JAD)A
REVIEW A R T I C L E S
Literature contrasting the use o f com posite resin sealants in the preventive resin restoration
to the am algam restoration is reviewed. In selected cases such as those involving anterior pits
and fissures with m inim al caries, sealants provide a valuable treatment alternative.
Preventive resin restorations
Edward J. Sw ift, Jr., DM D
I n describing cavity preparations for
smooth surface caries, G. V. Black said
that margins should be extended into
self-cleaning areas to prevent recurrence of
decay. T his doctrine of extension for pre­
vention has been broadened to include the
treatment of potentially carious pits and
fissures.1-3
In 192B, H yatt2-6 introduced the still-
used technique of prophylactic odontot­
omy, including preparation and restora­
tion of caries-susceptible pits and fissures.
Another method of treatment, less frequent­
ly used today, involves eradicating fissures
by mechanical shaping and smoothing.
Because of preventive practices in today’s
dentistry, such as using fluorides, the inci­
dence of caries has declined. T his has
allowed for a conservative approach to the
concept of extension for prevention. De­
spite modifications in Black’s original prin­
ciples, specifically an emphasis on preser­
vation of tooth structure, extension for
. prevention is the basic principle of opera­
tive dentistry.1
Pit and fissure sealants
An alternative to mechanically treating
potentially carious pits and fissures is use
of acid-etched resin sealants. Studies have
proved the safety and efficacy of sealants,
but surveys still indicate that pit and fissure
sealants are underutilized.7'8
Various reasons discouraging use of seal­
ants have been cited by practitioners.7’9
First, sealants have short longevity because
of poor retention. T his is a valid concern as
retention is an im portant determinant of
sealant success. A sealant is effective only if
it remains adherent to the tooth.10Contrary
to the belief of many dentists, several stud­
ies have shown good rates of retention.4"10-11
In addition, retention is highly dependent
on a meticulous technique of placement.10’11
Second, sealants can “seal in ” caries. How­
ever, this statement contradicts many stud­
ies showing that when the sealant remains
intact over a pit or fissure, only a limited
num ber of bacteria remain viable. Further­
more, those bacteria appear to be incapable
of causing continued dam age to the
teoth.412-15 T hird, patients and insurance
companies are reluctant to pay for sealants.
U nfortunately, this is true in many cases. It
is hoped that this problem will decrease as
both the public and third-party carriers are
informed of cost-effectiveness and other
benefits of sealants.10 Finally, some practi­
tioners believe that sealants are not effec­
tive in the prevention of caries. In a survey
of US dentists, sealants were rated very low
as an effective caries prevention procedure.7
However, studies have in fact shown a
dramatic reduction of caries after sealant
use during periods of 1 to 7 years.10’11
Preventive resin restoration
Sealants are often used as a preventive mea­
sure in treating noncarious pits and fis­
sures. In addition, sealants can be used to
treat pits and fissures that have minim al or
questionable caries.16Simonsen, who terms
this technique preventive resin restoration,
recommends it for restoring carious lesions
at the early stages with removal of m inimal
tooth structure, while simultaneously pro­
tecting unprepared areas from later caries
attack.5’6’9’17
T he preferred material for most poste­
rior restorations remains amalgam, as am al­
gam has proved durable during years of
clinical experience. However, some draw­
backs to its use include5,9’18:
—Amalgam preparations require remov­
al of a portion of healthy tooth structure.
Even small, conservative restorations can
significantly weaken the tooth.
—Secondary caries may occur at the
JADA, Vol. 114, June 1987 ■ 819
REVIEW ARTICLES
margins of a restoration and in unprepared
pits and fissures.
—M arginal leakage and breakdown of
amalgam can contribute to recurrent caries.
—Amalgam is not an esthetically pleas­
ing material.
The preventive resin restoration can elim­
inate these problems in certain cases. A
conservative method of preparation is used,
preserving sound tooth structure. Resin
restores the prepared area, with sealant
placed over adjacent, unprepared fissures.
Preventive resin restorations are contraindicated for large,
deep, or multisurface carious lesions, and are not intended as
substitutes for amalgam.
The result is a restoration that helps pre­
vent secondary caries and is more attractive
than amalgam .4'518
Several indications for the preventive
resin restoration include5'9'1920: question­
able caries, or an explorer catch in a pit or
fissure; m inim al, shallow pit and fissure
caries; deep pits and fissures that could
inhibit complete penetration of sealant
material or could be carious at their bases;
deep pits and fissures with extensive sup­
plemental fissuring and small areas of
decay; an opaque, chalky appearance along
pits and fissures that could indicate incip­
ient caries.
Preventive resin restorations are contra­
indicated for large, deep, or multisurface
carious lesions.5'20Therefore, these restora­
tions are not intended as a substitute for
amalgam, but as an alternative treatment
in selected cases.
Advantages and disadvantages
T he preventive resin restoration has several
advantages. As cited earlier, less tooth struc­
ture is removed than with a conventional
preparation, leaving a much stronger
tooth.5-9T his is in contrast to the extension
for prevention method by which removal
of sound tooth structure to prevent recur­
rent decay sim ultaneously weakens the
tooth.18'21 As mentioned, the sealed restora­
tion can eliminate recurrent caries. As less
mechanical preparation is required, the
patient suffers less discomfort and usually
does not require anesthesia. Finally, the
restoration may be added to, replaced, or
repaired w ithout further tooth prepara­
tion.5’9'10
A few disadvantages are associated with
the preventive resin restoration. As report-
820 ■ JADA, Vol. 114, June 1987
ed, the first and most im portant is the
requirement for absolute, meticulous adher­
ence to the principles of acid-etch tech­
nique (isolation from moisture). T his can
create a more time-consuming clinical
procedure. Also, long-term wear and reten­
tion, as compared with amalgam restora­
tions, have not been proved.5'9-19'20
Clinical technique
Several optio n s in the preventive resin restora-
tion technique are feasible, depending m ainly
on the size of the p re p ara tio n required. R egard­
less, the procedure involves a series of basic steps.
T h e tooth is first exam ined radiographically for
any evidence of in te rp ro x im a l o r occlusal caries.
T h en , the occlusal surface is carefully exam ined
w ith a sharp explorer. T h e p ractitioner m ust
check for explorer catch and resistance to rem ov­
al, soft o r o p a q u e areas, or discontinuity of the
enam el surface. Each of these factors can in d i­
cate the presence and degree of caries.5
Local anesthesia is adm inistered to the patient,
if necessary (w hen caries is present). Next, occlu­
sion is checked and m arked w ith a rticulating
paper. T h e to o th is isolated w ith cotton rolls or
rubber dam ; the latter is preferable. Regardless
of w hich m ethod is used, adequate isolation is
extrem ely im portant.e,i 6,i8,2 i \ sm all ro u n d bur
(no. 'A to 1) is used at h ig h or low speed to m ake a
m in im al exploratory prep aratio n in to any deep
pits a n d fissures.!-5-6-9.22 If caries is encountered,
better access m ay be g ained w ith a pear-shaped
b u r (no. 329 o r 3 30).20 T h is p rep aratio n exposes
caries. N o a tte m p t is m ade to create retention,
rem ove slightly underm ined enam el, or extend
Sealants can be used to treat pits and fissures that have
minimal or questionable caries in early stages with minimal
removal of tooth structure.
in to sound pits and fissures.18'21 If the p rep ara­
tion extends in to d e n tin , it m ust be checked care­
fully to detect any caries that spreads laterally at
the dentinoenam el ju n c tio n . Also, a liner, either
calcium hydroxide o r glass ionom er, should be
placed.20’22 In som e cases, a large a m o u n t of car­
ies m ay be discovered, and then a conventional
(am algam ) restoration can be initiated.
D epending on the extent of the preparation
required to exam ine for and remove caries, a
tooth m ay be restored in one of three ways. For
each, stan d ard acid-etching procedures are used.
All u n p re p are d pits a n d fissures, m inim al
exploratory preparations, and sm all carious
lesions are restored w ith a p it and fissure sealant.
Sim onsen refers to this as the type 1 preventive
resin restoration.23
If the p re p ara tio n m ust be m ade slightly
larger, a w ear-resistant posterior com posite resin
is indicated for its restoration. After a pplication
of a liner (on exposed dentin) and bonding
agent, the filled resin is gently placed. U sing a
bru sh or plastic instrum ent, the resin is extended
in to adjacen t fissures to create a filled sealant.
Any caries-susceptible areas o n the tooth, w hich
are not directly adjacent to the p reparation, are
treated w ith a conventional pit and fissure
sealant. In S im onsen’s classification, this m ethod
is called the type 2.23
D iffering som ew hat is the type 3 technique in
w hich the filled resin is used only to restore the
prepared cavity. A djacent fissures are covered
w ith a p it a n d fissure sealant.23 If light-cured
m aterials are used, they can be cured sim ulta­
neously.20 A lternatively, the posterior com posite
resin may be placed and cured first, then covered,
alo n g w ith adjacent fissures, w ith a sealant.18-21
F inally, the rubber dam is removed and the
occlusion is checked carefully for prem aturities
o r h ig h spots. T h is is especially im p o rta n t if a
filled m aterial is used, for it w ill n o t w ear as
quickly as the u n filled type. Any necessary
a d ju stm en t m ay be done, u sin g w hite stones or
fin ish in g b u rs.18'20-22
Results of research
T h e preventive resin restoration was first de­
scribed in the literature in 1977-78.9 E arlier
research o n the use of dilute com posite resin as a
fissure sealant laid the groundw ork for S im on­
sen’s preventive restoration technique.24'25
L ater clinical studies of u p to 7 years have
show n h ig h rates of retention and caries preven­
tion. 6,i7,2i-26-27 Most failures seem to be related to
im p ro p er techniques, such as lack of adequate
m oisture c o n tro l.16
In v itro research has been perform ed on the
m icroleakage characteristics of preventive resin
restorations. T h is research has show n th at the
preventive resin restoration possesses an in ti­
m ate enam el-resin interface and provides a good
seal, regardless of w hether the resin is filled or
u n fille d .19’28’29 An 18-m onth clinical study com ­
p a rin g preventive resin restorations w ith am al­
gam restorations in contralateral teeth found
th at the m arginal integrity of the resin restora­
tions was better. T h is same study also rated the
w ear of the c o m p o site/sealan t restorations as
excellent.30

Summary
T he modern decline in caries incidence has
caused many dentists to reconsider the tra­
ditional methods of preventing recurrent
caries. More emphasis is being placed on
the preservation of sound, healthy tooth
structure. T he proved success of pit and
fissure sealants has led to the development
of a relatively new restorative technique,
the preventive resin restoration. In selected
cases, this technique can be effective, in
terms of both caries prevention and preser­
vation of tooth structure. As resin materials
continue to improve and the caries rate
continues to decline, the preventive resin
restoration should become a fundamental
procedure of operative dentistry.
------------------ J liO A -------------------
Dr. Edw ard J. Swift, Jr., is clinical instructor, d ep art­
m ent of operative dentistry, College of D entistry, U n i­
versity of Iow a, Iow a City, 52242. Address requests for
rep rin ts to the au th o r.
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technology. D ent C lin N o rth Am 25(2):29I-305, 1981.
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caries. JADA 93(11):967-970, 1976.
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bacterial counts. J P rosthet D ent 42(5):521-526, 1979.
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Swift : PREVENTIVE RESIN RESTORATIONS ■ 821
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tion. Q uintessence In t 16(7):489-492, 1985.
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26. Sim onsen, R .J., an d Landy, N.A. Preventive
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