operative Dentistry

Preventive resin restorations: indications, technique, and success

Louis W. Ripa* / Mark S. Wolff* *

Although preventive resin restorations have been reported since 1977, there is little
uniformity concerning the indications for this procedtire, nor is there a standard
technique. This article proposes diagnostic criteria for pit and fissure occtusal caries
and diagnosis-related considerations for treatment planning for preventive resin re.storations. A step-by-step "laminate" technique, which includes, successively, a glassionomer cement liner, a posterior composite resin, and a sealant, is described. The
success rates reported for several clinical studies of preventive resin restorations are
presented, although the criteria for this restoration, treatment methodology, and the
determinates of success vary from sttidy to study.
(Quititessence Int 1992,-23.307-315.)

Introduction
Preventive resin restorations represent an evolution in
the use of dental resins on posterior teeth that began
with the studies of pit and fisstire sealants in the 196S.
Sealants are indicated for teeth with caries-free pits
and fissures, whereas preventive resin restorations are
used for pits and fissures with diagnosed earies.
A preventive resin restoration is a conservative
treatment that involves limited exeavation to remove
carious tissue, restoration of the excavated area with a
composite resin, and application of a sealant over the
surface of the restoration and remaining, sound, contiguous pits and fissures (Fig la). This treatment is an
alternative to the customary approach in which, in addition to carious tissue, sound pits and fissures are prepared and an amalgam restoration is placed (Fig lb).

The purposes of this article are to: (I) examine the

indications for preventive resin restorations, (2) describe the technique, (3) review the success of clinical
studies, and (4) discuss the advantages and disadvantages of this new technique.
Indications for preventive resin restorations

Preventive resin restorations are used on the oeclusal

surfaces of premolars, permanent molars, and primary
molars. Despite several clinical studies of the procedure, no uniform indications have been estabhshed.
A broad, but nonetheless encompassing, statement is:
A preventive resin restoration K indicated when tlie cariou
lesion in a pit orfissureis small and discrete. Thus, the
clinician must make diagnostic decisions concerning
the existence, size, and location of a lesion, and a
treatment planning decision that a preventive resin
restoration is the most appropriate treatment.
Diagnosis

* Professor and Chairman. Department of Children's Dentistry.

State University of New York at Stony Brook. School of Denial
Medicine, Stony Brook, New York 11794.
"* Clinical Assoeiate Professor, Direetor, Division of Operative
Dentistry, Department of Restorative Dentistry, State Universily ot New York at Stony Brook.

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Volume 23, Number 5/1992

Diagnosis involves radiographie, visual, and taetile

assessment. King and Shaw demonstrated that radiographs are insufficient for the detection of occlusal
lesions, presumably because many lesions are too small
to create a radiographie image.' For placement of a
preventive resin restoration, the radiograph must show
no evidence of proximal caries that would mandate a
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operative Dentistry

reventive Resin Resto

Fig 1 a Occlusal sutiace treated with preventive resin restorations. Excavation is limited to caries removai. Posterior
composite resin restorations are placed. The restorations
and all occlusai pits and fissures are covered with sealant.

Fig l b Occlusai surface treated with conventionai amalgam

restorations. Extension for prevention requires the elimination of sound, as well as carious, pits and fissures in the
outline form.

Table 1 Diagnostic and treatment planning consideration? for pits and fissures
Clinical sign
Explorer catch
Discoloration*
Enamel softness

No
No
No

Yes
No
No

Yes
Yes
No

Yes
Yes
Yes

Diagnosis

Sound

Sound

Questionable

Carious

Treatment options

No treatment
Sealant

Seaiant

Sealant

Preventive resin restoraiion

Conventional restoration

White, undermining de mineraliza! ion.

more extensive restoration. It should be remembered,

however, that clinical radiographs underestimate the
true extent of carious lesions,"'' and the actual size is
usually larger than its radiographie image imphes.
Although, for research purposes, teeth with radiographic evidence of dentinai caries have received preventive resin restorations,'' if occiusal caries extends
into the dentin so that it can be detected radiographicaily, the lesion is too large for a preventive resin restoration. Occlusai iesions that can be identified clinically, but are not radiographieally dctectabie, present
no radiographie contraindication to a preventive resin
restoration.
Lesions exhibiting frank cavitation are easy to detect
chnically. Borderline cases that fali between a sound
tooth surface and obvious caries are the most difficult.
It is tiiese less-obvious cases that demand ail tlie
operators diagnostic skili and usually require a pre-

308

ventive resin restoration. Visual and tactile inspection

is made with the teeth thoroughly air dried and properly illuminated. The pits and fissures of the occlusal
surface are carefully probed with a sharp explorer to
determine if the explorer tip "catches'" or resists removal after insertion into a pit or fissure with moderate
or firm pressure,' A catch alone is insufficient evidence of caries, because the explorer may be wedged
between the cusps or in a pit or fissure, but it is an
indication to more closely examine the area.
Drying the tootii will drive out fluids present in the
mieropores of demineraiized enamel, and the affected
area will appear a matte white in contrast to the gloss
of normal enamel. While a dark stain usually should
he ignored during diagnosis, a ioss of normal translucency of the ename! surrounding a pit m(.licates the
presence of demineraiization and suggests a develonine

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Operative Dentistry
Normal enamel is hard, and softness represents the
sine qua non of caries diagnosis. Softness is determined
by the taetile feel of the explorer. If the explorer penetrates at the base of a pii or fissure, or if chalky white
enamel ean be scraped oft' the walls, the area is carious.
Table 1 presents the possible permutations of the results of visual and tactile examinations of teeth thai
are radiographically sound, together with appropriate
diagnoses and treatments. While other visual and tactile combinations are possible, such as discoloration
without an explorer catch and softness, they are either
chnically illogical or highly unlikely.
Treattnent plan

When all the results of the examination for clinical

signs of caries are negative, the surface is diagnosed as
sonnd and requires either no treatment or a sealant.
The treatment options for sealants are discussed eisewhere.*"^ When the only sign is an explorer catch, the
surface is still considered to be sound.'' However, pits
and fissures that catch the explorer are difficult for die
patient to clean and can serve as niduses for caries
development (Fig 2); therefore, a sealant is recommended. Questionable surfaces are those with positive
visual and tactile findings, eg, explorer catch and discoloration, but that lack the definitive finding of softness at the base or sides of the pits or fissure. Sealants
are also recotnmended for those teeth.
In their review of the management of questionable
carious fissures, Meiers and Jensen^ cited four clinical
studies that evaluated "borderline" carious fissures
over a period of 24 to 41 months. It was reported that
47% to 73% of the borderhne cases progressed to a
stage of definite caries. These figures indicate that preventive treatment, such as the use of sealants as discussed above, is preferable to a philosophy of watchful
waiting. Too often, dentists "watch" as caries progresses.
Should a lesion inadvertently be sealed there is no
danger, because there is sufficient clinical evidence
demonstrating that properly sealed lesions do not advance and that the bacteria, which are isolated from
their principal nutrient source, decrease in viability
and number.*'''"'' As stated by the American Denial
Association,'^ "It appears that as long as the sealant
provides a physical barrier between the caries and the
oral environment the lesion does not progress and its
bacterial population decreases dramatically over time."
The combination of an explorer catch and definite
softness at the base or along the walls of a pit or fissure
is evidence of caries. Usually, a white halo of undermining demineralization also surrounds the affected

Quintessence International

Volume 23, Number 5/1992

Fig 2 Cross section of an occlusal fisstjre. Pits and fissures

are difficult to clean and encotjrage the dietobacterial factors
responsible tor caries.

area. When caries is diagnosed, either a preventive

resin or conventional restoration is indicated. The indication for a preventive resin restoration is that the lesion in the pit or fissure be small and diserete. Small
refers to the width of the lesion, rather than the depth,
and discrete means that the lesion does not extend
along a fissure. Although more than one discrete lesion
may be present, they should not be conftuent, which
would require a wider cavity preparation.
While the decision to use a preventive resin restoration is made during the treatment planning session,
the final confirmation of this decision may await the
actual treatment visit. Careful opening into the affected
area enables the operator to confirm the presence of
caries and determine its extent. Excavation should be
performed with a small round, pear-shaped, or roundended bur with a width not exceeding 1.0 mm to restrict
the size of the preparation (Table 2). If the width of the
preparation exceeds more than one third the distance
between the buccal and lingual cusp tips, a conventional restoration should be considered, because
cavosurface margins are likely to be placed in areas of
masticatory stress."*" Simonsen," however, has reported
use of preventive resin preparations slightly larger
than a No. 2 round bur, which would have a diameter
greater than l.tl mm.

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operative Dentistry
Table 2

Standard bur sizes aud shapes

Diameter (mm)

Shape

0.5

0.6

0.8

1.0

i.2

1.4

Round
Pear
Round-ended

1/4

1/2
329

1
330
245

2
331

3
332

Technique
Several methods for preparing preventive resin restoThe differrations are descrihcd in the literature.
ences between the methods are minor, and all are accomplished using the following treatment sequence;
(I) anesthesia and isolation, (2) preparation, (3) restoration, and 14) sealant application. The following description of the preventive resin restoration technique
is consistent with other published descriptions. Figures
3 to 10 show the principal steps of the clinical sequence.
1. Administer local anesthesia.
Rationale. Although optional, infiltration or block
anesthesia should be considered for the patient's comfort. Excavation with high-speed burs may be painful
despite the minimal instrumentation associated with
the procedure. Application of the rubber dam retainers
may be painful.
2. Isolate with rubber dam. Only the tooth or teeth
being treated need be isolated (Fig 3).
Rationale. A procedure involving conditionmg with
acid, application of composite resin and sealant, and
possible use of a glass-ionomer lining cement is techtiique sensitive and time-consuming. Each of these steps
is sensitive to moisture contamination, A rubber dam
prevents salivary contamitiation of the treatment area.
3. Remove caries. A small round, pear-shaped, or
round-ended bur is used (Fig 4 and Table 2). The cavosurface margin is not beveled.
Rationale. There are no rules of cavity design because
this is a bonded restoration. The goal is to remove all
caries and as little tooth structure as possible. Penetration beyond the dentoenamcl unction is not necessary,
if all caries has been removed. Small burs arc used to
conserve tooth structure and help ensure a narrow cavity preparation. Cavosurface margins are not beveled,
because Eisenberg and Leinfelder'^ found, in a 2-year
study, that beveling the cavosurface margin has no significant effect on the clinical performance oC posterior
composite resins.
4.

310

Provide pulpui protection if necessary. Calcium hy-

droxide is placed only on the floor of the preparation.

Glass-ionomer lining cement should cover all of the
dentin and not extend onto the enamel (Fig 5),
Rationale. If caries removal extends deeply into the
dentin, calcium hydroxide and glass-ionomer liners
are indicated.^*-" Calcium hydroxide stimulates reparative dentin when the preparation approaches the
pulp. Glass-ionomer lining cement bonds to dentin,-'^
is an insoluble barrier to the acid etchant,^'' provides a
surface to which the composite resin micro mechanically
bonds,''""" and releases fluoride to the cavity walls,"^
Shallow preparations in dentin should be lined only
with glass'ionomer cement. Preparations that are hmited to enamel do not require a liner.
5. Clean the occlusal stirface. An aqueous slurry of
fine pumice in a rotating rubber cup is used to clean
the occlusal surface, including the cavosurface margin
(Fig (>). The tooth is washed and dried.
Rationale. Maximal bond strengths are obtained when
a prophylaxis is given prior to acid conditioning.*^
While there is no evidence to confirm the value of using
pumice instead of other cleaning agents, it is beheved
that flavored, oil-based, or fluoride-containing prophylaxis pastes may adversely influence the conditioning
of the enamel.
6. Condition the entire occlusal suiface. The surface,
including the cavosurface margin and enamel cavity
walls, is etched with phosphorie acid gel or liquid,
then thoroughly washed and dried (Fig 7).
Rationale. Conditioning creates pores in the enamel and
enables the microseopie infiltration of dental resin into
the tooth surface, where it polymerizes and bonds."'''
The usual etching time is 60 seconds, although 20-second
etching periods have been studied."''' ""^ Etching of the
glass-ionomer cement surface is also re comme nded,"**
unless a light-curing product is used. Within the narrow
confines of the cavity preparation, it sometimes is
difficult to avoid etehing the glass-ionomer lining
cement: however, with careful application of a gel
etchant, it can be avoided. Etching for more than 30
seconds eauses a precipitate film to form over the glassionomer cement surface.''^ If acid is applied to the
glass-ionomer cement, formation of this film becomes
the time-determining cotisideration for the conditioning
step."*" Washing removes the calcium-phosphate reaction
products of the phosphoric acid conditioning agent
and enamel. The tooth is washed for 10 to 20 seeonds
to achieve maximal bond strength.^"
7. Place hotiding agent. The eavity walK ,-irid surface
of the glass-ionomer cement liner are euvcred with a
bonding agent (Fig 8).

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operative Dentistry

Fig 3 Tooth to be treated with a preventive resin restoration

is isolated with a rubber dam.

Fig 4 Caries removal. The No, 245 bur in this picture has
a rounded end and a diameter of 0.80 mm. Three discrete
carious areas are to be removed.

Fig 5

Fig 6 Occlusal surface is cleaned with an aqueous

pumice slurry to remove contaminants that might interfere
vith bonding.

Fig 7
add.

Placement of glass-ionomer lining cement.

Ail surfaces to be bonded are etched with phosphoric

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Volume 23, Number 5/1992

Fig 8 Bonding agent is placed on the oavity walls and

surface ot the glass-ionomer cement liner.

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operative Dentistry

Fig 9 Posterior eomposite resin restorative material

placed into the minimal cavity preparations.

Fig 10 Sealant has been applied to the tooth and the restoration surface.

Rationale. Use of a bonding agent improves the bond

strength between a glass-ionomer cement and composite
resin.^' Because some glass-ionomer cements include
resin, an intermediate bonding agent should facilitate
bonding between the glass-ionomer cement and the
composite resin. If the cavity preparation is limited to
enamel, and glass-ionomer cement is not used, a
bonding agent is still employed.
8. Place a posterior composite resin into the preparation
(Fig 9). If a light-curing composite resin is used, it is
placed in increments of 2 mm or less.
Rationale. The composite resin mieromeehanically
bonds to the conditioned enamei and provides an effective marginai seal.^"* Bonding occurs between the composite resin and prepared glass-ionomer cement and
dentinal walls.'"'"" An incremental buildup should be
used for light-curing composite resin, to ensure complete polymerization."^" Care should be taken not to
overfill the eavity preparation. Placing the proper
amount of composite resin is easier to accomplish
when a light-curing product is used, because the application is in small increments, and the initiation of
polymerization is controlled completely by the operator.

glass-ionomer cement minimizes microleakage.^''

10. Equilibrate occlusion. Ii a scmifilled sealant was
used, the occlusion must be equilibrated after removal
of the rubber dam.
Rationale. Unfilled sealants wear quickly to accommodate a patient's occlusion, but semifilled sealants are
more abrasion resistant and require removal of high
spots. ^'

9. Apply sealant. The previously acid-conditioned

occlusal surface and the restoration surface are covered with sealant, which is allowed to harden or light
polymerize (Fig 10). Retention and coverage of the
sealant are checked. If sealant can be pried from the
pits or fissures with an explorer, the tooth and restoration are re-etched for 10 seconds, washed, and dried,
and new sealant is applied. '
Ratiotmle. Sealant prevents caries of the pits and fissures
that were not included in the eavity preparation. The
laminate technique of sealant, composite resin, and

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Clinical success
Simonsen and Stallard,^'' in 1977, were the first to describe preventive resin restorations and to report the
results of a chnical trial. Since then, a number of clinicai
reports have appeared: however, studies have differed
in the seleetion of teeth to be treated, in whether
caries should be removed, and in the clinical technique
used. These differences make comparison difficult.

The results of several representative studies are

listed in Table ^.^^-^^-^"-''^ Only studies in which ther
was eomplete caries removal are included. Three of
the studies compared preventive resin restorations to
other treatments. Azhdari et aP'' treated a control
group of teeth with occlusal amalgam restorations and
noted that the preventive resin technique was 25%
less time-consuming than placing an amalgam restoration. Raadal^'' compared a sealant and composite resin
combination to sealants alone and found a slightly
higher retention rate for the preventive re^in restoration, indicating that placing sealant over ihc composite resin did not affect the longevity o rhe enamelsealant bond. Walls et ai""'' calculated that [eeth in their
study treated with amalgam restorations ],^^\ 250^ Q^
the occlusal surface involved in the restoration while

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Operative Dentistry
teeth restored with preventive resin restorations had
5% of the occlusal surface involved.
Although the cited studies employed different criteria
to judge the success of preventive resin restorations,
the evaluations principally were of the longevity of the
sealant portion, the amount of wear, and the presence
of a new carious lesion or restoration on the treated
surface. The results, judged by the gnerai term percent sticc ess. were highiy favorable (Table 3}, The most
common cause of failure was wear of the resin, which
could be compensated for by the addition of more
material at a recall visit, Houpt and coworkers''" reported that of 205 teeth treated with preventive resin
restorations, only 13 (6%) developed new lesions during
a 4-year period. After 6.5 years, of 104 teeth still in
the study, 11 (11%) had developed caries, and 65% of
restorations were considered completely successful."^

Table 3

Success of preventive resin restorations

Study

Duration
(yr)

Success"

1.0
1,0
1,25'''
1.5
2.0
2,5
2.5
3,0
3,0
4,0
6.5
7.0

100
86
82
91
97
96
84
99
11
64
65
90

Simonsen and Stallard

Azhdarietal-''"
Waliieretal'""'
Houpt etal**'
Walls et al''^
Simonsen and Jensen''^
RaadaP"*
Simonsen''
Houpt et al'''
Houpt et al *^
Houpt et a l "
Simonsen and Landy^''
' Complete retention and caries Iree.
^ Average,

Discussion
The principal advantage of preventive resin restorations
over conventional ones is that they are less invasive.
Hence, sound tooth tissue is not removed unnecessarily.
The most important and difficult decisions, namely
the caries status of the looth and the treatment plan,
are made before the aetual invasive step is begun. No
matter how scientificaliy founded, caries diagnosis is a
subjective determination that relies on the clinical skill
and experience of the operator. Dentists' diagnosis
and treatment planning decisions vary greatly.**
McKnight-Hanes and coworkcrs** reported considerable variation in the treatment decisions of 20 dentists
who evaluated the occlusal surfaces of extracted permanent molars. The greatest differences occurred
among teeth with questionabie or carious occlusal
surfaces. Treatment recommendations ranged from
sealants and preventive resin restorations to amalgam
restorations, Brownbill and Sctcos'"' conducted a similar
study in which 20 operators evaluated the caries status
of occlusai surfaces of extracted moiars. For some
occlusal sites, treatment recommendations ran the
gamut from no treatment to a sealant, preventive resin
restoration, or conventional restoration.

pit and fissure caries, the clinical signs of sound, questionable, and carious pits and fissures were listed and
the diagnosis was related to the appropriate treatment
(see Table 1 ). Whether use of these criteria by dentists
will reduce the variability reported in diagnosis and
treatment selection remains to be determined. Nevertheless, the caries criteria have been used in clinical
caries trials for nearly a quarter of a century, where
diagnostic reproducibility is paramount, and have
stood the test of time.
One reason for the slow adoption of sealants has
been dentists" concern that caries will be inadvertently
sealed.*^*^This same concern may extend to preventive resin restorations, A dentist could diagnose and
remove caries in one pit, only to leave an untreated
lesion in another pit. There is considerable clinical evidence that, once sealed, lesions will not progress and
will become inactive,''''""^ so this concern should not
constitute a barrier to the use of preventive resin restorations. In fact, cognizant of these results, some chnical
researchers recommend deliberately ieaving caries beneath a seaiant or preventive resin restoration, ''-''^2"

The problem in clinical specificity is rooted in the

subjectiveness of the diagnostic method as well as the
iack of specific criteria for the indications for preventive
resin restorations. This article attempts to ameliorate
the situation by recommending criteria for making
diagnostic and treatment planning decisions involving
occlusal pits and fissures. Through a modification of
V^ criteria for the visual and tactile diagnosis of

The method described in this article has been referred

to as the laminate technique because of the successive
use of different materials. Other versions of the preventive resin restoration technique have been pubiished.
One involves the use of a glass-ionomer cement, instead of a composite resin, restoration beneath the
sealant,""" The philosophy expressed by Croir"* that
resins bond to enamel, whiie glass-ionomer cements

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operative Dentistry
bond to dentin, influenced the choice of materials
described in the present article.
The laminate technique takes advantage of the desirable properties of each of the materials employed.
The glass-ionomer cements pose no significant threat
to pulpal vitality and are used to protect the pulp as
well as for their bonding properties to the dentin. The
release of ftuoride by glass-ionomer cements to adjacent tooih structure is an additional benefit, although
it may be superfluous, considering the low failure rate
reported for preventive resin restorations. Posterior
composite resins bond to conditioned enamel and to
the glass-ionomer cement surfaee. The interlocking
between the tooth and dental materials reduces gaps
between the cavity walls and cavosurface margin and
the restoration, thus making marginal leakage unlikely.
The sealant provides further micromechanical interlocking uver the entire occlusal surface and protects
from caries the sound pits and fissures not included in
the cavity preparation.
Because of the degree of reported success and its
minimal invasiveness, the preventive resin restoration
is the treatment of choice for small, discrete lesions of
the pits and fissures.
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: r ~ ' ' ? T ^ " ^ "'' '"' ^'^^^ -^lt

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Quinlessence International

Volume 23, Number S/iqqo

Operative Dentistry
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Quintessence Internationai

Volume 23, Number 5/t992

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