In the chapter dedicated to cavity prevention, we have mentioned, that within our possibilities, the best treatment is cavity avoidance

When a cavity appears, it is time for a dental intervention, conservative or restoring dentistry is then in charge of eliminating, healing and reconstructing the dental piece.

The cavity treatment consists on the elimination of affected tissue, that is also infected o contaminated by the bacteria that causes cavities

Once the cavity infected tissue is eliminated, the dental piece has also lost some of the tissues that compose it's normal anatomy, therefore the goal of the dental intervention is doubled, on one side to eliminate the cavity and on the other to restore the original shape of the dental piece, so that it can function to the maximum efficiency possible.

Resulting space after the elimination of a cavity	Reconstructed Piece (Filling)

The most simple cavity treatment is to do both goal mentioned before at the same time and this is what is called a filling.

A piece's filling consists of eliminating the affected tissue, disinfect the healthy tissue that might be contaminated by bacteria and restore the anatomical shape of the dental piece, using a variety of materials described in later chapters.

When the dental destruction is serious, then other forms of restoring treatments must be employed such as: dental crowns, inlays, etc.

Cavities should be filled as early as possible, even if they are too small filling them is recommended, they can not be left to grow and start affecting and/or destroying more dental tissue.

The only type of cavities in which treatment can be postponed, but under strict control, are those called dead or latent cavities. These are cavities that begun but have not advance, they remain as stains in the dental enamel without bacterial activity.

A common mistake between patients is to associate cavity with pain, this is why they need to be explained that cavities are painless when only the dental enamel is affected (first layer of the tooth), they are sensible to temperature changes, acids and sweets when the dentine is affected (second layer), and can only cause pain when the dental pulp (vascular nervous socket under tooth) is affected, in these cases, mentioned in other chapters, the pulp must be treated first by means of an endodontic (elimination of the dental nerve) followed by the restoration of the dental piece.

This is the reason behind sealing the dental pieces as soon as possible, DO NOT WAIT UNTIL PAIN IS PRESENT, also dental destruction is lessen and the sealing or reconstruction are easier to do and generally less expensive.

When the cavities are active, meaning that there is dental destruction, the sealing or filling is required, and if faced with the doubt of whether or not the cavity is active, have the patient came in for a check-up after 3 -6 months so you can keep track on the cavities' evolution

The cavity treatment can be done with or without the use of local anesthesia, we recommend the use of it, but some patients may be against this and prefer continuing the treatment without anesthesia. In the majority of cases professional criteria must prevail and discuss with the patient the need for a local anesthetic.

It is recommended to isolate the dental piece to be treated, the best way to do this is by means of a rubber dam, if this is not possible then at least isolate using cotton rolls and the help of a saliva aspirator.

Rubber dam placed on the dental piece to be treated

The elimination of carious dental tissue is done using a variety of instruments:

• Manual Instruments: The dentist eliminates carious tissue and forms the receptive cavity for the filling.

Manual Instruments for the removal of affected dental tissue

• Rotatory Instruments ( turbines and micro engines): They are use in the elimination of carious tissue in hard areas and to form the cavity. These are the patient's most feared instruments, since years back the majority of fillings where done without using anesthesia, and these rotatory instruments cause a great deal of pain at a dentine level. When used at high speed, we must irrigate using water the dental piece to avoid heat and the possible effect on the dental pulp.

Rotatory Instruments: Turbines and micro engines

• Làser: Although it has been in use for some years now, and knowing that laser technology advances on a day to day bases, still it is not used systematically by all dental clinics, but as laser technology improves it will be slowly introduced to all dental offices. Nowadays, in developed countries, the use of laser in dental procedures is minimum, instead it is very efficient in the surgery of soft tissue.

MATERIAL USED IN DENTAL PROCEDURES

The materials used in a dental sealing are very diverse: The restorations of a dental piece can be done directly at a dental clinic, but also the restoration can be done at a lab and then sealed at the clinic.

In order to place a direct filling or a restoration we can use:

• Silver amalgam
• Composites
• Ormoceres
• Glass ionomer

In order to do an indirect restoration:

• Gold inlays
• Ceramic inlays
• Ceramic laminated or fronts of ceramic
• Metal, ceramic-metal or ceramic crowns

DIRECT RESTORATIONS

SILVER AMALGAM

This material has been in use since the first half of the IXX century, and all throughout the XX century, it is the material of choice for most fillings in which the esthetic factor is not an issue, therefore it is widely use in molars, premolars, palatal faces (internal side of dental pieces) and in the vestibular faces (external) of some posterior pieces.

It is a mix of mercury wit other metals: silver, pewter, copper and zinc, where silver is found in greater proportion (65% or more).

The mix with mercury, makes possible a number of reactions and the mass crystallizes, causing the hardening of the mixture once it has been inserted in the already prepared cavity.

Due to a greater demand for esthetic fillings (white) and to the almost permanent controversy on whether or not mercury is toxic, has caused dentists to use amalgam less frequently and it has started to be substituted more and more with more esthetic materials.

Disregarding it's ant esthetic effect, silver amalgam is the hardest material that can be use for fillings.

Filling using silver amalgam

COMPOSITES

These are material that are use to cover cavity , made out of an organic matrix and filling particles.

The matrix is formed by monomers, when energy is applied over them it unleashes a chemical reaction which causes it's union, this is what is generally known as polymerization, a polymer has been formed which is then becomes the body of the filling. The beginning of the polymerization can be done by means of chemical substances (autopolimerization) or by means of applying fluorescent light (photopolimerization).

Fluorescent light lamps

The filling particles are responsible for the hardness and the resistance of the sealing material, and although as time passes there are harder material available in the market, none beat the durability of the silver amalgam. The number one advantage in using composites is the esthetic factor, being very hard for the patient to even notice which piece has been treated.

	Different composites in use today

Incisives before treatment	Incisives filled

Incisives before treatment	Incisives filled

Cavity in temporal canine	Reconstruction using composite

In order to reconstruct highly damaged dental pieces, we recommend the use of a composite resin mixed with titanium, that has shown positive results.

ORMOCERES

This is the most recent, it is a material made with an organically modified ceramic, it is biocompatible and presents great durability.

This kind of material frees fluorine ions, it is use mainly in posterior teeth although it can be use in frontal pieces. It does not flow as well as other materials, making its placement onto the dental cavity harder, easy to polish and up to now the results are optimum.

Ormocera

GLASS IONOMER

It is a material mainly composed of glass particles (aluminum silicate and calcium crystals), and a great amount of fluorine, this is why one of it's main characteristic is the freeing of fluorine ions, playing an important part in the prevention of cavities when used.

Glass ionomers cements (glues) have a wide range of uses:

• Glue Prosthesis
• Glue brackets or orthodontic bands
• As part of the cavity base
• Filling in temporal pieces
• Filling in definite pieces
• Fissure sealing
• Sealing of radicular conducts (endodontics)

Glass Ionomer Glues

Cermet Cement

This material is not use very frequently for permanent fillings, since composites are better, but it is used in temporal fillings and cervical dental wear.

There is another material, cermet cement, which is a mixture of glass ionomers with silver particles, it is use in the reconstruction of less damaged dental pieces, on top of which a crown is later placed. It can also be used for small fillings and in temporal teeth.

INDIRECT RESTORATIONS

Indirect restorations are done outside the mouth, generally they are elaborated in a dental laboratory using a dental impression (measurements )made at the dental clinic. After the impression is made, we can see ,in the working mold, the defect on the dental piece to be restored, the piece is then tailored and it will be later placed at the dental clinic using a dental glue.

GOLD INLAYS

Widely use in the past, but due to their anesthetic effect, their economic cost and the presence of other materials, they are no longer in use.

Gold Inlays Glues

CERAMIC INLAYS

These are inlays which, for the greater part, have substituted gold inlays due to their better esthetic effect. In reality their success is conditioned by the appearance of the acidetching, used for joining the ceramic to the enamel and dentine, making the joint so perfect that the inlay preserves the dental piece. First, a dental impressions is made, then the dental piece is tailored in a lab and fixed at a dental clinic using special cements (dual cements).

	Cavity
	Working Mold
	Ceramic Inlay
	Acidetching
	Placing and cementing the inlay

CERAMIC LAMINATED

Ceramic Laminated, also called facets or ceramic laminated fronts, date from way back but their success is relatively new since before we didn't count with an adequate fixture system, today with the development of resin cements, which adhere to the tooth and to the Ceramic Laminated, the problem has been solved, making it one of the most frequently used systems of esthetic restoration due to its positive results (see chapter on fixed prosthesis on the web).

Once the tooth is reconstructed, at the dental clinic the vestibular side of the tooth is cut, impressions are made and using the working mold the Ceramic laminated is developed with its corresponding anatomic shape as well as the color matching the rest of the patient's teeth.

The Ceramic laminated is made at the lab and then fixed at a dental clinic.

Incisive with cavity	Cemented Ceramic laminated

TOTAL CROWNS

In cases in which the cavity has destroyed a great deal of the dental piece, the reconstruction can be done using any of the materials mentioned before, but there are two risks involved; first, the fracture of the dental piece and second, the fracture of the reconstruction because of its extension, therefore the placement of a crown over the reconstruction is recommended as to protect both the original dental piece and its reconstruction. This technique is only to be applied in those teeth where the nerve has been previously extracted, since there is greater fragility in pulpless teeth.

Reconstructed premolar and cemented crown

Reconstruction on a group of superior incisive teeth using crowns and Ceramic laminated

Sometimes due to a number of reasons like lack of space, extreme tightness, economic, etc. a totally metallic crown can be placed, only if it does not interfere with the patient's esthetic.

Metallic Crown