GOALS OF OPERATIVE DENTISTRY

Monday, 30 January 2023 2:05 pm PRESERVATION

○ The instrumentation approach to removal of carious tissue and cavity design seeks
GOALS OF OPERATIVE DENTISTRY to retain uninvolved sound tooth tissue and to maintain pulp vitality as well as the
health of the supporting tissues
• DIAGNOSIS ○ Conservative approach during cavity preparation so that we preserve remaining
○ Identification of the disease sound tooth structure
○ Disease condition first before the treatment plan ▪ We only remove the defect
○ Dictate what will be the treatment outcome ▪ Minimally invasive treatment
○ Will give prognosis □ More conservative so that the remaining sound tooth structure is preserved
○ A problem in restoring the anteriors is that the demarcation line is visibly seen
○ Preservation of the vitality and periodontal support of the remaining tooth structure
• PREVENTION
▪ RTC is for inflamed or infected pulp
○ prevent any recurrence of the causative disease and their defect ▪ Cross out extraction
○ The primary goal of caries prevention program should be to ○ Consider restoring all correct tooth form (if cavity is extended sub gingivally, restore
reduce the number of cariogenic bacteria it properly to preserved the health of the periodontium)
▪ Limit pathogen growth and metabolism ▪ Overhang/overhanging fillings, failure to restore tooth form: prone to food
□ We have several bacterial strains in our mouth but it is entrapment causing gingival inflammation or gum recession (the bone support
in a regulated manner. will be affected as well).
▪ Increase the resistance of tooth surface to demineralization ▪ PRESERVE NOT ONLY THE TOOTH STRUCTURE BUT ALSO THE
□ One way is limiting microorganism to penetrate in the SUPPORTING TISSUES.
tooth structure
□ Pits and fissure sealants
 procedure
◊ Clean
◊ Etch (1 min) ○
◊ Apply sealant
 No need bonding
◊ Light cure (20 seconds)
◊ Check occlusion
 One problem is contamination with saliva so you
have to isolate the tooth properly before the RESTORATION
procedure ○ Includes restoring form, function, phonetics and esthetics
 Prevention of pits and fissure caries
○ PRESERVE NOT ONLY THE TOOTH STRUCTURE BUT ALSO THE
 Best time: when tooth erupts (new) and no gingival
SUPPORTING TISSUES.
obstruction on the occlusion
□ Topical fluoride application Restoring tooth through root (depends on the vitality of
 Prevention of smooth surface caries the pulp/enough tooth root surface that can support the
 No need to isolate fully the tooth surface restoration)
◊ Some methods of TFA you have to isolate the • RCT, POST, FINAL RESTORATION
tooth with cotton rolls • Consider RCT then post to support final restoration
 When using trays (4-5 minutes) ○ Impression is sent to laboratory for canal to have
 For fluoride varnish: just dry the surface then apply casted post
□ Proper diet and nutrition ○ Which support crowns/bridges
 In terms of sugar consumption, we have to limit if • Does not add strength it will only support
they are prone to frequent consumption
 Frequency>amount
◊ Due to acid attack
◊ If you ate in the morning, the MO will have food
then pH of the oral cavity will become acidic so
we have to wait for that to become neutral.
◊ Continuous so there is no way for the pH of Other types of restoration
saliva to lower Cervical lesions - place filling material,
◊ The more you eat sugar (frequency), directly follow correct anatomy/shade
related to the acidic level of the oral
environment
 Also meaning proper patient education
◊ We cannot fully eliminate sugar so we limit
◊ Or oral hygiene instruction and diet counselling Anterior with fractured incisal
• acid etch restoration
METHOD AND RATIONALE TECHNIQUE OR • no cavity preparation is done we
INDICATIONS MATERIAL only need to etch fracture side and
bonding then composite
A. LIMIT SUBSTRATE • Reduce the • Eliminate sucrose • Conservative treatment
Indications: number, duration, from between meal
• Optional
• Frequent and intensity of snack
: tooth preparation
sucrose acid attacks • Substantially reduce
exposure • Reduce selection and eliminate
• Poor quality diet pressure for MS sucrose from meal

B. STIMULATE SALIVA • Increases • Eat noncariogenic

FLOW clearance of foods that require PRINCIPLES OF CAVITY PREPARATION
Indications: substrate and lots of chewing ○ Principle according to GV Black
• Dry mouth will acids • Sugarless chewing ○ For amalgam filling
little saliva • Promote gum ○ Not for composites
• Red mucosa buffering • Medications to ○ Composites are only dictated by the presence of the carious lesion / defect
• Medication that stimulate salivary ▪ Remove the defect, put the composite
reduces saliva flow
flow ○ 7 principles: ORRCRFT
○ Fluoride to help absorb the minerals
OUTLINE FORM
• The shape or form of the cavity on the
C. PLAQUE • Prevents plaque • Brushing surface of the tooth
DISRUPTION succession • Flossing • Ex. You don’t just remove carious lesion
Indications • Decreases • Other oral hygiene aids but incorporate proper shape just like on
• High plaque plaque mass as necessary Mn Molar which has a common
scores • Promotes • Water pick shape/shade of
• Puffy red buffering • Tongue scraper • Always has the specific shape to follow
gingiva • Tooth pick
• High bleeding ○ Creation of black

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 • Tooth pick
• High bleeding ○ Creation of black
point score triangles RESISTANCE FORM
• Interdental brushes • "To resist masticatory force, load, prevent
○ Plaque behind the mandibular incisors because sometimes from fracture of resto and tooth structure"
the remnants of toothpaste which will eventually build up and ○ For teeth to not break/fracture
harden. ▪ Both for the tooth structure and
▪ Did you know? After eating you are not required to brush • The shape given to the preparation that
your teeth for at least 30 minutes due to the acid from the enables the restoration and the remaining
toothpaste and oral cavity after food. It will cause erosion. tooth structure to withstand masticatory
▪ You can remove toothpaste by brushing again. If the stress
toothpaste stays in the oral cavity for several hours, it may • "break"
harden (if left overnight as it dries up due to lack of saliva)
and cause plaque. Another way is to brush the teeth the
morning after.
○ High plaque scores: with disclosing solution, identify presence of
plaque then do proper oral regimen then plaque score again to
determine whether the oral routine is effective or not
▪ Disclosing solution RETENTION FORM
□ 2 drops at 10 ml water • For restoration to not be removed
□ Count the number of surface where you detect • The shape of the internal aspect of a
presence of plaque prepared cavity to prevent
□ After oral routine DISPLACEMENT/dislodgement OF THE
□ Do disclosing solution RESTORATIVE MATERIAL
□ Toothbrushing alone is not enough • "remove"
▪ Main use: • Conclusal convergence / \
□ To identify or locate debris that has adhered to the tooth It has wider insides and narrower outside, for it
surface to not be easily dislodge because it is in
□ Identify if oral hygiene routine is effective wedge-shape cavity prep
▪ Done in the clinic before OP • Use this cavity prep in indirect restoration
○ Floss
▪ Disclosing solution
▪ Remove interproximal debris
□ There are some instances where after toothbrushing
there is still debris left interproximally
▪ Ideal is before tooth brushing
□ Toothbrushing alone is not enough, that is why we use CONVENIENCE FORM
floss
□ Remove interproximal deposits through mechanical • The shape or form of the cavity ALLOWS
intervention, toothbrushing has a polishing effect ADEQUATE VISION, ACCESSIBILITY,
○ Proper sequence of routine oral regimen AND EASE OF INSTRUMENTION during
▪ Flossing cavity preparation as well as insertion of
▪ Toothbrushing the restorative material
▪ Rinse • To have a clear vision of what we are
○ High bleeding point score working on
▪ Indication of gingival inflammation ○ Space on the middle has to be
▪ Bleeding gums during toothbrushing is an indication of approx. 1-1.5mm
gingival inflammation • For instance, carious lesion is somewhere in
▪ There are some patients that do not brush the area that proximal without incisal. Convenience form is
bleeds allowing you to have accessibility and direct
□ The more there is bleeding, the more that area should vision on the tooth but since the defect is
be cleaned there then it could be lingual approach
□ Brushing/cleaning promotes gingival healing • However, labial approach can also be
○ Decreases plaque mass possible because when you cavity prep
▪ So there is not caveat for bacteria remaining tooth structure at the incisal
▪ Prevent plaque succession/ development of plaque edge could be fractured
□ Where caries starts • Cavity prep - remove unsupported tooth
○ Other oral hygiene aids structure eventually it will break
▪ Water pick ○ Labial approach ; convenience form
▪ Tongue scraper • Tooth that is tilted with caries
▪ Interdental brusher • Sacrifice the tooth structure above the
▪ Tooth pick carious lesion to gain access to the cavity
□ Use sparingly and properly to avoid black triangles for convenience form
• Negates concept of tooth preservation
D. MODIFY MICROFLORA • Intensive • Bacterial • Choosing to restore tooth by convenience
Indications: antimicrobial mouthrinse form
• High MS counts treatment to • Topical fluoride It always depends on your clinical judgement
(initial) eliminate MS treatment
• High lactobacillus from mouth • Antibiotic
counts (cavitated • Select against treatment
where the dentin is reinfection by MS
already affected)
○ We have streptococcus mutans and lactobacillus acidophils in REMOVAL OF REMAINING CARIOUS DENTIN
the oral cavity but at a regulated number • The mechanical elimination of carious dentin
○ Increase of MS/LB counts, increases progression of caries and debris from cavity preparations
○ Cervical/ root surface caries causing bacteria ○ In the principles of cavity preparation
▪ Actinomyces viscosus ▪ Incorporate outline, resistance,
○ Bacterial mouthrinse retention and convenience form The ideal outline for 2nd molar
▪ Concentrated 10ml of mouthrinse for 30 seconds to get full ○ As a beginner, do not think about carious • Correct shape and depth is
effect incorporated
lesion
○ Topical fluoride treatment ○ Depth – retention
▪ Instead, just follow the grooves / pits &
○ Antibiotic treatment ○ Thickness of filling
fissures area when doing the cavity
▪ In cases where there is uncontrollable amount of bacteria material – resistance
preparation
▪ To avoid cracks in
E. MODIFY TOOTH • Increase • Systemic fluorides the filling material
SURFACE resistance to • Topical fluorides • If after incorporating the
Indication: demineralization • Smooth surface principles (flat pulpal floor for
Incipient lesions • Decrease plaque well distributed force –
Surface roughening retention resistance form) and there is
○ Host factor still carious lesion left (red)

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 SURFACE resistance to • Topical fluorides • If after incorporating the
Indication: demineralization • Smooth surface principles (flat pulpal floor for
Incipient lesions • Decrease plaque well distributed force –
Surface roughening retention resistance form) and there is
○ Host factor still carious lesion left (red)
○ We make our teeth resistance/not susceptible in the formation of ○ Pulpally there is still
dental caries deeper carious part
○ When we have an incipient lesion, we want to arrest/ stop the ○ Remove the area with
progression of defect carious lesion (blue)
○ Decrease plaque retention ▪ Spot grinding –
▪ Smoothen roughened surface so they won't be prone to only remove the
plaque retention defect not minding
▪ Those wearing other areas because
□ Braces, retainers, dentures the correct principles
□ Can harbor plaque formation of cavity preparation
□ Eventually lead to caries are already achieved
□ Importance to have dental cleaning and proper ways to
clean for denture wearers
○ Supplement if we aren't getting enough fluoride

F. RESTORE Eliminate nidus of MS Restore all cavitated

TOOTH and lactobacillus infection lesions • Cavity preparation would be
SURFACES Deny habitat for MS for seal pits and fissures at like this
reinfection caries risk ○ The outline would be
Correct all defects different as a result of
○ In the case when there are cavitations, pit and fissure areas at removing the remaining
risk and defective restorations carious dentin
○ Still part of the preventive modality so they will not worsen ○ Consider factors such as
○ If there are cavitated lesions, restore if the caries is infected or
○ Pit and fissures should be sealed affected
▪ Best time: when the tooth erupts and there are no gingival
tissue that cover the gingival surface
□ May it be primary or permanent
○ If there is defective restoration, redo the restoration.

INTERCEPTION
○ Preventing further loss of tooth structure by stabilizing an active
disease process
▪ The disease condition has already started.
○ Main goal for this is to prevent further loss of tooth structure
▪ Stabilize the active disease process (stop and arrest to prevent
further development of the condition)
○ Patient education
□ Because there is already loss of tooth structure, then we
educate our patient on how we can prevent further damage
□ We intercept through educating our patients on how we can ○ Assess if the caries is affected or infected dentin
prevent further damage ▪ Use tactile and visual examination
□ e.g. early onset caries ▪ If the remaining carious lesion is hard, it can be left
 Discuss through oral hygiene instruction, proper tooth ▪ If the remaining carious lesion is soft, remove
brushing, floss, and mouth rinses □ If the pulp is exposed, treatment is direct pulp capping
 We show them the proper way (demonstrate the □ If the pulp is not exposed but the cavity preparation is very near it,
procedure instead of just telling them) treatment is indirect pulp capping
 For instance, if a patient cannot tolerate mouthwash, we ▪ If dentist will leave the affected dentin:
should instruct them to dilute the mouthwash □ Inform the patient
(antibacterial effect) with water □ Leave liner to protect the vitality of the pulp
○ Interception measures  Calcium hydroxide, GIC / IRM, then amalgam
▪ Changes in the patients home care procedure ○ GIC – for antibacterial, anticariogenic, fluoride release
▪ Removal of carious tooth tissue ○ IRM – sedative effect
□ remove carious defect and restore it
Affected dentin Infected dentin
▪ Altering tooth form through restoration or selective contouring
□ Enameloplasty ▪ Does not contain microorganism ▪ Contains microorganism
 Reduce tooth structure to make the deep pits and ▪ Can be remineralize by restorative • Cannot be remineralized by restorative means
fissures shallow means
▪ Enhancing occlusal ability ▪ It is accepted to allow affected ▪ It should be removed during cavity preparation
□ For patients with decreased vertical height dentin to remain in prepared tooth
□ Take a look at occlusion and evaluate if you can advise
• Discolored but HARD • Discolored and SOFT
them to have prosthodontics/prosthesis because there are
instances when you try to do restorative procedures it can
affect the patient's occlusion. This is where prostheses FINISHING OF CAVITY WALLS • After the removal of the remaining carious
enters. dentin, it will be clinical judgement to put
• Involved refining of certain areas medicaments (pulp protectors)
Remove existing amalgam restoration of the cavity walls; the dentin
and defects. Assess how deep is the • Before placing the amalgam filling
portion, the enamel portion and the materials, finish the cavity prep
cavity and whether there is a need to cavosurface margin
apply liner/bases. • To facilitate good adaptation of the final
○ Make it: restoration
▪ as smooth as possible
□ Refine cavity walls
□ Free from irregularities
• Free flowing cavity
preparation
□ So when amalgam is
compacted, it will adapt
properly to the prepared
cavity

▪ Have rounded internal line

angles
□ Not pointed
□ To avoid crack (increase

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 cavity

▪ Have rounded internal line

If the patient needs occlusal stability,
recommend prosthesis.
TOILET OF THE CAVITY
Abrasions, the effect of faulty brushing.
Other than restoring, Modify patient in
terms of proper tooth brushing to
prevent failure of restoration.
▪ Other than the restoration that we do if the patient needs
occlusal stability, we recommend dentures
○ Do not only treat the defect but consider the end result and how to
mitigate that problem so that we can stop the disease process.
angles
□ Not pointed
□ To avoid crack (increase
resistance form)
• Freeing the preparation walls and margin from objects that may interfere with
proper adaptability of restorative material
• "flush out" debris inside the prepared cavity
○ Clean it
• Cavity preparation should be clean and free from debris
• So that with the concept of adaptation will be achieved
• Once cleaned properly, place cavity varnish then amalgam
○ Cavity varnish is counterpart of bonding agent in composite
▪ Cavity varnish the walls before placing amalgam
▪ Then do finishing
▪ Check occlusion
▪ Dismiss the patient
▪ The patient will come back the next day
▪ Polish amalgam

MAINTENANCE
□ To maintain the proper health status of our patient
□ Recall the patient every 6 months (average); Patient can be recalled earlier
than 6 months depending on the caries risk level.
□ 1-3 months: high risk
□ 3-6 months: moderate
○ Clinical significance □ 6-1 year: low risk
▪ Always check occlusion of patient
▪ If there is high contact (seen thru articulating paper), recontour
the restoration/tooth structure to achieve the balanced occlusion.
▪ Correct occlusion: upper central incisors should coincides with
the lower central incisors

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