Quintessence International, 08/2000

The term minimal intervention is relatively new in dentistry and has been introduced to suggest to the profession that it is time for change in the principles of operative dentistry. The disease should be treated first; the surgical approach should be undertaken only as a last resort and then with the removal of as little natural tooth structure as possible. This article discusses the advances in techniques and materials that have led to change and attempts to put them into perspective. Treatment should begin with identification and elimination of the disease. There will then be a need for limited restoration of actual cavitation arising from demineralization of the tooth crown. Restorations, per se, will not prevent or eliminate disease. Caries is a bacterial infection and, until the microflora is controlled, all restorations are at risk of further demineralization in remaining tooth structure. This leads to the continuum of replacement dentistry that keeps the profession occupied for much of its productive time. If this cycle is to be broken, the profession must first acknowledge the primacy of prevention.

The use of modified cavity designs for the treatment of initial carious lesions can be justified on the grounds that, because no restorative material can adequately replace natural tooth structure for the long term, preservation of natural tooth structure is important. It is apparent that it is possible to remineralize and heal demineralized tooth structure to some degree. Therefore, neither enamel nor dentin should be removed simply because it has lost calcium and phosphate ions as a result of acid attack. The older surgical approach to cavity design was adopted in the absence of adhesive techniques and on the basis of Black's principle of 'extension for prevention,' but this theory is no longer tenable. The current availability of adhesive bioactive restorative materials makes it possible to maintain areas of tooth structure even though they appear to be undermined and weakened. Thus, the concept of geometric designs for prescribed cavities is no longer valid. The purpose of this article is to describe a series of simplified, modified cavity designs for small initial lesions; preservation of natural tooth structure is the principle objective of these designs.

Bondable reinforcement ribbon can be used in dentistry to splint periodontally involved teeth, to provide postorthodontic splinting, to reinforce provisional prostheses, and to fabricate direct adhesive prostheses. Four cases illustrate esthetically and functionally successful use of reinforced ribbon.

There continues to be a tremendous amount of confusion in the dental literature and among practitioners regarding the diagnosis and treatment of gingival discontinuities. The purpose of this article is to present a rationale for gingival recontouring, illustrated by a case report. A patient requested gingival recontouring. Because the preoperative evaluation was inadequate, a simple gingivectomy procedure was performed. After healing, the tissue had rebounded to its preoperative levels. The patient was then evaluated more comprehensively, and gingival recontouring was accomplished with a mucoperiosteal flap and osseous recontouring. The tissue subsequently healed at the correct position and remained stable. To reliably perform gingival recontouring procedures, the dentist must have a clear understanding of the biologic width. By using diagnostic bone sounding, the practitioner can determine the appropriate surgical procedure that will ensure an esthetic and stable postoperative result.

A technique for manufacturing direct resin composite veneers is presented. Described are the advantages of using an acrylic resin matrix, made before the preparation is begun, to copy anatomic details. An additional step to mask previously prepared dark enamel with opaquers is also described. The advantages and limitations of the procedures are discussed.

A self-etching adhesive agent for bonding polyacid-modified resin-based composite materials ('compomers') to enamel and dentin is now available. The Prompt L-Pop system simplifies and hastens dental bonding procedures and has proved itself useful in many adhesive dentistry applications. This article describes the bonding system and shows clinical examples of its use in children and teenagers. The concept will have further application in adhesive dentistry with introduction of a new formulation of Prompt, to be used with traditional resin-based composite materials.

Objective: This study was undertaken to compare the healing response of permanent primate pulps to pulpotomy procedures following hemorrhage control and adhesive hybridization to their response after conventional treatments. Method and materials: Forty-two cavities were placed throughout the dentitions of 4 adult monkeys. In 24 teeth, following mechanical bur exposure and pulpotomy, hemorrhage was controlled with application of 3% sodium hypochlorite. The cavity was rinsed and the enamel-dentin-pulp surface was restored with an adhesive system for 6 and 7 months. Calcium hydroxide, formocresol, and resin-modified glass-ionomer cement were placed as conventional treatments in 18 teeth for 70 days and cavities were sealed with resin-modified glass-ionomer cement. Following perfusion fixation, tissues were demineralized, sectioned, stained, and histologically graded using defined criteria. Results: Of 24 adhesive system pulps, 10 showed no or minimal pulpal response, 1 showed an acute response, 6 showed a chronic response, 2 showed a severe response, and 5 showed compartmentalized zones of localized necrosis. Only 8 adhesive system pulps showed stained bacteria associated with inflamed tissues. Thirteen adhesive system pulps showed dentin bridging directly at the adhesive system interface. Calcium hydroxide-treated specimens showed healing and dentin formation, while resin-modified glass-ionomer cement and formocresol treatments failed to result in any bridging. Apical tissues in all adhesive-treated specimens showed normal pulps and primary odontoblasts along their entire walls. Conclusion: Permanent pulps without periapical radiolucencies may survive pulpotomy, provided that hemorrhage is properly controlled and the pulp-restoration interface is hybridized to exclude all microleakage.