class="bi x0 y0 w1 h1"
FOURTH EDITION
EDITORS
THEODORE M. ROBERSON, DDS
Professor
Department of Operative Dentistry
University of North Carolina
School of Dentistry
Chapel Hill, North Carolina
HARALD 0. HEYMANN, DDS, MEd
Professor
Department of Operative Dentistry
University of North Carolina
School of Dentistry
Chapel Hill, North Carolina
EDWARD J. SWIFT, JR., DMD,
MS
Professor
Department of Operative Dentistry
University of North Carolina
School of Dentistry
Chapel Hill, North Carolina
with 2521 illustrations
A Harcourt Health Sciences Company
St. Louis

London

Philadelphia

Sydney

11830 Westline Industrial Drive
St. Louis, Missouri 63146
Printed in the United States of America
Library of Congress Cataloging in Publication Data
Sturdevant's art & science of operative dentistry-4th ed. / editors, Theodore M.
Roberson, Harald O. Heymann, Edward J. Swift, Jr.
p. ; cm.
Rev. ed. of: The art and science of operative dentistry / senior editor, Clifford M.
Sturdevant; co-editors, Theodore M. Roberson, Harald O. Heymann, John R. Sturdevant.
3rd ed. c1995.
Includes bibliographical references and index.
ISBN 0-323-01087-3
1.
Dentistry, Operative. I. Title: Sturdevant's art and science of operative dentistry. II.
Title: Art & science of operative dentistry. III. Roberson, Theodore M. IV Heymann,
Harald. V Swift, Edward J. VI. Sturdevant, Clifford M. VII. Art and science of operative
dentistry.
[
DLNLM: 1. Dentistry, Operative. WU 300 S9351 2001]
RK501 .A78 2001
617.6'05-dc21
2001045250
02 03 04 05 06 GW/RRD-W 9 8 7 6 5 4 3 2 1
Stephen C. Bayne, MS, PhD, FADM
Professor and Section Head of Biomaterials
Department of Operative Dentistry
University of North Carolina
School of Dentistry
Chapel Hill, North Carolina
James J. Crawford, BA, MA, PhD

Chapel Hill, North Carolina
Ralph H. Leonard, Jr., DDS, MPH
Clinical Associate Professor
Department of Diagnostic Sciences and General
Dentistry
University of North Carolina
School of Dentistry
Chapel Hill, North Carolina
Thomas E. Lundeen, DMD
Private Practitioner
Durham, North Carolina
Kenneth N. May, Jr., DDS
Professor and Associate Dean of Administration and
Planning
Department of Operative Dentistry
University of North Carolina
School of Dentistry
Chapel Hill, North Carolina
Jorge Perdigao, DDS, MS, PhD
Associate Professor and Director
Department of Restorative Sciences
Division of Operative Dentistry
University of Minnesota
Minneapolis, Minnesota
Patricia N.R. Pereira, DDS, PhD
Assistant Professor
Department of Operative Dentistry
University of North Carolina
School of Dentistry
Chapel Hill, North Carolina

Department of Operative Dentistry
University of North Carolina
School of Dentistry
Chapel Hill, North Carolina
Duane E Taylor, BSE, MSE, PhD
Professor Emeritus (Retired)
Department of Operative Dentistry
University of North Carolina
School of Dentistry
Chapel Hill, North Carolina
John R. Sturdevant, DDS
Associate Professor
Department of Operative Dentistry
University of North Carolina
School of Dentistry
Chapel Hill, North Carolina
Jeffrey Y. Thompson, BS, PhD
Associate Professor
Department of Operative Dentistry
University of North Carolina
School of Dentistry
Chapel Hill, North Carolina
Edward J. Swift, Jr., DMD, MS
Professor
Department of Operative Dentistry
University of North Carolina
School of Dentistry
Chapel Hill, North Carolina
Aldridge D. Wilder, Jr., DDS
Professor

This book presents the science of operative dentistry in
an evolved yet highly dynamic fashion. At the University
of North Carolina, the operative dentistry discipline is
constantly tested and evaluated and is forced to meet the
challenge of pedagogical Darwinism. That is, the con-
cepts that constitute operative dentistry practice are con-
tinually evaluated against the torrent of information
flowing from the basic and clinical sciences that shape
everything we do in the health care field. What is out-
dated is discarded, what remains applicable is updated,
and what is new and necessary is incorporated. Only the
best information and technologies survive to guide our
teaching and practice of operative dentistry. In this man-
ner, this book contributes to evidence-based dentistry.
Dental caries is not a lesion-it is a disease. This book
is
written with the explicit assumption that the disease
of dental caries must be thoroughly understood if ef-
forts to prevent and treat it are to improve. Molecular
biology and new diagnostic technologies have so al-
tered the field of cariology that its overview in the pres-
ent volume is only cursory. The increasing ability to di-
agnostically measure earlier stages in the caries process
is leading to a redefinition of caries and is changing con-
temporary approaches to caries treatment. The choice
between surgical and nonsurgical caries treatment is be-
coming more complex.
During the last 20 years, dental caries prevalence and
severity have declined in most of the industrialized
world, yet significant population components have re-

perience pertaining to these evolving technologies, and
they give an excellent account of what will surely be-
come an increasingly important component of operative
dentistry in the twenty-first century. Learn and enjoy as
much as I did from this outstanding textbook.
John W. Stamm, DDS
Professor and Dean
University of North Carolina
School of Dentistry
ix
In 1961, Dr. Doug Strickland said, "Cliff, we should
write a textbook." Three days later, still trembling over
the immensity of such an endeavor, we agreed to give it
our best. Thus resulted the first edition, in 1968, of
The
Art and Science of Operative Dentistry.
In 1994, dental educators and private practitioners had
available the third edition, which answered their earlier
query, "When will we see the next edition?" The appreci-
ation of these colleagues is a major stimulus for the tal-
ented faculty of our department to persevere under the
hardships that accompany this extensive project. To have
constancy in a talented, dedicated "in-house" faculty (the
textbook contributors) is a blessing for any senior editor.
Dr. Theodore (Ted) Roberson is the senior editor of
this fourth edition. I am confident the users of this book
will value Dr. Ted's unique and blessed talents in orga-
nization, writing, vision, and leadership, as well as his
hard work and long hours.
Congratulations and thanks to the editors and

to reflect Dr. Clifford M. Sturdevant's
relationship with this book for over 30 years.
Without
Cliff Sturdevant, there would never have been a text-
book, especially not one with this quality and reputation.
Almost all topics presented in the third edition are
still included.
We have added five new chapters:
Enamel and Dentin Adhesion
Preliminary Considerations for Operative Dentistry
Introduction to Composite Restorations
Introduction to Amalgam Restorations
Indirect Tooth-Colored Classes I and 11 Restorations.
This edition includes more than 2500 illustrations,
with an increased number of color photographs and
color-enhanced drawings, diagrams, tables, and boxes.
This edition also uses different terminology. The term
cavity is
used only in an historical context and is re-
placed by other terms such as
carious lesion
or
tooth
preparation.
This change reflects the continuing evolu-
tion of operative dentistry to represent treatment neces-
sitated by many factors, not just caries. Also, the term
composite is
used to refer to a variety of tooth-colored
materials that may be designated by

material being used; the indications, con-
traindications, advantages, and disadvantages of the
presented procedure; and finally the tooth preparation
factors and restorative factors that relate to the proce-
dure. Common problems (with solutions) for the pro-
cedure are presented, as is a summary of the chapter.
CHAPTER SYNOPSES
Chapter 1, Introduction to Operative Dentistry, empha-
sizes the biologic basis of operative dentistry and pre-
sents current statistics that demonstrate the continuing
need and demand for it.
Chapter 2, Clinical Significance of Dental Anatomy,
Histology, Physiology, and Occlusion, is similar to the
same chapter in the last edition, presenting sections on
the pulp-dentin complex and occlusion. The presenta-
tion of occlusal relationships and chewing movements
should aid in the assessment of occlusion and the pro-
vision of acceptable occlusion in restorations.
Chapter 3, Cariology: The Lesion, Etiology, Prevention,
and Control, has a different organization but still presents
the ecologic basis of caries and then deals with its man-
agement, which involves diagnosis, prevention, and
treatment. The caries control restoration is also described.
Chapter 4, Dental Materials, first presents a review of
materials science and biomechanics and then provides
updated information about direct and indirect restora-
tive materials, including the safety and efficacy of their
use. The topics of composites, sealants, glass ionomers,
and amalgam materials have been expanded.
Chapter 5, Fundamental Concepts of Enamel and

information for federal, state, and OSHA regulations. The
chapter emphasizes the importance of appropriate infec-
tion control procedures. Expanded sections are presented
on dental office water lines and handpiece sterilization.
Chapter 9, Patient Assessment, Examination and Di-
agnosis, and Treatment Planning, provides an excellent
reference for practitioners and students. Patient assess-
ment is presented, emphasizing the importance of a
medical review that includes relevant factors of sys-
temic and communicable diseases. Photographs of
some of these oral manifestations are presented in a
color insert. Factors affecting the determination of clini-
cal treatment are covered, with special emphasis on in-
dications for operative treatment, including the decision
to replace existing restorations.
Chapter 10, Preliminary Considerations for Operative
Dentistry, combines information from several chapters
from the third edition. The sections on local anesthesia
and isolation of the operating site have been updated.
Patient and operator positioning, instrument exchange,
and magnification are also part of this chapter.
Chapter 11, Introduction to Composite Restorations, is
a new chapter that provides an overview of the compos-
ite restoration technique. It reviews the types of esthetic
materials available, emphasizing the properties of com-
posite.
Additional information about polymerization of
composites is presented. (Some of this information is also
included in Chapter 6). Indications, contraindications, ad-
vantages, and disadvantages of composite restorations

ter and also new material. The chapter includes ex-
panded coverage of the indirect techniques and the
various materials and methods available. Information
about indirect restorations of composite, feldspathic
porcelain, pressed glass ceramics, and CAD/CAM are
covered. Another section discusses common problems
and solutions.
Chapter 15, Additional Conservative Esthetic Proce-
dures, provides an excellent resource for many esthetic
procedures. After reviewing the factors for artistic suc-
cess, the chapter presents detailed techniques for es-
thetic contouring and enhancements, bleaching, ve-
neers, splinting, and conservative bonded bridges.
These procedures are well supplemented with many il-
lustrations, most of which are in color.
Chapter 16, Introduction to Amalgam Restorations, is
a new chapter that presents fundamental concepts for
amalgam restorations. The material qualities of amal-
gam as a restorative material are identified, followed by
sections on the indications, contraindications, advan-
tages, and disadvantages for amalgam restorations. The
use of amalgam is still recommended, but emphasis is
placed on its use for larger restorations, especially in
nonesthetic areas. Fundamental concepts of both amal-
gam tooth preparations and restoration techniques are
included, and these are expanded upon in Chapters 17
through 19. Also included in this chapter are sections on
common problems (and solutions), repairs, and contro-
versial issues.
Chapter 17, Classes I, II, and VI Amalgam Restorations,

an update on gold foil restorations for Classes I, III, and V
Theodore M. Roberson, Chair, 1979-1988
Harald O. Heymann, Chair, 1988-2000
Edward J. Swift, Jr., Chair, 2000-present
Department of Operative Dentistry
University of North Carolina
School of Dentistry
In addition to teaching operative dentistry, the authors
practice the principles and techniques presented in this
book in a clinical setting and engage in clinical or labora-
tory research. Thus the restorative concepts presented here
are supported by both clinical activity and research results.
The editors express special appreciation to the
following:
Warren McCollum, Director of the Learning Re-
sources Center of the UNC School of Dentistry,
and his staff for their diligence in production of
illustrations.
Marie Roberts, Paulette Pauley, and Shannon Vec-
cia for their capable assistance in manuscript
preparation. In particular, a special thanks is ex-
tended to Ms. Roberts for her vital role in organiz-
ing the revision effort and communicating with the
publisher.
Drs. Roger Barton, Tom Lundeen, Ken May, Troy
Sluder,
Lee Sockwell,
Doug Strickland, Cliff
Sturdevant,
Duane Taylor, and Van Haywood,

Public's Perception of Dentistry, 9
Patient Visits, 9
FUTURE OF OPERATIVE DENTISTRY, 9
SUMMARY, 10
2 Clinical Significance of Dental
Anatomy, Histology, Physiology,
and Occlusion, 13
JOHN R. STURDEVANT
THOMAS F LUNDEEN
-
TROY B. SLUDER, JR,-
TEETH
AND INVESTING TISSUES, 15
Dentitions,l 5
Classes of Human Teeth: Form and Function, 15
Structures of the Teeth, 16
Physiology of Tooth Form, 32
Maxilla and Mandible, 35
Oral Mucosa, 35
Periodontium, 36
OCCLUSION, 37
General Description, 38
Mechanics of Mandibular Motion, 45
Capacity of Motion of the Mandible, 48
Articulators and Mandibular Movements, 55
Tooth Contacts During Mandibular Movements, 5
Neurologic Correlates and Control of
Mastication, 61
Cariology: The Lesion, Etiology,
Prevention, and Control, 63

General Health, 110
Fluoride Exposure, 110
mmunization, 112
Salivary Functioning, 112
Antimicrobial Agents, 113
Diet, 113
Oral Hygiene, 114
Xylitol Gums, 121
xix
Contents
Pit-and-Fissure Sealants,
121

ADVANTAGES OF ENAMEL
Restorations,
1
23

ADHESION, 238
CARIES TREATMENT, 124

ENAMEL ADHESION, 238
Caries Control Restoration,
1
26

DENTIN ADHESION, 239
SUMMARY, 130

Challenges in Dentin Bonding,

1
35

Clinical Factors in Dentin Adhesion,
257
Material Structure,
137

New Clinical Indications for Dentin Adhesives,
258
Material Properties,
137

SUMMARY, 261
BIOMECHANICS FOR RESTORATIVE
DENTISTRY, 145

6

Fundamentals in Tooth
Biomechanical Unit,
1
45

Preparation,
269
Stress Transfer,
1
46


70

STAGES AND STEPS OF TOOTH
Dental Adhesion,
1
77

PREPARATION, 272
Pit-and-Fissure Sealants,
1
87

FACTORS AFFECTING TOOTH
Composites,
1
90

PREPARATION, 273
Glass lonomers,
207

General Factors,
273
Direct-Filling Gold,
211

Conservation of Tooth Structure,
274
I
NDIRECT RESTORATIVE DENTAL

Tooth Preparation Terminology,
279
Classification of Tooth Preparations,
281
I
NITIAL AND FINAL STAGES OF
PREPARATION, 283
I
nitial Tooth Preparation Stage,
285
Final Tooth Preparation Stage,
294
ADDITIONAL CONCEPTS IN TOOTH
PREPARATION, 303
Amalgam Restorations,
303
Composite Restorations,
303
Bonded Restorations Strengthen Weakened
Tooth Structure,
304
SUMMARY, 305
Contents
I
nstruments and Equipment
for Tooth Preparation,
307
STEPHEN C. BAYNE
JEFFREY Y. THOMPSON
CLIFFORD M. STURDEVANT*

336
Other Abrasive Instruments,
338
CUTTING MECHANISMS, 340
Evaluation of Cutting,
340
Bladed Cutting,
340
Abrasive Cutting,
341
Cutting Recommendations,
341
HAZARDS WITH CUTTING
I
NSTRUMENTS, 342
Pulpal Precautions,
342
Soft Tissue Precautions,342
Eye Precautions,
343
Ear Precautions,
343
I
nhalation Precautions,
343
I
nfection Control,
345
JAMES J. CRAWFORD
RALPH H. LEONARD, JR.

EPIDEMIOLOGY, AND INFECTION, 358
Viral Hepatitis Infection, Symptoms, and Clinical
Findings,
359
Transmission of Viral Hepatitis,
359
I
nfection risks for Personnel from Hepatitis B
and C Viruses,
359
Serologic Tests Related to Hepatitis A, B,
and C,
360
Data Related to Control of Hepatitis B,
360
I
mmunization Against Hepatitis A, B, and C,
360
Tests for Hepatitis B Antibody and Boosters,
360
EPIDEMIOLOGY OF OTHER INFECTION
RISKS, 361
EXPOSURE ASSESSMENT
PROTOCOL, 361
Medical History,
362
Personal Barrier Protection,
362
Disposal of Clinical Waste,
364

Dry Heat Sterilization,
373
Ethylene Oxide Sterilization,
374
12
Advantages,

482

CLINICAL TECHNIQUE FOR
Disadvantages,
483

DIRECT CLASS IV COMPOSITE
RESTORATIONS, 523
CLINICAL TECHNIQUE, 483

I
nitial Clinical Procedures,
523
Initial Clinical Procedures,
483

Tooth Preparation,
523
Tooth Preparation for Composite Restorations,
486

Restorative Technique,
526


Clinical Technique,
534
Weak or Missing Proximal Contacts (Classes II,

GLASS-IONOMER RESTORATIONS, 535
III, and IV),
498

Clinical Technique,
535
I
ncorrect Shade,
498

SUMMARY, 536
Poor Retention,
498
Contouring and Finishing Problems,
498

13

Classes I, 11, and VI Direct
CONTROVERSIAL ISSUES, 498

Composite and Other Tooth-
Liners and Bases Under Composite

Colored Restorations,

539
Composite and Other Tooth-

Contraindications,
539
Colored Restorations,
501

Advantages, 540
THEODORE M. ROBERSON

Disadvantages,
540
HARALD 0. HEYMANN
ANORE V. RITTER

PIT-AND-FISSURE SEALANTS,
PATRICIA N.R. PEREIRA

PREVENTIVE RESIN AND
CLASSES III, IV, AND V DIRECT

CONSERVATIVE COMPOSITE
COMPOSITE RESTORATIONS, 503

RESTORATIONS, AND CLASS VI
COMPOSITE RESTORATIONS, 540
Pertinent Material Qualities and Properties, 503
I
ndications,

Tooth Preparation,
544
Restorative Technique,
548
Contents
Contents
CLINICAL TECHNIQUE FOR
DIRECT CLASS II COMPOSITE
RESTORATIONS, 550
CONSERVATIVE ALTERATIONS
OF TOOTH CONTOURS
AND CONTACTS, 599
I
nitial Clinical Procedures,
550
Tooth Preparation,
551
Restorative Technique,
558
Alterations of Shape of Natural Teeth, 599
Alterations of Embrasures,
601
Correction of Diastemas,
601
CLINICAL TECHNIQUE FOR EXTENSIVE
CLASS II COMPOSITE RESTORATIONS
AND FOUNDATIONS, 563
Clinical Technique,
564
SUMMARY, 567

574
CLINICAL PROCEDURES, 579
Tooth Preparation,
579
I
mpression,
581
Temporary Restoration,
582
CAD/CAM Techniques,
582
Try-In and Cementation,
583
Finishing and Polishing Procedures,
584
Clinical Procedures for CAD/CAM Inlays and
Onlays, 587
Common Problems and Solutions,
587
Repair of Tooth-Colored Inlays and Onlays,
588
SUMMARY, 589
15
Additional Conservative Esthetic
Procedures,
591
HARALD 0. HEYMANN
ARTISTIC ELEMENTS, 593
Shape or Form,
594

SPLINTS, 632
Periodontally Involved Teeth,
632
Stabilization of Teeth After Orthodontic
Treatment,
634
Avulsed or Partially Avulsed Teeth,
635
CONSERVATIVE BRIDGES, 636
Natural Tooth Pontic,
636
Denture Tooth Pontic,
638
Porcelain-Fused-to-Metal Pontic or All-Metal
Pontic with Metal Retainers,
640
All-Porcelain Pontic,
646
16
I
ntroduction to Amalgam
Restorations,
651
THEODORE M. ROBERSON
HARALD 0. HEYMANN
ANDRE V. RITTER
AMALGAM, 653
History,
653
Current Status,

657
RESTORATIONS, 736
Advantages,
658
SUMMARY, 737
Disadvantages,
658
CLINICAL TECHNIQUE, 658
18
Classes III and V Amalgam
I
nitial Clinical Procedures,
658
Restorations,
741
Tooth Preparation for Amalgam Restorations,
658
ALDRIDGE D. WILDER, JR.
Restorative Technique for Amalgam
THEODORE M. ROBERSON
Restorations,
664
ANDRE V. RITTER
KENNETH N. MAY, JR.*
COMMON PROBLEMS: CAUSES AND
POTENTIAL SOLUTIONS, 667
CLASSES III AND V AMALGAM
RESTORATIONS, 743
Postoperative Sensitivity,
667

Proximal Retention Locks,
668
Restorative Technique,
752
SUMMARY, 668
CLINICAL TECHNIQUE FOR CLASS V
AMALGAM RESTORATIONS, 754
Classes I, II, and VI Amalgam
Restorations, 669
I
nitial Procedures,
754
ALDRIDGE D. WILDER, JR.
Tooth Preparation,
755
THEODORE M. ROBERSON
Restorative Technique,
758
PATRICIA N.R. PEREIRA
ANDRE V. RITTER
19
Complex Amalgam
KENNETH N. MAY, JR
Restorations,
763
I
NTRODUCTION TO CLASSES I, II, AND
ALDRIDGE D. WILDER, JR.
VI AMALGAM RESTORATIONS, 671
ANDRE V. RITTER

687
CLINICAL TECHNIQUE, 766
Class I Occlusolingual Amalgam Restorations,
690
I
nitial Procedures Summary,
766
Class I Occlusofacial Amalgam Restorations,
695
Tooth Preparation,
769
CLASS II AMALGAM
Restorative Technique,
787
RESTORATIONS, 696
SUMMARY, 795
20
Class II Cast Metal
Restorations, 799
JOHN R. STURDEVANT
CLIFFORD M. STURDEVANT"
21
Direct Gold Restorations, 871
GREGORY E. SMITH
DIRECT GOLDS AND PRINCIPLES OF
MANIPULATION, 873
I
NTRODUCTION, 801
Material Qualities,
801

878
Tooth Preparation for Class II Cast Metal
I
nlays,
803
Tooth Preparation for Cast Metal Onlays,
826
RESTORATIVE TECHNIQUES FOR CAST
METAL RESTORATIONS, 837
I
nterocclusal Records,
837
Temporary Restoration,
837
Final Impression,
843
Working Casts and Dies,
846
Wax Patterns, 853
Spruing, Investing, and Casting,
856
Seating, Adjusting, and Polishing the Casting,
856
Trying-in the Casting,
858
Cementation,
866
Repair,
866
SUMMARY, 867

Dental health, 6
A. Indications, 3

D. Dental manpower, 8
B. Considerations, 4

E. Projected need for operative dentistry, 8
C. Conservative approach, 4

1.
New caries, 8
D. Dynamics of operative dentistry, 4

2.
Root caries, 8
III.

Factors affecting the future demand for operative

3.
Replacement restorations, 8
dentistry, 5

4.
Esthetic restorations, 8
A. Demographics, 5

F Public's perception of dentistry, 9
B. Economic factors, 5


nized, areas such as endodontics, prosthodontics, and
orthodontics became dental specialties. However, oper-
ative dentistry is still recognized as the foundation of
dentistry and the base from which most other aspects of
dentistry evolved.
In the United States, dentistry originated in the sev-
enteenth century when several "barber-dentists" were
sent from England. The practice of these early dentists
consisted
mainly of tooth extractions because dental
caries at that time was considered a "gangrene-like" dis-
ease.
Many practiced dentistry while pursuing other
livelihoods, and some traveled from one area to another
to provide their dental services. These early dentists
learned their trade by serving apprenticeships under
more experienced practitioners. Later, it became known
that treatment of the defective part of a tooth (the "cav-
i
ty") could occur by removal of the cavity and replace-
ment of the missing tooth structure by "filling" the cav-
i
ty with some type of material. Much of the knowledge
and many of the techniques for the first successful tooth
restorations were developed in the United States. How-
ever, much of the practice of dentistry during the found-
ing years of this country was not based on scientific
knowledge, and disputes often arose regarding treatment
techniques and materials. One such dispute concerning
the use of amalgam as a restorative material played a part

22
in 1926
further identified the need for establishing dental and
medical educational systems on a firm scientific foun-
dation. The primary needs reported by these studies
were relating clinical practice to the basic sciences, pre-
scribing admissions and curriculum criteria, and pro-
moting university-based programs.
Thus the early days of itinerant, and frequently uned-
ucated, dentists ended. Dentists began to be educated in
the basic sciences as well as clinical dentistry, resulting
in practitioners who possessed and demonstrated intel-
lectual and scientific curiosity. The heritage of operative
dentistry is filled with such practitioners. In addition to
the Blacks, others such as Charles E. Woodbury, E.K.
Wedelstaedt, Waldon 1. Ferrier, and George Hollenback
made significant contributions to the early development
of operative dentistry.
Although segments of what constituted early opera-
tive dentistry have now branched into dental special-
ties, operative dentistry continues to be a major part of
most dental practices,
4
and the demand for it will
not decrease in the foreseeable future.
48
However, the
number of restorative services provided by U.S. dentists
did decline from 233 million in 1979 to 202 million in
1990.

The indications for operative procedures are numerous.
However, they can be categorized into three primary
treatment needs: (1) caries; (2) malformed, discolored,
CHAPTER
I

I
ntroduction to Operative Dentistry
nonesthetic, or fractured teeth; and (3) restoration re-
placement or repair. The specific procedures associated
with these treatment indicators are covered in subse-
quent chapters.
CONSIDERATIONS
Before any operative treatment, a number of considera-
tions are involved, including: (1) an understanding of
and appreciation for infection control to safeguard both
health service personnel and patients (see Chapter 8); (2) a
thorough examination of not only the affected tooth but
also the oral and systemic health of the patient; (3) a di-
agnosis of the dental problem that recognizes the interac-
tion of the affected area with other body tissues; (4) a
treatment plan that has the potential to return the af-
fected area to a state of health and function, thereby en-
hancing the overall health and well-being of the patient;
(5) an understanding of the material to be used to restore
the affected area to a state of health and function, includ-
ing a realization of both the material's limitations and
techniques involved in using it; (6) an understanding of
the oral environment into which the restoration will be
placed; (7) the biologic knowledge necessary to make the

possible dramatic improvements in composite, ceramic,
and glass ionomer restorations and the development of
expanded restorative applications of these materials.
More conservative approaches are now available for:
(1)
many typical restorative procedures (Classes I, II, III,
IV, and V); (2) diastema closure procedure; (3) esthetic
and/or functional correction of malformed, discolored,
or fractured teeth; and (4) actual replacement of teeth.
When compared with past treatment modalities, these
newer approaches result in significantly less removal of
tooth structure.
Although these are only examples, they demonstrate
the current emphasis on conservation of tooth structure.
The primary results of conservative treatment are retention of
more intact tooth structure and less trauma to the pulp tissue
and contiguous soft tissue.
Not only will the remaining
tooth structure be stronger, but the restoration should
be more easily retained, offer greater esthetic potential,
and cause less alteration in intea-arch and inter-arch
relationships.
Efforts for the conservative restoration of teeth are on-
going. Research activity is continuing toward the devel-
opment of materials and techniques to completely bond
restorative
materials to tooth structure, the objectives
being to: (1) significantly reduce the necessity for exten-
sive tooth preparations; (2) strengthen the remaining
tooth structure; and (3) provide benefits such as less mi-

ative restorative bonding techniques.
Studies on filler com-
position and polymerization methodology for
composite
materials
have resulted in both increased esthetic quali-
ties and resistance to wear. Similarly, the benefits of
sealants
are becoming more widely accepted for the pre-
vention of pit-and-fissure caries.
CHAPTER
1

I
ntroduction to Operative Dentistry
Increased knowledge about the carious process and
the beneficial effects of multiple fluoride application has
resulted in a decrease in caries incidence. Likewise, the
increasing professional
emphasis on caries prevention is
as
i
mportant as the recent technologic and scientific ad-
vancements. The recognition that
most dental disease is
preventable
has resulted in better patient self-care and
more conservative efforts by dentists in treatment.
Increased research on biomaterials has led to the in-
troduction of

and dental health and the effect of these on the future
demand for dental services.
DEMOGRAPHICS
Between 1990 and 2050, the U.S. population is projected
to increase by 146 million people (to a total of 394 mil-
lion) 4
1
and the composition of the American population
at that time will also be different; almost one half (47%)
of the population will consist of minorities,
41
and the
numbers of older adults will be significantly higher.
These population changes will affect the entire profes-
sional lives of most of today's dental school graduates.
In October 1999, the world's population reached 6 bil-
lion,
which represented a 1 billion increase during the
previous 12 years. During the twentieth century, the
world population tripled, and by 2100, the world popu-
lation is expected to reach 12 billion. While the world
birth rate in 1999 was 370,000 births each day
52
more
than 50,000 Americans also reached the age of 50 during
that year
.
57
The percentage of
older adults in the population will in-

Since most of these individuals will retain more of their
teeth as they age,
they will create a continuing demand for
dental services
because they will not only want to keep
their teeth but also will experience a standard of living
that
will permit a degree of discretionary income for
health care expenditures.
Because of the aging of the U.S. population, emphasis
will shift from the needs of the young to the concerns
and demands of middle-aged people and older adults.
Although the absolute numbers of children will not de-
crease substantially in the future, their percentage in the
population and relative importance in health care poli-
cies will decrease. On the other hand, older adults will
increase in both absolute number and importance.
Al-
ready older adults (those 65 years old and older) are re-
ceiving a much higher percentage of health care benefits
than is their percentage of society. Such benefits will in-
crease as the political and economic clout of older adults
increases.
ECONOMIC FACTORS
No one can accurately project the economic future.
While the U.S. economy will be part of a more global
economy, the economic projections for the United States
appear bright. The national deficit may not be elimi-
nated, but it will become a lesser and lesser percentage
of the Gross Domestic Product (GDP). Annual improve-