Foreword · Department of Operative Dentistry and Periodontology, Dental Clinic, Albert-Ludwigs-University Freiburg, Freiburg, Germany Roswitha Heinrich-Weltzien Poliklinik für Präventive

Operative dentistry has been transformed in recentyears, and is expected to undergo further, far-reach-ing changes in the future. One of the most impor-tant and exciting innovations in the field is mini-mally interventive operative dentistry. This tooth-substance-saving concept spans advancedapproaches to the diagnosis of caries, risk assess-ment and minimally invasive operative procedures.This requires a rethink of the ‘drill and fill’ philos-ophy for the management of caries, leaving behindoutdated principles, in particular ‘extension for pre-vention’.

This book captures the quintessential content ofthe last two ConsEuro meetings of the EuropeanFederation of Conservative Dentistry held inMunich (2003) and Rome (2006), which focussedon state-of-the-art approaches to the managementof caries. The views expressed in this book are thoseof opinion leaders in the field in Europe. All aspectsof modern cariology, ranging from prevention tothe management of exposed dentine and pulp areconsidered, together with current thinking on the

repair and refurbishment of failing restorations asan alternative to restoration replacement.

The task of bringing together the current knowl-edge and understanding of multiple opinion lead-ers requires an exceptional editor with wide-rang-ing expertise, and an acknowledged and substan-tial reputation in the field of minimally interven-tive operative dentistry. Nairn Wilson fits this pro-file perfectly, and he is to be congratulated on hav-ing conceived, planned and edited this book, whichis an excellent addition to existing literature.

This book can be recommended to all practi-tioners, students and teachers as a valuable guideto developments in the rapidly developing field ofmodern cariology. All those who read and digestthe contents of this book will be enlightened andencouraged to explore new horizons in their clini-cal practice, with the aim of serving the needs andexpectations of patients to best possible advan-tage.

Reinhard Hickel

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Foreword

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Preface

This book stems from memorable ConsEuro confer-ences held in Munich in 2003, and in Rome in 2006.It is intended for busy practitioners and studentswishing to better understand the concept of mini-mally invasive dentistry and, in particular, theessence of minimally interventive management ofdental caries. Through an editorial insistence onfocus and brevity, readers will hopefully be sparedfrom having to subsequently assimilate largeamounts of existing literature, or resorting to heftytomes on caries and modern approaches to clinicalpractice to address their need for a good workingknowledge and understanding of minimally invasivedentistry, as it relates to the management of caries.As a consequence, this book may be likened to a well-balanced meal which leaves one satisfied, but notfeeling overwhelmed—a carefully selected menu, fullof diversity and interest, embracing modern themesand practices, with an emphasis on clinical applica-tion and quality rather than copious quantity.Hopefully, this is a recipe which pleases and satis-fies the appetite to learn and apply a modernapproach to managing caries efficiently and effec-tively.

As editor of this multi-author, pan-European text, I am deeply indebted to all the contributors, with-out whose work and subsequent patience this bookwould not have been possible. I can only take cred-it for bringing together, blending and presentingthe contents. The real credit for this book must goto the authors, who nurtured, developed and craft-ed the various chapters and sections, all of whichare special. That said, I have endeavored, throughthe editorial process, to give this book interest andzest to stimulate new thinking and changes in clin-ical practice.

In an ever changing world, change should be thenorm. Dentistry, much of which continues to involvethe management of caries, should be no exception.Indeed, if it were, this would be a great cause forconcern. My views have changed in the process ofediting this text. Hopefully this experience will beshared by all those who read the book.

As is said of a nenorable meal, it is not so muchwhat you get from it, but what you savor andremember. Hopefully, this book will be likered to anenorable meal, with lots to enjoy and reflect on.

Bon appétit.Nairn Wilson

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VII

Contributors

Birgit Angmar-MånssonDepartment of Cariology and EndodontologyInstitute of Odontology, Karolinska InstituteHuddinge, Sweden

Avijit BanerjeeRestorative Dentistry, King’s College LondonDental Institute, London, England, UK

Aylin BaysonRestorative Dentistry, King’s College LondonDental Institute, London, England, UK

Annerose BoruttaPoliklinik für Präventive ZahnheikundeFriedrich-Schiller-Universität JenaErfurt, Germany

Paul BruntonDepartment of Restorative DentistryLeeds Dental Institute, Leeds, England, UK

Paula CelibertiKlinik für ZahnerhaltungBern, Switzerland

Catherine Chaussain-MillerDepartment of Conservative Dentistry and EndodonticsDental Surgery Faculty, University of Paris VMontrouge, France

Marcus DellPoliklinik für Präventive ZahnheikundeFriedrich-Schiller-Universität JenaErfurt, Germany

Richard FoxtonRestorative DentistryKing’s College London Dental InstituteLondon, England, UK

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George FreedmanEsthetic Dentistry Education CenterState University of New YorkBuffalo, NY USA

Petra HahnDepartment of Operative Dentistry andPeriodontology, Dental Clinic, Albert-Ludwigs-University Freiburg, Freiburg, Germany

Roswitha Heinrich-WeltzienPoliklinik für Präventive ZahnheikundeFriedrich-Schiller-Universität JenaErfurt, Germany

Reinhard HickelProfessor of DentistryDirector of Department of Conservative Dentistry and PeriodontologyHead of Dental SchoolUniversity of Munich Germany

Jan-Willem HoekstraCollege of Dental SciencesUniversity Medical CenterNijmegen, The Netherlands

Karin HuberDepartment of Operative Dentistry,Periodontology and Preventive Dentistry, Dental Clinic, University of Saarland, Homburg, Germany

Jean Jacques LasfarguesDepartment of Conservative Dentistry andEndodontics, Dental Surgery Faculty, University of Paris V, Montrouge, France

Chris LoucaDepartment of Primary Dental CareKing’s College London Dental InstituteLondon, England, UK

Adrian LussiKlinik für Zahnerhaltung,Bern, Switzerland

Agustin Pascual MoscardoDepartamento de Estomatologia,Faculdad de Medicina y OdontologiaUniversidad de Valencia, Spain

Frauke MüllerDepartment of Gerodontology and RemovableProsthodontics, Dental School, University of Geneva, Geneva, Switzerland

Paul NixonDepartment of Restorative DentistryLeeds Dental InstituteLeeds, England, UK

Niek OpdamDepartment of Cariology and EndodontologyCollege of Dental Sciences University MedicalCenter, Nijmegen, The Netherlands

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CONTRIBUTORS

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George PaolinelisRestorative DentistryKing’s College London Dental InstituteLondon, England, UK

Gunnel Hänsel PeterssonDepartment of CariologyFaculty of OdontologyMalmo UniversityMalmo, Sweden

Alphons PlasschaertCollege of Dental SciencesUniversity Medical CenterNijmegen, The Netherlands

Joost RoetersDepartment of Cariology and EndodontologyCollege of Dental Sciences University Medical CenterNijmegen, The Netherlands

Xie-Qi ShiDepartment of Cariology and EndodontologyInstitute of Odontology, Karolinska Institute,Huddinge, Sweden

Christian SpliethDepartment of Preventive and Pediatric DentistryErnst Moritz Arndt UniversityGreifswald, Germany

Lutz StösserPoliklinik für Präventive ZahnheikundeFriedrich-Schiller-Universität JenaErfurt, Germany

Sofia TranæusDepartment of Cariology and EndodontologyInstitute of Odontology, Karolinska InstituteHuddinge, Sweden

Renier van den BoomenCollege of Dental SciencesUniversity Medical CenterNijmegen, The Netherlands

Timothy WatsonBiomaterials and Conservative DentistryKing’s College London Dental InstituteLondon, England, UK

Eric WhaitesDepartment of Dental Radiological ImagingKing’s College London Dental InstituteLondon, England, UK

Nairn WilsonKing’s College London Dental InstituteLondon, England, UK

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CONTRIBUTORS

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Chapter 1

Dental Caries, Minimally Invasive Dentistry and Evidence-based Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Nairn Wilson and Alphons Plasschaert

Chapter 2

Caries Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Christian Splieth

Chapter 3

Bacterial and Enzymatic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Parameters of Caries—Novel TestsLutz Stösser, Marcus Dell, Annerose Borutta, Roswitha Heinrich-Weltzien

Clinical ProceduresCatherine Chaussain-Miller and Jean Jacques Lasfargues

Chapter 4

The Diagnosis of Caries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Initial Clinical ExaminationsAylin Bayson

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Contents

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Radiographic ImagingEric Whaites

Fluorescence MethodsXie-Qi Shi, Sofia Tranæus and Birgit Angmar-Månsson

Chapter 5

Assessing Caries Risk: the Cariogram Model . . . . . . . . . . . . . . . . . . . . . . . .47Gunnel Hänsel Petersson

Chapter 6

Ozone, Remineralization and Sealants . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61OzoneAylin Bayson

RemineralizationAylin Bayson

SealantsPaula Celiberti and Adrian Lussi

Chapter 7

Cavity Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79Iatrogenic Damage and its PreventionAdrian Lussi

Sonic TechniquesPetra Hahn and Karin Huber

Air Abrasion and Bioactive GlassesTimothy Watson, Avijit Banerjee and George Paolinelis

Chemomechanical Treatment of CariesJean Jacques Lasfargues and Catherine Chaussain-Miller

LasersChris Louca

Polymer Cutting InstrumentsGeorge Freedman

CONTENTS

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Chapter 8

Managing Exposed Dentine and Pulp . . . . . . . . . . . . . . . . . . . . . . . . . . . .111Exposed DentineRichard Foxton

Iatrogenic Pulp ExposureAlphons Plasschaert, Renier van der Boorem and Jan Hoekstra

Chapter 9

Selection and Use of Restorative Materials . . . . . . . . . . . . . . . . . . . . . . . .125 Paul Nixon and Paul Brunton

Chapter 10

Restorations in Clinical Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137Performance and MaintenanceNiek Opdam and Joost Roeters

Repairs and ModificationsJoost Roeters

Chapter 11

The Ageing Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .147Frauke Müller

Chapter 12

The Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151Nairn Wilson and Agustin Pascual Moscardo

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CONTENTS

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SONICflexDamage to adjacent tooth surfaces is a commonoccurrence in completing the preparation of prox-imal cavities.1, 6 The smaller the cavity, the worsethe damage to the adjacent tooth surface. As aconsequence, considerable efforts have beenmade to develop systems to minimize iatrogenic

damage to tooth surfaces adjacent to, in particu-lar, minimally interventive occlusoproximal prepa-rations.6,9

The sonic oscillating, SONICflex system (KaVoDental) was developed to cut and finish small prox-imal cavities. This system uses highly frequent oscil-lating preparation instruments in an air-drivenoscillating handpiece (Airscaler , SONICflex 2003,KaVo Dental). The preparation instruments trans-fer their negative form to the tooth. Damage toneighboring teeth during proximal preparationand finishing is minimized by the use of safe-sided,diamond coated, round-ended preparation tips. Airpressure during preparation is 2.5–4 bar, the fre-quency of the sonic waves is 6.0 kHz, and the rec-ommended operating pressure during preparationis about 0.1 N.

For finishing, the frequency and operating pres-sure are reduced. Different tips are available, eachin a mesial and a distal form (Fig 7-8). The SONICflexmicro and SONICflex bevel tips are suitable for thecutting and finishing of cavities in all localizations.The SONICflex angle instruments may be used insituations in which access is especially difficult—forexample, in the cutting and finishing of the proxi-mal section of a tunnel preparation and in the directaccess approach to management of proximal caries.The SONICflex PrepGold and SONICflex PrepCeraminstruments are designed for minimally interventivegold and ceramic inlay preparations (Figs 7-9 and7-10). The SONICflex Approx instruments are

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Cavity Preparation7

Fig 7-6 A vertical slot preparation.

Table 7.2 Survival results of tunnel restorations in permanent teeth (N=number of teeth at last evaluation, y=year)

Source Duration (y) N Survival

Svanberg, 1992 3 11 91%

Strand et al, 1996 3 161 46%

Lumley and Fisher, 1995 5 33 79%

Hasselrot, 1998 7 121 39%

Hörstedt-Bindslev et al, 2005 4 84 46%

Fig 7-7 Schematic illustration of a horizontal slot prepara-tion.

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Sonic Techniques 7

Fig 7-8 Range ofSONICflex system tipsfor minimally interven-tive preparation.

Fig 7-9 Preparationwith SONICflex PrepCeram.

Fig 7-10 Preparation with SONICflexPrep Gold.

SONICflex prep ceram

SONICflex prep gold

SONICflex angle

SONICflex bevel

SONICflex microinvasiveSONICflex approx

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Air AbrasionAir-abrasion is a pseudo-mechanical, non-rotarymethod of cutting and removing dental hard tis-sue, originally conceived in 1945. After promisingearly clinical developments, the advent of the airturbine handpiece and burs resulted in the loss ofthis early technology to mainstream dentistry.Recent advances in adhesive dentistry have, how-ever, called for changes to concepts in cariesremoval, cavity design and preparation and air-abrasion has, once again, come to the forefront ofclinical operative dentistry. This chapter explainsthe mode of action of the current units and dis-cusses some of the clinical uses of this techniqueas well as potential pitfalls.

BackgroundOver the years, many new ‘revolutionary’ techniqueshave been advocated for consigning mechanical cut-ting techniques to history. It follows that with thedevelopment of new materials and treatment

philosophies some of the older methods are worthyof closer re-examination. In this context air-abrasionis as much a new technique as it is old. Robert Blackpioneered air-abrasion as early as 1945.8 Black wasaware that air-abrasion would not replace the useof rotary instruments and his initial aim was to eval-uate its potential as a valuable supplement in thetreatment of caries.9 With the invention of the air-turbine, air-abrasion was superseded by a technolo-gy more suited to the mechanistic approaches todentistry common both then and even to a degree,now. The safety and licensing for the clinical use ofalumina were supported by the fact that the parti-cles are large enough to exceed the upper limit(PM10) for respirable airborne pollutants.15

Nevertheless, the contamination of surgeries by pow-der, which is inherent with airbrasive cutting, haslimited the widespread acceptance of the technique.Recent work has raised some concern regardingchronic occupational exposure to alumina.35 Newmethods of powder containment and alternativeabrasives that are biotolerated, broken down andexcreted safely are therefore obviously desirable.

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Cavity Preparation7

Air-abrasion and Bioactive Glasses

Timothy F Watson, Avijit Banerjee and George Paolinelis

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Fig 7-13 Occlusal enamel fissure prepared using air-abrasion (27.5μm). Cavity width is approximately 500μm. Fieldwidth =3mm. Reproduced from Banerjee A, Watson TF Air-abrasion: Its uses and abuses (courtesy of Dental Update: Dent update2002;49:340-346).

With the advent and use of modern-day adhesiverestorations the concepts behind cavity designhave also altered, as have the methods of provid-ing the correct finish to the cavity surfaces.37

Further developments in the understanding of thecarious process have questioned the amount of car-ious tissue to be removed, increasingly permittingthe pulp/dentine complex to repair itself with aslittle intervention as possible, but relying on aneffective restoration-cavity seal.5

Dental rotary cutting instruments generate sig-nificant structural damage.27, 28 Air-abrasion offersmultiple benefits for cutting vulnerable materialswith minimal temperature changes (+/- 2°C) orvibration, so minimizing the cracking risk.9, 16, 22

Scanning electron microscope (SEM) studies reveala typically roughened, pitted finished surface,devoid of classical substrate features, for exampleenamel prisms and dentine tubules.2, 25 The round-ed cavity margins provide ideal contours for mod-ern dental adhesive restorative materials.27 Unlikerotary cutting instruments, the principal action ofair-abrasion has been demonstrated as end-cut-ting.10, 32

Air-abrasion has now become a popular part ofthe dental armamentarium in the USA, whilst itsuse is increasing in Europe. Recent work has been

published detailing clinical usage,17 but few stud-ies have shown actual mechanisms of cutting. It isgenerally considered that hard particles willremove hard tissue, whilst soft will remove soft.Therefore, interest is recurring using the principlesof air-abrasion as a selective cutting technique, tar-geting only softened diseased tissues.1, 2, 11, 25

Basic TechniqueAir-abrasion is essentially a pseudo-mechanical,non-rotary method of cutting dental hard tissuesutilizing the transfer of kinetic energy from a streamof desiccated abrasive particles bombarding thetooth surface at high velocity. The abrasiveemployed for cutting tooth structure is aluminumoxide (Al2O3: α-alumina) with an average particlesize of 27.5μm and possessing a hardness of 9 onMohs’ scale. It is stable, non-toxic and relativelyinexpensive. The exit pressure employed common-ly ranges between 60–120 pounds per square inch(p.s.i.) and this can impart a particle velocity inexcess of 1000 feet per second depending on thediameter of the nozzle tip. The alumina escapesfrom the nozzle tip in a cone-shaped stream, thewalls of which diverge from its long axis at an angleof approximately 3.5°. The dimensions of the cut-

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