1. Simplified and Modified Atraumatic
Restorative Treatment
(SMART)
Prepared by :Gholami hamed

2. Introduction:
• SMART: a Simplified and Modified
Atraumatic Restorative Treatment is a
method to remove caries and minimal
cavity preparation using only hand
instruments and fill it with glass ionomer
cement, can be applied to restorative
treatment of primary teeth.
• the method is showed to obtain sufficient
effect comparable to composite resin
fillings and amalgam fillings , without
inducing fear of children.

4. • SMART. is a slow and gentle technique
that is well tolerated by the most fearful of
patients. It is more comfortable than
standard techniques. No injections or
powered drills are needed. Young children
do very well with it

5. Applications:
• Good alternative in field conditions
• Excellent for fearful children
• Good alternative in medically
compromised patients
• Good alternative in mentally compromised
childs

6. Principles of SMART
A. removing carious tooth tissues using
hand instruments only
B.restoring the cavity with a restorative
material that sticks to the tooth.

7. cavities suitable for SMART:
1.involving dentin
2. accessible to hand instruments
3.one surface more than multiple surface
cavities

9. contraindications:
a.pulp disease at sequellae
chronic or irriversible pulpitis
pulpul exposure
abscess or fistula
b.inaccessible to hand instruments

10. instruments:
Mouth mirror
Explorer
Pair of tweezers
Dental hatchet
Spoon excavator, small
Spoon excavator, medium
Spoon excavator, large
Applier/carver
Glass slab or paper mixing pad
Spatula

11. Materials:
Cotton wool roll
Cotton wool pellet
Clean water
Glass-ionomer restorative material
liquid, powder and measuring spoon
Dentine conditioner
Petroleum jelly
Wedge
Plastic strip
Articulation paper

12. Outhers:
Examination gloves
Mouth mask
Operating light
Operation bed / headrest extension
Stool
Methylated alcohol
Pressure cooker
Instrument forceps
Soap and towel
Sheet of textile
Sharpening stone and oil

13. basic techniques:
a.good working invirinment
b.patient positioning
c.operator positioning
d.correct instruments
e.infection control
f.GIC material

14. Why glass ionomer?
bonds to enamel and dentin
fluoride release
Ease to use

15. instruments:
A small enamel hatchet used to open access to
underlying softened dentine

16. Two spoon-shaped excavators, one small with a
spoon approximately 1 mm across, another
slightly larger are used to excavate soft dentine

17. A small flat plastic
instrument is used for
applying the GIC and
for shaping the
restoration.

18. An Enamel Access
Cutter (EAC) can be
used to access the
cavity when the
enamel hatchet is too
large

19. The instruments are laid
out in the sequence
that they are going to
be used

20. operative procedures:
• PREPARING THE CAVITY
a. Place a cotton roll and dry the working tooth.
b .Use the dental hatchet to gain access and excavators
to remove soft caries and unsupported enamel.
It is very important that:
1. All soft caries is removed at enamel-dentinejunction.
2. To avoid exposure of pulp in deep cavities, leave asmall
portion of affected dentine near pulp region

22. The smallest excavator
is used to remove soft
dentine from the
enamel dentine
junction by making
circular scooping
movements under the
enamel

23. Where more access is
required, some of the
enamel can be gently
fractured off with the
blade of the hatchet
along the line of the
enamel prisms

24. • CLEANING THE PREPARED CAVITY
The purpose of cleaning the cavity walls is to improve
chemical bonding of GIC to toothstructure.
Cavity could be cleaned by:
1. Dentine conditioner (10% Polyacrylic acid)
2. The liquid supplied by GIC itself. With dentine
conditioner clean the cavity walls for10-15 seconds and
dry with cotton wool pellets.
Repeat the procedure if contaminated by blood or saliva

25. The GIC is inserted into
the cavity in small
increments using the
rounded end of the
applier/carver
instrument.

26. Slightly overfill the
cavity and then place
additional GIC in any
pits and fissures
adjoining the cavity

27. • RESTORING THE CAVITY
After cavity is washed and dried, start mixing GIC powder
and liquid.
Insert in small amounts using applier/carver to avoid air
bubbles and build the restoration slightly high on occlusal
surface.
Insert material into corners and unsupported enamel first.
With petroleum jelly on the gloved index fingerpress the
soft material into the cavity, this iscalled “the press-finger
technique”.
Do not disturb the restoration during hardening phase.

28. The tip of the index
finger is then placed
onto the central part
of the restorations to
enable the GIC to be
pressed firmly into the
cavity, pit and fissures

29. After 1-2 minutes check the
occlusion.
If the restoration too high,
remove the stained
portion of restoration with
a carver blade.

30. The finished restoration
is then covered with
petroleum jelly or
varnish and the
patient advised not to
eat for at least one
hour

31. A completed restoration
sealant

32. Glass-Ionomer Used as a Sealant
It is not always easy to see early dental
caries. Its progression can be rapid,
particularly in young people who have
already untreated cavities and/or
restorations.
If nothing is done, early dental caries can
develop to a cavity in less than 1 year.

33. Sealing pits and fissures with glass-ionomer can
control dental caries and prevent it from occurring.
The presence and viability of microorganisms
under pit and fissure sealants has bee
investigated.
It has been shown that when the sealant remain
intact, the number of viable microorganisms left
beneath the sealant decreases with time.

34. The destructive activity of the remaining
bacteria is reduced, leaving the bacteria
incapable of causing tooth destruction.
This is logical since remaining bacteria are
now cut off from their source of nutrients.
There is convincing evidence that pit and
fissure sealants are capable of arresting
the carious process.

35. Even when glass-ionomer sealants have
been partly or completely lost, there is
usually a benefit to the patient because
the fluoride released from the material will
have made the enamel harder.

36. Indications:
As glass-ionomer sticks chemically to enamel, it is
useful as a sealant. It also releases fluoride into
the enamel and this may stop development of
caries.
Experience has shown that sealants of glass-
ionomer remain in the deeper pit and fissures
that are most at risk for decay. In contrast,
sealants may be lost rather quickly in shallow
pits and fissures

37. Procedures:
notice:
Place the sealant only in the pit and
fissures. Take care not to cover the cusps
of the tooth

38. 1. Isolate the tooth with cotton wool rolls.
Keep the treatment area dry.
2. Clean the surface from debris with a
cotton wool pellet dipped in water.
3. Gently remove debris from deepest parts
of pit and fissures with an explorer
4. Apply dentine conditioner or diluted
glass-ionomer liquid into the pits and
fissures for 10-15 seconds

39. 5. Immediately wash the pits and fissures,
using wet cotton wool pellets to clean off
the conditioner. Wash 2-3
times.
6. Dry the pits and fissures with cotton wool
pellets.
7. Mix the glass-ionomer and apply it in all
pits and fissures with the blunt blade of the
applier/carver. Overfill slightly.

40. 8. Rub some petroleum jelly on the gloved
index finger.
9. Put the index finger on the mixture, press
and remove finger sideways after a few
seconds.
10. Remove visible excess of mixture with a
large excavator

41. 11. Wait 1-2 minutes till the material feels
hard, while keeping the tooth dry.
12. Check the bite using the articulation
paper and adjust the amount of sealant
with the carver if needed.
13. Apply a new layer of petroleum jelly.
14. Remove cotton wool rolls.
15. Ask the patient not to eat for at least one
hour