Essentials of Cavity Preparation

Reference
Fundamentals of Modern Operative Dentistry, 2nd Edition
Dr. Aly Nour Rizk
Professor of Operative Dentistry, Cairo University
BDS (Cairo University), MSD (Indiana university, USA), FICD.
 Adverse Influences of Cavitation

Cavitation occurs due to collapse of the acid-demineralized enamel when it is no more

amenable for remineralization. This creates adverse clinical influences including:

1. Exposure of the dentin-pulp system to environmental

irritants
The ectodermal enamel forms a protective barrier for the mesodermal dentin-pulp complex.
Enamel is hard, dense, impermeable and translucent.

Any disruption in enamel creates a wound that exposes the vital dentin-pulp system to
environmental irritants as occlusal forces, bacteria, thermal, osmotic and evaporative
stimuli.

This results in acute clinical problems as hypersensitivity, caries and adverse pulp reactions.

2. Increased fracture-vulnerability of the tooth

Cavitation weakens the tooth by loss of substance and by creation of structural discontinuity
that causes stress concentration, crack propagation and fracture. It also leads to loss of
support for enamel which causes its collapse.

3. Establishment of habitats for bacterial plaque

Cavitation provides sheltered niches for bacterial plaque thus forming foci of infection that
provides reservoirs for bacteria causing caries and periodontal diseases which is responsible
for spread of both infections.

4. Exposure of the investing tissues to irritation

Ragged margins, food impaction and plaque retention causes gingival irritation and
periodontal inflammation which later results in loss of the investing bone

5. Disturbed function
Cavitation may result in defective mastication, pronunciation and deranged esthetics. Arch
stability may get impaired by over-eruption, drifting, rotation and malalignment of teeth
with development of interferences, loss of inter-arch and interdental spaces.

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 General Fundamentals of Cavity Preparation
Cavity preparation describes the surgical procedures followed to eliminate lesions in hard
tooth structures and its adverse consequences and to establish compatible foundation for
restoration. The cavity design should be compatible with the requirements of the restorative
material and must comply with relevant bio-mechanical fundamentals that are very much
inter-related as well as esthetic fundamentals.

I- Biological Fundamentals
Include measures employed to control the adverse influences of the attacking mechanisms
and the surgical procedures followed during its elimination on the health of oral structures.

1. Control of caries
Aims at the eradication of the caries disease and prevention of its recurrence rather than the
simple mechanical excision of the carious lesions.

a. Elimination of septic foci of infection

All plaque retentive cavitated lesions that are in-accessible to oral hygiene measures and
irreversibly damaged tissues that harbor tremendous amounts of infectious cariogenic
bacteria must be totally eliminated to decrease the possibility of colonization and infection
of other sites on the same tooth or neighboring teeth by cariogenic bacteria.

b. Treatment of caries-vulnerable areas

Sound tooth areas that are retentive to bacterial plaque are potential sites for the
colonization and growth of cariogenic bacteria and therefore need to be treated by a
suitable preventive conservative modality starting from fluoride application, going through
pit and fissure sealing and enameloplasty reaching to preventive resin restorations.

c. Implementation of an anti-caries program

Specially indicated for high caries-risk patients to decrease cariogenic potentials. It include
measures to:
i. Prevent plaque retention by enhancing oral hygiene and elimination of retentive sites.
ii. Enhance remineralization by application of fluorides, calcium phosphates and the use of
cariostatic control restoration.
iii. Inhibit demineralization and cariogenic metabolic activities by control of diet and oral
habits.

2. Preservation of the tooth integrity

This is achieved by practicing absolute conservation in all surgical procedures required to
excise the lesion and prepare the tooth to receive the restoration as well as provision for
maximum protection for the remaining tooth structures

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3. Protection of the dentin-pulp system
The dentin-pulp system must be protected from the attacking mechanisms as well as
irritation potentials of cavity preparation to preserve the pulp vitality and keep the tooth
asymptomatic. This is achieved through

a. Elimination of infected dentin

All necrotic, irreversibly damaged infected dentin must be excised to stop the offensive
attack on tooth tissues and control the spread of infection. On the other hand, affected
dentin need to be preserved and re-mineralization enhanced whenever applicable.

b. Control of instrumentation
This includes preservation of sound and repairable tissues, avoid cutting across the
recessional lines of the pulp and control of thermogenesis by using sharp tools, efficient
coolants and avoiding excessive pressure application.

c. Conservation of enamel and dentin

Lateral cutting weakens the tooth and opens more dentinal tubules thus exposing a wider
area of dentin to irritation. Depth cutting thins out the remaining dentin bridge, widens the
opened dentinal tubules and increases potentials for adverse pulp reaction to thermal,
mechanical, chemical, osmotic and bacterial irritation. Furthermore, it increases chances for
creation of minute, clinically undetectable pulp exposures.

d. Preservation of pulp vitality

Partial caries excavation techniques must be employed whenever applicable for treating
pulp-approximating carious lesions and its prognosis enhanced by applying the peripheral
seal concept rather than the mechanical excision of all caries-affected structures.

4. Protection of the investing tissues and adjacent tooth

This is achieved by:
i. Rounding and smoothing ragged margins.
ii. Excision of irritating septic foci.
iii. Elimination of plaque habitats.
iv. Avoid subgingival extensions and protection of gingival injury during cavity preparation.
v. Protection of adjacent tooth surface during cutting by insertion of steel strips.

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II- Esthetic Fundamentals
Include all measure that contribute to a better esthetic appearance and enhance the
esthetic outcome of the surgical intervention.

1. Decrease area displayed of the restoration

Minimizing lateral extensions and approaching Class III carious lesions from the lingual side
while preserving the labial undermined enamel unless it’s carious, thin or discolored.

2. Elimination of conspicuous discolored tissues

Discolored and hypoplastic enamel at the cavity margins as well as discolored dentin in the
depth of the cavity that cannot be masked by opaquers, need to be included in the cavity
preparation unless its removal will compromise the tooth integrity.

3. Provision of symmetrical cavity outline

Cavity margins must be refined and run in smooth sweeping curves that are parallel to
respective tooth contours or anatomical landmarks as the gingival margin or lip line.

III- Mechanical Fundamentals

Include design features that provide favorable stress response in all components of the
restorative system thus contribute to its fracture-resistance and secured retention.

It's a function of balance between the magnitude of the significant destructive stresses
induced in the restorative system versus its inherent cohesive and adhesive strength. It
serves to decrease the magnitude of destructive stresses at failure-prone sites and increase
the fracture resistance of the restorative system.

All components of the restorative system are brittle and therefore sensitive to tensile
stresses. Their fracture vulnerability depends on type and magnitude of occlusal forces
versus the fracture-resistance of the loaded system. Fracture may occur cohesively within
the loaded structure causing its disintegration or adhesively at the interface causing
detachment. The resistance of restorative system to both cohesive and adhesive fractures is
a function of their intrinsic strength as well as design characteristics.

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1. Preservation of the tooth integrity
Adjacent cavities should be prepared separately as spot preparations and not joined
together unless the intervening enamel is less than 0.5mm in thickness. This preserves the
structural continuity of the tooth, prevents stress concentration at the base of cusps and
ridges and and achieves wider distribution of the occlusal loading.

Oblique and transverse ridges preserve the tooth against splitting by excursive lateral forces
of mastication. They strongly tie both halves of the crown, maintain their structural
continuity and prevent stress concentration. Therefore, they must be maintained unless
they are carious, undermined, thinned-out to less than 0.5mm by adjacent cavities, or
traversed by a carious fissure that is deeper than two-thirds the external thickness of
enamel.

Lateral extensions should be limited to a minimum to avoid encroachment upon cusps and
ridges. Radiating supplementary fissures may be sealed or eliminated by slanting the enamel
wall to a 110 degrees CSA to eliminate the defect in enamel without weakening the cusps or
ridges.

2. Elimination of fracture-prone undermined enamel

Undermined enamel that has lost the support of the underlying resilient dentin, will fracture
under occlusal forces with creation of marginal crevices. Such enamel must be removed if
it’s subjected to direct occlusal forces.

3. Reinforcement of Weak Tooth Structures

Reinforcement is defined as the ability of the restoration to participate in the load-bearing
ability of the tooth. It is indicated for thinned out, weak, tall or steep cusps and ridges and
for root canal treated teeth. Weak cusps structures must either be securely bonded to the
restorative material or reduced to allow for being capped by the restoration.

Occlusal coverage, onlays, cusp capping, collars, counter-bevels and efficient adhesion are
alternative methods for tooth re-enforcement. It strongly ties weak cusps and ridges
together into a stronger component, eliminate the discontinuity and stress concentration at
the load carrying portion of the occlusal surface, prevents the wedging action of food bolus
that may split cusps and distribute occlusal forces onto a wider area.

Cusp capping is indicated whenever the lateral extension along the cusp inclines is more the
two thirds the distance from the cusp tip to the central fissure or groove. It serves to protect
the weak cusp against fracture as well as to place the vulnerable edge of the restoration
away from the area of direct occlusal contact and maximum stress.

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4. Elimination of stress concentration
Material fractures are initiated as cracks. Cracks concentrate the stresses at their depths
causing crack propagation along lines of tensile stresses until finally fracture occurs. Usually
under static fatigue and at a load that could be far below the intrinsic strength of the failed
structure. Cavitation, scratches, voids, sharp angles, constrictions, and soft-spots constitute
structural discontinuities or an area of an initial crack that causes stress concentration at the
tiny tip of the discontinuity. Repetitive functional forces will later cause crack propagation
which ultimately results in fracture.
The cavity geometry should incorporate design features that prevent stress concentration at
the fracture-prone areas of the restorative system, i.e. the pulpal end of cusps and ridges of
teeth and the isthmus and margins of restorations. Cavity preparation weakens the cusps
and ridges not only by loss of substance but mostly by concentrating the stress at their
pulpal ends due to breaking the structural continuity at the occlusal surface. The taller the
cusp or ridge the more the induced torque at its base.
Keeping all cavity line angles rounded help in eliminating stress razors that concentrate
stresses at their depths. Roundation of axio-pulpal line angles help in decreasing the
vulnerability to isthmus fractures. Keeping all cavity outlines rounded decrease the liability
of tooth fracture specially at buccal and lingual walls of proximal preparations. Avoiding
abrupt changes in cross-section prevents stress concentration at isthmus areas.

5. Wide distribution of occlusal forces to minimize stresses

Any type of force (F) induces in the loaded structure multiple types of stresses (S), a principle
S that is typical to the type of the original F and other types of S(s) of minor magnitudes. A
compressive F induces compressive S of major values as well as tensile and shear stresses of
minor values. The amount of stress (S) induced in a structure loaded by force (F) depends on
the area bearing the load (A) as denoted by the equation S=F/A.
Fracture occurs if any of those stresses exceed the intrinsic strength of the restorative
system. The cavity geometry should incorporate design features that contribute to wide
distribution of the induced stress over a large area as well as reduction in the tensile
component induced by the occlusal forces at the fracture-prone areas of the restorative
system, i.e. the pulpal end of cusps and ridges of teeth and the isthmus and margins of
restorations.
Brittle materials suffer low tensile and lower shear strength. Incorrect cavity design (e.g.
incompatible CSA) and weak cavity bases may cause originally compressive forces to resolve
into tensile stresses of sufficient magnitude to cause tensile fracture of brittle restoratives.
Reduction of the lateral component of force, avoiding stress concentration and wide
distribution of stress all share in reduction of the destructive tensile stresses induced within
the restorative system.

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6. Reduction of tensile stresses

Lateral excursive forces caused by occlusal interferences, para-functional forces, over-

erupted (plunger) cusps, structural discontinuities, non-compatible ridge heights and mal-
positioning of teeth must be eliminated as they induce destructive lateral components that
tend to fracture the restorative systems.
Creation of spill-ways, restoration of non-functioning teeth, carving into physiologic
contours and occlusal anatomy generally reduce overloading of teeth.

Keeping all cavity walls either parallel or perpendicular to the direction of occlusal forces
help in the resolution of occlusal forces into compressive stresses that could be easily
absorbed by all brittle restorative systems while minimize the lateral components which
would create tensile stresses that results in failure of brittle systems. Box-form cavities with
straight, flat, parallel and perpendicular walls therefore provide for the most favorable stress
response in the restorative system. It favors wide stress distribution and prevent resolution
of occlusal forces into destructive lateral components that may cause fracture or
displacement of the tooth or restoration.

7. Provision for optimum thickness of the restorative

Brittle restoratives systems are sensitive to tensile stresses. Fracture is usually initiated at
areas where bending with development of tensile stresses is more likely. Such areas include
cusps, ridges, isthmus areas, margins and interfaces of intermediary materials. Sufficient
bulk and structural continuity are the most important factor in their fracture-resistance.

Bulk for each component of the restorative system can be satisfied only on the expense of
other components. It involves material thickness rather than width. Materials exhibit a 4th
power increase in strength with doubling their thickness as compared to doubling their
strength with doubling their width.

Fracture resistance of the restorative material could be optimized at isthmus areas by

saucering the pulpal wall at the isthmus to provide for an increase in thickness without any
increase in cavity width. Keeping the cavity width to a minimum would preserve sufficient
bulk for the cusps and ridges at their critical neck (pulpal end) to improve their fracture-
resistance.

Alternatively, the pulpal wall may be given a slight inward inclination to progressively
increase the bulk of restoration form gingival to occlusal to improve stress distribution.
Roundation of the axio-pulpal line angle decreases stress concentration at the isthmus and
improves fracture-resistance.

Right-angled cavo-surface margins provide for equally thick and strong margins in both
enamel and the restorative material. Adhesive restorations that are strongly anchored to
enamel with a reliable peripheral attachment may withstand less marginal bulk obtained

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 with CSAs of 100-110 degrees provided they are not involved in direct occlusion and the
restoration margin is well bonded to the surrounding enamel margin to provide for proper
marginal support and transfer of stress to the stronger tooth rather than its concentration at
the restorative margin.

8. Establishment of effective independent retention

Every portion of compound cavities must be provided with effective mechanisms of
retention that is independent of the principle portion. Anchoring the auxiliary portions to
the tooth independently from the principle portion, markedly reduces the build-up of tensile
stresses at the isthmus areas that join both portions together, during loading of the auxiliary
portion.

Similarly, adhesion can provide support for the margins and all weak components in the
restorative system. It helps in the transfer of stress to be distributed to all components of
the restorative system thus enabling the stronger components to share in the load bearing
ability of the weaker ones.

The intrinsic strength of the restorative systems is generally increased by providing self-
dependant retention for each portion of the restoration, because this minimizes the
development of tensile stresses while allow for stress transfer and wide distribution of load.

Steps of Cavity Preparation

I- Gaining Convenience to the lesion
Aims at complete exposure of the carious lesion while limiting all cutting to irreversibly
defective tissues that are indicated for excision. It includes eradication of all defective
enamel covering the carious lesion till the level of the DEJ. It results in complete de-roofing
of the lesion making it accessible for controlled excavation and clear inspection.

Depth cutting in enamel is initiated with a rounded ended bur at an area closest to the
pathology and carried till just below the DEJ (about 0.2-0.5mm below). Lateral extensions
are then performed with a straight sided bur to remove all fracture-prone, carious, cracked,
undermined and irreversibly damaged enamel covering the carious enamel. All cutting is
performed in a direction that is parallel to the orientation of the enamel rods in the three-
dimensional planes while keeping all point and line angles rounded.

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II- Removal of Carious Tissues
Aims at eradication of all septic foci and irreversibly damaged tissues while preserving the
pulp vitality. It involves removal of all irreversibly demineralized enamel, necrotic dentin as
well as caries affected dentin that does not threaten the pulp vitality. It results in the
attainment of a peripheral rim of sound tooth tissues that can securely bond to the
restorative material and maintain a leak-proof hermetic seal of all dentinal tubules thus
permanently isolating the dentin-pulp system from oral irritants.

The largest sharp excavator or round bur that can be conveniently manipulated inside the
cavity is used. All soft, necrotic dentin is excavated in a direction that is parallel to the
recessional lines of the pulp, and all irreversibly demineralized enamel is removed in a
manner parallel to the direction of the enamel rods.

III- Establishing a Resistance-Retention Form

Aims at providing the form that enable all components of the restorative system to sustain
occlusal forces without fracture or dislodgment.

It includes design features to achieve elimination of stress concentration, wide distribution

of force, reduction of tensile stresses, removal of fracture-prone tissues, provision for
reinforcement of weak tissues, provision for sufficient bulk for each component of the
restorative system and provision for efficient independent retention.

All fracture-prone undermined enamel is removed while weak cusps and ridges that are tall
and thin are tipped. All point and line-angles are rounded to keep the cavity outline running
in smooth sweeping curves. Sufficient bulk for the material is provided particularly at areas
subjected to high tensile stresses as the isthmus areas and the cavity margins.

Each part of the cavity is preferably provided with a mechanical mean of retention in dentin
in the direction of displacing forces. The maximum walls divergence that could be
considered retentive is 10-20 degrees for amalgam and glass ionomer restorations and 45-
60 degrees for adhesive resin composites depending on wall depth. Auxiliary retentive
means as locks, grooves, slots and coves need to be prepared in dentin in case any portion
of the cavity is found to be not independently retentive.

IV- Finishing of Enamel Walls

Aims to achieve strong, sound margins that is compatible with the restorative material being
used and can maintain a secured leak-proof attachment with the restoration under the
functional challenges present in the oral environment.

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 It includes removal of all weak, defective, cracked and esthetically objectionable enamel and
giving the cavo-surface angle the highest inclination that could be mechanically tolerated by
the restorative material to be used.

It results in strong, clean enamel wall that is well supported pulpally and well protected
occlusally while providing sufficient marginal bulk requirements for the restorative material.
It provides esthetic, sound and smooth margins which can maintain a secured, leak-proof
attachment with the restoration under the functional challenges of the oral environment.

Yellow-coded, tapered with rounded end, diamond stones of an ISO diameter 014 – 016mm
are used to finish all axial enamel walls, while larger diameter yellow-coded rounded end
diamond points are used to finish gingival seats. Alternatively, sharp enamel hatchets and
bin-angled chisels may be used for posterior teeth, while whedelstedt chisels used for
anterior teeth.

V- Cavity Debridement and Lining

Aims to achieve a clean cavity surface with permanently obliterated dentinal tubules that
can securely bond to the restorative material and totally isolate the dentin-pulp system. It
includes all procedures of cavity cleansing, modification of the smear layer, conditioning of
enamel and dentin, application of cavity varnishes, liners, bases and bonding systems.

Air-water spray is used to remove all debris from the cavity. Cavity conditioner of 20%
polyacrylic acid is used prior to glass ionomer cement to remove the smear layer while
preserving the smear plugs thus enhancing sealing and bonding to dentin without increasing
dentinal sensitivity. 35% phosphoric acid etchants are applied to all enamel walls prior to
bonding to adhesive restorations.

Calcium hydroxide or calcium silicate is applied to deep spots that are anticipated to be
0.5mm or less from the pulp to promote pulpal repair and deposition of reparative dentin.
Cavity varnishes or dentin sealants are applied prior to amalgam restorations to improve the
initial dentin sealing and decrease post-restoration hypersensitivity. Zinc phosphate cement
is placed to thermally insulate amalgam restorations in deep cavities. Glass-ionomer cement
could be placed to reduce polymerization shrinkage, improve pulpal response and seal
affected dentin under bonded restoratives.

Enamel and dentin are infiltrated by hydrophobic resin adhesives prior to the application of
adhesive restoratives and after impression taking for indirect restoration (for immediate
dentin sealing). Flowable composite is used to seal and line cavity irregularities prior to
direct resin composite restoratives and to block cavity undercuts prior to impression taking
for indirect adhesive restorations.

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