Longevity of Restorations in Posterior

Teetii and Reasons for Faiiure

Reinhard HickelVJuergen Manhart"^

Purpose: This article compiles a survey on the longevity of restorations in stress-bearing posterior cavities
and assesses possible reasons for failure.
Materials and Methods: The dental literature predominantly of the last decade was reviewed for longitudinai. controlled ciinicai studies and retrospective cross-sectionai studies of posterior restorations. Only
studies investigating the clinicai performance of restorations in permanent teeth were inciuded. Longevity
and annual failure rates of amaigam, direct composite restorations, giass ionomers and derivative products, composite and oeramic inlays, and cast gold restorations were determined for Class 1 and II cavities.
Results: Annual failure rates in posterior stress-bearing restorations are; 0% to 7% for amalgam restorations, 0% to 9% for direct composites. 1.4% to 14.4% for glass ionomers and derivatives, 0% to 11.8% for
composite inlays, 0% to 7.5% for ceramic restorations. 0% to 4.4% for CAD/CAM ceramic restorations, and
0% to 5.9% for cast gold inlays and onlays.
Conclusior): Longevity of dental restorations is dependent upon many different factors that are related to
materials, the patient, and the dentist. The principal reasons for faiiure were secondary caries, fracture,
marginal deficiencies, wear, and postoperative sensitivity. A distinction must be made between factors
causing early faiiures and those that are responsible for restoration ioss after severai years of service.

J Adhesive Dent 2001:3:45-64.

Submitted for publication:25.09.00: accepted for puOlication:07.01.01.

hanges in restorative treatment patterns, the introduction of new and improved restorative
materials and techniques, effective preventive programs, enhanced dental care, and growing interest
in caries-free teeth have greatiy influenced the
longevity of dentai restorations-^^.78 Alleged adverse health effects and environmental concerns
regarding the release of mercury gave rise to controversiai discussions about the use of amalgam in

several countries, especiaiiy in Sweden and Germany.3787.99 There is a growing concern about the
use of alloys in general. Besides cast goid inlays,
esthetic aiternatives to amalgam restorations include giass ionomers, resin-modified giass ionomers, compomers, direct composite restorations,
composite iniays, and ceramic iniays.

Faiiure of dental restorations is a major problem

in dental practice, especiaiiy in the treatment of
adults. Placement and replacement of restorations
still constitutes the major workload in general dentai practice, although preventive programs and an
a Professor and Chairman, Department of Restorative Dentistry and increased awareness of oral health have had poPeriodontclogy, Ludwig Ma/imiiians University, Munich. Germany.
sitive effects on the DMFT index in many counb Assistant Professor, Department of Restorative Dentistry and Peritries.^2.101 About 60% of all operative work done is
odontoiogy. Ludmig Maximilians University, Munich, Germany.
attributed to the replacement of resto rations.''^ The
ciinicai assessment of restoration failure differs acReprint requests: Prof. Reinhard HioKel, Department of Restorative
Dentistry and PerioOontology, Goethe Street 70, 80336 Municf), Ger- cording to the diagnostic criteria applied and will
many. Tel: *49-89-5160-3201, Fax: +49-89-5160-5344, e-mail:
reflect the interpretive variability of different operahickelden tmed.uni-muenchen.de

Voi 3, Mo 1 , 2 0 0 1

45

Hickei/Manhart

Table 1 Median values of annual failure rates (%) and minimum and maximum vaiues (range; %), as determined by a comprehensive review of tiie reievant iiterature^^ and subdivided for iongitudinal and cross-sectional studies*

Restoration type
Amaigam restorations
Ditect postenor cotnposite restorations
Glass-ionomer restorations
Composite inlays and oniays
Ceramic iniays and oniays
CAD/CAM inlays and oniays
Castgold iniays and onlays

Ali Studies
(range]

Aii studies
(median values)

0-7
0-9
1.4-14.4
0-11.8
0-7.5
0-4.4
0-5.9

3.3
2.2
7.7
2,0
1.6
1.1
1.2

Annual fai Ute rate (%)

Lon gitudinal studies
( nedian vaiues)

Cross-sectionai studies
(median vaiues)
3.7
3,3

1.1
2,1
7.7
2.3
1.3
1.1
1.0

0.6
3.2
1,3

Although it is problematic to flirectly compare different studiss of different authors, and keeping all the itnitat-one in mind, a trend CBH beet s e r . . .

tors. The examination of patients for treatment

needs frequently reveals restorations whicii do not
meet precise criteria for success, but are capable
of further clinical service and do not necessarily require replacement. In view of the high costs of delivering restorative dentistry to the community, t is
of particular interest to knew how long dental
restorations may be expected to survive.^^'Ss
A direct comparison of the longevity of different
types of restcrations in different studies reported
by different authors is problematic for various reasons.i'' The variables in the study designs are often
poorly described or omitted, or differences In ciinicai procedures, materiais used, and variations in
study characteristics make direct comparisons impossible. Irrespective of these limitations, however,
certain trends are apparent from comparisons of
the results of different ciinical studies. Cross-sectional surveys differ from controlled iongitudinal
studies n which the ciinicians operate under ideai
conditions for the materiais investigated. However,
results from controlled clinicai studies do not reflect the situation in gnerai dental practice.'^ Results from iongitudinal ciinicai studies may not be
generaiized and are difficult to compare with retrospective cross-sectional investigations, since the
outcome is highly dependent on the individuai skills
of the dentist and the care taken n piacing the
resto ration. 39

46

LONGEVITY OF POSTERIOR RESTORATIONS

(CLASSI AND II)

Tabie 1 presents the results of a comprehensive

survey of the relevant dentai literature primariiy of
the last decade on the iongevity of dentai restorations in stress-bearing Class I and

Amalgam Restorations

Tabie 2 summarizes the resuits of selected clinicai

studies on the iongevity of amaigam restorations.
Annual faiiure rates range between 0% to 7% for
non-gamma-2 and gamma-2 containing alloys with
observation periods of up to 20 years. Secondary
caries, a high incidence of bulk and tooth fracture,
cervicai overhang, and marginai ditching (Fig 1)
have been reported as being the main probiems
limiting the survival of amalgam restorations.8.12.45,71,78 J^Q ^nc and copper content of the
alioy has been found to have a strong impact on the
survival rates of amalgam restorations, as it influences the corrosion resistance of the amalgam.
High-copper amalgams have higher survival rates
than conventional amaigams.^" In contrast to the
adhesive capabilities with modern composite systems, the [ack of adhesive stabilization of the hard
dental tissues in combination with amalgam frequently results in the fracture of restored teeth.

The Journai of Adhesive Dentistrj

Hickel/Manhart

Table 2
Year

Longevity of amalgam restorations in posterior teeth

Firstautiior

Obser-

Black

vation

class

Restcrative materiais

fieriod
(years)
1969 Allani

10
1

Number

Number

of

of

restora-

patients

tions (n)

(1)

Study design

Sun/ival

Annuai

Median

rate (%)

failure

survivai

rate

time

%)

(years)

Amaigam (aiioys not

specified, 8rnma-2
alloys)

78
92

Crosssectional

54
39

4,6
6.1

22.8

3.9

Remarks

Siiglifly better
performance in
class 1 cavities.

1971 Robinson^'

30

andii

Amalgam (allo^ not

sftecified, Eamma-2
alloys)

145

Crosssectional

1976 Laveile^

20

and II

Amalgam(ailoinot
specified, gamma-2
alioys)

6000

Crosssectionai

4,8

1976 taveiie^

20

and il

Amalgam (alloys not

specified, gamma-2
aiioys)

400

Longitudinal

<10

1977 Allan^

20

ardil

Amaigam (alicys not

specified, gamma-2
ailoys)

148

Crosssectionai

14

4,3

19S1 CraDb"

10

Amaigam (alioysnct
specified, gamma-2
ailoys)

269
530

Crosssectional

59,5
37.2

4.1
6,3

=10
8

Slightly better
perfcmiance in
class 1 cavities.

Soiila

854
1490

Crosssectional

8
7

No difference
tietvieen class 1
and H amalgams.

Conventional and
liigh copper aiioy

2341

LongitudJnal

314

Amaigam (aiioys not

specified}

Amaigam {aiioys not

specified)

i
1984 Patersoii85

15
i

1989 Letzeisa

5-7

1989 Moffa'9

and

1990 QvisiSi

Main faiiure
reasons: secondary caries,
fracture.

2
5

Crosssectional

9.5
8

Longitudinal

100

Smaii restorations.

Longitudinal

92,7

1,5

Aliamalpms
failed due to
recurrent
caries.

73,5

2.7-3.8

Mam faiiure reasons: secondary

caries and ulk
fracture; no significant difference
between gamma-2
and nor^gamn^a-2
aiioys.

Longitudinal

87,2

0,9

Gamma-2 amalgams had 84%success rate, nongamma-2 aliens had

916St

139
413

Crassseclional

85,3

13^16

1680

Cross
sectional

Dispersaiioy

13

1990 Welburyi"'

Amaicap

150

103

1991 Jokstad't

7-10

4 non-gamma-2 alloys
loonventioriai aiioy

256

141

1991 OsbomeSS

14

ardii

5 gamma-Jailors and
7 non-gamnia-2 aiioys

367

40

1991 Ffepeifs

&U

Amaigam (allois rot

Specified)

1991 Smales^

U-IS

New Trie Denla ilcy,

[fepersallc, Indiioy,
Shofu Spliencsl

Vol 3, No 1, 2001

75% of the amalgam restorations

lasted=5 yeais.

88-91
90
75

1990 Smales'os

andli

10

10-1.7
and 6.3

Shofu Spherical
shoned an annuai
feiluierateof6,3ii
mtiile the other alleys failed 1-L7%a
year.

47

Hickel/Manhart

Table 2 (continued
Vear

First author

1991 Smales"*

Longevity of amalgam restorations in posterior teeth

Obser-

Biacit

vation

class

Reslorative materials

Number

Number

of

of

period

restora-

(years)

tions (n)

15

il

1992 M j o r "

Study design

Survival

Medran
Survival

patients

Annuai
failure
rate

(n)

l%]

(years)

rate (%)

72

Remarks

time

1.9

No difference in
sufvivai lime between cuspiovered ciass ii amalgartis and restoration s without
cuspcoverage.

Amalgam (alioys not

specified)

768

Amaigam (alloys not

specified)

350

Crosssectional

Dispersaiioy

88

Longilu dirai

Amaigam (aiicys not

specified)

803
>3000

Crosssectionai

14
7-11

increasing number
cfaflededsufaces
of class iireslorations results in a
lower median
longevity.

79
9

Study conducted
in Pakistan (P) and
Australia (A).

4.7

1993 MjDr'6

1994 Jokslad

>10

1994

>14

1 and ii

Amalam(aiioisnol
Specified)

245 (P)
455 (A)

Ctosssectional

1996 Smaiesno

15

li

Amalgam ailoys nol

specitiM)

160

Crosssecticral

47.8

3.5

Cuspccvered amaip m restorations.

1996 Wilson"s

i and il

H igiiDppe amaigams
(Sybraiioy, Dispersaiioy,
Tytin)

172

Longtudinai

94.8

Deterioration was
greater in moiars
and largesi?ed
restorations.

i and II

Amaigam (ali(^ not

specified)

1371

OnKSsectional

lanilii

Coniieiitioral one-free a.
Convent, ancioniain. a.
Highiopper ?inc-fiee a.
Highcopperzinciont.
ailoys

3119

Metaanaijsis

35
70
70
85

5.8
2.3
2.3
1.2

1997

MaiimoM

Hawtiiomes

1997 Letzei^

13

il

(all)

1997 Mji'8

>25

and II

Amaigam (allojsnol
Specified]

282

1997

RojIetM'

andli

5 high-copper amaipms
(Amaicap plus. Contour,
Permite C, Dispersaiioy,
S-Am-iap)

163

1997

Smaies"'

5
10
15

Amalgam [aiio^S not

specified)

160

1998 Kreuleii63

15

New True Dentailoy,

Tytir, Cavex

1117

1998 Maires

10

New True Dentalloy,

Soiila Nova

35

48

95

22,5

Crosssectionai

43

183

Esi mated suivival

function. Small
class I i cavities.

Zincand copper
content of tiis ailoy
contributed to the
cotrosion resetance
ofthe amaigams. Mam failure
reasons: fractures,
marginai ditching
recurrent caries.

Crossr
sectionai

875

2.1

Crosssectionai

776
66.7
478

4.5
3.3
3.5

Longiiudinal

83

1.1

Longitudinai

94.3

0.5

Life-table mefliod.

Main faiiure reasons: secondaiy

caries (50%) and
fracture (29t).
Kaplan-Meier method. Main reasons
for repiacement:
fracture.

14,6

Extensive amalgam restorations

Viith cusp repiacement.
Replacement risk
for MOD IS significantly higher than
for MC/OD restorations.

The Journal of Adhesive Dentistry

Hickel/Manhart

Longevity of amalgam restorations in posterior teeth

Table 2 (continued
Year

First author

1998 Plasmans

Number

Number

of

of

oeriod

restora-

patients

(yearsi

tions {n)

Obser-

Biack

vation

ciass

1999 BurkeS
1999 Cichonio

Restorative materials

Surviwi

Annuai

Median

raie [%)

faiiure

survivai

rate

time

(%)

(years)

Cavei (non-gamma-2)

266

1
Ii

Amalgam [aiioys not

specified)

268
1142

Crosssectionai

S20

Cross-

80

2.5

Severe mentally

seotionai

73.2

3.4

and/or physicaliy

71,1

3.6

handicapped

83,9
66.7

2.7
5.6

2-surface5 specified)

Longitud inai

Jsuriaces

88

15

Remarks

1-surface Amaigam (alioys not

130

Study design

Large amalgam
restorations in
molars with cuspreplacement.
74
6,6

patients.
1999 Hamann^

Luxalloy

62
21

Longitudinal

Mam reasons for

repiacement:
secondary caries.

Large amalgam restorations exhibit more deterioratioti than moderate- and smali-sized restorations,i29

Direct Posterior Composite Restorations

The results of selected clinical studies on the
longevity of direct posterior composite restorations
are summarized in Tabie 3. Annual failure rates
range within 0% to 9%, Insufficient wear resistance
resulting in loss of anatomic form and interproximai
contacts with general degradation were the main
probiems of direct composite restorations in the
seventies and eariy eighties,^'' improvements in the
filler technoiogy and formulation of composite materiais have resuited in changes in reasons for
restoration repiacement, aside from the increasing
trend to insert composite restorations in stressbearing areas of posterior teeth. Wear {Fig 2), fracture of the restorations, marginai deterioration,
discoioration, and marginai opening with secondary
caries [Figs 3a and 3b) are now the principai modes
of faiiure and reasons for limitations in the longevity of resin-based composites.25,78,i02,i07 Microfilied composites showed more fracture-related
faifures, especiaiiy in high-stress Ciass Ii cavities,
compared with hybrid composites because of their
inferior mechanical properties. The relatively high
incidence of secondary caries may be explained by
the iow efficacy of older generation bonding agents.

Vol 3, No 1, 2001

Fig 1 Amalgam restorations in maiiiiary moiars showing marginai ditching and marginal openings.

in particular when cavity finish iines lay within

dentin. Despite the improvements in the formulation of new bonding agents with enhanced marginal
adaptation and bond strengths, a perfect marginal
seal is still not achievable, Premoiars generally
offer more favorabie conditions for composite
restorations compared with moiars,25.ioi,io2 cavity
preparations are tending to become smaiier and, as
a consequence, the effect of the chewing forces is
less intense.
Besides wear, the negative effects of poiymeriza49

Hickel/Manhart

Table 3 Longevity of direct composite restorations in posterior teetii

Year

First auilior

Obser-

Black

uaiioR

class

Number

Number

of

Qf

Study design

Survival

Annual

Median

rate(%

failure

surviuai

period

reslora-

palienls

rate

time

(years)

tions (n)

(n|

1%)

(years)

Remarks

1988 Wilsoni^s

and II

Qcclusin

67

Longitud inai

86

2.8

LargeandmoderateieysizeOreslorations. Higher
failure rate in
classlltnanin
class 1.

1989 LetzelM

and II

Occiusion

711

Longitudinal

94

15

filulticenter clinical triat Main

reason loi lepiacementweafand
recurrent caries.

1989 Lundin^i

and II

Occlusin and PC 4503

137

Longitud inai

84

142 ijm airag6

wear after 4
lears. Mostof
tiie restoraons
faiied were
ciassified iarge.

1989 Moffa"

Composite resins (not

specified)

356

80
55

4
9

Inierprciimai gingivai area of class

Ii restorations was
found to be an
area of eaiiy failure.

'

1990 Mjor'

1990 QvislS2

65

Composite resins (nal

specified)

Composite resins (noi

specified)

1990 Smaies'f*

1990 Weljry""

1991 Barres^

5
8

1992 Feilicfi"

1993 Mjr'

1994 El MowafiW

1994 Jokslad"^

>10

1995 Wassell'sa

50

Restoraliue materials

Crosssectionai

Visio-Moiar
P-30

42
251

Pfisma-Fii and Prism aShield

150

and II

Ful-Fil

and II

and il

and II

MOD composite
restorations in
Scandinavia.

3
3

Longitud i na

93.9
100

2
0

Small restorations.

103

Longitud i na

94.7

1.1

Minimai composite restorations

combined with a
fissure seaiant.

33

12

Longitudinal

90
77

3
2.9

Main reason for

replacement: recurrent caries.

Heliomoiar, Maratnon,
P-30, Experimental
composite

105

46

Longitudinal

99

0.3

P-10

91

Longitudinal

85

Composite resins (nol

specified)

191

89.5

2.1

Composite resins (not

specified)

22
79

Bnlliant

71

Crosssectionai

54

Longitudina

Estimated sutvivat function.

Small ciass il cavities.

4
4-7

96

1.3

Main reason for

replacement: recurrent caries
(>65%1 and fracture (>20%).
61 % class Ii
restorations. No
secondary canes.

The Journai of A d h e s i v e D e n t i s t r y

Hickel/Manhsrt
Table 3 (continued) Longevity of direct composite restorations in posterior teeth
Year

First author

Obser-

Black

vation

ciass

Restorative materiais

Mum bet

Number

of

of

period

tesiota-

patients

(years)

tions (n)

(n)

Hetculite XR

109
1100

412

Composite resins (not

specified)

537

1997 Geunsen25

1997 Mjr's

>25

1998 Helbigsi

landii

P-50

27

1998 Mair

10

li

P-30,0cciusin,Cieattil
Postetiot

1998 MettzFairhurst

10

1
li

Study design

Ctosssectionai

Sutvivai

Annuai

Median

rate (%)

faiiure

survivai

rate

lime

il)

(yeats)

3.3

More Aiptia ratings in premoiars

tbar in moiars.
No difference between ciass i and
il cavities.

Mam reasons for

replacement: secondary caties (38
%) and fractute
(20%).

87

Crosssectional

22

Remarks

Longitudirai

88.9

2.2

56

Longitud inai

92.9

0,7

P-3DandOcciiisin
showed approximately 400 |jm
wear, Ciearfii Posterior 300 |jm
aftet 10 years.

Ml rada pt + Deiton
seaiant

85

Longitud u nal

80

Uitraconsetvative
restorations.

Longitudinal

5*60

4-5

Main ieason for

replacement: ioss
of anatomic form
and apptoiimal
contacts.

Longitudinal

90

Main reason fot

repi ace ment: recurrent caries.

Longitud mai

76

1.4

264 |jm wear

aftet 17 years.
Most weat occuted rn tiie first
5 years.

Longitudinai

87

4.3

Main reason for

replacement: recutrent caties.

Matginal integrity
and surface testute significantiy
deteriorated after
5 years.

'

il

Composite resin (rot

specified)

27
71

1999 Raskin's

1999 Buii<e^
10

ianQli

Ccciusin

100

1999 Scheiben
-bogen'f*^

i and il

Tetiic, Pertac-Hybtid
Unifil, blend-a-iuK

43

1999 Wilderi-i'

17

1 and il

Estiiux, Nuva-Ri,
Nuva-Fil PA, Uvio-Fil

85

2O0O Manhart^^

iandii

Tettic, Pertac-Hybrid
Un fil, biend-a-lux

30

tlon shrinkage were often cited as being common

causes of failure of direct posterior composite
restorations,^^ An inherent weakness of resin composite restorations has been attributed to the organic matrix component.

Voi 3, No 1, 2 0 0 1

Crosssectional
36

33

3.3
4.6

Giass-ionomer Cements
Annuai failure rates of posterior giass-ionomer
restorations range from 1.4% to 14,4%, Table 4
summarizes the results of selected clinicai studies,
Giass-ionomer cements are not considered to
possess adequate meciianicai properties for gen51

Hiokel/Manhart

Fig 2 insufficient direct composite restorations in a stressbearing maxiiiary molar and premolar. Distinct signs of wear
and a poor sHaping of the occiusai anatomy are observable.

Fig 3a Direct composite restoration in a maxillary first premolar after 9 years of clinical service. The composite restoration
exhibits deterioration and disooioration of the margins.

Fig 4 Faiied 3-surface restoration with a cermet cement

(Ketac silver, Espe, Seefeld, Germany) in a stress-bearing first
moiar. The bulk of the restoration is fractured because of insufficient mechanicai properties for this indication.

52

Fig 3b After removai of the composite restoration, the formation of secondary caries, especially st the gingival seat of the
proximal box, is ciearly observable.

eral use as definitive restorations in stress-bearing

posterior teetin.3"'.^2,75 iv)any glass-ionomer restorations failed because of bulk fractures (Fig 4) due to
their low mechanical strength,'"'"'^ Silver particles
sintered into the glass-ionomer pov/der particles increase the strength and radiopacity; however,
metal-reinforced glass-ionomer cements (cermet]
are not suitabie as a long-term restorative material
for use in Class II cavities,33,'i7,76
In contrast to expectations and despite the release of fiuoride ions, secondary caries has surprisingly been found to be the main reason for
the clinical failure of glass-ionomer restorations,8'2S,78 j[ie release of fluoride ions has been
anticipated to reduce the incidence of secondary
caries. The longevity of glass-ionomer restorations
is furthermore dependent on the use of appropriate
clinical techniques, as these materials tend to be
rather technique sensitive, especialiy with respect
to water adsorption and dehydration.^-le

The Journai of Adhesive Dentistry

Hickel/Manhart

Table 4 Longevity of glass Ionomer restorations In posterior teeth

Year

First author

Obser-

Biack

vation-

ciass

Number

Number

of

of

period

Restoraiive materials

restora-

patients

lyearsi

tions (n)

(n)

Study design

Suivivai

Annuai

Median

rate (%)

failure

survivai

fate

time

(%)

(years)

Rema i its

1938 Hickel^

3.5.

I
Ketac-Silver
II
(cermet)
li (modif,)

87
104
53

Longitudinal

88.5
50
80,8

3,3
14.3
5,5

Smaii class ii
(modif.) sliowed
better resuits
tlian reguiar class
II cavities.

1990 Smaies

132

Longitudinal

56,8

14.4

Main reasons fcr

replacement:
cratiirgandcraang

1991 Smales""

Aii classes Aaps. Fuji II, Ketac

465

CrosssecMnai

1992 Svanbergii6

li

Ketac-Silver

18

1993 Hasselrots'

3.5

i and il

Base Line and

Ketac-Siiver

1993Mjr'5

il

1994 Kramer"

1996 Frenckeni8

Ketac-Siiver
(ceimet)

Longitudinal

94.4

1.9

Canes-active individuals. Tunnei

restorations.

283

Longitudinai

73.5

7.6

Tunne restotat ons.

Ketac-S liver
(cermet)

95

Longitudinal

55

.sti mated surVvai function,

t mall ciass 11 cavit es.

i
il

Ketac-Silver
(cermet)

49
39

Longitudinal

89.8
71.8

2.6
71

Main reasons for

faiiure; bulkfractuie.

ChemFii Superior

213

Longitudinal

93,4

6,6

ART technique in
Zimbabwe. Nc secondary caries.

1996 Phantumvanit^

1
3
3

Glass ionomer
cement

241

144

Longitudinal

93
83
71

7
8.5
9.7

ART technique m
Thailand.

1996 Strandi-i

land il

Ketac-Silver
(cement)

61

85

Longitudinal

70

10

1unne restoraens, ilain failure

easo s: caries
m.n arginal ridge
lactun 14%.

1997 Mjr's

>25

All classes Glass ionomers (not

specified)

155

50 (all)

CfOSS-

sectionaf

Main reasons for

replacement: secontJary caries (5CK)
and fracture (18%).

Crosssectional

100

Vei smaii number

of restorations.

142

Longitudinai

98.6
93.8
88.3

14
3,1
3.9

ART technique m
ZimtHwe.

232
35

193 (all)

Longitudinal

Fuji ii

89

53

Longitudinal

Fuji IX
ChemRI Superior

55
45

21

1997 Mount'

10-12

Glass lonomeis (not

specified)

1998 fienckeni9

1
2
3

Fuji IX

397

1998 Hasseliw^s

1
II

Base Line
Ketac-Sitef
(cermet)

1998 MalioA^

1
3

1999 Ho33

Voi 3, No 1, 2 0 0 1

18

2.2

Longitudinai

7
7

763
57.9

14

93

3,5

6
6

uiine restoraons. * difference

nfail re rates beween classlandll.
ARTtechniquein
Cambodia. Placed
by dniai nurse
students.
ARTteclinique in
Asia. Small ciass i
caiiities in molars.
Main laiiure reasons:
wear, fracture, recurrent canes.

53

Hickel/Manhart

Table 5 Longevity of composite iniays and oniays

year

First authoi

1991 BesBing^

Obser-

Biacli

vation

class

tamber

Number

of

pf

pedod

restora-

patients

(years)

tions (n|

(n)
19

Restorative materials

Isosit

34

1992 Fiiemann' 1

landii

Briiiiant

24

1992 Haas26

Inlays

Coitne-composite
Kuizer-composite

30
30

1993 Wendti25

1 and il

Occiusin

60

1994 Krejci^^

Inlays
Onlays

APH

21
9

1994 Thordmpli

1 and Ii

Estilux, Bn i liant

29

1995 Wass6iii3

i and II

Briiiiant

71

1996 Krmer*

landii

Visio-Gem

118

1997 Wiedmer"

i and il

Brlliiam, APH

24

1999 Donly"

Iniays
Oniays

Concept

32
4

1999 Scrieiben-

i and II

Tetric, PertacHybrid Urifil,

biend-a-iu);

2000 Manhart^^

landii

2001 Manliart^'

landii

Survivai

Annuai

Median

rate(%)

failure

survival

rate

time

Remarks

(years)
Longitudinal
Longitudinal

88,2

11,8

100

SO
SO

10
10

No difference beween molars and

premoiars.

96,7

11

Longitudinai

100

Esceiientmargnai
integjity after 1 year.

Longitudinai

96.6

3,4

1 iniay: secondary
canes.

54

Longitudinai

92

2,7

66%ciassli restorations, Main failure

leasons: fracture
and postoperative

28

Longitudinai

41

9,8

Kapla-Meier-estjmator. Mam failure reasons: fracture, marginal opening and

postoperative sensk
tivity.

Longitudinai

100

Mo differences betvieen moiars and

premolara and between direct and
indirect iniays.

Longitudinai

75
75

3,S
3.6

Main faiiure reasons: secondary

canes and fracture.

45

Longitudinai

93

3,5

Tetric, PertacHybrid Unifil,

biend-a-iux

30

Longitudinai

93

2,3

Composite iniays
in reiativeiy i atge
cavities.

Tetric, PertacHybrid Unifil,

biend-a-iux

37

Longitudinai

89

3,7

Smail-snd mediurrv
sized ca\ities. Significantly more faiiures
in mciars compared
with premolais,

Composite iniays and Onlays

There have been only a few in vivo studies examining the long-term behavior of posterior indirect composite restorations. The resuits of seiected clinicai
studies are summarized in Table 5. Annuai faiiure
rates of posterior composite inlays and onlays
range from 0% to 11-8%, Many of the problems as54

Study design

24(all|

18 (al!)

sociated with the direct placement of iarge posterior composite restorations can be overcome with
the use of an indirect composite inlay technique. It
has been concluded that composite iniays are a
good, ionger-lasting aiternative to direct piastic
composite restorations in large Ciass II situations,120 Indications for esthetic inlays inciude
teeth in which strengthening of the remaining strucThe Journal of Adhesive Dentistry

Hiokel/Manhart

ture is indicated, the oavity is free from marked undercuts, and the patients are regular attenders requesting tooth-coiored restorations in posterior
teeth.'36 Strict patient and case selection, ie, frequent attenders with a good standard of orai hygiene and cavities which aliow adequate moisture
controi, wili increase the iongevity of adhesive inlays.
The indirect technique aliows the production of
restorations in the laboratory with appropriate proximai contours and contaots end controi of anatomic
form. Poiymerization shrinkage is iimited to the
width of the iuting space. Post ouring the inlay with
heat, pressure, and/or light increases the degree of
conversion through an annealing process, improving the mechanicai properties ofthe oom posite and
resulting in better wear resistance.'-iss.ias several
authors have indicated that premoiars offer more
favorable conditions for indirect composite restorations than moiars.^3.101.102 ^ premoiar restoration
is subjected to much iess ooclusal stress than a
molar restoration (Fig 5), the access for dental
treatment is easier, and oral hygiene measures are
more easiiy controlled by the patient.

Ceramic Inlays and Onlays

Ceramic Inlays can be made of feldspathic ceramic
materiais in a traditional way by sintering or, as a
more recent technique, by miliing. Giass ceramic iniays can be cast or pressed using the lost wax technique or they can be produoed by miiiing.^s-^s.^is
CAD/CAiVI technology is implemented in the Cerec
system, which mills ceramic Inlays from industrial
blocks of ceramic material that are prefabricated
under optimum and controlied conditions-^^ It is
possible to obtain a high and uniform quality ceramic without the inevitable materiai variations
seen in manually produced restorations.s^-^^ The
results of seiected clinical studies investigating ceramic inlays and oniays are summarized in Table 6.
Annual failure rates of ceramic inlay restorations
range from 0% to 7.5%. Table 7 presents the longevity data of computer-generated ceramic restorations. Annuai failure rates of CAD/CAM ceramic
restorations range from 0% to 4.4%. Bulk fracture is
a frequent cause of failure of ceramic inlays (Fig
6) 115.122 The risk of fracture of a ceramic inlay depends, among other factors, on the strength of the
material. Ceramic materials are brittle and susceptible to failure in tensile mode, while their resis-

Vol 3, No 1, 2 0 0 1

Fig 5 Failed composite inlov wuli oulk fracture ofthe restoration.

tance to compression is high. Flaws at internal or

external surfaces are in many cases the origin of
cracks, which can propagate and lead to catastrophic faiiure.9'68 other important factors, such
as the design of the cavity preparation, the shape
of the restoration (minimum thickness: 1.5 mm)
and internal fit influence the strength of the ceramic restoration. Strict case selection, avoiding the
placement of ceramic inlays in bruxists and situations that require crowns, increases the probability
for ceramic inlay success. In general, preparation
dimensions have an important influence on the
fracture resistance of all-ceramic resto ratio ns.^^'i22
Failure to achieve necessary cavity dimensions may
contribute more to faiiure by fracture than the nature of the ceramic system. Wear of the resin cement in the iuting gap results in marginai
deterioration of ceramic restorations, especially in
the first years after restoration placement (Fig
7).21,67

Cast Gold Oniays and Onlays

Limited data are auailabie on the longevity of goid
restorations. Usuaiiy cast gold restorations tend to
be used on patients with exceilent orai hygiene,
which influences the resuits of clinical studies significantly.'''' The results of selected clinical studies
examining the iongevity of cast goid inlays are summarized in Tabie 8. Annual faiiure rates of cast gold
restorations range from 0% to 5.9%. Compared to
other restorations for posterior teeth, cast gold
restorations are considered to be costiy but long
55

Hickei/Manhart

Tabie 6 Longevity of ceramic iniays and oniays

Year

First author

Obser-

Blacit

vation

ciass

Restorative materiais

Number

Number

of

of

Sutvival

Annual

Median

rate(%)

failure

sutviual
time
(years}

period

restota-

patients

tte

(yeajs)

tions (n}

(n)

{%}

59

1988 Jensen''^

1 and li

Mirage

310

1992 Haas^

Iniays

Dicot
Opteo
Hi-Ceram
Du-Ceram

30
30
30
30

1992 Hglund'"

)i

Mitage 1res m cement)

Mirage (Gl cement)

59
59

50

1992 Krejcil

15

li

Empress

10

10

1993 Stenberg i i 2

il

Dicot(GI cement)

25

1994 Hglund

il

Mirage (tesin cement}

Mirage (Gl cement}

59
59

1994 Ttiordruplis

iandii

Vita Dut N

14

1995 isidor

2-4.5

il

Mirage

25

1995 Tidetiagiis

il

Empress

62

1996 Ftiedl'"

il

Mirage ii

50

1996 Quailrough" 3

iandii

Mirage

50

1996 Studei"5

iandii

Empress

1997 Fradeani's

4.5

inlays
and
Oniays

1997 Friedi='

1997 RouletW

Remarks

95.8

2.1

93.3
80
80
90

2.2
6.7
6.7
3.3

Main reasons fot

repiacement: fracture of tiie inlays
and secondary
caries.

98
85

1
7.5

Comparison of a
tesin cement anda
giass ionomer cement as iuting
agent.

QO

Only inlajs in premoiats. Significant

deterioration of
marginai uaiity
overtime.

20

92

Glass ionomer cement as luting

agent

50

96.6
84.7

13
51

Comparison of a resin mentTd a gtes

ionomer cement as
iuting agett

Longitudinal

92.9

7.1

Fracture ofliniay.

Longitudinal

52

18

Longitudinal

98.4

O.S

20

Longitudinal

100

27

Longitudinal

82

Main failure reasons: inlay fractute.

More fa ilutes in
moiats(n^6)than
inpremolars(n^3)

130

36

Longitudinal

97.5

1.3

KaplanMeiet itietiipd. Mainteasons

fot repiacement:
ft3ctu(eoftheinia)s.

Emptess

125

29

Longitudinai

95.6

Kaplan-Meier method. Mam fa ilute

reasons: in iay fractute.

li

Mitage 11

5D

20

Longitudinal

100

64% of the matgins were perceptitile clinioaiiy after 4

yeats.

landli

Dicor

123

29

Cfosssectionai

76

i^apfenMeiermsKcd.
Main reasons ibr
tepiacement: ftactuteoftiieiniais.

Empress

14
37

11

100

Ail matgins iocated

within enamel. Significant deterioration of marginal
quality ovettime.

1997 Tiionemann'"2

"

56

Study design

Longitudinai

Longitudinal

Main reasons for

replacement: tracture ofthe inlay.
Fracture cflonlay.

The Journai of Adhesive Dentistry

Hickel/Manhart

Table 6 (continued) Longevity of ceramic iniays and oniays

Year

First author

ODser-

Biack

uation

iass

period
(years)

Restorative materials

NumBer

Number

of

of

restora-

patients

tions (n)

(n)

Dicor, Empress, Mirage

II, Cerec Vila Mark i,
Duceram LFC

287

106

Crosssectionai

94,2

0,8

Kaplan-Meier meUiod, 17 restorations failed (3 in

lays, 14 onlays).

Study design

Surviual

Annual

Median

rate {%)

faiiure

surviuai

rate

time

(%|

(years)

Remarks

1998 Feidenis

1998 Fuzzi^a

10

andli

Microbond Naturai
Ceramic and Fortune
Ceramic

183

67

Longitudinal

97

0,3

Kaplan-Meier method, Premolars

betlerthan molars
199% vs. 95%}.

1998 HayashiS"

andli

G-Cera Cosmotech li

49

29

Longitudinal

92

1.3

SEM shewed mar

ginal microfiacnJiesin49%cfthe
inlays.

1998 Lebnerse

niays
Iniays

Empress

138
17

43

Longitudinal

94,9

0.9

Kapian-Meier
meiliod. Nociassi
inlay faiied.

1998 Scheiben-

andii

Empress

24

Longtudinal

100

Student operators.

1998 vanDijhenii 6

Mirage (resin cement)

Mirage (Gi cement)

58
57

50 (aii)

LongitutJinai

88
74

2
4,3

Higher faiiure rate

in iniay group luted
ivitfi a gass ionomer (Gl) cement
raBier than a resin
cement (RC),

1999 Kramer's

nIays
and

Empress

96

34

Longitud Ina i

93

1,8

Kapian-Meier methcd. Main feiiure

reason: bulk fractures and need fci
endodoniic therapy.

2001 Manhart'

Empress

21

Longiludinai

100

Fig 6

nIays
and
Oniays

andii

Failed ceramic inlay with bulk fracture of the restora-

tion in a msxillary first premolar.

Voi 3, No 1, 2 0 0 1

Fig 7

Empress ceramio inlay 4 years after placement. The

resin cement in the luting gap is worn.

57

Hickel/ivianhart

Table 7 Longevity of computer-generated ceramic iniays and oniays (CAD/CAM)

ear

First author

Ottser-

Biack

valion

ciass

Restorative materials

Number

Nu muer

of

of

period

restora-

patients

(years)

tions (n)

(n)
142

Study design

Survivai

Annuai

Median

rate(%)

faiiure

survival

rate

time

Remarks

(years)
Longitudinal

95

1.7

Longitudinal

86.7

4,a
0

Kapian-Meier method. Main reasons

for repiacement:
fracture and postoperative symptoms.

1991 ReiSS^^

1 a/id ii

Cerec

426

1993 Haasse

iniays

Cerec

30

1993 Mormann^^

il

Cerec: Vita Cerec Mariil

and Mark il

1992 Sjogrenios

1-3

i and il

Cerer;; Vita Cerec Mark 1 205

and Mark II

1994 Thordruo"^

1
5

1 and ii

Cerec; Vita-Biocks

15

Longitudinal

100

1994 Walther^"

landii

Cerec

1011

299

Longitudinal

95

0
1

1995 Ottd^

Cerec: Vita-Blooks

100

62

Longitudinal

93

0.4

1996 Heymann32

1
li

Cerec; Dicor MGC

19
31

28 (all)

Longtudmal

100

1997 BergS

li

Cerec i

51

46

Longitudinai

94.1

1.2

Ail iniays s h o v ^
marginai defects
after 5 years.

1998 Reiss^^

7.5

fandii

Cerec

1011

299

Longitudinai

91.6

11

Kaplan-Meier methori.Premolars e/hibited a better performance than iriolars.

1998 ZuelligSinger""

II

Cerec; Vita Mark ii(RC)

Cerec; Vita Mark ii (GIC)

28
9

18 (all)

Longitudinal

96.4
100

1,2
0

Quantitative margin analtiis. RCresin cement; GIC ^

gass ionomer cement (Ketac-Cem).

2000 Reiss^

10
12

1 and il

Cerec

1010

299

Longitudinal

90
84.9

1
13

Kaplan-Meier mettiod. Premolars exhibited a better performance than moIars.

"

lasting.113 The relative cost factor of gold restorations has been calculated to be 3.8 to 6,3 times
that of amalgam restorations7'''ii Gold restorations are, however, considered to be the most
durable restorations for posterior teeth. Tooth fracture, marginal defects, insufficient retention, and
secondary caries (Fig 8) are the main reasons for
58

100

72

98

73.&B6% perfect
marins ill fie SEM.
4 iniays fractured.
14 % postoperative
sensitivity.
Kapian-Meier method. Main leasons
for replacement:
iniay fracture, tooUi
fracture, caries.
3 restored teeth required endodontic
therapy.

the failure of cast gold inlays,^3 if the size of a lesion requires the replacement of one or more
cusps, gold onlays or partial crowns are still an excellent method to achieve tooth restoration, despite
the possibilities offered by adhesively bonded allceramic restorations. Smales found that posterior
cast gold restorations had significantly greater lonThe Journal of Adhesive Dentistry

Hickel/Manhart

Tabie 8 Longevity of cast goid iniays and oniays

Year

First autrior

Number

Number

pi

of

period

restora-

(years)

tions (n)

Obser-

Black

vation

ciass

Restorative materials

1981 Crabbii

10

Ii

Gold

146

1985 Leempoel^^

Partial
crown
Partial
crown
Crown
Orpwn

Gold

895

Gold

11
5
11

Study design

Survival

Annual

Median

rate (%)

failure

sun/ivai

patients

rate

time

(n)

(%)

(years)

41,1

5,9

96

0.8

91

0.8

Crosssectionai

10

landii
Crown

1992 Fritz23

10

1
Gold
ll(2iurfaceB)
Il(3iurface5)
Partial
Cnjwn

1992 Haas's

Inlays

Gold (RC)
Gold(CC)

Cast golf Goid

Kaplan-Meierestimator.

99
97

0,2
0,3

Crosssectional

95
89

0,5
11

Lfe tabie
method.

Crosssectional

65
60
68
70

3.5
4
3,2
3

Kaplan.Meier-estimator. Mam reason

for faiiure: caries
(42%) and need for
endodontic tlieraoy
(18%).

30
30

Longitudina

100
100

0
0

No difference betiveen adhesively

inserted (RC)iniaiB
and conventionally
cemented (CQiniavs.

1689

Orosssectionai

725

Crosssectionai

785

1986 Bentley^

173
295
2717 (all)

548 (ali)

15-16

873

13

92,1

0,9

Partial
crown
Crown

Gold

1994 Johstad^^

II

Goid

>250

Cmsssectional

15-17

Goid

120 |P)
80 (A)

Crosssectional

5
10,6

>12

390

520

>10

56

Oniays

1996 Smales""

15

1997 Hawthome^
1999 Donly"

Pakistan (P) and

Australia (A).
Premo arsperfoimed better ian
molars and smali
restorations better
than large restorations.

94,6

78

1,5

Mainfailure reasons: secondary

caries and fracture.
Kaplan-Meier-estimator. Main reasons for faiiure:
caries, insufficient
retenton.endodon-

Goid

96

Crosssectionai

1 and II

Gold

49

Crosssectionsi

13,8

11

18 (all)

LongJtudlna

818
85.7

2,6
2

171
294

890 (ali;

II (MO)

Crosssectionai

Ii (MODI
Partial

862
1679

76.1
88,3
83,4
87,5
86,1

2.4
12
17
1,3
1,4

Goid

Study conducted in

Crosssectionai

landii

Inlays
Onlays

Main reasons for

failure: tooth fracture, recurrent
canes.
Life table method.

1993 Schlsser"'' 9

>10

Remarks

Ufeiabie method.

crown

Vol 3, No 1, 2001

59

Hickel/Manhart

Postoperative hypersensitivity is a complication

frequently encountered after the luting of an adhesive iniay.3''84.98,ic5,ii8 jf,e risk of post-placement
hypersensitivity has been attributed to the method
of iuting and could be significantiy reduced by improved dentin bonding agents and resin cements,
in addition to the meticuious use of recommended
techniques and avoidance of tooth desiccation.
Whiie in 1990 up to 16% hypersensitivity was observed after piacement of adhesive restorations,
these figures decreased significantly to an incidence of 0% to 3% today.^'i.es
Fig 8 Cast gold restoration with secondary caries at tfie buccal aspect of a mandibuiar first moiar. The margin of the
restoration borders on a zone of demineralized enamel.

gevity than cuspal repiacement amalgam restora-

Clinical Factors
iHandling of a dental restorative materiai under
ideal circumstances produces a restoration that
can last for many years. However, the iongevity of
the restoration is dependent upon many factors
which are patient-, dentist-, and material-related
(Table 9).35
The findings of several studies support the view
that single-surface restorations show greater longevity than multisurface restorations.^^'''SS'^s
However, restorations limited to the occlusai surface may be found to suffer significantly more faiiures due to caries than Class Ii resto rations. 22.97.113
The development of new carious lesions on unprotected approximai surfaces during the lifetime of
the Class I restorations was considered to account
for this phenomenon. Furthermore, premolars were
found to offer significantly more favorable conditions for the survival of adhesive inlays than moIa 1-5,23,25,ici,i02 j ^ e age of the patient had an important influence on the treatment outcome.^'^'i'^9
Smalesios mentioned an age effect, but found no
statistical evidence, whereas Plasmans^o and Bentley* found a superior survival rate for restorations
placed in younger patients compared with oider patients. Differences in the quality of orai hygiene
measures, fluoride availaibility, dietary habits, and
periodontal probiems may be associated with these
findings.

60

In gnerai, the distinction must be made between eariy failures of dentai restorations that are
encountered after weeks or months and late faiiures after several years of ciinicai service. The early
failures are a result of severe treatment faults (eg,
incorrect manipuiation ofthe materials, insufficient
polymerization that results in weak materiai properties), selecting an incorrect indication for the
restorative materiai, or postoperative symptoms.
Late failures are predominantly caused by fractures
(tooth and/or restoration), the occurrence of secondary caries, and wear or deterioration of the respective materials.

CONCLUSIONS
The iongevity of dentai restorations is dependent
upon many different factors, inciuding those related
to materials, the dentist, and the patient. The main
reasons for faiiure were the formation of secondary
caries, fracture of the bulk of the restoration or of
the tooth, marginai deficiencies, and wear. The importance of direct-placement esthetic restorative
materials is stili increasing. Amalgam restorations
are being repiaced because of alleged adverse
health effects and inferior esthetic appearance.
However, ali alternative restorative materials and
procedures have certain limitations. Direct composite restorations require a time-consuming and more
costly treatment procedure. Glass ionomers, at present, can oniy be considered as long-term provisionai restorations in stress-bearing regions. Future
treatment regimens - which will only be made possible by the deveiopment of sophisticated preparation techniques, improved dentin bonding agents,
and resin-based restorative materials - will comprise the treatment of more small-sized lesions
rather than large restorations. Emphasis will increasingly shift away from indirect inlay techniques

The Journal of Adhesive Dentistry

Hickei/Manhart

Tabie 9

Factors infiuencing tiie iongevity of dentai restorations

Patient

Dentist

Material

Oral hygiene
Preventive measures

Cortect indication
Cavity p te pa ration
(size, type, finishing)
Handling and appiication (eg,
incremental vs bulk piacement)
Curing mode (device, time,
light intensity)
Mode of finishing and
poiishing of the restoration

Strength (fractures}
Fatigue / degradation

Correct occlusion
Experience (with matetial)

Technique sensitivity
Caties inhibiting effects
(release of substances?)

Compliance in tecali
Oral environment (guaiity cf
tooth structure, saiiva, etc)
Size, shape, location of the
lesion and tooth (number of
surfaces,vital vs nonvital
tooth, premolar vs melar)
Cooperation dunng treatment
Btuxism/habits

toward the direct restoratives: f the cavities become smaller, it is to be expected that the use of
imoroved direct restorative materiais wiii provide exceiient longevity even in stress-bearing situations.

REFERENCES
1. fliian DN. The durability of conservative restoretions. Br
DentJ1969;126:172-177.
2. Alian DN. A longitudinai study of dentai restcrations. Br
DentJ 1977:143:87-89.
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