A 100-Year Journey from GV Black to Minimal Surgical Intervention

Abstract
Mark S Wolff. DDS, PhD
Professor and Chair

. Kenneth Allen, DDS, MBA

-'
I

Assistant Professor

James Kaim, DDS

Professor and Associate Chair Department ot Cariology and Comprehensive Care New York University College of Dentistry ,. New York, New York

Over the past 140 years, dentistry hi^ matured from ihe original tenets of GV Black hy moving from "extension for prevention" to a minimal intervention approach. This is part of an evolution that stresses a medical, rather than a surgical model for caries management. This transition has been facilitated by the iniroduciion and advancement of adhesive dentistry, which encourages preservation of tooth structure. Even with these changes, some of the original writings of Black are still relevant today: "The day is surely coming...when we will he engaged in practicing preventive, rather ihan reparative. deniLsiry"

Learning Objectives
Afier reading this article, the reader should be ahle to:

explain the hisior)' behind "extension for prevention" and why ii no longer applies. discuss why an indirect composite restoration may be a better choice ihan a crown when a single cusp is fractured.

explain how the introduction of eiching and bonding has played a key role in minimally invasive dentistry. describe the advanees achieved based on the changes made to the composition of amalgam.

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inimally invasive dentistry (MID), or minimal intervention dentistry, is a dental care concept hased on the assessment of a patients caries risk and the application of ihe current therapies to prevent, control, and treat the disease.'- It is often referred to as treating dental caries with a biologic, therapeutic, or medical model.' Tyas and colleagues state that the MID model has several teneis including, at a minimum, the following'; (1) remineralization of early lesions; (2) reduction in cariogenic bacteria to eliminate the risk of further demineralization and cavitation; (3) minimal surgical inter\'ention of caries lesions; (4) repair rather than replacement of defective restorations; and (5) disea.se control. Although MID includes risk assessment, remineralization, and bacterial management, this article will discuss the operative aspects of MID, The

minimal surgical procedures currently performed are different from the operative dentistry practiced a generation ago. This article will discuss how the new operative dentistry has been derived from the teneis of GV Black published over a century ago. Black published a series of papers and texts on denial materials and preparation and restoration techniques between 1869 and 1915. Although many current authors have credited or blamed these tenets for overly aggressive preparations and restorations in modern dentistry.'"' the present authors contend that Black was the first dentist to propose treating dental caries using minimal intervention based on the knowledge and materials available at that time. In the middle of the 19th centur>'. the exact cause of denial caries was unknown. Dental preparations were

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designed at the option of the operating dentist. Dental amalgam, frequently formulated by lhe dentist, had little standardization, which resulted in materials demonstrating poor performance. Black, a dentist of considerable experience and observational skills, noted the frequent failure of dental amalgam restorations with recurrent caries at the corroded margins of the restorations. The restorations of that time used an alloy that corroded rapidly and experienced problems with expansion; therefore, they failed relatively quickly Patients were observed to develop caries on virgin interproximal surfaces hecause of the stagnation of food in these uncleansable areas. Patients also were observed to develop caries around occlusal restorations that failed to include susceptible pits and fissures. Black wrote a series of papers that addressed the problems of caries at the margins of restorations.^' amalgam composition," and tooth restorations.' These papers represented the earliest workbooks on the quality of operative dentistry of that era, and these papers were based on the best knowledge available. Black described the placement of the outer enamel margins in "selfcleansable areas" so that they terminated in regions less susceptible to recurrent caries. Black wrote:

state of dental education and clinical practice until the 1950s, 1960s, and 1970s. During this period, several events occurred that allowed for ihe improvement of dental amalgams and the introduction of bonded restorations: (1) Amalgams were improved by the development of a process where the amalgam alloy was triturated with the ideal quantity of mercury (Eames Technique"); (2) clinical research resulted in the determination that higher copper content alloys have less creep and marginal breakdown'''"'; and (3) clinical research demonstrated that smaller preparations last longer.'^ These breakthroughs each led to changes in preparation design and restorations that were smaller and more effective.

During this period, several events occurred that allov^ed for the improvement of dental amalgams and the introduction of bonded restorations.

It is in the breakthroughs associated with bonding ihat MID has had its greatest advances. In 1955, Buonocore described a technique for etching enamel surfaces to make them retentive for a restoration.'* In 1962, "Certainly that portion near the proximate contact...is Bowcn submitted a patent, entitled a "Dental filling mosi liable to be attacked; and the Uabilily diminishes as we material comprising vinyl silane treaied fused silica and recede from that point.... It is to cut the enamel margins a binder consisting of BIS phenol and glycidyl acrylic," from lines that are not selj-cleansing to lines that are self- that enabled the restoration of a tooih with a tooth-colcleansing.... When a cavity has occurred in the occluding ored plastic better known today as Bis-GMA. These 2 surface of a molar, the dentist prepares for filling with the developments have led to the creation of tooth conservaidea that the fissures in this part ofthe enamd ha\e favored tion or minimally invasive surgical dentistry.
the occunencc ofthe cavity For this reason, the fissures and grooves adjoining lhe cavity, even though not decayed, are cut away to such a point as seems to give opportunity for a smooth, evenfinish of lhe margins of the filling. This is done as a prevention of future recunence of decay...."

Discussion
Dentists have a variety of treatment options for the restoration of cavitated caries lesions. Restoration options range from minimal tooth preparation on the occlusal surface to placement of a crown over the entire coronal tooth structure. What factors determine the treatment decisions? The minimal intervention philosophy mandates thai the least invasive effective therapy, preparation, and restoration be used to restore lesions with cavitation. This philosophy maintains as a tenet that surface deniineralization is the first stage in lhe development of a caries lesion and is a condition thai may be reversed with remineralization therapy (not discussed in this paper'"'"). The basic philosophy recognizes the fact thai all restorations have a finite life and thai large restorations (composite or amalgam) have a shorter longevity than smaller ones.'^ Black made a similar observation over a century ago (1891) saying: "...And if the filling should serve for five, ten, or fifteen years, valuable teeth will have been saved to the patient that much longer by filling and afterward crowning, than by present crowning...." In other words, always choose the least invasive option because the more invasive option is usually available for a later date. The

The restorations of that time used an alloy that corroded rapidly and experienced problems with expansion.
This led to the now infamous term "extension for prevention," which could be summarized as "...the removal of the enamel margin by cutting from a point of greater liability to a point of lesser liability to recurrence of caries...." Black developed an amalgam alloy less likely to corrode and suffer marginal breakdown, whose formula remained essentially unchanged until the 1970s when high copper silver amalgams were introduced.'" Black developed standard and meticulous placement techniques for dental amalgam diat used proper isolation: "...Restorations of cohesive gold and amalgam... require the apphcation of the rubber dam....The student or dentist who earnestly desires to give the best service will, when in doubt, apply the rubber dam.'' This remained the

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ble groove or grooves receive an acid-etched pit and fissure sealant material (Figure lC). The historic rationale for removal of the groove was prevention of future caries. The concern ol future caries in the groove is easily dealt with hy placement of a sealant, a technique well Figure 1 (A] MInoi decay Isolated to the pll areas on o maxillary molar, (B) Typical amalgam lesroration temoving lhe documented over the pasi entire groove. |C1 Preventive resin restoration, removing decoy from the pits and sealing the temainirg groove struclure 25 years to prevent caries.'' (odopted from Rlpa, LW and Wolff MS, 19921. It has even been demonstrated ihat properly placed sealants, even if placed over active caries, have the ability to arrest caries activity for more than a decade.^' This is the same concept as Black's extension for prevention but uses the advantages of the relatively new restorative materials without the need for surgical extension. Minimally invasive surgical procedures apply to restoration of the proximal surlace as well. A proper diagnosis of the location of the caries is essential. Caries that can be identified radiographically on the proximal surface as penetrating at least to the dentoenamel junction (some would advocate penetration even further before inter\'enlion) requires preparaiion and removal The conventional "Black" preparation requires the incorporation of the occlusal groove as part of the restoration. Minimal intenention mandates thai the groove remain intact unless there is caries on the surface (even if it is stained) (Figure 2). If the groove is intact, it can l^e sealed at the end of ihc procedure. The preparation of the proximal box for the "slot" preparation differs from the design discussed by Black, which requires thai the margins be brought into a cleansable area of the interproximal embrasure. Where possible, for composite restorations, the facial and lingual embrasure.s are designed to remain closed, providing that the decay can be accessed and removed. .\s proximal caries generally occur gingival to the contact area, the gingival embrasure must always be open to ensure the removal of all decay (Figure 3A). Afu-r ihe decay is excavated and the final restoration is placed, the remaining grooves receive a sealant to complete the restoration (Figure 3B).

Figure 2Canss p.';:;..cTil l^- ihe dentoenamel |unctian (DEJI on lhe diMul ul ide maxillary first and second bicuspid, almosl ro lhe DEJ on the mesial o( the moxillary second piemolar, and minimol penetrolion on lhe mesial of the maxillary first mdof. Note the cxxJusal caries on the mandibular first mdar.

following are a few examples of the application of MID principles with esthetic restorations: The changes in the paradigms for restoration of occlusal caries lesions using a bonded restoration are among Lhe most dramatic changes in treatment philosophy. Black recommended the removal of the entire groove and the placement of an amalgam regardless of the size of the caries lesion (Figure lA). This protected the uninvolved groove from future caries (Figure IB). Minimal intervention on the occlusal surface was first described by Simonsen'" and refined by Ripa and WolfP' as a preventive resin restoration. The preventive resin preparation requires the removal of only the caries lesion followed by a composite restorative material. The remaining suscepti-

Figure 3A-Decay 5 .covored. Focial and lingual ^^^alls may not require removal depending on Ihe extension of the cories.

Figure 3BToaih is restored wifh composite and the occlusal surface sealed.

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Figure 4Alateral Incisor with o diostemo

Figure 4Blateral incisor with diostemo closed wilfi compoMie

Posterior teeth requiring cusp replacement can be restored using gold restorations as described by Black over 100 years ago. These gold restorations may be an onlay replacing only missing tooth structure. The teeth also may be restored using full-coverage crowns. The process of preparing a full crown involves the destruction of a significant amount of sound tooth structure to develop parallel walls to create a retentive preparation. A minimally invasive esthetic alternative restoration could be the placement of a direct placement composite. However, large direct composite restorations are diflicult to place because of the need to both maintain strict and complete isolation for long periods of time and to achieve good physiological contours with well-polished interproximal areas. These teeth, requiring replacement of a cusp, also may be restored using indirect composite or porcelain materials. The indirect onlay restorations take advantage of the ability to design and produce a restoration outside the mouth. The restorations may he adjusted, modified, and recontoured, providing ideal contours in the dentists or technician's hands. These large, indirect esthetic restorations may be prepared with minimal destruction of additional sound tooth structure as would occur in the fabrication of lullcoverage crowns. The onlays are bonded into the preparation so that there is less need to design the restorations lo be mechanically retentive (beyond lhe bonding).

The philosophy of minimal surgical intervention and minimal tooih destruction extends lo lhe anterior esthetic procedures (eg, diastema closure atid peg laterals). The addition of a small amount of direct bonded composite, a well-respected art form in the 198()s, can still he used rather than aggressively preparing the tooth for a porcelain laminate or lull-coverage porcelain crown. The final restorative results are esthetic, functional, and can be repaired or replaced without any tooth destruction, (Figures 4A and 4B).

The final restorative results are esthetic. functional, and can be repaired or replaced without any tooth destruction.
Minimal surgical intervention possibilities have been further expanded by the introduction of new technologies. Hard-tissue lasers, air abrasion, and mini-burs make smaller, less invasive preparations possible. Fach device permits the clinician to use a more conservative, less destructive approach toward lhe removal of infected tooth structure. These devices, along wilh adhesive dentistry, allow for a truly defect-specific approach toward caries removal.

The changes in the paradigms for restoration of occlusal caries lesions using a honded restoration are among the most dramatic changes in treatment philosophy.
These restorations can be fabricated using either indirect laboratory techniques or using computer-aided design and computer-assisted manufacturing (CAD/CAM). The laboratory indirect technique involves making an impression of lhe preparation, temporizaiion, and the return for a second visit for the hna! insertion. The CAD/CAM technique involves an optical impression, computer design of the restoration, and a final milling of lhe onlay during the patient visit. These restorations, when etched and treated with silane, are honded in place using composite resins modified from the original Bowen composition.

Conclusion
MID is the natural evolution of dentistr)-. As new materials and techniques are developed, dentistry is obligated to review and use the most conservative techniques. Overly aggressive tooth preparation results in increased incidence of unneeded .sequelae, often at great pain and expense for the patient. The concept of MID is more than a series of "surgical" techniques. MID is a comprehensive package of dental care and caries intervention that involves: (a) identifying patients for risk of developing dental caries using existing oral and health conditions as a predictor'^ (b) itnplementing aggressive preventive strategies including fluoride therapy, antimicrobial therapy, diet modification, xylitol and calcium supplementation to reduce the risk such as those described in lhe lenet of minimal intervention^ and (c) conservative use of sitt;gical dentistry to improve the well-being of the patient at the

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lowest monetary cost, preserving the maximum amount of tooLh structure. MID recognizes that dental caries is a reversible disease that starts wiih deminerahzation of the tooth and may eventually progress to cavitation if the risk factors are not brought under control. Black commented hack in 1896 on the future of dentistrj' and the philosophy of prevention in a speech to young dentists": "The day is surely coming and perhaps within the lifetime of you young men before me, when we will be engaged in practicing preventive, rather than reparative dentistry. When we will so understand the etiology and patholog)' of dental caries that we will he able to combat its destructive effects witb a systemic medication."

11, 12, 1.5.

14. 15.

16.

17.

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