5

Cavity
Preparation

PHOTOGRAPH BY STANISLAV
GERANIN, POLTAVA, UKRAINE.
Principles of Cavity Preparation
Cavity preparation, the procedure used to remove demin-
eralized enamel and infected dentin consists of four steps:
1. Opening a cavity or removing a poorly fitting
restoration
2. Removing infected dentin
3. Evaluating residual tooth tissue and removing unsup-
ported or structurally compromised enamel
4. Finishing cavity margins
The extent of preparation always depends on clinical and
radiographic analysis of the caries lesion (Table 5-1). The
clinician will shape the cavity based on the extent of the
lesion and in keeping with the principle of minimal inva-
siveness. This chapter discusses the various levels of tooth
preparation according to the type of caries lesion and patient
risk level.
This chapter would have looked very different before the
advent of dental bonding.1 The principles of tooth prepara-
tion for direct bonded restorations have evolved because of
increased knowledge and application of caries prevention
as well as dental bonding and the improved mechanical
performance of contemporary bonding materials. Nowadays,
the principles of cavity preparation are simpler than in the
past. The requirements are as follows:
• Removing carious dental tissue
• Removing unsupported healthy tooth to prevent its
mechanical breakdown during function
• Preparing space required for the restoration material,
respecting the dental structural requirements and mini-
mum thicknesses for the material in question

TABLE 5-1 Treatment options based on the initial clinical situation

Clinical situation Therapeutic options

Unpronounced occlusal anatomy, no active No treatment

lesions, good oral hygiene

Very pronounced occlusal anatomy, no active • None for adults

lesions, good oral hygiene • Sealing if the patient is young2

Pronounced occlusal anatomy with suspect
grooves in patients at risk (eg, pigmented,
discolored grooves)
Ultraconservative opening of grooves for diagnostic purposes (preventive
resin restoration [PRR])
• In the absence of caries: restoration/sealant
• If caries present: Class 1 restoration

Small, medium, and large occlusal caries Class 1 restoration

lesions

Areas of interproximal demineralization • Remineralizing maneuvers and aids

• Infiltration method (only in strict accordance with guidelines)
• Class 2 restoration with direct access, preserving the marginal ridge
• Class 3 restoration with removal of marginal ridge

69
5 caviTy preparaTion
a b
c d
FIG 5-2 (a) Open V-shaped groove. (b) Closed V-shaped groove. (c) Drop-shaped groove. (d) I-shaped groove
With the phasing out of amalgam and gold preparations,
the following concepts have disappeared:
• Extending preparations into healthy adjacent grooves
• Accessory mechanical retention areas (swallowtails,
dovetails, etc)
• Occlusal convergence
• Using retention pins
Dental bonding has changed the preparation and resto-
ration of small, medium, and large caries-related cavities and
assumed a fundamental role in treatments on the borderline
between primary and secondary prevention: minimally inva-
sive seals and tooth preparations.
The level of destructiveness involved in treatment depends
on the initial clinical situation2 (see Table 5-1). A relatively
unpronounced occlusal anatomy without any diagnostic
problems does not require any type of treatment. Clinical
case management becomes more complicated if grooves
are more pronounced. No treatment will be performed in
a patient without active lesions, while it will be prudent to
70
FIG 5-1 Result of 3D microCT reconstruction
of the pits and fissures of a molar. Note the
extreme depth, steepness, and small size.
The base of these pits inevitably lies close to
the dentinoenamel junction (DEJ), which pre-
disposes the patient to rapid development of
caries if they are damaged. (Courtesy of Ben-
edicta D. Arhatari, ARC Centre of Excellence
in Advanced Molecular Imaging, Department
of Chemistry and Physics, La Trobe University,
Victoria, Australia, and Maurice White, Super-
tooth NDK, Victoria, Australia.)
perform minimally invasive treatment if the individual has a
medium or high risk profile.3
Types of Grooves
The anatomy of molar and premolar occlusal surfaces is
highly variable in terms of groove and pit depth. The enamel
anatomy can be more or less pronounced and more or less
complete, and this can generate grooves and fissures that
are particularly subject to caries. Arhatari et al4 used micro-
computed tomography (microCT) to show how deep and
variable grooves and pit anatomy can be (Fig 5-1). Longitudinal
sections through teeth show variable anatomies (open and
closed V-shaped, drop-shaped, I-shaped; Fig 5-2).
Under anatomical conditions favoring plaque accumulation
and where the enamel on the base of the groove is thin, any
newly established caries activity would lead to sudden spread
of the caries lesion. It is therefore imperative to be able to
effectively evaluate groove types (Fig 5-3).
 Types of Grooves

a b

c d

e f

g h

FIG 5-3 (a to h) Different types of grooves with varying depths, prognoses, and extent of demineralization.

71
5 CAVITY PREPARATION
a b
d e
Groove evaluation
The essential premise for reliable groove evaluation is that the
tooth surface should be clean and accurately observable. After
careful cleaning using a high-pressure glycine spray, it is always
advisable to observe the grooves using magnifying systems.
The possibility of diagnostic error must be considered.5
Magnification systems are an aid for more detailed diagnostic
evaluation of grooves. Galilean and prismatic lenses are most
commonly used in routine dentistry, but microscopy can be
used when the diagnosis is problematic. Once the occlusal
surface has been thoroughly analyzed in relation to the patient’s
risk rating, it will be possible to decide whether to do nothing,
carry out sealing, perform a preventive resin restoration (PRR),
or apply a direct bonded restoration (see Table 5-1).
Sealing
Sealing is a preventive procedure to prevent caries lesion
formation in deep occlusal surfaces that are difficult to clean.
It can reduce caries lesions by up to 51%.2 Filling difficult-to-
clean surfaces improves oral hygiene procedures and prevents
bacteria proliferating in their ideal habitat.
One of the biggest concerns raised about sealing is
the possibility that active caries lesions might be covered.
Although there are conflicting views about deliberate sealing
of active caries lesions, it has been shown that it is difficult for
sealed lesions to grow.6 These findings are reassuring when
a practitioner decides to carry out sealing in accordance with
the parameters set out in Table 5-1, because sealing could
stop the development of an (albeit minimal) early caries lesion
that was not identified during clinical evaluation.
72
c
FIG 5-4 (a) Initial clinical situation. Some grooves
are evidently cavitated but others are less clear.
(b) The grooves are thoroughly cleaned with a
glycine jet and inspected with magnification.
(c) Suspect grooves are opened using a very
fine flame bur (ie, size 005 or 007) to a depth
of no more than 1 mm. (d) Minimal opening
shows that some grooves are unaffected by
caries while others display caries activity. (e)
Minimally invasive Class I cavities are prepared.
The step-by-step procedure for sealing involves:
1. Thorough cleaning of grooves using glycine spray.
2. Removal of aprismatic enamel—which has been
shown to be resistant to orthophosphoric acid,
leading to an unreliable adhesive bond and loss of
sealant.7–9 Preparation must not be aggressive and
can be done with air abrasion, fissurotomy burs, or
very small-diameter burs.10
3. A total-etch bonding procedure (37% orthophos-
phoric acid and bonding system).
4. Light-curing sealant.
Minimally Invasive Cavity Preparation
As shown in Table 5-1, a minimally invasive cavity will be
made for exploratory purposes if the grooves are suspect.
This minimally invasive procedure involves an exploratory
preparation to dispel doubt about grooves that are difficult
to diagnose. After cleaning the grooves, they are opened
to no more than 1 mm to allow direct assessment of tooth
tissue quality. If the cavity is negative, ie, without caries, the
exploratory cavity can be sealed (type I PRR)11–13; otherwise,
it may be decided to proceed beyond the DEJ and carry out
a type III PRR (using restoration material and sealant) or a
true Class 1 restoration.
A cavity is negative even when it is pigmented with a
black line but cannot be probed by a dental probe. The
clinical case described in Fig 5-4 shows the approach used
for an occlusal surface characterized by grooves affected or
not by initial demineralization processes with more or less
pronounced cavitation.
 occlusal caviTies (class 1)

Handpieces
There are essentially two types of handpieces used to prepare
and finish cavities: a multiplier handpiece (Fig 5-5a) fitted with
“ THE EXTENT OF PREPARATION
ALWAYS DEPENDS ON CLINICAL
AND RADIOGRAPHIC ANALYSIS
high-speed burs and a contra-angle handpiece (Fig 5-5b) fitted
with low-speed burs. The high-speed turbine allows very high OF CARIES ACTIVITY AND MUST
speeds but limited control, so is not recommended as a tool
for preparation or for finishing and polishing. Two other useful ALWAYS OBSERVE THE PRINCIPLE
handpieces are oscillating/reciprocating (Fig 5-5c) and sonic OF MINIMAL INVASIVENESS.”
(Fig 5-5d). The nonrotary action of the latter allows certain
movements that facilitate cavity preparation and finishing
procedures.

Burs
Figure 5-6 shows a selection of preparation burs for conser-
vative direct restoration of posterior teeth. Although sonic or
a
oscillating tips are sometimes used, those described in Fig
5-6 comprise an essential set to manage almost all cavity
preparations in posterior sectors. Note that FG indicates friction
grip (high-speed bur, for multiplier handpiece) and CA indicates
contra-angle (burs for a contra-angle handpiece).

Occlusal Cavities (Class 1)

Occlusal cavities (historically defined by Black as Class 1 in
terms of topography and treatment type) are the only cavities
related to grooves and fissures. All the other classes relate
to caries activity on smooth surfaces. This also involves a
different caries lesion configuration and propagation rate
compared, for example, to interproximal caries lesions. The
classic caries lesion topography is a triangle with its tip at
the external surface and base at the DEJ. In interproximal
caries lesions, however, the external surface is larger, and
progression toward the DEJ is slower (ie, triangular topography
with base on the external surface and tip pointing toward the
DEJ). As mentioned at the beginning of the chapter, dental
preparation aims to remove both caries lesions and undercuts
in the cavity, evaluate residual structural factors, and provide
restorative material in the necessary thickness.
Essentially two types of burs are used to prepare the
cavity:
• Diamond cylindric burs with rounded head for a multi-
plier handpiece (see Figs 5-6a and 5-6b)
• Tungsten carbide multiblade round burs for a
contra-angle handpiece (see Fig 5-6c)
c
d
FIG 5-5 (a) The multiplier handpiece uses friction-grip (FG) burs and
operates at a speed that is a multiple of the contra-angle (generally
five times). This is fast enough for diamond burs (to cut the enamel),
while the electric motor simultaneously provides great control. The
use of a high-speed turbine is not recommended because it does
not allow enough control. (b) The contra-angle (CA) handpiece is
fitted with CA burs. It is used with tungsten carbide rosehead burs
to remove infected dentin. Rubber and other tips are then used for
finishing and polishing. (c) The oscillating handpiece (also referred
to as a reciprocating handpiece) moves a diamond file (with one or
both working sides) along a single axis to drill a wall in tight spaces.
This is an excellent system for modifying a Class 2 cavity in a me-
siodistal direction, removing, for example, horizontal overcontours
on a restoration. (d) The sonic handpiece allows high-frequency
movement of the diamond inserts, which drill the hard tissue in a
selective, conservative manner.

73
5 caviTy preparaTion

a b

c d

e f

FIG 5-6 Essential burs. (a) Very small-diameter flame bur (FG; 006–008):
used for conservative opening of suspect grooves. (b) Cylindric bur
with rounded head (FG; 007–0014): used for most Class 1 and 2 cavity
preparations. (c) Tungsten carbide rosehead bur (CA; 010–020): used
to remove infected dentin. (d) End-cutting bur (FG; 012): used to define
and finish a cervical step in Class 2 preparations. (e) Fine-grained
g flame bur (FG; 010): used to finish Class 2 box walls. (f) Arkansas
stone (FG): used to smooth the cavity margin. (g) Brownie polisher
(CA): used to polish the cavity margin.

The cavity margin is then finished and polished with fine-
grained or multibladed burs, stones, or polishers (see Figs
5-6f and 5-6g).
Step-by-step Class 1 preparation
Class 1 preparation (Fig 5-7) follows very specific criteria
whether used for treating established caries lesions, recon-
struction, or a PRR. As already mentioned, even if the caries
lesion is exclusively occlusal, it is advisable to isolate by
quadrant (see Fig 5-7a) in order to:
• Increase the visibility of the operating field
• Avoid the need to remove and refit a dam if there is an
interproximal extension (which may not be perceptible
radiographically)
• Reveal the anatomy of adjacent teeth (to help in
assessing the occlusal plane)
The operating field, particularly the occlusal surface, is
cleaned with a high-pressure glycine or bicarbonate spray
(see Fig 5-7b) or cleaned with a brush and a paste containing
pumice and chlorhexidine. When the biofilm is removed from
the occlusal surface, it is easier to see which grooves are
affected by caries and thus plan a more selective prepara-
tion. If possible, the cavity should be opened using a small-
diameter bur (size 006, 007, or 008; see Figs 5-7c and 5-7d)
to a depth of 1 to 1.5 mm. Once a small cavity has been
opened, the location of the caries lesion can be immediately
evaluated (more or less buccal, palatal/lingual, mesial, or
distal).
The next step is to increase the size of the cavity overlying
the caries lesion (see Figs 5-7d and 5-7f), stepping up to
a larger-diameter cylindric bur with a round head as soon
as possible. As a rule of thumb, it is always advisable to
use the largest-diameter bur that can freely enter the cavity.
Large-diameter burs allow greater control as well as faster
tissue removal. Once a cavity has been opened to allow
access, the infected dentin is removed using low-speed
tungsten carbide round burs (see Figs 5-7g and 5-7h). In this
case too, it is advisable to use the largest bur possible. This
allows effective removal of the infected dentin and excellent
control compared with small-diameter burs.
Caries lesions extend horizontally through the DEJ. This
very often means that the cavity in the dentin is larger than
the access cavity in the enamel. The numerous resulting

74
 occlusal caviTies (class 1)

Step 1 Step 2

a b

Step 3

c d

Step 4

e f

Step 5

g h

FIG 5-7 (a) Isolation by quadrant. (b) After cleaning with a brush and paste to improve visibility of groove anatomy. (c and d) Preparation of
a small cavity. (e and f) Extension of the cavity preparation. (g and h) Removal of infected dentin.

75
5 caviTy preparaTion

Step 6

i j

FIG 5-7 (cont) (i and j) Grinding to remove large undercuts. (k and l)

Step 7 Smoothing and polishing the margins.

k l

a b c d

FIG 5-8 (a) Initial situation with occlusal surface characterized by suspect grooves with negative results on probing and radiographic exam-
ination. (b) The tooth is isolated with rubber dam. (c) The occlusal surface is cleaned using a paste containing pumice and chlorhexidine.
(d) The grooves are further cleaned using high-pressure glycine sprays.

undercuts must be evaluated and ground down if neces-
sary (see Figs 5-7i and 5-7j). A cylindric diamond bur with
rounded head is reused to reduce or remove undercuts. Small
undercuts are permissible, particularly if they are positioned
deeply and if the enamel is partly supported by dentin. The
cavity margin is then smoothed using fine-grained diamond
burs (red/yellow ring), burs with a high number of blades, or
stones before polishing (see Figs 5-7k and 5-7l). The clinical
case illustrated in Fig 5-8 shows an exploratory approach
to suspect grooves that prompt Class 1 preparations. The
clinical case in Fig 5-9 shows the preparation and restoration
of an established occlusal caries lesion.

76
 Occlusal Cavities (Class 1)

e f g h

i j k l

m n o p

q r s t

FIG 5-8 (cont) (e) The glycine particles are small enough to clean all grooves very deeply and remove any pigment. The absence of caries
can sometimes be established at this early stage. (f) After cleaning, the groove still looks strongly pigmented, and underlying caries activity
is still suspected. (g) It is therefore justifiable to carry out a PRR, opening the suspect grooves in a conservative manner. (h) Opening the
grooves reveals areas of demineralization that must be cleaned. The status of the preparation has therefore changed from a PRR to a Class
1 preparation. (i) Appearance of completed cavity. It is permissible to keep small undercuts if they do not leave undermined enamel areas. (j)
The cavity margins are then ground with a fine-grained (40 µ) diamond bur. (k) Bonding procedures are carried out. In this case, a self-etch
system is used with selective enamel etching. (l) Application of the bonding. When performing the bonding procedure on minimal groove
cavities, it is advisable to apply the bonding using single-use brushes because they are smaller than microbrushes. (m and n) Although
optional, application of a flowable composite to the base of the cavity is a convenient way to perform a visual check that no spaces have
been left above the bonding interface. (o) Composite masses are added bit by bit. (p) A horizontal layer is added before modeling the final
layer. (q) Various modeling techniques can be used in small cavities. In this case, subtractive modeling (see chapter 7) makes it possible to
finalize the occlusal surface very quickly. (r) The restorations are finished and polished using fine-grained diamond burs and silicone tips. A
final step is carried out with silicon carbide brushes. (s) The restoration before removing the rubber dam. (t) Completed restoration.

77
5 CAVITY PREPARATION
a b
e f
i j
Should the margin be beveled?
In occlusal cavities, beveling of the margins is not required.
Because of the way the prisms are oriented at this level, the
enamel prisms are already cut correctly by a bur placed at
a right angle to the occlusal table.14,15
The cavity margin must be finished and polished. An unpol-
ished margin contains unsupported prisms that can be lost
by cohesive fracture during curing and over the lifetime of the
restoration, causing marginal pigmentation and, potentially,
secondary caries. A smooth margin also allows the bonding
and restoration material to adapt better and prevent the
incorporation of bubbles.16–19
78
c d
g h
FIG 5-9 (a to j) Step-by-step preparation and Class 1 restoration of
an established occlusal caries lesion.
Interproximal Cavities (Class 2)
Multisurface restorations in molars and premolars are the most
common type of restoration.20 Interproximal cavities (histori-
cally defined by topography and treatment type as Black Class
2) are very common, and their restoration, performed using
the techniques and materials indicated, is predictable and
supported in the literature by reviews and meta-analyses.21
Heintze and Rousson22 analyzed 59 clinical studies over at
least 2 years of observation, concluding that the most clini-
cally effective procedure for treating Class 2 preparations is a
bonding system including etching with 37% orthophosphoric
acid, a hybrid composite, a cavity with no need for a bevel,
and—when possible—rubber dam.
 Interproximal Cavities (Class 2)

a b

FIG 5-10 Options for protecting the adjacent tooth. (a) FenderWedge (Directa). (b) InterGuard (Ultradent).

a b

c d

FIG 5-11 (a to d) Class 2 cavity preparation in a marginal ridge. It is important to provide cervical and interproximal protection.

A Class 2 preparation procedure involves the following
steps:
1. Removing the caries lesion with access through the
marginal ridge, avoiding damage to the adjacent tooth
2. Defining the position of the cervical step
3. Defining the axial walls of the box-form preparation
(sometimes referred to in this text as box for brevity)
for reconstructive purposes
Accessing an interproximal lesion involves protecting
the adjacent tooth. Although an interproximal cavity can be
accessed while preserving the marginal ridge of the tooth
involved, it is better to insert a wedge and interproximal
protection or a system that includes both23,24 (Figs 5-10 and
5-11). After penetrating the lesion edges, it is advisable to
stop and visualize the position of the lesion and decide how
far to extend the preparation in a buccolingual direction
(Fig 5-12). Some lesions develop in a more buccal or palatal

79
5 CAVITY PREPARATION
a b
FIG 5-12 (a to d) In Class 2 preparations, the ridge must be opened gently to determine the direction in which the lesion has developed.
direction and allow a good portion of the interproximal wall
to be preserved.
The wedge plays a very important role in Class 2 prepara-
tions. The authors recommend positioning it before starting
the preparation. It offers certain advantages:
• Protects the interproximal dam
• Apicalizes the interproximal tissue (papilla) to provide
more space for rotary instruments
• Can be modified by grinding to make a custom wedge
for use during reconstructive steps (Fig 5-13)
If the cavity is clearly large, an opening can sometimes be
achieved correctly without the help of protection and wedges
since a very large cavity can be opened at the occlusal level
(Fig 5-14).
Step-by-step Class 2 preparation
The burs used to prepare a Class 2 restoration (Fig 5-15) are
the same as those used for a Class 1 restoration (see Figs
5-6a to 5-6c, 5-6f, and 5-6g) with the addition of a flame
bur (see Fig 5-6e) and an end-cutting bur (see Fig 5-6d). As
with Class 1 restorations, it is preferable to isolate the entire
sector (see Figs 5-15a and 5-15b) to manage sectional matrix
system sizes and evaluate the anatomy of the other teeth.
In a Class 2 preparation, it is always advisable to place the
clamp on the tooth distal to the tooth to be treated. Even
if the cavity is mesial, it is preferable to position the clamp
more distally to allow accessibility, visibility, and space for
reconstruction aids.
The wedge protects the deep interproximal area (see
Figs 5-15c and 5-15d; see also Figs 5-13b and 5-13c) as
80
c d
well as the dam, which could become damaged during
box preparation. The wedge can be inserted buccally or
lingually. It is advisable to insert it where the embrasures
are wider. Devices are available to protect the adjacent
tooth (see Figs 5-15e and 5-15f; see also Fig 5-10). As
discussed, Lussi et al showed that the adjacent tooth is
always involved during a Class 2 preparation, even when
magnification is used.23,24
A small round cylindric bur is used to prepare the inside
of the marginal ridge (see Figs 5-15g and 5-15h), preserving
the interproximal wall. The preparation is generally deepened
by 2 to 3 mm to gain a direct view of the extent of the caries
lesion (see Fig 5-12).
It often feels as though the bur is drilling into nothing as it
enters the demineralized area, which offers less resistance.
The preparation is carried out in a buccolingual direction,
preserving the marginal ridge (see Fig 5-15i). Maintaining
as much of the interproximal wall as possible, the cavity
design is finalized in buccolingual and mesiodistal direc-
tions (see Figs 5-15j and 5-15k). The final design will be
further modified after cleaning the dentin, given that enamel
walls often turn out to be unsupported. The same bur (or a
flame bur) is used to define the axial walls (see Fig 5-15l).
If not already removed, the interproximal wall is gradually
weakened to make it easier to remove (see Figs 5-15m
and 5-15n).
A flat cervical step is prepared (see Fig 5-15o).The cervical
step must be prepared accurately to achieve:
• A good fit for the sectional matrix
• Good bonding material wettability
• Good restoration material fit
• Correct emergence
 Interproximal Cavities (Class 2)

a b c

FIG 5-13 (a) Initial situation requiring two Class 2 preparations. The cavities still require cleaning to remove the infected dentin. (b and c)
Note that the wedge is prepared together with the tooth structure. Sacrificing the wedge protects the dam septum and compresses and
displaces the papilla. Once the preparation is complete, the customized wedge may be used for the restoration or replaced.

a b

FIG 5-14 (a and b) A clearly large cavity can have predominantly occlu-
sal access. Sometimes this means the use of interproximal protections
can be avoided. When reconstructing a restoration (recurrence of
caries), potential weakening of residual cusps must be considered.
(c) In this case, the mesiopalatal cusp looks intact. The palatal portion
of the box is still very conservative. Conversely, the mesiobuccal cusp
looked undermined, and this inevitably led to enlargement of the box.

81
5 caviTy preparaTion

Step 1

a b

Step 2

c d

Step 3

e f

Step 4

g h

FIG 5-15 (a and b) Sector isolation. (c and d) Inserting a wedge. In this example, the wedge is inserted palatally because those embrasures
are wider (ie, there is more space). (e and f) Protecting the adjacent tooth. (g and h) Preparing the marginal ridge.

82
 inTerproximal caviTies (class 2)

Step 5

j k

Step 6

l m

FIG 5-15 (cont) (i) The preparation is carried out in a buccolingual direction (double arrow), preserving the marginal ridge. (j and k) Cavity
design is defined based on the extent of the caries lesion and structural requirements. (l) Axial walls. (m) The small residual wall is often
detached while defining the axial walls.

83
5 caviTy preparaTion

Step 7

n o

Step 8

q r

FIG 5-15 (cont) (n) If the residual wall does not detach, it can be removed using manual tools or the same cylindric round bur used for
preparation. (o) Preparation of the cervical step. (p) The bur is moved quickly in a buccolingual direction (double arrow) without exerting a
great deal of pressure. (q) Defining the axial walls using a flame bur. (r) If buccal access is possible, reciprocating diamond files can be used.

84
 Interproximal Cavities (Class 2)

s t

u v

w x

y z

FIG 5-15 (cont) (s and t) This stage can also be performed using coarse-grained disks or manual tools (scalpels). (u and v) The axial walls
and cervical step also can easily be defined using sonic inserts. (w and x) Marginal finishing. If the margin is accessible, it can be prepared
using medium-grained disks. (y and z) Cervical step emergence can be modified in a mesiodistal direction. This modification must be per-
formed only when indicated.

85
5 CAVITY PREPARATION
a b
FIG 5-16 (a to d) End-cutting bur used to define a cervical step.
VIDEO: CLASS 2 PREPARATION
The margin can be easily achieved by using end-cutting
burs to avoid damaging the neighboring tooth (if protection
has been removed) or the axial walls (Fig 5-16). The move-
ment to be adopted when using this bur is gentle pressure
but relatively fast buccolingual movements (see Fig 5-15p).
The axial walls of Class 2 box preparations must be defined
and finished (Fig 5-17), and their surfaces must not be uneven.
Various options are available to achieve this end. The first
method is to use flame burs (see Figs 5-15q and 5-17a). If the
walls are diverging and can be accessed buccally or palatally,
reciprocating diamond files (diamond surface on only one side;
see Figs 5-15r and 5-17b) or coarse-grained disks (see Figs
5-15s and 5-17c) can be used. This allows the axial wall of
the box to be quickly defined and finished, but there must
be enough space to allow the disk to work inside the wall,
otherwise the outer wall of the box may be damaged. This
stage can also be performed using manual tools (scalpels; see
Figs 5-15t and 5-17d). Although this is an excellent method,
manual tools should be used with caution because there is a
risk of leaving steps and sharp angles in the transition between
the axial wall and the step. The axial walls and cervical step
also easily can be defined using sonic inserts (Figs 5-15u,
5-15v, and 5-17e). These tools are not essential, but they
are convenient and allow significant time savings. The axial
wall margin is smoothed using a medium-grained disk. This
86
c d
is not a bevel but simply a way of finishing the margin (see
Figs 5-15w and 5-15x).
Sometimes it may be necessary to modify the emergence
of the cervical step. This maneuver should be performed only
when strictly necessary. This can happen when:
• Cervical anatomy is not linear, and gaps arise between
the matrix and the cervical step when the sectional
matrix is fitted (imperfectly fitting matrix).
• The cervical step is too close to the adjacent tooth,
with consequent problems fitting the sectional matrix
and accurately managing the emergence profile.
Changes can be made to the cervical step anatomy,
provided these are contained within the enamel structure
and are of minimal size. The ideal tool for this modification
is a reciprocating file (see Figs 5-15y and 5-15z).
Defining the angle between the axial walls and the exter-
nal surface is important for determining the strength of the
restoration and the tooth tissue (Fig 5-18). The angle between
the outer surface of the tooth and the box wall should be
approximately 90 degrees (green angle, type 1 in Fig 5-18b).
More acute angles (red angle, type 3 in Fig 5-18b) must be
avoided because they indicate that the dental tissue is very
thin and more likely to fracture during function. More obtuse
angles (orange angle, type 2 in Fig 5-18b) are acceptable,
but they result in areas that are more difficult to fill during
reconstruction, making it necessary to apply only very thin
layers of restorative material.
 Interproximal Cavities (Class 2)

a b c d

FIG 5-17 Defining axial walls using a flame bur (a), files (b), a disk (c), a scalpel/manual enamel cutter
(d), or dedicated sonic inserts (e).

Sonic instruments and associated inserts are recom-

mended as a user-friendly method. For the same tip size,
rotary instruments need much more working space than a
sonic instrument. If preparation is carried out using sonic
instruments, cavity preparation on the most distal teeth
is a simpler process for the clinician and less stressful e
for patients, who will not have to put so much effort into
keeping their mouths open. Because sonic inserts come
in many types with many angles, they can easily reach
the most inaccessible areas of the tooth (Fig 5-19). If the
most appropriate angle is selected, they comply with the
Type 1

principle of preserving healthy dental tissue where possible,

which is not always feasible with the most common rotary
instruments.

Interproximal cavities without ridge

Type 2

access: Tunnel or slot technique?

Although the marginal ridge plays an important structural role,
it is often difficult to preserve in Class 2 preparations. Clini-
cians will ideally try to preserve it, relying on the fact that the
caries lesion is far from the ridge and often below the contact
Type 3

point. One tried and tested method is the tunnel technique.

This involves preparing the interproximal area from an initial
a b
occlusal access point. The literature reports highly variable
results and a high failure rate (50% survival rate after 6 years FIG 5-18 (a and b) Defining the angle between the axial walls and
in the longest-term study22,25). Failures arise due to marginal the external surface of the tooth.
ridge fracture and secondary caries. Failure also has been
attributed to residual caries that is impossible to remove with

87
5 CAVITY PREPARATION

a b

More space required:

Optimal ergonomics Suboptimal ergonomics

c d

FIG 5-19 (a to d) If little working space is available, some sonic tips can prepare a cavity in spaces that rotary instruments cannot access.

a blind access route. A caries lesion spreads significantly
through the DEJ, and with tunnel access it is impossible to
verify the DEJ coronal to the cavity. Until long-term studies
are conducted with favorable results, the authors consider
this technique to be risky.
Conversely, a review by McComb25 reports more promising
results for slot preparations, known also as proximal slot or
box-only preparations. The opportunity to view the cavity
directly and therefore remove all the carious tissue and be
able to predictably evaluate a compromised marginal ridge
makes the restoration prognosis more favorable. In a slot
preparation, marginal ridge height appears to be a critical
factor for survival. A thin ridge could lead to mechanical
failure. The authors suggest preserving a marginal ridge
height of at least 1.5 mm. For lower values, it is advisable to
form a traditional Class 2 preparation. Some slot preparations
and their restorations are shown in Figs 5-20 to 5-22. Prepa-
ration of such cavities often depends on access and is carried
out using round rotary instruments or angled sonic inserts
(Fig 5-23). Cavities can be reconstructed using different
composite material viscosities (flowable/paste) since these
areas are not subject to mechanical stress. Sometimes it
is not possible to perform a slot preparation if the marginal
ridge is compromised. In this case, a conventional Class 2
preparation is performed (Fig 5-24).

88
 Interproximal Cavities (Class 2)

a b c d

FIG 5-20 (a to d) Slot preparation on the mesial aspect of a mandibular right second molar.

a b c d

FIG 5-21 (a to d) Slot preparation on the distal aspect of a mandibular right second premolar.

a b

c d

e f

FIG 5-22 (a to f) Slot preparations on the distal aspects of a maxillary left second premolar and first molar.

89
5 CAVITY PREPARATION

a b

FIG 5-23 (a) Slot preparations are generally accessed using a round
diamond bur. (b) Dedicated sonic or ultrasonic inserts are available
to overcome the limitations of round diamond burs. (c) Preparations
in the dentin are completed using low-speed carbide burs.

FIG 5-24 (a) Moderately cavitated

direct access cavities often hide an
extensive area of demineralization
with significant structural involve-
ment of the distal marginal ridge.
(b and c) Despite the presence of
a prepared adjacent tooth (which
provides more space for direct ac-
cess), it is immediately clear that
the distal marginal ridge is struc-
turally impaired. (d) The cavity is
prepared using a conventional
Class 2 technique.

a b

c d

90
 Interproximal Cavities (Class 2)

a b c

FIG 5-25 (a) Hypothetical lesion positioned at the contact point. (b) The cavity can be considered potentially complete, even if it remains in
contact with the adjacent tooth. This condition can be considered acceptable but creates difficulties in restoration procedures (eg, matrix
insertion, finishing and polishing, control of restoration margin over time). (c) Moving the preparation margin to a more cervical level (remaining
within enamel cavity margins) facilitates reconstruction and checking of the margins.

a b c

FIG 5-26 (a) Initial hypothetical situation with

no contact point and a poorly fitting resto-
ration. (b) Cavity prepared without considering
the future emergence of the restoration. (c)
Hypothetical restoration with overly horizon-
tal emergence. (d) Emergence is accurate,
but the height of the restoration is insufficient
to achieve an effective contact point. In this d e
case, even though a contact point has been
achieved, the marginal ridge will be excessively
fragile. (e) Deepening the cervical step position
achieves an accurate emergence of the res-
toration and a contact point that is consistent
and well supported by restorative material.

Apicocoronal position of the cervical
step
The apicocoronal position of the cervical step in a Class 2
preparation depends on many factors. Though the approach
must always be extremely conservative, this does not rule
out the possibility of extending the preparation (cervically or
mesiodistally) in order to optimize:
• Restoration procedures (eg, matrix fitting)
• Marginal finishing and polishing procedures
• Marginal cleaning and checking
• Changing the emergence of the interproximal profile to
optimize contact points
cervically (seeking to stay within the enamel at all times)
to fit a matrix and finish and check the restoration margin
(note that the idea that the restoration can be purely self-
cleaning is now outmoded). The cervical step does not
require apicalization if enough space can be made for a
matrix through wedging or by using a mechanical separator.
In Fig 5-26, a cavity completed without allowing for future
emergence of the restoration may lead to a horizontal over-
contour (see Fig 5-26c) or an inconsistent emergence (see
Fig 5-26d) that is often accompanied by marginal ridge
fragility. In this case too, preparing the box more apically
makes for more consistent emergence (see Fig 5-26e). Given
the predictability of bonding, it is in any case advisable to
preserve the enamel cavity margins as much as possible.

The diagram in Fig 5-25 shows that, although the cavity

can be fully cleaned, the preparation must be extended

91
5 CAVITY PREPARATION
Decision-Making Criteria for Direct
Versus Indirect Restorations
Composite materials have become more popular mainly due
to two factors:
1. Development of dentin-enamel bonding systems
2. Development of composite resins
Since 1962, when Bowen resin was used for the first time,
the physical, mechanical, and esthetic properties of resins
have continually developed and improved, allowing compos-
ite materials to be used for more indications. Composite
resins advanced significantly due to:
• Introduction of fillers and particularly their silanization
(allowing a strong bond with organic resin)
• Different types of fillers
• Different sizes of fillers
• Inclusion of a light-curing system
This led to materials that performed better from an esthetic
and a mechanical viewpoint. Clinical procedures involving a
composite combined with a bonding system have been tried
and tested for years, displaying encouraging longevity.22–29 A
meta-analysis published by Opdam et al in 2014 established
the annual failure rate after 10 years to be 2.4%.29
With the passage of time, new material developments have
prompted clinicians to aim for bolder treatments. While in
1998 American Dental Association guidelines for a Class 1
or 2 restoration recommended a moderate size, nowadays
clinicians even aim for direct coverage of one or more cusps
with satisfactory results.30,31 Direct treatments have been
successfully used to treat clinical situations that are difficult to
resolve, such as cracked tooth syndrome.32 We must consider
that the more surfaces a restoration contains, the higher the
risk of failure,30 and if the margin position after preparation is
below the cementoenamel junction, the restoration is nearly
30% more likely to fail.33 These two reasons could make an
indirect composite restoration favorable to direct composite
treatment, because a prosthetic product confines shrinkage
problems to the cement film.
For example, an in vitro study by Dietschi et al34 comparing
direct and indirect Class 2 restorations shows that the seal
of indirect composite bonded restorations is superior to that
of direct restorations because there is less shrinkage due to
curing (only the cement shrinks). This was also confirmed
by Dejak and Młotkowski, who conducted a finite element
study (with all its attendant limitations) and established that
an inlay’s internal stresses are decidedly lower than those
92
of a direct restoration and that indirect restorations provide
a better seal than direct restorations.35
However, these findings do not seem to have any clinical
consequences. In an 11-year randomized clinical trial on
Class 2 restorations, Pallesen and Qvist established that
there were no significant clinical differences between direct
and indirect restorations and that indirect restorations did
not show improved marginal integrity. In this type of config-
uration (inlay versus direct Class 2), there is therefore no
justification for a more complex and costly treatment such
as indirect restoration.36
Cusp Coverage and Analysis of
Structural Factors
During cusp preparation, proximity of the cavity to a cusp
must prompt a biochemical and structural analysis of the
residual healthy tooth substance. Khers et al37 highlighted
how cusps weakened by restorations or caries are more
prone to fractures. Firstly, one must remember the principle
of cusp independence stated by Sakaguchi et al in 1991:
Cusps that undergo stress are subject to deformation that
does not extend to adjacent cusps. They can therefore be
kept intact, and only compromised cusps need be removed.38
A study by Hood39 emphasizes that the extent of cusp
deformation strictly depends on missing tissue depth: Total
deflection affecting a premolar cusp subject to an in vitro
load is 11 μm for a healthy tooth, 16 μm for a tooth with a
minimal Class 1 cavity, 20 μm for a mesio-occlusal cavity
with a narrow isthmus, 24 μm for mesio-occlusodistal (MOD)
cavities with a narrow isthmus, and 32.5 μm for extensive
MOD cavities.
How does the practitioner decide whether to remove a
cusp? When must it be removed? When is it acceptable
to take the risk of not removing it? Schillingburg et al and
Fichera et al identified deficiencies and structural factors
to be considered when deciding whether to cover cusps
adjacent to a cavity.40,41 In order of importance, the factors
to be considered are as follows:
1. Interaxial dentin
2. Marginal ridge
3. Pulp chamber roof
4. Residual cusp dentinoenamel complex
The roof of the pulp chamber (whose absence indicates
devitalization) is paradoxically much less important struc-
turally than the dentin present between the cusps (inter-
axial dentin) and marginal ridges. Many authors41–44 have
confirmed what initially seems a paradox: Teeth prepared
 Choosing Between Direct and Indirect Composite Restorations
for root canal access are much stronger than vital teeth with
missing structural factors, such as the two marginal ridges
and the interaxial dentin (MOD preparation). This concept
is further confirmed by Howe and McKendry (1990), who
state that “occlusal endodontic opening does not reduce
resistance to fracture, which is significantly higher than that
of a conservative MOD preparation.”45 These considerations
are crucial to the endodontist, who is free to perform conven-
tional access cavities without having to resort to pointless
ultraconservative root canal openings that prevent proper
cleaning and risk compromising the success of root canal
treatment.
A 1992 study by Goel et al46 confirmed the importance
of residual dentin, finding that the less dentin remains, the
more stress forms immediately above or immediately below
the cavity floor and that this can trigger a cusp fracture.
In another study on the importance of interaxial dentin in
relation to the marginal ridges, Larson et al claimed that
extending an occlusal preparation with a relatively shallow
Class 2 box preparation in the dentin does not significantly
alter tooth strength.47
However, many of the studies and models referred to
nowadays regarding fracture resistance following cavity
preparation are somewhat dated and do not consider the
use of bonding materials. Adhesive bonding can now add
to a tooth’s structural integrity by reinforcing residual tooth
structure.48,49 However, this alone cannot be relied on because
adhesive bond quality decreases over time.50
Although a bonding material acts as a reinforcement for
the intracoronal tooth structure, one study compared differ-
ent types of reconstruction systems (ie, direct composite,
amalgam, indirect glass-ceramic reinforced with leucite, CAD/
CAM lithium disilicate, lithium silicate reinforced with zirconia
CAD/CAM, ceramic-infiltrated resin CAD/CAM, and gold)
for devitalized teeth with the loss of one or more marginal
ridges. Researchers subjected them to simulated chewing
and heat cycles and claimed that the best solution (in terms
of fracture resistance) is still a full-coverage indirect cemented
gold restoration.51
Returning to the subject of structural factors, Shahrbaf et
al found that a marginal ridge of at least 2 mm in devitalized
premolars restored in composite offered increased fracture
resistance.52 The last structural factor to be considered is
the residual cusp. This must be evaluated at the base of the
cusp with the knowledge that at the cervical level, noncar-
ies cervical lesions, caries lesions, or preexisting Class 5
restorations can reduce residual cusp thickness.53 When
several structural factors are compromised, including the
roof of the pulp chamber (ie, when dealing with a severely
compromised devitalized tooth), the treatment of the residual
structures must be carefully considered, with the practitioner
often opting for total coverage of the occlusal surface (see
Fig 5-27). A highly conservative approach in such cases can
lead to radical consequences, as evidenced by the annual
failure rate reported by many authors.51,54–57
As has been shown, when dealing with a devitalized tooth,
one is faced with significant structural losses that often lead
to the breakdown of compromised cusps. Multiple recon-
structive strategies are available. Zarow et al58 classified resto-
ration types based on the residual structure of a devitalized
tooth. Direct restoration of a devitalized tooth based on this
classification can be performed mainly in Class 0 (without
the need for a fiber post) and in Classes I and II (fiber post
needed, without and with surgical lengthening of the clinical
crown). It is also important to consider which tooth is to be
constructed, its position, and its relationship with adjacent or
opposing teeth. The fracture risk of a tooth with both contact
points intact is lower than that of a tooth that has only one
adjacent element or—worse still—is isolated.59
According to Fichera et al,41 the cusps adjacent to a Class
2 box preparation can be maintained if they are at least 1.5
to 2.0 mm thick in a vital tooth (ie, if the pulp chamber roof
is present). If the tooth is devitalized, cusps that are not
at least 2.5 to 3.0 mm thick should be covered. Patient-
centered factors must also be considered. Teeth must never
be treated in isolation. They must be considered in the context
of the patient as a whole. Parafunctions such as bruxism
and grinding can cause premature wear of the restoration
and fracture of the restored tooth. Residual structural factors
must be evaluated by relating them to occlusal problems
affecting the patient.
If dental substance is to be removed as a precaution,
factors such as the material, the patient’s chewing pattern,
and the nature of the opposing tooth will help determine the
extent of removal. However, a certain amount of thickness is
required to distribute masticatory stress uniformly.60
Choosing Between Direct and
Indirect Composite Restorations
When we look at composite used for direct restoration or for
indirect restoration, we can highlight some of the strengths
of composite materials:
• Better mechanical properties. These are achieved using
postpolymerization treatments that can be carried out
only in the laboratory, where, the composite can be
cured under a vacuum; in the presence of inert gases;
and under light, heat, or a combination of all of these.61
• Greater wear resistance (for the reasons described).62–64
93
5 caviTy preparaTion

a b

c d

e f

g h

FIG 5-27 (a to h) It is preferable to carry out an indirect restoration when residual anatomical information cannot be interpolated because of
the loss (preexisting or resulting from structural strategies) of one or more cusps. (Laboratory work by A. Amato.)

94
 Choosing Between Direct and Indirect Composite Restorations
• Reduction in internal stress given increased polymeriza-
tion (for the reasons described).65 In direct restorations,
the material accumulates internal stress due to poly-
merization contraction. This is not the case for indirect
restorations, in which such stresses are limited to the
thin film of adhesive cement used for retention.
• Better repairability compared with other materials.
Indirect composite restorations offer the indubitable
advantage of easy repair. This is also possible in etched
ceramic restorations but is a much more complex
procedure.66
Clinical strategies
The question the clinician must ask is whether direct or indirect
restorations work better. Various systematic literature reviews
and meta-analyses have been conducted to establish whether
indirect restorations last longer than direct restorations. At
present, the literature reveals no significant differences in
longevity, meaning that there are no particular indications
for one over the other.67–69 No scientific evidence is available
to suggest that composite differs significantly from other
materials in this respect, although ceramic seems to fare
slightly better.70
The above meta-analyses do not seem to show significant
differences between direct and indirect restorations based
on the tooth to be treated (molars or premolars). Clinicians
therefore have a certain amount of decision-making freedom
and can make their choices based on different criteria: knowl-
edge, experience, patient type, patient’s chewing patterns,
patient’s socioeconomic and employment status, and so on.
As shown in chapter 7, it is possible to restore an anatomy
that is very faithful to the original if enough existing anatomical
information can be interpolated with the practitioner’s knowl-
edge of morphology. When this information is lost (minimal
residual cusp, missing cusp, or cusp requiring coverage)
nothing prevents a direct restoration, but the potential conse-
quences are unpredictable restorations requiring numerous
adjustments that detract from the anatomy and are very
time-consuming.
If little of the occlusal perimeter is present, it will not be
possible to interpret the gradient of the cusp slopes, and
the occlusal surface will probably be over- or under-modeled
as a result. If a cusp is missing or if it is decided to cover
it following structural assessment, it will be impossible to
determine:
• The mesiodistal, buccolingual, and apicocoronal posi-
tion of the cusp tip to be restored
• The geometry (inclination, convexity, etc) of the occlusal
and external cusp slopes constructed freehand
Indirect restoration provides clinicians with esthetic results,
benefits in managing polymerization shrinkage, as well as
an anatomy that considers all aspects of static and dynamic
occlusion. In addition, it will generally require minimal adjust-
ment (Fig 5-27). Under such conditions (eg, entire missing
cusp) a very large amount of composite would be used for
a direct restoration, with a consequent increase in internal
residual stress and conversion that is not optimal and not
comparable to that obtained in the laboratory. Based on all
these points, the authors propose the following guidelines
when deciding between a direct and indirect restoration.
Direct approach
• Minimally invasive cavities (Fig 5-28a)
• Class 1 cavities that retain peripheral anatomical infor-
mation (Fig 5-28b)
• Multiple cavities that maintain structural requirements
(Fig 5-28c)
• Small- to medium-sized Class 2 cavities (Figs 5-28d
and 5-28e)
• Class 1or 2 cavities with palatal or buccal extensions
(Fig 5-28f)
• MOD cavity with sufficient residual cusp thickness (Fig
5-28g)
• Large Class 2 cavities if there is sufficient residual cusp
and if conditions are right for reliably reestablishing the
contact area with the adjacent tooth (Figs 5-28h and
5-28i)
Direct or indirect approach (depending on
circumstances)
• Medium-sized MOD: Often a lot of material must be
inserted, and the residual cusps are not thick enough.
Coverage of one or more cusps is indicated (Fig 5-28j).
• A Class 2 restoration with considerable buccal and
lingual extension sometimes makes it difficult to achieve
an effective contact surface. In such cases, an indirect
restoration appears to be the best solution, even if the
residual cusps adjacent to the box preparation have
been assessed as structurally sound (Fig 5-28k).
Indirect approach
• A cusp is missing or is to be removed, and no informa-
tion is available on how to reconstruct it (Fig 5-28l).
• The entire occlusal surface is missing, or it has been
decided to remove it (Fig 5-28m).
95
5 caviTy preparaTion

a b c
Direct approach

d e f

g h i
direct approach
Indirect or

j k
Indirect approach

l m

FIG 5-28 Guidelines for choosing direct versus indirect approach. (a to i) Direct approach. (j and k) Indirect or direct approach, depending
on circumstances. (l and m) Indirect approach.

96

When an indirect approach is advantageous
• The cavity size has minimized the residual anatomy
(even though this reduction has left what seems to be
a sufficiently thick cusp), and this prevents the practi-
tioner from obtaining enough information to be able to
interpolate the preexisting anatomy.
• A structural diagnosis led to a decision to remove one
or more cusps with the same consequences as in the
previous point.
• The Class 2 box is so big that it becomes difficult to
reproduce the interproximal area (emergence and
contact point) using a direct method.
• The cavity is so large that too much material must be
placed even though residual anatomical information has
been retained. With direct restorations, it is very difficult
to effectively control shrinkage due to having to cure a
large amount of composite within a time frame compat-
ible with performing a direct restoration.
• For greater convenience: A tooth with a medium to
large cavity that would normally be treated by means of
direct restoration is located in a sector including other
teeth being treated by means of indirect restoration.
• The restoration to be performed is medium to large and
the operator has insufficient practical skill to model it
effectively.
Conclusions
As already mentioned, the criteria used to decide between
direct and indirect approaches set out in this chapter reflect
the authors’ own opinions and experience. However, every
clinical situation is different. In some instances, indirect resto-
rations are performed even for simple occlusal cavities. In
other cases, the patient’s socioeconomic circumstances make
it difficult if not impossible to offer an indirect restoration to
treat seriously compromised teeth.
Subgingival Margin Position
Contributed by Dr Roberto Kaitsas
Subgingival positioning of the caries lesion and its restoration
may or may not involve supracrestal connective tissue or
epithelial attachment (previously known as biologic width),
a structure that is always present at natural teeth.71–73 The
intrinsic relationship between the epithelial and connective
Subgingival Margin Position
tissue components of the restoration must always be consid-
ered, given the problems that may arise when this attachment
is invaded.74–77 Two clinical situations can be distinguished
based on the depth of the caries lesion, which determines the
future margin: (1) the restoration can be performed without
resective surgery, or (2) the situation requires resective bone
surgery78,79 (Fig 5-29).
A restoration margin that does not invade the supra-
crestal connective tissue attachment can be performed with-
out resective bone surgery. If the margin is supragingival or
in the sulcus and can be easily isolated (nonsurgical margin
exposure), a direct or indirect restoration will normally be
performed. If isolation is precarious given the depth of the
margin, especially for operational maneuvers that could move
the rubber dam and cause contamination, the margin can
be relocated for convenience (ie, deep margin elevation).80,81
This procedure involves applying restoration material to the
margin to create another more coronal margin with the aid
of circumferential matrices. After relocating the margin, a
choice can be made between direct or indirect restoration.
If the restoration margin does not invade the supracrestal
connective tissue attachment but cannot be isolated, the
cervical margin can be temporarily exposed using surgical
methods. After this, rubber dam is applied, the restoration
(direct or indirect) is performed, and the flap is reposi-
tioned without any resective bone surgery (surgical margin
exposure).82,83
The option of positioning the margin within the supracrestal
epithelial attachment (junctional epithelium) must be carefully
evaluated and limited to patients with exemplary maintenance
habits. Any change in the balance of this portion can cause
inflammation and loss of periodontal support. Sometimes,
when surgically exposing the margin of an interproximal resto-
ration, a decision is made to carry out simultaneous minor
remodeling of the interproximal bone tissue. Although this
may seem simple and convenient, it essentially amounts to
surgical clinical crown lengthening and risks creating buccal
and palatal/lingual bone overhangs if not combined with appro-
priate osteoplasty.84
Conversely, if the supracrestal connective tissue attach-
ment is involved, inflammation will certainly result with conse-
quent loss of periodontal support tissue; a clinical crown
lengthening operation will therefore have to be performed
with involvement of the underlying bone tissue (surgical crown
lengthening).84–86 Another option outside the scope of this
book is to use orthodontic extrusion to recover the tooth or
extract the tooth if it cannot be restored.87
97
5 CAVITY PREPARATION

No bone surgery

1
Sulcular
epithelium
2

Junctional
epithelium 3

Supracrestal Bone surgery

connetive 4
tissue

Direct restoration
No need for specific procedures
1
Indirect restoration

Isolation using rubber dam possible

Direct restoration
Coronal margin relocation*
2 Indirect restoration

Direct restoration
Isolation with rubber dam possible
only if performed at same time as Surgical exposure of margin
surgical exposure 3
Marginal relocation + indirect
restoration

Clinical crown lengthening

4
Isolation using rubber
dam impossible

If clinical crown lengthening not possible:

orthodontic extrusion or avulsion
5

*Positioning the margin within the supracrestal epithelial attachment (junctional epithelium) must be carefully evaluated and limited to patients
with exemplary maintenance habits. Any change in the equilibrium of this portion can cause inflammation and loss of periodontal support. If in
doubt, the best choice will be to place the margin above the epithelial supracrestal attachment.
b

FIG 5-29 Clinical strategies depending on restoration margin position. Note that the numbers 1 to 5 in the illustration (a) correlate to those
in the flowchart (b).

98
 Direct Pulp Exposure and Direct Pulp Capping
Direct Pulp Exposure and Direct Pulp
Capping
Contributed by Dr Lucio Daniele
Maintaining pulp vitality is one of the main aims of conservative
dentistry. Placing a dressing material on pulp that has been
directly exposed to caries or trauma has always be consid-
ered a controversial procedure, and in the past, conventional
endodontic therapy has often been recommended in such
situations.88–92
Clinicians have used many materials and techniques for
direct pulp capping, such as gold foil, zinc oxide–eugenol paste,
hydrophilic resins, resin-modified glass-ionomer cement,
lasers, and ozone technology to induce pulp defenses.93–98
Calcium hydroxide, once considered the gold standard for
capping materials, is one option for the formation of repar-
ative dentin, but long-term studies have shown variable and
unpredictable results.99–102 The material does not adapt well
to the surrounding dentin, does not promote odontoblastic
differentiation, and has been found to be cytotoxic in cell
cultures. More recently, clinicians have used mineral trioxide
aggregate (MTA) and bioceramic materials.
A recent study of 70 patients with 3-year follow-up showed
a success rate of 85% when MTA was used as a direct pulp
capping material and 52% in cases where calcium hydrox-
ide was used103; another study on 229 teeth with follow-up
for up to 10 years showed a success rate of 80.5% in the
group of teeth where MTA was used and 59% in the group
where calcium hydroxide was used.104 According to Li et al,105
groups of teeth treated with MTA showed a significantly higher
success rate than those treated with calcium hydroxide, with
a lower inflammatory response by the pulp and formation of
dentin bridges with more predictable durability. The advent
of MTA changed everything. This material can withstand
bacterial infiltration and provide effective protection for the
pulp, allowing its repair and maintaining tooth vitality when
used properly and in combination with appropriate crown
restoration.106–111
As its name suggests, MTA is an aggregate of mineral
trioxide. From a physical viewpoint, MTA is a powder made
up of fine hydrophilic particles that harden in the presence
of moisture. In chemical terms, MTA can mainly be divided
into calcium oxide and calcium phosphate. Further physical
and structural analysis demonstrated the coexistence of a
crystalline phase (rich in calcium, silica, and oxygen) and an
amorphous phase (rich in calcium and phosphates).108 The
crystalline phase turns into calcium hydroxide when it comes
into contact with the exudate, stimulating the formation of
reparative hard tissue.111–113 The material functions success-
fully because of its small particle size, ability to create a
marginal seal and fit, alkaline pH once set, and slow release
of calcium ions.114
The researchers reported that MTA induces pulp cell prolif-
eration and stimulates osteoblasts to release interleukins,
with consequent formation of hard tissue and an interface
with dentin that is very similar to hydroxyapatite in composi-
tion.109,114–117 The thickness and hardness of the resulting new
dentin bridge are far superior to the results obtained using
calcium hydroxide dressings.118 The material also sets much
more quickly than calcium hydroxide. It is not resorbable,
hardens in the presence of moisture, and has an alkaline pH
that enhances its antibacterial properties, but it has low resis-
tance to compression.108 Immediately after mixing, the pH is
10.2 and rises to 12.5 over the next 3 hours, stabilizing at
this value over the first few days and then decreasing slightly
with time.108,109 The setting time of MTA at a temperature
of 37°C with relative humidity of 95% to 100% is 2 hours
and 45 minutes; compression resistance after 24 hours is
40 MPa but increases to 67.3 MPa 21 days after mixing.109
An observational study conducted by Bogen et al in 2008
reported a success rate of 97.96% after 9 years on 49 teeth
in a total of 40 patients aged between 7 and 45 who had
undergone direct pulp capping using MTA.119 The clinical study
conducted by Daniele in 2017 showed a 10-year success
rate of 92.5% in 80 cases of direct capping with MTA.120 In
this study on 77 patients aged between 14 and 68, direct
pulp capping with MTA was carried out on 80 teeth affected
by caries in which reversible pulpitis had been diagnosed
by a cold thermal test and radiographic examination. Four
patients experienced painful symptoms. In three teeth, a small
area of bone rarefaction due to enlargement of the periodon-
tal space was observed on the radiograph. The caries was
removed using only rotary instruments, and a thin layer of MTA
was applied to the exposed pulp and surrounding dentin. In
some cases, a 5% sodium hypochlorite solution was used
to achieve hemostasis of the operating field. The teeth were
reconstructed during the second session with two-component
bonding systems and new-generation composite resins after
checking the material had set and evaluating pulp vitality by
means of a cold thermal test. The patients were recalled at
regular intervals for 10 years to evaluate pulp status, potential
formation of a reparative dentin layer, presence or absence of
pulp and canal calcifications or root resorption, presence or
absence of pain on percussion, and presence or absence of
an endodontic lesion visible on a radiograph. After a 10-year
observation period, 6 teeth out of 80 had undergone endodon-
tic treatment; no increase was observed in pulp calcifications,
presence of root resorption, or endodontic lesions visible on a
radiograph. All the remaining vital teeth responded positively to
a cold thermal test. The three lesions present had disappeared
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5 CAVITY PREPARATION
by the last radiographic check. All four symptomatic teeth
retained their pulp vitality.
More recently, numerous calcium silicate–based cements
known as bioceramics have appeared on the market. These
crown and root dentin substitutes are classified as a new
class of Portland cement with high mechanical properties,
excellent workability, radiopacity, and a much longer setting
time.121,122 Studies by Gandolfi et al confirm that calcium
silicate–based cement is bio-interactive (ion-releasing), bioac-
tive (apatite-forming), and functional.123–127 The high calcium
release rate and rapid apatite formation easily explains the
formation of a new dentin bridge, which constitutes an
effective scaffolding for clinical healing. In a recent study
examining 716 articles and 83 patents, a significant increase
was observed in patents for bioactive materials (containing
bioactive proteins), MTA-derived materials (calcium silicate–,
calcium phosphate–, and calcium aluminate–based cements),
and MTA.128 The study confirmed that MTA and bioceramic
materials could be successfully used to treat vital pulp and
that their benefits outweigh the disadvantages of materials
used in the past.
The great advantage of using calcium silicate–based bio-
ceramics is their low curing time of approximately 12 minutes.
When these materials are used for direct pulp capping, the
treated tooth can be reconstructed in the same session.
This is financially advantageous because everything can be
completed in one appointment. It is also operationally advan-
tageous because it prevents possible contamination of the
treated tooth if the temporary filling falls out or fails to seal
properly. If the exposure occurs on the axial wall of a cavity,
it is more difficult to manage and apply the material. Great
care must be taken, and it may be necessary to use special
application syringes.129 If the pulp exposure is mechanical (as
with a tooth fracture), bacterial contamination is absent, and
the long-term success of direct capping approaches 100%.118
Significant bacterial contamination is sometimes present in
the case of pulp fracture due to caries. Sodium hydroxide is
a pulp disinfectant that can achieve satisfactory hemostasis if
bleeding occurs during caries cleaning procedures.129,130 The
exposed pulp often begins to bleed when touched by rotary
or manual instruments. Bleeding can stop spontaneously after
a few minutes, and once the necessary time has elapsed,
the field will be ideal for direct pulp capping. If bleeding
does not stop after a few minutes, satisfactory hemosta-
sis must be obtained by placing a cotton pellet soaked in
5% sodium hypochlorite and maintaining it in contact with
the pulp from a time period ranging from 30 seconds to 1
minute. This procedure can be repeated twice if necessary.
If the exposed pulp continues to bleed after this procedure,
100
BOX 5-1 Step-by-step direct pulp capping
1. Confirm pulp vitality.
2. Isolate the operating field using rubber dam.
3. Carefully clean the cavity.
4. Control hemostasis.
5. Apply material in layers 1.5 to 2 mm thick.
6. Apply moist cotton pellet (if required).
7. Place temporary filling.
8. Check for effective material setting after 2 to 7 days.
9. Perform final restoration using a bonding technique.
10. Perform clinical and radiographic follow-up after 1, 3,
and 6 months; 1, 2, 3, and 4 years; and every 2 years
thereafter.
endodontic therapy is required because the pulp hyperemia
gives rise to internal inflammation, and irreversible pulpitis
will presumably result.
Direct pulp capping is more successful in young patients,131
but the worst results occur only after the age of 60.132 The
age factor therefore no longer affects the outcome of vital
pulp therapy, and nowadays direct pulp capping can even
be performed in elderly patients.
The step-by-step procedures for direct pulp capping are
outlined in Box 5-1. This 10-point operating protocol must
be rigorously implemented, including careful case selection,
to ensure effective treatment.
Clinical case 1
When the pulp is revealed during caries cleaning stages or
because of trauma with fracture of the tooth crown, the
clinician can consider direct pulp capping (Fig 5-30). First, a
condition of reversible pulpitis, which is not always easy to
diagnose, must be evaluated and ascertained. A total absence
of pain must be established. Even if the tooth to be treated is
subject to increased sensitivity from heat or electrical stimuli
(relatively common in the case of deep caries), this does not
affect the outcome of treatment. If strong spontaneous pain
is present, the pulp is presumably affected by irreversible
pulpitis. A pulp vitality test must be performed using a ther-
mal or electrical test, and pulp vitality must be ascertained.
A radiographic examination must also demonstrate a total
absence of any endodontic lesion, sometimes presenting as
a slight enlargement of the periodontal space near the root
apex. If only a bitewing radiograph has been taken (see Fig
5-30a), an apical diagnostic radiograph must also be taken
 Direct Pulp Exposure and Direct Pulp Capping
(see Fig 5-30b). In some cases, a 3D radiographic examina-
tion may also be carried out using cone beam technology to
establish the presence or absence of an endodontic lesion.
However, this can only be justified on medicolegal grounds
if the diagnosis is considered important enough to justify the
added radiation.
Examination shows the relationship between the caries
lesion and the pulp organ and highlights their proximity and
contiguity. During radiographic analysis, the clinician must
follow the lamina dura (the linear bone radiopacity between
the root-ligament cement and the alveolar bone along the
root surface contour) to establish it is intact throughout the
root’s external contour.
Before carrying out direct pulp capping, the clinician must
thoroughly anesthetize the tooth and isolate the operating
field using rubber dam (see Figs 5-30c and 5-30d). It is
advisable to put the tooth to be treated and the adjacent
teeth beneath the dam to have more space when using
tools and materials.
If the pulp is exposed because of trauma, the pulp need
not be treated using rotary instruments. Conversely, if the
pulp exposure is from caries (see Fig 5-30e), the clinician
must remove all caries present down to a layer of hard dentin,
which may retain a brownish discoloration. At this stage, it is
useful to use ceramic drills that can selectively remove only
the carious dentin. Manual instruments such as excavators
can be used to scrupulously clean the caries lesion. In the
event of pulp exposure, the clinician must continue to remove
all softened dentinal tissue, even if this involves repeated
contact with the tooth pulp.
If the pulp horn or exposed pulp bleeds (see Fig 5-30f), it
may take a few minutes to form a minimal clot on the superficial
pulp layer and for the pulp to stop bleeding (see Fig 5-30g). If
this does not happen, the clinician can place a cotton swab
soaked in a 5% sodium hypochlorite solution (see Fig 5-30h)
on the pulp for 30 seconds to 1 minute to achieve hemostasis.
This may be repeated several times. If the exposed pulp contin-
ues to bleed, it is not advisable to proceed with capping, and
the affected tooth will have to undergo endodontic treatment.
Once hemostasis has been achieved (see Fig 5-30i), the
material to be placed on the exposed pulp is prepared; it is
advisable to use calcium silicate–based bioceramic mate-
rials, MTA, or MTA-based materials. Various systems are
available: powder-liquid to be mixed by hand on a glass
plate, powder-liquid in capsules to be vibrated in a special
mixer (this starts the setting process, which takes between
7 and 12 minutes depending on the material type), paste in
a syringe, and light-cured flowable composite resin loaded
with capping biomaterial.
The capping material is placed on the exposed pulp to
a thickness between 1.5 and 2 mm (see Fig 5-30j) using a
special syringe consisting of a curved or bendable hollow
tube containing a finger-operated sliding plunger. The mate-
rial emerging from the syringe must be positioned using a
microbrush without packing it down too much on the exposed
pulp. Blood from the pulp may emerge below the material
during this stage. If the bleeding remains very slight, it should
not compromise the outcome of therapy. If the material dries
too much during the positioning stages, it can be moistened
by placing a microbrush wetted with physiologic water in
contact with it. Once the desired thickness has been achieved
(the classic composition of some materials such as MTA
need moisture to set), the material must be covered with a
damp cotton swab (see Fig 5-30k) before positioning the
temporary filling (see Fig 5-30l). A postoperative radiograph
is then performed to check that the material is correctly
positioned, evaluate its thickness, and check the tightness
of the temporary filling (see Fig 5-30m).
In the second session, performed 2 days to a week later,
the clinician takes a radiograph that is used together with a
clinical examination and tooth vitality test to establish the state
of vitality and the total absence of pain. (Hypersensitivity can
be considered normal in this type of treatment.) The clinician
then removes the temporary filling and the wet cotton pellet (if
used) and checks that the material has set. Because cotton
fibers sometimes remain attached to the capping material
(see Fig 5-30n), everything must be cleaned by passing a
bladed bur over the area several times to reveal as much
healthy dentin as possible at the cervical step and in the rest
of the cavity, away from the capped area, to obtain optimal
bonding (see Figs 5-30o and 5-30p).
The next step is the conservative reconstruction (see
Figs 5-30q to 5-30v). If fast-curing bioceramic materials are
used, the clinician can carry out reconstruction during the
capping session. Alternatively, if the classic MTA formulation
is used, the material can be covered with MTA-based global
composite resin, and the treatment need not necessarily
be performed in two sessions. The moisture required for
setting should be generated by the exposed pulp. During
the restoration stages, it is not advisable to etch the dentin
using strong acid concentrations but rather to use a multi-
step self-etching bonding system that only requires etching
of the enamel.
The clinician must carry out long-term clinical and radio-
graphic checkups at regular intervals on all teeth subject to
direct pulp capping (see Figs 5-30w to 5-30y). During the
follow-up visits, the clinician must ascertain tooth vitality by
means of a vitality test, the absence of an endodontic lesion
101
5 CAVITY PREPARATION

a b

c d

e f

FIG 5-30 (a) Diagnostic bitewing radiograph showing that the caries lesion is contiguous with the pulp organ. (b) Preoperative radiograph
showing the absence of apical and periradicular endodontic lesions. (c and d) Occlusal view of operating field before and after isolation
using rubber dam. (e) View of caries lesion. (f) Pulp exposure.

on a radiograph, integrity of the crown restoration, absence recommended; follow-up visits must be performed after 3
of pulp chamber and canal calcifications (or if present at and 6 months, then after 1, 2, 3, and 4 years; and every
the time of capping, that they have not worsened), and 2 years thereafter.
absence of root resorption. Following capping treatment,

102
 Direct Pulp Exposure and Direct Pulp Capping

g h

i j

k l

m n

FIG 5-30 (cont) (g) Spontaneous decrease in bleeding. (h) Placement of a cotton pellet soaked in 5% sodium hypochlorite solution to obtain
hemostasis. (i) Hemostasis achieved. (j) Positioning of capping material. (k) Positioning of moist cotton pellets to set the material. (l) Tem-
porary filling. (m) Postoperative radiograph. (n) Cotton fibers attached to the capping material.

103
5 CAVITY PREPARATION

o p

q r

s t

u v

w x y

FIG 5-30 (cont) (o) Cleaning of the cervical step. (p) The adhesiveness of the dentin surface as been increased. (q) Selective enamel etching.
(r) View of tooth after etching. (s) Applying bonding agent, preferably a self-etching product. (t) Applying flowable composite in contact with
the capping material as the first flexible layer. (u) Operating stages of restoration. (v) Completed restoration. (w to y) Follow-up radiographs
after 1, 2, and 3 years, respectively.

104

a b
d e
FIG 5-31 Radiographs for clinical case 2. (a)
Preoperative. (b) Postoperative with temporary
filling. (c) After direct composite restoration.
(d) Follow-up after 6 months. (e) After 2 years.
(f) After 4 years. (g) After 6 years. (h) After
11 years.
g h
Clinical case 2
Figure 5-31 shows a case of direct pulp capping performed
on a 25-year-old man with 11-year follow-up.
Conclusion
Direct pulp capping by means of a strict protocol (see Box
5-1) that requires careful case selection can be considered
an effective treatment in the event of exposure due to caries
or trauma. It is a valid option for teeth with a diagnosis of
nonsevere reversible pulpitis.
References
c
f
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105