recent preparation in operative dentistry.pptx

‫الرحيم‬‫الرحمن‬‫هللا‬‫بسم‬

Different techniques for caries removal

For more than a century, since the creation of
belt-driven handpieces, dentists have been
removing caries based on the concept of drill,
remove, and restore. The remaining dentin is an
essential feature for long-term pulpal health.
Translated, this realization clearly means that
removing excess dentinal tooth structure and
encroaching on the pulpal tissue directly
correlate to potential negative pulpal outcomes.

 Minimum intervention dentistry (MI) can be defined as a philosophy of
professional care concerned with the first occurrence, early detection, and
earliest possible cure of disease on micro levels, followed by minimally
invasive, patient-friendly treatment to repair irreversible damage caused by
such disease.
 The benefits for patients from Minimal Intervention are:
1. Better oral health through disease healing and not merely on symptom relief.
2. Assists in reducing widespread patient dental anxieties.
3. more conservative approach to caries treatment and simultaneously offer
patients less invasive, health-oriented treatment options.

 The philosophy of minimal intervention dentistry has now arisen in an attempt to
combine all the present knowledge of prevention, remineralisation, ion exchange,
healing, and adhesion with the object of reducing carious damage in the simplest
and least invasive manner possible.
 Minimal intervention operative dentistry is dependent on the following factors:
1. The demineralization - remineralization cycle
2. Adhesion in restorative dentistry
3. Biomimetic restorative materials

Principles of Minimal Intervention
Adopted by the FDI General Assembly, 1st October
2002, Vienna, (FDI Statement, 2002)
1. Control the disease through reduction of cryogenic flora
• Only in the absence of disease will restorative dentistry succeed.
• This is why control of the disease is the primary focus and only when
such control has been achieved will it be possible to offer long-term
repair of the damage.
• Correct diagnostic procedures must be carried out for any at-risk
patient to determine the potential for carious activity.
• Modification of the oral microflora is essential in the initial stage, and a
number of oral lavages are available to modify the balance of the oral
flora although chlorhexidine is probably the most effective of these.
Ref. pg no. 450-451, Nikhil Marwah, 2nd edition

2. Remineralize early lesions –
• Remineralization should be recognized and utilized as far
as possible for any tooth that has been subject to attack
by caries, because there is no real substitute for natural
tooth structure.
• It has been known for many years that “ white-spot”
lesions on the visible surfaces of teeth can be
remineralized and repaired.
• Successful remineralization requires intensive patient
must have a full understanding of the implication of food
types, the need for plaque removal, and the possible
need for additional oral lavages for control of bacterial
populations.

3. Perform minimal intervention surgical
procedures, as required-
• If the disease has progressed to cavitation on the tooth
surface, it is no longer possible to completely control
plaque accumulation without some degree of surgical
intervention.
• In view of the potential for remineralization and healing a
minimal intervention approach is encouraged.
• The principle of preservation of natural tooth structures
should dominate decisions about both new and old
lesions.

4. Repair, rather than replace, defective
restorations-
• The replacement of any failed restoration will also
lead to further loss of tooth structure and
subsequent weakening of the remaining crown.
• This steady progression should be limited as far as
possible; with the advent of adhesion, biomimetic
materials, and minimal intervention cavity designs,
it is often possible to repair, rather than replace, a
restoration that has suffered a limited failure.

I. BASED ON SITE AND SIZE OF LESION
(Mount and Hume, 1998)

Classification of Cavities based on site
and size of lesion

ATRAUMATIC RESTORATIVE TREATMENT (ART)
• The Atraumatic restorative treatment is a procedure based on
removing carious tooth tissues using hand instruments alone and
restoring the cavity with an adhesive restorative material.
• It is also known as “Alternative Restorative treatment”.
• ART is launched by the World Health Organization on 7th April, 1994
(world health day).
• Goals of ART are:
i. Preserving the tooth structure
ii. Reducing infection
iii. Avoiding discomfort
Ref. pg no. 443, Nikhil Marwah, 2nd edition
Ref. pg no. 320, S.G. Damle, 3rd edition

• The essential instrument used for ART
are:
1. Mouth mirror
2. Explorer
3. Pair of tweezers
4. Dental hatchet
5. Small, medium sized spoon excavators
6. Glass slab
7. Spatula
8. Carver
• The materials used are:
1. Gloves
2. Cotton rolls and pellets
3. Glass ionomer restorative material
4. Dentin conditioner
5. Petroleum jelly
6. Wedges
7. Plastic strips and water
Ref. pg no. 320, S.G. Damle, 3rd editio

Procedure for ART:
The tooth is isolated with cotton rolls
The tooth surface to be treated is cleaned with a wet cotton pellet
The entrance of the lesion is slightly widened by hand instrument to remove gross
overhanging unsupported enamel rods
The dental caries is removed by using either the small or medium size spoon shaped
excavator
If necessary provide pulpal protection by calcium hydroxide paste
The cavity surface along with occlusal margins are cleaned
The cavity is acid - etched

According to manufacturer’s instructions the glass ionomer cement is mixed
The mixed glass ionomer is inserted into the cavity and slightly overfield
A gloved finger, which is smeared with petroleum jelly, is pressed on top the entire
occlusal surface and slight pressure is applied
The bite is checked
Excess material is removed with a sharp carver
The bite is rechecked and all high points are removed
The filling is covered with petroleum jelly once again or the varnish may be applied
The patient is instructed not to bite with the tooth for at least half an hour

fig 1. preoperative
fig 2. excavation of caries
fig 3. cavity after caries removal
fig 4. cavity conditioning
Procedure for ART
S
T
E
P
1
S
T
E
P
2
S
T
E
P
3
S
T
E
P
4
Ref. pg no. 443, Nikhil Marwah, 2nd edit

fig. 5- Dispensing of GIC
fig. 6- Mixing of GIC
fig. 7- Insertion of GIC
fig. 8- Restored cavity
S
T
E
P
5
S
T
E
P
6
S
T
E
P
7
S
T
E
P
8

Advantages of ART
1. Easily available inexpensive hand instruments are used rather than the
expensive electrically driven dental equipment.
2. As it is almost a painless procedure the need for local anesthesia is eliminated
or minimized.
3. ART involves the removal of only decalcified tooth tissues, which results in
relatively small cavities and conserves sound tooth tissues as much as possible.
4. Sound tooth tissue need not be cut for retention of filling material.
5. The leaching of fluoride from glass ionomer probably remineralizes sterile
demineralized dentin and prevents development of secondary caries.
Ref. pg no. 443, Nikhil Marwah, 2nd

 The combined preventing and curative treatment can be done in one
appointment.
 Repairing of defects in the restoration can be easily done
 It is less expensive and less time consuming.
 It enables to oral health workers to reach people who otherwise never
would have received any oral health service.
Ref. pg no. 443, Nikhil Marwah, 2nd

Disadvantages of ART
 ART restorations are not long lasting. The average life is two years
depending upon the rate of caries activity of the individual oral cavity.
 Because of the low wear resistance and low strength of the existing glass
ionomer materials their use is limited.
 A relatively unstandardized mix of glass ionomer may be produced due
to hand mixing.
 The continuous use of hand instruments over long period of time may
result in hand fatigue.
 As fundamental principles of cavity preparation are not followed all oral
health workers may not accept it.

Site 2 Size 1 - tunnel
Fig. 1. Initial approach – Enter the
lesion from the occlusal fossa aiming
towards the lesion.
Fig. 2. Gain access – Turn the bur
vertical and lean it buccally and
lingually to ‘funnel’ the cavity for
visibility.
Fig. 3. Completed cavity – axial wall
left untouched.
Fig. 4. GIC Restoration done
Ref. pg no. 129, G.J. Mount and W.R. Hume, 2nd edition

T he early proximal lesion on a posterior tooth will commence in enamel
immediately below the contact area because this is where plaque will
accumulate and mature.
As the lesion develops, some degree of breakdown and cavitation of the
enamel will eventually occur, but this will remain confined to the area below
the contact until it is quite advanced.
There will generally be a zone of demineralized enamel surrounding the
cavitation, but as long as the surface is smooth, this remains capable of
remineralization in the presence of fluoride.
The contact area may remain sound and the marginal ridge may be quite
strong, provided the lesion is more than 2.5 mm below the crest of the
marginal ridge (Wilson and mcLean, 1988).
TUNNEL PREPARATION

 Access to the lesion through the occlusal surfaces should be limited to the
extent required to achieve visibility and should be undertaken from an
area that is not under direct occlusal load (Knight, 1984).
 Fossa immediately next to medial marginal ridge is the most suitable
position for entry.
 Glass ionomer is best suited for such cavities as it readily flows into a small
cavity and has the ability to remineralize the enamel margins and any
dentin on axial wall.
• Two variations are described:
Closed ‘tunnel’ : Which leaves the demineralized approximal enamel intact
Open ‘tunnel’ : Which is accessed from occlusal and exits through the
approximal surface

Indications and Contraindications
• Use of tunnel preparation can be considered
when small, proximal carious lesions necessitate
restoration
• Preparation should be avoided:
i. large carious lesion are diagnosed, where access is
particularly difficult
ii. Overlying marginal ridge is subjected to heavy occlusion
or demonstrates a crack

Advantages of Tunnel Preparation
• Preserves the marginal ridge - conservative approach
• Less potential for a restorative overhang
• Perimeter of the restoration is reduced, decreasing the
potential for micro leakage.
• Potential for disturbance of the adjacent tooth is reduced

Disadvantages of Tunnel Preparation
 Highly technique sensitive, demanding careful control of the
preparation by the operator
 Angulations of preparation often passes close pulp
 Visibility is decreased and caries removal is more uncertain -
caries detecting solution
 Fragile marginal ridge - at least 2.5 mm apical to crest of the
marginal ridge (Mount 1997)

Site 2 Size 1 – Minibox / Slot
Fig. 1. Small carious lesion on
the proximal surface of the
first bicuspid
Fig. 2. Slot cavity preparation
Fig. 3. Finished slot cavity Fig . 4 Resin modified GIC
Restoration done

“SLOT CAVITY PREPARATIONS”
 It could be used when the lesion is less 2.5 mm below the crest of the
marginal ridge.
 The basic principles of cavity design remain the same, with the objective of
removing only that tooth structure that has broken beyond the possibility of
remineralisation.
 If this is allowed to dictate the extent of the cavity, there will many occasions
with this design where there is sound contact with the adjacent tooth in one
or more areas. It is desirable to retain this to ease the problems of
maintaining a good, firm contact area.
 The outline form will be dictated entirely by the extent of the breakdown of
the enamel, removing only that which is friable and easily eliminated
without applying undue pressure .

 Retention will be through adhesion, so it is only necessary to clean the
walls around the full circumference of the lesion, leaving the axial wall
because it will be affected by dentin only.
 For such a lesion, resin composite may be a useful material because on
many occasions there will be a useful material because on many
occasions there will be an enamel margin around the full circumference.
 However, glass ionomer is still a sound option because the occlusal load
will not be great and the ion exchange will remain valuable both for
adhesion and remineralization.

Site 2 Size 1 – Proximal Approach
Fig. 1. Proximal approach. A
small proximal lesion becomes
accessible through a
traditional cavity prepared in
the adjacent tooth
Fig. 2. Restoration. The
cavity has been restored
with GIC before placing the
other restoration

Recent Cavity Classification Systems

The different concepts in caries removal
1-Ozone therapy
2-Air abrasion technique
3-Chemomechanical caries removal
4-Smart bur
6-Use of laser in tooth preparation
7-Use of ultrasonic in tooth preparation

Ozone therapy
Ozone is a gas made up of three
molecules of oxygen. When it is applied
to bacteria and other organisms, the
Ozone completely destroys them.
It is used in dentistry by utilizing a special
delivery system.
The portable apparatus includes a source of
oxidizing gas and a dental hand piece for delivering
the gas/water to the target tooth at a concentration
of 2100 ppm.

A cup attached to the hand piece is provided
for receiving the gas and exposing a selected
area of the tooth to the gas action.
The ozone gas is refreshed in this disposable
cup at a rate of 615cc/minute changing the
volume of gas inside the cup over 300 times
every second.
The cup forms a seal around the lesion being
treated so that ozone cannot leak into the oral
cavity.

Air abrasion technique*
•The use of air abrasion
techniques in dentistry
allows the removal of
decayed tissue without
the removal of the
healthy tooth
substance.
*Reis-schmidt T. Air abrasion cavity-preparation system provide cutting-edge option in
restorative dentistery :dent prod report 1998;32(12);57-60,108-9

Principles of Air abrasion
1. Accurate diagnosis of unsound tooth structure and
decay.
2. Accurate removal of unsound tooth structure with
minimal destruction of sound tooth structure.
3. Restorative treatment planning based on the
probability of longevity of the restorative material.
Ref. pg. no. 440, Nikhil Marwah, 2nd edition

Procedure of Air Abrasion
Take preoperative radiograph to determine if interproximal caries is present
Isolate preferably with rubber dam
Use caries detecting dye to know the carious lesions
Using air abrasive unit with high volume evacuation placed in the proximity of the
tooth prepare cavity
After a few seconds of initial preparation examine the preparation for decay
Re-apply caries detecting dye
Complete the preparation using the caries detecting dye until all caries is removed
Ref. pg. no. 440, Nikhil Marwah, 2nd edit

Apply the etchant for 20 seconds rinse with water spray
Disinfect the cavity preparation with chlorhexidine or other materials
Within 10 seconds apply the dentin-bonding agent
Immediately place the correct shade of composite and photo-polymerize the material
for 40 seconds
Use a carbide bur for initial shaping
A flexible polishing cup point or disc will provide the final polish for the restoration
Remove the rubber dam and check occlusion
Ref. pg. no. 440-441, Nikhil Marwah, 2nd edition

Precautions
1. Need to protect patient with glasses, rubber dam if possible.
2. Dental team needs masks and glasses.
3. Stop frequently to check the progress.
4. Start with low pressure and low power then increase as needed.
5. Hold tip 1-2 mm away from tooth at a 45 degree angle then
activate.
6. Always keep tip moving.
7. Requires external suction and air evacuation for the room.
8. Use disposable mirrors.
9. Like any air stream air abrasion can cause subcutaneous
emphysema.

Clinical uses:
• Class I, II, III, IV, V cavity
preparations
• Sealants and preventive
restorations
• Repair of composite and
porcelain especially margin of
veneers
• Removal of composite and
amalgam.

• The apparatus involves minute abrasive
particles which are too small to be seen by the
naked eye carried to the target tooth by a
stream of air gently and precisely acting to
remove away the decayed tooth structure
• It is recommended for treatment of children,
pregnant women and other medically
compromised patients.

Chemomechanical caries provides painless
and efficient removal of carious dentin and no
administration of local anaesthesia.
Chemomechanical caries
removal

 This techniques is based on altering the
secondary and /or quaternary structure of
collagen in carious dentin by chlorination
of the collagen.
 The hydrogen bonding in the collagen is
disrupted rendering it more friable and
easier to remove by scrapping the carious
fragments away.

Caridex
• Caridex was developed by CM Habib from a formula made of N-mono -
chloroglycine and amino butyric acid and was called as GK 101 E.
• It gained FDA approval in 1984.
• It was initially introduced on the US market in 1985.
• The system involved the intermittent application of preheated N-
monochloro-DL-2-aminobutyric acid (GK-101E) to the carious lesion.
• The solution was claimed to cause disruption of collagen in the carious
dentine, thus facilitating its removal.
• The mechanism of softening involved chlorination of remaining partially
degraded dentinal collagen and the conversion of hydroxyproline to
pyrrole-2-carboxylic acid, which initiated disruption of the altered collagen
fibers in the caries.
Ref. pg. no. 387, Nikhil Marwah

 Disadvantages-
1. Expensive
2. Large quantity required
3. Solution had to be heated
4. Short shelf-life
5. Hand instruments were not optimum

Carisolv
• During the 1980s studies at the universities by Malmo, Huddinge
at Chalmers Technical university in Goteborg was directed toward
a more efficient and effective chemomechanical caries removal
system than caridex.
• Carisolv key difference to other products already in the market
was the use of three amino acids – Lysine, leucine, and glutamic
acid – instead of the aminobutyric acid.
• These aminoacids counteracted the sodium hypochlorite
aggressive behavior at the oral healthy tissues.
• Despite its effectiveness, carisolv was not a blockbuster mainly
because it required-
1. Extensive training and registration of professionals
2. Customized instruments which increased the cost of the solution.
Ref. pg. no. 388, Nikhil Marwah, 2nd editio


Constituents of carisolv
• Syringe one: sodium hypochlorite (0.5%)
• Syringe two: three amino acids (glutamic
acid, leucine, lysine)
• Gel substance: carboxymethlcellulose
• Sodium chloride / sodium hydroxide
• Saline solution coloring indicator (red)
• Available as single mix or multi mix
syringes.
• New gel formulation

Indications of Carisolv
• Where the preservation of tooth structure is important.
• The removal of root / cervical caries.
• The management of coronal caries with cavitation.
• The removal of caries et the margins of crowns and bridge
abutments.
• The completion of tunnel preparations.
• Where local anesthesia is contraindicated.
• The care of caries in dentally anxious patients, notably needle
phobic's.
• Management of primary carious lesions in deciduous teeth.
• Atraumatic restorative technique procedures.
• Caries management in patients with special needs.

Cavity preparation using Carisolv
Mix the two components of carisolv (NaOCl and amino acid solution) thoroughly according to the
instructions included with the package. Put the required amount of gel into a suitable container.
Use a carisolv instrument to pick up the gel and apply it to the carious dentine
Soak the caries generously
Wait for at least 30 seconds, for the chemical process to soften the caries
Scraped off the superficial softened carious dentine. The hand instrument with the multistar tip may
facilitate the early penetration of the gel. Work carefully using scraping or rotating movements
Select a power drive tip or a Carisolv hand instrument to match the size, position and accessibility of the
cavity

Keep the lesion soaked with the gel and continue scraping. 30 seconds of waiting time is needed
Repeat until the gel no longer turns cloudy and the surface feels hard using the instrument
Check extra carefully for caries at the dentinoenamel junction. If you are using a drill to adjust the periphery
before filling, this can be done while the gel is still in the cavity
When the cavity feels free from caries, remove the gel and wipe the cavity with a moistened cotton pellet or
rinse it with lukewarm water, inspect and check it with a sharp probe
If the cavity is not free from caries, apply new gel and continue scrapping
If necessary the periphery of the cavity should be adjusted using hand instruments or the drill
Restore the tooth with a suitable filling material according to the manufacturer’s instructions for use
Remove the softened carious dentine with the instrument. Avoid flushing or drying the cavity

Advantages of Carisolv
• Three amino acids are incorporated instead of one, and the
different charges have improved the interaction with the degraded
collagen within the lesion, thus increasing the efficacy.
• Carisolv has a higher viscosity, which allows for the application of
higher concentrations of amino acids and sodium hypochlorite
without increasing the total amount of fluid used, therefore
reducing the total volume required.
• The solution does not need to be heated, or applied through a
pump mechanism.
• The increased viscosity of carisolv enhances precision placement.
• The overall stability is increased, giving an improved shelf life.

 Procedure for using carisolv gel:
1. The gel is applied to the carious lesion with a hand instrument.
2. After 30 seconds, carious dentin is removed gently by scraping
with a hand instrument.
3. More gel is then applied and the procedure repeated until no
more carious dentin remains, a guide to this being, when the gel
removed from the tooth is clear.
Ref. pg. no. 492, S.G. Damle, 3rd edition

CARIDEX CARISOLV
Chemical
Composition
Dye
PH
Physical properties
Volume Needed
Time Required
1% NaOCl
0.1 M aminobutyric acid
Glycine
NaCl and NaOH
----
11
Liquid
100-500 ml
5-15 mins
0.5% NaOCl
0.1 M glutamic acid /
luecine
NaCl and NaOH
Erythrocin (pink)
11
Gel
0.2-1.0 ml
5-15 mins
Comparison of two systems for chemicomechanical removal of caries
Ref. pg. no. 491-492, S.G. Damle, 3rd edition

(SFC-VIII gel)
Papain Gel
• In 2003, a research project in Brazil led to the
development of a new formula to universalize the use
of chemo-mechanical method for caries removal and
promote its use in public health.
• The new formula was commercially known as
papacarie.
• It is basically composed of Papain, chloramines,
toluidine blue, a phosphoric
• acid/sodium biphosphate buffer salts, thickening
vehicle, which together are responsible for the
papacarie’s bactericide, bacteriostatic and anti-
inflammatory characteristics.
• Papain comes from the latex of the leaves and fruits of
the green adult papaya.
PAPAIN GEL

• The main advantage of this new enzyme-based solution is that it
can be more specific by digesting only denatured collagen than
the sodium hypochlorite-based agents
• Papain promotes:
I. Chemical debridement
II. the phosphoric acid dissolves the inorganic component
III. pepsin access to the organic part of the carious biomass to
selectively dissolve the denatured collagen..

Mechanism of action
• used in combination with a prototype plastic
instrument having hardness
• between that of sound and infected
dentin.Since Papain can digest only dead
cells, it acts breaking the partially degraded
collagen molecules, contributing to the
degradation and elimination of the fibrin
“mantle” formed by the carious process.
• Heavily pigmented,
• arrested dentin caries is known to be more
resistant to pepsin digestion

• For removal, we recommended the use of the opposite side
of an excavator, like a pendulum movement and without
cutting.
• The instrument should scrap the carious tissue without
promoting any kind of stimulus or pressure.
• The main characteristics of the complete removal of the
infected dentinal tissue is the vitreous aspect of the cavity
which appears after using Papacarie.

Clinical procedure of Papain Gel
Radiograph of the target tooth
Prophylaxis of the region using rubber cup and slurry of pumice
Rinsing with air/water spray or cotton pellet with water
Isolation of target tooth
Application of Papacarie, allowing the chemistry to work for 30 to 40 seconds
Removal of the softened carious dentin using the opposite side of the excavator and promoting a pendulum
movement; the softened tissue must be scraped, not cut
Application of gel, if necessary

Rinsing 0.12%, 1% or 2% chlorhexidine or waterspray
Drying with moisture-free and oil-free air
Restoration with a suitable filling material according to manufacturer’s instructions
The vitrous aspect of the cavity appears when the cavity feels free from caries

1. Arrow indicating proximocclusal carious lesion
2. Isolation and application of Papain Gel
3. Caries had been removed
4. Arrow showing filled cavity with composite
Clinical procedure of Papain Gel

Advantages of chemico-mechanical method
• Its proven effectiveness
• Method’s safety
• Elimination of local anesthesia
• Lower anxiety built in patients
• Conservation of the sound tissue
• Only demineralised dentine containing collagen is
affected.
• Gel consistency simplifies control of the application and
reduces the risk of spillage.

Smartprep
(Smart bur)
 The SMARTPREP Instrument is a medical grade
polymer that safely and effectively remove decayed
dentin, leaving healthy dentin intact.
 The polymer instrument is self-limiting and will not
cut sound dentin unless applied with great force, and
then it will only wear away, rather than cut the
healthy dentin.

CeraBurs
• made of alumina-
• yttria stabilized zirconia

Ultrasonics in tooth preparation
The use of ultrasonic
tips has become an
alternative for cavity
preparation. However,
there are concerns
about this type of
device, particularly with
respect to intrapulpal
temperatures and cavity
preparation time.

• Cariex diamond-coated tips for
• enamel preparation
Cariex diamond-coated tips forenamel preparation.
Cariex tungsten carbide tips for
dentin excavation.

laser in tooth preparation
Lasers are used to
remove decay within
a tooth and prepare
the surrounding
enamel for receipt of
the filling. Lasers are
also used to "cure" or
harden a filling.

Refrences
Nisha Garg, Amit Garg.Textbook of
Operative Dentistry. Second
Edition.2013;ch.5,ch.6
Bjorndal L. in deep cavities stepwise
excavation of caries can preserve the
pulp.Evid based dent.2011;12(3):68.

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