Caries removal techniques and instrumentation: a review
Received: 4 May 1998 / Accepted: 20 July 1998
Abstract The invention of rotary instruments not only
improved the speed of caries removal but also the destruc- Introduction tion of sound tooth substance. Hence, as early as the 1950s, there were attempts to develop a less invasive technique, The gradual evolution of caries removal techniques has such as the air-abrasive and ultrasonic techniques, for the changed the concepts of cavity preparation in numerous purpose of caries removal. The proposed use of air-polish- ways throughout the last two centuries. Cavity prepara- ing was published in the early 1980s. Subsequent better tion with only hand instruments practised by the forefa- understanding of the carious process saw the introduction thers of dentistry entailed only the removal of discoloured of the enzyme technique in the late 1980s. Other tech- carious tissue and undermined enamel. The principles of niques, such as chemomechanical caries removal and la- cavity preparation proposed by G. V. Black in 1893 laid ser systems, have also been attempted and researched dur- the foundations for the latter technique, which in later ing the last four decades to minimise the unnecessary re- years were further modified due to the introduction of moval of sound tooth substance, although these and other man-powered rotary instruments. Essentially, Black’s phi- techniques reviewed in this article have not yet superseded losophy of “extension for prevention” has perpetuated an the use of rotary instruments. Furthermore, the concept of interventive procedure that removes a good proportion of micro-cavity preparation developed in recent years and the the sound tooth substance in addition to carious matter. introduction of acid-etch techniques, resin bonding and the The subsequent invention of high-speed rotary instru- use of glass-ionomer cements have also revolutionised the ments has not only fulfilled the essential process of car- principles of cavity preparation in conservative dentistry. ies removal but also the destruction of sound tooth sub- This article reviews the development of these various car- stance. ies removal techniques and instrumentation and the evo- In the middle ages, carious tissue was scooped out with lutionary philosophies of cavity preparation promulgated hand instruments prior to filling the cavity. The nature of over the last century or so. the softened decayed portion beneath the lesion was not appreciated. Even in the nineteenth century, the poor Key words Caries removal techniques · choice of filling material available made a lasting result Hand instruments · Atraumatic restorative technique · difficult. Various pastes and cements used for filling cari- Air-abrasive technique, air-polishing technique · ous cavities were too soft, and techniques with metallic Enzyme, ultrasonic, chemomechanical caries filling materials did not permit good adaptation of the ma- removal systems terial to the walls and margins of the cavity. Thus, the res- toration of decayed teeth, even in the nineteenth century, was seldom successful [1]. The methods which are currently available to remove caries include mechanical rotary techniques and mechan- ical non-rotary techniques. Non-rotary techniques includes hand instrument action and air-abrasive, air-polishing, H. K. Yip (½) · L. P. Samaranayake ultrasonic, laser, enzyme and chemomechanical tech- Discipline of Conservative Dentistry, Faculty of Dentistry, niques. The University of Hong Kong, The Prince Philip Dental Hospital, Rotary instruments were the first mechanical tech- 34 Hospital Road, Hong Kong SAR e-mail: [email protected] niques developed to remove caries, and comprised dental Tel.: +852-2859-0286 engines, handpieces and dental burs. The following re- Fax: +852-2559-9013 views each of these techniques in some detail. 149
the other to drive the instrument. The latter was connected
Instrumentation for mechanical non-rotary techniques via a universal joint to a spirally wound wire. This was the beginning of the separation of functions between the hand- In the sixteenth century, Giovanni da Vigo proposed re- piece components. moval of caries with drills, files and scrapers. Pierre Fau- A further evolution of functional components of the chard removed caries with strong probes and plugged the dental handpiece was the foot treadle, devised by Morri- dried cavities with lead or tin pupillary [2]. The demand son [2]. The mechanical foot pedal was eventually replaced for systematic conservation of teeth was largely an idea of by a new source of power, the electric motor, which was the nineteenth century, as only the removal of calculus and introduced in 1864. However, the wide use of electrically sharp edges on teeth and the unorthodox techniques of fill- driven motors was not popular until the end of the 1950s. ing cavities with a variety of materials were recognised and The direct predecessor of today’s air-driven dental turbine practised before then. was, however, introduced in 1868 by Green, who devised In 1815, Derabarre advocated the use of a burin (an in- an engine in which a foot-driven bellow transferred air strument used as an excavator) to remove only the caries, through a rubber tube to a handpiece [1]. The handpiece thus leaving the enamel intact. Some years later, in 1826, contained draught screens which rotated a canula within Koecker recognised that complete removal of caries was which various drills could be mounted. Subsequently, air- essential to prevent its recurrence [2]. The procedure of driven dental turbines were produced by the manufacturer cleaving away over-hanging enamel was undertaken by Norlen in 1955, termed Dentalair, and in 1957 as the Bor- hand instruments, termed enamel cutters, which enabled den Airotor. the underlying carious dentine to be scooped out with ex- cavators. These instruments were augmented by a wide range of long-handled burs having the same knurled hex- Dental handpieces agonal handles as the present-day hand instruments. Even- tually, different types of hand instruments evolved for car- Prior to 1870, dentists had no mechanically driven rotary ies removal as well as for filling the prepared cavities. Dur- tools for the removal of caries and cavity preparation. ing the middle of the nineteenth century, various other in- Straight handpieces with a variety of intricate chuck-clos- struments were devised such as the Merry’s drill, with two ing mechanisms were developed during the 1880s, and handles and a universal joint which permitted rotation of these were permanently linked to the flexible cable of a the bur by holding the lower handle still and twisting the foot engine. A subsequent modification of this device was upper handle. However, manual dexterity was essential to the angled handpiece, which held the burs in place by so- handle this rather cumbersome instrument. called lock-bit attachments to their front end. These lock- A number of factors may contribute to the iatrogenic bits were available in right angle, acute angle, and obtuse pathological changes induced in dentine and pulp when ro- angle patterns. Other early twentieth century developments tating instruments are used. These include speed, desicca- included right-angled handpieces fitted with a latch-lock tion, heat, pressure, cutting time, depth of the cavity and mechanism, balanced contra-angled handpieces and multi- area of prepared dentine. Although direct experimental ev- jointed engine arms. idence is unavailable, Massler [3] has noted that damage Although throughout the 1940s little change worthy of to the pulp appeared to be more severe when these early note occurred in dental handpiece design and in their driv- mechanical instruments were used for cavity preparation, ing mechanisms, the subsequent decades saw radical im- compared with electrically operated burs. provements to these features. Handpieces with water jets or water spray nozzles were introduced (by the Amalga- mated Dental Company) in 1955, and these permitted den- tine to be cut in a wet state. Further, due to the spray cool- Instrumentation for mechanical rotary techniques ing effect of water there was a dramatic increase in the maximum speed at which burs could be used. Studies have Dental engines shown that an efficient water spray keeps the cavity prep- aration under constant water cover, a factor crucial for min- The early models of dental engines and cutting instruments imising pulpal damage [4, 5]. used for the removal of carious material were primitive. Handpieces were subsequently improved to drive steel One of the earliest machines, developed in 1846 by West- and diamond burs at a much faster rate than the 9000 rpm cott, was a drill stock consisting of a finger ring and sim- which was the maximum permissible speed prior to the in- ple drill rotated between the thumb and forefinger [1]. Sub- troduction of water coolants. The handpiece bearings were sequently, in 1850, Chevalier devised a drill stock, oper- also improved to withstand the high speeds, which reached ated by a small crank and bevel gears, which was held at 20 000 rpm or more. an angle of 45° to the body of the instrument. Although Significant advances in handpiece development have there was a steady rotation in either direction, both hands occurred during the 1980s, these include the push-button were required for its operation. chuck, the multiple coupling, and fibre-optic lighting [6]. In 1858 a drill was devised by Merry, and this comprised The obvious advantage of the multiple coupling is that it two handpieces, one to hold the instrument in place and enables different types of handpieces to be inserted and re-
