• Concepts of ART
• Instruments & Materials used
• Causes of failure and treatments
• A new method for treating dental caries that
involves neither water nor electricity was
presented. The procedure called as ATRAUMATIC
RESTORATIVE TREATMENT. It Consists of manual
excavators until maximum amount of decayed
tissue is removed with hand instruments. A highly
density glass ionomer cement (GIC) seals the
cavity and a follow up is performed every year. In
this procedure oral health care workers need only
a few instruments that can be carried easily with
• ART was developed following the mentioned
principles and it is on line with the philosophy of
• What started as an alternative resource for out-
reach situations, it became one of the most
flexible methods for caries removal and
restoration of the cavity in many private dental
Traditional concepts of cavity design
‘The application of a mechanical design on a
Traditional concepts of cavity design
– Flat floors
– Vertical walls
– Triangular retention
– Undercut areas
Biological principals of cavity preparation
• Great technique for root caries
• Good alternative in out reach situations
• Excellent for fearful children
• Good alternative in medically compromised
• Good alternative in mentally compromised
It is popular among millions of peoples because:
• it is non threatening
• non painful
• low cost
• it is also simple to practice
• the instruments can be carried out in a bag
• it is more effectively reached to the community.
• and can prevent extraction in most cases.
• Biological approach with minimal cavity preparation.
• Gain all the advantage of the GIC as a restorative material.
• ART was pioneered in the mid 1980s in the Tanzania and the careful application of
ART decreases 85% of chances of caries for 3 years
INSTRUMENTS & MATERIAL USED
• The success of any treatment depends on the operator
knowing the function of the various instruments and
using them correctly.
• (1)Mouth mirror:-to reflect light onto the field of
operation, to view the cavity indirectly and to retract
the cheek or tongue.
• (2)Explorer:-to identify where soft caries dentin is
present. Do not poke the point into very small caries
lesion. This may destroy the tooth surface and the
caries arrestment process. Also do not probe into deep
cavities where you might damage or exposure the pulp.
• (3)Pair of tweezers:-to carry cotton wool rolls, wedges.
• (4)Small and medium sized spoon excavators:-this
instrument is used to remove soft carious dentine.
small excavator have a diameter of 1 mm. this
instrument is for use in small cavities and for
cleaning the enamel/dentin junction.
the diameter of this medium spoon is 1.5 mm. it is
used for removing soft caries from large cavities
rounded surface is used to push the material into
(5) Dental hatchets:-this instruments is used for
widening the entrance to the cavity, for slicing away
the unsupported and carious enamel left.
(6)Applier and carver:- this double ended instrument has two
functions. blunt end is used for inserting GIC into the cavity and sharp
end is used to remove the excess material and shape the restoration.
(7)Mixing pad and Spatula:-the mixing pad that is supplied with the
cement and the spatula may be metal or plastic.
(8)Light source that is powered by a rechargeable battery source is
The essential materials
• (1)Gloves:-for hygiene purpose.
• (2)Cotton wool rolls:-to absorb the saliva.
• (3)Pellets:-for cleaning the cavity.
• (4)Petroleum jelly:-prevents GIC sticking to the gloves and
for final insulation.
• (5)Wedges:-these are used to hold the plastic strips close to
the shape of proximal surface of a tooth so that restorative
material is forced between the tooth and gums.
• (6)Plastic strips:-used for contouring the proximal surface
in multiple surface restorations.
• (7)GIC material
• Known attributes of Glass Ionomer materials
– Adhesive properties
– Degree of wear resistance
– Fluoride release
– Remineralization capabilities
• Unknown effect on salivary mutans strep
WHAT TO DO BEFORE APPLYING ART?
• Before you actually start the atraumatic
restorative treatment of a carious lesion in a
tooth you should know how to
• (1)Arrange a good working environment.
• (2)Select and use the correct instruments.
• (3)Control cross infections.
• (4)Use the GIC material.
Arrangements of good working
• The correct positioning of both the operator and
patient is essential to achieve good quality care.
At the same time both patient and operator
should be comfortable.
• The distance from the operators eye to patients
mouth is usually between 30-35 cm. the operator
should be positioned behind the head of the
patient the exact position will depend on the area
of the patient mouth to be treated. The most
common position are 12 and 10 o’ clock.
• A dry operating area, A very important aspect for the
success of ART is control of saliva around the tooth
being treated. Cotton wool rolls are quite effective at
absorbing saliva and can provide short term
protection from moisture /saliva.
• HYGENE AND CONTROL OF CROSS INFECTIONS
Always wear gloves. Cleaning and sterilization is
necessary to prevent infection. Cleaning of the
surface can be done by cotton and methyl spirit. In
the clinic the instruments can be sterilized by
autoclave or a pressure cooker. All these preventive
measures prevent the spread of HIV and HBV.
The procedure for caries removal for
one surface cavities step by step
• (1)Place cotton wool rolls alongside the tooth to be treated.
• (2)Remove plaque from tooth surface with wet cotton wool
• (3)Dry the tooth surface with dry cotton wool pellets
• (4)If necessary make the entrance of the cavity wider with
• (5)Remove the carious dentin with excavators .
• (6)Remove unsupported thin enamel with the hatchet.
Make sure the enamel does not contain any carious lesion.
• (7)Clean the cavity with wet and then dry cotton wool
• Remove the caries near the pulp carefully, and provide pulp
protection if necessary.
• (9)Clean the cavity again with wet cotton wool pellets.
(8)insert the mixed GIC into the cavity and overfill slightly.
Press petroleum jelly with coated gloves fingers from the
top of the occlusal plane surface and apply slight pressure.
This is called Press finger technique.
• (10)ask the patient to bite to check the bite relations.
• (11)Remove the excess material with carver.
• (12)Recheck the bite and adjust the height of the
restoration until comfortable.
• (13)Cover the filling or sealants with petroleum jelly once
again or apply varnish.
• (14)Instruct the patient to not eat at least for one hour.
• In order to enhance the adhesiveness between
the tooth and GIC, cavity walls must be clean.
Other chemicals for this purpose are dentin
conditioners 10% solutions of poly acrylic acid
apply one drop to the cavity wall for 10-15
• Note:-In case of multiple surface restoration
plastic strips and wedges were used.
Failed or defective restoration:-
• A restoration may not be acceptable or
unsatisfactory anymore for several reasons. It
is completely missing, a large part of it has
broken, fractured restoration, the restoration
has worn away or caries has developed at the
restoration margin or elsewhere on the tooth
Restoration is completely missing due
• Restoration is completely missing
Contamination with saliva or blood during the
restorative procedure . Mix of material was
too wet or too dry. Not all the soft caries had
been removed. Thin undermined enamel had
been left behind and this later broke off.
2. Part of the restoration has broken
• it is probable that the restoration was too high
or air bubbles were trapped in the material
during the placement of the restoration.
whatever the reason clean the tooth surface
and/or remaining restorative material with an
explorer or small excavator and wet cotton
wool pellets first, before conditioning the
entire surface and material, fill the gap with a
new mixture of GIC and ensure that the
restoration is not too high
3. The restoration has fractured
• This most commonly happens in a multiple
surface restoration which was too high. the
way to repair it depends on the location of
the fracture line and the mobility of the
fractured part. If the fractured part is loose
and can be removed, repair the gap as
describe as above. however if the fractured
part can not be removed repair through ART is
not possible and traditional treatment using a
drill is needed.
4. The restoration has worn away
• Possible reasons, the patient eats very hard
food frequently, the patients clenches his/her
teeth frequently or the mixture had been too
wet or too dry. The restoration should be
rebuilt, ensure that all the surface of the tooth
and the remaining restoration are clean and
free from soft tissues.
• Apply dentin conditioner over the glass ionomer
and the cavity walls . Place a new layer of GIC on
top of the old one, finish the restoration as
5. Caries has developed
• May be in the adjacent fissure or pit. Remove
all the soft decay . Clean and restore the new
cavity adjacent to the restoration according to
the standard procedure.
Performance of ART Restorations
• ART needs to be considered as a caries treatment
modality that benefits people
• ART should be taken seriously by the dental
profession and dental schools
• Organized educational courses need to be taken
prior to applying the approach in the field and
• Art and Science
• Frenken J,Holmgren C The Atraumatic
Restorative Treatment approach. In tissue
preservation in caries treatment.
Quintessence Publications,2001 chapter 7.
• Gustavo F,Gaston P Diverse fields for ART