CONTENTS

1. Introduction to Operative Dentistry 1 Clinical Presentation of Dental Caries 43

Nisha Garg Calcium Ion Migration in Carious Process 44
Introduction 1 Histopathology of Dental Caries 44
Definitions 1 Classification of Dental Caries 46
History 1 Diagnosis of Dental Caries 50
Indications of Operative Dentistry 3 Recurrent Caries (Secondary Caries) 54
Objectives/Purpose of Operative Dentistry 4 Root Caries 55
Scope of Operative Dentistry 4 Caries Risk Assessment 57
Recent Advancements 4 Caries Activity Tests 57
Prevention of Dental Caries 58
2. Tooth Nomenclature 6 Current Methods of Caries Prevention 63
Am it Garg Management of Dental Caries 64
Introduction 6
7. Instruments Used in Operative Dentistry 67
Types of Dentition 6
Nisha Garg
Tooth Notation Systems 7
Introduction 67
3. Structure of Teeth 12 History 67
Amit Garg Materials Used for Manufacturing Cutting
Introduction 12 Instruments 67
Enamel 12 Heat Treatment of Materials 68
Dentin 15 Classification 68
Dental Pulp 18 Nomenclature by GV Black 68
Parts of Hand Cutting Instruments 68
Periradicular Tissue 19
Balancing 69
4. Physiology of Tooth Form 22 Instrument Formula 69
Amit Garg Different Instrument Designs 71
Introduction 22 Instrument Motions 71
Types of Teeth and their Functions 22 Description of Various Instruments 71
Hand Cutting Instruments 73
Functions of Teeth 22
• Excavators 73
Protective Functional Form of the Teeth 23
• Chisels 74
5. Occlusion in Operative Dentistry 27 • Other Cutting Instruments 75
Nisha Garg Restorative Instruments 76
Introduction 27 Instrument Grasps 77
Anterior-Posterior Interarch Relationship 28 Finger Rests 78
Interarch Tooth Relationships 28 Guards 79
Features of an I deal Occlusion 29 Methods of Use of Instruments 80
Sharpening of Hand Instruments 80
Factors of Occlusion Affecting Operative Dentistry 29
Rotary Cutting Instruments 81
Mandibular Movements 30
Handpieces 81
Occlusal Schemes 32
Dental Burs 84
Significance of Occlusion in Operative Dentistry 33
Factors Affecting Cutting Efficiency of Bur 88
Occlusal Interferences 33
Recent Advances in Rotary Instruments 89
Occlusion Indicators 35
Abrasive Instruments and Materials in Conservative
Trauma from Occlusion 36
Dentistry 91
6. Dental Caries 39 Hazards and Precautions with Rotary Cutting
Nisha Garg Instruments 94
Introduction 39 8. Principles of Tooth Preparation 97
Definitions 39 Nisha Garg
Theories 39 Introduction 97
Etiology of Dental Caries 40 Definition 97
xvi
Purpose of Tooth Preparation 97
Indications of Restorative Intervention 97
Objectives of Tooth Preparation 97
Terminology 97
Number of Line and Point Angles 99
Stages of Cavity Preparation 101
Initial Cavity Preparation Stage 102
• Outline Form and Initial Depth 102
• Primary Resistance Form 104
• Primary Retention Form 105
• Convenience Form 106
• Final Stages of Tooth Preparation 106
• Removal of any Remaining Enamel Pit or Fissure,
Infected Dentin and/or Old Restorative Material, if
Indicated 106
• Pulp Protection 106
• Secondary Resistance and Retention Forms 106
• Procedures for Finishing the External Walls of
the Tooth Preparation 107
• Final Procedures: Cleaning, Inspecting and Sealing
9. Patient Evaluation, Diagnosis and Treatment
Planning
Amit Garg
Introduction 110
Patient Evaluation 110
Clinical Evaluation 111
Treatment Planning 113
Quadrant Dentistry 113
Treatment Record/Documentation
10. Patient and Operator Position
Nisha Garg
Introduction 115
Operating Stool 115
Considerations for Dentists While Treating Patients
Dental Chair Positions 116
Four Handed Dentistry 117
Zones of Working Area/Activity 117
Visibility 118
11. Isolation of Operating Field
Nisha Garg
Introduction 120
Components of Oral Environment Need to
be Controlled During Operative Procedures
Advantages of Moisture Control 120
Methods of Moisture Control 120
Isolation with Rubber Dam 121
Pharmacological Means 130
Gingival Tissue Management 131
12. Gingival Tissue Management
Nisha Garg, Amit Garg
Introduction 132
Definition 132
Indications of Gingival Tissue Management 132
Contraindications of Gingival Tissue Management
Advantages 132
Methods of Gingival Tissue Management 132
Textbook of Operative Dentistry
13. Infection Control in Operative Dentistry 139
Amit Garg
Introduction 139
Rationale for Infection Control 139
Objective of Infection Control 140
Universal Precautions 140
Classification of Instruments 141
Instrument Processing Procedures/Decontamination
Cycle 142
Sterilization of Dental Handpiece 145
Disinfection 146
Sterilization of Dental Unit Waterlines 146
Infection Control Checklist 146
14. Pain Management in Operative Dentistry 149
Amit Garg
Introduction 149
Definition 149
Method of Control of Pain in Restorative Dentistry 149
108 Pain Management Protocol 149
Recent Advances in Local Anesthesia 151
Other Methods of Pain Control 153
15. Matricing 154
Nisha Garg
Introduction 154
Matricing 154
Parts of Matrix 155
Functions of a Matrix 155
Ideal Requirements of a Matrix 155
Classification 155
115
Ivory Matrix Holder (Retainer) No. 1 155
Ivory Matrix Band Retainer No. 8 156
Tofflemire Universal Matrix Band Retainer
(Designed by Dr BRTofflemire) 157
115
Steele’s Siqveland Self-adjusting Matrix Holder
for Tapering Teeth 160
Compound Supported Matrix 160
T-Shaped Matrix Band 161
S-Shaped Matrix Band 161
120 Aluminium or Copper Collars 161
Transparent Crown Forms Matrices 162
Window Matrix 162
Anatomic Matrix 162
120 Clear Plastic Matrix Strips 163
Aluminium Foil Incisor Corner Matrix 164
Preformed Transparent Cervical Matrix 164
Matrix Retainerless System 164
Recent Advances in Matrix Systems for
Class II Composite Restorations 165
Sectional Matrices and Contact Rings 166
132
16. Separation of Teeth 170
Nisha Garg
Introduction 170
Reason for Tooth Separation 170
132 Methods ofTooth Separation 170
Rapid or Immediate Tooth Separation 170
Slow or Delayed Separation 174
17. Pulp Protection 176
Contents

Advantages 225
kJ XVII

Nisha Oarg, Sanjay Miglani Disadvantages 225

Introduction 176 Indications 225
Pulpal Irritants 176 Contraindications 226
Effect of Caries on Dental Pulp 176 Types of Pins 226
Effect of Tooth Preparation on Dental Pulp 177 • Indirect Pins/Parallel Pins 226
Importance of Remaining Dentin Thickness 177 • Direct Pins/Nonparallel Pins 226
Need for Pulp Protection 178 Principles and Techniques of Pin Placement 229
Materials Used for Pulp Protection 178 Factors Affecting Retention of Pins in Dentin and
Cavity Sealers 178 Amalgam 231
Cavity Liners 179 Pins and Stresses 232
Base 179 Complications of Pin-retained Restorations 232
Guidelines of Using Liners, Bases, and Varnishes for Other Means of Retention in Complex Amalgam
Different Restorative Materials 180 Restorations 234
Management of Shallow, Moderate, and Deep Caries 181
Management of Deep Carious Lesion 181 21. Direct Filling Gold 237
Nisha Garg, Anil Chandra
Prevention of Pulpal Damage due to Operative
Procedure 184 Introduction 237
Properties of Gold 237
18. Interim Restorations 186 Advantages of Direct Filling Gold Restorations 237
Nisha Garg, Tom JM Dienya Disadvantages of Direct Filling Restoration 238
Introduction 186 Indications of Direct Filling Gold Restoration 238
Objectives of Interim Restorations 186 Contraindications 238
Requirements of Interim Restoration 186 Types of Gold 239
Purposes of Interim Restoration 186 Storage of Gold 241
Materials 187 Degassing/Annealing 241
For Intracoronal Preparations 187 Principles of Tooth Preparations 242
For Extracoronal Preparations 191 Class I Tooth Preparation 242
Class II Tooth Preparation 242
19. Amalgam Restorations 193
Nisha Garg Class III Tooth Preparation 242
Class V Tooth Preparation 244
Introduction 193
Compaction of Direct Filling Gold 245
Definitions 193
Steps of Direct Filling Gold Restoration 246
History of Dental Amalgam 194
Future of Gold in Dentistry 247
Classification 194
Composition 194 22. Cast Metal Restorations 248
Types 195 Nisha Garg
Setting Reaction/Amalgamation Reaction 196 Introduction 248
Physical Properties 196 Components of Cast Gold Alloys 248
Indications of Silver Amalgam 198 Classification of Cast Gold Alloys 249
Contraindications 199
Properties of Cast Gold Alloys 249
Advantages 199
Definitions 250
Disadvantages 199
Indications for Class II Gold Inlays 250
Recent Advances in Silver Amalgam 199
Contraindications 250
Class I Cavity Preparation for Silver Amalgam 202
Advantages 250
Class II Cavity Preparation for Amalgam Restoration 204
Disadvantages 251
Class III Cavity Preparation for Amalgam Restoration 210
Basic Design of Cast Metal Inlay 251
Class V Cavity Preparation 211
Cavity Preparation for Class II Cast Metal Inlays 255
Class VI Cavity Preparation for Amalgam Restoration 212
Modifications in Class II 257
Steps for Amalgam Restoration 212
Cast Metal Onlay 258
Life of Amalgam Restorations 215
Technique of Making Cast Metal Restoration 260
Failures of Amalgam Restoration 215
Casting Defects 267
Reasons for Failure of Amalgam Restorations 216
Mercury Hygiene 218 Pin-retained Cast Restorations 271
Is Dental Amalgam Safe? 220 23. Adhesion in Operative Dentistry 273
Amalgam Wars 221 Nisha Garg
Phase Down of Amalgam 221 Introduction 273
20. Pin-retained Restorations 225 Indications for Use of Adhesives 273
Nisha Garg Advantages of Adhesives 273
History 273
Introduction 225
Definitions 274
Definition 225
xviii Textbook of Operative Dentistry

Enamel Bonding 275 Advantages of Glass lonomer Cements 353

Dentin Bonding 277 Disadvantages of Glass lonomer Cements 354
Dentin Adhesive Systems 278 Indications of Glass lonomer Cement 354
Evolution of Dentin-Bonding Agents 279 Contraindications of Glass lonomer Cements 355
Hybridization 283 Clinical Steps for Placement 355
Smear Layer 283 Other Clinical Applications of Glass Ionomers 357
Classification of Modern Adhesives 284 Atraumatic Restorative Treatment 357
Glass Ionomer-based Adhesive System 285 Sandwich Technique 357
Failure of Dentin Bonding 285 Tunnel Preparation 359

24. Composite Restorations 288 27. Dentin Hypersensitivity 361

Nisha Garg Amit Garg, NeetuJindal
Introduction 288 Introduction 361
Definition 288 Definition 361
History 289 Historic Review 361
Composition of Dental Composites 289 Theories of Dentin Hypersensitivity 361
Classification of Composites 291 Incidence and Distribution 362
Types of Composites 292 Etiology and Predisposing Factors 362
Recent Advances in Composites 293 Differential Diagnosis 363
Properties of Composite 297 Diagnosis 363
Degree of Conversion in Composites 299 Treatment 363
Steps of Clinical Procedure for Composite Restoration 301 Ideal Properties of a Desensitizing Agent 364
Tooth Preparations for Anterior Composite Classification of Desensitizing Agents 364
Restorations 307 Recent Trends to Treat Dentin Hypersensitivity 365
• Class III Tooth Preparation 307
28. Tooth Whitening 367
• Class IV Tooth Preparation 309 Nisha Garg
• Class V Tooth Preparation 309
Introduction 367
Tooth Preparation for Posterior Composite Restoration 310
Classification of Discoloration 367
• Pit and Fissure Sealants 313
Bleaching 369
• Preventive Resin and Conservative Composite Bleaching Agents 369
Restorations 314 Mechanism of Bleaching 369
• Class I Tooth Preparation 314 Bleaching of Vital Teeth 369
• Class II Tooth Preparation 316 Vital Bleaching Techniques 370
Stamp Technique of Restoration 318 Bleaching of Nonvital Teeth 372
Failures of Composite Restorations 318 Effects of Bleaching Agents on Tooth and
Repair of Composite Restorations 322 its Supporting Structures 373
Indirect Resin Composite 322
Classification of Indirect Composites 323 29. Minimally Intervention Dentistry 376
Nisha Garg
Tooth Preparation for Composite Inlays and Onlays 325
Introduction 376
25. Smile Designing in Operative Dentistry 329 Definition 376
Nisha Garg, Poonam Bogra Principles of Minimal Intervention 376
Introduction 329 • Early Diagnosis 377
Elements of Dental Aesthetics 329 • Caries Classification Based on Site and Size of
Facial Composition 329 Lesion 377
Dental Composition 331 • Assessment of Caries Risk 377
Hard Tissue Components of Smile Design 331 • Decreasing the Risk of Further Demineralization and
Soft Tissue Component of Smile Design 336 Arresting Active Lesion 378
Aesthetics and Operative Dentistry 337 • Remineralization of Initial Lesions and Reduction in
Veneers 340 Cariogenic Bacteria 378
Repair of Veneers 344 Different Remineralizing Agents 379
• Minimal Intervention of Cavitated Lesions 381
26. Glass lonomer Cements 347 • Repair Instead of Replacement of the Restoration 383
Nisha Garg
• Disease Control 383
Introduction 347
Classification of Glass lonomer Cements 347 30. Noncarious Lesions of Teeth 386
History 347 NeetuJindal, Nisha Garg
Composition 348 Introduction 386
Recent Advances in Glass lonomer Cement 349 Attrition 386
Setting Reaction of Glass lonomer Cement 350 Abrasion 387
Properties of Glass lonomer Cements 351 Erosion 388
 Abfraction 389
Contents

Definition of Evidence-based Dentistry 414

kJ XIX

Localized Nonhereditary Enamel Hypoplasia 390 Need of Evidence-based Dentistry 414

Localized Nonhereditary Enamel Hypocalcification 391 Steps of Evidence-based Dentistry 414
Localized Nonhereditary Dentin Hypoplasia 391 Application of Evidence-based Dentistry from
Localized Nonhereditary Dentin Hypocalcification 391 Research Clinical Practice 415
Amelogenesis Imperfecta 391 Who Get Benefits from Evidence-based Dentistry? 415
Dentinogenesis Imperfecta 392
33. Nanotechnology in Dentistry 417
31. Dental Ceramics 395 Amit Garg, Shabnam Negi
Nisha Garg Introduction 417
Introduction 395 History 417
Definitions 395 Definitions 417
History 396 Approaches in Nanotechnology 417
Classification 396 Nanotechnology in Dentistry 418
Composition 396 Applications of Nanotechnolog)' in Dentistry 418
Properties of Ceramic 398 Barriers for Nanotechnology 420
Methods of Strengthening Porcelain 398
Advantages of Dental Ceramics 399 34. Lasers in Operative Dentistry 422
Disadvantages of Dental Ceramics 399 Amit Garg
Metal Ceramic Restorations 399 Introduction 422
Conventional Method of Fabrication of PFM History 422
Restorations 400 Classification of Laser 422
All-Ceramic System 402 Principles of Laser Beam 423
All-Ceramic Restorations 404 Laser Physics 423
Porcelain Laminate Veneers 406 Laser Interaction with Biological Tissues 425
All-Ceramic Crowns 408 Laser Safety in Dental Practice 425
Fabrication of Ceramic Restorations 411 Applications of Lasers in Operative Dentistry 426
Advantages and Disadvantages of Lasers 428
32. Evidence-based Dentistry 413
Amit Garg, Pranav Nayya A n n e x u re s 429
Introduction 413
What is Evidence-based Dentistry? 413 In d e x 435
Chapter
Introduction to Operative Dentistry
CHAPTER OUTLINE
«* Introduction
Definitions
* History
«* Indications of Operative Dentistry
■ INTRODUCTION
Operative dentistry is foundation of the dentistry from
which other branches have evolved. It plays an important
role in enhancing dental health and now branched
into dental specialties. Operative dentistry deals with
diagnosis, prevention, interception, and restoration of the
defects of natural teeth. Goal of the operative dentistry
is to maintain the health and integrity of teeth and their
supporting structures.
■ d e f i n it io n s
Sturdevant—"Operative dentistry is defined as art and
science of diagnosis, treatment planning and prognosis
of defects of the teeth that do not require full coverage
restorations for correction. Such treatment should result
in the restoration of proper form, function and aesthetics
while maintaining the physiologic integrity of the teeth in
harmonious relationship with the adjacent hard and soft
tissues, all of which should enhance the general health
and welfare of the patient’!
Gilmore—“Operative dentistry is that subject which
includes diagnosis, prevention, and treatment of defects of
the natural teeth, both vital and nonvital, so as to preserve
the natural dentition and restore it to the best state of
health, function and aesthetics.
Mosby’s dental dictionary—“Operative dentistry deals
with the functional and aesthetic restoration of the hard
tissues of individual teeth”
«*■ Objectives/Purpose of Operative Dentistry
"*• Scope of Operative Dentistry
<+ Recent Advancements
■ h is t o r y
The profession of dentistry was born during the early
middle ages. Barbers were doing well in dentistry by
removing teeth with dental problems. Baltimore College
o f Dental Surgery (1840) in Maryland was world’s first
dental college. Till 1900 AD, the term “Operative dentistry”
included all the dental services rendered to the patients,
because all the dental treatments were considered to be
an operation which was performed in the dental operating
room or operatory. As dentistry evolved, dental surgeons
began filling teeth with core metals. In 1871, GV Black gave
the philosophy of "extension for prevention’,’ for cavity
preparation design. D r GV Black (Greene Vardiman)
is known as the “Father o f operative dentistry". He
provided scientific basis to dentistry because his writings
developed the foundation of the profession and made the
field of operative dentistry organized and scientific. The
scientific foundation for operative dentistry was further
expanded by Black’s son, Arthur Black.
In early part of 1900s, progress in dental science and
technology was slow. Many advances were made during
1970s in materials and equipment. By this time, it was
also proved that dental plaque was the causative agent
for caries. In the 1990s, oral health science started moving
toward an evidence-based approach for treatment of
decayed teeth (Table l . l ) . The recent concept of treatment
of dental caries comes under minimally invasive dentistry.
In December 1999, the World Congress of Minimally
Invasive Dentistry (MID) was formed. Initially, MI dentistry
 2 Textbook of Operative Dentistry

Table 1.1: Evolution of operative dentistry.

Era Year M ajor inventions/events

Prehistoric era 5000 BC A Sumerian text describes "tooth worms"as the cause of dental decay.

500-300 BC Hippocrates and Aristotle wrote about dentistry, including the eruption pattern of teeth, treating
decayed teeth.

166-201 AD The Etruscans practiced dental prosthetics using gold crowns and fixed bridgework.

700 A medical text in China mentioned the use of "silver paste," a type of amalgam.

Pre 1700 1530 Artzney Buchlein, wrote the first book solely on dentistry. It was written for barbers and surgeons who
used to treat oral cavity, it covered topics like oral hygiene, tooth extraction, drilling teeth and placement
of gold fillings.

1563 Bartolomeo Eustachius published the first book on dental anatomy, "Libellus de dentibus".

1683 Antonie van Leeuwenhoek identified oral bacteria using a microscope.

1685 Charles Allen wrote first dental book in English "The operator for the teeth".

1700-1800 1723 Pierre Fauchard published "Le Chirurgien Dentiste". He is credited as "Father of Modern Dentistry"
because his book was the first to give a comprehensive system for the practice of dentistry.

1746 Claude Mouton described a gold crown and post for root canal treated tooth.
1764 James Rae gave first lecture on the teeth at the Royal College of Surgeons, Edinburgh.

1771 John Hunter published "The natural history of human teeth" giving a scientific basis to dental anatomy.

1780 William Addis manufactured the first modern toothbrush.

1790 • John Greenwood constructed the first known dental foot engine by modifying his mother's foot-
treadle spinning wheel to rotate a drill.
• Josiah Flagg invented the first dental chair

1800-1900 1832 James Snell invented the first reclining dental chair.

1830s-1890s The "Amalgam War" conflict and controversy generated over the use of amalgam as filling material.

1855 Robert Arthur introduced the cohesive gold foil method for inserting gold into a preparation with
minimal pressure.

1864 Sanford C Barnum developed the rubber dam.

1871 James Beall Morrison invented foot engine.

1877 Basil Manly Wilkerson invented first hydraulic dental chair and named it THE WILKERSON DENTAL CHAIR

1890 WD Miller formulated his"chemicoparasitic"theory of caries in "Microorganisms of the human mouth".

1895 Lilian Murray became the first woman to become a dentist in Britain.

1896 GV Black established the principles of cavity preparation.

1900-2000 1900 Federation Dentaire Internationale (FDI) was founded.

1903 Charles Land introduced the porcelain jacket crown.

1907 William Taggart invented a "lost wax" casting machine.

1930-1943 Frederick S McKay, a Colorado dentist showed brown stains on teeth because of high levels of naturally
occurring fluoride in drinking water.

1937 Alvin Strock develoed Vitallium dental screw implant.

1950s First fluoride toothpaste was marketed.

1949 Oskar Hagger developed the first system of bonding acrylic resin to dentin.

1955 Michael Buonocore described the acid-etch technique.

1957 John Borden introduced a high-speed air-driven contra-angle handpiece running up to 300,000 rpm.

1960s Lasers were developed.

1962 Rafael Bowen developed Bis-GMA.

1989 The first commercial home tooth bleaching product was made available.

1990s New advances in aesthetic dentistry including tooth-colored restorative materials, bleaching materials,
veneers and implants.
 Introduction to Operative Dentistry 3

focused on minimal removal of diseased tooth structure

but later it evolved for preventive measures to control
disease. Current minimally intervention philosophy
follows three concepts of disease treatment, viz. identify
the risk factors early, prevent disease by eliminating risk
factors and restore the health of oral environment.

■ in d ic a t io n s o f o p e r a t iv e d e n t is t r y
1. Dental caries: Restoration of carious tooth is most
common indication in operative dentistry. Caries
can be present on pit and fissures, proximal, and root
surface of the teeth (Fig. 1.1).

Fig. 1.3 : Fractured maxillary central incisor can be corrected by

restorative treatment.

Fig. 1.1 : Dental caries.

2. Noncarious loss o f tooth structure: Treatment of

lesions like attrition, abrasion, erosion to restore
function and aesthetics (Fig. 1.2).

Fig. 1.4: Operative dentistry is needed for aesthetic improvement.

Fig. 1.2 : Noncarious loss of tooth structure requiring restorative

treatment.
Fig. 1 .5: Replacement or repair of previous defective restoration.

3. Traumatic injuries: Restoration of traumatized or

fractured teeth involving the hard dental tissues and
pulp (Fig. 1.3).
4. Aesthetic improvement: Aesthetic corrections are
needed for teeth affected by caries, stains, fractures,
diastema, etc. (Fig. 1.4).
5. Replacement or repair o f previous defective resto­
ration: Existing restorations may fail due to various
reasons, these restorations can be repaired or replaced
in operative dentistry (Fig. 1.5).
6. Developmental defects: Management of enamel and
dentin hypoplasia, hypomineralization, amelogenesis,
and dentinogenesis imperfecta, tetracycline stains,
peg-shaped laterals is done in operative dentistry
(Fig. 1.6).
 Textbook of Operative Dentistry

■ SCOPE OF OPERATIVE DENTISTRY

Scope of operative dentistry includes the following:
To know the condition of the affected tooth and other teeth.
1. To examine not only the affected tooth but also the oral
and systemic health of the patient.
2. To diagnose the dental problem and the interaction of
problem area with other tissues.
3. To provide optimal treatment plan to restore the tooth
to return to health and function, and increase the
overall well-being of the patient.
4. Thorough knowledge of dental materials which can be
used to restore the affected areas.
5. To understand the biological basis and function of the
various tooth tissues.
6. To maintain the pulp vitality and prevent occurrence of
Fig. 1.6: Developmental defects. pulpal pathology.
7. To have knowledge of dental anatomy and histology.
8. To understand the effect of the operative procedures on
OBJECTIVES/PURPOSE OF OPERATIVE

I
DENTISTRY
1. Diagnosis
Diagnosis is determination of nature of disease, injury or
other defect by examination, test, and investigation.
2. Prevention
To prevent any recurrence of the causative disease and their
defects, it includes the procedures done for prevention
before the manifestation of any sign and symptom of the
disease.
3. Interception
It includes the procedures undertaken after signs and
symptoms of disease have appeared, in order to prevent
the disease from developing into a more serious or full
extent.
4. Preservation
Preservation of the vitality and periodontal support of
remaining tooth structure is obtained by preventive and
interceptive procedures.
5. Restoration
It includes restoring form, function, phonetics and
aesthetics.
6. Maintenance
After restoration is done, it must be maintained for
providing service for longer duration.
the treatment of other disciplines.
■ RECENT ADVANCEMENTS
Earlier concept of tooth preparation was the same as given
by GV Black for many decades following principles of
extension for prevention. But modem concept of operative
dentistry is based on the conservation and prevention of the
diseases. Many advancements have been made in the area
of operative dentistry so as to meet its goals in better ways.
1. Development in the diagnostic aids
• Ultrasonic illumination
• Fiberoptic transillumination (FOTI)
• Digital imaging
• Tuned-aperture computerized tomography (TACT)
• Magnetic resonance microimaging (MRMI)
• Qualitative laser fluorescence
• Diagnodent (quantitative laser fluorescence).
2. Recent advances in treatment planning
• Minimal intervention dentistry
• Ozone therapy.
3. Recent advances in tooth preparation
• Use of air abrasion technique
• Chemomechanical caries removal
• Use of lasers in tooth preparation
• Use of ultrasonics in tooth preparation
• Management of smear layer.
4. Improvements in adhesive dentistry
• Packable composites
• Flowable composites
• Smart composites
• Compomers
• Ceromers
• Nanocomposites
• Sonicfill composite
• Fiber reinforced composites.
 Introduction to Operative Dentistry
5. Recent advances in techniques and equipment
• Incremental packing and C-factor concept in
composites
• Soft start polymerization
• High intensity QTH polymerization.
6. Recent advances in handpieces and rotary
instruments
• Fiberoptic handpiece
• Smart prep burs
• CVD burs
• Fissurite system.
■ c o n c l u s io n
During the beginning of dentistry, it was merely an art
practiced by barber-surgeons or artisans. With time, due to
advances in science and technology, dentistry came into
hands of dentists/surgeons. Slowly and gradually operative
dentistry became one of the major branches of dentistry
and focus was on restoring and preserving of teeth. It is
especially the current age of cosmetic dentistry that has
been a real advantage for the public and the profession. It
has spurred the development of many new techniques and
materials and made a wide variety of cosmetic procedures
available to majority of patients.
With the innovations and discoveries of new equipment,
techniques, materials, and methods, operative dentistry
continues to refine and grow towards bright future of oral
health.
■ EXAMINER'S CHOICE QUESTIONS
1. Define operative dentistry. What is the scope of
operative dentistry?
5
2. List the indications for operative dental procedures.
3. Discuss various advancements that have revolu­
tionized the current practice of operative dentistry.
4. Write short notes on:
a. Scope and purpose of operative dentistry.
b. Recent advances in operative dentistry.
■ VIVA QUESTIONS
1. Define operative dentistry.
2. What is the scope of operative dentistry?
3. Who invented the first dental chair?
4. What was the name of first hydraulic dental chair?
5. Write the objectives of operative dentistry.
6. What is the name of “father of operative dentistry"?
7. Who gave the concept of "extension for prevention"?
■ b ib l io g r a p h y
1. Black AD. Operative dentistry: a review of the past seventy-five
years. Dent Cosmos. 1934:76(l):63-65.
2. Craig RB. Restorative dental materials, 10th edition. St. Louis,
Mosby-Year Book; 1997.
3. Fillebrown T. A textbook of operative dentistry. Philadelphia, P
Blakiston, Sons & Co; 1889.
4. Glenner RA. The modern reclining dental chair. J Hist Dent.
1996;44(3):122-24.
5. Morrant GA, Stephens RR. The development and application
of modern methods in cavity preparation. VI-The evolution of
turbine handpieces. Brit Dent J. 1960,109(6)215-19.
6. Prinz H. Dental chronology—a record of the more important
historic events in the evolution of dentistry. Philadelphia. Lea
and Febiger; 1945.
7. Schulein TM. The era of high speed development in dentistry. J
Hist Dent. 2002;50(2):131-7.
8. Webb MH. Notes on operative dentistry. Philadelphia, SS White
Manufacturing Company; 1883.
Chapter

Tooth Nomenclature

CHAPTER OUTLINE

»* Introduction «* Tooth Notation Systems

'+ Types of Dentition

■ INTRODUCTION Between six and twenty-four months of a baby life,

Man has a heterodont set of teeth, that is, different
forms and dimension of teeth. It is to meet the needs of
omnivorous alimentation. In each set, incisors and canines
are present to cut and tear food, molars and premolars are
present to mince the food (Fig. 2.1).
twenty teeth progressively appear: eight incisors, four
canines, and eight molars.
Around 6 years of age the eruption of 32 permanent
teeth begins. Total, 32 permanent teeth are present in an
adult mouth, 16 teeth in each arch. Maxilla and mandible
each has six anterior teeth which includes four incisors, two
canines, ten posterior teeth which include four premolars
and six molars.
Oral cavity has two arches; maxillary and mandibular.
For an easier identification of a tooth in the oral cavity,
whether the upper teeth or the lowers, they are divided by

Fig. 2.1 : Human dentition comprising incisors, canines,

premolars and molars.

■ TYPES OF DENTITION
Man has a diphyodont dentition, characterized by two
different dentitions during his life: deciduous dentition Temporary teeth
(primary orcalfteeth) and permanent dentition (secondary ( 20)

or definitive) (Fig. 2.2). Fig. 2.2 : Deciduous and permanent dentition.

 Tooth Nomenclature

an imaginary line, called median line, in two hemiarchs, Permanent Teeth

the right's, and the left's ones. Thus, the set of teeth are
Permanent teeth are numbered 1-8, where 1 is central
described into four quadrants as:
incisor, 4 is first premolar and 8 is third molar.
1. Maxillary right
2. Maxillary left
3. Mandibular right Primary Teeth
4. Mandibular left.
Primary teeth are designated as A, B, C, D, E, where A is
■ t o o t h n o t a t io n s y s t e m s central incisor and E is second molar (Figs. 2.3 and 2.4).
Each quadrant has unique L-shaped symbol to designate
There are different tooth notations for identifying specific
the quadrant to which tooth belongs. For example, for
tooth. The three most common systems used are the “FDI
maxillary right, maxillary left, mandibular right and
World Dental Federation” notation, the “Universal” system
mandibular left symbols are J , L ,- 1, F respectively.
and the “Zsigmondy-Palmer" system. The FDI system is
used worldwide and the universal is used predominantly
in the USA. Advantages
♦ Simple and easy to use
1. Zsigmondy-Palmer System/Angular/Grid
♦ Less chances of confusion between primary and perma­
System
nent tooth as there is different notation, e.g. permanent
This is the oldest method of tooth notation introduced by teeth are described by numbers while primary teeth by
Zsigmondy in 1861. Also known as angular or grid system. alphabets.

Figs. 2.3A and B: Zsigmondy-Palmer tooth notation system for permanent dentition.

Figs. 2.4A and B: Zsigmondy-Palmer tooth notation system for primary dentition.
8 Textbook of Operative Dentistry

Disadvantages ♦ If teeth have been extracted or missing, they are also

♦ Difficulty in communication
♦ Confusion between upper and lower quadrants, while
communication and transferring a data.
2. Universal (National) System/ADA System
This system was introduced by the American Dental
Association in 1968. It is most popular in the United
States. Universal numbering system uses a unique letter or
number for each tooth.
Permanent Teeth
Numbering starts from maxillary right posterior tooth
where tooth number 1 is the patient's upper right third
molar and follows around the upper arch to the upper left
third molar, tooth 16, descending to the lower left third
molar, tooth 17, and following around the lower arch to the
lower right third molar, tooth 32 (Figs. 2.5A and B).
♦ If a third molar is missing, the first number will be 2
instead of 1, acknowledging the missing tooth.
numbered.
Primary Teeth
♦ In the original system, primary teeth were numbered in
the same order as permanent teeth, except that a small
letter "d” followed each number, thus a first tooth on
the upper right side would be Id and the last tooth on
the lower right side would be 20d.
♦ But this method was modified where primary teeth
are by English upper case letters A through T instead
of numbers 1 to 20, with A being upper right second
primary molar and T being the lower right second
primary molar (Figs. 2.6A and B).
Advantage
Unique letter or number for each tooth avoiding confusions.
Disadvantage
Difficult to remember each letter or number of tooth.

Figs. 2.5A and B: Universal tooth notation system for permanent dentition.

Figs. 2.6A and B: Universal tooth notation system for primary dentition.
 Tooth Nomenclature 9

3. Federation Dentaire Internationale (FDI) 3—canine,

System
♦ This two-digit system was first introduced in 1971
and subsequently adopted by the American Dental
Association (1996).
♦ FDI system is known as a "Two-Digit" system because
it uses two digits; the first number represents a tooth's
quadrant, and the second number represents the
number of the tooth from the midline of the face (Figs.
2.7A and B).
♦ Both digits should be pronounced separately in
communication. For example, the lower left permanent
second molar is "37"; it is not termed as “thirty-seven",
but "three seven”.
Permanent Teeth
♦ In FDI notation, teeth are numbered as 1,2,....8 where
1— central incisor,
2— lateral incisor,
4 and 5—1st and 2nd premolars respectively
6, 7, and 8—1st, 2nd, and 3rd molars.
♦ Quadrants are designated 1 to 4
1— upper right
2— upper left
3— lower left
4— lower right.
♦ This results in tooth identification a two-digit combi­
nation of the quadrant and tooth, e.g. the upper right
canine is “13” (one three) and the upper left canine is
"23” (two three).
Deciduous Teeth
♦ In the deciduous dentition the numbering is corres­
pondingly similar except that the quadrants are
designated 5, 6, 7, and 8 (Figs. 2.8A and B).
♦ Teeth are numbered from number 1 to 5,1 being central
incisor and 5 is second molar.

Figs. 2.7A and B: FDI tooth notation system for permanent dentition.

Figs. 2.8A and B: FDI tooth notation system for primary dentition.
10 Textbook of Operative Dentistry

Table 2.1: Permanent teeth.

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

Universal Numbering System

Upper Upper
right left

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

32 31 30 29 28 26 25 24 23 22 21 20 19 18 17

Lower Lower
right left

FDI Two-digit Notation

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

Table 2.2: Deciduous teeth.

Palmer Notation
E D C B A A B C D E

E D C B A A B C D E

Universal Numbering System

Upper Upper
right left

A B C D E F G H I J

T S R Q P 0 N M L K

Lower Lower
right left

FDI Two-digit Notation

55 54 53 52 51 62 63 64 65

85 84 83 82 81 72 73 74 75

Advantages Zsigmondy Palmer and FDI system of tooth notations

each having own advantages and disadvantages. Tooth
♦ Simple to understand notations are necessary in clinical practice for recording
♦ Simple to learn data of present or missing teeth, for communication and
♦ Simple to pronounce reference purpose.
♦ No confusion
♦ Each tooth has specific number ■ EXAMINER'S CHOICE QUESTIONS
♦ Easy to record on computers
♦ Easy for charting. 1. What are the different nomenclatures of teeth? Discuss
the FDI system in detail. Why is it widely used?
Disadvantage 2. Write short notes on:
a. Zsigmondy-Palmer system.
Maybe confused with universal tooth numbering system. b. Universal system.
The summary of all the tooth notation systems have been c. FDI system.
described in Tables 2.1 and 2.2. d. Two-digit notation.

■ c o n c l u s io n
■ VIVA QUESTIONS
Tooth nomenclature is an established method as basis 1. Name different types of tooth notation system.
for communication. Though various tooth numbering 2. Which is the oldest method of tooth notation system?
systems have been given, most widely used are Universal, 3. What is another name of Zsigmondy-Palmer system?
 Tooth Nomenclature
4. W hat is the advantage o f universal system over other
tooth num bering system?
5. W hat is the another nam e of FDI system?
6. W hat does the two digits indicate in FDI system?
■ b ib l io g r a p h y
1. Ash Major M, Nelson SJ. Wheeler's Dental Anatomy, Physiology,
and Occlusion, 8th edition; 2003. p. 198.
2. American Dental Association. Council on Dental Practice:
Dental Abbreviation, Symbols and Acronyms. Designation for
11
teeth, 2nd edition; 2008. p. 35. Available from: http://www.
ada.org/sections/professionalResources/pdfs/dentalpractice_
abbreviations.pdf [Last accessed on 2008 Dec 14] FDI Two
Digit Notation. Available from: http://www.fdiworldental.org/
two-digit-notatio.
3. Blinkhorn AS, Choi CL, Paget HE. An investigation into the use
of the FDI tooth notation system by dental schools in the UK.
Eur I Dent Educ. 1998;2:39-41.
4. Carlsen O- Dental morphology, Copenhagen; 1987.
5. ISO 3950:2009 Dentistry—Designation system for teeth and
areas of the oral cavity.
Chapter
Structure of Teeth
CHAPTER OUTLINE
"* Introduction
"* Enamel
Dentin
■ in t r o d u c t io n
Tooth is composed of three hard mineralized tissues
(enamel, dentin, and cementum), and one soft tissue
(pulp). The outermost layer, enamel, is the hardest tissue
in the body. It covers the crown of the tooth. The middle
layer of the tooth is dentin, which forms the main bulk of
tooth and extends almost the entire length of tooth, being
covered by enamel on coronal portion and cementum on
root part. Dentin is nourished by the pulp, which is the
innermost portion of the tooth. In this chapter, we will
discuss the structures present in teeth and their clinical
significance.
■ en a m el
Tooth enamel is the hardest and highly mineralized tissue
which covers crown of the tooth. It is responsible for
aesthetics, texture, and translucency of tooth.
1. Composition
It is highly mineralized structure. The main inorganic
content is hydroxyapatite.
Composition o f enamel
♦ Inorganic contents (by volume): Hydroxyapatite—
96%
♦ Organic contents (by volume) organic content and
water 4%.
Dental Pulp
'* Periradicular Tissue
Significance: Poorly mineralized enamel appears whiter
and more mineralized enamel appears more translucent.
2. Structure
Enamel is mainly composed of enamel rods/prisms
covered by rod sheath and joined by interrod substance.
Their number ranges from 5 to 12 million. Each rod is
keyhole or paddle-shaped having head and tail, head
is directed occlusally and tail toward cervical area. In
transverse sections, enamel rod appears as hexagonal,
round or oval resembling fish scales.
Rods are oriented perpendicular to dentinoenamel
junction and follow a wavy course in clockwise and
anticlockwise direction. Toward incisal/occlusal surface,
these become almost vertical. At pit and fissures, rods
converge in their outward course. In the cervical region,
there is difference in the direction of the enamel rods of
deciduous and permanent teeth (Fig. 3.1).
Significance: Cervical enamel rods of deciduous teeth are
inclined incisally or occlusally, while in permanent teeth
these are inclined apically. Therefore to avoid unsupported
enamel rods at gingival floor, cavosurface bevel (15 to
20°) at gingival margin is given by using gingival margin
trimmer (GMT).
3. Thickness
Average thickness of enamel at incisal edges is 2 mm and at
cusp tip of molars, it ranges from 2.3 to 3.0 mm. Thickness
 Structure of Teeth
Cuspal direction
Cervical direction
Fig. 3.1 : Enamel rods showing keyhole pattern.
decreases gradually from cusps or incisal edges to cervical
area and terminates at cementoenamel junction (CEJ) as
knife edge (Fig. 3.2).
Enamel
Fig. 3.2 : Thickness of enamel at cusp tips is more which
ends cervically as knife edge.
4. Color
Enamel is translucent in nature. Color of tooth mainly
depends on:
i. Thickness of enamel; young anterior teeth appear
translucent gray or bluish near incisal edges. It
appears yellowish in cervical areas due to thin enamel
from which color of underlying dentin is visible (Fig.
3.3A).
ii. Shade of underlying dentin.
iii. Presence of stains in enamel.
iv. Anomalies occurring during developmental and
mineralization stage, antibiotic usage and fluorosis,
etc. affect the color of teeth (Fig. 3.3B).
13
Fig. 3.3A: Translucent gray or bluish color of enamel
at the incisal edges.
Fig. 3.3B: Fluorosis showing brown discoloration of teeth.
5. Hardness
Enamel is the hardest substance in human body. It is as
hard as steel. Its Knoop hardness number is 343, whereas
of dentin is 68. High modulus of elasticity and low tensile
strength makes it rigid and brittle in nature.
Significance: Because of more compressive strength of
dentin than enamel, dentin acts as a cushion for enamel
when masticatory forces are applied on it. Therefore, dur­
ing tooth preparation, to have maximum strength of un­
derlying remaining tooth structure, all enamel rods should
be supported by healthy dentin base.
6. Structures Present in Enamel
1. Gnarled Enamel
Gnarled enamel consists of bundles of enamel rods which
entwine in an irregular manner with other group of rods,
finally taking a twisted and irregular path towards the
tooth surface (Fig. 3.4). It is seen near incisal, occlusal,
and cervical areas.
Significance: In these areas, enamel is not easy to break as
regular enamel.