International Dental Journal (2000) 50, 112

2000 FDI/World Dental Press

0020-6539/00/01001-12
Minimal intervention dentistry a
review*
FDI Commission Project 1-97
Martin J. Tyas
Melbourne, Australia
Kenneth J. Anusavice
Gainesville, USA
Jo E. Frencken
Nijmegen, The Netherlands
Graham J. Mount
Adelaide, Australia
The concept of minimal intervention dentistry has evolved as a conse-
quence of our increased understanding of the caries process and the
development of adhesive restorative materials. It is now recognised that
demineralised but noncavitated enamel and dentine can be healed, and
that the surgical approach to the treatment of a caries lesion along with
extension for prevention as proposed by G V Black is no longer tenable.
This paper gives an overview of the concepts of minimal intervention
dentistry, describes suggested techniques for a minimally invasive opera-
tive approach, and reviews clinical studies which have been carried out in
this area.
Key words: Dental caries, cavity design, adhesive restorative materials
lor most or the twentieth century
the proression has used the caity
classirication designed by GV Black
1
whereby caries lesions were treated
by a surgical approach requiring the
remoal or diseased portions or the
tooth and extension to areas which
were presumed to be caries resistant.
1he reasons ror this included a lack
or understanding or the caries proc-
ess, in particular the potential ror
remineralisation, and the poor physi-
cal properties or aailable restoratie
materials. Probably the most serious
consequence or the surgical approach
was the extent or the caity which
had to be prepared to accommodate
the principles or extension ror
preention`. Since the deelopment
or ultra-high speed rotary cutting
instruments in the 1950s, there has
been a tendency to extend a caity
een rurther, and the resultant weak-
ening or the tooth crown has led to
a marked increase in replacement
dentistry`, wherein there is rurther
loss or tooth structure upon each
replacement or a restoration
2
.
It is now acknowledged that, in
the presence or the rluorine ion, it is
possible to remineralise or heal the
earliest caries lesion
3
, and thus in
many cases a surgical approach may
be unnecessary, and can be replaced
*Project initiated and report approved by FDI Commission
Correspondence to: Professor Martin J. Tyas, School of Dental Science, The University
of Melbourne, 711 Elizabeth Street, Melbourne 3000, Australia.
2
International Dental Journal (2000) Vol. 50/No.1
by a biological` or therapeutic`
approach. Howeer, in certain
circumstances, a surgical approach is
ineitable, and adhesion between the
restoratie material and both enamel
and dentine is an important compo-
nent ror preention or secondary
caries and or pulp damage. Adhe-
sion or resin to enamel became
possible in the 1950s
4
, adhesion to
dentine or polyalkenoic cements in
the 1960s
5
, and resin-dentine adhe-
sion is now becoming more reliable
6
.
Vhen a restoration is required, the
use or adhesie restoratie materials
is prererred because or the potential
to preent bacterial microleakage, as
well as the possibility or reinstating
some or the physical properties or
the tooth crown lost as a result or
caity preparation. It is also possible
that demineralised dentine on the
caity rloor may be remineralised to
some degree, such remineralisation
is only possible in the absence or
bacterial actiity, and is thererore
racilitated by an adhesie restoratie
material.
1he proression should now be
encouraged to adopt an entirely new
attitude to the repair and restoration
or demineralised tooth structure. 1he
scientiric knowledge is now aailable
to allow major changes to be intro-
duced into the science and art or
restoratie dentistry. It must be
acknowledged and understood that
neither rluoride nor the preention
or bacterial microleakage between the
tooth and a restoration will, by
themseles, be surricient to preent
rurther caries actiity in any gien
patient. No restoratie material can
be regarded as being completely
errectie in preenting recurrent
caries, although the deelopment or
materials with a therapeutic poten-
tial to stimulate and assist in
remineralisation is a possibility.
1hererore, all restoratie procedures
must be carried out only in the pres-
ence or well understood preentie
techniques, including carerul patient
education.
In addition, neither can a restora-
tie material be regarded as perma-
nent, and one or the major issues in
contemporary restoratie dentistry is
the diagnosis and management or the
railed` restoration, which is becom-
ing more common due in part to
increased lire expectancy or the
patient and tooth longeity. 1radi-
tionally, railed restorations hae been
totally replaced, but eidence is now
accumulating that a repair approach
should be adopted in many cases,
with the consequent preseration or
sound tooth structure

.
1he application or the aboe
concepts has been termed minimal
interention dentistry`, minimally
inasie dentistry` or preseratie
dentistry`. No rormal derinition
appears to hae been proposed ror
this style or operatie dentistry,
howeer, it embodies at least rour
principles:
remineralisation or early lesions,
reduction in cariogenic bacteria,
in order to eliminate the risk or
rurther demineralisation and cai-
tation,
minimum surgical interention or
caitated lesions,
repair rather than replacement or
derectie restorations,
disease control.
1he purpose or this paper is to
discuss the scientiric basis and the
principles or minimal interention
dentistry, to describe how these
principles can be translated into
practice, and to discuss ealuations
or their clinical applications.
Biological approach to early
lesions
At one time, the caries process was
thought to be an irreersible
sequence or eents, beginning with
enamel demineralisation rollowed by
protein collagen, degradation. 1hus,
the logical treatment was surgical
excision or the pathological tissue
and replacement with a restoratie
material. Howeer, it is now recog-
nised that enamel and dentine
demineralisation is not a continuous,
irreersible process. Rather, there is
a demineralisation-remineralisation
cycle, in which the tooth structure
alternately loses and gains calcium
and phosphate ions, depending on
the microenironment. Vhen the pH
drops below approximately 5.5, the
sub-surrace enamel or dentine will
begin to demineralise. As the pH rises
again, remineralisation may occur
8
.
lluoride plays a critical role in the
demineralisation-remineralisation
cycle because it enhances uptake or
calcium and phosphate ions and can
appear in the rorm or rluorapatite, in
which the rluorine ion replaces the
hydroxyl ion. lluorapatite begins to
demineralise at a pH or 4.5, rather
than 5.5 ror hydroxyapatite. 1hus,
the acid challenge needs to be greater
to dissole rluorapatite than to
dissole hydroxyapatite.
In the early stages or the caries
lesion there will be subsurrace
demineralisation or the enamel. As
the lesion progresses into dentine,
the surrace or the enamel will een-
tually become caitated, and it will
then be dirricult to control plaque
accumulation. In areas or dirricult
access, plaque may hinder the aail-
ability or calcium, phosphate and
rluoride ions, so remineralisation may
be less likely. Howeer, ror root
caries on an accessible surrace, the
remineralisation potential is much
higher. In any case, remineralisation
will be dependent on the mainte-
nance or the collagen matrix or both
enamel and dentine, which needs to
be present to allow rurther apatite
crystal depositions.
1he knowledge or the caries
process gained in recent years can
be applied as the rirst principle in
minimal interention dentistry`.
Specirically, the traditional surgical`
approach to the early surrace lesion
enamel or dentine,, can now be
superseded by the biological` or
therapeutic` approach, recognising
also that caries is an inrectious
disease. 1here are two elements to
the biological approach: alteration
or the oral enironment in order
to minimise demineralisation, and
application or agents such as
chlorhexidine and topical rluoride. A
complete discussion or the alteration
or the oral enironment is beyond
the scope or this paper, howeer,
the general modalities which are
important are: reduced rrequency or
rerined carbohydrate intake, opti-
mum plaque control, optimum
saliary rlow, and patient education.
Remineralisation or early enamel and
dentine lesions is enhanced by the
application or topical rluoride, and
the arious ehicles which are
3
Tyas et al.: Minimal intervention dentistry a review
aailable hae been clearly tabulated
by McIntyre
9
.
The concept of minimal
intervention dentistry
1he concept or minimal interen-
tion dentistry, sometimes called
preseratie dentistry, entails a
departure rrom the traditional surgi-
cal approach to the elimination or
caries lesions which hae been iden-
tiried as radiolucencies in the inner
halr or the enamel, at the dentino-
enamel junction DLJ,, and slightly
into dentine, but with little or no
eidence or caitation
10-15
. 1he delay
in treating lesions conrined to the
inner halr or enamel, and een slightly
into dentine, is justiried on the basis
that caries progression through
enamel, een in those with actie
caries, is slow
16,1
. 1he rate or caries
progression in deeloped countries
has been decreasing oer recent
decades
18
, and appears to be een
slower in patients who hae receied
regular rluoride treatment or who
consume rluoridated water
1,19
. In
some populations, it takes 6-8 years
ror a lesion to progress through
enamel
16,20-23
, and progress through
dentine may also be slow
24-26
.
lurthermore, the percentage or
radiographically isible approximal
lesions in the outer halr or dentine
that hae caitation in the enamel
has declined to approximately 41 per
cent
2
.
1he initial approach must be
rocused on the management or
caries as an inrectious disease. In
traditional treatment, patients with
caries lesions are assumed to be at
high risk or both lesion progression
and new lesion rormation, and
restorations are orten planned at the
rirst appointment. 1he most impor-
tant principles or preseratie
dentistry are to delay operatie inter-
ention ror as long as possible
13
, to
assess whether lesions hae resulted
in enamel caitation, and then to
assess whether they hae progressed
through one-third or more or the
thickness or dentine. In a broader
sense, the rocus is on maximum
conseration or demineralised, but
noncaitated, enamel and dentine.
Placement and replacement, or
restorations is aoided until the
disease is controlled and operatie
interention has become essential
because or caitation, patient discom-
rort, unacceptable rorm or runction
or poor aesthetics. Inrection control
is applied rirst, and then caries risk
status and eidence or lesion
remineralisation can be monitored
oer extended periods or time.
Preseratie dentistry is thererore
based on a rerined model or care
consisting or:
accurate caries diagnosis,
classirication or the caries seer-
ity using radiographs,
assessment or indiidual caries
risk high, moderate or low,,
arresting actie lesions,
remineralising and monitoring
or caitated arrested lesions,
placement or restorations in teeth
with caitated lesions, using mini-
mal caity designs,
assessing disease management
outcomes that is, change in
arious decayed,missing,rilled
indices, at predetermined time
interals.
1he bacterial inrection which
leads to the production or
demineralising acids should be
controlled to ensure the arrest or
demineralisation and the initiation or
remineralisation. 1o determine ir
inrection control is errectie, out-
comes must be measured, such as
the change in the size or caries
lesions. Vhite spot lesions should
be described at the initial and at each
recall examination, using a periodon-
tal probe to measure the dimensions
and location or the geometric centre
or the lesion relatie to landmark
rererence points such as cusp tips,
rissures, pits, and margins or resto-
rations. A change in lesion size can
then be accurately monitored
between successie examinations.
In order to assess radiographic
changes in approximal radiolucencies,
a suitable classirication is as rollows:
L1 ~ outer halr or enamel
L2 ~ inner halr or enamel
D1 ~ outer third or dentine
D2 ~ middle third or dentine
D3 ~ inner third or dentine.
A tooth or surrace with no cari-
ous lesion is designated L0`.
Dentine is diided into three zones
since it enables more conseratie
criteria to be established, relatie to
the point at which a decision is made
to place a restoration. 1raditional
dental practice generally adopts the
criterion that restorations should be
placed when an approximal radio-
lucency reaches the DLJ, een
though only 10 per cent or perma-
nent teeth and 3 per cent or primary
teeth show caitation
2
. Using the
preseratie dentistry model, resto-
rations are not indicated until the
lesion has extended to the D2
region, that is, where the probability
or caitation in the enamel is
between 10 per cent and 41 per cent
ror permanent teeth and between 3
per cent and 28 per cent ror primary
teeth.
1he preseratie dentistry model,
by rocussing on inrection control
rather than surgical interention,
could result in a 50 per cent reduc-
tion in restoration placement
14
. 1he
surgical management or noncaitated,
demineralised teeth should be the
treatment or last resort, especially ror
patients who hae been shirted rrom
a high or moderate risk status to a
low caries risk status.
Adhesive restorative materials
Ir the caries lesion has reached the
stage or caitation making plaque
control dirricult or impossible, a
surgical approach is generally
required. 1he inrected tissue must
be remoed and replaced with a suit-
able restoratie material, such that
rorm and runction are restored and
the patient is able to re-establish
excellent plaque control. 1he adent
or adhesie restoratie materials
has enabled minimal interention
principles to be applied to caity
preparation, and the materials which
can be used ror this purpose are
described here.
Glass-ionomer (polyalkenoate)
cements
28
Glass-ionomer cements are aailable
ror seeral purposes, howeer, there
are common properties which apply
to all the materials in this class. 1he
two most important properties in the
context or minimal interention
International Dental Journal (2000) Vol. 50/No.1
4
dentistry are adhesion to tooth
structure and release or rluoride and
other ions.
Adhesion arises as a result or an
ion exchange between the tooth
structure and the cement. 1he
polyalkenoic acid rrom the glass-
ionomer attacks the tooth surrace
releasing calcium and phosphate ions
which subsequently reprecipitate,
along with calcium, phosphate and
aluminium ions released rrom the
glass, rorming a new material which
unites the two. 1here will also be a
degree or adhesion between the acid
carboxylate groups and dentinal
collagen. 1he strength or the union
is dependent upon the tensile
strength or the cement itselr and any
railure will be cohesie within the
cement. 1hus, the stronger the
cement, the higher the measured
bond strength
28,29
.
1he setting reaction or the glass-
ionomer cements is an acid-base
reaction between the polyalkenoic
acid liquid, and the rluoro-
aluminosilicate glass base powder,
28
.
1he acid attacks the glass particles,
causing a release or calcium,
aluminium and rluoride ions. 1he
rluoride ions become incorporated
into the matrix, and can readily
dirruse into the surrounding tooth
structure and into salia. In addition,
set glass-ionomer can take up rluo-
ride rrom, ror example, a rluoride
toothpaste. It is commonly assumed
that glass-ionomer cements are
anticariogenic due to release or rluo-
ride, based on laboratory studies,
clinical models and retrospectie
clinical assessments
30,31
. Howeer, the
rew prospectie clinical trials which
assess this property hae been
equiocal
32
. Glass-ionomer cements
hae recently undergone rurther
deelopment by the inclusion or a
water-soluble polymerisable resin.
Although these products are orten
termed light-cured glass-ionomers`,
this is a poor term and resin-modi-
ried glass-ionomer` is prererred
33
.
1he physical properties or the
glass-ionomers are important in the
context or minimal interention tech-
niques. Like all water-based cements,
they are relatiely brittle and, imme-
diately arter placement, are not highly
wear resistant. lollowing proper
maturation, they hae been shown
to last well in low stress areas
30,34
,
and the resin-modiried materials can
be used ror rissure sealing, cerical
restorations, approximal anterior
lesions in permanent teeth and
approximal anterior and posterior
lesions in deciduous teeth.
Recent research Ngo, H, unpub-
lished, suggests that glass-ionomer
used to seal an extensie lesion will
encourage the remineralisation or
demineralised dentine on the rloor
or the caity. 1he errectie adhesion
will help preent bacterial
microleakage, thus arresting the
progress or demineralisation, and the
calcium, phosphate and rluoride ions
aailable rrom the cement will
enhance remineralisation. Scientiric
erirication is yet to be established,
but clinical obseration suggests that
it is a alid theory.
Resin composites/dentine
bonding agents
35
Lrrectie bonding or resin compos-
ites, particularly to enamel, is a key
ractor in minimal interention
dentistry. By designing caities to
consere maximum enamel, reten-
tion or the restoration can be
errected by enamel bonding, rather
than haing to remoe additional
sound tooth structure to achiee
macromechanical retention.
Although resin-based dentine
bonding agents DBAs, were rirst
synthesised in the 1950s, substantial
laboratory bond strengths were not
obtained until Nakabayashi
6
showed
that it was possible to etch` the
dentine, which remoes the smear
layer and a rew micrometres or
surrace hydroxyapatite, leaing a
zone or exposed collagen ribrils.
Application or a suitable hydrophilic
polymerisable monomer commonly
hydroxyethylmethacrylate, HLMA,
will inriltrate the wet, collagen and
establish a mechanical bond, this
layer has been ariously termed the
hybrid`, resin-reinrorced` or resin-
impregnated` layer. 1he surrace or
the hybrid layer is rich in metha-
crylate groups, enabling it to be linked
to the methacrylate groups or
the matrix or the resin composite.
Usually, an intermediate layer or
unrilled resin is placed to enhance
the wettability or the hybrid layer
surrace by the rilled resin. Clinical
success rates are much higher with
the hybrid layer-rorming DBAs than
with their chemical bonding pred-
ecessors, but the longeity or this
bond in the oral enironment
remains undetermined. 1here are also
some potential problems with the
resin composite itselr. In particular,
polymerisation shrinkage stress may
compromise the marginal integrity,
and concern has recently been
expressed that such stress may be
higher when using high intensity
curing lights, compared to the use or
lower intensity lights.
Lamination (sandwich)
technique
As noted aboe, adhesion or glass-
ionomer to tooth structure is ery
errectie, but the physical properties
or these materials rall short or the
uniersal restoratie. At the same
time, while the physical properties
or resin composites are higher, the
adhesion to dentine is still not
assured. 1he combination or the two
materials, where resin composite is
laminated oer glass-ionomer, may
orrer a userul alternatie in situations
where the occlusal load is heay and
there is a lack or enamel to proide
adhesion to resin composite.
Cavity designs
1he deelopments discussed clearly
justiry a new approach to the classi-
rication or caries lesions. 1he
proression must be encouraged to
adopt the biological preseratie
approach and to abandon the
traditional surgical approach. No
restoratie material can adequately
replace enamel and dentine, and their
preseration should be paramount
in any treatment plan. Preention and
hard tissue preseration are the
primary goals. Vithin this context,
the elimination or derects which are
likely to accumulate plaque must be
considered. lissure sealing with an
adhesie material has been shown to
be highly errectie
36
. 1he logical time
to seal is shortly arter eruption or
any tooth which demonstrates a deep,
Tyas et al.: Minimal intervention dentistry a review
5
tunnel` preparation
43,44
, by approach-
ing the lesion obliquely through the
marginal rossa, and retaining the
marginal ridge. Ir the approximal
enamel is caitated, the periphery
is gently cleaned in order to
remoe rriable enamel. No attempt
is made to remoe any intact but
demineralised enamel surrounding
the lesion, since it is likely that this
can be remineralised. 1he caity can
then be restored using glass-ionomer,
and ir necessary laminated occlusally
with a resin composite. Ir the
approximal enamel in relation to the
lesion is demineralised but not cai-
tated, it is not necessary to break
through the enamel because it is likely
that, with good preentie rollow up,
it can be remineralised. 1his latter
procedure has been termed an
internal` preparation
45
, although
other names such as partial tunnel`,
blind tunnel` and Class I tunnel`
hae also been used.
Ir the approximal lesion is close
to the marginal ridge, it may be prer-
erable to use a slot` or minibox`
preparation, by entering the carious
lesion through the outer slope or the
marginal ridge using a ery rine
tapered rissure diamond bur at inter-
mediate high speed under air,water
spray. As much as possible or the
marginal ridge is maintained, and the
occlusal rissure is not incorporated.
1he outline is extended to sound
enamel, and in most cases there will
be a normal contact remaining with
the adjacent tooth. 1he walls are
cleaned to allow adhesion to sound
dentine and enamel, but there is no
need to eliminate all demineralised
dentine rrom the axial wall. Glass-
ionomer alone is generally surricient
ror restoration, although resin
composite may be necessary ir the
occlusal stress is high. 1he same
principles apply to caity prepara-
tions in anterior teeth, although the
slot` caity is generally the prererred
approach. Occasionally, in the pres-
ence or a strong dominant marginal
ridge, it may be possible to employ a
tunnel design.
1he third alternatie ror access is
only aailable when a larger Black-
style caity has been prepared in the
adjacent tooth, reealing an initial
lesion on the approximal surrace.
Table 1 Classification of cavities
41
Cavity Size
Cavity Site Size 1 Size 2 Size 3 Size 4
Minimal Moderate Enlarged Extensive
Site 1 Pits and fissures 1.1 1.2 1.3 1.4
Site 2 Approximal surfaces 2.1 2.2 2.3 2.4
Site 3 Cervical region 3.1 3.2 3.3 3.4
poorly rormed or conoluted rissure
system, particularly ror patients in a
high caries risk group. Ideally the
rissure should be sealed prior to the
commencement or demineralisation
or enamel, although it has been
suggested that sealing or an appar-
ently actie caries lesion may be
surricient to arrest progress
3
.
Conersely, an approximal lesion may
not hae adequate access, and seal-
ing is generally not an option. As
noted aboe, caitation or the enamel
surrace is likely to occur late in the
process or demineralisation, but once
the surrace does break down it will
be no longer possible to preent
rurther plaque accumulation and
surgical interention will be required.
Howeer, regardless or the
extent or the caity, rormally
prescribed caity designs should no
longer be regarded as mandatory. It
is only necessary to gain access to
the caries lesion, and remoe those
areas or enamel and dentine which
are inrected, degraded and broken
down to a point where they are
beyond remineralisation
38
. Demin-
eralised enamel surrounding the
caity, and demineralised dentine at
the base or the caity, should be
regarded as pre-carious`, because
they can be remineralised and there-
rore retained
39
. Also, as an adhesie
restoratie material is to be placed,
there will be no need to remoe
undermined enamel, because it may
be able to be supported by the resto-
ration
40
. Both the occlusal load and
the wear ractor should be taken into
account ror any particular situation,
but as much original tooth structure
as possible must be retained.
A more preseratie attitude to
the restoration or a caries lesion is
thererore possible, and the introduc-
tion or a new classirication should
be regarded as an important step in
abandoning Black`s obsolete system.
It is possible to design a classirica-
tion
41
ror caries lesions which is quite
dirrerent rrom that or Black, and
which will help to guide the prores-
sion away rrom the surgical approach
towards the biological approach
1abe 1,.
Preparation ror restoration or the
minimal occlusal lesion analogous
to the preentie resin restoration
42
,
should be as conseratie as possi-
ble
9
. 1his lesion generally commences
within one section or the rissures on
the occlusal surrace or a molar.
Access is gained using a ery rine
tapered rissure diamond bur at inter-
mediate high speed under air,water
spray or an enamel hatchet in the
Atraumatic Restoratie 1reatment
AR1, technique, see below,, and the
caity only opened surriciently to
determine the extent or the caries
lesion. A small round bur or an
excaator is used to clean the walls,
but it is generally not necessary to
completely clean the dentine rloor
because remineralisation is possible,
proided that the margin or the
restoration is completely sealed rrom
the oral enironment
3
. 1he remain-
ing rissures are explored with the ery
rine bur only ir rurther sites or
demineralised dentine are expected.
1he subsequent adhesie restoration
will then act as both a restoration
and a rissure seal.
1he approximal posterior lesion
may pose problems or access and
possibly undermine the marginal
ridge. 1he potential occlusal load
must be taken into account, and
where possible the margin placed in
an area which is not subject to direct
occlusion. 1here are two main
options ror access, on both poste-
rior and anterior teeth, with a
possible third option ir the adjacent
tooth is being restored at the same
time. On a posterior tooth, ir the
lesion is more than 2.5 mm gingial
to the crest or the marginal ridge, it
is possible to prepare a so-called
International Dental Journal (2000) Vol. 50/No.1
6
Access will not always be easy, but
the situation orrers the possibility or
a simple and ery conseratie
caity design which inoles neither
the occlusal surrace nor the marginal
ridge. Preparation is straightrorward
using a tapered diamond bur and a
small round bur, possibly with a
long shank. A radiopaque adhesie
restoratie material is essential, in
order that the restoration is
radiographically isible.
1he same basic principles should
be applied to the treatment or all
other caries lesions. Preseration or
natural tooth structure should be the
guiding ractor ror the smallest as
well as the largest caity. 1he main
controlling ractor which will need to
be taken into account is the occlusal
load and thus the wear ractor ror any
gien restoration. An apparently
simple design may hae to be modi-
ried under certain circumstances to
allow greater strength or the restora-
tion at the expense or some loss or
enamel.
Lxtension ror preention` is an
outmoded concept and adhesie
restoratie materials can orten re-
establish support ror areas or
apparently unsupported enamel.
Vhile the adoption or the proposed
classirication may be inhibited by the
apparently proround change which
would be brought about, it is
eident that the proression has to
take this step ror the sake or its
patients. It is obious that the tradi-
tional surgical approach to the
control or caries leads only to a
destructie cycle, beginning with
excessie tooth reduction ror a rela-
tiely small lesion, rollowed by
restoration replacement, rollowed by
rurther caity modirication and een-
tual tooth loss.
Survival of restorations placed
using minimal intervention
techniques
As described aboe, seeral minimal
interention restoration techniques
hae been described in the literature,
including tunnel` and internal`
restorations, preentie resin resto-
rations, preentie glass-ionomer
restorations, posterior approximal
miniboxes` and microchips`
45
and
Table 2 Survival results of preventive resin restorations (PRR)
in permanent teeth. N = number at last evaluation.
Source Duration N Survival %
Kilpatrick et al., 1996
89
1.5 66 97
King et al.,1996
90
1.5 532 98
Granath et al., 1992
91
2 87 96
Roth & Conroy 1992
92
2.3 100 96
Simonsen, 1980
47
3 232 99
Welbury et al., 1990
50
5 150 95
Houpt et al., 1994
51
9 79 75
Mertz-Fairhurst et al., 1998
37
10 85 87
Atraumatic Restoratie 1reatment
AR1,
46
restorations. Unrortunately,
there are rew publications which
assess the clinical erricacy or these
techniques. 1his section reiews the
surial or preentie resin and AR1
restorations ror the treatment or
single-surrace lesions, and tunnel and
mini-box restorations ror the treat-
ment or minimal approximal lesions.
Preventive resin restorations
1he preentie resin restoration
PRR, was rirst introduced by
Simonsen and Stallard in 19
42,4
.
Since then, arious PRR techniques
hae been deeloped
48,49
, most or
which hae attempted to treat rather
small single-surrace mainly occlusal,
caries lesions.
1he saing in tooth tissue or a
PRR approach has been reported.
Velbury et a.,
50
compared the size or
conentional PRR and amalgam
caity preparations, and reported an
occlusal surrace coerage on aerage
or 5 per cent ror PRRs and 25 per
cent ror amalgam restorations.
1he adantages or the PRR ror
single surraces, in comparison with
conentional methods, include: tooth
structure is consered, the remain-
ing pits and rissures are protected,
the risk or microleakage is reduced.
Survival of preventive resin
restorations
Seeral studies, two or which are
long-term, hae been carried out in
order to assess the surial or
preentie resin restorations 1abe
2,, and the surial results are based
on the need to replace the restora-
tion, that is, a true railure. 1he
long-term surial or PRRs was ery
high 5 per cent and 8 per cent
arter 9 and 10 years respectiely,, and
the percentage that suried
decreased slowly oer time. Second-
ary caries was the sole reason ror
railure in the study by Houpt
51
, while
both caries and marginal breakdown
were the reasons obsered in the
study by Mertz-lairhurst et a.
3
.
1hese inestigations not only
assessed the surial or PRRs, but
also compared the surial or sealed
and non-sealed amalgam restorations.
Arter 10 years it was concluded that
sealed restorations perrormed better
clinically and exhibited signiricantly
rewer secondary caries lesions.
Atraumatic Restorative
Treatment (ART) restorations
1he Atraumatic Restoratie 1reat-
ment AR1, approach eoled in
response to the unaailability or
restoratie care in population
groups with limited resources
52
, and
inoles the remoal or only sort,
demineralised tooth tissue with hand
instruments, rollowed by rilling the
cleaned caity and associated pits and
rissures with an adhesie restoratie
material. As conentional high
powder:liquid ratio glass-ionomers
do not require the use or electricity
ror mixing and photopolymerisation,
their use as the restoratie material
in the AR1 technique makes it
possible to proide preentie and
restoratie care in any situation
52
. 1he
resulting restoration may thererore
be ery similar to Size 1 and Size 2
restorations described aboe.
Howeer, AR1 rerers to the situ-
ation where the dentine lesion is
accessible, or can be made so, using
hand instruments. 1his aspect was
studied in a low-caries prealence
population
53
, and access was achieed
in 84 per cent or the diagnosed
dentine lesions.
1he adantages or AR1 include:
only the remoal or sort, demin-
eralised dentine and rriable enamel
is possible, as no rotary instru-
ments are used. 1his results in
minimal caity preparations which
consere tooth tissue,
pits and rissures as well as the
caity can be rilled or sealed with
the restoratie material,
little or no pain is experienced,
thereby minimising the need ror
local anaesthesia,
anxiety, orten round with tradi-
tional restoratie procedures, is
minimised
54
,
only inexpensie and easily aail-
able hand instruments are used,
and consequently inrection con-
trol is straightrorward and
simple,
the cost is relatiely low.
Survival of ART restorations
Since its inception, AR1 has been
subject to ealuation through
community rield trials, and the
results or some or the more impor-
tant studies are summarised in 1abe
. Because AR1 is still relatiely new,
only three-year surial data are
aailable. Howeer, long-term
ealuations using other adhesie
restoratie materials are in progress.
1he short-term results ror
AR1 restorations are particularly
encouraging, considering that the
restorations were placed under less
than optimal rield` conditions. 1he
studies which commenced more
recently showed surial rates arter
three years or between 85 per cent
and 88 per cent, and compared
raourably with amalgam restorations
placed under similar conditions
55
.
One clinical trial was carried out in a
uniersity setting
56
. Some important
points to note rrom the collectie
results are:
the results or early studies
5,58
must be considered as proiding
baseline` data, since the approach
was still being deeloped at the
commencement time,
early studies used glass-ionomers
which were not designed speciri-
Table 3 Survival of single-surface ART restorations in the permanent dentition. N =
number at last evaluation
Source Period Patient age N Survival (per cent)
1y 2y 3y
Panthumvanit et al., 1996
58
199194 758 144 93 83 71
Mallow et al., 1998
57
199396 1217 39 78 59
Frencken et al., 1998a
46
199396 1316 197 93 89 85
Frencken et al., 1998b
93
199497 1316 206 99 94 88
Ho et al., 1999
56
199597 adults 100 98 93
Table 4 Survival results of total tunnel restorations in
permanent teeth. N = number at last evaluation
Source Duration (y) N Survival %
Svanberg, 1992
60
3 11 91
Strand et al., 1996
62
3 161 46
Lumle & Fisher, 1995
59
5 33 79
Hasselrot, 1997
61
7 121 39
cally ror AR1. Newer materials
designed ror AR1 are now being
used, which to some extent
accounts ror the improed treat-
ment outcomes,
inexperienced or inadequately
trained operators perrormed less
well, which emphasises the need
ror AR1 training courses,
the results pertain only to single-
surrace restorations in permanent
teeth, because these were the pre-
dominant caities in the study
populations.
1hus, there is a need ror addi-
tional research on the surial or
AR1 restorations in primary teeth,
the use or AR1 in multiple-surrace
caities and high-risk subjects, and
the use or other adhesie restoratie
materials. In addition, it is essential
that AR1 restorations are ealuated
oer periods longer than three years.
Tunnel and internal'
restorations
1he proposed adantages or the
tunnel preparation in comparison
with the conentional Class II prepa-
ration include the rollowing:
it is conseratie, in particular, the
marginal ridge is retained, which
contributes to the maintenance
or tooth strength,
the risk ror iatrogenic damage to
the adjacent approximal surrace
is minimised or non-existent,
a normal contact area is main-
tained,
the risk or approximal restora-
tion oerhangs is reduced.
Survival of tunnel and internal
restorations
Only rour studies, or relatiely short
duration, hae assessed the surial
or tunnel restorations 1abe 4,. In
two studies
59,60
, only a rew restora-
tions were aailable ror ealuation.
In the other two studies, railure rates
or 9 per cent and 18 per cent per
year were reported
61,62
. 1he reasons
ror railure included rracture or the
marginal ridge, caitation in
approximal enamel in internal
restorations, and secondary caries.
Because or the small number or stud-
ies aailable and the small sample
size in two or these studies, it is not
possible to present a comprehensie
summary or the perrormance or
tunnel restorations. Howeer, some
important obserations are:
there is a learning cure ror tunnel
preparations
34,61,63
. Complete re-
moal or inrected dentine is
demanding, particularly in small
tunnel preparations
64,65
,
the risk or railure ror internal
preparations is higher than that
ror tunnel restorations
62
,
tunnel restorations had a higher
surial rate arter three years than
slot type conseratie Class II
amalgam restorations
60
. Howeer,
this obseration is not entirely in
agreement with results reported
by Lumley and lisher
59
. 1hey
Tyas et al.: Minimal intervention dentistry a review
7
reported that there was no dirrer-
ence in surial between tunnel
restorations and small Class II
amalgam restorations arter three
years, but arter rie years the
perrormance or the amalgams was
superior,
equal amounts or tooth substance
were sacririced by tunnel and
minimal conentional Class II
preparations
64
.
Minibox restorations
1his preparation was also deeloped
in order to treat caries lesions in
approximal surraces, whilst preser-
ing as much tooth tissue as possible.
1he marginal ridge is remoed, which
makes it dirrerent rrom the tunnel
preparation, and the literature distin-
guishes between box-shaped and
saucer-shaped preparations, the
rormer has an angled rorm, while
the latter has a rounded rorm. 1he
caity is either rilled with a resin
composite or a glass-ionomer.
Survival of mini-box restorations
Unrortunately, only rour studies hae
been identiried 1abe :,, including
one or saucer-shaped glass-ionomer
restorations in primary teeth
66
which
yielded only nine restorations ror
three-year ealuation. 1he longest
study reported a surial or saucer-
shaped resin composite restorations
or 0 per cent arter, on aerage, .2
years. Caries and technical dericien-
cies were the reasons ror railures
6
.
No railures were obsered in box-
only resin composite restorations
arter two years
68
and rie years
69
.
Summary of clinical studies
Relatiely rew clinical studies or long-
term duration are aailable that hae
assessed the erricacy or minimal
interention techniques. Preentie
resin and mini-box restorations
consere tooth structure and hae
the potential to surie ror a long
time, howeer, this cannot be
concluded decisiely ror tunnel
restorations. 1he little aailable
eidence is inconclusie with respect
to the preseration or tooth struc-
Table 5 Survival results of mini-box restorations. N = number at last
evaluation
Source Duration N Survival %
Kreulen et al., 1995
68
2.2 64 100
Andersson-Wenckert et al., 1995
66
3 9 75
Kreulen et al., 1998
69
5 67 100
Nordbo et al., 1998
67
7.2 36 70
ture, but points towards insurricient
long-term surial or restorations.
Despite the AR1 approach being
relatiely new, a reasonable number
or studies has reported the erricacy
or this approach, and because or
the use or hand instruments, saing
or tooth material is, or necessity,
maximal. luture research will deter-
mine the long-term surial or
AR1 restorations, and the areas or
indication ror its use in minimal
interention dentistry.
Repair of defective restorations
Little attention has been gien to the
repair or derectie restorations. Most
practitioners choose repair as a treat-
ment option on a case-by-case basis.
Howeer, the repair procedure is not
well accepted by the proression since
it represents a departure rrom
conentional teaching and is consid-
ered by many to be patchwork
dentistry.` Replacement or existing
restorations world-wide accounts ror
between 50 per cent and 1 per cent
or each general dental practitioner`s
actiities
0-3
. 1he replacement or
amalgam and resin composite resto-
rations leads to larger restorations
which hae shorter lire spans than
their predecessors, and some replace-
ment procedures may cause damage
to adjacent teeth. lor example, one
study or resin composite restorations
reealed that the surrace area or
caity preparations increased by an
aerage or 5 per cent approximal
aspect, to 1 per cent occlusal
aspect, when clinicians were asked
to remoe direct and indirect Class
II restorations completely using
magnirying loupes and their normal
technique
4
. 1here is no question that
restoration replacement increases the
risk or more complex and more
costly subsequent treatment, includ-
ing root canal therapy.
1here hae been seeral studies
or repair strengths or old` material
compared to new` material. How-
eer, in the indiidual case, the
repair strength may not be an
important consideration ir it is
assessed that the repair does not
compromise the strength or the
restoration or the retention or the
old and new portions.
Amalgam
Hibler et a.
5
round that the bond
strength or conentional and high-
copper dental amalgam repairs was
approximately 50 per cent that or
non-repaired amalgams, and was
unarrected by the type or amalgam
alloy used, the time or the repair, or
the use or a mercury-rich interrace.
1he latter conclusion contrasts with
the earlier rinding or Jorgensen and
Saito
6
, who reported that the bond
strength or a conentional amalgam
was almost the same as that or the
non-repaired amalgam when the
surrace had been wetted by mercury
berore the repair. Howeer, the
wetting or the original amalgam
with mercury is not recommended
because or the risks associated with
mercury apour. Berge

reported
that the rlexural strength or repaired
specimens was 11 per cent to 51 per
cent or the non-repaired controls.
1he rracture toughness or repaired
amalgams was approximately 22 per
cent lower than that or the non-
repaired specimens.
Resin composite
Swirt et a.,
8
reported that abrasie
blasting or the original resin
composite surrace, prior to the
repair procedure, produced the great-
est repair strengths 60 per cent or
non-repaired resin composite
strength, compared with etching with
International Dental Journal (2000) Vol. 50/No.1
8
either hydrorluoric acid or acidulated
phosphate rluoride. 1he strength or
repaired resin composites ranges
between 25 per cent and 50 per cent
or the strength or unrepaired speci-
mens
9
. Although preious reports
indicate maximum repair strengths
or 8 per cent
80
and 99 per cent
81
ror
some resin composites, these stud-
ies were conducted using specimens
that were aged ror short times in
water.
Repair vs replacement
A correlation between the size or a
marginal discrepancy and the pres-
ence or secondary caries only exists
when the derect is ery large`
52
,
howeer, the traditional rationale has
been that marginal breakdown is a
precursor or recurrent caries, or is
associated with caries already present
below the derectie margin
82
. 1he
current recommendation is that
amalgam replacement is only neces-
sary ror ery large derects
82
. Because
or the wide ariability or repaired
amalgam and resin composite repair
strengths, repairs should be made
using caity designs that ensure
independent resistance and retention
rorm ror the repair
83,84
.
1he repair or restorations placed
by another clinician must be based
on the premise that all carious tissue
was remoed originally, and that
secondary caries has not deeloped.
lor a low caries risk patient, the
assumption that a caries lesion does
not exist beneath derectie restora-
tions is reasonable, but ror high risk
patients the procedure is not as
well justiried. Since little objectie
eidence is aailable ror a repair
approach oer a replacement
approach, it is too early to draw
derinitie conclusions on repair
criteria. Repair as a treatment option
must be based on the patient`s risk
ror caries, proressional judgement
or benerits ersus risks, and the
conseratie principles or caity
preparation. Lttinger
85
has published
a more complete reiew or this
complex decision-making process.
lor a small localised marginal
derect, recontouring and repolishing
should be the rirst option consid-
ered
86
. In a study or amalgam
restorations with small carious and
noncarious marginal derects, local-
ised repair with amalgam was round
to be highly successrul oer the
two-year obseration period

. 1he
application or sealant along an entire
derectie, but non-carious margin,
should extend the lire span or that
restoration and reduce the number
or replacement restorations.
lor resin composite restorations
whose gingial margins are located
along root surraces, good bonding is
more dirricult to achiee. 1hus,
repairs in these areas are more criti-
cally dependent on the patient's
caries risk, since plaque accumula-
tion and leakage at the gingial
margin region ror a high risk patient
is associated with an increased prob-
ability or secondary caries. Repair
with glass-ionomer cement may be
prererable in the cerical area,
because or the adantages or reliable
adhesion and release or rluoride.
Long-term success or the repair may
depend on the patient being moed
to a low risk status.
In deciding whether to leae or
to replace a derectie restoration, a
decision or no treatment` rather than
replacement` or a restoration is more
likely to be correct in a low caries
prealence population. lor low-risk
patients, the rate or caries progres-
sion should be minimal and little or
no irreersible change should occur
in six months to two years. Ir the
traditional decision is made to
replace a restoration independently
or the patient`s caries risk, the aer-
age size or the preparation will
increase, the lire or the subsequent
restoration will decrease, the risk or
subsequent endodontic therapy will
increase, and there is a 2 per cent
probability that caries may be lert in
the tooth arter the preparation is
completed
8,88
. Application or the
principles or minimum interention
concepts will delay restoration
replacement.
Howeer, more clinical research
is needed to answer some critical
questions regarding decisions to
repair or to replace restorations.
Vhen eidence or caries is round
and remoed at a repair site, is the
probability or caries at other sites
beneath the same restoration surri-
ciently high to justiry the complete
remoal and replacement or the
restoration lor high-risk patients,
ir a caries lesion exists beneath a
restoration with derectie margins,
will the application or a sealant or
dentine bonding agent preent
caries progression and initiation or
new lesions A partial answer to these
questions can be deried rrom the
systematic analysis or caries risk
ractors or indiidual patients and the
reduction or risk by traditional
and modern preention methods.
Proided that patients are shirted to
a low risk status, repair options will
become more justiriable gien the
absence or supporting scientiric data.
Vith respect to immediate amal-
gam marginal sealing, only one
long-term study has suggested the
reasibility or this procedure
3
. In this
study, no progression or sealed-in
occlusal caries lesions was detected
radiographically or using a mirror and
explorer at 10 years post-placement.
Secondary caries was detected adja-
cent to the sealant or margin in 12
per cent or teeth with unsealed amal-
gams, but in only 2 per cent or teeth
with sealed amalgams. Vhen carious
dentine was not remoed, and the
teeth were restored with resin
composite, only 1 per cent sustained
secondary caries at the margins.
Conclusion
In the twenty-rirst century, greater
emphasis must be placed on assess-
ing caries risk, shirting patients to a
low caries risk status, remineralising
noncaitated lesions, abandoning the
surgical approach to caries manage-
ment and repairing rather than
replacing derectie restorations.
1here is a clear need ror research to
improe the sensitiity or diagnostic
methods, to deelop site-speciric
indicators or ruture caries risk, and
to establish clear guidelines on
management or caries as an inrec-
tious disease.
1here is also a major need to
analyse the cost-benerit ratio or
minimal interention techniques, so
that the errectieness can be more
conincingly demonstrated to the
many proiders who continue to
Tyas et al.: Minimal intervention dentistry a review
9
use the traditional surgical model.
Howeer, the public must also be
inrormed or the benerits or these
modern methods or diagnosis,
preention, remineralisation, minimal
interention and repair, compared
with conentional restoratie proce-
dures. Patients` long-term biological
and riscal cost saings will be worth
this inestment.
Acknowledgements
1he contribution or one author
KJA, to this article was supported
by NIH-NIDR Grants DL0930 and
DL0662.
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