ART Manual - Chapter 5

Manual for the ART approach to control dental caries

Introduction

Chapter 1. Mouth, teeth and dental caries

Chapter 2. ART: What one should know

Chapter 3. What to do before applying ART

Chapter 4. Restoring one-surface cavities using ART

Chapter 5. Restoring multiple-surface cavities using ART

Chapter 6. Glass-ionomer used as a sealant

Chapter 7. Monitoring ART restorations and sealants

Chapter 8. ART: What not to forget

Chapter 9. List of essential instruments and materials

Chapter 5 - Restoring Multiple-Surface Cavities Using ART

This chapter describes the step-by-step stages and the instruments needed for placing ART restorations for treatment of multiple-surface cavities.

Preparing the Cavity

Basically, two types of multiple-surface cavities exist, those in front teeth and those in premolar/molar teeth. Those in front teeth are usually not very large, but multiple-surface cavities in premolars/molars vary and can be large.

In principle, the same stages described for one-surface cavity preparation and restoration have to be followed for multiple-surface cavities. A summary of the procedures is presented below.

It is usually not necessary to open the cavity. Start excavation at the enamel/dentine junction, then remove caries towards the pulp (Fig. 5.1). Ensure that the cavity outline is smooth and free of caries, particularly the outline in the proximal surface. Do this by placing the dental hatchet on the enamel close to the end of the cavity (Fig. 5.2). Then push gently down. Small pieces of enamel will chip off. Smoothen the outline further by scraping the dental hatchet over the enamel. Make sure that the dental hatchet is well supported by your fingers.

Figure 5.1

Using the spoon excavator to remove carious dentine in a multiple-surface cavity

Figure 5.2

The position of the dental hatchet for smoothing the proximal outline

Restoring the Cavity

Anterior teeth

Extra attention is needed when restoring large cavities to ensure that the restoration has the correct shape. A step by step description of the restorative procedure in anterior teeth is given in (Fig. 5.3).

Figure 5.3 Restoring a proximal surface cavity in various stages a. Positioning of the strip between the teeth
b. Insertion of a wedge c. The strip is pulled around the tooth while the mixture is setting d. A straight instrument is pressed against the strip to shape the restoration

The Procedure for Restoring multiple-surface Cavities in Anterior teeth step-by-step

1. Work in a dry environment using cotton wool rolls. Replace these as required.

2. Clean the cavity and ensure that the outline is smooth and free of caries.

Place a plastic strip between the teeth and use this to make the correct tooth contour of the proximal surface.

4. Insert a soft wood wedge between the teeth just at the gum margin to keep the plastic strip firmly in position.

5. Condition the cavity as described for the one-surface cavity.

6. Mix the glass-ionomer as described before and insert it into the cavity until it is slightly overfilled.

7. Hold the strip tightly with the index finger on the palatal side of the tooth. Wrap the strip firmly around to the buccal side to

adapt the restorative material well into the cavity. Hold the strip with the thumb on the buccal side for 1-2 minutes until the

material has set firmly.

8. Remove the strip and wedge, and cover the restoration with petroleum jelly.

9. Remove any excess material with the carver, check the bite with articulation paper and apply another coat of petroleum jelly.

10. Remove cotton wool rolls.

11. Ask the patient not to eat for one hour.

Posterior teeth

Restoring multiple-surface cavities in primary molars

In the primary dentition it is not always necessary to restore the proximal contour of the tooth completely. Much depends on the size of the cavity and the length of time the tooth will still remain in the mouth. Large proximal lesions in the primary dentition can be treated by flattening off proximal surfaces.

Restoring multiple-surface cavities in posterior permanent teeth

Multiple-surface cavities of posterior permanent teeth can also be restored using a plastic strip, which is held, in position by a wedge (Fig. 5.4). Try to avoid flattening off proximal surfaces. Before the strip is fitted, ask the patient to close the jaws together so that you can decide how much of restorative material should be trimmed later.

Note:

Large cavities need more restorative material than small cavities and, therefore, one drop of liquid and one scoop of powder may not be enough. Then use two drops and two scoops. If this still does not provide enough material, prepare a second mixture and insert on top of the first mixture. Make sure that the first mixture has not been contaminated with saliva or blood in the meantime. If this has happened, the first mixture should be allowed to become hard. Cut back the contaminated surface by a millimeter. Then clean, wash and dry the surface of the first mixture and any remaining uncovered dental tissues. Then insert the second mixture and complete the restorative procedure.

Figure 5.4 Restorative procedures for multiple-surface cavities in posterior teeth a. Plastic strip and wedge in position
b. Restorative material pushed into place under unsupported enamel c. Slightly overfilled sealed restoration
d. Finished sealed restoration

The procedure for restoring multiple-surface cavities in posterior teeth step-by-step

1. Work in a dry environment using cotton wool rolls. Replace these as required.

2. Clean the cavity and ensure that the outline is smooth and free of caries.

3. Place the strip between the teeth. Insert a wedge to support the strip under the contact point at the gum margin.

4. Condition the cleaned cavity and adjacent fissures as described for the one-surface cavity.

5. Fill the cavity completely with glass-ionomer. Insert material into corners and under unsupported enamel first.

Make sure that there is enough restoration material to fill the entire cavity and the adjacent fissures.

If material mixed is not enough to fill the cavity, mix a new lot and insert a second filling on top of the first material

(avoid contamination with saliva or blood).

6. Handle the plastic strip as explained for cavities in anterior teeth.

7. Try to place a petroleum jelly coated, gloved index finger on top of restoration and press slightly for a few seconds.

Remove finger sideways.

8. Remove excess glass-ionomer with a medium or large excavator. Leave the restoration to harden for 1-2 minutes,

then remove wedge and strip.

9. Check bite with articulation paper.

10. If necessary, remove excess restorative material with the carver.

11. Check that the cusps of the opposite tooth will not destroy the restoration.

It is better to have no occluding contacts than a contact that is too high.

12. Trim the proximal margins with the carver and apply new petroleum jelly.

13. Check the height of the restoration again with articulation paper and apply petroleum jelly if necessary.

14. Remove cotton wool rolls.

15. Advise the patient not to eat for at least one hour.