‫كل المعلومات الي فالمحاضرة دي‬ Lec 1 Operative (PART 3)

‫اتقالت فقط في الاليف ريكورد‬

)‫(مش موجودة فاالونالين‬ The Conservative Approach (PART 3)

The Preventive care advising to pt.

Are classified into :
1- Non-invasive approach (‫)خلصناه التوبيك كدا تماما‬
1-Modifying the biofilm by (A-Mechanical control ‫ دن‬, B- Chemical control ‫دن‬, C-Biological control‫) دن‬
2-Modifying the diet ‫دن‬
3-Enhancing remineralization ‫دن‬

2- micro-invasive approach (A-Pits & fissure sealing – B-Resin infiltration ) ‫هنتكلم على دا دلوقتي‬

The Restorative care advising to pt.

The Restorative care advising to pt. is : minimal invasive approach (ultra-conservative approach)

2- micro-invasive approach
(A-Pits & fissure sealing)
Pits and fissure sealing (Micro invasive) :
NOTE (LIVE): it is called (micro invasive BC: it is seen only on microscopic level when tooth is extracted)
Def. of fissure (LIVE): it is incomplete union between 2 Enamel lobes
Def. of pit (LIVE): it is incomplete union between 3 enamel lobes
NOTE (LIVE): Pits & fissure : are caries susceptible areas
Q/ why does the sealant do (what is the goal if pits & fissure sealant )?
A/ it converts the (retentive pits & fissures ) → to be (non-retentive fossae & grooves)
Q/ what is the act of pits & fissure sealing ?
A/ it is (micro invasive) as the Resin sealant is infiltrated on a microscopic level to seal the depth of
fissure
NOTE: Pits and fissure sealing → is the most effective way of Full caries prevention
as it converts the (retentive pits & fissures ) to be (non-retentive fossae & grooves) & preventing
food accumulation

Indication of Pits and fissure sealing

1-Deep fissures
2-Newly erupted teeth (as it is infra-occlusion)
NOTE: Newly erupted teeth → is not in occlusion and the food accumulate on it and
there is no clearance of food occur to it due to absence of masticatory process )
3-High caries index & high caries Risk Pt.
4-Children at early age (2-4 years after teeth eruption) to save their teeth from caries
 2- micro-invasive approach
(A-Pits & fissure sealing) cont.
Pic (1) shows (LIVE) → fissure under light microscope
(filled with food, bacteria) and the side walls shows demineralization

Pic (2) shows (LIVE) → Longitudinal section in lower 6 ,

-the yellow arrow shows → chalky white appearance at the side
of fissure (it represents demineralization )
-the red arrow shows → Brown discoloration in tooth
(it represents Denaturation )
-the green arrow shows → pulp healing power & Dentine sclerosis formation

NOTE: Caries in enamel → (apex → toward occ. Surface & base → toward DEJ )
NOTE: once caries passes the DEJ → lateral spreading of caries in dentin occurs .. so,
(caries base → toward DEJ & apex → toward pulp) this occurs due to lower mineralization content of
the dentin

Replica of fissures type

There are 4 types of Fissure

V&U types → are hallow & self cleansable

I&K types → deep, narrow & retentive (also

they are caries susceptible area )
 2- micro-invasive approach
(A-Pits & fissure sealing) cont..
Def. of Pt. At risk: it is the pt. who has the (Poor oral hygiene , Carious and restored teeth , eats
Cariogenic diet , has pits & fissures NOT fossae and grooves , has Defective enamel as hypoplasia ,
and wears Orthodontic appliance)
NOTE (LIVE): these pics shows pits and fissure sealant that has
been applied for (15-20 years) → they show some wear BUT the
fissure sealant is Still retained in the depth of (fissure)
NOTE (LIVE): pits and fissure sealant are → the Best caries preventive measures
NOTE (LIVE): pits and fissure sealant are Cost effective (‫)تمنها فيها‬

The following are some consideration regarding application of pits and fissure sealant
1- pits and fissure sealant are applied at → (Deep, retentive pits and fissure)
2- apply it when Adequate moisture control is possible → (bc; I do etching and bonding )
3- apply it when there is No evidence of dentinal proximal caries
(i.e: it is contraindication to apply P & F sealant on suspected caries )
4- apply it on Stained pits and fissures with appearance of demineralization (ICDAS 1 and 2)
5-Don’t apply it in Well-coalesced, self-cleaning pits and fissures (V&U types ‫) مبحطش سيلنت في دول‬

6- AVOID applying it proximal caries in the tooth that needs a restoration

7- AVOID applying it on Partially erupted teeth
8- AVOID applying it on Primary teeth
9- AVOID applying it when Moisture control is not possible
10- AVOID applying it when Patient is allergic to sealant material

Requirement of ideal sealing Indications of sealing material Contraindications of sealing

material (‫)من الكتاب‬ (‫)من الكتاب‬ material (‫)من الكتاب‬
1- Fast & easy application. 1- A history of dental caries. 1- A balanced diet low in sugars
2- Proper viscosity of material 2- Deep retentive pits and or carbohydrates.
that allows penetration into the fissures. 2- Exceptionally good oral
fissure. 3- Early signs of dental caries. hygiene.
3- Good and long-lasting adhesion 4- Poor plaque control. 3- Teeth with shallow, self-
to enamel walls. 5- Cariogenic diet. cleansing pits and fissures.
4- Thermal and mechanical 6- Enamel defects, such as 4- Teeth that are partially erupted
properties similar to enamel hypoplasia. which are very difficult to isolate.
characteristics of hard tissues of 7- Orthodontic appliances. 5- Teeth with previously restored
teeth 8- Patients or teeth that are at pits and fissures.
5- Must not disturb occlusion. 6- Carious teeth.
high risk of dental caries.
6- Non- toxic. 7- Primary teeth close to
7- Long-term Anticariogenic exfoliation.
activity. 8- Allergy to sealant material.
9- Patients or teeth that are at a
low risk of dental caries.
 2- micro-invasive approach
(A-Pits & fissure sealing) cont…

Requirements for success pits and fissure sealing

1-Sufficient infiltration → (I must insure that the sealant has reached the depth of the fissure )
2-Adequate retention & Adequate moisture control → (in aid to gain adequate bonding)
3-Should not interfere with occlusion → (to avoid breaking the sealant .. ‫) وماينفعش تقى على الكاسب سلوب‬
4-Anticariogenic → as it converts the (retentive pits & fissures ) to be (non-retentive fossae &
grooves)

The Pic shows (LIVE) → incomplete infiltration of Pits & fissure

sealant on microscopic level

Preventive Resin Restoration (PRR)

NOTE: it is a method used when (suspected stained pits OR fissures )
NOTE (LIVE): preparation of fissures using (Fissure bur Number 0 , air abrasion, or laser ) is done to
increase the width of fissure → the filling the prep. with a Flowable composite is done .

Types of pits & fissure sealants

Resin material Glass ionomer Compomer and resin modified
glass ionomer
1-No fluoride 1-Fluoride release 1-fluoride release
2-Technique sensitive 2-Less technique sensitive 2-Wear resistant
3-More wear resistant 3-Less wear resistant 3-Less Techniques sensitive
4-Less liable to desiccation 4-More liable to desiccation 4-Less retention
5-Best mechanical properties 5-Less mechanical properties
 2- micro-invasive approach
(A-Pits & fissure sealing) cont…
Sealant Placement Technique (EXTRA IN BOOK)
Using a Resin-Based Material (Traditional Technique):
1- Select teeth to be sealed and isolate.
2- Clean the tooth surfaces with an air polisher prophylactic paste (using a rubber cup or brush).
3- Enamel cleaned of debris
4- Etch the enamel (minimum of 15 seconds)
5- Rinse and dry etched enamel
6- Gently rinse etchant and look for a (frosty white appearance).
7- Apply sealant material
8- Light cure for time period recommended by the manufacturers' instructions.
NOTE: Colored sealant material turns from pink to tooth colored after light-curing
9- Check sealant coverage using articulating paper.

Advantages of use of dental sealants (EXTRA IN BOOK)

1-One of the best preventive measures we can offer patients. 2-Cost effective, simple and fast.
3-When properly placed and maintained. 4-Sealants have proven longevity.
5-Will aid in the prevention of caries. 6-Patients appreciate the preventive efforts.

Potential problems may arise (EXTRA IN BOOK)

1-If the lesion extends along the cuspal inclines → safely sealed margins can't be assured.
2-Progression of the lesion has severely weakened the remaining enamel → needed for bonding of
the resin.
3-Sealants can't withstand the forces of occlusal contact OR the contraction during polymerization.
4- Many sealants never penetrate far enough into the fissure and this can be enhanced by using
bonding agents due to its hydrophilic property.

To summarize
1- Sealants are effective in halting progression of existing carious lesion.
2- As long as the sealants effectively seals off the lesion, there is no reason to suspect any lesion
progression.
3- If sealant placed on top of lesions fails, the tooth is at no greater risk than if had never been
sealed.
 2- micro-invasive approach
(A-Pits & fissure sealing) cont….

Why and how do sealants fail? (EXTRA IN BOOK)

1-Lack of moisture control has a detrimental effect on the sealant success rate.
2-Occlusal forces constitute one of the biggest challenges to sealants.
3-Overfilled fissures expose the unfilled resin material to high occlusal forces that may help to
dislodge the sealant
4-The low retention rate of sealants on buccal pits & lingual grooves is probably due to (high
shearing forces in those locations) .

Maintenance of dental sealant (EXTRA IN BOOK)

1-When sealants are either partially or totally lost, it is important to maintain the tooth surface by
re-applying the sealant.
2-Risk assessment of the surface should be done
3-It is good practice to monitor sealed teeth on a yearly basis.

Factors affecting long-term success of sealant therapy (EXTRA IN BOOK)

1-Frequent recall and repair if necessary.
2-Preparation of the fissure by removal of plaque and debris prior to placement
3-Isolation of teeth from saliva during placement.
4- Good operator techniques.
 The Preventive care advising to pt.
Are classified into :
1- Non-invasive approach (‫)خلصناه التوبيك كدا تماما‬
2- micro-invasive approach (A-Pits & fissure sealing ‫ – خالص‬B-Resin infiltration )

2- micro-invasive approach
(B-Resin infiltration )
NOTE (LIVE): Resin infiltration is used with (white spot lesion)
NOTE (LIVE): Example on Resin infiltration kit → Icon infiltration
NOTE (LIVE): (white spot lesion) → means that there is Enamel demineralization
NOTE (LIVE): Etching is done to the tooth with white spot lesion (to refresh the surface ) → then
Resin infiltration material is infiltrated inside the demineralized enamel pores → then cured
Results of Resin infiltration:
1- Stops the progress of the non Cavitated lesions (Diffusion barrier)
2-Improves esthetics (Masking effect) → as the refractive index Resin infiltrated surface Become
(closer) to the refractive index of sound enamel
NOTE (LIVE): Resin infiltration is another approach to arrest caries

Q/what is the difference between (pits and fissure sealant) & (Resin infiltration) in the mode of
action?
A/
pits and fissure sealant → are external preventive Diffusion barrier (‫ )دهنته عالسيرفس‬and it result in
stabilization & arresting the caries progression (LIVE+BOOK)
Resin infiltration → is internal preventive barrier (it enters the demineralized enamel pores) , this
means that the Diffusion barrier is inside the lesion By infiltrating the pores in the lesion body with
low-viscosity light-curing resins (LIVE+BOOK)
 The Preventive care advising to pt.
Are classified into :
1- Non-invasive approach (‫)خلصناه التوبيك كدا تماما‬
2- micro-invasive approach (A-Pits & fissure sealing ‫ – خالص‬B-Resin infiltration )

2- micro-invasive approach
(B-Resin infiltration ) Cont.
Principals of Caries Infiltration (EXTRA NOTES IN BOOK) :
-Enamel is strongly mineralized surface layer & It should first be eroded with a hydrochloric acid gel,
(because this cannot be achieved with a phosphoric acid gel even after a long exposure time).
-The infiltrates penetrate natural caries lesions up to a few hundred micrometers.
Indications of Resin infiltration (IN BOOK) Contraindications of Resin infiltration (IN BOOK)
1-Mild fluorosis. 1-Erosion
2-Early carious lesion (interproximal in posterior 2-Deep carious
teeth). 3-Severe fluorosis
3-White spot lesion. 4-Deep stained lesion
5-Cavitated lesion

ICON (EXTRA NOTES IN BOOK)

1-ICON is the most efficient micro-invasive technique leading to satisfactory esthetic results.
NOTE: As a positive side-effect, enamel areas of caries lesions (lose their whitish appearance after
infiltration).
NOTE: This masking effect is based on a modification of the light refraction within the enamel lesion.
2-The micro porosity within enamel caries (has different refraction index) from normal sound enamel.
NOTE: The micro porosities → cause light to scatter at the surfaces, which gives these lesions a
whitish opaque appearance, particularly when dry.
NOTE: The micro pores when infiltrated with resin, there is a relatively slight difference between the
refractive indices of the infiltrated pores and that of the surrounding healthy enamel, the caries
appears much less white than before infiltration
Steps of icon infiltration: The teeth are etched with 2% hydrochloric acid then → dried with ethanol
→ then resin is applied.
NOTE: The icon shows better result in anterior teeth rather than posterior due to one for the
following reasons:
1-It has the aesthetic problem in anterior teeth
2-In posterior teeth we cannot determine well the extent of caries even with x-ray.
NOTE: The (enamel etching) for long time → affects the mechanical properties of enamel.
The icon could be an acceptable treatment but has the following drawback:
1-It uses hypo chloric acid which removes the outer layer of enamel.
2-Leave white halo sometimes (it needs sand blasting or over etching).
3-Stain by time (due to water sorption) 4-Need multiple applications (for better results).
 The Preventive care advising to pt.
Are classified into :
1- Non-invasive approach (‫)خلصناه التوبيك كدا تماما‬
2- micro-invasive approach (A-Pits & fissure sealing – B-Resin infiltration ) (‫)خلصناه التوبيك كدا تماما‬

The Restorative care advising to pt.

The Restorative care advising to pt. is : minimal invasive approach (ultra-conservative approach)

Minimal invasive approach

NOTE (LIVE): The minimal invasive approach is made to operative care advised pt.
NOTE (LIVE): The minimal invasive approach is made to prevent Tooth Death spiral
NOTE (LIVE): The successes of minimal intervention bonding depend on → Bonding
Death spiral → the pt. came with a tooth shows (1ry caries) and
ends with (Extraction)

NOTE (LIVE): The conventional approach (Of G.V black ) → all caries should be remove & all pits and
fissure are included in the design
NOTE (LIVE): The conventional approach (Of G.V black ) → are NOT used nowadays
NOTE (LIVE): Selective Caries removal approach & minimal intervention preparation → we make the
preparation size according to the caries extension
NOTE (LIVE): Selective Caries removal approach & minimal intervention preparation (are the
approach we are following nowadays )
NOTE (LIVE): minimal intervention preparation (is called No-outline outline)
 EXTRA NOTES IN BOOK (REGARDING MINIMAL INVASIVE DENTISTRY )
Def. of Minimally invasive dentistry (MID) : it is an evidence based intervention approach supported
internationally that aims to do the least harm to effected and surrounding tissues.

New classification
NOTE : G.V Black's rule "extension for prevention" is no longer considered generally valid (It is the
complete opposite of minimally invasive dentistry) In addition, the importance of site and size of
carious lesions for treatment,
NOTE : G.J Mount and colleagues have proposed a new classification, which classifies lesions by
combining both their site and size
CARIES CLASSIFICATION SYSTEM BASED ON LESION SITE AND SIZE
Location CLASSIFICATION
1=minimal 2=moderate 3=advanced 4=extensive
Site 1 1.1 1.2 1.3 1.4
( pits and fissures)
Site 2 2.1 2.2 2.3 2.4
( Proximal contact)
Site 3 3.1 3. 3.3 3.4
( Cervical surface)
Mount-Hume classification (Sista)

Firstly, lesions are classified according to their location:

• Site 1: pits and fissures (occlusal and other smooth tooth surfaces).
• Site 2: contact area between two teeth.
• Site 3: cervical area in contact with gingival tissues.
Secondly, the new classification identifies carious lesions according to various sizes:
• Size o: carious lesion without cavitation, can be Remineralized
• Size 1: small cavitation, just beyond healing through remineralization.
• Size 2: moderate cavity not extended to cusps.
• Size 3: enlarged cavity, with at least one cusp which is undermined and which needs protection from
occlusal load.
• Size 4: extensive cavity, with at least one lost cusp or incisal edge.
 Minimal intervention Cavity preparation (in Anterior Region)
Anterior Region In the anterior region, it is generally recommended to obtain access to the proximal
caries lesions from a palatal direction to minimize the extension into the visible area (IN BOOK)

Minimal intervention Cavity preparation (in posterior Region)

1-Occlusal slot
2-Facial OR Lingual slot
3-Vertical slot prep.
4-Box only (Class II Composite Restoration Cavity Preparation)
5-Tunnel preparation

1-Occlusal slot
NOTE (Book): It is done Rather than including all pits & fissures
these types of preparation extend to the extension of caries

2-Facial OR Lingual slot

NOTE (Book): Lesion in the proximal surface BUT the access is possible through the facial or lingual
surfaces; proximal caries removal without injuring any occlusal tooth structure with cavo-surface is
90°.
NOTE (Book): It is possible in cases of wide embrasures or
gingival recession

3-Vertical slot prep.

NOTE (Book): the preparation generally assumes the shape of a double drop.
NOTE (Book): This means that the prepared cavity looks like a drop from the proximal direction as well
as from the buccal/oral direction
Disadvantages (Book):To reach the actual caries lesion, a
considerable amount of the sound dental hard
tissues need to be removed in the area of the marginal ridge.
 Minimal intervention Cavity preparation
4-Box only (Class II Composite Restoration Cavity Preparation)
NOTE (LIVE): contact is preserved in box shape prep.
NOTE (LIVE): avoid bonding to (Chalky white enamel) if you will not remove the contact
NOTE (LIVE): bonding must be done to a reliable substrate
NOTE : Due to the shape of the bur, there will "loose" enamel at the margin (buccal and lingual proximal)
NOTE (IN BOOK): For small Class II direct composite restorations are often used for primary caries
lesions, that is, initial restorations.
NOTE (IN BOOK): A small round or elongated pearl diamond or bur with round features may be used for
this preparation to → scoop out the carious OR faulty material from the occlusal and proximal surfaces.
NOTE (IN BOOK): The (pulpal & axial depths) are dictated only by the depth of the lesion and are not uniform.
NOTE (IN BOOK): The proximal extensions likewise are dictated only by the extent of the lesion.

NOTE (IN BOOK): The objectives are to → remove caries or the defect conservatively and remove
friable tooth structure
NOTE (IN BOOK): Another conservative design for small
Class II composites is → the box only tooth preparation.
NOTE (IN BOOK): the box only tooth preparation design is
indicated when (only the proximal surface is defective, with
no lesions on the occlusal surface).
NOTE (IN BOOK): A proximal box is prepared with a small
elongated pear or round instrument, held parallel to the
long axis of the tooth crown.
NOTE (IN BOOK): The instrument is extended through the marginal ridge (in a gingival direction).
NOTE (IN BOOK): The axial depth is dictated by the extent of the caries lesion or fault.
NOTE (IN BOOK): The facial, lingual, and gingival extensions are dictated by the defect or caries

5-Tunnel preparation
NOTE (LIVE): it is done to approach the proximal surface form the occlusal surface
NOTE (LIVE): it can only be applied if the Marginal Ridge is thick
NOTE (Book): The idea is to reach the proximal caries from the occlusal fossa and largely bypass the M. ridge.
NOTE (Book): The approach of tunnel preparation most closely emulates the goal of minimal invasiveness
Disadvantages (Book):
1-Difficult to precisely excavate the caries at the DEJ
below the marginal ridge (can be overcome with
proper magnification).
2-Fracture resistance of the remaining marginal ridge
is also quite low (Byte registration prior to tooth
preparation).
 Equipment of Minimal intervention Cavity preparation
1- Preparation with hand instrument (IN BOOK)

2-Rotrary instruments → (Micro bur , polymer bur , ceramic bur)

A- The Bur (No. 245): is a micro bur which used in minimal intervention
preparation as it → (make Roundation to the line angles ) LIVE
B-Polymer burs (Smart burs ):
NOTE (LIVE): it is called smart as (its hardness) lower than the (sound enamel hardness) , so it will
not cut in sound enamel & it will break
NOTE : it is Controlled selective rotary excavation
NOTE : it is A "plastic" bur was made of a polyamide/ imide (PAI)
polymer, possessing slightly lower mechanical properties than sound dentin.
NOTE : it is hard enough to remove decayed dentin,
NOTE : it stops at hard healthy dentin
C-Ceramic burs (‫)صورتها الي فالنص بين الميتال والبوليمر‬

3- Oscillating Preparation
NOTE (IN BOOK): Oscillating preparation tools are helpful for the difficult access to the interproximal
region, since one side is nonabrasive, which makes them harmless to the neighboring tooth.
NOTE (IN BOOK): There are basically two types of oscillating preparation :
(the A-SonicSys system and B-bevel-shape files).
A-SonicSys:
NOTE (LIVE): it cuts by vibration + it is very conservative
NOTE (LIVE): Advantages → ( No pain , No noise)
NOTE (LIVE): Disadvantages → No tactile sensation

4- Laser
NOTE (IN BOOK): Lasers can remove soft caries, as well as hard tissue.
NOTE (IN BOOK): Lasers reportedly can allow the dentist to remove caries selectively while
maintaining healthy dentin and enamel.
NOTE (IN BOOK): They also can be used without anaesthesia most of the time.
Advantages of laser :
1-No vibration, little noise, no smell and no numbness associated with anaesthesia.
2-When dental lasers are used correctly, excessive heat generation and its detrimental effects on
dental pulp can be avoided.
 Equipment of Minimal intervention Cavity preparation (Cont.)

5-CHEMO MECHANICAL Caries removal

NOTE (LIVE) : The Carisolv system (a gel with amino acids and sodium hypochlorite, and special hand
instruments )
NOTE : The Carisolv system → solves the break down collagen (‫ )بيذوبه‬, though mixing amino acids
and sodium hypochlorite → then applying the mix inside the cavity → (this is the chemical part) ..
then I remove the denatured collagen by hand instrument (excavator) → (this is the mechanical part)
NOTE (IN BOOK): An alternative to the conventional mechanical removal of caries is chemo
mechanical method.
NOTE (IN BOOK): It is an effective alternative for caries
removal because it brings together :
1-traumatic characteristics
2- and bactericide / bacteriostatic action.
NOTE (IN BOOK): The chemicals used can be in the form
of liquid (caridex) or gel (carisolv).

5- Air abrasion
NOTE : it is a Handpiece that exert abrasive particles (aluminum oxide) by kinetic energy
NOTE (IN BOOK): Air abrasion Uses kinetic energy (to remove carious tooth structure).
NOTE (IN BOOK): A powerful narrow stream of moving aluminium oxide particles is directed against
the surface to be cut. When these particles hit the tooth surface, (they abrade it, without heat,
vibration or noise).
Advantages of Air abrasion :
1- Reduced noise, vibration and sensitivity.
2- Cavity preparations done with air abrasion have more rounded internal contours than those
prepared with a handpiece.
Disadvantages of Air abrasion :
1- Lack of tactile sense
2- Air abrasion cannot be used for all patients (It should be avoided in cases involving: Severe dust
allergy, asthma, chronic obstructive lung disease, recent extractions, or other oral surgery and open
wounds, advanced periodontal disease, recent placement of orthodontic appliances, Sub-gingival
caries removal).
3-Many of these conditions increase the risk of air embolism in the oral soft tissues.
4- Dust control is a challenge, and it necessitates the use of rubber dam and high-volume evacuation.

NOTE (LIVE): (Chemo-mechanical system , Laser , Air abrasion ) they have NO tactile sensation
NOTE (LIVE): ONLY BUR → give tactile sensation