HIGH SPEED CUTTING INSTRUMENTS IN PROSTHODONTICS

HIGH SPEED CUTTING INSTRUMENTS IN PROSTHODONTICS

Introduction

In order to perform the intricate and detailed procedures associated with restorative dentistry, the dentist must have a complete knowledge of the purpose and application of the many instruments required. During each day of his clinical experience the dentist operates on vital tissues within the oral cavity where a millimeter or a fraction there of, is a very significant dimension. A skillful application of sharp hand and rotary instruments requires ability and coordination gained only by extensive training.

Before the advent of rotary instruments, removal of tooth tissue was accomplished with sharp – edged chisels, hatchets, and hoes. These hand instruments possessed a cutting capability, which was used for clearing away unsupported and undermined enamel resulting from dental caries. Walls and floors of the cavity were formed by a planning and lateral scraping action of these sharp edged instruments. At best, such efforts were crude, time consuming and often difficult.

The first, rotary instruments for cutting tooth tissue were modified hand instruments. These, drill or bur heads could be twisted in the fingers to produce a cutting or abrading action. In 1846 the finger ring was introduced with a drill socket attached for adapting a series of long bundled burs or drills. This was the primitive application of the rotary principle. The first drill having flexible cable drive and the first angle hand piece were introduced by Charles Merry between 1858 and 1862. In 1871, Morrison modified and adapted the dental foot engine from the Singer Sewing machine. This was followed by the introduction of the electric dental engine utilizing a cable arm in 1883. In 1910 the endless cord on a jointed arm was made available. The earlier dental hand pieces were capable of speeds from 4500 to 6000 rpm.

In 1940 the use of diamond abrasive paints became widespread. The diamond point is compared of a number of small diamond particles bound on a rotary blank.

In 1945 Dr. G.V. black, published a report on the non mechanical preparation of cavities and in doing so introduced the air abrasive technique. The impact of Dr. Black’s revolutionary cutting technique on the dental profession was considerable. This was the first significant break in the long established traditional method of cavity preparation. The air abrasive principle utilized particles of aluminium oxide propelled against the tooth surface by a carbon dioxide stream under the pressure of 110 psi, and funneled through a tungsten carbide nozzle with a lumen of 0.018 inch. The penetration of enamel and dentin was rapid but some what difficult to control.

In 1949 Walsh and Symons published their initial findings relating to the removal of tooth tissue with diamond points at rotational speeds upto 70,000 rpm. This report indicated the use of lighter forces and a resulting increased cutting efficiency at these higher speeds.

In early 1950, the ball-bearing hand piece was introduced.

In 1963, following the work of Nelson the first fluid turbine type handpiece was introduced. This instrument was capable of rotational speeds of approximately 50,000 rpm and was limited to diamond instruments operated at one speed only. In 1954, air-driven hand pieces were developed. A continuous belt-driven contra-angle which utilized a friction grip chuck and bur was introduced, making possible cutting speeds of upto 150,000 rpm.

By 1957, many dentists were using rotational speeds upto 3,00,000 rpm. The introduction of air-bearing hand piece in the early 1950 made possible greater rotational speeds of approximately 5,00,000 rpm.

In 1953, an ultrasonic method of tooth tissue  removal was also introduced, which used suitably shaped tips vibrating at frequencies ranging from 2,50,000 to 3,00,000 cycles – per seconds.

This brief historical back ground reveals that the profession has been searching for a suitable method of tooth tissue removal. Only during last 30 years, this hunt has slowed down still the profession is trying to refine the procedure and instruments.

Review of literature

A search through literature reveals various methods used in the past for removal of tooth tissue. The continuous development of newer methods till 1960, indicates  that the earlier instruments had some disadvantages. Inspite of the introduction of numerous tooth reduction instruments, and procedures, the principles and the biologic objectives have remained the same. These are as follows.

1.      The operator should remove the least amount of tooth tissue consistent with necessary mechanical retention.

2.      This should be done with the least barm to the periodontal tissues and the pulp.

3.      It should be done with the least discomfort to the patient.

4.      No pathologic reactions should be initiated in the pulp.

Advantages of high speeds

1.      Smaller stones can be used at the increased speeds.

2.      Less fatigue results both for the patient and operator.

3.      Due to high speed, very light pressure is required.

4.      Less vibrations are felt by the patient.

5.      The chairside time for a given preparation is considerably reduced.

6.      Trauma to the pulp is reduced.

7.      The efficiency and life of the cutting tools is increased.

8.      Because of small tools, control is easy.

9.      Removal of old amalgam and gold restorations is easy.

Disadvantages of high speeds

1.      The increased speed creates increased temperatures in the tooth. Therefore some method of cooling the tooth more efficiently is required not to injure the pulp. This necessitates additional equipment.

2.      When a dentist changes from the lower speeds, which utilize a pressure in pounds, to high speeds which need only a pressure in ounces, he must develop a new technique and retrain himself to a new tactile sense.

3.      To operate at high speeds good visibility of the cutting instrument is necessary to avoid over cutting.

4.      Due to the ease with which tooth tissue is removed, caution must be taken not to injure the proximal enamel of the adjacent healthy tooth and the gingiva.

5.      High speeds result in greater wear on the working parts of the handpiece, necessitating more frequent repairs and replacements.

6.      Unless used properly, high speeds have a tendency to create striations on a tooth surface.

7.      The ideal preparation for any type of restoration cannot be accomplished by using high speed equipment alone. The final exactness and finishing line can best be established by instruments revolving at moderate speeds.

Types of high speed instruments

Hand piece can be divided into four types depending upon their speeds as follows.

1.      Low speed – upto 10,000 rpm.

2.      Intermediate speed – 25,000 to 45,000 rpm.

3.      High speeds – 50,000 to 1,00,000 rpm.

4.      Ultra high speeds 1,00,000 rpm and over.

Kilpatric has further classified the ultra high speed handpiece into three classes.

Type I – the gear driven centre-angle handpiece, upto1,25,000 rpm.

Type II – the belt driven contra-angle handpiece upto 2,00,000 rpm.

Type III – turbine driven air contra-angle handpiece upto 3,00,000 rpm and higher.

Heat generation:

Knowledge of the physics tells us that, whenever there is friction between two surfaces, heat is generated, which may bring about rise in temperature of either or both the surfaces. The same applies in the tooth reduction procedures. Here the rotating cutting tools come in contact with the tooth surface and the heat is generated.

It was not until 1930 that the workers began to investigate the heat rise in the dental pulp.

There are many factors that influence the rise in temperature which takes place in cutting operations. The greater the speed of rotation of the cutting tool, the faster the tool revolves, the higher the resultant temperature. It has been found that the temperature rise develops within 10-12 seconds, after the cutting operation is started. Size of the cutting instrument has an important bearing on heat generation, since, its diameter affects the cutting speed at its periphery. Larger the size of the cutting tool more the host generation.

A third factor is the pressure applied by the dentist during cutting operation. As the pressure increases, greater will be the rise in temperature.

Hudson and associates in 1954 conducted a study on temperature developed in dental cutting instruments from their study they have concluded that,

1.      The temperatures produced by dental burs in cutting human dentin ranged from 125°F to 275°F. Since these temperatures are above those, said to be tolerated by normal human dentin, it would seem advisable to use some form of coolant.

2.      A significant decrease in time required to accomplish a given operation is apparent, when high operating speeds are used.

3.      The amounts of heat transferred to the tooth from the bur decreases, at speeds above 12000 rpm, since cutting time at these speeds is reduced and bur temperature remains.

Substantially constant and there is less heat trauma to the vital structures.

Coolants:

From the study of Hudson and Sweeney, it is evident that the temperatures reached during tooth reduction procedures are above those said to be tolerated by normal human dentins. This indicates that, some form of coolant must be used, during the cutting operations, particularly when high speeds are used.

Every means should be employed to keep the temperature down as much as possible during cutting operations. Coolants must employed which, to be effective, should be applied at the point of contact between the cutting instrument and the tooth tissue. There are three types of coolants usually employed in dental practice.

1.      Water.

2.      Spray of air and water

3.      Air alone.

Peyton has shown that at speeds ranging from 30000 rpm to 170000 rpm and with an application of four ounces of pressure, a temperature rise within the tooth of less than 15°C occurred when water or air-water sprays were employed. He also found that even with a water coolant, excessive temperatures developed, when large diameter instruments or excessive pressure were applied with increased operating speeds. This indicates that the use of  a coolant, does not eliminate the danger of excessive temperature rise.

A reduction in concentration of the amount of water used during cutting procedure shows the significant temperature rise of the dental bur.

The minimum volume of water to be applied was estimated at 1.5 ml per minute.

The question whether water in spray form should be used at mouth or temperature seems to have no significance as far as temperature rise in the tooth was concerned. Tylman is of the opinion that if the water reservoir is kept at 100°F, it is most comfortable to the patient, less liable to be harmful to the pulp and still reduces the heat of friction during cutting.

There are certain other problems associated with the use of the highspeed cutting tools. Most of the hand pieces are so designed that a spray or stream of water is directed from the head of the handpiece directly onto the cutting operation. Where the water strikes the tooth and the cutting tool directly, full benefit is obtained from the coolant. Where however, the abrasive on the cutting tool, is on the surface away from the stream of water, water does not flood the tooth surface being cut, resulting in excessive temperature rise. The overcome this difficulty perforated disks have been developed, which permit the water to go through the openings and lubricate the disk and tooth on the cutting side. The use of perforated disk results in less temperature rise. Consequently when disks are non perforated, and when the stream of water cannot be directed to the cutting contact areas, they should be used at speeds not exceeding 10,000 rpm.

Another advantage of a water coolant lies in the fact that the tooth debris from the cutting is removed rapidly, preventing the clogging of the cutting tools. This results in greater cutting efficiency of the stone. Also, it prolongs the life and effectiveness of the instrument. It is essential that the water be in intimate contact with the revolving instrument and the tooth tissue.  To do this more effectively, Nelson recommended the addition of a wetting agent to the water spray.

Because the high speed technique requires a larger quantity of water as a coolant, there is the problem of removing this water from the mouth. To have the dentist stop frequently to allow the patient to spit out the excess water is time consuming. The customary saliva ejector has insufficient removal capacity.

To solve this problem, Thompson has suggested a washed field technique.

This technique adapts the suction or vacuum principle. It established and maintains a powerful but gentle negative pressure of air in the mouth, close to the field of operation.

Accompanying the air stream, is a flow of isothermal water which is projected copiously onto the operative field. This water is entrained into the vacuum air stream, which draws it rapidly across the operative area. The irrigant pulls away with it tooth cuttings and debris. These are taken into the vacuum air stream and disposed off in a filter system. A clean, clearly visible operative field is provided. This technique has the distinct advantages that it facilitates the use of high speed instruments, maintains visibility during copious irrigation of the operative field, reduces operating time, improves the patient’s well being and introduces a new concept of cleanliness. Human tissues are maintained in their natured wet safe pain, trauma and postoperative complication, which may arise due to ingestion of tooth debris are reduced.

Desiccation of hard and soft tissues is avoided. Heat is eliminated thus preserved the tissues.

Vibration:

Cutting a tooth may be very annoying and unpleasant to the patient but still not be painful. In pain there is usually an involvement of the nerve endings, either by trauma or extreme irritation, resulting in an acute, painful reaction. Most patients associate the sensation of vibration, noise, pressure and the slight increase in cutting temperature with the sensation of pain. Consequently, if the factors of vibration, heat and pressure are reduced to a minimum, the patient usually experience reduced or no pain.

One mechanical factor that influences vibration is the dental handpiece, whether it is friction-bearing, ball bearing, high speed belt driven or turbine ultra speed. When the friction bearing, conventional type of handpiece is used at a speed of 4500 rpm to 6000 rpm, it is connected by the conventional belt and pulley system of the dental engine. In this case one may expect a high order of vibration depending upon the condition of various mechanical parts, their adjustment and speeds of their operation.

Pulleys that are worn, a worn belt, or an improperly adjusted belt will cause vibrations that are transmitted down to the cutting tool. Similarly hand piece which do not hold the cutting tool properly, which have worm bearing or are out of adjustment will also cause vibration.

The investigations of Walsh and Symmoss showed that vibration, when applied to tooth, produced the most unfavorable response when the frequency was between 100 cps and 200 cps. When the frequencies were above 1000 cps, they were generally beyond the upper threshold of perception of the average patient. It is the lower frequencies, in the range of 100 – 200 cps, that are usually developed at the lower speeds, especially if the equipment is worm and maladjusted.

Hudson and Sweeney have reported the importance of having centricity in the cutting tool. They found that eccentric burs when rotated at 6000 to 10000 rpm produced a lower frequency in the range of 100-200 cps, whereas a true running bur at 10000 rpm produced vibrations in the frequency range above the upper threshold.

Tamner pointed out that only a part of an eccentric cutting tool is used as it rotates, thus causing unfavorable impacts and vibrations, which fall into the most annoying frequency range. The disks and stones that are unmounted and are screwed onto a mandrel very frequently are eccentric and therefore should not be used in high speed cutting operations. The permanently mounted instruments are indicated in preference to unmounted type.

Poorly built burs with blades not evenly cut or chipped will likewise cause vibration. In using carbide burs, it is very important the see that none have chipped blades.

Correct adjustment of the belt is important in the reduction on and elimination of vibration. A belt that is too loose increases the vibration pattern transmitted directly to the tooth.

In the ultra highspeed hand pieces the metal chuck holding the cutting instrument often is replaced by a rubber or plastic chuck. This lessens the vibration transmitted to the cutting instrument and facilitates the more rapid cutting action.

In cutting with a water turbine handpiece at 45,000 rpm the intensity of vibrations was well tolerates by the patient.

Morrison and Grinnel made the following observations.

The deleterious effects of vibration are two fold in origin.

1.      Amplitude.

2.      Undesirable modulating frequencies.

If we minimize or eliminate these factors, we can then reduce the undesirable effects of vibration.

Amplitude: The wave of vibration consists of frequency and amplitude.

At conventional speeds, amplitude is greater but frequency is less. At higher speeds the reverse is true. The greatest harm is caused by the amplitude of vibration which is the factor, most destructive of instruments and which causes the most apprehension in the patient and the greatest fatigue in the dentist.

By increasing operating speeds, the amplitude and its effects are reduced and a more satisfactory result is attained.

Vibration waves are measured in cycles per second. It has been shown that rotation of approximately 6000 rpm sets up a vibrational wave of approximately 100 cps. As the rpm is increased the cps of the fundamental vibration wave are increased until, at ranges of 100000 rpm, we have a vibration wave of 1600 cps. It has been demonstrated that at wave of vibration of over 1300 cps, vibration is practically imperceptible to the patient. The reason for this is not fully understood, but there are two theories for this phenomenon.

(1)  The Wedensky inhibition phenomenon – frequency increased to a point where vibratory perception diminishes due to failure to perceive vibration. This is because Stimulation occurs during Refractory Period of Recovery. 

(2)  Vibratory perception depends upon the product of the amount of stimulation (i.e. pressure) multiplied by the frequency of stimulation necessary for a reaction. This is called Chronaxie. As the speeds above 1,00,000 rpm, due to light pressure and high speeds, chronaxie is attained, which is necessary for reaction.

Thus it can be concluded that, the more the rpm, the less the amplitude, and the greater the frequency. Vibratory perception will be lost in the ultra highspeed range of 1,00,000 rpm or more.

Spread of pathogenic organisms by Ultra speed cutting procedures:

Atmospheric contamination through the spread of oral organisms particularly from air turbine action has been a concern of the dental profession for some time. Dental procedures tend to expose the operator to infectious diseases. Recent studies suggest that the extent of aerosol produced by air turbine may increase the normal hazard. A report involving patients with pulmonary tuberculosis cultures were demonstrated on all petri dishes exposed during cutting procedures, with the heaviest concentration being at 2 feet in distances from the patients mouth. This indicates that the dentist and his assistant are exposed to a serious health hazard when operating with an ultra speed exposed instrument on patients having such pathogens in their oral flora. When a patient’s history suggests the existence of tuberculosis, pneumonia, influenza, infections hepatitis or any infectious diseases including the common cold, a protective face mask should be worn by both dentist and assistant. During all ultrahigh speed cutting procedures, protective eye-glasses should be worm routinely.

SUCK-BACK PHENOMENON- The operation of the turbine is switched off by closing the compressed-air valve abruptly. Then, owing to its own kinetic energy, the turbine continues its rotation, so that the turbine starts operating as an air pump. This causes a negative pressure in the area of the turbine shaft. The negative pressure sucks air from the environment that can be contaminated by aerosols of saliva and blood of the patient.

Size of cutting instrument and cutting speeds:

It has been pointed out by Peyton, and Nelson that, the important factor of increased operating speeds is the instrument surface speed in fact per minute rather than the revolution per minute of the instrument.

The larger the diameter of the cutting instrument, the slower the speed required at the spindle. The specific phase in preparation of an abutment should determine the size of the cutting instrument and the rpm that should be used. Employing superspeed for all operations places unnecessary strain upon the patient and equipment. If the same effect can be accomplished by using a larger instrument at a lower speed, but still remaining above the threshold of perception, this should be done. However, oversized cutting tools should not be used at super speeds due to the difficulty of instrument control and accuracy of cutting.

VIBRATION SYNDROME : the perception of vibration, pain, touch and temperature deteriorates. The negative effect of local vibrations occurs within the range 5-1400 hz, the most harmful being those below 16 hz. mechanical vibrations arise because the various machines operating at the dentist’s workplace contain moving parts. The main source is vibrating power-driven or air-driven instruments, such as low- and high-speed handpieces as well as ultrasonic instruments.                               The vibrations emitted by these machines travel directly from the handles to the operator’s hand. These are local vibrations.

Biologic response of dentin and pulp to high speed cutting:

Dentin: As the contents of the dentinal tubules are in direct continuity with the odontoblasts, and pulp, cutting or grinding the dentin causes a reaction in the pulp and this may lead to changes in the dentin.

An early experimental investigation into the effect of cavity preparation on the dentin and pulp was carried out by Fish in 1932. He cut cavities in the teeth of dogs and left the cavities open to the saliva. By sealing dyes into the pulp chambers of the treated teeth he has shown that one of two reactions is produced in the dentin.

In some cases there was sclerosis of the cut dentinal tubules which forms a protective some sealing off the pulp from the injury and underneath this region, there is a further growth of tubular dentine. These reactions are produced by the stimulation of the odontoblasts. The other reaction that resulted was the formation of dead tracts. With this lesion some or all of the odontoblasts, that are in connection with the cut tubules die. On the pulpal aspect of these tubules, hyaline mineralized barrier, secondary dentine is laid down, thereby sealing the lesion from the pulp.

Pulp: The changes in the pulp have been studied by Langeland and Morslard and Shovelton. They state that the damage to the pulp is to a large extent due to the heat generated. They have shown that when precautions are taken to minimize heat production by using burs rotated slowly in a speed reducing handpieces, the only evidence of pulp damage was a slight reduction of the odontoblast layer with the displacement of a small number of odontoblasts into the dentinal tubules. When speeds upto 5,000 rpm were employed, there was more extensive displacement of odontoblasts associated with marked vacuolization of the odontoblast layer, and local hemorrhages may be seen in the pulp. As the speed was increased, the changes became more severe. When tooth reduction was done under a stream or spray of water, the damage to the pulp was markedly reduced.

Pulp changes associated with tooth reduction using the air abrasive technique have been studied by Kennedy and using ultrasonic technique by Mitchell and Jenson. The changes in both the cases are similar to those produced at the speeds of 5,000 rpm.

The effects on the pulp of using high speed rotary instruments such as the air turbine have been investigated by Marsland and Shovelton. The changes found are no severe than those produced at lower operating speeds provided that adequate cooling of the cutting instrument by water jet or air/water spray is ensured.

Alterations in the hard tissues of tooth cut by air turbines have been observed. The enamel over a wide area of crown may show minute cracks and the dentin shows altered staining reactions as a result a local overheating.

RECENT DEVELOPMENT:

‘ANTI-SUCK BACK’- Planmeca compact dental units, the turbine drive air is not shut off abruptly but controlled down by allowing the driving air to decrease gradually. The software of the dental unit will keep on supplying the drive air into the turbine according to carefully chosen parameters. This way there is no possibility for the build-up of a vacuum effect that would cause suck-back.

Ceramic bearings- no need of lubrication and more resistant to autoclave sterlization.

Use of quartz rods instead of fibre-optic.

Easy-to-use push-button bur releases.

Swivel systems.

Titanium handpieces.

Smaller head size.

n  ELECTRICAL HIGH SPEED HANDPIECES

advantages are:

More power and torque than air turbine handpieces. 

Better bur concentricity.

Less vibration and noise.

Broad, controllable speed ranges.

Forward/reverse option are available.

 With appropriate attachments, one system can be used for restorative, prosthodontics, prophies and endodontics.

Disadvantages are :

Heavier than air turbine.

More expensive.

Learning curve may be required.

Attachment heads not as small as the small-head air turbines.

May not be able to fully replace the air turbine.

Infection control concerns.

Discussion

It is for more than 125 years, that rotary instruments have been in use, for tooth reduction operations, in different forms, from a hand rotary instrument to ultra sonic instruments, which have the rotational speeds ranging from very low speeds in case of band rotary instruments to 5,00,000 rpm in case of air bearing hand piece. These remarkable advances in the instruments have greatly reduced fatigue in the operator because of the physical case of manipulation and have considerably increased the comfort to the patient by reducing the actual working time and pressures required for tooth reduction, thereby minimizing the factors of heat generation and pain. Though high speed techniques have been a born to the dental profession, they have their can limitations. It is interesting to not that, in spite of considerable improvements in tooth reduction procedures and the instruments used for the same, the principles and biologic objectives have not changed.

These improved methods of tooth tissue removal have a potential to damage the healthy teeth and surrounding structures, if they are used without proper understanding of their working and if they are used without taking proper care. Improper handling of these modern equipment may also be different to the longevity and working capacity of the instruments themselves.

For successful and efficient use of those cutting tools, certain factors should be given consideration. Heat that is generated, while the tooth tissue is being removed must be kept, down to the minimum and at the sametime, whatever heat is generated, must be eliminated as efficiently and as quickly as possible by employing coolants, in any one of three forms commonly used i.e. water, air/water spray or air alone. Simultaneously with the coolant, if water or air/water spray is used, an efficient mechanism for remove of the water from the oral cavity must be employed. Otherwise, the clinical procedure is delayed, if the patient has to spit out the water, every now and then. By eliminating the water evacuation equipment, we are losing one of the advantages of these high speed instruments i.e. reduced working time for a particular preparation. Use of efficient coolants, not only eliminate the heat generated, but at the same time, keeps the operating area clean and free of any debris.

High speed cutting methods have a further advantages in that, they reduce the annoyance that may be caused to the patient, when low speeds are used with the modern high speed cutting devices, the vibration produced is of a frequency that is generally beyond the upper threshold of perception of the average patient.

Pressures that have to be employed in the use of high speeds are considerably reduced, in comparison with those needed for low speeds.

Thus, when the factors of pressure, temperature and vibration are kept within the tolerance limits, the patient comfort is certainly improved.

Size of the cutting tool to be used for particular tooth reduction procedure is an important consideration, particularly while using high speeds. Oversized cutting tools should be avoided, as they are difficult to control and at the same time, the accuracy of tooth preparation on procedure is also adversely affected.

Biologic reactions of the tooth tissues, particularly dentin and pulp, should not be over locked, when high speeds are employed for tooth reduction operation. These responses have been studied by a number of people and they have shown that, the response are not significantly different from those, when low speeds are used, provided, effective coolants are employed.

Thus it can be concluded that, high speed equipments for tooth reduction if used with proper understanding and due care, provide definite advantages over the conventional low speed cutting procedures. This fact places the high speed devices at definitely a higher level as against their low speed counterparts.

Conclusions

1.      High speed cutting devices, if used with a thorough understanding of their mechanism and due care to the biologic integrity of teeth and surrounding structure, are a boon to dentistry.

2.      In the process of tooth reduction using high speeds considerable amount of heat is generated and an effective coolant is a must for preservation of tooth integrity and patient comfort.

3.      Vibration is increased with the increase in speed, but it is beyond the threshold of prerception of the normal human beings and hence not harmful.

4.      Biologic reactions of the dentin and pulp, to high speed cutting, cannot be overlooked.

Summary

A brief history of rotary instruments has been presented. A critical evaluation of the high speed cutting devices, as to their advantages, disadvantages, and precautions to be taken during their use, has been assessed at length. Biologic reactions of dentin and pulp, to high speed cutting have been discussed in brief.

 

 Contents

I.       Introduction

II.    Review of Literature

a.     Advantages of high speeds

b.     Disadvantages of high speeds

c.     Types of high speed instruments

d.     Heat generation

e.     Coolants

f.      Vibration

g.     Spread of pathogenic organisms

h.     Size of cutting instruments and cutting speeds

i.       Biologic responses of dentin and pulp to high speed cutting

III.             Discussion

IV.            Conclusion

V.               Summary