
the light-curing devices (TDV)

LOCKING VISE KNURLED INNER NUT

SCREW KNURLED OUTER NUTS

FRAME
GUIDE CHANNELS
DIAGONAL SLOT

..      Fig. 8.15  Tofflemire Matrix retainer types. (1) Straight. (2)
Contra-angled. The differences are indicated by the arrows
restoration, because this material takes longer to reach the
final crystallization and its maximum strength [5, 6].
. Figure  8.16 presents the different parts of the instru-
ment. On one of the ends is the head of the retainer, with the
U-shaped guide posts and the guide channels, where the
..      Fig. 8.16  Nomenclature of the parts of Tofflemire retainer
band must go through and then be positioned on the diago-
nal slot of the locking vise. On the other end are the knurled
outer and inner nuts, which tighten or loose the matrix from
the retainer and increase or decrease the band circumfer-
ence, respectively. The frame holds all the components and
guides the movement of the locking vise.
 272 C. R. Pucci et al.

To assemble the matrix band on the Tofflemire retainer,
the dentist must first verify the diameter of the tooth that will
be restored. When the band is bought in rolls, it must be cut in
a way to surround the entire tooth, leaving a small portion that
will be attached to the locking vise. In general, about 7 cm of
the matrix band is enough. Some matrix bands are sold already
cut on the final dimensions, such as the Tofflemire matrix,
receive the band, turning the inner knurled nut (larger) coun-
terclockwise until the locking vise is about 5  mm from the
head of the retainer. Holding the inner nut, the vise locking
screw must be unscrewed, turning the outer knurled nut
(smaller) counterclockwise until the pointed spindle is free of
the diagonal slot. The dentist folds the band end to end to form
a loop (. Fig. 8.17a), passing through the correct guide chan-

which facilitates the use. The retainer must be prepared to nel (. Fig. 8.17b), attaching the band inside the diagonal slot
 

a b

c d

e f

..      Fig. 8.17  Assembling of band on the Tofflemire matrix retainer.
a Folding the band end to end to form a loop. b passing the band
through the correct guide channel, attaching it inside the diagonal slot
of the vise. c the outer knurled nut is turned clockwise to tighten the
pointed spindle toward the band. d–f options to assemble the band
into the guide channels. g the inner knurled nut is turned clockwise,
adjusting the matrix to the diameter of the crown, tightening it.
h correct positioning of the retainer with the slotted side of the head
directed gingivally. i incorrect positioning with the slotted side of the
head occlusally
Matrix and Wedge Systems
g h
..      Fig. 8.17 (continued)
of the vise. Then, the outer knurled nut is turned clockwise to
tighten the pointed spindle against the band (. Fig.  8.17c).
 
The choices of which guide channel will be used depend on
the tooth that will be restored. In general, the retainer is placed
buccally with its long axis parallel to the teeth arch. However,
its position (right, left, or parallel) can vary according to the
convenience of each situation (. Fig.  8.17d–f). The matrix
 
band assembled in the retainer is placed around the tooth, and
the inner knurled nut is turned clockwise, adjusting the matrix
to the diameter of the crown, tightening it (. Fig. 8.17g). The
 
matrix retainer must be positioned on the arch with the slotted
side of the head directed gingivally, to permit easy separation
of the retainer from the band occlusally (. Fig. 8.17h). After
 
finishing the restoration, the retainer removal is made turning
the outer knurled nut counterclockwise to release the band,
pulling the retainer toward the occlusal surface, with the
matrix remaining in position. If the retainer is placed upside
down, with the slotted side of the head occlusally, its removal
before the matrix band will be more difficult (. Fig. 8.17l).
 
273 8
In . Fig. 8.18a, b, the Ivory No. 8 matrix retainer can be
observed. It works like Tofflemire retainer, with a difference
that there is only one guide channel. It also presents a locking
vise, a locking screw, and inner and outer knurled nuts. This
type of retainer also allows the removal of the retainer before
the matrix, by loosen the fixation outer nut.
Another type of popular matrix retainer is the Siqveland,
also known as Steele’s Siqveland retainer (. Fig.  8.19a). By
the fact that it does not have a fixation nut, the matrix must
be folded on a specific sequence so that it is assembled,
according to what can be observed in . Fig. 8.19a–l, and it is
necessary about 10  cm of the matrix band. It presents as
advantages the swivel locks, which can be turned from one
side or another, improving the adaptation of the matrix in the
cervical region of tapered teeth (. Fig. 8.19b, l). As a disad-
vantage, there is the fact that it is not possible to separate the
matrix from the retainer before its removal from the tooth
structure, unless the band is cut, which is a difficult proce-
dure to be made inside the mouth.
 274 C. R. Pucci et al.

a b

..      Fig. 8.18  Ivory No. 8 matrix retainer. a View of the instrument in different angles. b Matrix retainer assembled in position

8
a b

c d

..      Fig. 8.19  a Siqveland matrix retainer from different views. b Options to adjust the swivel lock for adaptation of the band on the cervical
region. c–j steps to assemble the band. k matrix properly assembled. l cervical adjustment by the correct positioning of the swivel lock
Matrix and Wedge Systems
275 8

e f

g h

i j

k l

..      Fig. 8.19 (continued)
 276 C. R. Pucci et al.
8.4 Wedges
The wedges are pieces of wood, plastic, or elastic material
introduced into the interproximal space, between the matrix
and the proximal surface of the adjacent tooth, over the inter-
dental gingival papilla, to guarantee the correct restoration of
the proximal surface. Among the functions of the wedges,
the following ones must be highlighted:
55 Helps to stabilize the matrix band
55 Aids on the restoration of the adequate contour of the
lost surface, because it approaches the matrix to the
remaining tooth structure on the cervical region of the
proximal surface
55 Prevent the extrusion of the restorative material in the
gingival margin of the preparation
55 Aids to retract the rubber dam and the interdental gin-
gival papilla
8 55 Promotes separation between the adjacent teeth to com-
pensate the thickness of the matrix band
Wedges are pieces of wood, plastic, or elastic material
introduced into the interproximal space, between the
matrix and the proximal surface of the adjacent tooth, to
guarantee the correct restoration of the proximal surface.
When made of a rigid material, it must have the exact shape
of the interproximal space as it can be observed in . Fig. 8.20a.
 
The interproximal space has a triangular shape, with the apex
toward the contact point and the base toward the gingival
tissue. Therefore, the wedge must also present a triangular
cross section, being named anatomic wedges (. Fig. 8.20b).
 
The wedges are inserted through the larger embrasure, once
they have a convergence toward the tip. The attempt to insert
the wedge from the smaller embrasure will hinder its com-
plete penetration into the interproximal space. On teeth that
are properly positioned on the arches, the lingual embrasures
are generally the largest ones, with exception between the
a b
..      Fig. 8.20  Correct shape of the anatomic wooden wedge. a Shape of the interproximal space – asterisk; b shape of the anatomic wedge
first and second maxillary molars, where the buccal embra-
sure is larger. However, if the tooth presents some rotation,
each case in particular must be evaluated, analyzing the
embrasures by looking at them from the occlusal point of
view, checking which one is the largest. The wedges must be
taken into position with a forceps that can produce a firm
grasp, such as the mosquito forceps, preferable with a curved
end to ease the access. The dental tweezer does not allow the
necessary grasp to firmly insert the wedge into its position.
Preferably, the wedges must be used associated with the rub-
ber dam isolation of the operating field. Otherwise, it can fall
into the oral cavity and be aspirate or swallowed.
>> The interproximal space has a triangular shape, with
the apex toward the contact point and the base toward
the gingival tissue. Therefore, the wedge should also
present a triangular cross section, being named
anatomic wedges.
Tip
The wedges are inserted through the larger embra-
sure, once they have a convergence toward the tip. The
attempt to insert the wedge from the smaller embrasure
will hinder its complete penetration into the interproxi-
mal space.
To restore a proximal surface of a tooth, a matrix band is
placed between the teeth, and then the restorative material is
applied. As the matrix occupies some space due to its thick-
ness, in case no wedge is used, when the matrix is removed
the space occupied by it will remain opened, resulting on
food impaction (. Fig. 8.21a–c).
When a wedge is placed between the matrix and the adja-
cent tooth, before the application of the restorative material,
besides preventing the extrusion of the material into the cervi-
cal region, it promotes the tooth separation to compensate for
the thickness of the matrix band (. Fig. 8.22a, b – arrows). The
wedges must be positioned in such way that it is held on the
tooth surface below the cavosurface gingival angle, effectively
Matrix and Wedge Systems
277 8

a b

..      Fig. 8.21  Importance of the space occupied by the matrix on the wedge. c restoration performed failing to recreate the interproximal
restoration of the proximal contact. a Preparation done removing the contact due to the space occupied by the matrix
contact with the adjacent tooth. b placement of the matrix without

a b

..      Fig. 8.22  Use of the anatomic wedge. a Dental separation to compensate the thickness of the matrix; b proximal contact reestablished

pressing the adjacent tooth without deforming the matrix. wedges in a set like a “comb.” They need to be removed and
When the matrix and the wedge are removed, the teeth come finished with an abrasive disc before used, adjusting its size
back to the normal position, and the contact is recovered. to the space between the teeth (. Fig. 8.23a, b). When finish-
 

The regular wedges can be made of wood or plastic mate-
rial. The wooden wedges present the advantage that when
they become wet, absorb a little water and expand, adapting
firmly into the interproximal space. Some manufacturer
offers on the market roughly finished anatomic wooden
ing the wedges, it is important that after the procedure, it
presents a gradual convergence toward the end, ensuring that
all interproximal space will be filled. The wedge must be
inserted under pressure between the teeth. Therefore, it
should not be so thin that it would not be able to separate the
 278 C. R. Pucci et al.

a b

..      Fig. 8.23  a Roughly finished anatomic wooden wedges supplied as a “comb”; b finishing of the wedge with an abrasive disc

8 a b

..      Fig. 8.24  Types of wedges. a Finished wooden wedges. b transparent and opaque plastic wedges. c curved wedges (Curvy – Voco)

teeth and may fracture. In addition, and it should not have
just a very short convergent tip, as a spear, which would not
be capable to penetrate the space between the teeth. Other
manufacturers produce finished individual wedges, identi-
fied by colors according to its several sizes (. Fig. 8.24a).
 
The plastic wedge is made in opaque or transparent mate-
rial (. Fig.  8.24b). The clear wedges, also  named reflective
 
wedges, were developed to be used in association with clear
matrix bands, to conduct light to the cervical region of the
shrinkage vectors toward this region. However, several stud-
ies have proved that this does not occur, making this tech-
nique each time less used.
The plastic wedges are generally  straight and anatomi-
cally shaped, similar to the wooden wedges, with a triangular
cross section. However, some manufacturers offer curved
wedges that also follow the contour of the bone crest and the
proximal surface of the teeth, improving the adaptation of
the matrix onto the tooth (. Fig. 8.24c). The colors indicate if

proximal surface, on the attempt to direct the polymerization they are recommended to restore the mesial or distal sur-
Matrix and Wedge Systems
279 8
faces, and they can be thinner or thicker, depending on the 8.4.1  requent Mistakes Related to the Use
F
size of the interproximal space. of Wedges

>> The wedge must separate the adjacent teeth enough
to compensate the thickness of the matrix band. It has
to be inserted under pressure into the interproximal
space. Therefore, it should not be so thin that it would
not be able to separate the teeth and may fracture. In
When using a rigid anatomic wedge, several mistakes can be
done that will seriously compromise the proximal contour of
the restoration, and consequently the health of the periodon-
tal tissue. The most common mistake is to insert the wedge
upside down into the interproximal space (. Fig. 8.25a). On

addition, it should not have just a very short this position, the wedge will deform the matrix, resulting in a
convergent tip, as a spear, which would not be capable concave proximal contour instead of a convex one, besides
to penetrate between the teeth. not being able to seal correctly the gingival margin, allowing

a b

c d

e f

..      Fig. 8.25  Mistakes during the application of wedges. a Inverted f rubber dam penetration inside the preparation. The arrows indicate
wedge. b wedge above the gingival margin. c wedge with a very the extrusion of the restorative material or defects of the restoration
large upper edge. d very high wedge. e very small and loose wedge. contour
 280 C. R. Pucci et al.

a b

..      Fig. 8.26  The use of a very short wedge. a Results on a wrong proximal contour b

8 the extrusion of the material producing overhangs. That will

result in bacterial biofilm growing, gingival inflammation,
and secondary caries lesions. Another very common mistake
is to place the wedge above the cavosurface gingival angle
(. Fig. 8.25b). Besides hindering the separating effect of the
 

wedge, it will deform the matrix and the proximal contour of

the restoration, other than allowing the extrusion of the
material and formation of overhangs. The wedges with the
upper edge too large will also result on the concave proximal
contour of the restoration (. Fig. 8.25c). If a wedge, besides
 

having a very large edge, is also very high in occluso-gingival

direction, the matrix will remain far from the proximal sur-
face of the adjacent tooth, and an open contact may also
occur (. Fig. 8.25d).
 

The wedges must be inserted into the interproximal space
in such way that they enter under pressure and remain tight
in position. If the wedge is smaller than the necessary,
remaining  loose between the teeth, it will  not produce the
necessary teeth separation, which  allow the extrusion of
restorative material into the gingival sulcus and occurence of
overhangs (. Fig. 8.25e). Another mistake that may happen
 
..      Fig. 8.27  Matrix and wedge positioned inside the preparation
tour, in the presence of part of the gingival wall exposed to
the oral cavity, causing postoperative sensitivity and resulting
in bacterial biofilm growing, gingival inflammation, and
carious lesion (. Fig. 8.27).

is the remaining of rubber dam or gingival tissue inside the In . Fig.  8.28a–d, there are radiographic images of the
 

gingival wall of the preparation, after the placement of the
matrix and the wedge. On those cases, after the application of
the restorative material and isolation removal, the space
occupied by the dam or gingiva will remain empty, allowing
the growing of bacterial biofilm, postoperative tooth sensitiv-
ity, and secondary carious lesions (. Fig. 8.25f).
 
On the other hand, the use of very small wedges in
occluso-gingival dimensions, even though they are tight
between the teeth, may result in the formation of a very large
contact area on the occluso-gingival direction, when the
restorations performed without the correct placement of the
wedges, resulting in overhangs and inadequate proximal
contours.
8.4.2 Elastic Wedges
The elastic wedges were developed to adapt to the proximal
surfaces, promoting a correct positioning of the matrix and
the tooth separation (. Fig. 8.29a–c). To be positioned, after

material is applied, specially in the case of the amalgam, that matrix placement, it must be stretched with a clamp forceps
is condensed under pressure, reducing the spaces for the gin- and taken in place (. Fig.  8.29b, c). They present different
 

gival papilla and the col (. Fig. 8.26a, b). Another very seri-

  thicknesses, indicated by colors, depending on the size of the
ous mistake occurs when the matrix is not taken beyond the interproximal space (. Fig. 8.29a). It has advantages to easily
 

gingival cavosurface angle over the proximal tooth surface, adapt to the different anatomic contours of the proximal sur-
and the wedge is applied, pressing the matrix inside the prep- face. They present small holes on the central region that
aration. This will result, besides an inadequate proximal con- allow, when stretched, to become thin enough to be posi-
Matrix and Wedge Systems
281 8

a b

c d

..      Fig. 8.28  a–d Restorative material overhang on the cervical region and the inadequate proximal contours (arrows)

tioned on the cervical region. They act simultaneously on the the cavity is shallower and lower on the side where the cavity
buccal and lingual surfaces, by the presence of the rubber is deeper. To solve this problem, the matrix band must be
handles. To remove them, one end must be pulled with for- assembled on the matrix retainer and taken in position. The
ceps to cut the wedge on the central part. exact position of the deepest box must be observed and the
matrix removed from the tooth. All the cervical contour of
the matrix, except the area that corresponds to the deepest
8.5  hallenges for the Correct Use of Matrix
C box, is cut with scissors, and the matrix is replaced
and Wedges (. Fig. 8.30b–d). Then, the wedges are applied and the resto-
 

ration can be properly made [6].

One of the challenging situations to the correct adaptation
of the matrix on the region of the gingival wall happens in
some MOD preparations, where one of the gingival walls is
located more cervically than the others. Taking into account
that the band must touch the proximal tooth surface, beyond
the cavosurface gingival angle of the preparation, what hap-
pens is that when the matrix is applied, it will firstly touch
the gingival tissue and sometimes the bone crest on the side
where the cavity is shallower, hindering the matrix to go fur-
ther cervically on the side where the cavity is deeper, leaving
a gap between the matrix and the cavosurface angle
(. Fig.  8.30a). This happens because the more the carious
 
lesion or the restoration goes further cervically, the greater
can be the bone resorption on this area, resulting in a bone
unevenness, i.e., the bone crest is higher on the side where
Tip
In case of MOD preparations with too different depth
and uneven bone crests, the band can be cut on the side
of the shallower preparation, allowing a deeper matrix
penetration on the opposite side, corresponding to the
deepest cavity.
Other challenging situations occur on the mesial surface of
the first maxillary premolar. At this place, there is an ana-
tomical peculiarity, where the root bifurcation produces a
fluted (concave) area on the proximal surface. Different cross
 282 C. R. Pucci et al.
a b
..      Fig. 8.29  a Elastic wedges (Elastic wedge – Danville). b Use of the forceps to stretch the wedge. c Elastic wedge in position associated to a
sectional matrix and separation ring
sections of this kind of tooth is presented in . Fig. 8.31a, b,
 
allowing to better visualize this concavity, showing that it
increases cervically.
The more cervically located is the gingival wall of the
preparation, the more the existing concavity hinders the
adequate adaptation of the matrix and wedge on the cavosur-
face margin. That creates a gap between the matrix and the
proximal tooth surface, allowing the extrusion of the restor-
ative material and overhangs (. Fig.  8.32a). To solve this
problem, two options are presented. The first is to use a small
cotton ball between the anatomical wedge and the matrix
band, which would press the band toward the external tooth
surface, closing the gingival margin (. Fig. 8.32b–e) [6]. For
 
that, the wedge is placed on the entrance of embrasure, but
before inserting it completely into the interproximal space,
the small cotton ball is positioned between it and the proxi-
mal surface of the tooth. When the wedge is completely
inserted, the cotton is forced toward the concave area, push-
ing the matrix and sealing the cervical region (. Fig. 8.32e).   In the case of shallow proximal box associated with gingi-
Other technique, known as wedge wedging, consist in using
an oblique wedge on the lingual side, preferably a toothpick
with round cross section or even a small anatomic wedge,
which is inserted between the matrix band and the wedge
already placed. The oblique wedge will press the matrix band
toward the tooth, closing the gap (. Fig. 8.32f) [2, 6].
 
Tip
On the mesial surface of first upper premolar, an ana-
tomical concavity can hinder the proper adaptation of
the matrix to the cavosurface angle. In order to improve
the band contact with the margin, a small cotton ball or
an oblique toothpick can be placed between the wedge
and the matrix.
When the space between the adjacent teeth is too wide and
a single wedge is not enough to fill the area, or when the
proximal box is wide in the buccolingual dimensions, the
double wedging technique can be applied. On this tech-
nique, one wedge is inserted from buccal embrasures and
another from the lingual, side by side. A melted com-
pound or light-­cured gingival barrier can be applied to sta-
bilize the wedges.
val recession, the wedge will remain significantly apical to the
gingival margin, not properly sealing the matrix.  In this
case, the piggyback wedging technique can be used. For that,
one larger wedge is inserted as normally used, while another
smaller wedge (piggyback) is applied above the first one, pro-
viding a good adaptation and contour for the matrix.
Matrix and Wedge Systems
283 8

a b

c d

..      Fig. 8.30  Proximal boxes with different depths in MOD prepara- side. b cutting of the band preserving the area corresponding to the
tions. a The applied matrix is not capable to reach the gingival margin deepest box. c matrix ready to use. d matrix properly positioned
on the deepest box, due to touching gingival tissue on the shallower

a b

..      Fig. 8.31  a Concavity on the mesial surface of the maxillary first premolar. b Cross sections of the crown showing the concavity on the mesial
surface which becomes deeper gingivally

8.6 Custom-Made Matrices made matrices, which are named  individual, anatomic,
or custom-made. One kind of custom-made matrix is the
In some specific situations, the uses of universal or regu- sectional Sweeney matrix for Class II restorations,
lar matrices supplied by the manufacturers do not allow which was already presented in . Fig. 8.7a–f. Other types
 

the correct reconstruction of the lost tooth structure. will be described next, with their indications and specifi-
Therefore, the dentist needs to prepare the special hand- cations.
 284 C. R. Pucci et al.

a b

c d

e f

..      Fig. 8.32  Techniques to allow a correct adaptation of the matrix to wedge. c cotton ball being inserted. d, e cotton in position allowing
the mesial surface of the maxillary first premolars. a Use of a wedge the correct adaptation of the matrix. f Technique of the oblique wedge
with a conventional shape resulting on a lack of adaptation of the inserted lingually
gingival cavosurface angle. b insertion of a small cotton “ball” with the

8.6.1 Spot-Welded and Riveted Matrix
When restoring the proximal surfaces of posterior teeth, the
straight matrix band attached to the matrix retainer solves
most of the cases. However, in some situations, such as on
cases where the tooth to be restored is also the anchor tooth
with the clamp, or when the clamp in the neighbor tooth
touch the matrix retainer/band set, hindering its correct cer-
vical adaptation, the use of the universal matrix is contrain-
dicated. In addition, on the cases of large preparation,
involving one or more lost cusps, the tensile on the band
created by the matrix retainer makes the matrix penetrate
the preparation, hindering the correct anatomic shape resto-
ration. On those cases, the custom-made retainerless spot-­
Matrix and Wedge Systems
..      Fig. 8.33  Welding the matrix
welded or riveted matrices can be used. To make it, a piece of
the straight band is cut and then positioned around the
tooth, drawn taut with flat-nosed pliers or mosquito forceps,
after which the band is removed. The demarcated matrix cir-
cumference can be fastened with a spot-welding device, gen-
erally used for the building up orthodontic bands, which
create a welded joint (. Fig. 8.33). Another option to fasten
 
the matrix is to use a No. 141 riveting plier as presented in
. Fig. 12.15.
 
8.6.2 Window Matrix
On large Class V preparations for amalgam, the direct appli-
cation of the restorative material is very hard, because when
it is condensed in one side of the preparation, it escapes on
the other, due to the fact that the cavity is large and the axial
wall is convex. To solve this problem, it was proposed the use
of a window matrix. It is prepared applying the universal
matrix around the tooth, using a matrix retainer on the
opposite surface to the one with the preparation, opening a
window on the region that corresponds to the preparation,
but with smaller dimensions. The material is then applied
through the window, allowing to obtain the desired shape of
the restoration. Details about this matrix can be found in
. Fig. 11.15a–o.
8.6.3 Barton Matrix
On compound Class I preparation, the application of amal-
gam on the lingual or buccal boxes is very difficult. That is
related to the fact that a universal matrix placed around the
tooth is not capable to correctly adapt onto those smooth
285 8
surfaces, due to its inclination toward the occlusal surface.
Therefore, a small piece of the matrix is placed on the exact
region of the buccal or lingual box, which will be pressed
toward the tooth surface using a wooden wedge. Details
about the preparation of this matrix can be found in
. Fig. 11.14a–u.
8.6.4 T- band Matrix
The T-band matrix can be obtained already shaped from the
manufactures or be prepared by the dentist. The prefabri-
cated band is made of brass or stainless steel and can be
straight or curved. It has two flanges on one tip, which gives
its T-shape (. Fig.  8.34). The flanges are folded forming a
U-shaped path. The free end of the band is slipped through
the U formation. The flanges are closed, and the free end is
bent or curled to produce a circle and surround the tooth
circumferentially.
The T-band matrix can also be hand made by the dentist,
using a straight band, as can be observed in . Fig.  8.35a–i.
For that, about 6 cm of the matrix strip is used. In one of its
ends, the corners are cut creating a spear-shaped
(. Fig. 8.35a). Then, a smaller piece of band is cut, with about
1.3 cm, and placed on the flat end of the already cut band,
creating a T-shape (. Fig.  8.35b). The ends of the smaller
band are folded, to adapt to the longer strip (. Fig.  8.35c).
The flat end of the longer strip is folded with the aid of a
tweezer (. Fig.  8.35d) and the smaller strip slide under it
(. Fig.  8.35e). Then, the matrix is turned upside down
(. Fig. 8.35f), and the spear-shaped end is pulled and passes
between the smaller and the larger bands, on the opposite
side of the folds (. Fig. 8.35f, g). The matrix is placed around
the tooth, and the spear end is pulled, adapting to the tooth
contour. Then, it is folded fastening the final position
(. Fig.  8.35h, i). This type of retainerless matrix presents
similar indications to the spot-welded and riveted matrix,
with the advantage that it can be prepared in advance, with-
out the patient on the chair.
8.6.5 S-shaped Matrix
The S-shaped matrix is indicated for restoration of horizontal
slot Class II preparations. In this case, the restorative material
must be applied through the buccal or lingual cavity access,
contraindicating the use of a matrix retainer. A straight
matrix band is shaped like an “S” and applied between the
teeth. A wedge with the heated compound is applied on the
opposite side of the cavity access. More details about this
technique can be seen in . Fig. 11.16.
 286 C. R. Pucci et al.

a b

c d

..      Fig. 8.34  a Prefabricated straight T band made of stainless steel or circle. d the flanges are closed. e the matrix is adjusted around the
brass (in the middle). b flanges folded forming a U-shaped path. c the tooth and the free end is bent to lock the matrix
free end of the band is slipped through the U formation to produce a
Matrix and Wedge Systems
287 8

a b

c d

e f

..      Fig. 8.35  a–i Technique for preparation of a custom-made T-band matrix

 288 C. R. Pucci et al.
g h
..      Fig. 8.35 (continued)
Conclusion
This chapter described the definitions, characteristics, and
importance of the matrix and wedge use during restorative
procedures. The different kinds of metallic and plastic matri-
ces (circumferential and sectional) and  the matrix retainers
were explained in detail, followed by its indications and tech-
niques of use. The frequent mistakes related to the use of
wedges and the solution for challenging situations were pre-
sented. The  various techniques to prepare custom-made
matrices were described. The clinician must know all options
available and its different indications and advantages, being
able to apply the best technique for each clinical situation.
References
1. Anauate Netto C, Fichman DM, Youssef MN. Estudo in vitro da rugosi-
dade superficial e do perfil proximal de amálgamas condensados con-
tra matrizes de aço inoxidável. Rev Odontol da Univ São Paulo [Internet].
1997;11:173–80. https://doi.org/10.1590/S0103-­06631997000300005.
2. Baratieri LN, Monteiro Junior S, Andrada MA, Ritter AV. Odontologia
Restauradora: Fundamentos e Possibilidades. Santos: São Paulo;
2001.
3. Gilmore HW, Lund MR. Operative dentistry. Saint Louis: Mosby; 1973.
4. Horsted-Bindslev P, Mjör IA. Modern concepts in operative dentistry.
Copenhaguen: Munksgaard, 1988. 
5. Mondelli J, Ishikiriama A, Galan JJ, Navarro MF.  Dentística Oper-
atória. Sarvier: São Paulo; 1976.
6. Roberson TM, Heymann H, Swift EJ. Sturdevant’s art and science of
operative dentistry. 5th ed. St. Louis: Mosby; 2006.
7. Summitt JB, Robbins JW.  Amalgam restoration. In: Schwartz RS,
Summitt JB, Robbins JW, editors. Fundam oper dent a contemp
approach. Illlinois: Quintessence Publishing; 1996.
8. Sweeney JT.  The class V amalgam restoration. J Am Dent Assoc.
1942;29:2140–4. https://doi.org/10.14219/jada.archive.1942.0342.
9. Versluis A, Tantbirojn D, Douglas WH. Do dental composites always
shrink toward the light? J Dent Res. 1998; ­https://doi.org/10.1177/0
0220345980770060801.
 289 9

Protection of the Dentin-Pulp
Complex
Adriana Cristina de Mello Torres, Ana Paula Martins Gomes,
Claudio Hideki Kubo, and Carlos Rocha Gomes Torres

9.1 Introduction – 291

9.2 Understanding the Dentin-Pulp Complex – 291

9.2.1  entin – 291
D
9.2.2 Pulp – 294

9.3 Defense Mechanisms of the Dentin-Pulp Complex – 295

9.4 Assessment of Pulp Condition – 296

9.4.1  namnesis – 296
A
9.4.2 Extraoral Clinical Exam – 296
9.4.3 Intraoral Clinical Exam – 296
9.4.4 Radiographic Examination – 300

9.5 Diagnostic Hypothesis – 301

9.6 Origins of Pulpal Alterations – 302

9.6.1  arious Lesion – 302
C
9.6.2 Tooth Preparation – 302
9.6.3 Occlusal Trauma – 303
9.6.4 Restorative Procedure – 303

9.7 Factors Affecting the Dentin-Pulp Complex Protection – 304

9.8 Cleaning of the Tooth Preparations – 305

9.8.1  emineralizing Cleaning Agents – 305
D
9.8.2 Non-demineralizing Cleaning Agents – 306

9.9 Protective Materials – 307

9.9.1  avity Varnish – 308
C
9.9.2 Desensitizing Agents – 308
9.9.3 Adhesive Systems – 308
9.9.4 Zinc Oxide-Eugenol Cement – 308

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_9
9.9.5  lass Ionomer Cement – 309
G
9.9.6 Calcium Hydroxide – 310
9.9.7 Mineral Trioxide Aggregate (MTA) – 310
9.9.8 Materials Containing Bioactive Molecules – 311

9.10 Techniques for Protection of the Dentin-Pulp Complex – 312

9.10.1 I ndirect Pulp Protection – 312
9.10.2 Direct Pulp Protection – 319

References – 329
Protection of the Dentin-Pulp Complex
Learning Objectives
The learning objectives of this chapter are related the follow-
ing topics:
55 The histology and physiology of the dentin-pulp
complex
55 Defense mechanisms of the dentin-pulp complex
55 How to perform the assessment of pulp condition and
create the diagnostic hypothesis
55 What are the origins of pulpal alterations
55 Factors affecting the dentin-pulp complex protection
55 How to perform the cleaning of the tooth preparations
55 To understand the characteristics of all protective
­materials
55 To perform different techniques for protection of the
dentin-­pulp complex
9.1 Introduction
Several factors can produce aggressions to the teeth, such as
the carious lesions, trauma, non-carious lesions of erosive
tooth wear, abrasions, abfraction, etc. Regardless of the cause,
the restoration must recreate the shape, function, and esthetic
of the tooth structure, avoiding producing alterations to the
biological equilibrium on the pulp tissue. Therefore, the pro-
cedures of the tooth preparation must be carefully performed,
avoiding overheating or exposure of the pulpal tissue. The
restorative material applied must not be an irritation source
to the pulp, but it must protect it from the external aggres-
sion. This way, the knowledge about the dentin-pulp complex
physiology, as well of the materials and restorative tech-
niques, are essential to perform a minimally invasive den-
tistry, with minimum intervention and a maximal
preservation of the tooth structure.
9.2 Understanding the Dentin-Pulp
Complex
The structural components of the dentin-pulp  complex
are the dentin, composed by the mineralized dentin
and the non-mineralized predentin, and the pulp, which is
a type of loose connective tissue. The dentin and the pulp
have the same embryonic origin, working as a single func-
tional unit [26]. Even though there are differences of
structure and composition between the dentin and pulp,
those tissues are closely connected, in a way that physio-
pathological responses in one tissue will also affect the
other [26, 107]. The close relation between the dentin and
the pulp can be observed since the developing of the den-
tal organ, when the odontoblastic cells from the pulp are
responsible for the formation, organization, and matura-
tion of the collagen fiber and proteoglycans for the dentin
formation. On the other hand, the beginning of the den-
tinogenesis determines the differentiation of the dental
papilla into pulp [168].
291 9
>> Dentin and pulp are closely connected, in a way that
physiopathological responses in one tissue will also
affect the other. Therefore, they form an integrated
system that is called the dentin-pulp complex.
The great interrelation between the pulpal tissue, represented
by the odontoblasts, and the dentin, complicates the separa-
tion of the physiopathological phenomena that occurs in one
or other tissue. Therefore, the pulp and the dentin form an
integrated system that is generally named dentin-­pulp com-
plex. The cut of the dentin tissue actually means the cut of a
living tissue, formed by mineralized and cellular parts, repre-
sented by the odontoblast process inside the dentin tubules.
A minimal intervention on the most external part of the den-
tin is immediately noticed by the pulpal tissue, and a corre-
sponding response, of local or general magnitude, starts to
develop [111].
9.2.1  Dentin
The dentin is an avascular mineralized connective tissue. It
is composed of approximately 45% of inorganic material
(hydroxyapatite and other ions), 30% of organic material
(collagen, lipids, glycosaminoglycan, and other substances
in smaller quantities), and 25% of water by volume. Its com-
position varies with the age due to the constant formation
of new mineralized tissue, even after the complete tooth
formation [108].
The basic structural components of the dentin are the
following: The odontoblast with the odontoblast process, the
dentin tubule, the periodontoblastic space, the intratubular
dentin matrix (peritubular), and the intertubular dentin.
The odontoblasts are peripheral cells which are responsible
for the formation of the dentin tissue and for the transmis-
sion of several stimuli to the pulpal tissue, because they are
in direct contact with the pulp. The dentin tubules hold the
odontoblast processes and are formed during the dentino-
genesis (. Fig.  9.1). The diameter and the volume of the
tubule’s lumen vary according to the age of the tooth and the
location inside the dentin. The closer the dentin is to the
pulp, the greater is the amount and diameter of the dentin
tubules (. Fig. 9.2a, b).
The periodontoblastic space is located between the tubule
wall and the odontoblast process. This space has tissular fluid
and some organic components, such as thin collagen fibers.
The intratubular dentin is deposited on the tubule walls, and
it is characterized by its high mineral content and the lack of
the organic components. The intertubular dentin is located
between the dentin tubules, around the intratubular dentin
[108]. Despite its high degree of mineralization, it is rich in
organic matrix composed of collagen fibers surrounded by
amorphous substances (. Fig. 6.5) [7].
The tissular fluid present in the pulp is under pres-
sure  due to the blood circulation, and it tends to overflow
through the dentin tubules if they are cut, being called den-
tinal fluid. The intrapulpal pressure, in normal conditions, is
 292 A. C. de Mello Torres et al.
estimated to be 25–30 mmHg, transferring part of this force
9 to the dentinal fluid [66]. Therefore, the dentin has a certain
permeability that varies according to some factors, such as
the proximity to the pulp, age, and the degree of dentin min-
eralization [107, 123]. The dentin permeability is propor-
tional to the number and the diameter of the tubules;
consequently the deeper the cavity is, the greater it will be
[168]. In . Fig.  9.3, there is an extracted tooth in which
occlusal surface was ground flat until the dentin is exposed.
After that, it was acid etched to open the tubules. As the
pulpal chamber follows the external anatomy of the tooth,
on the region corresponding to the cusp tips, the pulpal
horns are closer to the surface, and the dentin is deeper
[112]. The tooth was connected to a device to create a simu-
lated pulpal pressure. After some time, on the areas close to
the pulpal horns, it was observed a greater overflow of liq-
uid, showing the higher permeability at this region. The
..      Fig. 9.1  Microphotography of the dentin-pulp complex showing the
odontoblasts (black arrow) and the odontoblast process inside the
dentin tubules (red arrow). Mallory’s trichrome stain, 400× magnifica-
tion. (Photography kindly supplied by Prof. Dr. Miguel Angel Castillo
Salgado, Professor of Histology, ICT, São José dos Campos – UNESP)
a b
..      Fig. 9.2  Relation between the diameter and the number of tubules and the proximity of the pulpal chamber. a Superficial dentin with less
tubules; b deep dentin with more tubules
movement of the dentinal fluid inside the tubules due to the
exposure of the dentin by the operative procedures, traumas,
caries, and others is called transdentinal permeability or
simply dentin permeability [72, 168].
>> The dentin close to the pulpal tissue has tubules with
larger diameter, in higher amount, resulting in
increased dentin permeability.
Between the mineralized dentin and the odontoblast layer,
there is the predentin, a layer of non-mineralized matrix with
about 10–20 μm thickness. It is formed by the odontoblasts
and consists mostly of collagen fibers and proteoglycan. The
predentin exists not only during the dentinogenesis, but also
it is found covering the circumpulpar dentin of the teeth with
complete rhizogenesis and in function, once there is a con-
tinuous and slow deposition of dentin during the entire life of
the tooth [108].
The dentin can be classified into three basic types: pri-
mary, secondary, and tertiary [89]. The primary dentin is
..      Fig. 9.3  Regions of higher dentin permeability on the deeper areas
close to the pulpal horns
Protection of the Dentin-Pulp Complex
formed mostly before the tooth eruption and presents a regu-
lar tubule disposition. The secondary dentin is formed due to
the low intensity stimuli, resulting from the normal biologi-
cal function, during the clinical use of the tooth after its erup-
tion. It presents narrower and slightly sinuous tubules. It is
deposited all over the pulpal surface and especially on the
roof and on the floor of the pulpal chamber [7]. As a result of
the continuous deposition of secondary dentin, the volume
of the pulpal chamber is each time smaller with the passing
of the years (. Fig. 6.13a, b).
 
>> As a result of the continuous deposition of secondary
dentin, the volume of the pulpal chamber is reduced
with the aging.
The tertiary dentin is formed when there are pulp irritations,
such as caries, tooth preparations, erosion, abrasion, and
thermal, mechanical, chemical, or electrical stimulus, among
others. It is located on underlying irritation zones and pres-
ents scarce, tortuous, or absent dentin tubules [48, 85, 158,
167]. In relation to this point, it is important to make distinc-
tions between the tertiary dentin formed by the primary
odontoblasts, and the ones formed by cells differentiated in
a b
..      Fig. 9.4  a Presence of tertiary dentin on the region of the pulp
chamber roof on tooth with attrition (arrows); b tooth where the
defective restoration was removed, showing the presence of the
tertiary dentin on the region of the mesiobuccal pulp horn (arrow)
exposed during the preparation; c microphotography showing the
293 9
odontoblasts, after the death of the original odontoblastic
layers due to aggressions suffered by the tooth. The tertiary
dentin formed by the pre-existing primary odontoblasts that
survives the moderate irritation is called reactionary dentin,
while the dentin formed by newly differentiated odontoblast-
like cells formed due to the death of the original odontoblasts,
from a pulpal progenitor cell, is called reparative dentin
[147]. The formation of the tertiary dentin, reactional or
reparative, represents a defense mechanism that is important
for the dentin-pulp complex (. Fig.  9.4a–c). The interface
between the tertiary reparative dentin and the dentin formed
by primary odontoblasts is important, once the tubules
between both types of dentin do not communicate directly,
forming a barrier against the entrance of some aggressive
agents in direction to the pulp (. Fig. 9.4c).
Inside the dentin tubules, it can be observed the presence
of the odontoblastic process responsible for the formation of
the dentin matrix, besides the dentinal fluid and, occasion-
ally, amielinic free nerve ending [32]. Every stimulus, no
matter if it is mechanical, physical, chemical, or biological,
applied on the external surface of the tubule, causes the
movement of the dentinal fluid that reflects on the free nerve
ending that occasionally penetrates slightly on the dentin
difference between the secondary dentin (SD) with regular tubules and
the tertiary dentin (TD) with irregular deposition of the matrix and
tubules. Mallory’s trichrome stain, 400× magnification. (Microphotog-
raphy kindly supplied by Prof. Dr. Miguel Angel Castillo Salgado, Profes-
sor of Histology, ICT, São José dos Campos – UNESP)
 294 A. C. de Mello Torres et al.
tubules or on the ones located on the peripheral region of the
9 pulp. This explanation, named  hydrodynamic theory, was
stated by Brännstrom and is the most accepted one to explain
the dentin sensitivity [66].
9.2.2  Pulp
The dental pulp can be defined as a highly specialized loose
connective tissue, with an ectomesenchymal origin, sur-
rounded by the dentin wall, occupying the pulpal chamber
and the root canal. It is directly connected to the circulatory
and nervous system through the neurovascular bundle that
enters through the apical foramen [65]. The specialization of
the pulpal connective tissue is mainly due to cells that are
disposed on its periphery, the odontoblasts, which are
responsible for the formation of the dentin matrix [53]. The
pulp is composed of 25% of organic material and 75% of
water. It is basically formed by the following structural ele-
ments: progenitor cells (odontoblasts, fibroblasts, and undif-
ferentiated mesenchymal cells or stem cells), defense cells
(lymphocytes and macrophages), amorphous interstitial
substances (proteoglycans and glycoproteins), and intersti-
tial fibrous substance (collagen fibers) [27]. On the study of
the pulp structure, the dental pulp can be divided into two
zones: peripheral, composed of the odontoblastic and
subodontoblastic layers, and central core, composed mostly
by vessels and nerves (. Fig. 9.5). The most external layer of
 
the pulp, called odontoblastic, is formed by the cell bodies of
the odontoblasts, located underlying the predentin. The
main function of the odontoblasts is the production of den-
tin [26]. Below the odontoblastic layer, there is the cell-free
zone of Weil, rich in blood capillaries, amielinic nerve fiber
network (Raschkow plexus), and the cytoplasmic process of
the fibroblasts.
..      Fig. 9.5  Microphotography of the dentin-pulp complex showing
the odontoblastic layer (OL), acellular zone of Weil (AZ), cell-rich zone
(CZ), and pulp central region (CR). Mallory’s trichrome stain, 200×
magnification. (Microphotography kindly supplied by Prof. Dr. Miguel
Angel Castillo Salgado, Professor of Histology, ICT, São José dos
Campos – UNESP)
Below the cell-free zone, there is a cell-rich zone, com-
posed of fibroblasts, mesenchymal undifferentiated cells
(pre-odontoblasts), macrophages, and lymphocytes. When
there is the death of the odontoblasts, there is an increase of
the mitosis on the cellular zones and the migration of those
cells toward the odontoblastic layer, and this is the beginning
of the odontoblastic layer recovery process after pulpal dam-
age [168]. This process is possible due to the capacity of the
mesenchymal cells to differentiate into odontoblast-like cells
and, consequently, to reactivate the reparative capacity of
pulp on the injured region [111]. The central core of the pulp
has thicker blood vessels and nerves surrounded by connec-
tive tissue rich in fibroblasts, as well mesenchymal undiffer-
entiated cells.
The arterioles and venules that enter and exit the pulpal
cavity through the foramens and the apical ramifications
create the rich vascular supply of the dental pulp. Following
the track of the blood vessels, there is an abundant nerve
supply, originating from the trigeminal nerve. The nervous
fibers that enter the pulp are mielinic and mediate the pain
sensations caused by the external agents, while the amielinic
fibers are associated with the blood vessels, having, among
other functions, the vasomotor control. Those fibers are
basically classified into two types, according to the location,
function, diameter, and speed of nervous impulse conduc-
tion: A delta and C fibers. On the peripheral zone, there are
the A delta fibers, which are mielinic and thermoreceptors
for cold, with high-speed conduction of the nervous impulse
and not related to the tissue damage. On the central zone,
next to the blood vessels are the C fibers, amielinic, thermo-
receptors for heat, with low speed of nervous impulse con-
duction and related to the tissue damage (inflammatory
process).
The dental pulp has four basic functions: formative,
nutritive, sensory, and defense [47]. The formative func-
tion is related to the formation of the dentin during the
entire life of the tooth, being the most important one. The
nutritive function is related to its rich vascularization, by
the entrance of the nutrients and oxygen through the ves-
sels and exit of the tissue metabolic waste. The sensory
function is characterized by the capacity of the pulp to
respond with pain to different aggressive agents, by means
of the mielinic and amielinic nervous fibers. The defense
function may be observed when the pulp defends itself
from the aggressive stimuli with the formation of sclerotic
or tertiary dentin [27].
The dental pulp changes with the time due to the aging
physiological process. Those changes include the modifica-
tion of a young tissue (rich in cells and poor in fibers) to an
old tissue (poor in cells and rich in fibers), that is, changes
from the loose connective tissue to dense connective tissue.
Those changes are important from the clinical point of view,
because the defense capability of an old pulp is smaller than
the one of a young pulp [108] and the prognostic for keeping
of the pulp vitality after the direct protection of the dentin-­
pulp complex may be reduced. Young patients that submitted
their teeth to several “aggressive” stimuli (caries, trauma,
Protection of the Dentin-Pulp Complex
smoking, among others) throughout their lives may lead to
the reduction of the of pulp tissue defense capability by the
aging of the connective tissue.
>> The dental pulp changes with the time due to the
aging physiological process. Those changes are
important from the clinical point of view, because the
defense capability of an old pulp is smaller than the
one of a young pulp, and the prognostic for keeping of
the pulp vitality after some dental treatments may be
reduced.
9.3  efense Mechanisms of the Dentin-Pulp
D agent. The inflammation leads to vascular alterations, as the
Complex
The dentin-pulp complex can suffer changes when
exposed to different types of external aggressors, such as
the dental caries, traumas with or without tooth fracture,
tooth preparations, attrition, abrasion, erosive tooth wear,
restorative materials, orthodontic movement, and acid
etching. The dental pulp tries to block those aggressors by
means of three defense mechanisms: dentin sclerosis,
deposition of tertiary reactionary and/or reparative den-
tin, and pulpal inflammation. The response of the dentin-
pulp complex to the aggressors depends basically on the
pulpal condition and the maintenance of the pulp vitality.
The maintenance of the dentin-pulp complex vitality is
essential, because it is responsible for the response to the
external stimuli.
>> The dental pulp tries to block the aggressors by means
of dentin sclerosis, deposition of tertiary dentin, and
pulpal inflammation.
Under external aggressions, first, the tissue responds with
local tubular sclerosis by deposition of intratubular dentin on
the underlying region to the carious lesions, which reduces
the diameter of the dentin tubules [16, 47, 107, 157]. Clini-
cally, the tubular sclerosis results in the darkening of dentin
color (. Fig. 9.16a, b). The tubular sclerosis is produced by
 
light to moderate irritating agents, such as slow progression
carious lesions, moderate trauma after tooth preparation,
abrasion, erosion, attrition, and aging. The tubular sclerosis
will not happen if the odontoblasts have previously been
destroyed. When the aggression is too intense, the odonto-
blasts die and the corresponding tubules are referred as dead
tracts.
The second line of defense of the dentin-pulp complex
is a deposition of tertiary reactional dentin, with the inten-
tion to increase the distance between the aggressor agent
and the pulpal tissue [98]. The structure of the deposited
dentin matrix depends on the activity of the carious lesion.
The more active the lesion is, the more irregular the formed
tertiary dentin will be [15]. This tertiary dentin generally
presents more sinuous and less numerous tubules than the
primary dentin, and sometimes they are completely absent
295 9
(. Fig. 9.4c). It is characterized by being more mineralized
and less sensitive than the primary dentin due to the lack
of continuity of the tubules. If the odontoblasts are
destroyed due to external aggressors, they are replaced by
the mesenchymal undifferentiated cells that differentiate
themselves in odontoblast-­like cells and secrete dentin
matrix. They may not take the column-like and polygonal
shape of the odontoblasts but a cubic or flat appearance.
The resulting dentin has an interrupted continuity of the
dentin tubules, acting as barrier against the penetration of
external irritants [176].
The pulp inflammation must be understood as a defen-
sive response that has by objective to limit the aggressive
vascular dilatation and the increase of vascular permeabil-
ity. The anatomic location of the pulp, among hard and non-
elastic walls, associated to the lack of the collateral
circulation is a factor that makes the pulp expansion diffi-
cult, which is observed after the increase of the blood flow
(vascular dilatation) and vascular permeability, resulting in
the increase of the pulpal pressure. On the vascular conges-
tion, part of the interstitial liquid is pushed outward with
the intention to accommodate the increase of blood flow. At
the first moment, there is an increase of the arterial flow
(arterial or active hyperemia), and at the next stage, there is
a reduction of the venous flow (venous or passive hyper-
emia), producing the plasma exudation and the cell migra-
tion, characterizing the acute inflammation. However, the
inflammation is a more complex phenomenon, controlled
by the presence of chemical mediators that act on the
defined stages and with specific functions. The pain is a con-
sequence of the pressure increasing on the tissue due to the
hyperemia, the edema, and the release of the inflammatory
mediators (pain mediators).
>> The pulp initially responds to the different stimuli with
the dentin formation. If the intensity and the
frequency of the stimuli are below the defense
capacity of the pulp, there will be an inflammation
with different intensities but with a reversibility
potential of the inflammatory process. If the intensity
and the frequency of the aggression are above the
defense capacity of the pulp, there will be an
irreversible inflammation. This irreversible
inflammation can lead to the pulp necrosis.
The defense mechanisms of the dentin-pulp complex, even
when they are effective on the maintenance of the pulp vital-
ity, will have as a natural consequence the pulp aging process
[37]. At this case, there is a reduction of cellularity and on the
number of the vessels and nerves on the pulpal tissue. Conse-
quently, there will be a reduction of the reparative capacity
after the conservative treatments, such as the pulp capping
and pulpotomy, which will be described later. On those situ-
ations, the treatment planning includes a thorough evalua-
tion of the pulp condition, which will determine the clinical
treatment to be performed.
 296 A. C. de Mello Torres et al.
9.4 Assessment of Pulp Condition
9
The diagnosis of the pulp condition represents the base for
proposing the treatment, especially when the patient’s chief
complaint is related to pain. The pain is the most frequent
reason patients seek dental treatment. It is an important ref-
erence for the dentist to reach a diagnosis, since there is no
clear relation between the clinical symptoms and the histo-
pathological findings. Therefore, the histopathological results
cannot be extrapolated to the clinical conditions of treat-
ment. For this reason, nowadays, the diagnosis is defined by
the clinical conditions (pain) of the pathological pulp situa-
tion [36, 94, 97].
The challenge is to recognize the etiological factor respon-
sible for the pain on the oral structures, which is fundamen-
tal for diagnosis and the success of the dental treatment [53].
For the diagnosis of the pulpal condition, it is not only neces-
sary to understand the biological responses of the pulp, but
also the interpretation of those responses. The diagnosis of
the pulp condition can be divided in phases: anamnesis,
intra- and extraoral clinical exam, pulp testings, complemen-
tary testings, and radiographic examination.
9.4.1  Anamnesis
The anamnesis represents the subjective examination per-
formed through an interview to interrogate the patient,
which directs the investigation in relation to the signals and
symptoms associated with the pathological process. The
clinical history must be collected and registered in an orga-
nized manner, using objective and defined questions. The
anamnesis involves the analysis of the data obtained sepa-
rately and interpreted in an associated manner to integrate
the diagnosis process [53]. The anamneses are composed of
the chief complaint, history of the current and previous dis-
ease, and the medical history of the patient. In some cases,
the interaction with the doctor may be necessary to deter-
mine the general state and the medications used by the
patient, assuring adequate planning and treatment. It is
essential to ask the patient where and when the pain hap-
pens and if it is continuous, throbbing, spontaneous, or
provoked.
9.4.2  Extraoral Clinical Exam
As a basic protocol for an extraoral exam, the dentist must
observes the patient since  when entering into the  office.
Signals of physical limitations, as well signals of facial asym-
metry, may be present. A visual exam must be performed to
determine if there is edema, extraoral fistulas, lacerations,
excoriations, scarring, bruising, etc. The palpation of the face
and the neck allows the dentist to determine if really there is
an edema and if it is localized or diffused, firm, or fluctuating
(. Fig. 9.6) [36].
 
..      Fig. 9.6  Extraoral clinical exam showing a chronic draining fistula
9.4.3  Intraoral Clinical Exam
The intraoral clinical exam represents the objective exam
of the signals that identify one specific disease [53]. The
visual observation of the soft and hard tissues, associated
with the physical inspection (by means of the clinical mir-
ror, exploratory and periodontal probes), allows the identi-
fication of the carious lesions, crown and/or root fractures,
presence of fistulas, restoration fractures, periodontal
pockets, and pulp exposure. The intraoral clinical exam is
not conclusive to reach a diagnosis about the pulp condi-
tion, and it must be associated with other clinical testings
(. Fig. 9.7a–d).
9.4.3.1  Palpation
The palpation allows determining, using the tactile percep-
tion, the consistence and texture of the soft  tissues, adher-
ence, mobility, and smoothness, besides the presence of the
painful areas. On the periapical abscess without fistula, the
palpation allows verifying its stage of evolution  (initial, in
evolution, acute) and if it presents a fluctuation sign
(. Fig. 9.8) [53]. When it is pressed, the region correspond-
ing to the lesion produces a painful sensation.
9.4.3.2  Percussion
The percussion consists of a method in which the dentist
applies soft tapping on the tooth crown with the aid of the
handle of a clinical mirror, on the vertical and horizontal
directions (. Fig.  9.9a, b) [94]. Even though it is a simple
testing, the percussion is important to find the tooth
responsible for a pain of endodontic origin, or due to a pre-
mature occlusal contact. The positive response to the verti-
cal percussion  (the presence of pain sensation) may be
associated with periapical alterations while to horizontal
percussion can be associated with periodontal alterations
[47]. One positive response to the percussion testing must
always be confirmed by pulp sensitivity testing and radio-
graphic exams.
Protection of the Dentin-Pulp Complex
297 9

a b

c d

..      Fig. 9.7  Intraoral clinical exam visually analyzing the soft and hard tissues. a Fistula (arrow); b darkened teeth associated with the pulp necrosis; c
carious lesions; d fractured teeth showing a pink discoloration of the dentin due to the thin layer of remaining dentin over the pulp

ing must also be performed during the intraoral exam of the

patient. It can be performed by the digital palpation or with
the aid of dental instruments (. Fig. 9.10b).
 

9.4.3.4  Transillumination
It consists in the application of an intense light on the lingual
surface of a tooth. In the case of dental trauma, the transil-
lumination is important on the diagnosis of fractures or
cracks (. Fig. 9.11). On the tooth with necrotic pulp, gener-
 

ally the shadow of the pulpal chamber appears to be darker in

relation to the rest of the crown, due to the decomposition of
the pulpal tissue. On the teeth with vital pulp, this difference
is not too evident.

9.4.3.5  Pulp Sensitivity Testing

..      Fig. 9.8  Palpation of the periapical region
9.4.3.3  Periodontal Probing and Mobility
Testing
The periodontal probing allows to evaluate the presence or
not of the periodontal pockets, gingival exudation, or even
drainage via the gingival sulcus. The dentist must perform,
whenever necessary, the indicated periodontal treatment for
each clinical situation (. Fig. 9.10a). The tooth mobility test-
The pulp sensitivity can be evaluated using thermal (cold
and heat) and/or electric testing. The pulp sensitivity test-
ing aids on the differentiation of the teeth with normal
pulps to the ones with pathologically altered pulps, espe-
cially on the cases of pulp necrosis, when the other teeth
are used as control. Clinical studies were done to evaluate
the performance of thermal and electrical testing on the
determination of the pulp vitality [177]. It was observed
that 97% of the teeth which responded positively to the
 298 A. C. de Mello Torres et al.

a b
9

..      Fig. 9.9  a Vertical percussion with the handle of a mirror; b horizontal percussion

a b

..      Fig. 9.10  a Periodontal probing; b tooth mobility testing

a low cost, and reproducible, those testings indirectly

monitor the pulp vitality through the evaluation of the
pulp nervous response, and not of the pulpal blood flow
[83]. The thermal testing has a limited value to the diagno-
sis of the pulpal condition on the tooth with incomplete
root formation and large apical foramen. On those cases,
for the correct diagnosis, it must be considered the pres-
ence of irreversible pulpitis symptoms or periapical peri-
odontitis; clinical signals of periapical infection (edema,
sensitivity to percussion, mobility, and fistula); bone loss
detected radiographically; progressive root resorption; and
delay on the root development when compared with the
adjacent teeth [29].

..      Fig. 9.11  Transillumination showing the cracks on the tooth Tip

crown
testing presented pulp vitality, verified through the direct
visual inspection of the pulp chamber. However, the results
of the thermal testing must be interpreted with caution,
because even though they are noninvasive, objective, with
Almost all teeth which responded positively to the pulp
sensitivity testing presented pulp vitality. However, the
thermal testing has a limited value on the tooth with
incomplete root formation and large apical foramen, and
other analyses are required.
Protection of the Dentin-Pulp Complex
Understanding that the inflammatory pulp alterations are
related to vascular changes, agents that cause modification
on the blood flow (vasoconstriction or vasodilation) are
capable to produce stimulation on the nervous termina-
tion, characterizing the possible clinical situation of the
tissue (normal or inflamed, but still vital). However, sev-
eral agents are capable to stimulate the sensitivity on the
nervous termination, which will not necessarily certify
that the tooth is vital. The nervous fibers are the last ones
to suffer degeneration and, on the teeth with pulpal necro-
sis, can  sometimes still  respond with sensitivity when
stimulated [53].
>> The nervous fibers are the last ones to suffer
degeneration and, even on the teeth with pulpal
necrosis, can sometimes still respond with sensitivity
when stimulated.
Cold Test
The thermal stimulations of the pulp with cold can be per-
formed with an ice stick or cotton pellet soaked in a volatile
refrigerant, such as ethyl chloride, tetrafluoroethane (Endo
Ice®, Hygenic), dichlorodifluoromethane (DDM), carbon
dioxide (dry ice or carbon dioxide snow), or a propane/
butane/isobutane gas mixture (Endo Frost, Roeko)
(. Fig.  9.12a, b). Those agents promote a decrease of the
 
intrapulpal temperature, stimulating pulp nervous termina-
tions due to vascular changes (vasoconstriction), causing
pain. The greater the temperature reduction, the greater the
stimulus [53].
During the application of the cold test, cotton roll iso-
lation must be used. The test must be initiated on the adja-
cent teeth or even on the analog tooth of that under
suspicion of alteration, from posterior to anterior teeth, on
the facial surface, and, finally, on the suspected tooth. The
time of application of the cold test may vary from 1 to 4 s
[53, 94]. The absence of painful response after the applica-
tion of the thermal stimulus may indicate that the pulp is
necrotic.
a b
..      Fig. 9.12  Cold test. a Application of the Endo-Frost volatile refrigerant spray (Roeko) with a little cotton pellet; b touching of the small frozen
pellet on the tooth to be evaluated
299 9
Heat Test
On the thermal testing performed with heat, a heated gutta-­
percha stick is applied over the labial surface of the anterior
teeth or the occlusal surface of the posterior ones [94]. On
this test, it is difficult to precisely control the temperature
during the application. It is important that before the applica-
tion, the tooth is lubricated with saliva or petroleum jelly, so
that the gutta-percha does not stick to the surface. In the case
of a positive response, the heat must be immediately removed.
The excessive and prolonged heat must be avoided, which
may cause irreversible pulp alterations (. Fig. 9.13a, b) [137].
The testing of the pulp sensitivity to with cold does not
aggravate the situation of a normal or inflamed pulp.
However, the opposite may be observed with the heat test,
which should not be applied as a routine on pulps with nor-
mal characteristics [53]. The heat test is used in situations
where it is required to establish a differential diagnosis, when
the tooth with the symptoms is not easily identified. Due to
the fact that heating can promote vasodilation, on the teeth
with symptomatic pulp inflammation, depending on the
extension of the process, the painful response to the heat can
become intense and immediate.
>> The testing of the pulp sensitivity with cold does not
aggravate the situation of a normal or inflamed pulp.
However, the opposite may be observed with the heat
test, which should not be applied as a routine on pulps
with normal characteristics.
Electric Pulp Test
The electric test allows the evaluation of the pulp response to
electrical stimulation over the nervous fibers on the pulp. The
objective of this test is to stimulate the pulp sensitivity, but as
the thermal tests, it does not give information over the blood
supply, a determinant factor for the vitality [53].
The electric devices used for pulp sensitivity testing use
different types of electrical current, and the high frequency is
the most adequate, in which graduations may be regulated on
a continuous mode. The positive response to the electrical
 300 A. C. de Mello Torres et al.
a b
9
..      Fig. 9.13  Heat test. a Heating of the gutta-percha stick over the flame; b touching the stick on the tooth to be evaluated
..      Fig. 9.14  Device for electric pulp test. (Digitest Pulp Tester, Parkell
Inc.)
test is noticed by the patients as a heating or tingling sensa-
tion, that disappears after the removal of the electrode
(. Fig.  9.14) [94]. The absence of response to the electrical
test on the cases of vital pulp may indicate a false-negative
response, such as on the cases of traumas, calcifications on
the root canal, incomplete root formation, patients that used
analgesics or tranquilizers, or even defects on the device [33,
130, 132].
Test Cavity Preparation
The objective of this test is to evaluate the presence of painful
response during the cutting of the dentin. It should be used
if there is still doubt or inconclusive results about the pulp
condition, after the use of the sensitivity testing to cold. On
this testing, the dentin exposed by a caries lesion is removed
with excavators or large diameter burs, without the use of
anesthesia. The lack of painful response may indicate pulpal
necrosis [94].
Local Anesthetic Test
Sometimes, the symptoms are poorly referred or  localized,
and the patient has a difficulty to describe whether the pain
originated in the upper or lower arch. In addition, during the
clinical examination, there is not a clear indication of the
tooth with pulpal problem, and the results of thermal tests
are not clear. On those cases, the area of the most suspected
tooth can receive anesthesia, to evaluate if the painful sensa-
tion disappears. In case of a negative response, the next sus-
picion tooth or area also receives anesthesia, until the affected
tooth is determined.
9.4.4  Radiographic Examination
The radiographic examination is a complementary resource
used for the diagnosis of the pulpal condition, which allows
the evaluation of the tooth mineralized structure and the api-
cal and periapical regions. However, in some situations, the
radiographic appearance of a pathological process may be
very subjective. Therefore, the radiographic image is an
important method but only complementary to the diagnosis.
When not associated with anamnesis, clinical examination,
and pulp sensitivity testing, the radiographic examination
alone may lead to a wrong interpretation about normality or
disease.
>> When not associated with anamnesis, clinical
examination, and pulp sensitivity testing, the
radiographic examination alone may lead to a wrong
interpretation about normality or disease.
Several factors may influence the quality of the radiographic
interpretation, including the dentist’s ability when taking
the radiography, quality of the film, X-ray radiation source,
film processing, and the way that the radiography is visual-
ized. Controlling all those variables may be a hard challenge,
but it is essential to obtain a reasonable radiographic inter-
pretation [87].
Besides the conventional radiography, direct digital
images can be obtained with intraoral sensors. The digital
radiography does not use films and does not need a chemical
Protection of the Dentin-Pulp Complex
processing. A sensor is used to capture the image created
through a radiation source. This sensor is attached directly or
indirectly to a computer that interprets the signal and con-
verts it into a digital image using specific software, allowing
its exhibition and improvement. The image is stored and may
be revised whenever necessary. The quality of diagnosis using
digital radiography is comparable, but not superior to the
conventional radiographic film, when properly exposed and
processed [52, 87].
However, the exact pulp condition cannot be obtained
by  radiographic examination  alone. On cases of reversible
and irreversible pulpal alteration, the radiographic examina-
tion may show the presence of carious lesion or defective
restorations, but the apical periodontal ligament may  be
within normal limits or only slightly thickened, with an
intact lamina dura [94]. However, when the pulp is necrotic,
the examination may show the breaking of the lamina dura
and the presence of the periapical lesions.
9.5 Diagnostic Hypothesis
The diagnosis must be understood as a dynamic process, per-
formed with integrated stages (subjective and objective
exams, clinical testing, and radiographic examination).
Finishing the initial evaluation phase, the dentist must estab-
lish the diagnostic hypothesis, interpreting the collected data
to plan and execute the treatment. The treatment to be per-
formed (conservative or radical) will be based on the diagno-
sis of the pulpal condition, i.e., evaluating whether the pulp is
vital or not.
The odontogenic pain may basically have three origins:
exposed dentin, pulpal inflammation, and periapical inflam-
mation. Some clinical characteristics of pain collaborate dur-
ing the establishments of the diagnostic hypothesis. Among
them, it can be pointed the location of the pain, when it
appears, its duration, frequency, and intensity. The dentin
pain is generally acute and easily localized, provoked by spe-
cific stimulus, such as mechanic (touch), physical (cold or
heat), chemical (acids), osmotic (sugar), and dehydration
[111]. The pain occurs due to the movement of liquid inside
the tubules, creating shear forces that stimulate the free nerve
terminations, disappearing as soon as the causing agent is
removed. The mechanoreceptors detect those movements
leading to the generation of an action potential and conse-
quentially the perception to the pain [102].
>> The odontogenic pain has basically three origins:
exposed dentin, pulpal inflammation, and periapical
inflammation.
Diagnosis to the pain of pulpal origin generally is more
complex. The pain may be diffuse (referred or reflex), spon-
taneous, and throbbing, complicating the exact localization
of the compromised tooth. The report of spontaneous pain
discards almost always the possibility of the pulp to present
301 9
characteristics of reversible pathological alterations. In this
case, the pathological acute pulpal alterations can be classi-
fied, only with the objective of clinical treatment indica-
tion, in acute reversible pulpitis (conservative treatment
indicate) and acute irreversible pulpitis (radical treatment
indicated) [94].
The protection of the dentin-pulp complex, defined as a
conservative treatment, will only be indicated on the cases
where the pulp presents characteristics of reversible patho-
logical alterations. On those cases, the pain is acute and pro-
voked, generally localized, with the duration of no longer
than 1 minute, stopping after the removal of the stimulus.
The indicated treatment is conservative, such as indirect or
direct pulp capping, according to what will be explained later
on [94].
In the cases of acute irreversible pulpits, the pain is sharp,
spontaneous, and generally intense and throbbing, of long
duration and sometimes diffuse and/or reflex. The indicated
treatment is radical, through the biopulpectomy. On the
teeth with incomplete root formation, even when the pulp
has characteristic of irreversible alteration, the pulpotomy
will be indicated, which is the removal of the pulpal tissue
only on the crown area, allowing the finishing of root forma-
tion [94]. The acute irreversible pulpitis may develop slowly
to a chronic pulpitis. That pulp alteration is generally
observed on young patients, resulting from a low-level and
long-term irritation, over a pulp with great resistance.
Clinically, two types of chronicle pulpitis can be observed:
ulcerative and hyperplastic chronicle pulpitis. The ulcerative
chronic pulpitis is characterized by presenting an ulcer on
the exposed surface of the pulp, isolating the remaining pulp
tissue by means of a barrier of an ulcerated tissue and defense
cells. Generally, the pain is provoked, localized, and pro-
duced by the compression of food in the carious cavity. The
regular  indicated treatment is biopulpectomy. On the teeth
with incomplete root formation, the pulpotomy will be indi-
cated [94]. The hyperplastic chronic pulpitis is characterized
by the proliferation of a granulomatous tissue on the level of
pulp exposure, named pulp polyp. The pain is generally pro-
voked, localized, and produced by the compression of food
during mastication. The indicated treatment is the biopulp-
ectomy. On the teeth with incomplete root formation  the
pulpotomy is indicated [94].
The acute and chronicle pulpitis, depending on the pulp
condition and on the intensity of the aggressor agent, may
develop slowly or fast to the death of the pulp. The pulp
necrosis is generally asymptomatic and can produce a color
change of the tooth crown. Generally, there are no response
to the pulp sensitivity testing, but on doubtful cases, the cav-
ity preparation test must be performed. The indicated treat-
ment is the necropulpectomy.
>> The protection of the dentin-pulp complex, defined as
a conservative treatment, will only be indicated on the
cases where the pulp presents characteristics of
reversible pathological alterations.
 302 A. C. de Mello Torres et al.
Tip
9 trauma, operative procedures, and marginal microleakage,
The diagnosis of pulp condition can be summarized as
shown below:
55 Reversible pathological alterations: The pain is acute
and provoked, generally localized, with the duration
no longer than 1 minute, stopping after the removal
of the stimulus.
55 Acute irreversible pulpits: The pain is sharp,
spontaneous, and generally intense and throbbing,
of long duration and sometimes diffuse and/or
reflex.
55 Ulcerative chronicle pulpitis: Characterized by
presenting an ulcer on the exposed surface of
the pulp; the pain is provoked, localized, and
produced by the compression of food in the
carious cavity.
55 Hyperplastic chronic pulpitis: Characterized by the
proliferation of a granulomatous tissue on the level
of pulp exposure. The pain is generally provoked,
localized, and produced by the compression of food
during mastication.
55 Pulp necrosis: Generally asymptomatic, it can pro-
duce a color change of the tooth crown. Generally,
there are no response to the pulp sensitivity testing,
but on doubtful cases, the cavity preparation test
must be performed.
9.6 Origins of Pulpal Alterations
In the past, it was believed that the main causes of pulpal
inflammation were the toxic effects of the restorative mate-
rial. However, from the half of the 1970s decade, several
researches have shown that the pulp can tolerate a variety of
restorative materials if bacteria are absent, depending obvi-
ously on the type of material and whether it is or it is not in
direct contact with the pulpal tissue [74]. Therefore, the main
cause of the pulp alterations is the bacterial invasion and
their toxins on the pulpal tissues, especially by the lack of
sealing on the margins and of the dentin tubules that were
cut during the preparation [75]. However, the direct contact
of the materials with cytotoxicity and immunosuppressive
effect with the pulpal tissue contributed for the persistence of
tissue inflammation [83]. Cytotoxic materials may destroy
specific pulpal cell, reducing its capability to respond to a
future bacterial invasion [74].
>> The main cause of the pulp alterations is the bacterial
invasion and their toxins on the pulpal tissues,
especially by the lack of sealing on the margins and of
the dentin tubules that were cut during the
preparation. However, the direct contact of some
materials with the pulpal tissue may contribute to the
persistence of tissue inflammation.
Several factors such as caries, tooth preparation, occlusal
besides resinous components that may reach the pulp, have
the capability to promote pulpal alteration and will be dis-
cussed later [74]. The correct diagnosis of the pulpal
­condition and the knowledge about the factors that may pro-
mote pulpal alterations, separately or in association, are
essential to allow the dentist performing dental procedures
maintaining the vitality of the pulpal tissue, reducing the
damage, and promoting the rehabilitation.
9.6.1  Carious Lesion
The caries disease promotes alterations on the pulp through
the diffusion of bacteria and its by-products through the den-
tin tubules. The degrees of pulpal lesion are determined by
the characteristics of the patient (age, caries risk, and poten-
tial of tissue response) and by the characteristics of the lesion
(cavity depth, size of the lesion, and mineralization degree of
the dentin) [128]. Therefore, the maximum preservation of
remaining  dentin separating the pulpal tissue of the cavity
floor  is very important. On asymptomatic and well-sealed
teeth, the maintenance of the pulp vitality after tooth prepa-
ration on dentin without pulp exposure is excellent, even
when some residual carious dentin tissue remains [74].
9.6.2  Tooth Preparation
In order to perform the tooth preparation, a rotating cutting
instrument assembled on high- or low-speed handpiece, a
high-power laser, or an air abrasion device can be used [30].
Those instruments are capable to generate heat in a larger or
smaller degree, and it may cause alterations on the pulpal tis-
sue due to the temperature rise, producing postoperative
sensitivity or even necrosis [141]. According to Zach and
Cohen, the temperature rise of the pulpal tissue must not be
superior to 5.5 °C above the body temperature, due to higher
risk of irreversible tissue alterations and pulpal necrosis
[180]. Studies verified that the action of the rotary cutting
instruments produces movement of dentinal fluid, toward
the pulpal tissue and toward the tooth surface, due to the
heating generated by the use of a non-correctly refrigerated
instrument. This movement is also observed when the prepa-
ration is excessively dried with air stream [21, 122].
The excessive force applied by the dentist over the hand-
piece during the tooth preparation can also cause more heat
[159]. The increase of the force applied may be the result of a
small hand sensitivity, stress, and wrong dentist’s technique
or reduced cutting effectiveness of the rotary instruments
[141]. In order to minimize the trauma, new rotary cutting
instruments with high cutting effectiveness must be used,
associated with the abundant refrigeration and application of
small and intermittent cutting force. In addition, excessive
drying of the preparation with a strong air stream must be
avoided, being preferably performed with small cotton pel-
Protection of the Dentin-Pulp Complex
lets, absorbent papers, or small indirect and intermittent air
stream [128]. The use of unbalanced and eccentric cutting
instruments or handpieces causes a greater frictional heat by
the vibration and must be replaced or repaired [66, 128].
Tip
In order to reduce aggression during the tooth
preparation, the dentist needs to:
55 Reduce and apply intermittent force over the hand-
piece
55 Use new rotary cutting instruments and copious
refrigeration
55 Avoid excessive drying of the preparation
55 Not use unbalanced and eccentric cutting instru-
ments or handpieces
9.6.3  Occlusal Trauma
Restoration with excessive occlusal contact transfers the
chewing load to the tooth, pressing the periodontal ligament
on an abnormal manner, causing a periapical inflammation
and pain [128]. The pain is localized and throbbing. The
patient describes pain when the teeth are in contact, which is
related to a very slight dental extrusion, making the patient
avoid teeth contact [95]. In order to prevent or solve this
problem, the dentist must always adjust the interarch contact
after finishing the restorations, evaluating it on centric occlu-
sion and during the protrusive and lateral excursive move-
ments.
9.6.4  Restorative Procedure
The marginal microleakage is the passage of ions, fluids, and
bacteria through the tooth-restoration interface due to the
lack of sealing or a noneffective contact between the restor-
ative material and the tooth preparation. The microleakage is
associated with the bacterial infection of the dentin and sec-
ondary caries, favoring the infection and necrosis of the
pulpal tissue, and failure of the restorative material, with the
total or partial displacement of the restoration [66, 138].
The marginal microleakage is the passage of ions, fluids,
and bacteria through the tooth-restoration interface due
to the lack of sealing or a noneffective contact between
the restorative material and the tooth preparation.
The correct use of the adhesive systems allows an adequate
bonding of the restorative material to the tooth structure,
reducing the microleakage and extending the longevity of the
restorations [138]. However, in order to perform the adhe-
303 9
sive technique, operative procedures such as the acid etching,
hybridization, and light-curing of the restorative material,
besides the restorative material by itself, can cause pulp alter-
ations [128].
9.6.4.1  Acid Etching
The acid etching of dental enamel increases the surface
roughness and energy, by selective dissolution of the hydroxy-
apatite crystals, which is penetrated by the adhesive mono-
mers, creating resinous microtags and micromechanical
bonding. On the dentin, due to its composition and charac-
teristics, the etching tends to cause a movement of the
­dentinal fluid, due to its hypertonic action [124]. It promotes
a thorough cleaning of the surface, removing the smear layer
and the smear plugs, demineralizing the peritubular and
intertubular dentin and exposing the collagen fiber network,
increasing the dentin permeability due to the opening of the
tubules, and creating a direct path to the pulpal tissue. If the
dentin is not properly sealed by means of the adhesive system
application, the tubules will remain open, allowing bacteria
and their irritating by-products, as well as irritant compo-
nents of restorative materials, reach the pulp [109]. When the
self-etching adhesive systems are used, the demineralization
and the penetration of the adhesive monomers occur simul-
taneously. Therefore, instead of the tubules being opened and
then sealed later, as on total-etch materials, they remain
closed, reducing the chances of pulpal contamination.
9.6.4.2  Dentin Hybridization
The hybridization of the dentin consists in the impregnation
of the collagen fiber network exposed by the acid etching
with the resinous monomers of the adhesive system. This
procedure may produce an adequate sealing of the tooth-­
restoration interface, but not in a permanent way [113]. The
degradation of the interface allows pulp irritation due to
marginal microleakage into interfacial gaps and/or the
nanoleakage on the base of the hybrid layer, on interfibrillar
spaces not properly infiltrated by the adhesive [49, 86]. In
case of a heterogeneous impregnation of the hybrid layer, the
dentin tubules may remain open, allowing the movement of
the dentinal fluid, activating the pulp nociceptors, and result-
ing in a postoperative sensitivity [38, 128].
Besides the failures that may occur on the of hybridiza-
tion process, some components of the adhesive systems have
cytotoxic and immunosuppressive effects and can diffuse
through the tubules and reach the pulpal tissue, especially
on the very deep cavities, with less than 0.5 mm of dentin
remaining [38, 177]. A study evaluated the effect of acid
etching and application of an adhesive system on very deep
cavities, without the pulpal protection [69]. The authors
verified a persistent inflammatory response on the pulp
when the globules of the resinous materials reached the pulp
through the tubules, starting a foreign body inflammatory
pulpal response, characterized by the presence of the macro-
phages and giant cells with multiple nuclei. Another study
evaluated the response of the dentin-pulp complex on very
deep Class V cavities restored with total-etch adhesive sys-
 304 A. C. de Mello Torres et al.
tem and c­omposite resin [72]. The authors verified the
9 occurrence of hyaline changes of the cellular matrix, related
to the local edema and the overflow of the blood plasma
from the capillaries, which were dilated and congested on
the coronary pulp. The displacement of odontoblasts was
observed when the thickness of the dentin remaining,
between the pulp tissue and the pulpal wall, was smaller
than 0.3 mm.
The knowledge about the characteristics of the tooth sub-
strate may minimize the adhesion failures, and reduce the
diffusion of the adhesive system components to the pulpal
tissue, through the dentin tubules. Therefore, in deep and
very deep cavities, it is necessary to use a protective material
before the acid etching and hybridization, avoiding that the
adhesive system becomes a source of irritation of the pulpal
tissue.
>> In deep and very deep cavities, it is necessary to use a
protective material before the acid etching and
hybridization, avoiding that adhesive system becomes
a source of irritation of the pulpal tissue.
9.7  actors Affecting the Dentin-Pulp
F the bacteria, toxins, and acids. In vitro studies showed that a
Complex Protection
To protect the dentin-pulp complex means to protect the
dentin and the pulp against the action of external aggressive
agents, aiming to preserve its vitality. In order to do so,
besides the correct diagnosis of the pulpal condition, some
other factors must be considered, such as the depth of the
preparation, the age of the patient, the presence of sclerotic
dentin, the material used for the protection, and the type of
restorative material.
The depth of the preparation is determined by the
thickness of the dentin remaining between the cavity floor
and the roof of the pulpal chamber [26]. The clinical deter-
mination of the cavity depth is a difficult procedure, and it
must be assisted by the radiographic examination of the
tooth structures. The thicker is the dentin remaining
between the cavity floor and the roof of the pulpal cham-
ber, the better the prognostic for the pulp will be, because
the thickness of the remaining is the most important factor
to protect the pulp from external aggressions. As it has
already been stated in Chap. 5, the preparation can be clas-
sified, accordingly to their depth, in shallow, medium,
deep, and very deep. However, it is very difficult to clini-
cally determine the depth of the cavity, because it is not
only related to how many millimeters of depth the cavity
has, since the volume of the pulpal chamber decreases with
aging. Therefore, a cavity of only 2 mm deep on a first per-
manent molar of an 8-year-old child may be considered
very deep, but it may be considered shallow on this same
tooth when the patient reaches 40 years old. The teeth of
younger patients, with some exceptions, present a large
pulpal chamber and  dentin tubules, which will favor the
penetration of toxic or irritating agents. The only clinical
aspect that can give to the dentist an absolute information
about the cavity depth is when a pink discoloration is
observed on the pulpal wall, indicating that probably less
than 0.5 mm of dentin remaining is covering the pulp. In
this case, some small pulpal exposures can be present, not
visible to naked eyes, and the cavity is named very deep, as
it is observed in . Fig. 9.7d.
>> The depth of the preparation is determined by the
thickness of the dentin remaining between the cavity
floor and the roof of the pulpal chamber. The thicker is
the remaining, the better the prognostic for the
treatment. The conservation of the dentin remaining is
more important for the health of the pulpal tissue than
the application of a protective artificial material. When
a pink discoloration is observed on the dentin, that
indicates that less than 0.5 mm of dentin remaining is
covering the pulp and some small pulpal exposures
can be present, not visible to the naked eyes.
During the tooth preparation, the dentist must preserve the
largest amount possible of dentin, since the remaining dentin
will protect the pulpal tissue, acting as a thermal isolation
and physical and chemical barrier against the penetration of
dentin remaining of 0.5 mm thick is able to reduce the toxic-
ity level of restorative materials up to 75%, while 1 mm thick
reduces up to 90% [106]. With a remaining of 2 mm thick, on
most of the cases, the pulpal response is inexistent [75, 156].
The dentin has an excellent buffering capacity to neutralize
the acids that come from the cariogenic activity, as well as the
one used for the acid etching for the adhesive technique. The
conservation of the dentin remaining is more important for
the health of the pulpal tissue than the application of any pro-
tective artificial material [75].
In an attempt to perform a more objective estimate about
the amount of dentin remaining, the electrical conductance
of the dentin can be evaluated. The method is based on fact
that the smaller is the remaining, the greater is the passage of
an electrical current. The Prepometer® device (Hager) pres-
ents an electrode to be placed on the oral mucosa of the
patient, while the reading tip closes the circuit when touch-
ing the dentin (. Fig. 9.15). The visual indication about the
dentin remaining quantity is given by the LEDs that light up.
Depending on the cavity depth, the color of the LED that
lights up is changed. The green LEDs represent a safe dis-
tance, the orange ones represent a limit zone of safety, and
the red ones represent danger of pulpal exposure. In the
absence of this device, the dentist must develop a concept
about the cavity depth, through the observation of the cavi-
ties with exposed pulps or during the opening of the crown
for the endodontic treatment, associated to the analysis of the
radiographic images. Another possibility is the study using
extracted teeth, making cross sections on the mesiodistal and
facial-lingual directions.
Another factor that influences the necessity of a protec-
tive a material application is the presence of sclerotic dentin
on the cavity floor, which can be clinically seen as an area
Protection of the Dentin-Pulp Complex
with darkened brownish or black color, extremely hard to the
touch (. Fig. 9.16a). It indicates that a long-lasting and low-­
 
intensity aggression took place, allowing a deposition of min-
erals inside the tubule, leading to its sealing. Radiographically,
it can be seen as a radiopaque area (. Fig. 9.16b). The scle-
 
rotic dentin is capable to effectively seal the dentin and pro-
tect the pulp, making unnecessary the application of any
additional protective material.
>> The sclerotic dentin can be clinically seen as an area
with darkened brownish or black color, extremely hard
to the touch. It is capable to effectively seal the dentin
and protect the pulp, making unnecessary the
application of any additional protective material.
9.8 Cleaning of the Tooth Preparations
After the tooth preparation with hand or rotary cutting
instruments, an amorphous and thin layer is deposited upon
the tooth surface, named smear layer, composed of organic
and inorganic materials from the tooth structure, oil from
..      Fig. 9.15  Device to determine the cavity depth using the
measurement of electrical conductance (Prepometer—Hager)
a b
..      Fig. 9.16  a Sclerotic dentin on the floor of the cavity exhibiting the brownish or darkened coloration; b radiopaque aspect of the sclerotic
dentin in the radiography (arrow)
305 9
the rotary instruments, saliva, blood, and microorganism
from the carious process. This layer represents a natural pro-
tection of the dentin-pulp complex against the invasion of
bacteria and its toxic and acid by-products, because it
occludes the tubules and reduces the dentin permeability. On
the other hand, the presence of the smear layer also presents
disadvantages, as the direct interference on the bonding
mechanism of some adhesive systems and maintenance of
the bacteria in the preparation walls [111].
Due to those observations, the cleaning of the prepara-
tions is a recommended procedure, which allows the pro-
tection of the dentin-pulp complex by the reduction of
microorganisms through the friction, washing, or chemical
action. This procedure reduces the contamination, elimi-
nating residues of the preparation and loose enamel and
dentin fragments, oil from the handpieces, blood, and
saliva, besides contributing with the action of the protective
agents. The cleaning of the preparation is a continuous pro-
cess which starts with the use of cutting instruments and
washing the cavity with air/water spray, and continues with
the rubber dam placement and use of cleaning agents or
antiseptics, immediately before the application of a protec-
tive material and restoration of the tooth [111]. The clean-
ing agents can be classified in demineralizing, when react
with the smear layer removing it partially or completely;
and non-demineralizing, when they act by the simple wash-
ing action, removing the loose residues or promoting the
disinfection.
9.8.1  Demineralizing Cleaning Agents
9.8.1.1  Phosphoric Acid
The acid gels, mainly the phosphoric acid, promote an effec-
tive cleaning of the tooth surface [23, 62, 91, 101]. Several
acids may be used to produce the necessary microporosities
for the retention of the adhesive system on the enamel, but
the 30–50% phosphoric acid, more commonly 35–37%, is the
choice as a conditioning agent [2]. After the tooth prepara-
 306 A. C. de Mello Torres et al.
tion, washing, and drying, the phosphoric acid is applied
9 over the preparation for 15 s. Its thoroughly  washing with
water must be performed, at least, during  the same time it
was used for conditioning [111].
After the washing, the tubules will be opened and the
dentin collagen fibers network exposed. When the surface is
dried with a stream of air the water inside the interfibrillar
spaces, which maintains the collagen web expanded, is evap-
orated, producing its collapse and  closing the nanometric
interfibrillar spaces essential for adhesive monomer penetra-
tion. Therefore, the dentin overdrying must be avoided. The
fourth- and fifth-generation adhesive systems produce better
results when applied over a wet dentin, that is, when just the
excess of water is to be removed with the blot drying tech-
nique, using small cotton pellets, leaving the surface slightly
wet [145]. This procedure prevents the collapse of the colla-
gen fibers, allowing a deeper penetration of the adhesive sys-
tem and consequentially higher bond strength. In addition,
the blot drying also avoid the aspiration of the odontoblasts
cells into the dentinal tubules, generally observed when the
dentin is overdried with air stream.
9.8.1.2  Polyacrylic Acid
When the indicated protective agent is the glass ionomer
cement (GIC), the preparation cleaning can be performed
with 10–25% polyacrylic acid gel. It can be applied over the
preparation walls with disposable applicators during 10–30s,
followed by washing and drying with gently air stream. This
procedure increases the bond strength of the GIC to the
tooth structure, without the cause damage to the pulp on
shallow, medium, and deep cavities [39, 133]. As it is less
aggressive, it just removes the smear layer but does not
expose the dentin collagen or opening of the tubules.
Therefore, the cavity can be dried with soft air stream without
the risk of collagen collapse. However, some studies disagree
about the effectiveness of the previous application of the
polyacrylic acid on the tooth surface, even though other
studies stated that it really works [117].
9.8.2  Non-demineralizing Cleaning Agents
9.8.2.1  Detergent
The anionic detergents are cleaning agents that act reducing
the surface tension of the liquids. They do not have a bacteri-
cide action, but they interact with the residues of the tooth
preparation, keeping them suspended in the solution and
allowing its removal [111]. The detergent molecules have an
alkyl tail and a head formed by oxygen, sodium, and potas-
sium atoms. The tail is hydrophobic and lipophilic, and the
head is hydrophilic, characterizing an amphoteric substance.
When the tail acts as an anion, the solution is called anionic.
When the tail is a cation, the detergent is cationic [114]. The
anionic detergents are biocompatible, the opposite of the cat-
ionic ones, which have an antimicrobial activity, but harm
live tissues.
The most used detergent is the sodium lauryl sulfate
(SLS) solution on pH 6.4. It is efficient in the removal of
blood and oil from the preparation, and it has a moistener
and emulsifier action but does not remove the smear layer
[62]. It must be applied on the preparation using disposable
applicators, followed by washing and drying with soft air
stream. It may be used to clean the preparation walls before
the amalgam restoration procedure.
9.8.2.2  Aqueous Solution of Calcium
Hydroxide
The aqueous solution of calcium hydroxide may be used in
preparation of any depth, and is the most indicated to clean
deep and very deep cavities, during the stepwise excavation
and during the operative procedures for the direct protection
of the dentin-pulp complex. The aqueous solution of calcium
hydroxide, with pH 12, inhibits the enzymatic activity of the
microorganism, acting as a bacteriostatic and hemostatic
agent, besides stimulating the formation of sclerotic and
reparative dentin [111].
The solution can be prepared by the dentist, by adding 10
g of pure calcium hydroxide of pro-analysis (p.a.) quality
into 100 ml of distilled water. After the mixture, a suspen-
sion is produced that may be immediately used. After some
time, the calcium hydroxide that did not dissolve will deposit
at the bottom of the bottle. There is no need to shake the
bottle before use, because the alkaline solution created is
already saturated. The solution can be stored for up to 3
months [115].
After the end of the tooth preparation and isolation of the
operating field, the preparation can be washed with a calcium
hydroxide solution, using small hydrophilic cotton pellets or
disposable applicators soaked with the solutions, brushing it
for 15 s (active application) or using a Luer syringe with a
needle (passive application). Then, the cavity can be dried
with small hydrophilic cotton pellet or with soft air stream
[111]. In case of pulpal exposure, the solution is applied on
the cavity with the small sterile cotton pellet until the hemo-
stasis is obtained.
9.8.2.3  Chlorhexidine Gluconate
The chlorhexidine gluconate is an antimicrobial substance
commonly used as a mouthwash for the reduction of bacte-
rial biofilm formation in the oral environments. Due to its
positive charge is adsorbed during the topic application on
the tooth surface, biofilm, and oral mucosa, which present a
negative charge. Its releasing is gradual, allowing a continu-
ous antimicrobial effect (substantivity). It is also adsorbed by
the cellular walls  of the bacterias causing the lysis of the
microorganisms [178]. When used in low concentrations, its
action may be bacteriostatic by the inhibition of the ATP
synthesis by the bacteria. In high concentration, it presents
the bactericidal effect by the rupture of the cytoplasmic
membrane.
As cleaning agents of the tooth preparations, the 2%
chlorhexidine can be used for disinfection of the walls before
Protection of the Dentin-Pulp Complex
or after the acid etching, and it does not interfere in the adhe-
sion process [60, 103, 126]. The chlorhexidine has been used
to inhibit the action of the protease enzymes improving the
durability of the hybrid layer [24, 125]. The dentin matrix
metalloproteinases (MMPs) are a class of calcium- and
­zinc-­dependent endopeptidases, incorporated into the min-
eralized dentin matrix during odontogenesis. Those may be
released after acid etching, producing the degradation of the
unprotected collagen fibers inside the hybrid layer [58]. The
application of chlorhexidine on the collagen network exposed
by the acid etching, before the application of the adhesive,
reduces the degradation of the hybrid layer, increasing the
durability of the adhesion.
9.8.2.4  Fluoride Solution
The use of fluoride solutions has the aim to reduce the forma-
tion of secondary caries under amalgam restoration [2111]. A
2% sodium fluoride aqueous solution on a neutral pH can be
applied for 2–4 min [8]. The high concentrations of fluoride in
contact with preparation walls have a bactericidal or bacterio-
static effect, due to the capacity of the fluoride ion to penetrate
through the plasma membrane and destroy the bacteria [174].
Additionally, it promotes the deposition of calcium fluoride
over the preparation walls, acting as a fluoride reservoir that
will be released if there is a reduction of the pH. Its application
is indicated only before amalgam restorations because it can
impair the acid etching for adhesive procedures.
9.9 Protective Materials
The materials available to protect the dentin-pulp complex
have a large range of composition, depending on its physical,
chemical, mechanical, and biological behavior. In order for a
protective material to be considered ideal, it must be capable
to [111]:
55 Protect the dentin-pulp complex from thermal and
electrogalvanic shocks
55 Be bactericidal or inhibit the bacterial activity
55 Bond to the tooth structure and release fluoride
55 Remineralize the demineralized dentin remaining after
tooth preparation of teeth with carious lesions of fast
progression
55 Hypermineralize the underlying dentin
55 Stimulate the formation of tertiary reactional or repara-
tive dentin on the deep lesions or pulpal exposures
55 Be biocompatible maintaining the pulp vitality
55 Prevent the discoloration of the tooth, inhibiting the
penetration of metallic ions from the amalgam restora-
tions into the surrounding dentin
55 Avoid the penetration of toxic or irritating substances
from the restorative materials into the dentin tubules
and pulp
55 Improve the marginal sealing of the restorations,
avoiding the microleakage of the saliva and microorgan-
isms into the tooth/restoration interface
307 9
A protective material should also present a modulus of
elasticity similar to the dentin, adequate mechanical strength,
low solubility and copolymerize with the resinous restorative
material [40]. Unfortunately, no protective material presents
all those characteristics. The materials to protect the dentin-­
pulp complex are indicated for the application over the
remaining dentin tissue or directly over the exposed pulp tis-
sue. The dentist must evaluate the characteristics and the
properties of each material as well as carefully evaluate the
clinical case to be treated.
The materials to protect the dentin-pulp complex may be
classified in the following categories:
1. Sealers: They are materials that produce a thin protective
pellicle that covers the tooth structure recently cut
during the tooth preparation. They are applied over all
walls with the aim to seal the dentin tubules. Examples
are the varnishes, dentin desensitizer, and adhesive
systems.
2. Liner: They are materials applied in layers with a thick-
ness between 0.2 and 1 mm, over the pulpal or axial
walls. They are used to act as a physical barrier to the
microorganisms and its by-products, to seal the dentin
tubules bonding to the tooth structure, besides acting as
a thermal and electrical isolator. They may also present a
therapeutic action through the antibacterial effect,
fluoride release, pain relief, recovery of the pulpal tissue
health, or stimulation the of the calcified tissue forma-
tion. Some examples are the calcium hydroxide and glass
ionomer cements. They are generally applied only on the
deeper areas of the preparations.
3. Bases: They are materials used to protect and/or replace
the dentin, allowing that a smaller volume of the restor-
ative material is applied. It can also be used to fill reten-
tive areas in preparations for the indirect restorations or
to give an adequate geometry for amalgam preparations.
They are used in a thickness larger than 1 mm, according
to the need to reconstruct undermined walls. Some
examples are the zinc phosphate, zinc oxide-eugenol, zinc
polycarboxylate, and glass ionomer cements, besides the
flowable composites. The use of bases must be performed
with a caution for amalgam restorations, since the larger
the base thickness, the smaller the fracture resistance of
the amalgam restoration will be [55, 80].
There are several materials available to protect the dentin-­
pulp complex, which the most used ones will be described
next. The adequate choice of the protective material must be
based on the evaluation of the pulpal tissue condition and on
the factors that lead the indication of the protective materials,
as it has already been described.
>> The materials to protect the dentin-pulp complex are
applied over the remaining dentin tissue or directly
over the exposed pulp tissue. They are classified as
sealers (thin pellicle), liners (0.2 and 1 mm), or bases
(more than 1 mm).
 308 A. C. de Mello Torres et al.
9.9.1  Cavity Varnish
9 young patients, as well as on very deep tooth preparations,
It is composed of a natural (copal or colophony) or synthetic
(nitrocellulose) resin dissolved on an organic solvent, which
can be the acetone, chloroform, ether, etc. [111, 128]. It pres-
ents a moderate thermal and electrical isolating property.
The cavity varnish can be considered a sealer and used to
protect the dentin-pulp complex under the amalgam restora-
tions. The use of cavity varnish reduces the passage of the
electrical current and minimizes the diffusion of metallic
ions from the amalgam restorations into the tooth structure,
avoiding the darkening of the tooth when low-copper amal-
gam alloys are used. They allow an initial reduction of the
microleakage in association with amalgam restorations, and
would be indicated as a protective agent in shallow cavities or
in association with other protector materials in deeper cavi-
ties [26]. Due to the fact that the film thickness is very thin, it
does not act as a thermal isolator [75].
The use of the cavity varnish has been drastically reduced,
since the high-copper amalgam alloys used today do not
present a significant γ2 phase (Sn7-8Hg) and, consequentially,
suffer less corrosion (deposition of metallic ions of tin oxide
and/or tin oxychloride) on the tooth-restoration interface
[2]. Although they were largely used in the past, several
studies showed that the varnish is not capable to promote a
good sealing of dentin, even if applied on several layers. In
addition, it suffers dissolution with the time, leaving an
empty space on the interface that must be occupied by the
corrosion products of the amalgam. It is also less effective
than the use of the dental adhesives to reduce the marginal
microleakage [1]. For those reasons, they are almost not
used anymore.
9.9.2  Desensitizing Agents
Some studies indicate the use of a desensitizing agent after
the application of a liner or base, before amalgam restora-
tions, despite the preparation depth, replacing the cavity var-
nish [14, 139]. The goal of the desensitizer is to reduce the
dentin permeability and consequently the movement of flu-
ids through the dentin tubules. Among the available materi-
als, there are the aqueous solutions of 35% hydroxyethyl
methacrylate (HEMA) associated or not with 5% glutaralde-
hyde [138]. The glutaraldehyde-based solutions promote the
precipitation of the dentinal fluid proteins, through its dena-
turation, forming plugs inside the tubules [143]. Some stud-
ies analyzed the use of GLUMA Desensitizer (Heraeus
Kulzer) after the full crown preparation [57]. They concluded
that tooth sensitivity was significantly reduced in compari-
son to preparation where the desensitizer was not applied.
In relation to the biocompatibility of desensitizer agent
components, some studies observed that glutaraldehyde and
the HEMA present cytotoxic, mutagenic, and cytopathic
effects [41, 70]. Another study suggested that the use of
desensitizer containing glutaraldehyde and/or HEMA must
be performed with care, because they present a high diffu-
sion capability through the dentin, mainly on the cases of
where the dentin is very permeable [40].
9.9.3  Adhesive Systems
The mechanism of action of an adhesive system, as a protec-
tive agent to the dentin-pulp complex, is based on obtaining
a sealing zone on the tooth surface, by deposition of a
homogeneous layer of resinous material which occludes the
dentin tubules [40]. When applied on shallow and medium
depth cavities, they are biocompatibility and favorable for
the maintenance of the pulp vitality. However, on deep and
very deep preparations, its components can diffuse through
the dentin tubules and reach the pulpal tissue. Non-
polymerized residual monomers and resin globules that are
present inside the tubules may reach the pulpal chamber by
the dentin fluid. Some studies showed that the direct contact
of the resinous components with cell or pulpal tissue present
toxicity [41, 70, 81, 151, 161]. Therefore, the adhesive sys-
tems must be used with care. For the indirect protection, on
the cases of deep or very deep preparation, more biocom-
patible liners or bases must be applied before the adhesive
system application.
The use of the adhesive systems as materials for direct
protection of the dentin-pulp complex was described some
years ago [84]. Even though some studies have showed prom-
ising results on animals, the persistent inflammatory response
of the pulpal tissue was verified on the cases of direct pulp
capping of human teeth, resulting in the phenomenon of
anachoresis, where the microorganisms invade the inflamed
pulpal tissue with low defense capability. Therefore, the cyto-
toxic and immunosuppressive effects of the adhesive system
components and the possibility of increasing of adhesive fail-
ures, in case of pulpal tissue exposure, contraindicate the use
of those materials for the direct protection of the dentin-pulp
complex [173].
9.9.4  Zinc Oxide-Eugenol Cement
The zinc oxide-eugenol cements (ZOE) are generally available
as a zinc oxide powder and a eugenol-containing liquid. The
setting is based on an acid-base reaction that consists in the
hydrolysis of the zinc oxide and a later reaction between the
zinc hydroxide and eugenol to form a chelate. There are four
different types of ZOE cements: Type I, used for temporary
cementation; Type II, indicated for long-lasting cementation
of fixed prosthesis; Type III, indicated as a temporary restor-
ative material or base for the thermal isolation; and Type IV,
for long-lasting temporary restorations up to a year [2].
They were largely used in the past and, still today, are very
useful on dental procedures on the public health system as
temporary restoration. Although they present a deficient
marginal sealing, they are effective on the sealing against the
biological leakage due to its antibacterial properties [74, 119].
Protection of the Dentin-Pulp Complex
They must not be used in direct contact with the pulpal tis-
sue, because of its irritating and cytotoxic effect [44].
The liner and bases prepared with this material allow a
good thermal isolation [131]. However, they have
­non-­satisfactory mechanical properties and can increase the
microleakage under amalgam restorations [55, 99]. In addi-
tion, the presence of the free residual eugenol on the cement
can interfere in the adequate polymerization of composites,
and they should never be associated [2, 31, 179]. Based on the
fact that materials with better properties are available, such as
the GICs, the ZOE cements must be used only as a temporary
filling material or for temporary cementation [111].
9.9.5  Glass Ionomer Cement
The glass ionomer cement is composed of a powder and a
liquid that when mixed together start a setting reaction to
form a solid material [117]. On the conventional GIC, the
setting reaction is of the acid-base type, where the polyacrylic
acid attacks the surface of the glass particles (fluoride-­
containing calcium aluminosilicate), and the calcium, alumi-
num, sodium, and fluoride ions are released into the aqueous
mean. The polyacrylic acid chains cross-links with the cal-
cium ions, forming a solid mass (calcium cross-links). In the
next phase, the calcium is replaced by the aluminum ions in
24 h. The sodium and fluoride ions do not participate on the
cross-links of the cement, but they combine to be released as
sodium fluoride. The cross-linked phase becomes hydrated
throughout time, with the same water used for the mixture,
adding strength to the cement (maturation process). The por-
tion of the glass particles that did not react is covered by a
silica gel (silica gel sheath), formed by the leaching of cations
from the outer portion of the particles. This process may last
for up to 7 days [2117]. Right after the mixture of the mate-
rial, the pH is acid, but it tends to neutralize in 24 h [34].
On the resin modified glass ionomer cement (RMGIC),
additionally to the acid-base reaction, a mechanism of chem-
ical and/or light-activated polymerization was incorporated
to the material, so that some of the disadvantages of chemical
curing materials were minimized [2, 117, 160]. Therefore,
hydrophilic monomers and the methacrylate modified poly-
acrylic acid are used and allow fast curing of the material
when light-activated. On some systems, during the monomer
polymerization process, a chemical reaction also occurs, pro-
moted by an activator/initiator system, that has an advantage
to assure the complete curing of a resinous component even
in the absence of light.
The GICs present several positive properties for a protec-
tive material, such as the chemical bonding to the tooth
structure, fluoride release, and the antimicrobial effect [111,
116, 117]. The conventional GIC presents coefficient of linear
thermal expansion similar to the tooth structure, while on
the RMGIC, this coefficient varies according to the percent-
age of the resinous component incorporated to the material
[116]. In relation to the cytotoxicity, the conventional one has
been proven to be less toxic than the one modified by resin
309 9
[3, 153]. The incorporation of HEMA on the composition
increases the cytotoxicity of the material, probably due to the
residual uncured diffuses through the dentin tubules, which
is related its low molecular weight [3]. Some studies verified
that the RMGIC is toxic to the culture of human pulp cells,
and it is not recommended on the cases of direct pulp protec-
tion [90]. However, other  studies verified that the RMGIC
did not cause an inflammatory reaction on the pulpal tissue
when applied as a liner on deep Class V preparation, and
they can be used as a material for the indirect protection of
the dentin-pulp complex [74, 152, 154]. Although less toxic,
the conventional GIC should not be used as a material for
direct protection as well, because it presents certain toxicity
when in direct contact with the pulpal tissue, even though it
is very biocompatible when used for indirect protection,
even in deep preparations.
>> The GICs present several positive properties for a
protective material, such as the chemical bonding to
the tooth structure, fluoride release, and the
antimicrobial effect.
Before using the conventional GIC, a 10–25% polyacrylic
acid conditioner should be applied on the tooth surface, for
15–30 s, followed by washing for 20–30 s and drying with a
gentle air stream. When the conventional cement is applied
as a liner or base, the restorative material is applied over, pro-
tecting it from the syneresis and water absorption phenome-
non. However, when the conventional  GIC is applied
completely filling the preparation, getting contact with the
saliva, there is a need for surface protection of the material
with a layer of some impermeable substance, such as the cav-
ity varnish, clear nail varnish, or dental adhesives. When the
RMGIC is used, there is no need for a surface protection,
because the resinous matrix reduces drastically the syneresis
and water absorption by the material, resulting in the so-­
called umbrella effect.
When the conventional GIC is used as a line or base
before the adhesive restorative procedures, the acid etch-
ing of the cement must not exceed 20 s, in order to prevent
damages to the material. The acid etching of the GIC surface
increases its bonding to the composite applied later on, by the
increase of the superficial roughness of the cement layer [76].
Tip
55 For improving the bonding of GIC to the tooth
structure, a previous polyacrylic acid etching can be
performed.
55 When a preparation is completely filled with a con-
ventional GIC, the surface must be protected with a
thin varnish or adhesive layer until the ending of the
setting reaction. This procedure is not necessary for
RMGIC.
55 The GICs should not be directly applied over the
exposed pulp tissue.
 310 A. C. de Mello Torres et al.

9.9.6  Calcium Hydroxide 55 Cauterization of the pulpal tissue due to the alkaline
9 properties of the calcium hydroxide (pH >12). Some
The use of calcium hydroxide was introduced in Dentistry, in studies demonstrate that the calcium hydroxide is
1920, by Hermann [95]. Until today, the calcium hydroxide-­ capable to solubilize and release bioactive dentin
containing products are still used for protection of the molecules that stimulate the formation of the calcified
dentin-­pulp complex due to its capability to stimulate the tissue, such as the bone morphogenetic proteins and the
formation of tertiary dentin, protect the pulp against ther- transforming growth factor, which are important
moelectrical stimuli, antibacterial and acid neutralizer mediators of pulp repair [74].
action, antiexudative effect, besides promoting formation 5 5 On the first few days, it was histologically verified the
mineralized tissue. The calcium hydroxide-containing prod- formation of a superficial layer of necrotic tissue,
ucts are available, according to the clinical application, as a infiltrated of inflammatory cells and bleeding. The
powder, paste, suspensions, solutions or cement. alkaline pH neutralizes the lactic acid secreted by the
The application of the calcium hydroxide powder over the osteoclasts and may help to prevent the destruction of
pulpal exposure must be limited to the exposed pulpal tissue the mineral tissue, acting as a buffer against the effects of
area only, and never extends up to the dentin walls and mar- the inflammatory process [110]. In addition, the calcium
gins of the tooth preparation. The calcium hydroxide paste ions may reduce the capillary permeability, allowing a
may be prepared by the dentist with distilled water and cal- greater availability of the calcium ions on the mineraliza-
cium hydroxide powder or obtained readymade by a manu- tion regions [73].
facturer (Calcicur—Voco, UltraCal—Ultradent). As all 5 5 Throughout the days, the inflammatory response is
calcium hydroxide powder or paste does not set, it is neces- gradually reduced, and a matrix rich in collagen is
sary to cover it with a layer of calcium hydroxide cement and, formed in contact with the necrotic zone or directly
over it, a layer of GIC [111]. adjacent to the liner material, by the differentiation of
The calcium hydroxide is also available as chemically stem cells in odontoblast-like cells and production of
activated or light-cured cement and indicated as a cavity amorphous and non-tubular dentin matrix.
liner. The calcium hydroxide cement promotes protection 5 5 The mineralization occurs after the secretion of the
against the thermoelectrical stimuli. The chemically acti- amorphous tissue that is irregular and contains numer-
vated cement is presented in two pastes that must be mixed ous cellular inclusions. After that, a dentin-like tissue
before the use. Its mechanical properties, especially com- with tubules is formed, covered by odontoblast cells,
pressive strength 7 min after the mixture and shear strength called “dentin bridge.” It can be observed about 30–45
after 10 min, allow it to be indicated as a liner in cases of days after the direct capping.
indirect protection on very deep cavities, under the amal-
gam restorations, because it would resist to the condensation The calcium hydroxide also presents the antimicrobial effect,
stress [35, 100]. because few oral microorganisms survive on an alkaline
The solubility of the calcium hydroxide cements in acidic environment produced by this material, hindering the resid-
conditions, under restorations with the deficient marginal ual microorganisms that remain contaminating the site of
sealing, produces its softening and complete dissolution, exposure to interfere on the repair [13]. The low cost and the
resulting in empty spaces in the tooth-restoration interface, predictable repair of the pulpal exposure, when the treatment
that may increase microleakage and reduce the fracture is performed based on the correct diagnosis and technique,
resistance of the large restoration [22, 88, 129, 175]. To over- make the calcium hydroxide the best material for direct pulp
come this problem, light-activated materials were devel- protection procedures [74].
oped, being more acid resistant and having a higher >> The calcium hydroxide is considered the best material
compressive strength. These materials do not need to be for direct application over the exposed pulp, with a
mixed prior to use. The resinous monomers present on its large clinical and scientific evidence of its efficacy.
composition allow some bonding to the resinous restorative
materials.
According to several studies, the calcium hydroxide is
considered the most indicated material for direct application 9.9.7  Mineral Trioxide Aggregate (MTA)
over the exposed pulp, due to the consistent clinical and sci-
entific evidence [13, 74, 110]. In a revision of 14 clinical stud- The MTA was described initially by Lee et al., in 1993 [92].
ies, including more than 2300 cases of direct pulp capping Since then, it has been researched and indicated in several
with calcium hydroxide, a success rate above 90% was clinical situations, such as the direct pulp capping, pulpot-
observed [12]. The exact mechanism explaining how the cal- omy, retrograde obturation, sealing of root perforations, api-
cium hydroxide promotes the deposition of hard tissue over cal barriers for apexification or apexogenesis, and most
the pulp exposure is not completely understood; however, recently a sealer for root canal obturation [18, 74, 110, 120,
the sequence of repair after the treatment of a healthy exposed 140, 164].
pulp with the calcium hydroxide may be summarized as fol- The MTA is a mixture of the refined Portland cement,
lows [13]: bismuth oxide (that gives radiopacity), SiO2, CaO, MgO,
Protection of the Dentin-Pulp Complex
K2SO4, and Na2SO4. It must be mixed with sterile water, on
the ratio of 3:1 (three parts of powder to one of water) [120].
The Portland cement is a mixture of a dicalcium silicate, tri-
calcium aluminate, gypsum or calcium sulfate (added to con-
trol the setting time of the cement), and the tetracalcium
aluminoferrite [28, 142]. Portland cement is the worldwide
name for the material commonly known as a cement, used in
civil construction. It is defined as hydraulic binder, that is, a
product that hardens only through the reaction with water
but also forms a waterproof product.
However, the MTA and the Portland cement used on the
construction work are not identical materials, because the
first one has smaller and standardized particles and few toxic
heavy metals (such as copper, manganese, strontium, and
arsenic), following a strict manufacturing process for pro-
duction of medical materials, which allows the standardiza-
tion and purity of the composition, as well as the prevention
of the contamination [82, 121, 140]. After the hydration of
the MTA, the material forms a colloidal gel that gets solid
after 2–3 h [46]. The initial pH of the cement that has just
been prepared is 10.2 rising to 12.5 3 hours after the mixture.
When the MTA powder is mixed with water, there is a
formation of calcium hydroxide, which is responsible for the
high alkalinity after the hydration, allowing the material to
be considered bioactive and present a capacity to allow an
adequate environment for the repair of the pulpal and perira-
dicular tissue. The calcium hydroxide formed releases cal-
cium ions for adhesion and cell proliferation; creates an
alkaline mean with antibacterial and antifungal properties;
modulates the production of cytokines; promotes the differ-
entiation and migration of the hard tissue-forming cells; and
forms carbonated apatite when exposed to the physiological
solutions, promoting the biological repair [20, 59, 64, 140,
165]. However, different from the powder of calcium hydrox-
ide, the MTA promotes a sealing of the tooth structure, when
used to seal the root or furcation perforations or for retro-
grade obturation. It is available in white or gray colors [74].
Due to the fact that the gray MTA may cause tooth staining
by the presence of iron and manganese ions on its composi-
tion, the white MTA was developed to be used on regions
that might have an esthetic involvement, even though some
studies also have verified discoloration of roots obturated
with white MTA [74, 120]. The lower concentration of the
iron (FeO), aluminum, and magnesium ions on the white
MTA is responsible for its color [20, 46, 59]. The particles of
the white MTA are smaller than the ones of the gray MTA,
and its setting time is faster [121].
The setting time of the MTA is of 2 h and 45 min, which
requires, after the protection of the pulp tissue, the applica-
tion of a fast setting cavity liner or base over it, such as a GIC
or a RMGIC, making possible to restore the tooth at the same
treatment session [163]. Another option is to perform the
procedure to protect the pulp on two separate clinical ses-
sions. In the first one, the direct protection with the MTA is
performed, and a small sterile cotton pellet embedded on
distilled water or physiological solution is applied over the
MTA, to allow the setting of the cement, followed by a tem-
311 9
porary restoration. On the second session, the temporary
restoration is removed, and then a final restoration is made.
One disadvantage of the MTA is that its cost is higher than
the pure calcium hydroxide. The cost to buy 1 g of white
MTA corresponds approximately to the amount of money
enough to buy 276 g of calcium hydroxide cement or 816 g of
the calcium hydroxide p.a.
Clinically, the MTA has been used in the cases of direct
pulp protection. Many studies analyzed the effect of MTA on
pulp capping on intact teeth, using various animal models
(dogs, pigs, and cats) and demonstrate the capacity of the
MTA (gray or white) to promote the biological repair of the
exposed area with the formation of a thick barrier of the min-
eralized tissue, keeping the pulpal tissue without inflamma-
tion and maintaining the vitality [5, 11, 19, 25, 71, 104, 134,
144, 169]. Clinical studies have shown that the MTA has a
similar capacity of calcium hydroxide to promote the pulp
repair in the case of exposure. Up to this moment, there were
not enough number of scientific evidences to claim that the
MTA is better than the traditional calcium hydroxide, which
effectiveness and high percentage of success are largely
reported in the literature [74]. It seems that the greater
advantage of the MTA lies on the fact that it can set and a seal
by itself the exposed area. However, due to the long setting
time, it must be kept in mind the use of a GIC over the MTA
so that the immediate restoration can be performed, as it
happens with the calcium hydroxide p.a., which limits its
advantages on the cases of pulp exposure on a cavity that will
be immediately restored [74]. On the other hand, the use of
the MTA in other circumstances, such as perforations on the
root and the retrograde obturation, turns it into a material
with incomparable value, once the chemical setting will make
it remain in a position and seal the cavity after closing and
suture the flap.
>> There is not enough of scientific evidences that MTA is
better than the traditional calcium hydroxide for direct
pulp capping.
9.9.8  Materials Containing Bioactive
Molecules
Several dental materials have been studied and developed
based on the strategy of repair and regeneration of dentin,
through the stimulation of the pulpal cells by bioactive sub-
tances that would be incorporated to the restorative materials.
The scientific knowledge in relation to the development of the
new materials has been obtained through researches on molec-
ular biology, related to the odontogenesis and tissue repair
mechanisms [40]. Several proteins are produced by the pulp
and are incorporated in the dentin matrix during the odonto-
genesis, such as the bone morphogenetic proteins (BMP) and
the transforming growth factor beta (TGF-β), known to be
capable to stimulate the hard tissue-forming cells [50, 149]. The
proteins capable to modulate the cell  functions have been
called cytokines, growth factors, or cell modulators [79].
 312 A. C. de Mello Torres et al.
In the cases of caries lesions, the bacterial acids promote
9 the demineralization of the dentin and the release of the
modulator proteins, which bind to specific membrane recep-
tors of the odontoblasts and/or their cytoplasmic process.
That can stimulate the secretion of several types of specific
dentin proteins, resulting in mineral deposition inside the
dentin tubules near the carious lesion (dentin sclerosis), as
well the deposition of the reactionary dentin in the pulpal
chamber [98, 146, 148, 172].
When the aggression is of high intensity, such as in the
cases of dentin overheat, overdrying, or application of acid
etching on very deep cavities, the death of odontoblasts
may occur with the aspiration of those cells into the dentin
tubules. This way, the undifferentiated mesenchymal cells
or pre-odontoblasts, according to the conditions and the
characteristics of the pulp before the aggression, are stimu-
lated to differentiate into odontoblast-like cells and secrete
the amorphous and non-tubular dentin matrix, character-
istic of the tertiary reparative dentin. Several molecular
and biochemical events are involved in the process of the
biological repair of the pulpal tissue. However, the cell
membrane receptors may be activated by metabolically
active proteins [38, 40, 98, 146, 148, 172]. Some studies
have shown positive results with the use of those molecules
on the direct pulp capping [67, 170]. However, difficulties
on the developing of the materials containing those bioac-
tive molecules have also been verified, especially on the
development of a scaffold to lead the molecules to the site
of pulp exposure [171]. However, they may represent the
future of the protection agents for the dentin-­pulp complex
[38, 166].
Dental materials that contain bioactive glasses have been
added to composites and RMGIC to improve its biological
effects, presenting the capability to release calcium and phos-
phate and to form the hydroxyapatite over the dentin. The
β-tricalcium phosphate, a bioceramic material that presents
the biological property to work as a scaffold for the bone
development, being progressively reabsorbed as the growth
of the mineralized tissue takes place, was used in a study as
material for direct pulp protection [144]. The authors verified
that it promoted the repair of the pulpal exposure, with the
formation of the hard tissue and the preservation of the pulp
tissue vitality.
9.10 Techniques for Protection
of the Dentin-Pulp Complex
The techniques to protect the dentin-pulp complex may be
classified in two groups. The first one includes the techniques
of indirect protection, where the protective material is
applied over the dentin, while the second one includes the
techniques of direct protection, where the protective material
is applied over the exposed pulpal tissue.
9.10.1  Indirect Pulp Protection
The indirect protection of the dentin-pulp complex consists
in the application of the protective materials over the remain-
ing dentin, when pulpal tissue exposure has not occurred. It
can be performed after finishing the preparation and imme-
diately before applying the restorative material, in deep and
very deep cavities, named just indirect pulp capping. It can
also be done after the partial removal of the carious tissue,
when it is intended to reopen the cavity later to finish the
removal of the remaining carious tissue, in case of the step-
wise excavation procedure. In this last case, it is desired that
the protective material stimulates the remineralization of the
caries-affected dentin tissue, avoiding a pulpal exposure that
could occur if a total removal of the softened dentin had been
performed immediately.
The indirect protection of the dentin-pulp complex
consists in the application of the protective materials
over the remaining dentin, when pulpal tissue exposure
has not occurred. The techniques are the indirect pulp
capping (after total infected dentin removal) and the
stepwise excavation (after partial infected dentin
removal).
9.10.1.1  Indirect Pulp Capping
The aims of the indirect pulp capping are to block the ther-
mal, electrical, and chemical stimuli that come from the res-
torations and from the oral environment, to produce a
therapeutic effect over the dentin-pulp complex, maintain
the pulp vitality, avoid or reduce the microleakage and the
bacterial growth under the restorations, and improve the
marginal sealing properties [26].
The indirect pulp capping is performed immediately
after the end of the tooth preparation, as an additional pro-
tection to the pulp in deep and very deep preparation, where
there is no sclerotic dentin. Generally, the dentists used to
recommend that all carious tissue should have been removed
before the restoration. However, exactly defining where is
the carious dentin tissue is a very hard task. Due to the
demineralization process, the dentin tissue becomes soft-
ened, and the analysis of this parameter was initially recom-
mended in order to take a decision about what should be
removed. It was recommended that the entire softened den-
tin should be removed until a hard tissue was reached, which
could be identified due to a unique sound that the hard den-
tin produces when it was touched with the exploratory
probe. This procedure inevitably results in a great number of
pulpal exposures on deep and very deep cavities, especially
on acute lesions. Later studies have shown that the lesion
presents three distinct layers. The superficial layer corre-
Protection of the Dentin-Pulp Complex
sponds to a liquefaction necrosis, highly contaminated.
Below it there is an intermediary layer of demineralized and
highly contaminated tissue, known as the infected dentin,
and then a deeper portion that is demineralized but little
infected, known as the affected dentin. It was then recom-
mended that just the necrotic and infected dentin should be
removed, keeping the affected dentin which could reminer-
alize. However, although several attempts were performed
to differentiate both layers, with the use of dyes  or other
methods, this distinction was many times very difficult, if
not impossible. On the other hand, some studies have shown
that even when infected dentin remained in the preparation
walls, the restored teeth presented a similar success rate to
the ones that had the entire softened dentin removed [61,
105, 135, 136, 162]. It was shown that the softened carious
dentin can remineralize and becomes hard again, and the
viable bacteria can be reduced or eliminated when the prep-
aration is properly restored. It was proved that the removal
of the entire carious tissue is not necessary for the success of
the restorative treatment. However, it is essential to obtain a
restoration with an adequate marginal sealing in order to
eliminate the nutrition source for the remaining bacteria
[136, 162].
>> The removal of the entire carious tissue is not
necessary for the success of the restorative treatment.
However, it is essential to obtain a restoration with an
adequate marginal sealing in order to eliminate the
nutrition source for the remaining bacteria.
Apart from the kind of treatment to be selected, with the
total or partial removal of the carious tissue, when the prepa-
ration is deep or very deep, the use of a protective material
that stimulates the remineralization and isolates the pulp
from the irritating effect of the direct restorative material,
such as the adhesive systems and composite resins, or from
the thermal stimuli on the amalgam restoration, becomes
essential.
In order to make the indirect capping, after the end of the
tooth preparation, the cleaning of the cavity can be per-
formed with a of 2% chlorhexidine solution, anionic deter-
gents, or calcium hydroxide solution, before the application
of the protective agents of the dentin-pulp complex. The
materials indicated for indirect pulp capping are selected
according to the depth of the preparation and the restorative
material to be applied.
On shallow and of medium depth preparations, due to
the amount of remaining dentin protecting the pulp tissue,
no additional protective material is necessary, regardless of
the type of the restorative material to be used. For amalgam
restorations, a solution of anionic detergent can be applied
into the cavity, followed by washing and drying. The restor-
ative material may be directly applied. Another option is to
apply, after the detergent washing and drying, a 2% sodium
fluoride solution for 2–4 min on the preparation walls, fol-
313 9
lowed only by drying with an air stream, which will result
in the deposition of calcium fluoride on the walls, aiming
to reduce the chances of a future caries lesion in the tooth-­
restoration interface. Another possibility is to wash the
cavity with an air and water spray, followed by drying it
with air stream. Then, calcium hydroxide solution or 2%
chlorhexidine solution or a glutaraldehyde-based desensi-
tizer is applied, followed by another drying with the air
stream. When the amalgam is chosen as a restorative mate-
rial, the smear layer must not be removed, remaining on
the walls to seal the tubules and reduce the dentin perme-
ability. Therefore, the demineralizing agents should never
be used.
For composite restorations on shallow and medium
depth cavities, the 35–37% phosphoric acid gel is applied if
a total-­etch adhesive system will be used. After washing the
acid, the surface must remain wet, removing only the excess
of moisture by the blot drying technique, followed by adhe-
sive system application. Another option is to gently dry the
surface with a soft air stream and then to apply a of 2%
chlorhexidine solution to hydrate it again and to impregnate
the collagen fibril network, in order to reduce the long-term
degradation of the collagen fibers by the dentin metallopro-
teinases. Then, the drying is performed through the blot
drying technique, using a small cotton pellet, followed by
the adhesive system application, drying, and light-curing. In
those cases, the adhesive layer applied will promote the seal-
ing of the dentin tubules and control of the sensitivity,
besides bonding to the composite restorative material. In
case of the self-etching adhesives, the acid primer will pro-
mote the etching of the dentin and the formation of the
hybrid layer without the need of a previous phosphoric acid
application.
When performing amalgam restorations on deep prepa-
ration, when the proximity with the pulpal tissue is greater,
but it is not possible to observe any area in the pulpal or axial
walls with a pink discoloration, a protective material must be
applied in the internal walls in order to promote thermal iso-
lation to the metallic restoration; otherwise, tooth sensitivity
will probably come up when hot or cold food contacts the
tooth. The material of choice is usually the chemical or light-­
cured GIC. The previous treatment of dentin with polyacrylic
acid for 15–30 s can be performed, followed by the washing
and drying with a gentle air stream. For composite restora-
tions, the GIC should also be used (. Fig. 9.17a–d). The pref-
erable instrument used for application is the calcium
hydroxide liner placement instrument, which has a small
sphere at the end that allows to precisely apply the material
on the internal preparation wall (. Figs. 4.46b and . 9.17c).
The calcium hydroxide cement does not need to be used on
deep cavities.
On very deep cavities, where areas of the internal walls
with pink discoloration can be observed, some clinically
undetected pulp microexposures  may exist. Therefore, it is
 314 A. C. de Mello Torres et al.
a b
9
c d
..      Fig. 9.17  Indirect pulp capping on deep preparation using glass
ionomer cement. a Large carious lesion on tooth upper premolar; b
removal of the carious tissue, showing the deep internal walls; c mixed
necessary to use a material that is capable to stimulate the
odontoblasts to form mineralized tissue to protect the pulp.
The most adequate material for this situation is the calcium
hydroxide cement, which can be dispensed over a mixing
pad, mixed with a No. 22 spatula and taken into position with
a calcium hydroxide liner placement instrument. Its applica-
tion must be performed only over areas with pink discolor-
ation, in layers of 0.5–0.7 mm, and not over other regions
[139]. Over the calcium hydroxide cement and in the rest of
the pulpal or axial wall with deep dentin, a layer of GIC
should be used [75]. After the initial setting of the cement,
the amalgam or composite restoration can be performed
(. Fig. 9.18a–g) [139].
 
>> The indirect pulp capping is performed only in deep
and very deep preparation, when there is no sclerotic
dentin.
9.10.1.2  Stepwise Excavation
The stepwise excavation is indicated in the cases of very deep
acute carious lesion, in young patients, with the absence of
spontaneous pain and with response to the tactile and ther-
mal stimuli, specially to the cold with a fast relief [77, 150]. It
is applied in a situation where the pulp is separated from the
glass ionomer cement being caught by a calcium hydroxide liner
placement instrument; d liner material applied on the pulpal and axial
walls
oral environment only by a thin layer of the carious dentin,
which if removed may cause the exposure of the pulp. It is
also recommended when there is doubt about the capacity of
the pulp to keep the vitality after a strong aggression caused
by the carious process. For that, the removal of the carious
dentin is performed in two clinical sessions, being possible to
re-evaluate the condition of the pulp and allow a remineral-
ization of the dentin tissue.
On the first clinical session, the entire carious dentin is
removed from the external walls of the preparation, and only
the demineralized dentin tissue over the pulpal and axial
walls should remain, as it is shown in . Fig.  9.19a–f. After
that, the cleaning of the preparation is performed using a cal-
cium hydroxide solution or an anionic detergent or a 2%
chlorhexidine solution, followed by drying of the walls with
soft air stream. Over the softened tissue on the internal walls,
a layer of calcium hydroxide cement liner is applied. The
whole preparation is then filled with a temporary restoration
made of GIC or RMGIC. The surface of the material must be
protected with a varnish, if a chemical curing GIC is used,
avoiding the syneresis or water absorption. In cases of large
preparations, the use of a syringe is recommended for eas-
ier  material applications. Its technique of use is shown in
. Fig. 14.43a–f.
Protection of the Dentin-Pulp Complex
After finishing the temporary restoration, the occlusal
contacts must be adjusted and periapical radiography
obtained to use as control. This restoration can remain in
place for a period of 30–45 days up to 1 year, so that the cari-
ous lesion activity is reduced and allows that dentin-pulp
complex to remineralize the demineralized dentin and forms
sclerotic and/or tertiary, significantly reducing the number of
315 9
microorganisms and the risk of pulpal exposure during the
removal of the remaining carious tissue, on the next opening
of the cavity [17, 74, 93, 118].
On the second session, after the waiting period, the anam-
nesis, sensitivity, and pulp vitality tests must be repeated. The
radiographic exam may show the formation of sclerosis or
tertiary dentin below the remaining dentin. With a positive

a b

c d

e f

..      Fig. 9.18  Indirect capping in very deep preparation. a Initial
aspect; b opening the cavity to obtain full access to the lesion; c
removal of the carious tissue; d very deep region over the mesio-­
lingual pulp horn with pink discoloration; e equal portions of the base
and catalyst pastes of calcium hydroxide cement being placed over the
paper mixing pad; f material being mixed with a No. 22 cement
spatula; g mixed material being caught with the end of a calcium
hydroxide liner placement instrument; h application of the calcium
hydroxide cement over deepest area with pink discoloration; i
application of a layer of GIC over the entire pulpal wall; j application of
the primer; k application of the adhesive; l application of composite
increments in the undermined enamel areas; m placement of oblique
increments; n finished restoration
 316 A. C. de Mello Torres et al.

9 g h

i j

k l

m n

..      Fig. 9.18 (continued)
Protection of the Dentin-Pulp Complex
determination of the pulp vitality and absence of any symp-
toms, the treatment can be continued, removing the remain-
ing carious dentin. For that, the anesthesia and the isolation
of the operating field are performed. The cavity is open, and
the remaining carious dentin can be removed using large
diameter round bur (No. 4, 6, or 8) in low-speed handpiece.
Extreme care must be taken at this moment to avoid pulpal
317 9
exposure. Then, the preparation cleaning is performed using
calcium hydroxide solution, anionic detergent, or 2%
chlorhexidine solution. Considering that the stepwise excava-
tion is performed on very deep cavities, the protective mate-
rial indicated is the calcium hydroxide cement, applied only
on areas next to the pulp with pink color, if they exist. If there
were no areas with pink discoloration, just a layer of GIC is

a b

c d

e f

..      Fig. 9.19  Stepwise excavation. a Deep carious lesion in which the
entire removal of the carious tissue could result in pulp exposure; b, c
total removal of the carious tissue from the surrounding walls, without
touching the pulpal wall; d necessary materials (1, calcium hydroxide
cement; 2, glass ionomer cement powder and liquid; 3, protective
varnish); e application of a calcium hydroxide cement layer over the
demineralized dentin; f temporary restoration with glass ionomer
cement; g after the waiting period, removal of the temporary restora-
tion and remaining carious tissue is performed avoiding to expose the
pulp; h lining with glass ionomer cement; i application of the universal
matrix and wooden wedge; j after the application of the adhesive
system, the restoration of the proximal contact was done; k restoration
of the dentin with opaque composite; l finished restoration after the
application of the enamel shade composite (Grandio SO—Voco)
 318 A. C. de Mello Torres et al.

9 g h

i j

k l

..      Fig. 9.19 (continued)

applied, and the final restoration is performed. After that, the
occlusal contact adjustment is required (. Fig. 9.19g, h).
 
The aim of the stepwise excavation is to block the aggres-
sions that reach the pulp from the carious lesions through
dentin tubules, hindering the metabolic circuit that occurs
due to the oral fluids and the bacteria of the carious tissue,
inactivate the bacteria by bacteriostatic or bactericide effects
of the calcium hydroxide, remineralize the remaining demin-
eralized dentin, hypermineralize the underlying health den-
tin, and stimulate the formation of reactional dentin. Those
effects allow the complete removal of the remaining carious
tissue on the second clinical session, without the exposure of
the pulpal tissue [111]. Several studies have shown that when
the cavity is opened again, the color of the lesion changes
from light brown to dark brown, the consistency changes
from wet and soft to dry and hard, and the number of viable
Streptococcus mutans and Lactobacillus are significantly
reduced or even completely disappear. The radiographic
image may show no change or even decrease of the radiolu-
cent area, the dentin sclerosis, or the formation of ter-
tiary dentin [74].
Clinical studies reported high success rate with the step-
wise excavation and showed that, in 83% of the treated teeth,
the pulp presented normal clinical response to the vitality
Protection of the Dentin-Pulp Complex
tests [127]. They observed that the immediate success (60–
90 days after the treatment) depends on the initial clinical
condition of the pulp, and the long-term success is directly
related to the quality of the final restoration. They also veri-
fied that the age of the patient did not influence the success
rate. In addition, just the partial removal of the carious tissue
reduces the risk of pulpal exposure in up to 98%, when com-
pared to the removal of the entire carious tissue on deep
preparation [74]. In order to perform the treatment, the pulp
vitality must be confirmed with pulp sensitivity testing, and
the reversibility of the inflammatory response must be eval-
uated. The report of spontaneous pain that is not relieved
with the use of analgesics turns the prognosis of the treat-
ment somewhat doubtful. Radiographically, the tooth must
not present periapical alterations and internal or external
resorption.
The use of the calcium hydroxide on the stepwise excava-
tion has its effectiveness proved by several authors, promot-
ing the remineralization of the demineralized dentin and the
reduction of the inflammatory response of the pulp, due to its
bactericidal and bacteriostatic properties [51, 54, 155].
However, the type of the material used is less important for
the success of the treatment than to obtain a restoration with
an adequate marginal sealing, during the waiting period
between the first and second clinical sessions [56, 74, 127].
9.10.2  Direct Pulp Protection
The direct protection of the dentin-pulp complex consists of
the placement of a protective material directly over the
exposed pulp, to maintain its vitality and promote the pulp
healing and the formation of a mineralized barrier over it.
The technique for direct protection of the dentin-pulp com-
plex may be divided in three types: direct pulp capping, pulp
curettage, and pulpotomy.
The direct protection of the dentin-pulp complex
consists of the placement of a protective material
directly over the exposed pulp, to maintain its vitality
and promote the pulp healing and the formation of a
mineralized barrier over it. The techniques are direct
pulp capping, pulp curettage (superficial pulp removal),
and pulpotomy (pulpal chamber pulp removal).
9.10.2.1  Direct Pulp Capping
The direct pulp capping is indicated in the cases of mechani-
cal or accidental exposure, when the pulp is vital and sound,
or with a reversible inflammation [26]. This situation gener-
ally occurs during the tooth preparation, where the acciden-
tal exposure of the pulp may happen, and in the cases of
dental traumas. The most important factors directly related
to the success of the direct pulp capping are the correct diag-
nosis of the pulpal condition, the absence of bacterial
319 9
c­ ontamination, the use of adequate protective materials, and
the effective sealing of the cavity with a proper restoration
[74]. Some studies showed that it is more probable that the
treatment of the exposed pulp is successful, when the expo-
sure has happened due to mechanical reasons than when it
happens due to caries [74]. The penetration of the caries
lesion toward the pulp will result in the bacterial invasion
and the pulp inflammation. This causes the pulp to be less
capable to respond and to heal itself, compared to what is
seen when there is a mechanical exposure and the inflamma-
tion is not present [74].
>> The key factors for the success of the direct pulp
capping are the correct diagnosis of the pulpal
condition, the absence of bacterial contamination, the
use of adequate protective materials, and the effective
sealing of the cavity with a proper restoration.
The presence of bacteria on the pulp exposure areas must be
avoided, once several studies have shown the adverse effects
of the bacterial contamination [22, 42, 43]. Therefore, the
direct pulp capping is more indicated when the exposure is
recent, and any contamination is not associated with a real
pulp infection. In addition, the rubber dam isolation and the
operating field disinfection are important to reduce the con-
tamination possibility. In the cases of pulp contamination
due to trauma, it is important to evaluate the patient’s clinical
history, the time that pulp is exposed to the oral environ-
ment, the extension of the tooth fracture, the quality of the
tooth remaining, and the viability of the restorative treat-
ment. The most favorable responses are obtained when the
treatment of the pulpal tissue occurs up to 24 h after the
trauma [26].
The calcium hydroxide powder or paste is still the most
used material for the direct protection of the dentin-pulp
complex [74]. However, the MTA has also been indicated
and used for this purpose. A clinical study evaluated the
direct pulp capping made with the calcium hydroxide in 249
teeth, during 16 years [45]. The authors verified that the
treatment was most favorable in patients with age under 40
years old in relation to the patients with age over 60 years old.
They also verified that the probability of loss of the pulp vital-
ity after the treatment was significantly greater in the first 5
years of treatment. In the favorable cases, the dentin bridge
closing the exposure must be formed 30–45 days after the
procedure [4].
>> The greater chances of success of direct pulp capping
are on patients under 40 years old in relation to those
with age over 60 years old. After a trauma, the most
favorable responses are obtained when the treatment
occurs within the first 24 h.
If the exposure happens during the cut of healthy dentin, on
the final phase of the tooth preparation, the protection of the
exposed area must be performed before the preparation is
concluded. If the preparation is being performed without the
rubber dam isolation and an exposure occurs, the immediate
isolation and the antisepsis of the operating field with 2%
 320 A. C. de Mello Torres et al.
chlorhexidine solution should be performed before the cap-
9 ping. However, the chlorhexidine must not be applied over
the exposed pulp. If the exposure occurs during the removal
of a deep caries lesion, and the removal of the remaining
carious tissue will result in an increase of the exposure, it
must be interrupted and the capping be made. If the remain-
ing carious tissue does not coincide with the exposure area,
the capping should be performed and the remaining carious
tissue removed, since this procedure does not lead to new
exposures. To avoid the contamination of the exposed pulp
area, the complete removal of the surrounding carious tissues
is always recommended before using cutting instruments on
the internal walls, because if an exposure occurs, the con-
tamination will be reduced.
In . Figs. 9.20a–i and . 9.21a–d, it is shown the sequence
   
for the direct pulp capping. The preparation is irrigated with
a saline solution or calcium hydroxide solution, because
they are less aggressive to the pulpal tissue [74]. Bleeding
must be controlled to allow adequate contact between the
protective material and the exposed pulpal tissue. Among
the factors that have shown a significant role in the success
of the treatment is the bleeding control. The presence of the
interposed blood clot, between the calcium hydroxide or
MTA and the pulp, may make the lesion repair reactions dif-
ficult. In addition, the bleeding that does not stop may indi-
cate a greater degree of pulp inflammation, resulting in a
reduction of the reparative capacity. The moisture and the
contamination of the dentin area adjacent to exposure, due
to the bleeding, may turn it difficult to reach an adequate
sealing of the restoration and to prevent the later marginal
microleakage [74].
>> During direct pulp capping, the bleeding must be fully
controlled to allow adequate contact between the
protective material and the exposed pulpal tissue. The
presence of the interposed blood clot between the
calcium hydroxide and the pulp will make the repair
difficult.
After the hemostasis, the cavity is dried with sterile small cot-
ton pellets or a sterile piece of absorbent paper. After that, a
solution composed by an association of antibiotics and anti-
inflammatory, sold with the name of Otosporin® (GlaxoS-
mithKline—otologic suspension—association of
hydrocortisone, polymyxin B sulfate, and neomycin sulfate)
or Maxitrol (Alcon—ophthalmic solution—association of
dexamethasone, polymyxin B sulfate, neomycin sulfate), is
applied using small pellets soaked with the medication dur-
ing 10 min, directly over the pulpal tissue (. Fig. 9.20e). A
 
new irrigation with saline or calcium hydroxide solution is
performed to remove the medication. Then, the area is dried
with a sterile cotton pellet.
Then a material to stimulate the formation of dentin
bridge is applied over the exposed area. This material can be
the MTA or calcium hydroxide p.a. (powder or paste). The
protective material must be applied over the pulpal tissue,
without compression, and only on the surface of the exposed
pulp, and the excess is removed (. Figs. 9.20g and 9.21b). In
 
order to facilitate the placement of the material in the correct
place, an intraoral carrier can be used (. Fig. 4.50b), which is
filled with the material. It presents a plunger that, when
pushed, projects the material outward the tip, allowing its
application (. Fig.  9.20f). Over this material a layer of cal-
cium hydroxide cement should be applied, covering a little
further than the exposed area, in such a way that the applied
powder is protected (. Figs. 9.20h and 9.21c). As the calcium
hydroxide cement must be protected from the acid etching,
and the rest of the cavity is deep and also needs to be pro-
tected, a layer of GIC is applied over the whole internal wall,
in case the final restoration is immediately  performed
(. Fig. 9.20i) [75]. After the GIC setting, the cavity may be
restored with amalgam or composite, and then the occlusal
contact evaluated.
Another option is to completely fill the cavity with GIC,
to certify that there are no symptoms of pain on the days fol-
lowing the procedure (. Fig. 9.21d). It is necessary to wait a
period of 45–60 days for the postoperative control. After this
time the pulp sensitivity testing to cold is performed, and
also a new radiographic exam is done, in order to evaluate
the periapical area looking for signals of pulpal necrosis. The
tooth must remain without symptoms [63]. In the case of
pulp vitality, absence of symptoms and periapical lesions, the
removal of the superficial portion of the GIC can be done,
and the final restoration is performed.
9.10.2.2  Pulp Curettage
This procedure is recommended, for example, when the pulp
has been exposed due to a dental trauma and the pulp horn is
projected outward the dentin wall, or when the patient has
delayed some time to look for the dental treatment, resulting
in the contamination of the superficial pulpal tissue. It
is mostly indicated on teeth with incomplete apex formation.
The procedure consists in the superficial removal of a small
amount of the pulpal tissue, exposing the underlying tissue
without inflammation or bacteria, increasing the exposed
area available for contact with the protective material [111].
According to some authors, on the cases where the pulp is
too contaminated, this technique presents the inconvenience
of not knowing exactly if all the necrotic focus in the pulpal
tissue were removed, especially the ones that are on other
areas of the coronary pulp far from the pulp exposure site. In
this case, the pulpotomy should be the better indication [78].
Other authors claimed that the curettage must be performed
only on the cases of incomplete root formation, due to the
fact that in this case, the pulp presents a greater blood supply
[138]. In the cases where the root apex is complete, the pulp-
otomy should be performed to increase the success rates of
the procedure [9, 10, 26].
The sequence for pulp curettage is presented in
. Fig.  9.22a–l. To perform this procedure, the anamnesis,
radiographic exam, and clinical diagnosis of the pulp condi-
tion have to be performed. After that, the anesthesia, rubber
dam isolation and disinfection of the operating field with a
2% chlorhexidine solution are done. The complete removal of
any remaining carious tissue must be performed, and the
Protection of the Dentin-Pulp Complex
cavity irrigated with saline or calcium hydroxide solution.
After that, the superficial curettage of the exposed pulp is
done using a very sharp spoon excavator or a large diameter
round diamond point, on high-speed handpiece and copious
irrigation (. Fig.  9.22f) [68]. Then, an abundant irrigation
 
with saline or calcium hydroxide solution is performed, and
the walls and pulp tissue are dried with small sterile cotton
pellets until the hemostasis is reached. When the bleeding
321 9
stops, the characteristics of the remaining pulp tissue must be
evaluated, and it must have a firm consistency and bright red
color. Then, the corticosteroid/anti-inflammatory solution is
applied for 10 min, and a new irrigation with saline or a cal-
cium hydroxide solution is performed to remove the medica-
tion. The drying is performed with small sterile cotton pellet,
and the material to stimulate the formation of the mineral-
ized tissue is applied.

a b

c d

e f

..      Fig. 9.20  Direct pulp capping. a Initial aspect; b removal of the
carious tissue; c accidental exposure of the distobuccal pulp horn; d
materials necessary for the direct capping (1, Otosporin; 2, calcium
hydroxide p.a.; 3, calcium hydroxide cement); e application of the
association of corticosteroid/anti-inflammatory; f application of the
calcium hydroxide powder using an MTA carrier (Angelus); g calcium
hydroxide p.a. applied over the exposed pulp; h application of the
calcium hydroxide cement a little further than the area covered by the
powder, closing the exposure area; i protection of the pulpal wall with
glass ionomer cement; j acid etching; k application of the adhesive
system; l restoration with composite resin (Grandio SO—Voco)
 322 A. C. de Mello Torres et al.

9 g h

i j

k l

..      Fig. 9.20 (continued)

Over the exposed area, a thin layer of the calcium hydrox-
ide p.a. (powder or paste) or MTA is applied. The protector
material must be inserted with no compression over the pulp
tissue, and only over the exposed pulp surface, using an intra-
oral carrier (. Fig. 4.50b), and the excesses removed. Over
 
this material, a layer of the calcium hydroxide cement is
applied, covering the exposed area and a small region around
it. Over the calcium hydroxide cement and the rest of the
internal wall with deep dentin, a layer of GIC is placed, and
the final restoration can be immediately done. Another option
is to completely fill the preparation with GIC to follow up the
pulp tissue response after the procedure. A period of 45–60
days can be waited before the postoperative control. After this
period, the pulp sensitivity testing to cold can be performed,
as well a new radiographic examination to evince the status of
the periapical area. The tooth must have no symptoms [63]. In
the cases of pulp vitality, the absence of symptoms and peri-
apical lesion, a superficial layer of the glass ionomer can be
removed and the final restoration performed.
9.10.2.3  Pulpotomy
The pulpotomy consists of the removal of the inflamed coro-
nary pulp tissue, maintaining the integrity of the radicular
pulp. It is indicated on the tooth with incomplete root forma-
Protection of the Dentin-Pulp Complex
a b
c d
..      Fig. 9.21  Direct pulp capping associated to the temporary
restoration. a Accidental pulp exposure happened on the axial wall of
the distal box during the tooth preparation; b after controlling the
tion in which the pulp remained exposed for more than 24 h.
It is also indicated on teeth with large coronary destruction,
but just on cases where there is no necessity to place an intra-
canal post [6]. In order to perform the pulpotomy, a good
clinical and radiographic diagnosis is required. Some authors
verified that the percentage of success of the pulpotomy
(clinically and radiographically) was of 100% on young
patients and 84% on adults [63]. The pulpotomy must be
indicated only when there is no bone rarefaction on the peri-
apical region or internal resorption and there is an integrity
of lamina dura. In the clinical exam, the coronary pulp tissue
will be considered macroscopically vital when it presents
firm consistency, resistance to the  cut, followed by a  slight
bleeding with bright red color, that stops in a few minutes
after the cutting [95]. The pulpotomy may be performed on a
single session (immediate technique) or in two sessions
(delayed technique).
For the immediate technique, the anamnesis, radio-
graphic exam, and clinical diagnosis of the pulp condition
are performed. Then, the anesthesia, rubber dam isolations,
and the disinfection of the operating field with a 2% chlorhex-
idine solution must be done. The complete removal of the
carious tissue, when there is any, is performed with round
burs in a low-speed handpiece, and the opening of the pulpal
323 9
bleeding, application of the calcium hydroxide p.a. over the area of the
exposure; c application of the calcium hydroxide cement covering the
entire axial wall; d temporary restoration with glass ionomer cement
chamber is done  with diamond burs on high-speed hand-
piece. The cut of the coronary pulp tissue is performed with
sterile and sharp dentin spoon excavator or a round diamond
point on high-speed handpiece, with good refrigeration. The
use of burs on low-speed must be avoided, because dentin
shaves can be pressed over the pulpal tissue, interfering on
the reparative process [96]. The bleeding must be controlled
to allow the adequate contact between the protective material
and the exposed pulp tissue. In order to do this, the irrigation
of the cavity must be performed with saline or calcium
hydroxide solution. Then the cavity must be dried with sterile
small cotton pellets (. Fig. 9.23a–i).
The antibiotics/anti-inflammatory solution (Otosporin
or Maxitrol) is applied for 10 min over the pulp tissue with a
small cotton pellet soaked with the medication. A new irriga-
tion with saline or calcium hydroxide solution is performed
to remove the medication, and the cavity is dried with a small
sterile cotton pellet. Then, the pulp tissue must be covered by
calcium hydroxide p.a. (powder or paste) or MTA. The pro-
tective material must be inserted without any compression
over the exposed pulpal tissue, using an intraoral carrier, and
the excess be removed. Over it the calcium hydroxide cement
is applied covering the exposed area. The final restoration
may be performed on the same session, followed by the
 324 A. C. de Mello Torres et al.

occlusal contact adjustment. If the final restoration is not
9 performed in this same session, a temporary sealing of the
cavity must be done with GIC, waiting for 45–60 days for the
postoperative control. During the procedure, it is important
to analyze the details of the remaining pulpal tissue. On teeth
with several roots, there might be pulp with no conditions to
be preserved in one or more roots, and it will contraindicate
the pulpotomy. In this case, the conventional endodontic
treatment will be the first choice.
In the delayed technique, immediately after the removal
of the coronary pulp and the hemostasis, a piece of cotton
soaked on an association of corticosteroids/antibiotics is
placed over the pulp tissue for 48–72 h, which will be closed
with a temporary restoration. This procedure is performed to
reduce the inflammation caused by the cut of the pulp, reduc-
ing the increase of intrapulpal pressure, which could
adversely affect the reparative process [6]. After this period,
on the second session of treatment, the cotton pellet is

a b

c d

e f

..      Fig. 9.22  Pulp curettage. a, b Fracture of the tooth No. 21; c
surgically open area to expose the fracture limits; d fragment removed
showing the involvement of the pulp horn; e rubber dam isolation; f
curettage of the superficial contaminated pulp with a diamond point;
g application of the corticosteroid/anti-­inflammatory solution
(Otosporin, Glazo Smith Kline); h aspect of the pulp after curettage and
hemostasis; i application of the calcium hydroxide p.a.; j covering of
the region with calcium hydroxide cement; k finished restoration and
suture; l aspect after 3 weeks
Protection of the Dentin-Pulp Complex
325 9

g h

i j

k l

..      Fig. 9.22 (continued)

removed, and the root pulp is covered with an adequate pro-
tector material, according to what is described on the imme-
diate technique (. Fig. 9.24a–i).
 
After pulpotomy, the tooth must be preferably restored
at the same session. However, on the delayed pulpotomy
technique, it is necessary to use a material for temporary
restorative material. The GIC or RMGIC is the most indi-
cated one for the temporary sealing. Between the sessions of
treatment, it is very important that there is no displacement
or fracture of the temporary restoration, which would allow
the microleakage of microorganisms, leading to failure of
the procedure.
The postoperative follow-up must be performed at least
for 2 years. Once the coronary pulp is removed, the sensi-
tivity tests are not considered trustworthy for the evalua-
tion of the pulp vitality. To determine the success, it is
important to observe the absence of the signals and symp-
toms, as well the integrity of the lamina dura and the pres-
ence of a mineralized barrier or dentin bridge, although
is  not always possible seen on radiography, besides the
absence of a periapical lesion [6]. In the cases where the
teeth have incomplete apex and the pulp is already on
the initial phase of necrosis, apexification techniques must
be applied.
 326 A. C. de Mello Torres et al.

9 a b

c d

e f

..      Fig. 9.23  Pulpectomy with the immediate technique. a Fracture of
the tooth 21 resulted on a large pulp exposure on a tooth with an
incomplete apex formation; b, c surgery to expose the region and
rubber dam isolation; d curettage of the coronary pulp with the
spherical diamond point; e irrigation with saline solution to promote
the bleeding control; f coronary pulp removed; g application of the
calcium hydroxide p.a. over the pulpal tissue; h covering with the
calcium hydroxide cement; i closing of the cavity with the glass
ionomer cement
Protection of the Dentin-Pulp Complex
g h
..      Fig. 9.23 (continued)
a b
..      Fig. 9.24  Pulpectomy with the delayed technique. a–c Initial
aspect of the fractured incisor with an incomplete apex formation. The
pulp was exposed to contamination for more than a week. The
coronary pulp was removed and a medication with corticosteroid/
anti-inflammatory association applied, remaining for 48 hours; d the
coronary pulp on the second session; e application of the calcium
hydroxide p.a.; f after 90 days, testing of the presence of the dentin
327 9
c
bridge with a gutta-percha cone; g formation of the dentin bridge
clinically visible; h application of the calcium hydroxide cement over
the dentin bridge; i filling of the cavity with a glass ionomer cement.
(Images kindly supplied by Associate Prof. Carlos Henrique Ribeiro
Camargo, Professor of the Endodontics, ICT, São José dos Campos –
UNESP)
 328 A. C. de Mello Torres et al.

d e
9

f g

h i

..      Fig. 9.24 (continued)

Conclusion describing the different techniques and its indications. Due

The aim of this chapter was to teach about materials, tech-
niques, and principles currently available concerning the pro-
tection of the pulp-dentin complex. The histology and
physiology of this complex was explained, as well the origins
of pulpal alterations and the defense mechanisms. The meth-
ods to assess of pulp condition and create the diagnostic
hypothesis were also presented. The knowledge about the
cleaning and protective agents were presented, before
to the constant developments of materials and new scientific
findings, some recommendations will certainly be changed in
the next years. However, the search for the best technique
should be kept in the dentist’s mind. The particularities of
each human being must be considered by the clinicians, and
the procedures should not be always standardized but be
recommended according to the clinical conditions and par-
ticularities of each clinical case.
Protection of the Dentin-Pulp Complex
329 9
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156. Stanley HR.  Human pulp response to restorative dental proce-
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tion and prevalence of reactive and physiologic sclerotic dentin,
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158. Stanley HR, White CL, McCray L. The rate of tertiary (reparative)
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159. Taira M, Wakasa K, Yamaki M, Matsui A. Heat generated when cut-
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 335 10

Tooth Preparations
for Amalgam Restorations
Carlos Rocha Gomes Torres and Deepak Mehta

10.1 Introduction – 336

10.2 Instruments and Materials – 336

10.3 Previous Procedures – 336

10.4 Class I or Site 1 Preparations – 338

10.4.1 S imple Preparation – 338
10.4.2 Compound Preparation – 344

10.5 Class II or Site 2 Preparations – 350

10.5.1  ccess Through the Occlusal Surface – 359
A
10.5.2 Access Through the Buccal or Lingual Surfaces – 363

10.6 Class V or Site 3 on Free Smooth Surface – 365

10.6.1  utline Form – 366
O
10.6.2 Resistance Form – 368
10.6.3 Retention Form – 368
10.6.4 Convenience Form – 369
10.6.5 Removal of the Remaining Carious Tissue – 370
10.6.6 Finishing the Enamel Walls – 370
10.6.7 Cleaning of the Preparation – 370
10.6.8 Final Characteristics of the Preparation – 370

References – 370

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_10
 336 C. R. G. Torres and D. Mehta

Learning Objectives 10.2  Instruments and Materials

The learning objectives of this chapter are related to the fol-
lowing topics:
55 The instruments and materials necessary to perform a
tooth preparation for amalgam.
55 The previous procedures that must be performed before
starting.
55 The steps for Class I preparations of simple and complex
cavities.
55 The steps for Class II preparations by access through the
occlusal or free smooth surfaces.
55 The steps for Class V preparation on smooth surfaces.
55 The final characteristics of all kinds of preparation for
amalgam.
10.1  Introduction
The dental amalgam is a restorative material that has been 55 Rotary instruments for low-speed contra-angle (RA/CA)
used for a long time to restore teeth affected by the caries
disease. Although there is a huge discussion about its use
nowadays due to the presence of the mercury and the unfa-
To perform a tooth preparation for amalgam restoration in
preclinical dental training, the following materials and
instruments are necessary:
55 Personal protective equipment such as gloves, mask,
mob cap, and safety glasses.
55 Dental training model with simulations of the carious
lesions to be placed inside a dental simulator phantom.
55 Low-speed handpiece and contra-angle. Although most
dental procedures are performed in the real patient with
the high-speed handpiece, the initial training with dental
models should be performed in low speed, until the
students develop the manual skills and have complete
mastery of the technique.
55 Dental tweezer.
55 Flat first surface clinical mirror.
55 Double exploratory probe.
or for high-speed handpiece (FG) with an adaptor for
the contra-angle. It can be used the carbide or diamond
points (. Fig. 10.1). Those instruments are identified by

10 vorable esthetics, it is still largely used around the world to the shape of the head.
restore posterior teeth, especially because of its versatility, 55Round – No. 1011 diamond point or No. 2, 4, and 6
low cost, and excellent physical properties, resulting to high-­ carbide burs
quality and long-lasting restoration. As a great disadvantage, 55 Long inverted cone with flat end and round corners –
this material does not bond to the tooth structure, being nec- No. 1148 and 1150 diamond point or No. 245 carbide bur
essary that some specific characteristics are observed during 55Short inverted cone with flat and sharp edges – No.
the preparation, allowing that remaining tooth structure and 1031 diamond point or No. 33 ½ carbide bur
restoration may resist to the masticatory stress. On this chap- 55Cylinder with flat end and round corners – No.
ter, the necessary steps to make the tooth preparation for 1090A and 1092A diamond points
amalgam restoration are presented, in a way to allow the 55Conical with flat end – No. 1061 and 1063 diamond
reader to be able to perform this procedure. During the ini- point or No.169 carbide bur
tial training of the dental students, all the stages of the tooth 55 Enamel hatchet – 14/15 (10-6-14).
preparation should be performed on dental training model 55 Gingival margin trimmers – 28 (10-95-7-14) and 29
with simulations of the carious lesions. The use of dental (10-80-7-14).
models without the lesion simulation, with intact teeth, 55 Miller articulating paper forceps.
induces the student to learn stereotyped forms for the tooth 55 Thin double-sided articulating paper (<10 μm) of two
preparation, because they do not have any reference of what colors (e.g., black and red).
should be removed. On the modern perspective, only the 55 Tofflemire matrix retainer.
portion of the tooth affected by the lesion must be treated 55 Matrix band – 5 and 7 mm.
invasively, and the preparation must be smaller as possible. 55 Wooden wedges.
Therefore, for each lesion size, there will be different shapes
for the preparation, even though the general principles will The necessary instruments and materials must be placed over
always be followed. The extension for prevention must be the working area  in a logical sequence of use, as it can be
replaced by the implementation of preventive procedures, observed in . Fig. 10.2.  

such as to give instructions to the patient about the disease,

mechanical removal of biofilm, rational use of fluoride, and
when the biofilm control is hard, the use of pit and fissure 10.3  Previous Procedures
sealants. For didactic purposes, the different situations
involving the tooth preparations for amalgam will be pre- As it has already been mentioned on 7 Chap. 6, before starting
 

sented separately, according to Black’s and Mount and Hume’s the tooth preparation, some details must be evaluated to guar-
classifications. antee the success of the treatment. First of all, the conditions
Tooth Preparations for Amalgam Restorations
337 10
..      Fig. 10.1  Rotary instruments
used for the tooth preparation
for amalgam restorations

A
11

48

50

90

92

31

61

63
5
10

24

11

11

10

10

10

10

10

6
..      Fig. 10.2  Instruments and
materials organized for the tooth
preparation

of the periodontal tissues and pulp must be verified, taking a must also be evaluated if any tooth migration or extrusion has
radiography whenever necessary, to evaluate the depth of the happened that will adversely affect the correct restoration of
lesion and its proximity with the pulpal chamber (. Fig. 6.22a,
  the original tooth anatomy (. Fig. 6.21a, b). Then, the occlu-
 

b). The preprocedural antisepsis of the oral cavity is performed sion evaluation is performed making a two-tone representa-
with 0.12% chlorhexidine gluconate mouth rinse during 1 tion of static and dynamic occlusion, using a thin-articulating
min, followed by local anesthesia [4]. On the cases of restora- paper and a Miller forceps [22]. The first step is to inspect the
tions that involve the occlusal and/or proximal surfaces, it eccentric contacts (dynamic occlusion). The red side of the
 338 C. R. G. Torres and D. Mehta
a b
..      Fig. 10.3  Evaluating the occlusal contacts. a Using the Miller forceps to position the carbon-articulating paper between the dental arches;
b contacts marked during centric occlusion (black) and lateral movement (red)
paper is placed facing the tooth that will receive the treatment,
asking the patient to perform protrusive and lateral excursive
movements. The marked contacts are analyzed, as well as the
presence of interferences during the disocclusion movement.
10 The second step is to analyze the concentric contacts (static
occlusion). For that, the paper is turned in the forceps so the
black side faces the tooth to be restored. The patient is asked
to bite, registering the contacts in centric occlusion (CO)
(. Fig. 10.3a, b). The color sequence can, of course, be altered.
No contact with the antagonist tooth should be located at the
cavosurface angle (. Fig. 6.26a, b).
The preparation may be performed with or without rub-
ber dam isolation. However, if the dental floss tear when
passing between the teeth due to sharp areas, it may be better
to isolate later to prevent the tearing of the rubber sheet [22].
On the case of very deep and large cavities, the previous iso-
lation avoids the greater contamination of the pulp in case it
is accidently exposed, increasing the chances of success of a
conservative pulp treatment by means of the direct pulp cap-
ping [22]. If the preparation was started without the isolation
and the cavity is becoming too deep, with an increased risk of
pulp exposure, it should be stopped and the isolation applied
before continuing.
Tip
If the preparation was started without isolation and the
cavity is becoming too deep, with an increased risk of
pulp exposure, it should be stopped and the isolation
applied before continuing.
10.4  Class I or Site 1 Preparations
They are preparations located on the region of pit and fissures
and may include only one tooth surface, named simple prep-
aration, or more than one surface, named compound prepa-
ration.
10.4.1  Simple Preparation
Merely for illustrative purposes, examples of the complete
preparation sequence are presented on the tooth 34 and 37.
However, the principles presented may be applied for all the
posterior teeth (. Figs. 10.4a–i and 10.5a–f).
10.4.1.1  Outline Form
When treating a tooth with a hidden carious lesion, that can
be observed radiographically but with intact enamel surface,
the opening of the cavity must be performed with rotary
instruments, using a round diamond point or carbide bur,
with its long axis placed perpendicularly to the occlusal sur-
face, or a cylinder or long-inverted cone diamond point or
carbide bur, leaning at the mesiodistal direction at an angle of
45° (. Fig. 10.4b, c) [19]. With this leaning, the edge between
the bur’s tip and its side will contact the surface, increasing
the cut or grinding efficacy [25]. The cavity is gradually
enlarged to create access to the dentin. In some situations,
the cavity may have already open due to the collapse of the
undermined enamel, created by the caries lesion, so this step
will not be needed. The opening should begin on the groove
more affected by the caries lesion, or on the most distal one,
to get a better visibility for the mesial extension [12]. The bur
must penetrate the structure while spinning, and it should
not stop until it is removed away from any contact with the
tooth [22]. However, the handpiece should not go in or out
the patient’s oral cavity with the bur still rotating.
>> The bur must penetrate the structure while spinning,
and it should not stop until it is removed away from
any contact with the tooth. However, the handpiece
should never go in or out the patient’s oral cavity with
the bur still rotating.
After the cavity opening, the outline of the preparation can
be defined. The basic principle to be considered is the maxi-
mum preservation of the remaining tooth structure. In the
past, the width of the preparation in the buccolingual direc-
tion was standardized, defined by calculating 1/3 of the dis-
Tooth Preparations for Amalgam Restorations
tance between the tips of the cusps, which led to a considerably
weakening of the tooth, with reduction of approximately 33%
of its fracture resistance. More recently, this standard was
reduced to 1/4 of the distance between the tips of the cusps,
with a smaller reduction of the tooth resistance [27]. How-
ever, nowadays, the extension for prevention is no longer
recommended, as well as no stereotyped outlines must be fol-
lowed. Therefore, only the area affected by the carious lesion
339 10
is included in the preparation [11, 20]. The margins are cut
until they reach intact enamel, even though it is undermined.
The undermined enamel can be later reinforced with artifi-
cial dentin, using glass ionomer cements.
Other factor that determines the width of the preparation
is the need to obtain enough access to perform the restora-
tion. Therefore, even in a very small lesion, the outline must
have the minimum size that allows the use of the smaller

a b

c d

e f

..      Fig. 10.4  Class I or Site 1 tooth preparation on a mandibular molar.
a Marking the contacts with articulating paper; b opening of the cavity
with the round diamond point perpendicular to the occlusal surface; c
opening with a long inverted cone point leaned in relation to the
occlusal surface; d–f penetration of half head of the No. 1148 rotary
instrument and delimitation of the outline shape; g analysis of the
preparation walls to evaluate for the presence of remaining carious
tissue (arrows); h modification of the outline to remove the affected
areas; i final aspect
 340 C. R. G. Torres and D. Mehta
g h
10
..      Fig. 10.4 (continued)
amalgam condenser available, which can be considered a
convenience form [12]. When preparing tooth with small
lesions, the opening is started with the smallest rotary instru-
ment available [22]. The conservative preparation minimizes
the pulp response and keeps the resistance of the remain-
ing tooth structure, reducing the chances of cuspal fracture
[8, 12, 20]. In addition, narrow restorations, generally smaller
than 1 mm, present less marginal fractures and ditching than
the large ones, reducing the need of replacement later on [20,
23]. This happens due to the fact that the small occlusal isth-
mus usually locates the preparation margins far from the
contact areas with the opposite tooth, which allows contacts
occur over the remaining tooth structure [2, 7, 23]. In addi-
tion, the smaller restorations are better condensed due to the
use of small pluggers, which produce a greater condensation
pressure, removing more mercury and improving the adap-
tation of the restorative material [20]. According to Almquist
et al. [2], if the patient is taught to completely clean his teeth,
it is not necessary to extend the preparation margins more
than the necessary to give it an adequate form. Any restora-
tion that can be correctly polished by the dentist can be prop-
erly cleaned by the patient. If the patient does not clean his
teeth, it does not matter the amount of extension for preven-
tion performed because it will not be capable to prevent addi-
tional carious lesions and eventually the total destruction of
the tooth.
On the posterior teeth, the inclines of adjacent cusps are
separated by developmental grooves, which represent lines of
union between lobes of the crown during its formation. The
enamel of both lobes, on the bottom of the groove, may have
been perfectly connected during the tooth formation or a
linear fault may sometimes have happened creating a fissure,
which represents a lack of union between the cups inclines.
This fissure directly connects the oral environment to the
dentin on the dentinoenamel junction (DEJ) area. Even
though the carious lesion generally begins at an occlusal fis-
sure, it is frequently isolated in only one place or few places
along the extension of the groove. It rarely happens on the
entire groove. When there are lesions in fissures which are
not connected, separated by areas of intact groove, individual
preparations must be performed, without the need to con-
nect them, unless there is less than 0.5  mm between the
preparations (. Fig. 6.24a–c) [22]. After the preparations are
completed, if necessary, the areas of the groove not affected
by carious lesion but highly susceptible to caries can be pro-
tected with a pit and fissure sealant [20]. As a general rule,
the larger the restoration, the less it will last [20].
If the preparation is conservative, size 1 or 2 according to
Mount and Hume [18], the No. 1148 or No. 1150 diamond
point or the No. 245 bur, with a long-inverted cone shape
should be used (. Fig.  10.1). With these instruments, the
vertical surrounding walls will be slightly convergent toward
Tooth Preparations for Amalgam Restorations
341 10

a b

c d

e f

..      Fig. 10.5  Class I or Site 1 preparation on the mandibular first d delimitation of the preparation outline; e aspect of the surrounding
premolar. a Demarcation of the contact points; b opening the walls convergent towards the occlusal surface, due to the use of the
preparation with a round diamond point; c positioning of the diamond inverted conical- trunk instrument; f final aspect of the tooth
point perpendicular to the plane that tangents the tips of the cusps; preparation

the occlusal surface. If the preparation is large, No. 3 or 4 bur
or No. 1090A or No. 1092A diamond point, with cylinder
shape and round corners should be used (. Fig. 10.1). With
 
these instruments, the vertical surrounding walls will be
parallel to each other [11, 12]. At the moment of the outline
form of the preparation, the penetration of the rotary instru-
ment is restricted to about 0.2–0.5 mm [12, 16] further than
the DEJ, which will create a preparation with about 1.5 mm
deep on the central groove, or 2 mm in relation to the buccal
or lingual cavosurface angle [22]. It is considered as a refer-
ence area for the depth of the preparation the deepest area of
the central groove. Consequently, outside this area, the sur-
rounding vertical walls will have a greater height, allowing a
greater thickness of the restorative material. It is possible to
use the head length of a bur or diamond point as a reference
for the preparation depth evaluation [22]. The No. 1148 dia-
mond point and the No. 245 bur heads have a length of
3 mm. Therefore, the penetration of half its length into the
tooth structure will create the minimal necessary depth for
an amalgam preparation (. Fig.  10.4d–f). When using the
 342 C. R. G. Torres and D. Mehta
No. 1150, 1090A, or 1092A diamond points, which have the
head length of 4 mm, the use of half this length will also
provide a satisfactory reference value. After penetrating the
necessary depth into the carious lesion, the rotary instru-
ment should be moved on the mesiodistal direction, with its
long axis parallel to the long axis of the tooth, maintaining a
uniform preparation depth. At this step, the preparation
depth is maintained, even though old restorative material or
carious tissue remains on the pulpal wall, because they will
be removed during the final phase of the preparation. On the
other hand, the cavosurface angles of the vertical surround-
ing walls must reach sound enamel (. Fig.  10.4g, h). After
 
this step, the occlusal contacts with the antagonist tooth are
analyzed, checking if it will not be located at the interface
between the tooth and the future restoration. In this case,
the outline must be changed through an additional cut of
wall in this area, positioning the contact over the restorative
­material.
10.4.1.2  Resistance Form
To improve the resistance of preparation and restoration, the
walls must be flat, uniform, and smooth, improving the
10 adaptation of the restorative material. The flattening and the
smoothness of the walls can be obtained moving the rotary
instrument to and fro [13]. The depth of the preparation
should allow a minimum depth of 1.5 mm for the amalgam
on the contact area or at the center of the restoration, in the
region of the central groove [12]. The pulpal wall is flat,
which is obtained through the flat tip of the rotary instru-
ment’s head [12]. The flat pulpal wall allows a better distribu-
tion of the stress and prevents the rotation of the restoration
(. Fig. 6.28a–c). On most of the posterior teeth, the pulpal
 
wall must be parallel to the occlusal plane of the dental arch,
making it perpendicular to the direction of the occlusal
loads. To perform that, the long axis of the rotary instrument
is positioned parallel to the long axis of the tooth
(. Fig. 10.6a). One exception to this rule is the mandibular
 
first premolar, where there is a large difference on the vol-
ume of the buccal and lingual cusps. That creates the need
that the pulpal wall should be prepared parallel to the plane
a b
..      Fig. 10.6  Direction of the resulting walls in relation of the leaning of the rotary instrument. a Correct; b incorrect
touching the tip of both cusps, avoiding the exposure of the
buccal pulp horn, besides preserving the dentin under the
lingual cusps (. Fig. 6.14a, b). For that, the rotary instru-
ment is positioned perpendicular to the intercuspal plane
(. Fig. 10.5c, d).
The resistance form is also obtained with the use of rotary
instruments with round corners, which creates round inter-
nal line angles of the second set, and allows a better distribu-
tion of the stress, reducing the probability of fracture of the
remaining tooth structure (. Fig. 6.39) [2, 12, 23]. This is
particularly important on the cases of large preparations,
where the tooth structure is fragile [11, 16]. In addition, the
round angles allow a better adaptation of the restorative
material [2, 23]. The use of traditional No. 56 or No. 57
straight fissure or No. 1090 and No. 1092 cylinder diamond
points, even though create parallel vertical surrounding
walls, also produce sharp internal line angles of the second
set, which concentrate the stress in the angle area of the
remaining tooth structure, exactly on the cases where this
detail is more relevant, such as the large lesions.
In relation to the restoration margins, the resistance form
is obtained first by avoiding the contact of the antagonist
tooth on the tooth restoration interface, protecting it from
the occlusal loads [12]. Second, the resistance can also be
improved by the convergence of the buccal and lingual walls
toward the occlusal surface, which create a greater marginal
angle of the restoration, at least 70° [12, 13]. This greater
thickness of the restorative material on the restoration mar-
gins decreases its marginal degradation. However, on large
cavities, the preparation of parallel surrounding vertical walls
is more favorable because of the use of the convergent walls
may weaken even more the already fragile structure
(. Fig. 6.36a, b).
During the preparation, it is extremely important to eval-
uate if the long axis of the rotary instrument is properly posi-
tioned, perpendicular to the occlusal plane. Otherwise, in
one of the sides of the preparation, there will be undermined
enamel susceptible to fracture, while on the other side there
will be a thin margin of the restorative material and more
chances of pulp exposure (. Fig. 10.6a, b) [26].
Tooth Preparations for Amalgam Restorations
343 10

a b

..      Fig. 10.7  a Evaluation of the marginal ridge remaining using as a reference the No. 1048 diamond point; b preparation of the proximal walls
slightly expulsive towards the occlusal surface

a b

..      Fig. 10.8  Additional retention on the base of the cusps. a Position of the rotary instrument during the preparation, b retention test with an
exploratory probe

To preserve the resistance of the remaining tooth struc-
ture on large cavities, the mesial and distal walls in contact
with the marginal ridge should be slightly expulsive toward
the occlusal surface [12, 13, 16, 25]. This avoids that the
remaining dentin under the ridge is removed (. Fig. 6.41a–f)
 
[25]. This characteristic is obtained leaning the rotary instru-
ment toward the proximal surface in more or less 10°
(. Fig. 10.7b) [22]. Although the resistance of the remaining
 
tooth structure is preserved, this inclination produces thin
margins for the restoration, with a greater chance of fracture
[16]. On the other hand, on smaller preparations, where the
10.4.1.3  Retention Form
The retention of the restorations is obtained by the conver-
gence of the buccal and lingual walls when a long-inverted
cone-shaped rotary instrument is used. It is also achieved
when the preparation is deeper than wide when using a cyl-
inder rotary instrument. When the walls are prepared paral-
lel to each other and the buccolingual dimensions of the
preparation are wider than the depth, additional mechanical
retention must be prepared. Small coves are made under the
cusps, which are the areas with larger volume of dentin
(. Fig. 10.8a, b) [12]. For that, an inverted cone instrument

marginal ridge has more than 1.6 mm of thickness in premo- is used, such as No. 1031 diamond point or No. 33 ½ bur. A
lars or 2 mm in molars, those walls can be convergent toward small round instrument can also be used, such as No. ½ or
the occlusal surface [3, 22]. It is possible to have an idea about the No. 1011 diamond point (. Fig. 10.1) [3]. According to
 

the thickness of the marginal ridge using the diameter of the
rotary instrument head as a reference (. Fig. 10.7a) [22].
 
On cases of teeth with oblique enamel ridges, as the max-
illary molars, or the transverse ridge on the first mandibular
premolars, it is important its maximum preservation to keep
the resistance of the remaining tooth structure [13]. The
Sturdevant [22], the retentions performed with round
instruments are better than the ones prepared with the
inverted cone, because the amalgam can be better condensed
on round than on sharp areas, resulting on a better adapta-
tion of the restorative material. The cut must be performed
exclusively on the buccal or lingual walls (. Fig. 6.44a, b).

resistance of the tooth structures is greater than of amalgam. The retention can be tested by pressing the tip of an explor-
 344 C. R. G. Torres and D. Mehta
atory probe inside the cove and simultaneously pulling
toward the occlusal surface (. Fig. 10.8b) [16]. On the cases
 
where a cavity liner or base is applied, the additional reten-
tions are prepared only after the walls have been filled with
that material [3].
10.4.1.4  Convenience Form
In relation to the Class I preparation, the convenience form is
limited to the cases of small lesions. On this situation, the
fitting of the smallest amalgam condenser instrument inside
the preparation must be evaluated, allowing an adequate
condensation of the restorative material. If the contour of the
preparation is too small, it must be slightly enlarged, only
enough to allow an adequate restoration.
10.4.1.5  Removal of the Remaining Carious
Tissue
At this moment, in cases of small lesions, the entire cari-
ous tissue was already removed. In larger lesions, if some
highly infected dentin tissue remained in any region, it
can be removed with a round bur at low speed, of larger
size compatible with the preparation contour, or with a
10 spoon excavator. Those regions with irregular walls can
later be flattened with the application of a base mate-
rial, and the undermined enamel be reinforced with GIC
(. Fig. 6.6a–d).
10.4.1.6  Finishing the Enamel Walls
The smoothness of the preparation wall margins allows
removal of the undermined enamel susceptible to fractures
[12]. However, on this type of preparation, the use of cor-
rectly positioned rotary instruments will by itself create a
smooth surface, without undermined enamel prisms at the
margins. Therefore, no additional procedures would be
necessary. The final evaluation of the preparation is done
with an exploratory probe, to analyze if there is any resid-
ual carious tissue, the shape of the walls is correct, and the
enamel margins are supported by natural or artificial
dentin [12].
10.4.1.7  Cleaning of the Preparation
The preparation is cleaned with air and water spray and
then receives the application of an anionic detergent, with a
small cotton pellet or a disposable applicator, followed by
washing with water and drying with air stream [22]. After
that, the disinfection of the preparation can be performed
with a chlorhexidine solution followed only by drying [22].
Another option is to apply a 2% neutral sodium fluoride
solution for 2–4 min, followed by drying. This procedure
will promote the deposition of calcium fluoride over the
preparation walls, acting as a fluoride reservoir that will be
release if there is a drop of pH [3]. The application of the
fluoride solution can reduce up to 60% of the formation of
secondary caries on the amalgam restoration margins and
interface [1].
10.4.1.8  Final Characteristics
of the Preparation
Small- and Medium-Size Preparations (Sizes 1
and 2)
55 Flat, uniform, and smooth walls
55 Buccal and lingual walls slightly convergent toward the
occlusal surface
55 Mesial and distal walls in contact with the marginal
ridge slightly expulsive toward the occlusal surface,
when there is little remaining of the ridge, or convergent
toward the occlusal surface, when there is a large
marginal ridge remaining
55 Round internal line angles of the first and second sets
55 Walls in contact with the oblique enamel ridges, in the
maxillary molars, or the transverse ridge on the first
mandibular premolars, convergent toward the occlusal
surface
Large Cavities (Size 3 and 4)
55 Flat, uniform, and smooth walls
55 Buccal and lingual walls parallel to each other
55 Mesial and distal walls in contact with the marginal
ridges expulsive toward the occlusal surface
55 Round internal line angles of the first and second sets
55 Walls in contact with the oblique enamel ridges, in the
maxillary molars, or the transverse ridge on the first
mandibular premolars parallel to each other
10.4.2  Compound Preparation
For illustrative purposes, the details about the preparation
will be presented on the tooth 26. However, the same princi-
ples can be applied on other similar situation such as on the
mandibular molars (. Fig. 10.9a–r).
10.4.2.1  Outline Form
A round diamond point or carbide bur, with its long axis
positioned perpendicularly to the occlusal plane, or a cylin-
der or long-inverted cone diamond point or carbide bur,
leaning to the mesiodistal direction, can be used to open the
cavity (. Fig.  10.9b). On the maxillary and mandibular
molars, where both the occlusal and the buccal or lingual
surfaces were involved by the caries lesion, the outline form
of the preparation may be variable, as it can be observed in
. Fig. 10.10a–d. The occlusal cavity may connect to the buc-
cal or lingual cavity, or they might stay as two independent
simple cavities.
The outline must be the most conservative possible but
enough to remove the entire carious tissue until it reaches
intact enamel [22]. The depth of penetration is restricted to
0.2–0.5  mm beyond the DEJ on the region of the central
groove. The preparation starts by delimitation of the occlusal
outline, with a rotary instrument parallel to the long axis of
the tooth, maintaining a constant depth and coming closer to
the groove of the smooth surface (. Fig. 10.9c–e) [22]. Then,
Tooth Preparations for Amalgam Restorations
the rotary instrument is inserted on the region of the lingual
groove, with its long axis parallel to the surface, in a depth of
approximately 0.75 mm (. Fig. 10.9f) [22]. Considering that
 
the No. 1148 and No. 1090A diamond points have 0.8 mm of
diameter, it is possible to know that the preparation has the
minimum necessary depth when the instrument has pene-
trated almost completely on the tooth structure (. Fig. 10.9g).
 
345 10
10.4.2.2  Resistance Form
The walls must be flat, uniform, and smooth to improve the
stress distribution and adaptation of the restorative material.
The minimal depth is 1.5  mm on the region of the central
groove and 0.75 mm on the smooth surface to give resistance
to the restoration. The pulpal wall must be parallel to the
occlusal plane [19]. On small or medium preparations (Sizes

a b

c d

e f

..      Fig. 10.9  Class I or site 1 compound preparation on a maxillary
molar. a Marking of the contact points; b opening the cavity with a
round diamond point; c, d preparation of the occlusal part of the
groove with the long-inverted cone diamond point. e Finished occlusal
box; f–g lingual groove preparation with the long axis of the diamond
point parallel to the surface lingual; h analysis the preparation to verify
the presence of remaining carious tissue; i, j removal of the remaining
carious tissue; k filling of the region with the GIC as a base material;
l preparation of the mesioaxial line angle with the diamond point
perpendicular to the axial wall. m preparation of the distoaxial line
angle; n, o rounding of the axiopulpal angle with the tip of the
diamond point or with a gingival margin trimmer. p trimming of the
gingival cavosurface angle with a gingival margin trimmer; q, r final
aspect of the tooth preparation
 346 C. R. G. Torres and D. Mehta

g h

i j

10

k l

m n

..      Fig. 10.9 (continued)
Tooth Preparations for Amalgam Restorations
o p
q r
..      Fig. 10.9 (continued)
1 and 2), the surrounding walls of the occlusal box are con-
vergent toward the occlusal surface to increase the thickness
of the restoration margin, improving its resistance [22]. For
that, a No. 1148 or No. 1150 inverted cone diamond point or
a No. 245 bur must be used. If the marginal ridge is too frag-
ile, the wall that is in contact with it must be expulsive toward
the occlusal surface. On large cavities (Size 3 and 4), the sur-
rounding walls of the occlusal box are left parallel among
each other. For that, the No. 1090A or No. 1092A cylinder
diamond points are used. The distal walls of the occlusal box,
in contact with the marginal ridge, have to be expulsive
toward the occlusal surface to preserve its dentin support
[22]. The internal line angles of the second set are round,
which can be achieved when using the described rotary
instruments.
The axial wall must be expulsive toward the occlusal sur-
face, in a way to follow the leaning of the lingual surface and
allow a homogeneous thickness of the restorative material,
increasing the final resistance of the restoration. This is
achieved positioning the long axis of the rotary instrument
parallel to the lingual surface on the buccolingual direction,
penetrating about 0.2–0.5  mm further than the DEJ or
enough so that the carious tissue is removed and a minimum
thickness of the restorative material is obtained (. Fig. 10.9f,
 
g) [22]. The tip of the bur must be positioned at the end of the
lesion creating the gingival wall, with the internal line angles
347 10
of the first set round. The dentist must keep a good control of
the rotary instrument and not let it roll outside the prepara-
tion, over the lingual surface, which may damage the cavo-
surface margin [22]. When a No. 1148 or No. 1150
long-inverted cone diamond point or a No. 245 bur is used
for the preparation of the lingual box, the mesial and distal
walls will be slightly convergent toward the occlusal and lin-
gual surfaces (. Fig. 10.9r) [22]. If a cylinder instrument is
used, those walls will be parallel to each other.
To better define the mesoaxial and axiodistal angles, the
long-inverted cone or cylinder rotary instrument is posi-
tioned with its long axis perpendicular to the lingual surface,
with the tip touching the axial wall, and moved in the
occluso-cervical direction [22], without changing the axial
wall (. Fig. 10.9l, m). If a long-inverted cone point or burs are
used, the mesial and distal walls will be retentive toward the
lingual surface, while if cylinder instruments are used, they
will be parallel between each other [22].
The gingival wall must be parallel to the pulpal wall and
the occlusal plane, allowing the distribution of the occlusal
loads because they are perpendicular to the direction of the
load [19]. This is obtained by positioning the bur parallel to
the long axis of the tooth. The internal angles are round,
which is automatically obtained due to the round corners of
the rotary instrument heads, with the exception of the
axiopulpal angle. This must be rounded with a No. 29 gingi-
 348 C. R. G. Torres and D. Mehta

..      Fig. 10.10  Variations on the a b

preparation outline due to the
extension of the lesion on the
maxillary and mandibular molars.
a, c Preparation outline when the
lesions extend on the entire
groove of the smooth surface;
b, d preparation outline when
the lesion is restricted to the pits
on the smooth surfaces. The
occlusal and buccal/lingual
boxes should not be connected

c d

10

val margin trimmer, moved in the mesiodistal direction, or
with the flat tip of a rotary instrument adequately positioned
(. Fig. 10.9n, o) [15].
 
10.4.2.3  Retention Form
On the occlusal box, the retention is obtained by the conver-
instrument such as the No.1011 diamond point or the No. ½
bur. When a conical rotary instrument is used, it is leaned to
the mesiodistal direction so that the tip first touches the
region next to the mesiogingival or distogingival angles,
resulting on the pyramid-shaped retention and not surpass
the axiopulpal angle (. Fig. 10.11c–e) [22]. The retention is

gence of the surrounding walls toward the occlusal surface. tested inserting the tip of an exploratory probe and moving it
When the walls are created parallel to each other and the cav- toward the lingual surface [22]. The retention must hinder
ity is wider than the deep, additional retention like a cove can the probe to directly move toward the lingual surface
be made under the distobuccal cusp, as it was described for (. Fig. 10.11f) [22].
 

the simple cavity (. Fig. 10.11a, b). On the lingual box, when

 

the inverted cone instrument is used, the cavity is self-­

retentive toward the occlusal and lingual surfaces [22]. When Tip
the cylinder bur is used, the parallelism of the mesial and
Additional mechanical retentions must be always
distal walls already creates retention toward the occlusal sur-
prepared on dentin tissue and never on enamel or close
face. However, it can be not enough on the lingual direction,
do DEJ.
especially if the occlusal box is shallow and little retentive on
this direction. On this case, the additional mechanical reten-
tions can be created through the retention locks on the
mesioaxial and distoaxial line angles, on the dentin of the 10.4.2.4  Convenience Form
mesial and distal walls, but never on the enamel [22]. Those It is restricted at this preparation the necessary width so that
retentions may be created with a conic instrument, such as the smaller condenser instrument may reach the deepest
the No. 1061 diamond point or No. 169 bur, or a round areas near to the internal walls.
Tooth Preparations for Amalgam Restorations
349 10

a b

c d

e f

..      Fig. 10.11  Preparation of additional retentions. a, b Preparation of retention on the occlusal box; c–e preparation of retentions on the lingual
box, on the mesioaxial, and on the distoaxial line angles; f retention test

10.4.2.5  Removal of the Remaining Carious 10.4.2.6  Finishing the Enamel Walls

Tissue The undermined enamel at the region of the gingival cavo-
In general, at this phase of the preparation, no more carious surface angle is trimmed with a No. 29 gingival margin trim-
tissue probably remained. However, if there is any, it can be mer, by moving it to the mesiodistal direction (. Fig. 10.9p). 

removed as it has already been described for the simple cav-

ity, and the undermined enamel area filled with GIC 10.4.2.7  Cleaning of the Preparation
(. Fig. 10.9h–k).
  It is performed as it has already been described for the simple
cavity.
 350 C. R. G. Torres and D. Mehta
10.4.2.8  Final Characteristics
of the Preparation
Small- and Medium-Size Preparations
(Sizes 1 and 2)
55 Flat, uniform, and smooth walls
55 Buccal and lingual walls slightly convergent toward the
occlusal surface
55 Mesial wall in contact with the oblique enamel ridge
convergent toward the occlusal surface
55 Distal wall in contact with the marginal ridge convergent
toward the occlusal surface
55 Internal line angles of the first and second sets and
external line angle round
55 Mesial and distal walls of the lingual box convergent
toward the occlusal and lingual surfaces
Large-Size Preparation (Sizes 3 and 4)
55 Flat, uniform, and smooth walls
55 Buccal and lingual walls parallel to each other
55 Mesial wall in contact with the oblique enamel ridge
perpendicular to the pulpal wall
10 55 Distal wall in contact with the marginal ridge expulsive
toward the occlusal surface
55 Internal line angles of the first and second sets and
external line angle round
a b
..      Fig. 10.12  Vertical slot tooth preparation. a Marking of the contact
points; b proximal view of the lesion; c separated preparation of the
occlusal lesions; d access to the lesion through an opening in the
marginal ridge using a round diamond point; e the dentist feels a
sensation to fall on an empty space when reaching the lesion; f cavity
opened allowing access to the lesion. g, h penetration of the inverted
cone point, which is moved in the buccolingual direction and toward
the marginal ridge; i marginal ridge remaining; j–l fracture of the ridge
with an excavator spoon; m, n outline of the walls with the pendulum
motion on the buccolingual direction. o occlusal aspect after the
55 Mesial and distal walls of the lingual box parallel to each
other
55 Additional retention of the mesioaxial and distoaxial
line angles
10.5  Class II or Site 2 Preparations
This type of cavity involves the proximal surfaces of the poste-
rior teeth, where the caries lesions are located below the con-
tact point. When there are no carious lesions on the occlusal
surface, or when the occlusal lesion is far from the marginal
ridges, the preparation of the proximal area can be indepen-
dent from the occlusal preparation. The access to the proximal
lesion is performed in the marginal ridge, and this kind of
preparation is called proximal box preparation or vertical slot
preparation (. Fig. 10.12). If the occlusal surface has also been
affected  by the lesion and reaches the proximal lesion, the
preparation of the occlusal surface is connected to the proxi-
mal one, resulting to mesio occlusal, occluso distal, or mesio
occlusodistal preparations (. Fig.  10.13). When the caries
lesion is too far from the occlusal surface, such as on the cases
of teeth with long clinical crowns or on teeth with gingival
recession, with the carious lesion at the CEJ, the access can be
performed from the buccal or lingual surfaces, and the prepa-
ration is called horizontal slot preparation (. Fig. 10.16a–l).
opening; p preparation of the axial wall with the leaned diamond
point; q evaluating the presence of the residual carious tissue with an
exploratory probe; r removal of the carious tissue with the round bur; s
treatment of the tooth structure for the application of the base
material; t application of the glass ionomer cement; u, v preparation of
the mechanical retentions. w, x evaluating the retentions with an
exploratory probe; y, z finishing of the buccal and lingual cavosurface
angles; a′, b′ trimming of the gingival cavosurface angle; c′, d′ final
aspect of the preparation
Tooth Preparations for Amalgam Restorations
351 10

c d

e f

g h

i j

..      Fig. 10.12 (continued)
 352 C. R. G. Torres and D. Mehta

k l

m n

10

o p

q r

..      Fig. 10.12 (continued)
Tooth Preparations for Amalgam Restorations
353 10

s t

u v

w x

y z

..      Fig. 10.12 (continued)
 354 C. R. G. Torres and D. Mehta
a'
c'
10
..      Fig. 10.12 (continued)
a b
..      Fig. 10.13  MOD preparation. a Initial aspect; b radiographic aspect
of the proximal lesions; c opening of the cavity with a leaned inverted
cone diamond point; d, e outline of the occlusal box weakening the
marginal ridges; f–h fracture of the marginal ridges with a hand
instrument. Obs.: As shown on the picture a and b, on this example,
performed on extracted teeth, there is only a pigmented groove on the
occlusal surface, without the presence of the caries on the dentin. On a
real situation, this groove should not be prepared, and two separated
vertical slot preparation could be performed. On this example, the
occlusal surface was prepared only for didactic purposes to exemplify a
MOD preparation. i–l preparation of the buccal and lingual walls of the
b'
d'
mesial box; m–o fracture of the distal marginal ridge; p preparation of
the lingual wall of the distal box. q lingual wall of the distal box
prepared; r, s buccal wall of the distal box being prepared; t inadver-
tently grinding of the protective matrix band with the diamond point;
u, v evaluating the complete removal of the remaining carious tissue;
w, x dentin surface treatment and GIC-based material application. y, z
rounding of the axiopulpal angle; a′, b′ preparation of the mechanical
retentions in the proximal boxes; c′, d′ finishing of the buccal and
lingual cavosurface angles of the proximal boxes; e′, f′ trimming of the
gingival cavosurface angles. g′ final aspect of the preparation
Tooth Preparations for Amalgam Restorations
355 10

c d

e f

g h

i j

..      Fig. 10.13 (continued)
 356 C. R. G. Torres and D. Mehta

k l

m n

10

o p

q r

..      Fig. 10.13 (continued)
Tooth Preparations for Amalgam Restorations
357 10

s t

u v

w x

y z

..      Fig. 10.13 (continued)
 358 C. R. G. Torres and D. Mehta

a' b'

c' d'

10

e' f'

g'

..      Fig. 10.13 (continued)
Tooth Preparations for Amalgam Restorations
10.5.1  Access Through the Occlusal Surface
10.5.1.1  Outline Form
If there is an occlusal lesion near the marginal ridge, its open-
ing is performed as it has already been described for the Class
I preparation, and then the preparation is extended to the
proximal area. However, when the lesion is restricted to the
proximal surface, it is not necessary to extend the tooth prep-
aration toward the occlusal grooves, because it will unneces-
sarily weaken the tooth turning it more susceptible to
fractures [20]. Therefore, the vertical slot preparation is rec-
ommended. On this case, if necessary, the occlusal grooves
may receive a pit and fissure sealant to prevent new lesion,
but it should never be grinded or cut to receive a restoration.
A clinical study reported the effectiveness of sealant and
amalgam restoration association [14]. When there is a cari-
ous lesion on the occlusal surface far from the marginal ridge,
it is treated as a separated Class I lesion (. Fig.  10.12c).
However, if there is 0.5  mm or less of the tooth structure
remaining in between the occlusal and the proximal prepara-
tion, it is better to connect them, avoiding a later fracture of
this weakened area.
When the preparation to treat the proximal lesion is
made separately, the opening to the cavity to access the lesion
is performed directly over the marginal ridge. The proximal
box is always prepared on the direction of the interproximal
contact, despite the tooth position on the arch, i.e., if one
tooth is twisted and it is in contact with the adjacent tooth
through the buccal surface, the proximal box will be pre-
pared on this region [12].
The proximal surface of the adjacent tooth must be pro-
tected from the action of the rotary instrument, to avoid an
iatrogenic grinding. For that, an interproximal guard, as
shown on . Fig. 6.10a, b should be used, or even small piece
of the steel matrix strip assembled on the matrix retainer,
positioned on the adjacent tooth. This will avoid the bur or
diamond point inadvertently touches the intact proximal
surface of the neighboring tooth and causes, in fraction of a
second, something that the caries disease would take years
to cause [3]. Clinical studies showed that 69% of the adja-
cent teeth were damaged by the bur during the preparation
of the Class II cavities, and the risk of proximal caries on
those teeth is almost tripled, due to the bacterial biofilm
growing inside the iatrogenic cavitation [21]. It should also
be applied a wooden wedge in the interproximal space, to
protect the interdental papilla and the rubber dam, as it can
be observed on . Figs.  10.12d and 10.13e [22]. It can be
noticed that the wooden wedge is placed between the tooth
that is being prepared and the matrix strip in the neighbor
tooth [22]. If any undesired contact of the rotary instrument
with the proximal surface of the adjacent tooth happens,
when it is minimal, it will be possible to be corrected the
damaged proximal surface with abrasive strips. However, a
larger iatrogenic grinding would require a restoration of the
contour and smoothness of this surface, filling the cavity
created and allowing a correct cleaning of this area by
flossing [22].
359 10
Using a round diamond point, the opening of the cavity
until it reaches the lesion is performed. The rotary instru-
ment penetrates toward the cervical region, moving it in the
buccolingual direction, following the DEJ, which guides the
dentist helping to avoid the contact with the adjacent tooth.
It will create a ditch that should be 2/3 on the enamel and 1/3
on the dentin, taking care not to overextend this opening in
the buccolingual direction [3, 22]. If it is prepared only on the
dentin, the proximal box will be too large [22]. This penetra-
tion continues until it reaches the lesion, which depending
on its size, will produce a feeling of falling in a hollow space
(. Fig. 10.12d–f). Using the long-inverted cone rotary instru-
ment for the small and medium cavities or the cylinder ones
for large cavities, the grinding performed to access the lesion
is extended toward the marginal ridge, leaving a thin layer of
enamel (. Figs. 10.12g–i and 10.13d, e) [3, 13, 22, 23].
The mesiodistal extension of the gingival walls should
have the approximate dimension of 0.5–0.6 mm further the
DEJ on the dentin, in case mechanical retentions are needed
[22], allowing also enough thickness for the restorative mate-
rial [2, 12]. If there is no more enamel on the gingival cavo-
surface angle, it may have 0.8  mm of total extension that
corresponds to the tip of the No. 245 bur or the No. 1148
diamond point [22]. The lesions are located immediately
below the contact point, due to the lack of self-cleaning of
this region [12]. The thin layer of enamel still touching the
adjacent tooth generally breaks by itself due to the action of
the rotary instrument when making it thinner [13, 25]. If this
does not happen, the pressure of a hand instrument, such as
a dentin spoon, can be applied (. Figs. 10.12j–l and 10.13f–h)
[3, 15].
As the caries lesion on the proximal surface generally has
an elliptic shape, with its buccolingual dimension greater
than the occlusocervical, a pendulum motion is performed
to remove the entire carious tissue, without opening too
much the preparation in the marginal ridge area
(. Figs.  10.12m, n and 10.13i–k). That preserves this func-
tional area, leaving the restoration less exposed to the masti-
catory loads and consequently to a tooth fracture [6, 16]. This
way, the surrounding walls of the proximal box will be con-
vergent toward the occlusal surface, creating the self-reten-
tive preparation, which will also result to thicker restoration
margins on the marginal ridge area. The cervical limit of the
preparation is located at the end of the lesion, in a way that all
margins are placed in healthy enamel.
The white spot lesions on this region are removed,
because it can appear as a more radiolucent area than the
intact tooth in any future radiography, giving the idea of
recurrent caries. Because of that, it must be completely elimi-
nated. This does not mean, however, that the entire gingival
wall needs to be deepened. This reduction can be performed
only on the specific area that corresponds to the lesion.
The removal of the contact with the adjacent tooth may
simplify the matrix placement and the finishing of the resto-
ration, and it used to be generally recommended as a conve-
nience form. It was also considered as a kind of extension for
prevention, due to the fact that the margins are placed on a
 360 C. R. G. Torres and D. Mehta
more easy to clean region [12]. The classic recommendation
was that after the end of the preparation, there was a separa-
tion of about 0.2–0.3 mm of the adjacent tooth, which cor-
responds to the tip of a very thin exploratory probe passing
through this region [22]. However, considering that the
patient must initially have the caries disease controlled and
will undergo several preventive measurements, before and
after the restorative intervention, the simple reason of exten-
sion for prevention becomes unnecessary. According to
Almquist et al. [2], for a patient that uses dental floss on the
interproximal space, the extension of the proximal walls
must be limited necessary for removal of carious tissue and
finishing the restoration. An additional extension would only
make any sense if the oral hygiene of the patient was restricted
to brushing.
In some cases, such as on the maxillary premolars and the
first molars, the removal of the contact with the adjacent
tooth on the buccal wall of the mesial box can expose the
margin of the restoration and result in an unnecessary
esthetic involvement [3, 11, 20, 22]. In addition, it is possible
to make an adequate tooth restoration without removing the
contact. Therefore, the removal of the contact should never
10 be done intentionally and is not desired [3, 11, 20, 22].
10.5.1.2  Resistance Form
On the cases of small- and medium-size lesion, the conver-
gence of the surrounding walls toward the occlusal surface
creates thicker margins for the restoration [25]. On the
proximal box, the buccal and lingual walls are convergent
toward the occlusal surface aiming to remove the entire
carious tissue below the contact point with maximum pres-
ervation of the marginal ridge, making that food bolus to
contact mostly the remaining tooth structure, instead of the
restoration.
It is known that in a circumferential direction, the long
axis of the enamel prisms forms a 90° angle with the tangent
that touches the tooth surface on the region of the tip of each
prism [12, 22]. Keeping this in mind, it is important that after
the tooth preparation, there is no undermined enamel prism
on the region of the cavosurface angles. The preparation of
the buccal and lingual walls of the proximal box convergent
toward the proximal surface or parallel among each other
would leave undermined prisms that, with the time, would
fracture and result in a marginal ditching (. Fig. 6.38a–f).
 
The preparation of those walls divergent toward the proximal
surface solves this problem.
The morphology of most posterior teeth, with the buccal
surface larger than the lingual one, makes the proximal sur-
faces converge markedly to the lingual surface. That influ-
ences the cavosurface angle of the lingual and buccal walls, in
the proximal box of the preparation, and result in thin resto-
ration margins, mostly on the buccal wall (. Fig. 6.38a–f)
 
[25]. This problem is solved by preparing on the buccal wall
the Hollenback’s reverse curve or S-shaped curve [2, 12]. It is
performed in a way that the buccal wall of the proximal box
..      Fig. 10.14  Direction of the pulpal and gingival walls of the
mandibular first premolar
to have a concave contour toward the buccal surface of the
tooth. This curve is made only enough to create an amalgam
margin at 90° in relation to the external proximal surface. On
the lingual side, it is not necessary due to the larger lingual
embrasure [12, 22].
Other characteristics that give resistance to the prepara-
tion are the pulpal and gingival walls prepared flat and paral-
lel to the occlusal plane. That  allows a more homogeneous
stress distribution due to the occlusal loads hiting this area at
a 90° angle, besides to avoid the rotation and displacement of
the restoration when receiving an eccentric load [12, 22].
One exception happens at the mandibular first premolar,
because its lingual cusp is much smaller than the buccal one,
making the occlusal plane of this tooth very leaned in the
buccolingual direction. To avoid an exposure of the buccal
pulp horn, the rotary instrument is placed perpendicular to
the occlusal plane of this tooth, which tangents both cusps.
That will create a leaned pulpal wall in relation to the long
axis of the tooth (. Fig.  10.5c) [25]. However, the gingival
wall can be made perpendicular to the long axis of the tooth,
up to the cervical limit of the lesion, avoiding an unnecessary
invasion of the biological width (. Fig. 10.14, [25]).
Due to the use of rotary instruments with flat end and
round corners, all the internal line angles of the second set
and point angles will consequently be round, improving the
stress distribution adaptation of the restorative material. The
exception is the axiopulpal external line angle which will be
sharp. The buccogingival and linguogingival angles should
always be round, because the sharp angles can increase the
chances of failures during amalgam condensation and of
future secondary caries lesion on this region [9, 16]. The
axiopulpal angle must also be rounded to avoid the stress
concentration inside the restoration in this area, conse-
quently improving the final resistance [12, 22, 25]. This
rounding can be performed with a No. 29 gingival margin
trimmer by scraping from the buccal toward the lingual sur-
face and vice versa or with the side of the rotary instrument
correctly positioned (. Fig. 10.13y, z).
Tooth Preparations for Amalgam Restorations
10.5.1.3  Retention Form
On the occlusal box, when the preparation is performed
with the long-inverted cone instrument, it will be self-reten-
tive toward the occlusal surface. When it is done with a cyl-
inder instrument, if the resulting preparation is deeper than
wider, it will also be self-retentive. However, if the resulting
preparation is wider than deeper, it will be necessary to add
retention coves at the base of the cusps, as it has already
been described for the Class I preparation (. Fig. 10.8a, b).
 
Toward the proximal direction, the retention is provided by
the occlusal contour on the occlusolingual and/or occluso-
buccal developmental grooves or by a dovetail lock on the
triangular fossae (. Fig. 6.47b). In relation to the proximal
 
box, it will be self-retentive toward the occlusal surface due
to the convergence of the buccal and lingual walls. On the
proximal ­direction, due to the lack of retention related to
divergence of the buccal and lingual walls toward the proxi-
mal surface, the retention needs must be analyzed in rela-
tion to the occlusal box characteristics, because the amalgam
restoration isthmus that connects the occlusal box to the
proximal one aids to retain the restorative material in the
proximal box [20].
If the occlusal box of the preparation is narrow, with
about 1.2 mm or less on the buccolingual direction, the small
volume of amalgam may be not enough to prevent the frac-
ture of the restoration at the isthmus region [20]. This may
occur due to the masticatory load that hits the marginal ridge
of the restoration, which will cause simultaneously tensile
and flexural stress at the isthmus region [11]. On this case,
the retention locks must be prepared at the buccal and lin-
gual walls of the proximal box (. Fig. 6.47a). Some authors
 
recommend the use of those locks only on the cases that the
proximal boxes are wide. However, if the occlusal box of the
Class II preparation is wide due to the carious lesion exten-
sion or due to previous restorations, the retention locks on
the proximal box will rarely be necessary [20].
A study analyzed in vitro the resistance to displacement
of amalgam restorations toward the proximal surface when
different Class II preparation designs were performed [7]. A
vertical slot preparation, without any involvement of the
occlusal groove but with retention locks in the buccal and
lingual walls, resisted to a displacement load of 18.09 kg. A
preparation with the occlusal box in the central groove and
the dovetail lock resisted only 7.12 kg. On the other hand, an
association of the occlusal box with dovetail locks and proxi-
mal box locks resisted to a load of 22.77 kg. They proved that
the preparation of locks at the proximal boxes is much more
effective than the occlusal box, to retain a restoration on the
proximal direction, besides the fact that it preserves the
intact tooth structure on the occlusal surface.
To prepare the retention locks, the conical No. 1061 dia-
mond point or No. 169 bur is applied on the buccoaxial and
linguoaxial line angles, grinding or cutting dentin of the buc-
cal and lingual walls and never on the direction of the pulp,
avoiding a pulpal exposure (. Figs. 10.12u, v and 10.13a′, b′)
 
[11, 13, 20, 22, 25]. In case of large and deep carious lesions,
361 10
the locks must be prepared only after the irregular areas have
been filled with GIC and the walls have been flattened, avoid-
ing that the recently prepared retentions are covered by the
base material. Those locks are prepared with the one-third of
the rotary instrument active head near to the tip, grinding
more on the region closer to the gingival wall than to the
occlusal surface. The grinding is performed mainly with the
tip of the head, with the instrument leaning slightly toward
the direction of the wall, allowing the penetration at the same
depth of the tip diameter, near to the point angle. It is eco-
mended to reduce the depth toward the occlusal surface and
finish at the buccoaxiopulpal or linguoaxiopulpal point
angles in case of a preparation that involves the occlusal sur-
face (. Fig. 10.13a′, b′) or before the DEJ on a vertical slot
preparations (. Fig.  10.12u, v). This procedure results or
retention shaped like a pyramid (. Fig. 6.45b – retention 2)
[13]. A refrigeration only with air will improve the visibility,
and the reduced speed of handpiece will improve the tactile
feeling and the control of the instrument [22]. The end of the
retention must be located at 0.2 mm internally from the DEJ,
avoiding to produce undermined enamel. The retention effi-
cacy can be evaluated by positioning the tip of the explor-
atory probe at this region and pulling it toward the proximal
surface (. Fig. 10.12w, x). This retention can also be prepared
with a gingival margin trimmer, although some dentists pre-
fer to use the small round rotary instruments. The bur is
placed on the point angle near to the gingival wall and moved
along the buccoaxial and linguolabial, up to the point angle
with the pulpal wall [22]. However, the conical rotary instru-
ment is easier to control than a round one [25]. According to
Gilmore and Lund [12], this retention reduces the stress at
the restoration isthmus, also contributing for its resistance.
They make the masticatory loads over the proximal box of
the restoration dissipate on the vertical walls of the proximal
box, instead of creating high stress inside the amalgam, at the
isthmus region. This separates the retention and resistance of
the occlusal box from the proximal one [7].
10.5.1.4  Convenience Form
The axial wall must be slightly expulsive toward the occlusal
surface, and it is performed leaning the rotary instrument
(. Fig. 10.12p) [15]. This leaning allows a visualization of the
gingival wall during the preparation and simplifies the con-
densation of the restorative material. Therefore, it is a conve-
nience form (. Fig. 6.49a, b). In addition, it increases the
material thickness at the region of the limit between the
occlusal and proximal box, increasing the resistance of this
area. The axial wall is generally flat on the buccolingual direc-
tion [15].
10.5.1.5  Removal of the Remaining Carious
Tissue
The remaining carious tissue is removed with a round bur in
the low-speed handpiece. The irregularities of the prepara-
tion geometrical shape may be corrected by the application
of a GIC base (. Figs. 10.12q–t and 10.13u–x).
 362 C. R. G. Torres and D. Mehta

10.5.1.6  Finishing the Enamel Walls works on the buccal one (. Figs. 10.12y, z and 10.13c′, d′). At
 

The preparation of the proximal box of a Class II prepara-
tion with rotary instruments will, certainly, leave under-
mined enamel on the buccal and lingual walls near the
margins (. Fig. 10.15a–d), which will fracture with the time
 
and produce marginal ditches. A study showed that if not
correctly finished, the undermined enamel margins shown
the region of the cavosurface angle of the gingival wall, due to
the cervical leaning of the enamel prisms at this area, when
the wall is made parallel to occlusal plane, there may remain
undermined enamel prisms. They can be removed with the
gingival margin trimmers, working from buccal toward the
lingual surface and vice versa (. Figs. 10.12a′, b′ and 10.13e′,

microfractures after the application of the matrix bands dur-
ing the restorative procedure [5]. Therefore, the use of hand
instruments is essential. As it was mentioned by Howard
[13], to obtain a complete and conservative preparation,
which ensures a long-lasting restoration, is much more
important than save some few seconds that will be necessary
f′). For the mesial cavity, the No. 28 trimmer is used (10-80-
7-14) (R and L) [22]. The dentist should take care for not
making a large bevel but only to trim enough to remove all
the short and undermined enamel prisms [13]. The leaning
of this trimmed area will be of 15–20° toward the gingiva in
relation to the gingival wall surface (. Fig. 6.50) [22]. If there

to use the proper hand instruments [13, 20, 22]. The only
situation that the correct finishing of the buccal and lingual
wall margins of the proximal box can be achieved only with
a rotary ­instrument would be on the case of the absence of
the adjacent tooth. However, the use of the gingival margin
trimmer would still be indispensable at the gingival cavo-
surface angle.
The enamel margin trimming of buccal and lingual walls
of the proximal box is performed with a No. 14–15 enamel
10 hatchet, with the bevel facing inside of the preparation [25].
The No. 14 hatchet trims the lingual wall, and the No. 15
is no enamel at the gingival cavosurface angle, this procedure
will not need to be performed.
10.5.1.7  Cleaning of the Preparation
It is performed with air-water spray, followed by the applica-
tion of detergent solutions, which is washed, and the surface
dried with an airstream. Then, it is possible to apply 2%
sodium fluoride solution for 2 min, followed by drying, or
applying 2% chlorhexidine antimicrobial solution, followed
by washing and drying, according to what has been previ-
ously described for the Class I cavities.

a b

c d

..      Fig. 10.15  Finishing of the enamel walls. a Only with the rotary instruments; b–d with the hand cutting instrument (enamel hatchet)
Tooth Preparations for Amalgam Restorations
10.5.1.8  Final Characteristics
of the Preparation
Occlusal Box
55 The same as the simple Class I preparation.
Proximal Box
55 Flat, uniform, and smooth walls
55 Gingival wall parallel to the occlusal plane
55 Buccal and lingual walls divergent toward the proximal
surface and convergent toward the occlusal surface
55 Axial wall expulsive toward the occlusal surface
55 Internal line angles of the first and second sets, the exter-
nal line angles and point angles round
55 Round axiopulpal angle
55 Hollenback’s reverse curve on the buccal wall of the
proximal box
55 Trimming of the gingival cavosurface angle
55 Mechanical locks on the buccal and lingual walls of the
proximal box
10.5.2  Access Through the Buccal or Lingual
Surfaces
The access to a proximal carious lesion on a posterior tooth,
through the buccal or lingual surfaces, can be chosen when
there are cavitated carious lesions below the contact point,
preferably with a small depth in dentin, cervically located,
with a remaining tooth structure of at least 2 mm of intact
enamel below the marginal ridge [24]. It is especially advan-
tageous when the lesion is located slightly displaced toward
the buccal or lingual surfaces, reducing the amount of
structure to be grind or cut to access the lesion. This situa-
tion is commonly found on lesions at the root and on the
proximal surfaces of the patients with the gingival recession
due to periodontal problems (. Fig. 10.16a) [17]. This type
 
of lesion is classified as a Class II according to Black but is
considered Site 3 according to Mount and Hume. This kind
of preparation, named horizontal slot, was developed by
Roggenkamp et al. [24] and has advantages of saving time,
preservation of the tooth structure, and better esthetic
results, besides not changing the occlusal relations and the
natural proximal contact [10]. It also shows advantages on
rotated teeth. The preparation technique can be observed in
. Fig. 10.16a–l.
 
10.5.2.1  Outline Form
The opening of the cavity is performed with round-shaped
No. 1011 diamond point or No. ½ or 1 carbide bur, which is
placed below the contact point toward the lesion, at the buc-
cal or lingual surface, according to the proximity to the lesion
and the need to hide the presence of the restoration
(. Fig.  10.16b). The adjacent tooth must be protected by a
 
metallic matrix band, stabilized by a wooden wedge, inserted
on the opposite surface of which the access will be performed.
363 10
The outline is performed with the cylinder-shaped No. 1090A
diamond point or No. 56 straight fissure carbide bur. It will
enter the preparation until it reaches the limit of the lesion on
the opposite surface (. Fig. 10.16c) and moved on the occlu-
sogingival direction, creating this way the axial wall. Placing
the rotary instrument on the occlusal limit of the lesion, it is
then moved in the mesiodistal direction, creating the occlu-
sal wall (. Fig.  10.16d). The same procedure is repeated to
prepare the gingival wall (. Fig. 10.16e). This way, the occlu-
sal and gingival walls will be parallel between each other and
perpendicular to the axial wall. The wall opposite to the
lesion access will be flat and perpendicular to the other walls.
10.5.2.2  Resistance Form
The resistance form is obtained by the preservation of the
marginal ridge, which maintains the resistance of the tooth
structure. The surrounding walls form a right angle with the
external surface of the tooth, allowing an adequate thickness
of the restorative material on the restoration margins.
10.5.2.3  Retention Form
Toward the surface where the access to the lesion was per-
formed, the retention is obtained by the fact that the cavity is
larger on the buccolingual direction than on the gingivooc-
clusal direction. On the proximal direction, additional reten-
tion grooves must be prepared on the gingivoaxial and
occlusoaxial line angles, in a way to avoid the displacement of
the restoration. For that, a round No. 1011 diamond point or
No. ¼ or ½ carbide bur or even the conical No. 1061 dia-
mond point or No. 169 carbide bur is applied on an oblique
position in relation to gingival and occlusal walls, as it can be
observed in . Fig. 10.16f, g, on the entire extension of the line
angles. It is very important that the grinding or cutting is per-
formed exclusively on the occlusal and gingival walls, but
never on the axial wall, due to the complete lack of effective-
ness of this grinding on the retention and because of the
pulpal exposure possibility. The retention grooves do not
have to reach the external surface of the tooth, and it is prop-
erly prepared entirely on the dentin.
>> Additional mechanical retention locks or coves should
be never prepared on pulpal or axial walls.
10.5.2.4  Convenience Form
The access to the lesion by the buccal or lingual surface is
already a convenience form because it allows preservation of
the tooth structure.
10.5.2.5  Removal of the Remaining Carious
Tissue
If there is any remaining carious tissue, it must be removed
the way it has already been described for the other types of
tooth preparation, with round burs in low-speed handpiece,
using the larger diameter compatible to the size of the caries
lesion or using dentin spoon excavators.
 364 C. R. G. Torres and D. Mehta

10.5.2.6  Finishing the Enamel Walls apply 2% sodium fluoride for caries prevention, followed
It is performed on the gingival, occlusal, lingual, or buccal only by air drying, according to what has already been
walls, using the No. 14/15 hatchet (. Fig. 10.16h–j).
  described for Class I preparations.

10.5.2.7  Cleaning of the Preparation 10.5.2.8  Final Characteristics

It is performed with an air-water spray followed by a deter- of the Preparation
gent solution, which is washed, and the cavity is dried with 55 Access through the buccal or lingual surface
an air stream. The disinfection of the preparation walls can 55 Flat, uniform, and smooth surfaces
be performed with a 2% chlorhexidine antimicrobial solu- 55 Gingival and occlusal walls parallel between each other
tion, followed by washing and drying. Another option is to and perpendicular to the axial wall

a b

10

c d

e f

..      Fig. 10.16  Horizontal slot preparation. a Caries lesion on the CEJ; b retentions; h–j finishing of the gingival, occlusal and buccal cavosur-
access to the lesion with the round diamond point; c penetration with face angles (the arrows indicate the direction of the movement); k, l
the cylinder diamond point; d preparation of the occlusal wall. e final aspect of the preparation
preparation of the gingival wall; f, g preparation of the mechanical
Tooth Preparations for Amalgam Restorations
365 10

g h

i j

k l

..      Fig. 10.16 (continued)

55 Axial wall parallel to the proximal surface; buccal or
lingual wall perpendicular to the other walls
55 Additional retentions on the occlusal and gingival walls
10.6  Class V or Site 3 on Free Smooth
Surface
They are preparations performed on the cervical third of the
tooth crown. According to Black, it is considered Class V
only the lesions that are located on the free smooth surfaces
Hume, besides those, it is also considered Site 3 the cervical
lesions on the mesial and distal surfaces. In the following
explanation, it will be included the Site 3 preparations on the
buccal or lingual surfaces. Nowadays, the use of amalgam on
this type of cavity is restricted to the posterior teeth, when
there is no esthetics involvement, especially on molars. They
can be shallow lesions on the mechanical point of view, but
they are deep on the biological point of view, due to the
proximity to the pulpal chamber, and special care should be
taken to avoid an accidental pulpal exposure. In
. Fig. 10.17a–o, it is shown the preparation of a large lesion

(buccal and lingual), whereas according to Mount and on the buccal surface of the second mandibular molar.
 366 C. R. G. Torres and D. Mehta

10.6.1  Outline Form
In general, this kind of lesion is already open due to the col-
lapse of the carious enamel. If the lesion is closed, with only a
white or dark spot and intact surface, it is subsurfacial and has
ment create the surrounding walls of the preparation, and its
tip creates the axial wall [13], maintaining the depth of pene-
tration of the rotary instrument at 0.5 mm further than the
DEJ, even if still there is carious tissue further than this region
(. Fig.  10.17b, c). This creates a preparation depth of

to be treated only by preventive measures. The outline is per- 1–1.25 mm on the gingival cavosurface angle, allowing that
formed with a cone-shaped rotary instrument, such as the No. the retention grooves may be prepared later without leaving
1061 or 1063 diamond point or No. 169 carbide bur posi- any undermined enamel [22]. On the case of gingival margins
tioned perpendicular to the surface. The sides of the instru- on the cement, the penetration can be only 0.75 mm [22]. The

a b

10

c d

e f

..      Fig. 10.17  Class V or site 3 preparation on the buccal surface. a
Initial aspect of the caries lesion; b, c beginning of the preparation of
the occlusal wall with the conical diamond point; d–f preparation of
the mesial and gingival walls. g Preparation of the distal wall; h
removal of the remaining carious tissue with the round bur; i, j
treatment of the dentin and flattening of the axial wall with a glass
ionomer cement. k, l preparation of mechanical retentions on the
axiogingival line angle. m, n preparation of the retentions on the
axioocclusal line angle; o aspect of the preparation finished
Tooth Preparations for Amalgam Restorations
367 10

g h

i j

k l

..      Fig. 10.17 (continued)
 368 C. R. G. Torres and D. Mehta
m n
10
..      Fig. 10.17 (continued)
gingival margin generally follows the curvature of the mar-
ginal gingiva, because it is a place where the biofilm grows and
the lesion border is located. On the large lesion, the mesial and
distal margins generally reach the buccomesial and buccodis-
tal or linguomesial and linguodistal axial angles. In general,
those preparations take an oval or kidney shaped [12].
However, the dentist must keep in mind that the final dimen-
sions and the shape of the cavity must be a result of the lesion
shape and the extension, with maximum preservation of the
healthy remaining tooth structure (. Fig. 10.18a–c) [25].
 
10.6.2  Resistance Form
On this type of preparation, the restoration will not be sub-
mitted to direct masticatory loads but only to the stress dis-
tributed inside the tooth structure. However, specific
characteristics may favor its durability. During the prepara-
tion, the axial wall follows the contour of the external surface
of the tooth on the mesiodistal direction, creating a homoge-
neous thickness of the restorative material and the resistance
of the final restoration (. Fig. 10.19a, b) [22, 25]. If the prepa-
 
ration is large on the gingivoocclusal direction, the axial wall
can also follow the curvature of the tooth [22]. In narrow
cavities, the axial wall is generally flat on the gingivoocclusal
direction [13].
Due to the convex shape of the buccal and lingual sur-
faces, to the walls to follow the leaning of the prisms, the sur-
rounding walls must be divergent toward the external surface
of the tooth, to obtain a 90° cavosurface angle (. Fig. 10.20),
which is obtained with the use of cone-shaped rotary instru-
ments with flat tip (. Fig. 10.17c–g) [13, 22].
On the mesiodistal direction, due to the convex shape of
the tooth surface near to the axial angles, the mesial and dis-
tal walls must be slightly divergent toward the external sur-
face, in a way to follow the direction of the prisms and form
a right angle with the external tooth surface [13]. To improve
the adaptation of the restorative material and the mechanical
behavior of the restoration, the walls must be flat, uniform,
and smooth.
10.6.3  Retention Form
Due to the non-retentive shape of the surrounding walls,
additional retention must be prepared. For that, retention
grooves are prepared along the entire extension of the occlu-
soaxial and gingivoaxial line angles, on the occlusal and gin-
gival walls. It is done with a short inverted cone point (No.
1031) or carbide bur (No. 33 ½), positioned with its long axis
perpendicular to the axial wall, or with a round diamond
point (No. 1011) or carbide bur (No. ½), with a depth of
Tooth Preparations for Amalgam Restorations
369 10

a b

..      Fig. 10.18  a–c Variations on the outline form of the Class V preparation. The outline must be the most conservative as possible, involving only
the tooth structure affected by the lesion

a b

..      Fig. 10.19  a, b Contour of the axial wall in small and large preparation, respectively, in relation to the mesiodistal direction

0.25 mm, which corresponds to half diameter of the rotary 10.6.4  Convenience Form
instrument head (. Fig. 10.17k–n) [16, 22, 25]. The use of the
 

round rotary instruments is especially recommended on the In the case of large cavities on the mesiodistal direction, due
maxillary molars, once the access adversely affects the cor- to the fact that the free smooth surfaces of the tooth are con-
rect placement of the inverted cone instrument [16]. To ver- vex, the axial wall of the preparation should also be convex
ify the retention quality, the tip of an exploratory probe is (. Fig. 10.19b) [13]. It is also considered a convenience form
 

placed inside the retention groove and pulled toward the because it avoids an accidental pulpal exposure, which could
external surface. happen in case it was prepared flat [16, 25]. In the case where
 370 C. R. G. Torres and D. Mehta

55 Divergent surrounding walls

55 Additional retention grooves on the occlusoaxial and
gingivoaxial line angles

..      Fig. 10.20  Direction of the gingival and occlusal walls of the Class
V preparations
the cavities are small on the mesiodistal direction, the axial
wall is generally flat (. Fig. 10.19a).
Conclusion
This chapter described the principles associated with the
preparation of posterior teeth to receive amalgam restora-
tions. The preparation procedure for Class I, II, and V cavities
was presented, including all characteristics on each case to
get retention and strength for the restoration. Due to its non-
adhesive characteristics, the details shown are extremely
important for the durability of the restoration, and must be
kept in mind when this kind of procedure is performed by the
clinician. Although the use of amalgam is being extremely
reduced in recent years, it is still an excellent alternative in
cases where the control of moisture is difficult or the access
to modern material is restricted due to economic reasons.

References

10.6.5  Removal of the Remaining Carious 1. Alexander WE, Mc Donald RE, Stookey GK. Effect of stannous fluo-

10 Tissue ride on recurrent caries—results after 24 months. J Dent Res.

On this stage, any remaining carious tissue can be removed
with a large round bur at low speed, of a diameter compatible
of the preparation size, or with an excavator spoon
(. Fig.  10.17h). The undermined or irregular areas of the
remaining tooth structure can be filled with GIC and the geo-
metrical shape prepared over the base material (. Fig. 10.17i,   5. Boyde A, Knight PJ. Scanning electron microscope studies of class II
j). If a base is necessary, the retention grooves must be pre-
pared after its placement, in a way to avoid its closing during
the base material application.
10.6.6  Finishing the Enamel Walls
Due to the expulsive shape of the surrounding walls, no
undermined enamel prisms will be left after the use of the
rotary instrument.
10.6.7  Cleaning of the Preparation
It is performed in the same way as described for other prepa-
rations.
10.6.8  Final Characteristics
of the Preparation
55 Flat, uniform, and smooth walls
55 Round line angles of the first set
55 Sharp line angle of the second set
55 Convex axial wall following the contour of the buccal or
lingual surface on large preparation or flat axial wall on
small preparation
1973;52:1147. https://doi.org/10.1177/00220345730520052401.
2. Almquist TC, Cowan RD, Lambert RL. Conservative amalgam resto-
rations. J Prosthet Dent. 1973;29:524–8.
3. Baratieri LN.  Dentística. Procedimentos preventivos e restaura-
dores. 2nd ed. Sao Paulo: Santos; 1993.
4. Baratieri LN, Monteiro Junior S, Andrada MA, Ritter AV. Odontologia
Restauradora: Fundamentos e Possibilidades. Santos: São Paulo;
2001.
cavity margins. Matrix band application. Br Dent J. 1972;133:331–7.
6. Bronner FJ. Engineering principles applied to class II cavities. J Dent
Res. 1930;10:115–9.
7. Crockett WD, Shepard FE, Moon PC, Creal AF. The influence of proxi-
mal retention grooves on the retention and resistance of class II
preparations for amalgams. J Am Dent Assoc. 1975;91:1053–6.
8. Dérand T.  Marginal failure of amalgam class II restoration. J Dent
Res. 1977;56:481–5. https://doi.org/10.1177/002203457705600506
01.
9. Elderton RJ.  The prevalence of failure of restorations: a literature
review. J Dent Elsevier. 1976;4:207–10. https://doi.
org/10.1016/0300-5712(76)90049-X.
10. Ewoldsen N.  Facial slot class II restorations: a conservative tech-
nique revisited. Can Dent Assoc. 2003;69:25–8.
11. Fichmann DM, Santos W.  Restaurações à amálgama. Savier: São
Paulo; 1982.
12. Gilmore HW, Lund MR.  Operative dentistry. Saint Louis: Mosby;
1973.
13. Howard WW. Atlas of operative dentistry. 2nd ed. St. Louis: Mosby;
1973.
14. Mertz-Fairhurst EJ, Curtis JW, Ergle JW, Rueggeberg FA, Adair
SM. Ultraconservative and cariostatic sealed restorations: results at
year 10. J Am Dent Assoc Elsevier. 1998;129:55–66. https://doi.
org/10.14219/JADA.ARCHIVE.1998.0022.
15. Mondelli J, Franco EB, Pereira JC, Ishikiriama A, Francischone CE,
Mondelli RL, et al. Dentística: Procedimentos Pré – Clínicos. Santos:
São Paulo; 2002.
16. Mondelli J, Ishikiriama A, Galan JJ, Navarro MF.  Dentística Oper-
atória. Sarvier: São Paulo; 1976.
17. Mooney B. Operatoria dental. Panamericana: Buenos Aires; 1995.
18. Mount GJ, Hume WR. A revised classification of carious lesions by
site and size. Quintessence Int (Berl). 1997;28:301–3.
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19. Neto NG, Carvalho RC, Russo EM, Sobral MA, Luz MA. Dentística Res-
tauradora: Restaurações diretas. Santos: São Paulo; 2003.
20. Osborne JW, Summitt JB.  Extension for prevention: is it relevant
today? Am J Dent. 1998;11:189–96.
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in relation to iatrogenic preparation damage. J Dent Res.
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22. Roberson TM, Heymann H, Swift EJ. Sturdevant’s art and science of
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1972;68:132–8.
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24. Roggenkamp CL, Cochran MA, Lund MR. The facial slot preparation:
a nonocclusal option for class 2 carious lesions. Oper Dent.
1982;7:102–6.
25. Simon WJ.  Clinical operative dentistry. Philadelphia: Saunders;
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26. Stratis S, Bryant RW. The influence of modified cavity design and
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https://doi.org/10.1046/j.1365-2842.1998.00227.x.
27. Vale W. Cavity preparation. Iri Dent VRev. 1956;2:33–41.
 373 11

Amalgam Restorations
Carlos Rocha Gomes Torres, Shankargouda Patil, and Graziela Ribeiro Batista

11.1 Introduction – 374

11.2 Instruments and Materials – 377

11.3 Restorative Technique – 378

11.3.1  lass II Restorations (Site 2) – 378
C
11.3.2 Restoration of Compound Class I Preparations – 394
11.3.3 Restoration of Class V Preparations (Site 3) – 397
11.3.4 Restoration of Horizontal Slot Preparations – 397

11.4 Finishing and Polishing – 402

11.5 Durability of Amalgam Restorations – 405

11.6 Controversy About the Use of Amalgam – 407

References – 409

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_11
 374 C. R. G. Torres et al.
Learning Objectives
The learning objectives of this chapter are related to the fol-
lowing topics:
55 Instruments and materials necessary to perform the
restoration
55 Restorative technique for Class I (simple and compound),
II, and V preparations
55 Application of the matrix and wedge for Class II and V
restorations
55 Trituration and condensation
55 Pre-carve burnishing procedure
55 Carving of occlusal and smooth surfaces
55 Post-carve burnishing procedure
55 Occlusal adjustment or a new restoration
55 Finishing and polishing of amalgam restoration
55 Durability of amalgam restorations
55 Controversy about the use of the amalgam
11.1  Introduction
Amalgam means any material that contains mercury as the
main ingredient on its composition. A specific combination
based on the mixture of silver-tin alloy with mercury is called
dental amalgam. It is condensed into a tooth preparation,
11 becoming solid after crystallization [16]. It is one of the oldest
restorative materials that is still in use. An old Chinese medi-
cal text written by Su Gon in 659 a.d. describes the use of a
silver paste to restore teeth. Another text, from 1505, describes
the composition of such silver paste, which should be pre-
pared with 10 parts of mercury, 4.5 parts of silver, and 9 parts
of zinc. Around 1833, this material was brought from Europe
to the United States, causing being rejected from most den-
tists of that time which considered that only the cohesive gold
foil should be used for tooth restorations. That began the so-
called amalgam war, and the American Society of Dental Sur-
geons (ASDS) declared that the use of amalgam should be
considered malpractice, trying to oblige all members to never
use this material and sign a pledge to abstain from its use. This
attitude leads to the premature disbanding of ASDS because
most of its affiliated members decided to leave the society
[15]. The composition of amalgam alloy was studied by
the famous professor Greene Vardiman Black, in 1895, who
improved its physical properties and created its standardiza-
tion, which increased its acceptance by the practitioners.
Amalgam means any material that contains mercury
as the main ingredient on its composition. A specific
combination based on the mixture of silver-tin alloy with
mercury is called dental amalgam.
According to Markley, amalgam has saved and continues to
save more teeth than all the other restorative materials com-
bined [12]. Several factors contributed and continue to con-
..      Fig. 11.1  Restoration removed showing oxides deposited on the
walls, which promote the sealing of the interface
tribute for this material’s huge clinical success. Among them
are the low cost in relation to the indirect restorations and the
direct composite and its simple technique of use. It is also less
sensible to some variations of the restorative procedure. It
presents a high resistance to masticatory loads and wear.
After the polishing, its superficial roughness is satisfactory,
which results in a smaller bacterial adhesion in relation to the
other direct restorative material. It also presents the capacity
of self-sealing the tooth/amalgam interface, by deposition of
corrosion products, which progressively reduces the mar-
ginal microleakage with time, preventing the occurrence of
caries lesions in the interface and decreasing the postopera-
tive sensitivity [6]. The corrosion products deposited on the
interface are tin oxide, tin oxychloride, and some copper
oxides, as can be observed in . Fig. 11.1 [9]. All those factors
allow an excellent clinical durability for those restorations,
which can reach 20 years or more.
However, one of the most important deficiencies of the
silver amalgam is its metallic color, creating unesthetic resto-
rations with artificial appearance. This has resulted in the
decrease of amalgam use, especially on more economically
developed countries. Despite the efforts of the researchers to
develop an esthetic material that could replace amalgam, a
large number of restorations are still made using this material
worldwide [14]. However, on the economically deprived
countries, the access to dental treatment has increased, and
amalgam is still used for the treatment of teeth affected by
caries lesion. This made the amount of dental amalgam sold
on the entire world still big, despite the fact that the prefer-
ence for its use is decreasing.
Nowadays, the dental amalgam is indicated only for res-
torations on the posterior teeth, where the esthetics is not a
main concern, such as on medium- to large-sized Class I and
II preparations and large Class V preparation. Its choice as a
restorative material is based on the size of the area to be
restored; on the materials used on the nearby areas, such as
Amalgam Restorations
on the adjacent and antagonist teeth; economical factors; and
whether it will produce an acceptable esthetic result [10]. The
physical properties of the crystallized amalgam have a great
influence on its clinical applications. The compressive
strength of the enamel is about 400 MPa, while for the amal-
gam, it is around 340–510 MPa. However, its tensile strength
is only 48–70 MPa, which produces a good resistance to
compressive loads during mastication but predisposes to
fracture when strong tensile forces are predominant [16].
Therefore, its ideal indication is intracoronal tooth
­preparation, where it will mostly undergo compressive loads.
When comparing the characteristics between the amal-
gam and composite resin, some factors can be considered.
The amalgam has a coefficient of thermal expansion 2.5 times
bigger than the tooth structure, but smaller than composite
which is 3–6 times greater than the tooth. That makes the
restoration to suffer higher volumetric changes than the
tooth structure during thermal variations in the oral cavity.
In addition, it is more wear resistant than the composite and,
therefore, is indicated on restorations of teeth with heavy
occlusal load or when all the occlusal contacts of the teeth
must be restored, situations which are challenging to the
composites [16]. It is also indicated on the cases where the
lesions reach the root surface, with absence of enamel on gin-
gival margin, due to the poor adhesion of composites to the
dentin/cementum margin and formation of marginal gaps
[16]. It is also the best material on the areas of hard isolation
of the operating field, because of the higher risk of prepara-
tion contamination with water, saliva or blood. Even though
contamination is never desired, it is less damaging for amal-
gam restorations than for composite. However, due to its
adhesive properties, composites allow more conservative
tooth preparations than amalgam and are the first choice on
very small carious lesions [16]. Therefore, amalgam is mainly
indicated for large cavities on severely destroyed posterior
teeth [9].
Other advantage of amalgam over direct composite resto-
ration is that the first is condensed into the cavity instead of
just adapted into it. The condensation pressure toward the
gingival wall helps to assure that no internal empty spaces
remain along the margins. The condensation toward the
proximal direction aids to assure to obtain the proximal con-
tact and the adequate contour. When using composite resin,
the application does not move the band toward the contact.
The proximal contact and the contour are obtained mainly
due to the correct use of matrix and wedge system [16].
The dental amalgam alloy may vary according to its com-
position. Although the basic components are silver, tin, cop-
per, and zinc, the amount of each ingredient varies between
the commercial brands. Conventional alloys have 65–70%
silver, 25–30% tin, 0–6% copper, and 0–2% zinc [9]. Silver is
the main component, while tin is more soluble in mercury
and provides a better crystallization reaction, also improving
the characteristics for handling and adaptation in the prepa-
ration. The first dental amalgams used to contain less than
5% of copper and showed limited corrosion resistance. In
1965, the first high-copper amalgam alloy was available in
375 11
..      Fig. 11.2  Dental amalgam crystallization reactions
market, which was proved to be much more resistant to cor-
rosion. Amalgam alloys are considered high-copper-content
ones when they have 10–30% of this metal [9]. The higher
copper level of these alloys reduces the formation of λ2 phase,
produced by the reaction between tin and mercury, since tin
reacts with copper forming the ε and η1 phases (copper-tin)
[9]. Those alloys are preferred in relation to the low-copper
content ones because they produce more resistance and
durable restorations.
On . Fig. 11.2, it is shown the setting reactions of silver
amalgam, according to its composition. After the mixture,
mercury begins to dissolve and react with the external layer
of silver-tin particles. About 15% of these particles are con-
sumed to produce a complete reaction with mercury to
yield a matrix of solid materials derived from the reaction.
The particles of the alloy that do not react remain mixed
inside the matrix to contribute to the mechanical strength.
Initially, the material shrinks due to particle dissolution.
However, with the crystals growing, an expansion finally
happens and compensates the initial shrinkage. The amount
of copper on the alloy influenced the amalgam creep, which
is the plastic deformation of the material after its setting
when receiving a constant low-level load, such as the occlu-
sal contact over the restoration. When deforming, the amal-
gam is projected beyond the margins, resulting in marginal
degradation.  The larger the copper level in the alloy, the
lower the creep will be.
There are two types of high-copper-content alloys. The
first is a mixture of low-copper-content lathe-cut particle
with high-copper-content spherical particles. On this case,
the reaction occurs in two stages. On the first stage, the for-
mation of λ2 phase (mercury-tin) happens, but it is quickly
converted into ε and η1 phases (copper-tin) on the second
stage. The second type of alloy is a single composition with all
particles having high copper content. On this case, there is no
formation of λ2 phase (. Fig. 11.2).
 376 C. R. G. Torres et al.
The compressive strength of λ phase (silver-tin) is 4923
kg/cm2, while that of λ1 (silver-mercury) phase is 1758 kg/
cm2 [5]. On the other hand, the compressive strength of λ2
phase is of only 703 kg/cm2, and this way it is the most fragile
phase of the crystallized amalgam. It forms a continuous web
inside the material. This way, once the corrosion begins, it
continues through the whole restoration [9]. On the conven-
tional amalgam, there is selective corrosion on λ2 phase,
while on the high-copper-content amalgam, there is a selec-
tive corrosion on ε and η1 phases [9]. On the other hand, ε
and η1 crystals do not communicate with λ2 crystals, reduc-
ing the corrosion, which will happen only on the surface.
Therefore, the presence of λ2 phase must be avoided at all
costs, and it is recommended the use of high-copper-content
alloys. They show a higher corrosion resistance and compres-
sive strength, a smaller marginal degradation, and a higher
surface gloss after polishing in relation to the conventional
ones [9]. Both low- and high-copper-content alloys produce
corrosion products such as tin oxide (solid) and tin oxychlo-
ride (soluble) crystals. The solid corrosion products help to
seal the interface tooth restoration.
Zinc has been added to the alloys to act as a scavenger of
foreign substances, such as copper and tin oxides, during the
manufacturing process [9]. However, when in contact with
water during the condensation into the cavity, the formation
11 of ZnO and hydrogen gas (H2) occurs, which may result in
the delayed expansion of the material and cause the fracture
of the remaining tooth structure [12]. Clinically, it can be
observed that the material extrudes from the cavity, as can be
seen in . Fig. 11.3. It is considered acceptable a dimensional
 
change of approximately 20 μm/cm for the material after the
crystallization. However, on the case where the material
comes in contact with water, values up to 400 μm/cm are
observed after 8 h [6, 9]. On those cases, it is common for the
patient to report a delayed dental sensitivity, 5–7 days after
receiving the restoration, due to the stress caused by the
restorative material on the preparation walls [12]. The con-
tact with water can also produce porosity on the surface [12].
For this reason, some alloys have no zinc on its composition.
..      Fig. 11.3  Delayed amalgam expansion due to moisture contami-
nation at the moment of the amalgam insertion
However, the zinc-free alloys present an inferior clinical per-
formance than zinc-containing ones, because it increases the
corrosion resistance in the oral cavity and reduces the mar-
ginal failures [9]. This occurs due to the corrosion of the Zn
instead of the Cu-Sn phase [9]. The oxide scavenger proper-
ties of Zn keep the amalgam with a light color during the
manufacturing process and throughout the clinical life of the
restoration [6]. The zinc-free alloys used to be indicated on
pediatric dentistry, when the control of the moisture was
harder, mainly on deciduous teeth.
According to the method of production of amalgam alloy
particles, they may have different morphologies. The most
common type is called lathe-cut particles (. Fig. 11.4a). They
are irregular particles obtained by melting the metals to make
an ingot, which is ground to produce “shavings” of metal that
are milled to reach the recommended particle sizes, which is
verified by passing it through sieves [6]. Then, the particles
receive a thermal treatment to release the internal stress
induced by the grinding process. They can be classified
according to the particle size in regular cut, with larger par-
ticles, and fine cut, with smaller particles. The use of fine-cut
particles allows a better adaptation on the cavity angles than
the regular-cut ones and also a better surface smoothness
after polishing [6]. They also mix faster with mercury and are
better handled by the dentist, have a more uniform setting
reaction, and produce a higher initial strength for the resto-
ration [6]. The lathe-cut particles have the advantage that,
during the condensation procedure, the particles come close
and interlock, maintaining its position. During this proce-
dure, the total volume of the material is reduced by the elim-
ination of the empty spaces and the excess of mercury.
Therefore, it can be considered that amalgam really becomes
more dense. The average particle size of modern alloys is up
to 20–25 μm.
Other distinct types of amalgam alloy particle are
obtained through atomizing the melted alloy, spraying
through a jet nozzle under high pressure, inside a cold atmo-
sphere containing nitrogen gas, which protect the particles
from oxidation during the cooling period [9]. This proce-
dure results in the formation of small spheres (. Fig. 11.4b).
Then, they are treated with acid and undergo a thermal
treatment. The spherical alloys have the advantage to form
amalgams that better adapt to the irregularities of the prepa-
ration, need smaller condensation pressure, and are easier to
carve, producing a better superficial smoothness of the res-
toration [9, 16]. In addition, they need 10% less mercury for
amalgamation [14]. However, this material cannot be con-
densed with small instruments, because the particles “slide”
on each other. The smaller condensation force applied makes
more difficult to obtain an adequate contact point with the
neighbor tooth [9].
To associate the positive properties of both types of par-
ticles, the admixed alloy was developed with both lathe-cut
and spherical particles (. Fig.  11.4c) [19]. Also called dis-
persed phase alloy, it generally has 2/3 of spherical and 1/3 of
lathe-cut particles. Adjusting the ratio of the two particles,
the manufacturers were able to obtain the ideal material in
Amalgam Restorations
377 11

a b c

..      Fig. 11.4  Types of amalgam alloys. a Lathe cut; b spherical; c admixed

..      Fig. 11.5  Organization of the

clinical instruments for amalgam
restorative procedure

terms of physical properties and handling characteristics [9]. 55 Flat first surface clinical mirror
This material offers easy condensability, adequate adaptation 55 Double exploratory probe
into the cavity irregularities, and good surface smoothness. 55 Iris straight scissor
The selection of the alloy to be used must be performed con- 55 Rubber dam frame
sidering the setting time, consistency, carvability, and surface 55 Ainsworth or Ivory puncher
smoothness, inside the limits of the acceptable physical prop- 55 Palmer clamp holder forceps
erties [6]. 55 Rubber sheet
55 Clamps No. 200, 202, 205, 207, 209, and 14 A
55 Dental floss
11.2  Instruments and Materials 55 Number 1 plastic filling instrument
55 Amalgam carrier
To perform the restorative procedure using dental amalgam, 55 Amalgam well or a rubber dappen dish
the instruments and materials necessary are described below. 55 Tofflemire matrix retainer
A suggestion for organization of the instruments on a logical 55 Matrix bands of two widths (5 and 7 mm)
sequence of use can be observed in . Fig. 11.5.  55 Dentin excavator spoon (No. 17 and No. 19)
55 Amalgam alloy and mercury, preferably pre-­ 55 Alcohol lamp
proportioned capsules 55 Low fusing compound
55 Dental tweezer 55 Anatomic wooden wedge of several sizes
 378 C. R. G. Torres et al.
55 Curved Halstead mosquito forceps
55 Ward amalgam condensers (No. 00, No. 1, No. 2, and
No. 3)
55 Hollenback carvers (No. 3 and No. 3S)
55 Frahm carvers (No. 2, No.6, and No. 10)
55 Shoshan-A carver
55 Discoid-cleoid carver
55 Interproximal carver (IPC I)
55 Egg-shaped burnisher (No. 29)
55 Bennett burnisher (No. 33)
55 Hollenback burnisher (No. 6)
55 Miller articulating paper forceps
55 Thin double-color articulating paper (black and red)
11.3  Restorative Technique
When the tooth preparation is finished, the operating field
must be properly isolated, avoiding amalgam contamination
by moisture from saliva or crevicular fluid, which could
result in a delayed expansion, surface corrosion and tarnish
increasing, strength reduction, and premature failure of the
restoration. Preferably, rubber dam isolation should be made,
even though a well-performed and monitored cotton roll iso-
lation on a patient with a low salivary flow can also be accept-
11 able.
After that, the preparation cleaning is performed. On
shallow and medium-depth preparation, an anionic deter-
gent is applied, followed by washing with air/water spray and
drying with airstream. Then, a neutral 2% sodium fluoride
solution is applied for 2–4 min and dried with an airstream.
Another option is to rub for 30s onto the preparation walls a
dentin desensitizer, containing 5% glutaraldehyde and 35%
hydroxyethyl methacrylate (HEMA), which reduces the den-
tin permeability by protein precipitation inside the tubules
[16]. After that a gentle drying is performed, without desic-
cating the dentin. On deep and very deep preparations, the
need of a pulpal protection must be evaluated, with the appli-
cation of a liner material, as described in 7 Chap. 9. A base
can be placed on the pulpal wall, to create a flat surface, or on
the surrounding walls to fill the undermined enamel areas,
creating the artificial dentin. The amalgam has a high ther-
mal conductivity. Therefore, it should not be placed near the
dental pulp without a liner or a base [16]. It is important that
the liner or base material does not reach the cavosurface
angle, which must be in contact with amalgam.
>> Amalgam has a high thermal conductivity and should
not be placed in direct contact with pulpal wall of deep
preparations without a liner or a base.
11.3.1  Class II Restorations (Site 2)
The following sentences describe the entire restorative tech-
nique for a Class II preparation, involving the proximal sur-
face (. Fig.  11.6a–m′). Except the matrix and wedge
 
application steps, the restorative technique for Class I prepa-
rations is exactly the same. Therefore, it will not be described
separately.
11.3.1.1  Application of the Matrix and Wedge
For amalgam to reach the required and physical properties
produce a long-lasting restoration, it needs to be strongly
condensed on a space with rigid walls [12]. In case of Class II
preparations, a matrix and wedge system must be used,
according to what has been detailed in 7 Chap. 8. The type
most commonly used is the universal matrix, using a matrix
retainer. In case the tooth to be restored is the anchor tooth,
which will receive the retention clamp for the rubbed dam
isolation, a custom-made riveted, welded, or T matrix can be
chosen since the clamp interferes on the correct placement of
the matrix retainer [6, 13]. The same is valid when the proxi-
mal boxes are very large on the buccolingual direction or one
or more cusps were lost, which impair the proper contour of
the universal matrix.
First of all, a matrix band must be selected. The straight
or boomerang-shaped strip can be used. One of the two
occluso-­gingival widths (5 or 7 mm) is chosen. The correct
width is selected according to the occluso-gingival dimen-
sions of the tooth to be restored. To the gingival direction,
the strip width must be enough to surpass more or less
1 mm of the gingival cavosurface angle of the preparation.
To the occlusal direction, the edge of the band must go
1 mm further than the marginal ridge of the adjacent tooth,
allowing the correct reconstruction of the proximal surface
[9, 10, 12, 16]. About 7 cm of strip is used for the premolars
and molars.
The thickness of the matrix band varies from 0.03 to
0.05  mm [6, 9]. The thicker and thinner ones both have
inconvenients. The thinner ones are hard to pass through
the proximal contact area due to insufficient stiffness,
besides the fact that they can easily be deformed during
amalgam condensation, increasing the risks of overhangs
on the margins. The thicker ones remain more stable during
the condensation, but a proper wedging and burnishing of
the matrix are essential, to create an adequate proximal
contact.
After that, the matrix band can be assembled on the
retainer. If the Tofflemire type is selected, the model with
guide posts at a 90° angle is placed on the buccal side of the
tooth, while the model with the guide posts contra-angled is
placed on the lingual side, indicated when the preparation
extends to the buccal surface (. Fig. 8.15a) [6, 16, 20]. The
matrix retainer is placed with the slotted side of the head
directed gingivally to allow easy separation of the retainer
from the band occlusally [9, 16]. In general, the long axis of
the instrument is placed on the mesiodistal direction [6].
The buccal or lingual placement is a matter of convenience
and amount of remaining tooth structure. However, on the
mandible, the lingual placement is, sometimes, more ade-
quate due to the leaning of the buccal surface toward the
lingual side, providing better stability to the retainer [9].
Amalgam Restorations
Tip
The buccal or lingual placement of the retainer is a mat-
ter of convenience and amount of remaining tooth struc-
ture. However, on the mandible, the lingual placement is
sometimes more adequate due to the leaning of buccal
surface toward the lingual side, providing better stability.
Then, the contour of the matrix band can be modified to
adapt the convex contour of the proximal surface of the pos-
terior teeth. For that, it is analyzed which part of the matrix
will be responsible for the restoration of the proximal contour
and the contact point. Without removing the matrix from the
retainer, this section is placed over a paper mixing pad and
burnished with a No. 29 egg-shaped amalgam burnisher [10,
16]. It is rubbed perpendicularly to the long axis of the strip,
a b
c d
..      Fig. 11.6  MOD amalgam restoration. a Tooth preparation; b
burnishing of the matrix at the region of contact over the paper mixing
pad; c traction of the rubber sheet; d wedge application; e Test of
wedge retention; f checking the gingival margin matrix adaptation; g
burnishing of the matrix; h checking the positioned matrix and wedge
system; i application of amalgam; j, k condensation toward the internal
angles of the proximal box; l filled proximal boxes; m, n Filling and
condensation on the rest of the preparation; o condensations toward
the buccal restoration margin; p condensation toward the lingual
restoration margin; q pre-carve burnishing; r carving of the occlusal
embrasure in the marginal ridge; s carving of the cusps incline; t
379 11
as can be observed in . Fig. 11.6b. It can also be used for this
purpose a No. 144 contouring plier. Care must be taken to
establish the contour in harmony with the tooth to be restored,
with a particular curvature for that contact area [10]. Then,
the set is taken in position and the matrix is tightened. Care
on the assembling and the application of the matrix is more
important than tightening it. Tightening the matrix strongly
around the tooth does not necessarily mean that it will pre-
vent overhangs or produce the desired contour [10]. Instead,
this may result in an inadequate contour [6]. At this moment,
the selected matrix must be checked if it has the adequate
width, that is, if its margin is cervical to the gingival cavosur-
face angle and above the marginal ridge of the adjacent tooth.
The next step is the application of the wooden wedges
in the interproximal space, in a way to avoid the overflow
of amalgam to the cervical region, create a slight tooth dis-
placement, and compensate the thickness of the matrix band
removal of the matrix retainer; u, v Removal of the matrix band; w
adjustments of the height of the marginal ridge; x removal of the
cervical excess; y, z, a′, b′ use of the No. 3S Hollenback, cleoid, discoid,
and No. 2 Frahm carvers, respectively; c′, d′ Use of No. 6 and 10 Frahm
carver; e′ superficial smoothing with a small cotton ball; f′ visualization
of the proximal contour and the contact point; g′, j′ post-carve
burnishing with the exploratory probe and No. 6, No. 33, and No. 29
burnishers, respectively; k′ Passing the dental floss through the
contact point touching the adjacent tooth; l′ smoothing the cervical
region with the dental floss; m′ final aspect of the burnished restora-
tion
 380 C. R. G. Torres et al.

e f

g h

11

i j

k l

..      Fig. 11.6 (continued)
Amalgam Restorations
381 11

m n

o p

q r

s t

..      Fig. 11.6 (continued)
 382 C. R. G. Torres et al.

u v

w x

11

y z

a’ b’

..      Fig. 11.6 (continued)
Amalgam Restorations
383 11

c’ d’

e’ f’

g’ h’

i’ j’

..      Fig. 11.6 (continued)
 384 C. R. G. Torres et al.
k'
m'
11
..      Fig. 11.6 (continued)
[6, 12, 20]. They are applied through the larger embrasures
that in general are the lingual ones. There is an exception
between the first and the second maxillary molars, due to
the larger dimension of the lingual surface of the maxillary
first molar. However, on the cases of teeth that are rotated or
badly positioned somehow, the situation must be analyzed
to check which really the larger embrasure is. The wedges
are inserted with a curved mosquito-type forceps or with
specific forceps for this purpose to allow a better grasp [12].
Sometimes the rubber dam tends to loosen the wedge, due to
the fact that wedge application results in the stretching of the
rubber, which tends to go back to its original position, and
this pulls the wedge out of the interproximal space. To avoid
this situation, the rubber septum is stretched before and dur-
ing the application of the wedge, on the opposite direction
(. Fig. 11.6c, d) [16]. The wedge size is chosen according to
 
the size of the interproximal space. It is very important to
apply it between the teeth with some pressure; otherwise, it
will not work properly. When there is a MOD preparation
to be restored, the wedges are placed simultaneously on the
mesial and distal surfaces of the tooth. Amalgam overhangs
may happen as a result of the wedges loosening before the
condensation. To avoid this problem, it is important to check
if they are firmly settled in the interproximal space, trying
to pull it with a slight force using the tip of an exploratory
probe (. Fig.  11.6e). A slightly force should not cause its
 
displacement [16].
l'
After that, the adaptation of the matrix on the cervical
region is checked with the tip of an exploratory probe, which
is pressed toward the cavosurface gingival angle (. Fig. 11.6f)
[16]. The dentist must press and drag the probe’s tip along the
margins, on both direction, which also contributes to dis-
place any weakened and undermined enamel left. An air-
stream is then applied to clean all the fragments [16]. If the
probe penetrates between the matrix and the cavosurface
angle, that indicates the possibility of amalgam overflow dur-
ing the condensation. On this case, the wedge must be
removed and replaced by another with larger dimensions,
repeating the checking process. The width of the wedge base
must be slightly larger than the space between the tooth to be
restored and the adjacent one, to separate them [9]. It must
touch the external surface of the tooth cervically in relation
to the gingival wall of the preparation [9].
To guarantee the correct restoration of the proximal con-
tact, an additional burnishing of the matrix band toward the
adjacent tooth is performed using the back of a dentin spoon
or a No. 6 Hollenback’s burnisher (. Fig.  11.6g) [16]. It is
moved on the buccolingual direction. Then, the matrix is
checked to see if it is properly touching the adjacent tooth,
when observing it from the buccal or lingual direction, with
the aid of a clinical mirror (. Fig. 11.6) [16]. If there is still no
contact, the matrix retainer can be loosened slightly and the
matrix burnished once again. If the contact is still not estab-
lished, then a custom-made matrix should be prepared [16].
Amalgam Restorations
11.3.1.2  Trituration and Condensation
When the operating field is isolated, the cavity is cleaned, and
the matrix and wedge system is in position, the trituration or
mixing of the amalgam can start to fill the preparation. The
aim of trituration is to remove the thin layer of oxide that
covers the particles and make them come in perfect contact
with mercury, allowing an adequate and homogeneous set-
ting reaction [6]. On the market amalgam alloy powder or
tablets and mercury can be found in bulk on separated bot-
tles or in pre-proportioned capsules (. Fig. 11.7a, b).
 
The trituration of alloy in bulk can be performed manu-
aly or through a mechanical device. For the manual tritura-
tion, the alloy:mercury ratio  must be defined  by weight,
through a Crandall’s scale, and the mixture performed with a
ground glass mortar and pestle. Depending on the alloy type,
this ratio may vary. In general, a 1:1 ratio is used. However,
the alloys with spherical particles may use a 4:5 ratio, result-
ing in 42–44.5% of mercury. However, the correct ratio will
depend on the material to be used, and the manufacturer’s
instructions must be followed. The amount of mercury
required is the one enough to cover the individual particles of
the alloy [6]. The lesser mercury used, the faster the setting of
the material will be [6]. In general, the smaller the size and
the more uniform the shape of the particles are, the lesser the
necessary amount of mercury will be. The spherical particles
have a smaller surface area in relation to weight, and that is
why they require less mercury to be wetted [14].
On . Fig.  11.8a–o, it is presented the sequence for
 
Crandall’s scale use and the hand trituration. First, the desired
amount of mercury is placed on the scale according to the
size of the preparation, which will cause the scale to lean to
one of the sides (. Fig. 11.8a–c). The weights are moved until
 
it is once again on the horizontal position (. Fig.  11.8d).
 
Then, mercury is transferred to the mortar, which will cause
the scale to lean to the other side (. Fig.  11.8e, f). If a 1:1
 
a b
..      Fig. 11.7  a Mercury and amalgam alloy in bulk; b pre-­proportioned capsules
385 11
ratio  is used, the scale is already set. If necessary, a cross-­
multiplication can be used to find the correct amount of alloy
will reach the manufacturer’s recommended ratio for that
amount of mercury. The scale is adjusted, and the alloy par-
ticles are placed on the scale until it is once again on the
horizontal position (. Fig.  11.8g, h). Then, it is transferred
into the mortar (. Fig. 11.8i). The pestle must be held on a
palm-and-thumb grasp and moved on a circular motion,
with a load of 1–2 kg, at 150–180 rpm (. Fig. 11.8j) [8]. When
the mixture is correct, the amalgam begins to unstick of the
mortar walls (. Fig. 11.8k). This process takes about 1–2 min.
Then, the excess mercury that is present on the material can
be removed by squeezing it on a sheet of chamois leather and
twisting it with a tweezer (. Fig. 11.8l–n) [6]. The content is
moved into a rubber dappen dish to homogenize the mate-
rial, which is ready to be transferred into the cavity
(. Fig. 11.8o). Hand trituration is no longer used nowadays.
Mechanical trituration of the alloy particles and mercury
may be performed with a device called amalgamator, as the
ones shown in . Fig. 11.9a, b. They have a compartment for
alloy and another one for mercury. There is the possibility to
adjust the ratio of each component and the time of the mix-
ture. The mechanical trituration of the precapsulated amalgam
is also very simple (. Fig. 11.9c, d). The devices for this pur-
pose have a holder, where this capsule is connected, and the
only adjustment needed is the time for mixing the amalgam.
These amalgam capsules have the exact amount of mercury,
and they do not require to be squeezed through the chamois
leather [16]. The amalgamator should have a mixing speed
above 3800 rpm [14]. The material is then transferred to an
amalgam well and is ready to be placed into the preparation.
The correct trituration of the amalgam is very important
for the final quality of the restoration. When performed
properly, according to the manufacturer’s recommenda-
tions, the amalgam must be shiny and plastic. When a small
 386 C. R. G. Torres et al.
amount of a recently triturated amalgam is dropped onto a
hard surface, from 25 to 30 cm high, it will slightly flatten
but remains cohesive [9, 16]. The under- or overtrituration
of the material may seriously compromise the physical char-
acteristics of the crystallized amalgam. When it is under-
triturated, the material looks crumbly or textured, without
plasticity and with an opaque appearance, reducing the final
strength of the restoration and increasing the expansion and
porosity, predisposing it to fractures, marginal degradation,
and corrosion of the surface [6, 8, 9, 14, 20]. It can also be
a b
c
d
11
e
f
..      Fig. 11.8  Measurement of the alloy:mercury ratio and hand
trituration of the amalgam. a Scale on the horizontal position; b, c
mercury placed inside the dish of the scale; d adjust of the weight so
that it come back to the horizontal position; e mercury transferred to
the glass mortar; f the removal of mercury makes the scale lean to the
observed the increase of the setting expansion, leading to
undesired stress on the restoration. When the dropping test
is performed, the material will spread. In relation to over-
trituration, it can be observed that the resulting material is
very shiny but with low plasticity and some heated, increas-
ing the creep and shrinkage and reducing the setting expan-
sion [6, 8, 9, 14, 20]. When the dropping test is performed,
the material does not change its shape. On . Fig. 11.10a–c, it
can be observed the characteristics of an amalgam with dif-
ferent degrees of trituration.
weight side; g, h pouring of the alloy inside the scale until it is once
again on the horizontal position; i Alloy transferred into the mortar; j, k
trituration until the point where the material begins to loosen to the
mortar walls; l–n removal of the excess of mercury; o material
transferred into a rubber dappen dish
Amalgam Restorations
387 11

i j

..      Fig. 11.8 (continued)
 388 C. R. G. Torres et al.

An enough amount of amalgam must be triturated to fill

o
the preparation. However, it is not recommended to triturate
more than two spills at a time so that the material can main-
tain the adequate plasticity for condensation. In large cavi-
ties, new spills should be triturated only when the previous
one has been completely condensed.
The next step is to start the condensation, which has the
purpose of adapting the material into the preparation. That
will bring the particles close to remove the excess mercury,
reducing porosities and producing a solid metal mass that
can be carved and polished [6]. To take the material into the
cavity, amalgam carriers are used, as shown in . Fig. 4.50a.  

The application and condensation of amalgam must start in

the proximal boxes, pressing the material toward the line and
point angles, retentions, and gingival wall (. Fig. 11.6i–l) [10,
 

16]. Several consecutive layers can be applied and correctly

..      Fig. 11.8 (continued) condensed into the preparation until the complete filling

a b

11

..      Fig. 11.9  Mechanical amalgamator devices. a Device for the alloy and mercury; b containers to place the materials; c device for pre-propor-
tioned capsules; d opened capsule showing the alloy and the pre-dosed mercury
Amalgam Restorations
a b
..      Fig. 11.10  Aspects of amalgam with various degrees of trituration. a under triturated; b ideal trituration; c over triturated
with excess (. Fig. 11.6m–p). The condensation effectiveness
 
is related to the diameter of the instrument’s nib, the direc-
tion, and the amount of force applied [6].
>> The purpose of condensation is to adapt the material
in the preparation, bring the particles close together to
remove the excess mercury, reduce the porosities, and
produce a solid metal mass that can be carved and
polished.
The amalgam condensation must be finished before the ini-
tial setting time, which is around 3 min [20]. The amalgam
alloy can be classified on fast, regular, and extended setting
time. The setting time of the alloy can be adjusted by the
manufacturer through the thermal treatment of the alloy.
The fast-setting amalgam must be condensed in 2.5 min,
the regular in about 3.5 min, while the extended in about
5  min. The condensation of the material after this period
leads to a serious drop on the final strength of the restora-
tion [6].
Tip
The condensation must be started in the proximal boxes,
pressing the material toward the line and point angles,
additional retentions, and gingival wall, being finished
before the setting time.
The condensation of the amalgam can be performed manu-
ally or using mechanical condensers. The mechanical con-
densers may work by impact or vibration [12]. The ones that
work with impact, known as pneumatic condensers, are pre-
ferred because they produce an excellent condensation and
reduce the necessary load applied by the dentist to reach a
satisfactory result. However, they are applied only to ease the
dentist’s work because they do not produce better results
than the manual condensation [6, 20]. A disadvantage of the
mechanical condenser is the possibility of damage to enamel
margins of the preparation with the condenser’s nib,
389 11
c
besides  the patient complain related to the impact feeling
[16]. On the other hand, condensation by vibration using
ultrasonic devices, even though produces good results, leads
to the formation of small mercury particles which spread in
the air and evaporate and may be inhaled by the patient or by
the dentist [9]. For this reason, this technique is not recom-
mended. When mechanical condensers are used, the same
rules applied for the manual condensation must be followed,
except by the fact that the manual load will be reduced and
compensated by the increase of the frequency produced by
the instrument [6].
In relation to the hand condensation, instruments with
flat nibs with several different diameters are used. There are
three most common sets of condensers, as can be observed in
. Fig. 4.47. The condensers created by Black have nibs with a
cylindrical shape with several sizes and shapes, and the set is
composed by seven instruments. The instruments created by
Höllenback present conical trunk-shaped nibs, and the set is
composed by five instruments. The Ward instruments have
inverted conical trunk-shaped nibs with the larger diameter
facing the end tip and a narrow shank (. Fig.  11.11). The
advantage of this instrument is the fact that it simplifies the
removal of the superficial mercury-rich amalgam during the
condensation procedure, because the material flows over the
nib and can be gradually removed [9, 14].
To obtain a proper condensation, the material must
undergo the strongest load possible applied by the instru-
ment nib. Although the ideal condensation load is about 6.8
kg, it is almost impossible to reach it clinically. Some authors
recommend a load of about 4.5 kg, although a load of 1.5–
2.5 kg is considered acceptable [8, 12, 19]. The condensation
load can be tested by pressuring the condenser instrument
toward the regular scale. For smaller condensers, the load
can be reduced. A relevant factor is the relation between the
diameter of the instrument’s nib and the final pressure
applied over the material. Considering the application of a
2 kg load in an instrument with a nib of 2 mm in diameter,
the resulting pressure will be 62 kg/cm2, while the same load
when applied in an instrument with a nib of 3.5  mm in
 390 C. R. G. Torres et al.
..      Fig. 11.11  Ward condensers set with different nibs’ diameter
diameter will result in a pressure of only 20.8 kg/cm2. When
the diameter of the condenser is duplicated, it will be neces-
sary 4 times more load to reach the same pressure per unit of
area [16]. On real life, the load applied must be higher as pos-
sible but keeping the comfort of the patient. It is known that
the greater the condensation load, the greater the final resis-
tance of the restoration, because it decreases the total amount
of mercury and reduces λ2 phase, besides reducing the sur-
11 face porosity. Good condensations can almost double the
fracture resistance of the amalgam restoration.
The other factors that influence the condensation tech-
nique are the types of alloy. The amalgam prepared with
lathe-cut and admixed alloys is easier to condense, and a
sequence of condensers from the smaller to the larger must
be followed, although more load is required to obtain a
proper adaptation to the preparation angles and walls in
relation to the spherical alloys. However, amalgams pre-
pared with purely spherical alloys are more difficult to con-
dense. When the pressure is applied by the condenser nib,
the particles slide over each other, impairing the proce-
dure, especially if small condensers are used, because they
tend to penetrate the material and do not produce enough
pressure to adapt the amalgam to the preparation [16]. For
that kind of alloys the condensers with the largest diameter
capable to penetrate the preparation are used since the first
increment, because the material easily adapts to the walls
and angles [9, 16, 19]. This characteristic of the material
can result in difficulty to obtain proximal contact points of
the restorations with the adjacent teeth. For this reason,
purely spherical alloys are scarcely found on the market
today.
The condensation of amalgam prepared with lathe-cut or
admixed alloys must begin with the smallest condensers,
which are able to reach the gingival wall and press the mate-
rial toward the preparation angles (. Fig.  11.6j, k) [9]. The
material is applied in small increments, of about 1–2  mm
thick, until the complete filling of the preparation. Each
increment should fill a maximum 1/3 or half of the prepara-
tion depth. Each condensation mark over the amalgam over-
laps the anterior one, to assure that the entire material is well
condensed [9, 16]. The condenser nib must be directed
toward the cavity angles, avoiding the lack of adaptation at
those areas [14]. During the condensation, the excess mer-
cury that occasionally may migrate to the surface, with a
shiny wet appearance, can be gradually removed, using a
dentin spoon or even the sides of the Ward-type condensers,
which is moved toward the surrounding walls of the prepara-
tion and pulled outward [6, 13]. The excess mercury on amal-
gam increases the marginal degradation, staining
susceptibility, corrosion, and general degradation, reducing
the compressive strength and resulting in premature failure
of the restoration [6]. The residual mercury content of amal-
gam on different areas of the restauration was determined in
some studies, showing that the marginal areas and thin edges
have a larger amount than others, explaining its higher frac-
ture rate, small tensile strength, and greater degradation [21].
For this reason, bevels must not be made on the occlu-
sal cavosurface angles of the preparation [6]. Each amalgam
layer must be very well condensed before another portion is
added [6]. A mercury excess of only 1% in the amalgam
reduces its compressive strength in about 45–60 kg/cm2. The
removal of excess mercury improves the mechanical proper-
ties and decreases the corrosion and marginal degradation,
due to the reduction of the mercuroscopic expansion in the
final restoration [14].
During the preparation filling with amalgam, when it is
becoming full, the use of small condensers is hard because it
tends to penetrate into the material [6]. Therefore, larger
condensers are used, until the preparation is overfilled. A
minimum amalgam excess of 1 mm is left over the cavosur-
face angles, allowing the carving procedure to remove the
mercury-rich superficial layer, resulting in a restoration sur-
face with better physical properties [6, 13, 16]. At this stage
the material must be condensed toward the margins, perpen-
dicularly to the external surface of the enamel (. Fig. 11.6o,
p), assuring a perfect adaptation of the restorative material,
producing a restoration without gaps and hollow spaces, and
reducing the microleakage [9, 16]. At the marginal ridge
region, the material should also be applied in excess, higher
than the height of the adjacent tooth’s marginal ridge.
If the preparation is very large, it is recommended to
triturate separated spills to allow proper condensation dur-
ing the setting time [12]. In general, 4.5–5.5 g of the amalgam
can be condensed at this time period. This amount is enough
for a medium-sized occlusal preparation [6, 12]. Two or three
spills may fill a regular two-surface Class II preparation.
Some large restorations may require 10–12 spills. If the spill
is not condensed in 3 min, it must be discarded and another
one prepared [12]. In each minute that passes further than
the ideal setting time, the remaining material that has not yet
been condensed presents a strength reduction of about 10%
[1]. If a material on an advanced stage of crystallization is
Amalgam Restorations
used, it will not bond chemically to the portion that has
already been condensed and will be difficult to be adapted to
the preparation walls and angles and reduce the final strength
of the restoration [16]. At these conditions, the material has
reduced plasticity, adversely affecting the adaptations and
increasing the final mercury content [9]. A defective conden-
sation will reduce the strength and increase the creep, corro-
sion, and microleakage.
11.3.1.3  Pre-carve Burnishing
After the end of the condensation, the pre-carve burnishing,
which is a type of condensation, must be performed before
the carving procedure. For that, large instruments with
rounded edges are used, such as those shown in . Fig. 11.12a–
 
c. It is performed by moving the instrument from the restora-
tion toward the margins, with a strong pressure, in a way that
eventually the instrument touches the incline of the cusp but
not the margins [9]. The pressure applied is similar to the one
used during the condensation (. Fig. 11.6q) [16]. The aim of
 
the pre-carve burnishing is to optimize the condensation,
making the excess mercury flow to the surface and be
removed during the carving, leaving a margin with a more
dense and strong amalgam [14]. Furthermore, it also com-
pacts the particles to reduce the porosity [9].
11.3.1.4  Carving
The carving can begin at the same moment that the amalgam
is hard enough to resist to a soft pressure of the instrument
[6, 12]. When carving, it is possible to hear a “squeaking”
sound [12]. Most material can be carved up to 7–8 min after
the trituration although the same may vary from 4 to 13 min
[9]. The main goal of this procedure is to restore the lost
shape and function. Therefore, a deep carving may result in
the weakening of the restoration margin, predisposing it to
chipping due to the small thickness of the restorative mate-
rial on those areas, according to what has already been men-
tioned in 7 Chap. 6 [9, 13, 16, 20]. This way, the sculpture of
 
the complex small anatomic details is not as important as the
major ones which determine the tooth function [9].
Especially on cases of teeth with high cusps, where there is
a b c the displacement of the central groove toward buccal or lin-
..      Fig. 11.12  Amalgam burnishers. a No. 33 Bennett; b No. 29
egg-shaped; c No. 6 Hollenback
391 11
the tendency to produce very thin margins of restorative
material, which are prone to fractures, a shallow sculpture is
more adequate, reducing the probability of marginal chip-
ping. On the other hand, the permanence of flashes of restor-
ative material further than the cavosurface angle, over the
tooth surface, is completely unacceptable because it will eas-
ily fracture, creating an area adequate for biofilm deposition
[9, 16]. The contour of the preparation and the location of the
occlusal contacts, before the restorative procedure, should be
kept as a mental image before the amalgam condensation, to
simplify the location of the margins during the carving pro-
cess, avoiding amalgam flashes and helping the occlusal
adjustment [16].
For carving of the restoration, instruments with cutting
edges are used, as can be seen in . Fig. 11.13a–g, and they
must always be sharp [12]. There are several types available
on the market, and the choice will be more related to a per-
sonal opinion. However, the Hollenback carvers No. 3 and
No. 3S are the most commonly used.
The remainings of the cusps and ridges and the adjacent
teeth are used as guides to shape the restoration anatomy [6].
The sculpture of a restoration that involves the proximal
­surface must begin in the region of the marginal ridge, carv-
ing the occlusal embrasures [10]. The exploratory probe is
positioned touching the matrix band, leaning at an angle of
about 45° in relation to the long axis of the tooth, and the
instrument moved in the buccolingual direction (. Fig. 11.6r)
[9, 16, 19]. This procedure also removes the excess of amal-
gam in contact with the matrix, avoiding its fracture during
the band removal [13, 16]. The height of the ridge must be
similar to the one of the adjacent tooth.
Then, the carving of cuspal inclines is performed. For
that, the instrument is placed in a way that the cutting edge is
perpendicular to the preparation wall, touching the cavosur-
face angle and resting on the surface of the cuspal incline.
The tip is placed on the region of the planned central groove,
and it should be moved toward the mesiodistal direction,
parallel to the margins, with small strokes, initially on the
buccal cusps and then on the lingual ones or vice versa
(. Fig. 11.6s) [6, 10, 16, 20]. This way, there is a possibility to
correctly define the other grooves and the triangular and
central fossae. During the carving, it is important to avoid
gual sides because it may weaken the restoration [9, 13]. A
rough carving can be performed quickly, and the band is
removed to allow a more precise sculpture of the occlusal
surface.
Another option is to use Frahm carver instrument set.
The No. 2 is used on a similar way to the Hollenback carver,
with the cutting edge resting on the remaining cuspal incline,
with mesiodistal movements, to create the central groove and
restore the lost portion of the cuspal inclines (. Fig. 11.6b′)
[13]. The instruments No. 6 and No. 10 are moved on the
buccolingual direction to create the buccal and lingual
grooves (. Fig. 11.6c, d′). The discoid-cleoid carver may also
 392 C. R. G. Torres et al.
a b c d
..      Fig. 11.13  Amalgam carvers. a, b No. 3S and No. 3 Hollenback; c–e No. 6, No. 2, and No. 10 Frahn; f cleoid; g IPC 1
11
be used as observed in . Fig.  11.6z, a′. The discoid side is
 
used to start the sculpture on the region of the triangular
fossa, while the cleoid works similar to the Hollenback No. 3
carver [13, 16]. The Shoshan-A carver can be used like a
Hollenback carver.
The carving of the developmental grooves is essential to
recreate the anatomy of the occlusal surface. The carved res-
toration must work correctly and not cause discomfort to the
patient [6]. After carving, the outline of the restoration mar-
gin must match the outline of the preparation cavosurface,
showing a regular contour with soft curvatures. A larger and
irregular outline of the amalgam restoration means under-­
carving and requires additional sculpture while the material
did not set, or finishing with rotary instrument after setting
[16]. If the carving is performed quickly, the visualization of
anatomic details can be improved by rubbing a small cotton
ball over the restoration, showing those that need to be
improved (. Fig. 11.5e′). All amalgam residues are removed
 
with the aid of a powerful vacuum suction system or soaked
gauze [16].
It is important to remove the matrix band as soon as pos-
sible, to have enough time to remove excess material on areas
difficult to access, such as the proximal region, and to finish
the carving on the occlusal surface [16]. For that, the pad of
the index finger is to be placed over the occlusal surface to
stabilize the band, while the matrix retainer is removed first,
reducing the probability of restoration marginal ridge frac-
ture in relation to when the entire set is removed at once.
Otherwise, the rotation movement necessary to loosen the
vise locking screw of the matrix retainer may fracture the
e f g
amalgam recently applied [16]. The wedges are removed and
afterward the band, rising each side of the band at a time,
pulling it occlusally (. Fig. 11.6t–v) [6, 9]. The movement of
the matrix should primarily be toward the buccolingual
direction, while the matrix slides toward the occlusal surface
[19]. Some authors recommend to cut the matrix next to the
tooth on the lingual side and then pull it toward the buccal
side to reduce the risk of fracture of the marginal ridge [10,
13, 16, 19]. When a custom-made matrix is used, it must be
cut with scissors to be removed [13]. Some dentists prefer to
leave the wedge in position to maintain the tooth separation
while the matrix is removed [16]. If the amalgam restoration
fracture during the matrix removal, the defective area needs
to be repaired as it was a small restoration, and the adequate
depth and retention will need to be prepared, sometimes
completely inside the amalgam restoration that already
exists. If necessary, another band is placed, and a new amal-
gam is condensed directly on the defects, bonding to the
existing material [16].
After the removal of the band, it is possible to improve the
carving once there will be a better access to every region. The
first step is to check the height of the marginal ridge, using a
carver placed on the horizontal direction, in a way the one
side is held over the intact ridge of the adjacent tooth. It is
moved in the buccolingual direction, making the marginal
ridge of the restored tooth to have the correct height
(. Fig. 11.6w) [19]. The excess on the proximal region, spe-
cially on the buccal or lingual margins, near the buccogingi-
val and linguogingival line angles, can be removed with a
Hollenback carver instrument or an interproximal carver
Amalgam Restorations
(DeMeo or IPC) (. Fig. 11.6x). Even if the wedge is correctly
 
applied, the gingival margin may require to be carved to
remove the excess [6, 10]. Overhangs may occur as small
portions of amalgam had been projected further than the
gingival margin. The wedge prevents the occurrence of large
excesses on the periodontal area, but it does not guarantee
100% success on the formation of a smooth and exact resto-
ration margin [6]. The proximal area of the amalgam restora-
tion should always be visually evaluated, directing the light to
the interproximal area, through a clinical mirror, observing it
from the opposite side, to check the contour and to confirm
the presence of proximal contact (. Fig. 11.6f′). It is known
 
that the contact is proper when no light is seen on the corre-
sponding area.
11.3.1.5  Post-carve Burnishing
The next step is to burnish again the restoration after the
carving, which consists rubbing small burnishing instru-
ments over the restoration surface with a gentle pressure,
avoiding deforming it, adapting the particles that were dis-
placed during carving (. Fig. 11.6g′, j′) [8, 9, 14, 16]. The aim
 
of this procedure is to reduce the superficial porosities and
create a smoother surface, decrease the superficial corrosion,
improve the marginal adaptation and consequently reduce
the microleakage, and reduce the residual mercury content
on the margins, increasing the marginal integrity, besides
increasing the surface microhardness [2, 3, 9, 11]. The post-
carve burnishing produces a surface with silky appearance,
reducing immediately the roughness from 4 to 5 μm on the
carved amalgam surface to less than 0.4 μm on the burnished
amalgam. The interproximal area can be properly burnished
by rubbing softly the surface with the side of an exploratory
probe or a No. 6 Hollenback burnisher (. Fig.  11.5g′) [9].
 
The occlusal surface should be thoroughly burnished, avoid-
ing to change the carved morphology.
In addition, it is important to check and to smooth the
proximal surface with a dental floss (. Fig.  11.5k′, l′). It is
 
made carefully for not breaking the interproximal contact
that has recently been created, because amalgam is not com-
pletely crystallized. For that, the floss is taken to the contact
area, initially embracing the adjacent tooth and pressing this
tooth, instead of the restored one, while it is moved toward
the contact area. When the floss is in the interproximal space
close to the gingiva, it embraces around the restored tooth
and is moved in the occlusal and gingival direction, checking
if there is excess and smoothing the amalgam on the proximal
surface. If the excess exist and it is not removed by the floss,
the IPC can be used until a correct margin is obtained [16].
11.3.1.6  Occlusal Adjustment
The next step is to remove the isolation and perform the
occlusal contact adjustment, using a thin double-color artic-
ulating paper and Miller forceps [8, 10]. First, one of the col-
ored sides, the red side for instance, is placed facing the
restored tooth, and the patient is asked to perform the pro-
trusion and lateral movements, to mark the contacts during
the disocclusion guides. Then, the opposite side of the paper
393 11
is placed facing the restored tooth, and the patient is asked to
close the mouth in the maximum intercuspation position
(MIP). The contacts in MIP and the ones that occasionally
happen during the protrusion and lateral movements are
analyzed and adjusted, removing any premature contacts
that may lead to discomfort and fracture of the restoration
[9]. Contacts during excursive mandibular movements must
be removed, while the contacts on MIP can be preserved,
since they are not premature [19].
When anesthesia has been used, it is difficult for the
patient to know when the teeth are in contact and whether
there are premature contacts or not. Therefore, it is necessary
to use the marks left by the articulating paper to perform the
adjustment. It is important to evaluate if the contacts that
were occurring before the restoration are still happening or if
only the new restoration is contacting the opposite tooth,
which indicates a premature contact at this area [16]. The
contact load is recognized by the intensity of the mark left
and by the fact that on the stronger ones the center has no
color. The strong contacts are reduced until all marks are
similar, and the contacts previously observed before the
preparation can be seen [16, 19]. The patient is instructed to
close the mouth slowly and to stop as soon as any contact is
noticed [16]. Then, the contacts are evaluated and adjusted in
case they are producing interference. The articulating paper
use is repeated, and carving is performed until the patient is
able to properly close the mouth, without interference, with
the occlusion similar to the one before restoration. After the
adjustment, the surface must be burnished again [16]. While
carving, stable contacts must be created on correct places.
These contacts should be perpendicular to the direction of
the occlusal loads wherever possible. If the contact is on an
inclined plane, and not perpendicular to the occlusal load,
the dentist should try, while removing the excess of the amal-
gam, to remove the undesired portion from the contact area,
on the incline, or carve a platform perpendicular to the load.
In addition, an over-carved restoration, without occlusal
contacts, may result in an undesired tooth extrusion [16].
If the amalgam already is on an advanced stage of crystal-
lization, the adjustment must require the use of a finishing
bur [16]. A rotary instrument may be used to finish the carv-
ing if the amalgam has already hardened in such a way, that
the necessary force to carve it with hand instruments may
fracture portions of the restoration. Round- or flame-shaped
burs may be used to recreate the tooth anatomy [16].
However, the ideal is that all immediate adjustments would
be performed with hand instruments. As the amalgam
strength 20 min after the sculpture is of only 6% of the final
one after 1 week, the restoration must not undergo immedi-
ate strong chewing loads, and the patient must be warned not
to chew over this tooth. After about 8 h, the material presents
70% of the final strengths, and the patient can already nor-
mally use the restored tooth. However, the polishing of the
restoration should only be performed after at least 24–48 h,
even though the best would be after several days [8, 10, 12,
13, 16]. In some cases, the maximum strength is only reached
30 days after finishing the restoration.
 394 C. R. G. Torres et al.

11.3.2  Restoration of Compound Class I ficult [16]. On those cases, the matrix proposed by Barton
Preparations can be applied (. Fig. 11.14a, u) [16]. First, the tooth is sur-
 

rounded by a universal matrix with a matrix retainer or a

Due to the leaning of the buccal surfaces of the mandibular custom-made spot-welded or riveted matrix. When a univer-
molars and lingual surfaces of the maxillary molars, the use sal matrix is applied, the matrix retainer should be positioned
of a universal matrix will not result in the correct adaptation on the opposite surface to the one that will be restored. A
of these surfaces, making the restorative procedure more dif- small piece of the metallic band must be cut, in a way that it

a b

c d
11

e f

..      Fig. 11.14  Preparation of Barton matrix. a Application of the
universal matrix; b cutting the Barton matrix; c, d placing of band; e
adaptation with the No. 6 Hollenback burnisher; f displacement with
the exploratory probe; g insertion of a wedge with melted compound;
h adaptation over the lingual surface; i checking the adaptation with
an exploratory probe; j, k condensation of the amalgam; l burnishing;
m, n occlusal carving; o matrix removal; p carving of the lingual
surface; q carved restoration; r, s burnishing; t immediate aspect;
u result after the polishing
Amalgam Restorations
395 11

g h

i j

k l

m n

..      Fig. 11.14 (continued)
 396 C. R. G. Torres et al.

o p

q r

11

s t

..      Fig. 11.14 (continued)
Amalgam Restorations
is slightly larger than the height of the clinical crown, going
beyond the gingival cavosurface angle (. Fig.  11.14a). The
 
corners that will be placed facing the gingiva are to be cut
avoiding injuries to the periodontal tissue (. Fig. 11.14b). It
 
is applied between the universal matrix and the tooth surface
(. Fig. 11.14c, d). Then, a No. 6 Hollenback burnisher is used
 
to correctly adapt it to the surface (. Fig. 11.14e). A wooden
 
wedge with small dimensions or a piece of 1.3 cm of round
toothpick is selected, which must be covered with melted low
fusion compound, light-cured gingival barrier  or PVS bite
registration material [16]. The Barton matrix is displaced
with an exploratory probe, and the wedge is inserted into the
position, stabilizing the set (. Fig. 11.14f–h). If the wedge is
 
higher than the matrix, it must be cut, so it will not adversely
affect the next step. The adaptation of the matrix on the cavo-
surface angle is checked with the exploratory probe
(. Fig.  11.14i), and then the amalgam is condensed with
 
excess (. Fig.  11.14j, k). Then, the pre-carve burnishing is
 
performed (. Fig. 11.14l), and the carving of the region near
 
the matrix starts with an exploratory probe (. Fig. 11.14m)
 
and the occlusal surface with a carver (. Fig.  11.14n). The
 
matrix is completely removed, and the carver is finished
(. Fig. 11.14o–q). After that the post-carving burnishing is
 
performed (. Fig. 11.14r–t).
 
11.3.3  Restoration of Class V Preparations
(Site 3)
The amalgam restorations on Class V preparations are indi-
cated on areas where esthetics is not a concern, the access
and the visibility are limited, and the moisture control is dif-
ficult [16]. The cavosurface angles of the gingival wall in
Class V preparation are many times located inside the crev-
ice, beyond the gingival margin. On those situations it may
require the displacement of the gingiva with a retraction cord
or a rubber dam isolation, associated with cervical retraction
clamps, to allow the access while controlling the crevice fluid
flow. For the rubber dam isolation, the Schultz or W8A clamp
may be used [6]. Sometimes it is necessary that the surgical
displacement of the gingiva associated with relaxing inci-
sions allows the access to those areas. The retraction cord
must be packed before the preparation to reduce the possibil-
ity of damage to the gingiva. In general, about 8–10 mm of
cord is used, and it must always be longer than the mesiodis-
tal dimensions of the preparation. The cord thickeness must
be adequate to allow the packing into the crevice. It may be
used alone or impregnated by a homeostatic solution and
inserted into the sulcus with rounded tip of a retraction cord
packing instrument.
>> The Class V amalgam restorations are only indicted on
areas where esthetics is not a concern, the access and
the visibility are limited, and the moisture control is
difficult.
Most Class V preparations may be restored without the use of
matrix. On this case, the amalgam is condensed first toward
397 11
the retentions with a small condenser and then toward the
mesial and distal walls. After that, the central part is filled
[16]. However, on the case of large preparation, the conden-
sation becomes harder, because the amalgam tends to escape,
due to the fact that the applied portions are not held by the
surrounding walls or because the axial wall is convex [16]. On
this case, a window matrix must be prepared, as proposed by
J. M. Prime (. Fig. 11.5a–o) [8, 16, 20]. To do that, a universal
matrix is placed around the tooth, with a matrix retainer
located on the opposite surface to the one that will be restored
(. Fig. 11.15b). The position of the preparation is marked on
the band with an instrument with a sharp tip (. Fig. 11.15c).
It is then removed, and a “window” is opened with a cylinder
diamond point, with dimensions smaller than the prepara-
tion but large enough to allow the application of the restor-
ative material (. Fig. 11.15d). The matrix is once again placed
in position (. Fig.  11.15e). In case it is not stable enough,
wedges may be placed in the interproximal spaces on both
sides [20]. Then, the application of the restorative material
into the preparation is started, condensing it toward the
mesial and distal walls, with a small diameter condenser,
until the preparation is completely filled (. Fig.  11.15f–h).
The condensation on the region of the window opening can
be performed with an instrument of a larger diameter
(. Fig. 11.15i). The matrix is immediately removed, and the
restoration is burnished, following the carving of the surface
in two planes, according to the direction of the remaining
surface, reproducing the curvature of the region (. Fig. 11.15k,
l). The under-contour will result in the trauma of the gingiva,
while the over-contour will result in the reduced gingival
stimulation and self-cleaning of the tooth surface during the
mastication [16]. Then, the burnishing of the area is started
with the No. 6 Hollenback burnisher or No. 33 Bennett bur-
nisher (. Fig.  11.15m, n). Egg- or round-shaped burnisher
must not be used because they may deform the restoration
and result in a concave contour. The retraction cord interferes
on the carving of the gingival margin. On this case, first, a
rough carving must be performed, and then after the removal
of the cord, it can be improved [16].
Tip
During burnishing of Class V restorations, egg- or
round-shaped burnisher should not be used, because
they may deform the restoration and result in a concave
contour.
11.3.4  Restoration of Horizontal Slot
Preparations
For restorations of the horizontal slot preparations with
amalgam, the S-shaped matrix is the most recomended
(. Fig. 11.16a–n) [17]. About 2.5 cm of matrix band is pre-
contoured with the handle of a clinical mirror (. Fig. 11.16b–
e). The band is contoured touching the surface opposite to
 398 C. R. G. Torres et al.

a b

c d

11
e f

g h

..      Fig. 11.15  Restoration of a large Class V preparation with a
window matrix. a Tooth preparation; b application of the universal
matrix around the tooth; c marking the place of the preparation; d
opening of the “window” with the diamond point; e window matrix
positioned; f application of amalgam; g–h condensation of the
amalgam in the areas covered by the matrix; i Condensation of the
amalgam after the entire filling of the preparation; j pre-carve
burnishing; k, l carving in two planes; m, n post-carve burnish; o
finished restoration after the polishing
Amalgam Restorations
399 11

i j

k l

m n

..      Fig. 11.15 (continued)
 400 C. R. G. Torres et al.

the preparation access, passing through the proximal surface
and curved over the smooth surface of the adjacent tooth
(. Fig. 11.16f). It is placed in the interproximal space, and a
 
wedge is inserted through the opposite side of the prepara-
must be avoided the contact of heated instrument to the
preparation walls, as it could harm the pulp. The material is
condensed, and the carving can start with the exploratory
probe, toward the matrix band (. Fig.  11.16j, k). Then, the

tion access, being stabilized with compound (. Fig. 11.16g,   Hollenback carver is used. The wedge and the band are
h). If the internal contour of the matrix is not correct, an removed, and the carving is finished with an IPC or thin
amalgam burnisher can be heated and placed inside the exploratory probe (. Fig. 11.16l). The restoration is smooth-
 

preparation, rubbing it toward the matrix, softening the com- ened with a dental floss to produce a better cervical margin
pound and allowing the correct contour to be obtained. It (. Fig. 11.16m).
 

a b

11 c d

e f

..      Fig. 11.16  Horizontal slot restoration with the S-shaped matrix. a finished matrix; j–l condensation and carving; m removal of excess
Tooth preparation; b, c first folding of the band; d, e second folding of with dental floss; n polished restoration
the band; f matrix in position; g, h Stabilization with compound; i
Amalgam Restorations
401 11

g h

i j

k l

m n

..      Fig. 11.16 (continued)
 402 C. R. G. Torres et al.

11.4  Finishing and Polishing tact point, it can be necessary to cut the strip to make it
narrower. The overhang must be completely removed. When
The instruments and materials necessary for performing fin- it is not possible, the entire amalgam from the proximal box
ishing and polishing of amalgam restoration are described must be removed and the restoration replaced.
here: On the occlusal, buccal, and lingual surfaces, multibladed
55 Micromotor and contra-angle handpiece burs are used with air and water spray [9]. The regular burs
55 Clinical mirror have 6 blades, while the multibladed ones can have 12–30
55 Tweezers blades. The burs are placed parallel to the tooth surface on
55 Double-ended No. 5 exploratory probe the region of the margins, to prevent unnecessary removal of
55 Miller articulating paper forceps amalgam [9, 16]. Any premature contacts on the recently
55 Thin articulating paper (<10 μm) made restoration can be easily identified due to its shiny
55 Rubber cup and cone aspect. They can be checked with articulating paper. Each
55 Robinson brush bur shape fits a specific surface, as can be observed in
55 Multibladed bur (12 or 30 blades) . Fig.  11.17a–o . It is recommended that the rotary instru-
55 Abrasive rubber polishing instruments set for amalgam ments are used with care and handled softly. It should spin
55 Stainless steel abrasive strip slowly and be used with movements similar to brush strokes
55 Polyester abrasive strip while touching the surface, avoiding creating undesired small
55 Pumice powder cavities and scratches [10]. Care must be taken to avoid wear-
55 Zinc oxide or tin oxide ing the enamel at the restoration margins. The large round-
55 Abrasive discs and pyriform-shaped instruments are applied over the cusp
inclines while the small round ones on the grooves and fossae
The time necessary to finish and polish a restoration is (. Fig.  11.17c–e) [9]. The developmental grooves between
 

inversely proportional to its quality after the carving and bur- the cusps, the buccal and lingual surfaces, and the embra-
nishing. Therefore, the finishing and polishing may not be sures are finished with flame-shaped instruments
considered a substitute for the previous steps [16]. The fin- (. Fig.  11.17f–h) [14]. The embrasures can also be finished
11  

ishing procedure is the bigger removal of the material to with abrasive discs. The contact of the instrument with the
improve the contour and remove the excess on the margins, surface must be intermittent, to avoid heating and damage to
adjust the occlusion, improve the carving, and produce a the pulpal tissue, as well as the flux of mercury to the surface
fairly smooth surface [9]. In general, when the finishing is of the restoration [14]. After the finishing is completed, the
complete, a surface roughness of about 0.5–1 μm is obtained. tip of an exploratory probe must touch the surface and be
On the other hand, the polishing is the procedure of fine moved through the restoration margin, from the tooth sur-
removal of the restorative material, resulting in a very smooth face to the restoration and vice versa, without getting stuck.
and glossy surface, without visible scratches, simulating the The restoration must have a smooth continuation with the
dental tissues. That avoids irritation of the tongue or gingiva tooth surface contour, which is a requirement of all restora-
and discomfort, reducing the intraoral corrosion and the tions [16]. Much care must be taken not to over finish the
deposition of food residues, biofilm, and calculus. restoration, leaving a very thin margin which will be predis-
It is considered that a surface is glossy when there is more posed to fractures, as well as under finish, leaving excess of
specular reflection of the ambient light than the diffuse amalgam (flash) over the enamel surface on the cusp incline,
reflection. This is obtained when the surface roughness is which may also fracture. On cases of Class V preparations,
smaller than the average wavelength of visible light, which is when finishing the gingival margin covered by the gingiva,
around 0.5 μm. On the other hand, the tongue can feel as with rotary instruments, care must be taken to not remove
smooth when the surface scratches have a depth smaller than unnecessarily the cementum and produce a step on the root
2 μm and very rough when they are deeper than 20 μm. A surface, beyond the restoration margin (Fig. 14.66a, b) [16].
correctly polished amalgam restoration will resist more The polishing of restorations is based on the use of abra-
staining, corrosion, and marginal degradation, will be easier sive materials with decreasing particles size. This way the
for the patient to clean, and will not contribute to the recur- thinnest abrasive particles remove the scratches produced by
rence of caries [10, 16]. A study showed that even the well-­ the previous ones [14]. Two techniques can be used for pol-
condensed restorations undergo corrosion if they are not ishing amalgam restorations, and they are the abrasive rub-
smooth and polished [18]. bers rotary instruments and the abrasive pastes techniques.
On the proximal areas, the restorative material copies the Despite which one is chosen, care must be taken to not over-
smooth surface of the matrix band, and none additional pol- heat the surface above 60 °C, because this can cause irrevers-
ishing is necessary [8, 14]. However, if before the crystalliza- ible damage to the pulp, to the restoration, or both [16].
tion an overhang is detected and removed by carving, the When overheated, the surface of amalgam looks cloudy, even
polishing of that region will be necessary. After the final if highly polished, which indicates that mercury was brought
material setting, if an overhang is detected, abrasive steel to the surface and will increase amalgam corrosion and
strips can be used to remove it, taking care to avoid the con- strength reduction [12]. To avoid heating, well-lubricated
tact area. For short clinical crowns, to avoid wear of the con- polishing agents should be used [12].
Amalgam Restorations
403 11

a
b

c d

e f

g h

..      Fig. 11.17  Finishing and polishing with abrasive rubbers rotary polishing with points and cups with decreasing grit and different
instruments. a Burnished restoration; b Multibladed bur set (12 blades); colors; j–m polishing; n checking the margins; o finished restoration
c–h finishing procedure; i Abrasive of rubber rotary instruments set for
 404 C. R. G. Torres et al.

i j

k l

11

m n

..      Fig. 11.17 (continued)
Amalgam Restorations
405 11
For the technique using the abrasive rubber instruments,
a
cone or cup shapes are available, impregnated with abrasive
particles of different grits, identified with distinct colors
(. Fig. 11.17i). The cones are used on the occlusal surface, on
 

the inclines, and on the grooves, while the cups may be used
on the cusp inclines, marginal ridge, and embrasures.
Generally the decreasing grit size sequence is represented by
the colors brown, green, and blue (. Fig. 11.17j–m). They are
 

applied in low speed on an intermittent way, to reduce the

heating, preferably associated with airstream or a glycerin-­
based lubricating gel. Between the changes of abrasivity, the
surface should be washed to remove the remaining previous
abrasive particles. The cones should always have a sharp end,
which allows it to reach the bottom of the grooves [10]. If the
tip is thick or worn out, it can be sharpened with a silicon
carbide disc (. Fig.  11.18a–c) or a diamond dresser (. Fig.
   
b
4.29a–f) [16].
The abrasive pastes technique consists on starting using a
water-based pumice paste, applied with a Robinson brush
(. Fig. 11.19a–c) [10]. The brush must be kept impregnated
 

with the paste to avoid overheating and guarantee polishing

[14]. A surface with homogeneous aspect must be obtained,
removing visible scratches. For that the procedure has to be
repeated as many times as necessary to obtain the desired
result. After that, the surface is washed with water, and a
paste prepared with zinc oxide or tin oxide and alcohol is
applied, using a soft and flexible rubber cup, producing a
glossy surface (. Fig. 11.19d–f) [10, 19, 20]. On the proximal
 

surface, in case it has been carved with hand instruments or

finished with a metal abrasive strip, a piece of dental floss c
impregnated with the same pastes or polyester abrasive strips
can be used, moving it from buccal to lingual and from cervi-
cal to occlusal directions, below the contact point [14]. To
simplify the procedure, a small amount of the pastes can be
taken to the embrasures while the floss or the strip is being
moved.

11.5  Durability of Amalgam Restorations

The durability of amalgam restorations is related to factors

associated with the restorative material, the dentist, and the
oral environment. In relation to the restorative material, the
type of the alloy used has a large influence. . Fig. 11.20 shows
 

the survival rate of amalgam restorations in a clinical study,
according to its composition. It can be observed that when
high-copper and zinc-containing alloys were used, more
than 80% of the restorations remain after 13 years. For the
high-copper and non-zinc alloys, as well for the low-copper
and zinc-containing alloys, more than 70% were in good
conditions after 13 years. On the other hand, for the low-­
copper and non-zinc alloys, only 20% were in good condi-
tions after 13 years. A good amalgam restoration can last
from 15 to 20 years or even more [12].
In relation to the patient, the composition of the saliva,
eating habits, and oral hygiene may determine the caries
recurrence on the region of the tooth-restoration interface, as
..      Fig. 11.18  a–c Sharpening the tip of the abrasive point over the
silicon carbide disc
well as the increase of the superficial corrosion [9]. They
must be informed that the restorative treatment is not enough
to control the caries disease and recover patients’ health.
The dentist is the most important point on the determi-
nation of restoration quality and durability [9]. The proper
tooth preparation, the correct handling of the material, and
the use of a careful restorative technique are paramount [16].
A clinical study evaluated the reasons of restoration failures
and showed that 56% of the cases were attributed to incorrect
tooth preparation, 40% to improper handling of the material,
 406 C. R. G. Torres et al.

a b

c d

11

e f

..      Fig. 11.19  Polishing with abrasive pastes. a restoration after the finishing; b, c polishing with pumice using a brush with a conical and flat tip;
d, e polishing with zinc oxide/alcohol paste, using a rubber cup and cone; f polished restoration

and only 4% to periodontal disease, pulpal problems, and
others [7]. A survival analysis on the insurance claims data-
base reported that amalgam restorations are replaced seven
times more when patients go to another dentist than if they
continue to be treated by the same dentist [4]. In addition, it
is more common for dentists to replace an amalgam restora-
tion than to repair, even though there is a low incidence of
secondary caries over the time. That means patrictioners
have a lack of knowledge about the defined criteria related to
the need of replacement, resulting in excessive unnecessary
treatment.
The most common reason to replace an amalgam restora-
tion is the secondary caries. Several clinical studies have
shown that 50–60% of all replaced restorations have received
this diagnosis. However, the secondary caries term is not well
clinically defined. Many dentists consider that there is caries
lesion in any place where a probe gets stuck and where the
direct visual inspection is hard. Any gap, with or without car-
ies, would receive the diagnosis of secondary caries, even
though they may often be a result of the inadequate conden-
sation. Other reasons that are commonly used for the resto-
ration replacement are the fracture of the restorative material,
Amalgam Restorations
100
90
80
70
60
% 50
40
30
20
10
0
1 2 3 4 5 6
Anos
..      Fig. 11.20  Survival rate of amalgam restorations according to the alloy composition (HC/WZ – high copper with zinc; HC/NZ – high copper
and without zinc; LC/WZ – low copper with zinc; LC/NZ – low copper without zinc). (Based on R.W. Phillips)
mostly at the isthmus, marginal degradation, and fracture of
the remaining tooth structure. The fracture of the isthmus is
generally due to the incorrect preparation, while the mar-
ginal degradation depends on the relation between the stress
and the corrosion, which may be decreased by using a good
restorative technique and an amalgam with high copper con-
tent [16].
When an old restoration is replaced by a new one, there
are great possibilities that the preparation size increases.
Therefore, the unnecessary replacements must be avoided.
The repair of the old restorations may be performed, since
the access and a proper inspection of the defective areas can
be done. The entire restoration must only be replaced if the
caries lesion has spread under the old restoration or if there
is fracture of the isthmus [9]. An old restoration with a dark
and corroded surface does not necessarily require to be
changed. In many cases, a new finishing and polishing is
enough for making it in good conditions (. Fig. 11.21a, b).
 
The objective parameters for evaluating the restorations are
presented in 7 Chap. 1.
 
11.6  Controversy About the Use of Amalgam
Even though dental amalgam is a very effective restorative
material, the fact that there is mercury on its composition
makes it a potentially harmful material for human beings.
407 11
HC/WZ
HC/WZ
LC/WZ
LC/NZ
7 8 9 10 11 12 13
One of the risks is the occurrence of an allergic reaction.
However, according to the American Dental Association, it
is very rare, and it is estimated that just 1 of 100,000,000
patients suffers from it. Other concern is that the restora-
tions would release mercury vapor that would cause intoxi-
cation to patients and deposition on the kidneys, liver, and
nervous centers. However, some studies have shown that
8–10 amalgam restorations in the patient’s mouth release
only 1.1–4.4 μg/day. An acceptable and safe exposure, on
industry workers that handle mercury, is 300–500 μg/day,
which indicates that the amount released by the restorations
is very low [1].
Mercury exists in three basic forms: (a) elemental, pure
mercury; (b) inorganic (HgS), found in the nature; and (c)
organic, especially dimethylmercury, used on agricultural
fungicide. The absorption by the human body may occur
through the skin, lungs, and gastrointestinal tract. It has
small particle size and is slowly absorbed by the skin in any
forms. Mercury on the elemental and inorganic forms is
promptly absorbed by the lung alveoli, but it is hardly
absorbed by the gastrointestinal tract. Organic mercury is
hardly absorbed by the lungs, but it is promptly absorbed by
the gastrointestinal tract. In other words, mercury from
amalgam restorations that is released into the air  could be
inhaled and directly absorbed, but if it mostly  mixes with
saliva and is swallowed, it will not be absorbed. On the other
hand, organic mercury used in pesticides that contaminates
 408 C. R. G. Torres et al.
a b
..      Fig. 11.21  a, b Finishing and polishing of an old amalgam restoration
11
almost all food is quickly absorbed. Everybody has some
mercury circulating in the body due to the food ingested.
However, due to the fact that mercury is actively excreted, no
symptom of toxicity is observed on the population. The half-­
life of mercury on the body is approximately 55 days.
Therefore, in approximately 2 months, mercury absorbed is
completely eliminated.
Mercury is released from the amalgam but in very small
amounts. For patients, the mastication over the amalgam
places over it a mechanical energy that is converted to subli-
mation energy, causing mercury to be released, even though in
extremely small amounts. When the person stops to chew, the
release also stops. However, the people only masticate 1% of
the time. Most of mercury is quickly mixed with saliva and is
swallowed, and not inhaled, keeping the real exposure at a
minimum. Other concern is that during corrosion, mercury is
released from the amalgam. However, this does not happen.
The corrosion of an amalgam with low or high copper content
is basically the same. For low-copper amalgam, the phase that
undergoes corrosion is Sn-Hg, where tin is converted into SnO
(insoluble) or SnOCl (soluble) and deposits inside the amal-
gam and on the margins. Hg of the original phase quickly
reacts with the Ag-Sn residual phase that exists on the amal-
gam. Therefore, mercury does not leave the alloy during corro-
sion. On the high-copper amalgams, the Cu-Sn phase
undergoes corrosion. However, Sn once again forms SnO or
SnOCl, and copper forms Cu-Cl, and it does not involve mer-
cury [1, 16].
It is claimed that the patients with amalgam restorations
presented toxic levels of mercury in the blood. Patients with-
out amalgam restorations have a measured mean of 0.3 ng/
ml, while patients with restorations present 0.7 ng/ml.
However, the ingestion of a weekly meal with seafood results
in blood level of 2.3–5.1 ng/ml. Therefore, the presence of
­amalgam restorations is not capable to cause acute or chron-
icle intoxication. A study of 2-year clinical trial promoted by
the National Institute of Health (NIH) from the United States
concluded that amalgam restorations are safe for human
beings [1, 14].
However, the unnecessary exposure to this metal must be
avoided, working on well-ventilated place and choosing pre-­
proportioned capsules as well as correctly storing the resi-
dues. The scraps of the amalgam must be stored in containers
with developer solution for radiographic film or at least
7–8 cm of water. Skin contact with amalgam must be avoided
since penetration is possible. The removal of the old amal-
gam should always be performed under rubber dam isolation
and with water spray irrigation and high-power suction [9,
16]. If there is an accidental spill of mercury on the floor, the
plumb from the radiographic film package can be used to
collect it, as well as amalgam alloy powder, sulfur, adhesive
tape, or a dental vacuum system. Vacuum cleaner must be
avoided because it vaporizes mercury. The ventilation of the
office must be constant to maintain a low concentration of
Hg in the air. The contaminated instruments must be care-
fully cleaned before sterilization, avoiding the vaporization of
Amalgam Restorations
References
..      Fig. 11.22  Amalgam tattoo
mercury. Filters must be installed to prevent mercury from
being released into the environment through the sewage [9].
>> Unnecessary exposure to mercury must be avoided –
working on a well-ventilated office, choosing
pre-proportioned capsules, and correctly storing the
residues.
Other caution in relation to the use of the amalgam is  to
avoid its contact with a wound on the mucosa, as well never
hurt the mucosa during the application of the material. If the
amalgam comes in contact with the wounded tissue, it may
become encapsulated and result in a tattoo, as can be seen in
. Fig. 11.22.
Conclusion
The use of dental amalgam can produce strong and long-­
lasting restorations on the posterior teeth. The knowledge
about material properties and the restorative techniques
were presented. The details about the steps of matrix and
wedge placement, trituration of mercury and alloy, conden-
sation, pre-carve burnishing, carving, and post-carve bur-
nishing are the essential information. The finishing and
polishing techniques were also described, being very impor-
tant on the restoration durability. The controversy about
amalgam use in relation to mercury toxicity was discussed,
showing that it is completely safe when correctly used.
However, its metallic color and lack of bonding to the tooth
structure have dramatically reduced its use worldwide.
Despite that, it is an excellent material and still an option for
areas where esthetics is not a concern.
409 11
1. Anusavice KJ. Phillips science of dental materials. 11th ed. London:
Elsevier; 2005.
2. Arcoria CJ, Kelly GT, Icenhower TJ, Wagner MJ.  Microleakage in
amalgam restorations following burnishing, polishing, and time-­
varied thermocycling. Gen Dent. 40:421–4.
3. Ben-Amar A, Serebro L, Gorfil C, Soroka E, Liberman R. The effect of
burnishing on the marginal leakage of high copper amalgam resto-
rations: an in  vitro study. Dent Mater. Elsevier. 1987;3:117–20.
https://doi.org/10.1016/S0109-5641(87)80042-8.
4. Bogacki RE, Hunt RJ, del Aguila M, Smith WR.  Survival analysis of
posterior restorations using an insurance claims database. Oper
Dent. 27:488–92.
5. Fichmann DM, Santos W.  Restaurações à amálgama. São Paulo:
Savier; 1982.
6. Gilmore HW, Lund MR.  Operative dentistry, Saint Louis: Mosby;
1973.
7. Healey HJ, Phillips RW. A clinical study of amalgam failures. J Dent
Res. SAGE PublicationsSage CA: Los Angeles. CA. 1949;28:439–46.
https://doi.org/10.1177/00220345490280050301.
8. Hollenback GM. The economic value of amalgam in operative den-
tistry ant the technique of its use. J Am Dent Assoc. 1937;24:1318–
26.
9. Horsted-Bindslev P, Mjör IA.  Dentística operatória moderna. São
Paulo: Santos; 1990.
10. Howard WW. Atlas of operative dentistry. 2nd ed. St. Louis: Mosby;
1973.
11. Kato S, Okuse K, Fusayama T. The effect of burnishing on the mar-
ginal seal of amalgam restorations. J Prosthet Dent. Elsevier.
1968;19:393–8. https://doi.org/10.1016/0022-3913(68)90042-5.
12. Markley MR. Restorations of silver amalgam. J Am Dent Assoc. Else-
vier. 1951;43:133–46. https://doi.org/10.14219/JADA.ARCHIVE.
1951.0192.
13. Mondelli J, Franco EB, Pereira JC, Ishikiriama A, Francischone CE,
Mondelli RL, et  al. Dentística: Procedimentos Pré  - Clínicos. São
Paulo: Santos; 2002.
14. Neto NG, Carvalho RC, Russo EM, Sobral MA, Luz MA. Dentística Res-
tauradora: Restaurações diretas. São Paulo: Santos; 2003.
15. Ring ME.  História Ilustrada da Odontologia. São Paulo: Manole;
1998.
16. Roberson TM, Heymann H, Swift EJ. Sturdevant’s art and science of
operative dentistry. 5th ed. St. Louis: Mosby; 2006.
17. Roggenkamp CL, Cochran MA, Lund MR. The facial slot preparation:
a nonocclusal option for Class 2 carious lesions. Oper Dent.
1982;7:102–6.
18. Schoonover IC, Souder W.  Corrosion of dental alloys. J Am Dent
Assoc. Elsevier. 1941;28:1278–91. https://doi.org/10.14219/jada.
archive.1941.0194.
19. Schwartz RS, Summitt JB, Robbins JW.  Fundamentals of operative
dentistry. A contemporary approach. Chicago: Quintessence; 1996.
20. Simon WJ.  Clinical operative dentistry. Philadelphia: Saunders;
1956.
21. Swartz ML, Phillips RW. Residual mercury content of amalgam res-
torations and its influence on compressive strength. J Dent Res.
1956;35:458–66. ­https://doi.org/10.1177/00220345560350031801.
 411 12

Extensive Amalgam
Restorations
Carlos Rocha Gomes Torres, Shilpa Hanamaraddi Bhandi,
and João Cândido de Carvalho

12.1 Introduction – 412

12.2 List of Complementary Materials – 413

12.3 Cuspal-Coverage – 413

12.4 Restoration of Lost Cusps – 415

12.4.1  atural Retentions – 415
N
12.4.2 Artificial Retentions – 420

12.5 Bonded Amalgam Restorations – 426

12.6 Restoration of Extensive Preparations – 426

References – 433

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_12
 412 C. R. G. Torres et al.
Learning Objectives
The learning objectives of this chapter are related to the fol-
lowing topics:
55 How to perform extensive preparations on posterior
teeth, improving the retention and resistance of the
amalgam restoration but also protecting the remaining
tooth structure
55 Technique of cuspal-coverage of weakened cusps
55 Preparation of natural retentions (vertical walls, axial
offset, locks, coves, dentin pins, slots, amalgapin, and
pulpal chamber retention)
55 Preparation of artificial retentions (intradentinal pins and
endodontic posts)
55 Technique for bonded amalgam restorations
55 Restorative technique of extensive preparations with lost
cusps
12.1 Introduction
Due to its mechanical properties, amalgam restorations
should always be held and protected by the remaining tooth
structure. Amalgam has a high compressive strength but a
low tensile strength. Therefore, it is capable to resist heavy
occlusal loads, when the compressive stress is predominant,
but may fracture on cases of cusp restoration, when the ten-
sile stress can be strong. According to Barrancos Mooney, a
12 restoration will be more fragile when a larger tooth surface
needs to be restored, considering the extensive amalgam res-
toration as a semipermanent procedure [13]. In addition, on
large cavities, proper occlusal anatomy and contour are
sometimes hard to restore [18]. Ideally, when a cuspal resto-
ration is required, an indirect or semi-direct restorations
should be done, which may be produced with metal, ceramic,
or indirect composite [18]. On the other hand, the economic
reasons many times determine the choice of the restorative
material to be used. Whenever it is not possible to perform
an indirect restoration, a very good option is the dental amal-
gam [18]. When well-planned and done, an extensive amal-
gam restoration may show high durability [9]. For this, some
procedures to promote resistance and retention can be per-
formed, according to what will be presented next.
The extensive amalgam restorations are indicated to young
patients, whose teeth have not completely erupted, when it is
not possible to perform a proper gingival displacement and
isolation of the operating field. In addition, elderly and/or
debilitated patients who would not bear a long treatment may
also have their teeth properly restored with amalgam [18].
They can also be performed when the permanent treatment
must be delayed, such as in cases where the patients have a
great difficulty to control the biofilm, until they will be com-
pletely trained and motivated to control the caries disease, or
on patients undergoing orthodontic treatment. The same way,
when there is the intention to delay the treatment with a pros-
thetic crown or in the case of teeth with a pulpal or doubtful
periodontal prognostic, the amalgam restorations are a very
good option. The extensive amalgam restorations used tempo-
rarily may work as a core, during the tooth preparation for
indirect restorations, especially for the cast metal ones. On
those cases, the retentions prepared for the amalgam restora-
tions must not be removed during the preparation for the
indirect restoration [18]. There are some advantages of exten-
sive amalgam restorations in relation to the indirect ones. The
preparation is generally more conservative, the treatment
requires a single dental appointment and is less expensive. In
some cases, when the patient cannot afford the cost of an indi-
rect procedure, amalgam may be the only available alternative
to the extraction of severely damaged teeth [18].
The key to the success of the cuspal restorations is the
complete understanding of the mechanical principles to be
applied in the procedure. The preparations for amalgam res-
torations have traditionally been designed to obtain reten-
tion. The retention is defined as the prevention of restoration
displacement in the direction of the long axis of the tooth
when submitted to tensile forces. The resistance is defined as
to avoid the displacement or fractures caused by oblique or
compressive loads [17]. Although the retention form is
important on the extensive amalgam restoration, an empha-
sis must be given to the resistance of the restoration and the
remaining tooth structure [19].
Resistance is defined as to avoid the displacement or
fractures of the restoration caused by oblique or
compressive loads.
Retention is defined as the prevention of restoration
displacement in the direction of the long axis of the
tooth, when submitted to tensile forces.
The general principles of tooth preparation applied on an
extensive amalgam restoration are basically the same of the
regular-sized ones. The walls must be flat, uniform, and
smooth, and the vertical surrounding walls must be parallel or
convergent toward the occlusal surface, while the internal and
gingival walls are parallel to the occlusal surface [18]. The line
and point angles are round to dissipate the stress and improve
the adaptation of the restorative material. However, to improve
the resistance and retention, some changes are required. When
the amalgam cannot be held and surrounded by healthy
remaining tooth walls, its total volume must be increased, cre-
ating enough thickness to resist the occlusal loads [9]. There
are two situations that the extensive amalgam restorations are
indicated: the situations when the cusps are still present but
are fragile and prone to fracture and the cases when the cusps
have already been lost. Both situations are presented next.
>> When the amalgam cannot be held and surrounded by
healthy remaining tooth walls, its total volume must
be increased, creating enough thickness to resist the
occlusal loads
Extensive Amalgam Restorations
12.2 List of Complementary Materials
In addition to the materials and instruments indicated for
regular-sized amalgam restoration, the following items are
required for extensive restorations:
55 No. 329 or No. 330 bur
55 No. ¼ round bur
55 Self-threading pins and corresponding burs
55 Instrument to fold the pin
55 No. 141 riveting plier
55 Periodontal probe
12.3 Cuspal-Coverage
As it has already been mentioned on 7 Chap. 6, when the
amount of the lost tooth structure is more than 2/3 of the
distance between the central groove and the tip of the cusp,
its upper part should be removed and covered with the
restorative material (. Fig. 6.25a, b) [18]. Amalgam restora-
 
tions with cuspal-coverage or cuspal-capping significantly
increase the fracture resistance of weakened teeth when com-
pared with the amalgam restorations without coverage [12].
a b
c d
..      Fig. 12.1  Preparation with cuspal-coverage. a Tooth with defective
restorations and recurrent caries; b removal of the caries tissue; c filling
with GIC. It can be observed that the mesiobuccal cusp is fragile; d
evaluation of the height of the cusps; e Determination of the amount
413 12
The coverage of the weakened cusps reduces its risk of
remaining tooth fracture and extends its clinical life. When
this procedure is not performed, sometimes complex fac-
tures of the cusp can occur, invading the biological width and
requiring periodontal surgery. Amalgam restorations with
one or more covered cusps have a longevity increased up to
72%, after 15 years, and they do not show differences in rela-
tion to the smaller-sized restorations without the covering
(. Fig. 12.1a–i) [18].
Tip
When the amount of the lost tooth structure is more
than 2/3 of the distance between the central groove
and the tip of the cusp, its upper part should be
removed and covered with the restorative material.
If the tooth is correctly positioned, the supporting cusps are
reduced in approximately 2 mm, while the non-­supporting
cusps are reduced in about 1.5  mm. After analyzing the
occlusal interrelationship, if there is enough space between
the tooth to be restored and the opposing tooth, the reduc-
of the reduction; f evaluating the depth determined; g reduction of
the marked depth; h finished preparation involving the buccal surface;
i finished restoration
 414 C. R. G. Torres et al.

e f

g h

12
i

..      Fig. 12.1 (continued)

tion may be smaller [18]. A useful procedure is to evaluate
the height of the cusp and the location of its tips, in a way that
it can be later carved to its original height. For that, a peri-
odontal probe can be placed along the mesiodistal cusp
ridges of the cusps to be covered, touching the tips of the
No. 1148 diamond point and No. 245 bur are 3  mm long,
while the No. 1090A diamond point is 4 mm long. Initially,
depth cuts are made to delimitate the reduction, with the
instrument perpendicular to the long axis of the teeth
(. Fig. 12.1e). Then, the instrument is positioned parallel to

cusps of the adjacent teeth and memorizing or registering in the long axis of the teeth to verify the amount of reduction,
a paper the relation of the cusps with the probe (. Fig. 12.1d)
  depending on the type of cusp to be covered (. Fig. 11.1f).
 

[19]. If there is no adjacent tooth, the gingival margin can be After that, the instrument is once again placed perpendicular
used as reference. to the long axis of the tooth, and the depth cuts are connected
The determination of the amount of the reduction may be (. Fig. 12.1g). The cut surface must be as flat as possible and
 

obtained with a relative precision by using rotary instru- parallel to the occlusal plane, to produce a good stress distri-
ments with known dimensions. It is known that the heads of bution. The cusp reduction may be sometimes made at the
Extensive Amalgam Restorations
beginning of the preparation because it improves the access
and visibility for the next steps [18]. Any sharp angle formed
during the preparation is rounded to reduce the stress con-
centration in the amalgam, to increase the fracture resistance
of the restoration and tooth, preventing the fracture of the
remaining tooth structure.
12.4 Restoration of Lost Cusps
To restore teeth with lost cusps, the first step is to adapt the
remaining tooth structure to the basic principles of dental
amalgam preparations. First, the outline form of the prepara-
tion is defined, creating flat margins and walls, especially the
gingival wall, which extend from the proximal surface region
toward the buccal or lingual surfaces, helping to distribute
the stress generated on the occlusal loads. On the areas where
the remaining structures are more preserved, the general
characteristics of the amalgam preparations are followed,
considering the buccolingual dimensions when choosing the
direction of the vertical surrounding walls, convergent to the
occlusal surface or parallel to each other, according to what
has been described on 7 Chaps. 6 and 10.
On the other hand, the main challenge of the extensive
amalgam restorations is to obtain a satisfactory retention.
Due to the lack of natural adhesion of this material, the res-
toration retention must be mechanically obtained. However,
some micromechanical retention can also be obtained with
the bonding amalgam technique, which will be discussed
further on. The amount of required retentions will depend on
the amount of the remaining tooth structure of the tooth to
be restored. When more structure has been lost, more auxil-
iary retentions are required.
The mechanical retentions can be classified into natural
and artificial. The natural retentions are the ones obtained
through the specific characteristics of the preparation made
on the remaining tooth structure. The artificial retentions are
a b
..      Fig. 12.2  a Axial offset; b peripheral axial offset
415 12
the ones obtained using artificial materials, such as metallic
pins, which are anchored in the dentin or inside the root
canal. The retention characteristics must be distributed in all
areas of the preparation and not concentrate in only one. It is
known that more load is necessary to cause the displacement
and the fracture of the restorations when the characteristics of
the retentions are opposed to the direction of the loads [19].
12.4.1 Natural Retentions
12.4.1.1 Direction of the Vertical Walls
The easiest way to obtain retentions for a restoration is to pre-
pare the surrounding vertical walls convergent toward the
occlusal surface, despite the depth of the preparation, or par-
allel to each other if it is deeper than wide.
12.4.1.2 Axial Offset
A method that may promote retention is the preparation of
axial offset, according to what is shown in . Fig. 12.2a [17,
18]. This produces retentions by the presence of opposing
axial walls, which hinders the rotation of the restoration. A
study showed that axial offset may allow an effective reten-
tion even with a small depth, such as 0.75  mm [2]. The
peripheral axial offset can also be used, which will also hin-
der the rotation of the restoration (. Fig. 11.2b) [19].
12.4.1.3 Retentive Locks and Coves
Another possibility to obtain retention is the preparation of
undercuts in the walls, such as locks and coves. Locks are
prepared in a vertical plane and coves are prepared in the
horizontal plane. The locks are prepared using rotary cone-­
shaped instruments in the line angle between the vertical
surrounding wall and the axial wall (. Fig. 12.5j, k, o). The
coves are prepared in the line angle between the vertical sur-
rounding walls and the pulpal wall, at the region under the
cusps because this area has a larger volume of dentin
 416 C. R. G. Torres et al.

(. Fig.  12.5l–o) [18]. Rotary short inverted cone or round

  larger dimensions on the horizontal plane (. Fig.  12.4).  

instruments can be used, according to what was described on They are indicated on teeth with short clinical crowns and
7 Chap. 6 (. Fig. 6.44a, b).
    on cusps that have been reduced for capping with the resto-
ration [18]. It can be made on the gingival walls of the prep-
Tip arations using short inverted cone rotary instruments, such
as the No.33½ or No.34 burs or the 1031 diamond point.
Locks are prepared in the line angle between the vertical They can be continuous or segmented, depending on the
surrounding wall and the axial wall, while coves are amount of lost tooth structure [18]. It must be approxi-
prepared in the line angle between the vertical mately 0.5 mm wide in the entrance, according to the rotary
surrounding walls and the pulpal wall, at the region under instruments used, and 0.6  mm wide on the base, with a
the cusps, because this area has a larger volume of dentin. depth between 0.5 and 1  mm [7, 18]. Generally they are
between 2 and 4  mm long, depending on the distance
between the vertical surrounding walls, especially when the
gingival wall is long. It must always be made in dentin, at
12.4.1.4 Dentin Pins
least 1 mm away the DEJ. Some authors prefer to start the
When the tooth presents carious lesions shallow in dentin, preparation with a conical 169 bur, finishing it later to
with fracture of the enamel on the tip of the cusps, the so-­ ensure the convergence of the slot walls, using an inverted
called dentin pins can be prepared [13]. To choose this reten- cone instrument such as the No.33½ bur. They consider that
tion method, a minimum of 2  mm of space must exist this technique allows a better control during the prepara-
between the dentin wall and the opposite tooth, allowing the tion, due to the fact that the No.169 bur has a smaller cut-
necessary thickness of restorative material. If this space does ting end than the No.33½ one.
not exist, the surface must be cut with a cylinder-shaped As the retention will be produced by a projection of the
rotary instrument. After that, the region around the tip of the amalgam restoration inside the dentin, its resistance is related
cusp is cut, resulting in a pin shape, according to what is to the setting of the restorative material, which is completed
shown in . Fig. 12.3. Additional retention coves can be pre- at least only 24 h later. Therefore, extreme care must be taken
 

pared on the bases of the pins, using short inverted cone at the moment of removing the matrix band, because an
rotary instrument. abrupt movement may lead to a fracture of the amalgam on
12 12.4.1.5 Slots
the entrance of the slot [18].

The retentive slots for amalgam restorations were proposed 12.4.1.6 Channels for Amalgapin
by Outhwaite et al. [15] and are prepared in dentin, with its The preparation of a channel, in which the amalgam is
condensed, creating a retentive amalgapin, was proposed
by Shavell [20] (. Fig.  12.5a–i). It is  indicated when the
 

..      Fig. 12.3  Dentin pins ..      Fig. 12.4  Preparation of slots on gingival walls
Extensive Amalgam Restorations
gingival walls are small or when the maximum preserva-
tion of the remaining tooth structure is desired. They
should be preferably made with a long inverted cone bur
No. 329 or No. 330 or with a No. 1031 diamond point. A
channel of 1.5–2 mm depth and 0.8–1 mm diameter must
be prepared [7, 19]. The same way as the slots, the channels
are made in dentin at least 1 mm away from the DEJ. One
channel per lost cusp can be prepared, preferably on the
region near the axial angles to avoid perforation on the
furcation region. They have the advantage to require less
removal of tooth structure than the slots, even though they
also require careful removal of the matrix band to avoid
amalgapin fracture. To avoid the pulpal or periodontal
perforation during the channel preparation, it is impor-
tant that the long axis of the rotary instrument is placed
parallel to the nearest external surface of the tooth on that
area. The place where the channel is going to be prepared
can be initially marked with an indentation or starting
point, using a No. 1011 round diamond point or No. ½ or
No. ¼ burs.
If the extenal surface  of the tooth close to the area
where the retention will be prepared is exposed above the
a b
c d
..      Fig. 12.5  Preparation of amalgapin channel and other retentions
on a preparation with lost cusps. a Basic preparation finished; b No.
329 bur and No. 1011 diamond point; c–e adjusting of the bur
direction; f, g preparation of the channel; h bevel at the channel
417 12
gingival margin, the alignment of bur is easier. However,
in most cases, the soft tissue avoids the visualization of
the tooth surface adjacent to the area of the channel loca-
tion. To place the rotary instrument in the correct align-
ment, it is inserted inside the gingival sulcus, in a way
that it only touches the gingival cavosurface angle of the
preparation (. Fig.  12.5c ). Then, the bur is rotated in a
way that it is separated from the margin, indicating that
only the tip is touching the external tooth surface (. Fig.  
15.5d ). Then, it is rotated back slowly until it touches
once again the preparation margin, giving certainty that it
is parallel to the external surface of the tooth (. Fig. 12.5e ).
This alignment must be memorized and kept. The instru-
ment is then placed into the starting point, maintaining
the correct alignment (. Fig.  12.5f ). The bur must come
in and out turning, avoiding fracture inside the channel
[2]. The channel is prepared with the depth correspond-
ing to the length of the rotary instrument head that is
2  mm long (. Fig.  12.5g ). To finish the preparation, a
bevel is performed at the entrance of the channel, increas-
ing the thickness of the material at this area, reducing the
stress concentration on the base of the pin [17, 19]. The
entrance; i finished channel; j preparation of the retentive lock on the
mesiofacial line angle; k retentive lock on the buccoaxial line angle;
l-o preparation of coves under the cusps
 418 C. R. G. Torres et al.

e f

g h

12
i j

k l

..      Fig. 12.5 (continued)
Extensive Amalgam Restorations
419 12

m n

..      Fig. 12.5 (continued)

a b

..      Fig. 12.6  a, b Channels for the amalgapin

Tip

No. 1011 or No. 1012 diamond point or the No. 1 or 2
burs can be used, depending on the channel diameter. On
those channels, the amalgam condensation must be per-
formed with a thin amalgam condenser, such as the No.
00 from Ward set, taking care at the moment of the matrix
band removal to avoid the pin fracture [7]. In . Fig. 12.6a ,
b, some clinical examples of the amalgapin preparation
are presented.
As the retention provided by slots and amalgapins will be
produced by the amalgam condensed inside some very
small cavities, its resistance is related to the setting of the
restorative material, which is completed at least only 24 h
later. Therefore, extreme care must be taken when removing
the matrix band, because an abrupt movement may lead to
a fracture of the amalgam and total loss of retention.
 420 C. R. G. Torres et al.
12.4.1.7 Pulpal Chamber Retention
On the cases of pulpless teeth, after endodontic treatment, the
pulpal chamber can be used to obtain retention for the resto-
ration, and the amalgam is condensed inside it. This tech-
nique can be recommended when the dimensions of the
pulpal chamber are adequate, allowing proper  volume for
mechanical retention of the amalgam. In addition, the thick-
ness of the remaining dentin around the chamber must be
sufficient to give the necessary fracture resistance to the tooth.
A pulp chamber with a height of 4–6 mm is enough to allow
satisfactory retention for a direct amalgam restoration
(. Fig. 12.7a) [18]. If it is necessary to increase the retention,
coves can be prepared in the chamber walls, using a short
inverted cone rotary instrument. However, when the pulpal
chamber height is less than 2 mm, the use or artificial reten-
tion should be considered. Before condensing the amalgam, it
is convenient to apply a thin layer of GIC over the obturation
of the root canals, to simplify a future access in case an end-
odontic retreatment is required. Another option is to com-
pletely fill up the pulpal chamber with GIC, building a kind of
core, and then to prepare slots or amalgapin channels inside it
(. Fig. 12.7b, c). This way, the GIC will chemically bond to
 
a b
12
..      Fig. 12.7  a Application of the amalgam inside the pulpal chamber on a transversal section; b, c filling of the pulpal chamber with GIC
associated with mechanical retentions
the tooth, while the amalgam will be mechanically retained in
the cement. This last technique has the advantage to simplify
the access to the root canal, in case a retreatment is required.
12.4.2 Artificial Retentions
There are basically two types of artificial retention methods
that can be associated with amalgam restorations, the intra-
dentinal pins and the endodontic posts, which will be
described next.
12.4.2.1 Intradentinal Pins
They are metallic pins which are fixed in the dentin and capa-
ble to anchor the restoration. They can be made of stainless
steel, silver, platinum-iridium alloy, titanium, or gold. The
main requirement is that they must be resistant to oxidation.
The contact of the stainless steel with the amalgam generally
results in its corrosion. For this reason, some stainless steel
pins are coated with titanium oxide or gold [7]. They can be
cemented, friction-locked, or self-threaded. They are gener-
ally indicated on the cases that there is little or no vertical
Extensive Amalgam Restorations
wall and when there is space for the pin [18]. The pin channel
is prepared with a special twist drill, which cuts only on the
tip, different from a regular dental bur which cuts on the
sides too.
Although the intradentinal pins were first described in
the nineteenth century, it was Markley on the 1950s who
popularized the concept of the cemented stainless steel pins
on his lectures and articles [8, 10]. For its application, a chan-
nel slightly larger than the pin is to be prepared, of about
0.025 mm, with a depth of 3–4 mm [18]. Then, the cement is
applied into the channel with a lentulo spiral filler and the
pin is inserted. The friction-locked pins were proposed by
Goldstein and require the preparation of a slightly under-
sized channel, of about 0.025 mm, with a depth of 2–4 mm.
When pressed into the channel, due to the elasticity (resil-
iency) of the dentin, it penetrates under pressure. The
friction-­locked pins produce 2–3 times more retention than
the cemented ones (. Fig. 12.8a) [18].
 
The self-threading pins also use the elasticity of the den-
tin for its retentions since the drill used for the channel prep-
aration is 0.038–0.1 mm smaller than the pin (. Fig. 12.8b)  
[18]. The diameter of the pin in relation to the diameter of the
channel must be in a way that, the deformation produced at
the moment in which it is threaded, stay  inside the elastic
limit of dentin [19]. The use of this pin for amalgam restora-
tion was first described on a scientific publication by Going,
in 1966. They are the only ones that are still used
(. Fig.  12.10a–l) [18]. The channel depth must be around
 
1.5–2  mm. The thread is created when the pin is threaded
into the dentin. A larger retention may be attained increasing
the channel depth [18].
On a comparative retention analysis, a study showed that
the self-threading pin is 5–6 times more retentive than the
cemented ones and 2–3 times more retentive than the
friction-­locked. Therefore, to obtain the same retention
offered by 1 mm depth of the self-threading pin, it would be
a b
..      Fig. 12.8  Intradentinal pins. a Friction-locked; b self-threading (1 and 2, hand wrench and standard pins with different sizes; 3, 4, and 5,
self-shearing pins with different diameters attached to the chuck;  6 pin hand wrench connected to the chuck)
421 12
necessary to have a 2–3 mm depth for the friction-locked and
5–6  mm depth for the cemented [7]. Although the thicker
pins produce more retention, they also create more stress.
For this reason, the pins with smaller diameter are chosen,
such as 0.48 and 0.61 mm. The pins with 0.48 mm of diame-
ter are generally used because they are safer. However, the
pins with 0.61 mm of diameter are maintained as backup in
case the channel is over-enlarged or the thread was stripped
during the application of a thinner pin (. Fig. 12.8b). Vertical
and horizontal stress can be generated in the dentin when a
self-threading pin is inserted. However, cracks on the dentin
may be related to the diameter of the pin. The thicker it is, the
more cracks it causes, although they are more retentive than
the thinner ones [18]. Those cracks happen mostly if they are
incorrectly applied, which can predispose the remaining
tooth structure to fractures. Those stress and cracks can have
small or no clinical significance on most cases or may be
important when little dentin is available [18]. The main
requirement to avoid those problems is the preparation of the
channel in a region not closer than 0.5–1 mm of the DEJ or
not closer than 1–1.5 mm of the cavosurface angle in case of
no enamel in the margin. Other disadvantage of the pins is
the fact that they make the restoration more fragile, because
they are composed of a material with different physical char-
acteristics from the amalgam [7, 18].
To apply the intradentinal pin, a preoperative radiogra-
phy must be obtained, in such a way to analyze the tooth
position and any  leaning, the preparation depth, and the
extension of the pulpal chamber [7, 18]. The gingival sulcus
must be evaluated with a periodontal probe, determining if
there is some abnormal contour of the tooth structure, which
may predispose the tooth to an external perforation [18].
Then, the number and location of the pins are planned,
choosing the smaller number as possible, being usually rec-
ommended only one pin per lost cusp. However, the number
of pins may vary according to the diameter of the pin, the
 422 C. R. G. Torres et al.
amount of remaining tooth structure, and the use of other
retention forms, besides the functional requirements of the
restoration. In relation to the location, a distance of at least
3 mm must be kept among them. The larger this distance, the
smallest the stress level in the dentin [19].
There are certain locations more indicated to insert a pin,
while others must be avoided, as it can be seen in . Fig. 12.9.   this case, the wall which will receive the channel must be flat
In general, the preferred pin location must be on the regions
near the axial angles, due to the larger amount of the dentin
between the external surface and the pulpal chamber,
decreasing the risk of perforation [18, 19]. This risk is larger
on the region of root furcation. On the mandibular molars,
the regions between the mesiobuccal and mesiolingual roots
as well as between the mesial and distal roots must be
avoided, because a pin placed at this area may reach the fur-
cation region. On the same way, the middle of the distal root
should be avoided due to its concavity, which may also result
in perforation. On the maxillary molars, the pin channel
preparation on the region between the buccal roots and
between the buccal and lingual one must also be avoided. The
region of the middle of the lingual root, due to its concavity,
may also be potentially dangerous. On the first maxillary pre-
molars, the channel preparation between the buccal and lin-
gual roots can also result in perforation [19].
Ideally, a previous rubber dam isolation should  be per-
formed, eliminating the possibility of the patient to swallow
or aspirate the pin, besides avoiding pulp contamination in
12 case of perforation [19]. In case it is not possible, a piece of
gauze is placed covering the tongue and most of the throat,
and the pin hand wrenches is tied to a 30–35 cm piece of den-
tal floss. Those precautions reduces the chances of the patient
to swallow or aspirate the pin [18]. On the selected locations,
before using the twist drill for channel preparation, an inden-
..      Fig. 12.9  Locations for the pin insertion on upper premolar, upper
molar and lower molar (green, preferred locations; yellow, caution
location; red, locations with higher risk of perforation)
tation or starting point with 0.5 mm depth must be prepared,
using a No. ½ or No. ¼ round bur (. Fig. 12.10c) [18]. This
will avoid the drill used on the channel preparation to move
around at the beginning of the procedure [7, 19]. This type of
drill generally presents a stop to limit the adequate depth of
the finished channel, being called depth-limiting drill. On
and form a right angle in relation to the direction of the drill
insertion. The two cutting blades of the drill tip are sloped so
that they will cut only when the drill is turning in a clockwise
direction [19]. It has flutes with spiral patterns to remove the
dentin chips from the channel (. Fig. 12.10d) [2]. It is impor-
tant to preserve a space between the pin and the axial walls of
the preparation, because this can hinder the bur to reach the
adequate depth and also adversely affect the correct conden-
sation of the amalgam between the pin and the axial wall [18,
19]. If necessary, the axial wall can be slightly cut to create
space [19]. There must be a minimum of 0.5  mm of space
around the pin to allow the condensation of the amalgam on
its entire surrounding surface. The drill will enter and with-
draw from the channel spinning continuously. If it stops
inside the channel and a lateral load is applied, it may break.
The channel must be prepared parallel to the nearest
external surface of the tooth, avoiding to be directed to the
periodontal ligament, causing a constant inflammation and
bone resorption, or toward the pulpal chamber, causing
pulpal exposure [7, 18]. The dentist needs to be sure that the
bur is correctly positioned, with its long axis parallel to the
external surface of the tooth. The technique for the correct
placement of the bur is the same as the one previously
described for the preparation of the channel for amalgapin
(. Fig. 12.5c–g). During the channel preparation, it is advis-
able to withdraw the drill from the channel at least once, half-
way the total extension of the head, to allow the dentinal
cuttings to be cleared from the flutes of the drill, for a better
efficient preparation and less heat production [19]. Then it is
penetrated again until it reaches the stop and is completely
removed. That means the channel is finished with only two
consecutive penetrations. Care must be taken to avoid the
over-enlargement of the channel, with multiple entries and
withdrawals, due to the unavoidable small leaning of the bur
by the dentist hands [18].
Then, the pin is threaded with a small pin wrench or a
latch-type contra-angle low-speed handpiece [18, 19]. Some
self-shearing pins have a weak point between it and the chuck
in which they are attached. When they completely seat at the
end of the channel, they break at this area, disengaging from
shank and remaining in position (. Fig. 12.10g, arrow). The
standard pins do not have this weak point and will require
the use of a wrench (. Fig. 12.8b, 1 and 2). This type allows
the dentist to feel the insertion by tactile sense, and after fully
seated, which can be reverted one quarter turn, reducing the
stress on the dentin created at the apical end of the channel
[7, 18, 19]. Those pins also have the advantage to unscrew in
case it is required. In case the standard pin is still hand-­
threaded after reaching the bottom of the channel, it may
break or strip the threads in the dentin [18].
Extensive Amalgam Restorations
The fastest method to insert a pin is through the use of a
contra-angle, simplifying the procedure. In situations of dif-
ficult access, even the pins intended for being threaded with a
contra-angle may also be hand-threaded using a proper
wrench that comes with the set (. Fig. 12.8b). Preferably, the
 
gear reduction contra-angle handpiece (10:1) should be used,
which increases the tactile sense of the operator and reduces
the risk of stripping the threads [18]. To reduce the stress pro-
duction when the pin tip reaches the bottom of the channel,
some manufacturers produced pins with a shoulder stop [19].
423 12
After the pin insertion, besides the pin tip penetrating
1.5–2 mm inside the dentin, the other side remains in prepa-
ration. A space of 2mm should be left between the top of the
pin and the surface of the restoration, so that it can be cov-
ered with the restorative material and the final restoration
can be resistant enough [7, 18, 19]. If the pin is too long and
must be shortened, it can be cut with a cylinder or conical
bur, placed perpendicular to the pin, avoiding it to be
unscrewed with the rotation of the bur. To avoid heating, this
must be performed with a proper airstream cooling [18]. If

a b

c d

e f

..      Fig. 12.10  Technique for the use of the intradentinal pins. a Caries drills with different diameters; e, f preparation of the channel; g, h pin
lesions with loss of the distolingual cusp and cavitation under the being threaded (arrow – self-shearing weak area); i, j, k pin being
mesial marginal ridge; b tooth preparation and filling with GIC; c bended; l pin in position
marking the channel location with the No. ¼ round bur; d helicoidal
 424 C. R. G. Torres et al.

g h

i j

12
k l

..      Fig. 12.10 (continued)

the bur cannot be positioned perpendicular to the pin, it
must be stabilized with a hemostatic forceps or cotton twee-
zer without using a lever, avoiding it to unscrew the pin from
the dentin [19].
The preparation and the pin must be inspected, predict-
ing the final contour of the restoration, analyzing if the pin
will not touch or be too close to the matrix band, adversely
affecting the condensation, and leaving little restorative
Amalgam condensers and dentin spoons should not be used
to bend the pin, because the fulcrum of rotation would be at
the entrance of the channel, which could cause cracks or
fractures on the dentin, besides producing an abrupt bend
that increases the fracture risk of the pin [2, 18]. To perform
that, a fork-shaped bending tool must be used, which is con-
nected to the pin and rotated until the desired bending is
obtained (. Fig.  12.10i–k). This tool places the fulcrum of

material covering the pin. At least there must remain 1 mm rotation in another location of the exposed pin, increasing
of amalgam around the pin, between it and the external sur- the control of the pressure applied. If the amalgam restora-
face of the restoration. If necessary, it can be bended. tion will be eventually used as a core, the pins must be folded
Extensive Amalgam Restorations
correctly toward the center of the tooth, in a way they are
not exposed during the axial reduction during the full crown
preparation. If a drill or a pin fractures, its removal is diffi-
cult, if not impossible, and usually should not be attempted.
The best solution for this problem is prevention. An alterna-
tive position for another pin must be chosen and the new
pin inserted [2, 18]. If the channel is too wide and the pin
cannot be threaded, a drill and the pin with a larger diame-
ter are used. However, if this does not work, another option
is to perform the cementation of the pin, retaining it by
cement [19].
The penetration of the drill into the pulpal chamber is
noticed by bleeding through the pin channel, besides feeling
of sudden loss of bur resistance to hand pressure. The perfo-
ration can be also noticed when the pin goes further than the
depth of the channel when being threaded. The penetration
can also be noticed on radiography. However, the overlap-
ping of the images of the pin over the pulp chamber may
­happen, resulting on a false idea of penetration. If the pulp
penetration happens, the pin must be removed and the bleed-
ing controlled, washing the preparation with saline solution
or a calcium hydroxide solution and then drying with a small
sterile cotton ball. Then, the pure calcium hydroxide powder
is applied inside the channel, which must be covered with
calcium hydroxide cement, as is performed with any acciden-
tal pulpal exposure during tooth preparation [18]. A perfora-
tion of the external tooth surface, until the periodontal tissue,
may be suspected when the patient experiences symptoms
during the preparation of the channel on a non-vital tooth.
The perforation may be above or below the gingival margin.
On the first case, the excess of the pin must be cut off, or it
may be removed and the region restored with amalgam [19].
If it happened below the gingival margin, trans-surgical res-
torations, gingivectomy, or a surgery of crown lengthening
may be required. Despite the type of problem that may have
occurred, the patient must be informed of the proposed
treatment.
When the tooth to be restored lost both adjacent cusps,
such as the loss of both supporting cusps preserving the
a b
..      Fig. 12.11  Options to avoid the restoration rotation. a Additional orizontal pins; b multiple vertical pins
425 12
balancing cusps or both balancing cusps preserving the
supporting cusps, the use of one pin per cusp will not pro-
duce a satisfactory result, due to the lack of distribution of
resistance and resistance features. During mastication,
there will be nothing to attach the remaining cusps to the
restoration. Therefore, an oblique load over the restored
cusps will produce the rotation of the restoration, causing
fracture on the remaining tooth structure on the region
where the pins were inserted. On those cases, horizontal
pins inserted on the remaining cusps will reduce the likeli-
hood of fracture (. Fig. 12.11a, b) [18, 19]. In case it is not
possible due to the fragility of the remaining cusps, com-
plementary vertical pins may be an option on the gingival
walls, corresponding to the region of the marginal ridges,
as closest as possible to the remaining cusps, considering
that there is enough dentin between the gingival wall and
the furcation [19].
In a comparative analysis between the use of slots and the
amalgapin channels with the intradentinal pins, the first ones
are easier and faster to be performed, do not induce stress on
the dentin, and do not reduce the resistance of the restora-
tion. In addition, they do not present any cost and may be
indicated to teeth with short clinical crown or small cuspal-­
capping [18]. Some studies suggest that they are as retentive
as the intradentinal pins [1, 17–19]. As a disadvantage, the
natural retentions made directly with the amalgam require a
greater removal of the tooth structure and a more critical
restorative technique, especially at the moment of the matrix
removal [7, 18].
12.4.2.2 Endodontic Posts
If the pulpal chamber height is smaller than 2 mm, only the
condensation of the restorative material on its interior is not
enough to give the necessary retention for the amalgam res-
toration. To obtain additional retention in cases of severely
destroyed and pulpless teeth, metallic posts can be used,
which are cemented into the roots after its preparations. The
amalgam is condensed over the posts, which create retention
for the restoration (. Fig. 12.12).
 426 C. R. G. Torres et al.

without damaging the condensed amalgam [18]. The excess

must be removed with a dry applicator but never with air-
stream. This way, the amalgam particles will mechanically
interlock on the uncured adhesive layer while it is still fluid,
which after the polymerization will produce the retention.
If a light-cure adhesive is chosen, it must be applied
according to the manufacturer’s recommendations and light-­
cured. Then, a thin layer of dual-cure resinous cement is
applied. Before its self-curing, the amalgam must be fastly
condensed, promoting an interlock of the amalgam with the
resinous cement. In . Fig. 12.13a–i, an example of the bonded
 

amalgam technique is presented.

The bonding strength obtained may depend on the type
of amalgam used. The spherical amalgam results in higher
bond strength than the admixed or lathe cut. Some studies
have shown that some adhesives are very effective, resulting
on initial bonding strength values of 10–14  MPa [5, 16].
However, the characteristics of primary retention form
related to the preparation shape are still recommended when
an adhesive system is used, because it is not clear if the initial
adhesion may be kept on adequate levels with the years. The
..      Fig. 12.12  Use of endodontic posts bonded amalgam technique may reduce the marginal micro-
leakage and the postoperative sensitivity and improve the
fracture resistance of the remaining tooth structure [14, 21].
12.5 Bonded Amalgam Restorations The fracture resistance of the teeth with MOD-bonded amal-
gam restorations is two times higher than the regular ones
The dental adhesives may be associated to amalgam restora- [4]. However, the obtained retention is not high enough and
12 tions just with the aim to seal the dentin tubules and promote cannot replace the conventional retention and resistance
the pulpal protection; or with the aim of bonding the amal- forms [3, 18]. According to Sturdevant [18], the use of adhe-
gam to the tooth structure. If after the tooth preparation an sion, besides to increase the costs, the time spent, and the
adhesive system is applied on the preparation and light-­ complexity of the procedure, has not been proved beneficial
cured, and the amalgam is condensed afterward, it will not on the clinical studies throughout time, so it is not defended
bond to the tooth structure. The adhesive layer  will be as a routine procedure.
already polymerized/hard and will only act as a pulpal pro-
tection. On this case, the adhesive can be applied before the
placement of the matrix band [18]. 12.6 Restoration of Extensive Preparations
To promote the adhesion of the amalgam to the tooth
structure, there are two possibilities. The first one is to use a When using a universal matrix retainer in cases of loss of
dual-cure adhesive system, while the second one is to associ- three or more cusps, a gap of the matrix band at the region of
ate a light-cure adhesive system to a dual-cure resinous the U-shaped guide posts will face the preparation, allowing
cement. Even though the bonding mechanism between the the penetration of amalgam and impairing the restoration.
adhesive and amalgam is not completely understood, it may To obtain a proper contact of the band around the entire
be due to a micromechanical interlocking of the non-cured preparation contour, a small complementary matrix strip can
adhesive with the non-crystallized amalgam during conden- be applied on the region of the gap as it can be observed in
sation. . Fig. 12.14a, b [7].
 

First, the rubber dam isolation and then the matrix band On the other hand, on most large preparations, when it is
and wedges are applied to the tooth. However, some kind of necessary to restore a lost cusp, the use of a universal matrix
isolating coat must be applied to the band; otherwise the does not allow the desired contour (. Fig. 12.15b). Due to
 

adhesive will bond to it and to the amalgam. In that case, dur- the need to stabilize the band screwing the spindle of the
ing the matrix removal a portion of the amalgam will be matrix retainer, reducing the band diameter, it tends to
pulled out from the restoration, since the material has not yet deform on the region of the lost cusp and penetrate into the
reached the final strength. For that, casting wax or wax pen- preparation. To solve this problem, the operator can use riv-
cils can be used to isolate the matrix, rubbing the wax over eted (. Fig. 12.15a–o), spot-welded (. Fig. 8.33), or T-band
   

the band [18]. If a dual-cure adhesive system is selected, it (. Fig. 8.34) custom-made matrices or even retainer less
 

must be applied, and, before its chemical curing, the amal- circumferential matrices, with aluminum built-in tension-
gam must be fastly condensed [18]. Little adhesive must be ing ring (TDV) or AutoMatrix (Dentsply) (. Figs. 8.4a–d  

applied to reduce its overflow, since it is difficult to remove and 8.5a, b).
Extensive Amalgam Restorations
427 12
Tip To prepare a riveted matrix (. Fig.  12.15a–o), using a
 

stainless steel matrix band with a width slightly higher than

On large preparations with one or more lost cusps, the use
of a universal matrix may not allow the desired contour. In
those cases, riveted, spot-welded, or T-band custom-made
matrices or even retainer less circumferential matrices
with aluminum built-in tensioning ring (TDV) or
AutoMatrix (Dentsply) are more indicated.
the tooth to be restored, the operator measures the diameter
of the tooth and cuts the band with 1 cm of excess, so it can
be held tightly. In general, it is necessary about 5 cm of the
matrix band [11]. The band is placed and adjusted around
the tooth, and the dentist folds it with a flat nose plier or a
curved-end mosquito forceps, creating the correct diameter
(. Fig. 12.15a–d). The band is removed from the tooth, and

a b

c d

e f

..      Fig. 12.13  Restoration technique with bonded amalgam. a Large
caries lesion which led to the complete undermining of the distolin-
gual cusp; b preparation finished; c pulpal protection with the calcium
hydroxide cement; d the GIC artificial dentin was applied under the
mesiolingual cusp and riveted matrix surrounded by low fusing
compound wall was placed; e acid-etching; f dual-cure adhesive
system application; g amalgam condensation over the uncured
adhesive; h initial result; i restoration after the polishing
 428 C. R. G. Torres et al.

g h

12
..      Fig. 12.13 (continued)

a b

..      Fig. 12.14  a, b Use of the complementary strip in preparation with the loss of several cusps, on the region of the gap of the matrix retainer

the place marked with the fold is riveted one or two times matrix is placed in position on the tooth, and the operator
with a riveting plier No. 141. The initial perforation is made, evaluates its adaptation and folds the ends of the band over
and then the band is inverted, repeating the procedure and the external surface of the tooth (. Fig. 12.15j). The matrix is
 

creating the rivets (. Fig. 12.15e–i). If the dentist has a spot-­

  removed from the tooth and burnished on a paper mixing
welding device available, instead of riveting, the band can be pad, to create an adequate contour for the proximal surface
welded in an adequate diameter (. Fig. 8.33). After that the
  of the restoration (. Fig. 12.15k).
 
Extensive Amalgam Restorations
After that, the matrix is taken in position, and wooden
wedges are inserted on the mesial and distal interproximal
spaces, using a mosquito forceps with a curved end. It is
important to evaluate if the matrix is touching the adjacent
tooth, in a way to allow the correct restoration of the contact
point. The matrix is burnishing toward the adjacent tooth
using the back of a dentin spoon or a Hollenback No. 6 bur-
429 12
essary, this area must be burnished until it reaches the correct
contour.
The matrix and wedge system can be additionally stabi-
lized using heated low fusing compound, which is com-
pressed over the buccal and lingual embrasure, taking care
for the compound to not enter the tooth preparation
(. Fig. 12.15m, n). Besides to help on the stabilization of the

nisher (. Fig. 12.15l). Special attention must be kept to the

  matrix, the compound hinders the overflow of the amalgam
contour of the matrix on the region of the axial angles. If nec- on the buccal and lingual surfaces or the proximal surface

a b

c d

e f

..      Fig. 12.15  Riveted custom-made matrix. a Preparation finished; b procedure; i finished rivet; j bending the matrix end; k burnishing the
universal matrix applied resulted in deformation on the region of the contact point area; l burnishing toward the adjacent tooth; m,
distolingual cusps; c, d adjusting the matrix diameter; e–h riveting n stabilization with compound; o restoration concluded
 430 C. R. G. Torres et al.

g h

i j

k l
12

m n

..      Fig. 12.15 (continued)
Extensive Amalgam Restorations
o never be heated on the flame and directly applied over the
..      Fig. 12.15 (continued)
when there is no adjacent tooth [19]. The compound adhe-
sion characteristics are useful because it bonds to the matrix
and tooth at a low temperature, which will not cause damage
to the soft tissues and teeth.
When handled according to the correct technique, the
use of low fusing compound is simple, easing significantly
the restorative procedure (. Fig.  12.16a–i). Its correct use
just requires some training. For that, approximately 2.5 cm of
the tip of a compound rod is positioned over the flame of an
alcohol lamp. The rod is moved forward and backward while
it is turned between the fingers. After 5–10 s it is removed
from the contact with the flame so that the heat may diffuse
into the center. It is noticed that the rod end begins to bend,
indicating that it is soft (. Fig.  12.16b). The softened com-
pound is shortly immersed in a vial with water, preferably
warm, to create a non-sticky surface. The operator wets the
fingers and holds a small portion of softened non-sticky
compound, preparing a small sphere (. Fig.  12.16c). He
keeps the compound between his thumb, index, and middle
finger of one hand and passes it quickly over the flame, creat-
ing a sticky surface (. Fig.  12.16f, g). Then, he bonds this
surface to the index finger of the other hand and passes the
compound quickly over the flame, making this surface sticky
again (. Fig. 12.16h, i).
The compound is then immediately applied over the
matrix and the wedge (. Fig.  12.15m, n). The cold air of a
syringe is directed over the compound to speed the solidifica-
tion and stabilize the set. If excess of compound  overflows
over the matrix or inside the preparation, it can be easily
removed with cutting instruments. The compound must
431 12
tooth. This may cause damage to the pulp due to the pro-
longed application of heat [6].
If the matrix is slightly displaced from the contact or ideal
contour due to the compound application, the back of a
heated dentin spoon may be used, burnishing the matrix
toward the adjacent tooth, softening the godiva, and readapt-
ing the contour of the matrix. If the compound is applied
both at the buccal and lingual sides and it is necessary to sta-
bilize the set, a staple can be prepared using an orthodontic
wire or paper clip giving it a U shape. It is then heated and
inserted in the compound, connecting both sides. The com-
pound may be removed with a Hollenback carving and the
staple with a heated tweezer. The heat will diffuse through the
metal and melt the compound, allowing its removal [19].
For large restorations, it must preferably choose the amal-
gam of extended setting time, giving more time for carving
and adjusting of the restoration. Also, for increasing the
working time for carving due to the large preparation size,
the amalgam may be taken into the preparation in large
amounts. For that, instead of using the amalgam carrier, the
portion of the triturated amalgam may be divided into two
parts and taken into the cavity with a tweezer [19]. The con-
densation must start in the prepared natural or artificial
retentions [18]. The carving of the occlusal area must be fast,
even if coarse, allowing the prompt matrix removal and carv-
ing of the more difficult areas, such as the gingival and inter-
proximal margins, removing any excess.
Conclusion
This chapter describes the technique for extensive amalgam
restorations. The details of tooth preparations for improving
the retention and resistance were presented. The technique
of cuspal-coverage of weakened cusps can avoid aggressive
fractures of the remaining cusps, preserving the tooth struc-
ture. The different preparation techniques of natural (vertical
walls, axial offset, locks, coves, dentin pins, slots, amalgapin,
and pulpal chamber retention) and artificial retentions (intra-
dentinal pins and endodontic posts) can prevent the restora-
tion dislodging due to interarch teeth contact and chewing
forces. The association of adhesive systems with amalgam
can also be an alternative to improve the resistance of the
remaining structure, besides helping its retention. The amal-
gam can be an effective and a low-cost alternative of severely
damaged teeth, being an important part of the practitioner’s
dental knowledge.
 432 C. R. G. Torres et al.

a b

c d

12
e f

..      Fig. 12.16  Technique of low fusing compound handling. a, b preparation of a small ball; g superficial heating of the ball recovering
Softening of the compound over the flame; c, d superficial cooling of its bonding capacity; h sticking the ball at the tip of the finger; i
the compound and wetting of the finger; e, f removal of a portion and superficial heating of the small compound ball
Extensive Amalgam Restorations
433 12

g h

..      Fig. 12.16 (continued)

References 11. Mondelli J, Ishikiriama A, Galan JJ, Navarro MF.  Dentística Oper-
atória. São Paulo: Sarvier; 1976.
12. Mondelli RF, Barbosa WF, Mondelli J, Franco EB, Carvalho RM. Frac-
1. Bailey JH.  Retention design for amalgam restorations: pins versus
ture strength of weakened human premolars restored with amal-
slots. J Prosthet Dent. 1991;65:71–4. https://doi.org/10.1016/0022-
gam with and without cusp coverage. Am J Dent. 1998;11:
3913(91)90052-X.
181–4.
2. Baum L, Phillips RW, Lund MR. Textbook of operative dentistry. 3rd
13. Mooney B. Operatoria dental. Buenos Aires: Panamericana; 1995.
ed. Philadelphia: Saunders; 1995.
14. Neto NG, Carvalho RC, Russo EM, Sobral MA, Luz MA. Dentística Res-
3. Dias de Souza GM, Pereira GD, Dias CT, Paulillo LA.  Fracture resis-
tauradora: Restaurações diretas. São Paulo: Santos; 2003.
tance of teeth restored with the bonded amalgam technique. Oper
15. Outhwaite WC, Garman TA, Pashley DH.  Pin vs. slot retention in
Dent. 2001;26:511–5.
extensive amalgam restorations. J Prosthet Dent. 1979;41:396–400.
4. Eakle WS, Staninec M, Lacy AM. Effect of bonded amalgam on the
https://doi.org/10.1016/0022-3913(79)90036-2.
fracture resistance of teeth. J Prosthet Dent. 1992;68:257–60.
16. Perdigão J, Lopes M. Dentin bonding--questions for the new millen-
https://doi.org/10.1016/0022-3913(92)90325-5.
nium. J Adhes Dent. 1999;1:191–209.
5. Eakle WS, Staninec M, Yip RL, Chavez MA.  Mechanical retention
17. Plasmans PJ, Kusters ST, de Jonge BA, van’t Hof MA, Vrijhoef MM. In
versus bonding of amalgam and gallium alloy restorations. J
­
vitro resistance of extensive amalgam restorations using various
­Prosthet  Dent. 1994;72:351–4. https://doi.org/10.1016/0022-
retention methods. J Prosthet Dent. 1987;57:16–20. https://doi.
­3913(94)90552-5.
org/10.1016/0022-3913(87)90108-9.
6. Gilmore HW, Lund MR.  Operative dentistry. Saint Louis: Mosby;
18. Roberson TM, Heymann H, Swift EJ. Sturdevant’s art and science of
1973.
operative dentistry. 5th ed. St. Louis: Mosby; 2006.
7. Horsted-Bindslev P, Mjör IA.  Dentística operatória moderna. São
19. Schwartz RS, Summitt JB, Robbins JW.  Fundamentals of operative
Paulo: Santos; 1990.
dentistry. A contemporary approach. Chicago: Quintessence; 1996.
8. How WS.  Bright metal screw posts and copper amalgam. Dent
20. Shavell HM. The amalgapin technique for complex amalgam resto-
Cosm. 1889;31:237.
rations. J Calif Dent Assoc. 1980;8:48–55.
9. Howard WW. Atlas of Operative Dentistry. 2nd ed. St. Louis: Mosby;
21. Torii Y, Staninec M, Kawakami M, Imazato S, Torii M, Tsuchitani
1973.
Y.  Inhibition in  vitro of caries around amalgam restorations by
10. Markley MR.  Restorations of silver amalgam. J Am Dent Assoc.

bonding amalgam to tooth structure. Oper Dent. 1989;14:142–8.
1951;43:133–46. https://doi.org/10.14219/JADA.ARCHIVE.1951.0192.
 435 13

Light-Curing Units
Nicola Scotti, Andrea Baldi, Edoardo Alberto Vergano, Claudio Hideki Kubo,
and Carlos Rocha Gomes Torres

13.1 Introduction – 436

13.2 Fundamentals of Light – 436

13.3 Curing of Composite Resins – 436

13.3.1  ctivation Systems of Curing Reactions – 437
A
13.3.2 Chemically Activated Materials – 437
13.3.3 Light-Activated Materials – 437
13.3.4 Polymerization Kinetics – 438

13.4 Polymerization Shrinkage – 438

13.4.1 T he Material, in Terms of Volumetric Shrinkage and Elastic
Modulus – 439
13.4.2 The Geometrical Configuration of the Preparation or “C-Factor” – 439
13.4.3 The Speed of Curing and Shrinkage Direction – 440
13.4.4 The Substrate and Its Elastic Modulus – 441
13.4.5 The Layering Technique Employed – 441

13.5 Oxygen-Inhibited Layer – 441

13.6 Thermal Effects of Polymerization on Pulp – 441

13.7 Light-Curing Units – 442

13.7.1  uartz-Tungsten-Halogen Unit – 442
Q
13.7.2 Plasma Arch Unit – 445
13.7.3 Argon-Ion Laser Unit – 447
13.7.4 Light-Emitting Diode Unit – 448

13.8 Monitoring of the Light Output – 449

13.9 Curing Protocols – 453

13.9.1  onventional Protocol – 453
C
13.9.2 Gradual Curing Protocols – 456

13.10 Polymerization of Indirect Restorations – 457

13.11 Fiber Post Cementation – 458

13.12 Ocular Hazards of Curing Lights – 460

References – 461

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_13
 436 N. Scotti et al.

Learning Objectives
Radio
The reader will be given the opportunity to understand and
102 104
learn:
55 Fundamentals of light and polymerization in dentistry
Microwaves
55 Shrinkage stress: the problem and its management Invisible 770 nm
10–1
55 Effects on dental pulp thermal
waves
55 Light-curing units and their maintenance
Red
55 Clinical protocols in different situations Infrared
55 Ocular hazard and its management 10–2

620 nm
Visible light Orange
13.1  Introduction Visible Yellow 592 nm
10–5
575 nm
On the 1970’s decade, the use of light to promote the curing Ultraviolet Green
of a restorative material began to be used, pushing the devel- 500 nm
10–6
opments of several light-activated materials and the light-­ Blue
464 nm
curing units. Those began to be used on several dental X-rays Indigo 466 nm
Invisible
specialties, turning the use of the light something almost ionizing 10–8 Violet
indispensable for many clinical procedures. Therefore, the waves 390 nm
understanding of the concepts about the light activation pro- Gamma rays
cess, the physical properties of the light and chemical process
10–10 10–12
of curing, as well the basic understanding of the light-curing
devices became an essential knowledge for the dentist.
..      Fig. 13.1  Electromagnetic spectrum
However, a study showed that more than 37% of the compos-
ite restorations are unsatisfactorily light cured [28] showing
that the theoretical knowledge and the quality of the dentist’s cause the ionization of the molecules. Ultraviolet (UV) waves
work, when the light curing is involved, are far from the nec- are slightly longer and have the potential to cause damage on
essary. Thus, a correct curing protocol is fundamental in the cell DNA and produce skin cancer. Above the ultravio-
order to achieve good mechanical and aesthetical proprieties let wavelength, there is the visible light, which is on an inter-
13 with resin composite [66]. Although many different articles val between 390 and 770 nm, and is capable to stimulate the
are talking about this topic, a recent review showed that there photoreceptor cells in the eyes and be perceived by the
is not really accordance between the studies about the best human beings. The variation of the wavelength in this inter-
protocol available [114]. val determines its color. The white light is a mixture of several
wavelengths. The waves with a slightly longer wavelength
than the visible light correspond to the infrared, which is
13.2  Fundamentals of Light capable to promote the heating of the matter it interacts and
are known as thermal waves.
Light is electromagnetic radiation, i.e., energy in movement
that propagates through waves, and it is capable to cause a
visual sensation on an observer. This light wave behavior is 13.3  Curing of Composite Resins
explained by the theory of electrodynamics. Depending on
the wavelength (distance between two successive peaks of a The composite resins are basically composed of some main
wave), the light radiation will have distinct characteristics ingredients, which are methacrylate monomers (organic
and effects when interacting with the matter. matrix); filler particles (inorganic matrix); coupling agent
(organosilane) that bond the organic matrix to the filler par-
ticles; activator-initiator system of the polymerization reac-
tion; inhibitors to prevent the spontaneous polymerization of
Light is electromagnetic radiation, i.e., energy in move-
monomers; and optical modifiers to give coloration and
ment that propagates through waves, and it is capable
opacity to the material.
to cause a visual sensation on an observer.
The polymerization process consists of the conversion of
monomers to polymers, initiated by the formation of a free
radical with an unpaired electron, which reacts with one of
. Figure 13.1 shows the electromagnetic spectrum, on which
  the electrons of the unsaturated group (double bond) in the
the waves vary according to the wavelength. The shorter it is, monomer molecule, leaving the other electron in an unsatu-
the more energy the wave has, and more deeply is capable to rated state. Thus, this monomer becomes to act as a free
penetrate on the matter that receives the radiation. Gamma radical bonding to another monomer, which also becomes a
and X-rays, examples of high energy waves, are capable to free radical, adding successively to a large number of mole-
Light-Curing Units
cules so that the polymerization process continues through
the propagation of the reactive center.
13.3.1  Activation Systems of Curing
Reactions
The monomers polymerization may occur by two mecha-
nisms, called condensation and addition. On the condensa-
tion reaction, during the polymer formation, a by-product is
created, which in generally lost to the environment by volatil-
ization. However, in the addition reaction, all monomers will
be part of the polymeric chain, and no by-product is formed.
The restorative composites polymerize by an addition reac-
tion.
Even though condensation process is faster and less
expensive in terms of material used, the reaction incorpo-
rates disadvantages related to the presence of the by-product.
The loss of reaction product could create voids in the chemi-
cal structure of the polymer, leading to weaker zones and a
more evident shrinkage during the reaction. On the other
hand, addition-based reactions are more difficult to take
place as they require the presence of a catalyst and initiator.
Polymers obtained with such a process however are more
stable and precise.
The free radicals may be generated in four different ways:
1. Chemically, by the interaction between the initiator and
activator substances on a two-paste material when it is
mixed
2. By specific light wavelengths
3. By heating
4. By a combination of activation systems (light + chemical
reagents) [3]
13.3.2  Chemically Activated Materials
The chemically activated restorative materials, also known
as self-cure composites, are supplied as two-paste systems
either in jars or syringes (base and catalyst), which are mixed
before the use. The free radicals are generated by the chemi-
cal reaction between the benzoyl peroxide (initiator) on the
catalyst paste with the tertiary amine (activator) on the base
paste, which will begin the curing of the methacrylate
groups [3, 16]. The degradation of residual amines in the
composition on those materials contribute for the discolor-
ation observed after 3–5 years of intraoral service. The self-
cured composites have mainly aromatic tertiary amines,
while the light-cured ones generally have aliphatic amines.
Therefore, light-cured composites are expected to have more
color stability, since the amines in the composition are less
susceptible to oxidation. On the self-cured composite, the
need to mix pastes results in the formation of internal air
bubbles, that can contribute to the creation of internal
porosity and therefore an early staining. Furthermore, the
working time is limited due to the speed of the curing pro-
cess, taking more time to finish and polish the restoration,
437 13
because only a limited contour may be performed before the
curing is complete [88].
13.3.3  Light-Activated Materials
On the light-activated composites, the curing process starts
by the absorptions of the visible light on a specific wave-
length. The first light-activated composites used the ultravio-
let light, with wavelength from 320 to 365  nm. They
revolutionized the market and gained immediate acceptance
due to its inherent advantages. However, the harm caused by
the ultraviolet on the eyes and the limited depth of cure led
to its replacement by the visible light systems [16]. Most of
the current materials  have as a photoinitiator α-diketone
molecules, generally camphorquinone, which is excited by
the light and interacts with a reducing agent, known as the
activator, to produce free radicals, which start the curing
process. The activator is a tertiary amine, and its concentra-
tion on the light-activated composites is much smaller than
the one used on the chemically activated materials, which
significantly decreases the possibility of staining or discolor-
ation [87, 104].
The  light absorption range of the camphorquinone is in
between 450 and 490 nm, that is, in blue region of the visible
light spectrum, with a maximum peak on 468  nm [17, 70].
The camphorquinone presents, as its main disadvantage, a
yellow color, which adversely affects the production of com-
posites with lighter  colors [103]. After curing it becomes
whiter, resulting in a color difference between the material
before and after polymerization (. Fig. 14.21). The decompo-
sition of the photoinitiators may result in the material darken-
ing with time, when exposed to the environmental light,
causing esthetic problems (. Fig.  13.2). In attempt to solve
this problem, other photoinitiators were developed and tested,
such as the Ivocerin and PPD (phenyl-propanedione). The lat-
ter has a maximum absorption peak close to 390 nm and does
not have the characteristic yellow color of camphorquinone.
However, not all light-curing units emit a light spectrum capa-
..      Fig. 13.2  Color alteration of light-cured composite restorations
due to changes of reacted camphorquinone by the exposure to the
environmental light
 438 N. Scotti et al.
Camphorquinone
Phenyl-propanedione
Lucirin TPO
Absorbance (AU)
400 420 440 460 480
Wavelength (nm)
..      Fig. 13.3  Spectral absorption profiles of the camphorquinone,
phenyl-propanedione, and Lucirin TPO photoinitiator
ble to stimulate it, because its absorption range  is different
from the camphorquinone [91, 101]. Other photoinitiator
used as an alternative for camphorquinone is the Lucirin TPO,
which is becoming more popular by the fact it turns com-
pletely clear when the activation reaction ends. . Figure 13.3
shows the spectral absorption profiles of the most used photo-
initiators. The light-activated materials have a longer working
time, which results in less need of finishing the restoration.
They have more color stability and less internal porosity [88].
13.3.4  Polymerization Kinetics
13
During the curing reaction, the composite resins transform
from a plastic viscous material through a rubbery viscoelastic
into an elastic glassy stage, passing through three phases
identified as pre-gel, gel point, and post-gel phase [21].
>> During the curing reaction, the composite resins
transform from a plastic viscous material through a
rubbery viscoelastic into an elastic glassy stage,
passing through three phases identified as pre-gel, gel
point, and post-gel phase.
At the beginning of the polymerization, only some mono-
mers are chemically bonded, and the system is still mainly a
viscous liquid. During the conversion of monomers to poly-
mer, the formation of new monomer to monomer bonds
causes shrinkage, reducing the total volume. At this phase,
there is a predominance of linear polymer chains, which are
not well connected to each other, and the material may flow
and undergo molecular rearrangement. The system is in a
flow state, creating little stress on the adhesive interface. This
stage is known as the pre-gel phase.
When the degree of conversion reaches 10–20%, the
polymer chains are long enough to create a gel, and the
molecular movement of the organic matrix is reduced by the
formation of cross-linked bonds. The material stops to
behave as a liquid, which may flow, and begins to behave as a
solid, with physical and mechanical properties being modi-
fied [112]. This moment is known as the gel point. Further
than this point, the polymerization shrinkage creates stress
on the polymer chain, and the reduced mobility of the chains
hinders the stress to be accommodated internally by the
resin. This stress is transmitted to the tooth-restoration inter-
face and tooth structure and may promote the breaking of
the adhesive bond, cuspal deflection, or enamel microcracks
[87, 88, 112]. This stage is known as the post-gel phase. The
growing conversion until its final level at the glassy stage
increases the elastic modulus. Therefore, the degree of con-
version has a substantial effect on finally obtained mechani-
cal properties.
500 520
13.4  Polymerization Shrinkage
During the polymerization reaction, the intermolecular dis-
tance is reduced due to the formation of covalent bonds, thus
reducing the final volume [3, 42]. According to a recent
review, the shrinkage range is quite variable, and the final
volumetric contraction could reach 7%, with an average of
2–3% [55]. Moreover, during the first 24 h after the light cur-
  ing, this polymerization reaction continues, as well the
shrinkage, developing forces within the preparation walls
that could led to microcracks or interfacial opening, during
the first hours of clinical function [108]. This phenomenon is
usually named post-polymerization, post-cure polymeriza-
tion, or dark polymerization and is shown in . Fig. 13.4 [78].  
Following the vitrification of the material (post-gel
phase), all the free radicals and molecules containing double
bonds that have not reacted remain entrapped in the matrix,
without the ability to flow. Moreover, it has been observed
that, owing to photoactivation, once the composite material
has reached its vitreous form, some “free spaces” remain.
After the exothermic polymerization reaction, the composite
temperature is reduced to that of the oral cavity. A relaxation
Post-polymerization
0.6
0.5
Degree of polymerization
0.4
0.3
0.2
0.1
0
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5
Time [s] ´ 104
..      Fig. 13.4  Increase on the degree of polymerization after the end of
light-curing procedure, namely post-polymerization or dark polymer-
ization
Light-Curing Units
process follows, which is necessary for the structure to reach
a more stable crystalline form, and this is associated with a
partial reduction of the “free spaces” present within the poly-
mer network. This physical phenomenon is responsible for
the spontaneous approach of free radicals to the residual
double bonds. These may react, allowing the composite
material to further increase the conversion degree [109].
The volumetric shrinkage during polymerization pro-
duces stress on the tooth/restoration bonded interface, and is
transmitted to the remaining tooth structure. The shrinkage
stress can be thought as a negative pressure applied on cavity
walls. The shrinkage stress may lead to interfacial gap forma-
tion, because the vectors occur toward the center of its mass.
As the restorative material has been bonded to one or more
preparation walls, the stress generated will be affected by the
restriction’s conditions imposed by the bonded walls of the
preparation, and all the stress will be directed toward the
bonded surfaces. In vitro studies have shown that a continu-
ous increase of shrinkage stress occurs for different periods
of time after the photoactivation process [73]. The increase of
stress following light exposure is associated with the addition
polymerization and with the occurrence of thermal shrink-
age in the restorative composite [4, 32]. The volumetric
shrinkage may cause stress levels of 4–8 MPa or even more
on the tooth-restoration interface. This depends on several
factors, as described in the following sentences.
>> The internal stress created inside the composite during
polymerization is described as “shrinkage stress.” It is
transferred through the interface to the cavity walls,
leading to interfacial gap formation and cuspal
deflection.
13.4.1  The Material, in Terms of Volumetric
Shrinkage and Elastic Modulus
There are some very important factors which affect the total
volumetric shrinkage of composite materials [87]. The first
one is the organic matrix. It is composed of a monomers mix-
ture which is converted from a group of free-floating mole-
cules into a rigid cross-linked polymeric chain and is
responsible for the volumetric shrinkage during the polym-
erization [3, 10]. Therefore, the larger the percentage of the
organic matrix of a material, the larger is the polymerization
shrinkage.
Other important factor is the amount of filler particles in
the formulation. The higher is the filler content of a compos-
ite, the smaller is its organic content and, therefore, its volu-
metric shrinkage. However, the increase of the filler content
also influences the elastic modulus of the material [10]. Some
studies analyzed the polymerization shrinkage of several
composites and observed that the higher the filler ratio, the
greater is the elastic modulus and the stiffer the composite is,
producing a higher shrinkage stress [88, 95]. According to
Hooke’s law, stress is a product of the stiffness of the material
(elastic modulus) by a given strain (volumetric shrinkage).
439 13
Therefore, the shrinkage stress will be higher if the elastic
modulus and/or the volumetric shrinkage are also high.
However, the shrinkage stress of a composite is more related
to the stiffness of the material, which is proportional to the
content of inorganic fillers, than to the percentage of volu-
metric polymerization shrinkage [21, 42].
>> Some studies analyzed the polymerization shrinkage
of several composites and observed that the higher
the filler ratio, the greater is the elastic modulus and
the stiffer the composite is, producing a higher
shrinkage stress.
13.4.2  The Geometrical Configuration
of the Preparation or “C-Factor”
The cavity configuration factor or C-factor was proposed by
Feilzer et  al. [31], in 1987, and is the ratio of the bonded
surface area (B) in preparation for composite restoration to
the unbonded (U) surface area, expressed by the eq.
C-factor = B/U [31]. In . Fig.  13.5 are shown situations
with different C-factor values. The situation when the
C-factor is higher is on box-shaped preparation, with four
surrounding walls and an internal wall, such as on Class I
preparation. On this case, if the composite is applied in a
bulk increment, it will bond simultaneously to five walls
(buccal, lingual, mesial, distal, and pulpal), and only the
occlusal surface will remain unbonded. Therefore, the
C-factor will be equals five. On Class II simple proximal
box preparation (vertical slot preparation), the buccal, lin-
gual, axial, and gingival walls will be bonded, while the sur-
faces facing the occlusal and proximal areas will remain
unbonded, resulting on a C-factor equals 2. The case with
smaller C-factor occurs on restorations of fractured ante-
rior teeth, with only one bonded surface and five unbonded
ones, and a C-factor equals 0.2. In this case, the risk of
adverse effects due to polymerization shrinkage will be very
low [88]. Therefore, the C-factor varies according to the
shape and location of the preparation.
The cavity configuration factor or C-factor is the ratio of
the bonded surface area in preparation for composite
restoration to the unbonded surface area. It determines
the magnitude of the generated stress on the
tooth-restoration interface and may cause the rupture of
the adhesive interface or the cusp deflection.
>> The situation when the C-factor is higher is on
box-shaped preparation, with four surrounding walls
and an internal wall, such as on Class I preparation. On
this situation, if the composite is applied in a bulk
increment, it will bond simultaneously to five walls,
and only the occlusal surface will remain unbonded.
 440 N. Scotti et al.
0,2 0,5
1/5 = 0.2 3/3 = 1
..      Fig. 13.5  a Schematic drawing of the C-factor. (Adapted from Feilzer et al. [31]). b Pictures of actual cavities with different C-factor
13 Tip
The C-factor must be kept as lower as possible, which
can be obtained by the application of oblique composite
increments, connecting a maximum of two walls
simultaneously, leaving the larger number of free
surfaces as possible, and creating conditions to relieve
the stress.
When a composite is bonded to more than one preparation
wall, the remaining tooth structure to where it is bonded,
because of being rigid, will withstand the movement of the
shrinking material, producing stress. The unbonded surfaces
will deform whatever possible to reduce the stress. Since the
composite flow is more likely to occur from the free surfaces,
a higher proportion of free composite surface would repre-
sent a smaller restriction to shrinkage, therefore reducing the
stress. Therefore, the cavity configuration determines the
magnitude of the generated stress on the tooth-restoration
interface, which may cause the rupture of the adhesive inter-
face or the cusp deflection [87]. The greater the C-factor, the
greater the potential of rupture of the adhesive interface due
to the polymerization effects. To avoid this inconvenient, the
C-factor must be kept as lower as possible, preferably close to
0.5, which can be obtained by the application of oblique com-
posite increments, connecting a maximum of two walls
1,0 2,0 5,0
4/2 = 2 5/1 = 5
simultaneously, leaving the larger amount of free surfaces as
possible, and creating conditions to relieve the stress [7]. In
addition, if the material is cured in small amounts, less
shrinkage stress will occur. The volumetric shrinkage of an
increment is compensated by the next layer applied. How-
ever, as the C-factor consists of the ratio of the bonded sur-
face area to the unbonded free surface area, when comparing
two Class I preparations, with five bonded and one free wall,
with different depths but other dimensions the same, the
deeper preparation will have a greater C-factor than the shal-
lower one [87]. Despite the size of the preparation, each
increment applied must be small, with a maximum thickness
of 2 mm, as will be discussed later.
13.4.3  The Speed of Curing and Shrinkage
Direction
The unbonded composite presents isotropic shrinkage,
which means that shrinkage vectors are directed to center of
the mass [31]. On the 1980s, it was believed that only the
chemically cured composites presented this property. In
relation to the light-activated ones, it was supposed that the
polymerization shrinkage was directed toward of the light
source [62]. Due to this fact, Lutz et al. [62] described a tech-
nique for restorations of proximal preparations using clear
and reflective wedges that they had developed, associated
Light-Curing Units
with clear matrix bands. The light was first applied on the
buccal/lingual surface, over the wedge, which conducted the
light toward the gingival region. The authors believed that
the good results obtained with this technique, in relation to
the marginal integrity of the restorations, were due to the use
of reflective wedges, which directed the shrinkage, bringing
the resin toward the gingival wall, reducing the marginal
gaps. However, Lösche [61] demonstrated that the use of
reflective wedges only reduced the transmitted light, delay-
ing the gel point and thus improving the marginal adapta-
tion. Versluis et al. [113], using the finite element method,
demonstrated that the composites do not shrink toward the
light source but toward the bonded walls, and the shrinkage
vectors are mostly determined by the cavity configuration
[60, 113]
The chemically activated composites have slower cur-
ing reaction than the light-activated ones (more than 3
min). This gives the material a longer pre-gel phase, allow-
ing more flowing of the linear polymer chains recently cre-
ated, relieving the stress, and resulting in less failures on
the ­tooth-­restoration interface [25, 52, 87]. On the light-
activated composites, shrinkage stress created on the tooth
structure is greater than on the chemically activated ones,
because the curing reaction happens faster. That signifi-
cantly reduces the time for the polymer chains flowing dur-
ing the pre-gel phase and the stress relieving [87]. A way to
control the stress is changing the curing mode (gradual
curing/soft start), creating a slower start with less light
irradiation, in order to prolong the pre-gel phase. Those
techniques will be better explained at the end of this
chapter [8, 81].
Tip
On regions of hot weather, the composites are generally
kept inside a refrigerator, at about 5 °C, to increase its
shelf life. However, before the use, it must be left to reach
the room temperature, once the low temperature
adversely affects the curing reactions.
13.4.4  The Substrate and Its Elastic Modulus
The substrate could also play a role in the shrinkage stress.
More elastic substrates, such as dentin, could better tolerate a
volumetric variation, while rigid substrates, such as enamel,
don’t have this advantage. Following this reasoning, the use
of a liner layer between the adhesive and the restorative com-
posite, using a material with low elastic modulus such as
flowable composites, has been proposed, but its real effective-
ness is still controversial [53].
Dealing with natural tooth structure, we have to con-
sider that adhesion to dentin is less effective than to enamel,
which can result on interfacial debonding and gap forma-
tion, rather than a deformation of the substrate during
polymerization.
441 13
13.4.5  The Layering Technique Employed
Layering technique is a fundamental factor, which is closely
related to the “C-factor.” It has been shown that horizontal
layers create significantly higher stress than oblique layers,
since the bonded/unbonded ratio is clearly different [23, 50].
The thickness of each layer should be maximum 2 mm, to
reduce the total stress and allow a proper curing on the bot-
tom of the composite layer [53, 55]. It has also been shown,
in vitro with SEM and in vivo with sensitivity test, that bulk
techniques have inferior performances than incremental
ones [72].
13.5  Oxygen-Inhibited Layer
Light-cured resins leave behind a soft and sticky superficial
layer after polymerization. This layer is commonly referred to
as an oxygen-inhibited layer (OIL) because of its origin, and
it is always produced when a resin composite or dental adhe-
sive is cured in contact with air [102]. Oxygen reacts with
carbon-based polymerizing free radicals in a diffusion-­
controlled manner to form peroxy radicals. These peroxy
radicals preferentially react with oxygen, which significantly
retards the polymerization reaction [57]. They also quench
the excited triplet states of photoinitiators, such as cam-
phorquinone, thereby limiting the initiation stage of polym-
erization [54]. The OIL is primarily composed of unreacted
resin monomers and oligomers, and it possesses a gel-like
consistency. Previous studies have found that the OIL thick-
ness of adhesives and resin composites ranges from 4 to 40
μm [35, 90, 98]. The thickness and characteristics of the OIL
in resin-based materials depend on several factors, including
monomer chemistry, filler morphology, radical concentra-
tion, and the rate of oxygen consumption. Therefore, the
characteristics of OIL of dental adhesives might differ
depending on the types of adhesive systems.
A simple way to deal with OIL is to perform, once the
last composite layer is completed and cured, an extra curing
step after covering the restoration with a transparent glycerin
layer (. Fig. 15.6z, a´). This procedure avoids the contact
with oxygen and thus strongly reduces the OIL.
13.6  Thermal Effects of Polymerization
on Pulp
Curing times suggested by manufacturers are generally eval-
uated in  vitro under optimal conditions, which could be
totally different from the real clinical condition, leading to
an inadequate polymerization of the restoration [59]. This
might lead to negative mechanical properties and lower bio-
compatibility of the composite material. The simplest way a
practitioner can overcome this issue is by extending the cur-
ing time beyond manufacturer recommendations. This
approach has been shown to improve the degree of conver-
 442 N. Scotti et al.
sion and microhardness at the bottom of the composite
layer, while also reducing the amount of elutable species
[27]. However, curing with high emittance units for extended
time raises concerns regarding possible overheating of the
dental pulp [76]. The in vivo effects of pulp heating and its
biological consequences were studied since 1965 by Zach
and Cohen [120]. In their study, a 5.5 °C pulp temperature
variation was simulated in rhesus monkeys, through appli-
cation of a hot metal source to the facial enamel surface. This
led to necrosis in 15% of evaluated pulps. After their study
all in vitro and in vivo studies addressing the effects of LCU
light on pulp temperature assumed 42.5 °C as a cutoff tem-
perature.
On the other hand, in contrast with previous in  vitro
results, Schneider et al. reported that long exposure periods
(60 seconds) were clinically necessary to cause a pulp tem-
perature variation higher than 5.5 °C, when using a polymer-
ization device on intact premolars (radiant emittance values
of approximately 1200 mW/cm2) [96].
When blue light strikes the enamel surface, part of the
light energy is reflected and a part is converted into thermal
energy, while the remaining portion passes through the
­substrates below [22]. When blue light reaches the pulp tis-
sue, photons are strongly absorbed by the blood chromo-
phores to be partly converted into thermal energy [37],
resulting in a slower pulp temperature increase in vivo than
the one observed in vitro. Because of the constant blood flow,
the warmed chromophores from absorbed photons are
quickly replaced by other, cooler ones, so most of the heat
13 generated in this tissue is dissipated.
In general, most of the temperature rise occurred within
5–10 s after the start of light curing. Extending the curing
time to 30 s resulted in a minor additional increase. However,
a possible way to prevent overheating of the pulp seems to be
the contextual use of an air blowing directly toward the tooth
while performing photopolymerization.
13.7  Light-Curing Units
The light-curing unit is a device capable to emit visible blue
light required to activate the photoinitiators and start the
polymerization. The spectral power or output (radiant power
per wavelength) may vary among the devices but must be as
close as possible to the absorption range of the photoinitiator
within the composite. They can be classified according to the
type of emitted light and the range of the wavelength spec-
trum emission in two types, called narrow and broad spec-
trum.
The first broad-spectrum units generate white light that,
when passing through band-pass filters, emits blue in the
400–520 nm range [16]. As examples, there were the conven-
tional devices with quartz-tungsten-halogen lamps and the
xenon plasma arc curing lamps. As disadvantages, they pro-
duce heating and waste electric energy, but as advantage, they
have the capacity to activate other photoinitiators besides
camphorquinone [91].
The narrow-spectrum units emit light on a relatively nar-
row range such as the argon-ion lasers and light-emitting
diodes [43]. Those devices emit light mainly on absorption
range of the camphorquinone, the photoinitiator used by
most of the composite manufacturers. However, when using
narrow-spectrum devices, knowledge and attention from the
operator are required to properly select the restorative mate-
rials, to avoid those which do not contain camphorquinone
[87]. The general technical details of the different devices are
presented next.
13.7.1  Quartz-Tungsten-Halogen Unit
The quartz-tungsten-halogen (QTH) light-curing units were
the first visible light-curing devices created and were consid-
ered the standard curing units for several years. They have as
basic components the light emission source (light bulb and
reflector), UV and infrared band-pass filters, light guide,
cooling fan, and a circuit board as it can be seen in
. Fig. 13.6a–e [16].
13.7.1.1  Light-Emitting Source
The light sources on the conventional devices are incandes-
cent light bulbs. They have a quartz bulb, because this mate-
rial is much more resistant to the heating than the regular
glass, allowing smaller light bulbs to be manufactured. They
have a tungsten filament, surrounded by a halogen gas on its
interior to preserve the heated filament. They generally have
a power between 50 and 100 watts, so they can emit light with
the necessary radiant emittance [41]. Light is generated when
the filament is heated and starts to glow due to the passage of
the electrical current, which is called incandescence
(. Fig.  13.7). It emits a great variety of wavelengths, espe-
cially infrared, as it can be observed in . Fig. 13.8. Only 0.5%
of the emitted energy corresponds to the blue light, useful on
the light-curing process, representing only 1% of the electric
energy consumed, showing inefficient conversion of the elec-
b c e
a
d
..      Fig. 13.6  Internal components of a QTH light-curing unit. a Light
guide; b shield for protection of the operator’s eyes; c band-pass filters;
d QTH light bulb and reflector; e location of the cooling fan
Light-Curing Units
..      Fig. 13.7  QTH incandescent lamp attached to the reflector
UV Visible Infrared
Radiant flux (µW/nm)
500 1000 1500 2000
Wavelength (nm)
..      Fig. 13.8  Total emission spectrum of a QTH lamp (black line). The
blue area corresponds to the emission spectrum of the light-curing
unit after passing through the band-pass filters
tricity on light [87, 91, 107]. The emission spectrum of the
QTH devices coincides with the absorption range of the most
used photoinitiators, such as the camphorquinone and
phenyl-­propanedione (. Fig. 13.9).  
The reflector is an element that comes attached to the light
bulb, which reflects the light generated by the source toward
the exit of the light (. Fig. 13.7). It has a parabolic shape, and
it is covered by a highly reflective film, called dichroic. The
dichroic reflectors allow the light with wavelengths longer
than 700 nanometers to pass through, reflecting and selecting
only the visible portion of the light, reducing the heat emis-
sion [87]. Due to the heating and cooling cycles that occurs
during the use, there may happen condensation of vapors
over its surface, dulling or clouding the reflector, and decreas-
ing its ability to reflect light. It can be cleaned with alcohol
and cotton swabs to renew the its reflexivity [88].
443 13
Camphorquinone
Phenyl-propanedione
Lucirin TPO
Absorbance (AU)
Radiantflux
400 420 440 460 480 500 520
Wavelength (nm)
..      Fig. 13.9  Emission spectrum of a QTH light-curing unit (blue area)
in relation to the spectral absorption profiles of the more commonly
used photoinitiators (lines)
The light output of a QTH bulb reduces during the use,
and the speed of its degradation will depend on the time that
it is used and the number of times it turns on or off during a
given period of time [16]. Therefore, the light output must be
frequently evaluated (3–6 months according to the manufac-
turer) with devices called radiometers. When there is a
reduction in the output, the bulb replacement must be per-
formed. The QTH bulbs are rated for a lifespan of 80–100 h,
corresponding to about 2.5 years of clinical service, but may
last three times more under ideal conditions [88].
There are three main causes for the bulb degradation,
which may decrease the light output of the device, but that
may not be noticed by visual inspection:
1. Blackening of the bulb that covers the tungsten filament
due to the breaking of the halogen cycle, promoting the
reduction of the light output up to 70% [16].
2500 2. Bulb opacification or “frosting” is characterized by the
white opaque color of the bulb due to devitrification. It
happens because of the crystallization of impurities of
the bulb glass, which blocks the passage of light gener-
ated by the filament, because the penetration of air in the
bulb or by the evaporation of the cement that attach the
bulb to the reflector. This problem may cause a drop of
50% of the light output [16].
3. Degradation of the reflector, characterized by the loss of
the dichroic reflective film or a white or yellow coating
of oxides developed over the reflector surface. The
degradation of the reflector may promote the reduction
of the light output up to 60% [16].
13.7.1.2  Band-Pass Filters
They are placed between the bulb and the light pipe. As the
light source of QTH devices produces white light and infra-
red, two types of band-pass filters are used to make the
device emits blue light with reduced heat, eliminating a sig-
nificant amount of unnecessary light. The UV band-pass
filter helps to exclude the luminous energy with a wave-
length smaller than 400 nm, on the ultraviolet range, which
 444 N. Scotti et al.

..      Fig. 13.10  The UV and

a
infrared band-pass filters. a New;
b damaged

13

does not contribute on the polymerization of the resinous
materials and may damage the eyes. The infrared band-pass
filter blocks the infrared radiation, above 500 nm, gener-
ated by the halogen bulb. It also does not contribute on the
polymerization and may generate heating of the tooth
structure, promoting irreversible damage to the pulp and
soft tissues which are being irradiated [16]. The filters must
be cleaned on regular bases to remove any deposited resi-
dues that may reduce the passage of the light. On those
cases, a cotton swab soaked on a camera lens cleaning solu-
tion may be used [16]. In . Fig.  13.10a, b, new and the
 
degraded band-pass filters are shown, after a great number
of heating and cooling cycles [88]. The filters degradation
blocks the passage of light, resulting on an inefficient light
curing.
13.7.1.3  Light Guide
The light guide, also called light pipe or tip, delivers the fil- length between 38 and 85 mm  (. Fig.  13.11a–e) [16]. The
The early QTH light-curing units, namely  countertop
units, contain all the functional parts, such as the light source,
filters, and fan in one box located far from the hand of the
operator. The light was conducted through a flexible cord with
an optical fiber bundle or a conductive fluid. The great advan-
tage of those devices was that the noise of the fan and the heat
produced by the light source were located far from the operat-
ing field [87]. However, more than 20% of the optical fibers
would break due to folding or acute curvature of the cable
during the use and due to the extreme optical fibers fragility,
which generally have to be replaced due to the loss of the light
output [16]. They are no longer used in the current devices.
The light-curing units with a hard light guide or pistol
shaped are the most commonly used nowadays [87]. On this
model, the light bulb, filters, and light guide are held by the
operator during the use. The light guide is an optical fiber
bundle sheathed by an amber glass or metal coat with a

tered light energy to the area of application, inside the oral thin coating of amber-colored glass has a refractive index
cavity [16]. It is basically a fiber optical bundle that varies in that the light trying to escape is reflected internally back,
size, shape, and diameter according to manufacture of light-­ reducing the loss of light intensity through the sides of the
curing unit and can be a flexible cable or a hard tip [16]. guide. The diameter of the guide on the tip may vary between
Light-Curing Units
a b c d
..      Fig. 13.11  Light guides. a Metal sheathed guide; b glass sheathed
guide; c turbo guide; d acrylic guide; e light guide of small diameter for
areas of difficult access
2 and 13 mm, depending on the of application place and the
access [16]. Generally, the diameter is around 7–8 mm [16].
The varieties of the interchangeable light guide shapes allow
a more ergonomic use in several clinical situations.
Some manufacturers produce a turbo light guide, which
increases the light output in up to 52%, by decreasing the
diameter of the exit in relation to the entrance of light
(. Fig. 13.11c) [15, 16, 41, 87]. Recently, to reduce the cost of
 
the devices, the manufactures started to produce light guides
made with polymers, which are intended to be disposable
[16]. This type of guide must not be touched on the sides
during the light curing, avoiding that part of the light trans-
mitted would be lost (. Fig. 13.11d) [15].
 
The light transmitted through the light guide tip tends to
be concentrated in the center of the optical fiber bundle, with
a significant reduction on the periphery. That inhomoge-
neous emittance distribution across the light tips may cause a
nonuniform curing of the composite increment which
receives the light, being greater on the central area
(. Fig. 13.12). To evaluate the existence of large discrepancy
 
on this distribution, a piece of cardboard or thick paper can
be placed on the tip of the guide and then turning the light on
and observing if it is or not evenly distributed [16].
The optical fiber guide is composed by several fibers
grouped. To evaluate the quality of the guide, it can be
removed from the device and placed over the pages of a book
and observe the image formed. On the good quality guides,
the environmental light enters the optical fibers and reaches
the paper, being reflected back and forming a clear image on
the tip of the guide. On low-quality guides, the formed image
is not clear (. Fig. 13.13a, b).
 
An important aspect on the maintenance of the optical
fibers is to avoid its contacts with the uncured composite,
because it will stick to the tip of the guide and adversely affect
the passage of light (. Fig. 13.14a, b). For this reason, it must
 
be covered by a clear PVC cling  film sheet before the use,
which will not block the passage of the light.
445 13
e
..      Fig. 13.12  Image of the beam profile in a two-dimensional
representation of the emittance distribution. An inhomogeneous distri-
bution across the light tip can be observed. The red area represents a
greater emittance
13.7.1.4  Cooling fan
This component promotes the air circulation around the
light bulb, avoiding the overheating of the internal compo-
nents of the light-curing unit, and it must be kept  work-
ing the entire time of light production and for a certain time
after the end [87]. The cooling fan is responsible for the char-
acteristic noise of the QTH unit, which must never be used if
the fan is not working, because this would result in the over-
heating and burning out of the incandescent tungsten fila-
ment [41, 87].
13.7.1.5  Voltage Regulator
It allows maintaining a constant emission of light, without
having interferences of the electrical oscillations of the power
supply [41]. According to Fan et al., line voltage oscillation of
just 10 volts may result in up to 30% reduction of the com-
posite’s depth of cure [29]. The unit which does not have this
integrated component must be connected to an external
regulator.
13.7.2  Plasma Arch Unit
On the plasma arch curing units (PAC), the source of light
emission is a bulb with xenon gas and two electrodes, sepa-
rated by a small space. A very high electric current is used to
produce an electric arch between the electrodes, creating
light through the ionization of the xenon gas surrounding it,
forming plasma by the disintegration of the atoms of the gas
[11, 87]. The plasma is a highly energized and ionized glow-
ing environment, with very high temperature, that produces
 446 N. Scotti et al.

a b

..      Fig. 13.13  Light guides of different qualities placed over the same printed word. a In a good-quality light guide is possible to clearly see the
word; b in a budget poor quality light guide, the image suffers distortion

..      Fig. 13.14  a Unprotected

a b
light guide with composite
13 residues bonded to the surface; b
light guide correctly protected
by clear PVC cling film

a radiant white light. That is filtered to remove the ultraviolet
and infrared heating radiation, making the device to emitt
blue light [3, 87, 91].
Of all the produced energy, only 0.2% is used for the light
activation. The radiant emittance may reach 2400 mW/cm2,
emitting light with an emission spectrum between 380 and
500 nm, working with all photoinitiators (. Fig. 13.15). Their
 
higher emittence was claimed to substantially reduce the cur-
ing time. Some manufacturers claimed that a curing for only
3 s with PAC would produce similar material properties,
compared to 40 s of curing with QTH devices [47, 87, 91].
The lifespan of these units is greater than the ones of the
QTH and may vary from 500 to 5000 h [97]. It presents a
flexible cord with a conductive fluid, eliminating the fracture
Light-Curing Units
447 13
problem commonly found on optical fibers’ bundle cords
Camphorquinone
Phenyl-propanedione
(. Fig. 13.16). The cost of the equipment and its maintenance
 

Lucirin TPO is higher in relation to the QTH devices [91]. The PAC units
showed negative effects on the marginal integrity of the res-
Absorbance (AU)

Radiant flux
toration. That was due to the polymerization stress, related to
the higher radiant emittance and reduced pre-gel phase.
Besides, the raising of temperature turned its safety question-
able [91].

13.7.3  Argon-Ion Laser Unit

400 420 440 460 480 500 520
Wavelength (nm)
The word LASER is an acronym for light amplification by
stimulated emission of radiation. For the light production,
..      Fig. 13.15  Emission spectrum of a PAC curing unit (Sapphire – the device has the ionized argon as the active medium, inside
DenMat) (blue area) in relation to the spectral absorption profiles of
the more commonly used photoinitiators (lines)
an optical resonator cavity. It produces laser light by a quan-
tum process known as stimulated emission of radiation. The
argon-ion laser units (AL) have been used for curing of resin-
ous materials, emitting monochromatic blue light in a very
narrow emission spectrum, from 457 to 514 nm, coincident
with the absorption spectrum of the camphorquinone. The
peak of emission occurs in 488 nm, without production of
infrared or ultraviolet (. Fig. 13.17) [3].
 

The light beam produced by the laser is coherent, with all

photons with same frequency and polarization, besides
being collimated, with photons in the same direction of
motion and minimum divergence. These characteristics
result on a large amount of energy concentrated on a small
irradiation area. In addition, there is no significant loss of
energy reaching the material when the distance between the
tip of the light guide and the composite is increased, differ-
ent of what is observed with the other kinds of curing units
[36, 91, 107]. The radiant emittance varies from 700 to 1.200
mW/cm2. However, due to the typical photons concentra-
tion of the laser devices, the risk of damage to the retina is
increased, and there is the need to use safety glasses, for the
dentist and patient, to avoid the contact with the light on a
direct and/or reflected way [36, 43]. The AL units have as
disadvantages the high cost and the non-polymerization of

Camphorquinone
Phenyl-propanedione
Lucirin TPO
Absorbance (AU)

Radiant flux

400 420 440 460 480 500 520

Wavelength (nm)

..      Fig. 13.17  Emission spectrum of an argon-ion laser curing unit

(AccuCure – Laser Med) (blue area) in relation to the spectral absorp-
..      Fig. 13.16  Plasma arch curing unit (Sapphire – DenMat) tion profiles of the more commonly used photoinitiators (lines)
 448 N. Scotti et al.
..      Fig. 13.18  Argon-ion laser curing unit (AccuCure – Laser Med)
the composites with photoinitiators other than camphorqui-
none [69]. In addition, the emittance is also very high, which
reduces the curing time but also the pre-gel phase, increas-
ing the shrinkage stress. An example of an AL device is pre-
sented in . Fig. 13.18.
13.7.4  Light-Emitting Diode Unit
The light-emitting diodes, or LED units replaced the QTH
13 devices for light-activation of the composites [41]. The LED
technology was originally developed by NASA to stimulate
the growing of plants in space, and it is frequently used on
electronic devices and computers [115]. The light is produced
through a quantum process of luminous radiation emission
called electroluminescence, using junctions of doped semi-
conductors (p-n junctions) for the generation of light [107].
Under this situation, holes and electrons recombine at the
LED junction creating light that is focused by a small lens.
The composition of the semiconductor materials is the factor
which determines the wavelength and color of the light pro-
duced, without infrared emission. Therefore, it does not
require band-pass filters. On the case of the blue wavelength
LED, the semiconductors are composed of indium gallium
nitride (InGaN) with an emission spectrum between 450 and
490  nm and a peak at 470 nm, producing an almost ideal
bandwidth of the light, corresponding to the absorption
range of camphorquinone (. Fig. 13.19) [107].
>> The LED produces light through a quantum process of
luminous radiation emission called electrolumi-
nescence. Only blue light is created, without infrared
emission.
The LED lifespan is about 10,000 h, in comparison with the
80–100 h of the QTH lamps [97]. LEDs consume less electric
energy than QTHs and generally do not require external
cooling. The low heat emission, an important aspect in rela-
Camphorquinone
Phenyl-propanedione
Lucirin TPO
Absorbance (AU)
Radiant flux
400 420 440 460 480 500 520
Wavelength (nm)
..      Fig. 13.19  Emission spectrum of a narrow-spectrum blue LED
curing unit (blue area) in relation to the spectral absorption profiles of
the more commonly used photoinitiators (lines)
tion to the pulpal tissue damage risk, is one of the great
advantages of those devices [18]. However, light-activated
materials which do not use camphorquinone as the photoini-
tiators may not be properly cured by devices emitting only
blue light.
Chronologically, the LED units may be classified into
first, second, and third generations. The first light-curing
units produced, classified as the first generation, presented a
simple design, consisting of an array of several relatively low-­
powered LED chips assembled together, resulting on devices
with radiant emittance smaller than 200 mW/cm2
(. Fig. 13.22a) [68]. They showed poor curing performance
compared with conventional QTH lights, requiring much
longer exposure times to provide a similar level of curing.
The second-generation devices are characterized by hav-
ing a single high-power LED chip, of much higher surface
area and radiant emittance than the first-generation ones
(>1000 mW/cm2) (. Fig. 13.22b). The devices of this genera-
tions have an improved design; are more ergonomic and por-
table, with or without batteries (. Fig. 13.20a, b) [18].
The third-generation devices contain, in addition to the
blue wavelength  emission LED (450–490 nm), others that
emit light on the violet wavelength (around 400 nm). They
are called polywave or broad-spectrum light-curing LED
units [85]. As examples on the market are Valo (Ultradent)
and Bluephase (Ivoclair/Vivadent) units, allowing the light
curing of resinous materials with photoinitiators different
from camphorquinone (. Fig.  13.21). The Valo unit has an
emission spectrum between 395 and 480 nm, having LEDs
with three different emission peaks, which are 405  nm (1
LED), 445 nm (1 LED), and 465 nm (2 LEDs) (. Fig. 13.22c).  
The radiant emittance can be adjusted to 1000 mW/cm2,
1400 mW/cm2, and 3200 mW/cm2. The Bluephase device has
two LEDs, which emit blue light with a peak at 470 nm, and
one LED with peak at 410 nm. It has programs which allow
adjusting the radiant emittance on 650, 1200, and 2000 mW/
cm2. The programs for large irradiance are indicated for
cementation of indirect ceramic restorations and bonding of
Light-Curing Units
449 13
..      Fig. 13.20 Second-genera- a b
tion narrow-spectrum LED curing
units. a Free Light Elipar 2 (3 M);
b Radii-cal (SDI)

authors, through imaging capture of the beam profile, con-

Camphorquinone
Phenyl-propanedione
cluded that, regarding emittance uniformity, third-­generation
465nm Lucirin TPO
units have hot spots of high emittance related to the location
of the LED chips [84] and thus a nonuniform emittance out-
Absorbance (AU)

445nm put [99]. . Figure 13.23 shows the lack of emittance unifor-

Radiant flux

mity of different polywave light-curing units.

405nm
400 420 440 460 480 500
Wavelength (nm)
..      Fig. 13.21  Emission spectrum of a polywave third-generation LED
light-curing unit base (Valo – Ultradent) in relation to the spectral
absorption profiles of the more commonly used photoinitiators (lines)
orthodontic brackets. The main advantage of polywave LED
units is that all composites could be properly polymerized
with them.
In terms of composite wear resistance and curing effec-
tiveness, there is no consensus in literature whether
monowave are better or worse than polywave units. Minor
differences in both directions have been reported from dif-
ferent studies [1, 40, 63, 71, 93]. A study reported that poly-
wave curing units could provide a higher conversion degree
from Bis-GMA/TEGDMA mixture when compared to
monowave, regardless of initiator type [67]. However, it was
highlighted that the homogeneity of the radiation beam,
related to an accurate collimation of the different light-­
emitting diodes, is crucial. Price et  al. commented that the
not uniform spectral distribution in polywave curing lights
tips could affect the resulting properties of some light-curing
resins and their potential long-term success [82]. Several
However, it can be clinically appreciated that, depending
on the light-curing unit orientation, different parts of the
composite resin restoration in a MOD cavity would receive
very different wavelengths and energies. The wide range of
520 spectral radiant energy emitted on the surface consequently
result in a nonhomogeneous curing of the restoration [83]. It
could be suggested to move the polywave lamp by only few
millimeters when light curing a resin-based restoration.
However, the results of beam inhomogeneity may not be so
clinically evident [84].
>> The polywave curing units have lack of emittance
uniformity for the light produced by the different LEDs,
creating hot spots of high emittance related to the
location of the LED chips. The not uniform spectral
distribution in curing lights tips could affect the
resulting properties of the composites, by a
nonhomogeneous curing of the restoration, impairing
their potential long-term success.
13.8  Monitoring of the Light Output
For the proper curing of a composite, it is necessary a light
source with correct emission spectrum and enough light
intensity. A very important point, when performing the light
curing of a restorative material, is the fact that the dentist is
not capable to distinguish between a correctly and insuffi-
ciently cured composite, due to the fact that an improper
 450 N. Scotti et al.
a b
13
..      Fig. 13.22  LED chips of different generations of light-curing units.
a First generation, array of several relatively low-powered LED chips
assembled together; b second generation, a single high-power LED
light-curing device is capable to polymerize the surface of a
composite layer as good as a proper one [16].
Different from the chemically activated composites,
which cure on a uniform manner if the mixing of the two
pastes was effective, the light-activated materials polymerize
only where the light is capable to reach, since it is attenuated
during the passage through the material [16]. Frequent eval-
uation should be performed to ensure that the device is emit-
ting the required minimum amount of light. Despite what
may be thought, the bare eye is not sensible enough to detect
any change on the light-curing unit emittance, being required
the use of electronic sensors [16].
The radiant emittance, radiant exitance, or just emit-
tance of a light-curing unit is the radiant power (flux) emit-
ted by a surface per unit area. It is measured when the light
tip is in direct contact with the light detector. The SI unit
chip (Radii-cal – SDI); c third generation, group of high-power LEDs
with different emission spectrum (Valo – Ultradent)
for it is the milliwatt per square centimeter (mW/cm2) [3,
16, 87]. The most precise and recognized method for radi-
ant emittance evaluation is the integration sphere, being
considered the gold standard. However, it is very expensive
and not adequate for the dental office use. The radiometer
is a less expensive device developed for this purpose [16].
On the other hand, it cannot be calibrated and provide
only approximate values, being adequate just for relative
evaluation. It should be frequently used by the dentist to
follow the emittance of his device, detecting any significant
changes that could impair the proper curing procedure.
Due to its clinical importance, some companies provide
curing-light charging stations with an integrated radiom-
eter (. Fig. 13.24).
For the QTH units, the radiometer measures the wave-
length range from 400 to 550  nm (. Fig.  13.24a). In this
Light-Curing Units
a b
c d
..      Fig. 13.23  Images of the beam profile of different third-­generation
polywave LED units a–d, showing nonuniform emittance outputs, in
comparison to the homogeneous beam profile of a QTH unit (E). Hot
range is the maximum spectral absorption of camphorqui-
none, the most common photoinitiator of the resinous mate-
rials [16, 87]. Due to the fact that on the regular LED units
the emission spectrum is narrower, on the range from 460 to
470 nm, specific radiometers have been developed for them
(. Fig. 13.24c). Therefore, to measure the irradiance using a
 
radiometer, it is important to take into account the type of
light-curing device which is being evaluated (QTH, PAC, AL,
or LED) and the spectral measurement range of the radiom-
eter. The radiometer with a broad wavelength measurement
range will measure every light produced by a LED unit, but a
dedicated LED radiometer, with a narrower measurement
451 13
spots of high emittance are related to the location of the LED chips. a
Translux (Kulzer), b Valo (Ultradent); c Bluephase (Ivoclar Vivadent); d
Demi Ultra LED (Kerr); e Swiss Master Light (EMS)
range, will not measure the entire energy emitted by a QTH
or PAC. Most regular radiometers are also not adequate for
measuring the radiant emittance of polywave third-­
generation LED units, although some manufactures have
developed more advanced radiometers for those devices,
such as the Bluephase Meter II (Ivoclar Vivadent).
Since to the distance between the light tip and the target
can vary, the amount of energy measured when the light tip
touches the detector of a measuring device (radiant emit-
tance) does not represent the actual amount of light that will
reach the material to be light cured. The radiant power inci-
dent on a known surface area is called irradiance (incident
 452 N. Scotti et al.
a b
..      Fig. 13.24  a Radiometer for QTH curing units (3 K, Spirith Health); b heat/glare radiometer (Demetron); c radiometer for narrow-­spectrum LED
devices (Kondortech)
irradiance). At 0  mm of distance between the light source
and the surface of the light detector, the radiant emittance
and the incident irradiance will be the same.
According to the total energy concept, a proper curing of
the composite depends on the amount of energy absorbed by
13 the material and can be summarized by the multiplication of
irradiance by the time of exposure. The more recent studies
showed that an energy density of 16 J/cm2 (16,000 mWs/cm2)
is the necessary energy dose to properly cure a 2 mm incre-
ment of the composite. The curing time necessary to reach this
energy dose will depend on the final irradiance by the light-
curing device. Considering a composite in direct contact with
the light source (emittance = irradiance), for a curing unit
with radiant emittance of 400 mW/cm2, an exposure time of
40 s would be necessary (40 s × 400 mW/cm2 = 16,000 mWs/
cm2 or 16 J/cm2), while for a curing unit with radiant emit-
tance of 800 mW/cm2, an exposure time of just 20 s would be
enough (20 s × 800 mW/cm2 = 16,000 mWs/cm2 or 16 J/cm2).
Besides to control the visible light emission, the curing
units that generate infrared radiation, such as the QTH and
PAC, must be evaluated using a heat/glare radiometer
(. Fig.  13.24b). They measure the emittance in the wave-
 
length spectrum between 520 and 1100  nm. The infrared
emittance higher than 50 mW/cm2 will result on an intense
overheating of the tooth structure and damage to the pulpal
tissue. According to Zack and Cohen, on a study applying
heat on monkey’s teeth, an increase of the pulpal temperature
greater than 5.5 °C leads to pulpal necrosis in 15% of the
cases [120]. If the dentist does not have this type of device,
the pinky finger can be placed over the tip of the light guide
and the device activated for 3 consecutive min. If there is the
sensation of unbearable heat, the infrared band-pass filter
has a defect [16].
c
High-powered LED units, such as the second- and third-­
generation ones, can also produce potentially high thermal
emissions and damages to the pulpal tissue. Despite the
absence of infrared emission, the high emittance levels can
increase the chip temperature. Therefore, those devices need
a way to dissipate the internal heat, using thermal conductive
materials in the structure or cooling fans.
The evaluation of a new light-curing unit with a radiom-
eter should be performed to detect any manufacturing
defect, and the baseline radiant emittance be recorder for
relative further comparisons. When measuring the emit-
tance, the same light guide must be used every time the test
is performed, removing any cross-infection control barriers
from the tip. The surface of the light guide tip must be posi-
tioned parallel to the surface of the radiometer port. The
test must be repeated periodically, and if any reduction in
the light output is noticed, the components of the device
must be evaluated [16, 87]. An insufficient polymerization
reduces the strength of the material, increasing the wear,
solubility, and water sorption, making it more susceptible
to staining It also increases the potential of pulpal irritation,
due to the leaching of unpolymerized free residual mono-
mers [16].
Tip
The evaluation of a new light-curing unit with a radiom-
eter should be performed, and the baseline radiant emit-
tance be recorded for relative further comparisons. The
unit must be frequently checked to ensure the use of the
adequate amount of energy necessary for the selected
curing time.
Light-Curing Units
Moreover, the autoclave sterilization promotes the cloud-
ing of the optical fibers on the light guide tip after several
cycles, reducing the passage of light. Therefore, if there are
residues deposited on the light guide, or after 50 cycles of ster-
ilization, the surface must be polished with fine grains pol-
ishing discs or rubbers points, recovering the free passage of
the light. Between each patient, the external surface of the
light curing must be disinfected, and the light guide must be
disinfected or sterilized in autoclave. Then, the light guide
must be covered with clear PVC cling film sheet, as an infec-
tion control surface barrier, as well as the area where the den-
tist holds the device.
13.9  Curing Protocols
The knowledge about the kinetics of the composite polymer-
ization, the cavity configuration factor, and shrinkage vectors
direction allowed the development of special clinical proce-
dures to reduce the negative effects of the polymerization
shrinkage. Among them are the incremental layering tech-
nique, as described on the following chapters, and the differ-
ent curing protocols [3, 87]. The light-curing protocols may
be divided in conventional, where the irradiance is main-
tained in the full power during the curing time, and gradual,
where the irradiance changes during the cycle.
13.9.1  Conventional Protocol
453 13
Tip
If there are two preparations, the curing on the first one
must be concluded before starting on the second.
Therefore, the light must never be moved from one
preparation to another during the irradiation, trying to
accelerate the process, because none of them will
receive the required light energy dose
Another point to be considered is that, with exception to
AL, the curing-light beam has no collimation and the light
beam spreads in a certain angle. When the distance between
the light guide tip and the composite is increased, the light
spread is higher, reducing the amount of incident irradi-
ance. Therefore, distance from the light guide tip to the
material to be cured should be as close as possible, generally
1–2  mm. The incident irradiance striking the material is
inversely proportional to the distance, due to the divergence
of the light beam and the light scattering by the molecules in
the air on the path to the restoration, reducing the amount
of photons that may reach the surface of the composite [80,
88]. However, the ideal distance may not always be possible
on several dental procedures, due to the anatomy of the
tooth or the distance from the occlusal surface to some
walls, such as the gingival walls on Class II preparations.
Therefore, distances from 5 to 6  mm are frequently found
due to the depth of the preparation (. Fig.  13.25) [88]. In

general, the light dissipates proportional to the square of the

As known as uniform and continuous or full-power curing distance. That is, if the distance between the material and
cycle, the maximum power output is applied from the begin- the light is doubled, the incident irradiance will be reduced
ning to the end of the cycle, and it is maintained constant. In to 1/4 of the initial one [16].
order to obtain an ideal polymerization, it is important to
guarantee that the restorative material will receive the neces-
sary energy density [3, 80, 92]. Some studies evaluating the
radiant emittance of light-curing devices in use on dental
clinics have shown that 60% of the analyzed devices had an
emittance smaller than 400 mW/cm2, which is the minimum
acceptable level for the 40s of exposure and a 2  mm incre-
ment [87]. Therefore, even using the exposure time recom-
mended by the manufacturer, the composite will not reach
good mechanical properties due to the low emittance [87].
Other important aspect is that the light must be maintained
steady over the surface of the restoration, during the entire
irradiation time of the cycle. For that, the diameter of the
light guide must cover the entire area to be cured. If the diam-
eter is smaller than the preparation, the curing must be per-
formed in areas, and the cycle must be repeated on each one.
If there are two preparations, the curing of the first one must
be concluded, with the light being applied during the total
required time for the first preparation. After that, the proce-
dure is repeated on the second preparation. That is, the light
must never be moved from one preparation to another dur-
ing the irradiation, trying to accelerate the process, because ..      Fig. 13.25  Real curing distance on the proximal box of posterior
none of them will receive the required light energy dose. teeth when the composite is applied on the gingival wall
 454 N. Scotti et al.

Tip
900
When the distance between the light tip and the 800
composite is increased, the light spread is higher,
700
reducing the amount of incident irradiance. Therefore,
distance from the light guide tip to the material to be 600

cured should be as close as possible, generally 1–2 mm.

mW/cm2
500
400
300
. Figure  13.26 shows data of the relation between the dis-
 

tance of the light guide tip to the composite surface and the 200
incident irradiance reaching on the surface, using different 100
QTH and LED light-curing units. It can be observed that
0
when the distance was between 5 and 8 mm, every unit 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1617 18 1920
tested, despite the radiant emittance measured on the direct Distance (mm)
contact with the tip of the light guide, reached the critical Optilux Emitter A RadiiCal
level of incident irradiance below 400 mW/cm2 on the mate-
rial surface, showing the importance to maintain the light
..      Fig. 13.26  Relation between the distance of the light guide tip to
guide tip as close as possible to the material to be cured. the composite layer surface and the actual irradiance measured on the
It is also observed that irradiance reduction increasing surface, using three different light-curing units, QTH – Optilux/
the distance was greater for some devices than others, indi- Demetron; LED – Emitter A/Schuster; LED – Radii-cal/SDI)

a b

13

c d

..      Fig. 13.27  Angle of beam spread of different light-curing units. a Optical fiber light guide (CLK 200 – Kondortech); b optical fiber light guide
(Free Light Elipar 2, 3 M/Espe); c light guide free curing unit (Radii-cal, SDI); d light guide free curing unit (Valo, Ultradent)
Light-Curing Units
a b
c d
..      Fig. 13.28  Position of the light guide tip in relation to the occlusal
surface inside the simulated oral cavity, with a mouth opening of
43 mm. Depending on the bend of the light guide, the incident beam
angle in relation to the occlusal surface may vary. a, b Light-curing
cating that the angle of beam spread varies from device to
device (. Fig. 13.27). Trying to increase the irradiance, some
 
manufacturers produced tapered light guides with the tip of
smaller diameter than the entrance of light, called turbo light
guides (. Fig.  13.11c). Even though this characteristic may
 
concentrate the light on a smaller area on the tip of the light
guide, increasing the irradiance when on direct contact with
the material, it has an adverse effect on the angle of beam
spread, scattering the light even more. The higher is the angle
of beam spread, the smaller is the incident irradiance over
the material to be cured when the distance is increased. The
parallel-walled (standard) light guides present smaller angle
of beam spread (. Fig. 13.27a–d).
 
The average adult male open the mouth around 43 mm
from upper to lower incisor edges, with a maximum of
55  mm [39]. This represents a very small space, especially
when working on the posterior region. Most of the light-­
curing units on the market have a bended light guide to
access the posterior teeth. However, in most of the cases, it is
hard to place the tip of light guide perpendicular to the
occlusal surface of the tooth to be restorated, making the
light to strike the restoration at an angle, called incident
455 13
units with optical fibers light guide; c light guide free curing unit with
LED chip on the tip but with a bend on the handpiece (Radii-cal, SDI); d
light guide free curing unit with LED chip on the tip, with a
straight handpiece (Valo, Ultradent)
beam angle, generally close to 40° (. Fig. 13.28a, b). Another
location  where the access is also hindered is  on the buccal
surface of the posterior teeth, because the cheeks adversely
affect the proper position of the light guide tip. To overcome
this problem, some manufacturers developed light guide free
curing units. On the unit shown in . Fig. 13.28c, even though
the LED chip is on the tip and it has no light guide, the hand-
piece has an angle bend which adversely affects to place the
tip at 90° in relation to the occlusal surface. On the wand-­
style design unit shown in . Fig. 13.28d, there are no angles
on the handpiece, and the LED is placed perpendicular to the
long axis of the device. That simplifies the access to difficult
locations, even on patients with small mouth opening, allow-
ing the light to be applied in right angle  in relation to the
surface to be restored.
When the incident beam angle exceeds 30°, a large
amount of light energy reflects off the surface and is not
absorbed by  the composite (. Fig.  13.29). This results in a
critical loss of power, adversely affecting the polymerization.
On hard-to-reach restoration locations, the incident beam
angle is increased, reducing the incident irradiance and the
curing effectiveness, increasing the failures possibility.
 456 N. Scotti et al.
800
0%
700 4.1%
600
Irradiance (mW/cm2)
500 29.9%
400
300
70.0%
200
80.1%
100
0 composite manufacturer, since this time is calculated on
0 15 30 45 60
Incident beam angle
..      Fig. 13.29  Effect on incident beam angle in relation to the tooth
surface and the incident irradiance. At the top of each column, the
percentage of the irradiance reduction is presented. The higher is the
angle, the smaller is the irradiance
>> In some areas it is very hard to place the tip of light
guide perpendicular to the restoration surface, making
the light to strike the restoration at an angle, called
incident beam angle. The higher is that angle, the
smaller will be the incident irradiance and the light
curing.
Another point to be analyzed is that when the curing light
penetrates the composite layer, due to its absorption and
13 scattering, the amount of energy that reaches the bottom area
is smaller than the one that strikes the surface, reducing the
curing efficacy in this region [91]. Therefore, the depth of
cure consists on the maximum thickness that each composite
layer may be applied to reach a good conversion degree of the
monomers on its bottom [87]. According to Rueggeberg
et al. [91], increments of 2 mm thick are considered accept-
able, since the irradiance and the time of exposure allow the
total energy density required [87]. It is recommended  that
the microhardness, on the bottom of the composite layer,
should reach at least 80% of the value on the surface for a
material to be considered properly cured [9].
The depth of cure consists on the maximum thickness
that each composite layer may be applied to reach a
good conversion degree of the monomers on its
bottom.
Besides irradiance, other factors which can interfere on the
depth of cure are the shade and translucency of the restor-
ative material. The darker and less translucent the composite,
the larger is the addition of pigments and opacifying agents
on the formulation; this makes necessary an increase of expo-
sure time or the use of thinner increments (1mm) in order to
obtain the same depth of cure and degree of conversion [13,
87, 88]. The kind and size of filler particles on the composi-
tion may also interfere on the depth of cure by changing the
light scattering. The closer the filler particle size to the wave-
length of the curing light, the higher will be the scattering and
smaller the light transmission through the composite. The
microfilled composites have a significant level of scattering
and reduced depth of cure due to this filler characteristic [13].
For the new bulk fill composites, its higher translucency
allows a proper curing of increment up to 4–5 mm.
Due to all the difficulties to obtain an adequate polymer-
ization on the intraoral environment, the curing time should
be increase at least in 50% from the recommended by the
ideal conditions [16]. The time recommended by the manu-
facturer is the minimum necessary, assuming that all other
variables are not interfering. There is no damage for the res-
toration when receiving more light than the necessary,
although the opposite is not true [16].
Tip
Due to all the difficulties to obtain an adequate polym-
erization on the intraoral environment, the curing time
should be increased at least in 50% from the recom-
mended by the composite manufacturer, since this time
is calculated on ideal conditions. There is no damage for
the restoration when receiving more light than the nec-
essary, although the opposite is not true.
13.9.2  Gradual Curing Protocols
On this technique, the curing speed is diminished through
the reduction of irradiance on the beginning of the cycle,
prolonging the pre-gel phase [111]. It may be performed on
different ways, such as the pulse delay or soft start in ramp
and step. Several studies have shown the capacity of these
protocols on reduction of the shrinkage stress and improve-
ment of marginal integrity of the restoration.
13.9.2.1  Pulse-Delay Protocol
It is performed only on the last composite increment of the
restoration, which is responsible for the sealing of the resto-
ration margins [87]. The preparation must be filled with
composite increments of a maximum thickness of 2 mm;
each one is light-cured using a curing unit with a minimum
radiant emittance of 400 mW/cm2 for 40s. The last incre-
ment is light cured for only 3 s with low incident irradiance,
for example, 200 mW/cm2 in devices where the emittance
can be adjusted, or moving away the light guide tip from the
surface. Then the occlusal adjustment and finishing of the
restoration are performed, postponing the final curing,
increasing the pre-gel phase. After that, the final light curing
is performed with the maximum irradiance, during the cor-
responding exposure time to reach the total energy density
of 16 J/cm2 [87].
Light-Curing Units
457 13

a b
mW/cm2

mW/cm2
Time Time

..      Fig. 13.30  Graphic representation of the ramp curing protocol. a Automatic; b by hand

13.9.2.2  Soft Start Protocols curing is completed with maximum power for 40 s [87, 119]
With these techniques, the exposures to the light are per- (. Fig. 13.31a, b).
 

formed continuously, using light-curing units that have this

program on the software, or by hand using conventional 13.9.2.3  Indirect Curing Technique
units and moving away the light guide tip from the surface In order to either reduce the curing light irradiance or con-
[87]. Two methods can be used, which are the ramp and step. trol the shrinkage, an indirect curing technique could be per-
formed. In some clinical conditions, when remaining cavity
Ramp Cycle walls are thin, light cure through the access of the cavity
The ramp cycle may be performed automatically with light-­ using a high emittance light-curing unit can led to high
curing units that already have this curing mode (. Fig. 13.30a) deflection of the remaining tooth structure, in consequence
 

or by hand bringing the light guide close to the restoration of the shrinkage stress at the adhesive interface. Sometimes,
(. Fig. 13.30b) [87]. When performed automatically, the irra- an immediate crack propagation could be observed on the
 

diance starts low (generally close to 150 mW/cm2) and remaining cavity wall, leading to postoperative sensitivity
increases linearly during around 10s until the maximum out- and risks of fracture in the immediate future (. Fig. 13.22).  

put, remaining that way  during the rest of the cycle. On the In such conditions, Dietschi and Spreafico [24] suggested to
hand method, the light guide tip is maintained for 20 s at a perform an indirect curing technique: The curing tip is posi-
distance of more or less 2–3 cm from the tooth surface, result- tioned in contact of the residual wall, and the composite layer
ing on an irradiance of approximately ±100 mW/cm2, depend- is cured through the enamel and dentin (. Fig. 15.6l and o).  

ing on the maximum emittance of the curing unit [87]. The The final irradiance on the composite in contact to the prepa-
greater the maximum irradiance, the greater the distance must ration wall is reduced, due to the light-scattering effect of
be [87]. Then, the light guide is gradually brought closer during enamel and dentin tissues, which will increase the pre-gel
10 s up to 1 mm from the surface and kept for 40 s more [94]. phase and reduce the shrinkage stress.

Step Cycle
On this protocol, the polymerization process is started with a
relatively low and constant irradiance, which is maintained
for some seconds. Consecutively, the light unit automatically
increases the power output to a much higher power (usually
the maximum of light) for the rest of the cycle. This method
can be performed with units that have an automatic program
or through a hand technique. On the curing units where
emittance may be adjusted or have this curing mode, the
restorative material is exposed to the light with low irradi-
ance (100 mW/cm2) for 5–10 s, and the polymerization is
completed on the maximum output for the rest of the time.
On the hand technique, the light guide tip is maintained at a
distance of ±1 cm from the surface (200 mW/cm2) during 10
s. After 5 s, the guide is brought closer to the surface, and the
13.10  Polymerization of Indirect
Restorations
The light absorption of indirect restorative materials
depends on their composition, thickness, shade, and opac-
ity. The Beer–Lambert law relates the attenuation of light to
the properties of the material through which the light is
travelling. Lambert’s law stated that absorbance of a mate-
rial sample is directly proportional to its thickness (path
length). Much later, August Beer discovered another attenu-
ation relation in 1852. Beer’s law stated that absorbance is
proportional to the concentrations of the attenuating spe-
cies in the material sample. The modern derivation of the
Beer–Lambert law combines the two laws and correlates the
 458 N. Scotti et al.

a b
mW/cm2

mW/cm2
Time Time

..      Fig. 13.31  Graphic representation of the step curing protocol. a Automatic; b by hand

a b

13
..      Fig. 13.32  a Large cavity on lingual and proximal surfaces of a lateral incisor; b after composite restoration, an immediate crack propagation
was observed on the labial surface due to the shrinkage stress

absorbance to both the concentrations of the attenuating
species and the thickness of the material sample. Thus,
when curing an indirect restoration, light is attenuated by
the indirect materials employed, which are commonly com-
posite resins, glass, and polycrystalline (or zirconia) ceram-
ics, and presents different optical and light absorption
properties that influence light attenuation during light acti-
vation of an underlying resin cement (. Fig.  13.33) [74,
 
110]. To overcome the effects of curing-light attenuation,
dual-cured cementing systems were developed, having both
light and chemically activation mechanisms. Some of them
are used in combination with adhesive systems containing
co-initiators, such as sulfinic acid salts, that produce free
radicals and contribute to the polymerization reaction of
the resin cements [5, 14]. As  indirect restoration can
decrease the degree of conversion promoted by light polym-
erization of resin cementing systems, increasing the curing
time until 60 seconds can be recommended to compensate
the light attenuation [56, 65]. Some authors suggested to
lute indirect adhesive partial restoration with preheated
light-curing restorative composites instead of dual-curing
resin cements. Clinically, the use of a composite as luting
agent could give some  advantages, such as easy excess
removal and better biomechanics at the adhesive interface.
To limit the difficulties in reaching high degree of conver-
sion, a preheating until 55 °C is suggested [58] in order to
obtain a greater mobility of monomer molecules within the
resin matrix and enhances free radical formation, which
results in a higher degree of conversion and shorten curing
time [2, 19]. The increased mobility of monomers at ele-
vated temperature can lead to delayed auto deceleration
stage of the polymerization reaction, thus contributing to
increased monomer conversion [20].
13.11  Fiber Post Cementation
Fiber posts are nowadays widely used to restore endodonti-
cally treated teeth. They bond well to the tooth structure,
which increases retention of the post, reinforces root struc-
ture internally, and improves resistance to tooth fracture.
However, adhesion inside the root canal can be impaired by
several factors, such as the adverse geometric feature of the
root canal [105], the peculiar characteristics of the post space
Light-Curing Units
a b
c d
..      Fig. 13.33  a Replacement of a defective indirect restoration on
upper molar; b tooth preparation; c luting of a new indirect restoration
using dual-cure resin cement. The small penetration of light through
the restorative material does not allow a proper photopolymerization
[33], and possible incompatibilities between simplified adhe-
sives and dual-cure resin-based cements [105]
One of the most important aspect in luting of a fiber post
into the root canal is reaching an adequate degree of cure, at
deeper areas, of either the adhesive system or the luting
cement [86]. Although self-curing resins exhibit uniform
polymerization, the application of this type of resin into the
canal followed by the post positioning must be performed
very quickly, because polymerization starts  after the two
pastes are mixed [34, 117]. However, the use of purely light-­
cured cements is not indicated, because the polymerization is
also limited at depths beyond 2 mm, because the influence of
reduced irradiance produced by the shadowing of the tooth
structure, and the light scattering and attenuation within the
resin cement and the post [30, 117]. Therefore, dual-cure
cements are the best choice in the fiber posts luting [38, 75].
They have a chemical-curing system that can achieve a more
extensive polymerization in dark locations [48], while also
providing a light-curing mechanism that allows a rapid ini-
tial hardening of the resin cement to stabilize the restoration
[118]. Both the light- and chemical-curing mechanisms are
complementary but independent [77].
459 13
of the resin cement on deep areas of the preparation, requiring the
self-curing mechanism for adequate degree of conversion and
bonding; d Final restoration
Although chemical curing is responsible for polymeriza-
tion at sites not reached by light, the chemical polymeriza-
tion component in some dual-cure resin composites has
been described as slower, less effective [12, 79], or virtually
ineffective [6, 26]. Therefore, translucent fiber posts were
introduced to overcome the problem of lack of curing in
deep locations with limited penetration of light [75]. The effi-
cacy of these light-transmitting posts has been supported by
several studies [75, 89]. However, some in vitro studies stated
that widely used translucent posts have been shown to inef-
fectively transmit light to the apical region [51]. In fact, even
being translucent, fiber posts will limit light transmission to
values lower than 40% of incident light, and may not guaran-
tee an adequate degree of conversion of the resin especially at
the tip end (. Fig. 13.34) [106].
Thus, in order to reach the maximum degree of conver-
sion possible, besides using a dual-cure resin cement, the
increase of curing time is recommended. Clinically, an
extended time up to 60 seconds is suggested to obtain the
maximum mechanical properties of the luting cements,
which are directly related to the clinical performance and
outcome of fiber-supported restorations.
 460 N. Scotti et al.
..      Fig. 13.34  Transmission of light through a glass fiber post. The
resin cement was applied to the post, on the part intended to be
inserted into the canal (on the left of the image), and the light guide
was placed on the post tip (on the right side of the image). It is possible
to see that the light transmission is reduced during its penetration
through the post (red arrow), and no light reaches the resin cement
after a certain distance from the light source (asterisk on the dark area)
13.12  Ocular Hazards of Curing Lights
The light is a kind of radiant energy, and according to its
wavelength, the amount of energy carried and its effects can
vary. Its interaction with the matter will also depend on the
chemical and physical characteristics of the irradiated tissue.
13 Due to the intensity of emitted light, the light-curing units
are capable to cause ocular damage to the patient, dentist,
and dental assistant.
The environmental light enters the eyes through the cor-
nea, located in front of the anterior chamber filled with the
aqueous humor (. Fig. 13.35). Then, the beam of light pass
 
through the iris, a type of adjustable diaphragm, and then
reach the crystalline, a type of lens capable to focus the light
on the retina. It is surrounded by a circular muscle that allows
the constant modification of the focal distance of the eye.
After passing through the crystalline, the light beam crosses
the vitreous humor, hitting the retina. It is formed by a layer
of light sensible cells, which are concentrated on the area
called fovea centralis. This small area of the retina is the main
responsible for the vision [43].
The human eye is capable to respond only the electro-
magnetic radiation at the wavelength range between 390 and
770 nm, and the brain is able to interpret it as color. However,
when considering the harmful effects of the light on the eyes,
it is necessary to analyze the invisible wavelength near the
visible spectrum, that is, the ultraviolet (<390 nm) and the
infrared waves (>770 nm). The different parts of the eye act
as filters for the different wavelengths. In . Fig. 13.35, it is
 
shown the components of the human eye and its interaction
with the several wavelengths. The cornea is first irradiated
and filters the electromagnetic waves with wavelengths
smaller than 300 nm, which reduces the amount of UV that
enters the aqueous humor. The crystalline absorbs the waves
Iris
UV
Visible
Retina Infrared
Cornea
Vitreous humor Aqueous humor
Crystalline
..      Fig. 13.35  Cross section of the human eye illustrating the path of
light and its interaction with the different wavelengths (UV, visible
light, and infrared)
with wavelength between 300 and 400 nm, basically avoid-
ing that the UV radiation hits the retina. The visible light
freely goes through the cornea and the crystalline, hitting
the retina [49].
The excessive exposure and the absorption of the UV
radiation by the cornea lead to cellular damage due to the
nuclear fragmentation of the corneal epithelium. The loss of
the cohesion between the epithelium and the stroma also
happens on the crystalline and may cause a progressive loss
of transparency, called cataract, due to a cumulative photo-
chemical damage over the lens proteins [116, 121]. For this
reason, the UV light-curing units were totally removed from
the market.
In relation to the damage produced by the visible light
and infrared to the retina, Ham et al. described three types of
aggressions [44]. The first is the mechanical breaking of the
retinal structure, resulting from high-power shock waves,
using short radiation pulses absorbed by the retinal pigment
epithelium. The second is a thermal damage in the retina,
which results from the absorption of enough energy to
increase the retinal temperature in at least 10 °C above the
body temperature. The third is an actinic damage. It is called
actinic, the capability of light to produce chemical changes
on determined substance. The actinic effect, also called pho-
tochemical, is a result from prolonged exposure to short
wavelengths of visible light (400–550 nm), on irradiance too
low to increase the temperature in more than some degrees
above the body temperature.
The parameters which determine the type of damage to
the retina are the light intensity, duration of exposure, and
the wavelength (color). The intensity that enters in the eye
and the duration of the exposure determine if the damage is
mechanical or thermal. The thermomechanical damage
caused by visible light is intensified by greater irradiance and
small wavelength, such as the blue light, which carries more
energy and may cause true retinal burn [45, 49]. The greater
risks are attributed to the absorption of the focused light on
the retina by the melanin granules in the retinal pigment epi-
Light-Curing Units
thelium, which can produce a significant heating. This can
lead to the disruption of the photoreceptor’s outer segment,
in relation with the duration of the exposure. Ham et al. [44]
showed that the intense blue light, especially on the range of
460–480 nm, caused burn on the retina of monkeys, even on
short exposures, smaller than a second. The burns became
more serious with the increase of the exposure time, with a
mean healing time of 20–30 days. The healed areas became a
permanent degenerative tissue, histologically similar to the
age-related macular degeneration, which means that the light
exposure quickly ages the retinal visual cells and it is an irre-
versible phenomenon.
Using low irradiance and longer exposure time, there is a
point from which the thermal effects become minimal or
insignificant. On wavelengths range from 550 to 600 nm,
corresponding to green and yellow, the retinal temperature is
only increased some degrees above the body temperature,
and the retina is not damaged even after prolonged expo-
sures. For the wavelengths below 550 nm, the prolonged
exposures produce actinic effects on the retina even though
there are no thermal damages.
There is no clear marked line between the thermal and
actinic effects, and there is a point where the photochemical
and thermal effects overlap [45]. The action spectrum of the
actinic effects on the retina increases exponentially as the
wavelength decreases to 400  nm [46]. Below 450nm wave-
lenght, crystalline begins to absorb a little of the electromag-
netic wave, with some photons, between blue and violet
spectrum, reaching the retina. According to Ham et al., blue
light creates free radicals in the eye in a similar way to what
happens with composites [44]. On the retina, these free radi-
cals react with the aqueous content of the visual cells forming
peroxides, which are very reactive and cause denaturation on
the photoreceptors and severe visual damage.
Briefly, the thermomechanical lesions require the intense
exposure to light, while the photochemical is caused by pro-
longed exposures, primarily to blue or near ultraviolet, at
levels that probably would be well tolerated if they were tran-
sitory [64]. According to the American Conference of
Governmental Industrial Hygienists (ACGIH), looking to a
blue visible light source for more than 12 min represents a
potential risk to the eyes. A positive point is that the light that
the dentist or the assistant see is not direct light, but the light
reflected by the patient’s mouth, which represents about
20–30% of the emitted light [16]. However, there is the neces-
sity that both patients, dentist, and assistant be protected
[16]. For safety use of the light-curing units, it is necessary
the use of a light filter, such as orange safety glasses or hand-
held shields, with optical density capable to filter the blue
light [100]. The optical density is the capacity that a lens has
to attenuate the passage of light in a wavelength harmful to
the eyes. It is calculated in relation to the maximum permis-
sible exposure for each type of light source. The safety glasses
or shields offer comfort for the dentist work, which can
directly see the place of light application. The safety lens must
absorb most of the blue light but allow the observation of the
operating field [16]. According to Chain [16], good safety
461 13
glasses allow transmission of 1–5% of the light for the wave-
length smaller than 450  nm and 50% for the wavelength
greater than 550 nm.
Tip
55 Always extend curing time. The more you light cure,
the best mechanical and optical properties you’ll
obtain.
55 Visually check, with proper eyes protection, the
curing tip position while curing.
55 With long curing times, it is desirable to control the
temperature rise with air blow.
Conclusion
The world of operative and restorative dentistry is increas-
ingly turning to the use of polymeric materials. It is evident
that the polymerization of adhesive systems, composite res-
ins, and resin cements has a fundamental role in the optical
and mechanical performances of the materials themselves.
The photopolymerization phase must therefore be consid-
ered as a fundamental step in the clinical sequence, which
must be carried out carefully and with the right tools. The
dentist must understand how the polymerization reaction
occurs, as well the influence of the light irradiance on the
shrinkage stress, responsible for most of the problems related
to composite restorations. The gradual curing protocols are
options to reduce the shrinkage stress, besides the use of a
layering technique. The clinical use of the light-curing units
must be precise, mainly related to the positioning of the light
source in relation to the cavity entry, containing the restor-
ative material to be cured. The higher is the distance between
the end of the light guide and the surface of the composite,
the smaller will be the irradiance and the polymerization. The
light source must be placed as close as possible to the surface,
avoiding leaning the light guide. An increase in polymeriza-
tion times can also improve the degree of conversion of the
materials, either in direct or indirect techniques. The constant
exposure to the visible light can cause damage to the eyes,
and protective shields are recommended.
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 465 14

Composite Restoration
on Anterior Teeth
Carlos Rocha Gomes Torres and Rayssa Ferreira Zanatta

14.1 Introduction – 466

14.2 Basic Concepts About Color – 470

14.2.1  efinitions – 470
D
14.2.2 Optical Characteristics of Natural Teeth – 471
14.2.3 Shade Determination – 477

14.3 Selection of Composite Resin – 482

14.4 Indications of Composites on Anterior Teeth – 483

14.5 Esthetic Analysis of Anterior Teeth – 484

14.5.1 E namel Translucency – 484
14.5.2 Morphology of the Incisal Edge – 484
14.5.3 Surface Texture – 486
14.5.4 Dental Dimensions and Proportions – 488

14.6 Restorative Technique – 492

14.6.1  revious Clinical Procedures – 492
P
14.6.2 Tooth Preparation – 492
14.6.3 Restorative Procedure – 497
14.6.4 The Use of Color Modifiers – 559
14.6.5 Finishing and Polishing – 568

14.7  urability and Maintenance of the

D
Composite Restorations – 573

References – 574

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_14
 466 C. R. G. Torres and R. F. Zanatta
Learning Objectives
The aim of this chapter is to teach the readers the following
topics:
55 Basic concepts about color and optical characteristics of
natural teeth
55 How to make the tooth shade determination and select
the appropriate composite resin
55 Principles of esthetic analysis of anterior teeth in order to
reproduce the natural characteristics on the restorations
55 How to perform the restorative procedure for all kinds of
lesions produced by caries or other non-carious origin
55 How to perform restoration of fractured teeth with or
without the association of a surgical procedure
55 The reattachment of fractured tooth fragments
55 The use of composite for recontouring teeth
55 The use of color modifiers
55 Finishing and polishing procedure
55 Factors affecting the durability and how to perform the
maintenance of composite restorations
14.1  Introduction
The composite resin is the most popular direct restorative
material among the clinicians and the most requested by the
patients, either for anterior or posterior teeth. Its main
advantage is the esthetics because it presents shades compat-
ible with the remaining tooth structure. On anterior teeth, it
is the best option to restore the lost shape, function, and
esthetics. Another great advantage is its adhesion to the tooth
structure, which contributes to the retention of the restor-
ative material and helps to reinforce the remaining tooth
14 structure [31]. The development of the dental adhesives
allowed a deep change on the paradigms in relation to the
tooth preparation, contributing for the creation of the mini-
mally invasive dentistry.
With the recognition of the fact that caries incidence can
be significantly reduced or totally avoided, in addition to the
fact that some caries lesions can be arrested, remaining as a
scar, or even reversed and disappear, the necessity of tooth
restoration has decreased considerably. The invasive approach
of caries lesions treatment, without giving instructions for
patients in relation to the caries as a multifactorial disease,
results on the treatment failure in a short period of time. This
allows new lesions to occur on other areas of the same teeth
and/or on other teeth of the same patient. The restorations do
not cure the caries disease and do not promote health by
itself and failure earlier than most clinicians believe [3].
As discussed by Roulet and Degrange [32], in the past,
young clinicians could work their entire lives with the knowl-
edge that they learned at the dental schools. This is not true
anymore, since the adhesives and restorative materials
changed and continue to change the way that many restor-
ative procedures are performed. The dentists now need con-
tinuing education to update themselves in relation to new
alternatives of materials and techniques, to offer the best
treatment possible for the patients.
The first composite resin was developed in 1962 by Bowen
[8]. It is a polymeric restorative material composed basically
by three main ingredients. The first is the organic matrix,
formed by a blend of resinous monomers with molecular
chains of different lengths, which can chemically bond and
form a rigid material. Some of the most commonly used are
the bisphenol A-glycidyl methacrylate (Bis-GMA), urethane
dimethacrylate (UDMA), bisphenol A polyethylene glycol
diether dimethacrylate (bis-EMA), and triethylene glycol
dimethacrylate (TEGDMA). Even though the polymeriza-
tion reaction is essential to form a hard polymer, it results on
the volumetric shrinkage of the material by the reduction of
the intermolecular distance between the monomers, due to
the covalent bonding, creating stress at the tooth-restoration
interface [1]. The mean volumetric shrinkage of the current
methacrylate-based composites in around 1.3–4% by volume
[29, 33]. This shrinkage produces stress on the tooth-­
restoration interface of about 4–8 MPa, which can break the
bonding between the composite and the tooth structure, cre-
ating marginal gaps and allowing microleakage. This can
allow the occurrence of secondary caries lesions, besides
causing cracks or fractures on the enamel margin, cuspal
deflection, and postoperative sensitivity [1, 10].
The second ingredient is the inorganic filler, composed by
small glass or silica particles, which has the objective to
increase the mechanical strength of the restorative material
[31]. The presence of fillers also reduces the organic matrix
content, diminishing the volumetric polymerization shrink-
age. In addition, the strontium and barium elements in the
filler’s composition give radiopacity to the material, which
helps the diagnosis of secondary caries on restorations mar-
gins. The filler’s content reduces the coefficient of linear ther-
mal expansion in relation to an unfilled material, although
for regular composites it can still be up to three times higher
than the tooth structure. It also reduces the water sorption,
which can promote material’s degradation and staining [31].
The third ingredient is the silane coupling agent which
acts as a sort of intermediary, bonding the inorganic fillers to
the organic matrix. It produces the integration of the other
two main ingredients, making that all material’s components
behaves as a single body, increasing the mechanical strength
and reducing water sorption and solubility [31].
>> The composite resins have three main ingredients:
organic matrix (resinous monomers that allows
polymerization), inorganic filler (glass particles that
gives strength), and silane coupling agent (agent that
bonds monomers and fillers).
The composites may be classified according to the type and
size of the filler particles, because it has a great influence on
its mechanical characteristics. The first composites created,
also known as conventional or macrofilled, were character-
ized by having large filler particles, of very similar and homo-
geneous size, in a Bis-GMA organic matrix (. Fig.  14.1a).
They were introduced on the 1960s and had on its composi-
tion grinded quartz filler particles, with average sizes larger
than 15 μm (15,000 nm), due to the technical limitation on
Composite Restoration on Anterior Teeth
a b
d e
..      Fig. 14.1  Distribution of filler particles on different types of
composites. a Macrofilled (Concise, 3M/ESPE); b microfilled (Durafill,
Heraeus Kulzer) – the lighter areas correspond to the precured resin
filler particles; c hybrid (Surefil, Dentsply); d microhybrids (TPH,
that time to produce thinner particles by grinding quartz, a
very hard material. They had an average filler content of
75–80% by weight and a good compressive strength [31]. The
restorations made with these materials had a high surface
roughness, due to the large and extremely hard filler particles
difficult to cut by the polishing instrument. Therefore, they
were not indicated for preparations close to the gingiva
because promoted biofilm deposition. Also, this material
presented poor esthetic, high levels of wear, and low color
stability. When this material suffered abrasion, the polymer
between the fillers was removed, leading particles protruding
from the surface. With the time those particles were removed
creating craters. The craters and the protruding particles pro-
duce a rough surface, losing the surface gloss created by the
polishing procedures, making the restoration more suscepti-
ble to surface discoloration by extrinsic staining [31]. When
placed on contact areas, this composite suffered more wear
than the natural enamel [31]. Those materials were chemi-
cally activated, requiring a previous mixture of two pastes,
presenting only one shade. Due to the mixture, air bubbles
used to be incorporated into the material, increasing the
porosity of the restoration. In addition, the working time was
short and the color stability was reduced, due to the degrada-
tion of some chemical components, such as the amines [31].
467 14
c
f
Dentsply); e nanohybrids (GrandioSO, Voco); f nanofilled (Z350, 3 M/
ESPE). SEM images in backscattered electron imaging mode to show
the filler particles (1500×)
The amount of composite excess at the restoration’s margins
to the removed was also greater, due to the application in a
single increment. This type of composite is no longer used.
On the 1980s, an evolution of the conventional materials
came to the market, presenting thinner filler particles, with
the average size of 8 μm [31].
The microfilled composites were introduced as an alter-
native to solve the problems of high roughness and unsatis-
factory gloss of the macrofilled materials. They present as
filler particles the pyrogenic or colloidal silica, with mean
filler particle size of 0.01–0.04 μm (10–40 nm), resulting on a
very smooth surface after polishing, with less biofilm reten-
tion and extrinsic staining (. Fig. 14.1b) [3, 31]. They present
a surface roughness average (Ra) of approximately 0.035 μm,
about ten times less than the conventional macrofilled com-
posites (Ra = 0.30 μm). However, there was a technical prob-
lem to manufacture a high filler load when using those
particles, due to the greater surface area to volume ratio,
resulting in a too viscous material. To increase the total filler
loading without interfering on the viscosity, many manufac-
turers added to the formulation pre-cured resin filler parti-
cles. They are prepared by adding a large amount of silica
particles into the organic matrix, resulting in a viscosity
inadequate to the clinical use. The material is polymerized
 468 C. R. G. Torres and R. F. Zanatta

and grinded to form small particles. Those particles are then low surface roughness. The hybrids composites have a filler
added to more organic matrix and silica fillers, creating an loading of about 75–85% by weight, which produces adequate
adequate viscosity for clinical use. Even with this process, the strength of the material and allows it to be indicated on both
microfilled composites have smaller filler loading in relation posterior and anterior teeth. They have a mean filler particle
to the other ones, resulting in lower mechanical strength and size of 0.04–5 μm (40–5000 nm), which creates a smoother
wear resistance. They present an average filler loading of surface and an acceptable esthetical results [1, 3].
35–60% by weight [31], which results in small compressive To overcome the yet  unsatisfactory polishing of the
strength. They are contraindicated for situations that undergo hybrid composites, the manufacturers reduced the size of the
high occlusal load, such as on the restoration of the incisal larger filler particles used on those materials, maintaining a
edges, on the occlusal surface of the posterior teeth, and on high filler loading but having a significant improvement of
the lingual surface of the anterior teeth where there is occlu- the polishing results, being named microhybrid composites.
sal contact or disocclusion guide. They have a higher volu- They present a filler loading of approximately 75–85% by
metric shrinkage and a smaller depth of cure, due to the fact weight, with good strength, but the larger particles are not
that the small particles adversely affect the light penetration larger than 1 μm, having a mean filler particle size between
inside the material [3]. They are excellent in places where a 0.04 and 1 μm (40–1000 nm). They are indicated for anterior
high polishing is required, such as on the restorations close to and posterior teeth (. Fig. 14.1d) [1, 3].
 

the gingival margins or as on a surface layer of restorations of A nanoparticle is commonly identified as a particle
the labial surfaces of anterior teeth, where the gloss has a between 0.01 and 0.1 μm (10–100 nm) in size, therefore,
great influence of the final esthetic outcome. The surface below the wavelength of the visible light. Particles with nano-
roughness of the polished material is similar to enamel and is metric sizes, such as the pyrogenic silica used on the micro-
kept for a long time. In general, they become more translu- filled composites or others, have a large surface area to
cent with whiter shade after curing [3]. Some brands of volume ratio and, therewith, high surface energy. When
microfilled composites are still available on the market. added to the composite formulation beyond 40%, it creates
Considering that the greater the filler loading, the smaller an extremely viscous mass that may not be processed and
the resinous content and the volumetric shrinkage of the used as a restorative material. To overcome this problem, the
material, the manufacturers tried to add the maximum of manufacturers found a way to chemically inactivate the sur-
filler possible in the organic matrix. They observed that when face of the freshly generated nanoparticles, reducing its sur-
using particles with similar size, despite its dimensions, a face energy and its effects of increasing the viscosity.
maximum limit of incorporation was reached in a material Therefore, the inactivated nanoparticles were added to the
densely packed, with the particles the maximum close to each microhybrid composites, increasing, even more, the filler
other. In an attempt to incorporate even more inorganic con- loading, because it occupies the spaces between the smallest
tent, it was tested the addition of particles even smaller than particles. This material was named nanohybrid composite.
14 the first ones, trying to fill the gaps between them. The spaces According to the manufacturers, due to the fact that the
left between these smaller particles were then filed with even nanoparticles are smaller than the wavelength of visible light,
smaller ones. This method for increasing the filler content the light absorption does not occur on those particles, and
creates the concept of hybrid composite (. Fig. 14.1c). They the light is transmitted through the material, increasing its
 

associate the advantages of microfilled composites with the translucency. This would help to create a “chameleon effect,”
strength of the composites with larger particles, due to the allowing the adjacent and underlying tooth structure to
association of fillers with different sizes. To reduce the prob- reflect light through the restoration, which blends the resto-
lems of the high hardness of the quartz particles, softer or ration with surrounding tooth remaining and improves the
more friable glasses were developed, such as the barium fluo- esthetic outcomes. The addition of nanoparticles improved
rosilicate-aluminum glass, ceramic glass, zirconium-­ some characteristics of the material, but in general it has a
containing glass, lithium-aluminum-silicate glass, or similar clinical behavior in relation to the traditional micro-
strontium glass [1]. Those filler are easily cut by the polishing hybrid composites, with the same indications, advantages,
instrument and results on a smoother surface than the mac- and disadvantages (. Fig. 14.1e) [28, 42, 46].
 

rofilled ones, increasing also the long-term polish retention. Another kind of composite according to the filler parti-
This type of glass has also turned the material more cles is called purely nanofilled. This materials present indi-
­radiopaque, simplifying the detection of secondary of caries vidual nanoscale particles of 20 nm; and also nanoclusters of
on the restoration’s margins [31]. The filler particles are gen- those nanoparticles, with mean particle size of 0.075 μm (75
erally obtained by grinding glass, resulting in irregular shapes. nm). The nanoclusters are produced by a sintering process,
However, this technique to manufacture limits the size of the which results in loosely agglomerated nanoparticles.
obtained particles, being hardly smaller than 0.5 μm (500 nm) Although structurally different from the regular dense filler
[28]. Another way to produce particles is the sol-gel process, particles found in other composites, these nanoclusters
using liquid substances as precursors, resulting on spherical behaved similarly in terms of providing high filler loading,
fillers of several sizes. The larger particles presented on these which gives strength to the material. In . Fig.  14.1f, the
 

composites increase the strength, while the smaller ones fill nanoclusters of spherical shape can be observed. During the
the spaces between them, resulting in a high filler loading and polishing, the nanoclusters are easily  cut, resulting on a
Composite Restoration on Anterior Teeth
superficial smoothness similar to a microfilled composite.
They result on a better polishing than the microhybrid mate-
rials, even though are similar to the modern nanohybrid
composites [28]. According to the manufacturer, the wear
rate of the clusters is closer to the wear rate of the surround-
ing matrix, increasing the polish retention. They are indi-
cated for both posterior and anterior teeth and present good
strength and polishing.
The composites may also be classified according to its vis-
cosity in low, medium, or high viscosity (. Fig. 14.2a–c). The
 
low-viscosity or flowable composites generally have smaller
filler loading than the others, which is responsible for its flow-
ability, but results in inferior mechanical properties and
higher wear rate. They also generally present a larger volumet-
ric shrinkage [31]. Even though they are easy to use and have
good wettability and handling properties, its clinical indica-
tions are limited. They are indicated for: Class V restorations,
because this region undergoes compressive and tensile stress
but has no direct contact with the opposing tooth; as the first
layer under composite restorations on posterior teeth, because
it promotes a better adaptation to the internal angles of the
preparation; on restorations of small preparations in the
occlusal surface of posterior teeth; as pits and fissure sealants;
and for repair the defective margins of pre-­existing restora-
a b c deeply the light penetrates the tooth or restoration before it is
..      Fig. 14.2  Types of composites according to the viscosity. a Low; b
medium; c high
Incident light Incident light
Absorbed light
Opacity Translucency
..      Fig. 14.3  Differences among opacity, translucency, and transparency
469 14
tions. Some brands have different flowability levels, covering
more indications. In the recent years, flowable composites
with a higher filler content were developed, increasing its
indications for some more stress-bearing situations.
The medium-viscosity or conventional composites are
considered of universal indication, for both anterior and pos-
terior teeth, being the most widely used by the clinicians. Its
viscosity allows the application of increments, maintaining
the shape when in place without flowing, enabling the use of
a layering technique. The high-viscosity materials, namely
condensable composites, were developed for use on posterior
teeth for helping the restoration of the contact points with
the adjacent tooth. Its viscosity helps to press the matrix dur-
ing the application, although they were more difficult to
handle. However, some techniques can allow the proper res-
toration of the proximal contacts without the need of such a
high viscous materials. For this reason, those are currently
seldom used on the daily dental practice.
The composites may also vary according to the levels of
translucency. A material is considered translucent when part
of the light that hits its surface is transmitted through the
material, allowing the underlying background to show
through (. Fig. 14.3). It is possible to see through a translu-
cent material, but the image is not clear. This characteristic is
observed in variable levels on the dental enamel. The oppo-
site property of translucency is opacity. A material is consid-
ered a totally opaque when the light that hits its surface is not
capable to pass through it (. Fig. 14.3). Although the dentin
is not completely opaque, it has a higher opacity level than
the enamel. A material is called transparent when it allows
almost total transmission of the light that hits its surface
without being scattered, like a perfect glass, allowing to
clearly see through it. A perfect transparency is not observed
on the tooth enamel, even though they may be highly trans-
lucent. The translucency can also be described as partial
opacity or a state between complete opacity and complete
transparency. The degree of translucency is related to how
reflected outward [31]. The enamel has high translucency,
while the dentin has low translucency, even though it is not
completely opaque.
Transmitted light Incident light Transmitted light
Transparency
 470 C. R. G. Torres and R. F. Zanatta
>> A material is considered translucent when part of the
light that hits its surface is transmitted through it.
The opposite property is called opacity. The dental
enamel is more translucent than the dentin, which is
almost opaque. For the proper restoration of the
tooth structure, the use of composites with
translucency levels close to the natural dental tissues
is necessary. The translucency of a composite is as
relevant as its color, since it affects the final
restoration appearance.
The overlapping of the enamel over the dentin on differ-
ent thickness, according to the region of the tooth, is the
responsible for the polychromatic effect observed on the
natural teeth [3]. The thicker is the enamel or dentin layer,
the less translucent it appears. The dentin is thicker and
the enamel thinner  on the cervical region of the teeth,
which gives a general opaquer aspect to this region. The
shade is more saturated, with a greater inflence of the
dentin color. On the middle third of the crown, the differ-
ences of thicknesses between enamel and dentin are less
discrepant, making this region less saturated and more
luminous. On the incisal third, the enamel is thicker and
minimum or no dentin exist, prevailing the optical char-
acteristics of the enamel [1]. The enamel translucency is
not only due to its high degree of mineralization, but also
because of its internal mineral organization of low refrac-
tive index, which allows the transmission of most of the
incident light. The enamel prisms act similarly to the
optical fibers. The light that enters the prisms is reflected
by its crystals and remain on its interior, running through
14 it. This effect is empowered by its radial orientation from
the dentin-enamel junction (DEJ), directing the light to
the center of the tooth, toward the dentin [1, 22]. For the
proper restoration of the tooth structure, the use of com-
posites with optical characteristics close to the natural
tooth  is necessary to obtain excellence on the esthetic
results.
The dental composites are generally available with three
levels of translucency. The high-translucency one,  namely
incisal shade, are indicated for restorations of the enamel
on the highly translucent incisal edges observed on some
teeth. The composites with medium translucency, nemely
enamel shade, are indicated for restorations of the enamel
on most situations. They are also called by some manufac-
turers as universal or body shade composites. The low-
translucency composites, nemely dentin shade, are used to
restore the lost dentin tissue. They are referred by some
manufacturers as opaque shade composites. The translu-
cency of a composite is an essential optical property, as rel-
evant as to color, since it affects the composite shade
appearance. The knowledge about the translucency can
help the selection of the most adequate composite and
obtain the best esthetic results. The translucency of the
human enamel increases with the years since its mineraliza-
tion increases and the thickness decreases [2].
14.2  Basic Concepts About Color
14.2.1  Definitions
The color phenomenon is a psychophysical response to the
physical interaction between the luminous energy and an
object, associated with the subjective experience of an
observer [26]. Visible light is a form of electromagnetic radi-
ation, with wavelength range between 390 and 770 nm, which
is detected by the light-sensitive photoreceptor cells of the
human eyes. Each wavelength corresponds to a specific color.
A light source can emit a single wavelength (monochromatic)
or multiple wavelengths (polychromatic). When the light
source is observed directly, the color that human vision
detects is a result of the emitted wavelengths, which is the
color of the light by itself. The more colors are emitted simul-
taneously by a light source, the more it comes close to white
color. When the light hits an object, it can be transmitted
through it, absorbed, or reflected, and this last one is respon-
sible for the color perception that the humans have about the
object. The more the incident light is absorbed by the object,
the darker it is perceived by the observer. The more the poly-
chromatic light is reflected by the object, the whiter it appears
to the observer. Therefore, there is the color of the light,
which corresponds to the wavelength emitted by the light
source, and the color of the objects, which is the light reflected
by an object.
The color phenomenon is a psychophysical response to
the physical interaction between the luminous energy
and an object, associated with the subjective experience
of an observer. The color of the light corresponds to the
wavelength emitted by the light source, while the color
of an object corresponds to the light reflected by it.
There are three factors that may affect the color perception,
which are the light source, the object that is being seen, and
the observer that is looking at the object [21]. The light source
can emit luminous energy on a broad wavelength range, and
it is characterized by the relative amount of energy for each
wavelength on the visible spectrum. This way, the color per-
ception is affected by the light that illuminates an object,
because the different light sources have variable amounts of
each wavelength of the visible light [21]. In relation to the
object, its spectral reflectance or light transmission charac-
terizes its color. For example, a red object has this color
because it reflects the wavelength corresponding to the red
color more than the green or blue ones (. Fig. 14.4a–e). In
relation to the observer, the visual systems and the brain also
affect the color perception.
The primary colors are a biological concept based on the
physiological response of the color vision system in the
human eye to the light, and not a fundamental property of
light. Essentially, the light is a continuous spectrum of
Composite Restoration on Anterior Teeth
471 14
Incident light Incident light
a b

Reflected light

Absorbed light
c d e

..      Fig. 14.6  Value or the lightness of a color

..      Fig. 14.4  Color of the objects. a Every wavelength is absorbed

resulting in the black color; b every wavelength is reflected, resulting in
a white color; c–e prevalence reflection of a certain wavelength.
(Adapted from Fraser and Banks [15])

..      Fig. 14.7  Chroma or hue strength

color is strong or vivid (. Fig.  14.7) [21]. The combination

 

between the three-color dimensions gives the shade or tone

..      Fig. 14.5  Hue or color name
wavelength, with an infinite number of colors. However, the
retina of the human eye contains only three types of color
receptors, called cone cells, having a trichromatic color
vision. Each one of those cones is especially sensitive to cer-
tain wavelengths of light, which correspond to red, green,
and blue colors. Those colors are considered the primary
colors of the light source (RGB system  – red, green, and
blue), because each of them can independently stimulate
the cones, allowing a large range of color perception.
The color can be described according to the Munsell color
system, which is a three-dimensional model based on the
premise that each color has three qualities or attributes: hue,
value, and chroma. Hue is the actual color, for example, the
red, green, and blue (. Fig. 14.5). Value indicates the light-
 
ness of a color, ranging from for pure black to pure white
(. Fig. 14.6). The chroma is the intensity a color. When the
 
chroma is low, the color is weak, while when it is high, the
of a color.
>> The three dimensions of color are hue (actual color),
value (lightness), and chroma (intensity). The
combination between them gives the shade or tone of
a color.
14.2.2  Optical Characteristics of Natural
Teeth
Due to the large range of colors found on the natural teeth, it
may be hard to choose the proper shade for a restorative
material. Natural teeth are not monochromatic, and with a
single composite shade, it can be impossible to match the
polychromatism of teeth [3]. The natural polychromatism is
the result of several shades found on enamel and dentin,
influenced by the different thickness of those structures along
the crown [3].
When analyzed separately, the enamel color varies from
white to gray, while the dentin has variable amounts of yel-
low, orange, and red. The enamel is thicker on the incisal
 472 C. R. G. Torres and R. F. Zanatta
a b
..      Fig. 14.8  Tooth with completely removed dentin. a View under reflected light; b view under transmitted light
edge and thinner in the cervical region. When the incisal
edges are not worn, frequently have blue, violet, or gray tones,
due to the enamel translucency and absence of the dentin.
Therefore, a single monochromatic composite cannot match
the complex color of the natural tooth [3]. The translucency
of the composite varies according to the ratio between the
smaller and larger filler particles. The perceived color of a
composite restoration will also be influenced by the color of
the background (preparation walls) [3].
>> A single monochromatic composite cannot match the
complex color of the natural tooth.
When the environmental light interacts with the tooth sur-
face, the color perceived by the observer is a mixture of sev-
eral wavelengths reflected by the tooth. As enamel is a
14 translucent structure, when the light hits its surface, a certain
part is reflected, another is absorbed, and the rest is transmit-
ted through it, reaching the underlying dentin. From this
light, a part is absorbed or transmitted, and the rest is
reflected back to the enamel. The dentin is the main respon-
sible for the basic hue of the tooth, presenting a chromaticity
that varies from orange to yellow [1]. Therefore, the shade of
the tooth structure perceived by the observer is a result of the
light reflected by both dentin and enamel.
The degree of translucency is related to how deep the light
penetrated the tooth or the restorations before it is reflected.
The normal is that light penetrates through enamel up to the
dentin before it is reflected, which gives the lively and realis-
tic appearance of the intact teeth. The little light penetration
frequently results in the loss of the esthetic vitality for the
restoration. This is a common phenomenon found when
restoring teeth with veneers, a type of restoration that covers
the entire labial tooth surface of very dark teeth (7 Chap. 17).
Even though the opaque material is used to mask the back-
ground dark color, the loss of esthetic vitality usually is a
result on little light penetration. The illusion of translucency
may be created to increase the realism of the restoration.
Color modifiers, also referred as tints, can be used to obtain
the translucency appearance, darken the shiny stains, or
characterize the restorations [31].
The enamel has a peculiar characteristic called opales-
cence, due to its similar optical characteristics of the opal
stone. When the enamel receives white light, which is a com-
bination of different wavelengths, it is capable to reflect the
shorter wavelengths, specially the blue, and transmit the lon-
ger wavelengths, such as the yellow and the red [1]. This is
due to the mineral structure of the enamel, where the min-
eral crystals with 0.02–0.04 μm of thickness, smaller than
some wavelengths of visible light, cause the selective reflec-
tion of the blue waves. The longer wavelengths, correspond-
ing to the red and orange colors, do not deviate from its track
and are completely transmitted through the enamel [1, 23].
Opalescence is a capacity of some materials to reflect
the shorter wavelengths of light, mainly the blue, and
transmit the longer wavelengths, such as the yellow and
the red, like the opal stone.
The tooth has anisotropic optical properties, which means
that its visual appearance changes depending on the angle of
view or the angle of illumination. . Figure  14.8a, b shows a
tooth that had its entire dentin removed illuminate from labial
or lingual direction. When a white light source was positioned
in front of the labial tooth surface, the light reflected by the
enamel gave a bluish color to the structure. On the other hand,
when the white light source was positioned behind of the
tooth structure, hitting the lingual surface, the transmitted
light gave an orange appearance to the tooth, due to the fact
that enamel only allowed the transmission of longer wave-
lengths. However, in the daily life, where light source is always
locate outside the mouth, the light that hits the labial surface
is filtered by the enamel before reaching the dentin, which
only receives the longer wavelengths. Mostly of this light is
absorbed by the dentin, and a certain part is reflected, which
returns through the enamel to the external surface. Thus, the
light that observer sees when looking to a tooth is the addition
of the blue light reflected by the enamel and the yellow and red
wavelengths reflected by the dentin.
Composite Restoration on Anterior Teeth
..      Fig. 14.9  Bluish aspect of the incisal edge due to the opalescent
enamel (opalescent halo)
In relation to the general color of the tooth structure, in
which the dentin tissue is present, the amount of blue light
reflected is small in relation to the longer wavelengths. For
this reason, the teeth are seen as a combination of reflected
light colors, which is mainly a mixture of yellow and red in
different ratios, resulting on an orange shade, together with a
small amount of blue from the opalescence. The opalescence
can be seen on the entire enamel, and it is not influenced by
the thickness [1]. The enamel opalescence increases the light-
ness of the tooth and creates effects of optical depth and vital-
ity [1]. However, when there is an evident translucent incisal
edge, without underlying dentin, a preponderance of the
shorter wave reflection occurs in this area, giving it a bluish
appearance, known as opalescent halo (. Fig. 14.9). There are
 
composites which are really opalescent and may be used to
restore the lost enamel, and they should be applied over the
entire labial tooth surface. However, when a opalescent com-
posite is not available, the incisal edge with its characteristic
appearance can also be recreated with a color modifier with
bluish shade, covered by a highly translucent composite, even
though this composite is not really opalescent by itself [1].
On the other hand, some people have the dentin on the
tip of the developmental lobes of anterior teeth with intense
white opaque shade. This does the dentin in this area to have
higher light reflection capacity than the rest of the tooth.
Therefore, in this specific region, the reflection of yellow and
red light which crossed the enamel and hit the dentin will be
higher, resulting in an orange appearance  to the area
(. Fig.  14.10a–d). This phenomenon is called counter-­
 
opalescence. In . Fig.  14.11, clinical aspect of the counter-­
 
opalescence can be observed.
In . Fig. 14.12a–c, the counter-opalescence phenomenon
 
can be reproduced with some naturally opalescent compos-
ites, changing the background color. To obtain this effect
during the restorative procedure on anterior teeth, the tip of
the dentin lobes can be restored with wither and opaque
composite than the rest of the dentin. Then, it is covered with
a highly translucent layer of naturally opalescent composite.
The light transmitted and filtered through the enamel shade
composite layer is reflected by the white dentin composite on
473 14
the tip of the lobes, creating the orange appearance on this
area [1]. When truly opalescent composites are not available,
the effect can be recreated with orange color modifiers, creat-
ing an illusion of counter-opalescence [1].
The way the light waves pass through the composite is dif-
ferent from the way they interact with the natural crystalline
mineral tooth structure. When the light hit the filler particles
of different sizes and shapes of a composite, its scattering hap-
pens on an uneven way. This creates on a higher light refrac-
tive index than enamel. Therefore, it is difficult to guess the
ideal thickness of the enamel shade composite layer  neces-
sary on the labial surface of a tooth to be restored, without
compromising the final translucency and lightness [1]. The
thickness of the enamel and dentin shade layers of a compos-
ite is one of the main factors that modulate the final esthetic
result. Very thin enamel shade layer can allow us to look
through the dentin too much, resulting in restorations more
saturated (higher chroma) and with smaller lightness (smaller
value). On the other hand, a very thick enamel shade layer
results in a monochromatic and grayish restoration. However,
the restoration of lost enamel with a composite, following to
the natural enamel thickness, results in an optical behavior
opposite to the natural tooth when enamel illuminated.
While for the natural enamel the increase of its thickness pro-
duces the increase of the lightness, thicker composite enamel
shade layers reduce the final lightness. When the enamel is
reconstructed with anatomic thickness, the higher refractive
index of the composite results on a low lightness restoration,
with grayish appearance [1]. To overcome this difference, the
enamel shade composite layer must have about one-third of
natural enamel thickness, increasing the thickness of the den-
tin shade composite, allowing to ­recreate the enamel light-
ness without compromising its translucency [1].
>> The thickness of the enamel and dentin shade layers of
a composite is one of the main factors that modulate
the final esthetic result of a restoration.
Another optical property of the tooth structure which influ-
ences the restorative procedure is the fluorescence. It is a phe-
nomenon of spontaneous emission of radiation by some
atoms and molecules inside the tooth structure composition,
being considered a kind of photoluminescence. The photolu-
minescence is the light emission from any form of matter
after the absorption of photons. It occurs when an atom
receives stimulation by light waves of a specific wavelength,
and this energy is absorbed. The electrons change the atomic
energy level from a ground energy state to a more external
level, entering in an excited energy state. This excited state is
unstable, and the electrons spontaneously come back to a
ground energy state, releasing the difference in energy
between the two states as a photon of light, generally with a
wavelength different from the one that first exited the atoms.
There are two types of photoluminescence, named phospho-
rescence and fluorescence. The phosphorescence naturally
occurs in some mineral when the material is stimulated by a
light source. The energy is absorbed by the atoms, and a
phosphorescent light is generated and slowly released, even
 474 C. R. G. Torres and R. F. Zanatta
a b
c Opalescence
..      Fig. 14.10  Opalescence and counter-opalescence. a Whitish dentin
on the tip of the developmental lobes; b incidence of white light on
three different areas of the labial surface (1, incisal edge without
dentin; 2, tip of the whitish dentin lobules; 3, rest of the tooth
14 structure); c reflection of the blue light (shorter waves) by the enamel
..      Fig. 14.11  Clinical aspect of the counter-opalescence showing
orange areas on the incisal third of the labial surface, on both central
incisors
Opalescence
d Opalescence
on the three areas and transmission of the orange light (longer waves)
toward the dentin; d complete transmission of the yellow light through
the incisal edge without dentin (1) and reflection of the light by dentin,
more intense on the tip of the whitish lobules (2 – counter-opales-
cence) and less intense on the rest of the structure (3)
a b c
..      Fig. 14.12  Composite slabs placed over a white and black
background, showing the counter-opalescence over the white
background. a, c opalescent composites – over the white background,
they seem to be more yellow than over the black background; b
non-opalescent composite (the background has no inflence on its color)
Composite Restoration on Anterior Teeth
a b
..      Fig. 14.13  Patient with restoration with nonfluorescent materials. a under environmental light; b under ultraviolet light
after the end of the stimulation, making the object remains
glowing for a certain time. In case of the fluorescence, after
the energy from a light source is absorbed, the fluorescence
light generated is only emitted, while the object is still stimu-
lated by the light source.
Fluorescence is a phenomenon of spontaneous emission
of radiation by some atoms and molecules, consisting
on absorption of light in a certain wavelength (generally
UV) and emission in another, generally visible light.
A specific type of fluorescence can be noticed on the human
teeth after they are irradiated with ultraviolet light. This
wavelength is part of white light emitted by the sun, but it is
more evident on places illuminated with “black light,” gener-
ated by light bulbs that produce mainly ultraviolet light,
being used in nightclubs, theaters, stage, and as special
effects. This ultraviolet wavelength is almost invisible to bare
eye. However, when absorbed by the tooth structure, results
in the emission of visible light of whitish-blue color, which
does the tooth, appear brighter. Even though enamel and
dentin are fluorescent, this property is three times bigger on
the dentin than on the enamel. The enamel seems to act as a
filter, attenuating the intense fluorescent emissions that come
from the dentin [1, 43]. It is the result of the excitation of
some organic molecules specially located in the dentin, such
as the pyridinoline, thymine, and tryptophan. The fluores-
cence turns the natural teeth whiter and brighter under day-
light, seeming as they are internally illuminated.
Differently from natural teeth in which the dentin and
the enamel contribute to the final fluorescence emission, on
the composite restorations, the main responsible for this
effect is the superficial layer, despite the underlying layers
were or not restored with a fluorescent composite. It means
that a superficial layer with a nonfluorescent composite
blocks the emission of an underlying layer of fluorescent
material; and a superficial layer of fluorescent composite
gives fluorescence to the restoration when applied over
475 14
nonfluorescent composites. Therefore, it is a surface phe-
nomenon [1].
People with composite restoration made of nonfluores-
cent composites have its esthetics impaired on the places illu-
minated with black light, because the restorations become
evident as dark areas (. Fig.  14.13a, b). However, in an
attempt to simulate the dental fluorescence, some manufac-
turers to produced composites even more fluorescent that the
natural teeth, resulting in the opposite effect. The restora-
tions done with those materials appear brighter than the
teeth  under UV. This way is important that the composite
has fluorescence, but its intensity must be similar to the natu-
ral tooth structure (. Fig. 14.14a, b).
The DEJ is a thin partially mineralized layer, formed
mainly by collagen fibers. It works absorbing the forces
applied over the enamel, transmitting it to the dentin, playing
also an important role in the way the light is dispersed and
transmitted inside the tooth. The DEJ is a highly translucent
structure, of low refractive index, allowing all light that goes
through the enamel reaches the dentin. This contributes to
the feeling of depth and vitality of the natural teeth, and it is
important to the process of internal light diffusion and con-
trol of lightness. The reproduction of the DEJ on direct resto-
rations can be made with materials and techniques that allow
the same light interaction and optical results. A thin layer of a
flowable composite specially developed for this purpose can
be used (Glass Connector, Micerium), applied on the labial
surface in a thin layer between the dentin shade, composite
previously light-cured, and the enamel shade layer, increasing
the light diffusion and the lightness of the restoration [1].
The color of the natural teeth is something dynamic. It is
influenced by the incident light, topographical anatomy, and
hydration condition of the tooth structure, besides the indi-
vidual optical properties of enamel and dentin. Therefore, it
is not enough to understand the concept of the three-color
dimensions, but also its interaction with the translucency,
opalescence, counter-opalescence, fluorescence, and superfi-
cial enamel texture [1]. An important point when analyzing
tooth color is the fact that it is a polychromatic structure. As
the color observed is a result from the interaction of the light
 476 C. R. G. Torres and R. F. Zanatta

a b

..      Fig. 14.14  Comparison between the fluorescence of several composites (specimens in disc shape) and a human tooth fragment. a Aspect
under day light; b aspect under ultraviolet light (“black light”)

a b

Cervical third

Medium third

Incisal third

14
..      Fig. 14.15  a Transverse cut of an upper central incisor crown showing the enamel and dentin thickness on each third; b clinical aspect of the
teeth with noticeable shade differences from cervical to the incisal area

with the enamel and dentin, the amount of each tissue and its
individual chromatic characteristics will result on a specific
shade. In fact, the tooth color is mainly determined by the
dentin and modified by the enamel.
>> The color of the natural teeth is influenced by the
incident light, topographical anatomy, and hydration
condition of the tooth structure, besides the individual
optical properties of enamel and dentin. Therefore, it is
not enough to understand the concept of the
three-color dimensions but also its interaction with the
translucency, opalescence, counter-opalescence,
fluorescence, and superficial enamel texture.
. Figure  14.15a, b shows that enamel and dentin thickness
 
vary according to the region on the crown, resulting on dif-
ferent shades depending on the location. On the incisal third
of the crow, there is more enamel than dentin, while toward
the cervical third, the amount of dentin increases and of
enamel decreases, resulting on a darker shade [31]. The den-
tin chroma increases from incisal edge toward the cervical
area and from DEJ toward the pulp [1]. Therefore, the incisal
third has a higher value and translucency than the cervical
third, while the middle third is a mixture of the incisal and
cervical shades [31]. The use of several composite shades
may be required to esthetically restore the teeth. The dentin
shade must be taken looking directly to the dentin, whenever
it is exposed, or in the cervical region of the tooth, where the
enamel is thinner and more translucent, which allows the
best comparison with the underlying dentin chroma. The
enamel shade of a composite can be better taken on the mid-
dle third of the tooth to be restored, where the thickness of
the enamel is larger  than in cervical area and there is less
influence of the chromaticity promoted by the dentin. Even
though the enamel translucency can be evaluated on the inci-
sal third, the absence of the underlying dentin structure and
the presence on the dark background of the mouth on this
region, may confuse the clinician and lead to the selection of
excessively translucent composite [1]. Although the teeth are
polychromatic, many may present a single shade from cervi-
cal margin up to the incisal edge [3].
Composite Restoration on Anterior Teeth
477 14

a b

c d

..      Fig. 14.16  Use of the VITA Classical shade guide. It can be noticed variation on the chroma and value for each hue. a VITA Classical shade
guide; b selection of hue (A, B or C); c simultaneous selection of the chroma and the value (1, 2 or 3); d selected shade (A1)

14.2.3  Shade Determination (. Fig. 14.16b). They are placed near the tooth, choosing the
 

one that most match the tooth color. Then the tabs of the
When performing a composite restoration, the first step is to chosen hue, with different chromas/values (1, 2, 3, 3.5, 4) are
select a restorative material with similar shade to the remaining placed close to the tooth, and the one that best match is
tooth structure and/or the adjacent teeth. The teeth shades selected (. Fig. 14.16c, d).
 

were classified by the restorative materials manufacturers on
specific categories, which represent the most common teeth
colors. Different types of shade guides were produced, related
to the shades of their respective products. At the beginning,
each composite brand had its own shade guide, which made
To improve accuracy of the shade selection process, the
VITA Company developed a new shade guide, in which each
color dimension is selected separately, namely VITA
Toothguide 3D-MASTER.  It uses a dichotomic deci-
sion  method ( Yes/No or Better/Worse) (. Fig.  14.17a–i).  

more difficult for the dentists to move to another brand, because
they have to learn how to work and recognize the new shades.
However, with the time, most of the dental materials manufac-
tures started to match the shade of their product with the VITA
Classical shade guide (VITA, Bad Säckingen, Germany), devel-
First of all, the value is determined by selecting the one of the
lightness groups (0, 1, 2, 3, 4, and 5). For that, the upper
shade tabs are used (0M1, 1M1, 2M1, 3M1, 4M1, and 5M1)
by making a simple yes or no decision if they match the tooth
(. Fig.  14.17b, c). The selection should be started with the

oped for VITA ceramics. It presents four shade families that
differ according to the hue. The family A varies from reddish to
brownish, while the B varies from reddish to yellow. The C fam-
ily has grayish shades due to the smaller chroma. The D family
has the reddish-gray shades. The shades on each family vary
darkest group first. The second step consists on determining
the chroma. On the basis of the determined value level, the
middle hue group (M) is chosen, spreading the tabs out like a
fan. Then, one of the three shade samples (1, 2, or 3) is
selected (. Fig. 14.17d, e). Finally, the hue is selected looking

simultaneously according to the chroma and value, being clas- if the natural tooth is more reddish (R) or more yellowish (L)
sified by the numbers 1, 2, 3, 3.5, or 4 (. Fig. 14.16a).
 
as compared to the shade sample selected (. Fig. 14.17f–h).
 

To use the VITA Classical shade guide, first the hue Despite the efforts of the manufacturers to match the
should be selected (A, B, C or D). For that, shade tabs of dif- color of its direct restorative materials to the VITA shade
ferent hues but with the same chroma/value are selected guide, this last one is made of ceramic, with huge differences
 478 C. R. G. Torres and R. F. Zanatta

a b c

d e

14

f g

h i

..      Fig. 14.17  Use of the VITA Toothguide 3D-MASTER. a Shade guide; b, c selection of the value (group); d, e selection of chroma; f, g selection of
hue; h selected shade; i black and white image to confirm the value of the shade selected

in relation to composites, such as the presence of an organic c­ omposite to be used for the restoration. In addition, they
matrix. Therefore, this reproduction can never be exact [7]. should be kept hydrated by immersion in a water container,
The shade guides should rather  be made with the same because hydrated composites are always darker [1–3].
Composite Restoration on Anterior Teeth
a b
..      Fig. 14.18 Metamerism. a Shade determination of a natural tooth under environmental daylight; b natural tooth and shade tab under dental
light with halogen lamp
In order  to perform the shade determination using shade
guides, some basic principles must be followed. The first one
is to hold it at least at one arm’s length to the patient’s mouth.
To look the shade guide too close adversely affect the shade
selection. The teeth should be viewed along a line of sight per-
pendicular to the tooth surface. The shade tab should be
placed parallel to the tooth being matched and in the same
plane. The shade determination must be performed before the
rubber dam isolation, with the teeth clean and hydrated. It
must be done before the teeth undergoes any long drying
period, because the dehydration makes the teeth lighter, as the
result of the translucency reduction [31]. This way, if the shade
was correctly selected before the rubber dam isolation, imme-
diately after its removal, the restoration will appear darker
than the dehydrated tooth remaining. If the restoration shade
is similar to the dehydrated tooth remaining, it is probably
that the shade selection was incorrect and with the hydration,
after the contact with saliva, it will appear lighter [3]. The
complete hydration of the teeth may take several hours.
Another point is the color of the office room where the
shade determination is performed. The walls and other object
in dental office reflect the light in the wavelength correspond-
ing to its color. This will influence the color of the other
objects observed in the same room, such as the teeth. For this
reason, the walls, dental treatment unit and furniture must
have neutral colors. It is also important to ask the patients to
remove the red lipstick. If the patient is wearing colorful
clothes, it is advisable to cover them with a patient bib with a
neutral color, such as white or gray.
The observed color of objects depends on the characteris-
tics of incident light. If an object is illuminated with white
light, it will have a certain color, determined by its interaction
with the different wavelengths of this polychromatic illumi-
nant. This same object, when illuminated with another light
source which has the predominance of different wavelengths,
its final color can be different. This phenomenon is called
metamerism [31]. Each material interacts in a specific way
with the incident light from each light source. Therefore, the
color of objects with different compositions can change when
the illumination is modified. Two objects may have the same
479 14
color under a certain light source, but have very different
color under other illuminations. In the dental office, when
the teeth of a patient and a selected shade guide tab matching
its color are illuminated under natural sunlight they can
match perfectly [3]. However, when the same teeth and shade
tab are illuminated by an incandescent light bulb, such as the
one in most of the overhead chair lights, the teeth and the
shade tab atoms will not interact on the same way with the
incident light, because they are made by different materials.
This will result on different shades from those observed
under the natural light, making the initial shade determina-
tion to appear incorrect (. Fig.  14.18a, b). Therefore, the
shade taking must be performed under the natural light or
under artificial light that simulates the daylight (fluorescent
light bulb), because this is the illumination of the environ-
ment which they are exposed on most of their daily lives [31].
Another important point during the shade determination
is the fact that the dentist should not keep looking to the
teeth and shade guide for a long time. That must be done very
quickly. After about 30 s, the photoreceptor cells of retina
become saturated by the wavelengths reflected from the
teeth, creating a visual fatigue. That adversely affect the dis-
tinction of small differences on the shade from yellow to
orange range  observed on the tooth structure [31]. In case
that happened, it is convenient that the clinician relaxes the
eyes looking for a few seconds at an object of complementary
colors in relation to the teeth colors, such as the blue, violet,
or green [27, 31]. Blue is the complementary color of orange,
while violet is of yellow and green of red [31, 40]. When look-
ing at objects of complementary colors, the photoreceptor
cells of the eyes are recovered, increasing the sensitivity to
notice the small variations in yellow and orange [31]. Then,
the dentist can come back to the shade determination proce-
dure. Some clinicians ask the aid of the dental assistant as a
second opinion to help the shade match [31]. The shade
selected must be registered on the dental records of the
patient, as well as the composite brand that will be used [31].
If dental bleaching is planned on the patient’s treatment plan,
it must be performed before any restorative procedure with
composites [31].
 480 C. R. G. Torres and R. F. Zanatta

a b

c d

..      Fig. 14.19  Digital color image converted to black and white a, c color images; b, d the same images in black and white to evaluate the value
match between the shade guide and tooth

14 a b

..      Fig. 14.20  a VITA Easyshade spectrophotometer; b device being used

To evaluate the color match of the shade guide, besides value of the shade tab matches the tooth (. Fig.  14.19a–d).
 

other characteristics of the tooth, a photographic camera can
be used. The glossy areas can be eliminated through polarizing
filters, allowing observing more details of the inner dentin,
clearly identifying the translucent areas of enamel [2]. A digital
photography of the shade tab and the teeth can help to evaluate
Another possibility for shade determination is the use of intra-
oral spectrophotometers. They have the advantage of making
an objective color reading, without human interference, offer-
ing shade results according to the VITA Classical and
3D-MASTER shade guides (. Fig. 14.20a, b).

if the matching is correct. Using a photo editing software, the After the shade determination, a direct matching con-
image can be turned black and white, helping to evaluate if the firmation can be performed using the selected restorative
Composite Restoration on Anterior Teeth
a b
..      Fig. 14.21  a Composite portions without polymerization (to the left) and polymerized (to the right). a Palfique Estelite Sigma (Tokuyama); b
Z350 (3M/ESPE)
material. It is well-known that composites generally do not
perfectly reproduce the shade guides. This way, a small
portion of this material can be applied over the tooth to be
restored and light-cured, without previous adhesive appli-
cation, verifying if the selected shade was correct [31].
After that, the composite can be easily removed with an
exploratory probe [31]. It is important to light-cure the
materials because the composite shade slightly changes
after curing (. Fig. 14.21a, b) [2, 27]. A good polymeriza-
 
tion for the complete elimination of the camphorquinone
residues, responsible for this color changes, is necessary.
On the case of the teeth with several chromatic nuances, it
is possible to make a restoration mock-up, building the
entire restoration with the combination of shades and
opacities selected for the composites, without adhesive
application, evaluating if the final shade matching was
adequate [1–3, 27].
During the shade determination procedure, it must be
evaluated how translucent is the tooth enamel, verifying if it
will be required the use of a highly translucent composite
during the restoration. However, on older patients, its use is
generally not necessary [3]. Even though the shade determi-
nation is a very important step to obtain a good esthetic for a
restoration, this procedure by itself does not guarantee that a
perfect result will be obtained. The final shade of the restora-
tion is the result of the interaction between the color of the
background, if there is some remaining tooth structure, the
color of the dentin shade composite, and the color and trans-
lucency of the enamel shade composite applied over it.
. Figure 14.22a–d shows a shade guide simulation made with
actual composite, which allows to superimpose enamel shade
veneers over the dentin shade cores, being possible the color
analysis of various combinations. In . Fig.  14.22a, b, are
shown  different dentin shade cores covered by the same
enamel shade composite  venners, showing a different final
shade for each combination. In . Fig.  14.22c, d, are  shown
the same dentin shade cores covered by different enamel
shade composites  venners, creating different final shade
results.
481 14
Some manufactures produce actual shade guides following
the superimposition concept presented, in which are possible
to check the combination of enamel and dentin shade tabs. An
example is the Coltene Company, which named this method
as “nesting” shade selection (. Fig.  14.23a–c) because the
enamel shade tab has a veneer shape and nestle over the dentin
shade tab with a core shape. Using this shade guide is neces-
sary to place some water or glycerol between the veneer and
the core, creating an optical contact. That avoids possible
effects of light refraction at the transition and reveals the final
color, allowing the comparison with the tooth structure. If
there is no match, a different enamel or dentin shade can be
selected. The use of the same colors for enamel and dentin
shades, e.g., dentin A2 and enamel A2, results in the same final
color for the restoration, in this case, A2. However, as shown
in . Fig.  14.23a–c, when associating the dentin A1 with the
enamel A2, or the dentin A3.5 with the enamel A2, the final
color obtained will be intermediate between the original col-
ors. This must be considered when it is planned to combine
different colors for the enamel and dentin shades in a certain
restoration. The tooth color observed in the clinical exam
must match the resulting color of the shade’s combination.
Tip
In order to perform a good shade determination, the
following principles should be followed:
55 The dentin shade selection should be done taking the
shade tab close to some exposed dentin area,
whenever it is possible, or close to the cervical region
of the tooth.
55 The enamel shade of a composite can be better taken
on the middle third of the tooth to be restored.
55 The shade guides should be made with the same
composite to be used for the restoration and kept
hydrated by immersion in a water container.
55 The shade guide should be hold it at least one arm’s
length far from the patient’s mouth.
 482 C. R. G. Torres and R. F. Zanatta

14.3  Selection of Composite Resin

55 T he teeth should be viewed along a line of sight
perpendicular to the tooth surface.
After the shade determination is finished, the choice of the
55 The shade tab should be placed parallel to the tooth
kind of composite to be used on that particular restoration
being matched and in the same plane.
must to be performed. The first point to be evaluated is the
55 The shade determination must be performed before
stress level that the future restoration will undergo. In
the rubber dam isolation.
places where the restorations will not receive the direct
55 The walls and furniture of the dental office must
occlusal loads, such as on Class V and Class III prepara-
have neutral colors and the patient is asked to
tions without the involvement of the lingual surface, restor-
remove the red lipstick.
ative materials with inferior mechanical properties can be
55 If the patient is wearing colorful clothes, it is
used, such as the microfilled composites. However, if the
advisable to cover them with a bib with a neutral
restoration involves the lingual surface, on a contact area or
color, such as white or gray.
disocclusion guide, or even on restorations of the incisal
55 Shade taking must be performed quickly, under the
edge, it is necessary to use a stronger restorative material,
natural light or under artificial light that simulates
such as the hybrid, microhybrid, nanohybrid, or purely
the daylight.
nanofilled composites.
55 When taking too much time looking to the tooth to
Another point is the necessity of obtaining a high pol-
choose the right shade, it is convenient that the
ishing of the restoration surface. Mainly for those in the
clinician relaxes the eyes looking to an object blue,
cervical regions, the restorative material must be polished
violet, or green, for a few seconds, to recover the
until reaching a surface roughness similar to the natural
eyes from fatigue.
enamel, reducing biofilm deposition ang gingival inflam-
55 To confirm the shade selection, small amounts of
mation. For that, the microfilled, nanohybrid, purely nano-
composite can be applied and cured over the tooth
filled, or even microhybrid composites can be preferably
without adhesive, and mock-up restoration can be
used. The macrofilled and hybrid composites should be
performed.
avoided.

a b

14

c d

..      Fig. 14.22  Shade guide simulation allowing superimposition of enamel shade veneers over dentin shade cores. a, b Same enamel shade over
different dentin shades; c, d different enamel shades over the same dentin shade
Composite Restoration on Anterior Teeth
a b
..      Fig. 14.23  a Nesting shade guide of the Brilliant composite (Coltene) showing dentin shades on the left and enamel shades on the right; b, c
combination of the same type of enamel shade (A2) with different dentin shades (A1, A2, and A3.5) resulting on several final tones
Finally, an important point is the esthetic results pro-
vided by the material, which besides a proper color match,
must have translucency and gloss similar to the tooth
structure. It can be noticed that there are large differences
among the composites provided by different manufactur-
ers, mainly in relation to the optical properties. This way,
even if a correct shade determination has been performed,
the final esthetic outcome may not be adequate. In addi-
tion, certain brands may not have a composite that match
some specific patient’s tooth being restored. The clinician
must become familiar with the differences between the
products to be able to choose best alternative for each
patient. However, the composites that allow a better pol-
ishing have a higher chance to produce an adequate result.
The modern materials such as the microhybrid, nanohy-
brid, and nanofilled composites may allow these
required results.
14.4  I ndications of Composites on Anterior
Teeth
The composite restorations on anterior are indicated on
teeth that suffered carious or non-carious lesions, frac-
tures, or abnormal formation of the enamel. They can also
be indicated on teeth that require modifications due to its
shape, such as in the case of diastemas or peg-shaped teeth,
or due to its wrong position, such as rotated or inclined
teeth. The composite also can be applied on cases of teeth
with color alteration that could not be properly bleached,
when labial surface can be completely covered by the
restorative material to improve the esthetics of the
smile (see 7 Chap. 17).
 
As can be observed for all restorative materials, the com-
posites also do not show a good behavior in patients with
poor oral hygiene. The acids produced by the bacteria attack
the organic composite matrix, resulting in the softening of
the material, increasing its wear and premature staining.
Patients with parafunctional activities such as bruxism,
clenching, nail biting, and pencil chewing must be alerted
about the possibility of fractures or displacement of the resto-
ration. The excessive and cyclic  loads applied over the
483 14
c
restored teeth can generate fatigue of the restorative material,
resulting in fracture and/or displacement of the restora-
tion. The parafunctional habits must be treated, and, in some
cases, the use of an occlusal splint for an indefinite period of
time is necessary to protect the teeth and the restoration. The
smoking habit also causes premature staining of the restora-
tions, which will need to be often repolished to maintain the
good esthetic result. In the same way, deleterious eating hab-
its such as high intake of acidic food and drinks, as well as
food colorings agents  and alcohollic beverages, will also
result in the degradation of the organic matrix of the com-
posite.
Even though most composites allow a good polishing of
its surface, tooth preparations with cavosurface margins
inside the crevice represent a great challenge. First of all,
there is a difficulty to obtain proper isolation of the operat-
ing field, which may result in the contamination of the
preparation with the fluid from the gingival sulcus, blood,
or saliva. It is known that the adhesive procedure can only
be performed in a completely clean and dry preparation;
otherwise, the bonding to the tooth structure will fail [31].
In addition, in some cases, there is no enamel on the gingi-
val cavosurface angle. As the bonding to the dentin margin
is more difficult and less predictable than to enamel, more
marginal gaps can occur, increasing the microleakage and
the probability of secondary caries. Other than that, the dif-
ficulty to proper finish and polish the restoration margin
may result in the presence of overhangs or rough surfaces
that increase the biofilm deposition and cause constant gin-
gival inflammation.
The composite restorations are also indicated as part of
the treatment for the non-carious lesions of erosive tooth
wear, abrasion, or abfraction. The restorations are indicated
when the lesion is active and no success was obtained on the
attempts to interrupt its progression; the structural integrity
of tooth is threatened or there is a risk of pulpal exposure; the
structural defect is unacceptable on the esthetic point of
view; the dentin is hypersensitive and the sensitivity was not
reduced with the non-restorative treatment; or there are cari-
ous lesions associated [3]. Besides several other advantages,
the restorations decrease the rate of progression or even
arrest the structural loss process.
 484 C. R. G. Torres and R. F. Zanatta
a b
..      Fig. 14.24  a, b, c Pictures taken from different angles showing several topographical details of the surface that should be reproduced, such as
sulcus and lobes
a b
..      Fig. 14.25  a, b Translucent incisal edge and opaque halo (arrows)
14.5  Esthetic Analysis of Anterior Teeth
14 In 7 Chap. 1, several factors related with the smile esthetics
were discussed, based on the relations among the group of
teeth forming the dental arch and the positions of the lips
and gingiva. In the following sentences, aspects related to
tooth units alone will be discussed, which is important for
the proper restoration of the lost tooth structure.
According to Baratieri et al. [2], the hands are capable to
reproduce just what the eyes were able to see. In other words,
when trying to restore a tooth, it is important that the dentist is
capable to identify their multiple and complex anatomical
details. Therefore, a comprehensive  esthetic analysis of the
damaged tooth must be performed before performing a resto-
ration.  The contralateral tooth can  be used as a reference  to
guide the restoration of the lost tooth structure. The first strat-
egy for that is to observe the tooth from several angles, allow-
ing that all topographical details can be noticed
(. Fig. 14.24a–c). The restored areas on the teeth must reflect
 
the light in a similar manner to the intact adjacent surface [31].
14.5.1  Enamel Translucency
The translucency of the dental enamel must be evaluated
before performing a composite restoration. The anterior
teeth of many patients, mainly the younger ones, present a
c
translucent incisal edge that must be reproduced in the
composite restoration (. Fig.  14.25a, b). An opaque halo
can also be observed, which is an optical phenomenon pro-
duced by the changes in the enamel prism direction. The
halo thickness, contour, and proximal extensions can vary
from tooth to tooth [1]. The opaque halo effect is produced
by the total reflection of the light, because angle of inci-
dence is greater than the limiting angle of the enamel, that
is, 37° [2]. When the teeth are hydrated, the light refraction
is changed in relation to when they are dried, reducing the
thickness of the opaque halo and increasing the enamel
translucency [1].
14.5.2  Morphology of the Incisal Edge
The newly erupted anterior teeth have an irregular contour of
the incisal edge due to the presence of mamelons, which are
three-rounded protuberances formed by the developmental
lobes, separated by grooves, which can be compared with the
shape of the fleur-de-lis (. Fig. 14.26a, b). On patients with a
very translucent incisal edge, the contour of the dentin mam-
elons can be observed through the enamel (. Fig. 14.27a, b).
To improve its visualization, a digital photograph of the ante-
rior teeth can be obtained and manipulated in image editing
software, increasing its saturation (. Fig.  14.27b).  
. Figures  14.28a–d, 14.29a–d, and 14.30a–d show extracted
Composite Restoration on Anterior Teeth
485 14

a b

..      Fig. 14.26  a, b Incisal edge contour with shape of the fleur-de-lis (arrows)

a b

..      Fig. 14.27  a Demarcation of the lobes seen through the translucent incisal edge; b to increase the saturation of a digital picture allows better
observation of the dentin lobes

a b

..      Fig. 14.28  Outer and inner morphology of an upper central incisor. a, c With enamel; b, d enamel completely dissolved by immersion in the
acid solution, allowing dentin visualization

intact upper anterior teeth before and after its complete structure. With this technique, the outer morphology of the
demineralization, through the immersion of an acidic solu- enamel and the inner morphology of the dentin can be com-
tion for some days, remaining only its collagenous dentin pared, allowing a direct view of the dentin lobes.
 486 C. R. G. Torres and R. F. Zanatta

c d

..      Fig. 14.28 (continued)

a b

14 c d

..      Fig. 14.29  Outer and inner morphology of an upper lateral incisor. a, c With enamel; b, d enamel completely dissolved by immersion in acid
solution, allowing dentin visualization

14.5.3  Surface Texture
The surface texture of natural teeth is composite by macro-
and microtexture. The macrotextures are represented by the
depressions and elevations found on the enamel surface. On
the labial surface of an upper central incisor, the macrotex-
ture is generally characterized of three vertical lobes sepa-
rated by two grooves (. Fig. 14.31a, b). The macrotexture is
responsible for the areas of light reflection creating the relief
sensation of the surface. The visual impact and the dimen-
sion perception of width and length come from the interac-
tion of the light with those areas, which is reflected in the
more elevated areas on the surface topography [1].
The microtexture is created by the perikymata, which are
incremental growth lines in youthful teeth that appear on the
surface of enamel as a series of transverse parallel grooves,
Composite Restoration on Anterior Teeth
487 14

a b

c d

..      Fig. 14.30  Outer and inner morphology of an upper canine. a, c With enamel; b, d enamel completely dissolved by immersion in the acid
solution, allowing dentin visualization

a b

..      Fig. 14.31  a, b Macrotexture. Demarcation of grooves between the developmental lobes on the labial surface (lines)

affecting the light reflection and the lightness of a tooth, cre-
ating areas of light and shadows that give movement sensa-
tion. On young patients, the perikymata create a very
irregular surface. However, due to the enamel wear with the
years, the tooth surface becomes smoother, and the periky-
mata disappear (. Fig. 14.32a, b). For a better observation of
 
the surface details during the clinical exam, it is recom-
mended to place the index finger on the cervical region of the
teeth, creating shadows that better reveals the morphology
[2]. To obtain good esthetic results with composite restora-
tions, it is essential that the texture details are properly repro-
duced.
When the macro- and microtexture are recreated, with
glossy and light-reflecting areas, the lightness can be manip-
ulated and indirectly decrease or increase the translucency
of the restoration. A rough and irregular surface, rich in
 488 C. R. G. Torres and R. F. Zanatta
a b
..      Fig. 14.32 Microtexture. a Young patient’s teeth showing the transversal lines corresponding to the perikymata; b middle-aged adult patient
showing smooth labial surfaces
microtexture, reduces the tooth lightness but increases the
translucency, reducing the gloss and interfering with the
chromatic perception. A well-polished surface becomes less
translucent, reflects more light, and increases the lightness
[1]. The understanding about the relation between the
macro- and microtextures over the reflection and dispersion
of the light, as well as its influence on the lightness and
translucency of the restoration, is essential when perform-
ing the finishing and polishing procedures [1]. During the
esthetic analysis of the tooth to be restored and the neighbor
teeth, its shape and dimensions must be analyzed, as will be
mentioned further on, as well as the size and shape of the
incisal embrasures, according to what was described in
7 Chap. 1 (. Fig. 1.11a–d) [3].
   
14
14.5.4  Dental Dimensions and Proportions
The dental dimensions and clinical crown width-to-length
ratios, part of what is called microesthetics, have a large
influence on the esthetic of the smile. The presence of dispro-
portion on dimensions may be corrected in some cases
through a restorative treatment or periodontal surgery. The
length of the clinical crown on anterior teeth is the distance
between the incisal edge and the gingival margin. For some
individuals, the teeth may clinically seem to be shorter than
the anatomical crowns really are, because the gingival margin
is more coronal to the cementoenamel junction (CEJ) than
the ideal, due to an altered passive eruption [14]. On older
adults, it is expected the abrasion on the incisal edges, which
also causes the shortening of the clinical crown. In some
cases, the reduction of the teeth length due to the wear is
compensated by the gingival recession due to a gradual
reduction of the periodontal support [14].
Most of the studies about the dental proportion con-
cluded that the width of esthetically harmonic upper central
incisor corresponds to about 80% of its length, with varia-
tions between 75% and 85% (. Fig. 14.33a–f) [14, 37]. This
 
width-to-length ratio distinguishes its characteristic shape.
The length of the upper central incisor range between 10.4
and 11.3 mm and the width between 8.3 and 9.3 mm. Men,
generally, have incisors with a larger width than women,
while women generally have a clinical crowns with a shorter
length than men [14, 37]. The central incisors present a dom-
inance on the final aspect of the smile. A key point for esthetic
smile is the symmetry of those teeth that generally present
the same shape and size, as a specular image, even though in
nature it is hard to find those teeth perfectly identical, which
occurs in only 14% of the cases. The asymmetry is common
both on the width and on the length, although discreet differ-
ences are not noticed. However, discrepancies on the width
and length larger than 0.3 mm will be easily noticed by the
observers and may be convenient some kind of correction
[14]. The dimensions of the upper incisors also have a rela-
tion with the dimensions of the lower incisors. The width of
the upper central incisor corresponds to approximately the
width of the lower central incisor added to half the width of
the lower lateral incisor [25].
>> The width of esthetically harmonic upper central
incisor corresponds to about 80% of its length, with
variations between 75% and 85%.
The upper lateral incisors have the shape and contour similar
to the central incisors, although with a smaller width of about
2–3  mm [37]. The length of the crown is about 1–1.5  mm
shorter (approximately 20%) than the central incisors. The
differences of size and position between the lateral incisors
may be very large, not only from one person to another but
also inside the same mouth. The variations found in size of
those teeth allow that, if necessary, small changes in the
length and width can be performed in one or both teeth,
because it will hardly be noticed by the observers, since the
small differences are frequent on nature [14, 35]. On the
other hand, the presence of diastema may significantly
adversely affect the esthetics of the smile, requiring its closing
by means of an adhesive restoration, as will be discussed fur-
ther in this chapter.
Composite Restoration on Anterior Teeth
489 14

a b

c d

e f

..      Fig. 14.33  Width-to-length ratio (R) of the central incisors (W-width, L-length). a, b Teeth with normal proportions; c, d excessively long teeth;
e, f excessively short teeth

Tip
The variations found in size of lateral incisor allow that
small changes, in the length and width, can be
performed in one or both teeth using composite,
because it will hardly be noticed by the observers, since
the small differences are frequent on nature.
The upper canines are about 1–1.5 mm smaller in width than
the central incisors, even though having a similar length,
with a variation of only 0.5 mm [37]. They also have varia-
tions in the morphology. In some people, they have a sinuous
shape, with a sharp point that gives them a vigorous appear-
ance, while sometimes they are particularly round and deli-
cate. Their gingival zenith and the tips of the cusp are
generally not perfectly aligned to the horizontal plane. Its
faciolingual position is also asymmetric, and it may cause
disharmony on the progression of the inter-incisor angle or
incisal embrasures [14].
The analysis of the width-to-length ratio of the anterior
teeth may be performed directly in the mouth, using a bow
 490 C. R. G. Torres and R. F. Zanatta

compass with two needle points positioned on the teeth,
which is then placed over a ruler to measure the distances in
millimeters, or using calipers. The mathematical calculations
may be performed obtaining the proportions. However, this
process takes time and is preferred to be performed on a
study model. An alternative to simplify this procedure is to
use the proportion gauge developed by the professor Stephen
J. Chu, marketed by the name of Chu’s Aesthetic Gauge (Hu-­
Friedy) (. Fig.  14.34a). The complete set of instruments
 
includes a proportion gauge to measure the proportions of
the crown; a crown lengthening gauge to evaluate the need
for lengthening of the clinical crowns, due to discrepancies of
the gingival margin position by means of periodontal sur-
gery; and a special calibrated periodontal probe or sounding
gauge to verify the position of the alveolar bone crest in rela-
tion to the gingival margin.
The proportion gauge allows a fast diagnosis of the dis-
crepancy on the width-to-length ratio of the clinical crown,
directly inside the mouth through on a visual color-coded
system. One end of the instrument has a T-bar tip with

a b

c d

14

e f

..      Fig. 14.34  a Chu’s Aesthetic Gauge (T-bar and in-line tips); b e width and length of the lateral incisor in relation to the blue band; f width
width-to-length ratio on the T-bar; c intraoral analysis of the upper and length of the upper canines in relation to the yellow band; g width-to-
anterior teeth proportions; d analysis of width and length of the central length ratio on the in-line tip; h measurement of the crown length with
incisor in relation to the red bands on the horizontal and vertical arms; in-line tip; i measurement of the crown width with in-line tip
Composite Restoration on Anterior Teeth
g h
..      Fig. 14.34 (continued)
vertical and horizontal arms to measure length and width
at the same time, being used for teeth with normal align-
ment. The opposite end has an in-line tip with short and
long parallel arms, helping to measure the length and
width independently, in cases of crooked or crowded teeth
where the use of the T-bar tip may be difficult (. Fig.  
13.34a). Both tips have a predetermined ratio of about
78%, which is an average value for the population.
The T-bar tip has a vertical arm, a horizontal arm, and an
incisal guide. It is placed on the labial surface of the tooth,
with the vertical arm parallel to the long axis of the teeth, on
the central region of the crown, and the incisal guide touch-
ing the the incial edge. The vertical arm is used to measure
the length of the crown, while the horizontal one measures
its width. The instrument is made with a yellow material that
contains blue, red, and black color bands. A particular color
band on the vertical arm corresponds to the same color band
on the horizontal arm, helping to ensure that the tooth is in
proportion.
The most common width/length dimensions for the
upper central incisors (8.5/11 mm) correspond to the exter-
nal ends of the red bands (. Fig. 14.34b). The most common
 
dimensions for a lateral incisor (6.5/8.5 mm) correspond to
the external ends of the blue bands, while the average values
for the upper canines (7.5/9.5 mm) correspond to the exter-
nal ends of the yellow bands. In . Fig. 14.34b, f, the dimen-
 
491 14
sion corresponding to each band on the T-bar tip and in-line
bar tip can be observed. The measurements must begin on
the central incisor, looking for which size ranges the other
teeth must be evaluated (common, small, large, or extra-­
large), passing to the lateral incisor and then to the canine
(. Fig. 14.34c–f). This way, it can be known if the width -to-­
length ratio of each tooth is correct, as well to know if the
teeth have compatible sizes.
On the case of small teeth, the measurement of the crown
length will move downward (one full band) and the width
toward the center (one full band) of the most common mea-
surements. On this case, the measurement of the central inci-
sor begins on the internal part of the red band, while the
canine will start on the external end of the blue band and the
lateral incisor on the internal end of the blue band. In large
teeth, the measurement will move one band upward and out-
ward, while the extra-large ones will move two bands.
The in-line tip is designed to measure, independently,
the length of the teeth with the longer arm and the width
with the shorter arm, on the cases where the T-bar may
not be used (. Fig. 14.34h–i). It works in the same way that
the T-bar tip does, except by the fact that the horizontal
arm on T-bar becomes the short arm of the in-line tip. For
its use, first, the length of the central incisor must be mea-
sured, aligning the tool with the long axis of the dental
crown (. Fig. 14.34h). To start the measurement, the inci-
 492 C. R. G. Torres and R. F. Zanatta
sal guide, which is the first black band, must be placed on
the incisal edge as the starting reference to measure the
length. To measure the width of the crown, the short arm
must be aligned perpendicularly to the long axis of the
tooth parallel to the incisal edge (. Fig. 14.34i). The mea-
 
surements of the lateral incisor and canine are done in the
same way.
14.6  Restorative Technique
14.6.1  Previous Clinical Procedures
The first clinical step is the pre-procedural antisepsis of the
patient’s oral cavity, using a chlorhexidine digluconate solu-
tion or another type of antiseptic mouthwash. The patient is
asked to swish it in mouth for 30 s. The use of an antiseptic
mouth rinse reduces drastically the emission of the contam-
inated particles to the surrounding atmosphere, during the
use of a high-speed handpiece, helping to protect the dental
health-care workers of infections by pathogenic bacteria,
viruses, and fungi. A radiographic examination can also be
performed to analyze the lesion depth and evaluate if there
is any pathological periapical radiographic change. If the
lesion depth is shallow or medium and there are no periapi-
cal changes, the local dental anesthesia can be performed. If
the lesion is large and deep and there is doubt if the pulp has
turned necrotic or not, the sensitivity thermal testing must
be performed. In the absence of painful response after the
application of the thermal stimulus, the test cavity prepara-
tion can be done, starting the tooth preparation without
anesthesia, to evaluate if there is any painful response. If the
14 tooth has a painful response to the test cavity, the anesthesia
of the area should be performed. If the pulp has turned
necrotic and endodontic treatment is necessary, it must be
provided before the restoration is started. However, on the
cases where the esthetic re-establishment cannot be post-
poned, the restoration may be  done  first, followed by the
root canal access cavity preparation to start the endodontic
treatment.
In case the tooth is covered by biofilm or extrinsic stains,
a prophylaxis must be performed with pumice or prophylac-
tic paste without fluoride and brush, or with a prophy-jet
device, which uses pressurized slurry of sodium bicarbon-
ate or glicine powder, taking care not to injure the gingival
tissue leading to bleeding. After choosing the kind of com-
posite to be use, performing the shade determination, the
esthetic analysis of the tooth to be restored and of the adja-
cent teeth, the occlusion evaluation must be performed with
a thin double-sided two colors articulating paper (e.g., red
and black), allowing a two-tone representation of static and
dynamic occlusion. The first step is to inspect the eccentric
contacts (dynamic occlusion). The paper is placed on the
Miller articulating paper forceps, in a way that the red side is
facing the tooth to be restored. The patient is asked that to
occlude at centric occlusion (CO) and do protrusive and lat-
eral excursive movements. The patient must open the mouth
and the presence of interferences during disocclusion move-
ments be analyzed. After that, the paper is then turned in the
forceps in a way that the black side faces the tooth to be
restored. The concentric contact (static occlusion) is ana-
lyzed, asking the patient to close the mouth in CO and open
it again. The color sequence can, of course, be altered.
Whenever possible, the tooth-to-tooth contacts occurring
during CO should not be included in the preparation out-
line, remaining over the intact tooth structure. In case it is
not possible, care must be taken so that it will not be located
over the tooth-restoration interface. It must be verified
which teeth participate of the disocclusion guides, avoiding
its modification when guides are working properly.
Sometimes eccentric interferences can occur and should be
evaluated and adjusted. The presence of wear facets must be
verified, which indicates the presence of intense contacts on
that area [3].
14.6.2  Tooth Preparation
In case of a caries lesion located on the proximal surface,
without affecting the enamel on the labial or lingual surfaces,
it is necessary to choose the most convenient entry direction,
which can be the labial, lingual, or strictly proximal approach.
The proximal approach should be chosen every time is pos-
sible, because it promotes the maximum preservation of the
healthy remaining tooth structure. It can be performed in the
absence of adjacent teeth, when there are lesions on both
adjacent tooth surfaces, in a way that the entry may happen
through the preparation on the neighboring tooth. It is also
possible on cases of wrong positioning of the tooth or pres-
ence of diastemas, or even when the adjacent tooth has some
type of restoration or temporary crown that can be removed
(. Fig. 14.45a–l) [3].
Another option is to perform a dental separation. It can
be done in two different ways (rapid and slow separation).
The rapid or immediate separation uses mechanical separa-
tors which employ the wedge principle, such as the Elliot or
Ivory (. Fig. 3.47a–c).  On those cases, only a topical anes-
thetic should be used on the interdental papilla on the way to
reduce the painful sensation. The separation procedure must
be performed slowly, considering the sensitivity reported by
the patient. The injection of an anesthetic before the separa-
tion eliminates completely the sensitivity, increasing the
chances to harm the periodontal tissue. After the separation
is complete, obtaining the necessary access to the lesion,
anesthesia should be performed before the tooth prepara-
tion. However, the patient discomfort and the chances of
injuries to the periodontium have reduced the use of this
technique. The slow or delayed separation technique is less
traumatic. On this technique, the orthodontic elastic tooth
separator (rubber rings of different thickness  as shown on
. Fig.  3.48) is stretched with two pieces of dental floss and
applied between the teeth, remaining for 1 or 2 days before
the restoration. The ring must surround the contact area. If
the ring is breaking during the application, the teeth can be
Composite Restoration on Anterior Teeth
slightly separated with a wooden wedge and the region lubri-
cated with a water-soluble glycerin gel, so the rubber can
slide easily. It may be required, when the patient return on
the next appointment, to replace the ring for a thicker one to
be able to reach the necessary direct access to the proximal
area [2, 3]. After this period the rubber ring is removed, the
isolation of the operating field is performed, and a wedge is
applied to maintain the space obtained. Then, a conservative
tooth preparation and the restorative procedure are per-
formed.
When the gingival border of the caries lesion is subgingi-
vally located, a wooden wedge should be placed between the
teeth to protect the gingiva during the tooth preparation. In
case the rubber dam isolation has been previously applied,
the wedge will also protect the rubber sheet [31]. If the prox-
imal contact was removed during the preparation, the wedge
will promote an additional dental separation to compensate
the thickness of the matrix band and help the restore of the
contact point [31]. It must be inserted through the larger
embrasure. If the wedge is going to be applied after the rub-
ber dam isolation, the sheet must be stretched with the tip of
the finger, first pressing firmly the rubber and the underlying
soft tissues and then pulling the rubber and moving it far
from the tooth. The wedge is inserted and the rubber is
released (. Fig. 14.48b) [31].
 
After obtaining access to enter the lesion, the carious tis-
sue must be removed preserving the maximum of the healthy
remaining tooth structure possible. The entry must be per-
formed with a round diamond point in a high-speed hand-
piece. The carious dentin tissue is removed using a round
bur, of largest diameter possible, compatible with the prepa-
ration size, in a low-speed handpiece, or using dentin spoons
of adequate size [31]. The final preparation dimensions are
usually determined by the size, shape, and location of the
lesion, as well as the necessary extension to obtain access to
visualize the walls and use the instruments [31]. The prepara-
tion must be restricted to the removal of the carious tissue in
the most conservative way. On the case of proximal entry
approach, no bevels on the margins are necessary because
there is no esthetic commitment.
>> The tooth preparation is restricted to the removal of
the carious tissue in the most conservative way. The
final dimensions are determined by the size, shape,
and location of the lesion, as well as the necessary
extension to obtain access to the walls.
In case it is not possible to perform a dental separation, and
the lesion is restricted to the proximal surface, the lingual
entry approach should be chosen, preserving the labial
enamel, even if undermined, to guarantee good esthetic
results for not exposing the composite to visible areas. As the
indirect vision is frequently necessary, a first surface reflec-
tion, clean and without scratches mirror must be used, allow-
ing a clear view and without distortions [31]. Sometimes, on
the upper arch, the direct vision may be obtained leaning the
patient’s head backward, according to what is describe in
7 Chap. 2 (. Fig. 2.13a) [31].
   
493 14
Before touching the tooth, the rotary instrument is
positioned and activated on high speed with an air/water
spray. The assistant directs the airstream from the air/water
syringe toward the mirror and places the saliva ejector (SE)
next to the operating field. The ideal is the use of high-vol-
ume evacuator (HVE) with a plastic tip with beveled end,
placed close to the tooth surface (. Fig. 7.49a). The adja-
cent tooth must be protected with a steel matrix band. The
initial opening must be performed in the correct inciso-
gingival position of the lesion center, as close as possible to
the adjacent tooth, without touching it. The rotary instru-
ment is held perpendicular to the enamel surface, in a
mesiodistal angle that places the neck of the instrument
almost touching the adjacent tooth, in the region of the
embrasure. It is directed toward the lesion until feeling the
sensation of falling in a hollow space, which means that the
lesion was reached (. Fig.  14.35a–d) [3]. Incorrect entry
overextends the lingual outline to stress areas, such as the
marginal ridges, unnecessarily weakening the tooth. The
outline of the preparation must be the most conservative as
possible, as sometimes smaller than the internal dimen-
sions of the preparation (. Fig. 14.36a–f). The same instru-
ment is used to enlarge the opening only enough for caries
removal and convenience form, while establishing initial
axial wall depth. Using pendular movements, the carious
tissue is removed without increasing the opening size [3,
31]. Unless it is extremely necessary to remove the carious
tissue, the preparation should not include the contact area,
extended to the labial surface or subgingivally [31]. On the
case of lingual entry approach, no bevel on the margins is
recommended because no esthetic commitment occurs. In
addition, the bevel may extend the restoration margins
toward the centric contact areas or undergoes heavy masti-
catory forces, increasing the wear and susceptibility of
fracture [3].
The labial entry approach should be used when: the cari-
ous lesion has already reached and destroyed the enamel on
the labial surface; the labial surface was  destroyed and the
lingual surface is intact; both labial and lingual surfaces were
affected there is an faulty restoration on the labial surface;
there is an irregular alignment of the tooth or facial position-
ing of the lesion and  the lingual approach would require
excessive cutting of the tooth structure [3, 31]. The procedure
is simpler because the direct vision can be used and the lesion
or inadequate restoration are generally larger [31]. The open-
ing of preparation has to allow the correct removal of the
carious tissue but in the most conservative way possible.
When there are two adjacent lesions to be treated on con-
tiguous teeth, many times  one of them is larger than the
other. When the preparation of the larger lesion is performed
first, the preparation of the smaller lesion  can generally be
even more conservative, due to the improved access provided
by the larger preparation (. Fig.  14.48a–g). The opposite
sequence must be followed when the material is applied dur-
ing the restorative procedure, i.e. the smaller preparation is
restored first [31]. After the anesthesia, the preparation can
be done  before or after the rubber dam isolation. In both
 494 C. R. G. Torres and R. F. Zanatta
a b
c d
..      Fig. 14.35  Entry direction for preparation opening (incisal view of
extracted teeth assembled and cross sectioned to show the lesion and
illustrate the procedure). a Incorrect entry position; b, c correct entry
14 cases, a wedge should be placed on the interproximal space to
retract the rubber dam and the gingival papilla, improving
the access to the gingival margin of the lesion [31]. The entry
is performed with a round diamond point in a high-speed
handpiece, and the carious dentin tissue is removed with a
round carbide bur in a low-speed handpiece [31]. The tip of
an exploratory probe must carefully inspect the DEJ to detect
the presence of remaining carious tissue [31]. The removal of
the carious tissue must start on the surrounding walls, reduc-
ing the contamination of the preparation, finishing on the
axial wall. This way, if an accidental pulp exposure occurs,
the risk of contamination of the pulpal tissue is reduced. The
undermined enamel may remain since it will be reinforced
by the adhesive restoration [31].
Tip
When there are two adjacent lesions to be treated on
contiguous teeth, the preparation of the larger one is
performed first, which allows the second
preparation to be more conservative due to the
improved access. The opposite sequence should be
followed when the material is applied during the
restorative procedure.
direction; d cross section of the finished preparation preserving the
marginal ridge
Tip
The removal of the carious tissue must start on the
surrounding walls, reducing the contamination of the
preparation, finishing on the axial wall. This way, if an
accidental pulp exposure occurs, the risk of
contamination of the pulpal tissue is reduced. The
undermined enamel may remain since it will be
reinforced by the adhesive restoration.
Due to the important esthetic requirement on the labial sur-
face and the difficulty to mask a butt joint restoration margin,
a bevel can be prepared only on the cavosurface angle on the
facial tooth surface. The main purpose of this procedure is to
help masking the interface between the restoration and the
remaining tooth structure. It is a small cut performed on the
cavosurface angle on a 45° with the external surface, using a
conical, flame, needle, or round-shaped diamond point in
high speed, with an average width of 0.25–0.5 mm or larger
[3, 31]. The marginal bevel creates a progressive transition
between the restorative material and the tooth structure,
helping to mask the restoration and improve the esthetics
[31]. The larger the bevel width, the more likely is to obtain
an excellence esthetic result.
Composite Restoration on Anterior Teeth
495 14

a b

c d

e f

..      Fig. 14.36  Correct entry direction for opening the preparation surface; b access to the lesion; c, d pendular movements to produce
from lingual approach (proximal view of an extracted tooth used to the proximal outline; e removal of carious tissue with a round bur in
illustrate the procedure). a Correct entry angle in relation to the lingual low-speed handpiece; f preparation finished

When composite materials started to be used to restore
anterior teeth, the bonding to the tooth structure was
restricted to the enamel tissue. Due to its many advantages,
the bevel used to be always indicated on the entire enamel
cavosurface angle of the preparation on those days. It increases
the bonding area, improving the retention and the marginal
sealing of the restoration; exposes a more reactive enamel
which improves the quality of the acid etching; and cuts the
prism transversally to create a better end-on etching pattern
than when the prisms are etched sideways [3, 31]. The bevel
also removes the prismless enamel layer, providing more
micromechanical retention. However, more effective bonding
agents are available nowadays, for both enamel and dentin tis-
sues, and the retention does not depend only on bonding to
enamel. Therefore, it is no longer recommended to perform
the bevel on the whole cavosurface angle. In addition, the
bevel requires an extra cut of the tooth structure and makes
the preparation procedure more aggressive. Considering that
the restoration will probably fail after some year and will be
replaced, the most conservative preparation is desirable. This
way the bevel is currently only recommended on regions
where the esthetic is fundamental, such as in facial surfaces.
 496 C. R. G. Torres and R. F. Zanatta
Some authors just contraindicate the bevel on any prepa-
ration margins, aiming the maximum preservation of the
tooth structure. They suggest the application of some excess
of composite covering the margin and the near tooth surface,
creating some over contour, and attempting to mask the tran-
sition between the preparation and the restoration. It is also
possible to make a restoration mock-up without bevel on the
margins to evaluate the esthetical result. The composites of
selected shades and opacities are applied in the preparation
without any previous adhesive treatment. After curing, the
mock-up is evaluated in relation to the esthetic result and can
be easily removed afterward. If the result is not adequate,
after its removal, the bevel can be performed before doing the
final restoration. The restoration mock-up is more indicated
in cases of tooth fracture or large Class IV cavities, when the
preparation is not self-retentive, being easily removed by
pulling out on  its margin with the aid of an exploratory
probe. For Class III preparations, the removal of mock-up
will be more difficult, being necessary the use of rotary
instruments. In addition, the mock-up takes time and uses
more restorative material, which will interfere on the costs of
the treatment. However, it is certain that when a bevel is
made on the margins with esthetic commitment, the chances
to obtain a good esthetic outcome is higher, especially when
a mock-up is not made. For this reason, the bevel on areas
with esthetic commitment can be still recommended.
On the other hand, in the cases of large preparations or
fractured teeth, where the amount of tooth to be restored is
larger than the remaining tooth structure, a larger bevel with
0.5–2  mm width on the entire cavosurface angle may be
important to obtain the required retention [31]. The larger
the bevel, the higher is the bonding area and the retention
14 obtained. The dentist must take a decision on each case in
relation to do or not the bevel on the margin, choosing
between the maximum preservation and the esthetical or
retention requirement of each preparation. On preparations
where the gingival margin is too close to the CEJ, such as on
the gingival walls of large Class IV, III, or Class V prepara-
tion, a careful evaluation is important to analyze if the bevel
will not completely remove of the remaining enamel, result-
ing in bonding directly to the dentin and cementum on the
cavosurface angle, which is much poor in relation to the
bonding to enamel. If the gingival margin of the preparation
is located on the root surface, no bevel is done on the cemen-
tum margin [31].
When there is a cavitated lesion reaching dentin, sur-
rounded by a white or brown spot lesion on enamel that
extends over the tooth surface, beyond the preparation out-
line, after finishing the preparation on the cavitated area, the
margins should be extended to include all demineralized
areas, using an round diamond point, restricted to the enamel
tissue on the necessary depth to remove the lesion
(. Fig. 14.38g–i) [31].
 
Due to the proximity of the pulpal chamber, the Class V
carious lesions are shallow on the mechanic point of view, but
deep on the biological point of view, since a pulpal tissue
exposure may easily happen [3]. This must be avoided at all
cost, and a stepwise excavation can be indicated when the
dentist realizes that, if the preparation continues, an pulpal
exposure may happen. On the cases of non-carious cervical
lesions, it is important to identify its etiology before preceding
the restoration of the lost tooth structure, avoiding the relapse
of the problem. Once the etiological factor was diagnosed and
treated, the tooth can be restored. The preparation is restricted
to a small bevel on the incisal cavosurface angle, and a com-
posite that provides adequate polishing can be used [31].
The decision to restore or not a cervical lesion on the buc-
cal and facial surfaces is based on several factors. If it is a
white spot lesion, which is a subsuperficial carious lesion
without cavitation, preventive measurements can be applied
to reduce the caries disease activity and arrest the lesion, such
as biofilm control, dietary changes, and fluoride use, promot-
ing its remineralization. A restorative intervention is not
indicated [31]. The caries infiltration technique may also be
applied, completely stopping the lesion progression, as it is
described in 7 Chap. 16. If there is cavitation, the area must
be restored, unless it is too superficial and the patient is able
to clean, mechanically removing the biofilm from inside the
cavity with the toothbrush, and there is no esthetic commit-
ment. On the case of non-carious lesions, if they are small
and the etiological factors were  identified and controlled,
they can stay without being restored. If the area is hypersen-
sitive due to dentin exposure, a desensitizer agent can be
applied to reduce the pain, as discussed in 7 Chap. 18. If the
sensitivity persists after the treatment, it may be necessary to
restore the area, covering the dentin with composite [31]. If
the cervical lesion is identified as the cause of biofilm reten-
tion and gingival inflammation, it should also be restored
[31]. If a non-carious lesion is large and deep, the restoration
of the defects is recommended to avoid its progression
toward the pulpal chamber. In addition, very large lesions
may compromise the fracture resistance of the tooth. The res-
toration of the area reinforces the remaining tooth structure
and prevents the progression of the defect [31].
The inactive cervical caries  lesions may be stained
(brownish or black) and shiny, sometimes presenting scle-
rotic dentin with high mineral density, in which the dentin
tubules are obliterated by mineral deposition  and an
increased layer of peritubular dentin. They are more resistant
to the acid etching, impairing a proper bonding to the restor-
ative material. The increase of the etching time may be
desired on this situation or a gentle removal of the superficial
sclerotic layer with round burs, exposing an underlying less
sclerotic substrate [3]. If there are old faulty restorations, they
are removed with a round diamond point on high speed. In
case of large old restorations, sometimes it must be advisable
to remove only the defective part and to perform a repair [3].
When there are located areas of color alteration  on the
tooth surface, such as white, yellow, or brown, resulting from
enamel hypomineralization, they may be removed and
restored if the patient desires. The non-carious white lesions
are very common and may or may not reach the underlying
dentin. On this case, after the shade selection, the affected
tissue is removed with a round diamond point, followed by a
Composite Restoration on Anterior Teeth
bevel on the margins. As already described, the bevel is not
mandatory, and related only with the masking of the restoar-
ion margin. The acid etching and bonding application is per-
formed, followed by the composite increments [27]. Another
option for esthetic treatment of this kind of lesions is to use
the resin infiltration technique, which requires a previous
etching of the surface with a hydrochloric acid gel, followed
by dehydration with ethanol and application of an infiltrant
resin. Although this method was initially developed for caries
lesions, good results were also obtained when applied on flu-
orotic lesions and other hypomineralized enamel lesions. In
some cases, such as on Molar Incisor Hypomineralization
(MIH), a previous opening of the surficial enamel layer with
a bur is required before the infiltration (deep infiltration).
The resin infiltration technique is a more conservative way
for esthetical treatment of white lesions than the regular com-
posite restoration. More details are presented in 7 Chap. 16.
 
14.6.3  Restorative Procedure
For all types of preparations, it is important that before any
restorative procedure, the moisture of the operating field is
under control. Any moisture contamination by saliva, blood
and gingival crevicular fluid will result in total failure of the
adhesion to the tooth structure, and consequently to a defec-
tive restoration. Therefore, especially for the beginners, the
moisture control with the rubber dam isolation is easier and
reliable. When working on the anterior teeth, the rubber
sheet should be applied at least from right canine to left
canine, usually without any clamp. However, on patients
where the moisture control may be effectively performed by
the assistant, the cotton roll isolation may be safety used. For
that, the cotton rolls are placed and changed when moist,
associated with saliva ejector and cheek retractor [2]. On the
cases of cervical lesion, a retraction cord can be introduced
into the gingival sulcus.
When a total-etch adhesive system is selected, the next step
is the application of a 32–38% phosphoric acid gel in the entire
preparation. First of all, the proximal surface of the tooth adja-
cent to the preparation must be protected with the polyester or
polytetrafluoroethylene (PTFE) strip (. Fig. 14.49c) [31]. Even
 
though the accidentally etched enamel seems to be clinically
normal after a few days, scanning electron microscopy images
showed that the etched enamel is not completely remineralized
up to 90 days [16]. The adhesive system selected must be
applied according to the manufacturer’s recommendations.
The acid etching is started on the enamel of the surrounding
walls, up to 1 mm beyond the cavosurface angle or bevel, over
the external tooth surface. After that, the gel is applied over the
dentin, remaining undisturbed for 15 s [3, 31]. The etching
beyond the margin will prevent that any excess of composite
(flash) inadvertently applied over a non-etched area will stain
within a short period of time due to microleakage [3].
The phosphoric acid acts over the enamel promoting a
nonselective superficial removal of about 10 μm, followed by
a further selective demineralization of about 20–30 μm deep,
497 14
creating the characteristics of microporosities of the enamel
etching pattern (. Fig.  6.55b) [3]. The by-products of the
acid action over the enamel are water-soluble salts which are
removed by the rinsing. The acid etching increases the sur-
face energy and the surface area, allowing the penetration of
the resinous fluid monomers into the microporosities, creat-
ing resinous tags responsible for the micromechanical inter-
locking. On dentin, the acid etching removes the smear layer,
opens the tubules, and demineralizes about 5 μm of the
underlying dentin, which represents approximately the
thickness of a strand of hair divided by 10, exposing the col-
lagen fibers network (. Fig. 6.53b).
The preparation must be thoroughly rinsed away with an
air/water spray for about 20–30 s [3, 31]. The spray is first
applied on the adjacent teeth to prevent the acid-rich water
to be projected over the patient, dentist, and assistant. The
preparation must be carefully evaluated to verify if no acid
residues remained. Then, the excess moisture is removed
with the blot dry technique using a small cotton pellets, foam
pellets, disposable applicators, absorbent paper, or suction
with a cannula, resulting in a visibly moist surface but with-
out pooled water [3, 31]. The surface must have a glistening
aspect (. Fig. 14.38f‘). The dehydration of the etched dentin
results in the collapse of the collagen fiber network of the
intertubular dentin, preventing the monomer penetration
into the labyrinth of nanochannels formed by the dissolution
of hydroxyapatite crystals between the collagen fibers. On the
other hand, pooled moisture dilutes the adhesive and results
on the formation of bubbles and empty spaces in the adhesive
layer, which becomes weak areas of the adhesive interface. If
the access allows, a small cotton pellet may be placed inside
the preparation, and the tooth surface, adjacent teeth, and
the rubber dam can be dried with airstream, avoiding the
dentin dehydration [3]. If the preparation walls are occasion-
ally excessively dried, they can be rewet with an applicator
soaked in water, followed by the dentin blot drying [31]. If
any contamination of the preparation walls, with saliva or
blood, happens after the etching, it must be repeated for 10 s
on the entire preparation followed by rinsing and drying, to
remove the residues that could interfere with the monomer
impregnation [31]. When the cotton roll isolation is used, the
cotton rolls must be replaced after the rinsing, taking care to
prevent any contamination of the preparation [31].
Some authors recommend the application of a 2%
chlorhexidine digluconate solution for 10 s after the acid
etching, before the application of the adhesive, to promote
the antisepsis of the preparation [3]. In addition, the main
action of the chlorhexidine, in this case, would be the inhibi-
tion of the dentin matrix metalloproteinases, which are
enzymes present in the dentin matrix released and activated
by the acid etching. They are responsible for the degradation
of the unprotected dentin collagen that can sometimes
remain at the bottom of the hybrid layer, reducing the bond-
ing durability [47]. Several studies have shown that the appli-
cation of chlorhexidine after the acid etching is capable to
significantly increase the bonding durability to the dentin
substrate [9, 30], although the collagen degradation cannot
 498 C. R. G. Torres and R. F. Zanatta
be completely stoped. When applied as part of the adhesive
protocol, the excess must be removed with a small cotton pel-
let, leaving the surface visibly moist. The adhesive system
must be taken into the preparation using disposable applica-
tors such as Microbrush or small bristle brushes. They must
have an adequate size to enter the preparation and take the
solution to all surfaces. For that, different manufacturers pro-
duce applicators with several dimensions (. Fig. 14.37).
When a total-etch two-bottle adhesive system (fourth
generation) is selected, the primer containing hydrophilic
monomers and solvents is applied to all surfaces followed
by gently airstream, allowing the formation of a thin coat
and evaporation of the solvent [31]. It is important to high-
light that primer application to the enamel does not
adversely affect the bonding [31]. The preparation walls
must be inspected, and they should be uniformly shiny, as
an evidence of sufficient coating [3, 31]. If dry spots remain,
that means that, at this region, the collagen fibers were not
correctly impregnated and remain unprotected, as well as
dentin tubules are still open. On this case, the primer must
be reapplied and the walls, dried and the prepara-
tion inspected again, as many times as necessary [31]. After
that the adhesive (bond) is applied, which mainly contain
hydrophobic monomers, followed by a soft airstream to
leave a thin coat. As most adhesives are radiolucent, every
effort should be done to avoid its pooling on the margins,
which may create radiolucent radiographic images on the
interface and may be misdiagnosed as a caries lesion [3].
After that, the adhesive can be light-cured for 10 s. The tip
of the light guide must be placed as close as possible to the
tooth, without touching it [31]. Even though the internal
walls have to be entirely covered by the adhesive system, the
14 film must be thin.
Tip
To improve the bonding to the tooth structure, the
following steps are very relevant:
55 After washing the phosphoric acid gel, the blot dry
technique is recommended, resulting in a visibly moist
surface but without pooled moisture, showing a
glistening aspect.
55 After the application of the adhesive, the preparation
walls must be inspected, and they should have a
uniformly shiny aspect, as an evidence of enough
coating. If dry spots remain, the adhesive must be
reapplied.
55 The self-etching adhesive should be actively applied,
rubbing the impregnated applicator over the prepara-
tion walls during the whole time recommended by the
manufacturer.
When a total-etch one-bottle adhesive system (fifth genera-
tion) is selected, in which the primer and the adhesive are com-
bined in a single solution, it must be applied in a similar way as
it has already been described, followed by a soft airstream. If
..      Fig. 14.37  Disposable applicators. (1, 2, and 3) Applicators for
tooth preparations; (4) applicator for root canal (Cavibrush Longo,
FGM); (5) applicator for root canal (Endo Tim, Voco); (6, 7, and 8)
disposable bristle brush with several dimensions; (9) bended applica-
tors to improve the access to the preparation
dry spots remain, the adhesive must be applied once more until
a homogeneous coat is obtained, following a light-curing for 10
s. The excessive thinning of the adhesive coat with a strong and
too close airstream may adversely affect the bonding due to the
oxygen inhibition layer  occur inside the monomers impreg-
nated collagen network. This way, the hybrid layer will not be
cured when receiving the composite [3].
In the cases where the preparation or the area to receive
the composite does not present exposed dentin, after the
etching, the surface can be dried with an airstream since
there are no exposed collagen fibers that might collapse [31].
That will result in a white-opaque appearance. Therefore, the
etched enamel may be dry or wet before the application of the
adhesive system, but the etched dentin must never be dry.
When using a two-bottle adhesive, if the enamel is air dried,
the primer does not need to be applied. Just the hydrophobic
adhesive will provide an excellent bonding. However, if the
enamel is left wet, the primer must be applied, which is essen-
tial to interact with the superficial moisture.
When a self-etching adhesive system is selected, the
etching of the substrate is performed by the acidic mono-
mers in the adhesive formulation by itself, without a sepa-
rated etching step. In the two-bottle/two-step systems, the
primer is applied during the time recommended by the
manufacturer, generally from 20 to 30 s, followed by an air-
stream. After that the adhesive is applied and spread with an
airstream, followed by light-curing 10 s. For the two-bottle/
one-step and for the one-bottle/one-step systems, it is
applied during the recommended times, followed by an air-
stream and light-­curing. Similarly to the total-etch adhe-
sives, after the self-­ etching adhesive application, the
preparation walls should be uniformly shiny, as evidence of
sufficient coating. Some studies have shown that the double
application of the self-etching primers is capable to promote
a more effective etching of the substrate, increasing the bond
strength values [41]. In addition, the active application,
moving the applicator over the surface, also improves the
Composite Restoration on Anterior Teeth
etching pattern and bond strength [41]. However, despite
the kind of adhesive system selected, the manufacturers’
instruction should always be followed.
Some studies have shown that self-etching adhesives can
produce an insufficient enamel etching pattern, especially on
intact enamel surface or on those areas covered by prismless
enamel (. Fig. 6.1d). Therefore, when the retention is the
 
main point for a restoration, a selective acid etching just of
the enamel can be performed, leaving the dentin covered by
the smear layer. It is followed by rinsing with an air/water
spray, drying, and application of the self-etching adhesive on
the entire preparation following the manufacturer’s instruc-
tions.
On the cases where there is no exposed dentin on the area
to receive the restoration, such as on diastemas closure or
reanatomization of peg-shaped teeth, the use of acid etching
approach has advantages in relation to the self-etching, to
guarantee an effective etching pattern of the enamel prisms,
obtaining the necessary micromechanical retention.
When performing the restoration, it is important to
remind that the tooth is a polychromatic structure, com-
posed by tissues with different optical characteristics, being
the enamel translucent and the dentin more  opaque.
Therefore, to reach an optimal shade match, composites with
different translucency levels should be selected. The compos-
ite is applied on a stratified layering technique, restoring each
tissue with the most adequate material. It can be placed into
the preparation with a hand instrument or directly from the
composite capsule (compule). The first method is preferable,
especially in cases where the access is restricted, since the
diameter of the syringe tip is generally large [31].
14.6.3.1   ervical Lesions on Facial or Lingual
C retractor, which displace the cheeks and lips from the operat-
Surfaces (Class V or Site 3 on Smooth
Surfaces)
With the population aging associated with the success of the
caries disease preventive measures, people are keeping their
teeth much longer than in the past, sometimes during their
entire lives, allowing gingival recessions and non-carious
lesions to happen. This way, the number of Class V restora-
tions performed in the dental offices has been substantially
increased.
To perform the restoration, after the pre-procedural
mouth rinsing, prophylaxis, and shade selection, the anesthe-
sia of the area must be done. Then, the position of cavosur-
face margin is evaluated, determining if it is supragingival,
equigingival, or subgingival, which may adversely affect the
access to the lesion. On most of the cases, the rubber dam
isolation using a retraction clamp or the cotton roll isolation
using a retraction cord allows an excellent operating field.
However, if the biologic width has been invaded for a caries
lesion, for example, surgery for its re-establishment must be
previously performed [3]. In some cases, the gingival margin
of the preparation is subgingivally located, and, although
without invasion of the  biologic width,  the retraction cord
does not provide an adequate displacement of the gingival
499 14
tissue, and the use of a retraction clamp would excessively
harm the gingiva. On those situations, a trans-surgical resto-
ration is indicated. For that, an intrasulcular incision with or
without an internal bevel can be performed, producing a
small envelope flap, allowing the application of the retraction
clamp and rubber dam [3].
When the rubber dam isolation is selected in a single
Class V preparation, the No. 212 or No. 212M retraction
clamps should be used (. Fig. 14.39a–x). In case of prepara-
tions on two neighboring teeth, the No. 212L and 212R
(. Fig. 14.38f, b‘) will allow both restorations to be performed
simultaneously. If the clamp is not perfectly stable, low fusing
compound or a light-cured gingival barrier may be applied to
the region of the bow, touching the incisal edges or the occlu-
sal surface of the adjacent teeth, providing stabilization,
which prevents the clamp movement that could harm the
tooth and surrounding soft tissues [3, 31].
When the cotton roll isolation is selected, an extra fine
(size 000) non-impregnated gingival retraction cord is
applied into the gingival sulcus before the preparation, to
retract the gingiva and reduce the crevicular fluid flow
(. Fig. 14.44c, d) [3, 31]. If the control of bleeding is neces-
sary, the cord can be impregnated with an hemostatic agent.
For each tooth, about 8–10 mm of cord is required, besides
thin edge retraction cord packing instrument [31]. The cord
insertion inside the crevice should start in the interproximal
area, in the region of the gingival papilla, following to the
other end slightly further than the limit of the tooth prepara-
tion. When an additional gingival retraction is required, a
new cord can be placed over the first one. It should be avoided
at all cost to harm the gingiva or cause ischemia of the tissue
[31]. The gingival retraction can be associated with a cheek
ing field, allowing a proper restorative procedure to be per-
formed.
After the operating field isolation, the tooth preparation
is inspected, evaluating the proximity of the axial wall to the
pulpal chamber. On the cases of very deep preparations, an
area with pink discoloration on the axial wall indicated that a
remaining dentin layer of less than 0.5 mm exists, probably
associated with clinically undetected microscopic pulp expo-
sures [31]. On this situation, a thin layer of calcium hydrox-
ide cement is applied, only over the pink dentin, with the goal
to stimulate the formation of tertiary dentin. When acciden-
tally etched by the phosphoric acid gel during the adhesive
procedure, the calcium hydroxide cement is dissolved and its
by-products are deposited on the preparation walls, adversely
affecting the hybridization and the marginal sealing of the
restoration. For this reason, a protective layer of GIC should
be applied [11]. On the case of deep cavities, without any
pink discoloration area, only a thin layer of the GIC should
be used, restricted to the regions close to the pulp. On a shal-
low or medium-depth preparation, the application of any
protective material is not necessary. Further information
about the protection of the dentin pulp complex is available
in 7 Chap. 9.
 500 C. R. G. Torres and R. F. Zanatta

a b

c d

e f

14

..      Fig. 14.38  Patient with several carious lesions on anterior teeth. a
Baseline aspect; b application of a biofilm disclosing agent; c close view
of the central incisors; d 1 week after receiving the biofilm control
instructions; e shade determination; f rubber dam isolation using No.
212 L and R clamps. Removal of carious dentin tissue with round bur; g
removal of carious enamel with round diamond point; h, i bevels on
the incisal (conical diamond point) and cervical (round diamond point)
cavosurface angles; j finished preparations; k, l acid-etching; m blot
drying technique; n glistening aspect of the wet surface; o application
of the adhesive system; p application of a gently airstream; q light-
curing; r, s application of opaque dentin shade composite (Amaris,
Voco; shade O2); t application of translucent enamel shade composite
(Amaris, Voco; shade TN); u contouring of last composite layer with a
flat brush; v immediate result; w baseline aspect with lesions covered
by biofilm; x 1 week after receiving the biofilm control instruction; y
removal of the carious dentin tissue on the canine and lateral incisor; z
bevel on the incisal cavosurface angle with a conic diamond point; a′
bevel on the gingival cavosurface margin with round diamond point; b′
preparation complete; c′, d′ Acid-etching; e′ blot drying with cotton
pellets; f′ glistening aspect of the wet dentin; g′ application of the
adhesive system; h′ light-curing of the adhesive coat; i′, j′ placement of
matrix and wedge and restoration of the proximal walls with enamel
shade composite; k′ application of enamel shade composite over the
matrix band on the distal surface; l′ proximal surfaces restored; m′
application of composite in the undermined enamel areas; n′, o′
application of the dentin shade composite recreating the tooth
contour; p′ application of enamel shade composite; q′ surface
smoothening with a flat brush; r′ view of the recovered labial contour;
s′ preparation of grooves dividing the lobes on the labial surface; t′ and
u′ preparation of horizontal scratches to simulate the enamel
perikymata, moving mesiodistally the diamond point; v′ polishing with
a felt disc (Diamond, FGM) and diamond polishing paste (Diamond
Excel, FGM); w′, x′ aspect 2 weeks after the end of the restorations. The
white spot lesions on the premolars were still in a remineralization
process. A good option for immediate color masking of those lesions is
the use of the caries infiltration technique, described in . Fig. 16.12
Composite Restoration on Anterior Teeth
501 14

g h

i j

k l

m n

..      Fig. 14.38 (continued)
 502 C. R. G. Torres and R. F. Zanatta

o p

q r

s t

14

u v

..      Fig. 14.38 (continued)
Composite Restoration on Anterior Teeth
503 14

w x

y z

a’ b’

c’ d’

..      Fig. 14.38 (continued)
 504 C. R. G. Torres and R. F. Zanatta

e’ f’

g’ h’

i’ j’

14

k’ l’

..      Fig. 14.38 (continued)
Composite Restoration on Anterior Teeth
505 14

m’ n’

o’ p’

q’ r’

s’ t’

..      Fig. 14.38 (continued)
 506 C. R. G. Torres and R. F. Zanatta
u’
w’
..      Fig. 14.38 (continued)
Although not mandatory, a bevel can be performed on
14 places where there is enamel on the cavosurface angle, at 45°
with the external tooth surface, using a No. 1111 conical-­
shaped or a flame-shaped diamond point in high speed,
helping to mask of the tooth-restoration interface. On the
gingival margin, due to the lack of access for the proper
positioning of the conical or flame-shaped points, a No.
1011 or 1012 round diamond point can be used (. Fig. 14.38h,
 
i). However, when the amount of remaining enamel is very
small in this area, no bevel should be performed due to the
risk of its complete removal. The etching using 32–38%
phosphoric acid gel is applied first on the enamel and then
extended to the dentin, remaining for 15 s. Then, the prepa-
ration is rinsed with air/water spray for 20–30 s and blot
dried, using small cotton pellets, followed by the adhesive
system application.
The adhesive system should be dispensed from the bottle
only after the acid etching and rinsing. At the moment the
dentist is blot drying the preparation, the assistant dispenses
the material into a Dappen dish, and it is immediately
applied; otherwise the solvent in its composition will evapo-
rate and the adhesive will become ineffective.
The composite resins can be supplied in opaque syringes
or in capsules with an applicator tip, namely compules, to
be used with an injection gun. For the use of syringes, a
v’
x’
small amount is removed using a sterile spatula and placed
over a glass mixing slab or mixing pad. To avoid its curing
due to the environmental light, it must be covered with an
opaque object, such as a plastic opaque Dappen dish. Small
portions are taken with a non-stick composite filling
instrument and adapted into the preparation. The compos-
ite should be placed by using rapid shallow strokes, as
if you were thumping the composite in place, reducing the
chance of detaching from the cavity wall, which can create
voids. After finishing the restoration, any material left over
the glass slab is discarded. The encapsulated composites
can be taken directly into the preparation and adapted with
hand instruments [31]. However, on small cavities, it is
hard to directly insert the encapsulated material due to the
size of the delivery tip to be larger than the preparation
access, being more recommended to apply it with a hand
instrument [3].
After applying some increments into the preparation, the
composite can start to stick on the filling instrument. When
the instrument is taken away from the preparation, it can pull
the composite back, and a gap is formed between the mate-
rial and the wall. After curing, it will generate a permanent
interfacial defect [27]. Therefore, it is extremely important to
avoid the composite sticking to the instrument. For that,
non-stick filling instruments made of anodized aluminum or
Composite Restoration on Anterior Teeth
highly polished stainless steel, or coated with titanium nitride
or PTFE, as well as silicone or thermoplastic elastomer tips,
should be used. In addition, the instrument should be kept
clean during the procedure and the composite residues con-
stantly removed using damp alcohol gauze [27]. It must also
be evaluated if the instrument is not scratched, which will
increase the sticking. If the composite is still sticking too
much to the instrument, it can be wet with a very small
amount of adhesive [31]. The ideal are adhesives without sol-
vents, such as on the systems where the primer is in a sepa-
rated bottle. There are specific products for this purpose,
such as the Composite Wetting Resin (Ultradent)  and
Signum Liquid (Kulzer). Some studies have shown that this
procedure does not affect the bonding between the incre-
ments [6]. The primers or self-etching adhesives should be
avoided, because they contain water and other solvents that
adversely affect the bonding of new increments [5]. To avoid
premature polymerization of the composite during the place-
ment and modeling, the central focus of the overhead chair
light should be moved away from the operating field, using a
minimum illumination that comes from borders the light
beam [3]. However, some overhead lighting has a built-in
orange light source to prevent premature light polymeriza-
tion of composite materials.
To restore the dentin, a proper shade composite simulat-
ing the dentin opacity must be selected, according to the
method that has already been described. The chroma may
vary from the cervical region toward the incisal third, espe-
cially in the cases of the large restorations on anterior teeth.
Therefore, more than one dentin shade may be required.
Over it, an enamel shade composite must be applied. Besides
its hue, chroma, and lightness, the thickness of the enamel
shade layer will also interfere on the final color. To predict the
effect of the layers thickness, superimposed shade guides can
be used, as it can be observed in . Fig. 14.23 [2].
 
For Class V restorations, conventional viscosity or flow-
able composite can be used (. Figs. 14.38a–x‘, 14.39a–x, and
 
14.40a–i). It is important to select a restorative material that
provides good polishing, reducing the biofilm deposition and
gingival irritation. The microfilled composites are an excel-
lent option for the cervical restorations. Besides producing a
smooth surface, they have a low elastic modulus due to its
reduced filler content, being more flexible and capable to dis-
sipate internal stress generated during the masticatory loads,
generally responsible for restoration displacement [3].
According to some studies, the elastic modulus is relevant on
abfraction lesions, which are produced by stress concentra-
tion on the cervical area. The microhybrid, nanohybrid, and
nanofilled composites are also good options for Class V res-
torations [31]. The flowable composites also have the same
advantages related to the low elastic modulus, in a similar
way to the microfilled ones. Besides improving retention, it
also improves the adaptation of the restoration to the prepa-
ration walls [24].
On shallow Class V preparations, restricted to enamel, a
single increment is generally enough, considering the maxi-
mum layer thickness of 2 mm for obtaining a proper light-­
507 14
curing. For preparations with all the margins on enamel but
with loss of dentin tissue, generally two increments are indi-
cated. The first layer fills the lost dentin covering the axial
wall, using an opaque composite. The second replaces the
enamel using a more translucent material (. Fig.  14.38r–t).
The composite is applied using a hand instrument, adapted
on the preparation walls by gently thumping action with the
instrument nib, instead of rubbing it over the surface [27].
On preparations with gingival margins on cementum, if the
composite is inserted in a single increment, as the bond
strength to enamel is higher than to the dentin, the shrinkage
stress would break the interface between the composite and
the dentin, on the gingival margin, instead on enamel mar-
gin, resulting in marginal gaps on the gingival cavosurface
angle. A way to reduce this problem is to apply the first incre-
ments on the cervical and middle thirds of the preparation,
in a way that they do not contact the enamel. Large cervical
restorations may require the use of a darker shade on the cer-
vical third and a lighter one on the middle and incisal thirds
[3]. The increments must have a beveled transition and over-
lap in about 50% to avoid the sudden transition from one
shade to another, which could be noticed on the surface of
the restoration, impairing the esthetical result [3, 27]. A poly-
chromatic effect may also be obtained using special tints,
applied preferably over a cured composite layer and then
covered with a enamel translucent shade [3]. The opaque
dentin shade selected must partially cover the bevel when
performed, helping to mask the transition between the
restorative material and the remaining tooth structure. At the
end, dentin shade material must be completely covered with
a translucent enamel shade composite, recovering contour of
the external tooth surface. The last layer may be contoured
with a flat brush, for example, the No. 4A and 4B of Kota
Company (. Figs. 4.45d, 14.38z, and 14.39o).
Fahl [13] suggested the placement of final increment
using a small sphere of composite, prepared with the tip of
the index finger and thumb, which is placed in position and
contoured with a hand instrument and flat brush. The rubber
gloves must be thoroughly washed with water and dried
before manipulating the composite, avoiding contamination
with the glove powder, or use powder free gloves [27]. When
the external layer is placed on more than one increment, it is
common that air can be trapped on the junction between
those increments. Therefore, a single final increment could
cover the entire surface. As it is very difficult to place the
exact amount of composite, it is preferable to apply a slight
excess that can be removed during the sculpture or the finish-
ing procedure [3]. During the increment placement, the den-
tist must not touch the external oxygen inhibition layer on
the already light-cured increment, which has free methacry-
late groups working as adhesive between each composite
layer [3]. However, when the surface is touched by the den-
tist’s fingers, this layer is removed, being recommended the
application of an adhesive coat, followed by an airstream [31].
Each layer must be light-cured for at least 20 s with an
adequate light source (7 Chap. 13). The tip of the light guide
should be protected with the clear PVC film sheet. Each layer
 508 C. R. G. Torres and R. F. Zanatta

should not be more than 2 mm thick, to obtain an adequate
polymerization on bottom of the increment [31]. It should
also be avoided to connect more than two preparation walls
at the same time on each increment, due to the C-factor (see
7 Chap. 13). The light beam must reach the preparation on a
 
right angle with the tooth surface, where the preparation
access was made, and the light guide tip must be placed as
close as possible, almost touching the surface. The distance
between the light guide tip and the tooth surface must never
be larger than 1 mm. The dark shades are harder to light-cure

a b

c d

14

e f

..      Fig. 14.39  Restoration of the non-carious cervical lesion with
conventional viscosity composite. a Initial aspect; b shade determina-
tion; c rubber dam isolation using a No. 212M retraction clamp; d bevel
on enamel margin; e, f acid-etching; g rinsing; h blot drying; i
Application of the adhesive system; j light-curing of the adhesive coat;
(k–m) application of increments of dentin shade composite (Gran-
dioSO – Voco); n, o application of enamel shade composite and surface
smoothening with a flat brush; p restoration finished recreating the
buccal surface contour of the cervical area. It can be observed the
shiny surface that corresponds to the superficial oxygen inhibited
layer; q, r application of an oxygen blocking gel (Oxiblock, FGM) and
light-curing through it; s after the polymerization, it can be observed
the absence of the superficial shiny oxygen inhibited layer, compared
with Figure p; t marginal finishing of the with a fine grit conical
diamond point with non-cutting tip; u, v polishing with abrasive
rubber (Silicone points, Microdent) and abrasive disc (Diamond Pro,
FGM); w additional polishing with felt disc (Diamond Flex, FGM) and
diamond past (Diamond Excel, FGM); x final result
Composite Restoration on Anterior Teeth
509 14

g h

i j

k l

m n

..      Fig. 14.39 (continued)
 510 C. R. G. Torres and R. F. Zanatta

o p

q r

s t

14

u v

..      Fig. 14.39 (continued)
Composite Restoration on Anterior Teeth
w x
..      Fig. 14.39 (continued)
than the lighter ones; also the opaque composites are harder
to cure than the translucent ones. The manufacturer’s instruc-
tions must be followed in relation to the curing time. The
composites should be at room temperature before use, since
the materials that were recently removed from the refrigera-
tor have a smaller polymerization [3, 39].
The oxygen on the atmosphere inhibits the polymeriza-
tion of about 1–5 μm of the superficial layer of each compos-
ite increment. When a new increment is applied over it, the
air is eliminated, and the layer of uncured monomers polym-
erizes together with the new material, providing bonding
between them. However, the surface of the last composite
layer of a restoration will not be completely cured,
­compromising its mechanical properties, especially if the
surface does not receive a proper polishing. To overcome
this problem, after the polymerization of the last increment,
the surface can be covered by a transparent glycerin-based
oxygen blocking gel and light-cured through it, eliminating
the oxygen and allowing a complete polymerization, leaving
a glazed aspect (. Fig.  14.39q, r). The gel is then  removed
 
with an air/water spray [3]. The restorations must be ana-
lyzed in relation to the presence of flash or overhangs using a
dental explorer, mainly on the gingival margin where usually
more overhangs are detected. The explored must be placed
inside the gingival sulcus, touching the root surface, and
moved incisally. Any overhang detected must be removed
with a thin fine grit conical-shaped diamond point, with
non-cutting tip, as shown in . Fig.  14.66, avoiding an
 
unwanted grinding of the root (. Figs. 14.66a, b and 14.39t).
 
A scalpel blade can also be used to trim flashes and over-
hangs. The polishing may be performed with abrasive rubber
point, abrasive discs, or felt discs with polishing pastes
(. Fig. 14.39u–x).
 
After finishing the restoration, the patients must be
advised that abusive intake of staining agents, such as coffee,
certain dark colored tees and soft drinks, several times a day,
as well heavy smokers, can observe premature color altera-
tion of the restorations. [34]. However, the occasional con-
511 14
tact with such substances do not result in a significant color
change.
In some cases, the cervical lesions can be associated with
gingival recession, resulting on very long clinical crown.
When the restoration of the entire defect is done with a
tooth-colored composite, an esthetic commitment may
occur, breaking the harmony of the width-to-length ratio
and of the gingival zenith position. To overcome this prob-
lem, periodontal surgery, such as coronally positioned flap or
a gingival graft, can be used. However, some patients cannot
or does not want to undergo surgical procedures. On those
cases, a gingiva-colored composite can be used, such as the
Amaris Gingiva (Voco) or Beautifil II Gingiva shade (Shofu),
making the tooth appears to have a shorter clinical crown
(. Figs.  14.41a–l and 14.42a–a‘). The lost structure on the
crown must first be restored with a tooth-colored composite,
before restoring the most cervical area with the gingiva-col-
ored material.
First of all, the patient’s gingival shade is determined
using a shade guide. For Amaris Gingiva,  he different
shades are obtained associating one of three opaque flow-
able composites in the set, which is dark, light, and white,
with the more translucent composite of conventional vis-
cosity, with a standard pink shade (natural). Therefore, the
final shade of the restoration is determined mainly by the
selected flowable. It is also possible to combine the differ-
ent opaque flowable composites trying to reach the patient’s
gingival shade. The step-by-step procedure is presented in
. Figs.  14.41a–l and 14.42a–a‘. Cotton roll isolation are
used associated with a retraction cord, so the gingival
shade can be evaluated during the procedure. A cheek
retractor can also be very helpful for this kind of restora-
tion. The flowable opaque composite is applied on a very
thin layer and light-cured. Over it the composite with
regular viscosity is placed and shaped, creating the contour
of the edge of the free gingiva. The polishing is performed
with abrasive rubber points and polishing pastes associ-
ated with felt discs.
 512 C. R. G. Torres and R. F. Zanatta

a b c

d e

f g

14

h i

..      Fig. 14.40  Restoration of non-carious cervical lesion with flowable flowable composite Palfique Estelite Medium Flow (Tokuyama); g
composite. a Initial aspect; b isolation and prophylaxis; c bevel on application of the second increment; h immediate aspect; i result after
enamel margin; d application of the self-etching adhesive One-Up 1 week
Bond F Plus (Tokuyama); e, f application of the first increment of
Composite Restoration on Anterior Teeth
The cervical lesions can also be restored with conven-
tional GIC or RMGIC, being specially indicated to elderly
patients with high caries risk [31]. The tooth preparation is
the same as for composites, with exception that no bevel is
performed. Before the application, the preparation walls
are etched with 10–11.5% polyacrylic acid for 20–30 s, fol-
lowed by rinsing and drying. For the RMGIC the applica-
tion of a primer can be recommended, according to each
manufacturer’s instruction. The material is placed into the
preparation on a single increment, and the excesses are
quickly removed with hand instruments. To take the mate-
rial into the preparation, it is possible to use a calcium
hydroxide placement instrument, which has a small sphere
on the nib. Another option is to use a gun design Centrix
syringe (. Fig.  14.43a–f). A capsule (orange tube) model
 
with a thin tip can be selected, allowing a better control
during the application. The material is mixed and back-
loaded into capsule, no more than half full, followed by the
plug, which must be fully inserted. The capsule is then
a b
c d
..      Fig. 14.41  Cervical restoration with gingiva-colored composite. a
Initial aspect of the cervical lesions; b Amaris Gingiva composite
(Voco); c shade selection of the gingiva; d gingival retraction cord
inserted; e acid-etching; f application of the adhesive system; g
application of the selected opaque flowable composite; h application
of the pink shade composite; i contouring of the composite with a flat
513 14
placed into the syringe barrel. For the application, the
syringe is squeezed with a slow and steady pressure. An
amount of the material enough to fill the preparation is
applied on a single increment.
Due to its viscosity and sticky characteristics, the GIC
or RMGIC are difficult to contour and sculpt. For this rea-
son, cervical matrices are widely indicated for Class V
restorations, because they contour and maintain the mate-
rial in position during the setting or curing. When a con-
ventional GIC is selected, metallic matrices can also be
used (. Fig. 8.10a, b). However, when the light-cured
materials are chosen, clear plastic matrices must be
selected, holding the material while the light-curing is
performed during the time recommended by the manu-
facturer (. Fig.  14.44a–l). After its removal, the major
excesses are trimmed with a No.12 scalpel blade. When a
GIC is used, a thin layer of cavity varnish or a light-cured
adhesive must be applied over the restoration surface,
receiving a soft airstream to create a thin coat. When an
paddle-shaped filling instrument; j immediate result; k clinical aspect
after ending the adjacent teeth restorations and finishing procedures.
The crown of the teeth 34 was restored with a tooth shade composite,
before the restoration of the cervical area with a pink composite; l final
aspect of the teeth 44–34 with cervical restorations with gingiva-
colored composite
 514 C. R. G. Torres and R. F. Zanatta

e f

g h

i j

14

k l

..      Fig. 14.41 (continued)
Composite Restoration on Anterior Teeth
a b
d e
f g
..      Fig. 14.42  Esthetic appearance improvement of anterior teeth
using gingiva-colored composite. a Impacted right central incisor was
treated with orthodontic traction. However, the correct repositioning
was not obtained, and a composite restoration was previously per-
formed in the incisal third of the crown. After some time, gingival
recession resulted on the exposure of the root surface. The teeth 11
and 21 showed a strong darkening, in comparison with the other teeth
on the arch. b Tooth 11 suffered pulpal necrosis and the 21 a dystro-
phic calcification of the pulp, which explained the color changes; c on
close view, it was observed that even though the restoration of the
tooth 11 had an adequate shape, the shade and translucency of the
composite were not correct; d aspect after the endodontic treatment
and external and internal bleaching of tooth 11 and external bleaching
of tooth 21; e after the removal of the old restoration of the tooth 11, it
was possible to observe its real position; f test of the silicone index
previously made directly in the mouth over the old restoration; g
protection of the neighbor teeth with PTFE strip (IsoTape, TDV) and
515 14
c
acid-etching; h application of the adhesive system Solobond M (Voco);
i application of the opaque dentin shade composite (Amaris, Voco;
color O1), covering part of the labial surface to mask the transition
between the restoration and the tooth; j application of the enamel
shade composite (Amaris, Voco; shade TL); k smoothening of the
surface with a modeling silicone instruments (Micerium, Oraltech); l
finished restoration; m measurement of the clinical crown length of the
tooth 21 with a bow compass with two needle points; n and o
planning of the desired dimensions; p and q enameloplasty for
adjustment of the clinical crown length; r evaluation of the final dimen-
sions with the compass; s proportional clinical crowns of both the
upper incisors; t shade determination of the gingiva (Amaris Gingiva –
Voco); u acid-etching of the root surface; v application of the adhesive
system; w application of a pink color opaque flowable composite; x
placement of the regular viscosity composite (Nature); y finished
restoration; z and a′ clinical aspect of the smile before and after the
treatment
 516 C. R. G. Torres and R. F. Zanatta

h i

j k

l m

14

n o

..      Fig. 14.42 (continued)
Composite Restoration on Anterior Teeth
517 14

p q

r s

t u

v w

..      Fig. 14.42 (continued)
 518 C. R. G. Torres and R. F. Zanatta
x y
z a'
..      Fig. 14.42 (continued)
14 adhesive is used, its light-curing is performed for 10 s.
This procedure prevents the dehydration and cracks of the
restorations or water sorption from the saliva during the
initial setting stages. The RMGIC is generally more resis-
tant to dehydration or water sorption and does not require
protection. This is due to the fact that its resinous compo-
nents immediate polymerization provides an umbrella
effect, protecting the ongoing acid-base setting reaction.
However, the manufacturer’s instructions must be strictly
followed for each material [31].
The GIC restoration can be finished and polished only
after the end of the setting reaction, about 24 h the place-
ment into the preparation. However, the RMGIC may be
immediately finished and polished. Even after the final set-
ting, care must be taken to not dehydrate the GIC restora-
tion surface during the finishing and polishing procedures.
Conventional rotary instruments can be used under water
spray. Rubber points and discs may be used lubricated with
glycerin gel or petroleum jelly. Polishing pastes and felt
discs can also be used [31]. Some brands of RMGIC present
a fluid resin, called finishing gloss, that can be applied over
the restoration after the polishing, spread with an airstream
and light-cured.
14.6.3.2  Proximal Lesions Without
Involvement of the Incisal Edge (Class
III or Site 2, Sizes 1–3)
During the restorations on anterior teeth, every time possible
the rubber dam isolation at least from right to left canine
should be performed, because it allows a better visualization
of the lingual surface. In general, there is no need to use
clamps, unless it is not possible to stabilize the rubber sheet
with dental floss ligatures on the canines, or rubber stripes
on the distal surface of the last isolated teeth. In patients with
little salivation, the rubber dam isolation is acceptable. The
preparation is inspected and pulpal protection performed
when necessary.
For preparations restricted to the proximal surfaces,
without adjacent tooth or with a temporary crown or resto-
ration that may be easily removed, the restoration may be
performed with hand instruments, without the use of a
matrix, similarly a Class V restoration (. Fig.  14.45a–l).
However, every time there is contact between the tooth that
will be restored and the adjacent, a protective polyester or
PTFE strip (IsoTape – TDV) must be placed between them
during the acid etching, adhesive application, and light-
Composite Restoration on Anterior Teeth
519 14

a b

c d

e f

..      Fig. 14.43  Use of gun design Centrix syringe to apply restorative materials. a Different types of capsules; b loading the material into the
capsule; c, d placement of the plug; e placing the capsule into the syringe barrel; f syringe ready to use

curing. This procedure prevents undesirable etching of the Tip

intact neighbor tooth surface and bonding between the
tooth to be restored and the adjacent one. The strip used for
protection can be discarded, and a clean and new polyester
strip is placed and wedged before applying the composite to
perform the restoration (. Fig.  14.47a–u) [31]. The place-
 
ment of matrix after the bonding procedure reduces the
chances of adhesive pooling on the margins close to the
matrix.
When there is contact between the preparation be
restored and the adjacent teeth, a protective polyester
or PTFE strip must be placed between them during the
acid etching, adhesive application, and light-curing,
preventing undesired etching and bond to the
neighbor tooth.
 520 C. R. G. Torres and R. F. Zanatta

However, sometimes, the wedge insertion may cause
fracture of some undermined enamel on the cavosurface
angle, which will be permanently lost. In this case, the com-
posite is applied over non-etched and bonded enamel, result-
ing on marginal microleakage on this area. One possibility to
overcome this problem is to apply the matrix and wedge
before the acid etching. Therefore, it would at the same time
protect the neighbor tooth from etching and bonding and
assist the tooth restoration. However, special attention must
be given to remove any pooled excesses of adhesive on the
margins, using airstream, and dry microbrush applicators if
necessary.
The purpose of the matrix and wedge placement is to
hold the composite inside the preparation, helping the con-
touring and shaping of the external restoration surface,
improving the isolation, eliminating or reducing overhangs,
and simplifying the finishing procedure. The wedge holds the
strip in position, allowing a slight dental separation to com-
pensate the matrix strip thickness, if the contact has been
completely destroyed by the lesion [31].

a b

c d

14

e f

..      Fig. 14.44  Restoration with RMGIC using clear cervical matrix. a test of the cervical matrix; h restorative material application using
Cervical matrices (TDV); b initial aspect of the non-carious cervical Centrix syringe; i positioning of the matrix before light-curing; j
lesions; c, d placement of the gingival retraction cord; e primer polishing with abrasive rubber (Silicone tips, Microdont) after 7 days; k
application (Vitremer, 3M); f light-curing of the primer coat; g fitting application of the glaze coating; l final result
Composite Restoration on Anterior Teeth
521 14

g h

i j

k l

..      Fig. 14.44 (continued)
 522 C. R. G. Torres and R. F. Zanatta

Due to the fact that the proximal tooth surface is convex
inciso-gingivally and the polyester strip is flat, it may be
necessary to shape it to adapt to the desired tooth contour.
A way to do this is to draw it across a hard and rounded
object, such as the round end of a clinical tweezer. The
amount of convexity created will depend on the contour
necessary [31]. Several pull movements with strong pres-
sure may be required to obtain enough convexity
(. Fig. 14.46). The matrix strip is placed between the teeth
 
and analyzed if it provides the adequate contour to the sur-
face to be restored. It must be extended at least 1 mm fur-
ther than the gingival and incisal preparation margins. If
the strip does not slide through a tight remaining contact
or sharp preparation margin, a small immediate tooth sep-
aration can be obtained inserting a wedge in the interprox-
imal space, allowing the passage of the strip. After that, the
wedge is removed, and the matrix is taken in the desired
position inside the gingival sulcus, between the gingival
papilla and the tooth surface. Then, the wedge is inserted
tightly once again [31].

a b

c d

14

e f

..      Fig. 14.45  Restoration restricted to the proximal surface. a Carious blot drying; h adhesive system application; i, j application of dentin
lesion with direct access due to the absence of the adjacent tooth; b shade composite; k application of enamel shade composite; l final
opening of the preparation with round diamond point; c removal of result
the carious dentin tissue; d preparation completed; e, f Acid-etching; g
Composite Restoration on Anterior Teeth
523 14

g h

i j

k l

..      Fig. 14.45 (continued)

Tip vice versa, always apically to the gingival cavosurface angle.

To shape a flat polyester strip, draw it across a hard
and rounded object, such as the round end of a clinical
tweezer, until it creates the necessary contour.
The wedge is inserted into the interproximal space using a
mosquito forceps with a curved end, preferably on the
opposite side of the preparation entry. In other words, it is
It must be kept as short as possible to avoid conflicts with
the access area, not hindering the placement of the restor-
ative material [3, 31]. If the preparation has a facial access,
the pad of the index finger of the left hand, for the right-
handed people, or of the right hand for the left-handed ones,
can be positioned over the lingual aspect of the strip, press-
ing it toward the remaining tooth structure. The labial por-
tion is reflected away from the access with the thumb
(. Fig.  14.47o). If the wedge is too long and interferes on

facially inserted when lingual access was performed and this procedure, it must be shortened [31]. The convex shape
 524 C. R. G. Torres and R. F. Zanatta
..      Fig. 14.46  Contouring of the polyester strip with the round end of
a clinical tweezer
of the finger pad will allow the ideal contour of the lingual
surface, which is concave. Then, the composite is placed
inside the preparation using a stratified layering technique,
employing a non-stick composite filling instrument with a
flat- or round-shaped nib like a plugger (. Fig. 14.47p). On
the last layer, the material is placed with a slight excess. The
major excess is removed with the filling instrument or den-
tal explorer before closing the matrix. The labial aspect of
the matrix strip is placed over the labial tooth surface, keep-
ing in position with the thumb, applying a slight pressure for
contouring the composite. The material is then light-cured
through the matrix (. Fig.  14.47q–s) [31]. After that, an
additional light-curing is performed placing the light guide
tip on the lingual surface.
14
Tip
If the preparation has a facial access, the pad of the
index finger can be placed over the lingual aspect of
the matrix strip, pressing it toward the remaining
tooth structure, creating the ideal concave contour of
the lingual surface. The initial composite increments
can be placed inside the preparation using a non-stick
composite filling instrument with a flat- or
round-shaped nib like a plugger.
When there is no remaining dentin on the preparation or
when it extends from labial to lingual surface (. Fig. 14.43a),
the use of an opaque dentin shade composite is important;
otherwise, most of the incident light over the labial surface
will pass through the restoration instead of being reflected.
This will result on a darker aspect to the restoration, with
half-moon margins, due to the dark background of the
mouth. The use of an opaque shade composite eliminates this
problem, reflecting part of the incident light and increasing
the lightness of the restoration. On teeth with less translucent
natural enamel, the entire lingual and central area of the
preparation, including the contact area, can be restored using
dentin shade composite, leaving a small space on the labial
surface that later is covered by enamel shade material
(. Fig. 14.47p).
>> When there is no remaining dentin on the preparation,
or when it extends from labial to lingual surface, it is
essential to use an opaque dentin shade composite;
otherwise the restoration will have a darker aspect
with half-moon margins.
On teeth with very translucent enamel, it is advisable to
start the restoration on the lingual and proximal surfaces,
with a thin enamel shade composite layer, followed by the
restorations of the central area with dentin shade mate-
rial, which is finally covered with a thin enamel shade
layer (. Fig.  14.38i‘–r‘). On those cases, the composite
placement is started over the matrix on the lingual sur-
face, creating a background for the following increments.
After that the proximal surface is also restored with
enamel shade, leaving a space in the central area for
placement of dentin shade composite. The first incre-
ment of enamel shade composite must be very thin. After
its light-curing, the increment can be evaluated and, if
necessary, more material be applied to reach the adequate
enamel thickness. The enamel shade composite layer
should be about 0.2–1 mm thick, continuous and prefer-
ably of a single shade [2]. The dentin shade is then
applied, preferably in a cervico-incisal direction. An
enough space for the final enamel shade layer must be
left, which can be evaluated looking in an inciso-cervical
direction. A sphere of enamel shade composite is pre-
pared, placed, and contoured with a flat paddle-shaped
hand instrument [2]. After that, the matrix strip must be
reflected over the labial tooth surface, covering the com-
posite. The cervical edge of the strip is pulled toward the
incisal edge to avoid cervical overhangs [3]. The light-
curing is performed through the strip, creating a very
smooth surface. It is very important to ensure that the
entire area to be restored was filled with composite, espe-
cially on the margins [3].
If two adjacent restorations in neighbor teeth are per-
formed simultaneously, they can be restored at a single
appointment. The preparation with a smaller access must be
restored first (. Fig.  14.48a–a′). If there was any excess or
over-contour at the end of the restorative procedure, the fin-
ishing with an abrasive strip, abrasive disc, or diamond point
must be performed before starting the next restoration. If the
adhesive system was applied to both preparations simultane-
ously and the second preparation was contaminated with
residues generated by the finishing, it has to be rinsed and
etched and receive the adhesive application again, before any
composite is placed.
If a lingual access was performed, the same principles in
relation to the application of the increments are valid
Composite Restoration on Anterior Teeth
525 14

a b

c d

e f

..      Fig. 14.47  Composite restoration through the facial access. a
Defective restorations removed; b shade determination; c preparation
of a bevel on the labial cavosurface angle; d acid-etching; e rinsing; f
blot drying with a cotton pellet; g application of the adhesive system;
h application of a polyester matrix between the teeth to avoid
undesired bonding; i light-curing of the adhesive; j placement of
matrix and wedge and insertion of dentin shade composite (Opallis –
FGM); k, l last increment of enamel shade composite inserted followed
by matrix closing; m light-curing through the closed matrix; n aspect of
the first restoration completed; o placing of matrix and wedge and
positioning of index finger for the second restoration. p insertion of
the dentin shade composite, leaving enough space for application of a
enamel shade layer; q application of enamel shade composite; r matrix
closed; s light-curing through the matrix; t immediate results showing
the dehydration of the teeth; u final aspect after the polishing
 526 C. R. G. Torres and R. F. Zanatta

g h

i j

k l

14

m n

..      Fig. 14.47 (continued)
Composite Restoration on Anterior Teeth
527 14

o p

q r

s t

..      Fig. 14.47 (continued)
 528 C. R. G. Torres and R. F. Zanatta

a b

c d

e f

14

..      Fig. 14.48  Restoration of proximal lesions through the lingual
access. a Initial aspect of the lesion; b stretching the rubber before
placing the wedge; c opening of the larger cavity with a round
diamond point; d removal of the carious dentin tissue with round bur
in low-speed handpiece; e opening of adjacent lesion through the
access of the larger lesion; f removal of the carious dentin tissue; g
finished preparations; h acid-etching; i application of the adhesive
system; j application of the matrix strip between the teeth to avoid
undesirable bonding during the light-curing of the adhesive coat; k
insertion of matrix and wedge for restoration on the smaller prepara-
tion; l matrix closed over the lingual surface before light-curing of the
last increment; m insertion of matrix and wedge to restore the larger
preparation; n, o placement of composite (Opallis, FGM) and adapta-
tion of increments with round-shaped nib filling instrument; p
placement of the last composite increment; q closing the matrix over
the lingual surface; r initial aspect; s finishing with pointed football
shape fine grit diamond point; t removal of the cervical excess with a
contour carbide carver (TZC12, Thompson/Miltex); u removal of excess
with a No. 12 scalpel blade; v, w finishing of proximal surface with
abrasive strip (3M); x, y polishing of lingual surface with abrasive
rubber points in a decreasing grit size sequence (Microdont); z
polishing with felt disc (Diamond Flex, FGM) and polishing paste
(Diamond Excel, FGM)
Composite Restoration on Anterior Teeth
529 14

g h

i j

k l

m n

..      Fig. 14.48 (continued)
 530 C. R. G. Torres and R. F. Zanatta

o p

q r

s t

14

u v

..      Fig. 14.48 (continued)
Composite Restoration on Anterior Teeth
w x
y z
..      Fig. 14.48 (continued)
(. Fig. 14.48a–a′), even though the labial and proximal sur-
 
faces are restored first, and finally the lingual one. The lin-
gual surface does not require an enamel shade composite
because this area cannot be seen during the patient’s daily
life. On preparations restricted to the proximal surface, gen-
erally, there is no need to use dentin shade composite, unless
on large and deep preparations. Furthermore, on this situa-
tion, if there is no adjacent tooth, the composite may be
applied without the use of a matrix. However, if the access to
the strictly proximal preparation was made through the
lesion on an adjacent tooth, the use of the matrix simplifies
the restorative procedure, avoiding the occurrence of over-
hangs.
14.6.3.3   roximal Lesions with Involvement
P ble directions, to verify if on its interior there is an adequate
of the Incisal Edge (Class IV or Site 2,
Size 4)
This kind of lesion may be a result from carious lesion pro-
gression or fractures caused by dental traumas on this area.
The composite indicated for this situation must have good
physical properties to resist to the masticatory forces, besides
providing an adequate final esthetics (. Fig. 14.49a–o). The
 
procedures related to isolation of the operating field, pulpal
protection, and application of the adhesive systems are the
same as it has already been described. On this type of prepa-
531 14
ration, similarly to the lesions without involvement of the
incisal edge, the use of a polyester clear matrix is essential for
the correct restoration of the anatomical shape of the lost
surfaces. The matrix strip must be inserted into the gingival
sulcus between the papilla and the tooth surface. The dentist
folds the strip end to end to form a loop, which is placed and
pushed down toward the gingival sulcus with the tip of the
index finger (. Fig. 14.49f). The wedge must be inserted in
the largest embrasure, having a certain height that does not
invade the preparation. The index finger will be positioned
over the lingual aspect of the strip, pressing it toward the
remaining tooth structure, creating the lingual contour. The
labial portion is reflected away from the labial surface with
the thumb. After that, the matrix is evaluated from all possi-
shape and contour to restore the tooth’s anatomy. A very
common problem at this moment is the improper matrix
contour on the region of the mesiolingual or distolingual
external line angles to be restored [31]. Due to the flexibility
of the polyester strip and the fact that it is originally straight,
on the region of the external line angles, generally the matrix
does not present the adequate contour, which can be observed
by looking the positioned matrix from the incisal edge. To
create the correctly contour, a small fold on the matrix at this
region can be created with the tip of paddle-shaped hand
 532 C. R. G. Torres and R. F. Zanatta

instrument. While the index finger pad is kept pressing the over the matrix secured by the index finger pad, which is
matrix on the lingual surface, the instrument tip is moved light-cured, creating the contour of the lingual surface
incisocervically on the region of the lost external line angle, (. Fig.  14.49h). Then, the same composite is placed on the
 

toward the intact angle of the adjacent tooth (. Fig. 14.49g).

  region of proximal surface (. Fig.  14.49i). Before light-­
 

The enamel shade composite is placed on a very thin layer, curing, the matrix must be pulled over the labial surface,

a b

c d

14

e f

..      Fig. 14.49  Restoration of Class IV preparation using polyester clear
matrix. a Defective restoration removed; b preparation of a bevel on
labial enamel margin; c protection of the adjacent tooth with a PTFE
strip and acid-etching; d application of the adhesive system; e
light-curing of the adhesive; f insertion of the matrix into the gingival
sulcus, between the interdental papilla and the tooth, surrounding the
tooth, pressing it cervically with the index finger; g insertion of wedge
and placement of the index finger pad pressing the strip over the
lingual surface, followed by making a small fold on the matrix in the
distolingual external line angle, with the tip of paddle-shaped hand
instrument; h restoration of the lingual surface with enamel shade
composite Z350 XT (3M/ESPE); i application of enamel shade compos-
ite to restore the distal surface; j before light-curing the matrix is
closed; k distal surface completed; l insertion of dentin shade
composite; m insertion of enamel shade composite, followed by the
matrix closing. A paddle-shaped hand instrument may be placed
internally into the matrix, on the region of the external line angle,
while pulling the matrix, to guarantee the proper contour before the
light-curing; n aspect after finishing with the teeth yet dehydrated due
to the isolation; o result after polishing
Composite Restoration on Anterior Teeth
533 14

g h

i j

k l

m n

..      Fig. 14.49 (continued)
 534 C. R. G. Torres and R. F. Zanatta
..      Fig. 14.49 (continued)
avoiding the occurrence of excess on the proximal area
(. Fig. 14.45j, k). This way, the regions harder to restore will
 
be already concluded. After light-curing, the dentin shade
composite is then incrementally placed in the central region,
leaving space for the restoration of the labial surface with
enamel shade composite (. Fig.  14.49l). The dentin shade
 
composite should cover half of the bevel width, helping to
mask the tooth-­restoration interface. After that, the enamel
shade composite is placed and contoured, the matrix is pulled
over the labial tooth surface, and the light-curing is per-
formed through the matrix (. Fig. 14.49m). Care should be
 
taken when closing the matrix strip, avoiding pulling it too
strong. That would do the material flow toward the incisal
edge, resulting on a restoration subcontour on the region of
the external line angle with the labial surface. To avoid this
14 problem, paddle-shaped hand instrument can be placed
internally to the matrix, in the region of the angle, while pull-
ing the matrix, to guarantee the proper contour before the
light-curing (. Fig. 14.49m). If there is a failure on the con-
 
tour, more composite can be applied to obtain the required
shape. After the end of filling procedure and matrix removal,
an additional polymerization must be performed from the
labial and lingual approaches.
In case of large dental fractures or caries lesions that
resulted in the loss of the two incisal point angles (mesiola-
bioincisal and distolabioincisal), the same restorative proce-
dure described can be used, using polyester strips, first
restoring the lingual surface and applying enamel shade
composite over the matrix, secured by the index finger pad,
and then one proximal surface at a time. Then, the dentin
shade composite is applied, finishing with the application of
the enamel shade material over the entire labial surface.
However, in those situations, the transparent plastic crown
forms or the palatal silicone index techniques can also be
applied.
The transparent crown form technique consists in select-
ing a crown with a size compatible to the tooth to be restored
(. Fig. 8.13a, b). It must be cut to fit correctly to the remain-
 
ing tooth structure. It can be used in two different ways. On
the first way, the composite is applied inside the crown form,
..      Fig. 14.50  Transparent crowns forms with the labial side removed
placed on a fractured tooth
placed in position, the material excess that flowed through
the margins is removed, and the light-curing is performed.
On this case, it is important that, before filling the form, a
small hole is made in the incisal edge, which will help the
flowing of composite excess. This technique presents as dis-
advantage the fact that the composite is placed on a single
increment, making difficult to obtain a polychromatic resto-
ration simulating the natural tooth. It is also hard to control
the marginal overhangs, and there is a larger risk to have air
bubbles entrapped inside the restoration. As they have some
standard shapes, they may not adapt to all teeth, besides
being harder and thicker than the polyester strips, which
adversely affects the passage through the proximal contact
region [3]. The second way to use the crown forms is to select
a crown that better adapts to the tooth and then cut off the
labial side maintaining the lingual, proximal, and incisal
areas intact [3]. The crown is placed in position and wedged.
The composite is then incrementally applied, creating a poly-
chromatic restoration (. Fig. 14.50).
The technique of the palatal silicone index, which is a cus-
tom-made matrix, is performed using a plaster model of the
fractured tooth with the wax-up of the restoration
(. Figs. 14.51a–u and 14.52a–x) or directly in the mouth when
a defective restoration is present (. Fig.  14.62a–d′). On the
first way, an alginate impression of the dental arch must be
taken previously to the restorative procedure, obtaining a plas-
ter model [12]. Over this model, the wax-up of the future res-
toration is performed, sculpting the ideal anatomy on every
surface. A putty silicone impression material is applied directly
with the fingers to the model (trayless impression), over the
waxed tooth to be restored and some adjacent ones
(. Fig. 14.51j, k). After the curing, the impression is removed.
Then, with a scalpel blade, the labial part of the mold is
removed, remaining only the lingual and proximal areas and
the incisal edge (. Fig. 14.51l). The adaptation of the silicone
index is tested placing it in position. Outside the mouth, a thin
layer of the enamel shade composite is applied over the lingual
surface of the silicone index, on the area of the restoration,
slightly further than the cavosurface angle. It is placed in
Composite Restoration on Anterior Teeth
535 14
­ osition, evaluating if the composite applied is touching the
p (. Fig.  14.51p). Then, a thin filament of the opaque dentin
 

remaining tooth structure, followed by the light-curing shade composite is applied on the incisal edge to simulate the
(. Fig.  14.51m–o). It is always better to apply a thin layer
  effect of the opaque halo (. Fig. 14.51q) [2]. The opaque halo
 

because it is easier to add composite than to remove. The sili- has a similar shade to the cervical area; therefore, the same
cone index is then removed from the position, remaining the composite shade should be used [1]. Then, the dentin mamel-
layer of enamel shade composite on the lingual surface ons are made with the opaque dentin shade material

a b

c d

e f

..      Fig. 14.51  Restoration technique using palatal silicone index and
previous wax-up of the restoration. a Fractured teeth; b wax-up of the
restoration over a plaster model; c rubber dam isolation; d preparation
of bevel on the labial cavosurface; e acid-etching; f rinsing; g blot
drying; h application of the adhesive system; i Light-curing of the
adhesive; j, k silicone modeling of the over the plaster model; l cutting
of the labial side with a scalpel blade; m test of the silicone index; n
application of the enamel shade composite in the index (Amaris –
Voco, shade TN); o index with composite taken in position; p lingual
surface completed; q Application of a small filament of the opaque
dentin shade composite on the incisal edge to simulate the effect of
the opaque halo; r restoration of dentin lobes with dentin shade
composite (Amaris, Voco; shade O2); s application of high-translucency
composite between the lobes (Filtek Supreme, 3M/ESPE; shade TB); t
application of enamel shade composite (Amaris, Voco; shade TN); u
polishing with felt disc and diamond paste; v final result
 536 C. R. G. Torres and R. F. Zanatta

g h

i j

k l

14

m n

..      Fig. 14.51 (continued)
Composite Restoration on Anterior Teeth
537 14

o p

q r

s t

u v

..      Fig. 14.51 (continued)
 538 C. R. G. Torres and R. F. Zanatta

(. Fig.  14.51r). Between the mamelons tips and the opaque

 
halo, a highly translucent composite is placed to create an
opalescent halo (. Fig.  14.51s). The selection of the highly
 
translucent composite to be used must be performed before
the isolation, placing small portions (small spheres) of differ-
ent translucent composites touching the incisal edge of the
adjacent intact teeth, without any type of adhesive, followed
the light-curing. The patient is asked to open and close the
mouth. The effect can be verified with and without the lower
incisors on the back. For this step, really opalescent composites
can be used, or non-opalescent ones associated with a thin coat
of blue tints to increase the bluish opalescent effect between
the lobes. If present on the adjacent teeth, other esthetic char-
acteristics, such as white spots, may be created with white
opaque tints [31]. The external surface is covered by the
washed with sterile saline solution before the application of
the protector [3]. Then, the calcium hydroxide powder is
applied by means of a very small and sterile applicator, plac-
ing the material without pressure. When the pulp curettage
is performed, it must be done in the most conservative way
possible, cutting the contaminated superficial tissue and cov-
ering it with calcium hydroxide [3]. The pulpotomy should
only be indicated in the cases where there is incomplete root
formation, but pulpal tissue was contaminated due to expo-
sure to the oral cavity for a long period of time. It consists of
the removal of the inflamed coronary pulp tissue, maintain-
ing the integrity of the radicular pulp. However, the pulp tis-
sue must present characteristics of vitality, from a
macroscopic perspective, at the moment of cutting [3]. More
details can be seen in 7 Chap. 9. On the cases of complete

medium translucent enamel shade composite (. Fig. 14.51t).

  root formation but with large microbial contamination, due
. Figure 14.52a–x shows a sequence of clinical procedure
  to long time exposures to the oral cavity, the pulpectomy
to restore a fractured tooth using a silicone index, associated should be performed. When the pulp is necrotic, and the
with the cementation of a glass fiber post to improve reten- tooth has an incomplete root formation, apexification tech-
tion. After the preparation of the root canal with the adequate niques need to be applied.
bur, a dual-cure adhesive system was applied and then post When the dentist decides to maintain the pulp vitality
cemented with dual-cure resin cement. The enamel and den- and perform a pulpotomy, it should be verified if the tooth
tin shade composites were applied in the same way as it has does not present spontaneous pain and the pulp presents
already been described. On the attempt to reproduce the firm consistency, resistance to cut, and moderate to slight
opaque white patches on the adjacent teeth, which are areas bleeding with bright red color, that stops in a few minutes
of enamel hypomineralization caused by fluorosis, a white after cutting. Those parameters are the most important one
opaque tint was applied between the layers of enamel shade to determine the success. The more recent the pulp exposure
composite using a disposable applicator. had happened, the greater the success  probabilities of the
treatment, even though old exposures can still show positive
14.6.3.4  Restoration of Fractured Teeth results, especially in younger patients. In addition, the size of
The restoration of fractured teeth is a great challenge for the the pulpal exposure does not determine the success, because
operative dentistry. They may involve one or more tissues, it may be obtained in small as large ones. The consistency is
14 with different incidences:  only enamel (21%), enamel and also not a good parameter to predict the success. Liquefied
dentin (57%), enamel-dentin-pulp (6.4–18.3%), and enamel-­ pulps have a bad response to the treatment due to the insuf-
dentin-­pulp and periodontium (4.3–10%). In some cases, the ficient blood flow. Teeth with incomplete root formation and
conservative pulp treatment is possible and desirable, espe- thin root walls generally provide a better prognosis [3]. It
cially in the cases of incomplete root formation, where the must also be evaluated if the tooth may be restored without
tooth remains with a wide open apex and fragile root canal the need of retentive post inside the root canal.
walls, with enhanced risk of root fractures. The pulpotomy On the cases where no pulpal exposure occurred, but
will promote the pulp revascularization and the continued there is an area of dentin where it can be observed a pink
physiological development and formation of the root, both discoloration (. Fig. 9.7d), it indicates that a remaining den-
 

on apical and lateral direction. tin layer of less than 0.5 mm exists, probably associated with
To restore a fractured tooth, the first step is to take a den- clinically undetected microscopic pulp exposures. Therefore,
tal radiograph of the area to identify any nonclinically visible this region must be covered with a thin layer of calcium
fractures lines. If nothing abnormal was found, it is neces- hydroxide cement to stimulate the formation of reactionary
sary to verify if any  pulp exposure had happened. On the dentin.
cases of pulpal exposure, it is necessary to decide which pro-
cedure is more recomended:  pulp capping, pulpotomy, or 14.6.3.5  Trans-surgical Restoration
pulpectomy (details on 7 Chap. 9). On the case of fractured On the cases of fractured teeth, many times, the margin of
 

tooth with incomplete apex but recent pulpal exposure, a the fractured area is located below the edge of the free gin-
direct pulp capping can be performed with calcium hydrox- giva. On those cases a surgical access through a gingival flap
ide powder and calcium hydroxide cement. However, there is usually necessary to expose the fracture margin, allowing
are no objective criteria to determine the degree of contami- the correct restoration (. Fig.  14.53a–l). After the access, it
 

nation of an exposed pulp, so the symptoms are the most must be evaluated if the biologic width was invaded. On
important aspect [3]. If the direct pulp capping is performed positive cases, if the invasion is small and it is only restricted
without previous curettage, the risk of remaining bacterial to the lingual side, a small osteotomy can be performed to
contamination is greater, and the pulp must be thoroughly recover the biologic width. However, if a fracture below the
Composite Restoration on Anterior Teeth
539 14
alveolar bone crest has occurred on the labial side or the in esthetic problems. On those cases, an orthodontic extru-
invasion of the biological width happened on the proximal sion is required (. Fig. 14.54a–o). It can be performed with
 

area or on the labial surface, the osteotomy will lead to a fixed or removable orthodontic appliances. However, it is
change of the gingival position on the labial surface, resulting recommended to perform a weekly supracrestal fiberotomy,

a b

c d

e f

..      Fig. 14.52  Restoration of a fractured tooth associated with a glass
fiber post and silicone index. a shade determination; b restoration
wax-up in a plaster model; c application of silicone on the model; d
removal of the labial side of the index; e preparation of root canal; f
fitting test of glass fiber post (Whitepost – FGM) and the silicone index;
g bevel on the enamel margin; h protection of the adjacent teeth with
PTFE strip and acid-etching; i rinsing; j drying the canal with an
absorbent paper points; k application of the dual-cure adhesive system
Futurabond U (Voco) with a disposable applicator (Cavibrush, FGM); l
application of the silane over the post; m application of the dual-cure
resin cement directly inside the root canal (Bifix QM, Voco); n post
insertion inside the canal; o light-­curing after excess removal; p lingual
surface of the restoration performed with enamel shade composite
(Amaris, Voco, shade TN) using the silicone index; q placement of the
matrix and wedge to restore the proximal surface; r proximal surfaces
restored; s dentin shade composite inserted reproducing the dentin
mamelons and the incisal opaque halo; t high-translucency composite
applied between the mamelons; u insertion of a layer of enamel shade
translucent composite, followed by an opaque tint creating the white
areas scattered irregularly with a disposable applicator, an attempt to
simulate the white fluorotic spots on the adjacent tooth; v, w applica-
tion of the last increment of enamel shade composite; x final result
 540 C. R. G. Torres and R. F. Zanatta

g h

i j

k l

14

m n

..      Fig. 14.52 (continued)
Composite Restoration on Anterior Teeth
541 14

o p

q r

s t

u v

..      Fig. 14.52 (continued)
 542 C. R. G. Torres and R. F. Zanatta

w x

..      Fig. 14.52 (continued)

a b

14
c d

..      Fig. 14.53  Trans-surgical restoration. a, b Fracture bellow the application of the composite; i contouring of the composite surface
gingival margin; c incision to provide access; d open flap; e rubber dam with a flat brush; j finished and polished restoration; k flap reposi-
isolation; f acid-etching; g application of the adhesive system; h tioned and stitched; l final result after 2 weeks
Composite Restoration on Anterior Teeth
543 14

e f

g h

i j

k l

..      Fig. 14.53 (continued)
 544 C. R. G. Torres and R. F. Zanatta

where a scalpel blade is used to cut the supracrestal connec-
tive tissue fibers around the tooth, avoiding the bone forma-
tion as the tooth is extruded.
When a partially erupted anterior tooth suffers a fracture,
the lesion may apparently invade the biologic width, which is
still not defined. When that happens, it can be advantageous
to wait for the end of the tooth eruption and just then to
make the final restoration. Many fractures with invasion of
the  biologic width, with  the passing of time, become frac-
tures without invasion. In the meantime, the tooth could be
maintained without restoration, if the patient does not pres-
ent sensitivity, or with a temporary restoration, even with

a b

c d

14

e f

..      Fig. 14.54  Treatment of a fracture with pulpal and periodontal
involvement. a, b Fracture of tooth 21; c, d views of the fragment
showing the fracture below the CEJ; e fragment fitting test showing
the space loss due to the migration of the adjacent tooth; f, g
orthodontic movement with a removable orthodontic appliance to
recover the space; h open flap to perform a small osteotomy on the
lingual surface, allowing the positioning of a No. 212 clamp below the
fracture margin; i rubber dam isolation; j fitting test of a glass fiber
post; k as the fragment adaptation to the remaining tooth structure
was very poor, it was chosen to perform a direct restoration. Before
stitching the flap, the restoration was finished and polished. l flap
repositioned and stitched; m, n orthodontic extrusion to recover the
biological width; o final result
Composite Restoration on Anterior Teeth
545 14

g h

i j

k l

m n

..      Fig. 14.54 (continued)
 546 C. R. G. Torres and R. F. Zanatta
o
..      Fig. 14.54 (continued)
invasion of the biologic width. This can avoid the children
undergo unnecessary surgical procedures, which may cause
psychological traumas for the rest of the life [3].
>> When a partially erupted anterior tooth fractures, the
lesion may apparently invade the biological width,
which is still not defined. When that happens, it can be
advantageous to wait for the end of the tooth eruption
and just then to make the final restoration. Many of
them, with the passing of time, become fractures
without invasion.
To perform the rubber dam isolation, due to the large differ-
ence in the bone crest level position between the labial and
lingual surfaces, is frequently necessary to bend the lingual
jaws of the No. 212 clamp downward. For that, the technique
14 described in the . Fig. 7.12 can be followed. Although to per-
 
form the finishing and polishing procedures immediately
after the end of a composite restoration has its disadvantages,
and should be delayed on normal situations, it must be done
at the same appointment on the cases of trans-surgical resto-
rations, allowing the healing of the gingival tissue. After the
end of polishing, the area must be copiously irrigated with
saline solution to remove any residues and the flap pressed in
position for 5 min. Then, the flap is stitched and the region
protected with a periodontal dressing [3]. The patient must
receive analgesics, and an ice pack should be applied on the
surgical area (side of face) during the first 10 min.
14.6.3.6  Reattachment of Fractured Tooth
Fragments
When a dental fracture occurs, despite the involvement of
the pulp and/or periodontium, the best situation is when the
patient was capable to recover the dental fragment. This sim-
plifies the restoration of the esthetic and function through a
reattachment procedure. It has as advantages a better esthetic
result and function, besides this treatment  last longer than
direct composite restorations. In addition, the procedure is
simpler and faster than direct or indirect restorations. For the
patients, there is a positive emotional factor, since they do
not feel mutilated with the loss of part of his tooth. However,
the reattachment is not indicated on the cases of largely
restored tooth and less indicated when there is a shade con-
trast between the fragment and the remaining tooth struc-
ture or with the adjacent teeth. The esthetic result will also
not be ideal when the remaining tooth structure suffered
color changes due to intrapulpal bleeding that happened due
to the trauma [3]. After the traumat, the patient should be
instructed to maintain the toooth fragment inside, water to
avoid its dehydration, until the dental apointment .
The first step is to perform the prophylaxis of the dental
fragment and remaining tooth structure and do the shade
selection. This is important to choose the proper shade for
the resin cement or flowable composite that is required for
the bonding procedure [3]. The fractures with supragingival
margins may be treated with the rubber dam or cotton roll
isolation [3]. However, on the subgingival fractures, the use
of rubber dam isolation is mandatory [3]. When necessary, a
No. 212 retraction clamp can be placed, stabilized with low
fusing compound or gingival barrier to avoid its movement
during the treatment. The fragment must be fixated to the
heated tip of gutta-percha or low fusing compound stick, in a
way to allow  its manipulation. The adaptation of the frag-
ment to the remaining tooth structure must be evaluated
(. Fig.  14.55a–i). At this moments, the correct fitting posi-
tion to adapt the fragment should be memorized, training
how to place in at the moment of the bonding procedure [3].
It must be evaluated if any tooth movement happened in the
meantime between the trauma and the dental appointment,
which would close the space for the fragment fitting, being
required a previous orthodontic recovery of the lost space. It
must also be analyzed if the gingival tissue grown and cov-
ered the margins of the fractured area.
If there is any difficulty to correctly place the fragment in
the desired position, it is possible to prepare a positioning jig
[3]. For that, the fragment should be provisionally stabilized
in position with composite, without adhesive application,
which is light-cured. Over the incisal edge of the fragment
and the adjacent teeth, a water-soluble lubricant is applied,
such as a glycerin gel. Self-curing acrylic resin is applied over
the lubricated area using a brush, which is first soaked in
monomer and dipped in the polymer. After the curing, a
positioning jig is obtained and can guide the definitive seat-
ing. The fragment is then removed and cleaned and receives
the adhesive procedures. The jig may also be made with a
putty viscosity silicone impression material. When a layer of
calcium hydroxide cement is applied as a liner on the remain-
ing tooth structure, this additional volume will impair the
fragment adaptation. On this case, an internal space needs to
be created in the fragment by cutting the dentin in this
region.
In some cases, the fracture happens without any tissue
loss, and the fragment adapts perfectly to the remaining tooth
structure. On those cases, the reattachment may be performed
only with the adhesive system (. Fig. 14.55a–i). After prophy-
laxis of fragment and remaining tooth structure, the proximal
surface of the adjacent teeth must be protected with a polyes-
ter or PTFE strip. Then, the acid etching of the remaining
Composite Restoration on Anterior Teeth
tooth structure and the fragment is performed, followed by
blot drying and application of the adhesive system. The acid is
applied first over the enamel and then over the dentin. If a
liner was applied, the acid should not be applied over it.
Preferably a total-etch two-bottle and two-step adhesive
system, with a primer and adhesive separated, should be
used. After the acid etching, the primer must be applied to
both structures (remaining tooth and fragment), followed by
gently airstream to leave thin coat and evaporate the
­primer’s solvent. Then, the adhesive (which has no solvents)
547 14
is applied, and the fragment is taken in position. While held
firmly, the excess of adhesive is removed with an airstream or
brush, followed by light-curing for 40 s from the labial side
and for 40 s more seconds from lingual side. The gutta-­percha
or compound stick is removed. If a total-etch one-bottle sys-
tem is used, it would not be possible to remove the solvent
with airstream before bonding, without removing the neces-
sary adhesive for the reattachment of the fragment, so the
solvent would be trapped inside the adhesive interface creat-
ing weak areas.

a b

c d

e f

..      Fig. 14.55  Fragment reattachment procedure using only an fragment; f, g application of a total-etch two-bottle and two-step
adhesive system. a Initial aspect; b fitting test of the fragment adhesive system (primer + adhesive); h reattached fragment; i final
adaptation showing a perfect match; c prophylaxis with pumice; d result
acid-etching of the remaining tooth structure; e acid-etching of the
 548 C. R. G. Torres and R. F. Zanatta

g h

..      Fig. 14.55 (continued)

14
a b

..      Fig. 14.56  Fragment reattachment procedure using resin cement.
a Initial aspect; b rubber dam isolation; c fragment fixation in a low
fusing compound stick; d fitting test of the fragment showing
defective adaptation due to the loss of structure; e, f acid-etching; g, h
application of the adhesive system; i dual-cure resin cement applied
(RelyX ARC, 3M/ESPE); j reattachment with resin cement; k preparation
of a double bevel on the interface with round diamond point to mask
the interface; l acid-etching on the area beveled area; m Application of
the adhesive system; n placement of a composite on fracture line; o
result after 1 week
Composite Restoration on Anterior Teeth
549 14

c d

e f

g h

i j

..      Fig. 14.56 (continued)
 550 C. R. G. Torres and R. F. Zanatta

k l

m n

14

..      Fig. 14.56 (continued)

However, on most of the cases, the fragment does not fit
perfectly to the remaining tooth structure, and there is a loss of
tissue on the fracture line. On those cases, a material with
stronger mechanical properties should be used to fill the gaps,
such as resin cements (. Fig. 14.56a–o) or flowable composites
 
(. Fig. 14.57a–n). The adhesive system selected is used follow-
 
ing the manufacturer’s recommendations, similarly to an adhe-
sive cementation of an indirect restoration. The adhesive
system is applied, followed by a gently airstream to promote
the solvent evaporation and leave a thin coat. In general, it
should not be light-cured, in order to not adversely affect the
fragment fitting. The resin cement or the flowable composite
resin is applied on the fragment, which is taken into position.
The excess is removed with a brush and dental floss, followed
by light-curing using a high-output light-­curing unit. On most
cases, there is no need to use dual-cure resin cement, because
the labiolingual dimensions of the crowns of anterior teeth
allow proper polymerization by the light transmitted through
the tooth structure. However, depending on the fracture loca-
tion, on areas where the light cannot reach, such as on subgin-
gival fractures, dual-cure adhesive and resin cement must be
selected. On cases of large loss of tooth structure at the inter-
Composite Restoration on Anterior Teeth
face, the cement shade may not be adequate to mask the cement
line. On those cases, the double bevel can be performed on the
interface using a round diamond point, which will simultane-
ously produce bevels on the fragment and the remaining tooth
structure. The groove produced is restored with a composite
551 14
sion to recover the periodontal biologic width. However, on
cases where the fragment is kept in position and  holds the
gingival tissue, instead of immediately removing the frag-
ment, it is possible to make a temporary reattachment,
according to what is shown in . Fig.  14.58a–e. This allows

with proper shade and translucency (. Fig. 14.56j–n).

  maintaining the smile esthetic during the orthodontic extru-
On cases of dental trauma, when the fracture line extends sion or may reduce or eliminate the need for periodontal
beyond the alveolar crest on the region of the proximal sur- surgery on the cases of partially erupted tooth, besides to
faces, the most indicated procedure is the orthodontic extru- simplify endodontic treatment whenever necessary.

a b

c d

e f

..      Fig. 14.57  Fragment reattachment procedure using flowable applied (GrandioSO Heavy Flow – Voco); j application of composite on
composite. a Initial aspect; b shade determination; c Rubber dam the fragment; k fragment reattachment; l light-curing; m final aspect
isolation; d fitting test of the fragment; e, f acid-etching; g, h applica- with the tooth dehydrated because of the isolation; n result after 1
tion of Solobond M (Voco) adhesive system; i flowable composite week
 552 C. R. G. Torres and R. F. Zanatta

g h

i j

k l

14

m n

..      Fig. 14.57 (continued)
Composite Restoration on Anterior Teeth
553 14

a b

c d

..      Fig. 14.58  Oblique fracture below the alveolar crest. A temporary adhesive system with primer and adhesive separately (Solobond
reattachment was performed before the endodontic treatment and Plus – Voco); e fragment reattached and composite restoration of the
orthodontic extrusion. a Fractured tooth with the fragment in position; lost structure
b double bevel on the interface; c acid-etching; d application of the

Depending on the fracture line location, an intraradicu-
lar post can be used for retention ( . Fig. 14.59a–l). The indi-
 
cation of intraradicular posts is related to the dimensions of
the fractured area and the overbite. The larger is the fractured
area and/or the deeper is the overbite, the higher will be the
indication of a post to improve the retention of the fragment.
They are only indicated in the cases of large fractured areas.
Non-vital tooth with transverse fracture including the entire
clinical crown, requires retention and stabilization provided
by the intraradicular post [3]. When large fractures occur on
teeth with a deep incisor overbite and strong contacts of dis-
occlusion guides on the incisors, it is also advisable to use a
post; while on a patients with anterior open bite or minimum
incisor overbite, the post might not be necessary. For trans-
verse fractures located between the medium and incisal third
of the crown, the post is also not indicated. On cases of
oblique fractures, the use of a post for retention is also not
required, because there is a large surface area on the fracture
 554 C. R. G. Torres and R. F. Zanatta

line available for bonding [3]. When the fracture involves
two-thirds or more of the clinical crown and the fragment
was lost, a full-crown restoration is indicated, while on the
other situations, a direct composite restoration can be per-
formed [3]. It is important to remember that the post does
not increase the fracture strength of the tooth, more than the
adhesive composite restoration by itself, promoting only the
retention [3, 4]. Patients with deep incisor overbite, when the
edge of the lower incisors touch the cervical third of the lin-
gual surface of the upper incisors, as well as with sleep brux-
ism or clenching while awake, have not a good prognosis
when direct restorations or reattachment is performed. Large
bevels around the whole fractured area can be performed to
increase the retention, and occlusal splints are recommended
to protect the restorations during the night. The patients with
wear facets are not recommended for direct restorations or

a b

c d

14

e f

..      Fig. 14.59  Fragment reattachment procedure using intracanal glass
fiber post. a Initial aspect; b fragment fitting test; c internal cleaning of
the fragment, creating space for the glass post; d acid-etching; e
application of a dual-cure adhesive system inside the canal and on the
remaining tooth structure with a disposable applicator; f application of
the adhesive on the glass fiber post (Whitepost DC, FGM); g light-curing
of the resin cement after post cementation; h fragment fitting test; i
acid-etching of the fragment; j application of the adhesive system; k the
resin cement was applied inside the crown and then it was placed in
position; l final result
Composite Restoration on Anterior Teeth
555 14

g h

i j

k l

..      Fig. 14.59 (continued)

fragment reattachment. Those signs suggest extreme func-
tion or parafunction, which will produce severe stress over
the restorations [3].
If the fragment is stored dry after the fracture, before the
dentist appointment, it becomes dehydrated and whiter than
the remaining tooth structure. After the reattachment, it can
rehydrate and recover its natural shade after some days.
However, some fragments take some months to recover the
original color, while others will never recover to return to the
original appearance. Therefore, the tooth must preferably be
kept immersed in water after the fracture [3]. After reattach-
ment, the patient must be advised to avoid using this tooth for
biting and cutting hard food, as well as to avoid any habits that
may produce high level of stress over the fragment and dis-
place it, such as tearing into packaging with teeth, pencil
chewing, chewing ice, and using tongue piercings [3]. Mouth
guards must be used when playing any contact sports, as well
as occlusal splints are recommended in case of bruxism. The
patient must return to the office for periodic visits after 1
week, 1 month, and then each 6 months after fragment reat-
tachment, to analyze the pulp vitality, perform periodontal
probing, and analyze the color of the fragment and remaining
 556 C. R. G. Torres and R. F. Zanatta

tooth structure, as well as of the composite or cement used in width-to-length ratio. On median diastemas, close to 2 mm,
the bonding interface [3]. Pulp and periodontal complications besides adding composite to the both adjacent teeth, it may
are common after a traumatic accident and clinical evidences be convenient to make enameloplasty on the distal surface
can appear just after some time. The radiographic control of these teeth, slightly increasing the mesial surface of the other
the traumatized teeth is required due to the possibility of adjacent teeth, obtaining a better distribution of the space.
internal and/or external root resorption, which may appear in Large diastemas must be treated associating orthodontic
the radiographic image only after a long period of time. movement with composite restorations [35].
When patients with large median diastemas (larger than
>> After reattachment, the patient must be advised to
3 mm) are treated only with composite buildups, the restored
avoid using this tooth for biting and cutting hard food,
teeth will be larger than the natural teeth can be. For exam-
as well as to avoid any habits that may produce high
ple, the central incisors are rarely larger than 9.5  mm. If a
level of stress over the fragment and displace it, such
patient with incisors of 9.5 mm has a 3 mm width diastema
as tearing into packaging with teeth, pencil chewing,
and the dentist fills half of this space with composite, the final
chewing ice, and using tongue piercings. Mouth
dimensions will be 11 mm width. This will break the correct
guards should be used when playing any contact
width-to-length ratio, creating a non-esthetic result. In gen-
sports, as well as occlusal splints are recommended in
eral, the apparent width of upper anterior teeth should not be
case of bruxism.
higher than 80% of its length. This situation would require a
reduction of at least 1 mm on the distal surface of both cen-
tral incisors, which would result in dentin exposure on the
14.6.3.7  Recontouring Teeth with Direct proximal surfaces. On those cases, the orthodontic treatment
Composite Buildups is essential, promoting the redistribution of spaces, reducing
Some patients present anomalies of tooth formation which the diastemas between the central incisors, and creating
results in abnormal shape or size, such as misshapen peg-­ spaces between them and the lateral incisors, which could be
shaped maxillary lateral incisor, microdontia, dens in dente, closed by adding the composite on the mesial surfaces of the
and Hutchinson’s incisors. Others have generalized diaste- lateral incisors [27].
mas due to tooth size and arch length discrepancies or local- It is very important to measure the diastema size to plan
ized diastemas, such as the median diastema [36]. Despite the final width proportion among the anterior teeth. For that,
the reason, those disturbances may severely compromise the it can be used a plaster study model and a bow compass with
esthetics of the smile. In some cases, the orthodontic treat- two needle points, or a Chu’s Aesthetic Gauge to analyze den-
ment may completely solve the problem. However, in other tal proportion, as it has already been described. If the teeth
situations, only an artificial recontouring may be the solu- that are forming the diastema present an incorrect width-to-­
tion. The adhesive direct composite restorations are an excel- length ratio, with teeth narrower that could be, the diastema
14 lent alternative to the full crowns, because they are closure may be performed without any problem. If the teeth
conservatives and can reshape the teeth simply by adding are already larger than the ideal, to increase even more its
material, without requiring any cutting of the intact tooth width would result in a great esthetic problem, and it would
structure. be better to redistribute the spaces with orthodontic treat-
The median diastema, located between the central inci- ment.
sors, is the most frequent one. Its etiology was generally To preserve the anatomic proportions, sometimes when
related to the presence of enlarged labial frenum, which the width of anterior teeth needs to be enlarged with com-
could adversely affect the normal closing of the space between posite buildups, it may be also necessary to increase its
the teeth. Other causes include anodontia, very small or length. If the occlusal relations and the facial appearance
badly formed teeth, and tooth size discrepancy, which is a allow (see 7 Sect. 1.3.4 in 7 Chap. 1), the adequate dental
   

disproportion among the sizes of upper and lower anterior length may be obtained adding composite on the incisal
teeth (Bolton’s discrepancy), supernumerary teeth, and edge. The width-to-length ratio can also be improved through
hereditary factors. The diastemas may also result from other a gingival periodontal surgery, increasing the clinical crown
problems such as tongue thrusting, periodontal disease, or length [35]. It is advisable to previously simulate the changes
posterior bite collapse. The diastemas should not be closed making a diagnostic wax-up on a plaster model and a mock-
before to diagnose and treat its causes [31]. The occlusion ­up restoration, applying the composite on the teeth without
must be carefully evaluated. any previous adhesive procedure. This will give the patient an
When closing diastemas is important to keep an adequate idea about how the future restoration will look like, and if
width-to-length ratio to obtain an esthetically pleasant final that result is pleasant to him. The bow compass with two
results [35]. According to the size, the diastemas can be clas- needle points can be used to analyze the mock-up dimension
sified into three types, which are small (space smaller than 1 and do any correction [27].
mm), medium (space from 1 to 2.5 mm), and large (space For the restorative procedure, after shade determination
larger than 2.5 mm). For the small diastemas, a little amount and prophylaxis of the teeth surface, the rubber dam isola-
of composite can be applied on both adjacent teeth, until the tion can be performed. Ligatures with dental floss can be
total closing of the space, producing little interfering on the required to provide a good retraction of the rubber dam
Composite Restoration on Anterior Teeth
edges. As an option, cotton roll isolation with retraction cord,
associated or not with a cheek retractor, can also be per-
formed. When both teeth adjacent to the diastema will be
restored, the first restoration must be finished before starting
the second one (. Fig. 14.60a–o) [27]. First of all, the adja-
 
cent tooth to the one that will receive the first restoration
must be protected with a PTFE strip. Then, the acid etching
557 14
of the enamel is performed for 15 s and the surface is rinsed.
The acid etching must be extended to the middle of the labial
and lingual surfaces, from the gingival to the incisal third of
the crown. The restoration will cover about one-third of the
labial and lingual surfaces. It is important to be sure of not
covering with composite any non-etched enamel. Any etched
enamel areas that remain uncovered by adhesive and com-

a b

c d

e f

..      Fig. 14.60  Diastema closure. a Initial aspect; b shade determina-
tion; c protection of the adjacent tooth with PTFE strip and acid-
etching; d rinsing; e drying with airstream; f application of the adhesive
system; g light-curing; h application of enamel shade composite
(Amaris – Voco, shade TN) with the matrix in position, stabilized with
the index finger; i matrix closed over the labial surface for light-curing
the increment; j measurement of the tooth dimensions with a bow
compass with two needle points; k analysis the space left for the
restoration of the adjacent tooth; l acid-­etching; m application of
adhesive; n application of the last composite increment, closing the
matrix over the labial surface; o final result
 558 C. R. G. Torres and R. F. Zanatta

g h

i j

k l

14

m n

..      Fig. 14.60 (continued)
Composite Restoration on Anterior Teeth
o
..      Fig. 14.60 (continued)
posite will remineralize after the contact with the saliva [27].
The enamel may be dried with an airstream, since there is no
exposed dentin, observing the white-opaque appearance,
showing it was correctly etched. If an adhesive with separated
primer and bond bottles is selected, there is no need to apply
the primer [31]. However, if the enamel is left wet, the primer
application is important, since the bonding resin is hydro-
phobic. It is important to use a composite with enough phys-
ical properties to bear the masticatory forces to which the
restoration will undergo, such as the microhybrid, nanohy-
brid, or nanofilled. In the past, due to the insufficient polish-
ing provided by the hybrid composite, it was recommended
to use this material to restore only the lingual side, being
covered by a microfilled material on the labial surface. This
procedure is no longer necessary with the modern compos-
ites, because they provide good polishing and esthetics asso-
ciated with proper mechanical properties.
Before applying the composite, a polyester strip may be
contoured drawing it over the round back end of a clinical
tweezer and placed in position. The bow compass with two
needle points is used to measure the mesiodistal dimensions,
to guarantee the symmetry of the restored teeth. If one tooth
is larger than the other, this discrepancy can be compensated
with the restoration [31]. The restoration must start below
the gingival margin to create a natural contour and ensure
adequate gingival embrasure and emergence profile [31]. If
the cotton roll isolation is being used, a gauze bandage square
can be placed over the tongue to prevent undesired contami-
nation of the area with saliva [31]. The polyester matrix strip
must be inserted into the gingival sulcus between the inter-
dental papilla and the tooth. It is kept in position with a pad
of the index finger, pressing the lingual aspect of the strip
toward the remaining tooth structure, while the labial por-
tion is reflected away. Wedges are, generally, not recom-
mended because they could create an inadequate emergence
profile [31]. The composite is applied with a hand composite
filling instrument, pressing it toward the lingual side to
ensure that it will reach the lingual surface. The matrix is
gently closed on the labial side, pulling more the gingival
edge of the strip to prevent overhangs (. Fig. 14.60h, i). Care
 
559 14
should be taken not to pulling the strip too much, which may
result in the undercontoured restoration. Most of the small
diastemas may, in many cases, be successfully closed only
using enamel shade composites, which are more translucent
[35]. However, larger diastemas require the use of an opaque
dentin shade, to block the dark background of the mouth.
On those situations, the first increment of dentin shade com-
posite may be placed until it fills approximately half of the
labiolingual distance. The composite is light-cured, and a
new layer is applied, using enamel shade material. The matrix
is closed over the labial tooth surface, and the light-curing is
performed through the strip. The first restoration is finished
and shaped until obtaining the correct anatomical size and
shape [35]. The dimensions can be evaluated with a bow
compass to determine if they are correct (. Fig. 14.60j, k).
Tip
Wedges are not recommended when closing
diastemas with composite because they can create an
inadequate emergence profile.
After that, the restoration of the neighbor tooth is started.
The proximal contact may be obtained by displacing the
already restored tooth with the thumb and the index finger
slightly toward the distal side, while the matrix is maintained
in contact with the adjacent restoration. The polishing is only
performed after the second restoration is finished. The conti-
nuity of the cervical region of the restoration with the tooth
structure must be perfect, without overhangs. It is evaluated
by passing a dental floss embracing the tooth on the proximal
surface, moving it cervicoincisally. It should not shred and
fray, which would indicate the presence of defective contour.
Any overhang must be completely removed using abrasive
finishing strips. The occlusal contact during centric occlu-
sion (CO) and disocclusion guides must be evaluated and
adjusted [31].
On the case of medium and large diastemas, the palatal
silicone index technique, as already described, may simplify
the procedure to be performed, as it can be observed in
. Fig. 14.61a–q.
. Figures  14.62a–d′ and 14.63a–i show clinical cases of
dental recontouring of peg-shaped maxillary lateral incisor
using palatal silicone index, similarly to what was already
been described for fractured and caries-affected teeth. In
. Fig. 14.62a–d′, the palatal silicone index was made directly
in the mouth over the old unsatisfactory restorations.
14.6.4  The Use of Color Modifiers
The color modifiers, also referred as characterization mate-
rial or tints, are flowable composites with different colors and
opacities, intended to be used as an intermiediate layer
between the adhesive coat and the restorative composite or
between the composite layers (. Fig. 14.64). Before its use, it
 560 C. R. G. Torres and R. F. Zanatta

should be applied over a mixing pad and mixed with a hand
instrument with small circular movements. If it is too vis-
cous, it can be mixed with clear liquid resin (untinted), sup-
plied by some manufacturers, or with the adhesive of a
two-bottle (primer and bond) fourth-generation adhesive
system, which does contain solvents in the composition. It
must be applied the thinnest layer possible, enough to pro-
duce the optical effect desired, such as 0.25  mm or less,
because they have fewer inorganic fillers and more pigments,
with reduced mechanical properties. It is applied with a thin
brush in a way that, at the end, it would not be possible to
observe the marks left by the bristles. That would indicate
that the material is still too viscous [27].
On the case of teeth with darker shades on the cervical
region, a honey yellow or light brown tint can be applied
over the adhesive coat, producing a gradient of shades,

a b

c d

14

e f

..      Fig. 14.61  Diastema closure using a diagnostic wax-up and
silicone index. a–c Initial aspect; d aspect after dental bleaching; e wax-
up on the plaster model; f acid-etching; g etched enamel with
white-opaque appearance after the drying with air steam; h applica-
tion of the adhesive system; i silicone index fitting test; j index in
position with enamel shade composite to restore the lingual surface
(Opallis – FGM, shade E-Bleach); k lingual surfaces restored; l applica-
tion of the opaque dentin shade composite (Opallis shade D-Bleach);
m application of enamel shade composite; n aspect after polishing; o
final result. p, q smile before and after the treatment
Composite Restoration on Anterior Teeth
561 14

g h

i j

k l

m n

..      Fig. 14.61 (continued)
 562 C. R. G. Torres and R. F. Zanatta
o p
..      Fig. 14.61 (continued)
starting from the cervical area and extending 1–2 mm incis-
14 ally. The tint is light-cured and covered with dentin and
enamel shade composites. After polishing, the yellow back-
ground will be seen through. The final shade of the restora-
tion will depend on the amount and chroma of the tint
applied, as well as the thickness of the composite layer
applied over it. The tint color may be changed by mixing a
little amount of white tint or a clear liquid resin [27]. The
white tint is generally referred to simply as opaque, because
it is used mainly to mask or cover dark backgrounds, such as
metal or sclerotic dentin.
On most cases, a highly translucent incisal edge may be
restored associating opaque and translucent shades of com-
posite. However, if a highly translucent composite is not
available and the translucency of the incisal edge is intense,
with a grayish or bluish appearance (due to opalescence), a
gray, blue, or violet tint or a mixture of those can be applied
on the region to create the desired effect. They can be used
between the tooth and the composite, or between the layers
of the composite. First of all, it is necessary to analyze the
characteristics of the intact adjacent teeth to be recreated. It
must be done before the rubber dam isolation, because the
drying can adversely affect the observation of the details. The
tint is applied as a thin layer with a brush on the desired areas
and then light-cured [27].
The honey yellow, light, and dark brown tints, besides
being used to recreate the cervical shade, can also be used
to replicate the dark grooves on the posterior teeth (. Fig. 
15.17 t, u ) and enamel cracks. On cases of teeth with yellow
areas due to the counter-opalescence, the yellow tint may
also be used. Hypomineralized spots may be created with
white opaque tints applied over the dentin shade layer or
between  the enamel shade composite (. Fig.  14.52a–x).
Another possibility to simulate the hypomineralized spots
consists of making small cavities on selected areas, about
0.5 mm deep, on the already finished and polished surface
of the restoration, with a round diamond point, and apply-
ing a little amount of the opaque tint, covering it with the
same enamel shade composite previously used [27]. The
opaque tints can also be used to recreate the opaque halo on
the incisal edge and mask a dark background, such as on
darkened teeth or metallic restorations (. Fig. 15.16f) and
sclerotic dentin, or reduce the translucent aspect of some
composites [27].
To simulate enamel cracks on the restorations, the last layer
of enamel shade composite is applied but not light-­cured. A 10
Composite Restoration on Anterior Teeth
563 14

a b

c d

e f

..      Fig. 14.62  Recontouring of peg-shaped maxillary lateral incisors
using palatal silicone index prepared over the old restorations. a
Unsatisfactory restorations on teeth 12 and 22. Shade determination; b
preparation of the silicone index using putty silicone material over the
old restorations; c old restoration removed from tooth 12; d rubber
dam isolation and test of the silicone index; e protection of the
adjacent teeth with PTFE strip and acid-etching; f rinsing; g drying with
the stream. A white-opaque appearance is observed on the etched
area; h application of the adhesive system; i light-curing of the
adhesive; j application of enamel shade composite on the index (Z350
XT – 3M/ESPE); k lingual surface restored; l restoration of the proximal
surfaces using matrix strip and wedge; m placement of opaque
composite for the incisal opaque halo; n application of opaque
composite to restore the dentin lobes; o application of highly
translucent composite between the dentin lobes to reproduce the
translucency of the incisal edge; p application of a body opacity
composite over the remaining tooth structure and the dentin shade
composite; q application of enamel shade composite and contouring
with a flat brush; r immediate result; s finishing with polishing disc
(Super-Snap, Shofu); t, u preparation of grooves between the lobes
with fine grit diamond point (No. 392EF, Komet); v creation of scratches
to simulate the perikymata using a diamond point moved very slowly
mesiodistally; w polishing with felt disc (Diamond Flex, FGM) and
polishing paste (Diamond Excel, FGM); x, y final result of the tooth 12; z
initial aspect of tooth 22; a′ initial aspect of the tooth 22; b′, c′ final
result of the tooth 22; d′ final aspect of both restorations
 564 C. R. G. Torres and R. F. Zanatta

g h

i j

k l

14

m n

..      Fig. 14.62 (continued)
Composite Restoration on Anterior Teeth
565 14

o p

q r

s t

u v

..      Fig. 14.62 (continued)
 566 C. R. G. Torres and R. F. Zanatta

w x

y z

a’ b’

14

c’ d’

..      Fig. 14.62 (continued)
Composite Restoration on Anterior Teeth
× 4 mm piece of thin polyester strip is cut and inserted into the
composite, following the direction of the crack that is desired to
simulate. The light-curing is performed, and the stripe is
removed, leaving a small gap. This space is filled with the
selected tint, the excess is removed, and the light-curing is per-
formed [27]. On the case of a dark yellow background, the blue
color tint, which is complementary color of yellow, can be
applied over to reduce the yellowish aspect [31]. In Class IV res-
torations, it is possible to apply a little amount of white opaque
567 14
tint between the lobules made with dentin shade composite, in
the incisal area, to highlight this detail [19, 38]. Another possi-
bility to recreate the counter-­opalescence is to apply a small
amount of the white opaque tint on the end of the dentin lob-
ules, covering them with naturally opalescent composite. There
also some opaque tints with shades following the VITA Classical
shade guide, such as the A1 and A3 from Kolor + Plus (Kerr),
which may be used to bring the background shade closer to the
desired shade for the final restoration (. Fig. 17.6h, i).

a b

c d

e f

..      Fig. 14.63  Dental recontouring of peg-shaped maxillary lateral index; e application of enamel shade composite on the index; f finished
incisors using diagnosis wax-up and palatal silicone index. a Initial lingual surface; g application of dentin shade composite creating the
aspect; b wax-up on a plaster model; c removal of the old restoration dentin lobules; h immediate result; i final result after polishing. Clinical
and placement of gingival retraction cord; d fitting test of the silicone case performed by Dr. Taciana M. F. Caneppele
 568 C. R. G. Torres and R. F. Zanatta
g h
..      Fig. 14.63 (continued)
14
..      Fig. 14.64  Example of color modifier (Kolor + Plus – Kerr)
14.6.5  Finishing and Polishing
The finishing and polishing represent the last ones but
extremely important steps of a composite restoration. The
finishing  is the procedure of large removal of restorative
material to eliminate excess and overhangs on the margins,
improve contour, adjust the occlusion, and produce a
­reasonably smooth surface. On the other hand, the polishing
is the procedure of fine removal of the restorative material,
resulting in a very smooth and glossy surface, reproducing
the texture of the natural teeth and giving comfort to the
patient.
14.6.5.1  Finishing
Ideally, no cut or grinding on the restoration should be per-
formed immediately after the light-curing of the final compos-
ite layer, because it is not fully polymerized. However, it is
sometimes hard to obtain a perfect restoration contour during
the incremental composite placement, being necessary some
type of finishing. Therefore, to provide the adequate function
and comfort for the patient, just the essential adjusts should be
performed at this moment. The “dark-curing” of the compos-
ite continues for about 24 h after light-curing, when the mate-
rial reaches its maximum strength [3]. The friction produced
by a rotary instrument generates more aggression to a com-
posite recently placed than after the post-­curing.
Finishing is the procedure of large removal of restorative
material to eliminate excess and overhangs on the
margins, improve contour, adjust the occlusion, and
produce a reasonably smooth surface.
Composite Restoration on Anterior Teeth
It was proved that the polymerization shrinkage can pro-
duce marginal gaps on the tooth-restoration interface. In
addition, the use of rotary instruments can generate micro-
fractures on the tooth and restoration margins around the
gap, and the residues may penetrate into gaps, creating white
lines on the interface. When the dentist wait for a certain
period before polishing the restoration, the composite can
suffer water sorption and undergo a certain hygroscopic
expansion, of approximately 1% by volume, reducing the
size or even closing the marginal gaps and the possibility of
white lines [3]. The white lines observed clinically are cor-
related with the rupture of the adhesive bonding and the
lack of restoration adaptation to the tooth structure. How-
ever, it is important to highlight that, even though the gap
may be closed by the water sorption, the adhesive interface
will remain broken, allowing marginal microleakage. Other
reasons for white lines at the interface are the traumatic fin-
ishing and polishing procedure, improper etching and/or
adhesive application, and composite polymerization using
excessively high-emmitance light-curing units, creating
excessive shrinkage stress and not only gaps but also micro-
cracks of the enamel close to the margins [3]. Some studies
have shown that delaying the polishing procedure can
reduce the marginal microleakage and surface roughness,
besides increase the microhardness [18, 20, 44, 45]. How-
ever, in the cases where the gingival margin was accessed by
retraction clamps or by surgical means, the finishing and
polishing must be performed before the removal of the rub-
ber dam [3].
After the isolation removal is important to perform the
occlusal adjustment of the restoration, analyzing the con-
tacts in maximum intercuspation and during the excursive
movements of the mandible. The presence of the premature
contact or interference during the excursive movements
may lead to fracture or displacement of the restoration [31].
First of all, the CO contacts must be adjusted, evaluating if
the teeth adjacent to that restored are contacting the oppo-
site teeth the same way as before the tooth preparation. The
contacts on CO must be marked with one of the two colored
sides (e.g., black) of an articulating paper, placed facing the
restoration. If only the restoration contacts the opposite
teeth and the adjacent teeth do not show any contact, the
composite must be grinded and the contact evaluated once
again. If necessary, the adjustment must be repeated until all
the adjacent teeth that had contact before the preparation
start to contact once again. Then, the second colored side
(e.g., red) is placed facing the restoration, and the patient is
asked to perform lateral and protrusive movement on the
mandible. The restored tooth may participate on the disoc-
clusion guides but the stronger contacts should be, when-
ever possible, distributed on the intact neighbor teeth [3]. If
the anterior disocclusion guide is happening only over the
restored teeth, it must be adjusted until the adjacent teeth
start to participate.
569 14
If the restored tooth does contact or participate of the dis-
occlusion guides with the antagonist teeth on the remaining
tooth structure, no contact needs to be left on the restoration.
However, if before the restoration the tooth did not do any
contact or guides, it must be reconstructed with the restora-
tions and adjusted for not producing interferences during
functional movements of the mandible. The stress concentra-
tion over a single restoration may result on its fracture or
displacement [31].
The entire marginal area of the restoration, at the tooth-­
restoration interface, must be analyzed with an exploratory
probe. It has to be moved from the tooth surface to the restora-
tion surface and from the restoration to the tooth, detecting
excess or lack of material. The anatomical form must also be
analyzed, evaluating the presence of over or undercontour. The
proximal surface must be evaluated with dental floss. If it shreds
and frays, that will indicate the presence of overhangs or other
marginal disadaptations [31]. The dental floss must be placed
below the gingival cavosurface angle and pulled incisally on a
movement like the one used to polish shoes [31]. Any abnor-
malities must be corrected by removing or adding composite.
It is important to highlight that instruments to be used
during finishing and polishing must be adequate to the shape
of the surface to be worked, which can be flat, concave, or
convex. The marginal overhangs, mainly on the proximal
surfaces, may be removed with scalpel blades, such as the No.
11, 12, or 15, moved from the tooth surface to the restoration
or following the margin, using gentle cutting movements,
keeping the blade laying on the enamel surface as a guide to
prevent an over removal [31]. This prevents marginal frac-
tures, cutting small portions at a time. If a large area is
intended to be removed with a blade at once, the composite
may fracture inside the cavity preparation walls, being
required to repair this region adding more material. An
irregular gap is created and may allow biofilm growing, as
well as residues deposition that can promote marginal stain-
ing and the recurrent caries lesion. The No. 12 blade is useful
on the proximal areas due to its curved shape and a thin end,
making it ideal to remove excesses on the cervical regions
(. Fig.  14.48u) [31]. There are also dedicated hand instru-
ments for composite excess removal on the margins, such as
the contour carbide carver shown in . Fig. 14.48t.
Rotary instruments may also be used to remove excess on
the margins, such as the fine grit (average particle size of 25
μm) and extra fine grit (average particle size of 15 μm) dia-
mond points, multi-bladed burs (. Fig. 14.65a, b), or the alu-
minum oxide mounted stones (. Fig. 4.28a). The shape of the
rotary instrument must fit the surface to be worked on. The
egg (football) or pointed football-shaped instruments are
used on the lingual surfaces, which has a concave contour
(. Fig. 14.48s) [31]. Those instruments should be used under
air refrigeration from a three-way syringe, in reduced speed,
gently pressure, and intermittent contact [2, 3, 31]. The use of
air/water spray adversely affects the visualization of details in
 570 C. R. G. Torres and R. F. Zanatta
the area to be finished. The thin tip cone-shaped rotary
instruments, such as the fine grit diamond points or the alu-
minum oxide mounted stones, are indicated for difficult
access regions as the cervical area and embrasures or flat sur-
faces (. Fig.  14.39t). On the gingival margin of labial sur-
 
faces, the Zekrya gingival protector or similar instrument
can be used during the finishing avoiding harming the gin-
giva (. Fig. 6.16) [3].
 
The rotary instruments must be used with care in the
cervical region, especially on the root surface, to prevent
the incorrect and undesired removal of the tooth structure,
usually cementum and dentin. During the finishing proce-
dure on the gingival margin, to remove excess of composite,
the restoration surface only should be touched with a bur or
diamond point, while a mesiodistal swiping movement is
being performed. The marginal adaptation must be fre-
quently evaluated with an exploratory probe. If the rotary
instrument is activated touching the tooth/root surface
without being constantly moved, it can create a defect like a
groove on the surface that will require restoration [31]. The
difficulty is higher when the overhang is located in a gingi-
val margin of the preparation covered by the marginal gin-
giva. In an attempt to completely remove the excess, the
dentist sometimes grinds the root and creates a step
(. Fig.  14.66a, b) [31]. For safely finishing of the gingival
 
margins on that situation, 0.5 mm of the diamond coat can
be removed from the tip of the conical-shaped diamond
point. For that, the abrasive point is rotated over an abrasive
stone until the diamond particles are lost in this area
(. Fig. 14.66c). The safe end tip instrument can be used to
 
contour the cervical areas of the restorations. Touching the
safe end on the root surface inside the gingival sulcus, it can
14 easily reshape the cervical region without harming the root
surface (. Fig. 14.39t) [27].
 
If the matrix band has been properly placed in the proxi-
mal area, there is almost no need to finish or polish the prox-
imal surface of the restoration, because the composite is
capable to copy the roughness of the matrix strip. However, if
there are cervical overhangs, they must be removed without
damaging the proximal contact. For that, the abrasive strip
a b
..      Fig. 14.65  Rotary instruments for finishing procedure. a Fine grit diamond points of different shapes; b multi-bladed burs (30 blades)
should be used with a back-and-forth movement. The abra-
sive strip has two color-coded abrasive grades per strip,
sequenced from dark to light, with the center gapped for easy
interproximal insertion. One of the sides has thicker grit for
finishing and the other with a thinner grit for polishing
(. Fig. 14.67). Different strip widths are available on the mar-
ket. The narrow ones are indicated in short interproximal
areas to improve contour, remove excess, and polish the cer-
vical regions. The wide ones should be used carefully for not
removing the contact between the teeth [31]. When passing
the strip through the proximal contact areas, gapped center
without abrasives can be used without abrading the contacts.
When it is necessary to grind the entire proximal surface of
the restoration, the abrasive strip must simultaneously touch
the labioproximal and linguoproximal external line angles
(. Fig. 14.48w). However, if the grinding is required in only
one of the external line angles, the abrasive side of the strip
must touch the restoration only on that side, pressed over the
corresponding smooth surface with one of the hands, while
in the opposite side, it is moved away from the tooth with the
other hand (. Fig. 14.48v) [31].
Abrasive discs can be used on flat tooth surfaces such as
the labial surface and incisal edge (. Figs. 4.30a and 14.62s).
The finishing is performed with a more abrasive disc, while
the polishing is performed with a sequence of decreasing grit
size. They are used dry in low speed and intermittently [3]. In
the labial surface of the incisors, the discs are used in the flat
area located on the incisal and medium thirds. The cervical
third is convex and can be finished with a long conical-­
shaped rotary instrument, such as a fine grit diamond point,
multi-bladed bur, or aluminum oxide mounted stone.
During the finishing is important to pay attention to the
fact that the contour and surface topography of the restora-
tion must be similar to the adjacent or homologous tooth.
Young people present an irregular labial surface, showing the
developmental lobes. Before polishing, all those details must
be reproduced. For that, the tooth must have the essential
finishing complete, with the correct crown contour and with-
out marginal excess. Then, diamond points with different
shapes are used, depending on the surface characteristics to
Composite Restoration on Anterior Teeth
571 14

a b

..      Fig. 14.66  a, b Finishing of cervical restoration with gingival be created rotating the tip of a diamond point over a mounted stone,
cavosurface angle covered by the marginal gingiva may result on until complete removal of the diamond layer
wrong grinding of the root surface, creating a step; c a safe end tip can

contact, as brushing strokes, trying to create scratches per-

pendicularly to the axis of the tooth. If the perikymata of the
adjacent tooth or remaining tooth structure are deep, a coarse
grit diamond point can be used, while if they are shallow, a
fine grit point should be chosen. This procedure can be per-
formed without water spray, allowing the dentist to follow
the creation of the scratches (. Figs. 14.38t′, u′ and 14.62v).
 

14.6.5.2  Polishing
Even though it is impossible to obtain a perfectly smooth
surface of a restoration inside the mouth, the surface rough-
ness can be gradually reduced using a sequence of abrasive
agents, with particles progressively smaller, until reaching
the texture of natural enamel. . Figure 14.68 shows the sur-
 

..      Fig. 14.67  Abrasive strips face profile of a composite, measured using a laboratory a
device called rugosimeter. It has a diamond stylus tip that
be reproduced. The two grooves between the developmental does direct contact with the surface and is moved on it, gen-
lobes, on the labial surface of the adjacent intact teeth, can be erating a graphic representation of the surface profile. In this
marked with a pencil and reproduced over the restorations graph, it is possible to observe the higher points called peaks
[1]. The grooves may be prepared with a thin end conical-­ and the lower ones called valleys. The upper graphic in
shaped diamond point, as it is shown in . Figs. 14.38s′ and . Fig. 14.68 shows the surface roughness after the finishing
   

14.62u. The perikymata may be reproduced by moving a dia- procedure, while the lower shows the roughness after polish-
mond point over the labial surface in very slow speed, on the ing. It can be noticed that even after all efforts on the polish-
deceleration of the handpiece rotation, with intermittent ing procedure, a perfectly smooth surface is not obtained.
 572 C. R. G. Torres and R. F. Zanatta

..      Fig. 14.68  Surface profile of

a restorative composite after ROUGHNESS AFTER FINISHING
finishing and polishing proce-
dures 0.200

mm

–0.200

0.25 mm/div

ROUGHNESS AFTER POLISHING

0.200

mm

–0.200

0.25 mm/div

14 However, the resulting roughness must come close to the
natural teeth, below the visual detection level, and not be
noticed when contacting soft tissues, mainly the tongue.
Polishing is the procedure of fine removal of restorative
also be used. On the other hand, on cases of young patients,
where the surfaces have been characterized with grooves or
perikymata, the use of discs for polishing would remove the
surface details. On those cases, the labial surface should be
polished only with a felt discs and polishing paste, resulting
in a smooth but not flat surface (. Figs. 14.38v′ and 14.62w).

Another possibility to polish irregular surfaces is to use

material, resulting in a very smooth and glossy surface,
abrasive silicon carbide brushes, which bristles are impreg-
reproducing the texture of the natural teeth and giving
nated with abrasive particles(. Fig . 4.31a – 5 and 6) or abra-
comfort to the patient.
 

sive rubber spirall wheels (. Fig. 4.29d).

 

On the cervical region, the polishing can be performed

with a thin tip abrasive rubber point or disc, taking care of
The polishing must be performed keeping in mind that not creating a flat surface. It can also be used a felt discs with
surface details created by the finishing procedure should polishing paste (. Fig. 14.39u–w). A study showed that addi-
 

be kept after it. On the case of elderly patients, with a worn
and smooth labial surface, the polishing of the flat surfaces
can be performed with a sequence of decreasing grit discs.
Between each disc, the surface has to be rinsed and dried to
remove the residue of the previous abrasive particles [31].
The discs with a smaller diameter (1/2 inch) are ideal for the
cervical region, besides accessing better the embrasures and
the marginal ridges. The discs with smaller mandrel allow
more access and larger abrasive surface, while the ones with-
tional polishing with a diamond polishing paste after initial
polishing with abrasive discs reduces the surface staining of
the composites [17]. When a two-paste polishing system is
used, the paste with higher grit must be used first. Then, the
surface has to be washed, and then smaller grit one is
employed using a clean felt. Some felt discs already come
impregnated with abrasive particles and do not require the
associated use of a polishing paste. The blunt tips of the abra-
sive rubber points can be sharpened as shown in . Fig. 4.29.

out a metal center and with elastic silicone shank mount are The proximal surfaces can be polished with fine grit abrasive
easier to use. Abrasive rubber discs with a flat surface can strips (. Fig. 14.44v, w). The lingual surface may be polished
 
Composite Restoration on Anterior Teeth
using abrasive rubber points, felt points with abrasive paste,
abrasive silicon carbide brushes  or  abrasive rubber spirall
wheels (. Fig. 14.48y, z and 4.29d).
 
If during finishing and polishing procedures hollow
spaces appear on the restoration surface, due air bubbles
entrapped in the composite or defect of adaptation between
the increments, a small round diamond point is used to
remove the defective area. The area is acid etched and the
adhesive system is applied but not light-cured. The same
composite used to do the restoration is applied and light-­
cured. The surface is finished and polished [27]. It is impor-
tant that all the information regarding shades and brands of
composites and tints used for the restoration are registered
on the patient’s records. This information will be useful if any
repair is required in the future.
After ending the finishing procedure, the restorations
must be visually analyzed and the margins evaluated with
an exploratory probe. The proximal surfaces and the gingi-
val cavosurface angle have to be evaluated with dental floss.
The presence of marginal overhangs, white lines at the
interface, defective shape and contour, lack of proximal
contact, insufficient restorative material on the cavosurface
angle, and presence of air bubbles exposed on the surface
are evaluated. If there is any problem, it should be immedi-
ately corrected [3].
If the restoration is considered adequate, a surface seal-
ing procedure, also known as rebonding, can be performed
to seal microcracks on the composite surface generated by
the rotary instruments, as well as marginal gaps in the
tooth-­ restoration interface produced by the shrinkage
stress. For that, acid etching of composite surface and
tooth structure 1–2 mm beyond margins is performed for
15 s, which is rinsed with air/water spray and dried with
the airstream. The surface sealant is applied, followed by
an airstream to produce a very thin coat, which is light-
cured for 10 s. This procedure increases the marginal
integrity and reduces the composite wear. It may be
repeated at each patient return to the dental office, every 6
months or 1 year [3]. The product used for the surface
sealing is a dedicated material and is not related with pit
and fissure sealants.
14.7  Durability and Maintenance
of the Composite Restorations
The durability of the composite restorations depends on
three main factors: the dentist, the material, and the
patient. In relation to the dentist, the correct indication of
each restoration technique, the adequate tooth prepara-
tion, and the proper use of adhesive system and restorative
technique will guarantee a maximum quality esthetic res-
toration. However, technical failures during the restorative
procedure may drastically reduce the durability of the res-
toration, allowing premature degradation and intense
microleakage, leading to postoperative sensitivity and sec-
ondary caries lesions. The dentist is responsible to perform
573 14
each operative procedure very carefully; paying attention
to the technical details [31]. In relation to the restorative
material, good quality products correctly indicated will
match the efforts and correct technique applied by the
dentist, increasing the longevity of the restoration.
Material’s characteristics such as mechanical properties
and polishability are paramount for the correct indication
of each product on each clinical situation. In relation to
the patient, factors such as extension of the lesion, static
and dynamic occlusion patterns, the dietetic habits, and
oral hygiene are very important to determine the durabil-
ity of the restoration [31].
The larger the preparation, the more critical is the resto-
ration and greater are the chances of failure. People with high
consumption of acidic food and beverage, as well as high
level of chromogens, or heavy smokers may present faster
degradation of the composite organic matrix, as well as very
fast staining. The parafunctional habits may also lead to the
premature degradation of the restoration due to the great
stress they are subjected. The patients must be informed
about the etiology of the caries disease and non-carious
lesions they may have, and be motivated to practice preven-
tive measurements, including dietary changes, good oral
hygiene practices, and periodic visits to a dental clinic.
Despite the best material and restorative technique used by
the dentist, the long lasting of the restorations will mainly
depend on the patient’s oral care.
>> Despite the best material and restorative technique
used by the dentist, the durability of a dental
restorations will mainly depend on the patient’s oral
care.
Conclusion
This chapter presented all procedures necessary to restore
anterior teeth with composite-based materials. The con-
cepts related to shade determination and esthetic analysis
were discussed and must be kept in mind, whenever this
kind of restoration is planned by the dentist. In relation to
the tooth preparation, the maximum preservation of the
remaining tooth structure must rule the clinical procedures,
but always allowing the best esthetical results to be
obtained. The step-­ by-­step restorative techniques for all
classes of cavities were presented here, since selection of
appropriated composite, adhesive system application,
matrix placement, and incremental technique. For fractured
teeth, the diagnosis of the actual conditions and extension
of the damage is very relevant, determining the recommen-
dations about the treatments of the pulp and periodontal
tissue, when they were involved, or the choice for a fragment
reattachment or a full composite restoration. In addition,
composites can also be used for recontouring teeth, being
an excellent alternative to indirect procedures, since no
removal of sound tissue is necessary. However, despite the
best dentist’s efforts, the durability of the restoration
depends a lot of the patients’ oral habits and hygiene, and
they need to be informed about that.
 574 C. R. G. Torres and R. F. Zanatta

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14 11. Cox CF.  Microleakage related to restorative procedures. Proc Finn
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 577 15

Composite Restoration
on Posterior Teeth
Carlos Rocha Gomes Torres, Marcelo Balsamo, and Satoshi Imazato

15.1 Introduction – 578

15.2 Bioactive Restorative Materials – 581

15.3 Tooth Preparation – 583

15.4 Restorative Techniques – 585

15.4.1  cclusal Preparations (Class I or Site 1) – 586
O
15.4.2 Restoration of Proximal Lesions Through Occlusal Access
(Class II or Site 2) – 599
15.4.3 Restoration of Proximal Lesions through Buccal/Lingual Access – 621
15.4.4 Esthetic Improvement of Amalgam Restorations – 621
15.4.5 Repair of Ceramic or Composite Restorations – 622

15.5 Finishing and Polishing – 626

15.6 Surface Sealing – 628

15.7 Maintenance of Posterior Composite Restorations – 628

References – 629

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_15
 578 C. R. G. Torres et al.
Learning Objectives
The learning objectives of this chapter are related to the fol-
lowing topics:
55 To describe the indications and contraindication of direct
composites on posterior teeth
55 To explain how the characteristic of the composite
materials can influence the restorative procedure as well
the clinical behavior of the restorations
55 To teach how to perform the tooth preparation with
maximum preservation of the remaining tooth structure
55 To explain how to perform the restorations of cavities
involving the occlusal and/or proximal surfaces
55 The importance of the proximal contact between
neighbor teeth and how to properly restore it, using
different techniques
55 How to apply the regular and the bulk-fill composites
55 How to improve the esthetic or to repair old restorations
55 To describe the finishing and polishing techniques for
composites in posterior region
55 How to perform the maintenance of posterior composite
restorations to increase its durability
15.1  Introduction
The growing demand for esthetic dental procedures on the
past decades increased the use of composites for the restora-
tion of posterior teeth. Every time the patients are asked by
the clinicians about which restorative material they prefer,
one of metallic shade or one with the same appearance of
natural teeth, almost everyone choose the esthetic restora-
tions, even after being informed about the limitation of those
materials. Although they produce good esthetics results, the
composite restorations on posterior teeth present some dis-
15 advantages in relation to the amalgam ones. However, when
properly indicated and performed, they may present very
good clinical behavior. The composites are nowadays the
most used direct restorative material on posterior teeth [40].
They are necessarily indicated on cases where the esthetics
requirements are important, such as on situations where the
restoration will be visible in the normal interpersonal dis-
tance, during the conversation and social life.
An important advantage of composite restorations in
relation to amalgam is the bonding to the tooth structure.
That turns unnecessary to give any specific geometric form to
the tooth preparation. When performing amalgam restora-
tion, the restorative material and remaining tooth structure
behave as two independent structures in intimate contact,
with a mechanical interaction through the interface. On the
other hand, when an adhesive restoration is done, the loads
applied over the restoration generate internal stress, which is
transmitted through the interface to the remaining tooth
structure, causing both to behave as almost as a single body.
That does the restoration to reinforce the remaining tooth
structure [33]. The preparation is restricted to the removal of
carious tissue, with maximum preservation of the healthy
remaining tooth structure [33]. Another advantage of the
composite restorations is the fact that they can be easily
repaired, adding a new material on the old one [33]. In addi-
tion, it is also thermal insulator due to the low thermal con-
ductivity [33].
The light-curing composite seems to be easy to apply into
the tooth preparations, using a single paste which does not
cure spontaneously. However, the proper use of this material
is a little complex. Even though the tooth preparation for
composite restoration is simpler than for amalgam, the
restorative technique is much more critical and prone to fail-
ure [33]. To produce adequate composite restorations, the
clinician must have a good understanding about the bonding
process, the shrinkage stress generated during polymeriza-
tion, and the details and peculiarity about the light-curing
procedure [15].
When compared to the amalgam restorative technique,
the composite restoration takes 2.5 as much time to be done,
due to a more complex restorative procedure, turning it more
expensive [35]. More steps also increase the chances of mis-
takes. A great difficulty occurs during the restoration on
proximal preparations, being more difficult the correct resto-
ration of contour and the interproximal contact. Differently
from amalgam, regular composites will not push the matrix
toward the adjacent tooth during the application of the incre-
ments [33]. In addition, composites undergo a volumetric
shrinkage during polymerization, which may lead to several
problems on the restoration (. Fig. 15.1). Among them, gap
formation on the margins allows microleakage of pigments
and bacteria, leading to marginal staining and recurrent cari-
ous lesion (. Fig. 15.2a, b). In the internal walls, some debond-
ing areas at the interface may also happen, creating internal
gaps. The shrinkage stress may also generate enamel micro-
cracks, distributed approximately parallel to the cavity mar-
gin, besides cuspal deflection. The latter may lead to enamel
microcracks on buccal or lingual surfaces or even cuspal frac-
ture, besides postoperative sensitivity (. Fig. 15.1) [33].
>> Composites undergo a volumetric shrinkage during
polymerization, which may lead to several problems
on the restoration, such as gap formation on the
margins, microleakage of pigments and bacteria
leading to marginal staining and recurrent carious
lesion, enamel microcracks, cuspal deflection, cuspal
fracture, and postoperative sensitivity. The effects of
volumetric shrinkage must be controlled using an
appropriate restorative technique.
In the course of time, a degradation of the hybrid layer
occurs, reducing the bond strength and increasing the mar-
ginal microleakage. This is caused by the hydrolysis of the
dentin collagen fibers, exposed by the acid etching or acidic
monomers, besides the degradation of polymers created by
hydrophilic monomers in the adhesive system formulations
[47]. The hydrolysis of the dentin collagen is promoted by
Composite Restoration on Posterior Teeth
579 15

Recurrent
Gap caries

Enamel
microcracks
Microleakage

Marginal
staining

Marginal
enamel
microcracks

Internal gaps

Post-operative
sensitivity

..      Fig. 15.1  Clinical problems created by the shrinkage stress during composite polymerization. (Image kindly supplied from 3 M Espe
company)

..      Fig. 15.2  a SEM image of

a b
marginal gap on composite
restorations created by shrinkage
stress (red arrow – gap); b higher
magnification of the image shown Composite
in a Composite

Enamel
 580 C. R. G. Torres et al.
dentin matrix metalloproteinases (MMP), which are colla-
genolytic enzymes released during the bonding procedure
[41]. This bonding interface degradation is enhanced by the
mechanical stress produced by masticatory loads, and by the
stress generated due to the difference between the coefficient
of linear thermal expansion (CLTE) of the composite and
tooth structure, when exposed to hot or cold food and bever-
ages, resulting in the propagation of the interfacial defects.
The composite restorations also have higher wear than amal-
gam, mainly on the direct contact areas. The larger the resto-
ration, the bigger is the concern in relation to the wear. The
composite restorations are also more susceptible to occur-
rence postoperative sensitivity, especially when the adhesive
technique was not properly performed.
It must be considered that, the more posterior is the tooth
to be restored, the harder is the isolation of the operating field
and smaller is the esthetic demands of the restoration. Both
factors reduce the indications for composite restorations on
the second and third upper molars, where the esthetic is not
critical unless the preparation extends to the buccal surface
[33]. When the restoration is not visible during the conversa-
tion, some patients accept metallic materials, considering its
longer durability. However, many patients desire their teeth
with a natural aspect, even on areas where they cannot nor-
mally be seen [33]. Skinner stated that “the esthetic quality of
a restoration may be as important to the mental health of the
patient, as the biological and technical qualities of the resto-
ration are to his physical and dental health” [39]. However,
the esthetic demands are determined by the individual per-
ception and subjected to great variation. What may please
one patient may be completely unacceptable to another. Some
people may be happy and proud of having gold restorations
on their anterior teeth, while others think those restorations
are esthetic unacceptable. It is a dentist’s duty to inform the
15 patients about all restorative alternatives, but it must be given
to them the opportunity to take the final decision in relation
to which alternative will be chosen [33].
The composite restorations on posterior teeth are only
indicated in Class I and II preparations (Sites 1 and 2) that
can be properly isolated, since the adhesive technique is not
compatible with any kind of contamination, such as saliva or
blood. They are contraindicated on cases where it is impossi-
ble to obtain correct isolation of the operating field using rub-
ber dam or cotton rolls [34, 48]. This situation is more critical
on the mandibular molars or on preparations where the cavo-
surface angle of the gingival wall is located inside the gingival
sulcus [4]. On cases where the moisture control is extremely
hard or not possible, associated with the absence of enamel
available for bonding on the gingival margin of the prepara-
tion, an amalgam restoration should be performed [33]. On
teeth with weakened or cracked cusps, the use of an adhesive
restorative material is recommended, because it can bond to
and reinforce the remaining tooth structure [33]. The com-
posite restorations are also indicated to patients allergic to
certain metals. However, in large tooth preparations, the first
choice would be an indirect adhesive restoration.
>> The composite restorations are only indicated in
preparations that can be properly isolated, since the
adhesive technique is not compatible with any saliva
or blood contamination.
Ideally, occlusal contacts of the restored tooth in maximum
intercuspation should occur on the remaining tooth struc-
ture, because the composite wear resistance is smaller than of
enamel. When all the contacts are left over composite, it
wears out and allows a dental extrusion, leading to occlusal
disharmony [4]. The wear resistance refers to the material
ability to resist to the surface loss, due to attrition with the
opposite intact tooth or restoration (two-body wear) or abra-
sion with the food bolus or toothbrush (three-body wear).
Clinical studies showed that the attrition wear of composite
restorations, on contact areas with the opposite tooth, may be
3–5 times higher  than the abrasive wear on areas without
direct contact. For this reason, direct composite restorations
should preferably be performed on teeth which remaining
tooth structure has direct contact with the opposite tooth.
. Figure 15.3a, b shows a composite restoration with exten-
 
sive abrasive wear. The material was lost by the contact with
the food bolus, exposing the preparation walls.
>> Clinical studies showed that the wear of composite
restorations, on contact areas with the opposite tooth,
may be 3–5 times higher than on areas without direct
contact. For this reason, direct composite restorations
should preferably be performed on teeth which
remaining tooth structure has direct contact with the
antagonist tooth.
The fillers’ size, shape, and content in a composite affect the
restoration wear, as well as the location of the restored tooth,
dental arch, and occlusal contacts. The wear resistance of the
current composites is generally adequate for clinical use [11,
27]. Clinical studies have shown that the composite restora-
tion wear is smaller on premolars and increases the more
distally the restored tooth it is located. Of all teeth, the first
molars are in contact with food bolus more often and receive
the larger loads. Therefore, abrasive wear happens faster on
occlusal composite restorations of those teeth. The sequence
of wear severity can be described as first molar > second
molars > second premolars > first premolars. Thus, small
composite restorations on the first premolars present little
wear risk, while large restorations on the first molars have
larger risk [4].
The tooth preparation size must be considered when the
restorative technique is selected. The direct composite resto-
rations should be preferably done on small to medium size
cavities [33]. On extensive ones, when the buccolingual
dimensions are larger than half the distance between the
cusp tips (intercuspal distance), in cases of extremely weak-
ened teeth under heavy occlusal loads, or when one or more
cusps were lost, the ideal indication is an indirect ceramic or
composite restoration [33].
Composite Restoration on Posterior Teeth
581 15
..      Fig. 15.3  a Macrofilled
a b
chemically activated composite
restoration with extensive Enamel
abrasive wear. The tooth was
extracted due to periodontal
problems after a long time of
clinical use; b the composite wear
exposed the preparation walls
(arrow). A rough surface can be
observed due to protruding filler
particles and craters and by the
presence of air bubbles incorpo-
rated during the mixing process

Composite

Tips indicated. Due to its great hardness, the porcelain will pro-
mote unacceptable wear of the composite. In this situation, a
The direct composite restorations should be performed direct amalgam or an indirect ceramic or metal cast restora-
on small to medium size cavities. In case of large tion should be chosen [33].
preparations in weakened teeth, with cusp lost, indict It is also relevant to have enamel on the entire cavosur-
restorations are the best alternative. face angle, which provides a significantly more effective
bonding and marginal sealing than when the margins are on
cement or dentin. In general, when the gingival wall of the
Even though the large direct composite restorations on pos-
preparation extends to the root surface, without enamel on
terior teeth may have many disadvantages, they can be used
the gingival cavosurface angle, a gap is formed between the
as an esthetic treatment alternative. Many patients cannot
tooth and the composite. This happens because the compos-
afford the costs of an indirect restoration or have medical
ite shrinkage stress is greater than its initial bond strength to
conditions that do not allow a more complex dental treat-
the dentin [33]. In this case an amalgam or an indirect resto-
ment. On those cases, large direct composite restorations
ration should be better indicated [4]. The composite may
may be used as a reasonable option, when the more long-­
also be used to repair defective restorations, either amalgam,
lasting treatments are not possible [33]. The patient must be
composite, or ceramic. They are also used on posterior teeth
aware about the limitations in relation to the material’s prop-
on Class VI preparations, created by the wear on the cusp
erties, attending periodic dental visits to reevaluate the resto-
tips [33].
ration [33]. The ability to reinforce the weakened remaining
tooth structure turns this procedure a good option to a non-
adhesive amalgam restoration [33]. The direct composite
restoration in large cavities may also be indicated as a tempo- 15.2  Bioactive Restorative Materials
rary procedure while waiting to determine the pulp response,
when a conservative pulpal treatment was performed [33]. The traditional dental materials are designed to be biocom-
The direct composite can also be used as a base for indirect patible, having a passive and neutral existence in the mouth,
restorations. It can fill undermined areas and undercuts to not reacting with the oral environment. It is expected that
produce the required geometry to the walls, allowing a free the material will work properly by being well accepted and
path for insertion of the indirect restoration. causing no harm and injury. They are considered biomi-
In patients with heavy occlusal loads, due to bruxism or metic, restoring the tooth function and showing a natural
clenching, the direct composite wear can be excessive, result- appearance [2]. However, it loss the opportunity of positive
ing on a premature loss of the anatomical shape of the resto- gains, which a material with a more dynamic behavior
ration, besides showing a higher risk of bulk or marginal could exhibit, reacting to the changes in the environment
fracture. On those cases, a direct amalgam or indirect esthetic [20, 28]. The materials with such “smart” behavior are gen-
or metallic restoration should be chosen [33, 48]. The antago- erally called bioactive. There is not a consensus about the
nist tooth may also affect the wear, because a composite res- meaning of the word “bioactivity” in dentistry. However, it
toration in contact with the natural opposite tooth shows can be described as the capacity of the material to give to
more wear than in contact with another composite restora- the teeth something they need to keep its health and func-
tion [4]. In situations where the antagonist tooth has a feld- tion, by some kind of biologic effect. That can be related to
spar porcelain restoration, a direct composite should not be an antimicrobial capacity, to reduce the biofilm activity and
 582 C. R. G. Torres et al.
prevent demineralization of the surrounding tissues, or to
stimulate remineralization of the area previously affected by
caries disease, strengthening the tooth structure [10]. They
may have the potential to seal marginal gaps to reduce
microleakage, preventing secondary caries under restora-
tions and promoting a healthier tooth-restoration interface
over time. The bioactivity can also be related to healing
properties for the pulp tissue, stimulating tertiary reac-
tional or reparative dentin formation or tubular sclerosis,
protecting the pulp vitality [28].
>> The bioactivity of a restorative material can be related
to its antimicrobial capacity, remineralizing potential
or healing properties for the pulp tissue.
To offer those effects, the material must be able to release
ions, such as fluoride, calcium, and phosphate, or other active
substances, inhibiting biofilm formation, growing hydroxy-
apatite, or stimulating odontoblast cells to produce mineral
deposition. Those ions can be released by special bioactive
glasses or semipermeable resin microcapsules filled with
ionic solutions. The bioactive materials are moisture friend,
allowing a continuous ions exchange with saliva and other
oral fluids, releasing and recharging their ionic components
in response to pH changes.
Resin composites are more susceptible to bacterial col-
onization than other materials for direct restorations, such
as amalgam and glass ionomer cement (GIC). The
enhanced bacterial attachment and biofilm formation on
composites lead to occurrence of secondary caries, espe-
cially at proximal area where plaque control is difficult.
Therefore, many researches to provide composites with the
ability to prevent biofilm accumulation and achieve “bio-
active” properties have been conducted. Less plaque accu-
mulation on amalgam and GIC restorations are related to
15 the release of silver, copper, zinc, or fluoride ions, which
reduces  adherence and growth of oral bacteria on their
surfaces. Therefore, to add ion release capacity to compos-
ites, with antimicrobial properties, is a promising strategy.
There are few bioactive restorative materials currently
available on the global market, containing different kind of
ion releasing  glasses (e.g., Activa™, Pulpdent; Predicta™
Bioactive, Parkwell; Giomer™, Shofu) or microcapsules
a b
S-PRG
Surface modified layer
Glass-ionomer phase
Fluoro-boro-alumino-silicate glass
..      Fig. 15.4  Bioactive surface pre-reacted glass-ionomer filler (S-PRG – Shofu). a Three-layered structure; b ions released from the glass-ionomer
phase
(BioCoat™, Premier), associated with special monomers to
produce enough physical properties in association with its
bioactivity.
Surface pre-reacted glass-ionomer (S-PRG) filler is a
fine glass particle which has three-layered structure
(. Fig.  15.4a) [19]. It contains a multifunctional fluoro-
boro-­aluminosilicate glass core that undergoes an acid-
base reaction during manufacturing and is protected by a
surface modified layer. The stable glass-ionomer phase in
the middle layer allows ion release and recharge while pro-
tecting the glass core from the damaging effects of mois-
ture. Various restorative/coating materials containing
S-PRG fillers have been developed and commercialized by
Shofu INC., Japan, and named as “Giomer” products.
S-PRG filler releases multiple ions, i.e., fluoride (F−), borate
(BO33−), aluminum (Al3+), sodium (Na+), silicate (SiO32−),
and strontium (Sr2+), from its pre-­reacted glass-ionomer
phase (. Fig. 15.4b). By the release of Sr2+ and Na+, S-PRG
filler incorporated in resin composites can modulate the
pH of surrounding environment, shifting it to neutral or
weak alkaline regions. The release of F− and Sr2+ can
improve acid resistance of enamel and dentin by promoting
the conversion of hydroxyapatite to fluorapatite and stron-
tiumapatite. In addition to those protective effects against
demineralization, it  can reduce bacterial adherence and
prevent plaque formation on their surfaces. The release of
BO33− and F− significantly inhibits the growth and meta-
bolic activities of Streptococcus mutans, leading to inhibi-
tion of oral biofilm formation [21, 30]. Additionally, ions
released from S-PRG filler have the capacity to inhibit pro-
tease and gelatinase activities of Porphyromonas gingivalis
and also to prevent coaggregation of periodontal disease-
related bacteria [46].
Restoration of Class II cavities with deep preparation in
the proximal box, reaching the root surface and without
enamel in the cavosurface angle of the gingival wall, is always
a concern in relation to secondary caries. A marginal gap will
occur on almost every restoration, due to the lower bond
strength and high C-factor. On those cases, “bioactive” com-
posites with antimicrobial properties are expected to be
clinically very useful, improving the prognosis and durability
of the restorative treatment.
Ions release
F- Sr2+
Al3+
BO33-
Na+ SiO32-
Composite Restoration on Posterior Teeth
15.3  Tooth Preparation
Whenever necessary, prophylaxis with brush and pumice or
airborne particle abrasion device must be performed, remov-
ing extrinsic stains and biofilm. Then shade selection and the
local anesthesia are performed. It must be verified if the
patient presents highly translucent enamel, indicating the use
of a more translucent composite on the final layer. It is also
analyzed if the adjacent teeth have any type of special charac-
teristic, such as dark spots in the grooves or hypoplastic spots
that could be reproduced [4]. The occlusal harmony also
must be evaluated, verifying the teeth alignment on the arch.
When an opened cavity or defective restoration remains
untreated for a long time, the extrusion of the antagonist
tooth and the mesialization of the caries affected or neighbor
tooth may occur and must also be evaluated. The cusps of the
antagonist tooth may invade the preparation to be restored
during maximum intercuspation position, requiring reduc-
tion before starting the restorative procedures. The loss of the
mesiodistal distance, necessary to the proper restoration of
the proximal contour, may occur, due to mesialization,
requiring orthodontic movement before the restoration
(. Fig. 6.21).
Before starting the tooth preparation, the occlusion eval-
uation must be performed with thin double-sided two-color
articulating paper (e.g., red and black), allowing a two-tone
representation of static and dynamic occlusion. The first step
is to inspect the eccentric contacts (dynamic occlusion). The
paper is placed on the Miller Articulating Paper Forceps, in a
way that the red side is facing the tooth to be restored. The
patient is asked to occlude at centric occlusion and perform
protrusive and lateral excursive movements. The patient
must open the mouth, and the presence of interferences dur-
ing disocclusion movements must be analyzed. After that,
the paper is then turned in the forceps in a way that the black
side faces the tooth to be restored. The centric contact (static
occlusion) is analyzed, asking the patient to close the mouth
in centric occlusion and open it again. The color sequence
can, of course, be altered. Whenever possible, the tooth-to-­
tooth contacts occurring during centric occlusion should not
be included in the preparation outline, remaining over the
intact tooth structure. In case it is not possible, care must be
taken so that it will not be located over the tooth-restoration
interface. Not only should the contacts on the tooth to be
restored be evaluated but also on the adjacent teeth. That can
help the dentist to know when the contacts on the ­restorations
were correctly adjusted [33].
The anatomy and the cusp angle of the intact adjacent or
contralateral teeth must be evaluated and memorized, so that
similar anatomy can be reproduced on the restoration, pro-
viding the better function and esthetic. If the proximal sur-
faces need to be restored, preoperative wedging can be
performed in the interproximal space, on such a way to
increase the tooth separation, helping the reconstruction of
the proximal contacts [33]. For that, a wedge is placed in the
interproximal space corresponding to each proximal surface
583 15
to be restored. If only one proximal surface is prepared, the
wedge is placed only on that side. If both proximal surface
will be prepared, the wedges must be placed on the mesial
and distal interproximal spaces. The wedges must be tightly
readapted during the preparation, because when pressed
again, the teeth move even more, promoting additional sepa-
ration [33]. Another way to produce a progressive dental
separation is to use a separation ring, placed on the embra-
sures next to the surface that will be prepared. The prepara-
tion may be performed before or after the rubber dam
isolation when it is used.
Basically, the tooth preparation for composite restora-
tion on posterior teeth is restricted to the removal of carious
tissue, with maximum preservation of the healthy remain-
ing tooth structure [4]. The opening of the cavity must be
the most conservative as possible. On primary caries lesions
located on the occlusal surface, the opening is performed
using a round diamond point until reaching intact enamel
on the preparation outline, exposing the carious dentin tis-
sue (. Fig.  15.6a, b and . 15.7e–g). However, if the initial
opening is not providing the necessary access for removal of
remaining carious tissue, it must be enlarged as much as
necessary to every wall can be inspected, especially on the
region of the DEJ. This enlargement is considered a conve-
nience form. When it is predicted that the entire mesiodistal
extension of the central groove will be prepared, the open-
ing should start on the distal area and continued mesially,
allowing a better visualization during the procedure [33]. If
there are some separated small lesions, they do not need to
be connected during the preparation, remaining as separate
cavities. The highly infected superficial dentin must be
removed, although the more internal softened dentin can be
preserved, because it can be remineralized, as described in
7 Chap. 6. Other areas of the tooth surface that are not cavi-
tated but present a high caries risk, due to biofilm deposi-
tion, may be sealed (more information about that is available
on 7 Chap. 16).
Tips
Basically, the tooth preparation for composite restoration
on posterior teeth is restricted to the removal of carious
tissue, with maximum preservation of the healthy
remaining tooth structure.
The outline and depth of the preparation are defined by the
lateral extension and depth of carious tissue and other
defects. The main goal of this preparation is to remove the
infected tissue in the most conservative way possible. The
retention form is obtained mainly by the bonding to the
tooth structure, instead of by the mechanical characteristics
of the preparation [33].
There are two situations when a composite restoration is
indicated. The first one is when there is a previous defective
amalgam or composite restoration which needs to be
 584 C. R. G. Torres et al.
replaced, and the second is when there is a primary carious
lesion. When there is a defective restoration, it must be
removed avoiding any additional cut of the remaining tooth
structure. No modification of the preparation shape must be
done. The old restorative material must be completely
removed to evaluate the cavity walls. Leaving old amalgam
under a new composite restoration may result on poor
esthetic [33]. To avoid an additional cut of the preparation
walls, the amalgam restoration can be sectioned and the
fragments removed with a dental exploratory probe
­ formed, and any undermined enamel prisms will be left and
(. Fig. 15.8f–h). The amalgam oxide residues can be removed
 
with an airborne particle abrasion, followed by copious rins-
ing, avoiding the use of rotary instruments if no carious tis-
sue is remaining (. Fig. 15.8i).
 
The carious dentin tissue can be removed with a round
bur at low speed, of the largest size compatible with the prep-
aration dimensions. There is no need to remove the under-
mined enamel since the adhesive restoration will be able to
reinforce the remaining tooth structure. The same way, even
if the pulpal walls have different depths on each place, there
is no need to make it flat. In general, the vertical surrounding
walls will be convergent toward the occlusal surface, with a
concave pulpal wall. The internal angles will be round, as a
consequence of the round shape of the bur. Those character-
istics also contribute for the adaptation of the restorative
material on the region of the internal line angles of the sec-
ond set. The preparation of posterior teeth for composite
with a box shape, as used for the amalgam, increases the
negative effects of the C-factor and is not recommended [33].
No bevel should be performed on the occlusal cavosur-
face angle, avoiding thin restoration margins, which would
fracture under the occlusal loads [4, 33]. The bevel on the
occlusal cavosurface angle also increases the restored area,
which expands the composite surface subjected to wear. The
15 beveling on the gingival cavosurface angle should never be
performed too, because it  may completely remove the
remaining enamel on the region, resulting on bonding to
dentin or cement, which is worse than the one obtained to
enamel.
When the lesion is located on the proximal surface with
intact marginal ridge, the entry direction must be chosen. In
general, the caries lesions on the proximal surface are located
just below the contact area [33]. If the lesion is small and
close to the occlusal surface, or if the lesion is large, but there
is a small remaining of the marginal ridge, the access must be
done from the occlusal surface. For that, the adjacent tooth
must be protected with a steel strip and the gingival papillae
with a wooden wedge (. Fig.  15.11d) [4]. The preoperative
 
wedging is performed before starting the preparation, help-
ing to restore the proximal contact [33]. The preparation is
started with a round diamond point entering on the top of
the marginal ridge, opening a channel, mainly on enamel,
trying to keep a thin layer of remaining enamel between the
preparation and the adjacent tooth, avoiding to touch the bur
on the proximal surface of the neighbor tooth. The entry
should follow the DEJ.  When reaching the caries lesion, it
will be noticed by the dentist a feeling of falling on a hollow
space. Any remaining enamel still in contact to the neighbor
tooth can be fractured with a hand instrument or removed
with a bur. The remaining carious tissue is removed with a
round bur at low speed or dentin excavator [33]. The prepa-
ration outline must be the most conservative as possible but
allowing enough access for removal of remaining the carious
tissue. Because of that, generally the buccal and lingual walls
will be convergent toward the occlusal surface, giving the
proximal box the pear or drop shape [33]. No bevel is per-
reinforced by the adhesive restoration. The buccolingual and
occlusogingival dimensions must be the most conservative as
possible, determined by the lesion size [33]. The internal
angles will be round due to the shape of the rotary instru-
ment used for preparation. The gingival wall will be concave
and extended until the gingival end of the lesion.
The contact with the adjacent tooth does not need to be
removed, since this type of restoration should only be per-
formed on patients with good oral hygiene, and the region of
the tooth-restoration interface will be frequently cleaned by
flossing. Even though keeping this contact can adversely
affect the matrix placement, to get maximum preservation of
remaining tooth structure is more relevant than any techni-
cal difficulty. Conversely, to obtain adequate proximal con-
tact for the restoration will be easier [33]. When the visual
and/or tactile evaluation of the gingival or axial walls is dif-
ficult, the axial wall can be prepared expulsive toward the
occlusal surface, as a convenience form for visibility. Internal
stains on the buccal or lingual walls or under the occlusal
enamel, seen through the translucent remaining enamel,
even when related to intact sclerotic dentin should be
removed, because they can be misdiagnosed in the future as
recurrent caries lesion [33].
When the caries lesion is more cervically located or dis-
placed toward the buccal or lingual surfaces, the dentist can
choose to perform the access to the lesion through the buccal
or lingual embrasures, performing a horizontal slot prepara-
tion, obtaining the maximum preservation of the remaining
tooth structure (. Fig.  15.15a–f) [33]. This preparation is
similar to a Class III preparation on anterior teeth. The adja-
cent tooth must be protected with a metal strip and the access
performed with a small round diamond point. The instru-
ment must be placed on the correct occlusogingival position,
guided by the lesion position observed on the radiography.
The entry is performed as close as possible to the adjacent
tooth. The carious dentin tissue is removed with a round bur
at low speed or with a spoon excavator [33]. The access must
be the most conservative as possible, enough to allow the
removal of carious tissue. This way, the occlusal and gingival
walls generally will converge toward the entry surface. On
the other hand, when there is not an adjacent tooth, or there
is a preparation on the neighbor tooth that allows direct
access to the lesion, the entry direction can be strictly proxi-
mal. The final shape of the preparation will be the one that
results after the removal of the entire carious tissue. In gen-
eral, this type of preparation is only possible on the mesial
tooth surface because of visibility [4].
Composite Restoration on Posterior Teeth
Tips
When the caries lesion is located on the proximal
surface, with intact marginal ridge, the best entry
direction for the preparation must be chosen, in order to
obtain the maximum preservation of the tooth structure.
If the lesion is small and close to the occlusal surface, or
if it is large, but there is a small marginal ridge remaining,
the access must be done through the occlusal surface.
However, when the lesion is more cervically located or
displaced toward the buccal or lingual surfaces, the
access through those areas is recommended.
15.4  Restorative Techniques
For restorations of posterior teeth, the light-activated nano−/
micro-hybrid or nanofilled composites should be selected,
because they present the required physical properties to
undergo the stress generated by the occlusal loads. The
microfilled composite, even though having a good wear
resistance, when used on posterior teeth may fracture due to
its low filler content. The macrofilled composites showed
high levels of wear, creating a very rough surface due to the
exposure of the large filler particles after loss of the organic
matrix. Some filler particles are plucked from the surface,
resulting in craters. The chemically activated composites
should also be avoided, because the mixing procedure can
incorporate air bubbles into the material, which would
increase the surface roughness (. Fig. 15.3a, b).
 
If the prophylaxis has not been performed before the tooth
preparation, it must be done before starting the restorative
procedure. Then, the isolation of the operating field is per-
formed, and the need for additional pulpal protection is ana-
lyzed (see 7 Chap. 9). Whenever necessary, the application of
 
the most adequate protective material is performed. On shal-
low or medium depth preparation, it is not necessary any type
of lining material. On deep preparation, a layer of GIC can be
applied only on the pulpal or axial wall (. Fig. 9.17a–d).
 
However, if it is noticed the presence of dark and hard sclerotic
dentin on the internal walls, no additional protection is
required. When a pink discoloration is observed on the inter-
nal walls, in the region corresponding to the pulp horn, the
preparation is considered very deep. That indicates that less
than 0.5 mm of dentin is remaining and there might exist some
clinically undetected pulp microexposures. A thin layer of cal-
cium hydroxide cement is applied only over that area, which is
covered by a thin coat of a GIC, sealing the region and prevent-
ing that the acid used on the adhesive procedures dissolves the
calcium hydroxide liner (. Fig. 9.18d–i) [33]. It is recom-
 
mended to cover the minimum necessary of the preparation
walls, because the liner reduces the area of dentin available for
bonding [33]. In case of accidental pulpal exposure, the direct
pulp capping procedure can be performed (. Fig. 9.20).
 
A Class I preparation has a C-factor equals five, with five
bonded and one unbonded walls (see 7 Chap. 13). Therefore,
 
585 15
if a composite is applied in a bulk increment, there is a large
risk of bonding interface rupture during the polymerization,
due to the material shrinkage, especially along the pulpal wall
and on the marginal region. The shrinkage stress can be
reduced using a gradual curing protocol of soft start, in ramp
or step, as described in 7 Chap. 13, prolonging the pre-gel
phase during polymerization. For that, special light-curing
devices that automatically adjust the emittance (power emit-
ted) can be used. However, it is also possible to control the
irradiance (power incident) using conventional devices, by
changing the distance between the light guide tip and the
composite surface. In addition, the incremental or layering
technique proposed by Lutz et  al. [25] can be used, where
each increment is applied over fewer walls as possible, gener-
ally two at a time, always leaving the larger amount of
unbonded surfaces, creating conditions to reduce the stress
at the interface. Oblique increments should be applied,
touching the buccal and pulpal or lingual and pulpal walls,
avoiding connecting the buccal, pulpal, and lingual walls at
the same time. Techniques for stress reduction are extremely
relevant, especially on cases of weakened cusps, that may suf-
fer deflection of 15 μm on the first 15 min after the end of the
restoration and up to 18–30 μm after a week [7, 29]. After the
light-curing, the “dark-curing” of the composites continues
at a significant rate for about 20  min after the light-curing
and a slower rate for at least 24 h [4].
Some studies recommend the application of a thin layer
of flowable composite on the internal walls of the prepara-
tion, as a low-elastic modulus liner, which works as a stress-­
absorbing layer, before the application of a more viscous
material. This layer would reduce the stress on the tooth-­
restoration interface, preserving its integrity [4]. The flow-
able composite also fills more easily the undercuts and
irregularities on the walls and internal angles of the prepara-
tion [4]. This is even more relevant when replacing amalgam
restorations, which preparations have more acute angles. The
more viscous is the restorative composite to be applied, the
higher are the chances of a bad adaptation of the composite
to the preparation walls, and more advantageous is to use the
flowable composite liner [4].
The GIC can also be used as a base under composite resto-
rations as a stress-absorbing layer [33]. Many studies have
shown that GIC application, under composite restorations,
reduces the total amount of shrinkage stress that the remain-
ing tooth structure undergoes during composite polymeriza-
tion. In general, the more GIC it is applied, the less stress is
generated [18, 42]. An in vitro study showed that the use of a
GIC base significantly reduced the cuspal deflection in the
MOD preparation restored with composite [1]. Another study
has shown that the use of a GIC base applied before the com-
posite improves the marginal adaptation and reduces the
microleakage [37]. This technique is called “selective bond-
ing,” because the adhesive system will bond only to the walls’
areas not covered by the base material. On the “total bonding”
technique, the adhesive system is applied over the whole prep-
aration walls [37]. Besides the low-elastic modulus of the GIC
applied, which works as a stress-absorbing layer, the favorable
 586 C. R. G. Torres et al.
results of the selective bonding technique are certainly due to
the fact that the total volume of composite applied for the res-
toration is reduced, when the base material is applied. The
conventional GIC, which is the most indicated for this tech-
nique, may be associated with the previous etching of the den-
tin surface, to remove the smear layer, improving its bonding
to the tooth structure. A weak acid is used, such as the 10–25%
polyacrylic acid, applied on the tooth surface for 15–30 s, fol-
lowed by washing and drying with a gentle airstream. After the
initial set of the conventional GIC, its surface can be etched
with a phosphoric acid gel for 5 s, before applying the adhesive
system, improving its bonding to the composite applied above
[31]. The resin modified GIC (RMGIC) may also be used.
It should be avoided the use of sticky composites, because
this characteristic adversely affects its application into the
preparation, leading to voids on the tooth-restoration interface
or between the increments, creating weak areas where failures
can propagate, such as gaps or cracks [4]. They are also difficult
to be shaped for restoring the proper tooth anatomy [4]. In
addition, materials with excessively high viscosity shows bad
wetting properties to the preparation walls, being difficult to
adapt, leaving spaces and air bubbles at the interface [4].
One of the most important steps for proximal restorations
of the posterior teeth is the correct choice and placement of the
matrix band. Different from amalgam that can be condensed,
helping to create the proximal contact, the composite restora-
tion is almost completely dependent on the contour and posi-
tion of the matrix band to create the proper proximal contacts
[33]. Before applying the composite, the matrix strip must be
firmly touching the contact area of the adjacent tooth [33].
Tips
One of the most important steps for proximal
15 restorations of the posterior teeth is the correct choice
and placement of the matrix band. The composite
restoration is almost completely dependent on the
contour and position of the matrix band to create the
proper proximal contacts. The matrix strip must be firmly
touching the contact area of the adjacent tooth.
In the past, clear plastic bands associated with reflective
wedges were recommended to restore posterior teeth with
composite, because it was considered that the composite
shrinkage occurs toward the light source, and this procedure
would improve the marginal adaptation of the restoration
[26]. However, several studies proved that this does not hap-
pen and that the shrinkage occurs toward the bonded walls,
despite the position of the light source [4, 44]. In addition, the
plastic matrices are hard to contour and also hard to pass
through the proximal contact, on the intact surface of the
tooth to be restored. They are generally thicker than the
metallic bands and require more dental separation [4, 33].
Therefore, the metallic bands are nowadays the most indi-
cated for composite restorations on posterior teeth using
occlusal access. Besides being easier to use, they work as a
mirror that improves the polymerization, reflecting the light
transmitted through the composite back to the material [4].
The thinner strips, with about 0.03  mm (0.0015 inches),
should be chosen, instead of the thicker ones with 0.05 mm
(0.002 inches) commonly used for amalgam restorations, so
less dental separation will be required. The metallic strips may
be easily contoured and suffer less distortion under forces cre-
ated during the material adaptation into the preparation,
which is an important property when a more viscous com-
posite is used, reducing the overflow through the cavosurface
angle [4]. Clinical studies showed that the use of clear plastic
matrix associated with reflective wedge does not improve the
clinical behavior of composite restoration in relation to the
use of the metallic bands and wooden wedges [9, 12].
On cases where both mesial and distal surfaces were pre-
pared, after placement of the matrix band, it is recommended
to use of the wedge alternation technique. A single wedge is
inserted, starting in one of the interproximal spaces, followed
by restoration of this corresponding proximal surface and the
contact. Then, the wedge is removed and inserted into the
other interproximal space, and the second proximal surface
is restored. This procedure can allow the maximum dental
separation by the wedge at the moment to restore each prox-
imal box (. Fig. 15.10i, p).
Tips
On cases where both mesial and distal surfaces were
prepared, after placement of matrix band, it is
recommended to use the wedge alternation technique,
restoring one proximal surface at a time.
15.4.1  Occlusal Preparations
(Class I or Site 1)
On teeth with more translucent enamel, to obtain the better
shade and translucency match, the enamel and dentin shade
composite layers can be applied, similarly to the original
structure, using a stratified layering technique. On
. Fig. 15.5a–f are shown the external morphological aspects
of the tooth structure of some posterior teeth, as well the
internal morphology of the dentin tissue, after the dissolu-
tion of the enamel by the immersion in an acidic solution for
some days. It can be observed that the dentin follows the
external tooth morphology. This can be reproduced during
the restorative procedure.
To obtain an esthetic reconstruction of the lost tooth
structure, simulating the natural morphology, composites
with different translucency levels are used, restoring first the
lost dentin (opaque) and then the enamel (more translucent)
(. Fig.  15.6a–g´). The material must be applied in oblique
increments, leaving unbonded walls, avoiding connecting
more than two walls at the same time, in an attempt to reduce
the negative effects of the high C-factor. Each layer must have
a maximum thickness of 2 mm, to provide a good curing on
Composite Restoration on Posterior Teeth
587 15

a b

c d

e f

..      Fig. 15.5  External and internal morphological aspects of posterior teeth. a, c, e Intact teeth; b, d, f dentin view after the dissolution of the
enamel by the immersion in an acidic solution for some days

the bottom area. If there are regions of undermined enamel,
they must be filled first and correctly light-cured. The initial
polymerization of the composite on those areas can be done
through the tooth structure, reducing the amount of light
reaching the composite at the beginning of the curing pro-
cess, reducing the shrinkage stress. The curing is then com-
conical shape layer. The composite should be placed using
rapid shallow strokes, reducing the chance of detaching it
from the cavity wall, which can create voids. This first incre-
ment, using an opaque dentin shade composite, is applied
touching the pulpal wall and the lingual or buccal wall
(. Fig. 15.6p, q). Each increment is light-cured for at least 20

plemented from the occlusal surface (. Fig. 15.6i–o).

 
To simplify the placement of the increments, small
amounts of the composite can be shaped by hand as small
spheres, using dust-free gloves, and applied into the prepara-
tion using a nonstick composite filling instrument, creating a
s. The next increments touch the opposite external wall and
the pulpal wall at the same time, as well as the previous incre-
ment that has already been polymerized. It should be avoided
that increments of dentin shade composite reach the cavosur-
face angle, leaving space for the external layer of enamel shade
 588 C. R. G. Torres et al.

material (. Fig.  15.6r, s) [4]. If the dentist decides to create

  shaping the occlusal surface, nonstick instruments with a
effects of white spots, such as hypomineralized areas of enamel, probe- or conical-shaped nib can be used (. Fig.  15.6u, v).
 

small portions of white opaque tint can be applied over the
dentin shade composite already cured. The last layers are placed
using translucent enamel shades, shaping the occlusal surface,
preferably restoring each cusp at a time (. Fig. 15.6t–w). For
 
After inserting the material into the cavity, the instrument nib
must be placed on the region of the ­central groove to be cre-
ated, while the side rests over the remaining tooth structure of
the occlusal surface, touching the cavosurface angle. Then the

a b

c d

15
e f

..      Fig. 15.6  Restoration of Class I preparation. a Opening of the
cavitated caries lesion; b removal of the carious dentin tissue; c, d acid
etching; e blot drying; f visibly moist dentin surface; g application of
the adhesive system; h light-curing of the adhesive; i view of the
undermined buccal cusps; j, k filling the undermined areas; l light-
curing through the tooth structure; m, o filling the undermined
enamel on the lingual cusps and light-curing; p placement of oblique
increments using dentin shade composite (Grandio SO – Voco);
q, r placement of dentin shade composite increments; s space left for
the application of enamel shade composite; t–w application of enamel
shade composite using nonstick instruments of conical- and probe-
shaped nibs; x application of brown tint to simulate darkened grooves;
y tint applied into the grooves; z clear oxygen-blocking gel; a´ gel
application and light-curing through it; b´ finishing with fine grit
diamond points; c´, d´ polishing with silicon carbide brushes;
e´, f´ surface sealing; g´ final restoration
Composite Restoration on Posterior Teeth
589 15

g h

i j

k l

m n

..      Fig. 15.6 (continued)
 590 C. R. G. Torres et al.

o p

q r

s t

15

u v

..      Fig. 15.6 (continued)
Composite Restoration on Posterior Teeth
591 15

w x

y z

a’ b’

c’ d’

..      Fig. 15.6 (continued)
 592 C. R. G. Torres et al.
e’
g’
..      Fig. 15.6 (continued)
instrument is moved mesiodistally, copying the inclination
and all the existing details of the remaining cusp inclines and
groves, which guide the shaping procedure.
15 The use of increments on the stratified layering technique
reduces the shrinkage stress at the interface and the cuspal
deflection. It also reduces the incorporation of air bubbles on
the interface and improves the adaptation of the material on
the walls, decreasing the marginal microleakage. In addition,
it reduces the amount of excess of restorative material at the
margins and the use of rotary instruments to remove them
later on. It allows obtaining of a polychromatic restoration
and a more complete light-curing of each increment [4].
On the cases of neighbor teeth with darkened grooves,
tints can be used to reproduce this characteristic on the resto-
ration. However, it is always recommended to ask the patients
if they accept this characterization [4]. For that, very thin and
deep grooves can be shaped on the external layer of enamel
shade composite, using a sharp exploratory probe, followed
by light-curing. Then, a small amount of brown or ochre tint
is applied into the groove with a probe. The excess over the
surface is removed using a disposable applicator, and the tint
is light-cured (. Fig. 15.6x, y and 15.7t, u). Only the tint on
the deepest areas of the grooves should remain. Another
option is to apply the tint in the grooves shaped with the den-
tin shade composite, which will be covered with a translucent
enamel shade material. With the use of the layering technique,
f’
after curing of the last layer, the restoration should have an
almost perfect shape, being required only small finishing.
The external surface of the shaped composite will directly
contact the food bolus and the antagonist tooth, being sus-
ceptible to wear. As the oxygen in the atmosphere has contact
with the composite surface, it will prevent its complete polym-
erization, creating an oxygen inhibition layer, making this
critical region not reaching its maximum mechanical proper-
ties. To overcome this problem, the surface can be covered
with transparent glycerin-based oxygen-blocking gel. Then,
the light-curing can be applied through it for 20 s, completely
curing the composite surface (. Fig. 15.6z, a´). After that, the
occlusion must be evaluated using an articulating paper. Any
premature contact and interference during the excursive
movements must be removed. The patient goes home, and the
finishing and polishing can be performed on the next appoint-
ment, after the “dark-curing” of the composite has been com-
plete. Further details are presented at the end of this chapter.
Tips
To prevent the presence of an oxygen inhibition layer, the
last composite increment can be covered with transparent
glycerin-based blocking gel, followed by an additional
light-curing through it, creating a fully polymerized surface.
Composite Restoration on Posterior Teeth
593 15
On the cases of hidden caries lesions, when the occlusal sur- powder to carry it to the tooth surface (. Fig. 15.7d). Other
 

face is intact, a direct custom-made occlusal stamp can be
prepared to help the restoration of the tooth anatomy
(. Fig. 15.7a–a´). First, the occlusal surface is isolated with a
 
thin coat of petroleum jelly, and then the acrylic resin is
applied. That can be done using a brush soaked with the liq-
uid resin monomer, which is put in contact with the polymer
possibilities are to use light-curing transparent flexible tem-
porary filling material (e.g., Fermit -Ivoclar Vivadent or Clip
F -Voco) or a flowable composite (Clip flow - Voco). A small
handle can be prepared for the stamp with the same material
or using a disposable adhesive applicator. The stamp is
removed and works as an index, replicating the original

a b

c d

e f

..      Fig. 15.7  Direct custom-made occlusal stamp and hidden carious
lesion. a–d Copy of the occlusal morphology with acrylic resin;
e, g lesion opening and outline form; g removal of the carious dentin;
h finished preparation; i–k etching and application of the adhesive
system; l, m filling undermined cusp areas with dentin shade compos-
ite GrandioSO (Voco); n restoration of lost dentin area; o application of
a separating agent on the stamp; p enamel shade composite applied;
q, r stamp fitting and removal of excess; s light-curing through the
stamp; t, u application of brown tint into the grooves and excesses
removal; v application of oxygen blocking gel; w final light-curing
through the gel; x finishing with aluminum oxide mounted stone;
y polishing with diamond-embedded abrasive rubber point Dimanto –
Voco); z, a´ final result
 594 C. R. G. Torres et al.

g h

i j

k l

15

m n

..      Fig. 15.7 (continued)
Composite Restoration on Posterior Teeth
595 15

o p

q r

s t

u v

..      Fig. 15.7 (continued)
 596 C. R. G. Torres et al.

w x

y z

a'

15

..      Fig. 15.7 (continued)

anatomy of the tooth structure. After the operating field iso- way the ideal original occlusal anatomy is quickly restored
lation, bonding procedure and placement of the dentin (. Fig. 15.7o–s).
 

shade composite, the stamp receives a separating agent, such
as a hydrosoluble glycerin-based gel, liquid soap, or a piece
of PVC cling film, and a single increment of enamel shade
composite is placed into the preparation but not light-cured.
Then, the stamp is taken in the original position and pressed.
The composite overflow is removed, and the initial light-
In cases of replacement of several defective restorations,
to simplify the restorative procedure and save clinical time
during the shaping of the occlusal surface, indirectly made
occlusal stamps can be prepared. For that a plaster model of
the teeth to be restored is previously obtained, through an
impression with alginate (. Fig. 15.8). On the plaster model,

curing is performed through the stamp. Then, it is removed, the area corresponding to the old restorations is cut with a
and the light-curing is complemented for more 20 s. This bur to create space for waxing. The shape of the new restora-
Composite Restoration on Posterior Teeth
tion can be created on wax by the dentist or a laboratory tech-
nician (. Fig. 15.8b, c). An occlusal stamp can be made the
 
same way as already described, but now outside the mouth
(. Fig.  15.8d, e). When a flowable composite is used (e.g.,
 
Clip flow  – Voco), the handle can be prepared by applying
597 15
composite and light-curing at the same time. All the stamps
are previously prepared and then available for the dentist,
which can schedule the patient for a next appointment to per-
form the restorations, the same way that has already been
described for the stamp made directly in the mouth.

a b

c d

e f

..      Fig. 15.8  Indirectly made occlusal stamps. a Defective r­ estoration;
b, c grinding of the plaster model and waxing; d, e stamp preparation
using high translucency temporary flowable material (Clip Flow –
Voco); f careful sectioning of the old amalgam restoration, separating it
in small pieces, avoiding to touch the bur on the walls; g, h removal of
amalgam pieces with an exploratory probe; i preparation after cleaning
with prophy-jet device and pressurized slurry of sodium bicarbonate,
to remove the amalgam oxides, followed by thorough rinsing with air/
water spray; j removal of the remaining carious dentin tissue; k, l acidic
etching and application of the adhesive system; m placement of dentin
shade composite GrandioSO Voco); n application of enamel shade
composite; o Enamel shade composite applied but not light-cured;
p–r application of a separating agent on the stamp, fitting and
light-curing; s result without the characterization; t final result
 598 C. R. G. Torres et al.

g h

i j

k l

15

m n

..      Fig. 15.8 (continued)
Composite Restoration on Posterior Teeth
599 15

o p

q r

s t

..      Fig. 15.8 (continued)

15.4.2   estoration of Proximal Lesions

R help to obtain good isolation and prevent any contamination
Through Occlusal Access
(Class II or Site 2)
On preparations involving the proximal surface in contact
with a neighbor tooth, it will always be required to use matrix
and wedge. The wedge has the purpose to separate the teeth
to compensate the thickness of the matrix strip, stabilize the
matrix band, and prevent the overhangs at the gingival mar-
gin [33]. The application of the matrix before or after the
adhesive system depends on the clinical situation. Some den-
tists prefer to apply the matrix and wedge before, which can
of the preparation walls. It also allows evaluating if any frac-
tures occur on the cavosurface enamel margins, due to the
matrix and wedge placement, before performing the adhe-
sive application. However, in this case, care should be taken
to avoid adhesive pooling along the preparation margins,
which would create a radiolucent area on the interface
between the composite and the wall, that may be misdiag-
nosed as secondary caries. The excess of adhesive must be
removed with the airstream, dry disposable applicator, or a
thin aspiration cannula before light-curing. The application
of the matrix before the adhesive can be even more beneficial
 600 C. R. G. Torres et al.
when the gingival wall of the proximal box is very deep [33].
Other dentists prefer to apply the adhesive before placing the
matrix. The advantage for this is to avoid adhesive pooling
along the preparation margins and maximize the application
of the adhesive on the cavosurface angle. However, after
matrix application, the margins must be evaluated to see any
fracture of the marginal enamel has happened, which could
result on the composite placement over nonbonded enamel.
A frequent problem with this technique is the pooling and
curing of the adhesive beyond the margins, sometimes inside
the gingival sulcus, which adversely affects the adaptation of
the matrix to the external tooth surface. This excess of
cured adhesive must be completely removed with an explor-
atory probe before the matrix placement. Therefore, the
matrix can be placed either before or after the adhesive, since
a careful technique is performed [33].
Tips
The matrix band and wedge can be placed either before
or after the adhesive application, since a careful
technique is performed, avoiding pooling on the
margins, which can be misdiagnosed as secondary
caries.
The main challenge when using a composite to restore poste-
rior teeth is to obtain proper interproximal contacts. This is
related to the viscosity of this material, which is different
from amalgam and cannot be condensed and pressed toward
the matrix during the application into the preparation. Due
to this fact, some techniques were developed to overcome
this problem, which is presented next. To restore the proxi-
mal surface of posterior teeth with composite, sectional
15 matrix placed in only one proximal surface or circumferen-
tial matrix surrounding both proximal surfaces can be used
during the restoration.
15.4.2.1 Sectional Matrix with a Separation
Ring
An option to help obtaining adequate proximal contacts is
the use of a pre-contoured sectional matrix associated with a
separation ring (. Fig. 15.9a–u). It is especially advantageous
 
when only one proximal surface will be restored, because the
intact contact on the other proximal surface does not need to
receive the band, reducing the amount of teeth separation
necessary to compensate the thickness of the matrix. Some
in  vitro studies, measuring of the contact tightness, have
shown that separation rings and sectional matrices create
tighter contacts than the circumferential matrix [23, 24, 36].
The preoperative wedging used during the preparation
is  removed, the matrix band is placed, and a new wedge
is  inserted [33]. The convex matrix edge is placed cervi-
cally, while the convex side must face the adjacent
tooth  (. Fig.  8.8). A matrix with occlusogingival width
 
compatible with the dimensions of the preparation must be
chosen (. Fig. 15.9e). Its height must be enough to place the
 
gingival edge of the band 1 mm below the cavosurface angle
of the gingival wall and the occlusal edge 1 mm beyond the
marginal ridge of the adjacent tooth [33]. The wedge is
inserted from the larger embrasure. Then, the separation
ring is placed in the embrasure regions, separating the teeth
and stabilizing the band, also helping to compensate the
thickness of the matrix strip. In addition, the ring brings the
matrix borders in contact to the remaining tooth structure,
avoiding the composite overflow at those areas. The separa-
tion ring is taken in position with a clamp forceps and must
touch the proximal surface of both teeth in each embrasure
at the same time. For that, it must be placed over the wedge.
However, on the case of teeth with short clinical crown, the
ring may not obtain adequate stability. On this case, the
wedge can be shortened in a way to not adversely affect the
ring adaptation. An option is to use special separation rings,
such as Composi-Tight 3D (Garrison) or Palodent Plus
(Dentsply), with notches on its tines, which allows the
wedge to pass through it, not interfering on the ring adapta-
tion (. Fig. 8.9a–d).
Tips
The matrix band height must be enough to place the
gingival edge of the band 1 mm below the cavosurface
angle of the gingival wall and the occlusal edge 1 mm
beyond the marginal ridge of the adjacent tooth. The
wedge is inserted from the larger embrasure.
There are several types of separation rings. Some of them
have narrow tines with round cross section, while others
have larger and flat tines with a rectangular cross section
(. Fig. 8.8d). On the cases of preparations where the margins
of the buccal and/or lingual walls of the proximal boxes, in
the embrasure region, are too far from the proximal surface
of the adjacent teeth, the rings with larger flat tines are pre-
ferred, because they touch the external tooth surface beyond
the preparation margins (. Fig. 8.8d 2). In this kind of situa-
tion, the ring with thin round cross-sectional tines will pen-
etrate into the preparation, collapsing the matrix and not
promoting the required tooth separation. On the cases where
the buccal and lingual proximal extensions of the proximal
box do not extend significantly onto the buccal and lingual
surfaces, the rings with round cross-sectional tines are more
adequate, because they allow a better wrapping of the matrix
around the tooth (. Fig. 15.9g, h). After the ring placement,
the sealing of the matrix on the margin of gingival wall is
evaluated with an exploratory probe, followed by the bur-
nishing of the strip toward the adjacent tooth using the back-
side of a spoon excavator  blade. If pre-contoured sectional
matrices and separation rings are not available, the dentist
can prepare a custom-made sectional matrix, as described in
7 Chap. 8, using a piece of the straight band, a little longer
than the buccolingual dimensions of the preparation. It is
first burnished over a paper mixing pad using an egg shape
burnisher. Then it is placed firmly wedged, and then it is
Composite Restoration on Posterior Teeth
s­ tabilized with low fusion compound or light-cured gingival
barrier on buccal and lingual embrasures. When applying the
compound, the matrix must be kept in contact with the adja-
cent tooth using a burnisher. If extra contouring is required
at this moment, the backside of a heated dentin spoon can be
used [33]. Details of this matrix technique can be seen in
. Fig. 8.7a–f.
 
601 15
The restoration is started using enamel shade composite,
applied with the incremental technique, restoring the proxi-
mal surface. The first layer can touch the buccal and gingival
walls, being light-cure, while the next touches the lingual and
gingival walls, as well as the first already cured layer. The
preparation is filled until it reaches the marginal ridge height
of the adjacent tooth, shaping the outer incline of the

a b

c d

e f

..      Fig. 15.9  Use of sectional matrix and separation ring. a Initial
aspect; b–d tooth preparation; e different sectional matrix sizes and
separation rings; f placement of matrix and wedge; g use of ring with
rectangular cross-sectional tines; h better adaptation on the embra-
sures using a ring with narrow tines and round cross section; i, j acid
etching and application of the adhesive system; k placement of an
oblique increment restoring the proximal surface; l proximal surface
completed; m proximal surface restored after matrix removal; n, o
dentin shade composite oblique increments; p placement of the first
enamel shade increment; q last increment of enamel shade composite
(GrandioSO – Voco); r surface characterization of the groove; s finishing
with multi-bladed bur; t polishing with diamond abrasive rubber point
(Dimanto – Voco); u final aspect after hydration
 602 C. R. G. Torres et al.

g h

i j

k l

15

m n

..      Fig. 15.9 (continued)
Composite Restoration on Posterior Teeth
603 15

o p

q r

s t

..      Fig. 15.9 (continued)
 604 C. R. G. Torres et al.
­arginal ridge with a probe-shaped nib instrument
m the intact contact, reduces the teeth separation and makes
(. Fig. 15.9k–m). After restoring the proximal surface with a
 
thin layer of composite, the matrix can be removed, which
turns easier the rest of the restorative procedure. The internal
area of the preparation is restored using dentin shade com-
posite, through oblique increments, the same way as already
described for Class I preparations. Some space should remain
to be filled with an enamel shade composite. After the final
light-curing from the occlusal surface, the polymerization
can be complemented from buccal and lingual surfaces
through the remaining tooth structure [33]. The restorations
must be examined from different angles to analyze the final
anatomical reconstruction, the presence of hollows due to
the lack of material on the margins. The quality of the proxi-
mal contact can be evaluated by passing a dental floss between
the teeth. If corrections are required, new material can be
applied since the surface had not been contaminated. A new
layer of composite easily bonds to the oxygen-inhibited layer
of the light-cured composite [33]. However, if any finishing
has already been performed with a bur, and more material
needs to be added, the surface must be etched with phos-
phoric acid, for cleaning, and an adhesive be applied before
placing more material.
On MOD preparations, the restoration should preferably
be started in the distal box, reconstructing the distal surface in
contact with the adjacent tooth. After that, the wedge and
matrix should be removed and a new band and wedge placed
on the mesial box. A band should not be reused because it is
already deformed and may not produce a proper contour to
the restoration. After reconstruction of the mesial surface, the
wedge and matrix are removed, and the restoration of the
occlusal surface can be performed like in a Class I preparation.
Despite the restorative technique, the composite should
reach its maximum polymerization; otherwise, the success
15 of the restoration will be compromised, risking the adhesive
interface and the strength of the restorative material. The
composite should reach its maximum of conversion degree,
which is around 60–70% [32]. Even though the stratified
layering technique, using an enamel and dentin shade com-
posites, may produce excellent results for most patients,
some of them have a more opaque enamel and does not
required the use of two different materials. A single shade
with medium translucency can be used, simplifying the
placement technique.
15.4.2.2 Circumferential Matrix
In general, the circumferential matrices are not the first
choice to restore posterior teeth with composite, even on
MOD preparations [4]. If the dentist excessively tightens a
circumferential band around a tooth, a cuspal deflection of
about 10–65 μm can happen, sometimes resulting in cracks
or fractures of the remaining structure [17]. When restoring
a single proximal surface, on MO or OD preparations, the
double thickness of band, due to the presence of the strip on
contact harder to achieve [4]. Therefore, the sectional matri-
ces have advantages. However, when properly applied, the
circumferential matrices can also be used with great success.
For that, a very thin metallic band has to be chosen, as well
as some type of matrix retainer. There are available at dental
market different kinds of circumferential matrices, such as flat
straight and flat Tofflemire strips, as well as the pre-contoured
Tofflemire ones. Because the flat straight strip is not pre-con-
toured, after the assembling on the retainer, the area corre-
sponding to position of the proximal surface has to be
burnished over a paper mixing pad, using an egg shape bur-
nisher, creating a convex contour on the opposite side, similar
to the proximal tooth surface (. Fig. 15.10d) [33]. Then, it is
taken in position and the wedged is inserted. The wedges must
be firmly applied using a careful technique, because the sepa-
ration provided must compensate the thickness of the band
on the mesial and distal proximal surfaces [33].
When there are two proximal boxes to be restored, the
wedge alternation technique should be used (. Fig. 15.11). It
means that a wedge is first inserted in only one interproximal
space and this proximal surface is restored. Then, the wedge
is removed and inserted into the other interproximal space,
and then this area is restored. This promotes a greater dental
separation than if both wedges were inserted simultaneously
[22]. If both wedges are placed at the same time, they will
work one against the other, reducing the total teeth separa-
tion [4]. After each wedge placement, the gingival seal of the
matrix is evaluated with an exploratory probe, followed by
the band burnishing toward the adjacent tooth using the
backside of a spoon excavator  blade (. Fig.  15.11f). This
ensures that an adequate contact and contour of the band will
be obtained.
When used in association to circumferential matrices,
some accessory techniques can help to obtain a good proxi-
mal contact when making composite restoration. They are
based on the use of some contact forming instrument, to
keep the matrix pressed toward the adjacent tooth, at the
same time that a small increment of composite is light-cured,
stabilizing the band in contact with the adjacent tooth. An
in  vitro study showed that a handheld contact forming
instrument resulted on a significant increase of the contact
tightness, even though its effect is smaller to the one obtained
with the use of a separation ring [24].
Contact Forming Instruments and Light
Conducting Tips
The handheld contact forming instruments and the contact
forming light conducting tips are designed to be pushed or
pulled toward the direction of the contact, creating dental
separating force through the matrix band, holding the com-
posite in place during the light-curing procedure. Some
examples of handheld contact forming instrument are
Contact Pro 2 (Almore International), Trimax (AdDent),
Composite Restoration on Posterior Teeth
605 15

a b

c d

e f

..      Fig. 15.10  Use of handheld contact forming instrument. a–c Tooth
preparation; d burnishing of the matrix over the paper mixing pad;
e burnishing of the matrix toward the adjacent tooth; f acid etching;
g application of the adhesive; h first increment placed on the gingival
wall; i side view of the contact forming instruments Contact Pro 2
(Almore). The arrows show the flat area of the instrument handle. j view
of the instrument tip showing the black line, which is a marginal ridge
guide (red arrow), and the flat area of the handle (blues arrow);
k light-curing of the composite holding the flat area (white arrow)
parallel to the occlusal plane and pushing it against the matrix band
toward the proximal contact (red arrow). The marginal ridge guide is
lined up with the tooth’s marginal ridge (yellow arrow); l a small
impression in the composite is left on the gingival wall by the
instrument; m, n application of oblique increments to restore the
proximal surface; o matrix removal and placement of the first dentin
shade oblique increment; p second dentin shade increment; q, r place-
ment of enamel shade increments; s finishing with multi-bladed bur;
t polishing with diamond polishing paste (Diamond Excel – FGM) and
felt point (Felt FlexiPoint – Cosmedent); u final result
 606 C. R. G. Torres et al.

g h

i j

k l

15

m n

..      Fig. 15.10 (continued)
Composite Restoration on Posterior Teeth
607 15

o p

q r

s t

..      Fig. 15.10 (continued)
 608 C. R. G. Torres et al.

a b

c d

e f

15

..      Fig. 15.11  Use of the contact forming light conducting tip in the
mesial preparation and a prepolymerized ball in the distal preparation.
a Initial aspect; b–d tooth preparation; e matrix burnishing over a
paper mixing pad; f wedge insertion on the mesial surface and
burnishing of the band toward the adjacent tooth; g, h acid etching
and application of the adhesive system; i first increment placed
touching the matrix (GrandioSO – Voco); j contact forming light
conducting tips (Light-Tip – Denbur): on the left the E-Type (truncated
with elliptical tip) and on the right the C-Type (cone-­shaped with a
circular tip); k light-curing using the tip, pulling the matrix toward the
mesial surface (arrow); l impression left in the composite by the
elliptical tip; m, n restoration of the proximal surface with oblique
increments; o preparation and curing of a composite ball; p, q wedge
removal from the mesial interproximal space and insertion into the
distal space. Placement of a composite increment on the gingival wall;
r prepolymerized ball applied into the uncured composite layer, being
pressed toward the gingival wall; s ball in position pushing the matrix
strip toward the adjacent tooth; t restoration of the proximal surface
with oblique increments of enamel shade composite; u shaping of the
outer incline of the marginal ridge with a probe-shaped nib instru-
ment, creating the occlusal embrasure; v finished proximal surfaces;
w, x placement of oblique dentin shade increments; y increment
corresponding to the triangular fossa on the inner incline of the
marginal ridge, z, a´ increments of enamel shade composite; b´ finish-
ing with multi-bladed bur; c´ polishing with silicon carbide brush;
d´ final result
Composite Restoration on Posterior Teeth
609 15

g h

i j

k l

m n

..      Fig. 15.11 (continued)
 610 C. R. G. Torres et al.

o p

q r

s t

15

u v

..      Fig. 15.11 (continued)
Composite Restoration on Posterior Teeth
611 15

w x

y z

a' b'

c' d'

..      Fig. 15.11 (continued)
 612 C. R. G. Torres et al.
PerForm (Garrison), Forming XTS (Hu-Friedy), and
OptraContact (Vivadent) (. Fig.  15.10h–l). The light con-
 
ducting tips are clear plastic tips that are attached to the end
of the light guide, allowing the matrix to be pressed and light-­
cured at the same time (. Fig. 15.11j–l). Some examples are
 
the Light-Tip (Denbur) and Focu Tip (Hager). For all those
options, firstly a thin steel matrix strip must be placed,
wedged, and correctly burnished, according to what has
already been described. When indicated, the wedge alterna-
tion technique should be applied. Then, a small horizontal
layer of composite is placed on the preparation gingival wall.
The handheld instrument or light conducting tip must be
inserted inside this uncured composite and pushed toward
the direction of the contact with the adjacent tooth, creating
a separating force through the matrix at the exact place of the
desired contact (. Fig. 15.10k and 15.11k). This layer is light-­
cured, creating a composite bridge that stabilized the matrix
in contact with the adjacent tooth. The handheld instruments
are available in two sizes, one for molars and other for pre-
molars. In general, each end of the instrument is designed to
a different proximal surface.
When using the Contact Pro 2 instrument (Almore
International), the anatomy of the contact is shaped and
positioned ideally by holding the flat area of the instrument
parallel to the occlusal plane (. Fig. 15.10j, k). At the tip of
the instrument, there is a black line which is a marginal ridge
guide (. Fig.  15.10j). According to the manufacturer’s
instructions, this guide has to be aligned with the marginal
ridge of the adjacent tooth while creating the contact
(. Fig. 15.10k). The instrument is pressed toward the matrix
band, applying enough force to slightly bend the instrument.
The rounded ball at the center of the handle helps of the
operator to apply force on the band. The light-curing guide of
the curing device is held flat against the convex-shaped lens,
15 and the light emission is started while maintaining the force.
After curing, the instrument is gently rocked mesiodistally
and lift out occlusally. Then, it can be seen the impression left
by the instrument on the composite (. Fig.  15.10l and
 
. 15.11l). The proximal wall must be finished with compos-
 
ite, using oblique increments. If there are two proximal boxes,
wedge alternation technique should be used, restoring one
proximal surface at each time. After finishing both proximal
surfaces, the matrix can be removed and the occlusal box
properly restored, like a Class I preparation.
On the cases where the gingival wall is too deep, it is rec-
ommended to incrementally restore the deeper area with
composite, pressing the matrix with the contact forming
instrument before each light-curing. That will allow the cre-
ating of a proper proximal contour during the application of
the composite, since the deeper regions of the preparation. A
small impression of the instrument tip should be visible on
the gingival wall after each layer, confirming contact of the
composite with the instrument. When a flowable composite
is used as the first layer, to allow a better adaptation to the
preparation irregularities and work as a stress-absorbing
layer, the contact forming instruments should also be used
before its light-curing.
>> The contact forming instruments are designed to be
pressed toward the direction of the contact, creating
dental separating force through the matrix band,
holding the composite in place during the light-curing
procedure, and forming a composite bridge that
stabilized the matrix in contact with the adjacent tooth.
Prepolymerized Ball Technique
The prepolymerized ball or plunging ball technique is based
on the use of a small ball of the cured composite to press the
band, creating teeth separating force through the matrix,
helping to obtain an appropriate proximal contact. For that,
the tooth to be restored must receive a previously burnished
matrix and wedge, as it has already been described. After the
application of the adhesive system, it is necessary to produce
a small composite ball, with a diameter a little bigger than the
distance between the axial wall and the proximal surface of
the adjacent tooth (. Fig. 15.11o–v). It can be prepared using
powder-free gloves and then completely light-cured outside
the mouth. After that, a thin layer of uncured composite is
placed on the gingival wall of the preparation. The ball is then
placed over this layer and pressed toward the gingival wall,
using a hand instrument with a flat nib, such as an amalgam
plugger. It is important to be sure that the ball entered tightly
into the preparation, pressing the band toward the adjacent
tooth, creating the desired teeth separation. The excess of
composite over the ball is removed, and then a light-curing is
performed. Then, the proximal surface is restored with
oblique increments, until it reaches the height of the mar-
ginal ridge, shaping the outer incline of the marginal ridge
with a probe-shaped nib instrument. On MOD preparations,
each proximal box is restored separately, and the wedge alter-
nation technique is used. The occlusal surface is restored
using the stratified layering technique as already described.
Ceramic Inserts
The inserts are industrially prefabricated ceramic pieces with
several shapes, sizes, and colors. The technique of ceramic
inserts is a restorative procedure between the direct compos-
ite and the indirect ceramic restorations. One advantage of
the use of the inserts is to reduce the bulk of composite
needed to restore the tooth, therefore, reducing the amount
of polymerization shrinkage and the final shrinkage stress.
The inserts also reduce the thermal expansion of the restora-
tion, since they have a CLTE lower than of composites. This
characteristic can improve the marginal adaptation of the
restoration in relation to those made only with composite. In
addition, the use of some inserts on the proximal surface can
also help the restoration of proximal contacts [14].
There are two basic kinds of inserts. One of them consists
of inserts without specific instruments for the tooth prepara-
tion and was introduced in the dental market in 1991 by
Bowen, the inventor of composites for tooth restorations [6].
They were named “megafillers” and were placed inside the
non-cured composite to reduce the total volume of resin uti-
lized. A reduction of the final composite content in a restora-
Composite Restoration on Posterior Teeth
tion up to 20% could be reached, through a good selection of
shapes and number of inserts. The second kind of insert is
based on the development of tooth preparation instruments
that match the shape and size of the ceramic inserts. The
preparation is performed with rotary or oscillatory instru-
ments. After preparation, standardized inserts perfectly
adapt to the cavities, like an indirect inlay, which are luted
using flowable composite. The difference between the two
types of inserts is the amount of composite necessary to fin-
ish the restoration. The maximum reduction is obtained
when the inserts perfectly match the instruments for tooth
preparation. It must be considered that, even though the res-
toration using insert technique could have some advantages
in relation to the restorations only using composite, it takes
longer to be performed, can require an additional removal of
the remaining tooth structure, and is more expensive [14].
The SonicSys inserts (Vivadent) were made with
­leucite-­reinforced ceramic (. Fig. 15.12a–a´). The preparation
 
system SonicSys Approx/SONICflex (Kavo) allows the prepa-
ration of symmetrical proximal cavities. The preparation
points were selectively covered with diamond and available in
three sizes, which perfectly match the ceramic inserts. They
can be used for mesial and distal surfaces. The points have an
active side covered by diamonds and a smooth side, which
touches the proximal surface of the adjacent tooth. The begin-
ning of the tooth preparation is performed with rotary instru-
ments, followed by the standardization of proximal
preparation with the oscillatory points of the selected size
(. Fig.  15.12e–h). Then, the adhesive system is applied, fol-
 
lowed by the matrix and wedge. A layer of flowable composite
is applied, and the insert is placed in position; then a light-
curing is performed (. Fig. 15.12q–u). A very similar system
 
called Cerana was produced by the Nordiska Dental, includ-
ing conical inserts for the occlusal surface and proximal
inserts of several sizes. It also presented diamond rotary
instruments that match the shapes of the conical inserts, as
well as oscillatory instruments with selective application of
diamond for the proximal surface [14]. Although the use of
ceramic inserts can produce very good restorations, its use has
diminished in the recent years, due to the new direct compos-
ite technology, with low costs than an insert system. Therefore,
most of the systems are no longer available on the market.
15.4.2.3 Packable Composites and Low
Shrinkage Materials
The packable or condensable composites were created in the
late 1990s, in an attempt to replace the silver amalgam as the
main restorative material for posterior teeth, using a similar
restorative technique. Those materials presented an extremely
higher viscosity than the universal composites available,
close to amalgam, to be condensed into the preparation using
an amalgam plugger, which could press the matrix toward
the adjacent tooth, helping to create the proximal contact.
Despite the material stiffness contributes in forming tight
contacts, a study showed that the matrix system applied is
more effective than the composite viscosity for the final con-
tact tightness result [24].
613 15
Those composites cannot be considered as really condens-
able as amalgam, because they do not become denser when
they are pressed into the preparation. The term packable is
preferable for describing this class of materials. Due to its high
viscosity, it was difficult to obtain perfect adaptation to the line
and point angles, being recommended the use of an initial
layer of a flowable composite [33]. In addition, the use of hori-
zontal increments recommended by the manufacturers, like
the ones used for the silver amalgam, was not adequate for
composites. The simultaneous bonding to the buccal, gingival/
pulpal, and lingual walls increases stress generated by the high
C-factor. Another negative aspect of the first packable com-
posites was the higher surface roughness after polishing, in
relation to the regular ones, due to its different filler technol-
ogy. For this reason, its use was significantly reduced.
Considering that shrinkage is one of the major drawbacks
of composite materials and the main reason for restoration
failures after short and long term, the researches and devel-
opments were focused on its reduction. The first attempt was
to increase the filler content. Since the organic matrix was the
responsible for the volumetric shrinkage, the lower the
resin:filler ratio  in a composite, the lower the shrinkage
would be. However, the increase in the filler content also
increases the elastic modulus, creating stiffer materials.
Although the total volumetric shrinkage was reduced, the
shrinkage stress raised, impairing the marginal integrity and
increasing all the other negative consequences related. This
way, other options were attempted.
As the methacrylate resins’ intrinsic shrinkage cannot be
changed, exchanging the monomers seemed the most promis-
ing way to solve the shrinkage challenge. Therefore, low shrink-
age monomers, such as the silorane (3 M Espe), were developed.
On conventional methacrylate monomers, during the curing
process, the monomers molecules have to approach their neigh-
bours to form chemical bonds with them and create a polymer.
This reaction leads to a significant volumetric shrinkage.
According to the manufacturer, the polymerization process of
silorane occurs through a cationic ring-opening reaction. In
contrast to the linear reactive groups of methacrylates, the ring-
opening chemistry of the siloranes starts with the cleavage and
opening of the ring system. This process gains space and coun-
teracts the loss of volume which occurs in the subsequent step,
when the chemical bonds are formed. In total, the ring-opening
polymerization process yields a reduced volumetric shrinkage.
According to the manufacturer, a volumetric shrinkage of about
1% and low shrinkage stress of about 2  MPa are generated,
which represents a large reduction in relation to methacrylate-­
based material that shrinks up to 2–3% and generates shrinkage
stress between 4 and 8 MPa. For this reason, the manufacturer
recommended the use of horizontal increments, although with-
out significant changes in the depth of cure. Even though pre-
sented many advantages, the silorane-­based materials needed a
specific and compatible adhesive system, being more difficult to
repair the old restorations. The material did not provide a great
shade options and was more expensive than the regular ones.
After some year, it was also removed from the market, being
replaced by the new bulk-fill materials.
 614 C. R. G. Torres et al.

a b

c d

e
f

15

..      Fig. 15.12  Proximal restoration with ceramic insert (SonicSys
Approx – Vivadent). a Oscillatory instruments that match the shape
and size of the ceramic inserts; b ceramic inserts compatible with
preparation instruments; c fractured amalgam restoration; d defective
restoration removed; e, f standardization of proximal box shape with
the sonic instrument; g, h preparation shape standardized; i removal of
remaining carious dentin tissue with round bur in low speed;
j preparation completed; k-m fitting test of the insert; n insertion of the
matrix and wedge; o acid etching; p application of the adhesive
system; q placement of a small layer of flowable composite on the
walls; r application of the adhesive on the insert; s–u insert placement;
v matrix and wedge removal. Proximal surface restored; w placement
of dentin shade composite in the occlusal box; x placement of enamel
shade composite; y finishing and shaping of the ceramic insert with a
fine grit diamond point; z polishing with silicon carbide brush;
a´ restoration completed
Composite Restoration on Posterior Teeth
615 15

g h

i j

k l

m n

..      Fig. 15.12 (continued)
 616 C. R. G. Torres et al.

o p

q r

s t

15

u v

..      Fig. 15.12 (continued)
Composite Restoration on Posterior Teeth
617 15

w x

y z

a'

..      Fig. 15.12 (continued)

15.4.2.4 Bulk-Fill Composites
Although the layering technique can provide very good res-
torations, reducing the negative effects of the shrinkage
stress, it can be a little tricky and time-consuming, especially
on deep preparations. Therefore, most dentists would like to
have a simpler way to restore posterior teeth. The more recent
researchers were focused on creating a material that could
overcome these problems, allowing a quicker restorative pro-
cedure. The two main reasons for using the layering tech-
nique are the shrinkage stress and the depth of cure of the
universal composites. The first reason makes necessary to use
oblique increments, to reduce the stress over the bond inter-
face and remaining tooth structure, while the second one
obliges the use of a maximum 2 mm thick layers, for reaching
a good curing on the bottom of the material. Different strate-
gies were created by the manufactures to modify these two
important characteristics, producing materials that can be
used in horizontal and thicker increments, which were
named bulk-fill composites.
Analyzing the organic matrix of the dental composites,
shrinkage stress is mainly determined by the total volumetric
shrinkage, the internal flowability of the material, and the
polymerization kinetics (polymerization speed). A highly
shrinking material with a small internal flowability and very
 618 C. R. G. Torres et al.
fast curing speed will exhibit the highest shrinkage stress.
This way, manufacturers created new special monomers and
polymerization modulators for reducing the final stress. In
the Admira Fusion X-tra (Voco) restorative material, the
organically modified ceramic (Ormocer) is an oligomer with
an inorganic backbone and many polymerizable organic
groups, which reduces the volumetric shrinkage due to its
inorganic structure and the bigger molecular weight. Filtek
Bulk Fill (3  M Espe) contains an addition-fragmentation
monomer (AFM). According to the manufacturer, during
polymerization the AFM reacts to create a polymer as any
methacrylate, including the formation of crosslinks between
adjacent polymer chains. However, it contains a special reac-
tive site that cleaves through a fragmentation process during
polymerization. This provides a mechanism for the relax-
ation of the developing network and subsequent stress relief.
SureFil SDR (Dentsply) has a polymerization modulator
chemically embedded in the polymerizable resin backbone
of the monomer. It reduces stress buildup on polymerization
without a reduction in the polymerization rate or conversion.
The resin forms a more relaxed network and provides signifi-
cantly lower polymerization stress than the conventional
resin.
>> The shrinkage stress is mainly determined by the total
volumetric shrinkage, the internal flowability of the
material, and the polymerization kinetics
(polymerization speed). A highly shrinking material
with a small internal flowability and very fast curing
speed will exhibit the highest shrinkage stress.
In relation to the depth of cure, it is determined by three dif-
ferent factors, which are the monomers, the initiator system,
and the opacity and shade of the composite. The bulk-­fill
materials are more translucent than the regular composites,
15 which allow higher light transmission through the material,
resulting in adequate polymerization on the bottom of
thicker layers. The depth of cure of bulk-fill materials is
around 4–5 mm, in contrast to the 2 mm of the regular com-
posites.
a b
..      Fig. 15.13  Bulk-fill composites. a Base materials that require capping with standard composite; b restorative composites with regular
viscosity
The bulk-fill materials can be classified into two groups.
The first is the base material, which is flowable and used to
restore the internal and proximal parts of the tooth prepara-
tion. They have lower filler content than the corresponding
universal composites and low esthetics. Therefore, the exter-
nal occlusal surface must be covered with a 2 mm capping
layer of regular composite. Some examples are SureFil SDR
(Dentsply), Filtek Bulk Fill flow (3 M), Admira Fusion X-base
(Voco), and Venus Bulk fill (Kulzer) (. Fig. 15.13a). The sec-
ond group is the full restorative material,  represented by
regular viscosity composites, indicated to completely fill the
preparation without any capping. Some examples are Admira
Fusion X-tra (Voco), Beautiful Bulk (Shofu), Ecosite Bulk Fill
(DGM), and Filtek Bulk Fill Posterior (3  M Espe)
(. Fig. 15.13b).
>> The bulk-fill composites can be classified as base or full
restorative materials. The former are flowable and used
to restore the inner parts of the preparation, being
capped with a layer of a normal composite. The latter
have regular viscosity and are indicated to completely
fill the cavity.
When performing restorations with bulk-fill materials, spe-
cial attention should be given to the emittance of the light-
curing unit. The increased depth of cure of these materials,
claimed by the manufacturers, is always calculated consider-
ing certain power emitted from the light-curing unit and a
certain curing time, as described in 7 Chap. 13. The use of a
radiometer or another method to control the emittance is
advised. The instructions of each manufacturer must be fol-
lowed, and an additional curing through the buccal and lin-
gual surfaces is always recommended.
Before starting, the preparation depth should be mea-
sured using a periodontal probe, on the deepest area of the
cavity. If it is equal or smaller than the depth of cure recom-
mended by the manufacturer, a single increment of bulk full
restorative material can be used. When the preparation depth
is deeper, the first layer can be the maximum recommended
by the manufacturer, followed by other layers until com-
Composite Restoration on Posterior Teeth
pletely fill the preparation. For the base materials, a mini-
mum space has to be left for the capping composite.
. Figure  15.14 shows the restorative procedure using a
 
base bulk-fill flowable composite. The sectional matrix and
separation ring are placed, and the adhesive applied. Then,
the flowable base composite is applied directly from the
compule into the preparation using a syringe, with slow and
steady pressure. The application starts in the deepest areas,
619 15
maintaining the tip close to the material surface and gradu-
ally withdrawing, as the preparation is filled, up to 4  mm
thick increment or 2 mm short of the cavosurface margin. In
case of overfill or excess on occlusal margins, a flocked appli-
cator tip wetted with residual adhesive can be used to remove
excess. This layer is light-cured according to the manufac-
turer recommendations. As the base composites are more
translucent, if placed on the occlusal cavosurface margins or

a b

c d

e f

..      Fig. 15.14  Restoration using flowable bulk-fill base composite.
a Initial aspect; b carious tissue removed; c pulpal protection with GIC;
d, e acid etching and adhesive system application; f placement and
burnishing of sectional matrix; g, h restoration of the buccal surface on
distal box with nanohybrid composite (Esthet-X HD – Dentsply);
i Compules of SureFil SDR – Dentsply; j, k filling 4 mm of the prepara-
tion with flowable composite, leaving space for the occlusal capping;
l restoration of the proximal surface with nanohybrid composite;
m placement of sectional matrix on the mesial box; n, o application of
flowable composite filling 4 mm of the preparation; p restorations of
proximal surface; q finished proximal surfaces; r finished restoration
after capping and groove characterization
 620 C. R. G. Torres et al.

g h

i j

k l

15

m n

..      Fig. 15.14 (continued)
Composite Restoration on Posterior Teeth
621 15

o p

q r

..      Fig. 15.14 (continued)

on the buccal margins of a large proximal box, the restor-
ative material will be visible while the patient is talking or
smiling, adversely affecting the esthetic result. In case a very
dark sclerotic dentin is present, an opaque tint may be
applied over the adhesive layer, previously the composite
placement. Due to the low viscosity, the flowable composites
will not press the matrix toward the adjacent tooth. This way,
the proximal contact will totally depend on the matrix and
wedge system. For this reason, the sectional matrices with
separation ring are recommended. If necessary, complemen-
tary technique as contact forming instruments or others can
be used.
15.4.3  Restoration of Proximal Lesions
through Buccal/Lingual Access
ment with a flat- or round-shaped nib, like a plugger. On the
last layer, the matrix is pressed over the surface of access, and
the light-curing is performed through the strip.
15.4.4   sthetic Improvement of Amalgam
E
Restorations
Sometimes the patients have large and old amalgam restora-
tions in good conditions, but that are visible while talking or
smiling, negatively interfering on the esthetics. On this case,
instead of replacing the entire restoration, which can result
on the additional removal of the remaining tooth structure, a
small preparation can be performed inside the visible part of
the amalgam, and a composite veneer used to hide the metal
(. Fig.  15.16a–i). First, a prophylaxis is performed using

pumice and brush to remove extrinsic stains. The anesthesia

On preparations with buccal or lingual access, after isolation is not generally necessary since the preparation will be done
of the operating field, a clear plastic matrix strip should be mainly on the metal and enamel. When the metal extends
placed and wedged, which allows the composite to be light-­ beyond the gingival margin, the level of the gingival tissue is
cured through the band (. Figs.15.15 and 15.16c–f). The pad marked on the restoration with a sharp probe, placing a
 

of the index finger is placed on the tooth surface, opposite to retraction cord inside the gingival sulcus. The preparation is
the preparation access, holding the matrix in contact with the performed until the marked level. A round carbide bur or
surface and avoiding the overflow of the composite. The diamond point is used to cut the amalgam, removing a
material must be placed inside the preparation using a layer- homogeneous depth layer of about 1.5 mm, entering the
ing technique, employing a nonstick composite filling instru- embrasures only enough to hide the metal. Retentive coves
 622 C. R. G. Torres et al.

a b

c d

e f

15

..      Fig. 15.15  Proximal restoration through buccal access. a Proximal lesion close to the buccal surface; b protection of the adjacent tooth and
tooth preparation; c, d application of acid and adhesive system; e placement of clear plastic strip and wedge; f polished restoration

are prepared on the gingivoaxial angle and slots on the axial
wall inside the metal. A bevel on enamel is performed to
mask the restoration margin and improve the retention [33].
The preparation is acid etched to clean the surface and create
microretention on beveled enamel, and the adhesive system
applied. A thin layer of opaque tint must be applied over the
adhesive layer to mask the metal shade. The opaque is more
15.4.5   epair of Ceramic or Composite
R
Restorations
The indirect ceramic/composite restorations or crowns, as
well as direct composite restorations, can undergo small
cracks or fractures in the oral environment due to mechani-
cal load (. Fig. 15.17a–i). On those cases, the composite is an

effective when applied in thin layers and light-cured sepa-
rately. Then, an opaque dentin shade composite is applied
over the tint, helping to mask its white color, being covered
with an enamel shade composite (. Fig. 15.16f–i).
 
excellent option for repairing them instead of its total replace-
ment. Before starting the repair, the dentist should determine
and control the cause of the fracture and, whenever possible,
the type of restorative material used in the restoration. The
Composite Restoration on Posterior Teeth
vitreous ceramics can be etched with hydrofluoric acid gel to
improve the composite bonding. However, the non-vitreous
ceramics, such as those based on zirconium or alumina, are
not significant affected by this etching [31].
First, prophylaxis has to be performed to remove stains
and biofilm. The fractured area can be removed or a small
preparation performed on the fracture line, such as double
bevel using a round diamond point. The surface of vitreous
ceramics must be etched with 10% hydrofluoric acid gel for
the time recommended by the acid manufacturer, followed
623 15
by copious washing and air drying. Then, a silane coupling
agent is applied for 1 min, which also must be dried with air.
After that the adhesive system is applied and light-cured, fol-
lowed by the composite application and shaping. If there is
enamel on the interface, close to the fractured area, it must
never be etched with hydrofluoric acid, because it is too
strong and the products generated by the reaction will
deposit on the etched ceramic surface, adversely affecting
the bonding. The enamel must be only etched with a phos-
phoric acid gel.

a b

c d

e f

..      Fig. 15.16  Composite veneers in old amalgam restorations. a Initial system; f placement of a thin layer of opaque tint over the amalgam;
aspect; b preparation on the buccal surface and mechanical retentions; g placement dentin shade composite (Z350 XT – 3 M Espe); h use of
c bevel in enamel margin; d, e etching and application of the adhesive clear matrix to shape the enamel shade composite; i final result
 624 C. R. G. Torres et al.

g h

..      Fig. 15.16 (continued)

a b
15

..      Fig. 15.17  Repair of a fractured ceramic crown. a Initial aspect; adhesive system; g ceramic ready for the composite placement;
b removal of the fractured area; c etching with hydrofluoric acid gel; h composite applied; i result immediately after removal of rubber dam
d aspect after etching; e Application of silane; f application of the
Composite Restoration on Posterior Teeth
625 15

c d

e f

g h

..      Fig. 15.17 (continued)
 626 C. R. G. Torres et al.
In case of composite restorations, the fractured area must
be roughened by abrasion, with a coarse grit diamond point
or sandblasting with aluminum oxide particles, creating
micromechanical retention [3]. The surface is etched with
phosphoric acid for cleaning and the adhesive system applied,
followed by the composite placement. If any dentin is exposed
on the fractured area, the proper bonding technique to this
substrate must be used.
15.5  Finishing and Polishing
Ideally, no finishing and polishing should be required to a
new restoration, because the shape and surface smoothness
of the last composite layer applied should be perfect.
However, it is extremely hard to shape a perfect and func-
tional tooth anatomy, without evaluating the patient’s occlu-
sion. This way, almost always some adjustment will be
required, even if minimum. The friction of rotary cutting or
abrasive instrument over the composite produces mechani-
cal and thermal aggression. This creates microcracks on the
composite surface with depth between 25 and 50 μm, which
can adversely affect the wear of the restoration [4, 8]. Every
effort must be done to avoid and/or minimize the need for
rotary instruments [4].
Whenever necessary to correct the restoration’s anatomy
and remove excess of composite, the finishing procedure can
be started immediately after the light-curing. It has to be per-
formed with proper instruments, requiring ability and
knowledge about the correct dental anatomy [33]. Preferably,
the finishing of the margins should be performed before
removing the rubber dam isolation [4]. Excess or lack of the
material can be detected with the tip of an exploratory probe
touching the surface, moving from the tooth to the restora-
15 tion and vice versa, on the entire cavosurface margin. Excess
of material must be removed but avoiding undesirable wear
of the remaining tooth structure [4]. After that, the occlusion
should be evaluated and premature contacts removed.
A double-sided two-color articulating paper (e.g., black
and red) is held with a Miller forceps, in a way that the black
side is facing the restored tooth. First, the centric contacts are
analyzed, asking the patient to close the mouth in centric
occlusion and open it again. It has to be evaluated if the con-
tacts on adjacent teeth, which existed before the preparation,
can be seen now. If only the restoration is in contact with the
opposite tooth, just the marked contact place must be
grinded, and the articulating paper used again. Those steps
are repeated as many times as necessary, until the original
contacts of the adjacent teeth reappear, but keeping a contact
on the restored tooth. To analyze the presence of interfer-
ences during excursive movements, the paper is placed again
on the paper forceps, in a way that the red side is facing the
restored tooth. The patient is asked to occlude at centric
occlusion and perform protrusive and lateral movements of
the mandible to detect any contact. After that, the patient
opens the mouth, and the black side of the paper is turned in
the forceps. He is asked to close on centric occlusion again to
mark the centric contacts once more. The presences of inter-
ferences during disocclusion movements are analyzed. All
the contacts marked in red over the composite are removed
because they represent contacts during the excursive move-
ments, which should not happen. The centric contact in black
must not be changed. The procedure is repeated once again
to evaluate if no interferences have remained. For the occlu-
sal adjustment and excess removal on the margins, in the
occlusal surface, round- or pear-shaped fine grit diamond
points or multi-bladed burs can be used (. Fig. 14.65a, b)
[33]. Aluminum oxide mounted stones can also be used
(. Fig. 4.28a). The shape of the rotary instrument must be
compatible to the surface that is intended to be adjusted
(. Figs. 15.6b´, 15.7x, 15.9s).
Tips
The occlusal adjustment of the restoration must be
performed analyzing the centric contacts and those
during excursive movements of the mandible.
The rotary instruments should not remove enamel from the
margins, avoiding touching it, and the composite must not be
excessively grinded [33]. After finishing, the restoration must
have the ideal shape to allow masticatory function, without
overhangs on the gingival margins, which may promote bio-
film deposition and gingival inflammation. The evaluations
of proximal surface smoothness and contact tightness are
performed with dental floss, wrapping the proximal restored
surface with the floss, moving it gingivoocclusally. If the
matrix and wedge were correctly placed and the restoration
has not overhangs, there is no need to polish the proximal
area, because the restoration has copied the matrix strip
smoothness [4].
It there is gingival overhangs, they can be removed using
the coarse grit side of an abrasive strip. To avoid undesired
grinding of the proximal contact, narrow strips should be
employed. It can also be used for this purpose the stainless-­
steel serrated strip saw (. Fig.  15.18f). The marginal ridges
and buccal/lingual/occlusal embrasures may be finished with
small abrasive disks or flame-shaped burs or points
(. Fig. 15.18c, d). On the buccal and lingual embrasures, the
contour carbide carvers or No. 12 scalpel blade are also good
options (. Fig. 15.18a, b). A study proposed a supplemental
polymerization after the end of finishing procedures, since
the composite surface that was close to the light-guide tip,
and therefore with the best mechanical properties, was
removed [38].
The polishing may be performed using abrasive rubber
points or cups (. Figs. 15.7y and . 15.9t). There are single or
multiple steps abrasive rubber points. On the latter, the
coarse grit rubber is used first, which is gently applied over
the surface with intermittent movement, until a homoge-
neous surface roughness is obtained. The area must be
washed and dried to remove abrasive residues, and the fine
grit rubber is employed. The marginal ridge on occlusal
Composite Restoration on Posterior Teeth
627 15

a b

c d

e f

..      Fig. 15.18  Instruments for finishing proximal surfaces. a Contour ridge being finished with a multi-bladed bur; e abrasive strip placed
carbide carver (TZC12 – Thompson/Miltex); b use of contour carbide below the proximal contact; f serrated strip saws attached to the
carver in the embrasure area; c finishing of embrasures with the holders (1, strip holder (Coraldent); 2, Microcut (TDV))
abrasive disks (Diamond PRO – FGM); d outer incline of the marginal

embrasure and buccal and lingual embrasures can be pol-
ished with the fine abrasive disk. A felt point (Felt FlexiPoint,
Cosmedent) associated with aluminum oxide or diamond
polishing paste can also be employed (. Fig. 15.10t). Another
 
possibility is the use of silicon carbide brushes, which the
abrasive particles are embedded in the bristles. As the bristles
wear down, fresh abrasive particles are released (. Fig. 15.6c´,
 
d´, . 15.12z). It has different shapes to adapt to various tooth
 
surfaces. The abrasive rubber spiral wheels are also a good
option, adapting to all surfaces (. Fig. 4.29d). The correctly
 
finished and polished restoration must simulate the smooth-
ness of the dental tissue and not be noticed by the patient or
cause irritations to the tongue and oral mucosa. If the proxi-
mal surface has been finished, it must be polished with the
fine grit abrasive strip.
It is large the number of composite restorations inade-
quately finished and polished, most times due to the fact that
the dentist and patient are tired at the end of the restorative
procedure. This way, the composite should be polished on a
later appointment, when it will be possible a more detailed
 628 C. R. G. Torres et al.
evaluation of what must be done. In addition, the clinician
may have some difficulties to distinguish the interface
between composite and the preparation, problems of access
and visibility, and lack of know-how about the use of the
instruments, material, and techniques. A study showed that
to finish and polish a restoration on a later appointment also
improves the wear resistance of the composite [16]. This is
related to the fact that, immediately after curing, the compos-
ite has not yet reached its maximum degree of conversion and
physical properties, important to bear the stress generated by
the rotary instruments. The called “dark-curing” phase fol-
lowing application of light-curing continues up to 24 h.
Tips
Whenever possible, the finishing and polishing of a
composite restoration should be postponed for the next
dental appointment.
15.6  Surface Sealing
The microcracks created on composite surface, by finishing
and polishing procedures, can work as a path for the penetra-
tion of water, acids, and other substances available in the oral
cavity, coming from the human diet and bacterial metabo-
lism. Those substances soften the resin matrix and increase
the wear. A clinical study showed that finishing and polishing
procedures may increase up to 46% the wear rate of some
composites, in relation to when it was not performed [16].
The finishing and polishing may also increase the marginal
gaps formed during the polymerization [4].
In an attempt to control this problem, a procedure called
15 surface sealing, rebonding, or post-bonding was proposed. It
consists of the application of a liquid resin over the compos-
ite, like an adhesive, that penetrates and seals the microcracks
[4]. Some studies showed that this procedure is effective to
clinically reduce the wear rate, even though its effect lasts for
only 6 months and a new application is necessary [13, 45].
Besides sealing the microcracks on the composite surface, it
can also help to seal the cracks that may occur on the enamel
surface, close to the restoration margin, due to the shrinkage
stress, as well as the marginal gaps [4, 33].
For that, acid etching of the composite surface and tooth
structure 1–2 mm beyond the margins is performed for 15 s,
followed by rinsing with air/water spray and drying with air-
stream. The surface sealant is applied, followed by an air-
stream to produce a very thin coat and light-curing for 10 s.
The product used for surface sealing is a dedicated material,
basically an unfilled solvent-free monomer blend, and not a
regular adhesive or pit and fissure sealant. The surface sealing
technique may be observed in . Fig. 15.6e´–g´.
 
Tips
The surface sealing can fill the microcracks on composite
surface, enamel cracks close to the margin and interfacial
gaps, reducing the wear and increasing the durability of
the restoration.
15.7   aintenance of Posterior Composite
M
Restorations
When correctly indicated and performed, in a patient with
good oral health, composite restorations may show excellent
durability. The correct advice about restoration maintenance,
oral hygiene, dietary control, and use of fluoride must be
given to the patient during the dental treatment [4]. In addi-
tion, composite restorations must be frequently reevaluated
by the dentist to detect any problems, such as material chips,
bulk fractures, or marginal ditching. The patient can return
to the dental office every 6 months for evaluation and surface
sealing. Patients that intake large amounts of coffee and
­carbonated or alcoholic beverages must be aware of their
higher risk of restoration wear and staining [43].
Whenever possible, small defects on composite resto-
rations can be repaired by adding new material, since the
remaining restoration is in good conditions. However,
before performing a repair, the factor that caused the
defect should be determined and controlled. The repair
technique was already described in this chapter. When the
defect is located on the proximal surface, a small prepara-
tion is done to allow access to new composite placement.
A matrix and wedge must be applied, like for any restora-
tion. There are on the market some adhesives developed
specifically for composite restorations repair, such as
Ecusit (DMG). However, most adhesives can be used to
restoration repair, since the manufacturer’s instructions
are followed.
For many years, every dental composite and adhesives
were based on methacrylate monomers, which means that
they were all chemically compatible and could be used for
restoration repair. However, the silorane monomers do not
properly bond to methacrylate-based composites and vice
versa. Therefore, restorations made with this material
should be repaired with the same composite and with
silorane adhesive [5]. A great concern is the fact that the
dentist, who will perform the repair of an old restoration,
may not be the same to the one who originally did it and
does not know which material was used. For this reason,
the composite surface must always be roughen by abrasion,
with a coarse grit diamond point or sandblasting, creating
micromechanical retention in an attempt to increase the
bonding [3].
Composite Restoration on Posterior Teeth
Conclusion
The composite resin is the most widely used restorative mate-
rial for posterior teeth. The success of this kind of restoration
is related to the dentist’s understanding about the material’s
properties, following its indications, but respecting its limita-
tions. The tooth preparation procedure should always focus
on the maximum preservation of the remaining tooth struc-
ture, associated with a meticulous restorative technique.
Different strategies for proper restoration of proximal con-
tour and contact can be used, including preoperative and
alternation wedging, sectional matrix and separation rings,
contact forming instruments, prepolymerized ball, etc. The
use of layering technique is essential for regular composites;
however, the new bulk-fill materials are a quicker and viable
option. The finishing and polishing techniques are also
important for the quality and durability of the restoration,
although neglected by many clinicians. The dentist must
attempt to avoid unnecessary restoration replacement, try-
ing to repair the old ones whenever possible.
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 631 16

Preventive Measures
and Minimally Invasive
Restorative Procedures
Alessandra Bühler Borges, Carlos Rocha Gomes Torres, and Nadine Schlueter

16.1 Introduction – 632

16.2 Preventive Measures – 632

16.2.1  utrition – 632
N
16.2.2 Oral Hygiene – 634
16.2.3 Fluorides – 636
16.2.4 Additional Caries Preventive Strategies – 640

16.3 Pit and Fissures Sealants – 642

16.3.1 T ype of Sealants – 645
16.3.2 Longevity of the Sealants and Effect on Incidence of Caries – 650
16.3.3 Extended Fissure Sealant and Conservative Composite
Restorations – 650

16.4 Enamel Caries Infiltration – 652

References – 660

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_16
 632 A. B. Borges et al.
Learning Objectives
The learning objectives of this chapter are related to the fol-
lowing topics:
55 Basic information on types of preventive measures
55 The principles of prevention in dentistry
55 Relevance of nutrition recommendations with respect to
caries
55 Relevance of oral hygiene (mechanical plaque control)
with respect to caries
55 Principles of fluoridation – effects, types, and prepara-
tions
55 Measures for chemical plaque control
55 Principles of fissure sealing
55 Principles of caries infiltration
16.1 Introduction
The objectives of operative dentistry are to prevent, preserve,
and maintain the sound tooth structures and to minimize the
tooth structure removal required, if necessary, for restora-
tions. The minimally invasive dentistry is part of a develop-
mental progress, determined by the accumulation of
information from the cariology that involves the knowledge
of the caries disease, as well as the developing of techniques
and mechanisms aiming to prevent or arrest the lesion. It is
currently known that dental caries is an in part reversible dis-
ease that begins with enamel demineralization and it may,
eventually, progress up to a cavitation if the risk factors are
not controlled and if no preventive measures are imple-
mented [1].
The minimally invasive dentistry involves procedures
such as pit and fissure sealants, resin infiltration, and conser-
vative composite restorations. Together with the preventive
measures, as dietary advices, regular control of biofilm, and
improvement of oral hygiene habits as well as the application
16 of lowly and highly concentrated fluorides to improve remin-
eralization and to decrease demineralization, those proce-
dures may reduce caries development and preserve the sound
tooth structure [2].
16.2 Preventive Measures
Prevention in dentistry is one of the keystones in the daily
practice of each dentist. The preventive strategies are tradi-
tionally divided into primary, secondary, and tertiary pre-
ventive measures [3, 4]. The primary strategies aim to reduce
the number of new cases of a disease. This is normally
achieved by health-promoting strategies. For cariology such
strategies include nutrition advices, oral hygiene recommen-
dations, inhibition of demineralization by application of flu-
orides, and the application of fissure sealants. In the context
of secondary prevention, all measures are subsumed, which
aim to early detect a disease, preferably at a stage at which the
disease can be reversed or even healed. The major goal is to
avoid any additional coming down with the disease and to
limit the dental hard tissue loss. These measures include
application of fluoride preparations to enhance the reminer-
alization process and the infiltration of carious lesions. The
tertiary prevention that includes all measures specifically
treating defect oriented the sequelae of the disease aiming to
prevent further damage. This includes extended fissure seal-
ing, minimally invasive approaches as well as adequate treat-
ment techniques, such as use of restorative  materials. All
measures, preventive and restorative, should be accompanied
by the consideration of all factors potentially influencing the
disease, such as caries activity, caries risk, nutrition habits,
oral hygiene habits and devices, fluoride usage, socioeco-
nomic status, age, etc.
The four major parts of caries prevention comprise
advices regarding “nutrition,” “oral hygiene” (including
mechanical and chemical biofilm control), “fluorides,” and
also the “visits to the dentist” (including the application of
fissure sealants) [5]. These parts are substantiated by the local
legal framework for health promotion. Most evidence for
these measures exists for fluorides, followed by oral hygiene
advices and least for nutrition [6–10].
>> Prevention can be divided into primary, secondary,
and tertiary prevention. The four major parts of caries
prevention comprise advices regarding “nutrition,”
“oral hygiene” (including mechanical and chemical
biofilm control), “fluorides,” and also the “visits to the
dentist” (including the application of fissure sealants).
16.2.1 Nutrition
Doubtlessly, short-chain carbohydrates, also named sugars,
are one promoter of the development of caries, since no car-
ies occurs if the bacteria in the dental plaque or biofilm have
no access to metabolizable carbohydrates. After a sugar
intake of even small amounts (15 mg sucrose), relevant acid
production by the bacteria in the biofilm can be measured;
after an intake of 500 mg sucrose, the maximum of acid pro-
duction is reached.
Up to now, there is no diet completely inhibiting car-
ies. However, it is meaningful to reduce the daily intake to
a minimum, since by this measure the development can be
reduced. Therefore, nutrition advices or recommenda-
tions should be given as early as possible (in kindergar-
tens, schools) but should also be given on a regular basis
during the whole lifetime by parents, dentists, and teach-
ers and also in the later stage of life by nursing staff in care
homes.
Even if we have a decline in caries in most industrialized
countries, world consumption of sugars is still quite high
and ranges in these countries between 12.5 kg/capita and
year (China) and 71.8 kg/capita and year (Cuba) with a
mean of 39.9 kg/capita and year [11]. That there is a decline
in caries despite the high consumption of sugars depends
most likely on the regular use of fluoride products and oral
hygiene measures (see below). The WHO recommends
Preventive Measures and Minimally Invasive Restorative Procedures
reducing the sugar consumption to a maximum of 10% of
the total calorie intake; if the effect of sugar consumption on
caries development is considered, the WHO recommends
even a maximum of 5%. Sugar includes all free mono- and
disaccharides artificially added to and naturally contained
in food and beverages, including juices, honey, and syrup.
This means that in case of a 2000 kcal intake per day, a max-
imum of 10 kg/capita and year should be consumed [12].
Even the lowest consumer in the list mentioned above con-
sumes more than allowed according to the WHO recom-
mendations.
However, not only the absolute amount of sugar is rele-
vant. The frequency of intake might be more important, since
it has been shown that with an increase of absolute amount
and intake frequency, the caries increment increases more
than with the increase of absolute amount alone without
increase of intake frequency [13]. This depends most likely
on the asymptotic pattern of acid production after different
amounts of sugar consumption.
>> The frequency of sugar intake might be more
important than the absolute amount of sugar
consuption alone for the caries disease.
It is not clear which type of food is of particular cariogenicity.
The content of free sugars (mono- and disaccharides) is of
predominant relevance. However, also processed starch can
be metabolized by the plaque bacteria. The combination
between sugars and processed starch is highly cariogenic.
Furthermore, several other chemical and physical factors
contribute to or reduce the cariogenicity such as an increase
in saliva flow, stickiness, consistency, protein, or fat content.
Individual factors like the respond of the salivary gland on
stimulating impacts, tooth position, and bacterial composi-
tion are also relevant. Saliva flow and tooth position deter-
mine the oral clearance rate, the time between food intake,
and its elimination from the mouth.
With regard to caries, a tooth-friendly nutrition should
therefore contain low amounts of free sugars, should not be
sticky, and should have a consistency requiring chewing,
which leads to an increase of saliva flow. The frequency of
consumption at main meal or snack should be reduced to a
minimum, in order to give the saliva the chance to reminer-
alize initial carious lesions [13]. As snack milk products,
fruits and vegetables can be recommended. However, one has
to bear in mind that teeth can be damaged by other compo-
nents than sugar in the foodstuff, such as acids, which can
induce erosive tooth wear [14].
Nutrition advices should be given to everybody in terms
of primary prevention. In particular, if the caries risk is high,
nutrition recommendations should be an integral part of the
whole concept. Nutritional habits can best be recorded with a
nutrition protocol. Relevant food and beverages can easily be
identified, and alternatives can be recommended. In particu-
lar in the case of young children, nutrition advices are of
major importance in order to avoid the development of early
childhood caries. In this context also the effect of acidic food
and drinks should be pointed out.
633 16
Tip
Nutritional habits can best be recorded with a nutrition
protocol. Relevant food and beverages can easily be
identified, and alternatives can be recommended.
The cariogenicity of food and beverages can be assessed by
standardized test procedures. One is the intraoral plaque pH
measurement; the other is the assessment of degree of demin-
eralization of enamel samples in the oral cavity. It is mea-
sured in the plaque how deep the pH declines after a sucrose
consumption and whether the critical pH for caries is
reached. A foodstuff or beverage is defined as “tooth-friendly”
if the plaque pH does not sink below 5.7 within 30 min after
consumption [15].
There are alternatives to sugars, which have a sweet taste
but no cariogenicity. One can distinguish between caloric and
non-caloric sweeteners as well as between those having vol-
ume and being a substitute for sugar and those with a very
high sweetening power and without volume, which can only
be used as an additive to but not as a replacement for sugar.
The caloric ones are mainly the sugar alcohols mannitol, sor-
bitol, and xylitol. Both sorbitol and xylitol are part of plants,
from which xylitol is extracted; sorbitol is mostly produced
industrially by hydrogenation of glucose. Sorbitol can be
metabolized by Strep. mutans, however, only to a small extend,
and the pH decline is mild and ends at values higher than the
critical pH [16]. Therefore, sorbitol is classified as non-cario-
genic. There are several studies dealing with xylitol, all show-
ing a caries-reducing effect of this sugar alcohol [17–19].
Xylitol is not metabolized in the bacteria; rather the molecule
is transported inwards and later outwards the bacteria under
loss of energy [16]. Several other aspects are discussed to play
a role such as the reduction of Strep. mutans in the saliva or
reduction of virulence of Strep. mutans, both playing a role in
the reduction of cariogenicity in the oral cavity [20]. Xylitol
was at the beginning only used in chewing gums and some
oral hygiene products. Nowadays, a lot of xylitol containing
snacks, sweets, chocolate, and other foodstuff are available, as
it has been shown that xylitol is not only non-cariogenic but
also a good option for patients suffering from diabetes melli-
tus. A side effect of sugar alcohols is that they can lead to diar-
rhea due to slow resorption in the bowel; however, in most
cases this effect is only temporarily. Non-­caloric sweeteners
include cyclamate, aspartame, and erythritol. The first two
molecules have a very high sweetening power. It is often dis-
cussed whether they have a health-­harming effect, and some
countries have already forbidden the use in particular of cycla-
mate. Erythritol is a non-caloric sugar alcohol with nearly the
same volume as sugars but with a slightly less sweetening
power. It can therefore, at least in part, be used as a substitute.
First studies show that also erythritol has a beneficial effect on
oral health, maybe comparable to xylitol [21]. As mentioned
for other sugar alcohols, it can induce diarrhea; in addition it
can provoke during consumption a cooling effect on the oral
mucosa and the tongue, which is not accepted by all persons.
 634 A. B. Borges et al.
>> Sugar alcohols, such as xylitol, erythritol, and sorbitol,
are good alternatives to sugars, as they have a
comparable sweetening power, are voluminous, and
have a comparable taste but are not cariogenic.
16.2.2 Oral Hygiene
Oral hygiene is one of the key components of prevention. The
goal of oral hygiene measures is on the one hand the mechan-
ical removal of the plaque from the tooth surfaces and, on the
other hand, the administration of active agents such as fluo-
rides but also compounds for chemical plaque removal or
modification in order to maintain oral health. Plaque removal
is of major importance to avoid both caries and also peri-
odontal disease. In this chapter only the relevance of plaque
removal in the context of caries should be discussed.
As plaque is one of the key components in the develop-
ment of caries, the regular and sufficient removal of the bac-
terial biofilm is not only meaningful but also biologically
plausible. For most people oral hygiene is well integrated into
the daily routine and a basic element of the personal hygiene
and oral health maintenance. Different aspects in oral
hygiene contribute to success of the efforts, i.e., duration, fre-
quency, technique, systematics, and oral hygiene aids.
16.2.2.1  Duration and Frequency
While in the middle of the last century the mean brushing
duration ranged between 30 and 60 s [22–24], nowadays the
duration in most industrialized countries lays at 2–3 min [25,
26]. These changes to durations, which have been proven to
be most effective, are a result of structured preventive pro-
grams and can be rated as one of the successes of such con-
cepts. The recommendation to brush 2–3 min bases on the
findings that the efficacy of brushing can be enhanced by
approximately 55% by prolonging the brushing duration
16 from 30 s to 180 s; as from a duration of 150 s, a maximum of
enhancement is achieved [27].
It takes 24–36 h until a matured plaque has established on
the tooth surfaces. Therefore, biologically seen, it would be
enough to clean once per day the teeth to maintain their
health. However, most people are not able to remove plaque
sufficiently from all surfaces. Therefore, it is generally recom-
mended to brush the teeth two times per day. This recom-
mendation is supported by different studies. They have
shown that with a frequency of two times per day, the risk for
an increase of caries incidence and increment is lower than
for a frequency smaller than two times per day; a frequency
higher than two times per day has only limited additional
benefit [28].
>> Brushing teeth two times per day for two minutes each
is effective for preventive caries. This measure is
biologically plausible and he recommendation is
supported by various studies.  reach all areas.
16.2.2.2  Technique and Systematics
Several techniques have been developed for sufficient clean-
ing of teeth under various conditions. While during child-
hood easy motions are recommended such as circling on the
smooth surfaces and scrubbing on the occlusal surfaces
(Fones technique) [29], more complex techniques are recom-
mended, which require more dexterity, as soon as the patients
are able to perform these (usually if the patients reached the
school age).
The most recommended technique is the modified Bass
technique (MBT), where the toothbrush bristles have to be
positioned at the gingival margin in a 45° angulation with the
direction of the bristles towards the sulcus. The brush has to
be moved with small jiggling motions and wiped out towards
the occlusal area including a rotating movement. With these
motions the plaque will be loosened at the margin and
removed with the wiping [30, 31]. The MBT can be used if
the periodontal structures are healthy as well as if the peri-
odontium shows some preexisting damage. It is mostly rec-
ommended in case of intact interdental papillae and if the
gingival margin ends up at the cementoenamel border.
For the Charters technique, the bristles of the brush again
have to be positioned at a 45° angulation, however, this time
with the bristles directed towards the occlusal surface. Small
circling movements have to be done, and the bristles should
be pushed with small movements into the interdental space.
This technique is recommended to patients with residual
pockets after periodontal therapy and with free interdental
spaces.
The Stillman technique has been developed for patients
with healthy periodontal tissue but showing recessions. The
bristles of a soft toothbrush have to be positioned on the gin-
giva and wiped out towards the occlusal surface with a rotat-
ing movement (white to red technique).
Even if the MBT is named as the most recommended
technique, only a few persons use this complex technique
[26]. In addition, studies have shown that it is not better than
the others with respect to plaque removal; rather, it has been
shown that none of the mentioned techniques is superior to
another [32, 33]. Therefore, it seems of secondary impor-
tance which technique is recommended, provided that the
oral hard and soft tissues are not damaged during the brush-
ing process.
More important than the technique seems to be that
patients perform a systematics in order to sufficiently reach
all areas. An equal brushing of all areas most likely leads to
a better plaque removal, independent of the order of brush-
ing. A sufficient systematics should be taught as early as
possible [34, 35].
>> It seems of secondary importance which brushing
technique is recommended to the patient. More
important than the technique seems to be that
patients perform a systematics in order to sufficiently
Preventive Measures and Minimally Invasive Restorative Procedures
16.2.2.3  Oral Hygiene Aids
The most commonly used tool for cleaning teeth is the tooth-
brush, either a manual one or a powered one. The manual
toothbrush is currently the most used form of toothbrush,
since it is cheap, easy to acquire, and usable independent of
electricity. The manual toothbrush should have a short head
(max. 2.5 cm), equipped with rounded, elastic plastic bristles,
which are arranged in tufts (multi-tufted, 20–40 bristles in
each tuft), and should have a length of 10–12  mm and a
thickness of 0.18–0.25  mm [36]. Too hard or not rounded
bristles can lead to violation of the soft tissues. There are
brushes with different head designs available; however, stud-
ies have shown that the acceptance of the brush itself by the
patient has more impact on the cleaning efficacy  than the
brush head design. The force used should not exceed 200 g
(appr. 2 N) in order to avoid any damage of soft and hard
tissues [37]. The brush should be changed after 4–6 weeks or
in case of bending of bristles. In order to avoid unnecessary
accumulation of bacteria, the toothbrush should be allowed
to dry in the air. If more than one brush is used in parallel,
the bristles can completely dry within 24 h. The complete
drying can on the one hand reduce numbers of germs on the
tooth brush head and can in addition  increase  the tooth-
brush’ longevity. After each infection in the mouth-throat
region brushes should also be changed to avoid any reinfec-
tion.
Tip
There are brushes with different head designs available;
however, studies have shown that the acceptance of the
brush itself by the patient is more important for cleaning
efficacy than the brush head design.
Powered toothbrushes can be divided into rotating-­oscillating
brushes, wiping brushes, sonic brushes (amplitudes: ca. 250–
350 Hz), and ultrasonic brushes (amplitudes: ca. 1.5 MHz).
In principle, powered toothbrushes are highly effective and
could potentially be more effective than manual ones.
However, systematic reviews have shown that electric tooth-
brushes, at least the rotating-oscillating brushes, are only
marginally superior to the manual ones [38]. For the others
there are not enough studies available to give final conclu-
sions. That not a clear superiority of powered toothbrushes
was found might be due to lack of good designed studies, the
lack of use of a sufficient systematics [39], or the decrease of
“the charm of the new” in case of an electric device after a
short period. Due to the smaller brush head in case of an
oscillating-rotating model, the patients have to pay attention
on very systematic handling. Mostly, patients need more time
with the electric device than with the manual brush. Studies
have in addition shown that the force used with electric
brushes is mostly lower than with the manual ones [40]; this
might be an option for patients using habitually high brush-
ing forces. (Ultra)sonic brushes are particularly technique
sensitive. They should not be used with the same contact
635 16
pressure as rotating-oscillating brushes or manual brushes
and with different movements. These brushes work via the
formation of micro-flow and hydrodynamic effects in the
plaque and not by the direct removal of the plaque by the
movement of the bristles [41]. The brushes have to be placed,
like it was described for the modified Bass technique, in a 45°
angle on the gingival margin with the bristles directing api-
cally, however without any pressure. The brush has to be held
there for some seconds, and, optimally, afterwards the brush
has to be wiped out towards the occlusal surface. Using this
brush with normal or high pressure leads to a reduction of
efficacy. Patients have to be sufficiently taught in this special
technique; used without the correct technique but with
movements recommended for manual toothbrushes, the
benefits of the sonic technology will not be exhausted, and
the brush acts more or less like a normal manual toothbrush.
>> Powered toothbrushes are only slightly superior
compared to manual toothbrushes regarding plaque
removal. Sonic brushes seem to be particularly
technique sensitive.
Common to all toothbrushes is that they cannot directly
reach the interdental spaces, even if there are some in vitro
studies showing some effect of the sonic brushes on plaque in
artificial interdental spaces [42]; the final evidence, however,
is lacking. Therefore, additional aids are necessary to clean
these areas, which in sum account for 30% of the whole sur-
faces of the teeth. Interdental cleaning aids are dental floss
(waxed, unwaxed, tape, super floss, or devices with fixed den-
tal floss), medical toothpicks or interdental sticks, interdental
brushes (with metal core or metal free), and powered devices
including high-velocity microdroplet devices.
If dental floss is used, a piece of at least 50–70 cm will be
taken and winded around the middle fingers. With the
thumb and index finger, the floss will be tensioned and with
small sawing movements inserted into the proximal space.
Here, the floss will be moved up and down while cleaning
both surfaces of the adjacent teeth. If dental bridges or
blocked crowns are present, special dental floss with a stiff-
ened end for precise insertion of the floss under the pontic
is available. This floss has a fluffy part, with which the pontic
can be cleaned from below. Waxed floss can be inserted
easier into the interdental space, whereas unwaxed floss has
a higher cleaning potential. If the interdental spaces and the
contact points are very narrow, Teflon tape can be used.
Even if the evidence for use of dental floss is low [43], the
use of it is biologically plausible. It has been shown that the
professional use of floss can lead to a significant reduction
of caries increment compared to use of floss at home, where
sufficient use was not guaranteed [44]. An alternative to the
use of dental floss is the use of interdental brushes, which
seem to be slightly superior to dental floss [43, 45, 46]. In
addition, interdental brushes are often more accepted by
patients due to higher comfort; however, the brushes have
to be chosen according to the size of the interdental spaces.
In worst case different sizes have to be used, and the patient
has to identify which size fits into which space. A further
 636 A. B. Borges et al.
increase in ­comfort with a similar cleaning power can be
achieved if metal-­free interdental brushes, fabricated from
plastic or silicone, are recommended [47]. These products
do not provoke any gingiva abrasion [48]; in addition they
are very small in diameter and therefore even usable at
younger age with healthy periodontal conditions. Due to its
conical form, they cover different sizes and reduce the indi-
vidual fitting to each interdental space to a minimum. The
evidence on microdroplet devices is very low. There are only
few independent studies on them. It seems to be that at least
under short-term conditions, these devices have an efficacy
comparable to sufficiently used floss but are more comfort-
able in use [49].
Conclusively, the evidence for using interdental cleaning
devices with respect to reduction of caries increment is low;
however, their use is biologically plausible and should there-
fore be recommended.
>> The evidence for using interdental cleaning devices is
low; however, their use is biologically plausible and
should therefore be recommended.
16.2.3 Fluorides
Fluoride application in caries prevention is a central mea-
sure. It has worldwide been extensively investigated, and
there is a bulk of literature and knowledge on this issue. Not
only its efficacy but also its toxicology was subject matter of
numerous studies.
Already in the beginning of the twentieth century, it has
been recognized that children in areas with high amount of
fluoride in the drinking water (0.7–1 ppm) had less caries;
concomitantly, they very often show non-cariously caused
enamel spots (mottled teeth) [50]. Highest reductions were
found for smooth surfaces followed by proximal areas; in
16 the fissures on the occlusal surfaces, the effect was notably
lower. It was hypothesized that a fluoride content in drink-
ing water of approximately 1 ppm has a caries-protective
effect. Several other epidemiologic studies have been found
in the following comparable effects of fluoride in the drink-
ing water [51].
Two modes of actions of fluoride might be relevant.
The ion could either work systemically via incorporation
of the fluoride into the developing dental hard tissue (sys-
temic fluoridation) or locally by the contact between the
fluoride ion and the erupted teeth in the oral cavity (local
fluoridation).
Basing on the early observations from the areas with fluo-
ride in the drinking water, it has been assumed over a long
period that the systemic fluoridation plays the major role in
the caries-preventive effect of fluoride. However, it has been
turned out that not the systemic effect is of relevance but the
local effects of the fluorides [52]. There are no indications
that the preeruptively fluoridated teeth have a lower acid
solubility than not preeruptively fluoridated teeth [53, 54].
Consequently, the preeruptive retention of fluoride does not
ensure that the teeth do not develop caries: persons moving
away from an area with high amounts of fluoride in the
drinking water are at the same risk to develop caries in the
area without fluoride in the drinking water as persons never
lived in fluoride-rich areas [55]. Different studies have clearly
shown that an impact of a systemic fluoridation with fluoride
tablets during infancy and early childhood on caries incre-
ment in permanent teeth cannot be verified [56]. The same
applies for a fluoride supplementation during pregnancy [57,
58]. In fact, all systemically given fluorides in the form of
drinking water, fluoride tablets, or fluoridated table salt work
predominantly over the local effect during the oral ingestion
of the preparation. Therefore, the administration of fluoride
tablets should be accompanied by the clear instruction that
the tablets have to be sucked and not to be swallowed to take
advantage of the local effect. In particular those children hav-
ing no access to other fluoride sources could profit from this
measure; however, the overall balance of fluoride intake has
to be considered. In case of regular use of fluoridated salt or
fluoridated mineral or drinking water, no tablets should be
used. As regularities clearly differ between various countries,
no explicit dosage of fluoride supplementation or application
should be given here; in this context, reference is made to the
local regulations.
As it has been shown that the local fluoridation is of
major efficacy, most countries nowadays prefer the local
application of fluorides. Such approaches include the regular
home use of toothpastes, mouth rinses, and gels or the pro-
fessional application of highly concentrated preparations
such as varnishes or fluids. Already in the late 1890s, first
fluoride-containing oral hygiene products (rinses, tooth-
paste, and tooth powder) were fabricated. Mostly, hardly
soluble calcium fluoride was added, making the efficacy of
the compounds questionable. In the early 1960s first tooth-
pastes with stannous fluoride or amine fluoride were mar-
keted and comprehensively promoted. However, only in the
1990s, it has been shown that the comprehensive usage of
fluoridated toothpastes but also of other fluoride sources was
associated with a decline in caries prevalence [59, 60]. Later
on, several systematic reviews have shown that the regular
local use of fluorides is notably effective in reducing caries [9,
10, 61–65].
>> Fluorides can work systemically and locally. The
systemic effects of fluorides are very low. The major
share of fluoride effect in caries prevention depends
on the local effect of the ion after topical application.
16.2.3.1  Conventional Fluorides and Effect
of Fluoride Ions
Several fluoride compounds are used for prevention of caries.
These compounds can be divided into inorganic and organic
fluorides; the inorganic ones can be subdivided into those
having a monovalent ion as a counterion to the fluoride ion
(conventional fluorides) and those having a polyvalent metal
cation as a counterion (7 see 16.2.3.2). The conventional
Preventive Measures and Minimally Invasive Restorative Procedures
­ uorides include sodium fluoride (NaF), sodium monofluo-
fl
rophosphate (NaMFP), and amine fluoride (AmF, such as
dectaflur and olaflur or amine fluoride 297). While the fluo-
rides AmF and NaF can be easily split in aqueous solutions
into the ions, an intraoral enzymatic or acid-driven hydroly-
sis process is necessary to split the fluoride ion from the
NaMFP.
Four reactions between the dental hard tissue and the
fluoride can be distinguished. (1) The enamel is slightly dis-
solved at the surface and forms during reprecipitation CaF2-­
like precipitates. (2) The enamel is slightly dissolved and
forms during reprecipitation fluoridated hydroxyapatite or
fluorapatite. (3) The fluoride diffuses into the enamel and
specifically adsorbs to free binding places at the crystals such
as OH−, Ca2+, or phosphate compounds. (4) The fluoride dif-
fuses into the enamel and binds unspecifically in the aqueous
coverage of the enamel crystals.
In particular the first mentioned mode of action, the for-
mation of calcium fluoride (CaF2)-like precipitates on the
tooth surfaces, is of major importance. The CaF2-like pre-
cipitates are stabilized intraorally on the tooth surfaces by
phosphate groups and saliva proteins. In case of a plaque
accumulation and bacteria-induced pH decline in the bio-
film, parts of the CaF2-like precipitate are dissolved releasing
fluoride ions. This fluoride can diffuse into the enamel, and
the modes of action 2, 3, and 4 could take place. A sufficient
plaque removal with fluoridated toothpaste recovers the
CaF2-like precipitate, which again forms a reservoir for fluo-
ride ions. The CaF2-like layer is insofar of major importance
as it can protect the underlying enamel against acid impacts.
If this layer is incomplete, the underlying enamel can be dis-
solved, even if fluoride has been incorporated into the crys-
tals. However, the critical pH of fluoridated enamel is
decreased, which can lead to a lower solubility of the enamel
itself [66].
The amount of CaF2 formed on the tooth surface
depends on the concentration of fluoride in the prepara-
tion (the higher the more), the application duration (the
longer the more), the pH of the preparation (the lower the
more), and the fluoride compound [67]. It has been shown
that AmF leads to a higher CaF2 formation than NaF as
well as the fluorides containing polyvalent metal cations
[67, 68]. All fluoride preparations lead to an enrichment of
fluoride in the upper structures of enamel [69]; the pene-
tration depth is limited and depends also on the com-
pound used. While readily dissociating fluorides easily
diffuse into the upper enamel structures, this process takes
much more time in case of NaMFP, since this compound
has to be split enzymatically [70], with the consequence
that after NaMFP application, the fluoride uptake is lower
than after the other compounds [70, 71]. In case of healthy
enamel, there is a chemical balance between the saliva and
the dental hard tissue, leading also to a delivery of fluoride
into the environment. In case of a carious demineraliza-
tion and a fluoride application, however, the fluoride
uptake is much higher, leading to a permanent enrichment
with fluoride ions.
637 16
>> The formation of CaF2-like layers on the tooth surface
is of major importance for caries prevention as it
constitutes a fluoride reservoir from which fluoride can
be released during a cariogenic acid attack. The
amount of CaF2 formed on the tooth surface depends
on the concentration of fluoride in the preparation, the
application duration, the pH of the preparation, and
the type of fluoride compound.
Fluoride is also retained in the dental plaque in form of ion-
ized, ionizable (weakly bound), and bound fluoride. The
bound fluoride is connected to organic components in the
plaque and to the bacteria. The weakly bound fluoride is the
abovementioned phosphate-stabilized fluoride. At neutral
pH, only low amounts are present as ionized fluoride; in case
of pH decline, bound fluoride will be set free, both from
plaque, CaF2-like precipitates, and dental hard tissue, and the
absolute amount of ionized fluoride increases [72].
The basic principles of anticariogenic effect of fluorides
are (1) reduction of acid solubility of the dental hard tissue
and (2) inhibition of demineralization as well as promotion
of remineralization. The hydroxyapatite in the dental hard
tissue is not the stoichiometric form of this compound but a
deficient one. Several crystals show deficits and imperfec-
tions. In these areas, fluoride can be incorporated during
maturation of the teeth, in both preeruptive and Post-
eruptive enamel maturation. By the filling of the deficiencies
with fluoride, the crystalline structure is stabilized which
modifies or reduces the solubility of hydroxyapatite. Fluoride
ions, however, do not only fill the deficiencies but also
replaces the hydroxyl ions (conversion of hydroxyapatite into
fluorapatite). This leads also to a reduced acid solubility. The
replacement is limited: during preeruptive formation of
hydroxyapatite, approximately 10% can be replaced.
Posteruptively, the surface can also be enriched with fluoride
ions by a topical application of fluoride preparations.
Comparable, the interaction between the fluoride ion and the
surface causes also a substitution of hydroxyl with fluoride
ions. However, the depth penetration is limited.
The caries inhibition can only be partly be explained by
the mentioned effect on solubility. An equally important
mode of action is the impact of fluorides on de- and remin-
eralization. The enrichment of the tooth surface by the topi-
cal application of fluorides with weakly bound fluoride
(CaF2-­like precipitates) allows that during a carious pH
decline, fluoride can be released into the aqueous phase.
These free fluoride ions can protect the crystals of the dental
hard tissue by forming fluorapatite and by reducing their
solubility. During the neutralization process, the fluoride
ions precipitate together with calcium ions and dissolved
hydroxyapatite, forming fluorapatite and fluoridated apatite.
These fluoride-­enriched minerals precipitate earlier, as the
solubility product of hydroxyapatite and fluorapatite differs.
Therefore it can be concluded that the demineralization is
reduced by the inclusion of the fluoride but also the remin-
eralization due to the earlier precipitation [72–74]. This
chemical and dynamic balance prevents, if a good oral
 638 A. B. Borges et al.
hygiene and less sugar ­consumption are present, a dissolu-
tion and destruction of the teeth. However, in case of very
aggressive cariogenic demineralization, a net loss of mineral
can occur resulting in the formation of white spot lesions.
For the process of enrichment of the dental hard tissue with
fluoride ions, concentrations of 0.1 ppm fluoride in saliva
are necessary, which can be achieved by the regular applica-
tion of topical fluorides.
>> The basic principles of the anticariogenic effect of
fluorides are the reduction of acid solubility of the
dental hard tissue and the inhibition of
demineralization in combination with the promotion
of remineralization.
In addition to the effect on the tooth structure, fluoride has
also an effect on the bacteria in the dental biofilm. With
increasing fluoride concentration, first the metabolism of
bacteria is influenced, then the bacterial growth is inhibited,
and finally a bactericide effect can be reached, however, not
by the concentrations found in the dental plaque. The pH in
the dental plaque substantially influences the antibacterial
effect of fluoride; with decreasing pH values, distinctly lower
concentrations for inhibition of bacterial metabolism are
necessary. However, the more acid tolerant a bacterium is,
the higher is its fluoride tolerance. But luckily, in particular
those bacteria metabolizing glucose could be influenced by
fluoride. The fluoride can inhibit after uptake into the germ
an enzyme in the glycolysis, i.e., the enolase, responsible for
formation of phosphoenolpyruvate, an intermediate product
in the way from glucose to lactate [75]. In addition, the glu-
cose uptake can also be inhibited by fluoride. Two ways are
possible: (1) The phosphoenolpyruvate phosphotransferase
system – which is responsible for the conversion of glucose to
glucose-6-phosphate, the form necessary for uptake into the
bacteria – can indirectly be inhibited by the inhibition of the
enolase and the lack of phosphoenolpyruvate. (2) In case of
16 low pH in the plaque and at high concentrations of substrate,
the glucose can directly be taken up into the bacteria without
any transport systems driven by the pH-dependent proton
gradient between the outer and the inner part of the bacte-
rium. In case of presence of fluoride, a part of the protons will
be absorbed by the fluoride, leading to hydrofluoric acid
(HF), which can be directly transported into the bacteria. In
the bacterium the HF dissociates intracellularly and sets H+
ions free, which reduces the proton gradient and follows the
driving force of the glucose uptake. In parallel the dissocia-
tion of HF in the bacterium decreases the intracellular pH,
which in turn destroys the pH optimum of the enzymes of
the glycolysis [76]. Both the reduction of glucose uptake and
the reduction of enzyme activity inhibit the bacterial metab-
olism. Furthermore, the formation of intracellular storage
carbohydrates is inhibited, as well as the synthesis of lipotei-
choic acid, necessary for bacterial adherence. No impact on
the degradation of intracellular storage carbohydrates as well
as on synthesis of extracellular storage carbohydrates was
found [73].
Over time the oral microorganisms can adapt to the fluo-
rides (development of a type of resistance), in particular, if
high fluoride concentrations are used. However, the capacity
of the germs to metabolize sugars is reduced – the pH decline
is milder and shorter. The benefit of a milder pH decline is
that the ecological shift to more acid-tolerant and acid-­
producing bacteria is less pronounced [75].
>> Fluoride ions have an impact on cariogenic bacteria.
They can reduce the bacterial metabolism by inhibiting
the uptake of glucose into the bacteria, by inhibiting
of enzymes of the glycolysis, and by inhibiting the
synthesis of lipoteichoic acid, necessary for bacterial
adherence.
16.2.3.2  Fluorides with Polyvalent Metal
Cations
Besides the “conventional” fluorides, also fluoride com-
pounds containing polyvalent metal cations are available,
such as stannous, titanium, and silver ions or zinc and copper
ions. Titanium tetrafluoride is not approved for use in oral
hygiene products and should not be described here in detail.
The other ions have already been used at the end of the nine-
teenth and the beginning of the twentieth century in den-
tistry as an antibacterial agent.
Copper and zinc are able to increase the intra-bacterial
production of peroxides and superoxides, inducing a damage
of bacterial DNA and the inhibition of growth-relevant
enzymes [77]. Furthermore, all mentioned polyvalent metal
cations can react with sulfur compounds, such as thiols and
proteins, disturbing the protein function and the metabolism
of the bacteria. Stannous ions are able to inhibit in addition
to the enolase two further enzymes of the glycolysis, the
aldolase and the P-glycerin-aldehyde dehydrogenase, result-
ing in a lower pH decline in case of sugar intake [78–80]. It is
speculated that the polyvalent metal ions also react with the
lipids of the bacterial cell membrane provoking an impair-
ment of the membrane function up to a disintegration of the
whole membrane structure [81]. Often stannous ions are
used in combination with amine fluoride, which can easily
penetrate the bacterial membrane [82]; both compounds can
reinforce each other in effect. No development of resistance
of the bacteria against the polyvalent metal cations was
found, which is of major importance in the context of the
discussion about development of resistances due to antibiot-
ics. In addition, the toxicological potential of these ions is
very low [83]. Side effects could be a dull feeling on mucosa
and dental hard tissue as well as removable staining of the
dental hard tissue.
The metal cations have a high substantivity and are
retained in the oral cavity over a long period. In addition
to the effects on the bacterial metabolism, the metal cat-
ions, at least stannous ions, can be incorporated under
acidic conditions into the upper structures of the dental
hard tissue, leading to a reduced acid solubility of the den-
tal hard tissue [84, 85]. The application of stannous in
Preventive Measures and Minimally Invasive Restorative Procedures
combination with ­fluoride [68] as well as of silver ions in
the form of silver diamine fluoride leads to a higher forma-
tion of CaF2-like precipitates on the tooth surfaces, poten-
tially promoting the anticariogenic effect. However, the
additional effect of polyvalent metal cations to fluoride on
reduction of caries increment is negligible in case of a nor-
mal caries risk. If special care, however, is necessary (man-
ual or mental disabilities, dry mouth, root caries, early
childhood caries), the application of these fluoride com-
pounds appears meaningful. In particular silver diamine
fluoride and stannous in combination with fluoride could
be a good option [86–90].
>> Fluoride compounds containing polyvalent metal
cations, especially stannous and silver ions, could be a
good option in particular if the caries risk is high. The
cations lead to higher retention of CaF2-like material
on the surface, a change of acid solubility of the dental
hard tissue (stannous ions), and a more pronounce
impact on bacterial metabolism than the fluoride ions
alone.
16.2.3.3  Efficacy of Fluoridated Preparations
and Toxicology
As mentioned above, several systematic reviews show that
fluoride is of notable efficacy in preventing caries [9, 10, 61–
65]. The effect of preeruptive fluoridation by systemic admin-
istration of fluorides is considered to be small; the topical
effect of both highly and lowly concentrated fluoride mainly
contributes to the anticariogenic effect [91]. The effect of
fluorides is highest on smooth free surfaces than on proximal
surfaces and lowest on occlusal surfaces (in pit and fissures).
Here other preventive measures, in particular in case of high
caries risk, are more meaningful, such as pit and fissure seal-
ing (see below).
>> The effect of fluorides is highest on smooth free
surfaces than on proximal surfaces and lowest on
occlusal surfaces (in pit and fissures).
The efficacy of fluorides depends on the concentration and
on the form of delivery as well as on the lifetime duration of
fluoridation and on individual caries risk.
Systemic fluoridation can achieve a caries-reducing effi-
cacy. However, one has to bear in mind that these measures
mainly work via the direct topical contact between the fluo-
ride ion and the dental hard tissue. Drinking water fluorida-
tion and salt fluoridation is comparably effective with caries
reduction in the range of 50–60%. The results for fluoride
tablets are less homogenous; they have an effect in the range
of 28–61% of caries reduction.
Toothpaste plays the major role in fluoride delivery. It has
been shown that toothpastes, with a fluoride content in the
range between 1000 ppm and 2800 ppm, show an increase in
efficacy with an increase in concentration with a more or less
linear dose-response relationship. However, in most coun-
tries, toothpastes with a concentration higher than 1500 ppm
639 16
(in some countries even higher than 1000 ppm fluoride) are
not available as an over-the-counter product (for details
please take the local regularities into account). Toothpastes
show in various studies quite different efficacies, in particular
if used as a conventional fluoride preparation for daily oral
hygiene under unsupervised conditions. The caries-­
inhibiting effect most likely does not exceed 20%. In some
countries fluoride toothpastes with very high concentrations
(5000 ppm) are available but only on prescription for adults.
These products are indicated for therapy of root caries in
order to prevent the development of new lesions and to
reduce the progression of existing lesions. They could also be
significant in case of high caries risk (xerostomia, manual
disabilities, etc.). Beneficial effects of mouth rinses are mostly
masked by the regular use of fluoride toothpastes if the
patient has a normal to low caries risk. In case of high caries
risk, the benefit of this measure might be found. According to
systematic reviews, mouth rinses with a fluoride content
between 250 and 500 ppm can achieve 20–45% caries reduc-
tion. Fluoride gels and fluids with concentrations up to 1.25%
show a very high variation in efficacy (3–48%). This is mainly
due to the fact that they are used at home only weekly or even
more seldom. The professional tray application two to four
times per year shows a more constant efficacy with a caries
reduction between 20% and 40%. The effect of varnishes is
given with 20–75% caries reduction [9, 10, 61–65].
There is a bulk of knowledge on the toxicology of fluo-
rides from the dental literature but also from research on
osteoporosis. The used dosages in dentistry can be all classi-
fied as safe, and it is well-known that fluoride in oral hygiene
products and prophylaxis products is not toxic for human
being if used as intended. For sure, overdosages are possible,
if the preparations are misused. One has to distinguish
between acute and chronic overdosage. Signs of an acute
overdosage are typical signs of poisoning such as nausea,
vomiting, and stomachache. Additionally, symptoms like
sweating, headache, and increased saliva flow can occur fol-
lowed by spasms and tetany. Fluoride has direct impact on
the calcium-potassium equilibrium. The calcium level will
decrease if the potassium level increases. Potassium has a
direct impact on heart activity. As a consequence, arrhyth-
mia, low blood pressure, and reduction of breathing fre-
quency including a respiratory acidosis can occur; finally the
patient can die. As an antidote emesis should be induced, if
there is no aspiration hazard, or calcium-rich preparations
(CaCl2, Ca-gluconate or milk) should be given in order to
complex the fluoride ions [92]. In addition, the patient should
be hospitalized.
The acute lethal dose of fluoride ranges between 32 and
64 mg/kg body weight (certainly toxic dose, CTD). This
range is determined by the effect that different fluoride com-
pounds, the individual resorption velocity, and the pH of the
compounds impact the toxicity. But also below this, thresh-
old poisoning effect can occur, which can be extremely
deadly. In particular infants are at risk for probable toxic
effects. The probably toxic dose (PTD) is 5  mg fluoride/kg
 640 A. B. Borges et al.
body weight. If a child has ingested this amount of fluoride,
medical measures should be arranged [93]. This dose can be
reached in case of infant with 10 kg body weight by 100 fluo-
ride tablets with 0.5 mg, 50 liters of fluoridated mineral water
with 1 ppm, 156 g fluoridated table salt, 100 g (= 67 ml) of a
500 ppm fluoride toothpaste (approximately 1.25 tubes), or
50 g (= 33.5 ml) of a 1000 ppm fluoride toothpaste (approxi-
mately 0.5 tubes). Therefore, infants should not have access
to fluoride products, and oral hygiene should be performed
with supervision [93], preferably after meals as the resorp-
tion of fluoride is much higher if the stomach is empty than
after a meal. Higher concentrated gels (1.25% fluoride)
should be applied in children with individual trays [94].
Highly dosed fluoride preparations should only be applied by
professionals. Preparations which prevent any unnecessary
swallowing of fluoride should be preferred, for example, var-
nishes, which harden in case of contact with saliva. If such
preparations are used, no toxic relevant increase in  plasma
levels in (pre-) school children were found [95]. Chronic
fluoride exposure with more than 1.5 mg/day can induce
during enamel formation dental fluorosis [96]. In particular,
if several fluoride sources are combined, the risk for fluorosis
increases, such as tablets, salts, and/or drinking water.
>> The used dosages in dentistry can be classified all as
safe, and it is well-known that fluoride in oral hygiene
products, supplements, and prophylaxis products is
not toxic for the human being if used as intended.
16.2.4  dditional Caries Preventive
A intended to provide health benefits when consumed”
Strategies
16.2.4.1 Chewing Gums
Different clinical studies have shown that regular chewing of
sugar-free chewing gum can have an impact on oral health
16 [97]. It increases the saliva flow during the chewing process
and also the pH of the saliva. In addition, the plaque forma-
tion and concentration of mutans streptococci and lactoba-
cilli in saliva can possibly be reduced. Studies on children
investigating the effect of supervised chewing of sugar-free
chewing gum several times per day have shown that the car-
ies progression and the caries increment can be reduced by
this intervention. It seems that chewing gums containing the
sugar alcohol xylitol (for mode of action, see [16]) are of par-
ticular effectiveness [98]. As there is some evidence on the
positive effect of chewing gums, the recommendation of its
use up to three to five times per day should be included into
the preventive concept. It should be chewed in particular
after meals in order to increase the saliva flow and saliva pH
to enhance the clearance and the neutralization of acids from
the metabolism of plaque bacteria [99].
16.2.4.2  Chlorhexidine
Chlorhexidine (CHX) is a positively charged molecule,
which has at lower concentrations bacteriostatic and at
higher concentrations bactericide properties [100]. It
binds intraorally to the pellicle as well as to the bacterial
cell membrane, and the integrity of which can be disturbed
by this compound [101]. The efficacy spectrum of CHX is
broad; in particular Strep. mutans reacts very sensitively
[102]. CHX can provoke some local side effects such as
staining of teeth and restorations, changes in taste,
increased formation of tartar, and desquamation of the
oral mucosa [103]. CHX has a very good substantivity and
is potent in reducing the intraoral plaque level [103]. Due
to its potential side effects, it is not intended to use CHX
permanently; however, it is suitable in phases of high car-
ies risk, such as during eruption of teeth, when a fissure
sealing is not yet possible due to inadequate moisture con-
trol and shows efficacy comparable to fluoride varnishes
[104]. In these cases varnishes with at least 1% CHX should
be used [97]. If there is a high caries activity, a short-term
CHX therapy could be applied. During a period of 14 days,
1% CHX gel could be applied with a tray to decrease the
absolute number of bacteria [102]. In two clinical studies,
the caries-reducing effect of CHX application has been
shown [105, 106]. There is some evidence that the applica-
tion of CHX varnish during orthodontic treatment around
brackets can reduce caries increment [107]. Some other
studies give indications that also in case of root caries, a
beneficial effect by CHX application can be achieved [108].
However, the evidence for these recommendations is not
very high.
16.2.4.3  Probiotics
The definition of probiotics is “live microorganisms
[109]. Such approaches have been used since several
decades for the health of the gut. The idea beyond the
application of probiotics in the context of caries is to
reduce the virulence of the bacterial flora in the oral cavity.
It is important that the ingested bacteria have no harmful
impact, for example, if they recombine with other bacteria
leading to an increase of pathogenicity. The goal is to
incorporate probiotics into the biofilm and to replace more
pathogenic bacteria by formation of specific cellular medi-
ators, inhibition of bacterial growth, competitive displace-
ment, or modulation of the immune system [110, 111]. The
effect depends on what germ is used. Some positive effect
has been shown for lactobacillus species (L. rhamnosus, L.
reuteri) in the context of root caries. Furthermore L. reuteri
seems to have a positive effect on periodontal status.
However, even if there are some studies showing a benefi-
cial effect, the evidence is still low. In addition, one has to
keep in mind that there is only an effect of the probiotics
expectable while they are regularly (preferably daily)
ingested. Few days after termination of use, there are no
probiotics detectable in the oral cavity [112, 113]. Some
cautionary voices argue that by incorporating lactobacilli
species into the oral cavity, the number of acid-producing
bacteria could potentially be increased with the potential
effect of an increase of caries risk. However, there is no evi-
dence for this statement.
Preventive Measures and Minimally Invasive Restorative Procedures
641 16
16.2.4.4  Ammonia-Forming Agents f­ragments in combination with phosphate (CPP, patented
Urea and arginine can both be metabolized in the oral cavity as Recaldent™) are more effective than the casein itself
by specific bacteria, such as S. sanguis or S. mitis. In addition, [121]. In addition it has less allergenic potential [129] and
both molecules can be split by enzymes from the saliva, i.e., affects to a lesser extent the taste than casein. The CPP can
arginine deiminase or urease. During this biochemical con- stabilize calcium and phosphate in solutions forming amor-
version, ammonia is released from the molecules, which has phous calcium phosphate (ACP); both compounds form
an alkaline pH [114, 115]. The increase of pH by this process the colloidal complex. The complex is so small that it can
leads to a faster neutralization of cariogenic acids, and the diffuse through the enlarged pores of an initial carious
pathological shift to a higher occurrence of aciduric and lesion. As ACP is a metastable compound, the CPP acts as
acidogenic bacteria can be avoided [116]. According to the a carrier for calcium and phosphate in order to increase the
current level of knowledge, both compounds arginine and concentrations of these ions in the carious lesion to pro-
urea have no harmful side effects. mote the remineralization process.
There are some oral hygiene products and chewing gums Several products with CPP-ACP are available, such as
containing urea; however, the evidence on their efficacy is chewing gums, toothpastes, mouth rinses, and prophylaxis
low. Urea-containing chewing gums have no additional effect pastes, with and without fluoride additives. There are indica-
compared to other sugar-free chewing gums [114, 115]. tions in the literature that it has remineralizing potential;
Arginine is split by the complex arginine deiminase sys- however, the study situation is not fully clear. In particular,
tem, which occurs in both the saliva and specific bacteria. there is no evidence that this compound is better than the
Interestingly, in the biofilm from caries-free surfaces, the standard fluoride. There is also no clear evidence whether the
level of this enzyme system is higher than in the biofilm from combination between fluoride and CPP-ACP shows any ben-
carious surfaces. The same applies for the level of ammonia efit in comparison to fluoride alone; however, it shows better
and of the arginine deiminase system in the saliva – caries-­ remineralization potential than CPP-ACP alone [130]. The
free individuals show higher concentrations than persons use of a CPP-ACP in chewing gums seems to have no or only
suffering from caries. Arginine is used in toothpastes in a little beneficial effect [131]. In case of dental erosion, such
complex with insoluble calcium compounds in order to preparations fall short of expectation if used as an oral
increase the availability of calcium and the remineralization hygiene product [132]; as an additive to acidic drinks, it can
potential. It is used in combination with NaMFP due to the reduce their erosivity [133].
calcium-rich formulation in avoidance of reactions between Another calcium phosphate compound is the bioactive
calcium and fluoride in the preparation. Both modes of glass, which has been used as remineralizing agent. Even if
actions – of fluoride and of arginine – are independent, and there are some in vitro studies showing promising results, the
both compounds do not inhibit each other. There are some evidence on the efficacy of such preparations is very small, as
studies showing a benefit of arginine in stopping caries pro- controlled randomized clinical studies are lacking [134].
gression and in remineralization of carious lesions [117– Other preparations contain artificial hydroxyapatite,
120]. In particular for patients with high caries risk, which should fill submicron defects with the calcium phos-
arginine-­containing products might be of interest. phate particles in terms of a biomimetic approach. These
particles can be used at a microscale and at a nanoscale.
While minor effect was shown under in vitro conditions for
16.2.4.5  CPP-ACP, Bioactive Glass, the microparticles, the nanoparticles show some effect [135].
Hydroxyapatite The evidence for these compounds for the clinical use is very
Casein phosphopeptide-amorphous calcium phosphate low, as comprehensive clinical studies are lacking. In none of
(CPP-ACP) is a synthetic colloidal complex derived from the very few studies dealing with this approach, superiority
milk. It is well-known that milk can be anticariogenic to the conventional concept using fluorides was found.
despite its high content  of sugar [121]. Different mecha- Conclusively, none of the calcium and phosphate prepa-
nisms might be relevant. Milk is supersaturated with rations without fluoride has been investigated under clinical
respect to various calcium phosphate compounds, being conditions in a dimension that allows them to be recom-
part of the dental hard tissue [122]. Therefore, in the pres- mended as an alternative to fluoride in caries prevention.
ence of these compounds, the acid solubility of the dental
hard tissue (enamel) is reduced, and remineralization pro- >> None of the calcium and phosphate preparations
cesses are facilitated [123]. The pH decline after milk con- without fluoride has been investigated under clinical
sumption is relatively low, which is in addition in parts conditions in a dimension that allows them to be
buffered by the metabolism of protein compounds to alka- recommended as an alternative to fluoride in caries
line end products (e.g., [124]). One of the milk proteins prevention.
that is of particular importance is the casein [125, 126]. It
has been shown that this protein can bind to hydroxyapa- 16.2.4.6  Ozone
tite and can influence bacterial adherence and metabolism Ozone is a natural molecule which contains three oxygen
[127, 128]. On its own it cannot inhibit completely demin- atoms and has antimicrobial activity against bacteria, fungi,
eralization; however, it has been shown that smaller and virus [136]. The ozone therapy on carious lesions
 642 A. B. Borges et al.
involves the application of the ozone gas over the tooth’s
surface ­aiming its decontamination [137]. The ozone gas
can be produced from oxygen in the environment air (low-
dosage principle) or from pure oxygen supplied by an oxy-
gen bottle (high-dosage principle). The application of ozone
is usually performed through a handpiece, which has a dis-
posable silicone cup tip, with diameter in a dimension (usu-
ally 3–10 mm), which can be firmly attached to the selected
area of the tooth. It directs the ozone and prevents the
escape of the gas into the mouth. After the application, the
ozone gas is suctioned off and again converted into oxygen
by a neutralizer.
The intention of the use of ozone is to arrest caries pro-
gression, due to a reduction of the cariogenic bacteria by oxi-
dation processes, aiming to prevent or delay the need for a
restoration [138]. However, the ozone therapy did not meet
all expectations and can only be classified as an additional
option for controlling dental caries. The conventional strate-
gies, such as the dietary advice, oral hygiene instruction, and
use of fluorides, are still the primary strategies for caries con-
trol [138].
The ozone therapy could potentially be used for disinfec-
tion of fissures prior to fissure sealant application or as a non-
invasive initial caries lesion treatment. In cavitated lesions it
can be used to decontaminate the remaining infected dentin
after tooth preparation. The high-dosage ozone application
works with pressure. In this case the gas can penetrate into
the smallest pit and fissures to reduce or maybe inactivate the
bacteria [137]. However, the ozone acts on contact; therefore,
any lesions that do not allow the access of the equipment tip
or the surface sealing with the silicon tip cannot be treated.
These include proximal lesions, hidden caries, or lesions dif-
ficult to access. Thus, ozone is mainly used on the occlusal
and free-smooth surfaces.
There is good in vitro evidence of the prophylactic appli-
cation of ozone as antimicrobial treatment prior the acid
16 etching and placement of sealants and restorations. Positive
results have been obtained without interference on enamel
physical properties or adhesive restorative materials [139].
However, there is only limited information from clinical
studies, which are in addition in part contradictory.
According to manufacturer’s recommendations, the nonin-
vasive treatment of the incipient occlusal caries lesions
should be possible. This involves the application of the ozone
directly over the lesion for 20–120 s, followed by the applica-
tion of a remineralizing solution that contains fluoride, cal-
cium, zinc, and phosphate to increase remineralization of the
disinfected area. They also recommend the use of a fluori-
dated toothpaste and mouthwash, as well oral hygiene
instructions. The ozone application should be repeated after
3 and 6 months. Even though the first studies have shown
some effects on arresting caries and preventive treatment, the
use of ozone still requires further studies [140]. Reinfection
of the disinfected surface can rapidly occur in the oral cavity
if no sufficient sealing of the surface is performed.
16.2.4.7  Further Approaches
For a long time, caries has been classified as an infectious
disease. Therefore, it has been considered to develop a vac-
cine against Strep. mutans. As several bacteria contribute
to the development of dental caries, this strategy appears
not promising [141]. In addition, the resident flora in the
oral cavity is part of the immune system and cannot be
eliminated at all. It has also been proposed to avoid any
transfer of caries pathogenic germs from caries active par-
ents to the newborn baby; however, this recommendation
appears just as little meaningful. More reasonable is an
increase of preventive measures and restoration of frank
cavities in caries active parents. Such strategies are called
primary-primary prevention. Some studies give indica-
tions that the chewing of xylitol-­containing chewing gums
by the parents during the first time of life of the children
can reduce the caries incidence in children, most likely
due to the Strep. mutans-­reducing effects mentioned above
[142]; however the evidence for this measure is based only
on a single study.
Another possibility to reduce the biofilm on tooth sur-
faces could potentially be the photodynamic therapy. This
approach is regularly used in dermatology for skin tumor
therapy. The intention is to reduce pathogens by application
of light in combination with a photosensitizer. This molecule
will be incorporated into the bacterial cell membrane and
activated by impact of light with a specific wavelength,
depending on the sensitizer used. From the molecule oxygen
will be split off in the form of radicals, which should destroy
the bacterial membrane. This approach is in particular used
in areas difficult to reach, such as subgingival regions, what is
of interest for periodontal treatments; however, in case of
supragingival biofilm in the context of caries, its relevance is
questionable. Furthermore, it is not clear how deep the sensi-
tizer can penetrate into a matured biofilm and to what extent
the biofilm can be destroyed. In the context of caries, there is
no evidence for its efficacy [143].
Some other strategies for caries prevention have been dis-
cussed, such as the use of plant extracts, antimicrobial pep-
tides, enzymes, biopolymers, metaphosphates, quaternary
ammonium salts, or flavonoids [110, 144]. There is weak to
no evidence from clinical studies on anticariogenic efficacy
of these compounds, even if a reduction of bacteria can be
achieved. However, a reduction of bacteria does not neces-
sarily mean that a compound is caries inhibiting. It has also
considered to modify the communication between bacteria
in the biofilm (anti-quorum sensing), though without any
evidence at this moment.
16.3 Pit and Fissures Sealants
Pits and fissures are more susceptible for development of
caries than the other surfaces due to their morphology. The
occlusal surface of the posterior teeth presents develop-
Preventive Measures and Minimally Invasive Restorative Procedures
a b
..      Fig. 16.1  a Occlusal surface of molars with biofilm deposits; b mesiodistal cross section of a molar with a sealant applied on the occlusal
groove
mental grooves separating the cusp slopes, which is called a
fissure. In some areas of the grooves’ bottom, there is no
enamel coalescence from one cusp slope to the other, creat-
ing a direct path between the oral environment and the
dentin [145]. A pit is a located and small coalescence fault
on the tooth’s surface. It is generally found on the intersec-
tion of two fissures or at the end of a developmental groove.
The irregular anatomy of the grooves, pit, and fissures favors
food and plaque retention, being an area  at high risk for
developing dental caries. Even if the occlusal surfaces con-
stitute only 12.5% of all tooth surfaces, approximately 50%
of all caries lesions in school children occur at these sur-
faces. Regarding the distribution on the posterior teeth,
most frequently caries lesion development occurs at the
occlusal surfaces of the first and second molars, corre-
sponding to about 90% of all lesions present on children
and teenagers (. Fig. 16.1a) [146].
 
It can be distinguished between different types of fissures:
flat and wide, slit-shaped, or ampoule-shaped; in particular
the latter two shapes cannot be sufficiently cleaned. As a con-
sequence bacterial biofilm, food leftovers, and cell debris can
be retained in these areas. The neutralizing and remineraliz-
ing potential of the saliva and also the topical effect of fluori-
dation measures are also reduced in these areas, resulting in
a higher risk for the development of caries. Therefore, mate-
rials were developed to be applied into the grooves, closely
sealing the pits and fissures, reducing its irregularities, and
smoothing the surface. Those materials create a physical bar-
rier between the occlusal surface and oral environment,
hampering the deposition of bacteria and its nutrients, as
well as the progression of caries lesions (. Fig. 16.1b) [147,
 
148].
During many years, it was generally accepted that the best
way to maintain the molars sound is applying sealants right
after the eruption. However, with the reduction of caries
prevalence in the industrialized countries, resulting from the
progressive increase of the knowledge about the caries dis-
643 16
ease etiology and prevention, the caries risk assessment has
become evident for sealant indication [149]. Many occlusal
surfaces remained sound during the entire patient’s life with-
out any sealant. This way, the indiscriminate use of sealants is
nothing more than a modern version of the classic concept of
“extension for prevention.” This means that sealing all occlu-
sal surfaces to hinder the caries development is considered
nowadays as unacceptable and may be considered an over-
treatment, since by using other preventive measures caries
risk can be decreased and the disease can be controlled [150].
Therefore, monitoring of the etiological determinant factors
of caries disease is of major importance, as well as the correct
and sufficient preventive use of fluorides.
The operatory approach of the occlusal sites varies
according to its health and anatomical conditions, as well as
the patient’s risk of developing caries lesions. The latter one is
the most important factor to be considered when sealants are
indicated. Among the clinical parameters that are available to
evaluate the caries risk, the previous caries experience seems
to be the most accurate criteria [149]. Other factors that indi-
cate caries susceptibility are the retentive macro-morphology
of the occlusal surface (. Fig. 16.2a, b), frequent sugar intake,
inadequate exposure to fluoride, and poor oral hygiene [151].
In addition, people with hypomineralized teeth, fixed orth-
odontic appliances, general health problems, manual dis-
abilities, and xerostomia, the use of medication that reduces
salivary flow or the frequent intake of medication with high
sugar levels is potentially considered a high risk [147, 149].
Based on that, occlusal surface sealing is, in general, indi-
cated for patients at high caries risk and/or presenting teeth
with active occlusal incipient lesion, which show progression
during the treatment (. Fig. 3.5g, h). In addition, it can be
used in patients who are not responding to a treatment based
on the control of the disease [149]. It can also be recom-
mended, in case of high caries risk,  to apply fissure sealant
on deciduous molars or at the palatal pits of incisors or
canines.
 644 A. B. Borges et al.
a b
..      Fig. 16.2  a Posterior teeth with a smooth occlusal morphology and with shallow grooves; b molars presenting irregular morphology, with
deep grooves favoring the biofilm deposition
>> The indiscriminate use of sealants is unacceptable and
may be considered an overtreatment. Its indication
must be done only after the caries risk assessment. It is
recommended for patients at high caries risk and/or
presenting teeth with active occlusal incipient lesion.
Fissure sealing should always be accompanied by
other preventive measures, i.e., nutrition
recommendations, oral hygiene education, and
fluoride application.
The patient’s caries risk has to be periodically evaluated, since
it can change with time. In particular during the period nec-
essary for the eruption of molar teeth (12–18 months), the
risk for developing occlusal caries is high due to the lack of
chewing friction and natural cleaning mechanisms, as well as
due to difficulties to sufficiently reach the occlusal area with
mechanical oral hygiene devices. Immediately after eruption
the enamel does not have its maximum degree of mineraliza-
tion. During a period of approximately 2 years after eruption,
the enamel undergoes a secondary mineralization process
16 (Post-eruptive enamel maturation), in which minerals, such
as calcium, magnesium, and phosphate, from the saliva are
incorporated into the dental hard tissue. This complementa-
tion of the mineralization is supported by the application of
fluorides. These processes result in a reduction of the enamel
permeability, which can decrease the caries risk [152, 153].
However, this does not necessarily mean that the matured
tooth will be caries-free during the whole life span.
All in all, the sealants indication has to be based on the
caries risk assessment in different periods of patient’s life,
because the tooth can be at low risk immediately after erup-
tion, but due to changes in patient’s behavior or habits at high
risk at a later stage of one’s life, and vice versa [146]. To
achieve the maximum benefits of the sealants, these materi-
als should be applied only to those teeth judged as high caries
risk [146, 154].
Sealants are considered a valuable and low-cost
­preventive measure, and it is an adequate strategy for car-
ies prevention, if correctly indicated and made [155].
However, it has to be ideally used in combination with
patient education, effective personal oral hygiene, rational
use of fluorides, and regular dental visits [146]. As fissure
sealants are normally applied during age of childhood, the
parents have to be informed about necessary preventive
measures and the need of regular controls of sealants in the
dental practice.
Tip
As fissure sealants are normally applied during age of
childhood, the parents have to be informed about
necessary preventive measures and the need of
regular controls of sealants in the dental practice.
Sealants can also be applied over active incipient lesions on
the occlusal surface since it has been shown to be effective in
inhibiting the progression of demineralization confined to
enamel [156–158]. However, enamel demineralization can
be associated with the presence of dentin lesions, in particu-
lar if the fissure is very deep and close to the dentin enamel
junction. If there is no visible cavitation, such dentin lesions
can be sealed. Studies have shown that it can significantly
reduce the number of viable bacteria inside the lesion and
lead to caries arrestment [159–161]. In fact, there is a trend
towards noninvasive approaches, aiming the prevention,
arrestment, or management of caries. Following this, seal-
ants can be used both as a preventive measure in at-risk teeth
and as a therapeutic measure when applied over an incipient
non-­cavitated caries lesion [156, 162]. In case of cavitation,
however, an invasive treatment is not avoidable. In such
cases a  minimally invasive procedures should be per-
formed in order to avoid any unnecessary substance loss.
If one decides in favor of sealing a non-cavitated lesion,
the material used for the sealing is of major importance,
since a tight closure of all parts of the fissure is a prerequisite.
Resin-based material is recommended [163–165]; glass iono-
mers should not be used as a tight sealing cannot be ensured
Preventive Measures and Minimally Invasive Restorative Procedures
[166]. The sealing of carious deciduous molars is also possi-
ble and not worse in comparison to invasive measures [167].
In all cases of sealing carious lesions, a periodic evaluation is
essential, both in relation to lesion progression and to sealant
integrity and retention. A total or partial loss of the sealant
applied over a dentin lesion will open again the entrance for
bacteria and for the substrate for the bacteria in the resting
carious lesion, favoring the activation of the caries process
[154, 168]. One has to keep in mind that sealants placed over
dentin lesions, even in combination with adhesive systems,
present more micro-leakage and less retention than sealants
in sound fissures. Carious fissures are often surrounded by
demineralized enamel, which presents reduced adhesive
properties adversely affecting the proper adaptation of the
sealant in the fissure [169].
Except for a proven allergy, there are no absolute contra-
indications for a fissure sealant. The presence of a cavitation
into dentin, an inadequate moisture control, and deciduous
645 16
16.3.1 Type of Sealants
Different materials can be used as a sealant. Mostly resin-­
based sealants are recommended, either as unfilled resin for-
mulations or flowable composites. Glass ionomer cements
(GIC) are also a possibility; however, this material is in some
countries’ guidelines classified as a material to be used only
as an interim solution.
16.3.1.1  Resin-Based Sealants
These sealants are based on fluid resins associated or not with
filler particles. They contain traditional monomers, such as
BisGMA and UDMA, which are diluted with low molecular
weight molecules, such as TEGDMA, to obtain a proper vis-
cosity for clinical use. In addition, some products also have
white pigments such as titanium dioxide, to differentiate the
sealant from enamel, aiming to facilitate the application and
its later control during the clinical examination (. Fig. 16.3a,

teeth, which will exfoliate soon, can be judged as a relative
contraindication.
>> Non-cavitated dentin caries lesion can be sealed and
arrested. However, periodic evaluation is essential,
both in relation to lesion progression and to sealant
integrity and retention.
b). Clear sealants, however, allow controlling the underlying
fissure system. There is also a sealant available with a thermo-
chromic pigment. This pigment is transparent at the oral
temperature, but at temperatures below 31 °C, induced by the
use of air or water stream, it becomes bluish, which should
facilitate the identification of the sealant in the fissure system
(. Fig. 16.3c, d). To facilitate the application of the sealant,

a b

c d

..      Fig. 16.3  a, b Sealants with white pigment applied on the molars occlusal surface; c sealants with thermochromic pigment after the
polymerization; d bluish aspect of the sealant with a thermochromic pigment after receiving a water spray (Defense Chroma-Angelus)
 646 A. B. Borges et al.
companies developed materials which change the color from
the non-cured (other color than white or clear) to the cured
condition.
Resin-based sealants are normally light-curing, but
chemically curing materials are also available, both present-
ing comparable retention rates in long-term evaluations
[170, 171]. Some preparations contain fluoride; however,
studies have shown that fluoride release by the resin-based
sealants is minimal and there is no advantage over the seal-
ants without fluoride. Thus, it seems to be more of a market-
ing strategy than a real clinical benefit [154, 172, 173].
The addition of filler particles to the sealants aims to
improve surface hardness and reduce wear. Although they
present improved mechanical properties, they are more vis-
cous, and consequently, the penetration into the etched fis-
sures is more difficult. As the layer thickness is higher after
application, they mostly require occlusal adjustment after
application [149]. However, there is no evidence for superi-
ority of filled over unfilled sealants in relation to retention
rates and caries prevention [147, 174].
Tip
There is no evidence for superiority of filled over unfilled
sealants in relation to retention rates and caries
prevention. The same holds true for the presence or not
of fluoride in the composition and the use of light- or
chemical-curing materials.
The sealant application technique, which will be exemplarily
presented, does not require the use of an adhesive system
after the acid etching step, as it is possible to get similar reten-
tion rates with or without an application of a bonding agent,
in particular if the moisture management is excellent [175].
16 Thus, adequate isolation is an essential part of the technique,
and the use of rubber dam is strongly recommended.
Sometimes it is not possible to use rubber dam, and the cot-
ton rolls isolation has to be performed. Studies have shown
than when properly done, results similar to rubber dam can
be achieved by cotton rolls isolation. However, if this cannot
be ensured, such is the case in partially erupted teeth, glass
ionomer cement as sealant should be used instead of resin-
based materials (for details see below). Salivary contamina-
tion during sealant placement is the most common cause of
failure of the technique [154, 176, 177].
Most problems associated with retention loss of a sealant
do not occur when it is totally lost. That exposes the fissures
system to the oral environment, allowing mechanical removal
of the biofilm and contact with saliva and fluoridated oral
hygiene products. However, in case of a partial loss and insuf-
ficient retention of the remaining sealant, the areas below the
partially retained material will hardly come into contact with
saliva and fluorides, which can increase the risk for caries
development. Furthermore, in particular if dyed sealants are
used, the visual diagnosis is impaired [150].
The outer surface of enamel is prismless (. Fig. 6.1d),
which shows smaller porosities after acid etching and
impairs the retention of the fissure sealant. Besides, the solu-
bility of prismless enamel is smaller than of prismatic
enamel. A minimum etching time of 30 s is required. A
reduced etching time leads in most studies to a more hetero-
geneous retention behavior. It is important to highlight that
the acid etching has to reach a larger area than the sealant
will cover. The material should never be applied beyond the
etched enamel because no bonding would be obtained. After
etching and rinsing and drying, the surface should have a
chalky/frosty-white appearance as a result of the acid-
induced demineralization. The application of self-etching
adhesives before sealant application could be used as an
alternative to phosphoric acid etching before sealant appli-
cation; however, the retention rates do not reach those after
conventional acid etching [178]. The same applies for laser
or air abrasion conditioning [179]. The latter three methods
(self-conditioning, laser, air abrasion) cannot be recom-
mended without reservations.
To maximize the longevity, the retention, and the durabil-
ity of the sealants, the application has to follow a standard-
ized protocol:
55 Proper isolation of teeth, preferably with rubber dam
(. Fig. 16.4a).
55 Cleaning of tooth surface with pumice and prophylaxis
brush or with sodium bicarbonate Prophy-Jet to remove
the biofilm and debris from the occlusal surface, that
adversely affects the adequate enamel etching
(. Fig. 16.4b). The surface can also be cleaned with the
patient’s toothbrush without toothpaste [180]. Oily or
fluoridated prophylaxis pastes have to be avoided since
they may hinder the enamel acid etching.
55 Thoroughly rinsing with air/water spray and drying with
airstream.
55 A dental probe should gently be passed through the
bottom of the grooves to remove pumice residues and
debris.
55 Etching of the surface with 35–37% phosphoric acid gel
for at least 30 s (. Fig. 16.4c).
55 Thorough rinsing with air/water spray until complete
removal of the acid for at least 20 s (. Fig. 16.4d).
55 Drying of the surface with airstream (. Fig. 16.4e).
55 Applying of the sealant using a dental probe or the
applicator tip provided by the manufacturer, directing it
towards the center of the pits and grooves and taking
care not to incorporate bubbles into the sealant material
(. Fig. 16.4f).
55 Note: If it is a self-curing sealant, it is presented in two
bottles. One drop of each bottle has to be dispensed,
mixed, and applied to tooth surface. The curing time is
about 3 min. If it is a light-curing material, the sealant
has to be applied directly to the tooth surface and then
light-cured for 20–40 s according to manufacturer’s
instructions (. Fig. 16.4g).
55 Evaluating of the entire surface of the sealant with a
dental probe to ensure its integrity and to verify the
Preventive Measures and Minimally Invasive Restorative Procedures
homogeneity of the material and the absence of
bubbles as well as whether the sealant covers the entire
extension of pits and fissures (. Fig. 16.4h, i). If
 
necessary, the sealant can be reapplied if no contami-
nation with saliva has happened. If contamination was
the case, the acid etching procedure including rinsing
and drying has to be repeated before applying addi-
tional material.
647 16
55 Removal of rubber dam and evaluation of the occlusion
using an occlusion foil.
55 If there is any occlusal interference, the occlusion has to
be adjusted using a fine-grain diamond point, a multi-
bladed finishing bur, or an Arkansas stone.
55 If it is recommended in the respective home country,
application of a highly concentrated fluoride preparation
(varnish or fluid).

a b

c d

e f

..      Fig. 16.4  Light-curing resinous sealant application technique. a enamel; f application of the sealant using the tip of an exploratory
Teeth after rubber dam isolation; b prophylaxis with pumice and water; probe; g light-curing; h evaluating the sealed surface using the probe
c phosphoric acid etching; d rinsing; e opaque aspect of the etched tip; i final aspect before evaluating the occlusal contacts
 648 A. B. Borges et al.
g h
..      Fig. 16.4 (continued)
16.3.1.2  Flowable Composite Resins
Flowable composites, especially those with very low viscos-
ity, can be used as pit and fissure sealants. They present good
wetting properties and adequate wear and fracture resistance
[145]. Clinically, the results of flowable composites, if used
16 with an adhesive system, are comparable to those obtained
with unfilled resin-based sealants [181–184]. The use of an
adhesive system after etching is a prerequisite in case of the
usage of a flowable composite for occlusal sealing. Except for
this additional step, the application technique is similar to
the application of resin-based sealants. There is no need to
use the primer of the adhesive system, if a three-step adhe-
sive system is used (etching, primer, and adhesive), since
only enamel is involved; it is of major importance that in this
case the etched enamel is completely dry, to avoid any con-
tact between water and the hydrophobic bonding material.
For enamel bonding, the use of etch and rinse systems is
always the preferred choice, to achieve a stable and effective
bonding [185]. Self-etching adhesive does not lead to a suf-
ficient etching patter, in particular in the prismless enamel,
since the pH value of the self-etching primer is higher. As a
consequence, its application results in the formation of
shorter resin tags compared to the etch and rinse systems.
All in all, the self-­etching approach results in lower bonding
performance and a poor sealant retention [186, 187]. Thus,
the use of self-­etching adhesive systems is not recommended.
After polymerization, the finishing and polishing steps are
performed as in case of any regular composite restoration.
16.3.1.3  Glass Ionomer Cement
The use of GIC to seal pit and fissures is a controversial topic
in the literature. Some authors believe that they are not ade-
quate for occlusal sealing, because they show high wear and
low fracture resistance, as well as poor retention rates [145,
154, 188]. However, other studies showed success rates with
regard to occlusal caries prevention similar to the resin-based
ones [189]. Two reasons for this effect have been discussed.
On the one hand, even when the sealants apparently are lost,
residual material remains in the bottom of the fissures and
still protects against caries lesions. On the other hand, they
can act as a fluoride reservoir, reducing the caries progres-
sion [147, 190, 191]. The latter aspect is often subject for a
discussion, since it is not clear whether the fluoride effect is
measurable in case of the regular use of fluoride containing
oral hygiene products.
GICs are generally used in terms of a temporary treat-
ment, in particular in situations where sealants are indi-
cated, but adequate isolation cannot be achieved. Typical
clinical situations are partially erupted teeth with active
white spot lesions and/or patients with high caries risk and
Preventive Measures and Minimally Invasive Restorative Procedures
649 16

a b

..      Fig. 16.5  Mandibular second molar erupting into the oral cavity. a Initial clinical situation; b immediately after the application of the GIC as pit
and fissure sealant

a b

c d

..      Fig. 16.6  Application technique of the GIC used as sealant. a Initial application of the GIC with the tip of an exploratory probe; d case after
case – maxillary second molar erupting in the mouth of a caries high 6 months, showing the retention of the GIC on the pit and fissures. The
risk patient; b application of polyacrylic acid after the prophylaxis; c first molar also received the same treatment

previous history of caries lesions (. Fig. 16.5a, b) [152, 192,

 
193]. Even if they can be used in cases where an adequate
isolation cannot be guaranteed, GICs are technique sensi-
tive against desiccation on the one hand and high amounts
of saliva in the fissures on the other hand. Moisture control
is therefore also for GIC sealants an important factor.
Besides conventional GICs, the resin-modified glass iono-
mer cements (RMGIC) can be used. They have to be light-
cured but are less sensible to desiccation and water
absorption and have better physical properties and reten-
tion rates to enamel [152, 194].
The application of the conventional GIC as pit and fissure
sealant should be performed according to the following pro-
tocol (. Fig. 16.6a–d):
 650 A. B. Borges et al.
55 Cleaning of the tooth surface with pumice and prophy-
laxis brush or with sodium bicarbonate Prophy-Jet or
the patient’s toothbrush without toothpaste.
55 Thoroughly rinsing with air/water spray and drying with
airstream.
55 A dental probe should gently be passed through the
bottom of the grooves to remove pumice residues and
additional debris.
55 Isolation of the teeth using cotton rolls.
55 Application of the polyacrylic acid conditioner to
enamel, according to manufacturer’s instructions
(. Fig. 16.6b).
 
55 Note: The surface energy is increased by applying the
conditioner, which enhances the wettability and penetra-
tion of the GIC into the grooves.
55 Thoroughly rinsing with air/water spray to remove the
acid, for at least 20 s, avoiding saliva contamination.
55 Change of cotton rolls.
55 Note: This step is critical because unexpected saliva
contamination of the surface will negatively influence
the adhesion of the GIC to the tooth.
55 Gentle drying of the tooth surface with airstream. An
absolute drying of the tooth surface has to be avoided.
55 Note: The enamel surface will not show the frosty-white
appearance observed after the phosphoric acid etching.
55 GIC will be mixed from two components. The mixture
should be homogeneous, fluid, and shiny; if manual
mixing is performed, the incorporation of air bubbles
by strong mixing procedures has to be avoided.
Application of the cement using the tip of the dental
probe or the application syringe, directing it into the pit
and fissures, with care (avoid air bubbles; . Fig. 16.6c).
Pressure can be applied with a petroleum jelly-coated
index finger to improve the penetration of the material
into the pit and fissures [195]. During the initial setting
reaction, which takes about 5 min, the surface should
16 not be touched; any saliva contamination has to be
avoided.
55 Protect the surface with cavity varnish or bonding agent
to avoid syneresis and imbibition processes until the
final hardening, which would adversely affect the
materials’ physical properties.
55 Checking for bubbles and whether the GIC is correctly
applied to all pit and fissures.
55 Removal of the cotton rolls and evaluating of occlusion
with articulating paper.
55 If there is excess, manual shaping instruments should be
used to remove it.
55 Application of a coating (fluid resin) to protect the
surface.
If a resin-modified GIC is used, a tooth conditioner or a spe-
cific primer has to be applied following the manufacturer’s
instructions. Afterwards, the material is placed over the fis-
sures and light-cured. It is usually not necessary to protect
the surface of this material, since the resin component avoids
desiccation and water absorption. Finishing and occlusion
adjustment steps are similar to the conventional sealant tech-
nique presented above.
16.3.2  ongevity of the Sealants and Effect
L
on Incidence of Caries
The longevity of the sealants has been proven by clinical
studies, which have shown that the retention of the sealant is
the most important factor for occlusal caries prevention,
since it blocks the bacteria and/or its nutrients [196–198].
The survival rate of the resin-based sealants according to a
systematic review study was up to 90% after 1 year, 80–93%
after 2 years, 41–87% after 3 years, 70% after 4 years, and 39%
after 9 years [199]. A reduction of the sealant retention is
observed over the time. Therefore, periodic visits to the den-
tist are important so that the sealant margins and integrity
can be re-evaluated. If there is any fracture or loss
(. Fig. 16.7a–d), it should be repaired or replaced if neces-
sary, in particular when the patient still presents high caries
risk or when the sealant was applied on teeth with enamel
demineralization. Regarding the effect of fissure sealants on
caries incidence, it was reported that sealed permanent
molars presented up to 73–84% less caries lesions after 2
years compared to the non-sealed molars [199].
>> A reduction of the sealant retention is observed over time.
Therefore, periodic visits to the dentist are important.
 xtended Fissure Sealant
E
16.3.3
and Conservative Composite
Restorations
In 1977, when the extension for prevention principles was
still the state of the art for the invasive therapy of dental car-
ies, Simonsen and Stallard wrote the first reports about mini-
mally invasive or conservative preparations. They used
No.1/4 round burs to widen those pit and fissures affected by
incipient carious lesions (selective enameloplasty of the fis-
sures), which was followed by sealing with self-cure compos-
ite dissolved in fluid resin (extended fissure sealant) [200].
Later, the term “preventive resin restorations” was given to
small composite restorations, which were made after conser-
vative preparations of small lesions that extend up to the den-
tin. The preparation was defect oriented, and only the
caries-affected area was prepared. The small restoration was
associated with a sealant application on the adjacent pit and
fissures [201]. Today this kind of procedure is called a “con-
servative composite restoration” and still includes the same
steps: small preparation with minimum removal of tooth
structure, restoration with composite material, and sealing of
the pit and fissure on the healthy adjacent fissure system, in
particular if there is a high risk for new caries lesion develop-
Preventive Measures and Minimally Invasive Restorative Procedures
a b
c d
..      Fig. 16.7  a Partially retained sealant on the distal groove of the
occlusal surface of the maxillary first molar; b fractured sealant on the
mandibular second molar, with presence of a carious lesion; c partially
ment in this area [145]. Instead of the combination of regular
composites with sealants, a flowable composite can be used
both for restoring the prepared cavity and for sealing the
occlusal pit and fissures [202].
The conservative composite restoration technique
includes the following steps:
55 The preparation has to involve only the carious tissue,
using an ultraconservative diamond point, a small
diameter round diamond point, or a very small tapered
carbide bur, in high-speed handpiece, to allow access to
the underneath carious dentin (. Fig. 16.8a, b).
 
55 The caries-infected dentin is removed using a round
carbide bur, with diameter compatible to the cavity size,
in the low-speed handpiece. Attention has to be directed
to the dentin, to maintain the caries-affected demineral-
ized but not infected dentin, capable of remineralization,
according to what is described in 7 Chap. 6  
(. Fig. 16.8c–e). The rubber dam is placed, and the
 
surface is cleaned using pumice and prophylaxis brush
or sodium bicarbonate Prophy-Jet (. Fig. 16.8f). After
 
that, the tooth is thoroughly rinsed and dried with air.
55 Etching is performed with 37% phosphoric acid for 15 s
in dentin and for 30 s in enamel margins and the entire
fissure system adjacent to the cavity (. Fig. 16.8g).   (. Fig. 16.8l).
651 16
retained sealant on the mandibular first molar; d fracture of sealant of
the mandibular second premolar, with presence of carious lesion
Surface is thoroughly rinsed for at least 20 s until the
entire acid has been removed. Afterwards the area will
be gently dried.
55 The adhesive system is applied according to the manu-
facturers’ instructions (. Fig. 16.8h).
55 Afterwards, the composite is placed (. Fig. 16.8i). Both
conventional and flowable composite resins can be used.
If the depth of the preparation is more than 2 mm, the
incremental technique has to be used, and light-curing
will be performed on each increment for 20 s.
55 As a final step of filling, the sealant is applied on the
entire adjacent pit and fissure system, according the
procedure described above (. Fig. 16.8j). If flowable
composite is used, it can be placed both into the
prepared cavity and on the grooves.
55 The surface has to be evaluated for voids or bubbles.
55 The rubber dam is removed, and the occlusion has to
be evaluated using articulating paper (. Fig. 16.8k). If
an adjustment is necessary, fine-grain diamond points,
a multibladed finishing bur, or an Arkansas stones can
be used to remove it. Finally, polishing has to be
performed with abrasive rubber points or polishing
pastes with felt points or polishing brushes
 652 A. B. Borges et al.

16.4 Enamel Caries Infiltration
Every dentist regularly comes across incipient enamel cari-
ous lesions or white spot lesions in the daily clinical practice.
They are characterized by the presence of a pseudo-intact
mineralized surface (superficial zone) followed by a demin-
eralized subsurface lesion, also called as lesion body, as
described in 7 Chap. 3 (. Fig. 3.4a–d). If a progression of the
mineral loss is not stopped by adequate preventive measures,
enamel prisms collapse, the pseudo-intact surface layer will
be destroyed, and a cavitation process begins.
The treatment of proximal caries lesions generally involves
two approaches: the noninvasive (preventive) and the ­invasive
(restorative) treatment. When there is no enamel cavitation,
noninvasive remineralizing measures involving fluoridation
associated to dietary control and oral hygiene counseling rep-
resent the first option [203, 204]. However, this approach is
not always successful, as it requires compliance and change of

a b

c d

16
e f

..      Fig. 16.8  Conservative composite restoration technique. a
Ultraconservative diamond point (on the left) and round diamond
point (on the right); b minimum tissue removal to access the carious
lesion; c, d removal of the caries-infected dentin; e conservative
preparation completed; f prophylaxis with pumice and brush; g acid
etching; h adhesive system application on enamel and dentin; i
composite resin application into the preparation; j occlusal surface
with composite restoration and sealant on the adjacent grooves; k
evaluation of the occlusal contacts; l final aspect of the conservative
composite restoration
Preventive Measures and Minimally Invasive Restorative Procedures
653 16

g h

i j

k l

..      Fig. 16.8 (continued)

patient’s habits. Many patients do not follow the recommen-
dations and give up the treatment prematurely. As a conse-
quence, the lesion can progress, in particular if a high caries
risk exists. Cavitation can be the result, requiring an invasive
treatment including tooth preparation and restoration.
Especially in case of proximal lesions, the preparation of the
access cavity is associated with the loss of large amounts of
healthy dental tissue [205].
The caries infiltration technique, using very low-viscous
resin material, is a new alternative approach in minimally
invasive dentistry. As it is not associated with any prepara-
tory measures, it could also be classified as microinvasive.
Different from the pit and fissure sealants that cover the
enamel surface with a resin barrier to avoid carious deminer-
alization, this technique aims to fill the pores within the
carious lesion with liquid resin material, by penetration of
this material into the lesion body, in order to reinforce its
weakened structure. This makes the lesion on the one hand
more stable against mechanical impacts, in order to avoid
the breakdown of the surface layer, and, on the other hand,
the dental structure becomes more acid resistant. Both
mechanisms should lead to an arrest of its progression to a
cavitation stage. Resin infiltration technique represents an
intermediate treatment between the prevention and restora-
 654 A. B. Borges et al.
tion [205, 206]. This ­procedure, however, does not supersede
the well-established preventive strategies. Like any dental
treatment, it has to be performed in combination with edu-
cational procedures, such as oral hygiene and diet counsel-
ing, as well as fluoride application aiming the prevention and
control of the caries disease.
>> Different from the pit and fissure sealants that cover
the enamel surface with a resin barrier to avoid carious
demineralization, the resin infiltration technique aims
to fill the pores within the carious lesion with liquid
resin material, by penetration of this material into the
lesion body, in order to reinforce its weakened
structure.
The infiltration of a carious lesion is not a trivial process, as
the superficial layer of the incipient carious lesion is charac-
terized by precipitation of minerals from saliva on the
enamel surface and low porosity, blocking the penetration
of the resin into the lesion body. Thus, to allow the resin
penetration, the superficial zone has to be removed through
an erosive procedure using a strong acid. Different acids
were tested; however, the sole one able to sufficiently remove
the surface layer is 15% hydrochloric acid, applied for 2
min, followed by rinsing with water. To allow the infiltra-
tion of the  hydrophobic monomers into the lesion, the
etched surface has to be thoroughly dried. For this reason,
after drying with airstream, absolute ethanol is applied and
has to be dried completely in order to remove the remain-
ing water. This procedure improves the low-viscosity resin
(infiltrant) penetration, driven by capillary forces, into the
lesion body [207].
The infiltration technique is indicated only to those
lesions without cavitation implying that no bacterial con-
tamination within the lesion body has happened. The
indication for using it on smooth surfaces of free access
can be easily made. However, in the proximal area, the
16 clinical diagnosis of cavitation is quite complex.
. Figure  16.9 shows a scheme of the different depths of
 
carious lesions in the proximal area according to the
..      Fig. 16.9  Different depths of carious lesions according to the radiographic image and the treatment indications. E0, no lesion; E1, outer
enamel; E2, inner enamel; D1, outer third of dentin; D2, middle third of dentin; D3, inner third of dentin
radiographic image with the respective treatment option.
When nothing is seen, the score E0 is applied. The enamel
layer is divided into outer (E1) and inner halves (E2),
while dentin between the dentin enamel junction and the
pulp is divided into three thirds (outer, D1; middle, D2;
and, inner, D3) [208]. Studies comparing the radiographic
images with the actual presence of cavitation showed that
E1 lesions never had cavitation, while E2 is cavitated in
10–19.3% of the cases [209, 210]. However, 32% D1
lesions were cavitated, while 72% of lesions extending into
the inner 2/3 (D2 and D3) of the dentin also showed cavi-
tation [211]. In addition, some studies observed that when
the radiolucency reaches the inner third of dentin (D3),
cavitation was present in 100% of the cases [209, 210].
The resin infiltration technique is indicated for caries
lesions in the proximal region with radiographic image up
to external third of the dentin (D1), expecting that more
than 2/3 of the cases are free of cavitation [211]. However,
some studies showed a high prevalence of cavitation even
in D1 lesions [212, 213]. This way, regular radiographic
examination is recommended on cases where the infiltra-
tion technique has been performed, mainly on situation
where the radiolucency reaches the dentin. The best way
to have a more predictable evaluation of presence of cavi-
tation is to perform a temporary elective tooth separation,
followed by impression with a silicone material [214], as
described on 7 Chap. 3. In each case when a cavitation is
present, this technique is not indicated, and a restoration
is required, since at that stage, bacterial penetration into
the lesion has already occurred.
>> Infiltration technique can be used only in case of
non-cavitated lesions. The deeper a proximal lesion is,
the higher the probability that a cavitation is present.
In case of cavitation, an infiltration is not indicated,
and a restoration has to be placed.
To allow the resin application in the proximal lesion, a small
tooth separation is required using wedges in the proximal
space. Then, a special applicator device, a foil matrix delivery
Preventive Measures and Minimally Invasive Restorative Procedures
a b
..      Fig. 16.10  a Proximal tip foil matrix delivery system with micro-perforations in only one of the sides; b hydrochloric acid gel passing through
the perforations of the matrix
system that contains micro-perforations, has to be put into
the proximal space. The perforations point towards one of
the sides. This allows the product application only to the
affected proximal region, protecting the sound adjacent sur-
face (. Fig. 16.10a, b).
 
The treatment protocol for proximal surfaces includes the
following steps (. Fig. 16.11a–o):
 
55 Making of bitewing radiography for lesion diagnosis
(. Fig. 16.11a, b)
 
55 Cleaning of the teeth with prophylaxis paste and brush
and of the proximal surfaces with dental floss
55 Isolation of teeth with rubber dam in order to avoid any
harm by use of the strong hydrochloric acid
55 Separation of teeth using a wedge, which allows the
placement of the delivery device into the proximal
region (. Fig. 16.11c)
 
55 Connection of the applicator with the hydrochloric acid
syringe, insertion of foil matrix between the teeth, and
application of the acid for 2 min (. Fig. 16.11d, e)
 
55 Removal of the applicator and rinsing with water for at
least 30 s; drying with air (. Fig. 16.11f)
 
55 Connection of a new applicator with the ethanol syringe,
placement of it into the interproximal space, application
of the ethanol onto the lesion and incubation for 30 s;
drying with air (. Fig. 16.11g)
 
55 Connection of a new applicator with the infiltrant
syringe, placement into the proximal space, application
of the infiltrant, and incubation for 3 min. Removal of
the applicator and of any excess of the infiltrant with
dental floss. Light-curing of the infiltrant for 40 s from
all sides (occlusal, buccal, and lingual) (. Fig. 16.11h–k)
 
55 Rerunning of the last step, incubation for 1 min, and
light-curing from all sides for 40 s (. Fig. 16.11l)  due to inadequate oral hygiene, e.g., during an orthodontic
55 Polishing with fine grit polishing strips (. Fig. 16.11m, n)   treatment with brackets. The brackets are biofilm retention
One has to bear in mind that the infiltrant is not radiopaque;
therefore, a radiographic observation of the infiltrant pene-
tration into the lesion is not possible (. Fig. 16.11o). This is
 
even more important if the patient changes the dentist.
655 16
Furthermore, any follow-up can only be done indirectly via
the estimation whether there is a lesion progression on peri-
odically made bitewing radiographs. It is very important for
monitoring that the radiographs have always the same direc-
tion. A recent systematic review revealed that proximal caries
lesion progression was less likely to occur in permanent teeth
being infiltrated with resin material as compared to noninva-
sive methods, provided that oral hygiene instructions and
measures were performed [215, 216]. The evidence is at this
moment moderate to low, due to lack of high number of
studies. However, further newer studies not included in the
review show also quite positive results, in particular in
patients with high risk [217].
A second indication of the infiltration technique is the
color masking of initial carious lesions on smooth surfaces.
If an initial carious lesion occurs, the teeth get a whitish or
chalky appearance (white spot lesion). The whitish color is
due to the increase of the intercrystalline spaces of the
demineralized enamel  and creation of a high porous area,
which changes its the refractive index (RI). While the sound
enamel has a RI of 1.65, the lesion pores will be filled with
water, which has a RI of 1.33, or air (RI of 1.00). In this case,
the light waves reach multiples interfaces between the fluid
and the mineral phase, with different refractive indices. At
each interface the light is deviated and reflected, becoming
imprisoned in an “optical maze” that is over-luminous and
therefore perceived as white [218, 219]. The infiltrant has a
refractive index of 1.475, closer to sound enamel, resulting
in a masking effect of the white spot lesion, if deeply pene-
trated into the micropores, and in an improvement of the
esthetics [220–222].
Typically, white spot lesions on the smooth surfaces occur
sites; however, white spots can also occur without orthodon-
tic treatment in case of insufficient general oral hygiene.
Usually, oral hygiene education and the application of fluo-
rides are recommended to enhance remineralization of white
spot lesions. However, this procedure is not successful in
 656 A. B. Borges et al.

a b

c d

e f

16

..      Fig. 16.11  Resin infiltration protocol for incipient proximal caries
lesion. a Initial case without clinical evidence of cavitation; b radio-
graphic image suggesting enamel carious lesion on distal surface of
maxillary first premolar; c rubber dam isolation and tooth separation
with the plastic wedge; d placement of the proximal-tip foil matrix
applicator in the proximal region, with the perforations directed to the
affected tooth surface; e application of the hydrochloric acid; f rinsing
and drying; g application of ethanol; h application of the infiltrant
resin; i–k light-curing from occlusal, buccal, and lingual sides; l
reapplication of the infiltrant resin, followed by light-curing;
m polishing with fine-grain abrasive strip; n final case; o absence of
radiographic evidence of the infiltrant resin, since the material is not
radiopaque
Preventive Measures and Minimally Invasive Restorative Procedures
657 16

g h

i j

k l

..      Fig. 16.11 (continued)
 658 A. B. Borges et al.
m n
..      Fig. 16.11 (continued)
all cases and is dependent on the patients’ compliance. The
infiltration technique is a possible alternative. However, in
cases of inactive but still visible lesions, in which the surface
layer is thick and the lesion is in parts remineralized, the suc-
cess is often limited, most likely due to an incomplete infiltra-
16 tion of the lesion. This is the case if the surface of the white
spot has a glossy instead of a frosty appearance or shows even
a discoloration.
The technique for application is comparable to that of
proximal lesions except for the application device. Isolation
of the teeth is, as mentioned for the proximal lesions, a pre-
requisite. Both a conventional rubber dam and a liquid dam
are possible, depending on the extension of the lesion. The
patient should be informed about potential changes in color
and about the possibility of failure.
. Figure  16.12a–i shows a clinical case of infiltration of
white spot lesions as a sequela of bad hygine during  orth-
odontic treatment (. Fig.  16.12a). The following steps have
been performed: isolation of the teeth using a light-curing
liquid dam, application of the hydrochloric acid for 2  min
(. Fig. 16.12b), and rinsing for 20 s (. Fig. 16.12c). The step
was followed by air-drying, ethanol application, and drying
for 30 s each (. Fig. 16.12d, e). Afterwards, the infiltrant was
applied for 3 min (. Fig. 16.12e). Excess was removed, and
the infiltred surfaces were light-cured for 40 s. The infiltrant
application was repeated for 1 min and light-cured again for
40 s (. Fig. 16.12f). Finally, the surfaces were polished with
abrasive discs to remove any excess and create a smooth sur-
face. After these procedures, it was observed that the white
spot lesions’ masking was effective (. Fig. 16.12g–i)
Due to histological structural similarities between cari-
ous white spot lesions and fluorotic enamel, the infiltration
procedure can also be used in such cases. First clinical studies
showed good results [223], and it appears to be a promising
strategy [224]. In case of other hypomineralization such as in
case of molar incisor hypomineralization (MIH), the results
are less promising, mainly due to differences in histological
structure.
Tip
Besides arresting proximal caries lesion, the resin
infiltration can promote a color-masking effect of carious
white spot lesions and fluorotic enamel, on labial surface
of anterior teeth, resulting in esthetic improvement.
Preventive Measures and Minimally Invasive Restorative Procedures
659 16

a b

c d

e f

..      Fig. 16.12  a Initial situation showing white spot lesions; b isolation a smooth surface tip; f application of the infiltrant resin; g aspect
with light-curing gingival barrier and application of the etching gel; c immediately after the infiltrant application; h final result
rinsed teeth after etching with wet surface; d dried teeth, showing the
frosty-white appearance of the enamel; e application of ethanol using
 660 A. B. Borges et al.
g h
..      Fig. 16.12 (continued)
Conclusion
In modern preventive dentistry, micro- and minimally invasive
strategies are the key components, superseding the traditional
dentistry, which was based on the restorative-surgical model. The
reestablishment of the shape, function, and esthetics of the lost
16 tooth structures has been forced back, and approaches that
emphasize health promotion and disease prevention, represent-
ing a great advance in direction to the oral health maintenance,
are paramount. Contemporary preventive strategies comprise
caries risk identification, prevention of development and progres-
sion of incipient lesion, remineralization of initial lesions, sealing
of fissures to avoid biofilm accumulation in the retentive occlusal
area, minimally invasive (conservative) preparation for fillings,
and repair of the defective restorations instead of its replacement.
To reach this goal, the dentist must be proficient in the etiology,
pathogenesis, and development of caries as a disease, as well as in
the early diagnosis of carious lesions. That will allow the imple-
mentation of reasonable i­ndividual-based preventive and mini-
mally invasive strategies, together with measures that reduce or
eliminate the causes of the caries disease, reducing their recur-
rence with the goal to optimally preserve the dental structures.
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2019;38:295–302. https://doi.org/10.4012/dmj.2018-074.
224. Di Giovanni T, Eliades T, Papageorgiou SN. Interventions for dental
fluorosis: a systematic review. J Esthet Restor Dent. 2018;30:502–8.
https://doi.org/10.1111/jerd.12408.
 667 17

Aesthetic Veneers: What Are

They and How to Handle Them?
Maria Filomena Rocha Lima Huhtala, Clovis Pagani,
Carlos Rocha Gomes Torres, Pekka Kalevi Vallittu,
and Jukka Pekka Matinlinna

17.1 Introduction – 668

17.2 Basic Principles for Veneer Preparation – 669

17.3 Sequence of Tooth Preparation – 673

17.4 Direct Veneer Restoration – 678

17.5 Indirect Veneers – 681

17.5.1  ental Ceramics – 681
D
17.5.2 Impression/Scanning of the Tooth Preparation – 682
17.5.3 Provisional Restoration – 682
17.5.4 Extraoral Phase for Indirect Restoration – 682
17.5.5 Try-in Procedure – 683
17.5.6 Pretreatment of Veneers – 683
17.5.7 Cementation of Indirect Veneers – 686
17.5.8 Finishing and Polishing – 686

17.6  hanges of the Apparent Tooth Dimension by Optical

C
Illusions – 686
17.6.1 F lat Area – 686
17.6.2 Embrasures – 688

References – 689

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_17
 668 M. F. R. L. Huhtala et al.
Learning Objectives
The learning objectives of this chapter are related to the fol-
lowing topics:
55 Indications and contraindications for veneers
55 Clinical steps for tooth preparation
55 Direct resin composite veneers
55 Mock-ups and impressions for indirect veneers
55 Ceramics used as an indirect veneering material
55 Pretreatment, silanization of veneers, and luting
55 Changes of the apparent tooth dimension by optical
illusions
17.1  Introduction
Facial aesthetics plays an important role on an individual’s
well-being, self-esteem, emotional condition, social success,
and even chances to get a job. The smile is primordial in the
search for an optimum dentofacial aesthetic standard. An
aesthetic smile depends on the harmony of shapes and shades
of anterior teeth. In addition, the alignment of these teeth
and their harmonic positioning on the arch are the basics to
obtain this aesthetic balance [1–3]. However, teeth are not
always distributed on a harmonic way on the dental arch.
This lack of harmony may have different origins, such as
genetic or developmental tooth anomalies, structural changes
caused by caries, and chromatic changes or injuries in the
dental structure due to traumas.
When these alterations take place on the labial surface of
anterior teeth, or even on the buccal surface of premolars,
one treatment option can be the total covering of the surface
using a restoration called a laminate, veneer, or facet. This
restoration is used to cover an unsightly area by bonding to
the facial surface of the prepared tooth [4].
By and large, veneers can be made either by a direct tech-
nique, using resin composite, or by an indirect technique
using composite or dental ceramic. In dentistry, composites
are indicated for direct and indirect restorations or as a luting
cement, due to its light-­curing of self-curing mechanism,
17 while ceramics are used to prepare indirect restorations,
because require a laboratorial firing step for its manufactur-
ing. Resin composite materials consist of five key compo-
nents: (a) organic monomer (resinous) matrix, (b) Si-­based
glass fillers (for strength and X-ray opacity), (c) a silane cou-
pling agent (for adhesion promotion), (d) pigments (for aes-
thetics), and (e) activators, inhibitors, and stabilizers (for
setting reactions) [5, 6].
Veneering doesn’t aim only aesthetic recovery but also
preservation of tooth structure, limiting the periodontal and
pulp involvement that may result from more invasive proce-
dures, such as full crown preparations. However, the clinical
success of a dental restorations will depend on several clini-
cal steps, such as the tooth preparation, bonding procedures
and cementation (for the indirect ones). It is noteworthy that
adhesion takes places (at least) in two levels: on the one hand,
between prepared tooth tissue and, on the other hand,
between resin composite cement and dental indirect restor-
ative materials (of which the laminate is prepared). Adhesion
can be of chemical or retentive nature (macromechanical or
micromechanical retention). Chemical adhesion takes place
when the two dissimilar materials are close in a molecular
level and contact to form chemical bonds [7, 8]. Dentin
bonding is understood to be based predominantly on micro-
mechanical retention and is beyond the scope of this chapter
[9, 10].
At the chairside, the preparation for laminate veneers
starts with structural reduction of facial surfaces and must
generally be made only on enamel, even though in several
situations, they also involve the superficial layer of dentin.
However, those preparations must avoid unnecessary
removal of dentin, not only due to pulpal damage but also
because the bonding to etched enamel is always better than
to dentin. Aesthetic results with this technique are very good,
due to the  reproduction of the original shade and translu-
cency [11, 12].
The concept of coverage of the labial surface of anterior
teeth due to aesthetic reasons started back in the 1930s,
when Dr. Charles Pincus introduced the technique of
ceramic veneers, to attend aesthetic demands of Hollywood
artists [13]. It is well-known that the American cinema
played an important role on culture and people behavior
worldwide, and this demand had the merit to call the atten-
tion of dentists, who until then had the aim to restore mainly
function and occlusion of teeth than to restore the aesthet-
ics. However, those labial surface coverages with a very thin
layer of ceramic bonded to teeth were very expensive, and
only a few people had access to it. On an attempt to reduce
cost, clinicians start to cover the labial surfaces of teeth with
direct composite resin veneers. However, results were lim-
ited due to the aesthetic quality of restorative materials avail-
able at that time and the little retention that adhesive systems
provided. After the 1980s, the development led to new bond-
ing techniques, including the so-called adhesive resin com-
posite cements [14, 15]. The further development on the
composite sicience become possible to obtain direct restora-
tions that are very similar to tooth structure with esthetic
results close to those obtained with the ceramics, leading to
a even  broader use of the technique of labial coverage of
teeth [2, 16, 17].
Direct aesthetic veneers can be a very practical interven-
tion and the tooth preparation is usually limited to the labial
surface of the teeth. However, for indirect veneers, the prepa-
ration generally goes further than this surface and additional
steps are necessary, such as impression of the prepared area,
temporary restorations, and laboratorial procedures [1, 18].
The  tooth preparation  for direct venners is generally more
conservative and, in some specific situations, the restorations
can be done even without the need of any preparation, e.g.,
lingually positioned teeth in relation to the adjacent ones.
Direct veneer restoration is therefore a faster technique and
can be finished in a single appointment.
Among the indications for veneers are the teeth with dis-
coloration, such as those affected by amelogenesis imperfecta,
physiological aging, trauma, fluorosis, or stains caused by
Aesthetic Veneers: What Are They and How to Handle Them?
tetracycline intake. However, it is vital to note that dental
bleaching should always be the first treatment choice in those
cases, because it is much more conservative and does not
require any cutting of tooth structure. Therefore, only teeth
that do not show a satisfactory response to bleaching should
receive veneers. Other indications include teeth with exten-
sive caries lesions or fractures, presence of multiple restora-
tions with unsatisfactory shade, rotated or inclined teeth,
necessity of reduction and closing of diastemas, short teeth
which require increasing of its length, misshapen peg-shaped
maxillary lateral incisor, microdontia and Hutchinson’s inci-
sors, aesthetic transformation (canines into lateral incisors
and lateral into central incisors), alignment of teeth on the
dental arch, and, finally, anterior or premolar teeth with
extensive non-carious lesions. The contraindications for
veneers are patients with bruxism, parafunctional oral habit,
edge-to-edge occlusion of the anterior teeth, anterior teeth
with large destruction of the crown, when there is not enough
remaining tooth structure to support the veneer, high car-
ies  disease activity associated with bad oral hygiene, peri-
odontal disease, and teeth with excessive labial inclination. In
this last situation, a preparation would likely result in expo-
sure of the pulp.
Veneers allow very good aesthetical results because the
entire coverage of the tooth labial surface produces harmony
of shade and shape of the teeth. Veneers also allow the adjust-
ment of individual aesthetic parameters using characteriza-
tion colored materials. The large variety of resin
composites  and resin cements, with different shades and
translucency, allow to achieve adequate aesthetic standards
in relation to the adjacent teeth [1, 11, 16, 19, 20].
Indirect ceramic veneers have greater durability and
color stability and do not suffer abrasion or discoloration.
Conversely, for direct resin composite veneers, this color sta-
bility depends on factors inherent not only to the composite
used but also to some patient’s habits. Frequent consump-
tion of food and/or beverages with dyes, as well as smoking
habit diminishes the  veneer durability. Another disadvan-
tage of the direct veneers is the need of the clinician’s skills to
create the aesthetic characteristics, such as shape, texture,
contour, and shade. Thus, direct procedure takes more time
and is less indicated when all anterior teeth need to be cov-
ered by a veneer. There is also the possibility of incorpora-
tion of air bubbles during the composite layer application,
therefore creating areas even more  susceptible to staining
and degradation.
In the case of highly discolored teeth, it is hard to obtain
adequate color match and natural translucency with direct
veneers, because the slight depth of tooth preparation does
not allow enough composite thickness to mask the dark
background. Opaque masking agents can be used to hide the
dark background under the restoration. However, the thick-
ness of the composite layer applied over it will hardly be
enough to allow recovering the natural translucence of the
tooth.
A complete cosmetic change of all anterior teeth can be
accomplished using veneers. Not only the color but the shape,
669 17
size, position within the arch, and surface characteristics can
be modified. Before that, a treatment simulation can be per-
formed with a diagnostic wax-up in a plaster model, quickly
previewing the effects of the laminates, allowing the analysis
of the intended treatment by the patient. Another option is to
perform a digital smile design, using a picture of the patient’s
teeth or a previous intraoral scanning. In the latter case, a 3D
printing can be performed, obtaining a resin model which is
shown to the patient.
Using the wax-up or 3D model of the proposed treat-
ment, an intraoral mock-up can be produced. For that a tray-
less impression of the wax-up or resin model is performed
using a putty silicone impression material. The labial side of
the matrix is trimmed in the interproximal regions to allow
the excess material overflow. A bis-acryl composite is applied
inside the matrix and seated. After curing, an intraoral mock-
­up will allow the patient previewing of the final treatment
outcome. That can also be used as a guide during the tooth
preparation [21, 22].
>> It is necessary for the clinician to identify when direct
resin composite veneers are the option and when
indirect ceramic veneers are preferable. This should be
based on a comprehensive evaluation of the patient,
bearing in mind indications and contraindications and
the anticipated aesthetic outcome.
17.2  Basic Principles for Veneer Preparation
The preparation for direct veneers is very conservative as
only a thin layer of the labial tooth surface is removed. The
depth of the preparation will depend on the area of the tooth,
intensity of chromatic alteration, shape, and position. In rela-
tion to the area of the tooth, because the preparation should
be preferably performed only on enamel, it should be kept in
mind the enamel thickness on each part of the crown, thus
avoiding reaching dentin. It is known that the thickness of
the enamel in the cervical region on the upper central inci-
sors ranges from 0.5 to 0.7 mm, on the medium third from
1.1 to 1.4 mm, and from 1.2 to 1.8 mm on the incisal third.
The thickness of the enamel on upper and lower anterior
teeth can be observed in . Figs. 6.11a–i and 6.12a–i.
Therefore, the rotary instrument used for the preparation
should have a diameter compatible with the enamel thickness
of each area. In relation to the intensity of chromatic altera-
tions, for mild ones, a 0.4-mm-deep preparation on enamel is
done on the cervical third and 0.5 mm on the medium and
incisal thirds. For teeth with more severe discoloration, a
0.5-mm-deep preparation on enamel could be performed on
the cervical region and 0.7–1 mm on the medium and incisal
thirds. Concerning the tooth’s shape, small or peg-­shaped
teeth will require less removal of tooth structure to cover the
surface with restorative material, aiming to obtain the neces-
sary material thickness and good aesthetic results. In the
same way, lingually inclined teeth may require minimum or
no preparation of the labial surface.
 670 M. F. R. L. Huhtala et al.

In order to control the preparation depth and guarantee faces of the tooth that will be prepared and neighbour ones
the ideal amount of tooth structure removal, two prepara- (. Fig.  17.1b). After setting, the first  impression is gently
 

tion guides (or reduction guides) can be produced with a
putty viscosity silicone impression material. This technique
is shown in . Fig.  17.1a–l. For taking the  trayless impres-
 
sion, a putty silicone base and catalyst are mixed uniformly
removed, and a new impression is taken. One of impres-
sions will be cut perpendicularly to the long axis of the
tooth, at the center of the crown, and on the mesiodistal
direction (. Fig. 17.1c–i). The second one will be cut paral-

before being placed by hand on the labial and lingual sur- lel to the long axis of the tooth, at the center of the crown on

a b

c d

e f

17

..      Fig. 17.1  Preparation guides made with silicone impression
material. a Two portions of heavy putty silicone must be used; b after
mixing with the catalyst, it is applied over the teeth before preparation;
c–f to see the amount of tooth structure removal on the mesiodistal
direction, two parallel longitudinal cuts are performed on the first
guide, on the area that corresponds to half of the crown of the
adjacent teeth, followed by one perpendicular to the long axis of the
tooth to be prepared; g, h testing of the preparation guide. i evaluating
the tooth structure removal after preparation; j to evaluate the amount
of tooth structure removal on the cervicoincisal direction, the second
guide must be cut at the region corresponding to the center of labial
surface, parallel to the long axis of the prepared tooth; k testing of the
guide; l evaluation of the structure removal after the preparation
Aesthetic Veneers: What Are They and How to Handle Them?
671 17

g h

i j

k l

..      Fig. 17.1 (continued)

the cervicoincisal direction (. Fig. 17.1j–l). Those prepara-

 
tion guides are placed over the tooth during the preparation
procedure, to analyze if an adequate removal of the tooth
structure is being performed.
Tip
In order to control the preparation depth and guarantee
the ideal amount of tooth structure removal, preparation
guides can be produced with a putty viscosity silicone
impression material.
The outline form of the veneer tooth preparation is deter-
mined by the surrounding structures, i.e., gingiva and neigh-
bor teeth. Regarding the cervical cavosurface margin of the
preparation, the height of the lip line during the maximum
smile is important to determine its limit. In other words, it is
important to know if the cervical tooth region will be visible
or not during the smile. To obtain a completely hidden tooth-­
restoration interface, the margin of the preparation has to be
placed inside the gingival crevice. However, any defect inter-
facial defect of the restoration may promote biofilm deposi-
tion in this area, leading to gingival inflammation, even
though it might be mild. Thus, if the tooth-restoration inter-
 672 M. F. R. L. Huhtala et al.
face is prepared close to or slightly before the gingival mar-
gin, it may contribute to the health of the surrounding soft
tissues. However, this position of the margin can only be pos-
sible on patients that do not show gingival margin during
maximum smile and present little or no color alteration of
the tooth, or on the patients that do not mind having a less
favorable aesthetics at this area, aiming to protect the gingi-
val health. However, most people simply do not accept a vis-
ible margin, even if it cannot be noticed during conversation
on the social life situations. On these cases and on the situa-
tions where the lip line shows the marginal gingiva, the cervi-
cal cavosurface angle of the preparation should be placed
0.1–0.3 mm inside the gingival sulcus.
In relation to the proximal margins of the preparation,
on teeth with slight color alterations, they should be placed
before the proximal contacts. However, on teeth with
intense discoloration, the preparation must  go further as
half the contact area, in such a way that the dark back-
ground would not be visible after the restoration. When
there are diastemas, the preparation should extend to the
interproximal surfaces, allowing the correct restoration of
the proximal contour. Another aspect regarding proximal
limits of the preparation is the sight’s angle (or viewing per-
spective), when preparing the gingival embrasure areas,
below the interproximal contact. When teeth are observed
a b
17
c d
..      Fig. 17.2  Lateral view perspective of the embrasure area changing the sight’s angle. a–c Preparation without considering the dynamic area of
visibility. b, d preparation considering dynamic area of visibility
from a perpendicular direction (sight’s angle of 90 degrees)
in relation to the labial surface  – a position that dentists
generally use to evaluate the final preparation – there is a
poor vision of the gingival embrasure between contiguous
teeth. This viewing perspective is called “static area of visi-
bility” and does not represent the actual viewing perspec-
tive that the patient could be seen by other people in daily
life. This may lead to insufficient preparation of some areas
of the facial surface of the crown. On the other hand, when
the tooth is observed from a lateral perspective, in a sight’s
angle smaller than 90 degrees, the gingival embrasure areas
become more noticeable. If this is not taken into consider-
ation, the aesthetic outcome of the veneer restoration may
not be pleasant, due to the remaining  of the discolored
areas of the tooth uncovered by the veneer. The dentist
viewing perspective during preparation needs to change
constantly, to evaluate if the dark areas are not remaining
unprepared and exposed, when the patient is observed
from different angles. This active viewing perspective is
called “dynamic area of visibility” and is necessary during
the preparation (. Fig. 17.2a–d) [16, 23].
In relation to outline in the incisal edge, there are three
possibilities. The type I (or window preparation) has a feath-
ered edge, while the type II has an incisal reduction and a
butt joint; and the type III (or wrap preparation) has an inci-
Aesthetic Veneers: What Are They and How to Handle Them?
sal reduction associated with a palatal chamfer [24]. For
direct composite veneer restoration on teeth with thick inci-
sal edges, the feathered-edge preparation should be chosen.
However, on cases of patients with very thin incisal edges
that are susceptible to fractures, or when teeth need to be
elongated, as well for all indirect veneers, an overlapped inci-
sal edge preparation with butt joint or a palatal chamfer
should be performed. These preparations provide proper
thickness of the ceramic at the margin to prevent restoration
fracture, restrict the angle fractures, and enhance the aesthet-
ics of the laminate (. Fig. 17.5).
As in most clinical cases, the direct veneer preparation is
restricted to enamel, and it usually does not lead to postop-
erative complications, from the pulpal or functional point of
view. From the periodontal point of view, a correct cervical
anatomy and the perfect fitting of the veneer to the prepara-
tion, at this region, avoid alterations of the periodontal tis-
sues [18]. In some cases, veneers have shown to be a better
choice than full crowns, in particular for patients with deep
overbite, where there is usually not enough space on the lin-
gual tooth surface; or for the mandibular anterior teeth,
where it is easier to preserve the pulp integrity than on the
full crown preparation.
a b
c d
..      Fig. 17.3  Direct veneer tooth preparation. a Initial aspect;
b–e preparation of peripheral depth cut. f–i preparation of the
cervicoincisal depth cut; j reduction of the mesial half of the labial
surface; k analysis of the tooth structure reduction; l reduction of the
673 17
17.3  Sequence of Tooth Preparation
When a homogeneous reduction of the labial surface is
desired, the first step for the veneer preparation is to deter-
mine the maximum preparation depth, by making facial
depth cuts with known dimensions (. Fig.  17.3a–o). The
preparation is started with the peripheral depth cut following
the gingival contour, in a U shape (. Fig.  17.3b–d), with a
round diamond point, with a diameter compatible with the
size of the tooth and depth of aimed preparation, following
the contour of the gingival margin [11, 16]. By knowing the
diameter of the diamond point, it is possible to standardize
the depth of the preparation, by penetrating half of its diam-
eter into the tooth surface. For instance, the No. 1011 dia-
mond point has a 0.8 mm of diameter, while the No. 1012 one
has a 1.0 mm of diameter, and the No. 1013 one has a 1.2 mm
diameter. As mentioned above, for teeth with small color
alteration, a 0.4 mm reduction should be planned on the cer-
vical region, while for the ones with severe discoloration, this
reduction should be 0.5 mm. For that, half of the diameter of
the No. 1011 and No. 1012 burs, respectively, can be used as
references [25]. During the preparation of the peripheral
depth cut on the cervical area, it should be performed first
distal half and finishing of the preparation margin using a gingival
protector instrument; m analysis of the preparation on the mesiodistal
direction. n analysis of the preparation on the cervicoincisal direction;
o finished preparation with supragingival margin
 674 M. F. R. L. Huhtala et al.

e f

g h

i j

17

k l

..      Fig. 17.3 (continued)
Aesthetic Veneers: What Are They and How to Handle Them?
m n
..      Fig. 17.3 (continued)
before the gingival margin, even if later the gingival cavosur-
face margin will be placed inside the gingival sulcus. In doing
so, subsequent corrections of the preparation can be per-
formed without invasion of the biologic width.
Next, the peripheral depth cut should be extended along the
mesial and distal embrasures until the incisal edge (. Fig. 17.3e).
 
This proximal extension of the preparation should be guided by
aesthetics, reaching areas where the tooth/restoration interface
could not be seen, taking into consideration the dynamic area
of visibility (. Fig. 17.2a–d). The more compromised in terms
 
of color alteration is the tooth structure, the larger the extension
of the preparation toward the proximal surfaces should be  –
which can even involve half of the proximal contacts. In this
case, when performing the proximal reduction, the adjacent
teeth should be protected with a steel strip.
Next, a cervicoincisal depth cut should be prepared in the
center of the labial surface with a No. 2135 tapered diamond
point with a rounded tip, for teeth with slight discoloration,
or with a No. 4138 point for darker teeth. However, to obtain
a homogeneous reduction of the entire labial surface, the
cervical-incisal depth cut should be prepared in three planes,
following the convexity of the labial tooth surface
(. Fig.  17.3f–i). This way, the reduction will be performed
 
evenly over the tooth surface, allowing the application of a
homogeneous thickness of the restorative material over the
prepared area.
675 17
The following step is to connect the peripheral depth cut
to the cervicoincisal one, first on one-half of the tooth sur-
face, following the mesiodistal contour of the surface
(. Fig.  17.3j, k). Then, the reduction should be performed
on the other side (. Fig. 17.3l). The depth and homogeneity
of the reduction can be evaluated with the preparation
guides (. Fig.  17.3m, n). Then, the improvement of the
preparation margins can be performed, placing the gingival
margin 0.2 mm inside the gingival sulcus, if there is an aes-
thetic issue. Such procedure can be done using a No. 2135
tapered diamond point, for a chamfer finish line [16]. The
gingival tissue can be protected from the rotary instrument
using a metallic gingival retraction/protection instrument
(. Fig. 17.3l).
Another option to control the depth of the facial reduc-
tion is to use depth-limiting diamond points, available in
two different diameters. The No. 4141 three-wheeled dia-
mond depth cutter creates mesiodistal depth of cuts
0.3  mm deep, while the No. 4142 performs depth cuts of
0.4 mm deep (. Fig. 17.4a). Between the wheels covered by
diamonds, there are inactive areas, which will touch the
intact tooth structure and control the tooth removal. Even
when the depth-­limiting diamond points are applied, the
previous peripheral depth of cut can be performed first, to
facilitate the preparation (. Fig.  17.4b). Then, the depth-
limiting diamond point is to be used, followed by the
 676 M. F. R. L. Huhtala et al.

a b

c d

e f

17

..      Fig. 17.4  Preparation using depth-limiting diamond point. with No. 4141 point; e connection of all depth cuts to create a
a Three-wheeled diamond depth cutter points with different diam- homogeneous enamel reduction; f finished preparation with
eters; b peripheral depth cut; c, d mesiodistal depth cuts prepared intrasulcular gingival margin

No. 2135 tapered point to connect to the peripheral depth
of cut (. Fig. 17.4c–f).
 
For indirect veneers, overlapped incisal edge preparation
needs to be performed to avoid fractures of the restoration.
That can be done by a butt joint (. Fig.  17.5e, f) or a wrap
 
preparation (. Fig. 17.5i, k). In the first case, just an incisal
 
reduction is performed, while on the latter, it is followed by
an additional palatal chamfer. There is a discussion in the lit-
area, due to inter-incisor contacts during protrusive move-
ment of the mandible, allowing a safe incisal disocclusion
guide. This design also provides a definite seat during cemen-
tation [26].
Before preparing the palatal chamfer, an incisal reduction
of about 1  mm must be done. For that, three incisal depth
cuts are performed by placing a No. 2135 diamond point per-
pendicular to the long axis of the tooth (. Fig. 17.5c). They

erature about which would be the best design for the incisal are then connected, as shown in . Fig.  17.5d–f. Then, a
 

edge of ceramic veneer preparations [24]. However, the pala- 0.5–1-mm-­ long palatal chamfer is prepared. The palatal
tal chamfer effectively counteracts shear stress in the incisal depth of cuts is done with the No. 2135 diamond point posi-
Aesthetic Veneers: What Are They and How to Handle Them?
677 17

a b

c d

e f

g h

..      Fig. 17.5  Overlapped incisal edge preparation with a palatal chamfer. a, b Preparation restricted to the labial surface; c incisal depths of cuts;
d–f incisal reduction; g, h palatal depth of cuts. i–l palatal chamfer concluded
 678 M. F. R. L. Huhtala et al.
i j
k l
..      Fig. 17.5 (continued)
tioned parallel to the long axis of the tooth, which are then
connected to one another, including the proximal surfaces
(. Figs. 17.5g–l and 17.7c).
 
Tip
It is important to familiarize oneself with the detailed
steps in tooth preparation. One needs to have a clear
17 anatomical picture of teeth in mind during the
preparation. Selection of appropriate burs or points is
vital for the success of tooth preparation, because it is a
matter of tenths of millimeters.
17.4  Direct Veneer Restoration
To restore the labial surfaces of teeth after veneer prepara-
tions, a resin composite material with excellent polishing
characteristics should be selected. Those recommended
include microhybrid, nanohybrid, and nanoparticle compos-
ites, to recover the dental aesthetics. Before performing the
final veneer, a restoration mock-up can be done, using the
same composite, shades, and thickness layers of the final res-
toration. The materials should be applied over the teeth with-
out any previous adhesive treatment. After ­ curing, the
restoration mock-up is evaluated, and if it is not the one
desired, it can be easily removed by pulling out the veneer by
its margin, with the aid of an exploratory probe. Then a new
composite mock-up can be placed and evaluated. This will
also allow the dentist to evaluate whether the depth of the
preparation performed, when associated to characterization
material and composites, is enough to hide any altered back-
ground color the tooth may present. If necessary, a deeper
preparation can still be done.
Isolation of the operating field can be performed with
gingival retraction cord and cotton rolls, or with a rubber
dam associated with clamps to expose the margin of the
preparation. In those cases, the No. 210 or 211 clamps pres-
ent the ideal shape, allowing adequate displacement of the
gingival tissue. If the preparation is restricted to enamel, after
acid etching (with phosphoric acid gel) and rinsing, the sur-
face can be dried with air stream, resulting in a  opaque
chalky-white appearance. In this case, if the dentist is using
an adhesive system with separate primer and bonding bot-
tles, the primer does not need to be applied. However, if there
are areas of exposed dentin on the prepared surface, after
rinsing the acid gel, the surface should be blot dried. This will
leave the surface visibly moist (glossy), followed by an appli-
cation of a primer/bond adhesive system or a single bottle
adhesive system. Due to the abundant enamel availability on
this kind of preparation, the acid etching technique should
Aesthetic Veneers: What Are They and How to Handle Them?
be preferred in relation to the self-etching approach, result-
ing in higher bond strength values.
In the case of heavily discolored teeth or when there are
679 17
to mask the intense opacity of the tint, followed by a final
layer of more translucent enamel shade composite, to repro-
duce enamel characteristics (. Fig. 17.6a–o). If the adjacent

several shades on tooth surface after preparation, due to sev- tooth has a labial surface rich on macro and micro textures,
eral previous restorations, a thin layer of opaque light-curing they should be reproduced over the restoration according to
viscous liquid characterization material, also known as color what was described in 7 Chap. 14. When the tooth that will
 

modifier, tint, or masking agent, can be used to create a receive the veneer has Class III or IV restorations that require
whiter homogeneous surface color. Either white or VITA™ replacement, this should be made on a previous dental
shade opaque characterization materials can be used. After appointment. This would simplify the veneer preparation
that, a thin layer of dentin shade composite should be used, procedure.

a b

c d

e f

..      Fig. 17.6  Direct veneer restoration. a Tooth-shade evaluation; light-curing color modifier shade A1 (Kolor + Plus – Kerr); j application
b, c application of gingival retraction cord size No. 000; d protection of of dentin shade composite layer (Z350, 3 M/Espe); k, l application of
neighbor teeth with a Mylar strip and acid etching. e, f application of enamel opacity composite. m enamel shade composite applied;
the adhesive system; g light-curing; h, i application of opaque n, o final result
 680 M. F. R. L. Huhtala et al.

g h

i j

k l

17

m n

..      Fig. 17.6 (continued)
Aesthetic Veneers: What Are They and How to Handle Them?
o
..      Fig. 17.6 (continued)
When the teeth present only chromatic alteration and the
labial shape is intact, a custom-made matrix can be created
before the tooth preparation, copying the surface shape and
texture. It can be used later to restore the exact original anat-
omy, thus saving clinical time [16]. That matrix can be cre-
ated in two different ways. In the first, an impression can be
taken, and a plaster model obtained on a previous dental
visit. Over the model a matrix can be produced using a ther-
moplastic material, such as low-density polyethylene sheet,
and a vacuum thermoforming machine. It follows the same
technique applied to produce dental bleaching trays. Another
possibility is to create the matrix immediately before the
preparation, using self-curing acrylic resin. In this case, after
application of a retraction cord into the gingival sulcus, a
thin film of liquid petroleum jelly is applied over the tooth
surface, followed by the placement of acrylic resin, picking
up powder particles on wet brush, and applying over the sur-
face. It must be applied over the labial surface of the treated
tooth, incisal edge, and part of the labial surface of the adja-
cent teeth. A handle made of acrylic is created over the exter-
nal surface of the acrylic matrix to simplify its placement.
After curing, the margins of the matrix need to be finished
with an abrasive mounted stone. The acrylic matrix should
be tested in the position before and after the operating field
isolation.
After the preparation, adhesive procedures are per-
formed, and the dentin shade composite applied. Before
light-curing of each resin composite layer, the matrix should
be placed in the position to evaluate if there still is space left
to apply the enamel shade composite. The matrix must be
isolated internally with liquid petroleum jelly. The enamel
shade composite is then placed inside the matrix and taken
in the position. The excess of material is removed, and the
restoration is light-cured for only 10 s. The matrix is
removed, and the finishing of the margins should be per-
formed with a scalpel blade, followed by the final light-cur-
ing. The labial surface of the restoration will have the same
shape of the natural tooth, and just a polishing will be gener-
ally necessary.
681 17
17.5  Indirect Veneers
The indirect veneers can be performed with composites or
ceramics. As the restoration is prepared outside the mouth,
an impression or scanning of the preparation is necessary, in
order to create the restoration over a cast or milling it in
CAD/CAM machine. Before luting, a pretreatment of the
restoration is required, to improve its bonding to the tooth
structure. Those procedures are presented in the following
sentences.
17.5.1  Dental Ceramics
Ceramic is defined as something made from nonmetallic
material by firing at high temperature. The dental ceramics
are widely used biomaterials in prosthetic dentistry, because
of their attractive and well-studied clinical properties. They
have basically three indications in dentistry: (a) ceramic-­
metal crowns (porcelain fused to metal, PFM) and fixed par-
tial dentures; (b) all-ceramic restorations consisting of
crowns, inlays, onlays, indirect laminates (veneers), and
short-span anterior bridges; and (c) ceramic denture teeth.
Ceramics for dentistry are aesthetically pleasing by their
color, shade, and luster and are chemically stable.
A dental ceramic is best described as a complex multi-
phase system. It comprises a dispersed crystalline phase
which is surrounded by a glassy phase, actually a continuous
amorphous phase. The crystalline phase is mainly responsi-
ble for its physical properties, while the glassy phase gives its
aesthetic characteristics. Traditional feldspar-based ceramics
are also referred to as “porcelain.” They are silicon (Si) based
and made of aluminosilicate minerals, such as quartz (SiO2),
feldspar (KAlSi3O8–NaAlSi3O8–CaAl2Si2O8), and kaolin
(Al2Si2O5(OH)4). Typically, dental porcelain is composed of
ca. 73–75% feldspar and ca. 22–25% quartz. To increase the
workability of the unfired porcelain, and to impart X-ray
contrast, some kaolin needs to be added. Pigments are
important to provide the required aesthetic shade and hue
[4]. It is noteworthy that there is a crucial difference between
a regular ceramic (such as your coffee mug) and a dental por-
celain, which is related to the proportion of quartz, feldspar,
and silica (SiO2) contained in the ceramic matrix. Dental
porcelains (feldspathic-, leucite-, or fluorapatite-based) can
meet the highest aesthetic standards but have limitations:
they are brittle, with low fracture toughness and flexural
strength. This is a consequence of their very high glass con-
tent. Due to the limited thickness in indirect laminates and
the material’s properties, the clinical success of porcelain
veneers relies on reinforcement of the restorations by adhe-
sive cementation [27].
The new glass ceramics have improved mechanical prop-
erties due to a higher proportion of the crystalline phase that
strengthen the material [4]. As they possess higher fracture
strength and increased toughness, when compared to the
 682 M. F. R. L. Huhtala et al.
porcelain, they also have a wider application field. To the
group of glass ceramics belong the leucite-­based and lithium
disilicate-based (LiSi2O5) ceramics, as well the new zirconia-­
reinforced glass ceramic [27]. The stronger materials avail-
able are the so-called high crystalline ceramics, mainly the
Y-TZP zirconia-­ based ones. However, most are highly
opaque and have low aesthetics, not being generally recom-
mended for indirect veneers.
>> Identifying various dental ceramics and their correct
indications will guarantee success to the dental
treatment. One should never underestimate the
significance of etching, not only of the tooth structure
but also of the ceramic. In cementation it is vital to
carefully adhere to the luting protocol.
17.5.2  Impression/Scanning of the Tooth
Preparation
The first step to obtain a proper impression is to perform the
gingival displacement. For that, a retraction cord is gently
placed inside the sulcus using a retraction cord packer. The
cord must be placed beneath the finishing line to avoid inter-
ferences during the impression, for capturing the details of
the gingival cavosurface margin. After that a low viscosity
elastomeric impression material (addition silicones and poly-
ethers) is applied over the preparation, followed by the putty
material previously loaded inside an impression tray. The
retraction cord can be left in place during impressioning,
being generally removed in the mold. The gingival displace-
ment can also be performed with the double-­cord technique.
A thin retraction cord (000) embedded in hemostatic solu-
tion is placed inside the gingival sulcus, and over it a thicker
one (00). The one step putty-wash silicone impression tech-
nique can be used. For that, immediately before the impres-
sion, the thicker cord is removed, and the low viscosity
material injected around the tooth preparation. The putty
impression material is mixed, applied inside metal trays and
17 immediately placed intraorally, letting the materials to polym-
erize simultaneously. A high-accuracy type IV dental stone is
poured into the mold. After its hardening, a replica is
obtained, which is positive reproduction of the soft tissues
and teeth. The cast is then sent to the dental technician to
prepare the laminate.
Another option is to perform a 3D digital impression,
scanning the tooth preparation using an optical intraoral
scanner. The information is digitalized, and a virtual 3D
model is created. A dedicated software is used for restoration
design process. The milling unit is used to mill the laminated
from ceramic or composite blocks.
17.5.3  Provisional Restoration
Some indirect restorations are performed chairside, such as
when a CAD/CAM system is available in the dental office.
However, when the final restoration will be prepared by an
external laboratory, an interim restoration will be required.
When a single tooth will receive the provisional restora-
tion, a plastic clear crown form (. Fig. 8.13a) can be used as a
matrix to restore the external anatomy of the tooth. The crown
form is placed on the tooth and the excess is trimmed. A direct
composite or a bis-acryl composite is applied inside the form,
which is taken in position. The excess is removed with a sable
brush or disposable applicator moistened with bonding agent.
After light-curing the matrix is removed, while the composite
stays in place. The margins are checked, and any excess can be
removed with a scalpel blade. Generally, the temporary resto-
ration remains in place without any adhesive application,
solely through mechanical retention. The occlusion can be
adjusted with diamond finishing points. Any adjustments of
the interim restoration must not change the previous tooth
preparation. If the restoration dislodges, a temporary aesthetic
cement can be used (e.g., Bifix Temp, Voco; ClearTemp LC,
Ultradent). Another option is to etch a 1 mm diameter area on
the center of the preparation and cement the temporary resto-
ration with a flowable composite [21].
When the original labial surface has appropriate shape,
and the veneer indication is only related to color alteration, a
matrix can be prepared with a putty silicone material inside
the mouth, previously the tooth preparation. A trayless
impression is performed, by applying the material covering
the labial and lingual surface of the anterior and some poste-
rior teeth. Interproximal slits are cut on the buccal areas of the
matrix, which serve as vents through which the excess of the
provisional material will flow. An appropriate amount of the
bis-acryl composite is applied in the matrix, which is taken in
place until the initial cure of the material. The marginal fit is
analyzed, and finishing is performed. If the restoration is dis-
lodged, it can be cemented as described above. When the
teeth shape will be changed by the veneers, a diagnostic wax-
up can be used to prepare the silicone matrix, which will
guide the production of the temporary veneers. The patient
should always be informed about the low retention and fragile
characteristics of the provisional restoration [21].
17.5.4   xtraoral Phase for Indirect
E
Restoration
In modern dental laboratories, the ceramic veneers may be
prepared using various approaches. The first and oldest
method is the sintering, which consists in application of an
aqueous slurry of ceramic particles on a refractory cast. A
sintering is performed over the cast at a temperature above
the softening points of the ceramic, whereby the matrix par-
ticles melt and the particles coalesce [28]. Different layers of
ceramics, of different shades and opacities, are incrementally
applied, creating a polychromatic and natural look for the
final restoration. This method is used for feldspar and leucite-­
reinforced veneers [21, 28].
A second option is the direct casting or hot-pressing. In
this case a waxing of the restoration is performed that is
Aesthetic Veneers: What Are They and How to Handle Them?
683 17
embedded in a refractory material. The lost wax technique is thickness and high translucency of the laminates, an incor-
applied, creating a refractory mold. In this case a ceramic rect selection of the cement shade  can jeopardize the aes-
ingot is softened by heating and can be pressed or injected thetic outcome of the whole treatment. The try-in paste is
into the mold, creating monolithic and monochromatic lam- applied in the internal side of the restoration, which is placed
inate. It can be used for lithium disilicate glass ceramic and in position like will be performed during the final luting. The
leucite-containing glass ceramic [21, 28]. test should start with an untinted and transparent try-in
The last method is based on the use of a CAD/CAM sys- paste. If the first shade is not adequate, the laminate and the
tem. In this case an intraoral scanning or a scanning of a preparation are washed, and a new shade is tested, until
stone model is performed, creating a virtual cast of the teeth. defining the correct one for that clinical case. Different
The restoration design is done in the dedicated software, and options of cements/try-in pastes shades are available, e.g.,
the milling is performed on a ceramic bloc, also creating transparent, opaque white, bleach, yellow, brown, or follow-
monolithic and monochromatic laminates [21, 28]. The mill- ing the Vita Classical shade guide. After that, the dentist must
ing can take place chairside or in the dental laboratory. This thoroughly remove the try-in paste with water spray and dry
method can be applied for ceramic blocs made of feldspar the restoration with water- and oil-free air. No occlusal eval-
and leucite or lithium disilicate-reinforced glass ceramics, uation should be performed before the cementation, to pre-
zirconia-reinforced glass ceramic, and hybrid dental ceramic vent unforeseen fracture of the fragile laminate [21].
(ceramic network structure reinforced by a polymer net-
work). Recently high-translucent zirconia has been proposed
for veneer restoration, although not providing yet the best 17.5.6  Pretreatment of Veneers
aesthetic outcome in relation to the other options [29].
Feldspar and leucite are milled from fully sintered blocs. The Obviously, tooth tissues do not possess any natural affinity to
restoration is polished or glazed in a small ceramic furnace. dental ceramics. This explains why pretreatment of tooth tis-
Lithium disilicate glass ceramic, zirconia-reinforced glass sues and a ceramic restoration, in association with adhesive
ceramic, and Y-TZP monolithic zirconia are milled from system and a resin cement, are vital. Veneers as well other
oversized dimension from partly sintered blocs (precrystal- dental indirect restorations require a surface pretreatment
lized state). That initial lower strength allows the milling pro- for durable adhesion. This step is also called surface condi-
cess. They are then fully sintered in a furnace, shrinking to tioning. It is defined as one or a series of steps, including (but
the required size, reaching its final translucency and maxi- not limited to) cleansing, removal of debris, and modifica-
mum flexural strength. The restoration with hybrid ceramic, tion of internal restoration surface, over which a silane cou-
like a composite block, is just milled and polished. pling agent and adhesive will be applied, chemically bonding
A monolithic restoration means that the final shape of the to the resinous cement [3, 8, 31].
restoration was obtained with a single material, which lacks The surface treatment will prevent the formation of (or
the polychromatic characteristic of a natural tooth, such as remove) any weak surface layer on the substrate (debris,
the translucent incisal edge, opalescence, counter-­ grease, oil, contaminants). That will increase the surface free
opalescence, and defined dentin mamelons [30]. Those are energy and maximize the molecular interaction at the inter-
obtained when the hot-pressing and CAD/CAM methods facial layer, between the laminate and resin cement, optimiz-
are employed. In this case the restoration can be character- ing the adhesion at the interface. It can also create special
ized either externally, through glazing (staining), or alterna- surface micro-features for micromechanical retention [7,
tively cut-back and covered with layers of compatible sintered 31]. Sufficient adhesive strength can be provided and main-
ceramic [28]. tain a long service time.
Porcelains and the new glass dental ceramics are pre-
treated by acid etching using hydrofluoric acid, which is a
17.5.5  Try-in Procedure very corrosive and toxic agent. Great caution and care must
be exercised when using it. Acid etching is considered the
Each laminated must be tested into the preparation for fitting. most effective procedure in enhancing adhesion between
For that the provisional restoration is removed with an instru- feldspar-based and glass ceramic laminates and resin cement.
ment. The preparation is cleaned with pumice and a prophy- By etching the ceramic surface, a partial dissolution of the
laxis rubber cup or brush, followed by washing and drying. ceramic glass content occurs, creating a porous topography
Any residues of temporary cement must be removed that produces micromechanical retention between the lami-
(. Fig. 17.7c). The internal area of the laminate is moistened nate surface and resin cement (. Fig.  17.7g, h) [32]. Acid
   

with water or glycerin and the restoration is placed. Inadequate etching is normally performed using ca. 5–10% gel-like
seating can be diagnosed by using a low viscosity silicone hydrofluoric acid. Nowadays, the use of that acid etching is
material (Fit Test C & B, Voco). The internal adjustments can unanimously recommended [27]. For lithium disilicate and
be performed with small round fine diamond points. zirconia-­reinforced glass ceramic veneers, a 5% hydrofluoric
To verify the shade of the restoration, water-soluble try-in acid is applied for 20 seconds. For leucite-reinforced glass
pastes that simulate the optical characteristics of the resin ceramic and feldspar ceramic restorations, the recommended
cements can be used to select its color. Due to the small etching time is around 60 seconds.
 684 M. F. R. L. Huhtala et al.

A mandatory application of a silane coupling agent is around 1 minute, the adhesive and resin cement can be
needed to chemically bond the inorganic material (silica) of applied for final cementation of laminate (. Fig. 17.7i) [7, 8,
 

ceramic structure to the resinous monomers in the adhesive 31, 34, 35]. Some manufactures recommend the application
system and resin cement. The silane also allows the resin to of the adhesive over the silanized surface, which is not
better wet the ceramic surface that may easily penetrate into light-cured before the cementation (. Fig.  17.7j). Others
 

the porous structure [32, 33]. After silane solution dries for recommend the application of the cement directly over the

a b

c d

e f

17

..      Fig. 17.7  Indirect veneer restoration. a Color alteration on
nonvitalized central incisors; b internal and external dental bleaching
procedure did not significantly improve the aesthetics of the smile. The
initial uneven gingival zenith position of the right central incisor in
relation to the left incisor was corrected by a gingival surgery;
c preparations with incisal reduction and palatal chamfer; d placement
of a retraction cord into the crevice, protection of the neighbor teeth
with a clear strip and acid etching; e application of the adhesive
system; f glass ceramic veneers etching of the internal surface with
hydrofluoric acid gel; h etched surface after washing and drying,
showing a frosty appearance due to the surface roughness created by
the dissolution of the glassy phase. i application of the silane coupling
agent; j application of the adhesive system; k luting of the veneers with
a light-curing resin cement; l final result
Aesthetic Veneers: What Are They and How to Handle Them?
685 17

g h

i j

k l

..      Fig. 17.7 (continued)

silanized surface. Each manufacturer instruction must be Tip

followed.
For indirect composite veneers, the internal surface of the
restoration must receive sandblasting (air abrasion). This
procedure increases the surface roughness to provide micro-
mechanical retention. After that the surface is cleaned with
spray of air/water or ultrasonic bath. Some manufacturers
recommend the application of silane to promote bonding to
the inorganic matrix of the composite, exposed by the sand-
blasting procedure.
Understanding the various steps and rationale in ceramic
veneer pretreatment is important. The try-in must be
performed before the acid etching. After etching the
internal must not be contaminated. If any contamination
occurs, the surface needs to be cleansed with acetone or
ethanol or re-etched with phosphoric acid, followed by
rinsing with water.
 686 M. F. R. L. Huhtala et al.
17.5.7  Cementation of Indirect Veneers
The rubber dam isolation can be performed, in association
with clamps for anterior teeth, although it is not always
feasible or possible [27]. Another possibility is to apply a
lip and check retractor to create a soft tissue displacement.
The neighbor teeth surfaces are protected with a clear
mylar strip or a polytetrafluorethylene (PTFE) tape
(. Fig.  17.7d). The tooth preparation surface is etched
 
with phosphoric acid gel for 15 second (. Fig. 17.7d). If no
 
dentin was exposed during the preparation, the surface is
completely air dried, leaving a frosty-white appearance.
However, if any dentin was prepared, the blot drying tech-
nique is used, and the excess of moisture is removed with
a cotton pellet, leaving a visible moistened surface. The
selected adhesive system is applied, and the excess is
removed with air stream (. Fig. 17.7e). No light-curing is
 
performed.
The internal area of the restoration is etched with hydro-
fluoric acid, and the silane coupling agent is applied, as previ-
ously described. According to the manufacturer’s instruction,
the adhesive system can be applied over the silanized surface
(. Fig. 17.7j). The excess is removed with an air stream, but
no light-curing is performed.
The resin cement of choice is the light-curing one, which
allows a better color stability over time. The veneers are
held with a placement instrument that features a flexible
adhesive tip (OptraStick, Ivoclar Vivadent), charged with
the resin cement on the internal surface and then posi-
tioned with continuous digital pressure in the tooth. Excess
of cement can be removed with a brush. The proximal area
can be cleaned with dental floss. A light-curing is per-
formed for 10 seconds, to ensure the positioning and fitting
of the laminate. After the cementation of the last restora-
tion, a layer of glycerin gel is placed over the interphase
between tooth and restoration, to eliminate the oxygen
inhibition layer of the cement, and the light-curing is per-
formed again for 60 second on every side of the tooth. Any
additional excess can be removed with a No.11 scalpel
17 blade. In the interproximal area, a serrated separating strip
can be employed (. Fig. 15.18f) [21].
 
If more than one restoration will be cemented, the clini-
cian must try in the restoration that will be luted next,
because even small excess of cement from the previous
laminate will prevent the seating of the subsequent. The
laminates of  both central incisors are simultaneously
cemented, i.e. both laminates are place in position first an
then light-curing is done simultaneously,  following by  the
cementation on  those teeth  more distally  located. If any
error occurs, they will be located far from the midline and
will be less visible [21].
17.5.8  Finishing and Polishing
After cementation, the dynamic occlusion contacts must be
evaluated with a thin articulating paper. The anterior disoc-
clusion guide must occur without excessive stress concen-
tration in just one tooth. The canine disocclusion guide
must also be evaluated. Any adjustment can be performed
with a fine-grit diamond points or 30-flutted carbide bur.
The finished areas must be properly polished using abrasive
rubbers, disks, or polishing pastes with felt disks, using pro-
gressively finer abrasives (. Figs. 4.29a–d and 4.31b). The
whole margin must be evaluated with an exploratory probe.
Any excess must be removed using a very thin grit needle
shaped diamond point. Any excess in the interproximal
area  must be detected with dental floss and removed with
abrasive strips. The margins of the restorations should be
reevaluated in the next dental appointment to detect any
remaining discrepancy [21].
17.6  Changes of the Apparent Tooth
Dimension by Optical Illusions
In some patients, changes in the clinical width or length of a
certain teeth are desired for aesthetic improvement. For
that, orthodontic treatment or gingival surgery is usually
required. However, some patients might not desire to receive
such an invasive or prolonged treatment. For those cases,
some superficial morphology changes can be performed on
the labial surface, making the tooth look larger or shorter,
thereby creating an optical (and aesthetic) illusion. The art
of creating illusions consists of changing perceptions, caus-
ing an object to appear different from what it actually is.
This is performed by changing the so-called tooth face,
which is a flat area on the labial surface [36]. In the same
way, the size of incisal and cervical embrasures determines
the youth aspect of teeth and can be shaped when making
the restoration.
17.6.1  Flat Area
On the mesiodistal direction, the flat area or tooth face is
placed between the mesial and distal transitional line angles
(. Fig.  17.8a, c). The transitional line angles on the labial
surface of neighboring teeth form the labial embrasures.
Even though it may not be a perfectly flat surface, it is
responsible for reflecting the visible light and for the appar-
ent dimensions of the anterior teeth [16]. Light that reaches
the facial surface between the transitional line angles is
reflected to the observer, while the mesial and distal areas to
Aesthetic Veneers: What Are They and How to Handle Them?
a b
..      Fig. 17.8  Location of the flat area (tooth face) on the labial surface
of the central incisor. a On the mesiodistal direction, it is located
between the mesiolabial and distolabial transitional line angles. On the
cervicoincisal direction, it is located between the high of curvature and
those line angles deflect the light, making them appear
darker and less observable and seen. Reallocating the posi-
tion of the transitional line angles, the area that reflects light
can be increased or reduced [36]. The more the transitional
line angles approach the center of the labial surface, the nar-
rower this flat area becomes. On the other hand, the more
displaced toward the proximal surfaces these transitional
line angles are, the wider is the flat area. The increase of the
flat area width, on the mesiodistal direction, gives a widen-
ing illusion to the tooth. Given that, teeth with the same
actual anatomical width can have different apparent dimen-
sion if they have different width of the flat areas [16]. That
concept is described as the “law of the face,” [21] which
implies making dissimilar teeth appear similar by turning
the apparent faces equal.
. Figure 17.9a–d shows resin composite replicas obtained
 
from the natural tooth shown in . Fig.  17.8a–c, where the
 
width of the flat area was reduced to create a narrowing illu-
687 17
the transition line between the middle and incisal third of the crown;
b delimitation of the flat area from a proximal view; c delimitation of
the flat area from an incisal view
sion. The changes that were planned are seen in . Fig. 17.9a  
and performed in . Fig.  17.9b, c. . Figure  17.9d shows the
result after polishing. When performing a direct veneer res-
toration, the flat area can be adapted according to the indi-
vidual needs, either during the application of composite
increments or during the finishing procedures. To reduce the
width of the flat area and create a narrowing illusion, the den-
tist should enlarge the mesial and distal embrasures, using a
small diameter abrasive bur disk [16]
On the cervicoincisal direction, the labial surface of ante-
rior teeth generally has three inclinations. The flat area is
then defined by those inclinations, located at the medium
third of the crown, above the high of curvature, and below
the transition line between the middle and incisal third
(. Fig. 17.8a, b). The larger the flat area on the cervicoincisal
direction, the larger will be the apparent height of the tooth.
. Figure  17.10a–d shows composite replicas obtained from
the natural tooth, originally shown in . Fig.  17.8a–c. The
 688 M. F. R. L. Huhtala et al.

a b

c d

..      Fig. 17.9  Effects of flat area width on the apparent width of the angles by wearing with abrasive disk; c transverse cross section
crown using resin replicas of the same tooth. a Delimitation of the showing the changes performed; d original aspect of the light
actual width of the flat area on the left and drawing of the new reflection on the left and after changes on the right, creating a
dimension on the right; b changing the position of the transitional line narrowing illusion

changes were planned in . Fig.  17.10a and performed in

  Tip
. Fig. 17.10b, c through the cervical and incisal reduction of
 

the flat central area, using an abrasive disk. Finally, in To reduce the apparent length of long teeth, the flat area
. Fig. 17.10d is shown the result after polishing.
  should be reduced on the cervicoincisal direction and
Based on the above presented explanations, to increase increased on the mesiodistal direction.
17 the apparent height of short teeth restored with veneers, the
flat area should be enlarged in the cervicoincisal direction
and reduced in the mesiodistal direction. Conversely, to
reduce the apparent length of long teeth, the flat area should
17.6.2  Embrasures
be reduced on the cervicoincisal direction and increased on
the mesiodistal direction.
The size and distribution of the embrasures directly influence
smile aesthetic according to what was described in 7 Chap. 1  

Tip
(. Fig. 1.11a–d). Therefore, when making veneer restora-
 

tions on several teeth, dentists can change the embrasures to

To increase the apparent height of short teeth restored
with veneers, the flat area should be enlarged in the
cervicoincisal direction and reduced in the mesiodistal
direction.
make the smile look younger. Changes in embrasure shape
can be performed at the moment of the composite applica-
tion or during the finishing of the restoration, using scalpel
blades and thin polishing disks with small diameter [16].
Small or absent embrasures make the smile look older.
Aesthetic Veneers: What Are They and How to Handle Them?
a b
c d
..      Fig. 17.10  Effects of flat area length on the apparent height of the
crown using resin replicas of the same tooth. a Delimitation of the
actual flat area length on the left and drawing of the new dimension
on the right; b length reduction with abrasive disk; c longitudinal cross
Conclusion
Aesthetic treatment decisions should be based on prevail-
ing clinical conditions and the patient preferences and
anticipations, following the principles of maximum conser-
vation of the tooth structure. The veneers are restorations
restricted to the labial surface of aesthetically compromised
anterior teeth, on areas visible during smile or conversation,
keeping intact the proximal and lingual surfaces. The resto-
ration can be performed directly with composite or indi-
rectly with a ceramic or composite. The indirect technique
requires the impression or scanning of the preparation and
a provisional restoration. The cementation steps are critical
to the quality of the treatment, and a careful procedure
must be performed. The clinical success depends on durable
bonding between the laminate and prepared and primed
tooth substance. Whatever is the choice of veneering mate-
rial, the adhesive resin cement, and surface pretreatment
methods, it is very important for the dentist to gain confi-
dence with the use of the chosen laminate treatment
modality.
689 17
section showing the change performed; d original aspect of the light
reflection on the left and changes on the right, resulting in the
shortening of the apparent crown height
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8. Matinlinna JP, Lung CYK, Tsoi JKH.  Silane adhesion mechanism in
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9. Ekambaram M, Yiu CKY, Matinlinna JP.  An overview of solvents in
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10. Ekambaram M, Yiu CKY, Matinlinna JP, King NM, Tay FR. Adjunctive
application of chlorhexidine and ethanol-wet bonding on durabil-
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16. Baratieri LN, Monteiro Junior S, Andrada MA, Ritter AV.  Odontologia
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tion. In: Matinlinna J, editor. Handbook oral biomater. Singapore:
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34. Matinlinna JP, Lassila LVJ, Vallittu PK.  Evaluation of five dental
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35. Özcan M, Matinlinna JP, Vallittu PK, Huysmans M-C. Effect of drying
time of 3-­methacryloxypropyltrimethoxysilane on the shear bond
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São Paulo; 2006.
 691 18

Dentin Hypersensitivity
and Cracked Teeth
Eduardo Bresciani, Carlos Rocha Gomes Torres, and Annette Wiegand

18.1 Dentin Hypersensitivity – 692

18.1.1  efinition – 692
D
18.1.2 Epidemiology – 692
18.1.3 Etiology – 692
18.1.4 Dentin Hypersensitivity Mechanisms – 694
18.1.5 Diagnosis – 694
18.1.6 Management of Dentin Hypersensitivity – 694

18.2 Cracked Teeth – 696

18.2.1  efinition – 697
D
18.2.2 Epidemiology – 697
18.2.3 Etiology – 698
18.2.4 Diagnosis – 699
18.2.5 Mechanism of Pain – 699
18.2.6 Management of Cracked Teeth – 699
18.2.7 Prognosis – 702

References – 702

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0_18
 692 E. Bresciani et al.
Learning Objectives
The learning objectives of this chapter are:
55 To define the term "dentin hypersensitivity" and gain
knowledge on epidemiology, pain mechanisms, diagnosis,
and treatment options for dentin ­hypersensitivity.
55 To inform about diagnosis, epidemiology and manage-
ment of cracked teeth.
18.1 Dentin Hypersensitivity
18.1.1 Definition
Dentin hypersensitivity is defined as short and sharp painful
sensitivity, triggered by tactile, thermal, chemical, osmotic,
or evaporative stimuli applied to exposed dentin. It is not
related to any other pathology, so conditions with similar
symptoms, i.e., cracked tooth syndrome (to be discussed
further in this chapter), chipped teeth, fractured restora-
tions, postoperative sensitivity, or pulpitis, have to be
excluded [77].
Dentin hypersensitivity is also referred as dentin hyperes-
thesia, dentin sensitivity, sensitive dentin, and root sensitiv-
ity, among others. The term “dentin hypersensitivity” may
not be most adequate, as this scenario is not related to pulpal
inflammation, but it will be the preferred term in this chapter
as it is the most used term.
Dentin hypersensitivity is defined as short and sharp
painful sensitivity, triggered by tactile, thermal,
chemical, osmotic, or evaporative stimuli applied to
exposed dentin, not related to any other pathology.
18.1.2 Epidemiology
Epidemiological data on the prevalence of dentin hyper-
sensitivity vary distinctly depending on the study popula-
18 tion, methods of examination (clinical examination,
questionnaire), and diagnostic criteria. A recent review by
West et al. [77] showed that the prevalence of dentin hyper-
sensitivity ranged from about 2 to 98%, with periodontal
patients presenting higher values (60 to 98%) than adult
patients (up to 50%). Premolars are more often affected
from dentin hypersensitivity than molars and canines;
moreover, it is slightly more prevalent in the upper jaw than
in the lower jaw [52, 84].
Age and gender distribution of dentin hypersensitivity
show conflicting evidence. Mostly, a peak of dentin hypersen-
sitivity can be observed in patients around 30 to 40 years. In
older patients, dentin hypersensitivity is probably reduced due
to tertiary dentin formation and a lower number of teeth,
which potentially might be at risk for developing dentin hyper-
sensitivity [71, 77]. Conflicting data exist on higher prevalence
of dentin hypersensitivity in female patients [52, 61, 78], which
might exhibit a more healthy lifestyle (e.g., more extensively
brushing, higher consumption of “healthy,“potentially erosive
food) compared to men. Overall, prevalence of dentin hyper-
sensitivity seems to increase, as the population ages and teeth
are retained for a longer time period [47].
>> Dentin hypersensitivity is more prevalent on patients
with periodontal problems, and the premolars are the
more affected teeth. The peak occurs in patients
around 30 to 40 years.
Patients seeking treatment for dentin hypersensitivity report
a considerable impairment of their oral health-related quality
of life, as eating, drinking, and oral hygiene habits were
affected [8].
18.1.3 Etiology
Dentin hypersensitivity may occur when dentin is exposed to
the oral environment, as a result either of enamel loss or of
root exposure with loss of cementum (. Fig. 18.1). Attachment
loss is probably the most relevant factor leading to root expo-
sure and dentin hypersensitivity. Especially, patients with gin-
gival recessions (. Fig.  18.2) are affected from dentin
hypersensitivity [66, 78]. Gingival recession is defined as dis-
placement of the gingival margin apically to the cemento-­
enamel junction and is a common entity even in younger
adults with a healthy periodontium [55, 66]. Prevalence data
on the percentage of people affected from gingival recession
range from 30% to 100% [39]. Besides inflammation, predis-
posing factors for the development of gingival recession com-
prise morphological conditions of the bone (e.g., dehiscence,
fenestration) and soft tissue (e.g., thickness of keratinized
gingiva, frenum position), orthodontic tooth movement,
..      Fig. 18.1  Scanning electron microscopic image of a dentin surface
with open tubules
Dentin Hypersensitivity and Cracked Teeth
693 18

..      Fig. 18.2  Recessions at mandibular incisors due to exaggerated ..      Fig. 18.3  Patient with severe erosive tooth wear due to bulimia
brushing

and/or oral hygiene (e.g., toothbrushing frequency and dura-

tion, scrub method, bristle hardness) [26, 29, 39]. If left
untreated, gingival recession has a high probability for pro-
gression [14].
Dentin hypersensitivity can also occur as consequence of
periodontitis or periodontal treatment. Scaling and root
planing might lead to hypersensitivity in symptom-free teeth
and increased hypersensitivity in already affected teeth.
Potential differences with respect to dentin hypersensitivity
between various instruments and devices for scaling and
root planing were not investigated so far. Not only conserva-
tive but also surgical intervention increases dentin hypersen-
sitivity [18].
The main reason for enamel loss is tooth wear by erosion,
abrasion, abfraction, and/or attrition. Erosive tooth wear is ..      Fig. 18.4  Abrasive tooth wear and recession due to toothbrushing
defined as dental hard tissue loss due to a chemical-­ with self-made very abrasive toothpaste
mechanical process not involving bacteria [13]. Erosive tooth
wear is initiated by extrinsic or intrinsic acids undersaturated from antagonist tooth-tooth contact, and abfraction is dis-
with respect to tooth mineral, which demineralize the sur- cussed to be a result from abnormal occlusal loading leading
face and make it more prone to physical wear. Extrinsic acids to tensile stress in the cervical area [68]. Abrasion can be
come mainly from diet, and frequency and duration of con- caused by abnormal oral hygiene depending on toothpaste,
sumption determine the severity of erosive demineralization. toothbrush, and the toothbrushing frequency and force
Extrinsic acids from professional work and practice of sports (. Fig. 18.4) [79]. To a certain extent, erosive and mechanical
 

are also important; however, they might be considered as sec-
ondary factors regarding erosive tooth wear [7]. Exposure to
gastric acid by reflux disease, eating disorders, or alcoholism
might cause intrinsic erosion (. Fig. 18.3) [40]. Compared to
 
dietary acids, the pH of gastric acid is much lower, leading to
more severe erosive lesions.
Saliva plays an important role in the prevention of ero-
sion by deluting, removing, and buffering acidic substances.
Moreover, it forms a protective salivary pellicle on the tooth
surface. By providing mineral ions, saliva might also modify
the de- and remineralization process. Thus, patients present-
ing hyposalivation are more prone to erosion [24, 25].
Mechanical forces might increase erosive wear but might
also act as the sole factor causing tooth wear. Abrasion results
from friction between teeth and other materials and attrition
tooth wear can be considered as physiological, but especially
the interaction between erosion, abrasion and attrition might
lead to increased wear exposing dentin.
As erosive and mechanical processes often interact, a
precise differentiation of tooth wear lesions is often chal-
lenging. Erosive tooth wear affects initially the palatal and
occlusal surfaces (intrinsic erosion) or the labial surfaces
(extrinsic erosion). Erosive tooth wear starts with a silky-
shining surface progressing into concavities (smooth sur-
faces) or grooves (cusps). On smooth surfaces, erosive tooth
wear is characteristically located coronal from the CEJ and
presents an intact border of enamel along the gingival mar-
gin. On occlusal and incisal surfaces, progression of erosive
tooth wear finally results in a complete destruction of the
morphology.
 694 E. Bresciani et al.
Tip
Erosive tooth wear starts with a silky-shining surface
progressing into concavities (smooth surfaces) or
grooves (cusps). On smooth surfaces, erosive tooth
wear is characteristically located coronal from the
enamel-cementum junction and presents an intact
border of enamel along the gingival margin.
Attrition appears as flat facet with a shiny appearance and
distinct margins. Corresponding facets can be found at
antagonistic teeth. Abrasive defects can hardly be distin-
guished from primarily erosive lesions as these phenomena
clinically often overlap [20]. Non-carious cervical lesions
(wedge-shaped lesions) are probably the result of an inter-
action of erosion, abrasion, and attrition. The evidence for
abfraction to be causative in the development of wedge-­
shaped defects is meanwhile critically discussed [68]. In
contrast to erosive lesions, wedge-shaped lesions are
located apical from the CEJ and have sharp margins [20,
68]. Lesion depth and morphology contribute to dentin
hypersensitivity [44].
18.1.4 Dentin Hypersensitivity Mechanisms
Several mechanisms of action were described in the literature
to explain dentin hypersensitivity [9, 10]. The most accepted
mechanism defining dentin hypersensitivity is based on the
hydrodynamic theory described by Brännström [9]. This
theory proposes that dentin hypersensitivity is the result of
rapid fluid movement in the dentin tubules due to external
stimuli, typically thermal, tactile, evaporative, osmotic, and
chemical triggers. Stimulus-induced fluid flow might activate
nerve endings, (A-β and A-δ fibers) at the dentin-pulp inter-
face; the excited nerve terminations are considered as mech-
anoreceptors. The sudden movement of dentin fluids might
be directed outward or inward, depending on the kind of
stimuli. Cooling, drying, evaporation, and hypertonic solu-
tions produce an outward flow, which generates more pain
18 than inward flow due to heat application [17].
>> Dentin hypersensitivity is the result of rapid fluid
movement in the dentin tubules which might activate
nerve endings.
The other theories proposed to explain dentin hypersensitiv-
ity comprise the neural theory and the ondontoblastic trans-
duction theory. The neural theory suggests that dentin is
innervated and nerve endings within the dentinal tubules are
directly activated by the stimulus. The odontoblastic trans-
duction theory assumes that the stimulus is transmitted
along the odontoblast via synaptic junctions to the sensory
nerve endings [76].
Usually, the superficial dentin is less permeable than
deeper layers as the number and diameter of tubules per area
decreases from the pulpal dentin to the DEJ. Hypersensitive
dentin presents more and wider dentinal tubules than non-
sensitive dentin. However, exposed dentin is not necessarily
associated with hypersensitivity, as permeability is reduced
in sclerotic dentin. Also, the presence of a smear layer, i.e.,
resulting from removal of the cementum layer during root
debridement, might reduce permeability temporarily [49].
18.1.5 Diagnosis
Information about the presence and severity of dentin hyper-
sensitivity can be obtained from a proper anamnesis and clini-
cal examination, which should be routinely done. Verbal
screening includes questions about pain during drinking or
eating hot, cold, or acidic drinks or food or during tooth-
brushing. Furthermore, pain characteristics (site, severity,
duration, character) should be recorded. Then, information
about personal behavior patterns (consumption of acidic food
or drinks, intrinsic erosion, toothbrushing) and about previ-
ous dental treatment (restorative treatment, dental bleaching,
periodontal treatment) should be obtained before a clinical
examination is undertaken. During clinical examination, con-
ditions with similar symptoms, i.e., caries, fracture restora-
tions, teeth, postoperative sensitivity, microleakage, or pulpitis,
must be excluded. If dentin exposure due to enamel loss or
root exposure can be detected, tactile (dental explorer) and
thermal/evaporative stimulation (air stream) should be per-
formed. Ideally, two different stimuli should be applied to con-
firm the diagnosis. Pain intensity and quality should be
documented (e.g., by numerical rating scales) [21, 74]. One
frequently used score is the Schiff cold air sensitivity scale [62]:
0. Subject does not respond to air stimulus.
1. Subject responds to air stimulus but does not request
discontinuation of stimulus.
2. Subject responds to air stimulus and requests discon-
tinuation or moves from stimulus.
3. Subject responds to air stimulus, considers stimulus to
be painful, and requests discontinuation of the stimulus.
Additionally, the impairment of the oral health-related qual-
ity of life can be assessed by using suitable instruments like
the Oral Health Impact Profile [21, 74].
18.1.6 Management of Dentin
Hypersensitivity
The management of dentin hypersensitivity usually follows
a stepwise approach based on the extent and severity of the
condition. Based on a correct diagnosis, potential risk fac-
tors for tooth wear and gingival recession (diet, intrinsic
erosion, oral hygiene, etc.) must be identified and eliminated
or at least modified (dietary advice, oral hygiene advice).
Non- and minimally invasive strategies include the applica-
tion of products, which aim to suppress the pulpal nerve
response or to mechanically occlude dentinal tubules; prod-
Dentin Hypersensitivity and Cracked Teeth
ucts can be self-applied at home (e.g., toothpastes) or pro-
fessionally applied (e.g., sealants) in the dental office. If
dentin hypersensitivity persists and goes along with a cervi-
cal defect or gingival recession, restorative treatment or
mucogingival surgery can be considered [38, 63].
18.1.6.1 Elimination or Reduction of Etiological
Factors
Different etiological factors might contribute to the develop-
ment of dentin hypersensitivity. With regard to erosive tooth
wear, recording of dietary intake might be helpful to identify
acidic sources, i.e., fruit juices, soft drinks, sport drinks, or
sour sweets [59]. Frequency of consumption, i.e., by avoiding
dietary acids between meals, and contact time with dietary
acids should be significantly reduced [45, 46]. In case of
intrinsic erosion, referral to an appropriate medical specialist
becomes necessary. Stimulation of salivary flow or the use of
saliva substitutes might be indicated if erosive tooth wear is
associated with hyposalivation.
Tip
For extrinsic erosion, recording of dietary intake might
be helpful to identify acidic sources and frequency of
consumption. Thus, the contact time with dietary acids
can be significantly reduced. In case of intrinsic
erosion, referral to an appropriate medical specialist
becomes necessary. Stimulation of salivary flow or the
use of saliva substitutes might be indicated if erosive
tooth wear is associated with hyposalivation.
Incorrect toothbrushing might contribute to the develop-
ment of gingival recession and tooth wear [26, 79]. Oral
hygiene advice therefore comprises correct toothbrushing
techniques (depending on the kind of toothbrush used) and
reduced toothbrushing force. High-abrasive toothpastes
should be avoided.
18.1.6.2 Non- and Minimally Invasive
Treatment
The noninvasive treatment of dentin hypersensitivity com-
prises the occlusion of dentinal tubules or nerve desensitiza-
tion. For occlusion of dentinal tubules by mineral
precipitation, various products containing strontium, argi-
nine, stannous fluoride, or calcium compounds have been
developed. Nerve desensitization is induced by agents con-
taining potassium salts. An increase in extracellular potas-
sium is thought to result in a sustained depolarization and
axonal accommodation, making the nerve less excitable to
further stimulation [23, 37].
At-home treatment of dentin hypersensitivity is mainly
done by desensitizing toothpastes. Toothpastes containing
potassium, stannous fluoride, calcium sodium phosphosili-
cate, arginine, and nano-hydroxyapatite presented a signifi-
cant desensitizing effect compared to placebo treatment due
to mineral precipitation in the dentinal tubules, while stron-
695 18
tium or amorphous calcium phosphate-containing tooth-
pastes were less effective [3, 28].
A large number of prophylaxis pastes and varnishes are
available for professional application. Prophylaxis pastes
containing arginine and calcium carbonate or calcium
sodium phosphosilicate were shown to have some effect on
dentin hypersensitivity [19, 34, 41]. Varnishes form a water-
proof film on the surface leading to some physical occlusion
of the dentinal tubules. Additionally, different active agents,
like fluoride, oxalate, or glutaraldehyde, are incorporated.
Fluoride varnishes form calcium-fluoride precipitates and
fluorapatite which occlude dentin tubules and reduced den-
tin hypersensitivity for several weeks [50]. Glutaraldehyde
coagulates protein in the dentinal tubules; oxalate forms
­calcium oxalate crystals that occlude the dentinal tubules.
Systematic reviews found that these in-office treatments were
effective in reducing dentin hypersensitivity when compared
to placebo treatments [34, 41]. Alternatively, the use of lasers
has been suggested. High-power lasers, such as Nd:YAG,
Er:YAG, or CO2, may obliterate the dentinal tubules by a
melting or  thermomechanical ablation mechanisms and/or
the evaporation of superficial dentinal fluid, reducing flow
within the dentinal tubules. Low-power lasers, such as
GaAlAs and He-Ne, may reduce pulpal nerve impulse con-
duction and exhibit photobiomodulating effects on cellular
activity, enhancing the formation of tertiary dentin [36, 67].
However, different laser treatments were shown to decrease
dentin hypersensitivity compared to placebo treatment, but
mostly did not result in a superior performance compared to
agents inducing chemical or physical occlusion of dentinal
tubules [34, 36, 67].
Finally, dental adhesives (. Fig. 18.5) or sealants can be
used for physical occlusion of dentinal tubules [34]. In con-
clusion, various treatment agents and regimens were shown
to be effective in reducing dentin hypersensitivity compared
to placebo. Due to the high variety of products and tech-
niques and the heterogenous study designs, superiority of
one agent/regimen can hardly be demonstrated. Moreover,
placebo effects are commonly observed in the treatment of
dentin hypersensitivity.
18.1.6.3 Invasive Treatment
If dentin hypersensitivity is associated with a significant loss
of dental hard tissue, restoration of the defect is a valid
option, especially if non- and minimally invasive treatment
failed. The restoration of non-carious cervical lesions can be
done with resin-modified glass ionomers or composites, the
latter placed via two-step self-etch or three-step etch and
rinse adhesives (. Figs. 14.39, 14.40, 14.41, 14.42, 14.43, and
14.44) [60, 64]. Risk of retention loss is slightly lower for
resin-modified glass ionomers (annual failure rate: 1.8%)
than for composite restorations (3.4–4.1%) [64].
In case of gingival recession, surgical therapy for root
coverage can be performed, leading to significant reduction
of dentin hypersensitivity [16]. A variety of surgical proce-
dures have been introduced [73], but the decrease of dentin
hypersensitivity could not be related to a specific surgical
 696 E. Bresciani et al.

a b

c d

18
..      Fig. 18.5  Application of a desensitizing dental adhesive for mechanical blocking of dentin tubules. a Drying of dentin surface with air stream,
b product application, c slight drying, d light-curing, e cervical area covered by the material

procedure [16]. If gingival recessions are associated with

non-carious cervical lesions, a combined restorative surgical Cracked tooth syndrome is a group of clinical signs and
approach can be considered [2]. symptoms associated with the presence of incomplete
fractures involving enamel and dentin, often extending
to the pulpal chamber and/or periodontal area.
18.2 Cracked Teeth

Cracked tooth syndrome describes a group of clinical signs

and symptoms associated to the presence of incomplete frac- This is a situation of hard clinical diagnosis related to lack of
tures involving enamel and dentin, often extending to the knowledge by the dentists and to pain perception by patients,
pulpal chamber and/or periodontal area [12, 42]. often distorted. The clinical scenario is usually reported by
Dentin Hypersensitivity and Cracked Teeth
patients mainly as acute pain of short duration present dur-
ing mastication, or after thermal stimulus, generally related
to cold food or drinks [11, 12, 15, 72]. Other related symp-
toms may be pain after biting hard food (rebound pain) [11,
72] and/or after taking sugar or grainy food [5]. Radiographic
examination is inconclusive [5].
Tip
The clinical scenario of cracked tooth syndrome is usually
reported by patients mainly as acute pain of short
duration present during mastication, or after thermal
stimulus, generally related to cold food or drinks. Other
related symptoms are pain after biting hard food and/or
after taking sugar or grainy food.
The importance of this chapter is to help the readers to per-
form an early diagnosis and correct treatment plan, treating
the tooth and maintaining its vitality and function, avoiding
the fracture progression which would lead to complete frac-
ture and possible tooth loss.
..      Fig. 18.6  Craze lines in enamel on teeth 11 and 12
a b
..      Fig. 18.7  Cusp fracture. a Fractured lingual cusp of symptomatic tooth 15, disclosed by caries lesion indicator solution (5% basic fuchsin),
b cusp fracture on gingival level was confirmed during the restorative procedure
697 18
18.2.1 Definition
The American Association of Endodontists defines the term
cracked tooth as an incomplete fracture initiated from the
crown and extending subgingivally, usually directed mesio-
distally [56]. Cracked teeth belong to longitudinal tooth frac-
tures, which can be subdivided in craze lines, fractured cusps,
cracked teeth, split teeth, and vertical root fractures [57].
Craze lines extend over marginal ridges and buccal and
lingual surfaces in posterior teeth and appear as long vertical
lines in anterior teeth but are confined to enamel (. Fig. 18.6).  
Fractured cusps, cracked teeth, and split teeth begin occlus-
ally and extend apically, while vertical root fractures begin in
the root. Fractured cusps are defined as complete or incom-
plete fracture involving at least two aspects of the cusp and
extending to the cervical third of the crown or the root
(. Fig. 18.7). In contrast to fractured cusps, cracked teeth are
centered and the depth on the root varies (. Fig.  18.8).
Cracked teeth are also described as greenstick fractures or
tooth infractions. Progression of a cracked tooth results in a
split tooth, which is defined as complete fracture initiated
from the crown and extending the middle or apical part of
the root (. Fig.  18.9). Vertical root fractures are initiated
from the root and may involve one or both buccal and lingual
proximal surfaces [56, 57].
18.2.2 Epidemiology
In patients suspected of having tooth cracks or presenting
cracked tooth-like symptoms, about 10% of patients/teeth
were in fact diagnosed with cracked teeth [31, 33, 75].
Cracked teeth are more prevalent at middle-aged and older
patients [31, 53, 58, 75, 82], and molars are more often
affected than premolars [31, 58, 75, 82], probably due to
the proximity to the temporomandibular joint. Thus, eat-
ing course food, chewing on hard objects, and unilateral
mastication were identified as risk factors for cracked teeth
 698 E. Bresciani et al.
a b
c d
..      Fig. 18.8  Cracked teeth. a Incomplete fracture with mesiodistal
direction observed on the pulpal and gingival walls of tooth 46 after
removal of an extensive restoration; b mesiodistal incomplete fracture
on upper molar observed after removal of an occlusal amalgam
18
..      Fig. 18.9  Split tooth. Mesiodistal fracture extending to the apical
part of the root
[51]. Some studies found mandibular molars to be most
frequently involved [31, 82]. It is discussed that maxillary
molars are more resistant to cracks due the stabilizing
occlusal oblique ridge [22]. Moreover, loading during mas-
tication might be higher in mandibular molars, when the
mesiopalatal cusp of the maxillary molar leads to fatigue in
restoration; c tooth 17 presenting partial loss of amalgam restoration
and the presence of a crack line with buccal-lingual direction. d Tooth 16
after removal of extensive restoration. The fracture lines can be observed
on the lingual groove and on the linguogingival line angle (arrows)
the antagonist (wedging effect) [22, 31]. It is also discussed
that higher masticatory forces in men might be responsible
for a higher prevalence of cracked teeth [31], although
most studies reported a similar prevalence in men and
women [58, 82].
>> Cracked teeth are more prevalent at middle-aged and
older patients and molars are more often affected than
premolars. Eating course food, chewing on hard
objects, and unilateral mastication were identified as
risk factors for cracked teeth.
Cracks occur in intact and restored teeth. If cracks occur in
restored teeth, those with nonbonded restorations, such as
gold and amalgam (. Fig. 18.8), are more often affected than
teeth with bonded restorations (composite) or crowns [31,
58, 75, 82].
18.2.3 Etiology
Intact, non-restored teeth often exhibit tooth cracks at the sur-
face, developing in enamel or at the DEJ, which might progress
into dentin, but are less likely to cause tooth fracture. Tooth
fracture is more likely to occur from dentin cracks, which
Dentin Hypersensitivity and Cracked Teeth
might be a result of restorative procedures (e.g., removal of
tooth structure) or fatigue caused by the restoration geometry
[81]. The fatigue and fracture resistance of teeth is also depend-
ing on age, hydration, and temperature variations [81].
Natural predisposing factors responsible for the develop-
ment and progression of cracks in intact teeth include mor-
phological and physical factors, such as sudden biting on
hard substances, eccentric contacts and interferences, wear,
bruxism, malocclusion and anatomic form of the cusps, and
the occlusal morphology (so-called wedging effect; see
above) [35]. The fracture resistance of teeth is also reduced in
the presence of carious lesions, requiring extensive prepara-
tion and resulting in large and/or deep cavities. Occlusal load
stress during mastication and repeated thermal expansion of
restorative material might cause an increased cuspal flexure
inducing stress at sharp internal line angles of the cavity
(gold, amalgam) and producing microcracks. Inadequate
design features also comprise insufficient cuspal protection
in inlay/onlay design or a deep cusp-fossa relationship [35].
Finally, stress concentration due to pin placement, physical
forces during luting of indirect restoration, non-incremental
placement of composite restorations, etc. might predispose
crack formation [35].
18.2.4 Diagnosis
The main clinical signs and symptoms of cracked teeth are
pain on biting/chewing and sometimes on the release of pres-
sure (rebound pain) and/or sensitivity to cold thermal stim-
uli [5, 27, 65]. Symptoms might be present for periods
ranging from weeks to month, and patients might have diffi-
culties in identifying the affected tooth. In the absence of
pulpal inflammation, vitality testing usually gives a positive
response, but an exaggerated response to cold thermal stim-
uli is possible. The pulpal and periapical diagnosis depends
on the extent and orientation of the crack. Cracks might
become colonized by bacteria arranged in biofilms, which
might reach the pulp and periodontal ligament if the crack
progresses [54]. Cracks with pulpal involvement might result
in pulpitis or pulp necrosis, which makes the diagnosis of
cracked teeth sometimes challenging. Periodontal probing is
necessary to disclose the depth of the crack. Cracked teeth
with periodontal probing depths exceeding 4 mm are more
likely to show pulp necrosis than cracked teeth with a peri-
odontal probing depth of 3  mm or less [82]. Radiographic
examination rarely improves the detection of cracks, as frac-
tures in mesiodistal direction are usually not visible, but is
essential to determine the periodontal and periapical status.
Tip
The main clinical signs and symptoms of cracked teeth
are pain on biting/chewing and sometimes on the
release of pressure (rebound pain) and/or sensitivity to
cold thermal stimuli.
699 18
Symptoms can be provoked by loading of individual
cusps (so-called bite test) by specific instruments (Tooth
Slooth  – Professional Result and FracFinder  – Denbur)
(. Fig. 18.10). Each cusp should be tested separately. Biting
tests can be also performed with wood sticks or cotton rolls
(. Fig. 18.11), but instruments were shown to be more reli-
able [83].
Visual detection of cracks is improved by using magnify-
ing loupes/microscopes, dyes (. Figs. 18.7 and 18.12), fiber-­
optic transillumination (. Fig.  18.13), or light-induced
fluorescence (. Fig.  18.14). In case of restored teeth, espe-
cially in case of amalgam fillings or gold restorations, removal
of restorations is necessary to detect fracture lines
(. Fig. 18.8). Then, wedging forces can be applied to deter-
mine if tooth segments are separable (split tooth, see above)
or not (cracked tooth). As differential diagnosis dentin
hypersensivity, postoperative sensitivity, fractured restora-
tions, occlusal trauma or parafunctions must be considered.
18.2.5 Mechanism of Pain
The pain associated with loading or loading release is
explained by the movement of dentinal fluid due to move-
ment of fractures sites (hydrodynamic theory). In this case,
the painful response is fast and intense due to activation of
Type A myelinated nerve fibers [43]. Pain related to pulp
inflammation is characterized by a short, sharp pain, indica-
tive of A-delta fiber activation, followed by a prolonged, dull
ache, indicative of C-fiber activation [30].
18.2.6 Management of Cracked Teeth
Early diagnosis is very important to reduce progression and,
thus, involvement of pulp and periodontium. Ideally, predis-
posing factors (see etiology 18.2.3) should be controlled to
avoid the formation of cracks. Treatment of longitudinal
fractures depends on the extent and depth. Root canal treat-
ment might be necessary in case of pulpal inflammation/
necrosis. If the crack extends to the root surface and leads to
extensive attachment loss, extraction or  – in case of multi-­
root teeth  – hemisection/root amputation must be consid-
ered. Restorative treatment of incomplete coronal fractures
not involving pulp or periodontium aims to immobilize and
bind the fractured segments. If possible, the margins of the
restoration should cover the crack to its full extent.
Historically, orthodontic bands, copper rings, or tempo-
rary crowns were suggested for immediate treatment, but
such restorations are time-consuming, invasive, and/or costly
[6]. Alternatively, the placement of direct composite splints
for short-term management of cracked teeth is suggested, but
comes along with transient side effects, e.g., problems with
chewing [4]. In many cases, initial treatment can be per-
formed by placing intracoronal composite restorations to
control if treatment leads to an improvement or complete
relief of symptoms. Composite restorations can be also con-
 700 E. Bresciani et al.

a b

..      Fig. 18.10  Instrument for detecting cracked teeth. a The instrument that can be adapted to the suspected cusp, concentrating the load on
(FracFinder) presents a flat and non-skid surface to rest on the opposing the individual cusp. b Test being performed on buccal cusp of tooth 24.
tooth of that being tested. The opposite surface presents a concavity c Test being performed on the same tooth but on lingual cusp

a b

18

..      Fig. 18.11  Load test and devices used to stimulate painful roll. Both tests might detect teeth with fracture, but specific detection
symptoms during the detection of cracked teeth. a Test performed of the involved cusp is not clear
with wooden tongue depressor; b test being performed with cotton
Dentin Hypersensitivity and Cracked Teeth
701 18

a b

..      Fig. 18.12  Tooth 46 presenting incomplete fracture and rebound lingual groove extended gingivally (arrow); c fracture line observed
pain reported by the patient during mastication. a Clinical aspect of after removal of the restoration at the linguogingival line angle on the
the occlusal surface showing a class I amalgam restoration; b lingual distolingual cusp (arrow). The fracture was evinced by a plaque
view of the tooth, showing a clinically detected fracture line at the disclosing solution

a b

..      Fig. 18.13  Fiber-optic transillumination for detection of cracks. a Aspect of the cracked teeth under natural light; b fractures clearly visible
under transillumination
 702 E. Bresciani et al.
a b
..      Fig. 18.14  Observation of tooth cracks by light-induced fluorescence using intraoral QLF camera (Qraypen, Inspektor Research Systems). a
Tooth illuminated by white light. b Tooth illuminated by blue light, showing red fluorescence in the cracks due to the bacterial penetration
sidered for permanent treatment. Opdam et  al. [48] evalu-
ated the effectiveness of composite restorations without
cuspal coverage for managing cracked teeth and found a
mean annual failure rate of 6% (need for endodontic treat-
ment) after 7 years. No failures were observed when compos-
ite restorations were performed with cuspal coverage.
Seventy-five percent of teeth were free of any symptoms dur-
ing the observation period [48]. Another study evaluated
cracked teeth restored with indirect composite onlays and
found 93% of teeth free of symptoms after an observation
period of 6 years [69]. Krell and Rivera monitored the out-
come of symptomatic cracked teeth with reversible pulpitis
after treatment with a full coverage crown [33]. All teeth were
retained over a period of 6 years, but 20% needed root canal
treatment. A recent study by Wu et  al. [80] showed that
cracked teeth permanently restored with a crown had a better
pulpal prognosis than cracked teeth that remained cemented
with orthodontic bands. However, clinical trials comparing
different restorative approaches for successful treatment of
cracked teeth are missing so far, so superiority of full crown
coverages against onlay/cusp coverages and/or intracoronal
composite restorations is not proven yet.
18
18.2.7 Prognosis
In vital and asymptomatic or newly symptomatic teeth,
pulpal inflammation is considered reversible, and restorative
treatment of the cracked tooth is in focus. However, late diag-
nosis or crack propagation might lead to irreversible pulpitis
or pulp necrosis making root canal treatment necessary.
Studies by Abbott and Leow [1] and Krell and Rivera [33]
showed that about 20% of cracked teeth with reversible pul-
pitis required root canal treatment within the first 3 to 6
months after diagnosis, while 80% of the cases remained
stable over 5 to 6 years. Similarly, Wu et al. [80] found about
70% of cracked teeth with reversible pulpitis to remain
healthy over 3 years. The prognosis is less favorable in teeth
with deep probing depth, which indicates that the crack pro-
gressed into the root surface [32]. The survival rate of cracked
teeth after root canal treatment amounts to 90% over 2 years
[31] or 92% over 5 years [70]. Teeth with a probing depth of
more than 6 mm again had a worse prognosis compared to
teeth with a probing depth of less than 6 mm [31]. Moreover,
cracks with extension onto the pulpal floor increased the risk
of the tooth being extracted [70].
Conclusion
This chapter covered clinical conditions related to dental sen-
sitivity not associated  to the caries diseases, which are the
dentin hypersensitivity and the cracked tooth syndrome. The
most relevant information about dentin hypersensitivity was
presented, including its etiology, mechanisms, and diagnosis.
The treatment by elimination or reduction of etiological fac-
tors and other options were described. The importance of
performing an early diagnosis and correct treatment plan of
cracked tooth syndrome was described. The specific tools
and methods for diagnosis were explained, as well the treat-
ment options and prognosis. Many clinicians do not have
enough knowledge about this specific problem, and the lack
of a prompt and precise diagnosis can allow the progression
of the crack to a complete fracture that can cause tooth loss.
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 705

Supplementery
Information
Index – 707

© Springer Nature Switzerland AG 2020

C. R. G. Torres (ed.), Modern Operative Dentistry, Textbooks in Contemporary Dentistry,
https://doi.org/10.1007/978-3-030-31772-0
 707 A–C

Index

A
Anesthesia  200, 583, 621 Biological principles  185
Angle Biological sealing  90, 92, 97
–– axiopulpal 208 Biologic width  194, 197, 499, 538, 539, 544, 546
Abfraction  8, 9, 11, 483, 507, 693, 694
–– of beam spread  454, 455 Biomaterial 681
Abnormal formation of the enamel  483
–– cavosurface  172, 204 Biomimetic 581
Abrasion  6, 8–11, 27, 31, 125, 132, 141, 142, 151,
–– external line  170, 208, 350, 360, 363 Biopulpectomy 301
158, 159, 488, 693, 694
–– incisal line  172 Bis-acryl composite  669, 682
Abrasive  125, 131, 132, 139, 141–143, 145, 148,
–– incisal point  172 Bite test  699
157, 158
–– internal line  208 Biting blocks  251, 255
–– discs 402
–– line  170, 172 Biting force  184, 195
–– pastes  402, 405
–– margin 204 Black, G.V.  168, 172, 174, 177, 200
–– rubber  402, 405
–– point 170–172 Blade  125, 127, 128, 130–132, 139–141, 148,
–– rubber point  593, 626
Anionic detergents  306, 313, 317 152, 155
–– strip(s)  405, 627
Antisepsis  492, 497 Blot drying technique  306, 313, 497, 498, 686
Abrasive-impregnated rubber  143
Area of visibility Blue light  442, 443, 446–448, 460, 461
Absorbing pads  253, 256, 257
–– dynamic  672, 675 Bonded amalgam  426
Absorption range  437, 442, 443, 448
–– static 672 Bonding  578, 580, 583, 585, 586, 596, 623,
Accident  52, 59, 63, 64
Arginine  641, 695 626, 628
Acetate band  270
Argon-ion laser  442, 447 Bonding interface rupture  585
Acid etching  303, 307, 309, 312, 320, 578,
Arkansas stone  142, 143 Bone morphogenetic proteins (BMP)  310, 311
605, 628
Arms  45, 46, 50, 56, 65, 67, 70 Boomerang 263
Acidic monomer  578
Aromatic tertiary amine  437 Bow compass  556, 559
Acidogenic  79–81, 87, 119
Articulating paper  200, 336, 339, 492, 569, 583, Broad-spectrum  442, 448
Aciduric  80, 81
592, 626 Brushes  143, 145, 154
Actinic damage  460
–– forceps  336, 583 Brushing technique
Activator 437
Artificial dentin  378 –– Bass 635
Active medium  160, 161, 163, 447
Artificial retention  415, 420, 431 –– Charters 634
Addition-fragmentation monomer  618
Assistant  52–54, 56, 57, 59, 68 –– Fones 634
Addition silicone  682
Astringent solution  255 –– Stillman 634
Adhesive pooling  599, 600
Atomizing 376 Brush, interdental  635, 636
Adhesive restoration  185, 188, 197, 203, 205,
Attenuation of light  457 Bruxism  11, 12, 23, 31, 210, 483, 555, 556,
210, 218
Attrition  6, 8, 9, 11, 31, 693, 694 581, 669
Adhesive system  303–308, 313
Auxiliary  52, 58 Buccal corridor  23, 25, 27
Aesthetics  184, 194, 668, 669, 672, 675, 681,
Bulk-fill  617, 618
686, 689

B
Bulk increment  585
–– smile 668
Bur(s)
Aging physiological process  294, 295
–– cone  143, 146
Air abrasion  685 Bactericidal effect  306
–– cylinder  146, 348
Airborne particle abrasion  158, 583, 584 Band
–– inverted cone  135, 146, 155
Aliphatic amine  437 –– cellulose 268
–– multi-bladed 140
Allergy(ies)  2, 4, 5, 29, 407 –– clear  269, 586
–– neck  127, 138, 139, 147
Alloy –– matrix  378, 379, 384, 391, 392
–– round 146
–– admixed 376 –– Mylar 268
–– spherical 146
–– dispersed phase  376 –– plastic  270, 276, 277
–– straight fissure  146
–– fine cut  376 –– polyester 268
–– taper 146
–– lathe cut  375 –– polyvinyl chloride  268
–– tapered fissure  146
–– regular cut  376 –– pre-contoured polyester  269
Burnisher  152, 155
–– spherical  376, 390 –– straight  263, 264, 278, 285
–– egg  378, 391, 397, 600
Aluminum oxide  131, 143, 158 –– Tofflemire 263
–– round 397
Amalgam  184, 185, 187, 202, 204, 205, 208, 219, Band-pass filter  442–444, 448, 452
Butt joint  672, 673, 676
336, 374–379, 384–386, 388–393, 397, 402, Barton 394
405, 407, 408, 412, 413, 415, 416, 419–422, Base  307–309, 311, 581, 585, 618, 619
424–426, 429, 431
–– well 385
Beer–lambert law  457
Bennett  156, 378, 391, 397
C
Amalgamator  385, 388 Benzoyl peroxide  437 Calcium carbonate  143
Amalgapin  416, 417, 419, 420, 422, 425, 431 Bevel  493–497, 499, 506, 507, 513, 534, 551, Calcium compounds  695
Amelogenesis imperfecta  8, 15, 16 554, 584, 622, 623 Calcium fluoride  82, 695
American Dental Association (ADA)  146 Bioactive  581, 582 Calcium hydroxide  219
American National Standards Institute –– glass 641 –– cement  307, 310
(ANSI) 146 –– molecules 312 –– paste  310, 320
American Society of Anesthesiology (ASA)  29 Biocompatible 581 –– powder  309, 310
Ammonia forming agents  641 Biofilm  78–84, 86, 88, 89, 91, 93, 97, 100, 105, –– solutions  306, 313, 314, 323
Anamnesis  2, 3, 6, 7, 32, 40, 96, 296, 300, 110, 119, 194, 202, 204, 215, 218, 220, 467, –– suspensions 310
315, 320 483, 492, 496, 507, 569 Calcium sodium phosphosilicate  695
Anatomic wedges  276 –– control of  632 Camphorquinone  442, 443, 447, 448, 451
 Index
708

Canines  489, 491, 518 Cervical lesions  496, 497, 508, 511, 513 Condensable 613
Capping  618, 619 Cervicoincisal depth cut  675 –– composites 469
Capsules  499, 506, 513, 519 C-factor  439–441, 584, 586 Condensation  375, 376, 378, 384, 385, 388–391,
–– pre-proportioned  377, 385, 388, 408, 409 Chair  53, 54, 57, 58, 67, 68, 74 406, 409
Carbide  143, 145 Chameleon effect  468 Condensers 154
Carbon steel  139, 143 Chamfer finish line  675 Cones  139, 143
Carborundum 143 Characterization 592 Conical teeth  12
Cardiac disorders  4 Characterization material  559, 678, 679 Connective tissue attachments  194
Caries Cheek retractor  251, 254 Connective tissues  20, 28
–– active lesion  97 Chemically activated  437, 441, 450 Conservative composite restoration  632,
–– activity  632, 640 Chemical stimulus  694 650–652
–– acute lesion  89, 97, 312 Chewing gum  633, 640–642 Conservative preparation  650, 652
–– arrested lesions  93 Chief complaint  32, 33, 40, 296 Contact(s)
–– chronic lesion  87 Chip 628 –– centric 583
–– confounding factors  79, 80 Chipped teeth  692 –– forming instrument  621, 629
–– detector dyes  216 Chisel  125, 128, 129, 131 –– eccentric 583
–– disease  86, 90, 94, 95, 643, 654, 660 Chlorhexidine  219, 306, 492, 497, 640 –– tightness  600, 604, 613, 626
–– ecological plaque hypothesis  81 Chroma  507, 562 –– tooth-to-tooth 583
–– hidden lesion  89, 90 Chromatic alterations  669, 681 Continuous curing cycle  453
–– inactive lesion  88, 97 Chu’s Aesthetic Gauge  490, 556 Contra-angle  127, 134, 137, 139, 142, 149
–– infiltration 653 Circumferential matrix  600, 604 Control phase  29, 30
–– non-specific plaque hypothesis  80 Clamp(s) Convenience form  213, 340, 344, 348, 361, 363,
–– primary determinant factor  79 –– gingival retraction  227, 235 369, 493, 583, 584
–– rampant lesion  81 –– winged  227, 240 Conventional curing protocol  436, 453
–– risk  28, 633, 639, 640, 643, 644, 650, 653, 660 –– wingless  227, 229, 244 Copper  374, 375, 405
–– root  92, 114 Classification Cord
–– secondary determinant factor  79 –– artificial  174, 177 –– dental dam stabilizing  234
–– secondary lesions  110–114 –– Black’s  174, 177 –– retraction 255
–– specific plaque hypothesis  80 –– Class I  338, 359, 361, 363, 370, 580, 585, 604 Corrective phase  30
–– wall lesions  110 –– Class II  350, 361, 362, 582 Corrosion  374–376, 378, 390, 391, 393, 402,
Caries lesion –– Class III  482, 496, 584 405, 408
–– active 184 –– Class IV  496 Cotton roll  224, 247–254, 256–258, 260
–– inactive 184 –– Class V  365, 366, 469, 482, 496, 499, 507, Cotton roll isolation  256, 497, 499, 511, 546,
–– recurrent  578, 584 513, 518 557, 559
Cariogenicity 633 –– Class VI  581 Counter-opalescence  562, 567
Carious lesion  291, 295, 296, 302, 312, 315 –– etiologic 174 Coupling agent  436
Carious tissue, removal of  200, 209 –– Mount and Hume’s  177, 179 Coves  211, 214, 343, 363
Carpule syringe  157 Cleaning  219, 220 Crack(s)  421, 424, 698, 699, 702
Carriers  155, 156 Cleaning agents  305, 306 Cracked teeth  697–699, 702
Carver Cleaning of the preparation  344, 362, 364, 370 Cracked tooth syndrome  12, 696, 697
–– cleoid  155, 379, 392 Clenching 581 Cracking  12, 23
–– contour carbide  626 Clinical assessment  17 Craze lines  697
–– discoid  155, 379, 392 Clinical chart  23, 32, 33 Creep  375, 386, 391
–– Frahm  155, 378, 379, 391 Clinical examination  23, 33, 40, 296, 323 Crevice  483, 499
–– Hollenback  155, 378, 391–393, 400, 431 Coefficient of linear thermal expansion Crevicular fluid  499
Casein phosphopeptide-amorphous calcium (CLTE)  466, 580, 612 Cri dentinaire  216
phosphate (CPP-ACP)  641 Coherent 447 Critical pH  82
Cataract 460 Cold pulp testing  296 Cross-link  438, 439
Cavitation 185 Collagen fiber  188, 578 Crowding 12
Cavity(ies) Collimated  447, 448 Crown form  270, 682
–– complex 173 Color changes  14, 15, 21 Crystalline phase  681
–– compound 173 Color-masking 658 Crystallization  374, 376, 390, 393
–– configuration factor  439, 453 Color modifier(s)  472, 473, 559, 679 Cup(s)  143, 145, 405
–– floor 172 Color perception  470, 471 Curing lamp  442
–– preparation testing  301 Commissural line  23 Curing mode  457
–– simple 173 Composite  220, 466, 506, 550, 578–629, 668, Curing protocol  436, 453, 457, 585
–– varnish 308 669, 679, 687 Cusp
–– wall  187, 204 Compound Class I  394, 397 –– angle  187, 206, 207, 583
Cavosurface angle  494–497, 500, 506, 507, 520, Compound preparation  338, 344 –– elongation phenomenon  197
523, 534, 569, 573 Compression load  198 –– incline  187, 192
Cement  185, 209, 668, 678, 682–684, 686 Compressive strength  204, 412 –– lost  413, 426
Cementoenamel junction (CEJ)  192, 488 Compressive stress  198 –– restoration of  412, 415, 429, 431
Centric contact  583, 626 Compules 506 –– weakened 580
Centric occlusion (CO)  23, 200, 492, 559, 583, 626 Compulsory notification of infectious Cuspal-capping 413
Centric relation  23 diseases 4 Cuspal coverage  413, 702
Ceramic  668, 669, 681–685, 689 Computer-aided design/computer-assisted Cuspal deflection  12, 197, 438, 439, 585, 592, 604
–– ingot 683 machining (CAD/CAM)  185, 681–683 Cuspal fracture  578
–– laminate 683 Concentricity 147 Custom-made matrix  681
Index
709 C–F

D Dentin-pulp complex  291, 292, 294, 295, 301,

304, 305, 307, 308, 310, 312, 315, 319
Ectopic eruption  12
Edema  295, 296
Dappen dishes  157 Dentists  44–50, 52–58 Edge-to-edge occlusion  669
Dark-curing  568, 585, 592, 628 Depth cut  414, 673, 675 Education 67
Darkened groove  90, 97 Depth-limiting diamond point  675 Elastic deformation  198
Dead tracts  295 Depth-limiting drill  422 Elastic modulus  438, 439, 441, 507, 585, 613
Decay 32 Depth of cure  613, 618 Elastomeric impression material  682
Decision-making process  33 Depth of the preparation  304, 313 Elbows  46, 52, 53, 58, 67
Defense mechanisms of pulp tissue  295, 311, 313 Desensitizing agent  308 Elderly patient  2
Definitive phase  29, 30, 32 Detergents 219 Electrical conductance measurements  103
Deflection, cuspal  466, 578, 585 Developmental lobes  192 Electric pulp test  299, 300
Deformation  198, 199 Diabetes mellitus  81 Electromagnetic spectrum  436
Degradation  376, 390, 407 Diagnosis  17, 20, 30, 40, 694, 696, 699, 702 Embrasure(s)  384, 391, 402, 405, 531, 559, 570, 572
Degree of conversion  438, 441–442, 456, 458, Diagnosis of the pulp condition  295, 296, 301, Emergence profile  559
459, 461 302, 323 Emittance  442, 447–450, 452, 453, 456, 457,
Delayed expansion  376 Diagnostic 585, 618
Delivery unit  50–53, 56, 58, 64, 68 –– false-negative decisions  96 Enamel
Demineralization  78, 79, 81, 82, 84–86, 88, 89, 93, –– false-positive decisions  96 –– caries
95, 97, 99, 102, 104, 108, 119 –– true negative decisions  96 –– dark zone  82
Dens in dente  12, 13, 556 –– true positive decisions  96 –– lesion body  82
Dental arch  484, 534 –– wax-up 682 –– subsurface lesion  83
Dental bleaching  681, 684 Diamond  125, 131, 136, 141–143, 146, 147, 149–151 –– surface zone  82, 84
Dental dimensions  488 Diamond dresser  143, 144 –– translucent zone  82
Dental explorer  153 Diamond point  125, 141, 146, 149, 151, 494, 496, –– hatchet 362
Dental floss  635, 655 500, 506, 511, 524, 551, 562, 570, 571, 573, 583, –– prisms  203, 204, 208, 218
Dental floss ligatures  518 584, 588, 621, 623, 626, 628 –– undermined  187, 201, 207, 209
Dental history  2, 6, 7, 33 –– agglutinated diamonds  149 Enameloplasty  203, 650
Dental office  50, 52, 56, 57, 65, 67, 74 –– chemical vapor deposition (CVD)  149 Endodontic posts  412, 420, 425
Dental proportion  556 Diastema(s)  12, 13, 32, 483, 492, 499, 556, 559, Energy density  452, 453, 456
Dental separation  492, 493, 520, 583, 586, 604 669, 672 Energy dose  452, 453
Dental stone  682 Dichroic reflector  443 Entry direction  492, 494, 495
Dental team  52, 53, 74 Diet  78–82, 86, 90, 94, 97 Er,Cr:YSGG 161
Dental whitening  14–16 Dietary advices  632 Ergonomic(s)  44–46, 67–69, 74
Dentin Dietary protocol  28 Erosion  6, 8–11
–– affected 313 Digital imaging fiber-optic transillumination Erosive tooth wear (ETW)  8, 693–695
–– bridge  310, 320 (DIFOTI) 103 Er:YAG  125, 161
–– color 216 Digital smile design  669 Esthetic  15–17, 20, 21, 23–27, 30–32, 40, 184
–– dark color  295 Direct casting  682 –– analysis  484, 488, 492, 573
–– desensitizer 307 Direct pulp capping  301, 308, 310–312, 314, 319 –– assessment 20
–– firm  216, 217 Direct pulp protection  310–312 –– transformation 669
–– glistening aspect  497, 498 Direct technique  668 Etch-and-rinse adhesives  219
–– hard  209, 216 Discomfort  57, 63, 68 Etching 219
–– hypersensitivity  692–695, 702 Discs  132, 141, 143, 144, 146 Etiology  692, 699
–– intertubular 188 –– abrasive 572 EVA system  147, 149
–– leathery 216 Disease Evidence-based clinical practice  3
–– matrix metalloproteinase  219, 497, 580 –– multifactorial 78 Excavator(s)  125, 128, 600, 604
–– peritubular 188–190 –– occupational 67 Excursive movements  569
–– permeability  308, 313 Disocclusion guide(s)  23, 31, 32, 393, 492, 553, Exploratory probe  153, 343–344, 360, 361, 369
–– pink discoloration  304, 499, 538 559, 569 Extended fissure sealant  650
–– primary 188 –– anterior 668 Extension for prevention  201, 336, 339, 340, 360
–– reactionary  85, 86, 188, 312 –– canine 686 Extensive amalgam restoration  412, 415
–– reparative  86, 188, 293, 295, 306, 307 Displacement Extracellular polysaccharide  81
–– replacement  187, 207, 208 –– dental 185 Extraoral exam  2, 7, 296
–– sclerosis  295, 312, 318 –– of the restoration  360, 363, 569 Extrinsic acids  693
–– sclerotic  85, 86, 88, 188, 189, 191, 304, 305, 314 Disposable applicator  592, 599 Extrinsic stain  14, 15, 20, 467, 492
–– scream of  312 Ditch  17, 204, 206, 340, 359, 360, 628 Extrusion  200, 580, 583
–– secondary  188, 194, 292 Documentation  32, 33, 40 Eye protection  58
–– shade  586–588, 592, 604, 622 Dovetail lock  213, 361
–– soft  209, 216, 217
–– spoon  128, 129, 132, 359, 363
Dresser 405
Durability  405, 409 F
–– tertiary  85, 86, 188, 293, 295, 310, 315 –– restoration 359 Facet 668
Dentinal fluid  191 Dystrophic calcification  16 Fatigue  46, 49, 52, 56, 63–65, 68, 69, 199
Dentin caries Feathered-edge  672, 673
–– affected dentin  85
–– infected dentin  85
E Feldspar  681, 683
Felt  143, 627
–– necrotic dentin  85 Early childhood caries  633, 639 Fermentable carbohydrates  82
Dentinoenamel junction (DEJ)  191, 206, 207, 340 Eccentricity 147 Fiber optic transillumination (FOTI)  103
Dentinogenesis imperfecta  16 Eccentric load  360 Fiber post  458
 Index
710

Filler
–– content  439, 468, 469, 507 G Hearing damage  138
Heating 189
–– inorganic  466, 560 Galvanic 307 Heat test  299, 300
–– particle 456 Gap(s)  406, 466, 483, 550, 569, 578, 581, 582, 628 Height of curvature  17
–– ratio 439 Gear reduction contra-angle handpiece  423 Hidden caries  8, 201
Filling instrument  506, 524, 559 Gel High-copper  375, 376
Fingers  44, 46, 58, 70, 72 –– glycerin-based 592 High-speed handpieces  189
Finishing  392, 393, 402, 403, 407, 409, 488, 494, –– oxygen blocking  592 Hips  46, 47, 49, 70
496, 506, 507, 511, 518, 520, 524, 534, 559, –– point  438, 441 History of the present illness  3, 33
568–570, 592, 608, 612, 626, 628, 629 General principles  336 Hoe  128, 130, 131
Finishing of the enamel walls  218 Gingiva-colored composite  511 Holes 211
Fissure  80, 82, 88, 89, 192, 201, 338, 340, 359 Gingival barrier  248–250, 255, 499, 546 Hollenback  360, 384, 391–393, 397, 400
Fistulas 296 Gingival contour  24 Hooke’s law  439
Fitting  683, 686 Gingival displacement  682 Horizontal percussion  296, 298
Flame shaped  393, 402 Gingival line  23–25 Horizontal slot  363, 397
Flash  402, 497, 511 Gingival margin  194, 580, 599, 621 Hot-pressing  682, 683
Flat area  686, 687 Gingival margin trimmer  130, 131 Hue  471, 472, 477
Flat brush  507 Gingival protection instrument  683 Humidity  63, 64
Flexural strength  204, 681, 683 Gingival retraction  675, 678 Hutchinson’s incisors  12, 556, 669
Flowable composites  469, 507, 511, 550, 559, Gingival smile  24 Hybrid composite  559
648, 651 Gingival sulcus  483, 497, 499, 511, 522, 531, 532, 570 Hybrid dental ceramic  683
Fluorapatite  582, 637 Gingival zenith  489, 511 Hybridization  303, 304
Fluorescence  216, 473, 475, 476 Glass(es)  54, 58 Hybrid layer  219, 578
Fluoridated apatite  637 –– ceramic  681, 683 Hydrodynamic theory  11, 12, 294, 699
Fluoridation –– fiber post  538 Hydrofluoric acid gel  623
–– local 636 –– fillers  466, 468 Hydrophilic monomer  578
–– preeruptive  636, 639 Glass ionomer cement (GIC)  307, 309, 582, 585, Hydroxyapatite  78, 81, 82, 119, 637, 641
–– systemic  636, 639 586, 619, 645, 646 Hydroxyapatite crystals  185
Fluoride  79, 82, 86, 88, 89, 94, 119, 632, 634, Glassy phase  681, 684 Hydroxyethyl methacrylate (HEMA)  308
636–644, 646–648, 654, 655 Glazing 683 Hyperesthetics 23
–– acute lethal dose  639 Glutaraldehyde  308, 695 Hyperkyphosis 46
–– amine  637, 639 Gnarled enamel  186 Hyperlordosis 46
–– gel 639 Gradual curing protocol  456, 461 Hypersensitivity 185
–– inorganic 636 Grasp of hand instruments  59, 62 Hypomineralization 15–16
–– organic 636 Grinding  131, 132, 141, 142, 145–152, 158 Hypoplasia 16
–– probably toxic dose  639 Groove(s)  486, 487, 562, 563, 571, 643, 646, Hyposalivation  5, 28
–– silver diamine  639 650, 651
–– sodium 637
–– solutions 307
–– developmental  366, 370, 392, 402
Gummy smile  23–25
I
–– stannous 636 Gun design syringe  513 Iatrogenic  192, 359
–– toxicology 639 Illumination  57, 62–65
Fluorosis  15, 16, 640 Incandescent  442, 445
Food impaction  17–19
Forceps
H Incident beam angle  455, 456
Incident irradiance  451–456
–– clamp  156, 157 Habits 67–69 Incisal edge  468, 470, 472, 473, 476, 484, 488,
–– clamp holding  232 Half-moon margins  524 492, 499, 524, 531, 534, 538, 556, 562
–– Halstead hemostatic mosquito  153 Hand instrument Incisal embrasures  488, 489
–– Miller articulating paper  153 –– active  125, 126 Incisal line  24, 25
–– punch  225, 227 –– blade  125, 127, 128, 130 Incisal reduction  688
–– rubber dam punch  156 –– calcium hydroxide liner placement  154 Incisor  488, 491, 497, 553, 554, 556, 559
Forces  185, 191, 196, 198, 210 –– complementary  125, 152 Inclines, cusp  339, 342
Fork-shaped bending tool  424 –– formulas 130 Increment(s)  469, 497, 506, 507, 511, 524, 534, 539,
Four-handed dentistry  45 –– handle 128 559, 573, 585–587, 592, 596, 604, 613, 617, 619
Fracture(s) 296 –– plastic filling  154 Incremental technique  601
–– resistance  185, 187, 201, 426 –– retraction cord packing  154 Indirect ceramic veneers  669
–– toughness 681 –– shank  134, 139 Indirect curing technique  457
–– longitudinal  697, 699 –– sharpening 131 Indirect laminates  681
–– vertical root  697 Handpiece Indirect pulp capping  312
Fractured cusps  697 –– high-speed  134, 137–139, 150, 151, 158 Indirect pulp protection  312
Fractured restorations  692 –– low-speed  132, 134, 137, 139 Indirect restoration  581
Free radical  441, 458, 461 –– oscilatory 148 Indirect veneer  668, 676, 681, 682
Free smooth surface  365 –– straight  133–136, 138 Infected dentin  312, 313
Frictional retention  210, 213 Hardness  215, 216 Infiltration technique  653–655, 658
Friction grip (FG)  139 Harmful 407 Informed consent  33
Frosty appearance  686 Hatchet 128–131 Infrared  436, 442–444, 447, 448, 452, 460
Full crown  173 Head  46, 47, 49, 52–58, 67, 68, 70 Infrared band-pass filter  444
Full-power curing cycle  453 Headrest  54, 56, 58 Ingot 376
Furniture  45, 52, 53, 64 Healthy  56, 58, 68, 69, 74 Initiator 437
Index
711 F–M
Injuries  45, 65, 67 Laminate 689 Margin
Inlay 173 Laser  125, 159–161, 163, 447, 695 –– cavosurface 172
Inorganic matrix  436 Lateral excursive movement  583 –– preparation 168
Insert  612, 613 Law of the face  687 Marginal degradation  187, 204
Instrument(s)  50, 52, 53, 56, 57, 61, 66–69, 74, Layering technique  441, 461, 499, 524, 585, 586, Marginal ridge(s)  187, 203, 208, 494, 572, 584,
467, 468, 490, 491, 493, 499, 507, 513, 518, 592, 604, 612, 617, 621, 629 585, 600, 604, 605, 612, 626
524, 534, 568–570, 573 LED  448, 449, 451, 452, 454, 455 Marginal staining  20, 21
Interdental papilla  359 Left-handed  56, 70, 72 Marginal trimming  187, 218
Interdisciplinary 32 Leg  46–49, 54, 56, 57, 65 Masking agent  669, 679
Interface Lesion activity status  216 Masticatory stress  336
–– adhesive 203 Leucite  681, 683 Matrix  578, 580, 584, 586, 600, 601, 604, 612, 613,
–– tooth-restoration  185, 194, 200 Ligature 619, 626, 629, 669, 681, 682, 685
Interfacial defect  580 –– dental floss  233, 237, 239 –– band  336, 362, 363, 493, 500
Interferences  583, 626 –– elastic  234, 238, 246 –– Barton 285
Interim restoration  682 –– o-ring 234 –– boomerang-shape 263
Internal line angle(s)  347, 360, 363 Light  442, 444, 449, 468–470, 472, 473, 475, 476, –– cervical  269, 271, 281
–– first set  170 479, 481, 482, 487, 488, 498, 570 –– circumferential  264, 288
–– second set  170 –– conducting tip  612 –– custom made  264, 266, 283, 384, 392
Internal walls  203 –– overhead 57 –– metallic  263, 264, 268
International Organization for Standardization –– pipe  443, 444 –– retainer  156, 336, 359, 604
(ISO)  45–47, 146 –– reflection measurement  108 –– retainerless  265, 269, 285
Interprismatic enamel  185, 186 –– tip  445, 450, 451, 454 –– riveted  262, 285
Interproximal carver (IPC)  393, 400 Light-activated  436–438, 440, 441, 448, 450 –– sectional  264, 265
Interproximal contact(s)  17, 19, 262, 264, 270, Light-curing  436, 437, 442–445, 448–456, 458, –– shell 270
277, 600 460, 461, 585, 588, 592, 593, 596, 597, 604, 612, –– spot-welded  284–285, 394
Interproximal guard(s)  192, 193, 359 613, 618, 626, 628 –– S-shaped  285, 397
Interproximal space  262, 276, 277, 279, 280, 282, –– protocol 453 –– T 378
359, 360, 379, 384, 393, 397, 400 –– unit  436, 443, 444, 455, 460 –– universal  270, 284, 285, 378, 394, 397
Interpupillary line  23, 25 Light-emitting diode  442, 448, 449 –– welded 378
Interrod 185 Light guide  442, 444–447, 452, 453, –– window  285, 397, 398
Intervertebral discs  46, 47, 52, 69 455–457, 461 Maximum intercuspation (MIC)  200, 393,
Intoxication  407, 408 Light guide free curing unit  455 580, 583
Intradentinal pins  212 Line angle Mechanical principles  220
–– cemented 421 –– external 170 Medical history  2, 4, 5, 7
–– friction-locked  420, 421 –– internal 170 Medical interview  3, 4, 40
–– self-threading 421 –– round 208 Medication  2, 4–6, 9, 28
Intra-oral camera  108, 110 –– sharp 198 Megafiller 612
Intraoral clinical  7 Liner  307–311, 314 Mercury  340, 402, 407–409
–– exam 296 –– low elastic modulus  585 Mesenchymal cells  191, 294, 312
Intraoral scanner  682 Lip line  24, 671, 672 Metalloproteinases (MMP)  219, 307, 313
Intraradicular post  214 Lithium disilicate  683 Metamerism 479
Intrinsic acid  693 Load Microbiota  78–81, 89, 93, 94
Intrinsic staining  14 –– compression 198 Microcrack  438, 578, 626, 628, 699
Inverted cone instrument  361, 369 –– shear 198 Microdontia  12, 556, 669
Irradiance 585 –– tensile 198 Microesthetics  23, 488
Ischium  48, 49 Lobes Microfilled composite  467–469, 585
Isolation  375, 378, 393, 397, 408 –– dentin  473, 563 Microhardness 187
Isolation of the operating field  483, 493, 531 –– developmental  473, 484, 487, 571 Microhybrid composite  468, 585
Isthmus region  208, 209 Local anesthetic test  300 Microleakage  20, 308, 309, 312, 325, 483, 520,
Locks  210, 215 569, 578, 585, 592

J Long-inverted cone  338, 340, 347

Lost wax technique  683
Micromechanical interlocking  497
Micromechanical retention  499, 683, 685
Junctional l epithelium  194 Loupe  157, 158 Micromotor  133, 134, 138
Low fusing compound  264, 431, 432, 499, Microorganisms  305–307, 310, 325
546, 548 Microscope, dental operating  158
K Lubricating gel, glycerin based  405
Lucirin TPO  438
Microtexture 486
Migration, tooth  199
Kinetics  438, 453 Lumbar region  47, 52, 65 Miller forceps  626
Knees  46–48, 53, 69, 70 Mineral trioxide aggregate (MTA)  310
Knot Miniesthetics 23
–– double 233
–– running 233–235 M Minimally invasive dentistry  632, 653
Minimally invasive preparation  632, 650
Macroesthetics 23 Mirror  47, 56, 58, 62, 68, 69

L Macrofilled composite  467

Macrotextures  486, 487
–– first-surface 152
–– second-surface 152
Labial embrasure  686 Magnifier 157 Mobility test  297
Laboratory 74 Maintenance phase  29, 30, 40 Mock-up  556, 669, 678
Lactobacillus  80, 81, 94 Mamelons of dentin  473, 535 Molar incisor hypomineralization (MIH)  658
 Index
712

Monochromatic 683 Office  50, 65, 69 Periodont  6–8, 32

Monolithic 683 Older patients  5, 6 Periodontal examination  7, 8
Monomers  436–438, 441, 456, 458 Onlay 173 Periodontal health  194, 200
Mortar  385, 386 Opacity  469, 470 Periodontal probing  297
Mosquito forceps  384 Opalescence 472–476 Peripheral depth cut  673, 675
Mottled teeth  636 Opalescent halo  473 Pestle 385
Mounted stone(s)  142, 143, 569, 570 Opaque  469, 470, 472, 484, 506, 507, 511, 535, 562 Phenyl-propanedione  437, 443
Mouth  46, 52–57, 62 Opaque halo  484, 535, 538, 563 Phosphoric acid  219, 305, 306, 313
Mouthrinse 639 Opening of the cavity  201, 207 –– gel  497–499, 506
Movement(s) Operating field  224, 234, 244, 246–248, 250, 252, 260 Photochemical damage  460
–– excursive  583, 626 Optical density  461 Photodynamic therapy  642
–– lateral 583 Optical illusion  686 Photomechanic ablation  161
–– protrusive 583 Oral cavity  53, 54, 57, 58, 69 Piezoelectric 148
Mulberry molar  12 Oral environment stabilization  112 Piggyback wedging technique  282
Multi-bladed bur(s)  402, 569, 570 Oral health  200 Pink discoloration  585
Muscles  44–46, 49, 59, 64, 68, 72 –– impact profile  694 –– of dentin  304
Mutans  80, 81, 92, 94 –– records  32, 33 Pins 210
Oral hygiene  632–635, 639–644, 646, 652, 655 –– wrench 422

N
–– habits 632 Pioneer bacteria  81
Organically modified ceramic  618 Pit  89, 90, 98, 106, 115
Organic matrix  436, 439, 466–468, 483 Pit and fissures  174
Nanofilled composite  585
Ormocer 618 –– sealant  336, 642
Nanohybrid composite  468, 469, 619
Orthodontic extrusion  539, 551 Plane
Nano-hydroxyapatite 695
Orthostatic  45, 46 –– buccolingual  168, 169
Narrow-spectrum 448
Outline –– delimitation  168, 169
Natural retention  210–212, 214, 425
–– form  200, 204, 207, 209, 344, 359, 366, 671 –– dental 168
Nd:YAG  125, 161, 163
–– of the preparation  493 –– frontal 168
Near-infrared light transillumination (NILT)  103
Overbite  553, 554 –– horizontal  168, 172
Necrosis 85
Overcontour  8, 17, 397 –– mesiodistal 168
Needle shaped diamond point  686
Over finish  402 –– occlusal 169
Nerve desensitization  695
Overhang(s)  262, 263, 280, 282, 378, 379, 384, –– sagittal 168
Nibs  152, 154, 155
393, 559, 568–570, 573, 599, 626 –– section  168, 169
Noise  45, 63, 158
Overlapped incisal edge preparation  673, 676 Plaque
Nomenclature  168, 172
Overlay 173 –– chemical control of  632, 633
Non-adhesive restorations  185, 187, 203
Overtrituration 386 –– index 28
Non-carious lesion(s)  2, 8, 9, 483, 499, 573
Oxalate 695 –– mechanical control of  632, 634
Non-demineralizing cleaning agents  306
Oygen blocking gel  511 Plasma arch curing units (PAC)  445
Non-invasive measures  185
Oxygen inhibition layer  441, 592 Plastic deformation  198
Non-selective removal  216
Ozone 642 Plier  152, 157
Nonstick composite filling instrument  587, 621
–– riveting 157
Non-supporting cusp  413
Nutrition  632, 633
Nutrition habits  632
P Pluggers 154
Plunging ball technique  612
Packable 613 Point(s)  125, 141, 143, 146, 149–151, 388–390,
Packing instrument, retraction cord  499 397, 402, 405
O Pain
–– diffuse 308
–– angle 412
Polishing  374, 376, 393, 398, 402, 405, 407, 468,
Objective exam  7 –– odontogenic 301 469, 483, 488, 507, 511, 528, 559, 567, 568, 570,
Oblique crack  196 –– rebound  697, 699, 701 571, 573, 613, 626–628
Oblique increment  604, 612, 617 –– referred 300 Polish retention  469
Oblique ridge  197, 343, 344 –– reflex 301 Polyacrylic acid  306, 309, 313, 586
Occlusal adjustment  626 –– spontaneous  301, 302, 314 Polychromatic restoration  534
Occlusal frontal line  23, 24 –– throbbing  301, 303 Polychromatism 471
Occlusal frontal plane  23 Palatal chamfer  673, 676, 684 Polyether 682
Occlusal interrelationship  413 Palpation  296, 297 Polymer 436–438
Occlusal load(s)  347, 360, 375, 393, 412, 415, 580, Parafunctional activities  483 Polymeric chain  437, 439
581, 584, 585 Parafunctional habits  11, 23 Polymerization  437–442, 444, 447, 453, 455–459,
Occlusal plane  27, 342, 344, 347, 360, 363 Parafunctional oral habit  669 461, 586, 587, 592, 604, 612, 613, 618, 628
Occlusal splint(s)  23, 554–556 Parallel-walled light guide  455 –– shrinkage  438, 439
Occlusal stamp  593, 596, 597 Partly sintered blocs  683 –– supplemental 626
Occlusion  556, 568 Patient  44, 46, 47, 52–54, 56, 57 Polypharmacy  5, 6
–– centric  583, 626 Peg-shaped teeth  499, 669 Polywave 449
–– of dentinal tubules  695 Perforation  417, 421, 422, 425, 428 Porcelain 683
–– dynamic 583 Performance  49, 56, 57, 63 Position  44–47, 49, 50, 52–54, 56–58, 61, 65–68,
–– static 583 Periapical abscess  296 70, 72, 74
Ocular hazards  460 Periapical alterations  296 Positioning jig  546
Odontoblast  291, 293–295 Periapical infection  298 Post-bonding 628
Odontoblastic layer  191 Periapical inflammation  301, 303 Post-eruptive enamel maturation  79, 88, 637, 644
Odontoblast-like cells  293, 294 Perikymata  487, 571 Post-gel phase  438
Index
713 M–R
Post(s) 210 –– protection  309, 312 Resin infiltration technique  497
–– intraradicular 553 –– repair  310, 311 Resin modified GIC (RMGIC)  309, 586
Postoperative sensitivity  302, 303, 466, 573, 628, –– sensitivity testing  319, 320, 322 Resinous monomers  466
692, 694, 699 –– vitality  294, 295, 298, 307, 312, 319, 320, 325 Resistance  412, 415, 419, 425, 431
Post-polymerization 438 Pulpal alterations, origins of  291, 302, 328 Resistance form  203, 342, 360, 363
Posture  44–49, 52, 54–59, 65, 67–69, 74 Pulpal chamber  200 Rest  48, 52, 61, 62, 64, 65, 67, 74
Potassium salts  695 Pulpal condition  200 Restoration technique  5–12, 16–21, 23, 28–32,
Practice  44, 45, 65, 67, 74 Pulpal diseases  12 283–285
Precapsulated 385 Pulpal exposure(s)  174, 304, 307, 310, 312, 317 –– direct 185
Preclinical  45, 62, 68, 74 Pulpal inflammation  295, 301, 302 –– extraoral 185
Pre-contoured matrix  580 Pulpal pressure  295 –– indirect 184
Precrystallized state  683 Pulpal wall  172 –– intraoral 185
Predentin  291, 292 Pulpectomy 327 –– semi-direct  185, 211
Predisposing factors  699 Pulpitis Retainer
Pre-gel  438, 441, 448, 456 –– acute irreversible  301, 302 –– disposable 264
–– phase 585 –– acute reversible  301 –– integrated 264
Pre-odontoblasts 294 –– hyperplastic chronicle  301, 302 –– Ivory 270
Preparation  585–587, 599, 600, 604, 613, 618, –– ulcerative chronic  301 –– matrix  270, 272–274, 280, 284, 286
619, 621, 622, 629, 683, 686, 689 Pulpless  420, 425 –– Siqveland  157, 270, 273, 274
–– cavity  168, 172 Pulpotomy  301, 310, 319, 320, 323, 325 –– Tofflemire  157, 263, 270–273, 336, 377, 378, 604
–– components  168, 170 Pulse-delay protocol  456 –– universal  270, 284, 285, 317, 378, 394, 397,
–– deep 174 Pumice 143 398, 426, 427, 429
–– guide  670, 671 Punch  225, 228, 240, 242 Retention 412
–– horizontal slot  584 Pupal provocation tests  12 –– additional  343, 344
–– large size  350 –– artificial 210

Q
–– medium 174 –– axial offset  415
–– medium-size 350 –– cove  414, 415
–– prosthetic 173 –– form  210, 412, 426
Quality of life  692, 694
–– shallow 174 –– locks  348, 361, 415
Quantitative light-induced fluorescence
–– small size  344 –– micromechanical 219
(QLF)  105, 106
–– therapeutic 173 –– slot  416, 417
Quartz-tungsten-halogen (QTH)  442
–– tooth  174–176, 178, 182, 467, 482, 492, 493 –– undercuts 415
–– very deep  174 Retraction clamp  499, 508
Prepolymerized ball technique  612
Pre-procedural mouth rinsing  499
R Retraction cord  397, 499, 513, 557, 679, 681, 682
–– packing instrument  397
Pre-reacted glass-ionomer filler  582 Radiant emittance  442, 446–448, 450–452, 454 Reverse curve  360
Prevention Radiant exitance  450 –– Hollenback’s 208
–– primary  632, 633, 642 Radiant power incident  451 Right-handed  52, 53, 56
–– secondary 632 Radiographic analysis  200 Risk assessment  7, 28
–– tertiary 632 Radiographic examination  98, 100, 101, 296, 300, Risk communication  33
Preventive measure  632, 642–644 301, 304 Riveted matrix  427
Preventive procedures  336 Radiometer 452 Riveting plier  428
Preventive resin restorations  650 Ramp 585 Rods  185, 187
Primary dentin  295 Ramp cycle  457 Room  50, 52, 57, 63, 68
Primary prevention  81 Reattachment of fractured tooth  546 Root canal treatment  699, 702
Principle of gradation  27 Rebonding  573, 628 Root furcation  417, 422
Prismless enamel  185, 186, 495, 646, 648 Reciprocating movement device  148 Rotary instrument
Prisms  185–187, 189, 218 Recurrent carious lesion  578 –– abrasive  125, 131, 140
Probiotics 640 Re-dentistry 16 –– cutting  125, 126
Procedure  45–47, 52–54, 56, 57, 59, 61, 67, 68 Reduction guide  670 –– head  133, 135, 141, 149
Prophy-jet device  492 Reflective wedge  440, 441 –– neck 139
Prophylactic antibiotics  5 Refractory cast  682 –– shank  127, 130, 135, 139, 147
Prophylaxis  499, 546, 583, 621 Refrigeration  134, 135, 140–142, 147, 163 Rotation speed
Proportion gauge  490 Reinforce  578, 580, 581, 584 –– axial 146
Protective materials  307, 312, 319 Reinforcement 187 –– cutting  139, 146, 147
Protrusive movement  626 Reinforcing structures  197 –– peripheral 146
Provisional restoration  682, 683, 689 Relative air humidity  64 Roughness  140, 143
Proximal box preparation  350 Remaining tooth structure  199, 203, 208, 220, Round angles  342
Pulp  294, 295 412, 415, 417, 421, 422, 425, 426, 466, 477, 492, Round bur  584, 614
–– accidental exposure of  200 496, 523, 531, 546, 551, 555–556, 578, 580, Round diamond point  344, 359, 368
–– aging process  295 584, 604, 613, 621, 626 Round internal line angles  342, 344
–– capping 295 Remineralization  78, 79, 81, 82 Rubber dam  224–227, 233–242, 244–250, 252,
–– condition assessment  291, 296 Removal of the remaining carious tissue  361, 255, 260
–– curettage  319, 320 363, 370 –– frame 225
–– exposure  301, 302, 310, 312, 320 Repetitive restorative cycle  29, 30, 184 –– isolation  479, 482, 493, 497, 499, 500, 518,
–– horn 585 Repetitive strain  45, 65 546, 562
–– inflammation  295, 319 Resin-based sealant  645, 646, 648 Rubber sheet  225–227, 234, 237–242, 244, 246,
–– microexposures 585 Resin cement  539, 546, 548, 550 248, 493, 518
 Index
714

S –– site 1  338, 339

–– site 2  350
–– tensile 198
Stress-absorbing layer  585, 612
Safety –– site 3  363, 365 Strip, abrasive  511, 524, 570
–– glasses  147, 163, 165 Size 177–179 Strontium 695
–– procedures 147 –– size 1  340, 344, 350 Strontiumapatite 582
Saliva –– size 2  340 Students  46, 67, 68, 74
–– absorbers 224 –– size 3  344, 350 Subjective exam  3, 7
–– acquired pellicle  81 Sjögren’s syndrome  81 Sucrose  78, 80, 81
–– buffering capacity  81, 94 Sleeve technique  246, 248 Suction  52, 58, 63, 224, 247–253, 257, 260
–– clearance 81 Slots 211 Sugar alcohol  633, 640
–– ejectors  224, 250, 251, 256 Small preparations  370 Sugars 632–634
–– hygoformic 250–252 Smear layer  218, 219, 303, 305, 306, 313 Supine  53, 54, 58
–– flux 80–82 Smear plugs  218 Supporting cusps  209, 413, 425
Salivary glands’ ducts  250 Smile esthetics  484 Surface conditioning  683
Sandblasting  626, 628, 685 Smile line  24 Surface pre-reacted glass-ionomer (S-PRG)  582
Saphenous vein  49 Smoking habit  483 Surface pretreatment  689
Saw 626 Smooth surfaces  172–174, 177 Surface roughness  467, 468, 482
Scaffold 312 Smooth walls  203 Surfaces (tooth)  46, 47, 56
Scalpel blade  511, 534, 569 Sodium fluoride  219 Surface sealing  573, 588, 628
Schultz 397 Sodium lauryl sulfate (SLS)  219, 306 Surface texture  486
Scissor 156 Sodium monofluorophosphate  637 Surgical crown lengthening  12, 20, 25
Sclerotic dentin  312, 314, 496, 562, 694 Soft start  585 Symptoms  696, 697, 699, 702
Scoliosis  46, 52, 65 –– protocol 457 Syringes  493, 506, 513
Screwdriver-shaped incisors  12 Sonic 148–150 Systemic diseases  2, 4, 28, 30
Sculpture 391–393 Sound 63 Systemic phase  29, 30
Sealers 307 Spanish white  143
Secondary caries  185, 219, 303, 307, 466, 573,
582, 599, 600
Spatula  125, 152, 153
Spectral absorption  438, 451 T
–– lesions 20 Spectral output  442 Tactile feedback  216
Sectional matrix  600, 619, 629 Spectral power  442 Tattoo 409
Selective bonding  585, 586 Spherical particles  375, 376, 385 T-band  262, 285, 426, 427
Selective removal  216, 217 Spiral wheels  143, 144, 627 Technique
Self-cure 437 Split teeth  697 –– stratified layering  586
Self-etching adhesive  219, 303, 313, 498 Spoon excavator  128, 584, 600 –– wedge alternation  586, 612
Self-retentive preparation  359 Spot-welding device  428 Teeth clenching  210
Self-sealing 374 Spray of air-water  189 Temperature  44, 45, 63, 64
Sensitivity  694, 699 S-shaped curve  360 Templates  238, 239
–– scale 694 Staining 683 Temporomandibular joint (TMJ)  7, 23
–– thermal testing  492 Stainless steel  126, 141, 145 Tensile strength  412
Separation Stamp  238, 239, 241 Terminology  168, 182
–– ring  583, 600, 601, 604, 621 Standard light guide  455 Tertiary amine  437
–– technique 492 Stannous fluoride  695 Test cavity preparation  492
–– tooth  78–80, 82, 100, 109 Stem cells  310 Thermal 64
Serrated strip  626, 627 Steps  578, 585, 586, 626 Thermal expansion coefficients  210
Setting time  377, 389, 390 –– cycle 457 Thermoplastic material  681
Shade guide  477, 479–481, 511 –– of tooth preparation  200 3D digital impression  682
Shade selection  477, 479, 481, 496, 513, 546, 556, Stepwise excavation  217, 306, 312, 314, 318, 319 3D model  682
573, 583 Sternum bone  56 3D printing  669
Shade tabs  477, 481 Stimulated emission of radiation  447 Three-wheeled diamond depth cutter  675, 676
Shadows  57, 58, 64 Stimulus Thumping action  507
Shared decision-making  2, 29, 31, 33, 40 –– cold thermal  699 Tin  374, 375, 405
Shrinkage  386, 466, 468, 569, 573, 585, 586, 592, –– evaporative 692 Tint(s)  507, 538, 562, 588, 592, 622, 679
612, 613, 617, 618 –– osmotic  692, 694 Tofflemire  336, 378
Shrinkage stress  439, 441, 448, 457, 461, 578, –– tactile 692 Tongue retractor  251, 254, 255
581, 587, 613, 617, 618 –– thermal  692, 694, 699 Tooth  46, 47, 57, 61, 62
Sight’s angle  672 Stool  46, 48–50, 52, 54, 56, 57, 67, 69 –– contour 185
Silane coupling agent  436, 466, 668, 683, 684, 686 Strain 197 –– face 686
Silanized surface  685, 686 Stratified layering technique  499 –– fractures  6, 12
Silicon carbide (Sic)  131, 145 Strength  375, 376, 386, 389–391, 393 –– function 185
–– brush 627 Streptococcus  80, 81, 94 –– mobility testing  297
Silicone index  534, 538, 559 –– S. mutans  633, 642 –– preparation  184, 185, 189, 194, 196, 291, 295,
Silver  374, 375 Stress 302, 304–307, 319, 323
Simple preparation  338 –– compressive 198 –– separation 583
Simulator phantom  336 –– concentration 198–200 Toothbrush  634, 635, 650
Sintering 682 –– distribution 360 –– powered 635
Site 177–179 –– shearing 198 –– sonic 635
Index
715 S–Z
Toothpaste  636, 639, 640, 642, 650
Torque 147 V –– resistance 628
–– three-body 613
Torso  45, 46, 54, 56, 69, 70 Vacuum thermoforming machine  681 –– two-body 580
Total bonding  585 Value  471, 473, 477, 480, 491, 498 Wedge(s)
Total energy concept  452 Vapor 407 –– alternation technique  586, 604
Total-etch adhesive system  497, 498 Varicose veins  47, 65 –– curved 278
Training model  336 Varnish(es)  309, 695 –– effect  196, 198
Transforming growth factor beta (TGF-β) 311 Vascular changes  299 –– reflective 586
Transillumination  297, 298 Vasoconstrictors solutions  255 –– rigid  153, 263, 276, 279, 378, 440, 441
Transitional line angle  686, 687 Veneer  681–683, 686, 688 –– wedging 282
Translucent  468–470, 472, 473, 475, 484, 485, Vertical percussion  296 –– wooden  109, 149, 153, 195, 276–278, 285,
488, 499, 507, 551 Vertical slot preparation  350, 359, 361 317, 336, 359, 363, 377, 379, 397, 429, 493,
Transparent strip crowns  270, 271 Vertical walls  415, 431 584, 586, 700
Transposition  12, 13 Viewing perspective  672 Wedging, preoperative  583, 600
Trans-surgical restoration  538, 546 Viscosity  467, 469, 507, 513, 515 White light  436, 442, 443, 446
Tray  53, 56 Visible light  460, 461 Whitening 14–16
Trayless impression  669, 682 Vision  152, 157 White spot(s)  588
Treatment  44, 50, 54, 56, 63–69, 74 –– direct  52–54, 56, 58, 62 –– lesion  83–86, 97, 98, 100, 105, 638, 648, 652,
Treatment plan  2, 7, 8, 16, 22, 29, 30 –– indirect  56, 58, 62 655, 658
Triangular fossae  361 Visual examination  96, 98 Width-to-length ratio  488–490, 556
Trimmer, gingival margin  345, 349, 360–362 Vitreous ceramic  623 Window 65
Trituration  385, 389, 391 Volumetric shrinkage  439 Window preparation  672
Try-in procedure  683 Working areas  53, 64
Tubular sclerosis  295 Working field  250
Tungsten carbide  126, 131, 139, 143
Turbine  125, 132, 133, 137, 138, 147
W Work-related musculoskeletal disorders
(WMSD)  44, 45, 65, 74
Turbo light guide  455 Wall(s) Wrap preparation  672, 676
Tweezer  128, 153 –– axial  168, 169, 172, 347, 361, 363, 368, 370
–– buccal  169, 172
X
Twist drill  421, 422
–– convergence of  342, 360
–– distal 169
U –– external  170, 172
–– gingival  172, 347, 359–363, 368
Xenon plasma  442
Xylitol  633, 634, 640, 642
Ultrasonic  125, 132, 148, 150, 151 –– horizontal surrounding  170
Ultrasound 148–151
Ultraviolet (UV) light  475
–– internal  170, 172
–– labial 175 Y
–– radiation 460 –– lingual  169, 172 Y-TZP zirconia  682
Umbrella effect  309, 518 –– mesial  169, 172
Unbonded wall  585, 586
Z
–– pulpal  170, 172, 342, 347, 350
Under-contour 397 –– sub-pulpal 172
Under finish  402 –– vertical surrounding  170, 340, 342
Undermined enamel  84, 97, 187, 204, 208, 338, Zinc
Wand-style design unit  455
339, 342, 344, 349, 366 –– oxide 143
Water sorption  466, 518, 569
Under trituration  385, 389 –– phosphate 307
Wax-up  534, 669
Uniform curing cycle  453 –– polycarboxylate 307
Weakened cusps  413, 431
Upper lip curvature  24–26 Zinc oxide-eugenol cements  308
Weak point  422
Urea 641 Zirconia, high-translucent  683
Wear
Urgent phase  30 Zirconia-reinforced glass ceramic  682, 683
–– facet  23, 492
Zone  45, 52, 53, 58