Teaching of posterior composite resin restorations in undergraduate dental schools in Ireland and the United Kingdom

PURPOSE: The aim of this study was to investigate the current teaching of posterior composite resin restorations to undergraduate dental students in Ireland and the United Kingdom (UK). The investigation was a follow-up to a survey undertaken in 1997. MATERIALS AND METHODS: A questionnaire was distributed by e-mail to the Heads of Departments of Restorative Dentistry/Units of Operative Dentistry in each of the 15 dental schools with undergraduate dental degree programmes in Ireland and the UK. The questionnaire sought information relating to the teaching of posterior composite resin restorations in each dental school. RESULTS: Fifteen completed questionnaires were returned (response rate = 100%). All schools (n = 15) taught the placement of composite resin restorations in occlusal cavities, 14 schools taught composite resin placement in two-surface occlusoproximal cavities and nine schools taught composite resin placement in three-surface occlusoproximal cavities. Respondents anticipated that the amount of preclinical teaching of posterior composite resin placement will increase twofold over the next 5 years, whilst the corresponding teaching of amalgam will fall to two-thirds its current level. Variation was found between dental schools in the teaching of the principles of cavity design, contraindications to placement, indications for lining and basing techniques, matrix and wedging techniques, and the use of curing lights. CONCLUSIONS: The amount of teaching of posterior composite resin restorations in undergraduate dental schools in Ireland and the UK has increased since the time of a previous survey in 1997. Composite resin may soon equal or overtake amalgam as the material of choice when restoring posterior cavities in Irish and UK dental schools. There was, however, much variation in the nature and extent of the teaching and the techniques taught.     

Complete restoration with resin-bonded porcelain inlays

The use of porcelain inlays, instead of composite resin, as a restorative material for posterior teeth has greatly improved the standards of esthetic dentistry. The development of compatible materials enables the fabrication of all-ceramic restorations on refractory investment material without expensive technical equipment. Special care in and knowledge of this new technique by the dentist and the technician are necessary to obtain restorations with excellent marginal adaptation and a highly esthetic appearance.     

Two-year clinical evaluation of direct and indirect composite restorations in posterior teeth.

STATEMENT OF PROBLEM: Few long-term clinical studies have reported data of modern posterior composites as direct and indirect restorations. PURPOSE: This prospective, long-term clinical trial (1) evaluated direct and indirect composite restorations for clinical acceptability as posterior restoratives in single or multisurface carious teeth and (2) provided a survey on the 2-year results. MATERIAL AND METHODS: Nine dental students placed 88 composite restorations (Tetric, blend-a-lux, Pertac-Hybrid Unifil), 43 direct composite restorations and 45 indirect inlays, under the supervision of an experienced dentist. The first clinical evaluation was performed 11 to 13 months after placement by 2 other experienced dentists, using modified USPHS criteria. A second follow-up of 60 restorations took place within 20 to 26 months after placement. RESULTS: A total of 93% of indirect and 90% of direct composite restorations were assessed to be clinically excellent or acceptable. Two restorations (1 indirect composite inlay and 1 margin of a direct composite restoration) failed during the second year because of fracture. Indirect inlays demonstrated a significantly better "anatomic form of the surface" than direct composite restorations. Premolars revealed a significantly better margin integrity and postoperative symptoms than molars. CONCLUSION: Posterior composite restorations provided a satisfactory clinical performance over a 2-year period when placed by relatively inexperienced but supervised students.     

Tooth-colored inlays and onlays

Today's dental patient concerned about attractive restorations is looking for a dentist who incorporates the newest and best techniques into practice. This article discusses a newer concept that pleases both the patient and dentist: restorations that are bonded into acid-etched tooth preparations with composite resin cement--tooth-colored inlays and onlays. Basic questions asked by practitioners about these esthetic restorations are addressed; characteristics, performance expectations, comparisons with cast gold inlays and onlays, and comparisons with amalgam are presented, in addition to other relevant information for today's dental practitioner.     

Direct posterior resin composite restorations: new techniques and clinical possibilities. Case reports.

Direct adhesive resin composite restorations in posterior teeth are now a reality thanks to improvements in these restorative materials and adhesive techniques. However, correct selection and application of materials are vastly important to clinical success. Two restorative techniques are described in detail, in one, a low-viscosity resin composite is placed incrementally, and in the other a condensable resin composite is placed in bulk. The former allows for greater security, because it is more traditional and has already proved to have clinical longevity; the latter has the advantage of being a quicker and simpler procedure. However, both techniques provide restorations that faithfully copy the dental tissues and have all the advantages of adhesive procedures.     

Three-year clinical evaluation of direct and indirect composite restorations in posterior teeth

STATEMENT OF THE PROBLEM: Objective long-term clinical data are necessary to assess the performance of modern posterior composites as direct and indirect restorations. PURPOSE: This prospective, long-term clinical trial evaluated direct and indirect composite restorations for clinical acceptability as posterior restoratives in single or multisurface cavities and provided a survey on the 3-year results. MATERIAL AND METHODS: Under the supervision of an experienced dentist, 9 dental students placed 88 composite restorations (Tetric, blend-a-lux, Pertac-Hybrid Unifil), 43 direct composite restorations, and 45 indirect inlays. Clinical evaluation was performed at baseline and in yearly intervals after placement by 2 other experienced dentists, using modified USPHS criteria. A third follow-up of 60 restorations took place within 33 to 36 months after placement. RESULTS: A total of 93% of indirect and 87% of direct restorations were assessed to be clinically excellent or acceptable. During the third year, 1 direct restoration in a molar failed because of margin opening. Indirect inlays exhibited a significantly better anatomic form of the surface than direct composite restorations. Premolars revealed a significantly better marginal integrity and anatomic form of the surface than molars. Restorations in molars exhibited a significantly higher failure rate compared with premolars. CONCLUSION: Posterior composite restorations provided a satisfactory clinical performance over a 3-year period, even if placed by relatively inexperienced but supervised students.     

Trends in material choice for posterior restorations in an Israeli dental school: composite resin versus amalgam

According to a recent American Dental Association survey, posterior composite resin restorations now outnumber amalgam restorations in the United States. Dental schools around the world vary considerably in the extent to which they teach the use of composite resins. We aimed to determine if there has been an increase in the placement of posterior composite restorations in an Israeli dental school and if faculty experience affects the type of posterior restoration placed. In this retrospective study, we recorded and analyzed all the restorations performed by undergraduate students in the last five academic years at the Hebrew University Hadassah School of Dental Medicine in Jerusalem. All clinical records of student treatments between 2004 and 2009 were screened, and direct restorations were registered. Out of 6,094 posterior restorations performed during the study period, 42.3 percent were made of composite resin, increasing from 36.8 percent in 2004-05 to 48.5 percent in 2008-09, an increase of 11.7 percent. When clinical instructors were asked to state their preference if they themselves were to undergo posterior restoration, similar results were obtained. Instructors with less than ten years' experience preferred posterior composite resin restorations in 54.8 percent of the hypothetical situations, compared with 37.2 percent preferred by instructors with ten years of experience or more. It appears that the use of composite resin was influenced mainly by the prevailing trend and was not based on scientific evidence. Dental faculties should define criteria, based on up-to-date clinical studies, for using new materials, taking into consideration differences among instructors regarding treatment concept.     

Clinical challenges and the relevance of materials testing for posterior composite restorations.

Posterior composite restorations have been in use for approximately 30 years. The early experiences with this treatment indicated there were more clinical challenges and higher failure rates than amalgam restorations. Since the early days of posterior composites, many improvements in materials, techniques, and instruments for placing these restorations have occurred. This paper reviews what is known regarding current clinical challenges with posterior composite restorations and reviews the primary method for collecting clinical performance data. This review categorizes the challenges as those related to the restorative materials, those related to the dentist, and those related to the patient. The clinical relevance of laboratory tests is discussed from the perspective of solving the remaining clinical challenges of current materials and of screening new materials. The clinical problems related to early composite materials are no longer serious clinical challenges. Clinical data indicate that secondary caries and restoration fracture are the most common clinical problems and merit further investigation. The effect of the dentist and patient on performance of posterior composite restorations is unclear and more clinical data from hypothesis-driven clinical trials are needed to understand these factors. Improvements in handling properties to ensure void-free placement and complete cure should be investigated to improve clinical outcomes. There is a general lack of data that correlates clinical performance with laboratory materials testing. A proposed list of materials tests that may predict performance in a variety of clinical factors is presented. Polymerization shrinkage and the problems that have been attributed to this property of composite are reviewed. There is a lack of evidence that indicates polymerization shrinkage is the primary cause of secondary caries. It is recommended that composite materials be developed with antibacterial properties as a way of reducing failures due to secondary caries. Post-operative sensitivity appears to be more related to the dentin adhesives' ability to seal open dentinal tubules rather than the effects of polymerization shrinkage on cuspal deflections and marginal adaptation.     

A clinical evaluation of posterior composite resin restorations

There is a trend towards manufacturers seeking to provide dentists with a single, all-purpose composite resin, usually of the small particle hybrid type. This three-year clinical study compared the clinical performance of three different types of composite resin used in posterior teeth and identified several modes of failure. Of the 330 restorations (three composite resins and one amalgam control) initially placed in 72 patients, 223 restorations in 48 patients were available for evaluation at three years. Modified clinical criteria for assessing the restorations were able to discriminate among the composite resins. A microfilled composite and a small particle hybrid exhibited increasing evidence of marginal fracture (crevice) with time. In addition, the small particle hybrid showed evidence of wear at the margins more frequently than the other materials. Of the restorations available for assessment, four restorations of each of these two types of composite resin required replacement during the study. Coarse particle hybrid restorations showed evidence of wear but little evidence of marginal fracture.     

Survey on the teaching and use in dental schools of resin-based materials for restoring posterior teeth

A survey was conducted of 100 dental schools worldwide to investigate the current teaching of posterior resin composite restorations. A 20 multi-part question questionnaire was emailed to the selected schools. Schools were selected by ability to understand and respond in English. The questionnaire consisted of four open-ended questions and 16 closed questions on topics such as material selection for restoring posterior teeth, preclinical teaching of resin composite for posterior teeth, restoration size, contraindications, matrix placement methods, lining use, adhesive selection and finishing. Forty-six schools responded. The outcomes showed all schools included the teaching of resin composite for posterior restorations but varied. The majority of schools (63%) no longer taught amalgam as the preferred posterior restorative material. Half of the schools surveyed set numerical clinical requirements for restoration placement. Australian schools had no requirements whilst 92% of Asian schools did. There was a consensus that larger restorations were less suitable for resin composite. Selection of adhesives depended on region. Generally, the schools surveyed showed minor variations philosophically in teaching of the use and placement of resin composite restorations.     

Finishing and polishing of direct posterior resin restorations.

Direct composite resin materials have revolutionized the delivery of minimally invasive treatment in the posterior region. Contemporary resin formulations provide improved strength, wear resistance, and aesthetics. Microhybrid formulations have also been associated with enhanced polishability. Development of an optimal surface polish in turn reduces stain and plaque accumulation, minimizes wear, and enhances the appearance of the definitive restoration. This article presents a simplified technique and protocol for finishing and polishing composite resin materials following restoration of the posterior region. LEARNING OBJECTIVES: This article discusses techniques and a protocol for finishing and polishing posterior direct resin restorations. Upon reading this article, the reader should: Understand the clinical protocol necessary to create direct posterior resin restorations that require minimal finishing. Be able to select appropriate instrumentation for direct posterior resin finishing and polishing procedures. Understand the importance of correct finishing and polishing on plaque accumulation, stain resistance, and wear resistance.     

Assuring restorative integrity in extensive posterior resin composite restorations: pushing the envelope.

Clinicians are increasingly being called on to satisfy the restorative demands of patients who request tooth-colored restorations but are unable to afford an optimum indirect restorative option. Consequently, in clinical practice, the limits of the direct posterior resin composite technique are being stretched. There is a need for techniques that will satisfy the complex variables of clinical practice and allow for successful utilization of posterior resin composite in large cavity preparations. The objective of this article is to explain the rationale behind the materials and techniques involved in the delivery of these complicated restorations.     

Three-year randomised clinical trial to evaluate the clinical performance, quantitative and qualitative wear patterns of hybrid composite restorations

The aim of the study was to compare the clinical performance, quantitative and qualitative wear patterns of conventional hybrid (Tetric Ceram), micro-filled hybrid (Gradia Direct Posterior) and nano-hybrid (Tetric EvoCeram, TEC) posterior composite restorations in a 3-year randomised clinical trial. Sixteen Tetric Ceram, 17 TEC and 16 Gradia Direct Posterior restorations were placed in human molars and evaluated at baseline, 6, 12, 24 and 36 months of clinical service according to US Public Health Service criteria. The gypsum replicas at each recall were used for 3D laser scanning to quantify wear, and the epoxy resin replicas were observed under scanning electron microscope to study the qualitative wear patterns. After 3 years of clinical service, the three hybrid restorative materials performed clinically well in posterior cavities. Within the observation period, the nano-hybrid and micro-hybrid restorations evolved better in polishability with improved surface gloss retention than the conventional hybrid counterpart. The three hybrid composites showed enamel-like vertical wear and cavity-size dependant volume loss magnitude. Qualitatively, while the micro-filled and nano-hybrid composite restorations exhibited signs of fatigue similar to the conventional hybrid composite restorations at heavy occlusal contact area, their light occlusal contact areas showed less surface pitting after 3 years of clinical service.     

Clinical evaluation of a visible light-cured indirect composite for long-term provisionalization

OBJECTIVE: To clinically evaluate a visible light-cured (VLC) resin composite system for long-term provisional and esthetic diagnostic restorations, fabricated using indirect techniques. METHODS: One-hundred and nine teeth were restored in 31 patients. Preoperational impressions were used to create VLC resin composite restorations (Radica) using indirect techniques. Restorations were relined as necessary and placed using various provisional cements at a follow-up appointment, subsequent to preparation of the teeth. Both fabricating laboratory technicians and placing dentists rated the restorations for acceptability in esthetics, marginal fit, occlusion, and functionality in various stages of provisionalization. RESULTS: All restorations (100%) were rated acceptable for esthetics prior to relining. After relining, a majority (93-100%) of restorations were rated acceptable in esthetic and functional criteria. At the placement of the permanent restoration, a majority (96-100%) of restorations were rated acceptable in esthetic and functional criteria. Terms of service ranged from two to seventy-six days. CONCLUSION: In combination with in vitro results, the clinical performance of the Radica VLC system for provisionalization and esthetic diagnostic restorations was judged to be acceptable. The system offers esthetics that are superior to conventional provisional restorations, and should be a valuable option to practitioners considering longer-term provisionalization in complex cases.     

Clinical strategies for esthetic excellence in anterior tooth restorations: understanding color and composite resin selection

Direct composite resin restorations have become a viable alternative for patients that require anterior restorative procedures to be integrated to the other teeth that compose the smile, especially for presenting satisfactory esthetic results and minimum wear of the dental structure. Technological evolution along with a better understanding of the behavior of dental tissues to light incidence has allowed the development of new composite resins with better mechanical and optical properties, making possible a more artistic approach for anterior restorations. The combination of the increasing demand of patients for esthetics and the capacity to preserve the dental structure resulted in the development of different incremental techniques for restoring fractured anterior teeth in a natural way. In order to achieve esthetic excellence, dentists should understand and apply artistic and scientific principles when choosing color of restorative materials, as well as during the insertion of the composite resin. The discussion of these strategies will be divided into two papers. In this paper, the criteria for color and material selection to obtain a natural reproduction of the lost dental structures and an imperceptible restoration will be addressed.     

What German dentists choose for their teeth: A Web-based survey of molar restorations and their longevity

Statement of problemWhich restorative material is best suited for treating the posterior molar region is unclear. As dentists presumably choose the most appropriate restoration, German dentists were asked how their own molars were treated.PurposeThe purpose of this survey study was to examine molar restorations and their durability in German dentists.Material and methodsIn the official journal of the Federal Dental Association, German dentists were asked to participate in an online survey that gathered demographic data and information on the type and durability of their molar restorations. To reduce selection bias, the data were weighted for region, sex, and age of the dentist.ResultsThe data set consisted of 1719 molars from 288 dentists. Restorations included gold inlays (25%), composite resin (24.3%), amalgam (11.8%), ceramic inlays (5.4%), glass ionomer cement or compomer (0.8%), gold crowns (21.8%), ceramic crowns (6.6%), and metal-ceramic crowns (4.3%). Notable differences were identified based on the sex, age, and region of the dentist. Women selected increased esthetic options, as did young dentists. Restorations made of gold, amalgam, and base metal had the highest longevity, at more than 20 yearsConclusionsAmong German dentists, restorations with metallic materials dominated in molars, with gold accounting for the largest share. In recent years, the proportion of tooth-colored restorations has increased, and in particular, young dentists use composite resin and ceramics.     

Amalgam and composite posterior restorations: curriculum versus practice in operative dentistry at a US dental school

This study recorded the number of preclinical lecture and simulation laboratory sessions spent teaching the preparation and placement of amalgam and resin composite posterior restorations. These data were compared to the use of both materials in the operative clinic as placed by third- and fourth-year students. The number of posterior restorations inserted by the students, expressed as a function of the number of restoration surfaces, was also evaluated. The results show that the teaching of posterior restorations pre-clinically has consistently favored amalgam 2.5 to 1 during the last three years. However, clinically, resin composite is being used for posterior restorations 2.3 times more often than amalgam. The only instance that favored amalgam over composite during the last year was in the placement of four surface posterior restorations. This shift in emphasis from amalgam to composite needs to be addressed within dental educational institutions so that newly graduated dentists are prepared to place composite restorations properly.     

A new approach to restorative dentistry: fabricating ceramic restorations using CEREC CAD/CAM

Ceramic materials provide an alternative when choosing a tooth-colored restoration. Currently, posterior composite restorations can be used to achieve esthetic restorations; however, they have many disadvantages with regard to wear, polymerization shrinkage, discoloration, marginal leakage, and technique sensitivity. The use of CEREC CAD/CAM enables the dentist to place feldspathic porcelain (Vitablocs Mark II) and machinable glass ceramic (Dicor MGC) restorations in a single visit. When compared to composite materials, these materials closely approximate the physical properties of enamel in compressive and tensile strength and wear resistance. This study evaluated 50 CEREC CAD/CAM restorations after 4 years in service. Restorations ranged from Class I to 7/8s crown preparations.     

Critical appraisal. Class II composite resin restorations with gingival margins in dentin

The rising demand for esthetic restorations has considerably increased the number of direct composite restorations being placed in private practices. While composite resin is often selected primarily for its esthetic qualities, another significant advantage of direct composite restorations is the ability to perform conservative cavity preparations. The traditional configuration used for amalgam restorations is no longer mandatory; thus, more sound tooth structure can be preserved.
The technique of composite placement is complex when compared to amalgam placement. The use of adhesive systems prior to placement of composite restorations requires not only excellent isolation to avoid contamination, but also precise manipulation of the adhesive system. While stable bonds to enamel are routinely obtained, the heterogeneous composition and intricate morphology of dentin makes this substrate more challenging to restore. In addition, the cavity configuration (C-factor) and inherent polymerization shrinkage of composite resin play an important role in the durability of the composite–dentin interface. Class II preparations often have gingival margins in root surfaces because of the location of the caries lesion. Clinicians are then faced with a preparation that is challenging to isolate, has a relatively high C-factor, and relies on optimal bonding to dentin to secure long-lasting marginal integrity. Various restorative techniques, such as incremental placement or the use of an intermediate layer (flowable composite or resin-modified glass ionomer cements—open sandwich technique), have been some of the methods proposed to increase the longevity of composite restorations, especially those with margins in dentin. This review evaluates some of the published research on Class II composite resin restorations with margins in the dentin/cementum.     

Despite all--do we have an appropriate substitute for amalgam?

The ultimate success or failure of a restored tooth is largely dependent on clinical management. Clinicians may choose from a number of restorative materials, different clinical techniques and cavity preparation procedures. Composite resin has been used for nearly 50 years as a restorative material in dentistry. The use of this material has recently increased as a result of patients' demands for esthetic restorations. Failure of dental restorations is a major concern in dental practice. Replacement of failed restorations constitutes the majority of operative work. Clinicians should be aware of the longevity of, and likely reasons for the failure of, direct posterior restorations. Higher failure rates were observed in resin-based composite restorations as compares amalgam restorations. Secondary caries was the main reason for failure. Posterior interproximal resin-based composite restorations should be considered with caution, and their limited long-term performance should be kept in mind. Patients should be informed about the potential longevity of restorative treatment for posterior teeth as they make decisions about treatment for their oral restorative needs.