How would you decide between a bonded posterior composite resin

and a bonded amalgam for restoring a Class II cavity in a

? mandibular molar

Mohammed D. Ahmed B.D.S

Doha , Qatar

INTRODUCTION

For many years the restorative material of choice for direct placement restorations of

posterior teeth was dental silver amalgam. Although dental amalgam is the most used

restorative material for the posterior and has provided many years of outstanding

clinical service, there has been a trend in recent years to restore posterior teeth with

composite resin. The major contribution to the trend to use composite resin in the

posterior region has been the significant improvements in adhesion of to enamel and

.dentin and the physical properties of composite resins

The performance of dental restorations is influenced by several factors, including

,clinician’s level of experience, the restorative materials used, the type of tooth

the tooth’s position in the dental arch , the restoration’s design, the restoration’s

.size, the number of restored surfaces, and the patient’s age

Failure occurs when a restoration reaches a level of degradation that precludes

proper performance either for esthetic or functional reasons or because of inability to

.prevent new disease

-The two direct dental restorative materials most commonly used today are silver

.mercury amalgam and resin-based composites

PRACTICAL CONSIDERATION

Bonded Composite resin restoration

Although successful techniques for posterior resin placement have been developed

with the universal microhybrid materials, they present many challenges when

clinicians attempt to place morphologically correct and functional Class II

.restorations

Many hybrid composites are difficult to manipulate because of inherent stickiness and

.slumping. Stickiness can result in voids and porosity as materials are manipulated

Slumping increases the difficulty of creating proper anatomical form during

.incremental placement of the material

Another problematic physical property inherent to all composite resins is shrinkage

during polymerization. This, in turn, can lead to marginal gaps and microleakage at

gingival margins. Such leakage can cause postoperative sensitivity and possibly lead

to secondary caries. When all factors are taken into consideration, placing posterior

Class II resins is much more demanding and technique sensitive than placing

.amalgams

Finally, the time needed to place a high-quality posterior composite resin restoration

.can be considerably more than that needed to place an amalgam restoration

The current generation of direct, hybrid composite resins is approaching the

the wear resistance of amalgam. As a result, the direct, tooth- colored posterior

restoration is durable, aesthetic and resistant to recurrent caries is approaching

,reality. The categories of composite resin to restore posterior teeth include hybrid

nanofill hybrid, high density radiopaque microfill, low shrink nanocomposite and
high

.viscosity (packable) composite resins

The American Dental Association Council on Scientific Affairs stated that composite

resin restorations allow for more conservative preparations thereby preserving tooth

.structure

Consensus of the Council was not to use composites when teeth demonstrate heavy

occlusal stress, sites that cannot be isolated, and for patients who are allergic or
.sensitive to resin-based composites

The advantage of composite resins today over silver amalgam is that they are highly

esthetic, reinforce tooth structure and can conserve more tooth structure in their

.preparation design

An ideal composite resin for restoring posterior teeth should fulfill the following

:criteria

;Wear similar to natural tooth structure or dental silver amalgam .1

;Have no plastic deformation in function .2

;Have a simple technique for placement .3

;Have minimal shrinkage during polymerization .4

;Have excellent marginal adaptation and sealing .5

Have a radiopacity equal to or greater than enamel and dentin for ease of .6
;radiographic evaluation

Have a quick, exact, non-tooth destructive finishing technique; and .7

Be esthetically pleasing in color and translucency .8

The new resins can be described as packable and stay where placed, regardless

of the time required for sculpting before light-curing. In addition, these materials are

easily manipulated because they are virtually nonsticky when clean, scratch-free

.instruments are used

The change in composition of composite is the result of increasing the volume of filler

particles, varying the size and type of the of the resin matrix . Manufacturers are

claiming that these changes result in less shrinkage during polymerization as well as

.in improvements in workability, depth of cure, wear resistance and color stability

Bonded Amalgam restoration

Although resin-based composite and other types of relatively new restorative

,materials are being used extensively, they have not yet completely replaced amalgam

which still is a very popular direct restorative material. The composition and

properties of amalgam still are being improved, and there also has been considerable

progress in the technique of placing amalgam restorations. Along with dramatic

advances in dentin adhesives, techniques for bonding amalgam to tooth structure have

.been developed and tested

the most important advantages of bonding amalgam as the conservative preparation

it requires, they decrease the need to remove noncarious tooth structure for retention

the reduced marginal gap and postoperative sensitivity it produces owing to sealing ,

by resin adhesives, its reduction of secondary caries and its improvement of restored

.teeth’s resistance to fracture

Its disadvantages are the increased time required to perform amalgam restorations

compared with the time required to perform a conventional restoration), its)

.sensitivity to technique and its higher cost

When amalgam bonding with resins was developed, modern dentin bonding

agents were just becoming popular as a result of improvements, so the amalgam

. bonding technique was used with these new adhesives for both dentin and enamel

Bonded amalgam restorations may be useful for large lesions in posterior teeth, as

well as for teeth that have low gingival-occlusal height, because such restorations

.(eliminate retention pins and their inherent risks (pulp or periodontal perforation

.This technique also seals the pulpal dentinal complex biologically

CONCLUSION

Failure rates of posterior composite restorations was significantly higher than those of

amalgam restorations. This was true irrespective of the arch, type of tooth, number of

,restored surfaces or restoration size. The main reason for failure was secondary caries
followed by fracture. The overall risk of failure due to secondary caries was 3.5 times

higher in composite restorations than in amalgam restorations. The risk of failure due

.to fracture was equal in amalgam and composite restorations

.Bonded posterior amalgam restorations performed better than composite restorations

The difference in performance was accentuated in restorations with more than three

surfaces restored and in large restorations. When one takes into consideration that

certain factors such as poor training in adhesive procedures, a lack of adequate

equipment and insufficient conditions required to execute highly technique-sensitive

.composite restorations

Amalgam more often seems to be preferable to resin-based composites for use in

.direct restoration of large posterior teeth, particularly when the restorations are large

If a tooth colored restorative material is desired by the patient, then the bonded

. composite restoration is the choice

The literature supports the use of composite resin as an equivalent to amalgam in

moderately sized Class 2 preparations . Although longevity of a composite resin

. improves with conservative preparations

Contraindications to the use of composite resin as a directly placed posterior

restorative can include the inability to place a dental dam or adequately isolate the

area to ensure no contamination during restoration placement and patients that are

-allergic or sensitive to resin-based composites. Posterior teeth exhibiting moderate-to

severe wear due to attrition or parafunction habits are also not good candidates for

.posterior composite resins

REFERENCES

Howard E. Strassler : " Predictable Restoration of Posterior Teeth with . 1

" Composite Resin

Mario Bernardo, Henrique Luis, Michael D. Martin, Brian G. Leroux, Tessa Rue, .2
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amalgam versus composite posterior restorations placed in a randomized
clinical trial " JADA 2007;138;775-783

RONALD D. JACKSON and MICHAEL MORGAN : " THE NEW . 3

"POSTERIOR RESINS AND: A SIMPLIFIED PLACEMENT TECHNIQUE
J Am Dent Assoc 2000;131;375-383

John W. Simecek, Kim E. Diefenderfer and Mark E. Cohen : " An Evaluation of . 4

Replacement Rates for Posterior Resin-Based Composite and Amalgam
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2009;140;200-209

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ZBYNEK MACH, JAN REGENT, MICHAL STANINEC, LUBOR MRKLAS and . 6

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