Susanne Gerhardt-Szep1*, Elke Schröder-Schichtel2, Quanita Zücker3, Tugba Zahn4, Stefanie Feierabend5 and Stefan Rüttermann1
1Department of Operative Dentistry, Carolinum Dental University-Institute GmbH, J.W. Goethe University, Frankfurt am Main, Germany
2Bavarian Association Dental health e.V. (LAGZ), München, Germany
3Dental office, Riedstadt, Germany
4Department of Prosthetic Dentistry, Carolinum Dental University-Institute GmbH, J.W. Goethe University, Frankfurt am Main, Germany
5Department of Restorative Dentistry and Periodontology, University Medical Center Freiburg, Germany
Received: 23 June, 2016; Accepted: 12 July, 2016; Published: 14 July, 2016
PD Dr. Susanne Gerhardt-Szep, MME, Department of Operative Dentistry, Carolinum Dental University-Institute GmbH, J.W. Goethe University, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany, Tel: +49-69-6301-7505; E-mail:
Gerhardt-Szep S, Schröder-Schichtel E, Zücker Q, Zahn T, Feierabend S, et al. (2016) Problems of Direct Composite Posterior Restorations: A Clinical Study. J Dent Probl Solut 3(1): 035-039.10.17352/2394-8418.000032
© 2016 Gerhardt-Szep S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Resin composites; Clinical trial; Modified FDI criteria; In vivo; In vitro
The aim of this clinical study was to describe the quality of posterior composite restorations (n = 329) performed on a group of patients (n=219) during an observation period of three years at various intervals (6, 12, 18, 24 and 36 months) after application.
The parameters were assessed both In vivo and In vitro using clinical examinations, impressions and photography according to modified FDI criteria. For the statistical analysis of the results, the Wilcoxon test with a significance level of p = 0.05 was applied.
After three years, In vivo five from the seven parameters exhibited significant changes. Only “retention” and “approximal contact” remained unchanged. In vitro studied parameters “anatomical form”, “occlusal contour/wear” and “approximal contact” did not result in any significant changes, however “marginal adaptation”, “surface luster” and “overhangs” deteriorated significantly.
In summary, the results of this study show that composite posterior restorations were clinically acceptable in terms of specific parameters. However, unsatisfactory results have arisen in relation to the handling of composites, stated In vivo and In vitro especially in the reconstruction of the marginal adaptation, surface and overfilling.
In recent years, the increasing demand for aesthetically appealing, naturally-coloured dental restoration options has given rise to a growth in the use of composites in the posterior dental area [1-5]. The declining acceptance of dental amalgam and the mercury problem also makes an alternative to amalgam necessary [6,7]. In a statement from the German Scientific Association for Operative Dentistry and European Federation of Conservative Dentistry, it is defined, that indications for the use of direct composite systems may vary according to specific circumstances . Three different indications are named in this statement, including restorations of tooth structure and contour, shape changing restorations and combinations of these possibilities . However it remains clear, that restorations in the posterior area, which are subject to high mechanical stresses, should always be performed using materials with high strength and good radiopacity properties. Many authors of comparable long-term studies referred to the use of hybrid composites, as only such materials demonstrated both superior restoration margin stability and much better physical properties, including adequate abrasion resistance and flexural strength, which maked them suitable replacements for amalgam [1,9-11]. To meet the requirements of good long-term clinical and aesthetically appealing therapy results using a composite filling, it is also essential to consistently adhere to processing parameters. Even the smallest deviations from the application recommendations can cause clinical failures [7,12-14].
In order to carry out clinical investigations of composite materials most researchers used different criteria (for example the traditional United States Public Health Service / USPHS also known as 'Ryge criteria') . The 16 “FDI clinical criteria” for the evaluation of direct and indirect restorations were first published in 2007 and have since been applied by some investigators in clinical studies on resin composite restorations in posterior teeth . The criteria were categorized into three groups: esthetic parameters (four criteria), functional parameters (six criteria) and biological parameters (six criteria). Each criterion can be expressed with five scores, three for acceptable and two for non-acceptable (one for reparable and one for replacement) situations. They are however not definitely fixed; modifications and/or alterations are possible . Comparing the FDI- and the USPHS-criteria for the evaluation of restorations in deciduous teeth authors concluded that the newer FDI method was more sensitive for identifying differences in deciduous composite resin restorations . Potential clinically assessed problems can thus be elicited by using them.
Therefore, the purpose of this study was to evaluate the clinical performance and potential problems of posterior composite restorations in a period of three years after application at different time intervals on the basis of modified FDI criteria. The primary outcome was defined using functional parameters in regard of the approximal contact, marginal adaptation, occlusal contour / wear, overhangs and retention. Secondary outcomes included esthetic parameters like the anatomical form and surface luster of the restoration.
Material and Methods
In the context of this long-term study, posterior composite restorations applied using an ultra-fine hybrid composite (Herculite XRV, Kerr, Karlsruhe, Germany) in the student courses of the clinical semesters at the Department of Operative Dentistry, Carolinum Dental University-Institute GmbH in Frankfurt / Main (Germany) were given follow-up examinations. The restorations were all applied after predefined clinical protocol (for example: 1. no bevelling of the preparation; 2. Consistent rubberdam application; 3. consistent metal matrix band application; 4. Total-Etch-Technique performed with Optibond FL (Kerr, Karlsruhe, Germany); 5. Incremental composite application technique in 2 mm layers each and 6. Surface contouring / finishing using carbide or fine diamond burs).
Two trained examiners carried out the rating and ranking procedures. Finally, in a case of disagreement between both, the less favorable rating was noted. The evaluation intervals of 6, 12, 18, 24 and 36 months after the application of the restorations were selected. The fillings were examined and photographed In vivo at these intervals. To enable a differentiated evaluation, all restorations were additionally assessed on the basis of replica models.
Patient group and examination intervals
Patient selected met the following criteria: 1. absence of pain; 2. Application of posterior composite restorations in the student courses of the department of operative dentistry in the last 36 months; 3. Application after predefined protocol; 4. age 18-70 years. A total of 229 patients were requested by letter to participate in the program. 219 patients attended the follow-up examinations during which it was possible to examine 329 composite posterior dental restorations. Not all of the included restorations were examined consistently with the specified intervals.
Clinical follow-up examinations
The restorations were inspected and evaluated subjectively on all surfaces (mesial = m, occlusal = o and distal = d) in accordance with modified FDI-criteria (Figure 1). To assess the quality of the approximal restoration margin, dental floss (Johnson & Johnson, New Brunswick, USA) was used. If the dental floss got caught in the contact area or split open, it could be assumed that there was excess filling. The approximal contact was assessed using metallic matrix bands with a thickness of 0.03 mm (Hawe-Neos, Bioggio, Switzerland). The quality criterion for the contact point strength was defined as the subjective force required to overcome the resistance or the number of matrix bands that could be inserted into the approximal area. All data by clinical means were documented on follow-up examination forms standardised for this work. The parameters under examination were first graded individually (value A, B or C) on the corresponding surfaces (m, o, d) of the restoration. Finally, to be able to derive a clinical acceptance result in the form of an overall grade, the evaluation standards (A, B, C) were translated into individual grades (1, 2 and 4) based on their relevance (Figure 2).
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