Journal of Investigative and Clinical Dentistry (2012), 3, 167–175

REVIEW ARTICLE
Conservative Dentistry

Minimal intervention concept: a new paradigm

for operative dentistry
Mehmet Dallı1, Hakan Çolak2 & M. Mustafa Hamidi2
1 Department of Restorative Dentistry, Dicle University Dental Faculty, Diyarbakır, Turkey
2 Department of Restorative Dentistry, Kırıkkale University Dental Faculty, Kırıkkale, Turkey

Keywords
adhesive restorative materials, dental caries,
enamel therapy, minimally invasive treatment,
oral balance.
Correspondence
Assistant Professor Mehmet Dallı, Department
of Restorative Dentistry, Dicle University
Dental Faculty, Diyarbakır, 21280, Turkey.
Tel: +90-41-22-48-81-01
Fax: +90-41-22-48-81-00
Email: mdalli@dicle.edu.tr
Received 11 May 2011; accepted 6 November
2011.
doi: 10.1111/j.2041-1626.2012.00117.x
Abstract
The current treatment philosophy is to prevent and detect dental disease at the
earliest stage in order to avoid invasive treatment. With the current understand-
ing of the nature of dental disease and its process, the treatment philosophy is
now changing to a more conservative approach and the concept of minimal
intervention is gaining popularity in modern dentistry throughout the world. It
is now established that demineralized but non-cavitated enamel and dentine
can be healed and traditional surgical approach of drilling and filling may no
longer be necessary as this only treats the symptoms of the disease and not the
cause. However, when surgical intervention is indicated, the least invasive tech-
niques such as preventive resin restoration and minimal cavity preparation are
utilized. The aim of this article is to give dental professionals an overview of the
concepts of minimal intervention dentistry and recent innovations in dental
technology in both the diagnosis and treatment of dental caries.

Since the development of ultra-high speed rotary cut-

Introduction
The philosophy of the medical model and minimal inter-
vention dentistry involve prevention of disease and the
preservation of tooth structure.1 The concept of minimal
intervention dentistry has evolved as a consequence of
our increased understanding of the caries process and the
development of adhesive restorative materials.2 In today’s
world a modern, evidence-based approach to caries man-
agement in dentate patients uses a medical model in
which disease is controlled by the oral physician and an
affiliated dental team.3
During the most of past century clinicians have used
the G.V. Black cavity design and the ‘‘extension for pre-
vention’’ surgical approach to oral disease management
has been the cornerstone of 20th century dentistry.4 In
this concept the clinicians’ approach was purely surgical.
It was thought that the only effective method of eliminat-
ing disease was to completely remove all the demineralized
areas of the tooth structure and rebuild the tooth with an
inert restoration that would simply obdurate the cavity.1
ting instruments in the 1950s there has been a tendency
to extend a cavity even further, and the resultant weaken-
ing of the tooth crown has led to a marked increase in
replacement dentistry, leading to a further loss of tooth
structure upon each replacement of a restoration.5 Even a
minor change in occlusal anatomy can lead to the intro-
duction of increased stress on the remaining cusp inclines
or a movement of opposing teeth leading to the develop-
ment of deflective inclines and to functionally opening
contacts.6 Any or all of these changes may speed the
decline of the occlusion and may lead to periodontal
problems as well. It is logical, therefore, to retain as much
of the original tooth crown as possible and deal with a
lesion in a very conservative manner. The cavity designs
suggested by Black required geometric precision with
sharp line angles, flat floors and the removal of all signs
of demineralized tooth structure. The minimal interven-
tion strategy suggests the remineralization of any enamel
margin that is not yet cavitated as well as the remineral-
ization of the lesion floor to avoid irritation of the pulp.7

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A new paradigm for operative dentistry
Minimally invasive dentistry reaches its treatment
objective by using the least invasive surgical approach,
with the removal of a minimal amount of healthy tissue.
A carious dental lesion is the result of bacterial infection.
Restoration of the tooth does not cure the disease.8
Recent advances in technological innovation and dental
material science have given dentists access to new arma-
mentaria and tools to identify and heal early lesions by
therapeutic means and measures such as surface protec-
tion and internal remineralization.9 These require a risk
assessment for individual patients and the tailoring of care
based on the level of risk, which requires an understanding
of the caries process and its influencers.10 Demineraliza-
tion begins below a pH of 5.5 in the enamel, which is
attacked and infiltrated by acid. This results in the loss of
calcium and phosphate ions from the tooth. In fact, it is
possible to heal and remineralize a lesion providing it has
not progressed to the stage of surface cavitation. While
this approach is no easier than traditional surgery it is far
more conservative of tooth structure and offers the possi-
bility of far greater longevity for dentition in general. It
also means that it is unacceptable to sacrifice natural tooth
structure through the preparation of relatively large archi-
tecturally designed cavities on the assumption that this
will, in any way, prevent further disease.11
The introduction of fluoride in the oral environ-
ment plays an important role in modifying disease
pattern and progression.12,13 Fluoride plays a critical role
in the demineralization–remineralization cycle because it
enhances uptake of calcium and phosphate ions and can
appear in the form of fluorapatite, in which the fluorine
ion replaces the hydroxyl ion. Fluorapatite begins to
demineralize at a pH of 4.5, rather than 5.5 for hydroxy-
apatite. Thus, the acid challenge needs to be greater to
dissolve fluorapatite than to dissolve hydroxyapatite.14
A balance between demineralization and remineralization
inhibits the progression of the lesion.
The development of adhesive dentistry and scientific
progress in understanding the nature of caries has enabled
dentists to do more than simply remove and replace dis-
eased tissue. Extension for prevention has given way to
the new paradigm of minimally invasive dentistry, as seen
in a refined model of care that has been modified from
that described by Tyas et al.2 In this article, we review the
following concepts:
(a) Early caries detection;
(b) Remineralization of early lesions, reduction of cario-
genic bacteria and a biological approach to caries
lesion;
(c) Restorative materials used in minimal invasive treat-
ment;
(d) New cavity classification and minimal operative inter-
vention of cavitated lesions;
168
M. Dallı et al.
(e) The repair rather than the replacement of defective
restorations.
Early caries detection
The management of dental caries demands the detection
of carious lesions at an early stage. Since previous caries
experience is the best predictor for future caries, the
development of technology to detect and quantify early
carious lesions and to assess carious lesion status directly
(an active versus inactive technology) may prove to be
the best way to identify patients who require intensive
preventive intervention.15,16 Most studies do not report
the presence of non-cavitated lesions, though they have
been shown to have predictive value.17,18
The ideal caries detection method should capture the
whole continuum of the caries process, from the earliest
stages to the cavitation stage.19 It should be accurate, pre-
cise, easy to apply and useful for all surfaces of the teeth,
as well as for caries adjacent to restorations.20 Assessment
of lesion activity also is of importance. The accuracy of
any diagnostic test or evaluation is typically measured
according to its sensitivity and specificity. Sensitivity and
specificity refer to the capability of a test to diagnose dis-
ease correctly when disease is actually present and to rule
out disease when it is absent.21
The traditional tool for pit and fissure caries detec-
tion has, up until now, been the sharp tipped dental
explorer.21 The use of an explorer to detect caries has
been studied extensively. It has been stated that ‘‘a sharp
explorer should be used with some pressure and if a very
slight pull is required to remove it, the pit should be
marked for restoration even if there are no signs of
decay’’.22 There is a consensus that using an explorer to
forcefully probe suspected carious pits and fissures does
not add to the diagnostic yield and may be damaging.
More appropriate strategies involve using explorers to
remove plaque and lightly assess surface hardness.23 It is
important to remember that caries activity cannot be
determined at one point in time; it must be determined
by monitoring the lesion over time. Radiographs and
clinical information are usually used to make this deter-
mination.24 However, this is obviously limited where the
surface of the tooth is obscured and in occlusal surfaces,
where hidden lesions may be missed. Radiographs done
with bitewings have long been useful for detecting inter-
proximal lesions. The current standard of care is that if
an enamel lesion, as detected by the radiograph, is not
past the dentinoenamel junction it can be arrested or
reversed by remineralization, whereas an opacity into the
dentin requires clinical physical intervention (drilling and
filling).25 This method is quite reliable for these lesions.
However, occlusal surfaces are very different; though for
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M. Dallı et al.
this reason new technologies are emerging. Several new
technologies seem to be promising for detecting hidden
and incipient caries. Ranging from non-invasive to
slightly invasive strategies, these new devices include
optical coherence tomography, laser fiber-optic trans-
illumination, the operative microscope and operative
exploration of the fissure or pit using air abrasion, water
lasers and fissurotomy burs.26,27 Recently, the Food and
Drug Administration approved a device called the Diag-
nodent, (KaVo, III KaVo Dental GmbH, Biberach Riß,
Germany) which shines a red laser into the tooth via a
specially designed handpiece and tip.25 The tip is applied
to the occlusal pits and fissures individually. The red light
readily penetrates the tooth and if it interacts with a sub-
surface lesion that contains certain bacterial by-products
fluorescence is produced. The fluorescent light comes
back from the lesion into the handpiece, interacts with
the detector and is read out as a number and an audible
signal if there is a lesion. This instrument is a good first
step in providing the practitioner with a tool that can
indicate whether there is a hidden lesion under the occlu-
sal surface. Even better devices are expected to become
available to detect early enamel lesions in occlusal
surfaces.10
Remineralization of early lesions, reduction
of cariogenic bacteria and a biological approach
to caries lesion
At one time the caries process was thought to be an irre-
versible sequence of events, beginning with enamel
demineralization followed by protein (collagen) degrada-
tion; so the original approach to the treatment of caries
was purely surgical.25 In other words, the logical treat-
ment was surgical excision of the pathological tissue and
replacing it with restorative material. However, it is now
recognized that enamel and dentine demineralization is
not a continuous, irreversible process.28 Scientific research
has provided a very different concept of the nature of
dental caries. The first biological insight in dental caries
was revealed by W. D. Miller in 1890.29 In his chemico-
parasitic theory, Miller suggested that caries is not gan-
grene, but the dissolution of tooth structure resulting
from acids generated by microbial organisms in dental
plaques. During the last 50 years scientific research has
provided overwhelming evidence that caries is a specific
bacterial infection linked with certain host factors.30,31
Contrary to the earlier view, there is a demineralization–
remineralization cycle in which the tooth structure alter-
nately loses and gains calcium and phosphate ions,
depending on the microenvironment. When the pH drops
below approximately 5.5, the sub-surface enamel or den-
tine begins to demineralize.25 As the pH rises again,
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A new paradigm for operative dentistry
remineralization occurs. Fluoride enhances the uptake of
calcium and phosphate ions and can form fluorapatite.
Fluorapatite demineralizes at a pH lower than 4.5, making
it more resistant to demineralization from an acid chal-
lenge than hydroxyapatite.25 In early carious lesions there
is sub-surface demineralization of the enamel. As caries
progresses into dentin, the surface of the enamel eventu-
ally cavitates. Once cavitation occurs, it becomes difficult
to control plaque accumulation. In areas of difficult
access, the plaque also may hinder the availability of cal-
cium, phosphate and fluoride ions, which in turn may
decrease the potential for remineralization. Therefore,
surgical treatment – caries removal and restoration – is
indicated for the cavitated lesion.2
A balance between demineralization and remineraliza-
tion inhibits the progression of the lesion.32 Measure-
ments of cariogenic bacterial levels with simple in-office
saliva tests, the determination of salivary flow rates and
buffering capacity and an analysis of dietary intake are
needed. Patients who have active caries or who are at
high risk of caries should be put on a regimen that
attacks each part of the caries process: antibacterials (e.g.,
chlorhexidine), buffering agents such as baking soda
products, sugarless gum for increased salivary flow, office
and home fluoride applications, diet counseling to explain
the role of sugars and cooked starch in the caries devel-
opment process and use of sealants.8 When it has been
determined that a lesion needs to be restored, the removal
of decay with the maximal conservation of the healthy
tooth structure should be the main consideration.8
Calcium, phosphate and fluoride have all been shown
to aid remineralization.10–12 The key is to embrace this
knowledge and put it into practice in the real world – to
perform risk assessments, inhibit caries formation and
progression, enhance the natural repair process and per-
form minimal intervention dentistry. The success of clini-
cal cases is not measured just on the day of dental
treatment but also on the results 5–10 years later. Using
the medical model and minimal intervention dentistry
enhances patient care.
Restorative materials used in minimal invasive
treatment
A biological approach to caries lesion is main aim of
minimal intervention dentistry.2 In many cases operative
treatment is unnecessary and a lesion can be treated with
various preventive techniques.10 However, when cavita-
tion occurs, surgical treatment is indicated and should be
minimally invasive. In the presence of a cavitated lesion
plaque control becomes difficult or impossible.8 From this
moment infected tissue must be removed and filled with
suitable restorative materials.28 Preserving maximum
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A new paradigm for operative dentistry
tooth structure is the cornerstone of minimal invasive
treatment.3 Adhesive restorative materials are preferred
because of their potential to prevent bacterial microleak-
age, and provide a minimal operative approach together
with the potential to remineralize some degree of the
demineralized dentine.33
Adhesive dental materials
The effects of prevention on caries prevalence and the
advantages of improved dental materials have shifted the
focus in caries management from surgical methods and
restoring tooth structure to the development and use of
dental materials to prevent disease, develop remineraliza-
tion procedures, use minimally invasive treatments for
difficult-to-access regions and develop materials with
which early lesions can be impregnated to prevent further
progression.34,35
Adhesive dental materials make it possible to conserve
tooth structure using minimally invasive cavity prepara-
tions, because adhesive materials do not require the
incorporation of mechanical retention features.36 Adhe-
sive restorative dentistry originated with the work of
Buonocore in 1955 in bonding resin to etched enamel.
Since then, adhesive materials and techniques have devel-
oped at a rapid rate. The first chemically adhesive mate-
rial (zinc polycarboxylate cement) was marketed in the
late 1960s and glass ionomer cements and dentine bond-
ing agents have since become available.37 There are sev-
eral materials that can be used: glass ionomer cements
(GIC) or GIC resin-based composite/dentin bond-
ing agents; and a layered combination of resin-based
composites and GIC applied using a technique called
lamination.38
Glass-ionomer cements
Glass ionomers were introduced to the profession 25 years
ago and have been shown to be a very useful adjunct to
restorative dentistry.39 Glass ionomers are hybrids of the
silicate cements and the polycarboxylate cements. These
cements possess certain unique properties that make them
useful as restorative and adhesive materials, including
adhesion to tooth structure and base metals, anti-
cariogenic properties due to the release of fluoride,
thermal compatibility with tooth enamel and biocompati-
bility.40,41 Adhesion and anti-cariogenic properties have an
important place in minimal intervention dentistry. They
perform well in low-stress areas.28,40,41 GIC release fluo-
ride, calcium and aluminum ions in the tooth and saliva.
Moreover, set glass ionomer is rechargeable, meaning it
can take up fluoride from the environment, which is pro-
vided by exposure to fluoride treatments and toothpaste.42
170
M. Dallı et al.
Theoretically, this fluoride uptake and slow release can
have an anti-cariogenic effect, though clinical studies have
not proven it to be clinically significant.36
As mentioned above, one of the most significant prop-
erties of glass ionomer cement is adhesion to the calcified
tooth structure. Adhesion arises as a result of ion
exchange between the tooth and the cement.39 The poly-
alkenoic acid from the glass ionomer attacks the tooth
surface, releasing calcium and phosphate ions released
from the glass and forming a new material that unites the
two. There will also be a degree of adhesion between the
acid and dentinal collagen.2 In recent years there have
been considerable changes in the formulation, properties
and handling properties of glass ionomer cements for dif-
ferent clinical applications.
Resin-based composite/dentin bonding agent
The effective bonding of resin composites, particularly to
enamel, is a key factor in minimal intervention dentistry.2
Cavity preparations designed to conserve maximum
enamel can eliminate the need for macro-mechanical reten-
tion.36 The concept of bonding a restorative material to the
dentine surface is by no means a new idea. Even at the time
when Buonocore used phosphoric acid to bond to enamel,
the idea of bonding to dentine was considered.43 However,
due to limitations of materials and knowledge of the struc-
ture and nature of dentine this dream remained just that
until Nakabayashi’s laboratory research showed that it was
possible to etch the dentine, which removes the smear layer
and a few micrometres of surface hydroxyapatite, leaving a
zone of exposed collagen fibrils.42
The acid-etch technique has provided an ideal surface
for bonding to enamel using 30–40% phosphoric acid.
The resulting etch pattern is characterized by the profuse
formation of microporosities which allow the penetration
of monomers into those porosities to form resin tags that
provide micro-mechanical retention.44 Successful attempts
of bonding to dentin in a similar fashion have been
reported more recently. The bonding mechanism of
recent dentin bonding agents is based on the penetration
of ambiphilic molecules into acid-etched dentin to form a
lacework of dentin collagen and polymerized mono-
mers.45 Despite the advantages of resin composite resin,
polymerization shrinkage and marginal leakage remain
potential problem with these materials.
Lamination
Successful lamination relies on making the most of each
material and minimizing their disadvantages.2 As
described by Mount a lamination or sandwich technique
with two direct restorative materials can be used to
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M. Dallı et al.
‘‘make the most of the biological, physical or aesthetic
properties of each material, and in the presence of
adhesion, to achieve as close as possible a single mono-
lithic reconstruction of a tooth.’’ This technique is espe-
cially useful in situations when strength and pleasing
esthetics are essential.46,47
In this technique, the combination of the two materials
is used, where a resin composite is laminated over glass
ionomer.48 The main advantage of the glass ionomer
include its ion-exchange adhesion, which occurs with
both enamel and dentin, and the ion release, which
appears to be partly related to the pH of the environ-
ment.49 In addition to this, it can release fluoride ion so
it aids remineralization and assist in eliminating carious
lesions. The main properties of the resin composite
include its high strength, wear resistance and strong
adhesion to enamel.50
A new cavity classification
It is nearly 100 years since G.V. Black proposed a sim-
ple, five-stage classification for carious lesions based
upon the site of the lesion and the type of restorative
material likely to be used for restoration.51 There is a
basic problem within the concept of the original G.V.
Black classification because it identifies the position of a
lesion and prescribes a cavity design regardless of the
size and extent of the lesion. This means that there will
be a standard amount of tooth structure removed
whether it is involved with the disease or not.52 With
the development of adhesive restorative materials and a
far better understanding of the action of the fluoride
ion it is suggested that the time has arrived for a reas-
sessment of the traditional cavity classification as set out
by G.V. Black over 100-years ago.49 In response to the
importance of site and size of carious lesions for treat-
ment, Mount and colleagues have pro- posed a new
classification,53 describes dental caries by site (1 = pit
and fissure, 2 = contact area, 3 = cervical) and size
(from 0 to 4) (Table 1).
Firstly, lesions are classified according to their location:
Site 1: pits and fissures (occlusal and other smooth tooth
surfaces);
Site 2: contact area between two teeth;
Table 1. Mount and Hume classification system
Classification
Location 1 Minimal 2 Moderate 3 Advanced 4 Extensive
1: pits and fissures 1.1 1.2 1.3 1.4
2: proximal surfaces 2.1 2.2 2.3 2.4
3: cervical surfaces 3.1 3.2 3.3 3.4
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A new paradigm for operative dentistry
Site 3: cervical area in contact with gingival tissues.
Secondly, the new classification identifies carious
lesions according to various sizes:
Size 0: carious lesion without cavitation, can be reminer-
alized;
Size 1: small cavitation, just beyond healing through
remineralization;
Size 2: moderate cavity not extended to cusps;
Size 3: enlarged cavity, with at least one cusp which is
undermined and which needs protection from
occlusal load;
Size 4: extensive cavity, with at least one lost cusp or
incisal edge.
Prevention and hard tissue preservation are the pri-
mary goals in minimal intervention dentistry. Due to
recent innovations in enamel therapy and understanding
caries process is not an irreversible process professionals
should be adopt biological approach in management den-
tal caries.10 Furthermore, Clinicians should be abandon
Black’s traditional approach ‘‘extension for prevention’’
and design cavities with tooth friendly philosophy.
Minimal operative intervention of cavitated
lesions
Once the decision has been made to surgically treat an
initial lesion, minimally invasive techniques should be
used to preserve tooth structure, which will lessen the risk
of tooth fracture, iatrogenic damage and future tooth sen-
sitivity. The most reason for placing a restoration is to
aid plaque control. Elderton and Mjör54 formulated the
following indications for restorative treatment:
(a) The cavitated tooth is sensitive to hot, cold, sweet-
ness, etc.;
(b) Occlusal and proximal lesions extend deep into den-
tin (and cannot be reached by the toothbrush);
(c) The pulp is endangered;
(d) Previous attempts to arrest the lesion have failed and
there is evidence that the lesion is progressing (such
evidence usually requires an observational period of
months or years);
(e) The patient’s ability to provide effective home care is
impaired;
(f) Drifting is likely to occur through the loss of proxi-
mal contact;
(g) The tooth has an unesthetic appearance.
As mentioned above, minimal surgical intervention
should be applied when lesions become cavitated. Several
minimal surgical techniques are indicated, depending
on lesion depth and localizations. These include: (a) pre-
ventive resin restorations, (b) atruamatic restorative treat-
ment, (c) tunnel and internal preparations, and
(d) minibox or slot preparations.
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A new paradigm for operative dentistry
Preventive resin restorations
With the advent of adhesive dentistry and composite res-
ins a more conservative preparation has come into prac-
tice. This new approach is possible because of the
adhesive restorative products used in conjunction with pit
and fissure sealants. These restorations are indicated when
occlusal caries has involved a minimal amount of den-
tin.55 The lesion will usually be visible on a bitewing
radiograph as an area of radiolucency in the dentine. The
technique restores the carious area with composite resin
and seals the rest of the fissures. Studies show that pre-
ventive resin restorations’ long-term survival is satisfac-
tory. An approximately 75–85% survival has been shown
after 9–10 years. The main reasons for its failure are sec-
ondary caries and marginal breakdown.56
Atraumatic restorative treatment restorations
There is worldwide interest in and increasing usage of the
conservative atraumatic restorative treatment (ART)
technique or approach for the restoration of primary and
permanent teeth.57 ART was developed in the early 1990s
in response to the treatment need of deprived communi-
ties lacking sophisticated dental equipment and even elec-
tricity.58 ART takes a position between non-operative and
restorative care, since the treatment consist of removing
the superficial layer of carious dentin with only hand
instruments and using a GIC as a combined restorative
and sealing material.58 Success rates for ART restorations
depend on the material used, the training of the operator
and the extent of caries.59 Glass ionomer cement is the
material of choice for ART because of its bonding to
enamel and dentin, fluoride release and ease of use.60
Resin-modified glass ionomer material has been shown to
have a higher success rate than a low viscosity glass
ionomer cements due to increased strength and greater
resistance to loss.6 Local anesthetic is not always required
for this treatment and the technique has helped to bridge
the gap in the provision of treatment to rural communi-
ties, senior citizens and dental phobic patients.61 This tis-
sue preservative treatment approach appears to be less
painful and is, therefore, more patient-friendly than con-
ventional caries treatments.62 Follow-up studies have
revealed that the technique might arrest dentin caries
lesions and that a major factor for success is the proper
seal of the margins.63
Tunnel and internal restorations
It is currently increasingly accepted that once the decision
has been made to treat a cavitated dentin lesion surgi-
cally, minimally invasive operative techniques should be
172
M. Dallı et al.
used in order to preserve tooth structure.64 Tunnel prepa-
ration is a micro-conservative intervention, which was
initially applied in pediatric dentistry as a prophylactic
method.63 Tunnel preparations are technically difficult to
do because of access and visibility and the small amount
of tooth structure removed.65 The principle behind the
tunnel preparation is that decayed tissue emanating from
the approximal surface is exposed and removed without
this surface being touched externally so it is more conser-
vative than class II restorations and contributes to the
maintenance of tooth strength.66 Most clinical studies of
the efficacy of tunnel preparations were carried out in the
permanent dentition. From 57 to 90% of glass-ionomer
tunnel restorations were successful for up to 3 years.67–69
Minibox restorations
Minibox, or slot preparations, involve the removal of the
marginal ridge but do not include the occlusal pits and
fissures if caries removal in these areas is not necessary.70
The occlusal fissure is maintained intact and when the
cavity is restored with resin composite, the fissure can be
protected with sealant. The cavity design allows for better
visualization of the caries than the tunnel design, allowing
the removal of unsupported enamel. The cavity can be
restored with glass ionomer and a bonded surface lami-
nate of composite resin to resist heavy occlusal contact.71
The slot class II cavity preparation saves time, conserves
tooth structure, offers better esthetics, does not alter
occlusal relationships, may preserve a natural proximal
contact and enjoys greater patient acceptability than tradi-
tional approaches.72 The longest clinical studies of these
conservative restorations have shown a 70% survival after
on average 7.2 years.73
Repair or replacement
Dental filling is most common restorative procedures in
general dental practice.74 However, dental restorations do
not last forever. Over 60% of all restorative dentistry is
for the replacement of restorations.75 The replacement of
any failed restoration will also lead to a further loss of
tooth structure and successively shorter life spans than
their predecessors. The reasons for operative interven-
tion given by dentists in various studies include primary
caries, secondary caries, marginal fracture and non-
carious defects.76–78 In addition to this, they cite discolor-
ation, poor anatomic form, fracture of restoration and
other factors in replacement of restorations.79,80 Although
a fault may be identified, operative interference may not
be warranted. A minor defect of a restoration margin
with no signs of caries due to microleakage is a service-
able restoration. Where minor defects have occurred it is
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M. Dallı et al. A new paradigm for operative dentistry

often possible to adjust local features and avoid radical

reconstruction, for example, clearing occlusal interference
and removing ledges from restorations or making mini-
mal marginal additions.81
When a fault is present but is localized to one region
of the restoration, then consideration should be given to
repairing rather than replacing the restoration, such that
the intervention is minimized.82 When possible, not only
should the observable defect be corrected but preventive
factors established to reduce the incidence of recurrent
problems. When such additions and repairs can be made
the new preparation should be designed to be as much as
possible within the old restoration and shaped so that it
will afford sufficient extension to eradicate the old defect,
permit adequate operative access when inserting the new
restoration and provide sufficient resistance and retention
form to retain the new restoration. The decision to repair
rather than replace a restoration always must be based on
the patient’s risk of developing caries, the professional’s
judgment of benefits versus risks and conservative princi-
ples of cavity preparation.83–85
Conclusion
With the recent advances in dental technology in dental
materials and early caries detection devices, philosophical
changes have taken place in the caries management strat-
egy that has evolved from G.V. Black’s extension for
prevention-surgical approach to a concept based on
minimal intervention and a biological approach. This
concept includes early caries detecting, understanding
caries risk assessment, remineralization of subsurface
enamel lesions and minimal operative intervention of
cavitated lesions, using biomimetic restorative materials
and caries control.
This study has summarized a variety of recent scientific
findings and discussed minimal intervention dentistry.
Although we expect that ongoing innovative research and
development will have a great impact on dentistry, mini-
mal intervention currently offers dentists the potential to
apply a more conservative approach to caries treatment
and simultaneously to offer patients friendlier, health-
orientated treatment options.

7 Reynolds EC, Walsh LJ. Additional 14 Ogaard B. The cariostatic mechanism

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