Q U I N T E S S E N C E I N T E R N AT I O N A L
RESTORATIVE DENTISTRY
Hans Jörg Staehle
More conservative dentistry: Clinical long-term results of direct composite resin restorations Hans Jörg Staehle, Prof Dr med, Dr med dent1/Diana Wolff, Priv-Doz Dr med dent2/Cornelia Frese, Dr med dent3 Current treatment protocols and recent developments in composite resin technology allow for extended indication of direct composite resin restorations. This article presents clinical longterm observations of direct composite resin restorations indicat-
ed for primary and replacement therapy, repair restorations, direct crowns, and composite buildups for the correction of tooth form. (Quintessence Int 2015;46:373–380; doi: 10.3290/j.qi.a33718; originally published in Quintessenz 2014;65(5):547–555)
Key words: direct composite buildups, direct composite resin restorations, esthetic correction, long-term results, posterior dentition
Today, direct composite resin restorations are applied successfully for the minimally invasive treatment of all kinds of Black’s classes. Various treatment techniques (single-phase or two-phase) allow for the restoration of both small and extensive lesions of the dental hard tissues. In addition, in recent years, composite resin technology has opened new indications in restorative dentistry. New treatment techniques, including repair restorations, direct composite resin crowns of anterior and posterior teeth, and direct composite resin buildups, which are made in the anterior region mainly for esthetic reasons and in the posterior dentition for closing single-tooth gaps as an alternative to fixed dental prostheses or implants, have been described
1
Head of Department, Department of Conservative Dentistry, School of Dental Medicine, Ruprecht Karls University, Heidelberg, Germany.
2
Associate Professor, Department of Conservative Dentistry, School of Dental Medicine, Ruprecht Karls University, Heidelberg, Germany.
3
Senior Dentist, Department of Conservative Dentistry, School of Dental Medicine, Ruprecht Karls University, Heidelberg, Germany.
Correspondence: Professor Hans Jörg Staehle, Department of Conservative Dentistry, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany. Email: [email protected]
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recently.1-11 Furthermore, the use of fiber-reinforced composite materials in restorative dentistry contributes to the extension of treatment indications for composite resin restorations in conservative dentistry. Several investigations have been published with special regard to mid- and long-term clinical performance of extended composite resin restorations.1-11 However, clinical data with regard to the latest composite resin treatment techniques in restorative dentistry are limited. In the present article, clinical longterm observations of direct composite resin restorations, which were partly made in an unconventional manner, are presented. The following clinical treatment protocols are described: • long-term observations of primary restorative therapy in the posterior region • long-term observations of replacement restorations in the posterior region • long-term observation of a repair restoration • long-term observation of a direct composite resin crown in the anterior region • long-term observation of a direct composite resin crown in the posterior region
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Figs 1a to 1j Clinical long-term observation of direct resin composite restorations (primary therapy) after a period of 14.5 years. (a) Caries lesion on tooth 14 (occlusal) and tooth 16 (occlusal and distal). (b) Radiographic image of the initial situation (increased radiolucency on tooth 14 occlusal and tooth 16 buccal, ambiguous radiographic finding on tooth 17 mesial). (c) The situation after cavity preparation of teeth 14 and 16. No cavitation was visible on tooth 17 mesial. (d) Finished restoration on teeth 14 and 16; fissure sealing on teeth 15 and 17. (e) Detailed image of tooth 16. (f) Radiographic control: increased radiopacity due to direct composite resin restorations on teeth 14 and 16; ambiguous radiographic finding on tooth 17 mesial was still visible. During the follow-up period the clinical and radiographic situation showed no failure or pathologic findings. (g) Recall after 14.5 years revealed no pathologic findings. The direct composite resin restorations presented as clinically excellent. (h) Detailed image of tooth 16: the 14.5-year-old composite resin restoration (occlusal-distal) was hardly visible. (i) Clinical examination of interdental cleaning (no plaque accumulation, no bleeding). (j) Radiographic control image after 14.5 years. No pathologic signs were visible, even on tooth 17 mesial.
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long-term observation of a direct composite resin buildup for esthetic correction in the anterior area long-term observation of a direct composite resin buildup for interdental space closure in the posterior area.
Long-term observations of primary restorative therapy in the posterior region For primary restorative therapy in the posterior area, the options of a minimally invasive approach are particularly favorable. This also applies to subgingivally located defects beyond the cementoenamel junction, if they are sufficiently accessible, such as the example shown in Fig 1 on the maxillary right first molar (tooth 16 according to FDI notation, distal). Approximal surfaces, showing no cavitation in the clinical inspection (maxillary right second molar [tooth 17] mesial in this instance) can be subjected to monitoring, particularly if
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radiographic findings are unclear. Even by the use of a minimally invasive cavity preparation, Black’s principles of “relief form” should not be disregarded. On the maxillary right first premolar (tooth 14), it is clear that the ampoule-shaped occlusal cavity design restricts the visual inspection of the entire cavity. The currently available wear-resistant composites would also allow for a slightly larger occlusal cavity form without clinical disadvantages, and thus offer more convenience in cavity design and insertion of the restorative material. It is difficult to answer if the fissure sealing, which was made in addition to the restorative therapy in this case, contributed to better protection against caries lesions. In any event, the treatment result is successful even after almost 15 years.
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Figs 2a to 2d Clinical long-term observation of direct composite resin restorations (replacement restorations) after a period of 17 years. (a) Insufficient restorations with secondary caries on teeth 17 to 14. (b) Situation after cavity preparation and placement of rubber dam. (c) Extended direct composite resin restorations on teeth 14 to 17. The patient did not attend regular recall appointments. (d) After 17 years, the patient did attend a clinical examination. Apart from slight discolorations and marginal irregularities, the restorations presented as clinically excellent and no secondary caries occurred.
Long-term observations of replacement of restorations in the posterior region When replacing restorations, the restorative treatment is necessarily limited to the existing cavity shape. According to current principles of minimally invasive adhesive technique, as shown in Fig 2, extensive cavities could be restored on teeth 14 and 17. Despite the absence of regular recall appointments, after a period of 17 years, the restorations presented as largely intact, apart from some marginal discoloration and irregularities. In Fig 3, the typical approach of a direct composite resin restoration made in a single-step treatment procedure, the so-called R1-technique, is described in detail. Although the mandibular right second premolar (tooth 45) showed extensive destruction, with this R1-technique an adequate morphologic design, continuous marginal fit, and sufficient proximal contact was achieved. The prerequisite for a successful treatment is the use of appropriate materials and hand instruments, eg an anatomically pre-contoured sectional matrix, a separation ring, and a special hand instrument to create sufficient proximal contacts, as
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shown in Figs 3d to 3f. If there are deep and subgingival lesions next to the alveolar bone, the practicability of the single-step R1-technique is limited. Here, the so-called R2-technique, which is carried out in two steps of treatment, is preferable. Details of this procedure can be found in Frese et al.12-14
Long-term observation of a repair restoration Restorative materials based on different kinds of resin monomers can be adhesively polymerized to various substrates like enamel, dentin, cast metal alloys, ceramic materials, and composite resins, depending on the surface preconditioning. This material-specific possibility offers new options for repair restoration in diverse fields.15,16 Clinical observations of repair restorations are promising, although repair procedures can still be improved and optimized.6 However, randomized controlled clinical trials are needed to improve the reliability of the evidence.9 A repair restoration of a ceramic inlay located on a mandibular molar is presented in Fig 4. After an observation period of 14 years, the marginal quality of the
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Figs 3a to 3k Clinical example of the R1-technique. (a) Extensive caries decay on tooth 45 (occlusal-distal-oral). (b) Radiographic image of the initial situation (image was taken a few days before; therefore, radiopacity due to an insufficient interim restoration was visible). (c) The situation with rubber dam after cavity preparation of the vital tooth 45 showing no clinical symptoms of endodontic infection. (d) The situation after the placement of a sectional matrix and a separation ring, etching, rinsing, and application of an adhesive system after the manufacturer’s instructions (Optibond FL, Kerr). A small amount of flowable composite was applied on the bottom of the cavity and a second viscous composite resin was placed on the non-polymerized flowable composite. A special hand instrument to form tight proximal contacts was used here. (e) Detailed image of a proximal contact former (OptraContact, Ivaclar Vivadent). (f) The situation after removal of the proximal contact former. (g) Finished restoration. (h and i) Clinical follow-up after 1 year without pathologic findings. Periodontal probing depths were between 2 and 3 mm, with no bleeding on probing. (j) Radiographic image after one year without pathologic findings. (k) Clinical follow-up after 3 years, still without pathologic findings.
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Figs 4a to 4f Long-term observation of a direct restoration made for repair of a ceramic inlay after 14.5 years. (a) A mandibular molar with a fractured ceramic inlay. (b and c) The situation after minimally invasive cavity preparation, airborne-particle abrasion, etching with buffered hydrofluoric acid (Porcelain-Etch, Ultradent) and phosphoric acid, rinsing, drying, application of silane and an adhesive system, insertion of composite resin material, and finishing and polishing. (d) Clinical examination of interdental cleaning. (e) Recall after 8 years: no pathologic findings, the repair restoration (occlusal-distal) was hardly visible (arrow). (f) Recall after 14.5 years: still without pathologic findings (arrow).
composite-ceramic interface of the repair restoration is not worse than the ceramic-luting composite-enamel margin of the original restoration. Repair restorations are an important part of restorative therapy in conservative dentistry, including subtractive procedures like removal of marginal overhangs, finishing, and polishing, as well as various additive procedures.
Long-term observation of a direct composite resin crown in the anterior region Over a period of time, indirect fabricated cast metal or ceramic crowns have been the gold standard of treatment for restorative rehabilitation of extensively
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destroyed teeth (often combined with a root canal post after endodontic treatment). Today, adhesive composite technology offers the possibility of restoring extensive cavities with direct composite resin crowns. Although the stability has to be considered as limited, the choice of this treatment option seems to be justified with regard to minimally invasive principles, provided that the patient gives consent. Figure 5 shows a direct composite resin crown on a maxillary right lateral incisor (tooth 12) after an observation period of 15 years. If failure of the crown occurs after this time, this treatment option can still be classified as a success, as more invasive procedures could be delayed over a long period.
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Figs 5a to 5h Long-term observation of a direct composite resin crown in the anterior area after 15.5 years. (a) The situation after deep uncomplicated crown fracture of the vital tooth 12. (b) The situation after application of rubber dam. (c) Direct composite resin crown. (d) The periodontal situation without pathologic findings: probing depth was between 2 and 3 mm, with no bleeding on probing. (e) Clinical examination of interdental cleaning with dental floss. (f) Clinical examination of interdental cleaning with an interdental brush. (g) Recall after 15.5 years. (h) The direct composite resin crown presented as clinically excellent: probing depth between 2 and 3 mm, with no bleeding on probing.
Long-term observation of a direct composite resin crown in the posterior region The direct restoration technique of partial or complete cusp coverage in the load-bearing posterior region shows equal and, in some cases superior, clinical performance.2 Figure 6 shows a premolar with infaust prognosis that was scheduled to be extracted.17 As a conservative treatment was desired by the patient, a direct composite resin crown was built up adhesively after an endodontic revision of the root canal filling. The macro-retention of the composite crown was not realized not by an endodontic post but by a “composite tag” inserted in the upper third of the root canal system as part of the direct composite crown. Recent studies have shown that the geometric area of the adhesive surface in the root canal, rather than the accuracy of fit or the absolute length of the endodontic post, is crucial for fracture resistance.18,19 Although the observation period exceeded 15 years, the therapeutic option of a direct composite resin crown, as presented in Fig 6, has to be considered as experimental.
Long-term observation of a direct composite resin buildup in the anterior area The correction of tooth form and color in the anterior area can be realized by various direct and indirect res-
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toration techniques. In conservative dentistry, the technique of direct composite resin buildups is used to fulfill the principles of esthetic dentistry.3,20 Due to increased wear resistance and color stability of modern composite resin materials, direct composite resin buildups are even appropriate for corrections of severely discolored or hypoplastic teeth.21 Figure 7 shows the maxillary incisors of a 12-year-old girl. The maxillary central and lateral incisors (teeth 12 to 22) were treated with direct composite resin veneers to optimize the surface texture (the restorative treatment of the maxillary canines [teeth 13 and 23] followed a few years later alio loco). With regard to marginal quality, tooth color, and anatomic form, the direct composite resin buildups presented as clinically excellent after more than 12 years of observation. The incorporation of macroscopic elements into the buccal surface (grooves, pits, etc) is a possibility to improve the natural shape of anterior teeth. However, in this case it was not desired by the patient.
Long-term observation of a direct composite resin buildup in the posterior area In case of a single missing tooth in the posterior region, the gold standard of treatment is a laboratory-made prosthesis or an implant-supported single crown. In
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Figs 6a to 6p Long-term observation of a direct composite resin crown in the posterior area after 15 years. (a) The situation after loss of retention of the laboratory-made crown with endodontic post on tooth 14. (b) Extensive subgingival defect of the clinical crown. (c) Radiographic image showed a periapical translucency and an insufficient endodontic root canal treatment. (d) The situation after application of rubber dam. (e) The situation after revision of the root canal filling. (f) Direct composite resin crown. (g) The situation directly after restorative treatment. (h) Image of the radiographic control. (i to k) Recall after 7 years. (l to n) Recall after 12 years. (o and p) Recall after 15 years. The direct composite resin crown in the posterior region presented as clinically excellent. A slight discoloration was visible on the occlusal surface that could be removed by polishing (see Fig 6m).
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Figs 7a to 7h Long-term observation of a direct composite resin buildup in the anterior area after 12.5 years. (a and b) Discolored and hypoplastic teeth of a 12-year-old girl. (c and d) Tooth color and shape of teeth 12 to 22 were corrected by direct composite resin buildups. (e and f) The situation directly after restorative treatment. (g and h) Recall after 12.5 years; the patient was 25 years old at this point. The color and anatomical form of the direct composite resin buildups presented as clinically excellent (a few years later, direct composite resin buildups on teeth 13 and 23 were made elsewhere).
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Figs 8a to 8l Long-term observation of a direct composite resin buildup in the anterior area after 10 years. (a to c) Single missing tooth 15, the insertion of an implant-supported single crown or laboratory-made prostheses was not desired by the patient. (d to f) The situation directly after restorative treatment with composite resin buildups. (g) Radiographic control. (h and i) Clinical and radiographic control after 2 years. (j) Clinical examination of interdental cleaning with an interdental brush after 9 years. (k and l) Recall after 10 years: the direct composite resin buildups in the posterior area presented as clinically excellent.
rare cases, an orthodontic treatment is carried out. The abandonment of invasive procedures as a non-invasive treatment alternative can be an option in clinical situations that are esthetically and functionally uncomplicated. However, this treatment option is rarely proposed to the patient.22 Even an interdental space closure by direct composite resin buildups in the posterior dentition is rarely considered (Fig 8), although this treatment method offers various advantages. The technical procedure is described in detail elsewhere.23-29
CONCLUSION Although case reports represent a low level of evidence and do not provide complete representative data, the long-term clinical results of more than 10 years of obser-
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vation that are shown here emphasize that extended indications of direct restorations made of composite resin materials are a reliable treatment alternative. The underlying treatment concept can be summarized as follows: “Preventive interventions as offensive as possible, restorative interventions as defensive as possible”.23,24,28,30 This approach covers both medical decisionmaking and aspects of dental public health. Compared to extensive prosthetic and surgical treatment alternatives, this conservative and minimally invasive approach provides affordable and socially acceptable dental care that is beneficial for a wide part of the population.30,31 The developments expected in biomaterial research and the increase of skills concerning the processing and handling of direct restorations render this segment of conservative dentistry very promising.
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REFERENCES 1. Al-Khayatt AS, Ray-Chaudhuri A, Poyser NJ, et al. Direct composite restorations for the worn mandibular anterior dentition: a 7-year follow-up of a prospective randomised controlled split-mouth clinical trial. J Oral Rehabil 2013;40:389–401. 2. Fennis WM, Kuijs RH, Roeters FJ, Creugers NH, Kreulen CM. Randomized control trial of composite cuspal restorations: Five-years results. J Dent Res 2014;93:36–41. 3. Frese C, Schiller P, Staehle HJ, Wolff D. Recontouring teeth and closing diastemas with direct composite buildups: a 5 year follow-up. J Dent 2013;41: 979–985. 4. Frese C, Schiller P, Staehle HJ, Wolff D. Fiber-reinforced composite fixed dental prostheses in the anterior area: A 4.5-year follow-up. J Prosthet Dent 2014;112:143–149. 5. Opdam NJ, Bronkhorst EM, Loomans BA, Huysmans MC. 12-year survival of composite vs. amalgam restorations. J Dent Res 2010;89:1063–1067. 6. Opdam NJ, Bronkhorst EM, Loomans BA, Huysmans MC. Longevity of repaired restorations: a practice based study. J Dent 2012;40:829–835. 7. Peumans M, Van Meerbeek B, Lambrechts P, Vanherle G. The 5-year clinical performance of direct composite additions to correct tooth form and position. II. Marginal qualities. Clin Oral Investig 1997;1:19–26. 8. Peumans M, Van Meerbeek B, Lambrechts P, Vanherle G. The 5-year clinical performance of direct composite additions to correct tooth form and position. I. Esthetic qualities. Clin Oral Investig 1997;1:12–18. 9. Sharif MO, Catleugh M, Merry A, et al. Replacement versus repair of defective restorations in adults: resin composite. Cochrane Database Syst Rev 2014;2:CD005971. 10. Wolff D, Kraus T, Schach C, et al. Recontouring teeth and closing diastemas with direct composite buildups: A clinical evaluation of survival and quality parameters. J Dent 2010;38:1001–1009. 11. Wolff D, Schach C, Kraus T, Joerss D, Ding P, Staehle HJ. Fiber reinforced composite bridges: A retrospective clinical examination. J Adhes Dent 2011;13:187–194. 12. Frankenberger R, Hehn J, Hajto J, et al. Effect of proximal box elevation with resin composite on marginal quality of ceramic inlays in vitro. Clin Oral Investig 2013;17:177–183. 13. Frese C, Wolff D, Staehle HJ. Proximal box elevation with resin composite and the dogma of biological width: Clinical R2-technique and critical review. Oper Dent 2014; 9:22–31. 14. Roggendorf MJ, Kramer N, Dippold C, et al. Effect of proximal box elevation with resin composite on marginal quality of resin composite inlays in vitro. J Dent 2012;40:1068–1073.
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15. Staehle HJ. Reparatur eines frakturierten Keramikinlays – eine Langzeitbeobachtung. Quintessenz 2009;60:705–711. 16. Staehle HJ. Reparatur zahnärztlicher Restaurationen. Zahnärzteblatt BadenWürttemberg 2011;39:30–32. 17. Staehle HJ. Restauration eines “hoffnungslosen” Zahnes mittels direkter Kompositkrone – Langzeitbericht. Quintessenz 2006;57:531–537. 18. Krastl G, Gugger J, Deyhle H, Zitzmann NU, Weiger R, Müller B. Impact of adhesive surface and volume of luting resin on fracture resistance of root filled teeth. Int Endodont J 2011;44:432–439. 19. Scotti N, Scansetti M, Rota R, Pera F, Pasqualini D, Berutti E. The effect of the post length and cusp coverage on the cycling and static load of endodontically treated maxillary premolars. Clin Oral Invest 2011;15:923–929. 20. Klaiber B. Alles noninvasiv – Zahnformveränderung, Lückenschluss, Reduktion schwarzer Dreiecke. Zahnärztl Mitt 2006;96:52–59. 21. Staehle HJ. Zahnformanomalie - Langzeitbeobachtung nach minimalinvasiver restaurativer Therapie. Quintessenz 2009;60:1177–1183. 22. Staehle HJ. Nutzen-Risiko-Abwägung - Die Balance zwischen Unter- und Überversorgung. Zahnärztl Mitt 2010;100:892–898. 23. Staehle HJ. Minimally invasive restorative treatment (invited position paper). J Adhesive Dent 1999;1:267–284. 24. Staehle HJ. Prophylaxeorientierte Füllungstherapie. In: Roulet J-F, Zimmer S (eds). Prophylaxe und Präventivzahnmedizin. Farbatlanten der Zahnmedizin 16. Stuttgart: Thieme, 2003. 25. Staehle HJ. Lückenschluss im Seitenzahnbereich durch Zahnverbreiterungen. Zahnärztl Mitt 2007;97:410–417. 26. Staehle HJ. Eine neue Methode zum Lückenschluss im Seitenzahnbereich durch direkt vorgenommene Zahnverbreiterungen. Quintessenz 2009;60:145–154. 27. Staehle HJ. Lückenschluss im Seitenzahnbereich durch direkte Zahnverbreiterungen. Zahnmedizin Up2date 2010;4:283–299. 28. Staehle HJ. Lückenschluss im Seitenzahnbereich durch direkte Zahnverbreiterungen als Alternative zu prothetischen und implantologischen Eingriffen. Stomatologie 2012;109:103–110. 29. Wolff D, Hahn P, Ding P, et al. Proximal contact strength between directcomposite additions in the posterior dentition: an in vitro investigation. Oper Dent 2012;37:272–280. 30. Staehle HJ. Zahnmedizinische Unter-, Fehl- und Überversorgung. Stellungnahme. In: Sachverständigenrat für die Konzertierte Aktion im Gesundheitswesen (ed). Gutachten 2000/2001 Band III.4: Zahn-, Mund- und Kieferkrankheiten. Baden-Baden: Nomos Verlagsgesellschaft, 2002. 31. Staehle HJ. “Low-Tech”-Dentistry. Gasteditorial Dental Magazin 2010;28:99.
VOLUME 46 • NUMBER 5 • MAY 2015
RESTORATIVE DENTISTRY
Hans Jörg Staehle
More conservative dentistry: Clinical long-term results of direct composite resin restorations Hans Jörg Staehle, Prof Dr med, Dr med dent1/Diana Wolff, Priv-Doz Dr med dent2/Cornelia Frese, Dr med dent3 Current treatment protocols and recent developments in composite resin technology allow for extended indication of direct composite resin restorations. This article presents clinical longterm observations of direct composite resin restorations indicat-
ed for primary and replacement therapy, repair restorations, direct crowns, and composite buildups for the correction of tooth form. (Quintessence Int 2015;46:373–380; doi: 10.3290/j.qi.a33718; originally published in Quintessenz 2014;65(5):547–555)
Key words: direct composite buildups, direct composite resin restorations, esthetic correction, long-term results, posterior dentition
Today, direct composite resin restorations are applied successfully for the minimally invasive treatment of all kinds of Black’s classes. Various treatment techniques (single-phase or two-phase) allow for the restoration of both small and extensive lesions of the dental hard tissues. In addition, in recent years, composite resin technology has opened new indications in restorative dentistry. New treatment techniques, including repair restorations, direct composite resin crowns of anterior and posterior teeth, and direct composite resin buildups, which are made in the anterior region mainly for esthetic reasons and in the posterior dentition for closing single-tooth gaps as an alternative to fixed dental prostheses or implants, have been described
1
Head of Department, Department of Conservative Dentistry, School of Dental Medicine, Ruprecht Karls University, Heidelberg, Germany.
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Associate Professor, Department of Conservative Dentistry, School of Dental Medicine, Ruprecht Karls University, Heidelberg, Germany.
3
Senior Dentist, Department of Conservative Dentistry, School of Dental Medicine, Ruprecht Karls University, Heidelberg, Germany.
Correspondence: Professor Hans Jörg Staehle, Department of Conservative Dentistry, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany. Email: [email protected]
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recently.1-11 Furthermore, the use of fiber-reinforced composite materials in restorative dentistry contributes to the extension of treatment indications for composite resin restorations in conservative dentistry. Several investigations have been published with special regard to mid- and long-term clinical performance of extended composite resin restorations.1-11 However, clinical data with regard to the latest composite resin treatment techniques in restorative dentistry are limited. In the present article, clinical longterm observations of direct composite resin restorations, which were partly made in an unconventional manner, are presented. The following clinical treatment protocols are described: • long-term observations of primary restorative therapy in the posterior region • long-term observations of replacement restorations in the posterior region • long-term observation of a repair restoration • long-term observation of a direct composite resin crown in the anterior region • long-term observation of a direct composite resin crown in the posterior region
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Figs 1a to 1j Clinical long-term observation of direct resin composite restorations (primary therapy) after a period of 14.5 years. (a) Caries lesion on tooth 14 (occlusal) and tooth 16 (occlusal and distal). (b) Radiographic image of the initial situation (increased radiolucency on tooth 14 occlusal and tooth 16 buccal, ambiguous radiographic finding on tooth 17 mesial). (c) The situation after cavity preparation of teeth 14 and 16. No cavitation was visible on tooth 17 mesial. (d) Finished restoration on teeth 14 and 16; fissure sealing on teeth 15 and 17. (e) Detailed image of tooth 16. (f) Radiographic control: increased radiopacity due to direct composite resin restorations on teeth 14 and 16; ambiguous radiographic finding on tooth 17 mesial was still visible. During the follow-up period the clinical and radiographic situation showed no failure or pathologic findings. (g) Recall after 14.5 years revealed no pathologic findings. The direct composite resin restorations presented as clinically excellent. (h) Detailed image of tooth 16: the 14.5-year-old composite resin restoration (occlusal-distal) was hardly visible. (i) Clinical examination of interdental cleaning (no plaque accumulation, no bleeding). (j) Radiographic control image after 14.5 years. No pathologic signs were visible, even on tooth 17 mesial.
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long-term observation of a direct composite resin buildup for esthetic correction in the anterior area long-term observation of a direct composite resin buildup for interdental space closure in the posterior area.
Long-term observations of primary restorative therapy in the posterior region For primary restorative therapy in the posterior area, the options of a minimally invasive approach are particularly favorable. This also applies to subgingivally located defects beyond the cementoenamel junction, if they are sufficiently accessible, such as the example shown in Fig 1 on the maxillary right first molar (tooth 16 according to FDI notation, distal). Approximal surfaces, showing no cavitation in the clinical inspection (maxillary right second molar [tooth 17] mesial in this instance) can be subjected to monitoring, particularly if
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radiographic findings are unclear. Even by the use of a minimally invasive cavity preparation, Black’s principles of “relief form” should not be disregarded. On the maxillary right first premolar (tooth 14), it is clear that the ampoule-shaped occlusal cavity design restricts the visual inspection of the entire cavity. The currently available wear-resistant composites would also allow for a slightly larger occlusal cavity form without clinical disadvantages, and thus offer more convenience in cavity design and insertion of the restorative material. It is difficult to answer if the fissure sealing, which was made in addition to the restorative therapy in this case, contributed to better protection against caries lesions. In any event, the treatment result is successful even after almost 15 years.
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Figs 2a to 2d Clinical long-term observation of direct composite resin restorations (replacement restorations) after a period of 17 years. (a) Insufficient restorations with secondary caries on teeth 17 to 14. (b) Situation after cavity preparation and placement of rubber dam. (c) Extended direct composite resin restorations on teeth 14 to 17. The patient did not attend regular recall appointments. (d) After 17 years, the patient did attend a clinical examination. Apart from slight discolorations and marginal irregularities, the restorations presented as clinically excellent and no secondary caries occurred.
Long-term observations of replacement of restorations in the posterior region When replacing restorations, the restorative treatment is necessarily limited to the existing cavity shape. According to current principles of minimally invasive adhesive technique, as shown in Fig 2, extensive cavities could be restored on teeth 14 and 17. Despite the absence of regular recall appointments, after a period of 17 years, the restorations presented as largely intact, apart from some marginal discoloration and irregularities. In Fig 3, the typical approach of a direct composite resin restoration made in a single-step treatment procedure, the so-called R1-technique, is described in detail. Although the mandibular right second premolar (tooth 45) showed extensive destruction, with this R1-technique an adequate morphologic design, continuous marginal fit, and sufficient proximal contact was achieved. The prerequisite for a successful treatment is the use of appropriate materials and hand instruments, eg an anatomically pre-contoured sectional matrix, a separation ring, and a special hand instrument to create sufficient proximal contacts, as
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shown in Figs 3d to 3f. If there are deep and subgingival lesions next to the alveolar bone, the practicability of the single-step R1-technique is limited. Here, the so-called R2-technique, which is carried out in two steps of treatment, is preferable. Details of this procedure can be found in Frese et al.12-14
Long-term observation of a repair restoration Restorative materials based on different kinds of resin monomers can be adhesively polymerized to various substrates like enamel, dentin, cast metal alloys, ceramic materials, and composite resins, depending on the surface preconditioning. This material-specific possibility offers new options for repair restoration in diverse fields.15,16 Clinical observations of repair restorations are promising, although repair procedures can still be improved and optimized.6 However, randomized controlled clinical trials are needed to improve the reliability of the evidence.9 A repair restoration of a ceramic inlay located on a mandibular molar is presented in Fig 4. After an observation period of 14 years, the marginal quality of the
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Figs 3a to 3k Clinical example of the R1-technique. (a) Extensive caries decay on tooth 45 (occlusal-distal-oral). (b) Radiographic image of the initial situation (image was taken a few days before; therefore, radiopacity due to an insufficient interim restoration was visible). (c) The situation with rubber dam after cavity preparation of the vital tooth 45 showing no clinical symptoms of endodontic infection. (d) The situation after the placement of a sectional matrix and a separation ring, etching, rinsing, and application of an adhesive system after the manufacturer’s instructions (Optibond FL, Kerr). A small amount of flowable composite was applied on the bottom of the cavity and a second viscous composite resin was placed on the non-polymerized flowable composite. A special hand instrument to form tight proximal contacts was used here. (e) Detailed image of a proximal contact former (OptraContact, Ivaclar Vivadent). (f) The situation after removal of the proximal contact former. (g) Finished restoration. (h and i) Clinical follow-up after 1 year without pathologic findings. Periodontal probing depths were between 2 and 3 mm, with no bleeding on probing. (j) Radiographic image after one year without pathologic findings. (k) Clinical follow-up after 3 years, still without pathologic findings.
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Figs 4a to 4f Long-term observation of a direct restoration made for repair of a ceramic inlay after 14.5 years. (a) A mandibular molar with a fractured ceramic inlay. (b and c) The situation after minimally invasive cavity preparation, airborne-particle abrasion, etching with buffered hydrofluoric acid (Porcelain-Etch, Ultradent) and phosphoric acid, rinsing, drying, application of silane and an adhesive system, insertion of composite resin material, and finishing and polishing. (d) Clinical examination of interdental cleaning. (e) Recall after 8 years: no pathologic findings, the repair restoration (occlusal-distal) was hardly visible (arrow). (f) Recall after 14.5 years: still without pathologic findings (arrow).
composite-ceramic interface of the repair restoration is not worse than the ceramic-luting composite-enamel margin of the original restoration. Repair restorations are an important part of restorative therapy in conservative dentistry, including subtractive procedures like removal of marginal overhangs, finishing, and polishing, as well as various additive procedures.
Long-term observation of a direct composite resin crown in the anterior region Over a period of time, indirect fabricated cast metal or ceramic crowns have been the gold standard of treatment for restorative rehabilitation of extensively
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destroyed teeth (often combined with a root canal post after endodontic treatment). Today, adhesive composite technology offers the possibility of restoring extensive cavities with direct composite resin crowns. Although the stability has to be considered as limited, the choice of this treatment option seems to be justified with regard to minimally invasive principles, provided that the patient gives consent. Figure 5 shows a direct composite resin crown on a maxillary right lateral incisor (tooth 12) after an observation period of 15 years. If failure of the crown occurs after this time, this treatment option can still be classified as a success, as more invasive procedures could be delayed over a long period.
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Figs 5a to 5h Long-term observation of a direct composite resin crown in the anterior area after 15.5 years. (a) The situation after deep uncomplicated crown fracture of the vital tooth 12. (b) The situation after application of rubber dam. (c) Direct composite resin crown. (d) The periodontal situation without pathologic findings: probing depth was between 2 and 3 mm, with no bleeding on probing. (e) Clinical examination of interdental cleaning with dental floss. (f) Clinical examination of interdental cleaning with an interdental brush. (g) Recall after 15.5 years. (h) The direct composite resin crown presented as clinically excellent: probing depth between 2 and 3 mm, with no bleeding on probing.
Long-term observation of a direct composite resin crown in the posterior region The direct restoration technique of partial or complete cusp coverage in the load-bearing posterior region shows equal and, in some cases superior, clinical performance.2 Figure 6 shows a premolar with infaust prognosis that was scheduled to be extracted.17 As a conservative treatment was desired by the patient, a direct composite resin crown was built up adhesively after an endodontic revision of the root canal filling. The macro-retention of the composite crown was not realized not by an endodontic post but by a “composite tag” inserted in the upper third of the root canal system as part of the direct composite crown. Recent studies have shown that the geometric area of the adhesive surface in the root canal, rather than the accuracy of fit or the absolute length of the endodontic post, is crucial for fracture resistance.18,19 Although the observation period exceeded 15 years, the therapeutic option of a direct composite resin crown, as presented in Fig 6, has to be considered as experimental.
Long-term observation of a direct composite resin buildup in the anterior area The correction of tooth form and color in the anterior area can be realized by various direct and indirect res-
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toration techniques. In conservative dentistry, the technique of direct composite resin buildups is used to fulfill the principles of esthetic dentistry.3,20 Due to increased wear resistance and color stability of modern composite resin materials, direct composite resin buildups are even appropriate for corrections of severely discolored or hypoplastic teeth.21 Figure 7 shows the maxillary incisors of a 12-year-old girl. The maxillary central and lateral incisors (teeth 12 to 22) were treated with direct composite resin veneers to optimize the surface texture (the restorative treatment of the maxillary canines [teeth 13 and 23] followed a few years later alio loco). With regard to marginal quality, tooth color, and anatomic form, the direct composite resin buildups presented as clinically excellent after more than 12 years of observation. The incorporation of macroscopic elements into the buccal surface (grooves, pits, etc) is a possibility to improve the natural shape of anterior teeth. However, in this case it was not desired by the patient.
Long-term observation of a direct composite resin buildup in the posterior area In case of a single missing tooth in the posterior region, the gold standard of treatment is a laboratory-made prosthesis or an implant-supported single crown. In
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Figs 6a to 6p Long-term observation of a direct composite resin crown in the posterior area after 15 years. (a) The situation after loss of retention of the laboratory-made crown with endodontic post on tooth 14. (b) Extensive subgingival defect of the clinical crown. (c) Radiographic image showed a periapical translucency and an insufficient endodontic root canal treatment. (d) The situation after application of rubber dam. (e) The situation after revision of the root canal filling. (f) Direct composite resin crown. (g) The situation directly after restorative treatment. (h) Image of the radiographic control. (i to k) Recall after 7 years. (l to n) Recall after 12 years. (o and p) Recall after 15 years. The direct composite resin crown in the posterior region presented as clinically excellent. A slight discoloration was visible on the occlusal surface that could be removed by polishing (see Fig 6m).
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Figs 7a to 7h Long-term observation of a direct composite resin buildup in the anterior area after 12.5 years. (a and b) Discolored and hypoplastic teeth of a 12-year-old girl. (c and d) Tooth color and shape of teeth 12 to 22 were corrected by direct composite resin buildups. (e and f) The situation directly after restorative treatment. (g and h) Recall after 12.5 years; the patient was 25 years old at this point. The color and anatomical form of the direct composite resin buildups presented as clinically excellent (a few years later, direct composite resin buildups on teeth 13 and 23 were made elsewhere).
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Figs 8a to 8l Long-term observation of a direct composite resin buildup in the anterior area after 10 years. (a to c) Single missing tooth 15, the insertion of an implant-supported single crown or laboratory-made prostheses was not desired by the patient. (d to f) The situation directly after restorative treatment with composite resin buildups. (g) Radiographic control. (h and i) Clinical and radiographic control after 2 years. (j) Clinical examination of interdental cleaning with an interdental brush after 9 years. (k and l) Recall after 10 years: the direct composite resin buildups in the posterior area presented as clinically excellent.
rare cases, an orthodontic treatment is carried out. The abandonment of invasive procedures as a non-invasive treatment alternative can be an option in clinical situations that are esthetically and functionally uncomplicated. However, this treatment option is rarely proposed to the patient.22 Even an interdental space closure by direct composite resin buildups in the posterior dentition is rarely considered (Fig 8), although this treatment method offers various advantages. The technical procedure is described in detail elsewhere.23-29
CONCLUSION Although case reports represent a low level of evidence and do not provide complete representative data, the long-term clinical results of more than 10 years of obser-
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vation that are shown here emphasize that extended indications of direct restorations made of composite resin materials are a reliable treatment alternative. The underlying treatment concept can be summarized as follows: “Preventive interventions as offensive as possible, restorative interventions as defensive as possible”.23,24,28,30 This approach covers both medical decisionmaking and aspects of dental public health. Compared to extensive prosthetic and surgical treatment alternatives, this conservative and minimally invasive approach provides affordable and socially acceptable dental care that is beneficial for a wide part of the population.30,31 The developments expected in biomaterial research and the increase of skills concerning the processing and handling of direct restorations render this segment of conservative dentistry very promising.
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