Otari Khidirbegishvili, dentist, owner of the dental clinic Dentstar, Tbilisi, Georgia

Summary: The article presents the review of references on the issues of streamlining the
Blacks classification. The shortcomings of the current classification are described and the
principles of modern classification of localization of caries cavities are formulated.
Key words: recurrent caries, secondary caries, principle extention for prevention, etc. .


New Classification of Blacks Cavities Localization Part 1
Abstract
In 1873, the German scientist B. Baume introduced the term caries for the first time
as well as described its localization. However, one of the leading roles in the
development of cariesology belongs by right to the American scientist G. W. Black.
Many of things Black proposed at his time has not lost its relevance now as well.
However, his classification of caries cavity localization is considered the most important
contribution to the science. To the larger extent owing to this discovery, the name of
Green Wordiman Black, along with the names of Abraham Lincoln, Steve Douglas, and
other prominent figures of the State, is stamped on the frieze which encircles the top of
the building of the State Department in Illinois.

Introduction

Black proposed his classification for the use of inlays as well as fillings of gold, cement
and amalgam, the use of which assumed the removal of both carious and the
substantial amount of unaffected tissues of the tooth to ensure, first of all, the reliable
fixation of the filling. The classification was intended not so much to describe the
localization of caries cavities, but for the standardization of methods for preparation
and filling. A certain class of cavities should meet a strictly defined form of the prepared
cavity and relevant material for its filling. That is why at the time the classification met
the demands of clinicians because the preparation method and properties of materials
used at the time conformed to each other. However, after the death of the scientist they
strived to adapt any filling materials emerging on the stomatological market to his
classification. Even composites (1962) and glass ion meters (1970), by which, finally, it
was possible to conduct the methods of minimal invasive intervention (an alternative to
the Blacks Method), strange though it may seem, were adapted to this classification.
The supporters of this concept were not confused by the fact that Blacks surgical
approach was only meant for the use of fillings made of gold, cement and amalgam .
It went so far that in case of non-caries lesions they are also guided by this
classification, not realizing that clinicians need a separate systematization for
localization of caries cavities as the etiology, clinical features and treatment strategy of
caries and non-caries lesions are so different from each other, that, in my opinion,
these pathologies should not be considered together. It is unlikely that the legendary
scientist would agree with such tactics of construction and application of its
classification.
The surgical approach of Black is counted on the preparation principle extension
for prevention, which is based on the method of preventive expansion of carious
cavities to so-called caries-immune (non-caries) zones. The method envisages wide
excision of caries-sensitive zones (fissures, adjoining surfaces, cervical area) to
caries-immune (tubercles, equator) ones with the creation of cavity with the shape
resembling the box.
By the belief of Black and his followers, such preparation tactics would prevent the
emergence of the recurrent caries, therefore the design of the cavity was classified,
standardized, and healthy tissue of the tooth would be sacrificed for geometrical
perfection with the purpose of prevention of possible complications. As a result, the
standard system of preparation would be formed, and even the little centers of
demineralization would require the removal of significant amount of tooth tissues. At the
same time, the edges of the cavity would be formed within the limits of the zones of
natural auto-purification, which according to Black would prevent the resumption of
carious process in the filled tooth.
The Blacks Principle excludes the resumption of recurrent caries indeed, since the
demineralized tissues are removed completely. However, the application of this method
does not free from, and sometimes even facilitates, the emergence of even more
serious complications. In the first place, it is necessary to mention the possibility of
formation of the secondary caries, the main reason of the origin of which is the
appearance of micro-spaces between the filling and tissues of the tooth as a result of
the polymerization shrinkage of filling material, where subsequently bacteria penetrate
(Figure 1). In this case, according to Black, the extension of the preparation boundaries
to the zones of natural auto-purification does not prevent the reproduction and
colonization of bacteria in these micro-spaces, since the bacterial film is located not on
the plain surface of caries-immune zone, but in the artificial hollows emerged as a result
of the polymerization shrinkage of the material, where it is difficult to purify it
mechanically.


Figure 1. The consequences of the polymerization shrinkage

Exactly for this reason the contemporary science has proved that the main reason of
the resumption of carious process at the boundaries of the filling having been put is the
polymerization shrinkage of the material, since it is much more difficult to struggle with it
than to prevent the emergence of the recurrent caries by means of removal of
demineralized tissues. This is also testified by the fact that neither of the existing
methods of struggle with polymerization shrinkage gives full guarantee of prevention of
this complication, especially in the cavities with unfavorable C-factor (the relation
between the free and connected surfaces).
Besides, it has been proved that the larger is the dimension of the cavity, respectively
the volume of the introduced filling material, the more significant is the force and
consequences of the polymerization shrinkage. Consequently, not only the removal of
inert tissues according to Black for the expansion of boundaries of the cavity to the
immune zones does not make sense, but also brings about even higher probability of
the emergence of complications. Unfortunately, Black knew nothing about the
polymerization shrinkage, which, however, existed even then.
Proceeding from the above-mentioned, the paradoxical situation originates when
during the expansion of boundaries of carious cavity to the caries-immune zones the
emergence of recurrent caries is prevented, but at the same time the possibility of
emergence of secondary caries is increased.
Traumatic damage of the dental pulp, which is associated with the large volume of
excised dental tissues with the implied consequences (overheating of the pulp,
destruction of odontoblasts and etc.), is as serious complication as the previously
mentioned one during the application of the Blacks Method. Such a tactics of
preparation brings to the weakening of durability of dental crown and considerable time
expenditure (Kodola, 1975).
It is also important to understand that in those times while filling the cavities there would
emerge the necessity of removal of significant amount of intact tissues not only for the
prevention of recurrent caries, but also for the creation of more proper conditions for the
retention of weak filling material not having chemical adhesion to the dental tissues.
Considering that for the prevention of the recurrent caries it is fairly enough to remove
the affected tissues of the tooth, whereas the excision of the intact tissue to the immune
zones does not exclude the emergence of secondary caries, then the expansion of
preparation boundaries according to Black with the creation of the box-shaped cavity
actually facilitates the improvement just of the conditions for the retention of filling.
Therefore the Blacks tactics extension for prevention is expedient to be called
extension for fixation. I suppose, in such a context the philosophy of such an
intervention will be more grounded, since if after the removal of affected tissues the
conditions for the retention of the material allow to fix the filling on long-term basis, there
is no need of expanding the boundaries of preparation. In the given case the principle
extension expansion for fixation excludes the senseless removal of the intact tissues
of the tooth, which would by all means be conducted during the application of the
Blacks Principle, hence it becomes understandable how important is the right choice of
the method of preparation.
Fanatical faith of many clinicians into the Blacks surgical approach was not shaken
even by the method of biological expediency proposed in 1948 by I. G. Lukomskiy
according to which only caries-affected tissues within the limits of healthy are excised.
The main reason of rejection of this method, in Blacks supporters opinion, was
ostensibly absence in those times of relevant filling materials.
It is impossible to agree with this argument, since even then stomatologists were
using the amalgam some clinical indicators of which have not been excelled up to now.
For example, it undergoes the presence and reproduction of bacteria to significantly
lesser extent than modern composites (Meyer, 2000), which, probably, is connected
with the presence in its composition of the compounds of mercury. In spite of the fact
that the amalgam does not have the ability of chemical adhesion to dental tissues, its
micro-mechanical cohesion excels the analogous indicators of the existing filling
materials. Besides, it has such positive qualities which are not peculiar for other filling
materials. All the amalgams undergo corrosion during the contact with the environment,
as a result of which the products of electro-chemical destruction of metal fill both the
entrances into the dentinal tubules and the micro-chinks between the tooth wall and
filling. It seems that this is the only example when corrosion plays positive role
preventing the origin of hyper-sensitivity of tooth as well as of secondary caries blocking
the dentinal tubules and filling the micro-chinks. Of no small importance is that the
amalgam has the longest pre-gel phase of polymerization among all filling materials,
since the time of its full consolidation is 24 hours, hence actual absence of post-
polymerizational complications. Undoubtedly, the low percentage of complications
under the amalgam fillings should be explained just by these indicators, and not by the
Blacks Method in use. Thus, the revolutionary for those times Lukomskiy Method
could already then be successfully applied.
For many years of the use of the Blacks Classification the certain stereotype of
thinking has been developed, which is hard to change up to date. This is especially felt
during the reading of contemporary editions, where the mentioned Method is still
considered as panacea.Strangely enough, stereotype thinking of Black reflected itself
also in the method of preventive filling, the theoretical bases of which were set in
the works of T. Fusayama, J. McLean and other in 80s-90s of XX century. When
comparing the fourth and fifth variants of this method, the paradoxical situation is
revealed: while applying the Blacks Method in the era of adhesive stomatology, in the
fifth variant the significant amount of unaffected tissues of caries-immune zone is
removed, whereas in the fourth variant the situation is as follows: instead of the
separate filling of the cavity and invasive sealing of fissures they do not dare to sacrifice
the minimal amount of unaffected tissues of cariesogenic zone and open fully the
fissures having filled them together with the prepared cavity applying the Lukomskiy
method (Figure 2).

(4
th
variant)

(5
th
variant)

Figure 2. Formation and filling of carious cavities (4
th
and 5
th
variants)

It might seem that in modern conditions the Blacks Method should pass into history.
However, in some cases it gained even more destructive character. Let us consider, for
example, one of the contest papers at the international competition of Prizma-
Championship (Figure 3).

Figure 3

There is an impression that the teeth on the Figure 5 are prepared not for the conduct
of the direct restoration, but for the use of orthopedic constructions. Applying only
Blacks surgical method, it was impossible to impair the tooth tissues in such a way, fully
removing the enamel and mineralized pigmentations, therefore it is expedient to call this
preparation method extension for aesthetics. It was undoubtedly possible to avoid
this method of preparation and obtain the analogous result of the restoration using, in
case of necessity, camouflage agents for the isolation of pigmented, however vitalized
tissues.
In the era of aesthetic stomatology, particular attention is paid to the restoration not
only functional, but also aesthetic parameters of the tooth, therefore corresponding
methods of preparation should be applied. However, the tooth preparation should
always be started by using the Lukomskiy principle of biological expediency, i.e.
affected tissues should be removed within the boundaries of healthy ones. This
preparation principle should be considered the main and least traumatic one. If after the
removal of affected tissues there are corresponding conditions created for the fixation of
the filling, then there is no need of using the other methods. If such conditions are not
revealed, the forced excision of healthy tissues is necessary to create the conditions for
the restoration of functional and aesthetic parameters of the tooth. Such preparation
principle is expedient to be called functional-aesthetic one.

Conclusions

With the development of new filling materials, adhesive systems and modern
restorative methods, the Blacks Surgical Method has lost its initial significance.
Besides,theminimalinvasiveinterventionhasbecomethemainprincipleofmoderncarie
sology,forwhichreasonthefamoussloganofGreenBlackExtensionforPreventionat
presentisrephrasedintothePreventionofExtension.Consequently, the time has come
to adopt the new classification of localization of carious cavities for the use of
composites and other modern filling materials.

References
1. Black G V. A work on operati ve dentistry; The technical procedures in
filling teeth. Medico-Dential Publi shing Company. Chicago, 1917.
2. Mount G J, Hume W R. Preservation and restoration of tooth structure.
London. Mosby, 1998.
3. Roulet J F, Degrange M. Adhesion: the silent revol ution in dentistry.
Quintessence Publi shing Company, Paris, 2000.
4. Wilson A D, McLean J W. Glass-ionomer cement. Quintessence: London,
1998.
5. Mount G J. Letter to the Editor. Quint. Int. 2000; p. 31: 375.
6. Sturdevant C. M. The Art and the Science of Operative Dentistry. 1995. Mosby.
New-York. P. 289 324
bilisi,
Georgia Telephone: +(99532) 960769 (home)
E-mail: otari@inbox.ru