Conservative approach

in restorative dentistry
(Minimum Intervention)

part 1
For most of the 20th century, carious lesions were treated following
Black’s principles where diseased portions of the tooth were
surgically removed and the cavities were extended to areas which
were presumed to be caries-resistant.
The reasons for this approach were:

1. Lack of understanding of the caries process and particularly

the potential for remineralization.

2. The poor physical properties of the available restorative

materials.

Therefore, it is necessary to re-evaluate the surgical model of

treatment which deals with the defect only and to review Black’s
principle of “extension for prevention” to highlight it’s
consequences.
Black’s principle of extension for prevention:

Ø It sacrifices sound enamel & dentin for the sake of placement of

cavity margins into self-cleansing areas.

Ø Cavity preparations are extended through fissures to allow

cavo-surface margins to terminate on non-fissured enamel.

Ø This principle was justified to achieve resistance & retention

forms required for amalgam restorations.

Recently, the concept of “extension for prevention” is substituted

by the theory of “ prevention rather than extension ” by
implementing caries risk assessment, prevention and
remineralization of demineralized non-cavitated tooth structures.
Consequences of Black’s principle of extension for prevention:

1. Gross weakening of the remaining tooth structure.

2. Structural and marginal failure of the restorations.

3. Increased potential to pulpal irritation.

4. Increased gingival & periodontal irritation.

5. Increased restorative display.

6. More time & effort.

7. Difficult maintenance of the restorative system.

 Conservative approach

In the past, conservatism was targetting only the minimization of

tooth structure cutting. However, in the modern conservative
theory conservatism uses a medical model to avoid cutting in the
teeth if possible by detecting the lesion in its subclinical stage.

Advantages of the medical model of treatment:

• Prevents development of new lesions.

• Stops the progress of already existing lesions.
• Maintains the existing old restorations.
• Controls the defects without cutting in the tooth structures or if
cutting is necessary, it will be restricted as much as possible.
 Conservative approach

Principles of the conservative approach:

• Control of the causative factors.

• Remineralization of early lesions.

• Minimal operative interventon for cavitated lesions.

• Repair rather than replacing defective restorations.

 Essentials to allow conservation

Several factors contribute together to achieve conservation:

1. Operator.

2. Tools used.

3. Restorative materials employed.

4. Oral environment conditions.

5. Socio-economic conditions of the patient.

 1. Operator

The major role is played by the operator. Understanding the nature

of the defect affecting the hard tooth structures is very important in
deciding the line of treatment.

Previously, it was believed that caries is an irreversible condition.

N o w, i t i s e v i d e n t t h a t t o o t h s t r u c t u r e i s s u b j e c t e d t o
demineralization/ remineralization cycles in which it loses or gains
minerals.
 1. Operator

Thus caries can be treated by allowing remineralization to occur

more than demineralization to win the battle. This requires firstly
elimination of the micro-organisms to suppress demineralization
and secondly saturation of saliva with calcium, phosphates and
fluorides to enhance remineralization.
These changes in concepts require that the knowledge, experience
and skill of the operator should synchronize to outline of the
treatment strategy to be followed.
 2. Tools used

In order to practice minimal invasive dentistry, it is necessaryto

utilize:

1. Magnification.

2. Advanced diagnostic tools.

3. Non-invasive cutting tools.

 2.1. Magnification

Using the naked eye to perform restorative procedures sometimes

limits it’s accuracy. Magnifying the field of operation with loupes
or microscopes improves diagnosis of incipient caries and
minimizes cutting of healthy tooth structures.

• Loupes:

Similar in appearance to eyeglasses and allows magnification in

the range of 2X-5X.

It could be customized by the user and sometimes associated with

lighting to improve visibility.
 2.1. Magnification

• Microscopes:

Allow magnification in the range of 10X-25X.

The higher the magnification the smaller the field becomes so

frequent adjustments may be needed if the work is moved.

Microscopes are either fixed or mobile.

 2.2. Advanced diagnostic tools

The use of a sharp explorer and the analysis of bitewing

radiographs have been used for a long time ago and actually are
being used till now.

But, it was proved that by the time a good solid stick is achieved
with the sharp explorer, the lesion is already unnecessarily large.
Moreover, probing may disrupt the tooth surface and predispose to
cavitation or may lead to misdiagnosis due to stickiness of deep
non-carious fissures.
 2.2. Advanced diagnostic tools

This led to the development of several techniques that help the

operator to reach to an early accurate diagnosis. Such as:

a. Intra-oral camera.

b. Digital radiography.

c. Laser-based devices.

d. Digital imaging fiber optic transillumination (DIFOTI).

e. Electrical caries monitor (ECM).

 2.2.a. Intra-oral camera

It is a camera placed inside the oral cavity to allow displacement

of intra-oral images of exceptional quality on a computer screen.

It helps in patient communication and demonstration of the

treatment required.

They offer improved visual access to the cavities by lighting and

magnification.
 2.2.b. Digital radiography

Advantages over conventional radiography:

1. Lower radiation exposure for the patients.

2. No need for dark room.
3. Possibilty of image enhancement.
4. Possibility of magnification.

Helpful in diagnosis of initial proximal caries while it is not

helpful in detection of occlusal enamel caries.

The main disadvantage is that radiography underestimates the size

of the lesion.
 2.2.b. Digital radiography

In order to assess raiographic changes in proximal lesions, a

suitable classification is as follows:

E1 ; outer half of enamel

E2 ; inner half of enamel
D1 ; outer third of dentin
D2 ; middle third of dentin
D3 ; inner third of dentin

a tooth with no carious lesion in designated E0.

 2.2.c. Laser-based device (Diagnodent)

The device works on the fluorescent nature of bacterial metabolic

by-products.

A light with specific wavelength is transported through the tip to

the tooth surface and a photodiode measures the reflected
fluorescence which is transformed to a numerical value on a digital
display screen.
Two fiberoptic tips are available, a tapered one for the fissure
caries and a flat one for smooth surface caries.
2.2.d. Digital Imaging Fiber OpticTransillumination (DIFOTI)

Its technology is based on the fact that carious enamel has lower
index of light transmission than sound enamel. A high intensity
light is shone through the tooth and the transilluminated image of
the tooth is captured by an intraoral camera connected through a
computer software to display the image on a computer screen to be
diagnosed.

It is helpful in detecting incipient caries on the occlusal, facial and

lingual surfaces, and around restorations as well.
 2.2.e. Electrical caries monitor (ECM)

It is based on the difference of electrical conductivity between

sound and carious dental tissues. Measurements should be done in
absence of saliva (dry teeth). High measurements indicate well-
mineralized tissues while low values indicate demineralized tissues.

It is helpful in detecting occlusal caries at early stages. Moreover

lesion proression or lesion remineralization is another advantage of
this device.
 2.3. Non-invasive cutting tools

The ideal requirements for cutting instruments are:

1. Painless.
2. Ease of use.
3. Ability to discriminate and remove diseased tissues only.
4. Silent.
5. Does not generate heat.
6. Affordable.
7. Easy to maintain.

All this led to the appearance of several tools that tried to fulfill
these requirements.
 2.3. Non-invasive cutting tools

Examples of non-invasive cutting tools:

a. Air abrasion technology.

b. Chemo-mechanical removal of tooth structure.

c. Ultrasonic cutting.

d. Laser cutting.

e. Enzymes.

f. Ozone treatment.
 2.3.a. Air abrasion technology

Not considered a new technology but it’s use was limited in the
past due to the absence of restorative materials that would comply
with it.

It depends on the flow of a stream of compressed air that carries

aluminium oxide particles (20-50 microns) which strike the tooth
surface to remove enamel, dentin and defective restorations.
 2.3.a. Air abrasion technology

It is safe concerning tooth vitality and not harmful to the patient

nor to the operator as long as protective measures are taken into
consideration.

It is a messy procedure which requires the use of high volume

suction and face shields.
 2.3.b. Chemo-mechanical removal of tooth structure

A combination of aminoacids and a weak solution of sodium

hypochloride in a gel form is used.

The gel is applied over the diseased tissue for several minutes
where it selectively reacts by disrupting the denatured collagen in
demineralized areas. Then, a specially designed instrument is used
to remove the unsupported softened tooth structure.

It is effective only with carious dentin but does not affect enamel.
Therefore it can not be used alone.It is indicated in root caries and
in deep caries approaching the pulp.
 2.3.c. Ultrasonic cutting

Early generations were large in size and could not preserve tooth
structure, however, later on smaller sizes were incorporated and
were useful.

The preparation could not be performed totally using this

technique which limited their usage.
 2.3.d. Laser cutting

Several types of lasers are used for cutting tooth structures such as
CO2 laser and Nd:YAG laser.

Lasers are inefficient in removing large amounts of enamel or

dentin and result in excessive heat generation therefore it should
be used with caution.
 2.3.e. Enzymes

This approach is still under research. The enzyme pronase

disintegrates decayed dentin. It does not attack sound dentin but
solubilizes more than 90% of carious dentin. However, it has no
ability to remove sound or carious enamel.
 2.3.f. Ozone

No cutting is performed in this technique. It is a simple, time-

saving, effective approach wich uses ozone as a powerful biocide.

Ozone has a powerful bactericidal effect which kills bacteria

responsible for demineralization.

It is supplied by a device which produces ozone through a hand-

piece covered by a cup that is placed on the lesion for 10 seconds.
This results in deactivation of 99% of bacteria present.This step is
followed by remineralization measures to allow remineralizatin of
the demineralized tissues.
Thank you