Textbook of Operative Dentistry Satish Chandra, Shaleen Chandra, Girish Chandra
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Introduction, Aims and Scope of Operative Dentistry1

 
DEFINITION
According to Mosby's dental dictionary, Operative dentistry deals with the functional and esthetic restoration of the hard tissues of individual teeth. More appropriately Operative dentistry is defined as that branch or speciality of the science and art of dentistry which deals with diagnosis, treatment, and prognosis of defects of hard tissues of the teeth (enamel, dentin and cementum) which do not require full coverage restorations for correction. Such corrections and restorations result in the restoration of proper tooth form, function and esthetics while maintaining the physiological integrity of the teeth in harmonious relationship with the adjacent hard and soft tissues. Such restorations enhance the dental and general health of the patient.
 
HISTORY
Before 1840, dentists learned the trade by doing assistantship under more experienced dentists, but their knowledge was without any scientific basis, hence often disputes were there regarding various materials and treatment techniques. There was a dispute over the use of amalgam in 1840 which initiated formal dental education with the establishment of first dental college of the world at Baltimore in 1840.
Till 1900 AD, the term ‘Operative dentistry’ included all the dental services rendered to the patients, because all the dental treatments were considered to be an operation which was performed in the dental operating room or operatory. Later on due to development of techniques and knowledge, new dental specialities were recognized. Therefore, Operative dentistry is the mother of all the clinical subjects. At that time, relief of pain and extraction of teeth were the main objectives of Operative dentistry. Operative dentistry has been recognized as the foundation of dentistry because it has been the basic field for the development of other specialities of dentistry. Operative dentistry is an integral and important part of dental practice. Operative dentistry is fundamental to the restorative and other clinical disciplines. Scientific progress in the field of dentistry was started by the introduction of amalgam. A mineral paste “Royal Mineral Succedaneum” was developed by two French dentists by mixing and triturating filings of Mexican silver coins with mercury. At that time this material was used in all carious teeth and also in precarious deep pits and fissures for prevention of caries.
Dr. G. V. Black (1898) is known as the “Father of Operative dentistry”. He provided scientific basis to dentistry because his writings developed the foundation of the profession and made the field of operative dentistry organized and scientific. Dr. G. V. Black's writings, besides Operative dentistry also covered dental anatomy, caries, erosion and oral pathology, and were mostly related with the diseases of pulp and soft tissues and their appearance in clinical conditions. Principles of cavity preparation, teeth nomenclature, instrument formula and restorative materials were established by Dr. G.V. Black. Besides Black, other important early contributors to Operative dentistry were William Rogers, Charles Merry, S.C. Barnum, Jonathan Taft, W.H. Taggart, E.K. Wedelstaedt, Waldon I. Ferrier, Charles E. Woodbury and George Hollenback.
Till then dental caries was considered a gangrene-like disease. Louis Pasteur during the same period in France confirmed the role of microorganisms in diseases. Dr. Arthur, son of Dr. Black, continued his father's efforts to strengthen the scientific foundation of Operative dentistry. Later in the first half of twentieth century more emphasis was placed on the scientific foundation of dentistry. The practice of dentistry was regulated by the laws. Gradually frequency of untrained dentists was reduced. Continuous research resulted in further refinement of the techniques with better, long lasting and predictable results.2
Advances and development since 1950 have drastically improved and increased the scope of Operative dentistry inspite of recently separating the speciality of Endodontics from it. Development of new tooth cutting devices and tooth colored adhesive and bonding restorative materials has revolutionized the scope of operative dentistry. However the work of Dr. G.V. Black is still the baseline although due to the advancement in techniques and materials, developments and modifications are continuously taking place, like ozone therapy for dental caries.
 
CONSIDERATIONS AFFECTING OPERATIVE TREATMENT
 
Indications
Indications for operative procedures can be broadly divided into the following five headings.
  1. Caries
  2. Loss of the tooth structure due to attrition, abrasion, abfraction and erosion.
  3. Malformed, discolored, or fractured teeth.
  4. Esthetic improvement
  5. Restoration replacement or repair.
 
Factors
The following are the important factors which require serious consideration before undertaking any operative procedure.
  1. The condition of the affected tooth, other teeth and the oral and general health.
  2. The diagnosis of the dental problem and the interaction of the affected area with other bodily tissues.
  3. A treatment plan that can restore the tooth with all its functions.
  4. Thorough knowledge of properties of the materials which can be used to restore the affected areas to proper shade, shape with functions, with a realization of limitations of materials and requirement of the patient.
  5. The oral environment, like caries suspectibility of the patient.
  6. Biological basis and function of the various tooth tissues and supporting tissues.
  7. The knowledge of dental morphology, anatomy and histology.
  8. The effect of the operative procedures on the treatment of other disciplines.
  9. Infection control methods to safeguard dental personnel and the patients.
 
A New Concept of Operative Approach
The new concept of an operative approach to preserve maximum healthy tooth tissues during operative procedures is a result of the following.
  1. Use of fluoride releasing restorative materials.
  2. A reduction in the incidence of caries because of increased preventive emphasis.
  3. Use of multiple fluoride applications and proper sealant applications.
  4. The advantage of the supragingival placement of restoration margins.
Research in materials and techniques has provided much improved operative services. There have been revolutionary improvements in materials and techniques in composite resins, ceramic and glass ionomer restorations because of the bonding of these materials to tooth structure. High copper amalgam restorations have vastly improved in early strength, corrosion resistance, marginal integrity and longevity.
More frequent operative procedures are now used for restorations and corrections in the following.
  1. All classes of cavities,
  2. Esthetic and/or functional correction of malformed, discolored or fractured teeth.
  3. Diastema closure can be effectively undertaken. Recent approaches have resulted in conservation of tooth structure to the maximum extent. The advances in the operative procedures and techniques have resulted in preservation of maximum tooth structure and less trauma to the pulpal tissue and gingival tissue. The aim of the research activity is to develop the materials and techniques to completely bond restorative materials to the tooth structure. This has resulted in the reduction in extensive cavity preparations.
 
AIMS OF OPERATIVE DENTISTRY
There are six fundamental aims of operative dentistry, which are as follows:
  1. Diagnosis
  2. Prevention3
  3. Interception
  4. Preservation
  5. Restoration
  6. Maintenance
 
 
Diagnosis
It is the determination of nature of disease, injury or congenital defect by examination, test and investigation. Proper diagnosis of lesions, including their locations and extent, is vital for planning the treatment including the design of the tooth preparation and the selection of restorative materials and procedures.
 
Prevention
It includes the procedures undertaken for prevention before the appearance of any sign and symptom of disease. There are two main diseases usually managed in dental practice (1) caries and (2) periodontitis. Dental caries causes destruction of tooth structure, i.e. demineralization of inorganic structure and disintegration of organic structure, pulpal and periapical pathology. Dental caries is most significantly prevented by community water fluoridation. By community water fluoridation dental caries can be reduced by 55 to 60%. Use of sealing materials, for pits and fissures, can also reduce dental caries.
By regularly following meticulous oral hygiene instructions and dietary counseling, dental caries can be prevented to some extent.
Goswami and Bhuyan reported that tea is a rich source of fluoride and this fluoride has a strong binding ability to the enamel of tooth. The tea leaf also contains catechin and these catechins have significant antibacterial activity against S. mutans. The catechins can also inhibit the bacterial enzymes glucosyl transferase. Studies have shown that rinsing one's mouth with black tea significantly reduces plaque accumulation.
 
Interception
It includes the procedures undertaken after some signs and symptoms of disease have appeared, in order to prevent the disease from developing into a more serious or full extent. Interception is a procedure, by which the teeth are restored to their normal health, form and function. In this, restoration is done in the lost tooth structure. Tooth loss occurs due to dental caries, trauma, attrition, erosion, abrasion and malformation. Altering tooth form by restoration, selective recontouring, enhancing occlusal stability and changes in the patient's home care habits (i.e. proper tooth brushing and flossing) are also included in interception. By interceptive procedures, esthetics can be improved and it can prevent long-term psychological problems.
 
Preservation
One of the important concepts of operative dentistry is preservation of what has remained along with an effort to restore what has been lost. Preservation of optimum health of teeth and soft tissue of oral cavity is obtained by preventive and interceptive procedures.
 
Restoration
The ultimate goal of restorative treatment is re-establishment and maintenance of health, form, functions and esthetics. These restorative procedures have both scientific and artistic foundation. Successful placement of any restoration requires sound clinical judgement, both biological and mechanical, with an accompanying psychomotor skill capable of performing that which has been conceptualized.
 
Maintenance
After restoration is done, it must be maintained for longer useful service.
 
SCOPE OF OPERATIVE DENTISTRY
Operative dentistry is an integral part of dentistry. Dentistry involves vast and deep knowledge of the various specialities of science. All this knowledge is applied in operative dentistry for best achievement in dental and oral health and esthetics. Operative dentistry is continuously advancing, which directly affects dental practice through the development of new treatments and new biomaterials, and more sophisticated techniques to measure the health status of individuals.
 
Factors Affecting the Future Demand for Operative Dentistry
Among the various factors affecting the future demand for operative dentistry, most important are the following:4
 
Demographics
All over the world, except a few countries, the population is increasing. Health consciousness, improved diet and better medical facilities have increased life expectancy of people. The child mortality rate has very much decreased. The average life of a person in last fifty years has increased from 30 to 45 years.
 
Affect of General and Dental Health of the Population
General health: The general health of the people has improved. The ability to prevent or cure infectious diseases has led to an increase in life expectancy. The ability to control, partially or fully, some of the chronic diseases, is resulting in a larger proportion of elderly persons in the population.
Dental and oral health: The people of south east Asia in general are having bad dental and oral health. Though awareness towards good dental and oral health care has increased in the past few decades, the concept that teeth are for life time is being gradually accepted by the general public. Moreover, epidemiological studies indicate that the need for operative dentistry will increase in the future.
 
Economic Factors
Operative dentistry is an expensive treatment. Economic status of people is gradually becoming higher. With this, the consumption of refined carbohydrates is also increasing resulting in more caries. Thus, the demand of operative dentistry in future is likely to increase.
 
DENTAL STATUS
 
 
Caries
Only in few advanced countries the incidence of caries has decreased due to fluoridation of community water supply and use of supplements of fluoride in other forms, but in most of the countries it is gradually increasing. This will also favorably affect the future demand of operative dentistry.
 
Teeth at Risk to Dental Diseases
With the increase in the population as the number of adults and elderly persons is increasing, number of serving natural teeth will also increase. Hence, the number of teeth at risk to dental diseases is gradually increasing and many of these are likely to require operative care. So, this will favorably affect the future demand of operative dentistry.
 
Periodontal Status
Periodontal diseases are increasing with change in dietary habits and increase in life expectancy. In elderly persons and senior adults, gingival recession is a major factor in the development of root caries. Development of root caries is also likely to favorably affect the future demand of operative dentistry.
 
Missing Teeth
The number of natural teeth present in oral cavity will increase. Even though partial edentulism will continue in the adult population, total edentulism (total absence of teeth) is decreasing dramatically in the elderly population. After losing few teeth people realise the importance of the remaining teeth and try to preserve them. Therefore, the persons in the age group of 30 to 40 years will be dental patients for the next 30 to 40 years. Partial edentulism will continue and therefore will be a source of demand for operative care of the remaining standing teeth in the future.
 
Projected Required Hours of Need for Operative Dentistry Services
In general dental practice the projected required hours of need for operative dentistry services are gradually increasing. They are devoted mainly to the following operative procedures.
  1. Restorations of new lesions of enamel, dentin and cementum.
  2. Restorations to replace existing faulty restorations.
  3. Restorations in teeth with root caries.
  4. Restorations to enhance the esthetics of patients
Root caries: The elderly population is gradually increasing. These people will retain more natural teeth and experience more gingival recession which will result in more root caries. This will also affect the future demand of operative dentistry.
Esthetic restorations: A part of income of the dentist comes from esthetic restorations of malformed and malaligned teeth. Gradually people are becoming more 5and more esthetic conscious and serious towards esthetic aspects. This factor will also increase the scope and future demand of operative dentistry.
Replacement of restorations: Old restorations may need replacement because of the following reasons.
  1. Secondary caries
  2. Marginal leakage
  3. Fractured restorations
  4. Availability of improved restorative materials
  5. Changing esthetic concepts.
 
FUTURE OF OPERATIVE DENTISTRY
The future of operative dentistry is very bright. The use of high and ultra high speed instrumentation along with the acknowledged benefits of water and spray coolants have also led to the concept of four-handed dentistry.
The bonding of restorations to tooth structure by etching has led to the development of many new composite materials and bonding techniques. The use of these composite materials has led to both increased esthetic qualities and resistance to wear.
It is hoped that in the future, more advanced treatment techniques and materials will be developed. There may not be any need of cavity preparation. Adhesive materials having hardness of enamel will be developed. Partial success has also been obtained in the regeneration of enamel. The past has undergone maximum changes and the future illustrates the dynamics of operative dentistry which is a constantly changing and advancing speciality.
For the development and professional growth of any branch of clinical science, continuous research is the primary requirement. By research in operative dentistry, more knowledge is being added to the understanding of the etiology, diagnosis, materials, techniques and treatment of dental diseases. Continuous research will help in better understanding about cariology and etiology of other dental diseases. By the continuous research and improvements, better restorative materials with improved techniques are being continuously marketed. Important improvements are the following.
 
 
Acid Etch Technique and Composite Resins
In operative dentistry, acid etch technique is commonly used. More improved composite resins have been developed. In this way, more operative restorations requiring much less cutting in anterior and posterior teeth are being done. The use of this technique and composite materials has reduced the potential toxicity of older restorative materials like silver amalgam. In silver amalgam, mercury and nickel (being used in traces by some manufacturers) are harmful.
 
Lasers
Lasers are being used for prevention of caries, because they cause enamel to become more resistant to demineralization. Lasers are also being used in etching of enamel for composite restoration. They are also being used in cavity preparation. The use of lasers in dentistry may lead to a new mechanism for welding the dental alloys.
 
Castable Ceramic Materials
Now, after long research and clinical trials, castable ceramic materials are being popularly used in day to day clinical practice. They have significant advantages over old conventional ceramics and other restorative materials.
 
Computer Generated Ceramic Restorations or CAD-CAM Ceramic Restorations
A lot of interest has been shown for their day-to-day clinical use. Further improvements in technology are being tested for their wider use in all types of restorations.
 
Concepts of Cariology
Other techniques are being tested for treating dental caries, other than restorative materials. If carious lesions are beginning on surfaces of teeth, they can be intercepted by remineralization, and need for restorations can be eliminated. Enamel can be made more resistant to demineralization to prevent dental caries.
 
Adhesively Bonded Composite Materials
Attempts are being made to develop composite and other materials which will adhesively and absolutely bond to enamel and dentin. When developed, it will be a boon to operative dentistry. Restoration by this type of material will require only minimal or no preparation of teeth except the removal of only the carious portion which will eliminate the anxiety of patients, and uncooperative patients will become co-operative.6
 
Radio-Visio-Graphy (RVG) (Digitization of Ionizing Radiation)
It is a new radiographic system in which there is digitization of ionizing radiation. It provides instant image on the screen of a video monitor. It reduces radiation dose by about 80 percent. Its other main advantages are elimination of X-ray film and instant image display. It is very useful in the practice of operative dentistry as during cavity preparation the distance from the pulp can be constantly monitored and pulpal exposure can be easily avoided (Fig. 1.1).
 
Research will make the Treatment a Pleasure
Dental research and efforts will continue to seek newer materials and treatment methods, which will be more efficient and not at all stressful for all the patients, especially to children and elderly patients. This will make dental treatment a pleasure to all. In research work intraoral camera is very useful (Fig. 1.2).
Bogra et al reported the following
  1. Offering an alternative to conventional treatment, a new approach based on ozone, a powerful biocide, to rapidly penetrate the bacteria and kill them in their protected niche has been introduced.
  2. Ozone therapy involves a 10 seconds application of ozone gas to eliminate microorganism in caries lesions. Significantly reducing treatment time and cost, this therapy is less invasive than previous methods and conserves more of tooth's natural structure.
  3. This painless ozone gas treatment for tooth decay has been proven to halt primary root caries, primary pit and fissure caries and even clinically reverse the lesions.
  4. Ozone therapy is based on the premise that a normal bacteria type will re-grow over the clean surface, and minerals from the special mouth rinses and saliva will be absorbed into the tooth surface.
  5. Ozone alters metabolic products of bacteria that inhibit remineralization. It also removes plaque pyruvate which may suppress the development of tooth demineralization.
 
Dentinometer/Prepometer and Other Devices
These are small battery operated instruments which measure the thickness of remaining pulpal wall i.e. distance between pulpal wall and the pulp. They are highly thermosensitive instruments and very correctly measure the thickness of dentin over vital pulp when it remains less than two mm. The heat of vital pulp is transmitted through the remaining dentin to the dentinometer/prepometer, which is measured in numericals, thereby showing the correct thickness of the remaining dentin. Some devices measure the thickness by viscosity of the dentinal fluid and some by other means (Fig. 1.3).
zoom view
Fig. 1.1: RVG in use
zoom view
Fig. 1.2: Intraoral digital camera
 
Modification in the Black's Classification of Cavities
The modification includes divisions, subdivisions and types in each class and a new class VII. This modification also includes the proximity of the pulp to the pulpal wall where the pulpal wall is thinnest from clinical point of view.7
zoom view
Fig. 1.3: Prepometer
This classification is the most important factor to guide the treatment to be followed and gives indications about the prognosis of the tooth. This has been described in detail in chapter 8.
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