Amalgam Substitutes: A Critical Analysis

Purpose: Quality standards for restorations recently have been defined in Switzerland. Amalgam substitutes must meet restoration Grade 2 requirements (i.e., pulp and dental hard substance must be preserved, and both form and function of the tooth have to be reconstituted). The pertinent operative technique has to be simple and amalgam‐like. A minimum service life of 8 years is required. This in vitro study investigated the clinical potential of several amalgam substitutes, taking into account the operative requirements, the defined restorative guidelines, and the required service life. Materials and Methods: Potential amalgam substitutes evaluated in this study included compomers (Compoglass, Dyract, Dyract AP, Elan, F 2000) and resin‐based composites (Alert, Ariston, Definite, Nulite, Solitaire, Surefil). The composites Adaptic and Tetric Cream, using a simplified placement technique, were tested as negative and positive controls, respectively. Marginal adaptation and wear properties were measured in vitro in mixed Class II cavities. Relative radiopacity was measured in terms of millimeters of equivalent aluminum. Results: All compomers showed a radiopacity of 2.5 mm or more aluminum. Only Dyract AP and Elan were more wear resistant than amalgam. After stressing, the percentage of continuous margin was at best 31% overall and 17% in dentin only. Among resin‐based composites, the minimum requirements of radiopacity were fulfilled only by Alert, Surefil, and Tetric. Only Definite, Surefil, Solitaire, and Tetric exhibited wear resistance greater than amalgam. After stressing, the best marginal qualities were 41% continuous margin overall, and 8% in dentin only. CLINICAL SIGNIFICANCE Based on the requirements set for amalgam substitutes, results for the materials tested in this study indicated poor marginal quality and potential risk of secondary caries. Currently, the use of amalgam substitutes for stress‐bearing restorations in permanent teeth cannot be recommended without serious cautions. This is particularly true if a dynamic performance quality of the restorations is demanded, which guarantees the achievement of the restorative targets for 8 years, according to recently adopted quality standards.