Tunnel Restoration: A Minimally Invasive Dentistry Apply

Introduction

Standard cavity design is intensive for silver amalgam restoration to revive a caries lesion within the tooth’s interproximal floor, or a GV Black Class II cavity.1 The occlusal cavity needs to be a minimum of 1.5 to 2.0 mm deep, whatever the caries extension, to stop the fracture of the restorative materials throughout perform.2 Non-carious fissure areas within the occlusal floor needs to be eliminated for caries prevention. The carious tooth’s marginal ridge and the interproximal contact space additionally have to be eliminated to entry the caries lesion.3,4 Nevertheless, the intensive cavity design has penalties. A examine confirmed that dental restorations usually wanted to get replaced inside 3 to 10 years.5 The operative process of the restoration substitute additional enlarges the cavity and damages the tooth’s construction and vitality.6 As well as, the reconstruction of the eliminated interproximal contact space is method delicate. Poor reconstruction of the proximal contact typically causes meals impaction.4 Subsequently, a conservative cavity design needs to be really helpful.

Tunnel restoration is a minimally invasive method for restoring the caries lesion on the interproximal tooth floor. Tunnel restoration was proposed to revive disto-proximal carious lesions in deciduous second molars in Nineteen Sixties.7 Nevertheless, the failure fee of the restoration was excessive. With the advance in adhesives and restorative supplies, the brand new technology of small measurement electrical motor dental handpieces with light-emitting diode (LED) gentle and using magnifying loupes to extend the visibility, this strategy has been re-introduced and advocated as a conservative various to traditional cavity design for interproximal caries in posterior major tooth.8–11 The tunnel restoration preserves the marginal ridge by getting ready a tunnel from the occlusal floor to the carious interproximal floor.12 This examine critiques the literature on tunnel restoration and offers up to date strategies and scientific knowledge that can be utilized in tunnel restoration to supervise its limitations and the attitude on restorative therapy.

Cavity Preparation for Tunnel Restoration

The cavity preparation of tunnel restoration removes much less tooth tissue in comparison with the traditional Class II field and slot preparation (Figure 1). The demineralised enamel within the interproximal floor may be preserved in a tunnel preparation if it isn’t cavitated. With the preservation of various quantities of enamel within the interproximal floor, the tunnel preparation may be categorized as (1) complete tunnel (full elimination of the demineralized proximal enamel), (2) partial tunnel (partial elimination of the proximal floor with the preservation of some demineralized proximal enamel) and (3) inner tunnel (preservation of proximal enamel).11,13

Tunnel Restoration: A Minimally Invasive Dentistry Apply

Figure 1 Tooth structure loss in cavity designs. (A) Class II preparation – removal of occlusal and proximal tooth structure including the marginal ridge. (B) Slot preparation – removal of proximal tooth structure including the marginal ridge. (C) Tunnel preparation – removal of occlusal and proximal tooth structure.

Restorative Materials for Tunnel Restorations

After the tunnel preparation, restorative materials are filled into the prepared tunnel to restore the cavity. Dental materials such as silver amalgam, composite resin, glass ionomer, or a combination of glass ionomer and composite resin have been used for tunnel restoration. The selection of restorative materials affects the tunnel restoration’s clinical results.

Silver amalgam is suitable for tunnel restoration in patients who have less aesthetic demand. It has good compressive strength and is easy to handle. One study reported that less than 10% of the tunnel restorations needed to be replaced after 10 years.5 The packability of silver amalgam permits clinicians to create a decent interproximal contact space.14 That is tough to realize with glass ionomers or composite resins due to the fabric’s nature.

Composite resin is used to fill the entire tunnel preparation or cowl the occlusal floor of the tunnel preparation with glass ionomer beneath to extend the tunnel-restored tooth’s fracture resistance.15–18 Composite resin processes superior mechanical properties in comparison with glass ionomer for tunnel restoration. One examine discovered that composite resin restoration with applicable tunnel preparation confirmed comparable mechanical power to the sound construction of the tooth.3 The composite resin might bond to enamel and dentin with adhesives.19 It confirmed a sophisticated marginal adaptation in comparison with glass ionomer, metal-reinforced glass ionomer cements, or silver amalgams when used for tunnel restorations.20 Using flowable composite resin would possibly additional enhance marginal adaptation and sealing in tunnel restorations.21

Glass ionomer is used for tunnel restoration with out heavy occlusal loading.17,18,22,23 Glass ionomer possesses various fascinating properties to function a restorative materials for tunnel restoration, together with radiopacity, chemical bond to enamel and dentin, and fluoride launch.24–26 Nevertheless, glass ionomer exhibited insufficient mechanical and adhesive properties. It won’t be sturdy sufficient to face up to the occlusal drive.27 Moreover, glass ionomer or metal-reinforced glass ionomer exhibited numerous levels of microleakage.28–31 Research have demonstrated porosities throughout the restoration, and within the interface between restoration and the cavity wall have been 32%.32 Subsequently, glass ionomer was not really helpful as definitive restorations in everlasting dentition.33

Scientific Procedures of Tunnel Restorations with Totally different Restorative Supplies

Tunnel Restoration Utilizing Silver Amalgam

A affected person with caries within the distal facet of the left mandibular first molar was offered (Figure 2A and B). The affected person’s knowledgeable consent for the dental therapy, the publication of the scientific images, and the publication of the case report have been obtained earlier than the therapy. No institutional approval was required to publish this case report. Rubber dam isolation was utilized. An occlusal cavity was drilled within the distal triangular fossa utilizing the tapered diamond bur to achieve entry to caries. Caries have been additional eliminated utilizing a small diamond spherical bur. Unsupported enamel was trimmed with an excavator. The marginal ridge’s width on the finish of the preparation was 2 mm mesiodistally (Figure 2C). Tofflemire matrix band and picket wedge have been positioned. Then, a dentin bonding agent that bonds the silver amalgam (Clearfil Liner Bond 2V, Kuraray Co., Ltd., Tokyo, Japan) was utilized. The cavity was then overfilled with silver amalgam (Tytin FC, Kerr Company, Orange, CA, USA) (Figure 2D). The surplus silver amalgam was carved to breed the unique morphology (Figure 2E). The occlusion was adjusted after setting the silver amalgam. The postoperative radiograph confirmed the silver amalgam’s good adaptation in opposition to the cavity wall and the reconstruction of the proximal floor of the tooth (Figure 2F).

Figure 2 Radiographs and photographs (mirror image) of a tunnel restoration using silver amalgam. (A) occlusal view (preoperative). (B) preoperative radiograph. (C) occlusal view (after cavity preparation). (D) occlusal view (after silver amalgam insertion). (E) occlusal view (after silver amalgam carving). (F) postoperative radiograph.

Tunnel Restoration Using Composite Resin

A patient with caries in the distal aspect of the right mandibular second molar was presented (Figure 3A and B). The affected person’s knowledgeable consent for the dental therapy, the publication of the scientific images, and the publication of the case report have been obtained earlier than the therapy. No institutional approval was required to publish this case. A rubber dam was inserted earlier than the operation. Cavity entry from the occlusal distal fossa was achieved for caries elimination of the distal proximal floor. Remaining caries within the distal floor was then eliminated (Figure 3C). Selective enamel etching with 40% phosphoric acid (Okay-etchant gel, Kuraray, Co., Ltd., Tokyo, Japan) for 30 seconds was carried out. This was adopted by making use of a two-step self-etch dentin bonding system (Clearfil SE Bond 2, Kuraray Co., Ltd., Tokyo, Japan). The cavity was then restored with composite resin (Filtek Z250, 3M Firm, St. Paul, MN, USA) utilizing the layering method to attenuate polymerization shrinkage stress (Figure 3D and E). The occlusion was adjusted as obligatory. The postoperative radiograph confirmed the right adaptation of the restoration, although a negligible overhang may be seen (Figure 3F).

Figure 3 Radiographs and photographs (mirror image) of a tunnel restoration using composite resin. (A) occlusal view (preoperative). (B) preoperative radiograph. (C) occlusal view (after cavity preparation). (D) occlusal view (after composite resin insertion). (E) occlusal view (after composite polishing). (F) postoperative radiograph.

Tunnel Restoration Using Glass Ionomer/Composite Resin (Sandwich Technique)

A patient with caries in the distal aspect of the right maxillary first molar was presented (Figure 4A and B). The affected person’s knowledgeable consent for the dental therapy, the publication of the scientific images, and the publication of the case report have been obtained earlier than the therapy. No institutional approval was required to publish this case. After putting the rubber dam, entry to the caries was gained via eradicating the prevailing silver amalgam. A spherical bar was used for eradicating remaining caries (Figure 4C). Tofflemire matrix band and a picket wedge have been positioned. The cavity was conditioned with 20% polyacrylic acid (Ketac Conditioner, 3M Firm, St. Paul, MN, USA) for 15 seconds, rinsed and dried. The cavity was stuffed with glass ionomer (Ketac Molar, 3M Firm, St. Paul, MN, USA) and gently condensed with a condenser to kind a flat floor (Figure 4D). Selective etching of the cavity wall’s enamel and the occlusal fissure adjoining to the cavity with 40% phosphoric acid for 30 seconds was carried out (Okay-etchant gel, Kuraray Co., Ltd., Tokyo, Japan). This was adopted by making use of a two-step self-etch dentin bonding system (Clearfil SE Bond 2, Kuraray Co., Ltd., Tokyo, Japan). The cavity was then restored with composite resin (Filtek Z250, 3M Firm, St. Paul, MN, USA). The occlusion was adjusted as obligatory (Figure 4E). The postoperative radiograph confirmed the restoration’s good adaption (Figure 4F).

Figure 4 Radiographs and photographs (mirror image) of a tunnel restoration using glass ionomer and composite resin (sandwich technique). (A) occlusal view (preoperative). (B) preoperative radiograph. (C) occlusal view (after cavity preparation). (D) occlusal view (after glass ionomer insertion). (E) occlusal view (after composite resin insertion). (F) postoperative radiograph.

Potential Problems and Solutions in Tunnel Restoration

Tunnel restorations have strengths and challenges. It can (i) preserve the marginal ridge, which contributes to maintaining tooth integrity and strength; (ii) preserve proximal contour including the proximal contact; (iii) reduce the risk of iatrogenic damage to the adjacent tooth; (iv) reduce the risk of the restoration having an overhang; and (v) preserve more tooth structure compared to conventional Class II.34 Nevertheless, these benefits have to be balanced in opposition to potential issues together with (i) elevated danger of insufficient caries elimination attributable to extra restricted visible and instrumental entry, (ii) unintended or intentional elimination of the marginal ridge and (iii) elevated danger of pulpal publicity.35

Insufficient Caries Removing

Insufficient caries elimination contains under-preparing or over-preparing the tunnel. Beneath-preparing the tunnel leaves residual caries on-site, which can improve the danger of secondary caries and shorten the tunnel restoration’s lifespan. Of the partial tunnel preparations, 22–29% have been discovered to have residual caries after caries elimination.32,36,37 Over-preparation weakens or damages the tooth construction.

Correct visualization might presumably obtain satisfactory caries elimination. Three important situations needs to be attained within the operation course of to realize the right visualization for stopping insufficient enamel/dentin elimination within the cavity preparation: (i) a transparent operation subject, (ii) strict moisture management and (iii) appropriate magnification.38 A transparent operation subject needs to be obtained earlier than the operative intervention. Eradicating supra-/sub-gingival plaque, particles and calculus are important.11 As well as, to make sure that the lesion is cavitated and to enhance visible entry, it’s helpful to separate tooth by putting an orthodontic elastic separator for every week to develop a small interproximal house.38 Moisture management through making use of a rubber dam is useful for restoration with prime quality. As well as, utilizing magnifying loupes helped cut back marginal overhangs by as much as 40%.39 Overhang might have an effect on the analysis of the scientific results of the restoration on follow-up visits by inflicting the misinterpretation of the failure cause. The restoration failure could also be as a result of overhang and the leakage as a substitute of the tunnel itself. Different contradictory approaches to facilitate satisfactory caries elimination embody growing the scale of the occlusal entry32,36 and adopting radiographic examination. Nevertheless, growing the scale of the tunnel preparation lowers the tooth’s fracture resistance. One examine reported that even onsite radiographic examination throughout tunnel preparation couldn’t improve the efficacy of caries elimination. It recommended to not contemplate radiography as an acceptable diagnostic device for caries dedication throughout tunnel preparation.40

Fracture of the Marginal Ridge

Insufficient width or peak of the remaining marginal ridge after tunnel preparation will increase the danger of marginal ridge fracture. A tunnel preparation closed to the marginal ridge and/or that has a big occlusal opening results in lowered marginal ridge width. It had a 2–7 occasions greater danger of fracture in comparison with a tunnel preparation with a better distance to the marginal ridge or a smaller opening.41,42 The bur’s horizontal orientation in tunnel preparation lowered the marginal ridge’s peak. Research confirmed that complete tunnel preparation resulted in a weakened marginal ridge.39,41–43

To reinforce the tunnel restoration’s fracture resistance, the marginal ridge’s width needs to be a minimum of 2 mm41 and the peak needs to be ideally 2.5 mm.3 The occlusal opening of the tunnel restoration needs to be conservative. One examine found that small-sized tunnel preparations confirmed most marginal ridge power in comparison with sound tooth.41 The tunnel restoration with a 2.5-mm-high marginal ridge had comparable fracture resistance to that of sound tooth.3 As well as, having the bur angulation vertically initially after which altering to a extra horizontal angulation would possibly protect extra dentin underneath the marginal ridge when getting ready the tunnel. Nevertheless, be aware that this operation might lead to the next danger of pulpal publicity.44

Invasion of Very important Pulp

One other consideration is the violation or irritation of important pulp within the tunnel preparation or restoration. To keep away from pulp publicity, a cautious pre-operative examination with the help of a radiograph needs to be carried out. The bur’s orientation needs to be properly managed with the radiograph as a reference. To keep away from irritating the pulp throughout the operative process or as a result of restorative supplies, resin-modified glass ionomer or calcium hydroxylate liner is really helpful for oblique pulp capping if the tunnel is closed to the dental pulp.45 This layer of liner not solely acted as a protecting barrier for the pulp but in addition enhanced the remineralisation of the caries-affected dentin.

Scientific Outcomes of Tunnel Restorations Utilizing Totally different Restorative Supplies

Scientific research revealed previously 40 years on the survival fee of tunnel restorations have been searched to find the scientific outcomes of tunnel restorations utilizing completely different restorative supplies. Twenty-three scientific trials have been discovered and included within the search. Table 1 summarises survival fee of the tunnel restoration utilizing completely different restorative supplies and their causes of failure.

Table 1 The Survival Rate of Tunnel Restorations and Their Causes of Failure

Studies found the survival rate of composite resin and silver amalgam was higher compared to that of glass ionomer. The median survival time of glass ionomer tunnel restorations was 6 years, whereas those of composite resin and silver amalgam Class II restorations were between 9 and 13 years.27,54 The annual failure fee of glass ionomer in tunnel restorations was 7–10%,13,54,55 which was greater than that of typical Class II silver amalgam (3.3%) and composite resin (2.3%) restorations.54 The weighted imply survival fee of tunnel restoration restored with glass ionomer and silver amalgam as a perform of time was plotted (Figure 5). The weighted imply survival fee was calculated by

Figure 5 The survival rate of tunnel restorations using (A) glass ionomer and (B) silver amalgam.

Where “m” denotes the total number of studies which has covered the survival rate of the time in service of the restoration under consideration. With this plot, it can be assumed that the glass ionomer success rate steadily declined with time. However, the amalgam success rate drastically fell on long-term follow-up. The survival rate of tunnel restoration with composite resin was not plotted because there were only a few studies with a limited sample size.

Note that most of the reported studies were conducted approximately two decades ago. New technologies have been developed since then. These include magnifying loupes and light-emitting diode handpieces. These technologies enhance the micro-detailed visibility in the tiny operative field of dentistry.66,67 Digital radiography has improved the standard of dental imaging and lowered radiation hazards. This may increasingly facilitate diagnosing proximal caries and shut monitoring of post-treatment success.68–70 Therefore, clinicians can obtain greater success charges in contrast with these within the reviewed research. It was additionally discovered that the survival fee of tunnel restoration was considerably related to the clinician’s talent.13,47 The three-year failure charges of particular person dentists have been reported as starting from 9% to 50%.61 Though, greater success charges have been noticed for operators with extra expertise.61,71

Different components associated to the failure of tunnel restoration conflicted within the literature. A number of research discovered that the failure fee was not associated to the kind of tooth or the kind of tunnel restoration.13,54,61,62,72 Quite the opposite, some research noticed greater failure charges for molars than these for premolars.14,59 Some research discovered higher outcomes for partial tunnel restorations59,71 as a result of partial tunnel restorations would possibly lead to much less tooth construction elimination and thereby a stronger marginal ridge.59,71 Others noticed higher outcomes for complete tunnel restorations13,72 as a result of satisfactory caries elimination was extra simply achieved in complete tunnel preparation.13,72 Relating to the impact of caries danger on the failure fee, some research14,61 discovered no correlation between the 2. Nevertheless, a examine confirmed the next median survival time of tunnel restorations in sufferers with average caries danger in comparison with the median survival time of the restorations in sufferers with excessive caries danger.47 One other examine noticed considerably greater failure charges in sufferers with excessive caries danger.72

Subsequently, skilled operators adopting new applied sciences, equivalent to a magnifying loupe, and bonding, and utilizing sturdy supplies (composite resin, silver amalgam) might point out greater success charges of tunnel restorations.38,66,69

Conclusion

The tunnel restoration is a viable and conservative everlasting restoration process for proximal caries. There’s a clear want for analysis to enhance the diagnostic strategies, develop site-specific indicators of future caries danger and set up clear pointers on managing caries. Typically, tunnel restoration is a technically demanding process. Correct case choice, preparation method and number of restorative supplies are vital. Utilizing superior applied sciences, equivalent to magnifying loupes, digital radiography and dental handpieces with LED lights, is important. Additional long-term scientific research needs to be undertaken to find out the success and failure charges of those restoration strategies utilizing the most recent applied sciences obtainable in contrast with different restoration strategies.

Disclosure

The authors declare no conflicts of curiosity.

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